Tate, Jamie

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Jamie Tate,
a prisoner at HMP Manchester,
on 14 March 2021
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2024
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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 Jamie Tate died on 14 March 2021, having been found unresponsive in his cell at HMP
Manchester. Post-mortem examinations were unable to ascertain the cause of Mr Tate’s
death, although a seizure, medication or illicit drugs were possible causes. Mr Tate was
33 years old. I offer my condolences to Mr Tate’s family and friends.
Mr Tate suffered from seizures and psychosis and had a history of substance misuse. The
clinical reviewer found that, overall, the healthcare he received in prison was appropriate.
However, I am concerned that appointments were not always organised as they should
have been, and that mental health and substance misuse services did not always work
together effectively, a matter we have raised in previous investigations at Manchester.
I am also concerned that Mr Tate appears to have been able to access illicit drugs with
apparent ease while at Manchester, although I note the proactive steps that the prison is
taking to tackle and reduce their supply.
In addition, while I fully appreciate the difficulties of maintaining meaningful contact with
prisoners during the COVID-19 pandemic, I consider that more should have been done to
engage with Mr Tate in the months before his death.
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, CB
Prisons and Probation Ombudsman February 2022
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ......................................................................................................................... 14
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Summary
Events
1. In May 2014, Mr Jamie Tate was remanded to custody for aggravated burglary,
assault and false imprisonment. In November, he was sentenced to 11 years
imprisonment. He was later sentenced to another four and a half years
imprisonment for offences he committed in prison.
2. Mr Tate suffered from seizures and psychotic hallucinations and had a history of
substance misuse both in the community and in prison.
3. In July 2019, Mr Tate transferred to HMP Manchester. A psychiatrist assessed him,
concluded his current anti-psychotic medication was not effective and applied for
him to be transferred to a medium secure psychiatric unit where he could be more
closely monitored while he was prescribed different medication. Between July and
December, Mr Tate was admitted to the Humber Centre under the Mental Health
Act.
4. In December 2020, Mr Tate returned to Manchester. He said his hallucinations had
improved and he was reviewed regularly by the mental health team. In January
2021, staff suspected he was under the influence of illicit drugs on several
occasions. After this, his behaviour seemed to improve, although staff and
prisoners noted that he appeared sedated.
5. On 14 March, staff locked Mr Tate in his cell around 5.00pm. At 7.00pm, staff found
him lying on the floor of his cell unresponsive, with a vape under his face. They
went into the cell and started CPR. At 7.59pm, paramedics confirmed that Mr Tate
had died. Police found a homemade pipe and burnt remnants of a substance in his
cell. Intelligence reports submitted after Mr Tate had died indicated that he may
have been supplied with socks soaked in psychoactive substances (PS) or fentanyl
(an opiate painkiller).
Findings
6. Mr Tate’s death could have been caused by seizures, medication or illicit drugs.
Clinical care
7. The clinical reviewer concluded that, overall, Mr Tate’s healthcare was equivalent to
that which he could have expected to have received in the community.
8. However, she was concerned that Mr Tate had missed two psychiatric
appointments two months before he died, without any explanation noted on his
medical record. In addition, once Mr Tate had been reviewed by the psychiatrist, a
follow-up appointment was not booked as it should have been.
9. We are also concerned that communication between the teams responsible for Mr
Tate’s mental health and substance misuse care was inadequate.
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Substance misuse
10. Although no psychoactive substances were detected in Mr Tate’s system after he
died, it remains possible that they may have impacted on his death, given the
intelligence from prisoners, his history of drug misuse and the vape found under his
face when he was discovered unresponsive.
11. We are concerned that Mr Tate was able to access drugs in the prison with
apparent ease, although we note the proactive steps the prison is taking to try to
address this problem.
Meaningful interaction
12. Although key working was suspended during the COVID-19 pandemic, we are
concerned that it was not taking place in line with policy before this, and that welfare
checks were not being done on Mr Tate during the pandemic, contrary to national
policy.
Recommendations
• The Head of Healthcare should ensure that prisoners with a self-reported
condition such as epilepsy, which requires treatment in the form of medication,
should be started on a schedule of observations, with joint working between
healthcare and prison staff, to establish if the condition is present and the
patient’s reported symptoms are accurate.
• The Head of Healthcare should ensure that there is a system in place that
ensures follow up appointments are organised, confirmed and communicated
to prisoners.
• The Governor should ensure that:
• staff have regular, meaningful interaction with the prisoners in their care;
• key working sessions take place regularly in line with Prison Service policy;
and
• if the key worker scheme has to be suspended in response to the COVID-
19 pandemic, weekly welfare checks are conducted instead on all prisoners.
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The Investigation Process
13. The investigator issued notices to staff and prisoners at HMP Manchester informing
them of the investigation and asking anyone with relevant information to contact
her.
14. Due to the COVID-19 pandemic, the investigator was unable to visit the prison. She
obtained copies of relevant extracts from Mr Tate’s prison and medical records via
post and email. She could not watch CCTV footage, as it was not compatible with
PPO hardware.
15. The investigator interviewed seven members of staff and two prisoners. We have
removed the names of prisoners from this report in order to safeguard individuals.
NHS England commissioned a clinical reviewer to review Mr Tate’s clinical care at
the prison. The clinical reviewer and investigator jointly interviewed healthcare
staff.
16. We informed HM Coroner for Manchester City of the investigation. He gave us the
results of the post-mortem examination. We have sent the coroner a copy of this
report.
17. One of the Ombudsman’s family liaison officers contacted Mr Tate’s next of kin to
explain the investigation and to ask if she had any matters she wanted the
investigation to consider. (The next of kin had fostered Mr Tate when he was young
and then became his supported living provider when he was older. She said that
the term ’carer’ best described their relationship and we have used that term in this
report.) She said that the emotional and psychological care Mr Tate received at
HMP Manchester was “fantastic” and he was very positive about the staff at
Manchester. Mr Tate’s carer also asked the following questions:
• Did Mr Tate take drugs? If so, where did he get them from and how regularly
was he using them?
• What COVID vaccination did Mr Tate have and when? Did he report any
side effects to the vaccination?
• Did staff try to resuscitate Mr Tate? If so, did they follow the correct
procedure for resuscitation and calling an ambulance?
• Was Mr Tate in a good state of mind?
• Were Mr Tate’s clozapine levels carefully monitored?
18. These questions are answered in this report and the annexed clinical review.
19. Mr Tate’s carer received a copy of the draft report. They raised a number of issues
that do not impact on the factual accuracy of this report and have been addressed
through separate correspondence.
20. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and this report has been amended
accordingly.
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Background Information
HMP Manchester
21. HMP Manchester is a high security category B prison. HMP Manchester is a
training prison and accepts long term prisoners. There is a category A unit for
prisoners posing greater security risks. The prison holds up to 744 prisoners. This
is spread across nine residential units, a segregation unit, specialist intervention
unit and a healthcare unit. Greater Manchester Mental Health NHS Foundation
Trust provides 24-hour nursing care.
HM Inspectorate of Prisons (HMIP)
22. The most recent full inspection of HMP Manchester was in September 2021. The
findings of this inspection were not available at the time of writing our initial report.
Prior to this, a full inspection took place in June and July 2018. Inspectors reported
that they observed many positive interactions between staff and prisoners although
they also noted that a small but influential number of operational staff were
disengaged and distant. Inspectors noted that there was a wide range of primary
and secondary care services, with improved waiting times and some good practices
in systematic assessment of patients.
23. In June 2019, HMIP carried out an Independent Review of Progress to assess
progress against the key recommendations from the 2018 inspection. Inspectors
reported that promising work had recently begun to support prisoners in crisis but
was too new to be assessed, and that this was very concerning given that there had
been three further self-inflicted deaths since the full inspection. They commented
that it was bewildering to find that actions to prevent deaths in custody simply had
not been reviewed until shortly before their visit. Similarly, the introduction of key
work and wing peer support had been so slow that they could not yet see sufficient
progress in this area.
24. HMIP also conducted a Short Scrutiny Visit at Manchester in June 2021 to look at
the care of prisoners during the COVID-19 pandemic. They reported that the key
worker scheme had been suspended but that the safer custody team was proactive,
and they were pleased to see the use of trained counsellors to support individual
prisoners at risk of self-harm or in crisis. The counsellors could be directly involved
in the management of each case and provide additional support, such as promoting
coping skills, to those in crisis. However, they were concerned that routine mental
health referrals were not being assessed and no monitoring of those waiting was
taking place.
Independent Monitoring Board
25. 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 for the year to February 2020, the IMB reported
a number of positive developments during the year, including progression of the key
worker scheme showing evidence of closer engagement between officers and
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prisoners and the provision of in-cell telephones which was a major enhancement
for prisoners allowing contact with friends and family throughout the day.
Previous deaths at HMP Manchester
26. Mr Tate was the 13th prisoner to die at Manchester since March 2019. Of the
previous deaths one was self-inflicted, eight were from natural causes, two were
drug-related and in one case the cause of death was unascertained. There have
been three further deaths since that of Mr Tate, two of which were self-inflicted, and
one was due to natural causes.
27. We have previously made recommendations about reducing the supply of drugs at
the prison and improving care for prisoners with joint diagnoses of mental health
and substance misuse issues. (The prison’s response to these recommendations is
discussed later in this report.)
Assessment, Care in Custody and Teamwork
28. ACCT is the care planning system the Prison Service uses to support prisoners at
risk of suicide or self-harm. The purpose of the ACCT is to try to determine the
level of risk posed, the steps that staff might take to reduce this and the extent to
which staff need to monitor and supervise the prisoner. Checks should be made at
irregular intervals to prevent the prisoner anticipating when they will occur.
29. Part of the ACCT process involves assessing immediate needs and drawing up a
caremap to identify the prisoner’s most urgent issues and how they will be met.
Staff should hold regular multidisciplinary reviews and should not close the ACCT
plan until all the actions of the caremap are completed. Guidance on ACCT
procedures is set out in Prison Service Instruction (PSI) 64/2011, Management of
prisoners at risk of harm to self, to others and from others (Safer Custody).
Psychoactive Substances (PS)
30. Psychoactive substances, previously known as ‘legal highs’, are a problem across
the prison estate. They are difficult to detect and can affect people in a number of
ways including increasing heart rate, raising blood pressure, reducing blood supply
to the heart and vomiting. Prisoners under the influence of PS can present with
marked levels of disinhibition, heightened energy levels, a high tolerance of pain
and a potential for violence. Besides emerging evidence of dangers to physical
health, there is potential for precipitating or exacerbating the deterioration of mental
health with links to suicide or self-harm.
The key worker system
31. The key worker system is a key part of HMPPS’s response to self-inflicted deaths,
self-harm and violence in prisons. It is intended to improve safety by engaging with
people, building better relationships between staff and prisoners and helping people
settle into life in prison. Details of how the system should work are set out in
HMPPS’s Manage the Custodial Sentence Policy Framework. This says:
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• All prisoners in the male closed estate must be allocated a key worker whose
responsibility is to engage, motivate and support them through the custodial
period.
• Key workers must have completed the required training.
• Governors in the male closed estate must ensure that time is made available
for an average of 45 minutes per prisoner per week for delivery of the key
worker role, which includes individual time with each prisoner.
• Within this allocated time, key workers can vary individual sessions in order
to provide a responsive service, reflecting individual need and stage in the
sentence. A key worker session can consist of a structured interview or a
range of activities such as attending an ACCT review, meeting family during
a visit or engaging in conversation during an activity to build relationships.
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Key Events
May 2014 – July 2019
32. On 11 May 2014, Mr Jamie Tate committed offences of aggravated burglary,
assault and false imprisonment. The next day he appeared at court, was remanded
to custody and taken to HMP Leeds. In November, he was sentenced to 11 years
imprisonment.
33. During his time in prison, Mr Tate was sometimes subject to Prison Service suicide
and self-harm support measures, known as ACCT, after cutting himself. He had a
history of drug misuse, including PS, heroin, diazepam (a sedative), cannabis and
subutex (an opioid painkiller).
34. Mr Tate had experienced seizures since he was 12 years old and was prescribed
various medications to try to manage these seizures. In March 2019, a neurologist
diagnosed Mr Tate with non-epileptic attack disorder. This meant that his seizures
were not caused by abnormal electrical activity in the brain but by other factors such
as overwhelming stress, mental health issues or physical health issues, such as low
blood sugar. The attacks that Mr Tate reported as seizures were never witnessed
by staff or prisoners.
35. Mr Tate also suffered from visual and auditory hallucinations in the form of an
imaginary friend who made derogatory comments about him. He was prescribed
various anti-psychotic medications to try to reduce these hallucinations. Mr Tate
was also diagnosed with depression and prescribed antidepressants, as well as
methadone (a heroin substitute) due to his substance misuse.
36. Mr Tate’s behaviour in prison was variable. He was sometimes disruptive, fought
with other prisoners, was involved in drug taking and spent time in the segregation
unit. He was sentenced to a further four and a half years imprisonment for taking
staff hostage and assaulting them. However, Mr Tate also had periods when he
caused no issues and complied with the regime.
HMP Manchester: 23 July 2019 – 27 July 2020
37. On 23 July 2019, Mr Tate transferred to HMP Manchester. He engaged with the
prison’s Drug and Alcohol Recovery Service (DARS) and mental health teams
regularly. On 5 August, a psychiatrist assessed Mr Tate and concluded that he was
suffering from psychotic symptoms, complicated by seizures, which were not
responding to the medication he was currently prescribed. The psychiatrist wanted
to prescribe Mr Tate clozapine (an anti-psychotic medication), but was concerned
about the potential side effects, including the possible impact on Mr Tate’s seizures.
He therefore referred Mr Tate for transfer to the Humber Centre, a medium secure
psychiatric unit, for them to start the medication while closely monitoring Mr Tate.
38. Between July and January 2020, Mr Tate had monthly sessions with a key worker
at Manchester. These were with different prison officers each time. In January
2020, he had two sessions with the same key worker.
39. On 5 February 2020, the psychiatrist reviewed Mr Tate. He said that the voices he
could hear were getting more intense and that self-harming by cutting himself was a
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way of stopping the voices. Mr Tate said he was still having difficulty sleeping and
had seizures around twice a week during his sleep. The psychiatrist increased Mr
Tate’s prescription of mirtazapine (an antidepressant).
40. On 11 February, Humber Forensic Services refused to admit Mr Tate to monitor the
change in his medication. The psychiatrist appealed against this decision. He and
the mental health team at Manchester continued to review Mr Tate over the
following months. Mr Tate said he continued to have seizures twice a week and
that his hallucinations continued. He engaged with DARS but there continued to be
some intelligence that he was using illicit drugs.
41. On 30 March, a prison GP assessed Mr Tate’s seizures. Mr Tate said he was still
having around two seizures a week. The GP increased his prescription of
levetiracetam (to control Mr Tate’s seizures) and noted that he would chase Mr
Tate’s neurology referral.
42. In April, Mr Tate was accepted for assessment at the Humber Centre to start his
prescription of clozapine. Mr Tate was positive about this.
Humber Centre: 27 July 2020 – 8 December 2020
43. On 27 July, Mr Tate was admitted to the Humber Centre under Section 47 of the
Mental Health Act (which allows sentenced prisoners to be transferred from prison
to hospital for treatment by mental health professionals). A psychiatrist noted that
Mr Tate settled well and was prescribed clozapine. The psychiatrist noted that
sometimes Mr Tate appeared anxious but concluded that he had no symptoms of
psychosis.
HMP Manchester: 8 December 2020 onwards
44. On 8 December, Mr Tate transferred back to Manchester. He told staff he had no
thoughts of suicide or self-harm and he was happy to be back at Manchester. He
also told mental health staff that his auditory hallucinations had decreased, and he
was able to ignore his visual hallucinations. Mr Tate was added to the mental
health team’s caseload. A nurse from the substance misuse team assessed him
and agreed that he would be regularly reviewed. Mr Tate also said that his seizures
had reduced, and he felt well. He was referred to DARS.
45. Staff from the mental health team continued to review Mr Tate regularly. He said
that his medication was effective but that he felt tired, and healthcare staff noted
that he appeared sedated.
46. On 17 December, a Custodial Manager (CM) did a management check of Mr Tate’s
key worker entries. He noted that sessions had not taken place at the required
frequency, no targets had been set and no meaningful interaction had been
recorded. The CM noted that he spoke to Mr Tate’s key worker that day.
47. On 22 December, Mr Tate moved to I Wing from H Wing. He was happy to move
and knew staff and prisoners there as he had previously been located on the wing.
He was also sentenced to a further six months’ imprisonment for the assault of a
prison officer (committed in January 2019).
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48. On 30 December and 7 January 2021, Mr Tate was due to have an appointment
with the psychiatrist but did not attend. On both occasions he was told in advance
and knew about the appointments. The reason for his non-attendance was not
recorded.
49. On 18 January, the psychiatrist reviewed Mr Tate, who said that he was still having
fewer auditory hallucinations. Mr Tate said he had ongoing thoughts of suicide but
that they had reduced, and he could easily distract himself from them. He said that
his black eye was the result of a seizure, which he said he continued to have once a
week. The psychiatrist prescribed Mr Tate clonazepam (to assist with his mental
health and seizures) as a replacement for the lorazepam (a sedative used to treat
anxiety) that he had been receiving in hospital, but which was not available in
prison. He planned to review Mr Tate again two weeks later to see how the new
medication was working. He told the investigator that Mr Tate was more positive
about the future and his mental health seemed to be improving.
50. The same day, a nurse facilitated a telephone appointment for Mr Tate with a
consultant from the hospital neurology department. The psychiatrist received an
update from Mr Tate’s neurologist after his appointment indicating that they also
thought Mr Tate might have non-epilepsy attack disorder and they wanted to do
some further investigations.
51. On 19 January, Mr Tate was found under the influence of drugs twice by staff.
Healthcare staff were informed, staff submitted an intelligence report, a local
incident report, wrote in the wing observation book, warned Mr Tate about his
behaviour and referred him to DARS (with whom he was already engaged but were
offering a minimal service due to COVID restrictions).
52. A GP wrote to Mr Tate explaining the dangers of taking illicit drugs with the
medication he was prescribed and said that if he continued to do so his medication
may be reduced or stopped. The next day a substance misuse worker spoke to Mr
Tate who said he had used drugs as he was bored. They outlined the risk this
presented to Mr Tate and gave him a distraction pack and some library books.
53. A mental health nurse and a senior support worker also reviewed Mr Tate. He
admitted using illicit drugs. Officers had told healthcare staff that his black eye was
as a result of a drug debt, but Mr Tate denied this. He said he had no thoughts of
suicide or self-harm and his hallucinations were still much better.
54. On 21 January, staff found Mr Tate heavily under the influence of drugs. They
removed smoking paraphernalia from his room, including a vape which smelt
strongly of PS. They submitted an intelligence report and a local incident report and
made a note in the observation book. He was reduced to the basic level of the
Incentives and Earned Privileges (IEP) scheme. Healthcare staff spoke to him
about the dangers of taking illicit drugs as well as his prescribed medication.
Intelligence suggested that prisoners on I Wing were having clothes sent into them
by friends and family that had been soaked in PS, and then smoking the ripped-up
fabric.
55. During February, Mr Tate’s behaviour improved. He told staff he had stopped
taking PS and he was upgraded to the standard level of the IEP scheme. Staff from
the mental health and substance misuse teams continued to review him.
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56. On 22 February, a nurse completed an ECG on Mr Tate. She sent the recording to
a clinician for analysis. The result was normal, but they recommended a medication
review and a further blood test.
57. Mr A, a prisoner, said that when Mr Tate first returned to prison from the Humber
Centre, he had seemed much healthier and had been determined to be drug-free.
However, he said that Mr Tate then returned to using drugs, using his belongings as
payment. Mr A said that Mr Tate seemed to be sedated by his prescribed
medication, was lethargic and spent a lot of his time in bed. He said Mr Tate
tended to just sit on the stairs when he came out of his cell. Mr A said he tried to
encourage Mr Tate to come out of his cell and clean it. He said that he spoke to
staff about Mr Tate’s lack of self-care.
58. On 3 March, a DARS recovery practitioner introduced herself to Mr Tate as his new
substance misuse worker. She said that she would contact him the following week
on his in-cell telephone. He said he was not using any illicit drugs and had no
thoughts of suicide or self-harm. He did not raise any concerns. She told the
clinical reviewer that she had woken Mr Tate up when she went to see him, but he
did not seem sedated or under the influence of illicit drugs.
59. On 9 March, the senior support worker reviewed Mr Tate. She noted that he
appeared settled, said he had no hallucinations and did not report any issues. He
asked when he would next see the psychiatrist, as he had said he would see him
two weeks after their last appointment in January. She noted she would request an
appointment with the psychiatrist and did so after their meeting. This was booked
for 29 March.
60. That evening Mr Tate spoke to his carer. He was positive about his mental health
worker, and said his medication was working and everything was going well.
61. On 10 March, an officer introduced himself as Mr Tate’s key worker. He noted that
Mr Tate had recently progressed well and there were no reports that Mr Tate had
been under the influence of drugs for several weeks. He wrote that Mr Tate was a
complex person but that he said he felt comfortable on the wing, supported by staff
and other prisoners, and that he had no concerns. The officer spoke to Mr Tate
about his personal hygiene, and he said he preferred to shower alone due to his
scars. The officer said that he would see him again within the next few weeks. He
arranged individual showers for Mr Tate after their session.
62. The officer told the investigator that he assumed Mr Tate was on strong medication
for his mental health as he seemed sedated and “zoned out” during the day. He
said he came out of his cell for association and had a lot of friends on the wing. He
said that Mr Tate slept quite a lot during the day and would never go out for
exercise in the morning. He never witnessed Mr Tate having any seizures or
obviously hallucinating.
63. On 11 March, the substance misuse worker tried to call Mr Tate twice on his in-cell
phone, but it was engaged. She sent Mr Tate a letter to say that she would be out
of the prison until 22 March but would contact him on her return. She noted that he
could contact other DARS staff in her absence and gave instructions how to do this.
She also included harm reduction advice in the letter.
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64. Mr B, a prisoner, said he had known Mr Tate since 2018. He told the investigator
that he had never seen him having a seizure or hallucinating. Mr B said that Mr
Tate smoked PS throughout the time that he knew him and would take whatever PS
he could get. He said that Mr Tate always paid his debts with his canteen
[purchases from the prison shop] and was never bullied, and that he was a big
prisoner who could “handle himself”. Mr B said that Mr Tate seemed his “usual self”
in the days leading up to his death.
Events of Sunday 14 March 2021
65. The investigator listened to Mr Tate’s telephone calls from 4 March onwards. He
was in regular contact with friends and family, was looking forward to his release
and reported that “things were going well for a change”. On 14 March at 10.15am,
Mr Tate rang his carer. They had a general conversation for around 20 minutes.
Mr Tate’s carer told the PPO’s family liaison officer that he “seemed to be in the
best place he had ever been psychologically”.
66. Mr A said that he saw Mr Tate when they were unlocked that morning. He was
sitting on the stairs and he seemed lethargic, as he had done for a few weeks, and
it was hard to have a conversation with him.
67. Around 4.30pm, Officer A spoke to Mr Tate when he unlocked his cell for dinner
and medication. The officer said he asked Mr Tate if he was alright, and Mr Tate
confirmed that he was. Mr B and Mr Tate’s key worker saw Mr Tate when he
collected his dinner and medication. They had no concerns and said that Mr Tate
seemed his usual self. Mr Tate was locked back in his cell by 5.00pm.
68. At 7.00pm, Officer B started doing a roll check. When he got to Mr Tate’s cell, he
looked in through the observation panel and saw Mr Tate lying face down on the
floor. He kicked the door several times to attract his attention, but Mr Tate did not
respond. He thought that Mr Tate might have been under the influence of illicit
drugs. He shouted to Officer A on the landing below that a prisoner was
unresponsive.
69. Officer A ran to the cell, looked through the observation panel and saw Mr Tate
lying face down on the floor. He unlocked the door and went into the cell. He
shouted to Mr Tate, who did not respond, checked for signs of life and turned him
over. When he did so, he found a vape under his face. Another officer, who had
also responded, radioed a code blue (a medical emergency code which indicates a
prisoner is unresponsive or having difficulty breathing). Staff in the control room
immediately telephoned to request an ambulance. Officers began chest
compressions.
70. Prison staff estimated that two nurses arrived at Mr Tate’s cell with the emergency
equipment around four minutes after they had first got there. (The investigator has
been unable to watch the CCTV footage.) One of the nurses noted that Mr Tate
was on his back and had blood on his face. She shouted Mr Tate’s name, but he
did not respond. The nurse detected a weak carotid pulse but noted Mr Tate was
not breathing. She observed that Mr Tate’s limbs were blue and mottled with signs
of blood pooling but that he felt warm. She attached the defibrillator and began
chest compressions. Nurses inserted an airway and administered oxygen. Another
nurse administered naloxone (an opiate antidote) to Mr Tate.
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71. Paramedics arrived and took over Mr Tate’s care, helped by prison officers and
nurses. They attached their defibrillator, continued CPR and administered
adrenaline. At 7.59pm, the paramedics pronounced Mr Tate had died.
72. After Mr Tate had died, the police seized some vaping equipment from his cell,
along with a homemade pipe and burnt remnants of a substance.
Intelligence after Mr Tate had died
73. Mr B told the investigator that he beckoned an officer over to his cell after Mr Tate
had died and gave him a note saying that Mr Tate had got drugs from Mr A in a
parcel of socks. (The investigator has not seen this note as the prison could not
produce it.)
74. Mr B told the investigator that Mr A had told him that he had asked his mother to
dissolve 50mg fentanyl (an opiate painkiller) tablets in water and soak some socks
in them and send them to him. Mr B said that Mr A said that he had received them
on 14 March. Mr B said that Mr A had done this a few months previously with 30mg
fentanyl tablets and had distributed it on the wing and it had led to prisoners
collapsing. Mr B said that Mr A continued to sell pieces of these socks on 15
March. Mr B said that he told the officers that Mr A had sold a piece of sock to
another prisoner.
75. An intelligence report noted that at 2.30pm on 14 March an officer had given Mr
Tate some socks and boxer shorts which had been received through the post.
These items had been searched and X-rayed and checked by search dogs. No
concerns were noted about the contents.
76. Another intelligence report noted that on 15 March, Mr B handed a note to an
officer, which said that Mr Tate had got PS from Mr A, who had had a parcel of
socks delivered to him that afternoon which were all impregnated with PS. Staff
searched Mr A’s cell and an officer found a pair of socks which had some material
cut from them. He seized them and they tested positive for opiates. Police seized
the socks as evidence, but they were not tested further. The officer submitted an
intelligence report and spoke to his manager.
77. When asked about the socks, Mr A told the investigator that he had bought the
socks from another prisoner as he was told that they had PS on them. He denied
supplying them to Mr Tate but said that the person he bought them from supplied
them to Mr Tate. He was not willing to name the prisoner. Mr A said he had never
been involved in supplying drugs in the prison. He said he tried to buy more socks
soaked in drugs after he had them confiscated but the other prisoner was unwilling
to supply him with any after Mr Tate had died.
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Contact with Mr Tate’s family
78. A prison chaplain was appointed as family liaison officer. Due to restrictions on
face to face contact during the COVID-19 pandemic, he informed Mr Tate’s next of
kin of Mr Tate’s death by telephone and passed on his condolences. He remained
in contact with Mr Tate’s next of kin and offered a contribution to funeral expenses
in line with Prison Service policy.
Support for prisoners and staff
79. After Mr Tate’s death, a senior 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.
80. The prison posted notices informing other prisoners of Mr Tate’s death, and offering
support. Staff reviewed all prisoners assessed as being at risk of suicide or self-
harm in case they had been adversely affected by Mr Tate’s death.
81. Mr B said he had not felt adequately supported by the prison after Mr Tate died. He
said he was not offered support or asked how he was apart from by a member of
the chaplaincy. A nurse said that she had had good support from her colleagues
but would have liked more support from the prison.
Post-mortem report
82. The post-mortem report concluded that the cause of Mr Tate’s death was
unascertained. Methadone, levetiracetam and clozapine (all of which he was
prescribed) were detected in Mr Tate’s system. The pathologist noted that the
levels of methadone and clozapine were quite high, but fell within the range of
therapeutic levels, although this also overlapped with levels associated with toxicity.
However, the pathologist said that given Mr Tate’s longstanding prescriptions for
these drugs, it was unlikely that he had overdosed on either of these medications.
83. The level of levetiracetam was also at a therapeutic level but the toxicologist noted
that this would not necessarily mean that Mr Tate’s seizures were adequately
controlled. The pathologist said that she was not aware of the cause of Mr Tate’s
seizures but that the way he was found could be consistent with him having had a
seizure.
84. The pathologist also noted that Mr Tate had previously used PS. She noted that PS
covers a large number of compounds with variable and unpredictable effects. As
there are over 400 possible PS variants, they are not all tested for and identification
can be very difficult. Therefore, although no PS was detected in Mr Tate’s system,
it is not possible to rule out the possibility that he had taken PS before he died or
that it contributed to his death.
85. Another prisoner alleged Mr Tate had been supplied with fentanyl (an opiate) before
he died. No opiates were detected in Mr Tate’s system.
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Findings
86. The pathologist concluded that the cause of Mr Tate’s death was unascertained and
could have been caused by seizures, medication or illicit drugs.
Clinical care
Physical healthcare
87. The clinical reviewer noted that Mr Tate’s seizures were never witnessed by staff or
prisoners and there was no apparent monitoring of them. She considered that Mr
Tate should have been monitored to establish if he had seizures. The clinical
reviewer also noted that there were no care plans in place for Mr Tate’s non-
witnessed seizures.
88. The clinical reviewer also concluded that an appropriate referral was made to the
neurology department for a specialist review of Mr Tate’s condition, but that this
should have taken place earlier.
89. We recommend:
The Head of Healthcare should ensure that prisoners with a self-reported
condition such as epilepsy, which requires treatment in the form of
medication, should be started on a schedule of observations, with joint
working between healthcare and prison staff, to establish if the condition is
present and the patient’s reported symptoms are accurate.
Mental healthcare
90. The clinical reviewer concluded that there was evidence that Mr Tate received a
good standard of mental health care at Manchester. However, she was concerned
that Mr Tate had missed two appointments with the psychiatrist following his return
from the psychiatric unit, and there was no record to explain why.
91. The prison has since put into place a new process under which the mental health
team contact all prisoners on the day of their psychiatric appointment to ask them to
attend. If they do not attend, the mental health team will try to find out why and if
prisoners repeatedly do not attend, the psychiatrist will visit the prisoner to assess
them in their cell. All of this must be documented on their medical record. As the
prison has already taken action to address this, we have not made a
recommendation about it.
92. When the psychiatrist reviewed Mr Tate on 18 January 2021, he noted that he
would review him in two weeks. However, no appointment was made, and the
mistake was only rectified on 9 March when Mr Tate asked when his next
appointment was. It was booked for 29 March, after Mr Tate died.
93. The Healthcare and Drug Strategy Lead said that the psychiatrist should have told
administrative staff to book an appointment with him. It was not possible to
determine whether the psychiatrist had not communicated this or administrative
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staff had failed to book it. It could have been a vital missed opportunity to assess
Mr Tate. We make the following recommendation:
The Head of Healthcare should ensure that there is a system in place that
ensures follow up appointments are organised, confirmed and communicated
to prisoners.
94. The clinical reviewer noted that the psychiatrist took appropriate action when he
arranged for Mr Tate to be transferred to a medium secure psychiatric unit to be
prescribed clozapine. When Mr Tate returned to Manchester, he was required to
have regular blood tests to monitor his blood in line with mandatory prescribing
requirements for clozapine. The clinical reviewer concluded that Mr Tate had
appropriate blood tests and was appropriately monitored when he returned from the
Humber Centre.
Substance misuse
95. Mr Tate had a long history of substance misuse. There was intelligence both before
and after Mr Tate died about his use of drugs. However, there had been no drug
related intelligence submitted during the last six weeks of Mr Tate’s life. Despite
this, when Mr Tate was found, there was a vape under his face. Police also found
further vaping equipment, a homemade pipe and burnt remnants of a substance in
his cell.
96. Mr Tate was under the care of the DARS and engaged with them during the last
months of his life, despite their service being limited due to COVID restrictions. We
are satisfied that when Mr Tate was considered to be under the influence, staff took
appropriate steps to support him, educate him about the dangers of drug use and
issue appropriate sanctions for his behaviour. The clinical reviewer concluded that
Mr Tate’s substance misuse clinical care was equivalent to that he could have
expected to receive in the community.
Dual diagnosis healthcare
97. The clinical reviewer was concerned that the substance misuse and mental health
services were not working together effectively. The Healthcare and Drug Strategy
Lead told the investigator that he was concerned that there did not seem to be
adequate communication between the two teams about how they were going to
plan and manage Mr Tate’s care.
98. Following a previous drug-related death at the prison in August 2020, we
recommended that the prison develop a pathway between substance misuse and
mental health services for complex prisoners who require joint assessment and
management. The prison accepted this recommendation and said that they were
developing such a pathway and would also discuss such prisoners at the weekly
safety intervention meeting. They were due to complete these actions in October
2021, several months after Mr Tate’s death.
99. The Healthcare and Drug Strategy Lead said that since Mr Tate’s death, he had
asked the services to develop a pathway to manage prisoners with complex mental
health and substance misuse needs. He said joint team meetings have now started
to discuss such prisoners and how they will be managed from a multi-disciplinary
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perspective. He also expects that a prisoner’s physical healthcare would be
considered as part of this joint working.
100. We therefore make no further recommendation but are concerned to note that
integrated dual diagnosis care has once again been a concern at the prison.
Availability of drugs
101. Although post-mortem toxicology tests detected no PS in Mr Tate’s system, it
remains possible that he had taken PS before he died or that it contributed to his
death. A vape was under Mr Tate’s face when he was found unresponsive, along
with other drug paraphernalia in his cell, including burnt remnants of a substance.
There was also intelligence both before and after Mr Tate died that he took PS.
102. Although Manchester has a comprehensive drug strategy, we are very concerned
that Mr Tate appears to have had no difficulty in obtaining and using PS. More
needs to be done to reduce both the supply of, and demand for, PS.
103. Following deaths due to PS toxicity at the prison in 2019 and 2020, we made
recommendations about reducing the supply of drugs. In response, Manchester
said in August 2021 that the Head of Drug Strategy had been in contact with other
prisons to share learning and methods used to tackle and reduce the supply of
drugs. They had also sought prisoners’ views through surveys and forums and fed
the learning from these into a drug summit chaired by the Governor on how to
tackle weaknesses in reducing the supply of drugs.
104. The Healthcare and Drug Strategy Lead said that it is difficult to prevent drugs
being thrown over the walls in a city centre prison, but they are taking proactive
measures to reduce drugs coming into the prison in other ways. They had been
aware before Mr Tate’s death that drugs were potentially coming in soaked in
clothing and they had started testing clothing coming into the prison for drugs. He
said that they had also started photocopying all mail (aside from legal mail, which is
privileged) in case the paper had been soaked in drugs. They have also started
using a specific registered service for legal mail.
105. Drug taking and trading is a serious problem across much of the prison estate.
Individual prisons are, for the most part, doing their best to tackle the problem by
developing their own local drug strategies. In April 2019, the Prison Service
introduced a national drug strategy. This says that:
“Every prison is different and will benefit from tools to assess their specific
security needs. We have worked with prisons to carry out Vulnerability
Assessments in prisons to build a picture of the security risks and enable
establishments to better target their resources to tackle them. This resource
will continue to be offered across the estate.”
106. Manchester has a strategy to address both the supply of, and demand for, illicit
drugs. A revised version is due to be published imminently. It includes numerous
actions intended to reduce the supply of drugs into the prison and movement of
drugs around the prison. There are also measures to educate prisoners about the
dangers of PS and support those known to use drugs, plus disciplinary measures to
deter drug use.
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107. Given the proactive steps the prison has taken both before and after Mr Tate’s
death in addressing the issue of drug misuse at Manchester, we make no further
recommendation.
Meaningful contact with prisoners
108. The key worker scheme provides for a dedicated member of staff to establish a
relationship with a prisoner and should therefore provide opportunities to identify
any concerns a prisoner may have and help to put support in place. Key workers
are allocated 45 minutes per week per prisoner for this work.
109. Between July 2019 and January 2020, Mr Tate had monthly meetings with a key
worker. This was not in line with Prison Service policy as it was not sufficiently
regular and involved different members of staff on each occasion.
110. Mr Tate then met the same key worker twice in January 2020 but had no further
meetings before he transferred to a psychiatric unit in July 2020. After he returned
to Manchester in December 2020, he had no key working sessions until 10 March
2021. He died four days later.
111. In December 2020, a manager reviewed Mr Tate’s key worker entries. He noted
that sessions had not taken place at the required frequency, no targets had been
set and no meaningful interaction recorded. The manager noted that he spoke to
the key worker that day.
112. Key working was suspended across the prison estate in response to the COVID-19
pandemic, although prisons were expected to maintain key working for particularly
vulnerable prisoners and to conduct weekly welfare checks on all other prisoners.
113. In June 2020, Manchester restricted key working to priority groups. We are
surprised that Mr Tate was not considered to be in a priority group. Manchester
was categorised as a COVID outbreak site on four occasions over the following 18
months and they only managed to progress to another stage of regime delivery
twice (in November – December 2020 and April 2021). The prison told us that due
to high levels of staff sickness, they struggled to deliver monthly key working
sessions throughout this period, so they continued to focus on the most vulnerable
prisoners.
114. There are no welfare checks recorded for Mr Tate. We appreciate the difficulties
that COVID-19 has presented in terms of maintaining meaningful interaction
between staff and prisoners, but we are concerned that in Mr Tate’s case key
working sessions were not taking place as they should have before the COVID-19
pandemic. In addition, the manager checking Mr Tate’s key worker entries in
December 2020 was not satisfied they were sufficient at that time.
115. We are concerned that the lack of regular welfare checks on Mr Tate was a missed
opportunity to identify his needs. We therefore make the following
recommendation:
The Governor should ensure that:
• staff have regular, meaningful interaction with the prisoners in their
care;
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• key working sessions take place regularly in line with Prison
Service policy; and
• if the key worker scheme has to be suspended in response to the
COVID-19 pandemic, weekly welfare checks are conducted instead
on all prisoners.
Entering Mr Tate’s cell
116. Officer B said that when he found Mr Tate unresponsive in his cell, he initially
thought that Mr Tate might have been under the influence of drugs, and that is why
he had called to another officer before going into the cell. We are satisfied that he
made a dynamic risk assessment, and we are not critical of this decision.
117. However, Officer B also said that he would never enter a cell on his own even if
there was a clear risk to life. This is not in line with Prison Service policy. Since it
was not relevant to the death of Mr Tate, we have not made a recommendation, but
we have flagged our concerns to the Head of Safer Custody.
Inquest
118. The inquest into Mr Tate’s death concluded in April 2024. The Coroner found that
although the medical cause of Mr Tate’s death was unascertained, there was a
possibility that the use of an illicit substance and/or an unwanted side effect of
medication (clozapine) were contributory factors.
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