Individual at Cardiff

Investigation into the circumstances surrounding the death
of a man at HMP Cardiff
on 10 June 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2008
This is the report of an investigation into the circumstances surrounding the death of a
man at HMP Cardiff on Sunday 10 June 2007. At about 6.00pm that evening, the man
was found hanging in his single cell in the prison’s First Night Centre. He had been in
prison custody for just two days, having been locked out of HMP Swansea for one
night under Operation Safeguard. The man was 27 years old.
The post mortem examination concluded that the man’ death was caused by pressure
to the neck. A toxicology report commented that the man tested positive for
benzodiazepines but these were consistent with therapeutic use. The report also
commented that:
“… the observed low concentration (trace amount) of diazepam found in
the post mortem blood would be consistent with therapeutic use and
does not indicate an overdose of this drug prior to death.”
I offer my sincere condolences to the man’s family and friends for their tragic loss.
The investigation was conducted by one of my colleagues. My family liaison officer,
liaised with the man’s family. I also commissioned an independent clinical review of
the management of the man’s health needs while he was in custody. As on previous
occasions, I am most grateful to the clinical reviewer for her contribution to the
investigation.
The investigation found that the man gave prison staff no indication he was actively
contemplating suicide. While I am critical of some aspects of his care, I conclude that
his death could not reasonably have been predicted or prevented.
I make one recommendation. I also commend the Prison Service and paramedic staff
for their attempts to revive the man in very harrowing circumstances. The clinical
review makes two recommendations, one of which I endorse.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2008
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CONTENTS
Summary
Investigation process
HM Prison Cardiff
Key events
Issues
Recommendations
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SUMMARY
The man was arrested on Thursday 7 June 2007 on suspicion of criminal damage and
possessing an offensive weapon. He had apparently damaged premises above his
own flat in Swansea. The man appeared before Magistrates’ Court that day and was
remanded in custody. He would normally have been taken to HMP Swansea.
However, as Swansea had no vacancies, the man remained in police custody
overnight.
The next day, the man was transferred from police custody to HMP Cardiff. On arrival
at Cardiff, he refused to disclose his next of kin as he did not want anyone to know
where he was. The man gave his date of birth. His family later confirmed another
date of birth. The man said he had been in prison many times before and had last
been released in February 2006 from HMP Parc in Bridgend.
During his reception health screen, the man said that 17 years earlier he had received
treatment from a psychiatrist in the community, although not as an inpatient. He said
he did not currently have a psychiatric care worker and had never received medication
for mental health problems. However, the man did disclose that, in May 2006, he had
attempted to hang himself but gave no details. The man said that, despite being in
prison, he did not feel suicidal. In view of his mental health history, the nurse who
carried out the reception health screen decided to refer the man for a mental health
assessment. The man was nevertheless considered to be fit for accommodation in a
residential wing rather than in the healthcare centre.
During the reception procedures, a cell sharing risk assessment was carried out. The
man was judged as presenting a low risk of harming others and was considered
suitable to share a cell. He was therefore placed in a shared cell in the First Night
Centre.
During that night (Friday/Saturday), there was an altercation between the man and his
cell mate. The investigation found that, whilst his cell mate was asleep, the man
inflicted upon him a very minor injury to his head. The cell mate did not retaliate as he
thought the man was simply behaving strangely rather than maliciously. The next
morning, the cell mate reported the incident to wing staff. In liaison with healthcare
colleagues, they decided to separate the two prisoners, leaving the man in a cell on
his own. The injury received by the cell mate was not examined by anyone from the
healthcare department because no one completed a form F213SH (report of an injury
to a prisoner).
There were no further events of any significance until the following afternoon (Sunday)
when the man began to demonstrate further bizarre behaviour. Officers in the First
Night Centre repeatedly called the healthcare centre to see the man, but no one did
so. An officer took it upon himself to ask a member of the healthcare department on
duty in the wing treatment room on the landing above the First Night Centre to see the
man. The officer was told that the man was due for a mental health assessment the
following day and felt reassured by that. Meanwhile, a member of staff in the
healthcare centre was asked by a manager to see the man that evening. This was
due to take place at about 6.00pm. Before this happened, the man was found
hanging from the window bars of his cell. Attempts by prison staff and a paramedic
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crew to revive him were unsuccessful. The man was pronounced dead at
approximately 6.20pm.
I am concerned at the apparent failure by healthcare staff to see the man after
repeatedly being asked to do so by wing staff. My investigator was told that this was
due to the combination of a shortage of healthcare staff and a heavy workload for
those who were on duty. The investigation could not prove conclusively that these
factors prevented anyone seeing the man before he died. However, despite my
evident concern, I am reluctant to criticise individual members of staff. My reluctance
is based on the following factors:
(cid:127) Although his behaviour was bizarre, the man did not present as suicidal. It
was, in my view, reasonable for staff to consider him as non-urgent.
(cid:127) The man had appropriately been referred for mental health assessment during
the reception procedures on Friday 8 June. This assessment was likely to have
taken place during the following week. (An entry made in a diary kept in the
healthcare centre shows that a request was made for the man to be seen on
Monday 11 June.)
The author of the clinical review, suggests that the man’s death might have been
prevented had his mental health assessment taken place earlier. The clinical reviewer
also recommends that the full complement of healthcare staff is present to maintain a
safe level of care for prisoners who need it. I accept that staffing levels are a critical
factor in ensuring the delivery of the Prison Service’s duty of care. However, for
reasons explained in detail in the body of this report, I have not endorsed this
recommendation.
The investigation found that no urine test was carried out during the man’s reception
health screen. As a result, it was not clear to healthcare staff whether the man had
taken drugs shortly before his arrival at the prison and, therefore, what interventions
were necessary. The clinical review makes a recommendation about the
management of the man’s health needs in which she points to the need for routine
urine tests for prisoners who admit to abusing drugs and alcohol.
I am concerned that no one completed a form F213SH (report of an injury to a
prisoner) when it became obvious to staff that the man had assaulted his cell mate. I
have recommended that the Governor reminds his staff of the importance of doing so.
Finally, I commend the prison staff and paramedics who attempted to revive the man
in very harrowing circumstances.
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INVESTIGATION PROCESS
The investigation commenced on 18 June 2007 when my investigator met the then
Governor of HMP Cardiff, together with representatives of the local Independent
Monitoring Board and the local branch of the Prison Officers’ Association. The
prison’s investigation liaison officer was also present. My investigator briefed the
meeting on the nature and scope of the investigation. The same day, notices were
issued to staff and to prisoners announcing the investigation and inviting anyone with
information or concerns about the man’s death to make themselves known to my
investigator.
An independent clinical review of the management of the man’s health needs while he
was in custody was conducted by the Investigations Manager, Health Inspectorate
Wales.
Fifteen members of staff and one prisoner were interviewed during the course of the
investigation. In addition, my investigator and family liaison officer visited the man’s
mother, uncle and former partner on 13 July at their home in Swansea. During the
visit, the family raised a number of concerns they wanted my investigator to
investigate. The matters they raised have been addressed in this report.
My investigator spoke to the solicitors, who represented the man in court on 7 June.
He also spoke to a representative of Reliance, the private security company
contracted by the Prison Service to escort prisoners between courts and prisons.
During the course of the investigation, my investigator kept the Governor apprised
of the issues that emerged. On 9 August 2007, he wrote his initial observations and
findings, emphasising that these were, at the time, subject to further examination.
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HMP CARDIFF
Cardiff prison, situated near the town centre, is a local and a training prison. It can
hold up to 754 adult male prisoners. The prison has six residential units, one of which
is used exclusively to hold life sentenced prisoners. The prison also has a
detoxification unit for up to 52 prisoners and a healthcare centre that provides 24 hour
nursing and medical cover and beds for up to 16 in-patients.
In February 2005, Cardiff was inspected by HM Chief Inspector of Prisons, Dame
Anne Owers. The report of that inspection commented as follows:
“Two years ago, we described Cardiff prison as being at a crossroads
as it struggled with competing pressure, including the inexorable rise in
population. This unannounced follow-up inspection records that
Cardiff had achieved a great deal despite these unpropitious
circumstances. We found that most of our recommendations had been
implemented and in some key areas the prison had gone significantly
further.”
A non-executive member of the then Home Office’s Group Executive Board and author
of the Report of the Review of the Correctional Services that led to the establishment of
the National Offender Management Service, visited HMP Cardiff on 21 December 2005.
He commented on his visit as follows:
“I have been in a large number of prisons both in this country and in
other parts of the world and against that background I have to say that
Cardiff was one of the best establishments that I have ever visited.
From the first moment, the appearance of the building, the friendly
attitude of staff and the air of professionalism were manifest.”
In their report on Cardiff prison for the period 1 September 2005 to 31 August 2006,
the Independent Monitoring Board drew attention to the fact that two prisoners had
apparently taken their own lives during the reporting period. The Board commented
that my office had investigated both those deaths and that my reports had described
the Safer Custody Policy in place at Cardiff as the most comprehensive my
investigators had witnessed in the Prison Service. Nothing found in the investigation
into the man’s death detracts from that observation.
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KEY EVENTS
Thursday 7 June: Arrest, appearance in court and remand into custody
At about 12.45am on 7 June 2007, police were called by the occupant of a flat on the
floor above the man’s flat in Swansea. The occupant told police that the man had
shouted at him and had tried to damage the entrance door to the flat. When the police
arrived, they arrested the man and took him into custody at a police station in
Swansea where they charged him with criminal damage. Later, when they searched
him, the police discovered the man had secreted a knife about his person. They
therefore also charged him with possessing an offensive weapon. According to his
legal adviser, the man admitted both offences.
The man’s solicitor told my investigator that, at about 9.30pm, he arrived at the police
station and stayed with the man until about 11.30pm. the solicitor explained to my
investigator that the man was known to his firm of solicitors in Swansea from previous
court appearances. The solicitor knew the man as quite a reserved man. He
regarded the man’s demeanour when he saw him as normal.
However, the solicitor said the man told him he had fallen out with all his family and
had nobody to turn to for support. The solicitor thought the man felt anxious about this
but did not appear to be depressed. He did not think the man was suicidal. The
solicitor recalled that the police might have been told by the man that he had taken
amphetamines. The solicitor thought there had been a long delay before he could see
the man at the police station because of this.
Appearance in court and remand into custody
The man appeared at Magistrates’ Court, charged with criminal damage and
possessing an offensive weapon. The man’s solicitor told my investigator he made an
application to the magistrates for bail. It was rejected because the man’s bail address
would have put him back at the scene of his alleged offence. In addition, the charge
of possession of an offensive weapon was likely to be dealt with by the Crown Court.
The man was therefore remanded in custody and ordered to appear again before
magistrates via video link on 13 June.
In ordinary circumstances, the man would have been held at HMP Swansea. This
was not possible on 7 June as the prison had reached its maximum capacity. A
representative of Reliance, the private security company contracted by the Prison
Service to escort prisoners between courts and prisons, confirmed that, for this reason
alone, the man was returned to police custody at a police station in Swansea under
Operation Safeguard. (This is a Prison Service contingency plan to ensure that
prisoners “locked out” of a prison because of overcrowding are placed in secure
custody elsewhere.) The man was held at the police station overnight and taken to
HMP Cardiff the next day.
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Friday 8 June
Reception at Cardiff
The man arrived at Cardiff prison at about 1.00pm on Friday 8 June. The prisoner
escort record (PER) for the journey between the police station and the prison carried
no notation of any risk of self-harm.
The man told reception staff at Cardiff that his home was in Swansea but gave no
details of his next of kin because he did not want anyone to know where he was. The
man was offered a free telephone call and a free letter but he refused both, possibly
for the same reason. He said his date of birth was 21 July 1979. (His family later
confirmed he was born on 22 July that year.) The man also underwent an initial health
screen and a cell sharing risk assessment.
Reception health screen
The purpose of the health screen is to gather information about each prisoner’s
current and past mental and physical health, as well as to ensure that appropriate
interventions are made in relation to any immediate and longer term health needs.
The man’s health screen was carried out by a staff nurse. The man told the staff
nurse he had not recently seen a doctor and had no outstanding appointments.
However, the staff nurse noticed the knuckles on the man’s left hand were bruised and
swollen. The man said he received this injury on 2 June but gave no further details.
He said he had no concerns about his physical health. However, he admitted to being
a “binge drinker” and to indulging in substance abuse. He said he normally took
benzodiazepines and amphetamines fortnightly. The man also said he had used both
sorts of drugs 18 days earlier. The staff nurse asked the man if he was currently
taking any prescribed medication. He said he was taking Valium but later explained
that this had not been prescribed. At interview, the staff nurse said this was why he
initially wrote in the health screen form that the man was taking Valium on prescription
and then crossed his entry out.
When asked about his mental health, the man said he had undergone treatment from
a psychiatrist in the community 17 years earlier, although not as an inpatient. He said
he did not currently have a psychiatric care worker in the community and had never
received medication for mental health problems. However, the man disclosed that he
had tried to hang himself in May 2006, but gave no details.
The staff nurse told my investigator that at no stage during the health screen did he
think the man was exhibiting any signs of strange behaviour. He said the man did not
appear to be suffering from the effects of drugs, or from the effects of withdrawal. In
keeping with normal practice, the staff nurse asked the man if he felt suicidal because
he was in prison but he said he did not. At interview, the staff nurse said the man was
not subdued, depressed, or preoccupied but was vague and would not engage easily.
Consequently, the staff nurse decided to refer him for a mental health assessment. In
reaching this decision, the staff nurse took into account the man’s admission that he
had received psychiatric care 17 years earlier and had tried to hang himself in May
2006. The staff nurse made an entry in a diary kept in the healthcare centre asking for
the man to be seen on Monday 11 June.
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At the end of the health screen, the staff nurse concluded that the man was not at risk
of self-harm or suicide and was fit for work and for normal location (in other words in a
wing rather than in the healthcare centre or separation unit.)
Cell sharing risk assessment
The cell sharing risk assessment is designed to measure the risk each prisoner
presents of harming others. Those who present such a risk are normally placed in
single accommodation. Judgements as to risk are based on whatever documentary
evidence is available during the reception procedures and on the answers prisoners
give to the questions listed on the cell sharing risk assessment form. The risk of
harming others has to be balanced with the risk of self-harm if the prisoner is left in a
single cell.
A prison officer, who normally worked in the First Night Centre at Cardiff, was
deployed to the reception building on the afternoon of 8 June in order to complete cell
sharing risk assessments on new prisoners. The man told the risk assessment officer
he was not a person who became angry or frustrated easily. He said he did not have
any concerns about sharing a cell. He also said he had not formerly been subject to
any self-harm monitoring procedures. The risk assessment officer judged that the
man presented a low risk of harming others, meant he could be allocated to shared
accommodation.
The cell sharing risk assessment process also requires a member of the healthcare
team to assess the risk the man presented of harming others. This was done by the
staff nurse. He wrote on the form, “No concerns, normal location.” In answer to the
question at section three of the form, “Following the self-harm assessment have any
concerns been raised”, the staff nurse wrote that none had been raised.
After the reception procedures had been completed, the man was allocated to the
First Night Centre where he was placed in a cell with another prisoner.
Saturday 9 June
Report of altercation with cell mate
A prison officer recorded the following information on a retrospective security
information report:
“At approx 9am on 9.6.07, whilst sitting in the office on F1 landing
inmate approached the entrance of the office and said he had received
a blow to his right eye. Staff present risk assessment officer, prison
officer, and myself. We all questioned the other prisoner on how he
received the injury to his face. He said his cellmate the man struck
him on the eye through the night. He stated I didn’t see the man hit
me, but it must have been him because there was no one else in the
cell. The other prisoner kept saying the man was very strange and
was talking to himself through the night. The prison officer went and
spoke with the man and immediately removed the other prisoner from
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cell F1-17 and put the man on as a single cell occupant until assessed
by hospital staff.”
My investigator interviewed the prisoner, the prison officer that completed the security
information report, the other prison officer and the staff nurse about this episode.
The prison officer that completed the security information report, said he was an
experienced member of the induction team at Cardiff, having worked on F1 landing for
five years. He explained that, because of the amount of other work he had to
complete at the time, he did not submit his report straightaway. He could not
remember exactly when he did submit the document but confirmed that he did so after
the man had died.
The other prisoner said that within ten minutes of being in the same cell together, he
knew there was something wrong with the man. The other prisoner said the man kept
mumbling about religion and talking to his friend as if he was in the cell with him.
According to the other prisoner, the man said he was hearing voices. The man kept
mumbling until about midnight when the other prisoner made up his mind to ignore
him and to try to go to sleep. He told my investigator he managed to fall asleep, but
some time later was woken by the man hitting him on the back of his head. When the
other prisoner turned over to see what was happening, the man hit his face. The other
prisoner said that he did not retaliate. Instead, he turned over again and went to
sleep. In the morning, he reported the incident to staff and was placed in a different
cell away from the man. The other prisoner told my investigator the man made him
feel uncomfortable. He thought the man might have been hallucinating, possibly
because he was experiencing the effects of drugs or was withdrawing from them.
The prison officer that completed the security information report, remembered that the
other prisoner bore a slight mark near his right eye. He described the injury as a small
bruise. The officer was not aware of whether any anti-bullying measures were taken
in the aftermath of the altercation. He said that he and the prison officer made
numerous calls to the healthcare centre to ask one of the nursing staff to assess the
man. The officer said no one from the healthcare centre did so that day.
The prison officer confirmed the other officer’s account. He told my investigator he
was on duty in F Wing during the morning of Saturday 9 June. At about 9.00am, the
other prisoner approached the wing office and told him he had been hit by the man
during the night. The prison officer said he went to have a word with the man who
denied that he had hit the other prisoner. The prison officer became concerned about
the man. At interview, he said:
“The reason that I was concerned at that point was because he was a
slight, small bloke, certainly smaller than the other prisoner. But the
reason I was concerned was that he was quite vacant in his
expression and his words were very monotone, very flat …”
The prison officer said he rang the healthcare centre to ask someone to assess the
man. He said he spoke to a healthcare manager. The prison officer told my
investigator that he was on duty until 5.00pm that day, and during that period no one
from the healthcare centre came to see the man. My investigator was unable to
interview the healthcare manager as he was on long term sick leave.
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The staff nurse told my investigator he took a call about the man during the morning of
9 June. He said he was told that there had been an altercation between the man and
the other prisoner. The staff nurse said he advised that the man should be separated
from the other prisoner and placed in a single cell until such time as his mental health
could be assessed.
The prison officer found another cell for the other prisoner and kept the man on his
own. He wrote in the man’s prison record:
“Complaint by cell mate of altercation with the man. Subsequent
interview revealed strange behaviour. Single cell until review by
mental health nurse.”
The prison officer said that as far as he could tell, the altercation between the man and
the other prisoner was not related to bullying. He told my investigator he did not think
the man appeared suicidal
No officers completed a form F213SH (report of an injury to a prisoner) after it became
obvious that the other prisoner had been assaulted. The staff nurse said he was not
made aware of any injury to the other prisoner. Had the form F213SH been
completed, the other prisoner would have been examined by a healthcare
professional, which might have led to an assessment.
Resettlement planning
As part of the resettlement planning process, the prison officer completed what is
known as a passport form with the man. This contains a series of questions about
such subjects as housing, employment, health, education, finance, relationships,
attitudes, behaviour and institutional skills. The man told the prison officer he had
never worked and would have no job available on release. He was entirely dependent
on benefits. The man said his income would be about £155 per fortnight. He admitted
he had taken drugs since he was 11 years old, at a cost of £30 a day. The man told
the prison officer he had never tried to seek help for his drug addiction and did not
want any help from the CARATs (Counselling Advice, Referral, Assessment and
Throughcare service) now that he was in prison. The man told the prison officer there
was nothing about himself he wanted to change and he had no plans to stop re-
offending. He said most of his friends were in trouble with the police. He had been in
prison on 14 occasions and had been last released in February 2006. Finally, the
man told the prison officer he had nobody to turn to in the community.
Seen by chaplain
After seeing the man as part of the induction procedures, the chaplain, noted
in the man’s record that he thought he was a “strange character”.
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Sunday 10 June
Nothing of note seems to have occurred during the morning of Sunday 10 June.
However, at 3.15 pm, an officer who was on duty on F2 landing, noticed the man
walking up the stairs from the landing below. The man said to the officer, “Do I have to
go to heaven tonight?” At interview, the officer on F2 landing explained that 3.15pm
was the usual time at which prisoners on F1 landing were allowed to go to the treatment
room on the landing above to collect their medication. Thus, it was in order for the man
to move out of the First Night Centre to F2 landing above. The officer asked the man
what he meant by that question and whether he needed any medication. The man did
not answer, but walked back down the stairs towards the First Night Centre. The officer
told his colleagues in the centre what the man had said. The officer told my investigator
that, a little later, he saw a member of staff on duty in the First Night Centre, take the
man to the treatment room.
At interview, the officer from the first night centre explained that at about 3.30pm the
man had approached the office in the First Night Centre and started mumbling. The
officer from the first night centre was in the office. He heard the man say, “When will I
go?” the officer said to him, “Where?” The man replied, “To Guys Marsh.” The officer
then said to him, “If you are convicted and sentenced, you may go to Guys Marsh if you
meet the criteria for that prison.” The officer told my investigator the man then started
talking about religion. The officer was aware that other staff had earlier asked someone
from the healthcare centre to see the man. He knew that no one had yet seen him.
The officer thought it wise to take the man to the treatment room on the landing above
where he knew there would be a member of the healthcare staff on duty. The officer
wanted to know whether the man needed any medication. A healthcare officer was on
duty in the treatment room. At interview, the healthcare officer said he could remember
the officer from the first night centre bringing the man to the room. He said he rang the
healthcare centre and spoke to a healthcare manager. The healthcare officer told my
investigator that the healthcare manager advised him that someone would go and see
the man that evening. The man was then taken back to F1 landing. According to the
officer from the first night centre, the man stayed outside his cell for the remainder of
the association period. This ended at about 4.00pm with the serving of the tea meal.
According to the prison officer that completed the security information report, further
calls to the healthcare centre were made that day. He said he spoke to the healthcare
manager who arranged for a nurse to see the man after the tea meal had been served.
The prison officer that completed the security information report saw the man take his
tea meal at about 4.00pm and noticed he was quiet. However, he did not think there
was anything particularly wrong with him. At no stage did the man give the prison
officer that completed the security information report, any reason to believe he was
contemplating suicide. the prison officer that completed the security information report,
who went off duty that day at 5.00pm, said the nurse did not see the man that evening.
The officer from the first night centre was on duty that evening. He was responsible for
supervising F1 landing where the man was located. At about 6.00pm, when all
prisoners were locked in their cells, the officer was patrolling the landing. After
checking several prisoners, he arrived at the man’s cell.
The officer opened the observation hatch in the cell door and saw the man hanging. He
was suspended from the window bars by a ligature made from his sheets and a belt.
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The officer from the first night centre sent a message over the radio to the control room.
He said there was a “code blue” in cell F1-17. (“Code blue” is a term used to alert key
staff to a hanging without giving any details that might distress other prisoners who are
within earshot.) The officer repeated his message. He then entered the cell and took
the man’s weight. He was soon joined by an officer who cut the ligature, using a
special knife issued to staff for that purpose. Three other prison officers had also
arrived by this time. They helped take the man’s weight so that he could be lowered
and carried out onto the landing where there was more space available. An other
prison officer checked to see whether the man had a pulse and if he was breathing. He
could detect no signs of life. Between them, they started to apply cardio-pulmonary
resuscitation (CPR). At this point, the healthcare officer arrived and gave his
assistance.
The healthcare officer said he was on the healthcare landing when the code blue
message was broadcast on his radio. He said he picked up the resuscitation bag and
proceeded to F1 landing by the shortest possible route. He said it probably took him
about 60 seconds to reach the man’s cell. The healthcare officer said that, as he was
not designated as a “first responder”, he did not take the defibrillator. He told my
investigator he was not sure who took it but remembered that it arrived within minutes of
his arrival at the cell. The healthcare officer assisted in applying CPR. He also gave an
instruction for an ambulance to be called. By this time, two senior officers arrived. The
first senior officer used her radio to ask the officer in the control room to call for an
ambulance. The log of events kept by the prison shows that this was done at 6.02pm.
Despite the fact that the healthcare officer thought the man might have been dead for
some time, he applied the defibrillator. However, the man did not respond. CPR was
maintained until a paramedic crew arrived at approximately 6.06pm. They continued to
administer CPR until approximately 6.20pm when they pronounced the man’s death.
Informing the next of kin
The chaplain together with a principal officer, took it upon themselves to inform the
man’s next of kin of his death. Although the man had refused to declare his next of kin
during the reception procedures, he did give details of what he said was his own
address in Swansea. The chaplain and the principal officer drove there, expecting to
meet the man’s mother. As they approached, they realised there was an incident in the
vicinity that the police were handling. They therefore called in to a nearby police station
to seek advice. The police, who knew the man well, agreed to accompany them.
However, when they arrived, they discovered that nobody was in.
The police suggested another address. On arrival at that address, they once again
found nobody at home. They therefore returned to the police station where they were
given a third address to try. When they arrived they were told that the man’s mother
had moved. Upon arrival at that next address, the principal officer was told by the
occupant that she had never heard of the man’s mother. The principal officer then
approached the next door neighbour who said she knew the man’s mother well and had
her mobile telephone number which she disclosed to the principal officer. He rang the
number. The call was answered not by the man’s mother but by the man’s former
partner. The principal officer explained who he was, then told the man’s former partner
that he and the chaplain needed to visit to speak to her about the man. The man’s
former partner gave him her address. They arrived at about 10.00pm and stayed with
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her for about an hour. During that time, the man’s former partner phoned other
members of her family and tried to track down the man’s mother but was unable to do
so. (The man’s former partner broke the news of the man’s death to his mother later
that day.) With the man’s former partner’s agreement, the principal officer and the
chaplain then left.
The principal officer told my investigator he later arranged for the man’s belongings to
be returned to his family. He said the funeral costs were paid in full by the Governor.
The principal officer also confirmed that the Governor was keen for a representative of
the prison to attend the funeral but the man’s mother did not want this. The principal
officer extended an invitation to the man’s mother and the man’s former partner to view
the man’s cell if they wished. This too was declined.
15
ISSUES
Here I examine:
(cid:127) Whether the man’s health needs were properly met while he was in custody at
Cardiff.
(cid:127) Whether his risk of suicide was properly assessed, monitored and managed.
(cid:127) Whether the response by staff when the man was found hanging was prompt
and effective.
(cid:127) Whether appropriate courtesies were offered to the man’s family in the aftermath
of his death.
Were the man’s health needs properly met while he was in custody at Cardiff?
Physical health needs
I repeat here extracts from the clinical review of the management of the man’s health
needs conducted by the Healthcare Inspectorate Wales:
“The First Reception Health Screen form was completed on 8 June
2007. No significant physical illnesses were mentioned. The man was
noted as appearing ‘spare but muscular’. It was also noted that the
man was receiving prescribed medication, but Reception Nurse
mentioned at interview that the medication was Valium and not
prescribed by The man’s GP. Therefore, this was not continued in the
prison. The reception nurse noted that the man had bruised and
swollen knuckles on his left hand. The man mentioned that he ‘binge
drank cider fortnightly’ but showed no signs of withdrawal to the
reception nurse. The man also mentioned that he had taken
benzodiazepines and amphetamine but had not taken any for the past
18 days. No test was performed on the man’s urine to verify this
statement.”
The clinical review goes on to make the following recommendation:
“Prison authorities should give consideration for routine urine testing
for drugs in prisoners who admit taking drugs and alcohol to excess in
the past.”
I endorse this recommendation.
Mental health needs
I quote again from the clinical review:
“In the mental health section of the First Reception Health Screen
form, it noted that the man had received psychiatric treatment
outside prison 17 years ago, for abuse. The man also mentioned
that he had attempted hanging in May 2006, but there is no record of
why he did this. This shows he had the ability to harm himself. At
interview, the reception nurse said that the man ‘had wanted to die’
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in 2006, but the man refused to expand on the event to the reception
nurse.
The reception nurse… recommended a Mental Health Assessment
and also entered this on the 8th June in the Continuous Medical
Record. It states, ‘Slightly vague and difficult to engage. For MHA
(Mental Health Assessment) please.’ At interview, the reception
nurse told us that the man said he was not considering suicide and
did not appear to be mentally unwell at that time and so the reception
nurse did not open a self-harm at risk (ACCT) form.”
In this regard, the clinical reviewer summarises her views as follows:
“The man’s behaviour was unusual and worrying for wing staff, who
tried to get him assessed by an RMN. However, he was not overtly
aggressive or expressing a wish to kill himself and was, therefore,
not deemed a mental healthcare emergency. Low health care
staffing levels and a high emergency workload on the Saturday (i.e. 9
June) did not allow the man to receive a routine mental health
assessment before he died. It could be hypothesised that if the man
had received a mental health assessment on Saturday or Sunday
morning, he might have been diagnosed with a mental illness or drug
withdrawal and been admitted to healthcare for observation, thus
preventing his suicide later on Sunday ”
(I agree with the clinical reviewer’s conclusion that the man might have been diagnosed
with a mental illness or a drug related condition had he received a mental health
assessment - I note particularly the indication that he had been hearing voices.
Whether this might have prevented his death is necessarily a matter of speculation for
which there is no direct supporting evidence.)
The clinical reviewer makes the following recommendation:
“Healthcare management must give regard to ensure that the
recommended full complement of staff is present to maintain a safe
level of care for prisoners who need it.”
Although I too am concerned at the apparent failure by healthcare staff to see the man
after repeatedly being asked to do so by officers on the First Night Centre, I do not
endorse this recommendation for the reasons I set out below.
My investigator interviewed staff all of whom were on duty at various times during the
weekend. The staff nurse said that on Saturday 9 June, there was a staff shortage in
the healthcare centre. He said there should have been five members of staff on duty
but that day there were only three, possibly four on duty. The staff nurse told my
investigator he remembered taking a call from someone that day about the man’s
altercation with the other prisoner during the previous night. The staff nurse said he
advised that the man and the other prisoner should be placed in separate cells and that
the man should remain single cell status until his mental health assessment was
completed. When my investigator suggested to the staff nurse that thereafter staff in
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the First Night Centre were still sufficiently concerned about the man to ring the
healthcare centre again to ask for someone to see him, he said:
“… it couldn’t happen again because there was a staff shortage and because
there were all sorts of incidents going on in the prison. There was a code red
(i.e. a life threatening situation) and a number of other things that were
happening that took them away from the ability to see the man”.
The staff nurse claimed that the combination of the staff shortage and the fact that
numerous incidents occurred in the prison that day meant that no one could be made
available to see the man.
The duty manager told my investigator that during the preceding week, they were aware
that there would be a shortage of healthcare staff over the weekend. The duty manager
explained that on Saturdays there should be a minimum of five healthcare staff on duty
in the morning and afternoon and two during the evening. On Sundays, there should be
five staff on duty in the morning, four in the afternoon and two in the evening. The duty
manager explained that the higher staffing level on Saturdays was necessary because
there were newly received prisoners to be seen on those days, whereas on Sundays
there were no new receptions. He went on to say that on both Saturday 9 June and
Sunday 10 June there was a shortage of two members of staff: a qualified nurse and a
healthcare officer.
The duty manager said he asked the healthcare manager to sanction overtime for the
period during which the staff shortages were expected. The duty manager said that the
healthcare manager refused to do so because the overtime budget was overspent. He
also said that at about 11.30am on Sunday another healthcare manager, voluntarily
came in to the prison to make up the shortfall of staff. The deputy manager said this
meant that the correct staffing levels were achieved for the rest of the day.
The healthcare officer confirmed he was on duty in the treatments room on F2 landing
on Sunday 10 June. He could remember the officer from F1 landing approaching him
at about 3.30pm to tell him that he had concerns about the man who was behaving in a
bizarre fashion. The healthcare officer said he rang the healthcare centre and told the
duty manager that the staff on F1 landing wanted someone from the healthcare centre
to see the man. The healthcare officer was concerned that he personally could not see
the man because he was a Registered General Nurse rather than a Registered Mental
Nurse. The healthcare officer said he was also restricted because he was working with
an unqualified Grade B Nurse and so he could not leave the treatments room.
According to the healthcare officer, the duty manager said he would ask someone to
see the man during the evening.
The healthcare officer told my investigator he was aware of staffing difficulties that
weekend but explained that this was not unusual. He said:
“Staffing at weekends is always just enough to do the job. There is
never any spare capacity to go and see if there is a fight or an incident
for those to be taken away from their existing jobs. There is no one left
in the wings as such, so yes we were thin but that has been the case
many times. So it wasn’t exceptional to be short that weekend
because we have been thin at other weekends but nothing has
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happened so therefore the powers that be won’t provide the funds to
have more staff.”
When asked by my investigator if he knew anything about attempts by managers to
make up the staff shortages, the healthcare officer said,
“Well yes. In fact I was one of those staff. I was on overtime
that day.”
The nurse told my investigator that, at about 5.00pm on Sunday 10 June, he was asked
by both the healthcare managers to go to F1 landing to see the man. The nurse said
he checked with them how urgently he should see the man. He said he was told it was
not urgent and it was alright to see the man during the evening as soon as he had time.
The nurse said he knew a phone call had been made to the healthcare centre at about
3.15pm from F1 landing. However, the managers who took the call had waited until he
and the healthcare officer returned to the healthcare centre before they asked him to
see the man. The nurse explained that as soon as he arrived at the healthcare centre
he was due his 30-minute meal break. He then had to issue medication to the
inpatients in the healthcare centre until 6.00pm. The nurse said he told the healthcare
officer he would therefore see the man at about 6.30pm. Unfortunately, the man died
before the nurse was due to see him.
`
On 3 September, my investigator returned to Cardiff to discuss the question of
healthcare staffing levels with the deputy governor and the principal officer, the Safer
Custody Manager. They explained the agreed staffing levels for the healthcare centre
and confirmed that there were no staff shortages on 9 and 10 June. The principal
officer also showed my investigator details of the events that occurred in the prison on
9 and 10 June. These showed there was only one event of any significance over that
weekend for the healthcare staff to deal with. This was a minor self-harm that took
place at 7.30pm on 9 June. The principal officer stressed that his examination of the
agreed staffing levels for healthcare staff, and the number of staff on duty over the
weekend of 9/10 June, was discussed with two healthcare managers as well as a
healthcare trade union representative. The principal officer’s findings showed no
evidence of any shortfall in the agreed staffing levels for the material time.
As noted above, those healthcare staff interviewed felt strongly that the number of staff
on duty on 9 and 10 June was insufficient to enable them to cope with the demands
placed on them. Some of them shared a perception that overtime was not sanctioned
to make up for shortfalls. However, the healthcare officer confirmed that he was in fact
working overtime on 10 June for that very reason. Both healthcare officers were
adamant that the number of healthcare staff on duty over the weekend was in keeping
with agreed staffing levels. They also showed my investigator evidence to suggest that
that the only incident that occurred on 10 June prior to 6.00pm was what they described
as a relatively minor act of self-harm.
In all these circumstances, I do not think it can be conclusively said that the number of
healthcare staff available on 9 and 10 June, or the workload they faced that weekend,
were the reasons that the man was not seen before he died. However, while with the
benefit of hindsight it is easy to judge that the man should have been seen more
promptly, I am equally reluctant to criticise staff for not doing so. My reluctance is
based on the following factors:
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(cid:127) Although his behaviour was bizarre, the man did not present as suicidal. It was
reasonable for staff to consider him as non-urgent.
(cid:127) The man had appropriately been referred for a mental health assessment during
the reception procedures on 8 June. This assessment was likely to have taken
place on Monday 11 June. Given his presentation, I consider this timing to have
been reasonable.
Completion of form F213SHSH
The investigation found that form F213SHSH was not completed after the other
prisoner had sustained an injury following an assault by the man during the night of
8/9 June. Had this been done, the other prisoner would have been examined by a
healthcare professional. This, in turn, might possibly have led to an examination or
assessment of the man.
The Governor should remind his staff that, whenever a prisoner sustains an
injury not caused by self-harm, a form F213SH (report of an injury to a prisoner)
must be completed and the prisoner must be examined by a healthcare
professional as soon as possible afterwards.
Was the man’s risk of suicide properly assessed, monitored and managed?
When the man entered Cardiff prison, he told reception staff he had undergone
psychiatric treatment in the community 17 years earlier and had tried to hang himself in
May 2006. However, he gave no indications that he was currently at risk of suicide.
Consequently, no formal self-harm monitoring procedures were initiated. Nevertheless,
the member of staff who completed the reception health screen, taking account of the
man’s pyschiatric history, decided to refer him for a mental health assessment.
Thereafter, as I have said above, although the man’s behaviour was at times bizarre, at
no stage did he give any obvious indications that he was contemplating suicide. The
only remark he did make that could have been interpreted as an indicator of the
presence of suicidal thoughts was his question to an officer, “Do I have to go to heaven
tonight?” But this remark was, to say the least, oblique. I make no criticism of the fact
that it did not trigger the opening of an ACCT form.
The clinical reviewer comments as follows:
“One hypothesis for the man’s withdrawn and unusual behaviour over
the weekend, culminating in suicide, was that he was withdrawing from
drugs and/or alcohol. A simple urine test could have verified his (the
man’s) statement that he had not taken drugs for 18 days. If found
positive on entry to prison, he might have been treated on the
detoxification unit for his withdrawal.”
Whilst I am concerned that no urine test was carried out on the man, and that it was
therefore possible that his death may have been linked to his abuse of drugs, there is
no direct evidence to prove this. As I have said in my foreword to this report, the
toxicology report that followed the man’s post mortem examination established:
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“… the observed low concentration (trace amount) of diazepam found in
the post mortem blood would be consistent with therapeutic use and
does not indicate an overdose of this drug prior to death.”
I am satisfied that the decision only to refer the man for a mental health assessment,
following his disclosure of his psychiatric history and his apparent attempt to hang
himself in May 2006, was justified. In reaching that conclusion, I have taken into
account the fact that during the reception health screening process the man said that he
was not feeling suicidal.
Was the response by staff to the discovery of the man hanging prompt and
effective?
As soon as the officer from the first night centre saw the man hanging in his cell, he
called for emergency assistance over the radio. He then entered the cell and, with the
assistance of a colleague, cut the ligature away from the man’s neck. They lowered the
man so that he could be carried out onto the landing where there was more space in
which to apply emergency first aid procedures. Checks were made promptly to
ascertain whether the man had a pulse or if he was breathing. Having found no signs
of life, the staff started to apply CPR. After about a minute, a Healthcare Officer arrived
and gave his assistance. The full range of emergency first aid equipment was taken to
the cell. An ambulance was called at 6.02pm. A paramedic crew arrived at 6.06pm.
The crew continued to administer CPR until approximately 6.20pm when they
pronounced the man dead.
I am satisfied that the response to the discovery of the man hanging was prompt.
Although it was apparent that the man was beyond the point where his life could
be saved, prison staff and paramedics made determined attempts to revive him in
very harrowing circumstances. I commend them for doing so.
Were appropriate courtesies offered to the man’s family in the aftermath of his
death?
The ability of staff at Cardiff to inform the man’s family of his death promptly was
significantly impaired by the absence of any next of kin details. It is unfortunate that the
man did not disclose such details when he was admitted to Cardiff on 8 June.
However, the investigation found that the principal officer and the chaplain, with help
from Swansea police, did their best to ascertain who was the man’s next of kin and to
break the news of his death as quickly as was reasonably possible under the
circumstances.
The man’s belongings were returned to his family. The Governor met the funeral costs
in full. He was also keen for a representative of the prison to attend the funeral but the
man’s mother, as was her right, did not want this.
Family concerns
The family asked for the following questions/concerns to be answered during my
investigation:
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What were the man’s legal representative’s thoughts on the man’s mental health when
they saw him? What did the man say to his legal representative and how did he seem?
Has he represented the man before and did the man seem the same?
I have covered this matter on page 9 above.
Did the man leave a note?
No note of any kind was found in the man’s cell after he was found hanging.
Were there any writing implements in his cell? (I.e. could he have written a note if he
wanted to?)
My investigator asked to see a copy of the cell clearance certificate in respect of the
man. The cell clearance certificate completed after the man’s body had been removed
shows that he had no writing implements in his possession. My investigator was told
that, if a prisoner arrives at Cardiff without any writing implements, staff will provide
what he needs on request.
Why did CID take the man’s watch and necklace off his bunk after the man was found?
Shouldn’t they have been left as evidence because of the severity of the situation? The
man didn’t normally take his jewellery off. Were they on him or were they as CID said
taken off his bunk?
My investigator attempted on a number of occasions to contact this police officer but
was unsuccessful. He was therefore unable to investigate this matter.
The man was referred for a full psychiatric assessment (on Monday because the
psychiatric nurses only work Monday to Friday). Why wasn’t he put on a ‘suicide
watch’? If there was an inkling that something was wrong, which obviously there was
because of the referral, why wasn’t he put on a watch?
I have considered this important issue at various points in my report. The man was not
made subject to any formal self-harm monitoring procedures because he gave no
indications that he was currently at risk of self-harm or suicide. He was referred for a
mental health assessment because of his strange behaviour. (See pages 11, 12, 13,
17-25.)
A suicide prevention officer was appointed. What was his involvement? Did he see the
man.
The role of the Safer Custody Manager is to quality control the suicide and self-harm
policies and procedures in place in the prison. At Cardiff this role falls to the principal
officer. However, the role does not require him to undertake the personal management
of individual prisoners.
The chaplain spoke to the man on Saturday morning and his words were “saw no cause
for concern.” The health worker saw the man the same day because of an altercation
with his cell mate on the Friday evening and stated that they wanted to see the man
again on the Sunday. Despite the fact that he was having a full assessment on the
Monday – obviously saw concern again – why wasn’t he put on suicide watch? What
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was the concern to see him again on the Sunday? The health worker was due on the
man’s block at 7.00pm (estimated) and he was found at 5.55pm.
These matters are covered on pages 17 - 25.
If the man wasn’t on ‘suicide watch’ why was he checked again at 5.00pm then again at
5.55pm? Where are the logs stating the checks? Who was the last person to see the
man alive? What was the last thing the man said to a guard or prisoner?
The man was seen by the same prison officer that completed the security information
report at 4.00pm on Sunday 10 June while he was taking his tea meal. The prison
officer noticed nothing amiss at that time. There was no requirement for the prison
officer to make a record of what he saw. At about 5.00pm, the prison officer from the
first night centre checked the man in his cell as a matter of routine. The officer from the
first night centre told my investigator he saw the man lying on his bed. The officer from
the first night centre said he tapped the glass window in the cell door and asked the
man if he was alright. The man waved at the officer from the first night centre. Again,
there was no requirement for the officer to make a record of this check. It is highly likely
that this officer was the last person to see the man alive.
The officer from the first night centre checked the man again at 6.00pm. It was at this
time that he found the man hanging. The officer’s check of the man at that time was
part of a routine check of all prisoners in the first night centre, and not part of any
assessment of a risk of self-harm (because the man was not thought to be at risk).
Why was the man pronounced dead almost an hour later? What took so long? Was he
actually alive when they found him?
The man was found at 6.00pm. The ambulance crew arrived at 6.06pm. The man was
pronounced dead at 6.20pm.
What was the fight about? What was said? Why was the man moved and not the cell
mate?
These matters are dealt with in the main body of the report. See pages 12 and 13.
Why didn’t they have his records? Isn’t it compulsory to obtain a prisoner’s file on
remand? If not, why not? Especially as the man was not known to the Cardiff Prison
staff?
My investigator was told that it is not current practice to call for previous prison records.
However, my investigator asked to see records kept at HMP Swansea and HMP Parc.
Two records were sent from Swansea: one for the period 28 April to 27 July 2004, and
the other for the period 6 June to 1 August 2003. My investigator later received a copy
of the record relating to the man’s time at Parc prison. None of these files contained
any evidence of previous attempts at self-harm.
When was the last time the man was at Cardiff Prison?
There is no evidence that the man had been at HMP Cardiff before.
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Why didn’t the representatives from Cardiff go to the man’s mother’s home? Where did
they go? Why didn’t they get her address from the police in Swansea?
These matters are dealt with in the main body of the report. See pages 16 and 23.
The man’s family are certain that this was a cry for help. The man had ample
opportunity to do this in his flat where people wouldn’t visit for days at a time. Why in
jail and not at home? The man had two beautiful children and he would not leave them.
The investigation found evidence that the man was in poor mental health immediately
before his death. Moreover, the experience of being locked in a cell is very different
from that of living alone in a flat. We cannot know if his death might have resulted from
a cry for help.
Why was the man’s mother told by the principal officer that it was determined effort?
What did he mean by that?
I understand that the principal officer’s remark was said in the context of explaining to
the man’s mother how the man was found. The principal officer told my investigator he
meant that the man’s method of hanging himself was such that he seemed to have
made a determined attempt to kill himself.
The family were also told that sometimes these things are premeditated i.e. the man
initiated the fight in the cell to be alone so he could do this. Do they think this was the
case? If so why?
I have found no evidence that the man deliberately manipulated his being placed in a
single cell.
How many offers of making a phone call was the man given? Why did he refuse?
What were his reasons for refusing?
It is known that the man was offered a free telephone call and a free letter during the
reception procedures at Cardiff on 8 June. He refused both. It is possible that the man
did so because he did not want his family to know he was in prison.
The man’s death certificate shows the wrong birth date. Why?
This is probably because the man gave the wrong date on reception.
Why was the man remanded in the first instance? Apparently they were not serious
offences.
This too is covered on page 9 of this report.
Conclusion
I have the sad duty of investigating the deaths of many young men in prison. Very
often those deaths can be related to mental health problems. It is clear that the man
was one such young man, but my investigation found that he gave prison staff no
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indication he was actively contemplating suicide. While I am critical of some aspects
of his care, I conclude that his death could not reasonably have been predicted.
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RECOMMENDATIONS
1. The Governor should remind his staff that, whenever a prisoner sustains an
injury other than by self-harm, a form F213SH must be completed and the
prisoner must be examined by a healthcare professional as soon as possible
afterwards.
I also repeat here the recommendations made in the clinical review of Health
Inspectorate Wales. As noted, I have endorsed only the first recommendation.
2. Prison authorities should give consideration for routine urine testing
for drugs in prisoners who admit taking drugs and alcohol to excess in
the past.
3. Healthcare management must give regard to ensure that the
recommended full complement of staff is present to maintain a safe
level of care for prisoners who need it.
Commendation
I am satisfied that the response to the discovery of the man hanging was prompt.
Although it was apparent that the man was beyond the point where his life could
be saved, prison staff and paramedics made determined attempts to revive him in
very harrowing circumstances. I commend them for doing so.
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