Individual at Leeds

The Murder of a Man by his Cellmate on 2 April 2004
whilst in
the Custody of HMP Leeds
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2005
Foreword
The murder of a man by his cellmate in Leeds prison on 2 April 2004 was the
very first death in custody referred to my office after I took responsibility for all
such investigations. In the event I have conducted probably the longest, and
certainly the most extensive, investigation of any death ever to have occurred in
a British prison.
Throughout the investigation, I have endeavoured to engage the man’s family
and their legal representatives. I first met with members of the family in the
immediate aftermath of the man’s death and I pay tribute to their decency and
compassion in the face of the tragedy that overtook them. I offer here in public
what I have said in private: my sincere condolences of the loss of their beloved
family member. Theirs is a close-knit family, and the man is mourned as a son,
brother, husband and father.
The family has had many questions about the circumstances that led to his
death. I have endeavoured to answer all those questions – an endeavour that
explains in part the great length of this report. However, I am conscious that
some of my answers may not satisfy family members and few offer any comfort.
I am also aware that the family has been dissatisfied by my reliance on
investigators employed by the Prison Service. In a letter from their solicitors
dated 10 August 2004, I was told that “the family has no confidence in the
investigation process because Prison Service personnel are carrying out the
interviews”. A similar message was expressed at my final meeting with the family
in April 2005. At that meeting, I was also asked to bring this investigation to as
speedy a close as was possible, the family wanting me to do nothing that might
delay the forthcoming inquest. I have followed that advice. This final report has
been amended from earlier drafts to reflect comments from the family, the Prison
Service and the Commission for Racial Equality.
In view of the family’s concerns, it may be helpful to explain here exactly the way
in which this investigation has been conducted. The announcement that I was to
become responsible for the investigation of all deaths in prison custody was
made at the beginning of January 2004. Given a start date of 1 April, it was
clearly impossible for me to recruit, train and induct the number of new
investigators I would need. I therefore agreed transitional arrangements with the
Prison Service whereby I could call upon the Service’s trained investigators and
senior investigators who would work under my overall direction. In practice, this
system worked extremely well and I am greatly indebted both to the individual
staff concerned and to the Prison Service as a whole. That said, I was pleased
when the transitional arrangements came to a close on 30 November 2004.
In the case of this investigation into the murder of the man who is the subject of
this report, I have every confidence in its thoroughness, rigour and impartiality.
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Indeed, I am proud of the extent to which the investigation has established new
standards on the disclosure of information to the family (something I believe is
both right in itself and necessary in terms of the investigative obligation upon the
state under Article 2 of the European Convention on Human Rights). In light of
the family’s observations, witnesses have been re-interviewed and documents
repeatedly assessed. In addition, the findings of the investigation team have
been scrutinised by one of my most experienced colleagues and investigators.
Significant amounts of further information have been requested and further
interviews undertaken under her direction. This report has been written entirely
by myself and members of my independent office.
The original Terms of Reference for this investigation set the objective of
establishing the circumstances and events surrounding the man’s death. I met
his family in June 2004 to discuss progress and initial findings from the
investigation. I agreed at this meeting to widen my terms of reference to include
an incident that occurred on 11 March 2004 when the man ended up in the
segregation unit. The family was concerned that this incident was connected to
the tragic events of 2 April and I agreed to try and establish whether this was so.
West Yorkshire police conducted simultaneous investigations into the murder of
this man and the incident of 11 March. They too looked closely at the decision to
allocate him to the cell on A wing where he was killed and any link with the
events of 11 March. A protocol was quickly established between the police and
my team and a significant amount of information was shared between the two
investigations. I have also received from the Coroner a copy of the entire police
evidence. No charges, save for the charge of murder against the defendant,
were made as a result of the police investigation.
During the course of the past 15 months, some 120 people have been
interviewed and over 200 documents have been examined and considered.
Other issues emerged that, though not necessarily of direct relevance to the
murder of this man, are important outcomes of the investigation. I have been
particularly concerned to look at Leeds’s approach to issues of diversity and race.
I have considered these under the heading ‘The management of race issues’ at
Annex B. It does not make happy reading.
I also received from the man’s family’s solicitors other documentation relating to
the handling of prisoners’ complaints at HMP Leeds and a copy of a dossier,
subsequently investigated by the Prison Service, alleging more systematic
discrimination against black and Asian prisoners. It has been accepted that
neither the documentation nor the dossier were directly relevant to the
circumstances of the man’s murder, and given that they have been addressed
elsewhere, I make no further reference to them in this report. However, given
that the man was an Asian man murdered by a white man, issues of race have
never been far from my mind.
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I am most grateful to members of the investigation team for their efforts on my
behalf. The team was led by the former Governor of HMP Hull, very ably
assisted by the Intelligence and Investigations Manager for the Yorkshire and
Humberside Area Office and the Head of Custody at HMP New Hall.
I also wish to acknowledge the ready assistance I have received from the West
Yorkshire police, in particular by the Detective Superintendent, the Detective
Inspector, the Detective Constable and the Family Liaison Officer.
This report considers in detail the circumstances that led to the man who died
and the defendant being placed together in a cell on A Wing. A particular focus
is upon the system of cell sharing risk assessment (CSRA) as it applied to the
defendant. The information upon which staff at Leeds based their decision was
extremely limited, and I am particularly concerned that the situational aspects of
the defendant’s previous violence were not identified. A later warning about the
defendant from a probation officer was not acted upon. My office has shared
views on CSRA with the Zahid Mubarek Inquiry.
I am conscious of the pressures placed on staff at Leeds and other local prisons
given the size of the prison population. All cell sharing necessarily carries some
risks. Those risks are magnified by levels of overcrowding and turnover (‘churn’)
on the scale that obtains at Leeds. I note that the Annual Report of the prison’s
Independent Monitoring Board explicitly draws attention to the strain this places
on prisoners and staff alike. The Board refer tellingly to “the tacit acceptance of
overcrowding”. Overcrowding undermines the ability of the Prison Service to
provide individual care of those in its charge and significantly increases the risks
posed by violent offenders to their fellow prisoners. I expressed my concerns
when I investigated the murder of another man. The man who is the subject of
this report died in similar circumstances only seven months later. In this report, I
draw attention to aspects of the cell sharing risk assessment process in general
and as specifically applied to the defendant’s. The imbalance between the
number of prisoners and the number of reception staff expected to make the
assessments can only serve to overburden and diminish the effectiveness of the
risk assessment process.
I also consider the prison’s response to the attack on the man who is the subject
of this report. I am particularly impressed by the compassion and
professionalism shown by the member of staff and the nurses who were (in the
Prison Service’s rather antiseptic jargon) ‘first on scene’. The clinical review
draws attention to some important areas where improvement in practice can be
made. I thought the notices issued by the Governor were sensitively worded,
and he gave conspicuous leadership by returning to the prison from
commitments elsewhere and remaining in the jail over the weekend immediately
after the murder. I was also pleased to learn that the Director General of the
Prison Service had sent a personal letter of condolences to his wife.
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However, other aspects of family liaison were much less well handled. The
family remain angry at the delay in informing them of what had occurred. I share
their concerns.
The defendant and the man shared a cell together for around 30 minutes on that
fateful morning in April 2004. What exactly happened during that time I cannot
say. What I do know is that the victim was a young man who died of horrific
injuries while in the care of the state. He leaves a large, loving family including a
wife and two young children.
Stephen Shaw
Prisons and Probation Ombudsman October 2005
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Contents:
PART 1: The murder of a man and the circumstances surrounding it
Section 1: Background
- HMP Leeds
Section 2: The events of 2 April and the aftermath
- The allocation and transfer of the man and the defendant to A wing
- From when the alarm was raised to when death was pronounced
- What happened to the defendant
- Timings
- The prison’s immediate response to the murder
- Family liaison
- The experience of the man’s family
- The Post Mortem report
Section 3: Risk assessment
- Cell Sharing Risk Assessment (CSRA)
- Cell Sharing Risk Assessment at Leeds
- The assessment process applied to the defendant
- Indicators of the defendant’s risk pre-2004
- Defendant’s fight with a former cellmate in February 2004
- The incident at a hostel in March 2004
- The defendant’s pre-sentence report and the Security Information Report
of 1 April 2004
- What other prisoners said about the defendant
PART 2: Conclusions, Consideration and Recommendations
Section 1: The murder of a man and the prison’s response
- The discovery of the man and the attempt to save his life
- The aftermath of the death
- The care offered to staff and prisoners
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Section 2: Risk Assessment
- Cell Sharing Risk Assessment (CSRA) in the Prison Service
- CSRA in Leeds
- The assessment of the defendant
- The man’s transfer to A wing and allocation to a cell with the defendant
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PART ONE: The murder of a man and the circumstances surrounding it
Section 1: Background
HMP Leeds
Leeds is predominantly a Victorian prison. The four original wings (A, B, C and
D) were built in 1847. Two further wings (E and F) were opened in 1994 together
with new kitchens, gymnasium and Healthcare Centre.
Leeds is a category B local prison accepting adult male prisoners from West
Yorkshire. It has 680 cells on the main wings and has space for up to 55
prisoners in the Healthcare Centre.
The man was murdered on A wing. A Wing consists of four landings. The bottom
landing, A1, also contains the segregation unit which is known as S1. A1 is used
for the dirty protest cells, the cleaners and "overflow" from the segregation unit.
The two areas are separated by a metal gate, which is generally left open.
Segregation unit staff decide which prisoners are located on A1.
A wing was used to house the vulnerable prisoner (VP) population until 2003
when most of the VPs were transferred to a new unit in HMP Hull. It was
intended that a few VPs on trial at courts in Leeds would remain on A wing. On
conviction they would be transferred to Hull. When spaces at Hull became
restricted, A wing became a hybrid wing with VPs populating the outer part of A2,
A3 and A4 landings, and ‘normal location’ prisoners occupying the cells on the
inner part of these landings. Staff tried where possible to keep one empty cell
between the VPs and the other prisoners. The two regimes ran separately and
the number of cells occupied by VPs fluctuated with the VP numbers. In April
2004, ‘normal location’ prisoners occupied cells on A2 and half of A3 and VPs
occupied cells on half of A3 and all of A4. A wing is now once again entirely
populated by VPs.
Her Majesty’s Chief Inspector of Prisons (HMCIP) undertook an unannounced
inspection of Leeds between 30 June and 4 July 2003. The report commented
that Leeds presented as a typically overcrowded and pressurised local prison. At
the time of the inspection Leeds held 60 per cent more prisoners than it was
designed for, and almost all of them were two to a cell designed for one. In one
month over 400 new prisoners had to be settled into the prison. Reception staff
dealt with 150 prisoner movements a day in “cramped and unsuitable conditions”.
The average stay for a prisoner was 12 weeks.
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In March 2004, Leeds was still 52 per cent overcrowded with an average
population of 1227. There were 611 new prisoners and 1578 separate prisoner
movements through reception. The average stay for a prisoner was eight weeks.
Section Two: The events of 2 April and the aftermath
(i) The allocation and transfer of the man and the defendant to A wing
On the morning of 2 April 2004, both the man and the defendant were located on
D wing. The men was sharing a cell with a fellow inmate and the defendant was
sharing a cell with his fourth cellmate. As noted, D wing is the first night and
induction wing. Prisoners are allocated to D wing on first entering Leeds and,
after a period of induction, are then moved to one of the other wings as spaces
occur.
On D wing on the morning of 2 April one of the duties of the movements officer
was to identify prisoners on D wing who were ready to be moved to other wings
and match them to the spaces on them. On that morning the movements officer
was told there were three spaces on A wing, one in a cell with a prisoner already
in it and two in an empty double cell. She said that she was aware that the
defendant had put in an application to go to any wing where there were
workshops, which A wing had. She said that she went to see the man’s former
cellmate because he had asked for a move. When she was in the cell the man
told her that he too would like to move wings, and she asked him where he would
like to go. She said he replied that he would prefer to go to A or F wing. The
movements officer said that she wrote the destination cell as A3/02 on the man’s
cell card and told him to pack his kit. The movements officer said she did not see
any interaction between the man and the defendant that morning.
The man’s former cellmate said that on 2 April a female officer came to their cell
to talk to him about the move he had requested to E wing. He said that the man
asked her if he could move to F wing and she asked him whether they would
have him back on F wing. He said that the man had replied “I don’t know” and
then said, “Well what about a space on A wing?” The female officer told him that
there were spaces on A wing if he wanted to go there. His former cellmate said
that he thought the man had previously spoken to another prisoner, probably a
friend, who had encouraged him to go to A wing. The man’s former cellmate
moved to E wing that morning.
The defendant’s former cellmate said that on the morning of 2 April staff came to
the cell and told the defendant he was moving to A wing. He said “they just
moved me straight on A wing”. He said he wasn’t given a choice and could not
remember whether he was told he would be sharing a cell.
The other prisoner who moved from D wing to A wing on the morning of 2 April.
He said that he had been in Leeds prison before and at about 9.30-10.00 on 2
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April, he asked the movements officer (whom he described as a woman with long
blond hair) if he could move to A wing and she replied that he could. He said he
had been on A wing before and thought it was the “best” wing. He said that he
packed his kit and went to the wing office where he waited with the man and the
defendant to be taken over to A wing. He said that he had never met either of
them before.
He said that the man was talking to one of the wing cleaners and the defendant
was sitting in a chair by the door of the office. He said he spoke to the defendant
but he seemed “not there” and did not really respond to him. He also said that
after about ten minutes another female officer came to the office and told all three
of them to pick up their kit. He said that the defendant asked where they were
going but otherwise there was no conversation between the party until they got to
A wing.
The defendant said that the first time he had seen the man was when he went to
wait by the wing office at the bottom of D wing. He said that a blond haired
female officer moved him over to A wing. He said that the man was “okay” on the
way to A wing.
It was the responsibility of the movements officer on duty on D wing on 2nd April
to collect prisoners from their cells and escort them to their new wings. She
remembers escorting the man, the defendant and the other prisoner to A wing.
She said that the only conversation during the move took place between her and
the man. She said that the man had joked that she would want to move to A
wing now that he was leaving D wing. She said they were laughing when they
arrived at the office on A wing and that the man had been “his usual cheerful
chatty self”.
The other prisoner said that when they arrived at A wing office the movements
officer Alpha 7, called them in to the office and explained the regime to them. He
said there was another officer in the office but he could not remember his name.
The other prisoner said that the only conversation in the office was when he had
seen the man’s name written down and asked him whether it was his name or his
location as he couldn’t tell. He said that the man had laughed and said it was his
name. He said that the defendant still looked “out of it”. The other prisoner said
that he asked movements officer Alpha 7 if he could go to his cell and he agreed
that he could as he knew where he was going. He said he did not see either the
man or the defendant again.
The movements officer said that it was approximately 10.30 when the man, the
defendant and the other prisoner came into the office. He looked at their
respective history sheets and CSRAs and then gave them a brief overview of the
rules and expectations of A wing. He said that the other prisoner had been on
the wing several times and had been a cleaner there. The defendant was
extremely quiet and did not make eye contact. He likened him to “a heroin
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addict, just totally not there, just nothing there”. He said the man was “quite jovial
really”. He said he commented to the man that there were several negative
entries on his history sheet and He replied that he was coming to A wing for a
fresh start, and that he had friends on the wing and that he would not be a
problem. The movements officer said he seemed sincere.
The movements officer said that the cell allocation was conducted on D wing so
each prisoner knew which cell they were going to before they came over to A
wing. He said that at some point while they were in the office the man had asked
if he could share a cell with a friend. He said he told him that this would not be
possible because his mate had just been moved to share with one of his friends
and the move had “taken quite a lot of moving about to get done”. He said that
the man had reiterated that he would prefer to share with his mate and also at
some point had asked to share a cell with another Muslim. The movements
officer said he had told him that the wing was full and that he would go in the cell
allocated to him. He said that he had told the man that, if he conformed to the
regime as he had said he would, then they would look at moving him in the
future. He said the man was happy with that and had said “right thanks boss”.
The movements officer said that all three prisoners then signed their compacts
and went up to their cells with their property.
Senior Officer SO Alpha 1 said that he was the SO in charge of D wing on the
morning of 2 April. He said he went into the wing office when the man, the
defendant and the other prisoner were in there and, out of curiosity, he read their
wing files. He said there was “nothing” in the defendant’s file but that the man
had paperwork resulting from his periods on the ‘basic’ regime. He said that he
had a brief conversation with the man during which he told him that, whatever
had happened on previous wings was behind him, and he was on A wing for a
fresh start. SO Alpha 1 said that the man had told him he had “no problems” with
this.
SO Alpha 1 said that as they were leaving the office the man was the last
prisoner out. He said he heard the man ask the movements officer Alpha 7 if he
could share a cell with another Muslim prisoner. He said that the officer
explained to the man that there was not enough space to do this at present but
that it would be possible and there would be a “rotational process”. He said that
the man was “quite happy” with this explanation.
The officer on duty on A3 landing on the morning of 2 April said that he saw the
man’s and the defendant coming up the stairs with their cell cards and their bags
of property. He thought it was approximately 10.45. He asked for their cell cards
and then took them to cell A3/02 and opened the door. The duty officer said that
the cell had not been cleaned after the previous occupant had left it that morning
and it was quite dirty. He said that the man asked him if he could quickly clean
the cell before they took their bags in and he agreed he could. The duty officer
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said that he then noticed a wing cleaner on the landing and called him over to
sweep the cell out.
The duty officer said his first impression of the two men was that the man was
quite friendly to him and the defendant was very quiet. He said that the
defendant did not seem interested in cleaning the cell and was leaning on the
railings and looking round the wing. The duty fficer said that the wing cleaner
went to get a dustpan and brush and the man swept the cell out and put the
rubbish in a bin. The duty fficer said that he remained by the cell while the man
was cleaning it. He said the only conversation took place between the man and
the wing cleaner. He said they spoke in English and another language that he
didn’t understand. Once the cell had been swept, the man asked if he could mop
it and the Officer gave the wing cleaner permission to get a mop and bucket. The
man then mopped the cell.
The duty officer said that he tried to encourage the defendant to speak because
he seemed very quiet. He said he told him he could smile if he wanted to at
which point the defendant made a half-hearted attempt to smile but did not
speak. The duty officer said he left the man and the defendant for a short time to
open a cell for another prisoner at the other end of the landing. (The VPs were
on ‘association’ when the man and the defendant arrived at their cell.) He
thought that the wing cleaner had gone downstairs at this point. He said he did
not know at the time but later found out that a second cleaner, had gone over to
talk to the defendant while he was gone.
The duty officer said that as he returned to the cell the the first wing cleaner
came up the stairs with a “green scrubber”. He said he couldn’t remember
whether the cell door was open or closed at this point but he let the wing cleaner
pass the scrubber into the cell and then closed the door. He said he went back
to his duties looking after A3 landing and shortly afterwards VP association
finished. He said that VP association usually took place between 10.00 and
11.00.
SO Alpha 1 said that he checked the wing before the prisoners returned from the
workshops. He said that VPs return first and he wanted to be sure that normal
location prisoners were in their cells. He said he was on A2 landing when he
looked up and noticed the man and the first wing cleaner cleaning a cell. He said
he saw an A3 landing officer and asked him what was happening. The officer
told him that they were just cleaning the cell and then they would be locked up.
SO Alpha 1 said prisoners usually return from the workshops at about 11.20.
The first wing cleaner said that he first saw the man when he was on his way
over to A wing from D wing. He said that he was standing near the A wing gates
waiting to go to the store as part of his duties as a wing cleaner. He said he
called out to the man who told him that he was coming over to A wing. He said
he thought the man seemed very happy. The first wing cleaner said he knew the
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man from the Muslim service on Friday afternoons and had been a close friend of
his since late February 2004. He said he did not see the man talking to either the
other prisoner or to the defendant as they approached A wing. He said that as
soon as the defendant came onto A wing he began to “stare out” the first wing
cleaner’s cellmate who was making a phone call.
The first wing cleaner said he stood next to the gate near the wing office while
the man and the others went in to have their induction. He said he heard the man
ask the movements officer Alpha 7 whether he could share with a Muslim
prisoner because he prayed several times a day, rose very early and had
previously had problems with non-Muslims who did not like this routine. The wing
cleaner said he heard the movements officer Alpha 7 tell the man that he would
go “where we fucking put you”. He said that when the man came out of the
office he told him that the officers were “fucking about” with him again. He said
he told the man to go to the cell he had been allocated and he would try and talk
to an officer about getting him a move another day.
The first wing cleaner said he carried one of the man’s property bags up to A3
landing. He said the defendant was very quiet and did not say anything as they
went upstairs. He said that cell A3/02 was a complete mess and the duty officer
agreed to let them clean it before they went in. He said that he and the man
cleaned the cell while the defendant leaned up against the railings. The wing
cleaner said he asked the defendant if he was going to help and that He made a
gesture as if to say “am I fuck”. He said he warned the defendant that the
officers on A wing would not like his attitude but He did not say anything. He said
that the man and the defendant did not speak to each other at all. The wing
cleaner interpreted this to mean that they did not get on because he said normal
procedure would be to introduce yourself to your cellmate.
The first wing cleaner remembered that a second cleaner, spoke to the defendant
while he was outside the cell. He said that the defendant did not go into the cell
until it was clean. He said that the duty officer was not away for long and when
he came back he shut the man and the defendant in the cell. The wing cleaner
said that he then remembered that the man had asked for a green pad and a
“squirter” and went to get them for him. He then asked the duty officer to open
and close the cell door again. He said the last time he saw either the man or the
defendant they were both standing in their cell.
The second wing cleaner said he was a cleaner on A wing and one of his tasks
was to post the menus through the cell doors. He said on the morning of 2 April
he passed cell A3/02 and saw the man, the defendant and the first wing cleaner
standing outside. He said the man was talking to the first wing cleaner. As he
went past the defendant said “you alright?” He said he did not know the
defendant but he obviously knew him. He said he had a brief conversation with
the defendant about which wing he had come from and asked him if he was
going to share a cell with the man, to which the defendant replied that he was.
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The second wing cleaner said that the defendant asked him if there were any
empty cells on the wing and he told him there were. He said that, before asking
him about the spare cells, the defendant had first looked at the man and at the
first wing cleaner to make sure they were still talking. The second wing cleaner
said that it was quite common for prisoners who were new to the wing to ask the
cleaners about spare cells as the cleaners knew where they were and would
know the best officer to approach about a move.
The second wing cleaner said that his first impression of the man was that he
was “a bit loud for his own good”. He thought he was “beating himself up” by
talking loudly to the first wing cleaner and swearing. He said he did not know
what the man and the first wing cleaner were talking about as, although he said
they spoke mostly in English, they reverted to “their own language” for parts of
the conversation. He said that the defendant did not seem bothered that he was
going to share a cell with the man, but observed that he had made an effort to
talk to him about finding another cell at the earliest opportunity. The second wing
cleaner said that he told the defendant that he would have a look about and talk
to him later. He then walked off and did not see the defendant again.
The defendant said that he had thought that the man was “ok” when they were
moving from D wing. He said when they got to the cell on A wing “one of his
Asian mates” came to the cell, and that was when they started trying to “bully”
him into cleaning the cell. He said that the man had changed his attitude. He
said he had talked to him before the first wing cleaner arrived and he had thought
that the man was “alright”. The defendant said that the first wing cleaner told him
to clean the cell toilet and he replied that he would not as it was the cleaner’s job
to clean the toilet. The defendant said that after that the man and the first wing
cleaner started talking in “Asian” and he thought,
“I know what is going to happen in here, next thing you know I got banged
up in my cell and me and him started fighting.”
The defendant said that he and the man started fighting “straightaway” because,
“…he started speaking in Asian and I don’t know, I said why don’t you
speak English, why don’t you speak English, why don’t you speak English,
talk to me properly and he said he swore at me and he was carrying a
knife in there [indicates his waist] and next thing you know we were
fighting in the cell and it just all went you know wrestling and that and I got
the knife off him and that’s when I tried striking across his face or his neck
wherever I cut him and that were it.”
The defendant also said in interview that he had grabbed the man by beads he
was wearing, hit him with a chair and kicked him in the face. He was unable to
remember how long he had been in the cell before the fight started as he said he
was “confused” about this period.
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(I would like to emphasise that I am reporting the defendant’s account of the
events of 2 April and do not make any judgment as to the credence of his
version. There is no evidence that the man was in possession of a knife on that
day or indeed on any other day he spent in Leeds prison. The evidence is that
the man died as a result of an attack that was frenzied and involved extreme
violence.)
(ii) From when the alarm was raised to when death was pronounced
The security governor, was conducting an adjudication (a prison disciplinary
hearing) on a non-compliant prisoner in the segregation unit at the bottom of A1
landing on 2 April 2004. He said he heard a loud screaming, “a sort of shrieking
noise”, like “an animal in distress”. He said he looked at the first senior officer
SO and he left the room to find out what was going on. The security governor
said that the windows were shut in the adjudication room but the noise could be
heard clearly “through the window”. He said that the first SO returned to the
room and told him that there had been an incident and he thought the
adjudication should be adjourned. He said he adjourned the hearing and the
non-compliant prisoner was taken back to his cell. He remained in the room to
complete his paperwork.
The first SO said that the acoustics were very good in the adjudication room and
it was possible to hear “quite a lot that goes on” on the rest of A wing regardless
of whether the window was open or not. He said that he heard someone
“moaning and screaming” as if they were in pain. His first thought was that it
sounded like someone was being raped. He left the room and asked a second
SO, who was standing outside the adjudication room, to ask A wing staff to check
the cells. He said that he saw that the second SO start walking up the stairs and
returned to the adjudication room. He did not hear any further screams.
A first officer said that he was in the adjudication room when he heard screaming
coming from one of the landings “upstairs”. He said there was also a lot of noise
on the wing from the prisoners collecting their lunches. He too thought the
screams sounded like someone being raped.
The non-compliant prisoner said he was taken to the adjudication room at
approximately 11.00 on the morning of 2 April. He said he remembered there
were three staff and the Security Governor in the room with him. He said that
after about five minutes he heard a “single loud scream” and he and the staff all
looked at each other. He said that the “Senior Officer” asked one of the other
officers to find out what was happening on the landings and the officer left the
room. He said that shortly afterwards his adjudication was adjourned and he was
returned to his cell.
-10 -
The second SO said she was walking past the adjudication room on her way to
the main office when the first SO asked her to investigate noise “upstairs” that
sounded like somebody “being beaten or raped”. She said she went up the stairs
and saw about five officers standing on A2 landing by the stairs. She said they
were almost directly underneath cell A3/02. She told the movements officer
Alpha 7, that the adjudications had been interrupted by what sounded like
someone being beaten or raped. She said that the movements officer said that it
must be coming from A3 landing and that he and the first officer went to
investigate.
The second SO said that she did not hear any of the noises described by the first
SO, either on S1 landing by the adjudication room or A2 landing where she
spoke to the movements officer Alpha 7. She said that she could see that the
VPs on A4 were coming down to A2 to collect their lunches and there was a lot of
noise from prisoners “clattering” trays and talking. She said that prisoners on the
segregation unit were about to be given their lunch and this involved the cleaners
going up to A2 in the lift to collect the meals for them. Taking this into
consideration, she thought the first SO must have asked her to speak to A wing
staff at about 11.40. She said that, apart from the noises heard in the
adjudication room, there was no disruption and no sign that anyone was aware of
anything being wrong.
The movements officer Alpha 7 said that he was on A2 landing during prisoners’
lunchtime. He said that the prisoners had been collecting their lunches for
maybe five or ten minutes when the second SO came out of the segregation unit.
He said the segregation unit steps led to exactly where he was standing. He said
that the second SO told him that screams had been heard and that it sounded
like someone was being raped. He said that he asked her where the noise was
coming from and she told him that it was from somewhere above the adjudication
room. He thought the time was approximately 11.50. The movements officer
said he immediately went up to A3 landing followed by the first officer. He said
he saw another officer, the second officer on A3 landing and told him that he
thought something was happening in the A3 cells, probably a fight. He said he
went along the cells looking through the observation panels. As he neared A3/02
he said he heard two loud bangs, “like wood being hit onto the floor”, coming
from the end of the wing. He said he went to cell A3/02 and saw the man on the
floor of the cell with the defendant standing over him looking at him. He said he
could see nothing in the defendant’s hands.
The movements officer Alpha 7 said he realised that for someone as powerful as
the man to be on the floor a violent act must have occurred and shouted to the
SO Alpha 1 to lock the wing He then opened the cell door and told the
defendant to leave the cell. He said that the defendant walked straight out of the
cell and at this point he noticed blood on the cell floor. The movements officer
Alpha 7 said he asked the second SO to take the defendant’s straight to the
segregation unit and get his clothing “bagged and tagged”. He then entered the
-11 -
cell and saw that the man was badly injured. He stepped back on to the landing
so he could use his radio to call for medical assistance.
The movements officer Alpha 7 said another officer passed him some rubber
gloves and he went back into the cell. At this point he saw a serious injury to the
front of the man’s throat and placed a towel over the injury. He turned the man
more into the recovery position” and saw another large laceration across the
back of his head. He said the first officer passed him another towel and he
placed this onto the second injury. The movements officer said that the man had
a pulse and he tried to speak to him to calm him down. He said the man tried to
move and stand up and he had to pin him on the floor. He said he tried to
reassure the man that help was on its way and tell him to lie still as he had hold
of his wounds. He said that the first officer helped to control the man’s legs. He
said that the man did not try to speak but he thought he could hear him. After a
while, when the man seemed to be getting “quite low”, he asked him to blink if he
could hear him and the man tried to blink.
The movements officer Alpha 7 said that the man was lying two or three feet from
the cell door with his head facing the door. He said his jeans were “pulled down
around his thighs” revealing his boxer shorts. He noticed that a packet of cereal
and some milk had been spilled on the floor and that there were two large
property bags in the cell with their tops open. He thought these belonged to the
man
The movements officer Alpha 7 said he remained with the man for maybe 10 or
15 minutes while nursing staff tried to give him oxygen. He said that he noticed
Healthcare Officer HCO in the cell doorway and asked him to take over as he
was physically drained. He said he left the cell and the HCO took over applying
pressure to the man’s wounds.
The first officer said he was on A2 landing at about 11.50 when the second SO
came up from the segregation unit. He said she told him that an adjudication had
been stopped and asked if the wing officers could investigate a noise. He said
that he and the movements Officer Alpha 7 went up to A3 landing where they met
the second officer. He said the movements officer Alpha 7 opened the flap to
A3/02 and called for medical assistance. He saw the movements officer open
the cell door and tell someone to leave the cell. A prisoner, whom he now knew
to be the defendant, walked out of the cell and the Second officer asked him if he
had any weapons. He said he saw the defendant hold out his hands in front of
him. He heard the defendant say something to the second officer but could not
distinguish the words. The Second officer then escorted the defendant to the
segregation unit. The first officer said the defendant looked “calm” and “very
passive”.
The first officer said that he and the movements officer Alpha 7 waited for some
latex gloves to be brought from A2 landing and then went into cell A3/02. He
-12 -
said this took a matter of seconds as the gloves were passed through the netting
between A2 and A3 landings. He said the movements officer got a towel and
applied pressure to the wound on the man’s throat. The first officer said the man
tried to get up and he helped the movements officer keep him on the floor by
keeping his knees in the recovery position. The first officer could not remember
there being a towel at the back of the man’s head. He said he did notice that,
although the man’s head was towards the cell door, there was a significant
amount of blood under the bed at the opposite end of the cell. He said he could
see the man’s s beads under the bed. The first officer said that the man was
wearing tracksuit bottoms and they were round his ankles. He was also wearing
boxer shorts but these were in place.
The first officer said that two nurses next entered the cell and one of them
dressed the man’s ear, which was badly cut. He thought the nurses, with the
movements Officer help, then gave oxygen to the man but said it was difficult for
him to see as he was down by the man’s feet. The first officer thought that he
was in the cell for maybe 10 or 15 minutes. He said he thought the medical staff
arrived within one or two minutes of the radio call. He said a doctor appeared in
the cell doorway but did not enter the cell. He said that he knew the man was still
alive when the oxygen mask was put on because he could see his breath as he
breathed out. The first officer said he and the movements officer left the cell
when the paramedics arrived.
The second officer said that he was standing on A3 landing at approximately
11.50 assisting with the flow of prisoners collecting their lunches when the
movements officer and the first officer approached him and told him that there
was “a commotion” or “a fight” somewhere on the first quarter of A3. He said he
was “surprised”, as he had not heard anything. He said that he had been
standing at the top of the stairs on A3 landing for about 15-20 minutes and had
not heard anything untoward at all. He confirmed that the VPs were coming
down from A4 to collect their lunches. This meant that the first quarter of A3
landing that contained prisoners on ‘normal location’ was still locked up. The
second officer agreed that there would have been noise from cell doors being
opened and closed but said that the noise levels on the wing were not out of the
ordinary.
The second officer said that the movements officer Alpha 7 asked him to “give
him a hand” and he followed the movements officer and the first officer down the
wing. They each checked the cell observation flaps. He said that the
movements officer looked into A3/02, opened the door and asked someone to
leave the cell. He said the defendant came out of the cell and walked towards
him. He said the defendant was “compliant” and he asked him whether he had
any weapons. The second officer said he was about to search the defendant
when he noticed that his right hand was covered in blood. He did not have any
surgical gloves with him and so did not perform the search. He said that he did
not see any blood anywhere else on the defendant’s.
-13 -
The second officer said he ordered the defendant to go directly to the
segregation unit. He said that the defendant said to him, “I’m not a racist, I took
the blade from him”. He said that as He approached the stairs he made another
unsolicited comment, which was "he attacked me". The second officer said that
this was all that the defendant said to him on the way to the segregation unit. He
said that the defendant appeared “very calm”.
The second officer said he left the defendant in the segregation unit and ran back
up to A3/02 to see if he could be of assistance. He saw the movements officer
trying to stem the flow of blood from the man’s throat. He said by this time
nursing staff were in the cell and the SO Alpha 1 was in charge outside the cell.
He said that the Deputy Head of Residence asked him to search outside the cell
for a weapon. He left the wing and searched outside but could not find a
weapon. He returned to the wing, told the Governor that he had not found
anything and, as there was nothing else he could do to help, went to the wing
office to write his report.
Nurse Hotel 3 said she was carrying the radio with call sign Hotel 3. This means
that she was designated to respond first to an emergency call. She said she was
in A wing treatment room when she received a call to go to cell A3/02 urgently for
a “red call”. Nurse Hotel 3 said that a red call indicated that there was bleeding
and the fact that the call was urgent indicated to her that it was “a big bleed”.
She said she grabbed a “slash pack”, which has gauze swabs and saline
solution, locked the treatment room and went straight to A3/02. Before she got to
the stairs she saw the defendant on A2 about to go down the steps to the
segregation unit.
Nurse Hotel 3 said that, when she arrived at the cell, she saw one officer
kneeling by the man’s chest and another at the back of the cell. She said she
could see a lot of blood at the bottom of the cell. The man had his head near the
cell door and was bleeding heavily. The nurse said that she realised how serious
the situation was and, before entering the cell, she asked control to call for Hotel
4 and an ambulance. She was told that Nurse Hotel 4, was already on her way.
She then entered the cell.
She said that the movements officer Alpha 7 was applying pressure to try to stop
the bleeding. She said that the man kept trying to get up which made applying
constant pressure difficult. She said both she and the officers talked to the man
and tried to keep him calm and reassure him. She said the man appeared to be
aware of what they were saying because he looked at them when they were
speaking and he did calm down. She said she tried to find a pulse. The
movements officer was happy to continue applying pressure to the wound, which,
she said, was good as he was doing an “excellent” job. She then asked
somebody to get the emergency equipment, a doctor and more healthcare cover.
-14 -
She said that the duty doctor arrived within a couple of minutes and inserted a
cannula [a narrow tube for removing fluid from bodily cavities] into the man’s.
Nurse Hotel 3 said that the HCO arrived at about the same time as the doctor
and he took over putting pressure on the man’s wound as the movements officer
was tired. She said she managed to get a pulse reading on the man’s after
giving him oxygen and he was breathing. Nurse Hotel 3 said that the man was
wearing prison issue jeans, which were around his ankles. She said he had
socks on his feet and she thought his trainers were by the cell door. She thought
that paramedics arrived after she had been in the cell for about five or ten
minutes. She said that she had called the control room after the event and had
been told that she received the emergency call at 11.49.
Nurse Hotel 3 said that, as the man was breathing, the main task for staff was to
stop the bleeding. She said that all of the equipment available to them was
adequate apart from the suction machine, which was “a bit dated”. She said that
the ambulance paramedics took over when they arrived and she went to the
ambulance with one of them to collect a backboard and some more equipment.
When she returned to the wing she waited outside the cell as the paramedics
were giving the man cardiac massage. She said she thought this was to get his
blood to pump more quickly rather than because his heart had stopped. She said
that the man was then taken to hospital by ambulance.
Nurse Hotel 4 said that, on the morning of 2 April 2004, she was working on D
wing treatments. She said she held the radio with call sign Hotel 4, which meant
that she carried the back up radio for calls for medical assistance. She said she
heard the call for Hotel 3 to go to A wing and thought that it sounded like a
“serious event”. She said she immediately picked up a ‘slash pack’ and made
her way to A3 landing. As she arrived on A3 landing she received a call from
Hotel 3 asking for assistance. She said that she called the control room later and
was told that Hotel 3 was called at 11.49 and Hotel 4 was called at 11.50.
Nurse Hotel 4 said that when she entered cell A3/02 she could see the man laid
in the recovery position and the movements officer Alpha 7 holding a towel
around his neck. She said that the movements officer was reassuring the man
and the bleeding seemed to be under control. However, because there was a
large amount of blood in the cell she put out a call for a doctor and more help.
This call was made at 11.52. She said that the blue light ambulance had already
been requested by the time she arrived at the cell. There was another officer in
the cell but she did not know his name.
Nurse Hotel 4 said she got on her hands and knees with the movements officer
and tried to reassure the man. She said he was fighting to get up but did not
speak at all. The oxygen arrived and the man was given “oxygen at 10 litres”.
She said they tried to assess his pulse and oxygen levels using the “stats
machine” but could not get a result. Two more healthcare officers, the
-15 -
Healthcare Principal Officer HCPO and the Healthcare Senior Officer HCSO,
arrived together with the duty doctor. The doctor ‘cannulated’ the man, gave him
more fluid and tried to check his pulse. The healthcare officers removed the
furniture from the cell to give them more room to work. She said the paramedics
arrived and took over. She said they moved the man into a position where he
could be given cardiac massage and intubated him to make sure he was
breathing properly. They then “boarded” him and he was taken to hospital.
Nurse Hotel 4 said that the emergency equipment was brought to them as quickly
as possible. She said that the only piece of equipment she had any concerns
about was the suction unit, which was “difficult to work”. She said that the man
was wearing jeans, which were around his ankles, and he was wearing boxer
shorts. She said that she thought that the movements officer had been
“absolutely outstanding”. She said that when she arrived he had the situation
under control and was reassuring the man.
The doctor said that, on the morning of 2 April 2004, the HCPO came to his
office and told him that there had been a serious assault on A wing and he was
needed. He said he could not be sure of the time but thought it was around
11.20. He said he immediately went to A wing. When he entered the cell he saw
the man lying on the floor in the recovery position being attended by two prison
officers and two nurses. He said the man was breathing but not moving. The
doctor said he was told that the man had a “cut throat” and that paramedics were
on the way. He said he tried to feel for a femoral pulse (the pulse at the top of
the leg) but could not find one.
The doctor said paramedics arrived at the cell at about 12.00 and immediately
tended to the man. He said he gave him fluid and started to feel the femoral
pulse. The cardiac monitor showed that the man’s heartbeat was “40 per minute
regular”. He said one of the paramedics was inserting an endotrachial tube to
make his breathing easier and he was asked to check that it was in the correct
place. This he did and confirmed that he could hear the man breathing. The
doctor said that about 12.25 he noticed that the man had stopped breathing
spontaneously and the cardiac monitor was showing a flat line. He said the
paramedics started cardio pulmonary resuscitation (CPR) and after about five
minutes they decided to take him away. He said that the man’s condition at this
point was “very poor” and “in all practical purposes I felt that he was probably not
alive”. The doctor said that after the paramedics had left with the man he went
back to his office and wrote up his notes. He said he had written on his notes
that the time was 12.32. He said he was satisfied with the first aid given to the
man.
The HCO said that he was in the Healthcare Centre on 2 April 2004 when
another officer told him that he was needed on A wing. He said he walked to the
centre (the central area from which access is gained to A, B, C and D wings),
which was about 250 yards away, because that was where the emergency
-16 -
equipment was kept. He said he saw a nurse opening the emergency equipment
cupboard. She told him that nurse Hotel 3 and nurse Hotel 4 were already on A
wing and he said that he noticed that they had already taken the ‘ambu bag’. He
explained that the ‘ambu bag’ contained oxygen and resuscitation equipment.
He said that he assumed he was attending a ‘blue call’, which meant that the
person is not breathing, so he took the defibrillator from the cupboard and made
his way to A wing.
The HCO said he was directed to A3/02 by staff. In the cell he saw two nurses,
two officers and the man lying on the floor. He said one of the officers was
holding a towel to the back of the man’s head and one to his throat. He said that
the officers were talking to the man, trying to calm him down. He said that the
man was lying in the recovery position with his head towards the door. He said
that he helped put the oxygen mask over his mouth. He saw a deep cut, maybe
four inches long, to the back of the man’s head. He said he realised that the man
had lost a lot of blood and that he needed to be cannulated to get more fluid into
him. He said he asked the HCPO to get the fluid kit from the centre and
meanwhile checked the man’s airways. He said that the man kept trying to get
up and he told him to lie still so that he could help him. He then took over from
the movements officer Alpha 7and held the towel to the man’s throat.
The HCO remembered that one of the officers had told him that man’s jaw was
very loose. He said that he felt it slightly and thought that it might be fractured.
He said that he heard on the radio that the ambulance had arrived and felt
relieved. He said that the doctor then arrived and tried to feel for a femoral pulse.
The HCO said that at this point he noticed that the man’s jeans were around his
ankles. The doctor asked him to confirm that there was a femoral pulse, which
he did. He said that the man was obviously in a state known as ‘bretocardio’,
which means that his pulse was starting to slow. He said that the HCPO returned
to the cell with the fluid kit and the doctor cannulated the man.
The HCO said the ambulance crew then arrived at the cell. He said they were
not paramedics but Emergency Medical Technicians (EMTs), which surprised
him as he had expected at least one paramedic. He said he remembered the
HCPO asking them if a paramedic supervisor was coming and being told that a
paramedic team was seconds behind. The HCO said that the paramedics did
arrive very quickly after the EMTs. He said that nurse Hotel 4 continued to give
him fluids, although he said that ideally the man should have been given blood.
The HCO said that one of the EMTs went to get their own defibrillator because it
had a screen attached and they would be able to see the man’s heartbeat. The
EMTs cut the man’s sweatshirt off and put the defibrillator on his chest. The
machine showed that he had a heartbeat but that he was in ‘Electrical
Mechanical Disassociation’ (EMD). This meant that his heart was beating but
that nothing was happening. This was probably due to the loss of blood. One of
the EMTs began chest compressions. The paramedics arrived and the EMTs
-17 -
handed over to them. It was decided that one of the paramedics would intubate
the man and he was laid flat on the floor. The HCO said he took off the man’s
jeans because they were making it difficult to move him.
The HCO said that the man went into cardiac arrest. He was given oxygen and
fluid and the paramedics and nurses continued CPR until the stretcher arrived in
the cell. He was put on the stretcher and CPR was stopped. He said, at this
point, he realised that the man was not going to live. He followed the stretcher to
the ambulance and then went back to the treatment room on A wing.
The HCPO said that he was in the Healthcare Centre talking to the HCSO when
he heard the radio call for Hotel 3. He was holding the radio with call sign Hotel
9, the unit manager’s radio. He said when he heard Hotel 3 call for Hotel 4 and
general medical assistance he called a colleague to ask the HCO to go to A wing.
This was because the HCO was a trained EMT and had most expertise in dealing
with emergency situations. He said he and the HCSO then made their way to A
wing. On the way he heard the call for the doctor and stopped in the Doctor’s
office to tell him he was needed on A wing.
On arrival at A wing the HCPO said he did not go into the cell but he could see
nurse Hotel 3, nurse Hotel 4, the HCO and two officers in there with the man. He
said that the doctor arrived within minutes and went into the cell. He said that the
HCO asked him to bring another oxygen cylinder and the intravenous infusion kit
and he went to get these from the emergency treatment area on the centre. He
passed them into the cell and then moved further down the corridor with the
HCSOas the paramedics arrived.
The HCSO said that he was talking to the HCPO when he heard the calls on the
radio for Hotel 3 and Hotel 4. He said that the second call alerted him to the fact
that the incident was serious and he and the HCPO decided to go to A wing to
see if they could help. He said the HCPO went to tell the duty doctor that he was
needed on A wing and then they walked over together. He said that he could see
through the cell doorway that the movements officer Alpha 7 was trying to stem
the flow of blood from the man’s neck. He said that he could see the man lying
with his head towards the bed and his feet slightly under the bunk beds. He
noticed that He did not appear to be wearing trousers. TheHCSO said that he
passed medical equipment into the cell and also removed the cell television,
locker and chair to give the medical team more access.
The HCSO said that he heard on the radio that two ambulances had arrived and
four ambulance staff arrived simultaneously on the wing. He thought that they
arrived at about 12.05. He said that after about five minutes the ambulance crew
decided that the man needed to be taken to Accident and Emergency at Leeds
General Infirmary (LGI). He said they discussed this with the duty doctor, who
agreed that nothing further could be done in the prison.
-18 -
The SO Alpha 1 said that, on the morning of 2 April 2004 at about 11.50, he was
standing on A2 landing supervising the VPs collecting their lunches when the
movements officer Alpha 7 shouted to him from A3 landing that there had been
an incident. He said he went up to A3 and saw the movements officer, the first
officer and the second officer standing outside one of the cells. He then saw the
defendant walk out of the cell with his hands covered in blood. The second
officer escorted him to the segregation unit and that was the last he saw of the
defendant.
The SO Alpha 1 said he looked into cell A3/02 and saw the man on the floor
clutching his neck. He said there was blood, milk and other debris on the floor
and his first impression was that there had been a fight. He said he called for
Hotel 3 on his radio and then called down to the other wing SO on A2 landing
and told him to start locking the prisoners away and not to unlock anyone else for
lunch. He said that the movements officer Alpha 7 and the first officer were given
gloves and went into the cell. The movements officer persuaded the man to
remove his hands from his throat so that he could apply pressure to the wound
with a towel.
The SO Alpha 1 said that nurse Hotel 3 arrived within seconds of the call for
Hotel 3 as she was in the treatment room downstairs. He said she immediately
asked for help and he used his radio to put a ‘red’ call for Hotel 4, the doctor, any
available Hotel staff, Oscar 1 (call sign for the orderly officer who is nominated to
manage incidents), the duty governor, security and the police liaison officer. He
said that at this point the control room had switched the radio to ‘talkthrough’,
which enabled him to speak to anyone holding a handset. He said he also asked
for an ambulance. He said that nurse Hotel 4, healthcare staff and the duty
doctor were very quickly on the scene. He said that the Duty governor and Oscar
1, the PO from Security, were also very quick to respond. The security SO
responded from Security and the wing governor, deputy head of residence, was
also present. He said he briefed everyone as they arrived.
The PO from Security, said that he was orderly officer (Oscar 1) on 2 April. He
said he was in the security office when he heard a call on the radio from the SO
Alpha 1 that there had been a serious assault on A wing. He said he told his two
senior officers to go straight to the wing. He stopped off at the police liaison
officer’s room and asked the Detective Constable Police Liaison Officer to
accompany him to A wing. When he arrived at A wing, The PO Oscar 1 said he
could see that the man was receiving medical attention and so he took on the
role of liaising with control and ensuring a clear passage for the ambulance and
paramedics. He said he told the first Security SO to go to A2 landing, organise
the escort equipment and make sure access was clear. He told the second
Security SO to start a log of all the people who entered the wing. PO Oscar 1
said that he instructed the control room to leave the vehicle gates open to ensure
that the ambulance could leave as quickly as possible. He escorted the
-19 -
paramedics and the man to the ambulance and watched it leave with two
escorting officers on board.
The second security officer said he responded to the call that there had been a
serious assault on A wing. He took his camera and some tape to seal off the
landing if required. He said that he looked briefly into cell A3/02 and could see
that the incident was very serious. He said he opened a log at approximately
11.55 to record who entered the landing and the cell and made sure that only
staff who were required were allowed into the area. He said that the primary duty
of security staff was to preserve evidence and keep the area as sterile as
possible. He remembered that the man’s trousers were partially down and that
they were later removed in order to help them move him. He said that, once the
man had been taken to the ambulance, he sealed the cell, taped off the end of
the wing and sealed the areas used to transport the man to the ambulance. He
said it was roughly 12.30 by the time he had sealed the area. He thought that the
paramedics arrived at approximately 12.05 or 12.10.
The duty governor on 2 April said he heard three calls over the radio, increasing
in urgency, from about 11.50. After the third call he decided to go to A wing and
arrived there at approximately 12.00. He said he was briefed by the SO Alpha 1
outside cell A3/02 but did not go into the cell. At about 12.10, he said, the first
ambulance crew arrived and he collected them and brought them to the cell. He
said the second ambulance crew arrived shortly afterwards but he couldn’t
remember who brought them to the wing.
The first accompanying officer said that the accompanying SO told him to
accompany the man in the ambulance to the hospital together with a second
accompanying officer. He said he travelled in the front of the ambulance, which
arrived at Leeds General Infirmary (LGI) at approximately 12.50. He said that
ambulance staff put the man in the resuscitation room and he and the second
accompanying Officer waited outside. He said that a “few minutes” later a doctor
told him that the man had died. The Prisoner Escort Record (PER) form
completed by the first accompanying officer shows that the ambulance left Leeds
prison at 12.40 and arrived at LGI at 12.45. He recorded on the PER that he was
told at 13.00 that the man had died and that he phoned the control room to report
the death at 13.05.
There is only one cell adjacent to cell A3/02. The first prisoner said he was in cell
A3/03 on 2 April. He said he and his cellmate went to the gym at about 8.00 and
returned at about 9.00. He said that, at about 11.30, he heard officers shouting
outside on the landing and someone calling for an ambulance. Some time later,
he thought about 12.00, he said he was let out to collect his lunch and returned to
his cell. At about 3.30 a notice about the man’s death was put under his door.
The first prisoner said he had not heard any noise from the cell next door until he
heard the officers outside.
-20 -
The second prisoner said that he returned from the gym at about 9.00. He said
he went to collect some hot water at about 10.30 and then put his music on loud
and started to “work out” in his cell. He said he heard no noises from cell A3/02
and was not even aware that the cell was occupied. At approximately 11.30 –
11.45 he said he noticed several officers outside his door but it was only later that
he became aware that someone had died in the cell next door.
(iii) What happened to the defendant
The second officer took the defendant to the segregation unit (S1) from A3/02.
He said he took him to the “sterile cell” and told colleagues that there had been a
serious incident and the defendant’s clothing would require “bagging and tagging”
(being sealed as evidence). He then returned to A3 landing.
The second SO said she was supervising lunch on S1 when the second officer
brought the defendant down the stairs. The second SO said she went into the
cell with him and saw that the defendant appeared “dishevelled” with “glistening”
skin and “red raw” hands. She said his face appeared “totally blank”. She then
left the cell while the defendant was strip searched by male officers. She
collected some evidence bags from the PO’s office and left them outside the cell
door.
The first Incident officer said he took the defendant to cell S1/33 where he and
the second incident officer instructed the defendant to remove his clothes. He
placed the defendant’s clothing in nine separate evidence bags. The first
incident officer said he did not realise the severity of the incident because the
defendant appeared like “a normal prisoner, not so much shocked as withdrawn”.
He said the defendant complied with everything he asked him to do. He said he
spoke to the defendant only to ask about his trainers, which were new.
The second Incident officer said that the defendant had not spoken during the
strip search. He said he had blood on his hands but he did not notice any injury
on the defendant. He said that the defendant was taken to the “special” cell
S1/33. This is a cell with nothing but a plinth with a mattress on it at one end and
a toilet.
The deputy head of residence said that, as he was the governor in charge of the
segregation unit, it was his job to see every prisoner located there. He said he
and the the Disciplinary Hearing SO went to see the defendant who told him, “he
was making racist remarks to me, he pulled out a knife and we fought for it. I got
the knife off him and did him”. The governor said he told the defendant not to say
anything else to him. He said he had simply wanted to know if the defendant was
alright and he was concerned not to prejudice police enquiries. The governor
said that the defendant was very calm and seemed “totally unconcerned” by what
had happened.
-21 -
The Governor said he left the cell and went to speak to the Detective Constable
Police Liaison Officer and to the Police Liaison Officer. As a result of their
conversation he asked staff in the segregation unit to watchthe defendant and
stop him washing himself or getting rid of evidence in any other way. The
defendant was not allowed a drink or a meal either.
The SO conducting the disciplinary hearing said that the deputy head of
residence told staff to keep watch on the defendant until the police arrived. He
said staff kept watch in twos and sat on chairs in the cell with the defendant. He
shared a watch with the SO colbeck and with the First Watch Officer. He said the
defendant yawned when he spoke to him. He asked the defendant if he was
tired and He replied that he was “bored”. They had a short conversation about
the defendant’s sentence.
The first watch officer remembered the defendant talking to the disciplinary
hearing SO. He said he remembered the defendant saying he was bored. The
first watch officer said that the first and the second incident officers relieved him
and the SO.
The second incident officer said that he was taking his turn watching the
defendant when the police arrived to arrest him. He heard them charge him with
murder and he accompanied them to the police car. He said that the defendant
did not speak at all during this time.
The defendant was taken to Pudsey Police station at 14.33. He was
subsequently charged with the murder of his cellmate. He remained in police
custody until 5 April when he was transferred to HMP Wakefield. In July 2004 he
was convicted of murdering his cellmate and sentenced to life imprisonment.
(iv) Timings
D wing movements book shows that the man moved from cell D4/07 to cell A3/02
and that the defendant moved from cell D4/26 to cell A3/02. There is no time
recorded against the entry. The movements officer on D wing confirmed at
interview that she made the entries in the D wing movements book. A wing
movements book records that the man, the defendant and another prisoner
arrived on A wing at 10.30. The kitchen records show that the lunchtime meal
was ready to be delivered at 11.30. The Kitchen Principal Officer is the PO with
day to day responsibility for the kitchen. He was not on duty on 2 April but
estimated that it takes between five and ten minutes for the food to be
transported to the wings via trolleys. The F256 Record of Hearing and
Adjudication for charge number 679-04 brought against the non-compliant
prisoner on 2 April shows that the adjudication was opened at 11.40 in front of
the security governor. Part three, the Record of Hearing, states “opened and
adjourned, serious incident in prison”.
-22 -
The exact timing of events between 10.30 and 11.49, when the control room log
records the call for Hotel 3, is uncertain. The following approximations have
been pieced together from the relevant interview transcripts. The first wing
cleaner estimated that the man and the defendant arrived at their cell 15 minutes
after arriving on A wing. The second wing cleaner who also saw them arrive on
the wing, puts them outside the cell after ten or 15 minutes. The Duty Officer
recalled that he first saw the man and the defendant at about 10.45.
The SO Alpha 1 said that the association period for VPs is usually between 10.30
and 11.15. VPs who attend the workshops usually return to the wing at 11.20.
The duty officer and the SO Alpha 1 both recalled that the VPs were on
association when the man and the defendant were outside their cell. The SO
Alpha 1 recalled that he saw the man and the first wing cleaner cleaning the cell
about half an hour after he had first seen the man in A wing movements office.
He said he was checking the wing to make sure prisoners on normal location
were in their cells before the VPs returned from the workshops. The first wing
cleaner remembered the SO Alpha 1 looking up at them from A2 landing shortly
before the door to cell A3/02 was closed. This evidence suggests that the man
and the defendant were shut in their cell at approximately 11.15.
The disciplinary hearing SO thought that he asked the second SO to speak to A
wing officers about the screams heard in the adjudication room at “five or ten to
12.00”. The second SO said that the food was ready to serve and the cleaners
had gone to collect it from A2 (on S1 the lunchtime meal is taken to each cell by
the wing cleaners). She said the cleaners normally collect the meals at about
11.45. When she spoke to staff on A2 landing she noticed that A wing prisoners
were collecting their food. When she returned to S1 she said that the cleaners
were serving the food, which led her to estimate the time at 11.50 at the latest.
The movements officer Alpha 7 remembered that the prisoners had been
collecting their lunches for five or ten minutes before the second SO came up to
the landing. The second officer estimated that it takes between eight and ten
minutes to provide food to each section of A wing. He thought that nearly all the
VPs had collected their meals when the second SO appeared. If the lunchtime
meal was ready to leave the kitchen at 11.30 and took a maximum of ten minutes
to arrive on the wing then these timings would be consistent with the alarm being
raised on the segregation unit shortly after 11.45. This would mean that the man
and the defendant were in cell A3/02 together for approximately 30 minutes
before the alarm was raised on the segregation unit. (This fact means that the
defendant’s account – cited earlier – that he and the man had started fighting
“straightaway” is most implausible.)
The control room log was opened at 11.49 when Alpha 7 called to report a
serious assault on a prisoner and requested Hotel 3 be called. The log shows
that nurse Hotel 3 arrived at the scene at 11.50 and called the control room to log
her response. Also at 11.50, Alpha 1 requested further assistance from Hotel 4
and Health Care and asked for a blue light ambulance.
-23 -
At 11.51 the radio net was put on ‘talkthrough’ allowing anyone carrying a
handset to talk to each other. Also at 11.51 the doctor was requested and an
ambulance called. At 11.58 the first ambulance arrived at the prison and at 12.07
the second ambulance arrived. The log records both ambulances left the prison
at 12.40. The post mortem report records the man’s time of death as 12.58. At
13.05 one of the escorting officers, the first accompanying officer, called control
to tell them that the man had been declared dead.
The security SO kept a log of who entered and left cell A3/02. When he arrived
on A3, nurses Hotel 3 and Hotel 4 and the HCO had already arrived. In his
incident report [doc 12] he gives the following timings:
“11.55 Hospital PO and SO entered cell to assist
12.00 Duty doctor entered cell
12.05 Movements officer Alpha 7 and first officer left cell
12.10 Paramedics arrived, first two paramedics, followed at
12.15 by two more paramedics
12.15 Hospital staff, PO and SO left sterile area
12.20 Nurse Hotel 3 and one paramedic left cell for a stretcher,
returning a short time later with the equipment
12.30 All personnel left the cell with the inmate to the ambulance.”
(v) The prison’s immediate response to the murder
The action checklist completed by staff on 2 April shows that the inner part of A3
landing was isolated at 11.50. From this time onwards only persons who needed
to enter the area were allowed to do so. Cell A3/02 was sealed at 12.30. The
whole of A wing was sealed at 13.00 and the incident log officer kept an incident
log , which recorded who entered the wing and at what time, until 18.50. Scene
of crime officers were on the wing between 15.02 and 15.10. They attended cell
A3/02 again at 15.52. It is not recorded when they left the wing, but presumably
this happened after the log was closed at 18.50.
The action checklist shows that the post-incident care team officer of the post-
incident care team was informed of the attack on the man at 12.30. The Area
Manager was told of the death of the man at 13.15. The Chaplain was told at
13.30, Safer Custody Group were informed at 14.00, the Independent Monitoring
Board were told at 14.10, National Operations Unit were told at 14.15 and the
Governor was told at 14.25.
The duty governor, said that, after the man was taken to hospital, he had a brief
conversation on the Centre with the PO Oscar 1. As a result of that conversation
he decided that the death in custody contingency plans should be activated even
though the man had not yet been pronounced dead. He went to the Governor’s
office and saw that the head of the central business unit had already got the
-24 -
contingency plans out. The duty governor said the head of the central business
unit began going through the action checklist and assigning tasks to managers as
they arrived in the office. He said he began to collate paperwork relating to the
man and to the defendant. He remembered leaving the office to get the security
files from the security office. The duty governor said he recognised the
defendant’s name and prison number from a Security Information Report (SIR)
that had been partly processed. (This is discussed in more detail in Section 3
(vii) below.)
The duty governor said he attended the hot debrief shortly after 13.00. He
remembered receiving a call from control room staff telling him the man had died.
He could not remember whether this was before or after the hot debrief. The
duty governor said the hot debrief lasted for about 15 or 20 minutes. Afterwards
he returned to the Governor’s office and continued to work through the
paperwork. He could not remember when the decision to try to contact the man’s
family was taken. He said that this was normally done by a member of the
Chaplaincy team. He did remember that he was listed as the liaison for the
family on the action checklist.
The head of residence, said that he went directly to the Governor’s office when
he heard there had been a serious incident. He said there were already several
managers in the office. He said he left to lead the hot debrief, which he thought
took place at about 14.00. Afterwards he returned to the Governor’s office. He
remembered the Deputy Governor, the head of the central business unit, the duty
governor, the new race relations officer, the head of regimes learning and skills
and, later, the Muslim chaplain, all being present. He said that, in practice, he,
the head of the central business unit and the duty governor managed the
incident. He said tasks from the action checklist were allocated around the
different managers and not completed in strict numerical order. He said he was
not involved in the initial attempts to contact the man’s next of kin but
remembered being told that the family could not be contacted by phone. The
head of residence said that he authorised the Muslim chaplain and the head of
regimes learning and skills to drive to the family home.
The head of the central business unit said that he made his way to the
Governor’s office as soon as he was made aware that a serious incident had
occurred. He could not recall the exact time he got there but said that the head
of residence, new regimes learning and skills and duty governor were already
there. He said that the death in custody contingency plan was activated as soon
as the prisonwere notified that the man had died. He confirmed that most of the
entries on the action check list were in his handwriting and that the entries timed
prior to 13.05 (when the log records that the prison were informed of the man’s
death) were taken retrospectively from the control room log. He has confirmed
that his first timed entry on the checklist was 13.50. He said that he remembered
the Muslim chaplain trying without success to contact the man’s family by phone.
He said that he and the Muslim chaplain were named on the action checklist as
-25 -
contacts for the next of kin. The head of the central business bnit said that the
managers who were mainly responsible for managing the incident were himself,
the head of residence and, initially, the duty governor.
The Deputy Governor contacted my investigators following receipt of my draft
report. The Deputy Governor was not interviewed during the course of the
investigation as it had been believed that he was peripheral to events. The
Deputy Governor said that, in fact, he was present in the Governor’s office at the
time of the man’s murder and that he remained there to co-ordinate the prison’s
immediate response.
Members of the post-incident care team were on A wing from 12.30 and available
to staff. A hot debrief led by the head of residence took place in the multi-faith
centre some time after 13.00. The hot debrief was co-ordinated by PO Oscar 1.
PO Oscar 1 noted, in a memo to the Governor of 5 April, that the purpose of the
hot debrief had been threefold: to provide an overview of the incident, to make
staff aware that the care team and chaplaincy team were available to them
immediately and in the future, and to thank staff for their support and actions
taken during the incident. He said that, after consultation with the police, staff
had not been given the opportunity to discuss the incident in detail. Those
present included nurses Hotel 3 and Hotel 4, the HCO, The HCPO, HCSO and
two members of the staff care team. The healthcare and nursing staff held a
clinical debrief in the Healthcare Centre prior to the hot debrief.
On the advice of the police, Senior Officer Alpha 1 and the Movements Officer
Alpha 7, the first and the second officer and were kept separately from other
staff. They had their uniforms removed as evidence and were interviewed by the
police at about 15.30. The head of residence debriefed them separately in A
wing movements office. The Post-incident Care Team Officer also visited them
and stayed while the police interviewed them.
Most of the staff directly involved in the events of 2 April were off duty on 3 April,
a Saturday, and report that members of the care team phoned them at home to
see if they were alright.
At 12.45 staff were called from D wing to perform a controlled unlock of prisoners
on A wing so that the remainder of the lunches could be served. The incident log
officer said the deputy head of residence and other staff visited prisoners on A
wing who were due for domestic visits. They explained that there had been a
serious incident and that staff would contact their families to explain why the
visits could not go ahead at the usual time. All visits were re-arranged for later
that afternoon.The man’s friend on A wing, said that “a governor” came to his cell
to tell his cellmate that his special visit had been cancelled and about ten or
fifteen minutes later a notice was put under the door about the death of the man.
-26 -
The Imam, said he and the Muslim chaplain, began visiting the Muslim prisoners
just before 14.00 to tell them that Friday prayers were cancelled. He went to
every wing except A wing, which was cordoned off. He said the prisoners asked
him why prayers were cancelled and he told them there had been an incident.
He said some of the prisoners knew that the incident involved the man and asked
about him.
There was a concern that prisoners seen at risk of self-harm would be especially
upset and officers from the care team remained on A wing during the afternoon in
case they were needed. The first officer said that during the debrief in A wing
movements office he was specifically told to be aware of the prisoners’ feelings,
especially those on open F2052SH forms (those seen at risk of self-harm). The
Suicide Prevention Co-ordinator, sent a memo to all group managers on 2 April,
reminding them of the requirement in the Suicide Prevention Strategy that all
prisoners who had an F2052SH form closed in the previous three weeks should
be seen by staff. All prisoners on open F2052SH forms should have a full multi-
disciplinary review. On 14 April, he sent a memo to the the head of the central
business unit, confirming that these reviews had taken place.
Notices to staff and prisoners were issued on the afternoon of 2 April. The notice
to prisoners was put under the door of each cell on A wing. The notice to staff
advised those who felt they needed support to contact the care team or the
senior management team. Prisoners were advised to ask any member of staff if
they wished to contact their personal officer or a Samaritan-trained Listener.
A cooked meal was provided for the wing that evening. The meals were
delivered to each cell by staff.
A police search team searched cell A3/02 on Saturday 3 April. On the outside of
the window ledge, concealed by rubbish collected between the window and the
mesh, they found a disposable plastic razor. The handle had been melted to
allow a razor blade to be fixed to it. A second razor blade, which had been fixed
to the handle parallel to the first blade, was recovered from the wounds on the
man’s throat during the post mortem examination. [Confirmed the police exhibits
officer, in telecon with the Intelligence and investigations manager of the
Yorkshire and Humberside Police 25 January 2005]
All staff received a thank you letter from the Deputy Governor on Tuesday 6 April.
Unfortunately it has not been possible to obtain a copy of this letter. A Critical (or
Operational) Debrief was held on 27 April. The Critical Debrief was arranged by
the care team leader, and was attended by 12 of the 24 staff identified as having
been involved at or away from the scene of the man’s murder.
The first officer wrote to the Governor after 2 April to express his disappointment
that staff who had been directly involved in trying to resuscitate the man had not
been spoken to personally by governors. He said he received a typed response
-27 -
from the Governor through internal mail. The first officer also complained to my
investigators that none of the senior management team had attended the critical
debrief on 27 April. The records appear to confirm this. The first officer also
wrote to the Prison Officers’ Association magazine Gatelodge to express his
dissatisfaction.
In his reply of 16 April, the Governor said he was sorry that the first officer had
thought the efforts of those who were first on scene were not appreciated. He
thanked him for his efforts on 2 April and said that his Principal Officer would
make arrangements to see him personally when she returned from leave. He
said that the first officer would have an opportunity to air his grievances at the
critical debrief.
(vi) Family liaison
At approximately 12.30, the Muslim chaplain said that the head of residence
came to the chaplaincy room and told him that a serious incident involving a
Muslim prisoner had occurred. He was not at this time the designated family
liaison officer. He said he was taken to the hot debrief in the multi-faith centre
where he learned that, although it was not officially confirmed, the man had died.
Afterwards he went to the Governor’s office to find out whether the man’s next of
kin had been contacted. It seems that at this point the Muslim Chaplain was
asked to take responsibility for contacting the man’s family. The man had given
his wife’s name as his next of kin when he first arrived at Leeds. The Muslim
chaplain said that the Head of the central business unit retrieved the man’s wife’s
name name and contact details from LIDS (the Local Inmate Data System, a
computerised system with information on current prisoners). The Muslim
chaplain said he tried on at least three occasions from about 14.15 to contact the
wife by telephone but each time there was no answer. In the absence of any
other contact details for the man’s family, the decision was taken by the head of
the central business unit that he and the head of regimes learning and skills,
would go to the wife’s address.
The head of regimes learning and skills said that, at about 13.10, he was told
that there had been a serious incident in the prison and made his way to the
Governor’s office at about 13.15. He said that the Governor and the head of the
central business unit were already in the office. He said that the man’s family
contact details had to be obtained from his records in the Prisoner Administration
department which is outside the main prison building. He remembered the
Muslim chaplain trying unsuccessfully to contact the family by telephone. It was
then decided that he and the chaplain should drive to the wife’s home to break
the news. He said that he and the chaplain left the prison at about 14.30. They
had some difficulty finding the address and arrived at 15.50.
A statement made by both men shows that at 15.50 they visited the wife’s house
in Dewsbury and broke the tragic news of the man’s death to his wife. The
-28 -
Muslim chaplain said he spoke to the man’s first brother on several occasions
throughout the rest of the day, and visited the family again on 3 April. He said he
had remained in telephone contact and on several occasions the man’s first
brother had visited his house. He also attended the man’s funeral. The man’s
brothers visited Leeds prison and met the Governor on 21 April. They also
attended Muslim prayers on Friday 23 April.
The Governor’s contact log records that He spoke to the Muslim chaplain before
his second visit to the man’s family on 3 April. He asked the chaplain to convey
his personal condolences and to ask the family if it would be appropriate for him
to visit them. The chaplain told him later the same day that the family had said
that, for the time being, they wanted to concentrate on the funeral. On 4 April,
the Governor spoke to the police family liaison officer and, after some brokering,
he visited the man’s brothers. He offered his personal condolences and those of
the Director General of the Prison Service. The Governor said he explained the
process of investigation and offered the family ongoing contact and support.
The Director General of the Prison Service wrote personally to the man’s family
on 2 April.
-29 -
(vii) The experience of the man’s family
At my meeting with the man’s family on 29 April 2005, I agreed to include a
written statement of their experiences. I received this on 8 August and it is
reproduced in its entirety below:
“On 2 April 2004, the wife left home at about 2.15 p.m. to go to
town. She had wondered why her husband had not phoned
her that day as he would normally do so at some point during
the morning. At about 3.10 p.m. she picked up her children
from school and by the time she got home it was coming up to
3.30 p.m. As she walked into her house her phone rang and it
was her brother-in-law, the second brother, asking her if the
man had phoned. She said that he had not called and asked
her brother –in-law why he was asking. He said that he had
heard that there had been a fight in the prison and that her
husband was involved. (She later learned that some prisoners
who were unlocked in the early afternoon made ‘phone calls to
friends and family in the area, so that well before 3.00p.m.
rumours had spread throughout Dewsbury that the man was
seriously injured.
Less than five minutes after the first call, around 3.30p.m.,
another of his brothers ‘phoned her and told her the same
thing, about a fight in the prison involving her husband. She
started crying as she knew that something was wrong. She
started looking for the number to call at the prison and by the
time she found a ‘phone number the second brother had
already arrived at her house. Both tried ringing the prison.
Eventually He got through and asked if his brother was okay,
explaining that they had heard that he had been in a fight and
was injured. The person who answered the call told him that
someone would call them back in 5 minutes.
While the second brother and the wife were waiting for a
‘phone call back from HMP Leeds there was a knock at the
door. Two men were outside and she immediately knew that
something was seriously wrong. They came into the house
and stood in the middle of the room and said that they had
some bad news and that her husband had been involved in a
fight and as a result had been killed. The two gentlemen left
the house five minutes later, saying that they were sorry. At
about 3.50 p.m. two police officers came to tell her what had
happened. She cannot remember what they said as she was
in a state of shock.
-30 -
The widow does not understand why she was only told of what had
happened in the prison more than 2½ hours after the events. The family
now knows that by midday on 2 April 2004 a very large number of staff at
HMP Leeds were aware of just how seriously the man had been injured
and rumours reached the community well before contact was made with
his wife. How did it happen that by noon it had not yet become an urgent
task of one member of staff to notify the family that the ambulance
service had been called and that the man was being taken to the hospital
with very serious injuries? That is information that the family believes
they were entitled to know very soon after noon on 2nd April 2004.
Instead, the man was pronounced officially dead at 12.58 p.m. and yet
the family were none the wiser at that time, when they should have been
at the hospital already.”
(viii) The post mortem report
A post mortem was carried out at Pinderfields Hospital on 2 April between 19.05
and 21.30. A second examination was carried out on 8 April, also at Pinderfields
Hospital. The post-mortem doctor carried out both examinations.
The cause of the man’s death is recorded as “multiple injuries”. He suffered
lacerations to his head caused by impacts with a blunt instrument or impacts
against a firm surface and incised wounds of the neck and ear caused by a sharp
edged weapon. He was also strangled with a ligature – most probably the flex
from the television aerial – and suffered a fractured jaw. The toxicology report
did not show the presence of any drugs in his system.
Section three: Risk assessment
(i) Cell Sharing Risk Assessment (CSRA)
The Prison Service introduced a national cell sharing risk assessment system in
2002. Its origins lay in a judgement by the European Court of Human Rights in a
case brought by the parents of a murdered prisoner. The court found that the
Prison Service was in breach of article 2 of the European Convention on Human
Rights (ECHR) in that it failed to have in place an adequate risk assessment
procedure. The murder by his cellmate of Zahid Mubarek in 2000 alerted the
Prison Service to continuing weaknesses in its ability to risk assess and track
potentially violent prisoners who should not share cells with other prisoners.
The risk assessment system introduced by Prison Service Instruction (PSI)
26/2002 sought to:
- draw together and pool information about risk from operational and health
care staff
- make best use of documentary evidence
-31 -
- support staff judgements about allocation to cells
- where cell sharing is unavoidable for a high risk prisoner, provide for senior
managers to decide and record additional operational precautionary
measures
- provide a readily accessible record about risk of harm to others as a prisoner
moves between wings/prisons
- record decisions about managing and reviewing risk to enable early
identification of racist, homophobic or violent prisoners to ensure that other
Prison Service procedures to protect potential mans are followed.
The form it introduced (XF001) was intended to be a live document and to be
revisited whenever a prisoner’s location was being considered. PSI 26/2002
states that a review of prisoners with ratings other than ‘high’ need only take
place when a prisoner is transferred, is having his cell location changed, or there
is a change in the prisoner’s circumstances. Part two of the form (XF002) should
be used for this purpose.
According to the User Guide issued with the PSI the levels of risk are:
(cid:127) High – Clear indication of high level of risk that prisoner might assault their
cellmate.
(cid:127) Medium – No immediate risk, but situation will need to be reviewed regularly.
(This rating may also be used where staff feel that there are some signs of
risk but there is not enough information available to be sure. Staff are asked
to note on the assessment form why they feel there are some signs of risk.)
(cid:127) Low – No current evidence/indication of risk. Suitable for multi-cell location.
The Prison Service had further cause to revisit its policy on CSRA after the
murder of another inmate in 2003 in Manchester – a case I investigated myself.
The Prison Service formed a working party consisting of Governors and staff
from Safer Custody Group who were asked to consider the cell sharing risk
assessment process and the broader context of risk minimisation. It was
reported to the working party that some staff had found forms XF001 and XF002
to be unwieldy and unworkable in practice. The review also highlighted the
particular problems faced by local prisons facing a high number of receptions and
a strategy for these prisons was to be given priority.
One outcome of the review was the introduction of a risk minimisation plan. This
is a live document designed to work on reducing identified risks. The review also
gave responsibility for the risk management process to the Safer Custody officer
in each prison. Part of their role is to provide on-going risk assessment relating
to cell sharing. The review stipulated that a register of high risk prisoners should
be held centrally in each prison to provide a reference point and an audit trail of
open and closed cases.
-32 -
A new PSI on risk assessment was published with new review forms and a risk
management template on 29 July 2005. The Prison Service will keep cell sharing
risk assessment under review until the outcome of the Zahid Mubarek Inquiry.
(ii) Cell Sharing Risk Assessment at Leeds
Instructions on the new cell sharing risk assessment process were first issued at
Leeds in Governor’s Order 123/01. A further Order, number 8/02, was issued on
1 October 2002 by the Governor. The Order reiterated the purpose of CSRA and
highlighted what was expected of staff when completing forms XF001 and
XF002. The Order stated that, if a prisoner was judged to present a high risk to
others, the duty governor and orderly officer (Oscar 1) would make a decision on
the prisoner’s location. If medium risk was indicated, then the duty governor and
Oscar 1 should be consulted and a decision made on available evidence.
Order 8/02 gives guidance on how and when to complete the various sections of
XF001 and XF002. The guidance for section seven of XF002, which should be
completed when a prisoner changes cell, states:
“Section 7 should be completed:
(cid:127) At three monthly intervals (until he is assessed as low risk) [NB this
refers to high and medium risk prisoners]
(cid:127) When there has been a significant event (assault on another prisoner,
member of staff etc)
(cid:127) When a prisoner is transferred to another prison.”
Since the murder of this man each residential unit holds a list of their prisoners’
CSRA forms and a record of when reviews are due. Wing managers undertake
reviews at present but it is intended that residential managers will initiate future
reviews. I am also told that staff are working on a protocol that will ensure the
use of available documentation when completing CSRA reviews, rather than
simply relying on the prisoner's input.
(ii) The assessment process applied to the defendant
The defendant’s prison record (F2050) shows that he was the subject of a CSRA
on five occasions after 2002 when the process was introduced. Mr McCann’s
first CSRA was completed at Leeds in September 2002 when he was remanded
on charges of burglary and theft. Section One shows that the form was
completed with the aid of the Prisoner Escort Record (PER) and the warrant.
The defendant’s pre-convictions and pre-sentence report (it is unlikely there was
one at this stage) were not available. Question one of section two refers to
previous convictions for violent or other serious offences against the person or
any schedule 1 offence. The ‘no’ box is ticked and the source of the information
is recorded as “I” to signify ‘inmate’. In fact, the defendant had a conviction for
Assault Occasioning Actual Bodily Harm in 1995. He also had a conviction for
Wounding With Intent To Cause Grievous Bodily Harm in 1999, a schedule 1
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offence because his man was under 18 years of age. Question four of section
two relates to anti-social behaviour “if the prisoner is known to the Prison
Service”. All of the boxes are ticked ‘no’ and the source is recorded as the
‘inmate’. The defendant’s conviction for wounding resulted from his assault on a
fellow prisoner with a wooden mallet at HMYOI Hatfield and would have merited
a tick in the box marked ‘assault on others’. He admitted he had abused alcohol
or drugs in the past and was currently dependent on them. He said he had not
been subject to F2052SH procedures before when in fact he had, at Doncaster in
1998. (He took an accidental overdose of heroin in 1997. Policy at Doncaster
dictated he was put on a F2052SH but he did not show any cause for concern
and denied any need for form to be opened.) He was deemed to present ‘low’
risk and be suitable for sharing a cell. Section three, which should be completed
by a member of the healthcare team, is blank.
The defendant’s second CSRA took place in HMP Holme House on 9 November
2002. The record’s officer completed the form and his offence is wrongly
recorded as ‘wounding’. In fact he was on remand for burglary. On this occasion
the only document available to the record’s officer was his warrant. The answer
to question one of section two, about previous offences against the person, is
ticked ‘yes’ with the source recorded as the defendant. The record’s officer also
ticked the yes box to indicate his current offence was one of those listed on the
form, when it was not. Question four shows a tick in the box to indicate a
previous ‘assault on others’ with the source as the defendant. The record’s
officer rated him as presenting a ‘medium’ risk. A member of the healthcare
team completed section three. None of the boxes indicating particular signs of
risk to others are ticked but the member of staff indicated that he should be
regarded as presenting medium risk. (Healthcare staff are not allowed to enter a
level of risk lower than that made by reception staff.) Section four, completed by
the duty manager, states “no immediate concerns”.
The defendant was next subject to a CSRA at Leeds on 4 September 2003. The
CSRA Officer, who had the benefit of the PER, the warrant and a pre-sentence
report, completed the form. The source for the answers to all of the questions on
the form is recorded as the defendant. He did not say that he had a previous
conviction for ABH, or a schedule 1 offence, or that he had assaulted at least one
other prisoner or that he had been subject to F2052SH procedures. He did say
that he was currently dependent on heroin. The CSRA Officer assessed him as
presenting low risk. A Nurse Hotel 3 completed section three. She recorded that
there was “insufficient evidence to give an opinion” on whether the defendant
might be at risk of harming others and assessed his risk as low.
He was assessed again on 14 February 2004, also at Leeds. The reception
officer indicated he had the PER and the warrant. Part A of the PER form
recorded that the defendant was a heroin user and the risk category
“drugs/alcohol issues” is ticked. The defendant said he had a previous conviction
from the list given in section one but did not say he had assaulted anyone in
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prison or been the subject of a F2052SH form. He was assessed as presenting a
low risk. The member of the healthcare team who completed section three
indicated there was insufficient evidence to give an opinion on whether He
presented a risk to others and assessed him as low risk.
The defendant’s most recent CSRA before the murder of his cellmate took place
on in March 2004. He had been found in possession of a sharpened dinner knife
at the hostel and returned to Leeds on remand. The reception officer completed
the CSRA. The form shows that she had received the PER form and the warrant.
The PER, completed by the police, indicated the defendant was “no known risk”.
The section ‘Further information about risk’ reads “States fit and well (ex-drugs
user)”. There was nothing on the form to show why he had lost his place at the
hostel. Apart from confirming that he had previously been dependent on drugs,
he answered ‘no’ to all the questions. She assessed him as presenting low risk.
The reception officer made a statement to the police and was interviewed by my
investigators. She said she did not remember him as she dealt with numerous
prisoners on a daily basis. She said that it was not unusual to receive only the
PER and the warrant. In most cases, reception staff relied on the prisoner to
provide the information needed to complete the form.
Nurse Hotel 3 completed section three of the CSRA. She indicated that there
was “insufficient evidence to give an opinion” on whether the defendant
presented a risk to others and marked him as low risk. At interview, nurse Hotel
3 said that he remembered her from when he last saw her, which was in the
segregation unit in February 2004. Then she said he had been “quite paranoid”.
However at his CSRA she said he was “very cheerful, quite happy, very lucid,
very reasonable, well mannered”. She said she thought that his behaviour in the
segregation unit must have been “an isolated incident”. Although there was
insufficient evidence to give an opinion, she said there were no indications that
anything was wrong.
In addition to the CSRAs two Custody Care Plans were prepared for the
defendant while at Leeds. Custody Care Plans are designed for prisoners who
are new to prison and seek to identify and help with problems such as drug
dependency. They are generated when prisoners enter prison on a new prison
number. The care plan officer completed a Custody Care Plan on the defendant
on 18 February 2004. She referred him to the CARAT (Counselling Assessment
Referral Advice Throughcare) team because he was undergoing detoxification
but had not seen a drug counsellor. She assessed him as presenting a medium
risk for the purposes of work after ticking the boxes marked ‘any offence of
threats, assault or use of weapons’, ‘would the prisoner pose a risk to staff and
others when using tools or implements?’ and ‘would the prisoner require
supervision when working?’ The care plan officer said she had known him for
some three years and he had never presented as a problem to her.
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The second care plan officer completed a second Custody Care Plan for the
defendant in March 2004. He said that the defendant had seemed unwilling to
answer the questions put to him and his attitude was “a bit funny”. He said he
had known him on A wing from previous sentences and he did not remember him
as a difficult person. In section 7, assessment for work suitability, he has ticked
both yes and no in answer to the question ‘any offence of threats, assault or use
of weapons’. He explained in interview that the defendant did not give him an
equivocal answer to this question. He assessed him as presenting a medium risk
in a work situation. He commented at the end of the plan that the defendant had
a “poor attitude”.
(iii) Indicators of the defendant’s risk pre-2004
His prison record shows that he was involved in, or was suspected of being
involved in, five fights or other incidents of violence. The defendant described two
other incidents, which do not appear on his record, during his interview with my
investigators. I shall look at each in chronological order.
In his interview, he described an incident when he was 14 and a group of Italian
children came to his school as part of an exchange. He said that he was playing
football with them when he had a fight with one of the boys. He said that the fight
was about “just football and he was speaking Italian and he spat at me”. As a
result of this, the defendant said, he was sent to what he described as a “special
school”. A pre-sentence report completed in 1999 suggests that he went to
Armley Park special school because of learning difficulties. A pre-sentence
report written by his probation officer says it was as a result of his increasingly
poor behaviour.
In 1995, the defendant was convicted of Assault Occasioning Actual Bodily Harm
(ABH). I have not been able to find details of this offence but it resulted in him
being fined and paying costs. In March 2004, in an interview with his probation
officer, he said that he had been acting in self-defence.
In 1999, he was convicted of wounding after hitting a fellow prisoner at HMYOI
Hatfield over the head with a mallet and sentenced to an additional 12 months.
The police liaison officer at Leeds, confirmed that the man had been hit about the
head and body with a wooden mallet and had sustained a gash three inches long
on his head. The pre-sentence report was based on the defendant’s version of
events at the time. It states that he and his younger brother were taken to
Hatfield following sentence for offences of burglary. The defendant’s brother told
him that he was being bullied by another prisoner and he asked him to point out
the perpetrator so that he could deal with him “in a similar bullying way”. On the
day of the offence all three prisoners were in the woodwork shop. The defendant
went up behind the man and struck him several blows to the back of the head.
During the interview with my investigators, he said he was in the workshop when
an argument started over which radio station prisoners were listening to. He said
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that another prisoner was “mouthing” and threatened his brother, so he hit him
with a mallet. The defendant said that he had never met the prisoner he hit
before. He denied he was a hot-headed person and said he would not start a
fight but he would protect himself.
He received a caution at an adjudication for fighting a prisoner in Doncaster
prison in February 2000. The record of hearing shows that he was charged with
fighting in the same month. The first hearing took place the next day. The
defendant pleaded guilty to the charge and was asked why he was fighting. The
record shows he said:
“I got a job in laundry he didn’t like it. I confronted him on Tuesday he said
let’s sort it. I went in his cell on Wednesday morning to sort it out, he was
sat on his bed making a roll up. He looked at me and went for me. I
grabbed his hand because he was holding a razor.”
The defendant said he realised he had grabbed the razor and pushed the other
prisoner off him. He said the Doncaster prisoner advised him to “sort yourself
out” so he left the cell and returned to his own cell. He said that the Doncaster
prisoner then came to his cell with another prisoner and hit him about the face
before running out.
The hearing was adjourned for evidence from two prisoner custody officers
(PCOs) and resumed on another day. The first PCO said, when he arrived at the
Doncaster prisoner’s cell, the prisoner was “cut on his arms” and said that he had
been “slashed” by the defendant. The second PCO said the defendant told him
that “the blade” belonged to the Doncaster prisoner. The deputy controller said
that he was satisfied that a fight had taken place but there was insufficient
evidence to say who had used the “blade”. He said that the defendant’s
presence in the other prisoner’s cell had caused the confrontation and he
therefore found him guilty and gave him a caution.
A Report of Injury to Inmate form (form F213) completed on 2 February showed
that the defendant had “small cuts” on his right thumb and middle finger and to
his left arm.
The other prisoner’s record of hearing shows that he was charged with fighting in
February. The Doncaster prisoner pleaded not guilty and indicated that he
wished to call witnesses. He was asked why he had pleased not guilty. He said:
“The previous night we had an argument. The next day I was on my bed.
The light was on, the defendant was over me with a blade, he said I have
a blade and I will use it. He swung at me and I tried to grab him. We
struggled I pushed him out of the cell. I saw my shirt was cut, my arm had
been cut and I was taken to the hospital. I had three sutures in the cut.”
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A witness called by the Doncaster prisoner, said that he saw the defendant come
out of the Doncaster prisoner’s cell and went over. He said the Doncaster
prisoner was in shock and there was blood on the floor. He said the Doncaster
prisoner was holding his arm and they both went to tell the officers what had
happened. The witness said he and the “wing rep” went to the defendant’s cell
and he told them “it’s nowt to do with you. I have sorted it out.” The witness said
he did not appear injured but was angry and they left. The second PCO said he
was in the servery when the incident happened and he was told by the “wing rep”
that the Doncaster prisoner had been “slashed”.
The Deputy Controller dismissed the charge against the Doncaster prisoner on
the grounds that there was insufficient evidence to show who had used the
“blade”. The completed F213 completed showed that he had a cut two inches
long to the back of his left upper arm and a small cut below his left eye. The cut
on his arm required three sutures.
At interview, the defendant described how he had become involved in another
fight at Moorland when he was 20 or 21. He was in Moorland between May 2000
and January 2001 but there is no record of this incident in his prison record. He
said that another prisoner threatened a friend of his and they started fighting.
The defendant said that he joined in and hit the other prisoner over the head with
a tin of rice pudding.
In November 2002, while on remand in Leeds, he said that he was sitting in his
cell with his cellmate when another prisoner came into the cell and tried to “tax”
(steal) one of his CDs. The defendant said that he “stood up” and the other
prisoner left the cell. Later, during the association period he said the prisoner
“wanted a fight”. He said that his memory was unclear but he thought his
cellmate got a pool ball and assaulted the other prisoner. The defendant said that
he too “whacked” him. A security summary dated reads:
“"DL5441 attempted to assault HB9925 with a pool ball in a sock. JN4165
stepped in to stop the assault. It is believed that DL4341 was also
involved (cellmate of DL5441)."
There is no other documentary evidence about this fight.
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(v) Defendant’s fight with his former cellmate in February 2004
In February 2004, while on remand on B wing in Leeds, the defendant had a fight
with his cellmate, and was removed to the segregation unit. The B wing SO
remembered that the defendant and his cellmate were both strip searched in the
segregation unit because there was information that a weapon might have been
used in the fight. No weapon was found. On his arrival in the segregation unit
staff realised that, earlier the same day, the defendant had assumed the identity
of his cellmate and attended an adjudication in his stead. He was charged with
pretending to be his cellmate and also with fighting. Both charges were proved at
hearings in February. There is little information on the charge sheet for either
charge. At the hearing for the charge of fighting, the reporting officer’s statement
simply said that he had seen the defendant and his cellmate fighting in their cell.
The defendant’s history sheet is similarly unforthcoming and simply records that
he was taken to the segregation unit after having been found “fighting” with his
cellmate. The record of events completed in the segregation unit states that the
defendant was taken there for “assaulting” his cellmate. When asked why he was
fighting, the record of hearing shows the defendant said that he and his cellmate
had “a disagreement”. On the charge of impersonating his cellmate at an
adjudication, he said he thought that the reporting officer had called his name out
instead. When it was pointed out that he had told the officer his cellmate’s name,
he said he was hard of hearing. His cellmate was approached by my
investigators and the police but declined to give an interview with either party.
In his interview, the defendant said that his cellmate had “started attacking me
with a knife”. He said he accused him of stealing his property and they started
fighting. He described it as “a little fight” and said his cellmate banged on the
door causing prison officers to come to the cell. They were both taken to the
segregation unit where the defendant said he “got the blame”. He said that the
knife was plastic and had snapped during the fight when his cellmate had gone
for his neck.
His cellmate was also charged with fighting and was due to appear at
adjudication in February. The hearing was opened and adjourned because his
cellmate was in court that morning. The charge was later dismissed when his
cellmate did not return from court.
The defendant remained in the segregation unit until he appeared at Wakefield
Magistrates Court in February and was bailed. While in the segregation unit,
staff became concerned about his "extremely strange” and “bizarre behaviour”
and opened a F2052SH form as a precaution. This is the form used to record
staff concerns that prisoners are at risk of harming themselves. The prisoner is
then watched more closely and the situation is reviewed regularly. The form
remained open until he was bailed.
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The B wing SO said that he remembered the defendant and his cellmate and
being brought to the segregation unit after their fight. He said he was involved in
“processing” the cellmate. The SO remembered that the cellmate was strip
searched because they had been told that there might have been a weapon
involved. He said no weapon was found on the cellmate. There is no record of
whether their cell was searched but this is standard procedure. In the event
neither prisoner returned to that cell. The SO said that later that afternoon staff
told him that they were concerned about the defendant’s behaviour. He
described him variously as “difficult to speak to”, “uncooperative”, “abusive” but
also “normal”. He said an F2052SH was opened as a precaution and the
defendant was placed in the cell with a camera in it so he could be observed
constantly. He was also subject to regular checks by staff. The B wing SO said
a decision was made to contact the Mental Health Inreach Team (MHIRT) but
could not remember doing it himself.
The wing officer remembers the defendant as “not normally active in the way he
was thinking and talking” and “very strange”. He thought he might have been
bullied but could not get “any sense out of him”. He said that he and another
Officer had spent about 10 minutes talking to him trying to find out why he had
taken his cellmate’s place at adjudication that morning but could not get a reason
from him. The wing officer said that the defendant looked stressed and:
“…the more you started to go on with him it was as if he was, I don’t know,
either on drugs or withdrawing from drugs or in the process of being off his
head on drugs to be honest. He just didn’t seem to know what were
happening, he’d say one thing and then retract it and say another thing,
you’d ask him if he were getting bullied, he’d say ‘yes’ and then say ‘no I’m
not’ instantly after.”
The wing officer thought that the MHIRT had been contacted about the
defendant that afternoon.
The second SO said she thought that the defendant had taken the place of his
cellmate at adjudication because his cellmate wanted to go to his domestic visit
instead of to the hearing. She described the defendant’s behaviour on the
segregation unit as “erratic”. She said he was constantly moving around the cell,
shouting and pressing his cell bell. She said at one point he tried to tie his
medication to a line and send it to B wing. The defendant was given a total of
four “strikes” - formal warnings from staff, which would affect his standing in the
Incentives and Earned Privileges Scheme (IEPS). The strikes were for misusing
his emergency cell light, shouting out of his cell and telling officers to “fuck off”.
The second SO said she thought that he was on a detoxification programme.
Nurse Hotel 3 said that she completed a segregation unit safety algorithm (the
form used to check that a prisoner is suitable for segregation) when the
defendant was originally brought to the segregation unit at 14.00. She said he
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was calm and settled when she completed the algorithm but later, when she
completed the healthcare assessment required as part of the F2052SH
procedures, he appeared to be agitated because he thought people were going
to “get him”. She thought he might have taken a drug of some description
because he was laughing and chuckling, then becoming paranoid and his eyes
were glazed. She said she thought his behaviour had settled by the end of the
evening of 20 February. She said this supported her belief that he had taken
something earlier in the day and that it was working its way out of his system.
The defendant’s F2052SH review record shows that the form was opened
because he was in “a distressed state” and displaying “bizarre behaviour”. The
form records that he was making “bizarre comments” and appeared unaware of
his situation. At 15.20, Nurse Hotel 3 noted that he was “extremely anxious and
behaving oddly”. He was unable to have a rational conversation and appeared
disoriented and confused. At 15.30, The B wing SO recorded that he was
concerned about the defendant’s “extremely strange” behaviour and that
healthcare staff were arranging for him to see the duty Medical Officer (MO). The
defendant was placed in the cell with a camera and the B Wing SO ordered five
checks to be made on him every hour. The duty MO saw the defendant at 16.50
and reported that there was “no indication for any self-harm”. He recommended
the defendant be returned to a residential unit. He said he was “not mentally ill or
depressed”.
The defendant was reviewed the next day, Saturday 21 February, at 11.45. The
B wing SO, the second SO, nurse Hotel 3 and a second wing officer attended the
review. The B wing SO noted that the defendant was not present because he
was being abusive and aggressive to staff. The record shows that he was still
behaving strangely and unpredictably and it was decided to keep him under
observation and to contact the MHIRT.
On Monday 23 February, the defendant was reviewed again by the B Wing SO,
the first SO, the deputy head of residence and the incident review nurse. An
improvement in his behaviour was noted but the review said he continued to
switch between being approachable and talkative to being agitated, aggressive
and talking nonsense. The review also noted that the defendant was due in court
the following day, which left little time for staff to work with him or for the MHIRT
to intervene. The review panel thought that the defendant needed specialist help
and scheduled a further review for Wednesday 25 February. On 24 February, he
attended court and was released on bail. The PER form accompanying him
indicated that he was considered to be at risk from self-harm. It did not indicate
that the defendant had recently been involved in a fight.
The clinical team manager for Leeds MHIRT, confirmed in a memo to my
investigators that they had no record that the defendant had ever been referred
to them. My investigators were unable to find a copy of the defendant’s IMR for
this period.
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On 4 April 2004, following the murder of the man, the segregation unit began
issuing a memo to wing managers when prisoners were returned to residential
wings following a finding of guilt at adjudication for violence. The memo
instructed wing managers to carry out immediate CSRAs on all such prisoners.
(vi) The incident at the hostel in March 2004
In 2004, the defendant appeared at Wakefield Magistrates Court on charges of
theft and possession of a sharply bladed instrument. The police case summary
describes this knife as a “lockable folding knife”. He was already on bail charged
with the burglary of a car dealership and was remanded to a hostel in Leeds.
The defendant’s personal file from the hostel shows that he was seen at Leeds
Addiction Unit in March. His care plan front sheet shows he had indicators for
violence and intravenous injection but not for self-harm. He was prescribed a
subutex detoxification programme consistent with a heroin addiction of between
£20 and £30 of heroin per day. He completed this in mid March. He was urine
tested during his detoxification and returned negative samples. His hostel risk
screen showed he was considered a low risk to staff and others and at no risk of
harming himself.
The defendant’s keyworker at the hostel, also completed an Offender
Assessment System (OASys) report while he was at the hostel. She decided
that he presented a medium risk to the public because he was a schedule 1
offender and had a “previous history of violence”. She decided he would present
a low risk to other prisoners if he were in custody. She noted there was no
evidence that he was suffering from any mental illness or that his offending
history showed any evidence of racial motivation or hatred of other identifiable
groups.
His keyworker told my investigator that, in March 2004, she was a trainee
probation officer on a placement at the hostel. She said that OASys reports were
designed to consider an offender’s lifestyle with the object of producing a risk
assessment. At the hostel their primary use was as a tool to provide a risk
management plan for the person’s time in the hostel. She said that, as a trainee,
all her reports were double checked by her supervisor. She said that three main
risk factors were identified in his case. The most significant risk factor was his
misuse of drugs. Secondly, the report highlighted that he required activities to
prevent him from being bored. Thirdly, it was recognised that he was a schedule
1 offender. The keyworker said she spoke to a probation officer in Wakefield and
was told that his schedule 1 status was as a result of violence towards another
prisoner in 1999. She said that the fact that this offence had occurred 5 years
previously meant that it was seen as less significant than his drug use. She said
that staff were made aware of the defendant’s previous violence so that they
could monitor him.
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His keyworker said that she had two meetings with him at the hostel about a
week apart. On the first occasion she said he was positive, admitted his
shoplifting charges and was willing to undergo detoxification. On the second
occasion he denied his charges and appeared uninterested. She said that she
next saw him when he was discovered with a knife. She thought the knife was a
dinner knife that had been sharpened. She said she did not review his OASys
report as a result of this incident because that would have been a matter for his
probation officer, when she completed his pre-sentence report.
At 9.30 on a day in March 2004, a residential officer at the hostel said he went
into the TV room and saw the defendant with what looked like a knife in his
trouser pocket. He asked him to go to the office with him and on their way there
he noticed the defendant trying to conceal something in his left hand. In the
presence of his keyworker, the residential officer asked the defendant to empty
his pockets and take his jacket off. He did this but no knife was found. The
keyworker said that, when the residential officer questioned the defendant about
the knife, he denied that he had one and became abusive. The residential officer
then called the police so that a proper search could take place and told the
defendant to pack his bags as he was withdrawing his bed. The police arrived
and searched him. They found a knife concealed down his trousers. The
residential officer said he recognised the knife as similar to the dining knives at
the hostel but said that this one had been deliberately sharpened to a point.
The defendant said in his interview that he took the knife because:
“There was a black lad in the hostel and someone had said something that
he’d broken one of the doors off and he was, you know, robbing the rooms
and stuff like that. Thought I’d put a knife in my room, it was only a butter
knife as well…”
He said that it might have simply been a rumour that the other resident was
stealing from people’s rooms but “you can’t tell can you?” He said:
“Nobody tell you do they? Nobody tells you anything what’s happening.
So you’ve just got to sort it out yourself.”
The defendant was taken to Leeds prison and appeared before Wakefield
Magistrates in late March. He was remanded back into custody in HMP Leeds.
(vii) The defendant’s pre-sentence report and the Security Information
Report of 1 April 2004
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On 31 March, his probation office, interviewed him in Leeds prison for the
purposes of a pre-sentence report relating to the charge of burglary on a car
dealership. In compiling her report she also had access to papers from the
Crown Prosecution Service, a list of previous convictions and sight of Probation
Service records relating to supervision between May 1999 and June 2003. She
also spoke to staff at the hostel and to the defendant’s previous supervising
officer.
In her report, the probation officer said that he told her that, when he committed
the offence, he was carrying a knife for his own protection. She said he was
unable to tell her where or from whom he perceived there to be a threat. She
judged that he presented a medium risk to the public given his two previous
convictions for violence and the fact that he had been in possession of offensive
weapons on two occasions in the previous month. She added:
“His view of violence and carrying weapons is that he is protecting himself.
In my opinion, those most at risk are likely to be other offenders whom the
defendant perceives to be provoking or threatening him. This risk is raised
when proximity is enforced such as in a prison or hostel environment.”
Following the interview, she updated his OASys report on 31 March.. She noted
that his recent tendency to carry a knife was a concern, particularly as he could
not say whether anyone had threatened him. She said that he told her he had
argued with another resident at the hostel and this was why he had taken the
knife for protection. She said that the defendant would not say much about his
previous offences of violence beyond the fact that he saw it as a response to
provocation and self-defence. She said he spent the interview with his hand over
his mouth, did not answer some questions and would not engage. (This is
entirely consistent with the experience of my investigation team when they
interviewed the defendant in HMP Wakefield on 6 April 2004.) In section R8 of
the Risk of Harm screening, the probation officer indicated that the defendant
could be a serious risk to others. She noted:
“Assault with a weapon if feeling provoked. Could be that he either feels
vulnerable when in criminal justice institutions and perhaps reacts out of
proportion or perhaps is trying to set up a reputation. Or it could be that
he is trying to protect himself albeit inappropriately. But he is not willing to
talk about it and this is unclear.”
In section R11.12 Risk Management Plan, the probation officer wrote:
“liaise with prison re risks and inform of concerns re assault on prison
inmate and possession of knife for protection at hostel. Suggest regular
checks to ensure he has not obtained a weapon.”
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The West Yorkshire probation area contact sheet shows that his probation officer
telephoned Leeds prison on 31 March. She spoke to the discipline office and
was told to contact the security department. The contact sheet shows that she
could not get a reply from either the security office or the probation department at
Leeds. On 1 April, she again phoned the prison and spoke to the SO in the
security department. She informed him of his schedule 1 status and told him that
he had previously wounded a fellow prisoner. She also raised her concerns
following the defendant’s behaviour at the hostel and his reason for carrying a
knife.
His probation officer told my investigator that she became aware that the
defendant was a schedule 1 offender when she returned from her interview with
him to complete the OASys report. She said she knew that he had been
convicted of assaulting another prisoner in 2000. She was concerned by this and
decided to phone Leeds prison to pass on the information. She said she tried on
several occasions on 31 March but could get no reply from the extensions given
for the probation and prisoner administration departments. She tried again on 1
April and was advised by the switchboard to speak to the security department.
She said she spoke to the SO in the security department sometime in the mid-
morning of 1 April. She said that she regarded the defendant as a medium risk to
staff and prisoners. Her expectation in passing on the information was that
prison staff be aware of it, monitor his moods and take whatever action they
thought appropriate. The probation officer said that she did not believe that the
defendant was an imminent threat to staff or prisoners and, had she done so, she
said she would have assessed him as high risk.
SIR number 649/04 showed that the security SO received a telephone call from
the probation officer at 11.30 on 1 April. She told him that the defendant was a
schedule 1 offender, because he had wounded another prisoner on a previous
sentence in a YOI. She did not know which YOI he was in but gave the
conviction date in April 2000. She also told him that he had lost his place at his
bail hostel on the previous Friday because he had concealed a knife from the
kitchen following an argument with another resident. The security SO completed
sections 1–3 of the SIR and passed it to the security office at 11.40. A security
administrator, completed sections 4-7 of the SIR at 10.30 on 2 April. She
completed the evaluation section to indicate that the source was ‘known to be a
true source’ but was ‘untried’, rather than ‘very reliable’, ‘reliable’ or ‘unreliable’.
The ‘consequence code’ section is left blank. The security administrator
indicated that she had looked on the defendant up on LIDS to search for related
intelligence but had found none. Section 8, for the security manager’s comment,
is blank.
The security SO said he received a telephone call from the probation officer on 1
April. He said she told him that the defendant had lost his place at a bail hostel
for concealing a knife after an argument with another resident and also that he
had a previous conviction for wounding. He said he completed a Security
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Information Report (SIR) and passed it to the administrative staff for processing.
As he was the person who opened the form he would not see it again. He said
that the information provided by the probation officer did not cause him sufficient
concern to take it immediately to his security manager. He said that there would
need to be supporting intelligence to warrant this and the information would need
to indicate a high level of risk with immediate consequences (consequence code
‘HH’). In his opinion, the information from the probation officer did not fall into
this category, which meant that the target for processing it would be 72 hours.
The security administrator said that she remembered the security SO completing
a SIR on the defendant on 1 April after receiving information via a telephone call
the probation officer. The security administrator said that in April 2004 Leeds
security department were processing about 50 SIRs per week. There were two
staff, herself and another administrator, employed to provide the intelligence
officer’s assessment for each one. She said that she examined sections 1 and 2
of the SIR and noticed that there was no verification of the probation officer’s
identity. She noted that the Senior Security Officer had written in section 2 that
the defendant had been convicted of “wounding another inmate (conviction date
14/4/2000)”. She said she logged onto LIDS to confirm current information about
him and also accessed IIS (the Inmate Information System) to check for
background information from his previous sentences. She said she identified two
YOIs that the defendant had been allocated to in 2000 and rang the security
departments in both. She remembered that Doncaster was one of them but
could not remember the other. Neither YOI had any record of the defendant
being involved in a violent incident. The security administrator was told during
her interview that the incident the probation officer was referring to actually
occurred in 1999, although he was convicted of the offence in April 2000. She
said that, had she discovered that the defendant had previously been involved in
an incident of violence towards another prisoner, she would have sought advice
from her manager as to whether a ‘H/H’ marking was appropriate. She said she
would also have alerted the relevant wing manager to her concerns. However,
as at the time she could find no evidence to corroborate the probation officer’s
information she completed sections 4-7 and passed the form to the SO’s in-tray
at 10.30 on 2 April.
The duty governor said he helped the head of the central business unit collate
information about the man and the defendant on 2 April in the aftermath of the
murder. He said he recognised the defendant’s name from a partly processed
SIR and went to find the relevant document in the security department. He said
he phoned the probation officer to confirm some of the details and finished
processing the SIR. The duty governor said that the information provided by the
probation officer was not sufficient to place the SIR in the highest risk category
(‘HH’). He said that the information was “sketchy” and required further
investigation. He said that it was not unknown for prisoners to have previous
convictions for violence. He said that a normal course of action on receipt of this
sort of information would be to recommend a review of the prisoner’s CSRA.
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(viii) What other prisoners said about the defendant
The defendant’s former cellmate was visited by the police after the murder. He
agreed to give only a verbal account to the Detective Constable Police Liaison
Officer. The former cellmate said that,during the time he shared a cell with the
defendant in February 2004, the defendant talked to himself regularly. He said
that the defendant appeared to talk to someone through a crack in the door even
though there was no-one there. He said that one day he was sitting down writing
a letter when the defendant jumped off the bunk bed and attacked him with a
homemade knife. The defendant attacked his cellmate from behind and stuck
the knife into his left cheek. The cellmate said he fought back and was able to
raise the alarm by kicking the cell door.
The first inmate said he knew of the defendant through mutual friends. He
described him as “quiet” and a “loner” who wouldn’t tolerate anyone “taking the
piss” but would “sort it out”. He said he did not think the defendant was a bully or
would “go out looking for trouble” but he wouldn’t want to be in a cell with anyone
who was “in his face”. He did not think the defendant was violent although he
had heard rumours that he had threatened his cellmate on B wing with a plastic
knife.
The second inmate shared a cell with the defendant on the night of 25 March
2004. At interview he said that the defendant appeared “blank” and did not listen
or reply appropriately to anything he said to him. He said that the defendant
appeared a little bit paranoid and kept going to the cell door as if someone were
coming. The second inmate said he thought that the defendant had mental
health problems. He said he thought he was “slow” and would be a target for
bullies. He said he felt “a bit uneasy” with him but not in danger.
The defendant then shared a cell with another prisoner.He described this man as
“an Asian kid” and said he was “alright for an Asian kid”. Prison records show
that the defendant shared a cell with a third Inmate from 26-31 March. The third
Inmate was a fine defaulter and his ethnic code is recorded as white. He was
released from Leeds on 31 March 2004. The police interviewed him on 14 April
2004. The third inmate said he found the defendant “strange”. He said the
defendant smoked cannabis and made funny noises, sometimes laughing for no
reason. My investigator spoke to the third inmate at his home address in June
2005 . He said he could not remember what wing he was located on. He could
remember a couple of the people he shared a cell with but did not remember the
defendant’s name. He did not recognise the defendant from a detailed
description.
The fourth inmate shared a cell with the defendant between 31 March and 2
April. At interview with my investigators on 7 April, he said that the defendant
seemed confused, talked to an imaginary friend and pointed at the cell door. He
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said that the defendant told his imaginary friend that he had “slashed his last pad
mate’s throat”. The fourth inmate said the defendant stared at him “like he was
stoned” and had “no emotion in his eyes at all”. In the exercise yard, the
defendant did not speak to anyone but rocked on his heels. The fourth inmate
said that he thought the defendant had been “close to flipping” and would have
“flipped if someone had been on his case”. When he moved to B wing on the
morning of 2 April, The fourth inmate said he told two members of staff in passing
that the defendant “wanted watching” (although he said he did not mention him
by name). He added that he was more concerned that the defendant would harm
himself.
In his statement to West Yorkshire police of 27 April, the fourth inmate said he
found the defendant’s behaviour unnerving because he always seemed to be
standing behind him or to the side. He said that whenever he turned around the
defendant was staring at him. He said his behaviour became worse on the
second day he shared a cell with him. The defendant spent more time walking
around the cell and staring at him. He said that the defendant started talking at
the cell door. He said the defendant had told him that he could tame wild bears
and that he had “stabbed or slashed a padmate in the past”. The fourth inmate
said that friends of his who saw the defendant behaving oddly on the exercise
yard told him, “he will do you in that one”. He was so disturbed by the defendant
that he made him sleep on the top bunk and turned his bedding around so that
he could see across the cell. The fourth inmate said that he thought the
defendant was mentally ill and that he might harm himself or someone else.
He said that the defendant had been in his sight except for a single 10 or 15
minute period during association on 1 April and for a period of about 40 minutes
on the morning of 2 April. He said he left the cell to sort out an education course
and when he returned the defendant was sitting on his bunk with his belongings
packed. He said that the defendant had been allocated to A wing but he could
not tell whether the defendant was happy about this because his face was
expressionless. When the defendant left, the fourth inmate noticed he had left a
razor in the sink. He said he had given two razors to the defendant and he
thought he had only left one behind. He said he also noticed that the defendant
had swapped his plastic knives. He said his had been clean and the defendant
had left him with two that had been burnt at the ends so the plastic melted. The
fourth inmate confirmed that the defendant had not collected any prescribed
medicine on the days he shared a cell with him, nor had he smoked drugs. He
said that he was so concerned about the defendant that, when he moved to B
wing that morning, he told two officers on D2 landing, “you want to watch my last
padmate, he’ll either harm somebody or himself”.
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PART 2: Conclusions, Consideration and Recommendations
Section one: The murder of a man and the prison’s response
(i)The discovery of the man and the attempt to save his life
The evidence shows that the man’s screams were heard first in the segregation
unit some two floors below his cell, where the alarm was immediately raised. My
investigation team discussed the possibility of conducting acoustic tests on A
wing with the police. The chances of replicating noise levels with any degree of
certainty and accuracy was deemed to be virtually impossible so tests were not
undertaken. (My team was also concerned should ‘mock’ screams be heard by
staff and prisoners present at the original incident.) Statements taken from the
inmates in the cell next door show they heard nothing. The first inmate said he
had his music on loud because he was working out. The Muslim chaplain was in
the chaplaincy room, which is located on the centre and abuts cell A3/02, for a
significant part of the morning of 2 April. He did not hear any screams. The
accompanying SO commented that noise seems to echo down to the segregation
unit. He said that staff on this unit often call up to wing staff after having heard
noise on the wings. The first wing cleaner was in his cell on A3 and did not hear
anything. Lunch was being served to the prisoners and there was considerable
noise on the wing.
Despite the short delay in getting to the man’s cell caused by staff being alerted
from the landings below, the response was swift. Nursing staff arrived within a
few minutes. The HCO, who relieved the movements officer Alpha 7, is a
qualified EMT. The ambulance staff arrived on the wing within 25 minutes of
being called. Efforts were made in advance to ensure that the ambulance had
the quickest possible journey out of the prison. This was good practice.
I commend all the staff for the attempts that were made to save the man’s life. I
particularly commend the movements officer Alpha 7 who happened upon a
horrifying scene and proved by all accounts to be immensely professional and
capable. I note especially the praise he received from the qualified nurses who
attended.
When questioned, staff said they were happy with the medical equipment they
had apart from the suction pump, which was old and not very easy to use.
Tragically, the man’s injuries were so grave that only a surgeon with supplies of
replacement blood would have had any hope of saving him. I do not believe that
staff could have done anything more to save his life.
Nevertheless a more detailed examination of the attempt to save the man’s life
can be found in the Clinical Review. The doctor that wrote the Clinical Review
highlights important areas in which improvement in practice could be made
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although he accepts that, even had these been made at the time, a different
outcome was unlikely. I endorse the doctor’s recommendations and have added
them to my own. (The doctor’s recommendations are the final four in the list
below.)
If he has not already done so, I recommend that the Governor of
Leeds considers if individual members of staff, particularly the
movements officer Alpha 7, should be acknowledged through the
Prison Service’s Performance Recognition Scheme.
I recommend that Leeds purchase updated suction pumps, which are
easier for staff to operate.
I recommend that staff in prisons use a recognised code when
calling for ambulances so that paramedics are aware of the nature of
the incident they are attending and the right sort of ambulance staff
is dispatched.
The quality of note keeping in the Inmate Medical Records at Leeds
needs to be substantially improved.
A policy should be developed for the management of serious clinical
events.
All healthcare staff should regularly practise basic life support
including airway management.
Medical officers should be trained in Advanced Trauma Life Support.
(ii) The prison’s immediate response to the murder
Members of the senior management team began gathering in the Governor’s
office on the Centre at about 12.50. The duty governor, said that he waited until
the man had been taken from A wing by ambulance staff and then, after a short
conversation with the PO Oscar 1, went to the Governor’s office. We know from
the control room log that the man left the prison at 12.40. We can reasonably
expect that the duty governor entered the Governor’s office at about 12.45 or
12.50. The head of residence and the head of the central business unit , the
other managers who accepted responsibility for decision making during the
aftermath of the man’s death, were either already there or joined him there
shortly afterwards. The Duty governor and the head of the central business unit .
They both agree that they began working through the death in custody
contingency plan and gathering information on both the man and the defendant
The duty governor and the head of the central business unit agree that the head
of the central business unit took responsibility for completing the action checklist
from the death in custody contingency plan. It is generally agreed that the plan
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was activated before the prison received confirmation at 13.05 that the man had
died.
There is some evidence to show that around this time the head of residence, the
Governor and the duty governor began to gather staff together for a hot debrief.
The Muslim Chaplain said that he head of residence came to the chaplaincy
office and told him about the incident and that he was taken to the hot debrief in
the multi-faith room. He remembers that the head of residence told him at 12.30
but this is clearly too early as the head of residence did not enter the Governor’s
office until after Theduty governor at 12.45. The HCSO said that he helped take
the man to the ambulance at 12.40 and then collected the nursing staff and
returned to the treatment room. There they washed their hands and then moved
to the healthcare centre clinical room where they had a quick debrief of their own.
He said that the duty governor came to the room and told them that there was to
be a hot debrief. They went to the multi-faith room and were the first staff to
arrive. The HCO confirmed that the nursing staff had time to write their
statements as well as have a quick debrief in the clinical room. The A wing log
kept by the incident log officer shows that the duty governor was on the wing
between 13.05 and 13.07. The action check list records that the new race
relations liaison officer informed the Area Manager of the man’s death at 13.15.
(The Area Manager was actually in the prison at the time on his first visit since
taking up the post. The Deputy Governor was escorting him.)
The PO Oscar 1 said that the head of residence led the hot debrief which lasted
about 20 minutes. The record of attendance shows that the head of the central
business unit, the duty governor and the new race relations liaison officer were
also there from senior management. The PO Oscar 1 said that, following the hot
debrief, the head of residence went to A wing to give a hot debrief to the staff
who were being kept separate for forensic purposes. The movements officer
Alpha 7 confirmed that the head of residence, the deputy head of residence and
the new race relations liaison officer came to see him in A wing office for this
purpose. The A wing log shows that head of residence and the deputy head of
residence were on the wing between 13.47 and 14.02, and that the new race
relations liaison officer was on the wing between 13.52 and 14.02. The log also
shows that the muslim chaplain was on the wing between 13.52 and 14.03.
The hot debrief must therefore have taken place at some point between 13.15
and 13.47. The head of the central business unit confirmed that his first
contemporaneous entry on the action checklist was timed at 13.50, which is
consistent with this timing. The head of residence remembered the debrief
occurring at about 14.00 but clearly he was on A wing at that time. Given the
short distance from A wing office to the Centre, he probably returned to the
Governor’s office at about 14.04 and the muslim chaplain followed him at about
14.05. It is apparent that the chaplain was at this time asked to contact the
man’s next of kin. The action checklist records that the chaplain was appointed
at 14.00. He remembers that the head of the central business unit retrieved the
family contact details from the man’s record on LIDS. He recalls making “at
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least” three phonecalls in quick succession at around 14.15. As these were
unsuccessful, it was decided that the chaplain and the head of regimes learning
and skills would drive to the contact address and await the family. They left at
about 14.30.
It appears that, during the attempt to save the man’s life and in the aftermath of
his death, no single manager assumed overall responsibility for taking control of
the ‘incident’. On 2 April, a governor was designated duty governor and a
principal officer was designated orderly officer, Oscar 1. It is common practice
that during an ‘incident’ the duty governor assumes initial command of the
situation, usually from the control room or other communications centre. The
orderly officer is required to attend the scene and direct procedures from there.
In this case both the duty governor and the PO Oscar 1 and attended the scene
on A wing. The Deputy Governor said that he co-ordinated the response to the
murder from the Governor’s office. The interviews with the duty governor, the
deputy head of residence and the head of residence do not specifically refer to
his role.
When serious incidents occur, there is always confusion, uncertainty and shock.
Following the murder of the man I am not clear that there was sufficient overall
management of events. I am especially concerned by the length of time before
anyone tried to contact the man’s family. The prison was told at 13.05 that the
man had died but the chaplain was not appointed to contact the family until at
least an hour later. This is unacceptable. Given the serious nature of the man’s
injuries, I think that a member of the senior management team should have taken
responsibility for trying to contact the next of kin immediately the man was
discovered with such serious injuries.
I am pleased that staff decided to travel to the family home in an effort to make
sure they were the first to break the news. Given the length of the journey it
would also have been prudent for someone to have continued to try to contact
the family by telephone. I note as I have in other investigations that a problem
surfaced because there was only a single next of kin on the man’s record.
Unfortunately, when only a single name is given, this can cause delay when they
cannot be contacted.
When I met members of the man’s family on 29 April 2005, they expressed
concern that contacting the family appeared at number 22 on the action checklist.
I accept that this list is not intended to reflect a hierarchy with the most important
contact at number one. I also accept that, in practice, there are usually several
staff tasked simultaneously with contacting the names on the list. Nevertheless I
believe that contacting the family should be given the highest priority. This is not
least because such news often makes its way out of the prison by other means
and can result in families finding out about the death of their loved ones via the
media or the local grapevine (as it did in this case). I note also that the Death in
Custody contingency plans in operation at Leeds at the time place the next of kin
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third on the list of persons to contact. Clearly these contingency plans were not
followed on 2 April.
I recommend that the Governor amends Leeds’s death in custody
action plan to emphasise that the next of kin should be contacted as
a matter of urgency.
I recommend that the Prison Service gives consideration to
extending the next of kin provision on LIDS to include contact details
of other significant persons.
I recommend that family contact details should be reviewed on a
regular basis, and that prisoners should be reminded to keep them
up to date.
(iii) The care offered to staff and prisoners
I am pleased to see that the other prisoners on A wing and in the rest of the
prison were told quickly about the death of the man and that staff visited those
prisoners who should have had visits personally to explain what was happening.
Muslim prisoners also received a personal visit to explain why prayers were
cancelled. I am also pleased that the required attention was paid to prisoners
subject to, or recently removed from, F2052SH (self-harm) procedures.
Prisoners were more generally advised to ask any member of staff if they wished
to contact their personal officer or a Samaritan Trained Listener. I note from the
first wing cleaner’s experience that the Muslim chaplain and the Rev chaplain,,
were also active in offering help to prisoners upset by the man’s death. It seems
that efforts were made to return the wing to normality as soon as possible.
All of the staff interviewed told my investigators that members of the Care Team
contacted them on at least one occasion after the man’s death. Most people said
they were happy with the level of support offered, indeed some commented that
they would have been happy with less. Nurse Hotel 3 and nurse Hotel 4 were
happy with the support offered by their line management. I note, however, that
the movements officer Alpha 7 and the first officer were unhappy that no senior
manager spoke to them about their experiences. The movements officer was
interviewed by the investigation team on 15 April 2004. He said that, since he
had returned to duty, no staff above the rank of Senior Officer had spoken to him
about the death of the inmate. He described the thank you letter he received
from the Deputy Governor as a “standard” letter.
I have not inquired in depth into what the movements officer and the first officer
have said. I simply draw their comments to the attention of Leeds’s senior
management.
Section 2: Risk Assessment
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(i) Cell sharing risk assessment in the Prison Service
I had cause to examine the process of cell sharing risk assessment (CSRA)
during my investigation into the murder of another prisoner at HMP Manchester
in 2003. The death of that prisoner served to highlight weaknesses in how risk
assessment is carried out in the Prison Service. I said then that reviewing risk
assessment was a matter of urgency. In particular, the flow of information into
prisons from agencies such as the Crown Prosecution Service and the National
Probation Service needed to be improved. I also said that, given the size of the
prison population, a large degree of cell sharing (and, necessarily, some risk of
prisoner-on-prisoner violence) was unavoidable. I accepted that, even if the
Prison Service were to come up with a system that was robust and workable,
given the extent of compulsory cell-sharing, and the make-up of the prison
population with its growing proportion of violent offenders, some risk would
remain. Much that I said then is unfortunately still true today.
Risk assessment and the management of risk are not exact sciences but in order
for them to work successfully the nature of the risk must first be identified. The
identification of risk is a major difficulty faced by the Prison Service. Once risk is
identified the Prison Service appears to have developed some strategies to
monitor it. At Leeds my investigators saw good use of a ‘high risk log’ used
regularly to bring high risk prisoners to the attention of group managers. This is
direct evidence that the risk minimisation plan brought in by the review of 2003
has had an effect. The problem remains how to get information into the prison so
that staff are able to identify risk. Until the problem of ensuring the flow of
information into prisons is overcome the system will remain fundamentally
flawed.
Research from RDS (Research Development and Statistics department of the
Home Office) into the CSRA forms, under the direction of a working group
including policy, research and operational staff, prepared for the Prison Service
review in November 2003 showed that the information gleaned from the prisoner
interview was only 45% accurate. The graded risk ratings were inconsistent and
there was rarely any commentary to explain the nature of the risk identified. The
report also showed that in only two fifths of cases (43%) where prisoners had
relevant previous convictions did the CSRA form identify them. Interviews with
staff conducted by RDS suggested that the amount of time and information
available to officers in reception made the quality of the information on the form
questionable. Staff were concerned about relying on information received from
prisoners to complete most of the form.
As indicated by this research, staff are reliant on prisoners for most of the
information gathered during the CSRA. In a local prison such as Leeds it is
comparatively rare for a prisoner to turn up in reception with a pre-sentence
report, OASys report or risk assessment information from a previous
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establishment. The most common documents available to staff are the PER form
and the warrant, which typically hold too little information to form a valid judgment
on risk. For example, the PER for the defendant’s most recent recall to Leeds
before he murdered the man (after he was found with a sharpened knife in the
hostel) has no information on it about the reasons for his breach of bail.
The CSRA review of 2003 recognised that arrangements needed to be made to
get pre-conviction data to reception/induction staff on the first night. The review
suggested that greater numbers of prison staff be allowed access to the Police
National Computer (PNC) to obtain previous conviction data during the CSRA
process. While this is a good idea it may be easier in the short term for staff
involved in the CSRA process to be able to access LIDS and IIS. It was also
hoped that OASys would provide more regular, more joined up information from
the Probation Service to prisons. I am aware that OASys’s ‘connectivity’ does
not come on line until October 2005 but there is little evidence that prison staff in
busy local prisons like Leeds are able to access to this data or use it as part of
CSRA. I am told by the National Offender Management Service (NOMS) Safer
Custody Group that from 2006 all prisons will have access to the police’s Violent
Offender and Sex Offender Register database (VISOR). It is recognised that
reception staff will need to access this.
Given the pressure on reception staff caused by the numbers of prisoners
arriving each day, and the absence of much documentation relating to them, it
may be that the Custody Care Plans used in Leeds (which are done in a
prisoner’s first few days in prison) can be tailored to supplement the CSRA
process. I have seen an example in another of my investigations where wing
staff are responsible for completing risk assessments. I can see a lot of merit in
a system where the staff who make the assessment then have a greater
involvement with the prisoner, and can observe him or her on a day to day basis.
Wing staff could also be required at a very early stage to read a prisoner’s file
including pre or post sentence reports and OASys reports.
As I noted in Part 1 Section 3(i) of this report, a new PSI (PSI 32/05) on risk
assessment has now been published with new review forms and a risk
management template. The subject of cell sharing risk assessment will be kept
under review until the outcome of the Zahid Mubarek Inquiry. I am disappointed
that this new PSI was not published until 22 months after the death of the
prisoner that died at HMP Manchester and some 15 months after the death of
this man in HMP Leeds. I welcome the direction in paragraph eight that the PER,
warrant, probation reports, OASys and previous convictions must be consulted, if
available, when the CSRA is being completed. I am pleased that paragraph 26
provides for reviews of a prisoner’s risk assessment after a significant event and
states that the OASys document must be consulted during this review. I also
welcome paragraph ten which states:
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“10 – A prisoner with a history of violence in custody (situational violence)
presents a heightened risk… In compiling any subsequent risk
minimisation plan and/or reviewing the risk assessment, a prisoner who
has exhibited over-reactive behaviour in response to perceived threats or
who is known to have armed themselves with a weapon whilst in custody,
should be managed with extreme care.”
However, I am aware from many of my investigations how rare it is for staff to
have the information listed in paragraph eight available on reception or for them
to have the time to read it. I also believe that a more sophisticated approach to
understanding the nature of violence and risk is needed within the Prison Service
generally. The defendant did not present as a violent offender but he was violent
in prison. The information which identified him as a risk to his peers was there in
the documentation but was not seen. The current system relies too heavily on
staff identifying a prisoner as violent by the nature of their offence. This is not
necessarily an indicator of violence in prison. People who have committed the
most terrible crimes can be model prisoners and petty thieves can become
murderers in prison.
Staff given the task of making cell sharing risk assessments need time to gather
and digest the documents listed in PSI 32/05. They need to know what
information they are looking for. The Prison Service should re-evaluate the staff
time devoted to risk assessment and provide additional training to those staff who
are expected to carry out the process. I invite the Prison Service to consider
these proposals during its consideration of any proposals emerging from the
Zahid Mubarek Inquiry.
(ii) CSRA in Leeds
The number of new prisoners received each month at Leeds runs into many
hundreds. At the time of the man’s death, the average stay was eight weeks.
The sheer numbers and the transient nature of the population mitigate against
the effective operation of CSRA.
In her interview the reception officer described the process from the point of view
of the officer in reception. She said that she read out the questions on form
XF001 “parrot fashion” for the prisoner to reply to. I am left with the impression of
busy officers with several prisoners to process and a set of questions that has
become routine.
As in the Manchester investigation, there was no use of the form XF002 and
seemingly no awareness amongst staff that prisoners are required to have their
CSRA reassessed when moving cells. In this investigation the evidence
suggests that prisoners have their CSRAs checked visually by movements
officers on both the sending and receiving wings but there is no auditable trail to
show that this occurs. Leeds’s Governor’s Order 8/2002 on CSRA does not say
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that CSRAs should be reviewed during cell moves. Moves appear to be
arranged on a relatively ad hoc basis. The man and the other prisoner that
moved from D wing to A both asked on the morning of 2 April if there was a
chance of moving wings and both moved immediately because there happened
to be spaces on A wing. This informal approach necessarily reflects the
hundreds of cell moves that occur during a week in a busy local prison like
Leeds. It reinforces the need for a CSRA process that can be workable in such
an environment.
The defendant’s CSRA of September 2002 was incomplete. I accept that the
completion of CSRAs has since improved and the Governor should be vigilant
that this is maintained. Similarly, when faced with a prisoner with a conviction or
previous conviction for a violent offence, staff should be required to make the
nature of this conviction clear. If the box is simply ticked, anyone looking at the
form later will be none the wiser as to the specific nature of the prisoner’s risk. I
note that this is now a requirement of PSI 32/05.
Governor’s Order 8/02 provided that prisoners should have their CSRA reviewed
after significant events, for example an assault on another prisoner. Accordingly,
before the man was murdered, procedures were in place at Leeds to ensure that
prisoners found guilty at adjudication for assault had their CSRA automatically
reviewed. Shortly after the man’s death this was widened to include findings of
guilt for fighting. Given that a fight is in fact a mutual assault, I am surprised that
it was not previously deemed to have been an event of enough significance to
warrant a CSRA review, particularly if a weapon were to be involved. Had it been
deemed so earlier in 2004, it might have brought the defendant’s propensity for
fighting with his peers to the attention of staff. Nevertheless, I welcome this
change. These procedures should of course be subject to regular management
checks.
I also welcome the news that staff are working on a protocol that will ensure the
use of available documentation when completing CSRA reviews, rather than
simply relying on the prisoner's input.
I recommend that a new Governor’s Order is issued on the operation
of CSRA in Leeds. Staff and managers should be made aware of
their responsibility to keep CSRA an ongoing process throughout
every prisoner’s time in the prison.
I recommend the Governor satisfy himself that he has in place
appropriately robust management checks that CSRA forms are
completed in full at all times.
I recommend that the protocol being worked on at Leeds which
ensures the use of available documentation when completing CSRA
reviews is brought into operation as a matter of the highest priority.
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Below is a list of examples of reasons why nine current prisoners are rated high
risk at Leeds:
1. A member of combat 18
2. Is displaying “bizarre behaviour”
3. Is awaiting outcome of psychiatric assessment
4. Is a prolific self harmer
5. Has superbug M.R.S.A
6. Has thoughts of killing pad mate, and also of killing his counsellor
7. Took his cellmate hostage
8. Two incidents of taking his cellmate hostage
9. Involved in a barricade incident
With the obvious exception of the MRSA superbug these are all behaviours that
would probably not be picked up on first reception in the current system of risk
assessment.
(iii) The risk assessment of the defendant
The records show that the defendant had been involved in eight violent incidents
before April 2004. Of these eight incidents four involved violence towards other
prisoners. Of these prisoners, one was known to be black. On four occasions
both inside and outside of prison, the defendant was known to be or accused of
carrying a knife. He was risk assessed five times by the Prison Service between
September 2002 and April 2004. In March 2004, he was also the subject of two
OASys reports compiled by staff from the Probation Service. Some of these
reviews noted that he had a previous conviction for assaulting another prisoner in
a YOI in 1999. Only one, the OASys report written by his probation officer,
concluded that his pattern of behaviour indicated that he posed a threat to his
fellow prisoners. I believe that this serves to highlight two issues: the focus of the
Prison Service on violence per se as a risk factor and the necessity of getting
information from other agencies into the prison risk assessment process.
The CSRA user guide written by the Prison Service states that, “the most reliable
predictor of future violence is a history of past violence”. It follows that the most
reliable predictor of situational violence is a history of past situational violence. I
reiterate my belief that the Prison Service must look closely at how it views
violence as a risk factor. A common opinion expressed by staff during this
investigation is that the defendant did not stand out as a violent prisoner. There
are countless prisoners in the system who have committed extremely violent
offences and on the face of it would have appeared to be far more of a danger
than the defendant appeared to be before he murdered his cellmate. Therein lies
the problem of confusing the violence used when committing an offence and the
violence demonstrated when placed in a custodial setting. The Prison Service
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risk assessment process is simply not set up to recognise such a pattern of
situational violence.
Analysis of the defendant’s fights in prison reveal a striking similarity in his
descriptions. He was ‘on his own’ and had to ‘sort things out’. He regularly
describes himself as the man who was ‘stitched up’. He reacts to perceived
threats but there is no real evidence of a threat existing. He is prepared to arm
himself and to use a weapon.
The sad circumstances of the murder of this man also ably demonstrate how
important information about risk is not transferred around the prison system, even
when the prisoner returns to the same prison. The defendant arrived back in
Leeds in March 2004. He had been previously released from Leeds in February
2004 on an open F2052SH form after a fight with his cellmate and a period of
extremely strange behaviour in the segregation unit, which had resulted in a
recommendation that he be referred to the MHIRT. Since then he had been
charged with having a weapon in a public place and lost his place at a bail hostel
for being found in possession of a sharpened knife. None of this information was
available to the member of staff in Leeds who completed his CSRA. (I recognise
that nurse Hotel 3 did his medical screening and she remembered him from his
previous time on the segregation unit but this was quite by chance.)
Nurse Hotel 3 commented that it was a shame that the defendant returned to
Leeds on a different prison number. This too presents a hindrance to relevant
information on risk following a prisoner around the system. SO Alpha 1
commented that, because the defendant had come in on a new number, they had
no information on him on the morning of 2 April when he was received onto A
wing. I note too the B wing SO assertion that, despite all the worry over the
defendant’s behaviour in February 2004, staff from the unit would not have been
involved in any CSRA should the defendant have been returned to a residential
wing instead of being taken to court.
I am dismayed by the manner in which the information provided by his probation
officer in her phonecall of 1 April was dealt with by staff. I do not take particular
issue with the security marking accorded to the information but I do not think a
SIR was appropriate as the sole medium for the probation’s officer message.
She did not believe that the defendant posed an imminent threat to other
prisoners, but she did think he posed some threat and was concerned to pass
this information on so that staff who dealt with him could monitor his moods. She
was not ringing to instigate a SIR, indeed it was only because she could not
contact the probation department that she ended up speaking to the security
department. The probation officer is a criminal justice professional and had
access to far more information on the defendant’s likely risk than the prison.
Whereas staff in the security department routinely process about 50 SIRs in any
given week, it is extremely rare for a probation officer to call the prison to raise
concerns about a prisoner’s risk. I think that it would have been the right course
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of action for security staff to ring the residential wing manager and pass on her
concerns. I also believe that this information should then have been sufficient
grounds for wing staff to initiate an immediate review of the defendant’s CSRA.
Wing staff could also have considered at this point whether it was appropriate to
search the defendant for a weapon. In fact, the OASys report does say that he
should be searched regularly for concealed weapons. I am inclined to think that
staff should have requested a copy of this report as a matter of urgency.
I should add that I do not share the duty governor description of the information
provided by the probation officer as “sketchy”. She was quite specific that the
defendant was a schedule 1 offender as a result of an incident in a YOI for which
he received a conviction for wounding on 14 April 2000.
I consider that, based on the information available to staff at the time, the
defendant was correctly assessed as presenting a low risk when he returned to
Leeds in March 2004. However, the information available to staff was a woefully
inadequate basis on which to make such a judgment. That said I do not think
that prison staff would have put him at anything higher than medium risk had they
been privy to all the information. That is because the risk assessment system at
the time was not geared to recognising a history of situational violence. It is clear
from the tragic events of 2 April that in fact the defendant was a high risk to his
peers. As I have said, I welcome the changes made in PSI 32/05 which followed
the Prison Service’s receipt of an earlier draft of this report.
I recommend that the Governor reminds all staff of the need for
speedy and determined action when information relating to risk of
harm is received from other criminal justice agencies.
(iv) The man’s transfer to A wing and allocation to a cell with the defendant
The process of cell allocation during wing transfers in Leeds is undertaken by the
movements officer on the wing the prisoners are transferring from. The
movements officer has a list of available cells and a list of prisoners due for a
move. It is their job to match the prisoners to the spaces. Despite apparent
contradictions in the interviews with the movements officer Alpha 7 and the D
wing movements officer, the man and the defendant were allocated to the same
cell by the movements officer on D wing.
Both the man’s former D wing cellmate and the D wing movements officer agree
that, on the morning of 2 April 2004, the man asked the movements officer on the
off chance whether he could move to a different wing. The man had been
encouraged to seek a transfer to A wing by one of his friends and former
cellmate. (In fact the man asked if there was a possibility he could share with his
friend when he arrived on A wing.) By chance there was a space on A wing and
the movements officer agreed to the transfer. The other prisoner that moved
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from D to A wing also gave evidence that he asked for a move to A wing on the
off chance on the same morning.
I conclude that the placing of the man and the defendant together was a totally
random decision. I have said elsewhere in this report that staff in Leeds prison
were completely unaware of the terrible threat that the defendant posed to his
fellow prisoners.
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