Individual at Forest Bank

Investigation into the circumstances surrounding the
death of a man at Hope Hospital, Salford,
on in September 2008, whilst in the custody of
HMP Forest Bank
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2010
The man (hereafter referred to as “the man”) was 35 years old when he died on 19
September 2008 at Hope Hospital, Salford. He had been the subject of a brutal
attack at HMP Forest Bank. Three prisoners were originally charged with his death,
and one was convicted. The prisoner (hereafter referred to as “the prisoner”)
concerned pleaded guilty to manslaughter.
The investigator and Family Liaison Officer (FLO) join me in offering our sincere
condolences to his family and friends for their sad loss. I wish to thank the Director
of Forest Bank for making the necessary facilities and information available to the
investigator. I also thank the prison’s liaison officer for her assistance.
As the circumstances of the man’s death have been fully investigated by Greater
Manchester Police and in the prisoner’s trial at Manchester Crown Court, I have
limited my investigation to events after 19 September 2008. However, for
completeness, and by reference to police records, I do summarise the events of that
day. For the purpose of this report and chronology, I begin the key findings section
with the basic details of the prisoner’s movements within the prison system from 26
September 2006 when he was in custody at HMP Risley.
The man had been serving a three month prison sentence for breach of bail. It was
his first time in custody. Under the terms of the End of Custody Licence (ECL)
procedure the man was eligible for release on 15 September 2008. However, before
anyone is released on ECL, further background checks are carried out on the Police
National Computer (PNC) to ensure they fulfil the criteria. Forest Bank do not have
their own PNC terminal, and instead have to request the information from HMP
Hindley which is the designated reference point for Forest Bank and two other
prisons in the area.
Unfortunately, at the time in question there were severe delays at Hindley in
processing PNC applications. This caused a backlog of applications, including the
man’s and meant that the PNC information did not arrive at Forest Bank in time for
them to consider his suitability for release on the appropriate date. In an effort to
speed up the process, and frustrated by the delays, the Director of Forest Bank had
regularly sent a member of his staff to Hindley to collect any PNC documents that
were ready. Sadly, when his check was finally collected, it was on the day he was
assaulted. But for the delay in accessing PNC information, there is no reason to
suppose he would not have been released on 15 September. It will be of no comfort
to his family to learn this.
I make two recommendations. One is to the National Offender Management Service
concerning the routine examination of back records. The other is for the Director of
Forest Bank regarding the introduction of an audit trail for the recording of equipment
failure and repair. Not surprisingly, my report also comments on the current position
regarding individual prisons’ access to the PNC.
Jane Webb
Acting Prisons and Probation Ombudsman September 2010
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CONTENTS
Summary
The investigation process
HMP Forest Bank
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
On 20 August 2008, the man was sentenced to three months imprisonment after
breaking the conditions of a supervision order imposed earlier that year. It was his
first time in custody.
On reception at HMP Forest Bank he underwent a cell sharing risk assessment
(CSRA) and was judged to be low risk for sharing a cell. Shortly after he was
allocated to a cell, another prisoner joined him. Less than a month later, on 19
September 2008, that prisoner assaulted the man so badly that he died from his
injuries. The prisoner had earlier been assessed in another prison as being a high
risk to other prisoners if he shared a cell. However, he moved to Forest Bank after
that assessment was made, and, on this occasion, had returned to custody after
breaching the conditions of his release. Staff at Forest Bank did not have access to
his previous prison record when he arrived, and did not refer to his previous risk
assessments when they became available.
I conclude that the attack on the man could not reasonably have been predicted.
The man might have been eligible for release on 15 September 2008. Sadly, there
were failures in accessing routine information. A PNC check was delayed as staff at
HMP Hindley had a backlog of information requests, which meant the man’s
previous convictions were not properly assessed in time for his potential release
date. This delay caused him to be kept in prison longer than he should have been
under the End of Custody Licence (ECL) scheme.
Two recommendations are made in this report. The first is that the National Offender
Management Service (NOMS) should consider issuing guidance advising Governors
and Directors that, once back records are received, previous CSRAs should be
checked and the most recent assessment reviewed. The second recommendation
(which is directed to Forest Bank) should ensure that equipment faults are logged
and rectified. I also comment on the issue of Prison Service access to the PNC.
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THE INVESTIGATION PROCESS
1. Once the Ombudsman’s office was notified of the man’s death, the
investigation was allocated to a senior investigator. He was assisted by two
Family Liaison Officers (FLOs).
2. On 23 September 2008, the investigator travelled to Forest Bank where he
met the Director, the prison’s liaison officer, the prison’s Operations Manager
and the Police Liaison Officer. The Director gave the investigator an overview
of what had occurred.
3. Additionally the Director explained the difficulties he was experiencing in
obtaining PNC checks and his own terminal. My investigator immediately
reported to me personally about this issue and, because the investigation was
to be suspended in light of the police investigation, my Deputy Ombudsman
raised it at a high level with the National Offender Management Service.
4. Every death in prison custody is reported to the police as soon as it is
discovered. In the first instance, the police treat the area where the person is
found as a potential crime scene. When the police are satisfied that the death
is not suspicious, PPO investigators are able to begin their own investigation.
5. The investigator shared a copy of the Memorandum of Understanding
between this office and the Association of Chief Police Officers with the police
officer in charge of the investigation. This document sets out the protocol for
investigating deaths in prison and sharing information.
6. The man’s death was not confirmed until he had been taken to Hope Hospital,
Salford, and assessed. Following confirmation that he had died, police
officers treated the incident and area where he had been found as a murder
scene.
7. In agreement with the police investigators, my investigation was suspended
pending the outcome of the criminal case. It was resumed only after the
police confirmed that their own case had been concluded.
8. On July 2009 at Manchester Crown Court, the prisoner pleaded guilty to
manslaughter. The police officer in charge of the case at that time contacted
our investigator and gave him permission to recommence the investigation.
9. The investigator and FLO met members of the man’s family and their solicitor.
The purpose of the meeting was to identify any issues they wanted the
investigator to consider. However, as the circumstances surrounding the
assault and death had been fully investigated by police and subsequently
explored at court the investigator told them that he would limit the scope of his
investigation to events after 19 September. The man’s family and solicitor
agreed and have contributed towards the investigation. I am grateful for their
assistance at what was a very difficult time.
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10. On 19 August 2009, the investigator, FLO and two police officers from Greater
Manchester Police attended a meeting in Bolton with the Coroner for West
Manchester. The investigator shared the family’s concerns and the revised
scope of the investigation with the coroner. Following the meeting the coroner
confirmed that she would be reopening the inquest into the man’s death.
11. During that meeting, the police told the investigator that it had been suggested
by the prisoner at his trial that he had warned the Prison Service that he was
a risk to other prisoners. The investigator has carried out extensive searches
of the prisoner’s prison record, and I am grateful for the assistance of staff at
HMP Liverpool which is where his record was at the time of this investigation.
12. Following the meeting the investigator returned to the prison to recommence
the investigation. Over the next two days he carried out a number of formal
and informal interviews with prison staff. The formal interviews were recorded
and the transcripts of those interviews are attached to this report.
13. On 21 August 2009, the investigator met the Director and liaison officer to
feed back his findings. The investigator told the Director he was likely to
make a recommendation regarding the checking of back records. The
Director accepted the finding and suggested it was probably an issue that
should be raised nationally with NOMS.
14. Two months later, on 14 October the investigator returned to Bolton to meet
with the Coroner and police. The purpose of the meeting was to update the
Coroner on progress and give an indication on when the investigation report
would be completed.
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FOREST BANK
15. HMP Forest Bank is a privately managed prison operated by Kalyx. It is
situated on the outskirts of Salford. The prison opened in January 2000. The
prison has a certified normal accommodation figure of 800, and an operational
capacity of 1160 prisoners.
Her Majesty’s Chief Inspector of Prisons
16. Her Majesty’s Chief Inspector of Prisons reports on all prison establishments.
The majority of inspections are announced and allow the prison being
inspected to prepare. However, a number of inspections are carried out
without prior warning and are known as unannounced inspections.
17. In September 2007, the Chief Inspector of Prisons carried out a five day
unannounced inspection of Forest Bank. In the introduction to her
subsequent report she said that Forest Bank’s first inspection in 2002 had
been relatively positive. After a second inspection in 2005, the inspectors
were not as positive and she said there were significant concerns about
safety. However, in her 2007 report the Chief Inspector of Prisons said that
safety had improved and overall the prison was not unsafe.
Independent Monitoring Board
18. Each prison has an Independent Monitoring Board (IMB) and their role is to
monitor the prison and to report any concerns that they have regarding how
prisoners are treated. They feedback in the first instance to the
Governor/Director, but may raise matters directly with the Secretary of State.
Board members are able to visit any area of the prison at any time and have
direct access to any prisoner who they wish to see, or who requests to see
them. The Board holds regular meetings in the prison, with the
Governor/Director attending for part of the meeting. The Board produces an
annual report to the Secretary of State for Justice.
19. In their latest annual report, covering the period December 2007-2008, the
Forest Bank Board said: ‘We draw to your attention that for a number of years
the prison management have been attempting to obtain PNC facilities. The
prison already has a dedicated Police Liaison Officer and it would greatly
reduce the amount of time in dealing with all prisoner administration as well as
being a useful intelligence tool. We would ask that this matter receives your
urgent attention.’
Prison Service Orders (PSOs)
20. Prison Service Orders contain long term, mandatory instructions, which are
intended to last for an indefinite period. Any mandatory instructions to
Governors/Directors are written in italics. Each PSO is given a title and
unique reference number.
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PSO 2750 Violence Reduction
21. PSO 2750 is a document which introduces a strategic approach to the
prevention of violence. It is constructed to enable each establishment to
develop a local approach within existing resources.
22. The PSO includes a requirement for a cell sharing risk assessment (CSRA)
which was initially introduced by the Prison Service in June 2002 and revised
in 2005. Contained within PSO 2750 are four annexes:
(cid:127) A. On the safe side.
(cid:127) B. Cell sharing risk assessment. Risk of harm to others.
(cid:127) C. First Steps – Early Intervention.
(cid:127) D. Model procedure for informing staff of the issue of Prison Service
Orders and instructions relating to the management of prisoners
For the purpose of this investigation, I concentrate on annex B. At section two
and three of the CSRA form contained within this annex, the assessor is
asked to indicate the level of risk the individual poses to others. There are
three specific areas:
(cid:127) Low. No current indication/evidence of risk, suitable for multi-cell
location.
(cid:127) Medium. No immediate risk, but situation will need to be reviewed
regularly.
(cid:127) High. Clear indication of high level of risk that prisoner might assault
cell mate.
Police National Computer (PNC)
23. Access to the PNC is allowed under an agreement between the Association of
Chief Police Officers, the National Police Improvement Agency (NPIA) and
NOMS. The NPIA is the agency responsible for running the system. The
agreement for use of the PNC is to allow checks on previous convictions,
which in turn are used to inform decisions for release on licence.
24. At the time of the man’s death, the Prison Service was allowed direct access
to the PNC in 46 prisons. Because not all prisons have a PNC terminal,
NOMS had made arrangements for those with a terminal to share information
with other prisons. Forest Bank accessed the PNC installed at HMP Hindley.
HMP Drake Hall and HMP Askham Grange also used this terminal.
25. On 17 October 2008, after she had raised the issue with NOMS, the Chief
Operating Officer wrote to my Deputy Ombudsman. In his letter he said there
had been some problems with the use of PNC. He said these had led to the
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NPIA imposing a moratorium on any further expansion of its use in the Prison
Service, and, in particular, the installation of new terminals.
26. The Chief Operating Officer went on to say that NOMS had been working with
the NPIA to develop a way forward and determine how PNC access could be
improved. He said that, subject to effective audit and control mechanisms
being in place, the moratorium on the installation of new PNC terminals would
be lifted. Finally he said establishments wishing to pursue the installation of
terminals should, in the first instance, contact the NOMS Security Group,
adding that Forest Bank had done so and was trying to obtain a terminal.
27. At the time of issuing my draft report (November 2009) I understand approval
has been given for a PNC terminal to be installed at Forest Bank. Although
no date has been scheduled, I am told that it is expected to be before January
2010. In the meantime, the Director has trained two of his staff to use the
equipment and they travel to Hindley as and when required to collect the data.
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KEY FINDINGS
Prior to the man’s reception into custody
28. On 29 September 2006, the prisoner was received into prison custody at HMP
Risley. During the standard reception procedure, a Cell Sharing Risk
Assessment (CSRA) was carried out. The member of staff completing the
assessment deemed his risk as low.
29. Two months later, on 27 November 2006, the prisoner transferred from Risley
to HMP Garth. In contrast to the previous risk assessment, the assessor at
Garth raised the level of risk to high as he had assaulted another prisoner and
set fire to a cell. The assessor also wrote, “Due to recent events, would not
double this man [put him in a shared cell], although he stated he did not have
a problem sharing.”
30. The following year the prisoner moved from Garth to HMP Rye Hill. He
arrived there on 15 March 2007. As at Garth, the assessor at Rye Hill
deemed him as high risk. It was noted that the prisoner told the assessor that
he would assault anyone else in his cell that night.
31. On 25 June, the prisoner transferred from Rye Hill to HMP Gartree.
Unfortunately, despite extensive searches by prison staff the investigator has
been unable to find any record of a CSRA being completed there. The
investigator contacted Gartree and was told that they did not have a copy.
However had the prisoner been regarded as medium or high risk, his name
would have appeared in the prison risk register, which it did not. On that
basis, the member of staff at Gartree suggested he was probably assessed as
low risk.
32. Three days later the prisoner moved from Gartree to HMP Nottingham. Other
than noting the number of prison moves, there is no reference on the CSRA to
the concerns raised previously. The assessor on this occasion recorded the
level of risk as low.
33. On 15 January 2008, the prisoner moved from Nottingham to HMP Forest
Bank. At the time, Forest Bank was not carrying out the correct CSRA
procedures or completing them.
34. The investigator discussed this issue with the Director. He said that, when he
took over responsibility for the prison in 2008, he recognised that the prison
was not complying with the correct CSRA procedures. Although there was a
system in place, it was not the correct one and he gave instructions for the
proper procedures to be introduced. He added that CSRAs were only
completed for new arrivals, and not for prisoners already at Forest Bank. In
March 2008, CSRA was introduced fully to the prison, but only for arriving
prisoners. It was not backdated to include those already there.
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35. On 19 February 2008, the man appeared at Stockport Magistrates’ Court,
having been charged with assault on a police officer and breach of conditional
discharge. At court he was given a three month prison sentence, suspended
for 12 months. As well as the prison sentence, he was given a supervision
order and required to work unpaid in the community for 200 hours.
36. In the meantime, on 7 April, the man was released from Forest Bank under
the terms of End of Custody Licence. However, he broke the conditions of the
licence by committing further offences. On 3 July, the licence was revoked
and he was returned to Forest Bank to continue his sentence.
37. On this occasion a CSRA was completed by a Senior Officer (SO) who
recorded the level of risk as low. At interview the SO told the investigator that
the prisoner had been taken to the prison by police officers. He said the only
documents available to him at that time were the Prisoner Escort Record, the
licence revocation and, as far as he could recall, a warrant detailing the
further offences.
38. The SO said that, had the prisoner been transferred from another prison, his
prison records would have accompanied him. He explained that, because this
was not the case, he did not have access to the records. The investigator
asked the SO whether it was possible to obtain the records of prisoners
released and returned to prison. The SO said it was, but they would not have
been available at the time when the CSRA was carried out. He added that
the prison administration department would request the records from the last
known establishment. The SO was unaware that the prisoner had been
released from Forest Bank and that his records were still there.
39. The investigator asked the SO what he would have done had he known there
was information to show that the prisoner had previously been assessed as
high risk. The SO said he would have interviewed him in greater depth to
determine why he had been considered as high risk. He added that, as he did
not have the records and was unaware of the previous high risk, he had to
take the information given by the prisoner at face value.
40. After making his own assessment, the SO passed the CSRA form to a nurse
to add his comments and assessment. The nurse was also working in the
reception area as part of the normal routine for receiving new prisoners. He
agreed with the assessment carried out by the SO and assessed the prisoner
as low risk.
41. After going through the reception procedure the prisoner was taken to a cell in
the First Night Centre. The following day, he was moved to a cell in the
detoxification unit.
42. In order to understand the procedure for obtaining prison records the
investigator spoke informally to the Custody Clerk at Forest Bank. She said
that, whenever a prisoner arrives, a temporary file is made up in reception.
The Custody Clerk also said that, once it is known that another record exists,
the old record is sent for and married up with the temporary file. She
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confirmed that the prisoner’s record was still held at Forest Bank. The
investigator asked her whether, when the previous records do arrive, they
were routinely checked for any information regarding CSRA or violence
reduction. She said that, as far as she was aware, they were not.
43. The manager of B wing is also the prison safer custody lead with
responsibility for CSRA. She told the investigator that all staff at Forest Bank
required to complete CSRAs have received training in how to do so. The
investigator asked the manager whether she is routinely notified when old
records are received and of any previous information noted in other CSRAs.
She said she was not, adding that it was a gap in the information system.
She went on to say that it would be reasonable for her and her team to be told
of previous CSRAs and to be given the opportunity to review their own
assessments. The investigator also asked her what might have happened
had such a system been in place and the high risk assessment noted at Rye
Hill identified. She said a case review would have taken place and a new
CSRA carried out. This could have led to the low risk assessment being
raised to medium or high.
The man’s reception into custody
44. Unfortunately, the man failed to comply with the court order imposed on 19
February and, on 20 August; he appeared again at Stockport Magistrates’
Court. On this occasion, because he had breached the supervision order
imposed in February, the suspended prison sentence was activated and he
was taken to Forest Bank to begin serving his sentence.
45. When the man arrived at the prison he went through the normal routine for
receiving prisoners. As part of that procedure, a CSRA was completed before
staff allocated him a cell. The risk assessment was set as low, which meant
there was no reason not to allocate him to share a cell with another prisoner.
However, it was noted in section two of the CSRA that the man was
concerned about sharing a cell, although there was no explanation why he
was worried. After completing the assessment he was allocated to B wing,
landing two, cell 13 (B2 13).
46. From what has been gleaned, it would appear that the man settled in well. He
did not appear to be overwhelmed by his first experience of prison and gave
staff no cause for concern.
47. Due to the length of the man’s sentence, and providing he met the criteria for
release under the End of Licence provisions, he was eligible for release on 15
September. On 27 August, in order to assess his suitability for the scheme,
his previous conviction history, which was held on the Police National
Computer, was requested from Hindley. (Unfortunately, there were delays
obtaining the information and requests for information were not being dealt
with as quickly as they should have been. I deal with this later in this report.)
48. In the meantime, the prisoner had completed the detoxification programme
and preparations were made to move him to another wing to continue his
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sentence. As there was nothing to suggest he should not be allocated to a
shared cell, on 2 September he moved into the same cell as the man. The
investigator has confirmed with the prison that there were no recorded
problems between the man and the prisoner.
49. Five days later on 7 September, the man wrote a letter to his mother. In that
letter he told her that he was to be released on 16 September, and asked that
someone should collect him from the prison. He later spoke to his mother on
the telephone and still believed he was to be released on that day. (It is not
clear why he said the release date was 16 September.)
50. Under the impression that the man was being released, the man’s mother
went to the prison on 16 September to collect him. When she arrived, she
was told by prison staff that he was not being released that day.
19 September
51. I understand from police records that, at about 7.00am, prisoners were
unlocked from their cells to collect their breakfasts. About 45 minutes later,
two prison officers became aware of a disturbance outside the man’s cell and
went to investigate. When they arrived, they found the man lying on the floor
unconscious, with a group of prisoners around him.
52. The officers raised the alarm and, once other prison staff arrived, all the
prisoners in B wing were locked back into their cells. Prison medical staff
arrived and, after assessing the man’s condition, began resuscitation
attempts. In the meantime, an ambulance had been requested. It arrived at
7.59am after which paramedics transferred him to Hope Hospital.
53. Having been told by police of the seriousness of the man’s condition, I
understand his family arrived at the hospital at about 12.40pm. There they
met the prison chaplain. The man’s family were with him when he was
pronounced dead at 5.47pm.
54. The post mortem report noted the cause of death as a traumatic fatal sub
arachnoid [brain] haemorrhage, bruising to left eye and temple, bruise above
right ear and top of head, broken top vertebrae. It adds that the injury caused
massive bleeding to the brain which resulted in death.
Following the man’s death
55. The man’s mother told my investigator that the prison chaplain had acted as
the prison’s family liaison officer. She said he had contacted her a few times
and had been helpful.
56. I understand from the mother that the Director arranged for flowers to be sent
to the man’s funeral and that prisoners held their own collection. She said the
money collected has been distributed between the man’s children.
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57. The man’s mother said she had been given the opportunity to meet a number
of the prisoners. The man’s mother and his brother also went to see the
man’s cell. They were accompanied by the prison chaplain and, after viewing
the cell, they met the Director.
58. The man’s mother said she had received money from the prison which had
been held in the man’s account, and also a number of letters. However, she
added that his clothing was returned to his girlfriend, although she was not
listed as next of kin. The investigator asked for an explanation, but at the time
of completing this report, he has been unable to throw any light on why this
happened. The Director may wish to make his own inquiries and to satisfy
himself that staff understand the importance of ensuring that personal
belongings should properly be returned to named next of kin.
59. An inquest into the man’s death was held in October 2010. The jury were
asked to provide answers to 15 questions, and found that the man had been
unlawfully killed. The questions and answers provided were:
1) When the CSRA relating to the cell mate was carried out on the 3rd July 2008, was
further information available which could have been taken into account?
Yes, we believe further information was available.
2) Would further information probably have caused that CSRA to have been
completed differently?
Yes
3) If that CSRA had been conducted differently or completed differently, is it probable
that the cell mate would initially have been allocated to a single cell?
Yes, it is probable.
4) On the basis of the information actually available, were reasonable conclusions
probably reached by the staff completing that CSRA?
Yes, we believe so
5) In the light of any events after the CSRA of the 3rd July 2008, would it have been
reasonable for staff to reassess the cell mate’s suitability to share a cell?
Yes, it would be reasonable to reassess.
6) In the light of events after 3rd July 2008 was it reasonable or unreasonable for the
cell mate and the man to continue to share a cell?
In light of our findings to question 5, we consider it reasonable that a review of the
cell mates CSRA would probably have impacted on whether cell sharing with the
man should continue.
7) Were the systems for managing and sharing information which might potentially
have a bearing on cell sharing at HM Prison Forest Bank reasonable?
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We believe the systems to be inadequate at the time of the incident.
8) Did the systems for managing and sharing information at HM Prison Forest Bank
have any effect on the decision that the cell mate was suitable to share and continue
to share a cell?
Yes
9) Were adequate attempts made to obtain and/or provide the PNC information
record for the man?
The request and provision were both inadequate.
10) If the PNC information had been received before the 15th September 2008, would
the man probably have been released on either the 15th or 16th September 2008.
Yes
11) Was the man unhappy about sharing a cell with the cell mate?
Yes
12) If so, did the man express any such unhappiness to staff at the prison?
There was no evidence to that effect.
13) Did the man have enough money to repay a debt of two packets of tobacco?
Yes
14) Is it likely that the man took a fan owned by the cell mate in order to repay a
tobacco debt?
We feel it is unlikely.
15) Was the man unlawfully killed by another prisoner or prisoners?
Yes
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ISSUES
Cell Sharing Risk Assessment for the man
60. On 20 August 2008, the man was taken to Forest Bank to begin his sentence.
As part of that procedure, he was interviewed in the prison reception area and
a cell sharing risk assessment was completed. This is normal procedure.
61. The officer completing section one and two of the document recorded his
answers by way of a tick box. At section two, box nine and ten, the officer
ticked the yes option. This indicated that he was concerned about sharing a
cell (box nine) and that he said that he got angry or frustrated quickly (box
ten). Unfortunately, there is little else recorded other than that the man
preferred his own company. As a result, I do not know what he was worried
about, or what efforts were made to find out.
62. The investigator discussed the assessment with the prison’s safer custody
lead. She said that all staff responsible for completing the CSRA forms at
Forest Bank have received specific training in how to do so. She said that her
expectation is that, after ticking the two boxes the man’s risk assessment
ought to have been at least medium. She was surprised in retrospect that the
assessment was set at low. She said during her interview with the man:
“In my view, I would have expected the officer to have investigated a
little bit further in interview. The comment “just prefers own
company” … I would have expected perhaps at that point for it to be
a medium, with further review on section 2 and section 4 as to how
the prisoner presented.”
63. The prison safer custody lead added that all first and second sections are
reviewed by a nurse, who then completes section three. She said that section
four is then completed by the locating officer. She explained that this gives
them the opportunity to disagree with the first assessment, or at least discuss
the decision and rationale behind the risk level. On this occasion, the nurse
and locating officer agreed with the officer’s low risk assessment and the man
was allocated to shared accommodation.
64. I understand that the NOMS is reviewing the CSRA procedure. In the
meantime, whilst I make no formal recommendation, the Director may wish to
consider whether there is a case for further training for his staff.
Cell Sharing Risk Assessment for the prisoner
65. When a prisoner is released, their record is stored at their last prison for a
minimum of six years. After this period, depending on the length of sentence,
the record is either destroyed, or sent to a central store where it is kept for up
to 99 years. However, if the released prisoner is later returned to prison, and
providing the receiving prison knows that the prisoner has been in custody
before, they can request the original records from the previous prison or the
central store. (Stored records are often referred to as back records. I
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recognise that obtaining back records can be time consuming and that it could
be several days before the prison receives them.)
66. The prisoner arrived at Forest Bank on 3 July 2008 after his licence had been
revoked. The reception officer carried out a cell sharing risk assessment
unaware that his prison record was stored there. This meant the officer did
not know of the high risk assessment completed at Rye Hill on 15 March 2007
or indeed any other assessments. At interview, the officer said that, had he
known of the high risk assessment, he would have questioned the prisoner in
greater detail about why he had previously been assessed as high.
67. Although I make no criticism of the officer, even if he had looked at the file I
doubt whether he, or anyone else, would have looked back much further than
the most recent assessment. In this case, that would have been the
assessment carried out at Nottingham, which was low risk.
68. The investigator has tracked the prisoner’s movements following his reception
into Rye Hill. On 25 June 2007, he moved from Rye Hill to HMP Gartree
where he stayed for two nights. I have been unable to establish why he
remained there for such a short time. The prisoner then moved from Gartree
to HMP Nottingham where he was assessed as low risk and remained there
until 15 January 2008 when he was transferred to Forest Bank.
69. Whenever a prisoner moves establishment, the sending prison must ensure
that an up to date CSRA accompanies the prisoner. If a CSRA is received,
there is no expectation that the receiving prison should complete a further
assessment. When this investigation was underway the prisoner was in HMP
Liverpool. In an effort to clarify whether his risk remained high following his
arrival at Rye Hill the investigator asked for the prisoner’s file to be checked
and copies of the CSRA forms to be sent to him. I am extremely grateful for
the assistance of two members of staff at Liverpool, for their assistance.
Unfortunately, despite extensive searches, they have been unable to find all
of the CSRA documents covering the period in question. I am unable to
explain why the record appears to be incomplete.
70. In the case of a prisoner assessed as medium or high risk, their details are
recorded separately in a risk register and other violence reduction
arrangements are put in place. The investigator contacted Gartree and was
told that the prisoner did not appear in their register. Given that there is no
information recorded in their risk register, I can only presume he was not
considered to be medium or high risk at that time. I also presume that there
was no repetition of the assault on another prisoner
71. I have considered carefully the impact of the high risk assessment in 2007
and the officer’s low risk assessment when the prisoner returned to Forest
Bank. It is clear from prison records that, after he left Rye Hill in March 2007,
he then went to three other prisons including Forest Bank where there
appears to be no record of him being assessed as medium or high risk. On
that basis I assume that he was assessed as high risk only at Rye Hill and did
not cause concern at the other prisons.
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72. That said, the circumstances surrounding the man’s tragic death beg the
question as to why information held in stored records is not considered, and
what would be the outcome if it was. The investigator asked the prison’s
safer custody lead whether there was a system in place to ensure back
records received from storage were routinely checked for CSRA assessment
information. She said that there was not. The investigator asked whether, in
her opinion, there was a gap in the procedures. She said that there was,
adding that introducing such a system would trigger a review of the original
assessment. I agree.
73. The investigator discussed the issue with the Director. He agreed that there
was a gap, stressing that it should be looked at as a national issue rather than
a local one. I make the following recommendation to NOMS:
The National Offender Management Service should consider whether
there is a need to issue guidance advising Governors and Directors that,
once back records are received, previous CSRAs should be checked
and the most recent assessment reviewed.
Video monitoring
74. Within the wings at Forest Bank there are a number of video cameras, linked
to video monitors and recording equipment. The monitors are not under
constant surveillance, but the recorded information is available to be played
back as necessary.
75. I understand that when police officers tried to view the images following the
fatal assault on the man they were unable to do so as the particular camera
equipment was faulty. Although the investigator has been unable to
determine exactly when the equipment was known to be faulty, it would
appear to have been in that condition for some time.
76. It is my understanding from the police that, whilst the video evidence would
have been useful in determining who went into the man’s cell, it did not affect
their enquiries. That said, there has to be a robust system in place to ensure
any faults with such important equipment are properly logged and followed up.
The Director of Forest Bank should ensure there is a proper auditable
system in place to show when faults are reported and when they are
repaired.
Police National Computer
77. At the time of writing this report, Forest Bank is still without a PNC terminal,
although I understand it has been agreed that one will be supplied. In the
meantime, the Director has arranged for checked documents to be collected
from Hindley twice weekly. Additionally, he has arranged for two of his staff to
be trained in the use of the terminal. I understand the situation has improved
greatly since the man’s death, and, since the publication of the draft report, I
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have been informed that Hindley has put further management checks to
ensure that there are no further issues surrounding PNC access there.
78. Given the circumstances described at paras 23-27 above, I do not think it
would be useful for me to make a national recommendation to NOMS in
respect of individual prisons’ access to the PNC. It is self-evident that there
would be practical benefits if all prisons had their own PNC terminals (and
there is the separate issue of whether they should have the right to update the
PNC as well as read from it). I simply note, therefore, that a joined-up
criminal justice system is necessarily dependent upon joined-up Information
Technology. I hope and trust that all prisons will soon enjoy their own
terminals to access the PNC.
Family meeting
79. The man’s mother told the investigator that her son was a good achiever at
school and a keen sportsman. She added that he was always laughing and
liked to play jokes. The mother said her son was a hard worker and, as well
as being a good brother, he was very popular.
80. The man’s family asked a number of questions of my investigator that I hope I
have answered earlier in my report. During their meeting the man’s mother
said her son had told them he was unhappy about sharing a cell with the
prisoner. She said he told them he was having difficulty sleeping and that the
prisoner was smoking drugs. The man’s mother asked whether the man had
ever asked to move to a different cell. The investigator has been unable to
find any evidence to suggest that the man had ever asked to move to a
different cell, or told prison staff he was unhappy sharing a cell with the
prisoner.
81. His mother also asked what rules existed regarding prisoners smoking in
prison. In general, prisoners are allowed to smoke in designated areas only
(including their cells). Unless there are operational reasons that makes this
impossible, non-smokers should not be expected to share with those who do
smoke.
82. The man’s brother asked whether the wing staffing levels were correct and
whether the officers were trained. I understand the staffing levels were
correct. All prison officers must undergo specific training on entering the
Prison Service.
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CONCLUSION
83. It is clear that had the proper systems been in place to ensure that the PNC
checks were carried out efficiently, the man would have been released on End
of Custody Licence on 15 September 2007 and almost certainly still alive
today. For the reasons I have given above, I do not think it would be useful
for me to make a national recommendation to NOMS in respect of individual
prisons’ access to the PNC. However, it is self-evident that there would be
practical benefits if all prisons had their own PNC terminals. I have been
pleased to learn that Forest Bank will be receiving a PNC terminal early in
2010.
84. I have considered the cell sharing risk assessment relating to the prisoner.
Although there is evidence to show that he had previously been regarded as
high risk, the risk was later reduced to low, with no further instances where
the risk was any greater. Additionally, the information from Forest Bank is
that, from the time when the prisoner moved into the same cell as the man,
there were no recorded problems between the two of them. Notwithstanding
what the man’s mother has reported (above, para 79), this would suggest that
both men were content to share a cell.
85. As well as the risk assessments I have considered whether the man was
someone who ought to been considered as vulnerable. Again I can find no
evidence to suggest that he should have been; in fact, the opposite appears
to be true in that he settled into prison life well. I conclude, therefore, that the
fatal attack upon him could not reasonably have been predicted.
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RECOMMENDATIONS
1. The National Offender Management Service should consider whether there is
a need to issue guidance advising Governors and Directors that, once back
records are received, previous CSRAs should be checked and the most
recent assessment reviewed.
2. The Director of Forest Bank should ensure there is a proper auditable system
in place to show when faults are reported and when they are repaired.
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