Individual at Sudbury

Investigation into the circumstances surrounding the
death of a man, a prisoner released from HMP Sudbury on
temporary licence
in March 2010 who died the same day
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2010
The man was in his early forties when he died on 13 March 2010. He had been
approved for day release to undertake community work as part of his resettlement
plans and was released from HMP Sudbury on temporary licence on 13 March. It
was the fourth time that he had been released and he was found later that morning
hanging from a tree in a public park. For the purpose of this report, I have
concentrated in the main from the time when he arrived at Sudbury in August 2009,
although I have included background information from when he first went into prison.
As part of the normal process for receiving prisoners the man was asked by officers
and healthcare staff whether he had any suicidal thoughts. None were noted and I
am satisfied that throughout his imprisonment there was never any suggestion that
he was at risk of suicide or harming himself.
The investigator and Family Liaison Officer join me in offering our sincere
condolences to his family and friends for their sad loss.
I wish to thank the Governor of Sudbury for making the necessary facilities and
information available to the investigator. I also thank the prison Liaison Officer for
his assistance.
In the course of the investigation, I asked for a clinical review to be carried out into
the medical care and treatment of the man received in custody. The clinical review
was led by a doctor and he had an assistant. I am grateful for their assistance and
report.
Jane Webb
Acting Prisons and Probation Ombudsman August 2010
2
CONTENTS
Summary 4
The investigation process 6
HMP Sudbury 7
Key findings 8
Issues 14
Conclusion 16
3
SUMMARY
In April 2008, the man appeared at a Crown Court having been charged, along
with his son, with causing grievous bodily harm. They were found guilty and
remanded into prison custody pending sentence and taken to HMP Nottingham.
The man had been imprisoned on three previous occasions. His prison record
suggests that he settled in well after being sentenced, although on one occasion
it was suspected that drugs had been sent to him. This was later found not to be
the case and he was recategorised as a category D prisoner and transferred to
Sudbury.
Whilst at Sudbury, and as part of the normal routine for preparing prisoners to
return to the community he was given temporary day release to be with his
family. Although prison authorities and probation staff were unaware the man’s
relationship with his wife was in difficulties. Those difficulties eventually led to his
wife wanting to end the relationship.
On 13 March 2010, the man was released for the fourth time on temporary
licence. He was expected to return to the prison that evening. However, after he
returned to his home, it would seem that his wife confirmed she wanted a divorce.
From what has been learned from the police, the man left the family home and
went to a local pet shop where he purchased a dog lead. After leaving the shop
he telephoned his wife to say he was going to a local park and intended to end
his life. His wife telephoned police and they commenced a search of the park
and, as part of that search, scrambled the police helicopter.
In the meantime, a member of the public walking her dog found the man hanging
from a branch, high up in a tree. She telephoned the emergency services and
they attended. Due to the height, it was some time before the man was taken
down. Because the police had prevented the paramedic from climbing the tree or
approaching the body, by the time he was taken down, it was too late for
paramedics to attempt to resuscitate him. I understand the man had used the
dog lead to hang himself.
The clinical reviewer mentions a medical procedure at HMP Nottingham (which
had no bearing on the man’s death) I have forwarded a copy of his report to the
prison Head of Healthcare for consideration. Finally, although I make no formal
recommendation, I invite the National Offender Management Service (Prison
Service) to remind prison healthcare what the Chief Inspector of Prisons said in
her most recent document “Expectations” about continuity of care.
In her introduction she said “Expectations is the basis for robust, independent
and evidence-based assessment of conditions in prisons and the treatment of
prisoners. Its content and approach have proved helpful to others who are
monitoring and examining prisons, here and in other jurisdictions. It is, and
should remain, a core part of the methodology of effective prisons inspection in
England and Wales.”
4
The Chief Inspector of Prisons said “Prisoners should be cared for by a health
service that assesses and meets their health needs while in prison and which
promotes continuity of health and social care on release. The standard of health
service provided is equivalent to that which prisoners could expect to receive in
the community.”
5
THE INVESTIGATION PROCESS
1. When the Ombudsman’s office was notified on 13 March 2010 of the man’s
death, the investigation was allocated to a Senior Investigator. He contacted
the prison and arranged to open the investigation on 17 March.
2. On 17 March, the investigator a met Detective Constable (DC) at the prison.
The DC is the prison intelligence officer and he gave the investigator further
information about what had occurred. He added that the Coroner had held a
post mortem and the cause of death was hanging.
3. The following day the investigator met the Deputy Governor, prison Liaison
Officer, two prison Family Liaison Officers, Clinical Nurse Manager, and two
members of the prison’s Independent Monitoring. The purpose of the meeting
was to explain the Ombudsman’s role in investigating deaths in custody and to
identify those people who the investigator wanted to speak to.
4. Over the two days the investigator was at the prison, he carried out a number
of informal interviews with prison staff and prisoners. One of the prisoners
was the man’s son.
5. In the meantime Derbyshire County Primary Care Trust (DCPCT) appointed a
doctor to carry out a clinical review. The doctor is a general practitioner and
partner of a practice in Buxton, Derbyshire. He was supported by the Head of
Clinical Quality (commissioning) for DCPCT. He is an experienced registered
nurse within the National Health Service.
6. On 15 April, one of my Family Liaison Officers (FLO) contacted the man’s
wife. He told her about the Ombudsman’s investigation and invited her to
contribute to the investigation. His wife told the FLO she had no concerns
about the care provided to her husband while he was at Sudbury, but did ask
to see the results of my investigation.
6
HMP SUDBURY
7. The prison is situated in the East Midlands area. It is a category D open
prison holding medium to long term adult male prisoners, including a number
of men serving life sentences. Originally the site was used as an RAF airfield,
but was converted to a prison in the late 1940s. Since then the prison has
undergone extensive refurbishment and modernisation. Accommodation is
provided for a maximum of 571 prisoners.
Her Majesty’s Chief Inspector of Prisons
8. Her Majesty’s Chief Inspector of Prisons reports on all prison establishments.
The majority of inspections are announced and allow the prison being
reported on to prepare for inspection.
9. In the introduction to her latest report on Sudbury, following an announced
follow up inspection carried out in 2007, the Chief Inspector of Prisons said
the prison was basically safe. She went on to say it was a good prison
despite population pressures which meant it had been receiving short
sentence prisoners. She said work was required to improve healthcare,
ensure there were sufficient activities and training for all prisoners and to
ensure resettlement was a core function of the prison.
Independent Monitoring Board
10. Each prison has an Independent Monitoring Board (IMB) made up of
members of the public and their role is to monitor the prison and to report any
concerns that they have regarding the prison, or how prisoners are treated. In
the first instance, the Board report any concerns they may have to the
Governor, or, if considered necessary, reports directly to Parliament. Board
members are able to visit any area of the prison at any time and have direct
access to any prisoner who they wish to see, or who requests to see them.
The Board holds regular meetings in the prison, with the Governor attending
for part of the meeting. The Chairperson of the Board produces an annual
report to the Secretary of State for Justice.
11. In its latest report, the Board said they considered the relationship between
staff and prisoners to be good. They added that standards had been
maintained and in many instances improved. The Board also pointed out that
the prison had won a number of awards for performance and community work.
7
KEY FINDINGS
12. Imprisonment was not a new experience for the man. Prior to receiving his
latest prison sentence, he had been imprisoned on three different occasions,
beginning in December 1988 when he was sentenced to three years in a
young offender centre. In October 1996, he received his second term of
imprisonment and he was also imprisoned in 2000.
13. On 23 April 2008, the man appeared at Nottingham Crown Court having been
jointly charged, with his son, with grievous bodily harm. They were found
guilty and remanded to HMP Nottingham pending sentencing. (It is worth
noting that the man and his son have been at the same prisons throughout
their sentences, but for ease, unless I specifically say so, the remainder of this
report refers to the man.)
14. All prisoners arriving at an establishment undergo an initial health screening.
In his clinical review the clinical reviewer said the routine healthcare check
carried out by a nurse during the reception procedure asked relevant health
questions and had specifically covered issues relating to deliberate self harm
or suicidal ideas. There were no concerns identified. However, he noted that
the screening document had not been fully completed by the person
responsible for filling out the document, with gaps in the section dealing with
mental state.
15. The clinical reviewer added that his enquiries had shown that the reception
healthcare information did not match the information contained in the man’s
primary care medical record. In that record, it had been noted by the man’s
own doctor that there had been a previous history of amphetamine drug use
by the man. There was no indication on the health screening form that the
man reported any problems with drugs. The clinical reviewer commented that
the man’s medical records from his own general practitioner had not been
requested by prison healthcare and therefore it was not possible for prison
healthcare to confirm the medical history.
16. The man’s blood sugar was also tested at this time. A level of 7.1 was
recorded, which is above the upper end of normal, 6. The clinical reviewer
said that in a primary care setting the figure would have prompted a fasting
blood glucose test, which is a diagnostic test for diabetes.
17. On 15 May, the man was sentenced at Nottingham Crown Court to six years
and six months imprisonment. Following his appearance at the court, he was
taken back to Nottingham, where he was assessed as being suitable for
allocation to a category C prison.
18. The following week, on 23 May, the man was transferred to HMP Stocken, a
category C prison located in the County of Rutland. Prison records show that
he settled in well and in November was being considered for transfer to a
category D open prison at a later date. (Open prisons have the lowest level of
security measures with no perimeter fence or wall to prevent prisoners
leaving.)
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19. On 11 November, some seven months after the initial blood sugar test was
conducted at Nottingham, a fasting test was carried out. The clinical reviewer
said in his clinical review that the test was part of enquiries relating to
cardiovascular risk. The doctor said the results were normal at 3.7.
20. The test had been carried out after the man was seen by one of the prison
doctors. This consultation focussed on smoking and how to reduce the risk of
heart disease. Additionally the doctor examined a skin lesion under one of his
eyes, which was thought to be xanthelasma which is a potential sign of high
cholesterol. The clinical reviewer said blood tests were promptly taken and
reviewed.
21. On 18 November, the man was seen by a doctor and his medical notes show
that there was a discussion about cardiovascular risk. It would appear that his
father had suffered heart disease and so the man was prescribed statin
treatment, which is used to lower cholesterol.
22. In February 2009, the process for considering the man for category D status
which had started the previous year was stopped after a suspected security
breach by a member of his family. An attempt had been made to bring drugs
into the prison, which were apparently concealed in a picture. It would appear
from the notes that a routine security check had taken place on the incoming
post and that traces of drugs had been detected.
23. Further entries in the man’s prison record show that, despite this, he settled
down and there were no further concerns about him. In April he was again
considered for category D status and on 1 August his security category was
reduced.
24. Ten days later the man was taken to Sudbury. During the routine reception
procedure no risks of suicide or self harm were identified.
25. From then on the man appears to have settled into open conditions well.
However, there was one occasion when, in January 2010, an officer went into
his room and believed he could smell cannabis smoke. A routine drug test
was carried out on him, which showed that he had not used cannabis. No
further action was taken.
26. There is little in the man’s healthcare record other than minor ailments. The
man sought help and advice in early January about stopping smoking. The
clinical reviewer regarded this as positive behaviour and something which
would not have led to concerns about the man’s safety.
27. On 8 February, the man began working in the staff restaurant which is outside
the prison and is commonly referred to as the “officers’ mess”. The
investigator met the manager and she told him that she had known the man
since he arrived at the prison. The manager said initially he worked in the
prison kitchen which is where she first met him. She described him as a quiet
man, who would often be seen staring through the windows into the air. She
said it was similar to day dreaming.
9
28. The manager said soon after the man began working in the officers’ mess,
she had to speak to him about his appearance. She said he had not had a
shave and that he looked untidy. The manager told the investigator that he
apologised and said he had a few problems. She said he did not say what the
problems were and nor did she ask. The manager said the man would
regularly ask to be allowed to return to the prison during the morning and was
anxious to see if there had been any mail for him, and he would also ask to
use the telephone. Asked if she had ever been concerned about the
behaviour the manager said that she was not.
29. The following month, on 9 March, a resettlement meeting took place to
consider a paid community work placement for the man. This would mean he
would be allowed out of the prison each day to work in the local community as
part of the preparation for his release. The meeting, chaired by one of the
prison Family Liaison Officers, identified the man as suitable and he was
scheduled to join the scheme on 12 July.
30. The liaison officer said the man had been at the meeting. He was in a very
good mood and had not given any cause for concern. The man told the
meeting that his resettlement plans were to return to his wife, as he wanted to
help support his family.
31. The next day, the man discussed his relationship problems with another
prisoner employed in the officers mess, although he did not go into detail. The
prisoner described the problem as “a bad patch”. He told the investigator that
the man had asked him to write a poem, which he wanted to copy and post to
his wife that day, to ensure it would arrive at home for Saturday which is when
he would next be there. Although he did not keep a copy of the poem, he said
it related to “breaking up”. The prisoner said he was certain that the man had
posted the poem that evening.
32. The investigator asked the prisoner if he had any concerns about the man’s
safety. He said that he did not. He said he suspected the man might well
have been drinking, but did not have any evidence to support his view.
13 March
33. On 13 March, the man was released from Sudbury on temporary licence
known as “Resettlement Day Release”. He left the prison at 8.00am and
returned to his home address in the Nottingham area, which is about one hour
away from the prison. As the licence was a day release licence, it was
expected that he would return to the prison later that day.
34. As part of this investigation the investigator spoke to the prison’s Head of
Offender Management. He is responsible for the prison policy for releasing
prisoners on licence. He said the man had been released on licence on three
other occasions and had always returned to the prison on time. The Head of
Offender Management said he was not aware of any problems with the man’s
relationship. Had he known of any difficulties, he would have carried out a
new risk assessment before deciding whether he could be released or not.
10
He added that an additional safeguard is feedback from the field offender
manager. The Head of Offender Management said had the field offender
manager been concerned about the relationship, the manager would have
contacted him to make him aware and would have to approve any further
release. He said there had been no such contact or concern raised.
35. I understand from the Detective Constable (DC) that when the man arrived
home, his wife told him that she wanted a divorce. During a conversation with
our FLO, the man’s wife told him that her husband knew they were going to
separate and could not understand why this upset him so much.
36. The DC said the police incident log shows that at 10.46am, the man’s wife
telephoned Nottinghamshire Police to tell them that her husband had left the
house in a depressed frame of mind and she feared for his safety. At
11.10am, she telephoned the police again to say he had telephoned her using
a mobile telephone to say that he had purchased a dog lead. He told her that
he was heading for Bestwood Park, where he said he intended to hang
himself from a tree. He also told her that he was going to visit his mother who,
I understand, had died and is buried in a cemetery some way from the park.
In the meantime, the police sent officers to the park and also scrambled the
police helicopter in an effort to find him.
37. At 11.49am, a member of the public was walking her dog in the park when she
saw the man hanging from a branch high up in a tree. She contacted the
police. Two minutes later and in response to the telephone call, police officers
who had been searching nearby arrived. Unfortunately they were unable to
reach the man who was suspended high up in the tree and so they asked for
the fire brigade to attend. (I understand that the man had used the dog lead
and choke chain to hang himself.) Paramedics also arrived, but they too were
unable to do anything for him until he could be taken down from the tree. (It is
estimated by the paramedics that he was suspended about 20 feet above the
ground.)
38. In his clinical review the clinical reviewer said the ambulance log obtained as
part of his enquiries show that the emergency ambulance call was allocated to
the Paramedic at 11.56am. The log shows he arrived into the area at
12.02am, but had to walk part of the way, arriving about one minute later.
39. When the paramedic arrived at the scene, a police officer prevented him from
going any further. In his evidence to the clinical reviewer the paramedic said
that, when he arrived, he could see the man suspended from the tree. He
said he looked to try and find a way to climb the tree with the intention of
cutting the man down and assess his clinical condition. The paramedic said
the officer would not let him proceed and thought it might have been for his
own safety, or because the officer believed there was nothing which could be
done for the man. He went on to say that, from what he could see, he tended
to agree that there was nothing which could have been to save the man. The
paramedic said that, although he did not make a written record, he told the
officer that without examination the man he could not pronounce that he was
dead.
11
40. Police records show that at 1.50pm, undertakers arrived and removed the
man’s body to the mortuary at Queens Medical Centre, Nottingham. At
7.59pm a doctor examined the man’s body and certified his death.
Events following the man’s death
41. After being told about his death, a Senior Officer (SO) arranged to meet his
son to break the news to him. Unfortunately the son was not in the
establishment as he was representing the prison at a football match in the
community. As he too was temporarily released from the prison for the day,
he was also allowed to take with him his mobile telephone. (Ordinarily
prisoners are not allowed to have a mobile telephone in their possession,
unless working in the community.)
42. During the son’s return to the prison, he received a telephone call from his
partner. Although she did not tell him what had happened, he realised that
something was wrong. When he arrived at the prison, he was met by the SO
and taken to a private room where the news of his father’s death was broken
to him.
43. The SO told the investigator that he had arranged for the son to be allowed to
use the prison telephone to call his family. Additionally he arranged for
prisoners and staff to support him.
44. The investigator spoke to the man’s son. He told the investigator that he had
been with his father throughout the sentence and on no occasion had his
father ever discussed ending his life. The son said that over the previous few
weeks before his death his father had been unhappy and they had spent a lot
of time together in his cell. He said that, although his father was unhappy, he
had not been concerned for his safety, adding that had he been, he would
have told prison staff. The son said his father’s death was something “out of
the blue” and believes he would have left a goodbye note had it been planned.
45. The son said help is available at the prison for anyone wanting it. He said he
felt well supported by prison staff and other prisoners following his father’s
death.
46. I understand the Governor informed prisoners of the man’s death. Prison staff
were on hand to support any prisoner affected by his death. Additionally, the
prison care team were available to any member of staff requiring their support.
47. On 14 March, a prisoner at Sudbury told an officer that he and the man
worked together in the officers’ mess. The prisoner told the officer that the
man had been “depressed” because his relationship had broken down.
Having been given this information the officer reported it to the prison security
department. In a note to the Security Department, the officer said a prisoner
had told him that the man had been on home leave the previous weekend. He
was depressed when he returned to the prison depressed due to his
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relationship breaking down. The officer added that the prisoner had been
given no indication that the man was intending to “commit suicide”.
48. As part of the investigation process the investigator met an officer who knew
the man well. The officer said he had known the man since his arrival at
Sudbury in August 2009. He described him as someone who did not come to
the attention of staff but would chat about everyday things. The officer said
the man never mentioned anything to do with his relationship and was
unaware of a breakdown. He added that there had never been any
suggestion that he was suicidal.
49. On 19 March, two members of staff both of whom act as prison family liaison
officers, travelled to the man’s home address to speak to and offer what
support they could to his wife and family. Additionally they offered the man’s
wife the opportunity to visit the prison and see where he lived. They also
offered to assist with the cost of his funeral.
13
ISSUES
Release on temporary licence
50. The man had been out of the prison on a number of occasions and returned
successfully, without incident. There appears to have been no reason to
prevent the licence being issued for 13 March. I am satisfied that had any
been risk identified, a new risk assessment would have been completed.
The man’s son
51. Prison staff and prisoners do not always receive the credit they deserve and I
have been pleased to learn that the man’s son felt well supported by staff and
prisoners. At a time when he was deeply upset at the death of his father he
clearly recognised the support offered to him and appreciated the kindness
shown to him. I invite the Governor to share my comments.
Clinical care
52. The clinical reviewer said the man’s healthcare whilst in prison was equivalent
to that he could have expected to receive in the community. He added that all
the assessments and practices were consistent with accepted practice. The
doctor went on to say there had been no indication at any stage of the man
intending to harm himself, adding that by seeking health advice it suggested
there were no major depressive episodes or suicidal intentions. He does
however make a number of recommendations aimed at improving processes.
General practitioner medical notes
53. Under the heading “Health Services”, the Chief Inspector of Prisons said in
her “Expectations” document “Prisoners should be cared for by a health
service that assesses and meets their health needs while in prison and which
promotes continuity of health and social care on release. The standard of
health service provided is equivalent to that which prisoners could expect to
receive in the community”. At section four, paragraph 32 she said:
“The prisoner’s GP and any relevant care agencies are contacted at
the beginning of custody, with the prisoners consent, to provide
relevant information to ensure continuity of care”.
54. In his clinical review, the clinical reviewer said that had the prison healthcare
requested the man’s medical notes from his own community doctor, it would
have allowed them to confirm his medical history. For example, he told a
nurse that he had no problems relating to drug misuse while his medical notes
showed that he has previously been dependent on amphetamines. He said
that had the man had been transferring from one NHS practice to another it is
something that would have been routinely done. He stressed that by not
requesting the man’s medical notes from his own doctor the care was not
equitable but does add that in his case it would not have identified any history
of suicidal ideation.
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55. The clinical reviewer makes a specific recommendation in his clinical review
that prison healthcare should request patient medical notes, or a summary
from the prisoners own doctor when received into prison custody. However, I
am content that the omission had no bearing on the circumstances of the
man’s death. The Chief Inspector of Prisons has made it clear what her
expectations are and, although I make no formal recommendation, I suggest
prison healthcare managers are reminded of what is expected.
Blood sugar tests
56. The clinical reviewer said that blood sugar results of 7.00 or more should be
followed up by a fasting test. This, he said, is to investigate the possibility of
diabetes. He said that in the man’s case this did not take place straight away
and was only carried out as a result of cardiovascular tests. He stresses there
had been no harm done as the subsequent test had found the level to be
normal. As the issue refers to a time when the man was at HMP Nottingham
a copy of the clinical reviewers’ review has been forwarded to the prison Head
of Healthcare for consideration.
Recording medical information
57. The clinical review has identified that a number of consultations with prison
medical staff took place but no entry was made in the clinical entry record.
The clinical reviewer is satisfied that the information relates to what he
describes as administrative matters rather than clinical contact. He does
though suggest the record keeping should be improved. Again there is no
bearing on the circumstances of the man’s death and so I do not make a
recommendation. However, the Head of Healthcare at HMP Sudbury will wish
to ensure that entries in patient medical records are written in such a way as
not to cause confusion.
The attempt to resuscitate the man
58. Although a matter for the police and not for my report the clinical reviewer
does make a recommendation to the ambulance service in his report, a copy
of which will be sent by the PCT to the service for its consideration. The
police would not allow the paramedic to attend the man and from what we
know it would appear to have been too late to effect a successful resuscitation
attempt. The clinical reviewer suggests the ambulance service should ensure
that there is a clear record of why they have been refused permission to
attend to a patient.
15
CONCLUSION
59. I am satisfied that the man had given no indication that he had thought about
harming himself or taking his life and that prison staff did not identify any risks
around the planned day release for 13 March. His actions that day appear to
have been planned after he left the prison, or if they were considered
beforehand, he kept his thoughts to himself. I am pleased that Sudbury took
good care of his son in what must have been difficult circumstances.
60. I make no recommendations in my report but do identify learning points for
healthcare at HMP Nottingham and the ambulance service local to HMP
Sudbury.
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