Individual at Bedford

Investigation into the circumstances surrounding the
death of a prisoner
at HMP Bedford in August 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2010
This is a report of an investigation into the death of an immigration detainee at HMP
Bedford. The man had entered the UK illegally and was awaiting deportation back to
Vietnam. He was found hanging in his cell shortly after 4.00pm on 14 August 2008.
Despite every effort to resuscitate him, he was pronounced dead at 4.37pm the
same day. He was 28 years old.
The loss of a loved one is always distressing and I extend my sincere condolences
to the man’s family for their loss
The investigation was undertaken by my two of my colleagues. I would like to thank
the Governor of HMP Bedford and his staff for their participation and assistance.
Particular thanks go to Mr M who acted as the liaison officer.
A clinical review was commissioned by Bedfordshire Primary Care Trust and
completed by the Head of Healthcare at another prison. I extend my thanks to the
clinical reviewer for recommendations drawn from her findings.
For a number of reasons outlined in my report, the man who died was very
concerned about being deported back to Vietnam. I would not normally detail the
reasons for imprisonment in my report and I understand that this might be distressing
to his family. However in this case, his offence and the shame he felt as a result of
committing the offence, are relevant to his state of mind at the time of his death.
I have made four recommendations, one for the Primary Care Trust regarding the
quality of record keeping, two for the attention of the Governor of HMP Littlehey, and
one for the Governor of HMP Bedford. All have been accepted.
Jane Webb
Acting Prisons and Probation Ombudsman July 2010
2
CONTENTS
Summary 4
The investigation process 6
HMP Bedford 8
Key findings 9
Issues 15
Health care services
Communication
Deportation procedures
Education at HMP Bedford
Family Liaison
Conclusion 18
Recommendations 19
3
SUMMARY
The man who died arrived in the United Kingdom in October 2003. He had entered
the country illegally and was arrested the day after his arrival. He applied for asylum
but was refused. In April 2004, he was admitted to hospital and found to be suffering
from tuberculosis. Further tests showed that he was also HIV positive and suffering
from hepatitis C.
In June 2005, the man was sentenced to six years imprisonment for rape and
aggravated burglary with a recommendation for deportation to Vietnam at the end of
the sentence.
During his time in prison, the man maintained regular contact with his family in
Vietnam. He told them he was in prison for robbery as he was deeply ashamed of his
offence and the shame that it would bring on his family. He conformed well to prison
life and took the opportunity to learn English and receive treatment for his medical
conditions. There is one recorded incident of self-harm in May 2005 when he made
superficial cuts to his wrist because he was not allowed to return a CD that he had
borrowed.
The man was very concerned about being deported. He was frightened for his life
because he had stabbed a man, in defence of his mother, prior to leaving Vietnam
and he owed money that he had borrowed to finance his travel to the UK. He feared
rejection by his family because of his offence and his medical conditions. He was
also concerned that the medication that was controlling the HIV and hepatitis would
not be available to him in Vietnam and even if it was, he and his family could not
afford it. In an assessment interview with his probation officer in 2007, the man said,
that he would kill himself rather than go back to Vietnam.
The process for deportation began shortly before the man completed his prison
sentence on 11 June 2007. As a result of his offence, the UK Borders and
Immigration Authority (UKBIA) authorised his continued detention in prison custody
while the process was completed. Around this time, wing staff at HMP Littlehey
started to notice that he was worried about being held as a detainee awaiting
deportation. An officer documented his concern in the man’s wing record and
reiterated the risk identified by the man’s probation officer the previous year.
However, no consideration was given to opening an Assessment, Care in Custody
and Teamwork (ACCT) document (a procedure that monitors and supports
individuals thought to be at risk of self-harm).
The man was transferred to HMP Bedford as an immigration detainee on 18 June to
await the deportation decision. The Prisoner Escort Form (PER) that accompanied
him to Bedford failed to highlight the potential risk of self-harm identified and
documented by the probation officer and reiterated by the officer who was
concerned.
By late July 2008, deportation was almost inevitable and the man decided to
withdraw his appeal against the decision to make a deportation order. His reasons
for withdrawing the appeal are not known.
4
At approximately 4.04pm on 14 August, an officer was unlocking the man’s cell to
allow his cell mate to go in. The man was found hanging from the bars of the cell
window by part of a bed sheet. Every attempt was made to resuscitate him by
prison staff and paramedics. A prison doctor, pronounced the man dead at 4.37pm.
The family were contacted through the British embassy in Vietnam and informed of
the man’s death. His parents, who were not able to leave Vietnam, nominated a
family friend in the UK to represent the family. Their friend accompanied the man’s
ashes back to Vietnam and passed them to the family.
I have made recommendations relating to recordkeeping, self-harm monitoring and
communication regarding deportation procedures.
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THE INVESTIGATION PROCESS
1. Notices were issued to staff and prisoners informing them of the investigation and
its terms of reference, and inviting them to contact the lead investigator should
they wish to do so.
2. My investigator opened the investigation by visiting HMP Bedford on 19 August
2008. She spoke to the Governor, a member of the Independent Monitoring
Board (IMB), the chairman of the Prison Officers’ Association, and the Family
Liaison Officer. She visited the cell where the man spent the last few months of
his life. All available documents likely to be required for the investigation were
collected or requested at this time.
3. My investigator and a colleague carried out nine interviews with members of staff
on 29 and 30 October 2008. They also spoke to two prisoners who knew the
man who died.
4. The man’s clinical records were passed to the clinical reviewer who conducted a
clinical review on behalf Bedfordshire PCT and made appropriate
recommendations that have been incorporated into my report.
5. My investigators contacted the Coroner to inform him of the nature and scope of
the investigation and to request a copy of the post mortem report. A copy of this
report was sent to the Coroner, on completion, to assist in his enquiries.
6. One of my Family Liaison Officers contacted the representative of the man’s
parents in this country, to offer the opportunity to participate in the investigation.
He raised two questions on behalf of the family, which I hope have been
satisfactorily addressed within my report. The family asked why the man took his
life and why he was unable to return to Vietnam, which was what he had told
them? I hope that my investigation has helped the family to better understand
the events leading up to the man’s death.
6
HMP BEDFORD
7. HMP Bedford was built in 1801 and is located in the centre of Bedford, a town to
the north of London. It serves Luton Crown Court, and Magistrates Courts within
the Bedfordshire and Hertfordshire counties. It can hold up to 506 male category
B prisoners and often takes prisoners transferred from London prisons. (Category
B prisoners are those for whom the highest security conditions are not necessary
but for whom escape must be made very difficult.)
8. The prison accommodation is divided into six wings. “A” wing holds 138
prisoners over three floors. When prisoners are on the unit, five prison officers
are on duty, this is reduced to four when prisoners are at work and education.
9. The former Chief Inspector of Prisons, conducted an unannounced short follow
up inspection of HMP Bedford in April 2006. Her report commented that, “at the
time there were 11 immigration detainees being held on immigration warrants
(Form IS91), who had completed their prison sentence ... but were confused as
to their status and what the future holds” The Chief Inspector recommended:
“Recommendation 2.5 ... There should be systems in place to
identify and meet the needs of foreign national prisoners”.
10. In every prison in England and Wales there is an Independent Monitoring Board
report (IMB). The members are volunteers who monitor the day-to-day life in
their local prison and ensure that proper standards of care and decency are
maintained. The Bedford IMB annual report for 2007-2008 reported that a
comprehensive foreign national prisoner strategy had been agreed by the
Governor in June 2008. At the time of writing their report, 25 per cent of the
prisoners held at Bedford were foreign nationals. The IMB deemed the service to
foreign nationals to be “very good.” They noted that induction packs were
available in 16 languages and immigration clinics were held every six weeks to
offer support and advice. The Refugee Legal Centre gives legal advice and
represents foreign national prisoners at legal hearings as required. The report
also recognised the “outstanding service” offered to many prisoners with mental
health issues by the mental health in-reach team.
11. There were two self-inflicted deaths in Bedford in 2007. However, the
circumstances were not similar to those surrounding this death.
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KEY FINDINGS
12. The man who died arrived in the United Kingdom on 27 October 2003. He was a
Vietnamese national and had entered the UK illegally. He was seen by Surrey
police the next day, walking along the M25 motorway and was arrested. He
spoke little English and was interviewed by immigration officers. During this
interview, he claimed asylum in the UK. This application was refused in
November 2003. The man lodged an appeal which was dismissed in February
2004.
13. The man lived with friends in London and worked illegally in restaurants to pay
his rent. He was also in debt to those who had funded his travel to the UK. In
April 2004, he was admitted to Homerton hospital in London with a fever and
night sweats. He was found to have tuberculosis and tested positive for HIV and
hepatitis C. He was transferred to St Bartholomew hospital (also in London) for
treatment. It is not known how long he stayed there.
14. Offences of rape and aggravated burglary were committed in February 2004,
against two Vietnamese girls. The man who died was charged with these
offences, along with two other Vietnamese men, and remanded into custody at
HMP Chelmsford in June. He pleaded guilty and gave evidence in court that
helped convict his co-defendants. He was sentenced to six years imprisonment,
with a recommendation for deportation back to Vietnam at the end of his
sentence.
15. The man transferred five times during his sentence. Despite this, it is clear from
his medical records that he received good continuity of specialist care to treat his
HIV and hepatitis C conditions. He only missed one clinic appointment in four
years, due to operational reasons, when he first arrived into custody at
Chelmsford.
16. Prison records describe the man who died as a quiet man who kept himself to
himself. He initially struggled with the English language which made participation
in offending behaviour programmes difficult. In spite of this, he refused to be
transferred to HMP The Mount to undertake a specialised sex offenders
programme that had been adapted for non English speakers. However, by the
end of his sentence, according to his education teachers, he spoke and
understood English very well. During his imprisonment, he maintained regular
phone contact with his family.
17. On 4 May 2005, at Chelmsford, the man attempted self-harm by inflicting
superficial cuts to his wrist. He said that he had cut himself because he was
angry that he was not allowed to return a CD that he had borrowed from another
prisoner. He was concerned that he would be accused of theft. He was
assessed by a senior mental health nurse who opened an F2052SH document in
order to provide some structured support. (F2052SH was used to monitor and
review prisoners at risk of self-harm and has since been replaced by the
Assessment, Care in Custody and Teamwork process). A translation service,
Language Line, was used to enable the assessment to take place. He agreed to
receive help from the mental health team but said that he had no thoughts of
8
suicide. The F2052SH was closed on 26 May 2005. There is no evidence of
further attempts at self-harm during his sentence and no record of further contact
with the mental health team.
18. On 15 January 2007, at HMP Littlehey in Cambridgeshire, an OASyS
assessment) was completed with the man who died. (OASyS is a sentence
planning and risk assessment system using reports from various prison
specialists to inform individual targets agreed with the prisoner.) During the
assessment interview, the man said to the officer who conducted it, that while he
was in Vietnam he had stabbed a man who had assaulted his mother. He said
that his family knew he was in prison but not that he had committed a rape as he
did not want to bring shame on them. He admitted that he had suffered from
depression because of his difficulty communicating and his health problems.
However, at that point he had no problems in coping in custody, therefore no
concerns about suicide or self-harm were recorded.
19. A prison probation officer interviewed the man on 22 February 2007, in order to
complete a parole report. (Parole is a system that allows a prisoner to be
released before they have served their full sentence. It is considered on the
basis of reports by prison and probation staff. The decision is based on a
number of factors, including the nature of a prisoner's offences, their home
circumstances, plans for release and behaviour in prison.) During this interview,
he expressed considerable concern over his possible deportation. He was
concerned about his family rejecting him because of his offence and his medical
conditions. He said that there was no state health provision for HIV medication,
he would therefore be dependent on his own and his family’s private means. He
knew that his family did not have sufficient money and said that he would rather
kill himself than return to Vietnam. The probation officer noted this in his report
and in the man’s prison record, Local Inmate database (LIDs) and his probation
file.
20. On 2 March, the man was issued with a notification of liability to deportation by a
senior officer. This is likely to have been a form ICD0350 from the Immigration
authorities. He was advised to provide reasons as to why he should not be
deported. The senior officer discussed the risk highlighted during the man’s
interview with the probation officer and advised him that “any deportation would
not happen until 2008”.
21. Early release on parole was refused on 14 May due to the seriousness of the
man’s offence and that he had not completed offending behaviour work to reduce
his risk of reoffending.
22. The man regularly attended hospital appointments to monitor his HIV and
Hepatitis C conditions. Letters from a consultant gastroenterologist at
Addenbrookes Hospital in Cambridge dated 30 August, 20 November 2007 and
25 February 2008, all indicate that the medication was working well and he was
responding to the treatment.
23. A form IS91 was issued by the Immigration Service, Criminal Casework
Directorate (CCD), on 6 June. This provided the legal authority to detain the man
9
in custody after he had served his prison sentence, to await the outcome of the
deportation proceedings. There is no right of appeal against the IS91.
24. The man completed his sentence on 11 June 2008, but had to remain in prison to
await the decision on his deportation. He was not released to await this decision
in the community or transferred to an Immigration Removal Centre because of
the seriousness of his offence and the potential risk of reoffending. A doctor at
Littlehey wrote to the UK Border Agency (UKBA) to confirm that the man had
been diagnosed with HIV and hepatitis C.
25. An officer at Littlehey noticed that the man was worried that he was now being
held in custody as a detainee. On 14 June, the officer noted in the man’s prison
file, that he was scared of being deported back to Vietnam. He also reminded
staff of the probation officer’s concern in February 2007 that the man might try to
take his own life. There is no record of the officer who made the entry
considering monitoring the man under the Assessment, Care in Custody and
Teamwork (ACCT) procedures.
26. A Prisoner Escort Record (PER) form accompanies each prisoner when they
move between prisons. It provides information about both the prisoner’s needs
and the risk he poses to others. The man was transferred to a local prison, HMP
Bedford, on 18 June to await the deportation decision. The PER completed by
staff at Littlehey highlighted that he had a medical condition and that he was
threatening and violent. The box relating to the potential for self-harm was blank.
27. At Bedford, the Cell Sharing Risk Assessment (CSRA) form was completed the
same day, using information from the PER, IS91, previous convictions record, the
pre sentence report and his responses to set questions. (The CSRA ensures that
prisoners are suitable to share a cell by assessing their risk of harming a
cellmate.) An officer completed the CSRA, but failed to note the previous sex
offence or aggravated burglary. The man also denied any acts of self-harm in the
past and was therefore assessed as low risk. In interview, the officer who
completed the CSRA said that he deliberately listed the man’s offence as
burglary for his own safety as, “he’s going to have an easier time in prison if it’s
known that he’s in for burglary rather than rape”. It should be noted that the
CSRA is a document for staff information only.
28. A nurse, in her assessment in the CSRA, said that the man did have a history of
self-harm but “no self-harm ideation at present”. In interview, the nurse who
conducted the assessment said that he told her that he had cut his wrist four
years ago but had not attempted anything since and that he had no self-harm
issues.
29. On 26 June, the Criminal Casework Directorate (CCD) of UKBA wrote to the
Governor of HMP Bedford asking him to inform the man of the decision to make a
deportation order against him. This was signed on behalf of the Secretary of
State on 2 July and officially delivered to the man by the foreign national clerk, on
9 July. The documentation given to the man included a disclaimer to be
completed if he did not wish to appeal, an appeal form and a letter from CCD
10
outlining the deportation process. The foreign national clerk spoke to him and
explained the paperwork and the appeals process to him.
30. The foreign national clerk explained the deportation process to my investigators.
He said the man had an opportunity to appeal against the decision to make a
deportation order. If this was unsuccessful and the order was made, he would
have had another opportunity to appeal at that later stage.
31. The man lodged an appeal against the decision to make a deportation order on
21 July, which was arranged to be heard on 25 September at Nottingham
Magistrates Court. However, he signed a disclaimer withdrawing his appeal on
30 July. The disclaimer appears to have been sent to CCD either directly from
the man or from his solicitor as there is no record of the document in his prison
files. My investigator was unable to determine why he had changed his mind
and withdrawn his appeal.
32. CCD send monthly reports to detainees to keep them advised of progress. The
man received a progress report dated 11 August that noted the withdrawal of his
appeal. The report advised him that CCD would be making arrangements for him
to be interviewed regarding an emergency travel document that would allow him
to be deported back to Vietnam. The prison received a copy of this report.
33. The weekday routine at Bedford is for all prisoners on a wing to attend work and
education either in the morning or the afternoon and have the opportunity for
exercise, gym and association during the other half of the day. The next day the
routine is reversed.
34. The man who died attended key and life skills education classes in Bedford. My
investigator interviewed one of his tutors (who taught him on Monday, Tuesday
and Friday). She described the man as “the perfect student”, whose attitude was
“absolutely brilliant”. He always shook her hand at the end of the Friday session
and said, “Thank you Miss, have a lovely weekend”. On the Monday before his
death, he knew that she would not be in on the Tuesday. She recalled that, at
the end of the session, he took her hand but then took her other hand as well and
said, “Goodbye Miss, thank you”.
35. The support lecturer, in the Education department, also taught the man key skills.
He described the man as quiet with a good understanding of English. In
interview, the lecturer recalled that he attended his class a few days before his
death. They had discussed assertiveness and addressing personal issues and
concerns in a positive way. During the class, the man became very outspoken
and angry about not being given help with his problems on the wing. He did not
specifically say what help he needed but was very animated which was out of
character. The class discussed the process for getting help and the lecturer was
pleased with the man’s ability to articulate his feelings. He did not think that his
behaviour was a “cry for help”.
36. On Thursday 14 August, one of the man’s friends was on his way to work and
saw him leaning against the landing on the third floor, where his cell was located.
He asked him if he had education and the man, with what his friend described as
11
“a wry smile”, said he did not. The man’s friend said that his friend appeared
relaxed and was smoking a cigarette.
37. At approximately 4.04pm, an officer was escorting the man’s cell mate back to his
cell from his computer course. When he unlocked the cell, the cell mate stopped
abruptly at the door and the officer saw the man hanging from the bars of the
window by part of a bed sheet. The officer immediately raised the alarm using
his radio, he also shouted to another officer, who was on the upper landing, and
entered the cell to cut him down. The two officers then tried to resuscitate the
man.
38. A nurse arrived a few minutes later and continued attempts to resuscitate the
man using an Automated External Defibrillator (AED). (This device measures
electrical activity in the body and advises on action to be taken.) The ambulance
arrived at 4.15pm. The paramedics removed the AED and attached a cardiac
monitor which showed no electrical activity. They carried out advanced life
support (ALS), giving adrenalin and atripene and continued cardio pulmonary
resuscitation (CPR) for another 20 minutes. This is in accordance with the ALS
guidelines. Every effort was made to resuscitate the man. The prison doctor,
oversaw the ALS attempts and agreed that efforts should cease. The man was
pronounced dead by the doctor at 4.37pm.
39. The contingency plans for a death in custody were activated and all relevant
authorities were advised. A “hot” debrief was conducted for all staff involved, by
one of the governors and no issues were raised. All staff were offered support
from the staff care team. A critical incident debrief was held approximately two
weeks later and attended by staff from the Prison Service area office. (A debrief
is a meeting for staff to discuss any lessons learned as the result of a serious
event.)
40. The prison records listed a family friend as the person the man would have lived
with in the UK, if he had been released from prison. One of the prison chaplains,
contacted the Metropolitan Police who informed the family friend of the man’s
death later that evening. The Governor appointed a senior officer as the prison
family liaison officer. It was confirmed that the family friend was their
representative in the UK and he and his family notified the deceased man’s family
in Vietnam on 15 August.
41. The Governor published a Notice to Staff and Prisoners to inform them of the
man’s death and offered support to anyone who felt they needed it. The notice
included the name of a contact person for both the Coroner’s office and my
investigation team should anyone have information they wished to share.
42. The family liaison officer accompanied the family representative and his family to
identify the man’s body and offered advice and support. She also liaised with the
Vietnamese Embassy in London and the British Embassy in Vietnam to ensure
that the man’s parents were formally informed of his death.
43. The family representative was offered a meeting with the Governor and the
opportunity to view the man’s cell, both were declined. The Governor offered to
12
repatriate the man’s body to Vietnam as the family were not able to come to the
UK for the funeral. The family decided to cremate the body in the UK and the
Governor contributed to the cost of the funeral and to the travel costs for the
family representative to return the ashes to the man’s parents in Vietnam. Prison
staff attended the funeral on 16 October, which was very much appreciated by
the family.
13
ISSUES
Health care services
44. The man who died was diagnosed as both HIV and hepatitis C positive. Both
conditions required consistent monitoring and treatment. He was transferred five
times in the four years he was in custody. Nevertheless, it is clear from his
medical records that there was consistency in the quality of healthcare provided
to him. Hospitals were informed when he was being moved and care was
appropriately transferred to another hospital as required. It is worth noting that
He only missed one clinic appointment during his time in custody and this was
due to operational reasons when he first arrived at HMP Chelmsford. The clinical
reviewer assessed the consistency of his care as excellent. I agree with her
assessment.
45. The continuity of the man’s clinical notes was difficult to establish and
handwritten entries, including the signatures, were often illegible. This is a
common finding in my investigations and once again I make a recommendation
to Bedfordshire PCT that applies equally to most PCTs in the country.
Bedfordshire PCT should ensure a common standard of record keeping
across the prisons where they deliver services. Clinical notes, both hand
written and summaries from IT systems, should be kept in chronological
order. Handwritten notes should include the time the entry was made, a
clear signature, a printed name and the date.
46. Staff involved in the attempt to resuscitate the man were appropriately trained
and responded quickly and professionally. They used the correct equipment that
was made available without delay. I share the clinical reviewer’s conclusion that
staff acted professionally and every attempt was made to resuscitate.
Communication
47. In January 2007, an officer interviewed the man for an OASyS assessment
report. During this interview, he expressed concern about returning to Vietnam.
He said that he had stabbed a man who had assaulted his mother and was
frightened to return. He also said that he did not want to bring shame on his
family who did not know that he had been convicted of rape, as he had told them
he was in prison for robbery. The man admitted to suffering from depression,
however, the officer did not record any concerns about potential self-harm.
48. The prison probation officer interviewed the man in February 2007. During this
interview, the man first expressed his considerable concern over his potential
deportation back to Vietnam. He was deeply ashamed of his offence and
concerned about the shame that it would bring to his family and the possibility of
rejection. He was also concerned about his health. He knew that even if his
medication (which was recognised as working) was available in Vietnam he or his
family would have to pay for it themselves. He knew that they might not be able
to afford it. The man said that he would rather kill himself than return to Vietnam.
14
The probation officer took this threat seriously and correctly noted it in the report,
in the man’s F2052A (his prison wing file), his probation file and on LIDs.
49. This risk was discussed with the man again the following month when a senior
officer gave him immigration forms that required him to provide reasons why he
should not be deported. The senior officer advised him that any deportation
would not happen until the following year.
50. The man completed his sentence on 11 June 2008, but was detained in custody
to await the outcome of the deportation proceedings. A Form IS91 had been
issued to him by the UKBA. He was, therefore, aware of the reasons for his
continued detention and why he had not been released on 11 June. At this point
the issue of deportation must have become a reality for him and therefore the risk
of self-harm identified earlier should have been acted upon.
51. An officer noticed that the man had become more concerned and recorded on 14
June that he was scared of being deported. He also reminded staff of the
probation officer’s concerns that the man might try to take his own life. Despite
these concerns, there is no record of staff considering placing the man on ACCT
monitoring and support to help him cope with his fear of deportation. Had the
self-harm prevention procedure been activated, the risk would have been
highlighted to everyone who came into contact with the man, including staff in
HMP Bedford where he was transferred on 18 June.
52. The PER that accompanied the man to Bedford on 18 June made no reference to
any potential for self-harm. In view of the concerns raised by staff at Littlehey,
this is a serious omission.
53. The risk of suicide identified by the prison probation officer was not recorded in
the medical file and therefore was unknown to the nurse who conducted a
medical assessment with the man when he arrived at Bedford. From her
discussion with him, the nurse recorded that whilst he did have a history of self-
harm four years before, he had no thoughts of harming himself at that time. If the
PER had identified potential self-harm or the man had been on an active ACCT,
the nurse’s assessment might have been different.
The Governor of HMP Littlehey should ensure that consideration is given to
whether additional support such as ACCT monitoring is required whenever
there is a change in an individual’s status from prisoner to detainee and
that this is documented.
The Governor of Littlehey should ensure that PER documents are
completed correctly and contain all the known information on the
transferring prisoner’s risk profile.
54. During the interview with my investigator, an officer admitted that he had
incorrectly recorded the man’s offences in order to give him “an easier time in
prison”. This issue is not relevant to the man’s subsequent death but might be
something that the Governor of Bedford will wish to address.
15
Deportation procedures
55. The administration of the deportation procedures at Bedford is carried out by the
foreign national clerk, working in the discipline office. He impressed my
investigators with his knowledge of the immigration system. The foreign national
clerk took pride in personally serving immigration documents on detainees and
ensuring that they understood the process. This is commendable, however, it
could result in wing staff being unaware of the current status of their detainees
with regard to their deportation. It is possible that wing staff did not know that the
man had withdrawn his appeal against deportation. Had they known this and
read the entries in his F2052A made by staff at Littlehey, they would have had an
opportunity to discuss his concerns and fears with him and offer support.
The Governor of Bedford should ensure that wing staff are advised of
progress with deportation procedures and a note of meetings between the
foreign national clerk and detainees is entered into the detainee’s F2052A
held on the wing.
Education at HMP Bedford
56. The teachers who taught the man life skills, spoke highly of him. They both,
during interview, spoke of a noticeable change in his behaviour that in hindsight
may have indicated his intentions, in the days before he allegedly took his life.
My investigation has found that the man was a quiet individual who did not share
his problems with staff unless directly asked. With the exception of the
conversation that he had with the prison probation officer over a year previously,
there was no record of any known risk of suicide. The teachers were neither
aware of this risk nor of his impending deportation. In the circumstances they
could not have been expected to link his change in behaviour to his decision to
take his own life.
Family Liaison
57. Family liaison was complicated by not having address details for the man’s next
of kin. He had stated to prison staff that he did not have any next of kin. The
prison’s family liaison officer is to be commended for her work in liaising with the
Vietnamese Embassy in London and the British Embassy in Vietnam as well as
the families authorised representative in the UK.
58. The family representative and the family confirmed to my family liaison officer
that the prison was “very helpful” with all the arrangements and they particularly
appreciated staff attending the funeral to pay their respects.
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CONCLUSION
59. The man who died was a young Vietnamese man who did not share his feelings
with prison staff unless directly asked to. He had entered the UK illegally and
was evidently afraid of being deported back to Vietnam. He was ashamed of his
offence and feared rejection by his family if they found out the nature of it. He
was also in debt for money loaned to fund his trip to the UK, which he had not
repaid and was concerned about the potential repercussions for stabbing a man
in Vietnam, in defence of his mother, prior to his departure.
60. Medication for his HIV and hepatitis C conditions was likely to be expensive in
Vietnam, if it was available, and he was concerned about how he and his family
would fund his continued treatment.
61. It is clear that the man had serious concerns about returning to Vietnam, so much
so that he had said to his probation officer that he would kill himself rather than
go back. He had put a case forward for remaining in the UK which had been
rejected. My investigators were not able to establish why he decided to withdraw
his appeal. As a result of this withdrawal, deportation was inevitable.
62. Whether additional support from prison staff could have prevented the man’s
actions will remain unknown. It is certainly evident that, from the information
available, he should have been assessed for ACCT support. However this would
not have changed the deportation decision which, from my investigation, is the
probable reason that he decided to take his own life.
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RECOMMENDATIONS
1. Bedfordshire PCT should ensure a common standard of record keeping across
the prison contracts. Clinical notes, both hand written and summaries from IT
systems should be kept in chronological order. Hand written notes should include
the time the entry was made, a clear signature, a printed name and the date.
This recommendation was accepted. The response was:
“This is a qualified nurse duty and is mentioned in the code of conduct which
should be adhered too. All nursing staff will be reminded of these requirements at
team meetings.”
2. The Governor of HMP Littlehey should ensure that consideration is given to
whether additional support such as ACCT monitoring is required whenever there
is a change in an individual’s status from prisoner to detainee and that this is
documented.
This recommendation was accepted. The response was:
“Staff have now been informed to action this.”
3. The Governor of Littlehey should ensure that PER documents are completed
correctly and contain all the known information on the transferring prisoner’s risk
profile.
This recommendation was accepted. The response was:
“Staff have been advised to ensure that PERS are correctly completed.”
4. The Governor of Bedford should ensure that wing staff are advised of progress
with deportation procedures and a note of meetings between the foreign national
clerk and detainees is entered into the detainee’s F2052A held on the wing.
This recommendation was accepted. The response was:
“A system has been introduced to ensure that wing staff are advised of progress
with deportation procedures and note of meetings between the Foreign National
Clerk and detainee is entered in the F2052A.”
There were no comments from the man’s family.
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