Huckle, Richard

Independent investigation into
the death of Mr Richard Huckle,
a prisoner at HMP Full Sutton,
on 13 October 2019
INITIAL
A report by the Prisons and Probation Ombudsman
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to
any cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Richard Huckle was killed in his cell at HMP Full Sutton on 13 October 2019. He was
33 years old. I offer my condolences to his family and friends. In November 2020, Mr
Paul Fitzgerald, a prisoner who lived on the same wing, was convicted of Mr Huckle’s
murder.
Homicides in prison are rare and identifying likely perpetrators can be difficult.
Nevertheless, I am concerned that there were missed opportunities to identify that Mr
Fitzgerald was at increased risk of committing an act of serious violence in the time
leading up to Mr Huckle’s death. Security intelligence reports indicating risk were not
analysed on time and recommended actions, including referral to the mental health team,
were not completed. Mr Fitzgerald had presented with risk indicators throughout his years
in prison and had been involved in, or suspected of involvement in, violent acts. Prison
staff told us that he was a prisoner on whom they were sometimes asked to keep a closer
eye. When such information is available about a prisoner, it is important that prison staff
identify any indication of increased risk and take appropriate action.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister
Prisons and Probation Ombudsman May 2024
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ......................................................................................................................... 14
Summary
Events
1. In October 2008, Mr Paul Fitzgerald was remanded in custody. He was later
sentenced to an indeterminate sentence for public protection. Mr Fitzgerald was
diagnosed with a personality disorder with psychopathic traits. During his time in
custody, Mr Fitzgerald said that he experienced violent fantasies and described
having thoughts of rape and torture. He was frequently assessed and reviewed by
prison mental health teams as a result.
2. In February 2015, Mr Richard Huckle was remanded in custody. He was later
sentenced to 25 years in prison for many serious sex offences. In July 2016, Mr
Huckle was transferred to HMP Full Sutton. During his time in prison, he was
sometimes the victim of violence and bullying and some prison staff told us that the
high-profile nature of his offence might have made him more of a “target” for
assault.
3. In January 2016, Mr Fitzgerald tried to take a member of staff hostage. He was
later sentenced to an additional two years and four months in prison and was
transferred to HMP Woodhill, a high security prison.
4. In 2017, Mr Fitzgerald applied for a place at a personality disorder unit at HMP
Frankland. His application was later rejected.
5. On 27 November 2018, Mr Fitzgerald wINITIAL as transferred to Full Sutton. Over the
following months, he sometimes spoke to staff about extremely violent fantasies.
6. On 9 July 2019, Mr Fitzgerald moved to D Wing, where he lived on the same wing
as Mr Huckle.
7. On 3 October, Mr Fitzgerald told an officer that he had constant thoughts of murder,
rape, cannibalism and torture. He said that he had committed a very violent act on
a prisoner at Woodhill, who had not reported this at the time. On the same day,
staff found a note on another wing addressed to Mr Fitzgerald. It indicated that he
would be paid to assault a specific prisoner (not Mr Huckle). Staff submitted
security information reports about both incidents.
8. On 7 October, Mr Fitzgerald met his prison offender manager in the presence of an
officer. During the meeting, Mr Fitzgerald said that he enjoyed hitting women and
made “veiled threats” that he was planning to commit an act of violence. The officer
submitted a security information report.
9. At 10.30am on 13 October, Mr Fitzgerald went to Mr Huckle’s cell and committed a
sustained and violent assault. At around 11.45am, a prisoner, who had disturbed
the incident, informed prison staff in the wing office. They went to the cell, removed
Mr Fitzgerald and began emergency first aid. At 12.30pm, paramedics confirmed
that Mr Huckle had died.
Prisons and Probation Ombudsman 1
Findings
Assessment of risk
10. We are concerned that the security intelligence reports about Mr Fitzgerald,
submitted in the ten days before Mr Huckle’s death, were not analysed within local
timescales and recommended actions were not completed. Each piece of
intelligence was considered in isolation and there was no evidence that anyone
considered whether, cumulatively, they might indicate a higher risk. At the same
time, a wing manager did not interview Mr Fitzgerald in light of the intelligence, as
should have happened. There was also no referral to the mental health team,
despite one of the reports explicitly referring to Mr Fitzgerald’s “poor mental health”.
Events of 13 October 2019
11. CCTV footage shows that only one member of staff spent time on Mr Huckle’s
corridor during the period that Mr Fitzgerald was in his cell. This was a missed
opportunity to identify the assault.
Recommendations
• The Governor should ensure that security intelligence reports indicating violence
are analysed promptly and in line with local targets, and that actions are completed
as recommended.
• The Governor should ensure that wing managers interview any prisoner whom
intelligence indicates might be considIeNITIAL ring committing an act of violence and take
appropriate action when indicated.
• The Governor should ensure that officers undertake frequent patrols during
association periods and are alert for signs of violence.
2 Prisons and Probation Ombudsman
The Investigation Process
12. The investigator issued notices to staff and prisoners at HMP Full Sutton informing
them of the investigation and asking anyone with relevant information to contact
him. She obtained copies of relevant extracts from Mr Huckle’s and Mr Fitzgerald’s
prison and medical records.
13. We suspended our investigation at the request of the police and resumed it after Mr
Fitzgerald’s trial had concluded in November 2020. We regret the subsequent
delay in issuing this report.
14. Another investigator interviewed nine members of staff at Full Sutton in May 2021.
NHS England commissioned a clinical reviewer to review Mr Huckle’s clinical care
at the prison, and another clinical reviewer to review Mr Fitzgerald’s clinical care in
custody. The investigator and the second clinical reviewer jointly interviewed
healthcare staff.
15. We informed HM Coroner for Hull and the East Riding of Yorkshire of the
investigation. He gave us the results of the post-mortem examination. We have
sent the Coroner a copy of this report.
16. The Ombudsman’s family liaison officer contacted Mr Huckle’s parents to explain
the investigation and to ask if they had any matters they wanted us to consider.
They asked the following questions:
• Why was Mr Fitzgerald able to spenINITIALd over an hour in Mr Huckle’s cell, during
which time he carried out a sustained attack, without any member of staff being
aware of the incident?
• Should Mr Huckle have been identified as vulnerable to assault and offered
vulnerable status?
• Why did it take around 24 hours, and after they had already learnt the news from
another source, for the prison to inform them of Mr Huckle’s death?
17. We shared the initial report with HM Prison and Probation Service (HMPPS).
Following discussion with HMPPS, we have amended one of the findings.
18. We also shared the initial report with Mr Huckle’s parents. They asked some
additional questions, which we have addressed through separate correspondence.
Prisons and Probation Ombudsman 3
Background Information
HMP Full Sutton
19. HMP Full Sutton is a high security prison that holds up to 626 adult men. Spectrum
Community Health CIC provides health services, and healthcare staff are on duty
24 hours a day.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Full Sutton was in February to March 2020.
Inspectors reported that the level of reported violence was low compared to similar
prisons, although some incidents were serious and there was evidence of some
incidents not being reported and investigated. Inspectors found that there was a
good approach to managing perpetrators of violence. Inspectors also reported that
security intelligence was managed well and there was no backlog.
21. Inspectors also found that mental health services had improved and met most
prisoners’ needs.
Independent Monitoring Board
22. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report forI NITIALthe year to 31 December 2020, the IMB
reported that safety was well-maintained during the reporting year and incidents of
violence between prisoners decreased.
Previous deaths at HMP Full Sutton
23. Mr Huckle was the seventh prisoner to die at Full Sutton since November 2017, and
the first victim of murder in this period. There are no significant similarities between
our investigation findings into Mr Huckle’s death and those of the previous deaths.
4 Prisons and Probation Ombudsman
Key Events
Mr Richard Huckle
24. On 3 February 2015, Mr Richard Huckle was remanded in custody to HMP Lewes.
It was his first time in prison. Mr Huckle had no significant recorded history of
physical or mental ill health. In September, Mr Huckle was transferred to HMP
Belmarsh.
25. In June 2016, Mr Huckle was sentenced to 25 years in prison for many serious sex
offences against children. His trial and sentencing received significant media
coverage. The next month, he was transferred to HMP Full Sutton. Other than six
weeks spent at Belmarsh in late 2017, under the accumulated visits scheme, Mr
Huckle lived at Full Sutton for the remainder of his life.
26. From 2016 to 2018, prison staff opened local violence reduction procedures seven
times, following reports that Mr Huckle was under threat from or being bullied by
other prisoners. He was assaulted twice by other prisoners during this period.
Some reports suggested that Mr Huckle deliberately “goaded” other prisoners. In
November 2018, an unidentified prisoner wrote a note to staff saying that they
would kill Mr Huckle “if he steps out of line one more time”.
27. Mr Huckle lived on D Wing at Full Sutton, a unit for ‘vulnerable’ prisoners, including
those who have been convicted of sex offences or have asked to live separately
from the general population for other re asons. Prison staff told us that Mr Huckle’s
high-profile offence might have made hINITIALim more of a “target” for other prisoners. A
Supervising Officer (SO), a wing manager on D Wing, said that there were several
prisoners on the wing of a similar nature and there was no intelligence to indicate
that Mr Huckle was at particular risk. Mr Huckle’s prison offender manager (POM)
told us that he understood that Mr Huckle was not particularly liked by other
prisoners, in part due to the nature of his offence but also because he “antagonised”
others. An officer said that Mr Huckle kept to himself and lived on a quieter part of
the wing.
28. On 1 March 2019, Mr Huckle was assaulted by another prisoner. Although he did
not need hospital treatment, the assault was reportedly of a serious nature and staff
recorded that Mr Huckle was punched over 20 times. He spent two days in the
healthcare inpatient unit afterwards before returning to D Wing. Prison staff began
a Challenge, Support and Intervention Plan (CSIP). (CSIP is a Prison Service
violence reduction tool used to identify and manage prisoners at raised risk of
harming others and to protect potential victims of violence.)
29. On 9 July, Mr Paul Fitzgerald moved into a cell on D Wing. (Mr Fitzgerald had
previously lived on the same wing as Mr Huckle for one day when he first arrived at
the prison. There is no intelligence to indicate that he was involved in any of the
above incidents.) A SO told us that Mr Huckle and Mr Fitzgerald were quite friendly
and that Mr Fitzgerald was one of a small handful of prisoners with whom Mr Huckle
socialised.
30. On 3 October, Mr Huckle’s key worker recorded that Mr Huckle appeared “settled
and relaxed”. He recorded that Mr Huckle said that the wing was “better and more
Prisons and Probation Ombudsman 5
settled”. On 9 October, the key worker recorded his final key work session and
noted that Mr Huckle did not have much to say but appeared well.
Mr Paul Fitzgerald
31. On 16 October 2008, Mr Paul Fitzgerald was remanded in custody to HMP
Doncaster, charged with actual bodily harm, false imprisonment and a sex offence.
He had previously served two prison sentences for indecent assaults. In February
2009, Mr Fitzgerald was sentenced to an indeterminate sentence for public
protection (IPP) with a minimum time to serve of four years.
32. In September 2011, Mr Fitzgerald was transferred to HMP Isle of Wight. In
November, a psychiatrist diagnosed a severely disordered personality, with
prominent psychopathic traits.
33. At around the same time, prison staff reviewed Mr Fitzgerald’s cell sharing risk
assessment (a form designed to assess the risk of violence a prisoner poses to a
potential cellmate) and concluded that his risk of severe cell violence was high (on a
scale of standard and high). The review followed several entries by members of
staff describing violent sexual fantasies that Mr Fitzgerald said he had experienced.
34. In March 2012, Mr Fitzgerald was found guilty at a prison disciplinary hearing of
having had a weapon in his possession.
35. In June 2014, an officer recorded that Mr Fitzgerald had spoken to her about daily
fantasies of mutilation, cannibalism and necrophilia. A mental health nurse
INITIAL
assessed Mr Fitzgerald and concluded that he should engage with a psychologist.
36. In January 2015, staff found coded notes in Mr Fitzgerald’s cell, which appeared to
indicate a desire to mutilate a female officer. The following month, he was charged
with a disciplinary offence after being found with a weapon. In April, Mr Fitzgerald
began the Thinking Skills Programme, a course designed to address the way
offenders think and behave.
37. In September, a psychiatrist assessed Mr Fitzgerald, who said that he was keen to
try medication to control his fantasies. The psychiatrist recorded that he would
consider this.
38. In November, the psychiatrist reviewed Mr Fitzgerald and explained that he did not
think that medication was appropriate. The psychiatrist recommended instead that
Mr Fitzgerald should engage with prison offending behaviour programmes.
39. In January 2016, Mr Fitzgerald tried to take a member of staff hostage and
threatened to stab her. The offence was reported to the police, and Mr Fitzgerald
was later sentenced to an additional two years and four months in prison.
HMP Woodhill
40. In April, Mr Fitzgerald was transferred to HMP Woodhill in the High Security Estate,
as a result of the incident three months earlier.
6 Prisons and Probation Ombudsman
41. In May, Mr Fitzgerald spoke to his offender supervisor about previous fantasies of
committing offences in custody and of kidnap, rape, cannibalism and necrophilia.
42. In December, a psychiatrist assessed Mr Fitzgerald and recorded a diagnosis of
anxiety and a cluster B personality disorder (where the patient has difficulty
regulating their emotions and behaviour). The psychiatrist began a trial of
pregabalin (anxiety medication). Mr Fitzgerald said that he would like to be
transferred to Rampton Hospital, a high security psychiatric hospital. The
psychiatrist recorded that a personality disorder pathway (in prison) was more
appropriate and should be followed before transfer to a secure hospital was
considered.
43. Early in 2017, a move to a personality disorder treatment unit at HMP Frankland
was discussed and Mr Fitzgerald signed an application for the move. In June, his
application to Frankland was refused due to concerns about Mr Fitzgerald’s conduct
in prison.
44. In August 2018, a psychiatrist reviewed Mr Fitzgerald. She identified a diagnosis of
psychoneurotic personality disorder (a personality disorder characterised by
emotional symptoms such as morbid fears, obsessive thoughts or depression). The
psychiatrist highlighted that Mr Fitzgerald was a risk to other prisoners due to his
thoughts of “bad things”. She prescribed a course of quetiapine (an antipsychotic).
45. On 16 October, prison staff saw Mr Fitzgerald in possession of a handmade
weapon. They subsequently searched his cell and found a second weapon. Mr
Fitzgerald was charged with an offence against prison discipline and punished with
a period of cellular confinement in the sINITIALegregation unit.
HMP Full Sutton
46. On 27 November, Mr Fitzgerald was transferred to Full Sutton. He initially lived on
C Wing.
47. On 4 December, healthcare staff recorded that Mr Fitzgerald had not collected
quetiapine for a week. They subsequently stopped the prescription. The next day,
Mr Fitzgerald told the Recovery Team manager that he had stopped taking
quetiapine as it was “over-sedating” him.
48. On 8 January 2019, Mr Fitzgerald was charged with a disciplinary offence after
being “aggressive and threatening” to an officer. He spent a short period of time in
the segregation unit as a result.
49. On 31 January, the Recovery Team manager and a senior mental health nurse
assessed Mr Fitzgerald. They identified that Mr Fitzgerald had previously been
considered for admission to Rampton Hospital and to the personality disorder unit
at Frankland. The manager recorded that Mr Fitzgerald’s diagnosis was a
personality disorder (consisting of dissocial, paranoid and emotionally unstable
traits) with psychopathic traits. They referred Mr Fitzgerald to the prison psychiatrist
and created a mental health care plan offering support as needed.
50. On 27 February, prison staff held a sentence planning meeting. During the
meeting, Mr Fitzgerald spoke in detail about ongoing violent sexual fantasies. He
Prisons and Probation Ombudsman 7
said that he wanted to be transferred to a secure hospital. The senior mental health
nurse attended and recorded that she advised Mr Fitzgerald that he might first have
to move to a prison personality disorder unit. Mr Fitzgerald said that this was not a
route he was willing to follow. His sentence plan included the requirement that he
should engage with the mental health team and be assessed for a move to a
suitable unit.
51. On 18 March, a prison psychiatrist assessed Mr Fitzgerald. He recorded that Mr
Fitzgerald presented with typical features of psychopathy and “enjoyed” talking
about rape, murder and the mutilation of women. He told us that it was unclear
whether Mr Fitzgerald was speaking of genuine fantasies or saying such things in
an attempt to shock. After the review, the mental health team concluded that Mr
Fitzgerald’s care should be transferred from the senior mental health nurse to a
male clinician. Mr Fitzgerald was now managed under the enhanced care
programme approach with the Recovery Team manager as his care coordinator.
(The care programme approach is for people with severe or complex mental health
problems, or those that require support from multiple agencies. Its key principles
for care include that the patient should receive support from a care coordinator,
have a full assessment of their needs and a written care plan.)
52. In April, officers twice recorded that Mr Fitzgerald had not attended his workshop.
On the first occasion, Mr Fitzgerald said that he had been threatened by another
prisoner there and that if it happened again he would “stab” the individual. On the
second occasion, Mr Fitzgerald said that there was not enough work to do and that
if he was sent there again, he would “use the sharp tools to hurt someone”. Mr
Fitzgerald continued to refuse to attend work and subsequently lost his job.
INITIAL
53. On 1 May, the senior mental health nurse spoke to Mr Fitzgerald about his
treatment plan. She explained that the psychiatrist was considering Mr Fitzgerald’s
history and previous treatment plans and would see him in July. Mr Fitzgerald
spoke of fantasies of rape, murder and cannibalism and said that these were
becoming more frequent. When asked about current plans, Mr Fitzgerald did not
give an answer but said that he had “acted on impulse in the past and raped
prisoners”. The nurse recorded that wing staff were “very aware that he poses a
risk to others”.
54. On 7 May, the psychiatrist and the senior mental health nurse reviewed Mr
Fitzgerald. The psychiatrist prescribed aripiprazole (an antipsychotic) to help Mr
Fitzgerald control his thoughts.
55. On 14 May, officers searched Mr Fitzgerald’s cell and found several illicit items.
That day, he told an officer that another prisoner on the wing was annoying him and
that he was ready for “stabbing someone up”. After further negative entries in the
following days, prison staff reduced Mr Fitzgerald to basic status on the prison’s
Incentives and Earned Privileges (IEP) scheme (which aims to encourage and
reward responsible behaviour in prisons).
56. On 26 June, Mr Fitzgerald destroyed some of the fittings in his cell. He was
removed from the wing and taken to the segregation unit.
57. On 2 July, the psychiatrist and senior mental health nurse reviewed Mr Fitzgerald,
who said that he was feeling positive effects from the aripiprazole. Mr Fitzgerald
8 Prisons and Probation Ombudsman
also said that he had been buying venlafaxine (an antidepressant) illicitly as he also
found this beneficial and asked for it to be prescribed. The psychiatrist recorded
that he would consider this at their next review.
58. On 9 July, Mr Fitzgerald left the segregation unit and moved into a cell on D Wing.
(He now lived on the same wing as Mr Huckle.) Three days after the move, he
spoke to his key worker, who recorded that Mr Fitzgerald saw the move as a fresh
start and wished to continue working with the mental health team to help him settle.
59. On 19 July, Mr Fitzgerald told prison staff that he had thought about taking
hostages and causing them significant harm. He indicated that he was keen to
transfer to Rampton Hospital but did not want to move to a prison personality
disorder unit.
60. On 30 July, the psychiatrist reviewed Mr Fitzgerald. Mr Fitzgerald said that he
experienced panic attacks and anxiety as side effects of aripiprazole. The
psychiatrist agreed to change his prescription to venlafaxine. He explained that he
had discussed Mr Fitzgerald’s treatment pathway with NHS commissioners and
agreed that he should be referred to a personality disorder unit in prison before he
could be considered for a psychiatric hospital. He told us that Mr Fitzgerald
indicated that he was now willing to consider this pathway. The next day, Mr
Fitzgerald signed referral forms for the personality disorder unit at Frankland. He
later also completed an application for a similar unit at HMP Whitemoor.
61. On 2 September, the Recovery Team manager spoke to Mr Fitzgerald and
recorded that Mr Fitzgerald presented w ell, said that the venlafaxine was working
well and that he had no concerns. On INITIAtLhe same day, the key worker recorded that
Mr Fitzgerald had no current issues.
62. On 12 September, prison staff found illicit alcohol in Mr Fitzgerald’s cell. They
again reduced his IEP level to basic. A wing manager referred Mr Fitzgerald to the
substance misuse team.
October 2019
63. On 2 October, a substance misuse recovery worker assessed Mr Fitzgerald. Mr
Fitzgerald said that he had no issues and did not need to engage with the service.
He said that he drank alcohol but found that it helped him cope with his thoughts
and feelings. The recovery worker told us that he tried to explore this further, but
Mr Fitzgerald did not go into any more detail about his thoughts. Mr Fitzgerald also
said that he felt more settled at Full Sutton than Woodhill but felt he needed a
change so was awaiting the outcome of his referral to the personality disorder unit.
The recovery worker said that Mr Fitzgerald stated that he “wouldn’t mind” going to
the unit at Whitemoor but worried that it might prolong his time in prison.
64. On 3 October, an officer recorded in the D Wing observation book:
“Staff to be aware of [Mr] Fitzgerald’s poor mental health. He has thoughts
of killing/raping/eating/torturing people constantly. Has previous in Woodhill
of raping and taking hostage a prisoner. Risk to females particularly. Wants
to torture/rape/kill someone again, wouldn’t say prisoner or staff.”
Prisons and Probation Ombudsman 9
65. The officer submitted a security intelligence report with similar content. In this
report, he also wrote that Mr Fitzgerald said that it would be easier to carry out such
an act on a prisoner although indicated that he would prefer to attack a female
member of staff. He also recorded that Mr Fitzgerald said that the prisoner he
claimed to have attacked at Woodhill did not report the incident. The officer left the
Prison Service before our investigation resumed and we have not therefore been
able to interview him about his conversation with Mr Fitzgerald. During the night,
the duty manager annotated to the officer’s observation book entry, “All staff to be
fully briefed, no staff to be left alone with Mr Fitzgerald”.
66. On the same day, staff on another wing found a note in a prisoner’s cell that
appeared to be addressed to Mr Fitzgerald. The note referred to an unnamed
prisoner on D Wing who had “grassed” on this prisoner and stated, “You should
fuck him up and I’ll pay you”. The note also speculated that Mr Fitzgerald would
move wings if he carried out an assault and that this would be to a wing where
drugs were more readily available. Prison staff recorded that the note was believed
to refer to assaulting a specific prisoner (who was not Mr Huckle).
67. On 4 October, an officer submitted a security intelligence report in which he said
that a prisoner had named several other prisoners on D Wing, including Mr
Fitzgerald, as using psychoactive substances. (Mr Huckle was not named on this
list of prisoners.)
68. On 6 October, the key worker conducted a key work session with Mr Fitzgerald and
recorded that he had no current issues.
69. On 7 October, Mr Fitzgerald met his neINITIALw POM. An officer attended the meeting.
This was presumably as a result of the duty manager’s note on 3 October, although
both members of staff told us that they were not sure exactly why Mr Fitzgerald was
not allowed one-to-one contact with staff. The POM recorded that Mr Fitzgerald
was annoyed that he had a new offender manager. Mr Fitzgerald said that he had
nothing to get out for and was not interested in sentence progression. The POM
also recorded that Mr Fitzgerald was “agitated” as the wing staff were “watching
him” because they “said he was going to assault a female”. He noted that Mr
Fitzgerald initially denied that he planned to assault anyone but, when asked
directly, would not answer. He told us that his impression was that Mr Fitzgerald
was deliberately trying to shock him but also that Mr Fitzgerald was frustrated as he
thought he was being unjustly treated.
70. The officer submitted a security information report in relation to the meeting. He
recorded that Mr Fitzgerald made “veiled threats” towards staff and said:
“Staff can watch me all they want. If I decide to do something they won’t be
able to stop me … I’m not stupid enough to say I am [planning something]
but I’m not going to say that I aren’t.”
71. The officer also recorded that Mr Fitzgerald said that he “enjoys hitting and
humiliating women”. He told us that Mr Fitzgerald was often mentioned in staff
briefing as a prisoner on whom staff should “keep an eye”. He said that this meant
monitoring Mr Fitzgerald’s more closely than other prisoners. He told us that his
recollection of the meeting was that Mr Fitzgerald’s focus was on women and that
his impression was that Mr Fitzgerald was clear that he did not want to be released
10 Prisons and Probation Ombudsman
because he intended to “assault and humiliate” women if this happened. He said
that his understanding therefore was that female staff were at greatest risk from Mr
Fitzgerald.
72. On the same day, security staff analysed the intelligence report submitted on 3
October about the note found that was understood to be addressed to Mr
Fitzgerald. They assessed that the level of risk was medium (on a scale of low,
medium and high) and highlighted that it was “highly likely” that Mr Fitzgerald was
being asked to assault a named prisoner as payment for drugs.
73. On 8 October, security staff analysed the intelligence report submitted by an officer
on 3 October. They assessed that the level of risk was low. The intelligence
assessment identified that Mr Fitzgerald had “multiple” reports of threatening to take
staff hostage and had tried to do so when at HMP Isle of Wight. It highlighted that
he was a risk to females and should not be left alone with any female staff. The
assessment also identified that staff should be vigilant as Mr Fitzgerald had said
that his mental state was not good, and he felt he could do something. Two action
points were noted: for the intelligence to be passed to the wing manager to make
staff aware, and for it to be passed “to psychology” for information. The Recovery
Team manager told us that such reports were usually sent to him by the security
team but that he had not received this intelligence report.
74. On 9 October, an officer’s security intelligence report was analysed. Security staff
assessed the level of risk as medium. They noted that the intelligence should be
passed to Mr Stewart and to “psychology”. There is no record that this was
received by the mental health team.
INITIAL
75. On 11 October, staff at the personality disorder unit at Whitemoor contacted the
POM, as he had asked for a progress update following his meeting with Mr
Fitzgerald. They said that they were currently reviewing Mr Fitzgerald’s case.
13 October 2019
76. At 9.13am, an officer unlocked Mr Huckle’s cell. Mr Huckle spent the first hour of
the morning going in and out of his cell, before making a telephone call. At
10.28am, Mr Huckle returned to his cell.
77. At 10.30am, Mr Fitzgerald went into Mr Huckle’s cell. He did not leave the cell until
removed by officers later that morning.
78. At 11.08am, a prisoner pushed open the cell door and stood at the doorway. The
prisoner told Humberside Police that he found Mr Huckle “sitting on the lap” of Mr
Fitzgerald. The prisoner said that he thought the men were having a consensual
encounter and left the cell.
79. At 11.42am, another prisoner went to Mr Huckle’s cell. CCTV footage showed him
briefly speak to and then gesture to someone in Mr Huckle’s cell before going into
the cell opposite. The prisoner told police that he saw Mr Fitzgerald seriously
assaulting Mr Huckle and that Mr Fitzgerald threatened that he “would be next” if he
told officers what he had seen.
Prisons and Probation Ombudsman 11
80. At 11.43am, a SO walked past Mr Huckle’s cell before being called back by the
prisoner who had just entered the cell opposite. They spoke for ten seconds before
the SO walked away. The SO told us that this was a general chat, and the prisoner
did not give any indication that there was an ongoing incident. The prisoner told
police that he did not tell the SO about the incident as he was concerned for the
SO’s safety were he to intervene by himself.
81. At around 11.45am, the prisoner went to the wing office and told staff there to go to
Mr Huckle’s cell. Several officers went to the cell, where they restrained and
removed Mr Fitzgerald. An officer pressed an alarm button, to alert all staff to an
incident, and another officer radioed a code red medical emergency, indicating a
life-threatening situation.
82. Prison and healthcare staff began chest compressions and emergency medical
treatment. At around 12.16pm, paramedics arrived and took charge of the
resuscitation efforts. At 12.30pm, they confirmed that Mr Huckle had died.
83. In November 2020, Mr Fitzgerald was found guilty of Mr Huckle’s murder. He was
sentenced to life in prison with a minimum time to serve of 34 years.
Contact with Mr Huckle’s family
84. At 12.50pm, a family liaison officer (FLO) contacted Humberside Police and asked
them to ask Kent Police to visit Mr Huckle’s parents to inform them of his death. At
4.59pm, the FLO spoke to a Detective Inspector (DI) at Kent police and asked to be
informed when they had spoken to Mr Huckle’s parents. The DI confirmed that
INITIAL
Kent Police had been instructed to deliver the news. The FLO recorded that he did
not hear anything further from Kent Police despite leaving a message on their
answer service.
85. Mr Huckle’s family had changed their address following his conviction, and he had
not been permitted to receive their new address. As such, the address held in
prison records was out of date. We were told that Kent police twice visited the old
address on the evening of 13 October.
86. Another officer was subsequently appointed as the new FLO, as the other FLO had
attended the emergency response. The usual practice is to appoint a family liaison
officer who did not have any involvement in the events surrounding the death.
87. At 9.00am on 14 October, the FLO attended a meeting with a Humberside Police
family liaison officer, at which she was told that Mr Huckle’s parents had not yet
been informed of his death. She recorded that she was told that Kent Police had
visited an old address for Mr Huckle’s parents.
88. The FLO therefore contacted HMP Eastwood Park, which was the nearest prison to
Mr Huckle’s parent’s address. At around 12.30pm, a family liaison officer from
Eastwood Park visited Mr Huckle’s parents and informed them of his death.
12 Prisons and Probation Ombudsman
Support for prisoners and staff
89. After Mr Huckle’s death, an operational manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
90. Prison staff spoke to the prisoner who raised the alarm and offered him support.
Post-mortem report
91. A post-mortem examination established that Mr Huckle was the victim of a
sustained attack that involved makeshift weapons being used to inflict multiple
injuries. The pathologist concluded that Mr Huckle died from ligature compression
of the neck.
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Prisons and Probation Ombudsman 13
Findings
Assessment of risk
92. Prison Service Instruction (PSI) 64/2011 on safer custody requires all staff who
have contact with prisoners to be aware of the risk factors and triggers that might
increase the risk of violence and to take appropriate action when indicated. Risk
factors for violence include a history of violence (particularly in prison), lack of social
support, substance misuse and personality disorder.
93. Mr Huckle had been convicted of numerous high-profile and very serious offences
against children. He was the victim of several acts of violence and bullying during
his time in prison. Some prison staff told us that Mr Huckle’s offence made him
more of a “target” for other prisoners. There were also suggestions that his manner
in prison meant that he was unpopular with others. Prison staff must be vigilant to
indicators that prisoners like Mr Huckle might be at an increased risk of assault at
any given time.
94. Mr Paul Fitzgerald had a long history of violent risk indicators in prison. He was
diagnosed with and was being treated for a personality disorder with psychopathic
traits. He had no social support outside prison. Mr Fitzgerald had often spoken to
staff about extremely violent fantasies and, sometimes, his desire to act on them.
He had been involved in, or was suspected of involvement in, violent acts in prison,
some of them very serious. He had also threatened serious violence against other
prisoners or staff. D Wing staff told us that he was a prisoner who had been
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identified as a potential risk and that they had been told in meetings to “keep an
eye” on him.
95. In the ten days before Mr Huckle’s death, prison staff submitted four separate
security intelligence reports about Mr Fitzgerald:
• On 3 October 2019, Mr Fitzgerald spoke of violent fantasies including rape,
cannibalism and torture and indicated that he wanted to “do [these acts]
again”.
• Also on 3 October, staff found a note in a cell on another wing indicating that
Mr Fitzgerald would be paid to assault a prisoner (who was not believed to be
Mr Huckle).
• On 4 October, Mr Fitzgerald was named as one of several prisoners on D
Wing who used drugs.
• On 7 October, Mr Fitzgerald made “veiled threats” and indicated that he might
be planning an act of violence.
96. The Head of Security and Intelligence told us that intelligence submitted to the
security team should be analysed within 24 hours and all recommended actions
completed within seven days. (This excludes intelligence classified as high risk,
which must be analysed within one hour.)
14 Prisons and Probation Ombudsman
97. The security intelligence reports submitted on 3 October were analysed on 7
October and 8 October. The intelligence submitted on 7 October was analysed on
9 October. There is no evidence that the referrals to “psychology” recommended by
the analysts were completed. There is also no evidence that the staff who
submitted the original intelligence reports referred Mr Fitzgerald to the mental health
team, including an officer who explicitly referenced Mr Fitzgerald’s “poor mental
health”.
98. These pieces of intelligence, including the two submitted on the same day, were
considered in isolation and there is no evidence that anyone considered whether,
cumulatively, they might indicate a higher risk.
99. A D Wing manager told us that the officer’s observation book entry on 3 October
should have prompted either the wing custodial manager or one of the supervising
officers to speak to Mr Fitzgerald to discuss the matter further and determine
whether any further action was required. The Head of Security and Intelligence
also said that he would expect a wing manager to have such a conversation and
that options including CSIP, a wing move, or segregation might have been
considered as a result. There is no evidence that a wing manager spoke to the D
Wing manager either in the aftermath of the officer’s entry or following that made by
another officer five days later. We make the following recommendations:
The Governor should ensure that security intelligence reports indicating
violence are analysed promptly and in line with local targets, and that actions
are completed as recommended.
The Governor should ensure that wiINITInAL g managers interview any prisoner
whom intelligence indicates might be considering committing an act of
violence and take appropriate action when indicated.
Healthcare provision for Mr Fitzgerald
100. The clinical reviewers identified that Mr Fitzgerald presented extreme healthcare
challenges relating to issues including his personality disorders, fantasies, self-harm
and non-compliance with treatment plans. They highlighted that there is no
definitive treatment for a patient such as Mr Fitzgerald and that any treatment would
rely on his ongoing co-operation. The clinical reviewers found that the mental
health team at Full Sutton engaged well with Mr Fitzgerald with their focus being to
establish an effective therapeutic relationship with him.
101. For much of his time in custody, Mr Fitzgerald expressed his desire to transfer to a
high security psychiatric hospital. The clinical reviewers found that there was no
evidence that he had a treatable mental health condition which required transfer to
such a setting and that he did not meet the criteria for admission.
102. Mr Fitzgerald had previously applied to a personality disorder unit and been
rejected. After some time of expressing reluctance, at the time of Mr Huckle’s
death, he had reapplied to a prison personality disorder unit. As the clinical
reviewers note, this placement might have provided the support he needed.
Prisons and Probation Ombudsman 15
103. The clinical reviewers concluded that the healthcare Mr Fitzgerald received was
appropriate and equivalent to that which he could have expected to receive in the
community.
Events of 13 October 2019
104. Mr Fitzgerald went into Mr Huckle’s cell at 10.30am on 13 October 2019. He
remained in the cell until prison staff removed him 78 minutes later. We do not
know the exact sequence of events in the cell, but it is apparent from the post-
mortem report that Mr Huckle was the victim of a sustained attack in which multiple
injuries were inflicted. Such an assault would likely have taken place over some
time.
105. CCTV footage of Mr Huckle’s corridor during the morning shows that only one
member of staff spent time on the corridor. We appreciate that wing staff are busy,
but it is hard to understand how they might identify illicit behaviour if they spend little
time patrolling and interacting with prisoners. While more frequent patrolling would
not necessarily have identified the assault, this is particularly important on a wing
that holds prisoners who have been identified as a risk of perpetrating violence. We
make the following recommendation:
The Governor should ensure that officers undertake frequent patrols during
association periods and are alert for signs of violence.
Family liaison
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106. PSI 64/2011 instructs that, wherever possible, the family liaison officer and another
member of staff must visit the next of kin in person to break the news of the death.
It highlights that time is of the essence to ensure that the family do not find out
about the death from another source. PSI 64/2011 also instructs that where the
prisoner is located a long distance from the next of kin, consideration must be given
to requesting the assistance of a family liaison officer from the nearest prison. It
states that, in the case of a suspected homicide, the police are also likely to use
their own family liaison officer so a co-ordinated approach must be in place.
107. Mr Huckle’s parents told us that they first learned of his death at around 11.20am
on 14 October from a relative, who had read about it on the BBC website. It is very
disappointing that they heard of their son’s death in this manner rather than from a
prison or police family liaison officer. It was around 24 hours after Mr Huckle’s
death that his family were contacted by a family liaison officer, which is too long.
108. Breaking the news of a death following a homicide is not always as straightforward
as following other deaths in custody. As national instructions highlight, the police
will usually also use a family liaison officer and it is therefore important that a
working relationship is established quickly between prison and police. Following Mr
Huckle’s death, there was the added complication that his parents lived a
considerable distance from the catchment areas of Full Sutton and Humberside
Police. We also understand that they had changed their address and that Mr
Huckle had not been permitted to be told of the update – which meant that the
address held at Full Sutton was out of date.
16 Prisons and Probation Ombudsman
109. In such scenarios, it is particularly important that prison and police family liaison
officers work together to share information and ensure that the news of the death is
broken promptly and in an appropriate manner.
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Prisons and Probation Ombudsman 17
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