Individual at Chelmsford

Investigation into the circumstances surrounding the
death of a man at HMP Chelmsford in October 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
July 2007
This is the report of an investigation into the circumstances surrounding the
death of a man at HMP Chelmsford in October 2006. The man was found
hanging in his cell. He had been remanded into custody the previous day.
The loss of any family member is distressing, but especially so in these
circumstances. I offer my sincere condolences to the man’s family and
friends.
The investigation was undertaken by two of my colleagues. I would like to
thank the Governor of Chelmsford for making my investigators welcome, and
for arranging the necessary facilities to enable them to carry out their work.
Particular thanks go to the liaison officer and her colleagues for gathering all
relevant documentation and ensuring it was made available in a timely way.
Their assistance and support throughout the investigation was invaluable.
The Primary Care Trust carried out an independent clinical review into the
care and treatment the man received at HMP Chelmsford. I am grateful to the
clinical reviewer for completing the review. My investigators also contacted
the office of HM Coroner for the district and the investigating police
representative. I am grateful to both for providing relevant and useful
information.
The man had a history of alcohol and drug misuse, and had developed mental
health problems. He had been released from HMP Chelmsford in early 2006,
having completed a short sentence. Whilst serving that sentence, he had set
fire to his cell.
The man was arrested and again remanded to Chelmsford in October 2006.
He arrived in the early evening, went through the reception process and was
located on a wing in the main prison. This was contrary to the prison’s
practice of placing all new prisoners on the induction wing. The man died
during the night but was not discovered until 9.00am, the morning roll check
not having been carried out properly if at all. An internal Prison Service
investigation is underway to establish why this occurred.
My report makes six recommendations for the Prison Service and highlights
one example of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2007
CONTENTS
Summary 4
The Investigation Process 5
HMP Chelmsford 8
Key Findings 13
Issues 26
Conclusion 31
Recommendations 32
SUMMARY
Early in October 2006, North East Essex Magistrates’ Court remanded the
man into custody, following his arrest for driving whilst disqualified and driving
with excess alcohol. He was ordered to reappear in court late October.
Following his arrival at HMP Chelmsford, the man went through the First Night
in Prison (FNIP) interview and reception process. This included a cell sharing
risk assessment (CSRA). The officer completing the CSRA assessed the
man as low risk and recorded this on the form. It also showed that the man
had previously been in custody at Chelmsford. No drug or alcohol issues
were noted, and the man disclosed no special needs to staff. As part of the
reception process, he was interviewed by a FNIP Officer, and information
from the interview was documented. Officers detailed to carry out this work
are primarily located in E wing, the first night in prison induction wing.
The man was also seen by the registered mental health nurse (RMN) who
completed a first reception health screen. No issues or concerns were
recorded.
It is normal practice for new prisoners to be located in the first night wing, E
Wing, following their reception. This is a relatively new building. However,
the man was located on C wing in the original Victorian part of the prison. He
was given a flask for hot water and placed on his own in a cell on the third
landing. En route to his cell, the man expressed no concerns to the senior
officer who escorted him.
The night Operational Support Grade (OSG) completed the evening roll check
at approximately 8.45pm, before the man arrived on the wing. The next roll
check was scheduled for 6.00am the following morning, but it was not carried
out at the correct time if at all. At about 9.00am, a senior officer on C wing
received a telephone call instructing her to collect the man and take him to
healthcare for the remainder of his induction. The duty was delegated to an
officer who made his way to the third landing. When the officer went into the
cell, he saw the man hanging by a ligature from the window bars. The alarm
was raised and three prisoners helped the officer. Other staff then arrived
and took over the emergency response. The officers checked for signs of life,
and began to administer cardio pulmonary resuscitation (CPR) until
healthcare staff and the paramedics arrived. All attempts to revive the man
failed and he was pronounced dead at 10.10am.
My investigation into the man’s death started in October 2006. As part of my
investigation, I have looked into the concerns of his family about what might
have led to him apparently taking his own life and whether more could have
been done to prevent it.
THE INVESTIGATION PROCESS
1. In October 2006, one of my investigators opened the investigation and
met the Deputy Governor, Prison Family Liaison Officer, Prison Liaison
Officer and the Head of Healthcare at HMP Chelmsford. My
investigator was briefed about the circumstances leading to the man’s
death and a number of relevant files and records were examined. My
investigator also met a member of the local branch of the Prison
Officers’ Association (POA), and with a member of the Independent
Monitoring Board (IMB), to brief them about the investigation process.
They were informed that they could speak with my investigator at any
time during the course of the investigation, should they or others have
any further information.
2. My investigator visited the wing and cell where the man was discovered,
and viewed the window bars used to secure the ligature. He also visited
the prison reception area and the First Night in Prison (FNIP) wing. He
observed the environment and clarified the procedure for prisoners who
cannot be located in a first night cell when the wing is at full capacity.
3. The Governor commissioned a separate investigation to ascertain the
last time that the man’s cell was checked. The internal investigation
was launched with immediate effect following verbal evidence that C
wing’s roll check had not been carried out at 6.00am that morning of
October 2006. A member of staff was suspended from duty as part of
this ongoing investigation.
4. My investigators wrote to a number of prison staff and two prisoners,
inviting them for interview. They also wrote to the suspended member
of staff to provide them with the opportunity to participate in the
investigation. Interviews took place between November 2006 and
January 2007. A third prisoner, present when the man was found, had
moved prisons and other witnesses have referred to his role.
5. Later in November, my investigators met the Governor for a debriefing
when the emerging findings and recommendations were discussed.
The Governor welcomed the feedback and confirmed that he had
instigated his own investigations. I welcome the Governor’s prompt
actions.
6. A Medical Records Reviewer of the Primary Care Trust carried out a
clinical review into the care and treatment the man received at HMP
Chelmsford.
7. One of my Family Liaison Officers (FLOs) contacted the man’s next of
kin shortly after the investigation was opened. My FLO explained the
role of the Ombudsman’s office and provided information about the
investigation process. My FLO also offered the dead man’s family the
opportunity to meet her and one of my investigators to discuss issues or
concerns. My FLO and one of the investigators later visited the man’s
family at their home where the following concerns were raised:
(cid:127) The family told us about the man’s previous period at Chelmsford
during which they said he became depressed and suffered a
breakdown. He set his cell alight, was hearing voices, and did not eat
for some days. They contacted the prison on several occasions and
asked for him to be moved to the healthcare centre. He was eventually
relocated to the healthcare centre where he harmed himself and was
placed on a ‘suicide watch’. They said he was not assessed by a
psychiatrist, and was only prescribed a sedative. The family raised
concerns about the lack of care they said the man had received on his
last time in the prison.
(cid:127) The family said that the man’s mental health needs were assessed
after he was released. He was diagnosed as paranoid schizophrenic
and prescribed medication, which he took until his arrest. The family
said they informed the police the he was on medication, but believe
that he did not receive it between being arrested and his death. They
do not think that the information was passed to the prison and are
addressing the matter independently of this investigation.
(cid:127) They asked for information about the likely effects of withdrawal of the
medication.
(cid:127) The family asked whether the man had legal representation at Court.
(cid:127) The family said that prison staff had failed to identify the man’s mental
health needs on this occasion. They argued that his previous
imprisonment was so eventful that staff should have remembered him
and known about his needs. The family said the man was assessed by
the same healthcare professional on both occasions, and the member
of staff should have remembered him, regardless of what the man
said. They believe the man would have displayed visible signs that
should have been recognised.
(cid:127) The family consider that staff should have had access to the man’s
previous prison records.
(cid:127) The family think that the man should not have been in a single cell or
one with ligature points.
(cid:127) The family are concerned that the man was not checked more often in
the night and morning.
(cid:127) They asked us to clarify what time the man was found.
(cid:127) They asked us to say what the man had used as a ligature as they had
been given conflicting information.
(cid:127) The family were concerned that one of the prisoners who assisted with
the emergency response had now moved prisons and would not be
able to speak to the investigators.
HMP CHELMSFORD AND YOUNG OFFENDER INSTITUTION (YOI)
8. HMP Chelmsford is a category B local male prison holding remand,
unsentenced and sentenced adult men and young offenders. It
predominantly serves the courts of Essex and adjoining areas, but also
takes some young offenders from London. Chelmsford is essentially
two prisons made up of original Victorian wings and newly built
residential units. Wings A to D, in the Victorian part of the prison,
contain the segregation unit, two adult male and young offender wings
and a vulnerable prisoner unit (VPU). The new part of the prison
contains C wing, which is mixed with 132 young offenders and adult
men, E Wing, which has the First Night in Prison (FNIP) wing, and G
wing for employed and enhanced status prisoners.
9. As a local prison, Chelmsford receives a large number of prisoners
direct from the courts and there are constant population pressures. The
new wings were designed to relieve overcrowding and increased the
prison’s capacity by 75. The overall capacity is now 575 but the jail
remains one of the most overcrowded in England and Wales.
10. Her Majesty’s Chief Inspector of Prisons (HMCIP) inspected Chelmsford
in 2002 and 2004. The second inspection was unannounced and
reported a prison making good progress after a difficult history. A
number of recommendations had been achieved or partly achieved,
including the introduction of an effective first night in custody risk
assessment, although a lack of information from the courts still hindered
Chelmsford’s attempts to carry out thorough assessments.
11. The reception area is currently under development to enlarge and
improve it. HMCIP reported in 2004 that, despite the number of
prisoners coming through each day, reception was staffed well and was
a welcoming place for new arrivals. The inspectors witnessed
approximately 100 movements on any given day, and noted that the
figure increased on Fridays (the day the man arrived at Chelmsford).
Inspectors were impressed with the priority given to cell sharing risk
assessments and noted further improvements in staff-prisoner relations.
(The man was not identified in the reception checks as someone who
posed a risk to himself or others.)
12. The induction wing (E wing) is staffed at night by prison officers, but C
Wing (where the man was located) is staffed by an Operational Support
Grade (OSG). No prisoners on either wing are checked at night unless
they are on the escape list or being monitored under suicide and self
harm procedures.
13. Unlike the original residential wings, E wing is a modern building with
newer cells, both single and double, though none is designated as a
safer cell. It holds a maximum of 126 prisoners, the majority of whom
will be new arrivals. Staff are specifically selected to work on the wing,
and it has its own consistent management team. There is a 24 hour
Listener service. (Listeners are prisoners trained by Samaritans to offer
help to their peers.)
14. A welcome pack containing a pen, a bowl, plastic cutlery and a tea
pack, is placed on the bed for new prisoners. New prisoners located
elsewhere in the prison may not receive the welcome pack
straightaway.
15 The HMCIP report said that the prison’s induction programme had
improved and areas of good practice had emerged. There was a full
programme for new prisoners, irrespective of where they were initially
held and whether they had been in custody previously. Clear
information was available from booklets, notices and the Insiders
(prisoners trained to support and assist those newly arrived from court)
who made presentations using their own materials. The Insiders
travelled around the wings to repeat their induction presentation to
prisoners held on other wings. They helped to identify prisoner’s needs
and assist with any concerns.
16 Suicide and self harm prevention at Chelmsford had improved and
HMCIP reported positively on the monitoring systems in place for those
identified as at risk.
17 HMCIP found a noticeable commitment to reducing self harm and
suicide in the prison. They observed that prison staff adopted a caring
approach to prisoners at risk.
Suicide and self harm monitoring
18. The F2052SH was a Prison Service document used to assess and
observe prisoners at risk of self harm. The F2052SH has now been
replaced by the Assessment Care in Custody and Teamwork (ACCT)
system. An ACCT form carries out a similar function to the F2052SH,
but additionally highlights the problems and possible trigger points of a
prisoner at risk of self harm, and develops a multi disciplinary plan to
give support and help through a period of crisis. When the prisoner is
no longer considered at risk, the form is closed.
Reception
19 On arrival at the prison, all paperwork for prisoners is checked before
they are taken off the escort vehicle. Staff check warrants to ensure
they have the correct prisoners in custody, and then set up the
necessary records. The prisoner is taken from the vehicle and booked
in by the senior officer on the front reception desk. Personal and
offence details are taken, along with any known or identified concerns.
Reception staff do not have access to any previous custodial history at
this time.
20 All prisoners see the first night in prison officer (FNIP), reception
officers, and the nurse on duty. During this process, staff obtain
address and next of kin details. The new arrivals are allocated a new
prisoner number, irrespective of whether they have been in prison
before. Prisoners are strip searched, their property is logged, and they
are health screened, before being placed in a holding cell, ready for
locating staff to take them to a wing.
Local inmate database system (LIDS)
21 All prisons use a local database computer system to store basic details
about a prisoner from their arrival to their release. It holds personal
details along with movements of the prisoner whilst in custody, for
example dates he or she went to court.
Emergency alarm codes
22. The alarm system used in Chelmsford is a two tone system. If a
member of staff presses an alarm bell, it is transmitted over the hand-
held radios. A code 1 alert indicates a life threatening situation.
Locating officers
23. When prisoners complete the reception process, locating officers
assess them by checking the records and the cell sharing risk
assessment before taking them to a wing. Locating officers usually
come from A wing but, when the reception is busy, staff from other
wings may assist. They are expected to work in pairs in accordance
with the Local Security Systems instructions (LSS). Prisoners returning
from court usually go back to the wing where they came from earlier in
the day. New prisoners are usually located in the First Night in Prison
wing. The duty governor or principal officer is informed when high risk
or vulnerable prisoners are received.
Movement officers
24. During the course of the day, movement officers are used to move
prisoners to other parts of the prison and create space, primarily on E
wing, for new prisoners.
Insiders and Listeners
25. As noted and in common with most prisons, Chelmsford uses
experienced prisoners to operate as Insiders and Listeners. Insiders
welcome new prisoners, highlight any concerns and explain the
processes they will encounter in the early days of custody. Listeners
assist those prisoners who require additional support at any time in their
period in custody. They are provided with training from the Samaritans
to support them in this role.
Roll Check
26. The roll check is the physical count of the number of prisoners on each
wing within a prison. Roll checks occur on a number of specified
occasions during the day, and staff must sign that the roll is correct.
The prison’s local instruction states that:
1. Roll checks will take place and be signed for at the following times:
(cid:127) By the night staff before handing over to the oncoming day staff
at approximately 0600hrs.
(cid:127) The end of the morning activities at approximately 12.30hrs.
(cid:127) The end of afternoon activities at approximately 17.00hrs.
(cid:127) The end of the evening activities at approximately 20.30hrs.
2. Night staff will conduct Roll Checks at the following times:
(cid:127) At the start of duty prior to the day staff finishing their duty.
(cid:127) At 06.00hrs.
Safer cells
27. Chelmsford has a number of ‘safer cells’, which are specially designed
to contain as few ligature points as possible. They are used for
prisoners assessed to be at risk of harming themselves.
Detoxification addiction team
28. Chelmsford has a team of addiction nurses whose role is to work with
prisoners who are withdrawing from drugs or alcohol. They offer
detoxification programmes, look at harm minimisation, harm prevention
and blood borne viruses. Prisoners may be referred to other agencies,
including the Counselling, Assessment, Referral, Advice and
Throughcare (CARAT) team and doctors and drug services in the
community.
29. The prison’s general protocol for prescribing medication to new
prisoners is that, if they do not bring medication with them, none is
prescribed until the following morning when they see a doctor and/or
detoxification nurse. Staff then contact the prisoner’s doctor or hospital
to check the details. Medication is removed from prisoners so that staff
can check that the label is correct.
Weekend regime
30. The weekend prison regime differs from weekdays. Staff numbers are
reduced at weekends and employed prisoners do not go to work. A
small number of prisoners may attend workshops or an education class
in the morning, or attend the chapel and visits. Their cells are opened
at around 8.30am and the wing cleaners are unlocked around 9.00am.
Others are unlocked according to whether they are using the gym or on
association.
KEY FINDINGS
The man’s previous imprisonment at HMP Chelmsford
31. The man was arrested in November 2005 and remanded in custody at
Chelmsford. He was assessed as a low risk prisoner. He saw the
healthcare staff as he suffered from sleeplessness, and was prescribed
zopiclone. In January 2006, the man went to court. Staff commented
that he was in good spirits and presented no concerns. He was further
remanded in custody until the start of his trial in February, and returned
to Chelmsford where he was located on E wing.
32. On 18 January, a F2052SH document was opened on the man and he
was described as low in spirits, possibly because his court case was
imminent. Although the man was described as demanding, staff said
that he caused no problems. He was placed on an hourly observation
watch, and was in a shared cell.
33. The F2052SH remained open until 26 January. The man told staff that
he was depressed, had heard voices telling him to kill himself, and was
not eating or sleeping very well. The staff ensured that the man had
access to Listeners and the Samaritans. They also monitored his eating
patterns. A mental health assessment was carried out by a Registered
Mental Health Nurse on 22 January. No mental health concerns were
noted. The man told her that he was stressed because of his
forthcoming court appearance, and he constantly kicked the cell door
and rang the cell bell. His moods fluctuated from good to bad. Some
days he mixed with other prisoners and presented no concerns, but on
others he reported hearing voices, failed to eat and stayed in his cell.
34. On 27 January, the man was assessed by a consultant psychiatrist and
disclosed that he had been sectioned to a hospital approximately four
years earlier for what he described as “drugs and things”. He said he
was a heavy user of alcohol, cannabis and cocaine, was hearing voices
and thinking of taking his life. The man said he had been seeing things,
such as animals, which he believed was because he had not had any
alcohol or drugs for several days. The psychiatrist recommended that
the man undergo a detoxification regime and be referred to the CARAT
team. The consultant also suggested requesting a second opinion, as
he was doubtful about the authenticity of the man’s statement that he
was hearing voices.
35. The man saw a doctor the same day. This second doctor assessed that
his descriptions of hearing voices and seeing things were very vague.
The doctor said that, whilst it was possible that the man was
experiencing hallucinations, he wondered what his agenda was and
whether he was trying to gain anything such as medication. The doctor
concluded that the man should remain on medication to keep him
relaxed, and suggested that a drug test should be undertaken. Should
the test produce a negative result, the nurse should treat him with
rispiradone, which is usually used to treat psychosis, schizophrenia and
hypomania.
36. Later that day, the man barricaded himself in his cell and set it alight.
He failed to comply with staff instructions, and entry to his cell was
forced. Control and Restraint procedures were then used to remove
him. He was taken to healthcare, where the F2052SH was re-opened
and he was constantly watched by healthcare staff. Again, staff
reported the man as depressed and at risk of suicide or self harm. He
said he was hearing voices. The next day, the observations were
reduced to 15 minute intervals and he was monitored regularly by
nurses, the doctor, and consultant psychiatrist, but displayed no obvious
psychotic symptoms.
37. The man stayed in healthcare until 20 February, and the F2052SH
remained open. Weekly case reviews took place and his mood was
generally more settled, although staff said that occasionally he had bad
days. On 20 February, the man was escorted to appear in court where
the charges against him were dropped and he was released.
Final period of imprisonment
38. The man was arrested again one evening in October 2006 for a drink-
driving offence. Police custody records confirm that he was taken to a
Police Station and remained in custody. His sister said that she went to
the police station the following day and told the custody officer that the
man was on medication. She was assured that the man had seen a
doctor and was being looked after. She was also told that her brother
would undergo a thorough health assessment in prison. (From the
police documentation provided to my investigators, there was nothing to
confirm that her visit had taken place.) The man was charged with
driving whilst disqualified and driving with excess alcohol, and remained
in police custody until a court date was set.
39. The man was taken from the police cells to the Magistrates’ Court at
around 9.00am. The escort records indicate that he presented a risk of
violence, but had no known risk of medical problems or any other
issues. The court records show that the man was checked
approximately every ten minutes whilst in the holding cells. No
concerns were noted. The records indicate he was also visited twice
during the course of the day by the duty solicitor. The man was
checked continually until he was placed in the escort vehicle at 5.45pm
for his transfer to Chelmsford. The magistrates remanded him into
custody for one week.
40. The escort van arrived at Chelmsford at 6.20pm. The evening was
described as a typical busy Friday night, with approximately 41
prisoners arriving. My investigators were unable to identify how many
were new prisoners and how many were returning from court
appearances.
41. The man was seen at the reception desk and booked in at
approximately 6.50pm by a Senior Officer (SO). The Senior Officer told
my investigators that the man did not stand out, and no issues were
raised when she spoke to him. She received all the relevant paperwork
from the escort staff for him. None contained issues or concerns from
the court or from the police custody records. The Senior Officer passed
the man to the second stage of the reception process, the First Night in
Prison (FNIP) interview, which takes place whether or not the prisoner is
newly received or returning from court. The man was interviewed by an
officer for five to ten minutes and was asked for basic details which
were recorded in a FNIP “Passport”.
42. The officer told my investigators that information for the “passport” is
obtained from the prisoner, and so the quantity and quality of the record
depends on how forthcoming the prisoner is. The “passport” contains
five pages and asks about drug or alcohol problems, next of kin details
and housing issues. It also introduces prisoners to the prison’s regime
and tells them what they can expect to happen. The “passport” is
passed through the reception and induction process. Should the
prisoner need help or have any special needs, they are identified and
recorded. The prisoner is then referred to the necessary agencies.
43. The man was asked whether he had been in prison before, and told the
officer that he had. My investigators asked the officer whether he had
access to previous prison records, and he said that he did not. The
man denied having any drug or alcohol problems, and said that he had
no worries or special needs. The man provided no next of kin details,
something which the officer said was quite normal for a lot of prisoners.
He signed the passport, stating that he had received a timetable for the
next 24 hours, an induction booklet, a reception visiting order, and
copies of the standard compact, education and employment compact.
The man confirmed that all the information he had provided was correct.
The officer explained the terms and conditions for the PIN phone
system, as well as providing information about his history sheet,
Listeners, Insiders and Samaritans, the prison’s diversity and violence
reduction policies, together with the use of the emergency cell bell.
When the interview was complete, the man was placed in the front
holding cell to await a further interview with the reception officers.
44. Another officer interviewed the man to gather further information about
his background, history, and whether he had any outstanding court
dates. A core record document (F2050A) was opened and information,
including his next of kin details, previous period in custody at
Chelmsford and release date (February 2006) were recorded.
45. The officer also completed the cell sharing risk assessment form
(CSRA). The man told her that he had previously abused alcohol and
drugs and was currently dependent on both. The officer recorded this in
Section 2 of the CSRA, before assessing the man as a low risk prisoner
who was suitable to share a cell. The officer told my investigators that,
although staff may know that a prisoner has been in custody previously,
it is at least the next day before previous files are retrieved. The man
was given the opportunity to make a telephone call and my investigators
were told by his family that he telephoned his mother. He said that he
was okay and told her not to worry. She told him not to do anything
stupid, and the man said he would phone her again soon.
46. For the next stage of the reception process, the man was interviewed in
private by a Registered Mental Nurse (RMN). The nurse completed a
screening of the man’s immediate physical and mental health needs
and the relevant section of the CSRA. She asked if he had sustained
any injuries over the last few days, which he denied. The nurse told my
investigators that the man’s record showed that he had been released
from Chelmsford in February 2006, but she did not remember him and
had no access to his previous records at that time.
47. The nurse asked the man a number of questions, with the aim of
assessing the level of risk he posed to himself and others. She
recorded on the CSRA that no risks had been identified. She ticked the
“Low” indicator, meaning the man was suitable for a shared cell. The
nurse said that she had no concerns about self harm and said that, if
she had known his history, she would have questioned him further and
considered opening an ACCT document. She said that two high risk
factors on the CSRA were whether it was an individual’s first time in
prison, and the type of offence. The man had been in prison before,
and was on remand for a driving offence, both indicating that he was
low risk of suicide or self harm.
48. The nurse asked the man a number of questions about his general
health. He denied having seen a doctor in the last few months, having
any outstanding hospital or doctor’s appointments, receiving any
prescribed medication or having any concerns about his physical health.
Under the section headed Substance Use, the nurse asked the man if
he had a drug or alcohol problem and he said that he had taken
benzodiazepines, amphetamines and cocaine approximately two days
before coming into prison. She asked if this was a problem. He said it
was not and refused the offer of a referral to the prison doctor. She said
that he showed no symptoms of withdrawing from drugs or alcohol,
such as shaking, shivering or sweating.
49. The final part of the CSRA relates to Mental Health, and the man told
the nurse that he had never received medication for mental health
problems or been treated by a community psychiatrist. He said that he
had never harmed himself and had no current thoughts of doing so.
The nurse completed the man’s assessment by referring him to see the
substance misuse nurse the following morning.
50. After the interview with the nurse, the man waited in the back holding
cell until a location officer was available to escort him to a cell.
51. The man’s induction booklet said that he would see an Insider either on
the induction wing or wherever he was located. The Insiders live and
work on E Wing, and do not work in reception. There is no record that
the man came into contact with an Insider.
52. Another officer came on duty as a locating officer at about 5.30pm. He
said that he expected new prisoners to be placed on E Wing, the
induction wing. He had experience of the wing being full, but said that
staff made every effort to make space available and accommodate the
new prisoners. This occurred throughout the day and into the evening
when prisoners arrived late. The officer explained that E wing staff
moved prisoners who had completed their induction to other wings in
the morning and afternoon.
53. A Principal Officer (PO) was the Orderly Officer on this day in October,
which meant he was in charge of the prison. He came on duty at about
5.45pm and began visiting various parts of the prison. He remembered
receiving a telephone call soon afterwards from an officer who was
working in reception as a locating officer. The locating officer was
asked to locate a different new prisoner on C Wing. The prisoner was
well known and, during previous occasions in custody, had been held in
the vulnerable prisoners unit.
54. The Principal Officer said that he was strict about the locating
procedures, and so told the locating officer that under no circumstances
should a new prisoner be located anywhere other than on the Induction
Unit. The Principal Officer said that staff should seek the permission of
the Orderly Officer before digressing from the established protocol, the
Chelmsford Locating Policy. He believed that the protocol was
commonsense, because the first days were the most worrying time for
new prisoners and the infrastructure in the unit provided better support.
55. The locating officer began his reception locating duty at around 6.15pm.
He described it as a busier night than normal because it was necessary
to move some prisoners about to make space. He said that, shortly
before he went off duty at 9.15pm, he located a prisoner onto E Wing
and so was aware that limited space was available. He remembered
moving a prisoner who was on his own to share with another prisoner
and free up a space. This was because a single cell was needed for a
new prisoner.
56. The locating officer told my investigators that he knew that the majority
of new prisoners should go to E Wing. As he came on duty, he would
contact the wing to ask the number and type of spaces available. On
arrival in reception, he would therefore be able to compare the E Wing
capacity with the number of new prisoners. If it was apparent that there
was insufficient space, it would be highlighted to staff and the Orderly
Officer. Measures would then be taken to make space available. The
locating officer said he was not aware of a written procedure for what to
do when E Wing was full, but he had been instructed to identify
prisoners who had completed their induction and could be moved. The
prisoners would be told to pack their belongings and move to wings B
and C. This had previously happened late into the evening and early
part of the night.
57. The Operational Support Grade (OSG) came on duty at 8.30pm and
was working on C wing. He told my investigators that this was his first
set of nights after training, which had consisted of shadowing another
OSG for one night then doing another night by himself. He said that his
training was limited, and he had not been trained on ACCT or the use of
the Local Inmate Database (LIDS). He knew that he had to check
prisoners on ACCT or on the escape list, but did not check others. He
also knew that two roll checks were required in the course of each night.
His duty rota begun the previous Sunday, and so the Friday was his
sixth consecutive night. He said he was feeling very tired, but described
the night as normal compared with his experience so far.
58. When the OSG arrived on C Wing, he noticed three or four officers
booking in what he believed were a couple of new prisoners. They
completed their paperwork and updated the information board in the
office. The OSG asked where the prisoners on ACCT and escape list
were, and noted their location. The officers did not draw any matters to
his attention, and when they left the wing the OSG began to carry out
the evening roll check of C wing.
59. At around 8.30pm, a Prison Officer assisted in reception where he was
very familiar with the routine. He had not been informed that the prison
wing capacity was limited and so had not made any arrangements to
create space on E wing.
60. A Senior Officer (SO) completed her normal C wing duties and made
her way to the gate to leave for the day. She was told that reception
was still busy and prisoners were still waiting to be located. She agreed
to stay on duty to assist, and reported to reception shortly afterwards.
She took on the role of a locating officer, along with three other locating
staff who remained on duty. She spoke to one of them (whose name, in
interview, she could not recall) who told her that E wing was full. She
and another officer immediately began to locate prisoners. The officer
was an A Wing officer who was also assisting in reception. He told my
investigators that he accompanied the SO to locate two other prisoners,
and that locating in pairs was the prison’s policy.
61. The officer from A wing did not recall seeing the man who died in
reception, but did remember him from a previous period in custody.
When he and the Senior Officer returned to reception, they collected
another prisoner who was returning from court and was to be located on
B Wing. They left reception again and returned at around 9.05pm. The
officer from A wing went off duty at 9.15pm after about 45 minutes
locating prisoners, none of whom went to E wing.
62. At about 9.00pm, the locating officer returned from locating prisoners on
E wing where he had checked the roll board. He told the officer, who
was helping with the location, that there were five empty adult spaces in
shared cells on the wing. He left reception with more prisoners at about
9.20pm, and then went off duty.
63. The Senior Officer told my investigators that she had located prisoners
on B wing, and was aware of the wing capacity. She said it was normal
to try and keep the numbers on B and C wing equal, and so she
expected the next two prisoners to be located on C wing. An officer
asked her to hand out food packs, and she went to the servery to check
how many meals were in stock. She became aware of the man who
died standing next to her, and passed him a sandwich pack and some
cake which he put in his bag with his cereal and bedding pack.
64. The senior officer told the man that, if he waited where he was, she
would locate him instead of putting him in the back holding cells. Whilst
she was attending to the man, another prisoner whom she knew
finished seeing the nurse. She picked up another sandwich pack,
handed it to him, and told both men that she would locate them to C
wing straightaway. The other prisoner was a young offender who was
returning from court. Because of his status, he would automatically
return to the wing he had left.
65. The Senior Officer escorted both prisoners to C wing at around 9.30pm.
In interview, she confirmed that officers usually worked in pairs, but on
this occasion she went alone as nobody else was available to assist
her. She said that she was happy to do this and, although she did not
know the man, she did know the other prisoner. She described the man
who died as quiet, well behaved and observant. He was communicating
and responded when he was spoken to.
66. When the Senior Officer and the two prisoners arrived at C Wing, it was
quiet as all prisoners had been locked in their cells from around 6.45pm
that evening. The Senior Officer did not see the OSG on duty and
thought that he was dealing with a prisoner on another landing. The
Senior Officer first took the young offender to his cell on the first landing
where the majority of the young offenders were located, and the man
who died stood and waited for her. It was now around 9.40pm.
67. The Senior Officer told the man that there was a cell for him on the third
landing, and told my investigators that he responded saying, “ok miss.”
She said that en route to the cell they did not discuss whether he
preferred to share a cell or not. However, a single cell was available,
and she identified it for him. It was a normal prison cell, rather than a
safer cell.
68. On arriving at the cell, she opened the door, turned the light on and
asked the man if he had a cup. He said, “no, I haven’t.” The Senior
Officer then left, and went to the office where she found a flask for the
man to use. She returned and said that the man could use the flask
until the following day when his cutlery was sorted out. She said that
the man responded, “that is fine miss.” He went into the cell, and the
Senior Officer shut and locked the door behind him. She said that the
man seemed fine.
69. The Senior Officer went to attend to another prisoner who had been
banging his door opposite the cell where the man was located. She
then went downstairs to the wing office and recorded both the man’s
and the young offender’s names on the wing board and wing book to
inform the OSG that there were two additional prisoners. She spoke to
the OSG and helped him with some difficulties with another prisoner.
The Senior Officer said that she eventually left the wing around
10.10pm and returned to reception. Although there were some
prisoners still waiting to be located, she was told that she could go
home and eventually left the prison at approximately 10.15pm.
70. The OSG told my investigators that his memory of the evening was
vague, and he thought that the man and another prisoner were brought
to the wing by a male officer at approximately 9.30pm. He said that he
might have been on one of the landings or in the office when the officer
arrived. He recalled the officer asking if there were any free cells, and
replied that the board in the office would provide the information. He
checked the board and found that there was a space on the ground
floor. The OSG said he did not know the prisoner located on the ground
floor landing, but did know that the man was located on the third landing
because the information board in the office had been updated. He also
knew that neither prisoner was subject to ACCT or on the escape list.
The OSG also remembered speaking with the SO on the third landing,
and said that she assisted him with a prisoner who had asked to see a
nurse. He described the night as a normal night duty shift, and he was
busy doing paper work and other tasks which he said were part of the
OSG role. The OSG said no call bell went off for the man’s cell
throughout the night.
71. The OSG said that the local procedure was that the morning roll check
should be carried out at approximately 6.00am. However, because he
was tired, he decided to carry out the roll check earlier between 4.00am
and 4.30am. He said that he checked the man’s cell and he was
asleep. After completing the roll check, the OSG signed the roll sheet to
confirm that the numbers were correct for each landing. The roll check
sheet would signify that the 6.00am roll check had been done.
72. The Night Orderly Officer on duty the evening the man was admitted to
Chelmsford visited all the wings throughout the night as a matter of
course. She recalled visiting C wing and no issues or concerns were
brought to her attention. She spoke to the OSG who was a little
flustered, as he said he had some personal problems, but said he was
fit to carry out his duties. As the roll check figures have to be in by
6.00am, she visited each wing beforehand to collect the wing roll
sheets. She arrived at C Wing at 5.35am, and remembered the OSG
saying that he had not yet completed the check.
73. My investigators checked the wing roll sheet to see if it had been
completed and signed to confirm that all prisoners in cells had been
checked. It was signed by the OSG who had recorded that the check
was completed at approximately 6.00am.
74. The OSG finished his night duty at 7.35am. He was relieved by another
officer and the relieving officer was updated on the ACCT and escape
list prisoners as well as the roll count.
75. An officer came on duty at 7.45am to take over from the OSG who
reported that there were no problems. She checked the prisoners on
ACCT and the escape list, but was not required to carry out a further roll
check. She realised that the canteen sheets had not been handed out
during the night, and went to every cell to slide the sheets underneath
the door. The officer said that all seemed quiet on the wing, and she
returned to the office after completing the task. Other staff started to
arrive at around 8.30am and the Senior Officer briefed them on their
responsibilities.
76. The Senior Officer came on duty at 8.30am on Saturday morning and
briefed her staff. At about 9.00am, she received a telephone call for an
officer to escort the man to the healthcare centre to continue his
induction programme. She passed the request onto an officer who had
just unlocked the cleaners and was about to escort an escape list
prisoner to chapel with another officer.
77. The officer to whom the Senior Officer’s instruction was given asked
another officer to unlock the ecape list prisoner, while he unlocked the
man. Security instructions state that two officers are required to escort
an escape prisoner from one location to another. The officer said he
would bring the man downstairs and would meet the other officer back
in the office. The Senior Officer would take the man to healthcare and
the two officers would escort the escape list prisoner to chapel.
78. The officer told my investigators it was approximately 9.30am when he
got to the man’s cell door on the third landing. On unlocking the door,
he said that it did not immediately register that the man was hanging
and thought it took a couple of seconds for him to realise what had
happened. The officer shouted at the two cleaners on the landing to
come and help, and put out an “urgent message” over the radio to say
that assistance was required. They ran in and he lifted the man while
the prisoners untied him from the window bars and lowered him to the
floor.
82. Three prisoners carrying out their cleaning duties responded to the
officer’s shout. They ran into the man’s cell and also saw him hanging
from the window bars. The two prisoners helped the officer support the
man’s body, whilst the third jumped up onto the top bunk bed and untied
the sheet from the window bars.
83. The other officer, who was supposed to meet the first in the office, was
on the second landing and heard on another officer’s radio that an alarm
had gone off. (The alarm system is a two tone system that means that,
if a member of staff presses an alarm bell, it comes over the radio.) The
officer saw the other officer running towards him, shouting that the
alarm was on level three. The officer ran to the third landing and saw a
prisoner enter the man’s cell. He followed the prisoner in, saw the first
officer struggling, and put his arms around the officer and the man’s
body and lifted them both up. The officer saw three prisoners in the cell,
and that one was on the top bunk trying to untie the sheet from the
window bar. The officer told my investigators that, once the bed sheet
was freed, they laid the man on the floor as gently as possible. He
described the man’s body as cold and he looked dead. The first officer
then began to carry out cardio pulmonary resuscitation (CPR).
84. The officer was closely followed by a Principal Officer (PO) who was
orderly officer that day. The Principal Officer told the prisoners to return
to their cells to make way for staff. (Although I make no formal
recommendation on this point, the Governor should endeavour to pass
on my commendation of the actions of those prisoners who assisted
staff.)
85. A Prison Officer who had been in the governor’s office when the alarm
came over his radio responded immediately and went to the man’s cell.
He told my investigators that, as he got to the third landing on C wing,
the alarm changed to a Code 1 which indicated that the incident was life
threatening. He arrived at the man’s cell where there were several staff.
The man was on his back on the floor and being moved to the centre of
the cell. The Prison Officer saw that he still had a bed sheet around his
neck. He was given a fish knife (a knife specifically designed for cutting
ligatures). The Prison Officer began to cut the ligature from the man’s
neck, and noticed that it was already loose and not restricting his
airway. He then noticed a thin line or mark around the man’s neck and
saw a shoe lace hanging from the bars.
86. The Prison Officer explained to my investigators that he experienced
great difficulty in opening the man’s airway, and said his main priority
was to open his mouth and give mouth to mouth resuscitation. He was
unable to unlock his jaw, which was rigid, even with the assistance of
another officer to tilt the man’s head back.
87. Another officer also heard the alarm over the radio, and arrived at the
cell with Physical Education Instructor as the man was laid on the floor.
He assisted the Prison Officer by tilting the man’s head back to try and
get some air into the man. However, there was still no movement and
the officer said that the man’s body was very stiff and rigor mortis
appeared to have set in.
88. The officer removed a respiratory aid (a small breathing instrument)
from his belt pouch, and put it over the man’s lips and mouth to aid
resuscitation. The Duty Governor arrived at the cell and saw the
officers carrying out chest compressions on the man. (The duty
governor had overall responsibility for the prison, taking charge of the
death in custody contingency plans.)
89. Two nurses arrived at the same time as a Senior Officer and he told
three of the five prison officers in the cell to leave the cell so the nurses
had room to work. The other two officers stepped aside so the nurses
could try to resuscitate the man but would assist occasionally, at their
request. Although all officer grade staff who attended to the man felt
competent in trying to resuscitate him, none had had any recent first aid
training.
90. The Prison Officer continued CPR until the nurses took over. One of
the nurses also struggled to open the man’s airway while the other
nurse passed a nasal tube to insert through his nose before connecting
an oxygen tank. She continued CPR until the paramedics arrived. One
of the nurses told my investigators that when she received the
emergency call over the radio, she met another nurse who followed her
to C wing. As they made their way to the wing, they saw the third nurse
who also joined them. The nurse collected the emergency bag and took
it to the man’s cell. The nurse recalled that the man was very cold to
the touch and had been incontinent of urine. The nurses remember
seeing three officers on the floor and two were administering CPR. The
nurse gave one officer a face mask and told him to administer mouth to
mouth resuscitation, using the nose, until another nurse inserted a tube
and linked the man to the oxygen.
91. The Duty Governor did not know whether an ambulance had been
called, as the staff in the cell were trying to treat the man. He called for
an ambulance over his radio via the control room, and spoke with the
emergency services. The Duty Governor assigned log keeping
responsibilities to the Senior Officer and remained outside the cell.
92. A Prison Officer told my investigators that they had been working on the
man for about six minutes before the paramedic arrived. When the
nurses had arrived, he decided to step back to allow them to continue
trying to revive the man, and he began to instigate the crisis
management procedures, liaising with the governor as necessary. The
Prison Officer said that the paramedic took charge when he entered the
cell, telling the nurses to stop what they were doing. He examined the
man, and said (at approximately 9.50am) that he had died. The Prison
Officer recalled that the paramedic then used his radio to inform the
ambulance crew, who were following behind him, that he no longer
needed assistance.
93. The Duty Governor told my investigators that he and his staff suspected
that the man was already dead when they arrived at the cell, but as it
was unconfirmed he had not called the police until he was sure of the
type of incident he was dealing with. He said that he was disappointed
when the paramedic said that he thought that the man had been dead
for five or six hours.
94. The post mortem report confirmed that the cause of the man’s death
was suspension. There was a thin ligature mark running around his
neck described as consistent with that of a ligature such as a shoe lace.
The toxicology report found that the man was not under the influence of
any drugs or alcohol at the time he died. There was also no trace of
olanzapine, a commonly used drug in the treatment of schizophrenia,
which the man had apparently been prescribed. However, the report
does say that olanzapine is unstable in post mortem blood tests. The
result therefore does not necessarily indicate that the man was not
taking his medication.
After the man’s death
95. As soon as the paramedic pronounced the man’s death, the Duty
Governor informed the police and the locum doctor (who was already in
the prison). The doctor certified the man dead at 10.10am. The Duty
Governor ensured that full contingency plans were implemented,
gathered as much information as possible about the man’s short time at
Chelmsford, before opening the command suite. He told my
investigators that, because it was a Saturday and he had fewer staff, it
was difficult to ensure that the contingency plans were followed. Staff
normally deployed to log activities, inform statutory bodies of a death in
custody and draft a timeline of events, were not in the prison and he had
to explain to weekend staff what was needed. The Duty Governor was
relieved of his duties in the command suite when the Deputy Governor
arrived at the prison.
96. During the course of the day, the Senior Officer interviewed on a one to
one basis all the prisoners subject to ACCT, ensuring that their thoughts
and feelings were listened to. This was extended to any other prisoner
who had concerns. The chaplaincy also visited the wing, making sure
all the prisoners were aware that help and support could be offered.
97. An officer spoke to one of the prisoners who assisted another officer in
the dead man’s cell. The prisoner asked to be moved off the wing
where he found it hard to cope. The officer spoke to him about the
importance of sticking together after a serious incident. He said that the
chaplain and the Samaritans spoke to the prisoners who assisted the
officer, and they each received canteen packs.
98. The Governor held a hot de-brief meeting later that morning, attended
by all the staff involved. Written statements of their involvement were
completed and they talked through the events of the morning. An officer
remembered a discussion about E wing, and whether it had been full or
not when the man arrived. Despite not being on duty, a member of the
care team attended the prison to offer support to staff. I consider this
good practice and very timely. All staff who were interviewed, including
senior staff, said they were more than happy with the level of support
available to them.
99. The man’s cell was sealed until the police arrived to carry out their
investigations.
100. The prison’s family liaison officer, who was off duty, was informed by
telephone of the man’s death. She attended the prison as soon as
possible, so that arrangements could be made to visit and inform the
family.
101. At approximately 2.45pm, the prison’s family liaison officer and the
Deputy Governor visited the man’s family to inform them of his death.
The man’s sister was listed as next of kin, and she was at home with
her partner and their child. The man’s brother arrived a short time
afterwards. The circumstances surrounding the man’s death were
explained, and his brother said that the prison should have been aware
of the man’s mental health problems. They discussed the release of the
man’s body and when family could see him. The prison’s family liaison
officer told the family that she would be in touch with the coroner’s office
to see when this would be possible. Funeral arrangements were also
discussed.
102. Undertakers arrived at the prison around 3.00pm and the man’s body
was removed and taken to the local hospital mortuary. At about
5.20pm, the man’s elder sister telephoned the Deputy Governor and
arranged to visit the prison the following day. She also asked when the
man’s body would be released. She told my investigators that prison’s
family liaison officer told her that this was not possible and that they
were not allowed to see the man until the mortuary gave permission.
The man’s mother was understandably distressed and desperate to see
her son. His sister contacted an acquaintance who owns a funeral
parlour. The funeral director telephoned Chelmsford Police who
contacted the mortuary, and it was agreed that the man’s mother could
see the man. The funeral director drove the man’s mother to the
mortuary to see him that evening, and whilst there they arranged for the
rest of the man’s family to view the body on Sunday morning. The
prison was unaware of the visit.
103. Later that evening, around 5.45pm, the Duty Governor telephoned the
OSG at home, and informed him of the man’s death. During their
conversation, the OSG said that he had not actually carried out the roll
check that morning. He said he was asked to put this in writing along
with the events for the evening. He submitted a statement to the
Governor confirming this. This statement was only made available to
my investigators in February 2007.
104. At 9.20am the next day (Sunday), the prison’s family liaison officer
telephoned the man’s elder sister and said she had contacted the
hospital to arrange for the family to view the man’s body and needed to
know when they could do this. The family liaison officer was unaware
that the man’s mother had already seen the body the previous night.
The man’s sister was unhappy about the delay, but later confirmed that
she would visit the prison at 12.00pm, after which she and other
members of her family would go to the mortuary to view the man’s body.
The prison’s family liaison officer said she would contact the coroner’s
office to inform them of the time that the family intended to arrive. She
also told the man’s sister that his property could not be released until
the police gave their authority.
105. The family visited the prison at approximately 12.00 noon, and spoke
with the family liaison officer and the Governor. They asked a number
of questions, which are detailed in this report. The role of the Prisons
and Probation Ombudsman was also explained to the family, and they
were told that they would be contacted shortly about the investigation
into the man’s death.
106. Later, the family contacted the prison regarding the man’s funeral. The
prison assisted with the funeral costs and offered to lay a wreath and
send an officer to the funeral, if it was acceptable to the family.
ISSUES CONSIDERED
Clinical Care
107. The man’s family say that he was receiving prescribed medication at the
time of his arrest, but it is not known whether he was given any to take
whilst he was in police custody. When he was escorted to court, and
during the course of the day at court, there is no reference to medication
in the man’s possession, or his having to take medication. There are
also no prison records to suggest that he arrived at HMP Chelmsford
with any medication. No concerns were reported by the escorting staff
when the man was handed over to prison staff. This evidence, along
with the man’s own admission that he was not receiving any medication,
leads me to suggest that he did not arrive at Chelmsford in possession
of any medication and had not taken any since being arrested.
108. A clinical review was conducted on the man’s healthcare at the prison.
No criticisms are made about the healthcare reception screening, and
the reviewer notes that the man did not admit to any previous mental
health problems or attempts to harm himself. Despite the number of
prisoners arriving at Chelmsford, nursing staff said that they do not rush
their interviews. All the necessary information was requested of the
man and, as far as the nurse could ascertain, he replied accurately. He
admitted using drugs and was appropriately referred to the
detoxification nurse the next day. The nurse understood the risks of
suicide and self harm, and assessed on the basis of the available
information and the man’s demeanour that he was not at risk.
109. The Prison Service does not have the technology to provide staff with
immediate access to the previous records of returning prisoners, and it
takes between 24 and 48 hours to retrieve historical data. Staff
therefore have to rely on prisoners being honest about any physical or
mental ailments, together with their own visual observations.
110. The clinical reviewer writes in strong terms about the absence of
systems or programmes that can identify those who may be at risk of
self harm. Had such a system been in place, the reception nurse would
have been aware of the man’s previous history of harming himself, his
prescribed medication and the psychiatric assessments. She would
have been able to use the information as part of her assessment of the
man’s current health, and might have reached a different decision about
his risk of deliberate self harm.
111. The clinical reviewer was unable to answer conclusively whether the
man would have shown any effects of withdrawal from his medication,
which it appears he had not been taking since his arrest. However,
there was no evidence in any of the prison records or from interviews
with officers or healthcare staff that he displayed any signs of
withdrawal or of mental health symptoms.
Assessment of risk of suicide and self harm
112. Reception staff had no knowledge of the man’s previous periods in
custody or of the events which had led to suicide and self harm
monitoring, and none of the staff recognised him. He was assessed on
the basis of his presentation and the information he provided. None of
the reception staff identified any risk, and neither did the experienced
member of staff who escorted him to the wing that night. The records
and their statements in interview for this investigation consistently say
that opening an ACCT document was not considered appropriate
because they assessed the man as low risk.
Locating staff working in pairs
113. The man and another prisoner were located by a single member of staff.
This was contrary to Chelmsford’s Safe Systems of Work policy
(OpRSO9) which states that escorting prisoners to and from wings is a
task to be carried out by a minimum of two staff.
114. The staff interviewed were aware that there were health and safety
reasons why they should not locate alone. It is unfortunate that
Chelmsford regularly receives large numbers of prisoners on Friday
evenings and can struggle to find adequate numbers of staff at busy
periods. The usual practice is to rely on the goodwill of staff to remain
on duty and assist with locating, even though it is not one of their
regular duties. (The willingness of staff to take on these extra duties is
very worthy of note and of commendation.) In this case, no harm was
done to the officer or the prisoners, but a second colleague might have
allowed more opportunity to engage and assess the prisoners’ frame of
mind.
The Governor should remind staff carrying out locating duties of
the policy of escorting prisoners between wings.
Locating new prisoners
115. In a prison where cells are at a premium, it was evident from interviews
that even though the first night centre was occasionally full, new
prisoners should and could be located there. This would happen even if
it meant that other prisoners had to change wings late in the evening.
Staff were also aware that the authorisation of a senior member of staff
on duty was necessary if a new prisoner was to be located anywhere
other than E wing.
116. The man was correctly classed as a new prisoner but was not located
on E Wing, supposedly because E Wing was full. However, when my
investigators checked the records they confirmed that this was not the
case and there were spaces on the wing. The orderly officer confirmed
that no staff sought permission to locate the man on C Wing, and he
had refused the request for another prisoner earlier in the evening.
117. I cannot dispute the Senior Officer’s account that another, unidentified,
member of staff told her that E wing was full. Nevertheless, this was
about an hour before she located the man, and there is no evidence that
a further enquiry was made before he was located. My investigators
were told that about half an hour before the man went to C wing, there
were five adult spaces on E wing.
118. The Head of Residence was asked about the normal procedure for
allocating new prisoners to single and double occupancy cells. He
expected all new prisoners, especially on their first night, to be located
in a shared cell with another prisoner, unless they were identified as
high risk under the CSRA. He said that, more often than not, low risk
prisoners had no choice about whether they would share a cell. The
prison was very busy and under enormous pressure to take new
prisoners every day, and it was important to utilise all available space.
119. Had the man been in E wing rather than C wing, there would have been
no difference to his level of supervision except that it would have been
by an officer rather than an OSG. He would still not have been subject
to enhanced levels of observation during the night. However, it might
have affected his attitude to his location, and he might have thought that
more support would have been available the next day.
The Governor should remind staff of the importance of locating
new prisoners appropriately to the induction wing. This should be
formalised in policy, and should include a clear instruction that
staff must obtain authorisation to locate new prisoners anywhere
outside of the First Night Centre.
In the unusual event of a new prisoner being located on any other
wing, the Governor should ensure that they are placed in a shared
cell and that prisoners who cannot share cells are always located
in the induction wing.
Training for night duty
120. At the time when the man died, some wings were staffed at night time
by officers, and others by OSGs who are not expected to have contact
with prisoners. The OSG on duty on C wing expressed concerns about
the level of training he had received, and whether it was adequate for
his duties. No formal training is provided by the prison and he said that
his knowledge was gained during a single night shadowing another
OSG. He said that he had no knowledge of the ACCT procedures, even
though he had to monitor the welfare of ACCT prisoners and should
have known how to recognise when the procedures should be initiated.
The Governor should review the local procedures regarding
training for Officer Support Grades, including their understanding
of the ACCT procedures.
Roll Checks
121. Few tasks can be more critical in prison than roll checks, including
signing to say that they are correct. However, there is confusion about
whether the check was carried out during the morning of the day of the
man’s death, and if it did, the time that it took place. The OSG told the
principal officer that morning that he had not yet done the check. He
subsequently signed the roll check log to say that it was carried out in
accordance with the 6.00am due time. When told about the man’s
death, the OSG admitted failing to do the check at all. At interview with
my investigators, he said he had carried out the check two hours early,
around 4.00am - 4.30am.
122. I am aware that the Governor is investigating the actions of the OSG.
Since my investigation began, I am also pleased to learn that the
Governor has issued a revised local instruction to improve the process
of weekend roll checks.
Contact with the family
123. The man’s body was taken from the prison at about 3.00pm on the day
of his death, some five hours after he was found. At the same time, his
family was told that he had died. I strongly believe that next of kin
should be informed as quickly as possible. I understand that there was
an issue about the immediate availability of staff (notably the family
liaison officer) to do this. I also appreciate how important it is that the
news of a death in custody is handled sensitively (and family liaison
officers have been appropriately and very well trained to do this).
However, timing is an important element in sensitivity, and I regret the
delay in telling the man’s family of his passing.
124. When the family was informed of the man’s death, they understandably
wanted to see his body quickly and relied initially on the prison to inform
them of the arrangements. No immediate information was forthcoming
and so the family made independent arrangements. I do not think that
the delay by the prison was intentional, rather that circumstances and
timings transpired against a quicker reply. Nevertheless, immediate
provision of the mortuary contact details would have assisted the man’s
next of kin.
The Governor should review the death in custody contingency plan
in relation to the contacting of next of kin to ensure they are told as
quickly as possible.
The family liaison officer should ensure that the next of kin are
provided with all necessary information after the death of a
prisoner, including information about how they can see their loved
one in the Chapel of Rest.
Staff Support
125. The death of a prisoner is very traumatic for staff as well as prisoners.
The willingness of a member of the care and support team to come into
the prison on her day off to offer support to staff immediately following
the man’s death is to be noted.
The Governor should commend this particular staff member for her
compassionate approach.
CONCLUSION
126. The man showed no obvious signs of unease, no mental health
problems, no illnesses, no symptoms of taking medication, and no
indications of drug withdrawal when he arrived at Chelmsford. No
difficulties were reported by the police, court or escort officers. I
acknowledge that during the man’s previous spell of imprisonment his
behaviour was disturbed, and this may have been related to mental
health problems. However, the information was not available to
reception staff, and he was I believe correctly assessed.
127. Regrettably, the man was not located in the induction wing, where he
would have been with other new prisoners and with experienced and
specially selected staff.
128. A proper morning roll check would have found the man earlier on the
day of death. This might have meant that the valiant attempts by staff
and prisoners to resuscitate him would have had a better chance of
success.
RECOMMENDATIONS
1. The Governor should remind staff carrying out locating duties of the
policy of escorting prisoners between wings.
2. The Governor should remind staff of the importance of locating new
prisoners appropriately to the induction wing. This should be formalised
in policy, and should include a clear instruction that staff must obtain
authorisation to locate new prisoners anywhere outside of the First
Night Centre.
3. In the unusual event of a new prisoner being located on any other wing,
the Governor should ensure that they are placed in a shared cell and
that prisoners who cannot share cells are always located in the
induction wing.
4. The Governor should review the local procedures regarding training for
Officer Support Grades, including their understanding of the ACCT
procedures.
5. The Governor should review the death in custody contingency plan in
relation to the contacting of next of kin to ensure they are told as quickly
as possible.
6. The family liaison officer should ensure that the next of kin are provided
with all necessary information after the death of a prisoner, including
information about how they can see their loved one in the Chapel of
Rest.
Good Practice
7. The Governor should commend a particular staff member for her
compassionate approach to duty.