Individual at Bristol

Investigation into the circumstances surrounding the
death of a man in May 2006, shortly after his release from
HMP Bristol
Report by the Prisons and Probation Ombudsman for
England and Wales
February 2007
This is the report of an investigation into the death of a man who died in May 2006,
apparently of a drug overdose, shortly after being released from HMP Bristol. Each
year a significant number of former prisoners die in similar circumstances. In line
with my terms of reference, I investigate a number of such deaths on a discretionary
basis, looking for lessons to be learned.
In spite of the man’s untimely death, many of the lessons that emerged from the
investigation were positive. He was assisted by many people and the support that
he was given, particularly as he approached his release date, was impressive. A
number of agencies worked with him to make sure that he was transferred
seamlessly from prison to a hostel (Approved Premises). He was told about the
dangers associated with the reduced tolerance to drugs which is common after a
period of imprisonment. Through the auspices of the charity Mind, he was met at the
prison gate, and was going to be driven to the Approved Premises.
Sadly, even with the best efforts of many members of staff, and a range of specialist
services, the lure of drugs was too strong for the man to resist. His death occurred
the morning after release, less than 24 hours after leaving prison.
The man was no longer in contact with his family and he did not provide next of kin
details to the prison or probation services. Efforts to trace family members have
been unsuccessful. However, it is known that the man had been married and had
two children, and I offer my sincere sympathy and condolences to them, should they
ever see this report. I also extend my sympathy to the man’s friends and those who
worked with him.
The investigation was carried out by one of my investigators. I am grateful to the
Governor of Bristol and the Assistant Chief Officer of Avon and Somerset Probation
and their staff for their assistance during the investigation.
I have highlighted the work of both the prison and local probation as examples of
good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2007
2
CONTENTS PAGE
Summary 4
The Investigation Process 5
HMP Bristol 7
Key Events 8
Issues 16
Good Practice 19
3
SUMMARY
The man was born on in January 1969, and died in May 2006 aged 37. He
began using drugs as a teenager and continued to do so for the rest of his life.
As a result of sharing drug equipment, he developed hepatitis B and then
hepatitis C. Doctors told him that, as a result of his illnesses, his life expectancy
was greatly reduced. He funded his drug use by committing crimes, followed by
numerous terms of imprisonment.
On 26 August 2004, the man was remanded into custody at HMP Bristol, after
being charged with a number of offences. He was well known to staff at the
prison and quickly settled into the routine. However, he sometimes found it
difficult to cope with prison life, as he found it difficult to relate to other people.
He spent most of his time on the vulnerable prisoners wing. As well as physical
ailments, he had mental health problems and had frequent contact with
healthcare staff. He also regularly asked for help from the mental health
advocate from the charity Mind, who worked on D wing.
On 23 February 2005, the man was sentenced to three and a half years
imprisonment. He applied for a transfer to a category C prison, but this was
refused. An application for early release under the Home Detention Curfew
(HDC) scheme was also turned down, as he had broken the terms of a previous
HDC licence.
At the beginning of 2006, staff from the prison and the local probation area began
to prepare for the man’s release in May. Prison staff monitored his health
carefully and worked to ensure that his needs were met. The Mind advocate
helped the man obtain a Community Care grant. He also arranged to drive the
man from the prison to the Approved Premises where he was to stay on release.
His offender manager and key worker from the hostel both visited him in prison to
help prepare him for his release. Two weeks before his release, the man moved
to the healthcare centre, which provided a ‘halfway house’ between life on the
wing and life in the community.
On 26 May 2006, the man was released. The Mind advocate accompanied him
to a Post Office where he cashed his care grant, which meant that he had almost
£250 in cash. They drove into Bristol as the man said he had to make a brief
stop to collect some of his possessions from friends. He did not return to the car.
The following day, he was found having died of an apparent drugs overdose.
The occupants of the flat where the man was discovered told police that he had
taken about £250 worth of heroin and cocaine.
4
THE INVESTIGATION PROCESS
1. My investigator opened the investigation by letter on 2 June 2006. She was
sent copies of the man’s prison and probation records.
2. On 25 September, she visited HMP Bristol where she interviewed a member
of staff, and then spoke to a prisoner who had known the man very well. The
following day, she interviewed a member of the mental health charity Mind
who helped the man during his final prison sentence.
3. At a later date, she spoke by telephone to the man’s probation officer in the
community and his personal officer in prison. She also spoke to the head of
the detoxification team.
5
HMP BRISTOL
4. HMP Bristol receives men and some young offenders, from the local courts,
both on remand and following conviction. It also serves as a Category B
facility for the West of England. According to the Prison Service website,
Bristol places “great emphasis” on prisoners confronting their offending
behaviour. There are courses in inter-personal skills, enhanced thinking and a
focus on employment, with some prisoners employed in the prison
workshops. On 31 January 2006, the operational capacity was 606 men.
5. All prisoners who are drug users when they enter the prison undergo a
detoxification programme to help them come off drugs. There is also a re-
toxification programme. This option is considered for prisoners who are at
risk of reverting to drug use on release from prison, or who are vulnerable to
taking an overdose. Re-toxification consists of prescribing a maintenance
dose of a drug substitute such as methadone (a synthetic medication which
mimics the effects of heroin).
6. The healthcare centre provides 24-hour care and has 20 in-patient beds. It
provides a full range of primary healthcare services. There is a Mental Health
Support Team for prisoners with mental health problems. The treatment
offered includes a Day Care Unit where prisoners can take part in
occupational therapy sessions.
7. The HDC scheme is designed to help prisoners prepare for life after their
release. HDC is not an entitlement and can only be granted subject to
prisoners meeting the eligibility criteria and passing a risk assessment,
including a home circumstances check.
6
KEY EVENTS
The man’s prison sentence
8. The man was arrested in August 2004 and charged with two counts of theft,
robbery and breach of an Anti-Social Behaviour Order. The offences were
committed while he was on police bail. In late August, he appeared at the
local magistrates’ court and was remanded into custody at Bristol. He had
been in the prison before and was well known to staff.
9. During the First Reception Health Screen assessment, the man listed his
recent drug use as daily usage of heroin and anti-depressants and occasional
use of crack cocaine. He also said that he had taken methadone the previous
day, which was when he was in police custody. He said that he had been
prescribed various anti-depressants for his mental health problems. There
was no entry in the record about hepatitis, although the man did inform the
nurse that he was taking a dietary supplement four times a day. (In 1998, he
had been diagnosed with hepatitis B. In or around 2001, he developed
hepatitis C and was informed by a specialist that he had a greatly reduced life
span. As a result, when at liberty, he lived on Disability Living Allowance.)
The nurse referred him to the doctor and the detoxification team because of
his use of drugs.
10. A prison doctor saw the man later that day, and began the de-toxification
programme by prescribing dihydrocodeine and valium. He noted that the
man’s mood was low but stable, and he was not suicidal. He also recorded
that the man had hepatitis B and severe hepatitis C, and referred him to the
hepatitis nurse. The man then went through the process of detoxifying from
drugs.
11. He quickly settled into the routine of life on the wings. Four days after his
arrival, he referred himself to the Counselling Assessment Referral Advice
Throughcare (CARATS) team for help with his drug addiction. He told them
that he was ‘desperate to change’ and needed their help to do so.
12. On 8 September, the man spoke to the Advocacy Services Co-ordinator for
the Bristol branch of the mental health charity Mind. The man told the
advocate that he had been on the wing for six months and had been having a
difficult time. He said he had been attacked in prison and was suffering from
post-traumatic stress disorder (PTSD). He added that, before coming into
prison, he had been an in-patient at a local psychiatric hospital. (The man
appears to have been counting his previous prison sentence when saying that
he had been on the wing for six months.) The advocate provided him with a
Mind booklet on PTSD, and contacted healthcare staff on the man’s behalf.
From then until the man ’s release, the two men spoke on over 40 occasions
and the man asked the advocate to help with a number of issues.
13. On 15 September, the man had an initial assessment meeting with a member
of the CARATS team. They discussed the dangers of sharing drug taking
equipment, reduced tolerance and the risk of accidental overdose. The man
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was given a self-study programme to work through in his cell. The course
included a question about the man’s hopes for the future, to which he replied
that he would like to be sentenced to a drug rehabilitation programme.
14. Two weeks later, the man asked to be referred to a psychiatrist, saying that
he had previously been a psychiatric in-patient for ten weeks. On 10 October,
he told a nurse from the Mental Health Support Team (MHST) that he was
having flashbacks of a traumatic life event and was feeling paranoid. The
nurse made a note to contact the hospital for details of the man’s stay, and
said that he would review him in three days time. His medication was
changed the following day. On 14 October, he was assessed by a
psychiatrist who arranged to see him again in a month’s time.
15. In spite of the man’s contact with healthcare staff, he told the advocate that he
felt that they did not really believe that he was unwell and were not providing
enough support. The advocate contacted the psychiatrist who had treated the
man in the community and discovered that prison healthcare staff had already
requested the records.
16. In November, the man began working as wing cleaner. He pleaded guilty to
the offences and was further remanded for probation, psychiatric and
physiology reports to be prepared. At the end of the month, he moved to a
single cell, and his personal officer noted that he seemed a lot happier. By
this time he had completed the work for the CARATS course, for which he
was awarded a certificate. At his next appointment with the psychiatrist, the
man said that he had chosen to stop taking one of his medications and had
seen no difference after stopping it. The doctor noted that the man was
feeling very vulnerable and decided to see him again in a fortnight’s time.
17. However, the man did not actually meet the psychiatrist until 6 January 2005.
He told the doctor that taking valium left him “in a haze” and said he felt better
when he did not take it. They decided that he should stop taking it, and
another appointment was arranged for 24 February. (However, according to
the medical record, the next psychiatric review was held on 21 April.)
18. The probation report requested by the court was written in the middle of
February. The writer highlighted the man’s need for accommodation as a
stable base and treatment for his illness. He assessed the man’s risk of re-
offending as high, due to his use of drugs, and recommended a custodial
sentence. A second report noted that the man had a history of relapsing into
drug use immediately on release from custody. A week later, the man was
sentenced to three and a half years imprisonment.
19. After being sentenced, the man appears to have become depressed. He
refused to work and so lost his job and Incentive and Earned Privileges (IEP)
enhanced level. His personal officer, who was also the labour officer, looked
for an in-cell job where he could work without having to mix with others.
However, the workshop had nothing suitable at the time. On 12 March, the
man failed a drugs test. He was contacted a week later by the CARATS
team, and reminded to make contact if he needed to see someone. Two
8
weeks later, the consultant treating the man’s hepatitis wrote to the prison
doctor to say that the hepatitis B infection had been cleared after a course of
treatment with interferon. However, he was still suffering from hepatitis C,
and being seen by a specialist hepatitis nurse.
20. On 15 April, the man was referred to the Mental Health Support Team
because he was tearful and finding it difficult to cope. The mental health
nurse suggested reviewing his medication and noted that he should see the
psychiatrist as soon as possible. When he saw the psychiatrist the following
week, the man said that he felt that valium was helpful. The doctor prescribed
additional medication for the following two weeks. They discussed his
sentence and probable release date.
21. On 5 May, the man said that he still felt anxious and paranoid all the time, but
that he was not struggling as much as before. The psychiatrist made a note
to see him in three weeks’ time.
22. At the beginning of May, the psychiatrist reassessed the man’s medication
and he prescribed diazepam (valium) and pain killers. A mental health nurse
noted that he was much calmer and was sleeping better. However, the man
told staff that he did not want to attend any further assessments with the
psychiatrist. From then on, he was treated by different psychiatrist. Later that
month, he began to interact more with other people to the extent that he
intervened to break up a fight between two prisoners.
23. In June, the man’s in-possession medication was checked and he could
produce only the empty packet. He explained that he had taken all the
medication. There is no record of any action being taken as a result.
24. Later that month, the man began work as a painter. He also applied to be re-
categorised as a category C prisoner, which would have meant a transfer to
another prison. However, this was refused because of his many previous
offences.
25. In August, the man began to consider being released early from prison under
the Home Detention Curfew (HDC) scheme. He asked the advocate to liaise
with his probation officer and St Vincent’s House in Bristol where he hoped to
stay on release. The man’s original plan had been to move away from Bristol,
but he decided against it. He wanted to get his life back on track, and then
move north to re-establish links with his children.
26. On 17 September, the man was referred to the Mental Health Support Team.
He had given different information to two nurses and healthcare staff were of
the opinion that he was becoming paranoid. He was not taking the dietary
supplements and was increasingly spending time alone in his cell. He asked
to move to the healthcare centre for a short break from life on the wing. This
was agreed, although he did not move until a week later. Staff weighed the
man and discovered that he had lost weight. As a result, they regularly
monitored his weight and diet. They also monitored his medication. After
three days, the man told staff that he wanted to return to D wing, as he found
9
healthcare too noisy and this prevented him sleeping. In fact staff noted that
when they had checked him during the night, he had been sleeping. After two
weeks in healthcare, he returned to D wing.
27. A month later, on 17 October, the man asked to speak to a member of the
Mental Health Team. He said that he was feeling paranoid, and needed night
medication. Staff tried to persuade him to give his new medication time to
work, and made a further appointment for him to see a member of the team.
A week later, the man was again admitted to healthcare for another respite. A
care plan was opened which stated that his food intake and weight should be
monitored and recorded, as should any behavioural changes. The following
morning, the man told staff that he had been awake since 2:00am due to
stomach pain. However, the nurse on duty noted that he had been asleep
each time she checked him through the night. He then complained that he
was not allowed to have possession of his medication as he did on the wing.
It was explained that the protocol in the healthcare centre was for all
medication to be held and administered by staff.
28. On 26 October, the man asked to return to the wing, but as there were no
spaces available, he had to remain in healthcare. The records describe him
shouting at staff, and his personal officer commented that he had “become a
very angry young lad”. A later observation from the same officer noted that
the man did “not like the word no”, and got upset if he did not get his own way.
29. On 10 November, the man told the nurse who was giving out medication at
the treatment hatch that he would not take his medication in protest at his pain
killers being reduced. He said that if she did not arrange for it to be increased
within 30 minutes he would cut himself. The nurse told him that she could not
deal with his problem until after she completed the morning treatments. The
man left the treatment hatch, and the nurse immediately briefed an officer
about the situation, asking him to speak to the man.
30. Minutes later, at 8:25am, the man cut his wrist with a razor blade. The staff
immediately opened an Assessment, Care in Custody and Treatment (ACCT)
plan. (The ACCT document describes the problems facing a prisoner at risk
of harming himself, and implements a plan to give him the support he needs
to help him through a period of crisis.) The man said that he felt that
healthcare staff did not take him seriously, and he was worried about how he
would cope in future. He added that the D wing staff meant a lot to him, and
he did not want to disappoint them. After further discussion of his needs, the
staff agreed with the man that it would be best if he remained in his own cell.
31. Later that morning, the pharmacist discussed the man’s medication with him
and said that she would speak to the doctor. The doctor discussed the man’s
medication with the pharmacist and a nurse. At 2:45pm, the doctor asked the
man to continue taking his current medication until the following morning
when it would be reviewed. Staff observed him regularly throughout the night.
32. At the assessment interview the following morning, the man said he had
problems coping with imprisonment, and hated the system, but was ‘terrified’
10
of being released. Despite his words, the case review meeting that afternoon
agreed that the ACCT plan would be closed. The man was present, and said
that he surprised himself by cutting his wrist and would not harm himself
again. The meeting also noted that the questions about his medication had
been resolved. His medication was not altered, but would be reviewed at his
appointment the following month with a consultant psychiatrist.
33. On 14 November, information was received from security staff that the man
was suspected of being involved in the supply of drugs on the wing. He was
warned that his security clearance for work would be withdrawn unless he
stopped doing so. At the end of December, he successfully re-applied for
enhanced IEP status, but failed a drugs test two weeks later and was returned
to standard level.
34. On 6 December, a member of staff of St Vincent’s House assessed the man
by telephone, and then faxed an acceptance to the CARATS team. However,
a week later, the man learned that he had been refused HDC. When he
asked for the reasons for the refusal, he was told that it was because he had
breached an HDC licence in 1999.
35. My Investigator interviewed a registered mental nurse (RMN) in the Mental
Services Team at Bristol who had worked with the man during an earlier
sentence. She said that he was in much better health this time. She said that
he was still quite ill with hepatitis and liver disease, but his general physical
condition was much improved. His weight was healthier, he interacted more
with other prisoners on the wing and was speaking to his personal officer.
She saw her role as keeping a general eye on him, with particular attention to
his medication.
36. In January 2006, the RMN began to spend longer periods talking to the man,
and she realised that he needed support making arrangements and facing up
to his release at the end of May. She referred him to the psychiatrist to initiate
a care plan for his release. The appointment took place on 12 January, and
the psychiatrist prescribed diazepam and listed him for the clinic on 30 March.
(Diazepam is an anti-depressant and the RMN said that the doctor prescribed
it to help the man cope with the run up to his release.) A major part of the
plan was for the man to transfer to the healthcare centre for the last two
weeks of his sentence. This would act as a half way house so that he would
not go straight from the wing to a new environment.
37. On 15 January, the man met his personal officer and they considered his
short term aims and the help needed to achieve them. They discussed the
plan to attend day care in the healthcare centre to focus on being released.
They also talked about his accommodation and benefit needs, and his health
issues. The personal officer referred the man to the prison’s resettlement
team, and continued to meet with him every two to three weeks. The major
topic for their discussion appears to have been his release. The officer
recorded the man’s moods as either ‘Good’ or ‘Very good’. I may say in
passing that it is pleasing to see the personal officer scheme working so well.
11
38. The following week, on 22 January, the man told staff that he had been
assaulted by his cell mate several times during the previous few days. His
cell mate was moved to the Segregation Unit, and the man was treated for
minor bruising. It appears that his cell mate had tried to involve the man in
smuggling drugs into the prison, and the man was assaulted when he refused
to participate.
39. A few days later, the man met the advocate and asked him to meet him at the
prison gates on the morning of his release. The man explained that he had
never been met at the gate previously, and so he had returned to using drugs.
The advocate agreed to the request.
40. On 3 March, the man was visited by his probation officer. She agreed that he
should consider staying at an approved premises outside Bristol, which would
be away from his usual environment. The possibility of going to an approved
premises in Bridgwater was discussed.
41. A few days later, the man arranged with CARATS staff to attend the Short
Duration Programme (SDP) drugs course scheduled for later that month.
However, after the first day of the course, he decided against continuing as he
did not get on with some of the other participants. On 10 March, one of the
CARATS team telephoned the man’s probation officer, and then referred him
to the Somerset Drugs Intervention Programme (DIP) in preparation for his
release. At the end of the month, the man told his drugs worker that he was
scared of being released from prison, and asked for “more regular support” as
his release date approached.
42. As part of the preparation for the man’s release, staff in the detoxification
team assessed whether he should be put on a re-toxification programme. It
was agreed that the man should re-toxify, and he was prescribed methadone.
43. At the beginning of April, his personal officer had another discussion with the
man about his release, after which he made a long entry in the record of
events. The man told the officer that he would not cope outside prison, and it
would only be 24 hours before his return. He said he could keep clear of
drugs in prison (although the evidence suggests otherwise), but it was
impossible outside. He asked the officer to keep his cell and job open for his
return. The officer tried to motivate him, pointing out that a lot of people were
working hard to help him.
44. Later that month, the man learned that he had been accepted by the
approved premises in Bridgwater, and would be assisted by the DIP team.
The advocate helped him apply for a Community Care Grant for his needs
and expenses on release from prison. The man was eventually awarded a
grant of £155 towards bedding and clothes for an anticipated stay in hospital
after his release. (He was waiting to go into hospital for a liver biopsy with a
view to having interferon treatment for the hepatitis.) On 15 April, the man
refused to show a member of staff at the medication hatch that he had
swallowed his medication, after which he received an IEP warning.
12
45. For the last three months on D wing, the man shared a cell with another
prisoner. The two men had had served several prison sentences together
and had known each other for about 20 years. The cellmate told my
investigator that the man spent a lot of time each day looking for drugs or
tobacco to “help him cope”. He said that the man would try to persuade other
prisoners to give him drugs or medication and, if that failed, he would look for
tobacco. When the man had tobacco, he would try to swap it for medication.
46. His cellmate also said that the man had a plan for what he would do on his
release. He did not intend to go to the approved premises which he knew
would be in breach of his licence conditions and would lead to recall to prison.
He planned to use the Community Care Grant to buy drugs, hand himself into
the police and smuggle the drugs into prison. If the man’s plan was
successful, he promised to share the drugs with others on the wing. For
about a month before his release, he spoke openly to other prisoners about
his plan, and they gave him their medication on the strength of his promise.
47. On 5 May, the man attended a discharge board where reduced tolerance to
drugs and the danger of overdoses were discussed. On 16 May, an officer
reported to the security department that a prisoner had said that the man
planned to bring drugs back into prison shortly after his release. Reception
staff were informed of this and told to notify the security department if the man
returned to prison shortly after release.
48. Two weeks before the man’s release date, he moved as planned from D wing
to the healthcare centre. He met new people and adapted to a new routine
intended to build his self confidence before release. He also attended the day
care centre, where he took part in activities such as art therapy. However,
after a few days, the man asked to return to D wing. The RMN was under the
impression that it was because he owed tobacco to another prisoner.
However, once back on D wing, the man changed his mind and wanted to
return to the healthcare centre. The RMN and the healthcare manager visited
him on the wing, after which he returned to the healthcare centre.
49. The RMN liaised with the member of staff from the approved premises who
was to be the man’s key worker. The key worker visited the man two weeks
before his release, and spent around 90 minutes talking to him. He described
the hostel, the requirements for residents and how staff would help him settle
in. Following the visit, the man’s medication was changed from methadone to
subutex.
50. On 25 May, the man’s CARAT worker sent a list of his medication to the DIP
team. The same day, the DIP nurse sent him an appointment for the following
week.
The man’s release from prison
51. The man was released from prison at about 10:00am, and was met by the
advocate at the gate. He had agreed to drive the man to the approved
13
premises, first stopping at a nearby Post Office. At the Post Office the man
cashed his Community Care Grant cheque. The grant, together with his
discharge grant and other money, meant that the man had £250 in cash in his
possession.
52. Two weeks previously, the man had asked the advocate if they could call at a
friend’s flat to collect some belongings. On the way to the block of flats, the
man talked about the World Cup, and about buying an England football shirt.
He also spoke of getting a bicycle, and going cycling in the countryside. The
advocate thought that the man appeared to be very happy to be out of prison.
The man directed the advocate to his friend’s home, where he got out of the
car, leaving his bag behind and saying that he would be back in five or ten
minutes.
53. However, the man did not return to the car. The advocate waited for two
hours, as he was concerned that the man would not get to the approved
premises on time if he had to make his own way there. He also went into the
block of flats to try to trace where the man had gone, but this proved to be
impossible. Eventually the advocate returned to his office and told approved
premises staff that the man was travelling to the hostel by himself. The man
did not arrive at the hostel, and staff began the procedures to revoke his
licence. This meant that the police would be informed, and would arrest the
man and return him to prison.
54. The man’s body was found the following morning in one of the flats, and he
was identified through his fingerprints. The occupants of the flat told the
police that the man had taken £250 worth of heroin and cocaine.
55. Efforts were made to trace the man’s relatives, but he had not given any
details of next of kin to either prison or probation staff. After three weeks, it
proved impossible to trace his relatives and the enquiries were closed. His
funeral took place at Canford Crematorium in Bristol. Prisoners held a
collection at HMP Bristol and sent flowers and a wreath in his memory.
14
ISSUES
The man’s health needs
56. When the man arrived at Bristol prison, he told staff that he had hepatitis B
and hepatitis C. Prison staff liaised with staff in the local hospital, and he was
seen by the specialist who had treated him previously in the community. She
continued to treat him during his sentence, and arranged for him to be put on
the waiting list for a liver biopsy and a course of treatment with interferon.
(Interferon is a medication that destroys the virus that causes hepatitis C.)
The man was referred to the specialist hepatitis nurse who visited him in
prison, and was prescribed medication to reduce the pain caused by hepatitis.
57. The man was also in frequent contact with the prison’s Mental Health Support
Team (MHST), and staff consulted the psychiatrist who had treated the man
in the community. He had regular appointments with a psychiatrist throughout
his sentence, and staff closely monitored his medication (which sometimes
caused friction). On several occasions, wing officers referred the man to the
MHST because they were concerned about his mental health. When the man
found it particularly difficult to cope with life on the wing, he was admitted to
the healthcare centre for respite care.
Drug use
58. The man began using heroin at the age of 16. He developed hepatitis C as a
result of sharing drugs paraphernalia. In spite of warnings that continued use
would further shorten his life, he carried on taking drugs. A pre-sentence
report said that he was known to resume his use of drugs as soon as each
prison sentence ended.
59. The evidence gathered during the investigation reveals a man who - like many
drug users - was extremely ambivalent about drugs. He referred himself to
the CARATS team, and told his drugs worker that he was desperate to
change. He discussed his future plans with his probation officer, saying that
he wanted to break his addiction and re-establish links with his children. He
asked to be accommodated in a hostel away from Bristol, as he wanted to
keep away from his old friends and haunts.
60. However, there is evidence that the man continued to take drugs during his
imprisonment. He failed two mandatory drug tests and on two occasions was
recorded as using his medication inappropriately. His cell mate said that a
great deal of the man’s time each day was spent trying to obtain drugs to
“help him cope”.
61. The man’s cell mate also described a very different release plan. The man
hoped to smuggle drugs back into prison, both for his own use and to share
with others on the wing.
62. Whatever his intentions in respect of drugs, what is certain is that the man did
not express any thoughts of suicide or self harm before his release. Everyone
15
who spoke to my investigator was absolutely clear that the man was focussing
on his plans for the future.
Preparations for the man’s release from prison
63. During the man’s time in prison, he had contact with an impressive number of
staff who helped prepare for his release, particularly in the months
immediately beforehand. My reports often highlight occasions where
communication has broken down to the detriment of the prisoner. It is
pleasing to see how closely staff from a number of agencies worked together
and how open the lines of communication were. The planning was detailed
and comprehensive. I commend the multi-disciplinary care provided for the
man.
64. In January 2006, the man’s personal officer discussed his release plans and
referred him to the resettlement department. Shortly before the man’s
release, he told the officer that he would soon return to prison and asked him
to keep his cell and job open for him. The officer encouraged the man to be
more positive by pointing out all the people who were helping him. He said
that if the man returned to prison shortly after release, he would be letting
them all down. Over the months, the officer had regular conversations with
the man, recorded in his core record as well as making full use of the new
personal officer forms introduced in the prison in January 2006. I commend
the officer for the level of support he gave the man, both as personal officer
and in general.
65. The MHST also worked hard to help the man adjust to leaving prison, and to
deal with new people. His appointments with the psychiatrist in January and
March 2006 focussed on preparation for his release. Two weeks before
release, the man moved from the wing to the healthcare centre where he
attended occupational therapy sessions in the day care unit and had to
interact with people he did not know. One of the sessions he attended was
art therapy.
66. Additional support and assistance came from the CARATS team. The man’s
drugs worker warned him several times about the danger of reduced
tolerance to drugs after being in prison. Along with CARATS, the
detoxification team decided it would be best for the man to be re-toxified. He
was initially prescribed methadone, but the medication was changed to
subutex following the visit from the key worker at the approved premises. The
CARATS team liaised with the local DIP team, which would have worked with
the man in the community. He was informed of his first appointment before
leaving prison, and it was scheduled for the week after his release.
67. The man was also helped by the mental health advocate employed by Mind.
The advocate had very regular contact with the man, and helped particularly
with applications and arrangements during his sentence. As the man’s
release date approached, the advocate arranged to meet him at the prison
gate and drive him to the approved premises. In his dealings with the man,
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the advocate was an effective liaison between the man and various
departments in the prison and probation services.
I commend the multi-disciplinary care that the man received from staff
working in the prison and the community. In particular, the
communication between departments ensured that his needs were met
in an appropriate and timely manner. I would be grateful if these
comments can be brought to the attention of the advocate and relevant
members of staff of HMP Bristol.
68. Probation staff also worked hard to ensure that the man’s move from prison to
the approved premises on licence went smoothly. The National Standards
require an offender manager to have a minimum of two contacts with a
prisoner before his release on licence, but it does not stipulate the nature of
the contacts. The man’s probation officer visited him in prison at the
beginning of March and discussed the plans for his release. She followed the
meeting by writing in April, informing him that he had been accepted by the
approved premises and the DIP, and letting him know that his supervision
would be transferred to the local Probation team. I commend the probation
officer for visiting as well as writing to the man, and for arranging suitable
accommodation.
69. It is usual for a person released from prison to an Approved Premises to meet
their key worker only after they arrive at the hostel. However, the man’s key
worker visited him whilst he was still in prison and spoke about the hostel and
his medication. The visit was an excellent example of how to meet a future
resident’s needs in an individual way.
I commend the timely and individual assistance that the man received
from probation staff, particularly the efficient communication between
the various parts of the Avon and Somerset Probation Service. Again, I
would be grateful if these comments can be drawn to the attention of the
staff concerned and their managers.
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GOOD PRACTICE
I commend the multi-disciplinary care that the man received from staff working
in the prison and the community. In particular, the communication between
departments ensured that his needs were met in an appropriate and timely
manner. I would be grateful if these comments can be brought to the
attention of the advocate and relevant members of staff of HMP Bristol.
I commend the timely and individual assistance that the man received from
probation staff, particularly the efficient communication between the various
parts of the Avon and Somerset Probation Service. Again, I would be grateful
if these comments can be drawn to the attention of the staff concerned and
their managers.
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