Individual at Brixton

Investigation into the circumstances surrounding the
death of a man
at HMP Brixton on 27 February 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2008
This is a report of an investigation into the circumstances of the death of a man at
HMP Brixton on 27 February 2007. The man was found hanging from the bars of his
window when an officer opened his cell for lunch shortly before noon. Despite staff
attempts at cardiopulmonary resuscitation and the attendance of paramedics, he
could not be revived. The man had been remanded in custody five days earlier. He
was 51 years old.
I offer my sincere sympathy and condolences to the man’s family and friends for their
loss.
The investigation was carried out on my behalf by my colleague, Mrs Ruth Houston.
A clinical review of the man’s healthcare at HMP Brixton is being carried out by
Lambeth Primary Care Trust but, to date, it has not been completed.
I would like to thank the Governor of Brixton, and his staff for their co-operation and
assistance. Particular thanks go to the prison’s liaison officer, for his help throughout
the investigation process.
When the man arrived at Brixton, he had already served 12 years of a life sentence.
At the age of 51, he faced the possibility of a second life sentence and the prospect
of spending most of the rest of his life in prison. In a letter he wrote on the morning
of his death, he described his unwillingness to outlive the former partner he was
accused of killing.
Although I have identified two failures in Brixton’s procedures, it is clear that the man
gave staff no concern for his welfare. I make two recommendations designed to
address those failures.
Stephen Shaw CBE
Prisons and Probation Ombudsman May 2008
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CONTENTS
Summary 4
The Investigation process 5
HMP Brixton 6
Key findings 7
Issues 11
Recommendations 13
Annexes
1. Documents considered during the investigation
2. Transcripts and notes of interviews with staff
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SUMMARY
The man died on 27 February 2007 in his cell at HMP Brixton. He had been
sentenced to life imprisonment for the murder of his wife but in 2005, he absconded
from an open prison. On 22 February 2007, he was remanded in custody and
charged with the murder of a former partner with whom he had a relationship during
his two years unlawfully at large.
When he arrived at Brixton, the man was seen by the duty nurse in reception who
completed the first reception health screen. During the process, the man mentioned
problems with his right knee but denied any thoughts of harming himself. In view of
the offence with which he had been charged, the nurse should have automatically
referred the man for a mental health assessment. However, she was unaware that
the man had been charged with murder and did not make the referral.
The following day (23 February), the man was classified as a potential category A
prisoner and placed on hourly observations. He was also moved to a single cell. On
the afternoon of 26 February, he was informed that he had been given category A
status and would be transferred to HMP Belmarsh as soon as possible.
Staff on the wings were very busy on the following morning. As a category A
prisoner, he was subject to hourly checks, but there is no record of any checks on
him after 10.00am.
Just before noon, an officer unlocked the man for lunch and discovered him hanging
from the window bars at the back of the cell. Both officers and healthcare staff tried
unsuccessfully to resuscitate the man. Ambulance paramedics also attended but
nothing more could be done. A prison doctor certified his death at 2.33pm.
On arrival at Brixton, the man had given no information about next-of-kin. As a
consequence, staff had great difficulty in trying to obtain contact details after his
death. Unfortunately, whilst attempts were still being made to trace his relatives,
members of the family learned of the man’s death from newspaper reports.
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THE INVESTIGATION PROCESS
1. My investigator visited HMP Brixton on 1 March to open the investigation. She
met senior managers, as well as representatives of the Independent Monitoring
Board and Prison Officers’ Association. She also saw the man’s cell and walked
around the first night centre.
2. The investigator returned a number of times to interview staff who had talked to
the man during his time in prison and those who had attempted to resuscitate
him.
3. One of my Family Liaison Officers wrote to the man’s family to ask if they wished
to raise any concerns. The family did not respond.
I commissioned a clinical review from Lambeth Primary Care Trust. The report of
the review is not yet available. I expect it to be completed within the next few weeks
and the findings will be included in my final report.
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HMP BRIXTON
4. Brixton’s original buildings date from 1819. In 1898, they were enlarged and
improved and the prison became the trial and remand prison for the whole of the
London area.
5. The prison now serves the local magistrates’ courts and Inner London and
Southwark Crown Courts. It holds remand and sentenced prisoners committed
from these courts. Convicted prisoners have an initial interview and are then
categorised and allocated to another prison with facilities appropriate to that
sentence and the prisoner's needs.
6. Brixton holds 800 men in four main residential units and a healthcare wing.
During the man’s time at the prison, the induction unit was on G wing. It has now
been located on C wing.
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KEY FINDINGS
7. The man arrived at Brixton on the evening of Thursday 22 February 2007. He
was seen in reception by an officer who completed the Personal Summary Sheet.
The man said that he was of no fixed abode and gave no name or contact details
for his next of kin. The reception officer noted that the man was suffering from
pain in his right leg.
8. The staff nurse then interviewed the man and completed the First Reception
Health Screen form. This is an assessment of a prisoner’s physical and mental
health and any substance misuse problems. The information entered on the form
is obtained from other documents and from what the prisoner himself says. The
staff nurse told my investigator that she remembered the man who died. He was
an older man who walked with a limp and had laughed during the assessment.
9. On the first page of the form, staff record personal details and information on the
prisoner’s status. The staff nurse told my investigator that she obtains some of
the basic information from the prisoner’s personal summary sheet. The staff
nurse did not complete the box marked ‘Current Charge’ as she did not have the
man’s personal summary sheet in front of her at the time. She said that she had
seen it briefly before she spoke to the man but she had not noted that he had
been charged with murder. She also said that she does not always ask prisoners
about their offence as sometimes they do not give her the correct information.
The man told her he was of no fixed abode and added that he had previously
been in prison in 2005. He then said that he was not registered with a General
Practitioner.
10. The second page of the health screen form records a new prisoner’s physical
health and needs. At the very top of the page, above the heading ‘physical
health’, an instruction states, “If charged with murder or manslaughter, refer for
mental health assessment.” As the staff nurse did not know that the man was on
remand for murder, she did not refer him for a mental health assessment.
11. The staff nurse recorded that the man’s right knee was swollen and that he had
been prescribed a strong painkiller for this. She also noted on the form that he
was allergic to penicillin, but she did not record this information on the continuous
clinical record as required. When asked whether he used alcohol or drugs, the
man replied no to both. The next section of the form covers the prisoner’s mental
health. The man said that he had never been treated for such problems, nor had
he ever tried to harm himself. A further question is whether coming into prison is
so difficult that the prisoner is considering harming himself. When the staff nurse
asked this question, the man responded by laughing and saying, “Oh Miss, no.
An old man like me?” The staff nurse told my investigator that this reply and the
man’s manner throughout the assessment led her to have no concerns about his
mental health. She ended the interview by referring him to the doctor about his
knee.
12. Reception procedures at Brixton are kept as brief as possible so that new
prisoners are only held in the reception area for a short time. The remainder of
the induction process is carried out on the wing. After the health assessment, the
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man went to the induction unit. At the time, this unit was located on G wing,
along with the detoxification unit. It is now on C wing. In the induction unit,
prisoners are interviewed by the first night officer. The officer completes the first
night in custody questionnaire and cell sharing risk assessment (CSRA) to decide
whether the prisoner should be put in a shared cell. He also provides information
about the prison and again assesses how well the man is coping with custody.
13. The reception officer asked the man about the charge against him and was told it
was murder. He told my investigator that he recalled the man as a mature man
who was very calm and very matter of fact about the charge. The reception
officer usually completes the first night form first as he has found that this ‘breaks
the ice’ and helps with the later risk assessment. When prisoners are asked if
their family know they are in prison, the usual answer is “no”. The man must
have given this reply as the word ‘no’ is ringed. Although the reception officer
cannot remember whether the man wished for his family to be contacted, he is
likely to have asked as it is noted on the form. When a prisoner wants to contact
his family, the reception officer explains that it is up to them to do so using the
Pinphone system. He asks if they know how to use the system and briefly
explains the process to those who do not.
14. The reception officer then completed the CSRA. This form asks whether a
prisoner has concerns about sharing a cell and the man who died said he had.
He was assessed as medium risk rather than high risk. The reception officer also
noted that the man was a non smoker. He told my investigator that he had no
concerns about the man, otherwise he would have opened an ACCT document.
(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.)
15. The man who died was then seen by a doctor. The doctor noted that the man
was suffering from dyspepsia and that he was walking with a limp. The man told
the doctor that he had injured his thigh three weeks previously. He added that he
was waiting for a right patella (knee-cap) replacement. The doctor prescribed
medication for the dyspepsia and referred the man for an x-ray of his knee.
There is no record of the man being prescribed pain killers or any evidence that
he had such medication in his possession.
16. During the evening, prisoners are given a hot meal and are free to move about
the wing. They can also have a shower, use the telephone and talk to a Listener
if they wish. (Listeners are prisoners who have been trained by the Samaritans
to offer confidential emotional support to fellow prisoners in distress. There are
always Listeners on duty in the induction unit at Brixton.)
17. The following morning (23 February), the induction process continued. Prisoners
were given information about prison procedures and the help offered by prison
staff and outside agencies. On that day, staff at Brixton identified the man who
died as a potential category A prisoner and moved him to G3-21, a single cell on
G wing. While the decision was being made, the man was subject to certain
category A measures, including regular checks. It appears that the man spent
the remainder of his time in Brixton on G3 landing which is on the first floor.
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18. On Monday 26 February, the senior officer (SO) on G wing was informed that the
man’s category A status had been confirmed. The senior officer went to the
man’s cell between 4.00pm and 5.00pm to pass on this information. He told my
investigator that it did not seem to come as a shock to the man who said that he
had been charged with a murder committed two weeks earlier. The man sat on
the edge of the bed, very relaxed and asked questions calmly. He made eye
contact with the senior officer and his body language was positive. The senior
officer is an ACCT assessor and case manager. Accordingly, he has a great deal
of experience in looking for signs that a prisoner is not coping. He said that the
man appeared fine and, in his opinion, the news probably did not come as a
surprise. The senior officer told the man that he would be transferred to HMP
Belmarsh, which holds category A prisoners, as soon as possible.
19. On 27 February, a prison officer was the landing officer for G3. His duties
included carrying out hourly checks on the man and signing the record to show
that he had done so. The prison officer explained to my investigator that he
checked the man once each hour between 7.00am and 10.00am but not
necessarily at regular intervals. He signed the man’s category A booklet to this
effect. After 10.00am, there are no further entries in the booklet. The prison
officer said that he might have checked on the man between 10.00am to 12.00
noon and not had time to make the entries in the booklet, but he could not be
sure.
20. The prison officer told my investigator that he looked through the observation
hatch in the door to check that the man was in his cell but did not speak to him.
He could not recall what the man was doing at the times he looked, but he was
clear that the man gave him no cause for concern during the morning.
21. At lunchtime, a second officer assisted in unlocking the prisoners on the landing
and supervising them whilst they collected their lunch from the servery on the
ground floor. When the landing officer unlocked the man’s door he glanced in,
realised something was wrong and entered the cell. He saw the man standing
under the window, facing the door and looking down slightly. As he moved
closer, he realised that the man was hanging from the window bars. A bed sheet
had been used as a ligature. The officer immediately went to the door and called
a ‘Code 1’ to alert the other staff that there was a medical emergency.
22. The second officer ran along the landing and called Code 1 over his radio. He
also told the prisoners on the landing to ring the cell bell to alert other staff to the
emergency. He then went into the cell and supported the man’s weight whilst the
landing officer cut the bed sheet from the window bars. They laid the man on the
floor and removed the ligature from his neck. The landing officer then raised the
bed onto its end to make more room in the cell.
23. Another officer and senior officer arrived at the cell and began to administer first
aid. The officer tried to put an airway into the man’s mouth to start
cardiopulmonary resuscitation (CPR). However, he could not do so because the
man’s jaw was shut tight as rigor mortis appeared to have set in. The senior
9
officer then tried but he too was unsuccessful. The staff then began CPR and
continued until healthcare staff arrived.
24. The duty staff nurse heard the alarm bell and went to the man’s cell. As the
officers continued CPR, she examined the man. She could not find a pulse and
noted that he was cold and his legs and arms were quite stiff. She then took over
the chest compressions. A senior healthcare officer arrived, as did other staff
with oxygen, the resuscitation kit and a defibrillator. (A defibrillator is a machine
that treats victims of sudden cardiac arrest by delivering a shock to the heart.)
The senior healthcare officer attached the defibrillator to the man. It showed no
heart activity. He tried to insert an oropharyngeal tube into the man’s mouth and,
when he was unable to do so, he used a bag-valve mask to try to get oxygen into
him. He told my investigator that, although he did all this, his professional opinion
was that the man was already dead. At approximately 12.15pm, he and the other
healthcare staff agreed that nothing more could be done. At that point, the
paramedics arrived and attached their equipment to the man. The reading on the
machine confirmed that he had died so the staff ended CPR at 12.17pm. At
2.33pm, one of the prison doctors came to the cell and, after examining the man,
certified his death.
25. At 12.40pm, staff spoke to the prisoners in the neighbouring cells and informed
them of the man’s death. One of the men in cell 3-20 said that he had heard
kicking on the pipes at approximately 11.00am that morning.
26. The staff who found the man and those who attempted to resuscitate him were
then taken to the rest area in the gymnasium where they wrote out their
statements. Members of the care team were available for staff who needed to
speak to someone. Afterwards, the staff attended a hot debrief in the prison
chapel. The healthcare staff attended an additional debrief at which the
resuscitation attempt was the main focus of discussion.
27. Meanwhile, prison managers began trying to trace the man’s next-of-kin. He had
given no family details when he arrived at Brixton. The police were contacted,
but the address they provided was out of date. Staff at Brixton were still making
enquiries two days later when tabloid newspaper reported the man’s death. His
son contacted staff at Brixton who confirmed his identity and then gave the family
the assistance they needed.
28. After the man’s death, several letters were found in his cell addressed to the
police, his lawyer and the family of his ex-partner. In the letter to the police, he
had written, “…we loved each other so much … I cannot live out (sic)....” followed
by his former partner’s name. The letter had been written at some point on the
morning of Tuesday 27 February.
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ISSUES
29. On completing the health screen, the reception nurse did not refer the man for a
mental health assessment as she should have done. She explained that,
because of time pressures, she had not made a note of the charge against him
when she looked at his documents in reception. This meant that she was
unaware that he had been charged with murder and so did not refer him to the
mental health in-reach team.
30. However, during the assessment, the man said and did nothing to cause the
nurse any concern. She recalled him actually laughing when she asked if he felt
like self-harming. Had she had any concerns, she is quite clear that she would
have referred him to the mental health team or opened an ACCT. The man was
later interviewed by an officer in the induction unit. He had no concerns either.
The Head of Healthcare should remind staff of the importance of obtaining
all the information necessary to complete the first reception health screen
fully and to transfer important information into the continuous clinical
record.
31. As a category A prisoner, the man should have been checked once an hour. On
27 February, the records show no checks after 10.00am. The landing officer that
morning signed three times to show that he had completed the checks between
7.00am and 10.00am. He told my investigator that on the morning of 27
February he had been very busy looking after the prisoners on the ‘threes’
landing. Several were subject to ACCT monitoring and two of them needed a lot
of attention. He said that he might have checked the man after 10.00am and
simply not had the time to record it.
The Governor should remind all staff of the absolute necessity of carrying
out and signing to confirm all required checks on category A prisoners.
32. Notes that were found in the man’s cell after his death indicate his intention to
take his own life. In one, he appeared to refer to a previous unsuccessful attempt
involving pills, although there is no indication of when this took place. There is no
evidence from his prison records that it happened whilst he was in prison as such
action would have led to the involvement of healthcare staff and an ACCT
document being opened. Therefore, it may well have occurred before his arrest.
33. The failure to ensure a mental health referral and the possible failure to carry out
category A checks are matters that the Governor will need to address. However,
even if they had been completed, I suspect that the man was a sufficiently
experienced prisoner to have worked round the procedures. The letters in his
cell expressing regret for his former partner’s death and his unwillingness to
outlive him would point to his resolve to end his life.
34. After the man’s death, prison managers liaised closely with the police to try to
obtain the contact details for his next-of-kin. However, on 1 March, his son
contacted the prison after seeing a report of his father’s death in a newspaper. It
must have been a great shock to the family, particularly as the tone of the report
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was sensationalist. However, I am satisfied that staff at Brixton did all they could
to try to trace the family. When the man’s son contacted the prison, the Governor
and his staff offered a good level of support and care.
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RECOMMENDATIONS
The Head of Healthcare should remind staff of the importance of obtaining
all the information necessary to complete the first reception health screen
fully and to transfer important information into the continuous clinical
record.
The Governor should remind all staff of the absolute necessity of carrying
out and signing to confirm all required checks on category A prisoners.
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