Individual at Leeds

Investigation into the death of a man
who was discharged from HMP Leeds on in October 2004
and died at the home of a friend on the same day
Prisons and Probation Ombudsman for England and Wales
October 2005
This is the report of an investigation into the circumstances surrounding the
death of a man who was discharged from HMP Leeds in October 2004. The man
was found unconscious at the home of a friend at approximately 3.45 pm that
day. Despite efforts to assist him, he was pronounced dead at 4.18 pm.
Although he was not in custody at the time of his death, I authorised this
investigation under my discretionary powers. The fact that this man had been at
liberty for such a short time meant that there might be lessons for the prison
authorities in terms of meeting prisoners’ resettlement needs. One of my senior
investigators conducted this investigation.
A post mortem examination on 18 October found that the likely cause of death
was a drugs overdose. There were needle puncture marks to the man’s groin.
A gash mark was found above his right eye that was thought to be consistent
with him having fallen and hit his head as he collapsed.
I offer my sincere sympathy and condolences to the man’s family and friends.
My thanks go to the Governor and all Leeds staff. I appreciate their willing
cooperation which has enabled the investigation to be completed.
I make one recommendation.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2005
1
Contents
Summary
Investigation
Leeds Prison
Time at Leeds
Post release events
Conclusion
Recommendation
2
Summary
This is the report of an investigation into the death of a man in October 2004 at a
private residence. This man had completed a sentence at Leeds prison and had
been released that day. My investigator reviewed the man’s prison records and
spoke to staff and prisoners at Leeds. Contact was also made with the man’s
family and with the North Yorkshire police.
This man was a heroin user and had been in custody since 18 August 2004 at
HMP Leeds. He had a history of excessive alcohol use going back to when he
was a young man. He later became involved with illicit drugs, with heroin having
become the dominant substance for the six years prior to his death.
At approximately 3.45 pm on 15 October, the man was found unconscious in the
bedroom of a friend’s house. He had been discharged from Leeds that morning.
His friend tried to help him and called an ambulance. CPR was administered but
the efforts to revive him were not successful. The man was found with drugs
paraphernalia, and a substance thought to be heroin.
This report describes the circumstances of the man’s death and looks at the care
that he received while in prison custody. He was not thought to be actively
suicidal while at Leeds.
There are no indications in his prison record that the man had any particular
problems during his sentence. He joined the drug treatment programme and
underwent a detoxification programme to help him with withdrawal from drugs.
When he was discharged, he left the prison and soon afterwards obtained a
quantity of heroin and a syringe. It is not clear what his movements were that
morning, or from whom or from where he obtained these items. Later on he went
to the address of a friend. It seems that his main motivation in going there was to
ask if he could stay for a period. The man was told that he could stay for that
night only, and that accommodation beyond this was not possible.
While this death occurred after the man left prison, issues concerned with the
resettlement of short term prisoners have emerged during the investigation. The
report recommends that the resettlement arrangements at Leeds be reviewed.
3
Investigation
The investigation was opened on October 21 2004, when my investigator met
with the acting Governor at Leeds. Ombudsman’s notices were then issued to
staff and prisoners, identifying the scope of the investigation and inviting anyone
who wished to see the investigator to make themselves known.
North Yorkshire police were contacted and they provided additional information.
One of my Family Liaison Officers telephoned the man’s father. He did not want
to raise any issues for the investigation, but wanted to know the outcome. The
man’s ex-partner was also contacted, but she did not want to be involved in the
investigation.
4
Leeds Prison
Built in 1847, Leeds is a category B local prison. It accepts all adult male
prisoners from courts in West Yorkshire. It has 680 cells plus rooms and wards
for 55 in the Healthcare centre. Recent refurbishment has addressed many of
the issues associated with previous under-investment in Victorian prisons,
although further work is needed to upgrade the buildings and facilities. A new
gate complex opened in September 2002, providing staff facilities and an
improvement to the entry point for all visitors and staff.
Leeds has an operational capacity to accommodate a total of 1,254 prisoners. It
is understood that the prison always functions at or near this figure which is the
maximum population level. It was expanded from four to six wings in 1994.
Leeds was last visited by HM Chief Inspect of Prisons approximately two years
ago. The Inspectorate noted that almost half of short term prisoners discharged
from the prison were not asked about their resettlement needs. The work in this
area was described as fragmented and not always followed through. The Chief
Inspector also thought that a coherent local strategy was needed to ensure
positive outcomes for discharged prisoners.
5
The man’s time at Leeds
He was received at Leeds on 18 August 2004. A cell sharing risk assessment
was conducted and, in the light of his background of drug taking and self harm,
he was allocated to shared accommodation. This was in C 4-07 which remained
his cell until he was discharged.
The man was assessed by the prison doctor. At this point, he was not thought to
be depressed and was considered unlikely to self harm. However, the
prescription for treatment for depression that he had been given by his own
doctor was continued and he was given medicine to help him with withdrawal
symptoms while he underwent drug detoxification.
The man was referred to the Counselling, Assessment, Referral, Advice and
Throughcare Team (CARATS) and was seen and assessed by the CARATS
worker on 19 August. He appeared to be well motivated to change his life style,
but it was thought that he had reached a very low point in his life. He was
referred to throughcare in the community so that he could continue his treatment
on release from prison.
The man does not appear to have come to particular notice in the short time that
he was at Leeds. There were no entries in the wing observation book that
related to him and he appears to have had a largely uneventful stay. He had a
number of cell mates in the period up to 9 September. Thereafter, he shared
with a prisoner who described the man to be a quiet person with whom he got on
reasonably well. The cellmate described how in conversations with the man he
had spoken of his partner and his children. He also said that the man had stated
to him that on release he would be going back to the area he came from and
would be buying a £40 bag of “gear”. (This is a reference to heroin, and would
represent quite a large amount of the drug.)
On 20 September, a release plan for the man was agreed with the CARATS
worker. It included an arrangement for him to see the doctor at a local drugs
clinic when he left prison. This was so that he would be supported in the
community with his efforts to become drug free. The treatment was to include
medication and the counselling and group work sessions that were available at
the clinic on a drop in basis. It was noted that accommodation was available to
the man on release. The address referred to was the home of his partner.
On or about 23 September, the man received a letter from his partner’s solicitor
dated 21 September, telling him that she no longer wished to have any contact.
It also told him that he was not to approach her under any circumstances.
Injunction proceedings would be issued without further notice should he attempt
to do so.
6
In a letter received on 12 October by a friend, the man wrote and asked if he
could stay with her on release from prison. This friend did not reply straight
away. She later said that, had she replied, she would have told him that he
could stay for two days but no longer than that.
The man was released from Leeds on the morning of 15 October and it is not
known where he went until he arrived at the home of a friend later that afternoon.
7
Post release events
At approximately 3.30 pm, the man arrived at his friends address and asked if he
could stay with her. She was reluctant to take him in but said that he could stay
on the settee for one night only. The man then asked if he could go upstairs to
the bathroom to have a wash. She said that he could and she made herself
some tea.
At approximately 3.40 pm, the man’s ex-partner received a telephone call from
the man during which he asked if he could meet with her in Leeds. She replied
that she would not see him as she did not wish to resume their relationship. His
response was to say that he had no life and that he would go and kill himself. At
about 3.45 pm, his friend heard banging upstairs and thought perhaps the man
had slipped or got into the shower. Shortly afterwards the friend became
concerned and went to the bathroom to check that he was alright.
When she entered the room, she found the man half sitting and half crouched
between the bath and the sink. She noticed that he had a gash above his right
eye and was very still. She attempted to stir him but there was no response.
After unsuccessfully trying to find a pulse, she telephoned the emergency
services who despatched an ambulance. A telephone adviser was provided to
assist the friend in her efforts to help the man.
The friend maintained attempts at CPR until the ambulance arrived, but neither
she nor the paramedics were able to revive him.
It was noted that around the body there was drugs paraphernalia. This included
needles, syringes, a bag of white powder and a spoon.
It is assumed that the gash to the man’s head was sustained when he became
unconscious, striking his head as he fell.
8
Conclusion
This was a man with alcohol and drug addictions who had experienced failed
relationships and family breakdown. When he went to prison for the last time, he
seems to have had few stable points in his life. His relationships with the
mothers of his children had ended, and his children were either in the care of the
local authority or adopted.
He left prison on 15 October without a job or accommodation. He made an
attempt to find somewhere to stay on that day but this not successful.
It appears that the man took a significant dose of heroin intravenously. The
timing of this action, the amount of drug apparently involved and the telephone
call to his ex partner are suggestive of an act of despair. His intentions cannot
be known, however, and his tolerance of the drug would have been reduced by
his period of detoxification in prison.
When the man was discharged from prison there was no requirement for a
discharge plan for short term prisoners. There was, however, an expectation that
prisoners in the man’s position would receive assistance with resettlement
issues. It is noted in the man’s CARATS documentation that he said that he had
accommodation on release. It must have become clear to him soon after that
entry was made that in fact he did not. It is not recorded whether he told anyone
about this or not.
There was good work done by Leeds prison in helping the man arrange post
release support to help him with his drug habit, but there would not seem to have
been the same level of input into his other resettlement needs. This echoes the
finding of HM Chief Inspector. There does not seem to have been a lack of will
to provide quality arrangements for the man’s discharge, but it was not well
coordinated and resulted in patchy delivery. It would seem that the man simply
stated to staff that he had somewhere to go on release, and this was accepted
without further checking or confirmation.
It is questionable whether the resettlement arrangements for short term prisoners
at Leeds are as coordinated as they might be.
9
Recommendation
In light of the findings of this report, the Governor of HMP Leeds should review
resettlement arrangements with the aim of ensuring that the needs of short term
prisoners are clearly established before discharge.
10
11