Individual at Manchester

Investigation into the circumstances surrounding
the death of a man at HMP Manchester
in September 2004
Prisons and Probation Ombudsman for England and Wales
December 2005
This is the report of an investigation into the death of a man at HMP Manchester on 4
September 2004. The circumstances in which the man died were very rare. Both he
and his cell mate were found hanging in their shared cell.
I wish to offer my sincere condolences to the family and friends of the man, for their
tragic loss. I know the staff and prisoners at Manchester who knew him share those
sentiments.
I am grateful to my Deputy Ombudsman, for leading this investigation. She was
assisted by the Assistant Ombudsman. I also wish to extend my thanks to the Governor
of Manchester, and his staff for their help and co-operation during this investigation.
There is necessarily some overlap in content, findings and conclusions between this
report and the one following the death of the man’s cell mate.
Stephen Shaw CBE December 2005
Prisons and Probation Ombudsman
2
SUMMARY
1 The man who died was 32 years old when he took his own life whilst in prison
custody at HMP Manchester. He had convictions dating back to 1987 when he
was 15 years old and attributed his offences to misusing drugs. The man had
received a variety of punishments from the courts, including custodial sentences.
2 In March 2003, the man was remanded in custody to HMP Durham. He was
charged with robbery and possession of firearm (imitation), offences committed a
year earlier.
3 Two days after his reception at Durham, the man took an overdose of prescribed
diazepam. A Self-harm at Risk form (F2052SH) was opened. A multi-
disciplinary review took the decision to close the F2052SH on 30 March 2003.
Later the same day, he transferred to Leeds at his request as it made visits
easier for his family.
4 On 22 December, the man was sentenced to life imprisonment with a tariff of two
years eight months. This meant he would have been eligible for release on
licence from August 2006 onwards. The post conviction immediate needs
assessment was not completed for over three weeks. Furthermore, he was not
seen for his post-conviction induction interview until the end of March 2004.
5 The man transferred to HMP Dovegate in April 2004. On 19 May, he lacerated
his left wrist and was admitted to healthcare for assessment. Whilst at Dovegate,
he admitted to using heroin and having got himself into debt with other prisoners.
6 In mid-June, the man transferred to Manchester to make a new start. However,
his drug debt followed him and in August he requested vulnerable prisoner (VP)
status for his own protection. The man moved into the cell with another Prisoner
on 28 August. On 1 September, the man and his cell-mate refused to go back
into their cell, and expressed concerns about their personal safety. After
discussion with staff, they did return to their cell and apparently settled down.
7 Three days later at 6:47 a.m. on 4 September, the man and his cell-mate were
discovered hanging in their cell. A suicide note was found in the cell in which the
man apologised to his family for all he had put them through. His cell-mate had
also left a note.
9 During the investigation, Manchester’s standards of record keeping were found to
be less than adequate. It was also discovered that the night patrol officer had
undertaken the head count between 2:30 am and 3:00 am, by his own
admission, rather than at the required time of 6:00 am. This will have
undoubtedly delayed the discovery of the man and his cell mate.
3
10 Nothing I have seen has suggested that the actions of the two men could have
been predicted or directly prevented. The report makes seven
recommendations.
4
BACKGROUND
The Man
10 The man who died was born in August 1972, in Huddersfield, Yorkshire, the third
of five children. When he was seven years old, his mother was unwell and so he
was placed into the care of the local authority. The man attended school
regularly, but left without any formal qualifications.
11 After leaving care, the man described his lifestyle as unsettled. He began to
misuse substances during this time. Initially, this involved glue sniffing. He
subsequently misused illicit drugs such as ecstasy and amphetamines, before
finally falling prey to heroin and crack cocaine. Misuse of substances resulted in
him appearing before the courts and receiving custodial sentences. The
sentences, coupled with misuse of drugs and his unsettled life-style, meant that
the man was unable to sustain regular or long term employment.
12 During the mid 1990s, the man was in a stable relationship for about two years
and had a daughter with whom he maintained regular contact. At the time of this
conviction, he told the authorities that he still maintained an amicable relationship
with his ex-partner.
13 The offences of robbery and possession of an imitation firearm with intent were
motivated by the need to fund his drug habit and to repay a drug related debt.
HMP Manchester
14 HMP Manchester is a core local establishment managed under a Service Level
Agreement. Its Mission Statement aspires to provide a safe, secure and
purposeful environment.
5
THE INVESTIGATION PROCESS
11 The investigation was conducted my Deputy Ombudsman and Assistant
Ombudsman. This high-level team reflected the highly unusual circumstance of
a double apparent suicide.
12 The Governor of HMP Manchester and his staff produced well presented files
containing all the relevant documents and policies.
13 The investigation team met with representatives of the Prison Officers’
Association and Independent Monitoring Board and informed them of the scope
of the investigation.
14 Documents pertaining to the man’s cell-mate time in custody were examined and
prison staff interviewed.
18 Following the discovery of the man and his cell-mate, a full police investigation
was opened. After extensive forensic examination, it was decided there were no
suspicious circumstances or third party involvement and so the police closed
their investigation.
6
CUSTODIAL HISTORY
19 The man committed the offences for which he was charged in February 2002, but
was not remanded into custody until March 2003. He was initially received at
HMP Durham on 17 March.
20 On reception at Durham, he was seen by a healthcare worker and an initial
health assessment was undertaken. The man advised the healthcare worker
that he was seeing his General Practitioner due to his substance misuse, and
was receiving diazepam and subutex for the management of his withdrawal. He
had no other concerns about his physical health.
21 When asked about his mental health, the man told the interviewer that he was
being seen by a psychiatrist as a result of childhood abuse. He also informed
them that he had previously received Prozac. There is no indication that he was
still on that medication at the time of his reception. He stated that he had never
previously self-harmed and did not feel suicidal at that time. However, a
subsequent pre-sentence report states, “Previous reports indicate there have
been previous instances of self-harm.”
22 The man indicated that he would like to see a doctor, specifically in relation to
withdrawal from illicit substances. He was seen by the duty medical officer who
carried out a physical examination, which included obtaining base-line
observations of his temperature, pulse, breathing and blood pressure. He was
offered and accepted a detoxification programme using lofexidine.
23 A Cell Sharing Risk Assessment (CSRA) was carried out in accordance with
national policy. It did not identify any concerns and the man was considered to
be low risk and suitable for multi-cell location. There is no available CSRA to
indicate that the risk assessment was reviewed after one month in accordance
with policy.
24 On 19 March, the man told staff that he had overdosed on diazepam. He said he
had done so in order to get a “buzz” rather than because he was suicidal. He
was re-located in healthcare and a Self-harm at Risk form (F2052SH) was
opened by a discipline officer. The man was placed on an intermittent watch and
observed for any side-effects of the overdose. The F2052SH clearly
demonstrates that he was observed regularly and checks were made to ensure
there were no adverse effects from the alleged ingestion of 28 diazepam tablets.
25 The man remained on the F2052SH until 30 March. The entries indicate that he
had settled well, was interacting well with his peer group on the residential wings
and required no further interventions from healthcare. Following a multi-
disciplinary case review which included the man, it was decided to close the
F2052SH on the morning of 30 March.
7
26 The man was transferred to HMP Leeds on the same day. The transfer was at
his own request because of his mother’s ill health, and it enabled him to be
nearer his family. On his arrival at Leeds, a “health screen update” was
undertaken. The mental health section of this document indicates that he had no
history of deliberate self-harm and no concerns had been expressed. There
does not appear to have been any consideration of the closure of the self-harm
at risk form earlier that day.
27 A Cell Sharing Risk Assessment was completed on the man’s arrival at Leeds,
which again identified him to be a low risk and suitable for shared
accommodation. This document was completed with little knowledge of the man
and no documentation to support the decision making process. There are no
entries in the man’s history sheets from his time at Durham. Thus, when staff
completed the CSRA at Leeds, they would not have had any knowledge about
his previous behaviour, his compliance with regimes and his relationships with
staff and other prisoners.
28 On arrival at Leeds, a history sheet was opened but it does not contain any
entries that indicate how the man was coping with custody. The first entry is
dated 2 July and it is a stamp noting information from the Prisoner Escort Form
(PER) and that he was discharged to court.
29 An entry in the medical record shows that the man had pleaded guilty at court
and returned to Leeds, on the Judge’s Remand, to await sentencing. The entry
also notes that he was not depressed or suicidal, and he declined to see the
medical officer.
30 An entry in the medical record on 18 July, and a further entry on 25 July,
indicates that the man may have been using illicit drugs as he was requesting
detoxification. It was only after the second consultation that he began a subutex
reducing programme. Towards the end of the 14 day programme, he again
attended healthcare and requested a maintenance programme. He was advised
by the medical officer that healthcare did not provide maintenance and so he was
referred to the establishment’s drugs services provider, RAPT. The man was
seen by a drugs worker, but declined the help and support of the available
services.
31 He had attended court on 22 December for sentencing and received an
automatic life sentence. When he returned to the prison, he was seen by a
healthcare worker and said that he had been “expecting some big bird”. He said
he was not depressed or suicidal.
32 Despite being sentenced to life imprisonment, he was not interviewed for the
Post Conviction Immediate Needs Assessment (form LSPIA) until 13 January
2004. He told the interviewer that he had been in shock initially, but had settled
8
down and wanted to get on with his sentence, particularly because of the short
tariff of two years and eight months. The man again said that he had no history
of harming himself and that he was not suicidal. There is no reference to the
F2052SH which was opened and closed after a period of approximately two
weeks in March 2003. The initial allocation documentation was also completed
that day. He said that HMP Gartree would be able to offer everything he needed
to progress through his life sentence, but that he was prepared to change his
allocation if it meant he would move to a first stage lifer unit at an earlier date.
33 Once again, there are no entries in the man’s history sheet to indicate how he
was coping with his sentence and custody in general. An entry in his medical
record dated 29 February 2004 notes that he was admitted to healthcare with
chest pains. By 2 March, this had settled down and he asked to return to the
main prison. He was assessed as fit for return to ordinary location that day, and
discharged from healthcare with a diagnosis of anxiety.
34 The man was seen on 23 March for his post-conviction induction interview, some
three months after sentencing. The report indicates that he had earned
enhanced status under the Incentives and Earned Privileges scheme. This is the
first documented evidence of his behaviour whilst in custody. The report also
notes that he had been employed as a cleaner whilst he was located on B wing.
35 The man’s ‘Lifer Profile’ was completed on the same day. It stated that he was
able to cope adequately in custody and was suitable for normal location. It also
referred to adjudication for fighting which occurred at the end of February. This
was his first adjudication during his sentence and he received seven days’ loss of
privileges following the finding of guilt.
36 The third report completed that day was the pre-first stage report. It noted that
he had come to terms with his sentence and was willing to participate in
whatever courses were necessary to affect an early release. Once again, his
behaviour was said to be good and that he followed wing regimes well. He
appeared to have a good rapport with staff and associated with a small group of
other prisoners. He was keen to move to a lifer unit and get on with his sentence
plan.
37 The next entries in both the medical record and history sheet refer to him being
assessed as fit for transfer to HMP Dovegate. They are dated 1 April, and he
transferred the following day when he was seen by healthcare staff who noted
that he had no medical problems. Once again there are no entries in his records
regarding the transfer.
38 An entry in the medical record refers to the man making lacerations to the inside
of his left wrist on 19 May. Healthcare staff attended and he was admitted to
healthcare for assessment. An entry in the medical record notes “awaiting
F2052SH” but no F2052SH is available for the incident and no entry is recorded
9
in the available history sheets. A history sheet was opened which detailed his
stay in healthcare. It is supported by a nursing care plan and a multi-disciplinary
evaluation sheet. The entries suggest that the man settled in the healthcare
regime and was polite and courteous to staff.
39 Shortly before he harmed himself, the man submitted an application to
healthcare stating that he had been using heroin since arriving at Dovegate and
had got into trouble. A pre-first stage lifer report indicates that he had been
purchasing drugs for £50 for each purchase from other prisoners. He was
unable to pay his debts and consequently had been subjected to bullying,
intimidation and physical violence.
40 It was considered that due to the size of the drugs operation, “there has been no
wing safe enough to house him” and so, for his own protection, he remained in
healthcare whilst a transfer to another establishment was arranged and he could
make a fresh start. Meanwhile, he agreed to engage with the local drug services
and was assessed by the RAPT team who provide the Counselling, Assessment,
Referral, Advice and Throughcare (CARAT) services.
41 The man was seen by the drugs worker on 27 May, and expressed a wish to
address his substance misuse problem. He said that he wanted to get help and
support, to avoid returning to drug use and ultimately to achieve complete
abstinence. The drugs worker thought that he appeared motivated to address
his drug problems and acknowledged the connection between his substance use
and his offending behaviour. A care plan was formulated and agreed with him.
42 A transfer was arranged to Manchester in mid June. The RAPT team completed
a form outlining the main issues the man had at the time and the outstanding
goals that he still wanted to achieve.
43 The man transferred to Manchester on 16 June. The medical record notes that
he was fit for transfer and had no outstanding medical appointments. There is no
entry in his medical record to demonstrate that he was seen by healthcare staff
on his arrival at Manchester. A Cell Sharing Risk Assessment was completed.
He was initially allocated to G wing which is the induction wing, and remained
there for a day before being transferred to C wing. He was given information
about the prison during his first 24 hours.
44 Three days later on 19 June, the man was told that he would start work in
Workshop 5 on 21 June. However, on 24 June he failed to attend work. The
entry in the history sheet does not indicate the reason for his failure to attend or
what, if any, action was taken. He again failed to go to work on 20 July and he
was later given a warning, apparently for adverse comments. The same day he
was moved from the 3’s landing on C wing to the 4’s.
10
45 The following day, the man was moved back to his old cell on the 3’s landing
after pleading guilty to a drug related charge at adjudication. He had tested
positive for opiates during a mandatory drug test. The man lost 14 days’
association, recreational PE, in-cell electricity and 50% of his earnings.
46 He appeared to settle down on the wing. On 15 August, the man’s Personal
Officer introduced himself and noted that the man said he was happy on the
wing.
11
EVENTS BETWEEN 24 AUGUST AND 4 SEPTEMBER
47 Just over a week later, the man applied for vulnerable prisoner status. He said
that he made the application as he had, “Fears for his safety due to being in
debt”. He said he had got himself into debt through purchasing drugs. Initially,
he had thought he could manage the situation himself but now realised that he
could not do so. He was seen by a Governor, who approved his transfer to a
wing. The man told the security department who was making the threats, and a
Security Information Report was completed. The Security Manager’s response
to the information was to interview the man to ascertain the level of threat and
also to implement the Anti-Bullying Strategy against the alleged bullies if there
was substance in the perceived threat. The action plan was agreed by another
Governor, but there is no evidence that it was carried out.
48 The man transferred to A wing during the afternoon of 24 August. Prior to being
relocated, the CSRA was checked and he moved into cell A2- 105 with his cell-
mate.
49 On 29 August, an entry in the wing observation book notes that the man and his
cell-mate had allegedly received threats from the main prison. They were seen
by an Officer who offered support and advised other staff to be alert to potential
incidents.
50 From the information given by the man and his cell-mate, it became clear there
was a complicated relationship between them and another prisoner, who they
perceived was behind the threats. On 30 August, The man’s cell-mate passed a
note under his cell door indicating that he and the man believed that their lives
were in danger from another prisoner. They were interviewed the next day about
their concerns. His cell-mate said that he believed there was a “large price on
his head”. They were anxious about what he might do and expressed concerns
about their personal safety.
51 A further entry in the wing observation book notes that the man and his cell-mate
refused to go back to their cell on 1 September. There are no entries in the
man’s history sheet to indicate the reasons for refusing to relocate, or of any
subsequent support or advice to the man and his cell-mate. However, they did
return to the cell peacefully after discussions with staff.
12
DISCOVERY OF THE DEATHS
52 On 4 September, the Officer in charge carried out the morning check. He started
on the outer part of A wing and worked his way up the landings, before crossing
to the inner part where he started on the 4’s landing, working down. He got to
cell A2-105 at 6:48am and looked through the observation hatch. He noticed two
prisoners apparently standing up, one facing the window and the other facing the
door. Despite the dim light, he was able to see that the man and his cell-mate
were hanging with ligatures around their necks. He immediately put out a radio
call for urgent assistance and ran to pick up the suicide box.
53 When he tried to open the cell door, the officer in charge found that it was
blocked and he had to kick it several times to gain entry. It had been blocked
using the wardrobe unit. He entered the cell, together with three other officers,
who had responded to the urgent message.
54 The four staff began to take the man and his cell-mate’s weight and remove the
ligatures, which was made more difficult because the space was limited and
because both men had oil on their feet which made them slippery. By the time
they had removed the ligatures, healthcare staff had arrived. The staff withdrew
from the cell to make space for healthcare staff to work. Two Nurses
immediately assessed the situation. It was evident to them that both men had
been dead for some time. The nurses made the appropriate clinical decision that
they would not attempt to resuscitate the men.
55 The ambulance, with paramedics, arrived at the prison at 7:01am. They were
quickly escorted through the prison and entered the cell. The paramedics noted
that both bodies were cold to the touch and the pupils were fixed and dilated.
The Paramedic attached a defibrillator, first to the man’s cell-mate, and then to
the man, but there was no cardiac output from either. There was nothing more
that they could do to assist and so they departed.
56 The Doctor attended at 10:35am and certified the deaths of both the man and his
cell-mate.
13
ACTIONS AFTER THE DISCOVERY OF THE TWO MEN
57 The control room log states that the deaths were discovered at 6:47am, and all
available staff were asked to attend A wing. The ambulance service was
contacted at 6:51am. One ambulance arrived at 7:01am, and another arrived
two minutes later. By 7:08am, it was evident that two ambulances were
unnecessary and so the second left the prison.
58 The police were contacted at 7:19am and arrived at the prison at 7:43am. They
were escorted to A wing and taken to the cell, which they noted was locked and
secure. A prison officer was located outside the cell to act as a log keeper.
59 The Governor arrived at the prison when the message requesting immediate
medical assistance came over the radio. At the same time, a nurse also arrived.
She hastened her progress through the staff search and, along with the gate
Senior Officer, all three made their way to the wing. The Governor was satisfied
that everything was being well managed and he went to the control room to
activate the contingency plan.
60 The Governor, the Duty Governor, the Care Team, Independent Monitoring
Board and Chaplaincy were all notified of the events. When the Governor and
Deputy Governor, arrived at the prison, they were briefed by the first Governor
that arrived.
61 The Duty Governor and chaplain were asked to visit the families of both men,
after the chaplain first contacted them by telephone and informed them of the
tragic events of the morning. Because of concerns expressed by the police,
there was considerable delay leaving Manchester to travel to the man’s cell-
mate’s home. On arriving in his area, the Duty Governor, the chaplain and the
two Family Liaison Officers (FLO) went with local police to visit the man’s cell-
mate’s family. The man’s family had apparently declined a visit from the prison
staff, and so the Greater Manchester Police FLOs went alone to visit them.
62 Significant numbers of police were in attendance at the prison to assess whether
there was any indication of foul play. The police are satisfied that there is no
suggestion or evidence of any suspicious circumstances.
63 The Operation Support Grade (OSG) had been the night patrol on duty during
the night of 3/4 September and carried out a roll check in the morning that the
men were discovered. He had gone off duty by the time that they were
discovered, and at 7:40am a message was left on his mobile phone at the
Governor’s request. At 7:57am, The Night patrol Officer contacted the prison to
inform them that he was returning. He arrived at 8:25am and made a statement
to the Governor and a witness statement to the police.
14
64 The residential night patrol orders require the night patrol to conduct a full wing
roll check at 6:00am and report the figures to the Night Orderly Officer. The
Night Patrol Officer said that he had carried out the check between 2:30am and
3:00am on 4 September, and no further checks were carried out. The Governor
immediately commissioned an internal disciplinary investigation, which has now
concluded.
15
FINDINGS AND CONCLUSIONS
65 The man did not cope with prison custody. He moved from Dovegate to
Manchester after being bullied and getting into debt for continued substance
misuse. He had previously harmed himself by taking an overdose of prescribed
medication on one occasion, and cutting his left wrist in a separate incident.
66 Following sentence, the man was required to have an immediate assessment to
enable the completion of the Post Conviction Immediate Needs Assessment
(LSPIA). This did not occur for over three weeks after sentencing. Whilst the
delay in the man’s case would not have had any bearing on his tragic death, it
could be of significance in other cases.
The Governor of Leeds should remind staff of the importance of
completing such documents in a timely manner to ensure their immediate
post-conviction needs are met promptly.
68 The man transferred to Manchester on 16 June, but the very limited entries in his
history sheets do not provide a satisfactory picture of his time there. He asked
for vulnerable prisoner status in August, and requested a move from C wing for
his own protection. He said that he feared for his own safety, stating that threats
were coming from one prisoner and others acting on his behalf. The man also
gave information to staff about a weapon hidden on C wing.
Staff should be reminded of the need for appropriate, accurate and
contemporaneous records to protect the welfare of prisoners and enable
appropriate management.
69 The Wing Manager did not follow up the action points identified by the Security
Manager following the Security Information Report (SIR) submitted on 24 August
2004. He was required to speak to the man and establish the level of threat, but
this did not happen.
A review of the SIR action and follow-up procedures should be undertaken
to ensure that there is an auditable record of compliance with follow-up
action points and the outcome of such actions.
70 The F80, Report of Locking Up, did not show times that roll checks took place.
Furthermore, the night patrol undertook the 6:00am head count several hours
earlier than required and no more checks were carried out. The matter was
commendably identified by the Governor and an immediate internal investigation
was commissioned.
A review of the local procedures for completing the F80 should be
undertaken to include the requirement to state clearly the times of roll
checks and observations of prisoners as required.
16
All night staff should be reminded of their roles and responsibilities during
the night patrol period.
71 There is clear evidence of appropriate levels of support for staff directly involved
in the tragic deaths of the man and his cell-mate. However, other staff working
on the wing, not on duty at the time, were not offered support, although they too
felt involved with the deaths from their normal day to day knowledge of the two
men. Staff should be reminded how they can access care and support services.
Governors should be reminded to extend post incident support/care
arrangements to all staff, and ensure that all staff involved with prisoners
are afforded appropriate care and support.
72 Nothing I have seen has suggested that the actions of the man and his cell mate
could have been predicted, or directly prevented by prison staff.
17
RECOMMENDATIONS
1. Governors should be reminded to extend post incident support/care arrangements to
all staff, and ensure that all staff involved with prisoners are afforded appropriate
care and support.
2. A review of the SIR action and follow-up procedures should be undertaken to ensure
that there is an auditable record of compliance with follow-up action points and the
outcome of such actions.
3. Staff should be reminded of the need for appropriate, accurate and
contemporaneous records to protect the welfare of prisoners and enable appropriate
management.
4. A review of the local procedures for completing the F80 should be undertaken to
include the requirement to state clearly the times of roll checks and observations of
prisoners as required.
5. All night staff should be reminded of their roles and responsibilities during the night
patrol period.
6. The Governor of Leeds should remind staff of the importance of completing such
documents in a timely manner to ensure their immediate post-conviction needs are
met promptly.
18