Individual at Wymott

The Death of a man at HMP Wymott on 14 September 2005
Report by the
Prisons and Probation Ombudsman for England and Wales
July 2006
This report of an investigation into the death of a man at HMP
Wymott on 14 September 2005 is one of the saddest reports I have
ever issued as Ombudsman. The man was found hanging in his cell
on B3 landing, part of the vulnerable prisoner accommodation at
Wymott. He had been held at Wymott since January 2004 and was
just 22 years old at the time of his death.
I offer my profound condolences on their loss to the man’s mother,
grandmother and other family members and friends.
The purpose of my investigation was to establish the circumstances
and events surrounding the man’s death, including the quality of care
provided by the Prison Service. One of my Family Liaison Officers,
made contact with the man’s grandmother to explain how my
investigation would proceed. The investigation was conducted by two
investigators from my office. I also commissioned a Clinical Review
from Chorley and South Ribble Primary Care Trust (PCT) and I am
most grateful to the Head of Service Development at the PCT for
undertaking that review. I must also thank the Governor of Wymott
and her staff for the cooperation my investigators have received. I
owe a special word of thanks to the Principal Officer who was
appointed to liaise with my investigation team. The Principal Officer
has acted professionally and effectively throughout the investigation.
Notwithstanding the seriousness of the offences that the man had
committed, I must emphasise his own vulnerability and the learning
and developmental difficulties with which he had to cope. At Wymott,
he seemed to many staff and prisoners to be a boy in a man’s world.
He was not criminally sophisticated and had not been in prison before
his current sentence. He was accustomed to receiving significant
support whilst living in the community, and did not possess the life
and social skills that would have enabled him to cope easily with
imprisonment. The level of individual care and support he received
during his months at Lancaster Farms YOI was extremely impressive.
At Wymott, as an adult prisoner, he was expected to fend much more
for himself. The man received notable support from some of the
prisoners on his landing, but prison staff were unable to give
equivalent support because they were unaware of his basic human
needs and, in particular, of his bowel problem.
The circumstances of this young man’s death are deeply saddening.
Two haunting images remain in the mind. The first is the list,
scrawled in his childlike hand, of the gambling debt of 27 Mars Bars
that he owed to five separate prisoners. The second image is the pile
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of soiled clothing that he tried to hide in his cell or in the wing laundry
because he could not bring himself to tell staff about his bowel
problem and they did not seem to know. By a tragic irony, a good-
hearted officer discovered this problem on the last afternoon of the
man’s life, but he was found hanging before the officer could return to
tell him of the help he had already arranged.
I have made a number of recommendations with particular reference
to the Adapted Sex Offender Treatment Programme (ASOTP) which
had reached an especially stressful stage on the day of the man’s
death.
Stephen Shaw CBE
Prisons and Probation Ombudsman
July 2006
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CONTENTS
Page
SUMMARY 5
THE INVESTIGATION 8
HMP WYMOTT 10
THE MAN
12
THE MAN’S TIME IN PRISON 16
THE MAN’S DAILY LIFE AT WYMOTT 22
14 SEPTEMBER 2005 29
CLINICAL REVIEW CARRIED OUT BY Head of Service
Development at the PCT
38
THE ADAPTED SEX OFFENDER TREATMENT PROGRAMME 40
FINDINGS AND CONCLUSIONS 47
RECOMMENDATIONS 54
4
SUMMARY
1. The man was born in November 1982. He was found hanging in his
cell at HMP Wymott on 14 September 2005. At the time of his death,
he was just 22 years old.
2. During her pregnancy, the man’s mother was taking anticonvulsant
medication. After the man’s birth, his family noticed a number of
problems associated with foetal anticonvulsant syndrome (FACS).
These problems include developmental delay, difficulties interacting
with peers, poor fine motor control (holding a pen or knife) and bowel
problems such as constipation and soiling. In childhood, the man
was also given a diagnosis of dyspraxia (an impairment or immaturity
of the organisation of movement). Developmental milestones may be
delayed and dyspraxic children have difficulty in planning and
organising thoughts. The man received significant community
support during his boyhood and teenage years which were spent in
Salford.
3. On 12 September 2003, the man was sentenced at Manchester
Crown Court to six years detention in a Young Offender Institution for
committing a number of serious sexual offences. He had been held
in custody from 26 March that year so that psychiatric reports could
be prepared. He had never been in prison before.
4. After brief spells at Forest Bank and Altcourse, the man was
transferred to HMYOI Lancaster Farms on 27 June 2003. He
received impressively detailed personal care during his time at
Lancaster Farms. The man was admitted as an inpatient to the
Healthcare Centre at Lancaster Farms on 2 October, when his
primary problems were described as his learning disabilities and
personal hygiene problems. He remained continuously in the
Healthcare Centre until he was transferred to HMP Wymott, an adult
prison, on 7 January 2004.
5. On 15 October 2003, the man made a noose from a radio lead. An
officer patrolling his wing at the time noticed that he had red marks on
his neck. A Self-Harm at Risk Form (F2052SH) was opened so that
he could be given as much help and observation as possible whilst he
was thought to be at risk of further self-harm. The form was closed
just five days later and no further F2052SH was opened before the
man’s death.
6. Throughout the man’s time in custody, there are references to him
being tormented, bullied, exploited and mocked by other prisoners.
However, once he was allocated to work in the Weavers’ Shop at
Wymott, he received commendably pragmatic and flexible support
and guidance from the instructor, over the next 18 months.
5
7. During the last months of his life, the man also received excellent
practical support from an older prisoner whose cell was on the same
landing (B3). Several of the wings at Wymott, including B wing, are
occupied by vulnerable prisoners. The older prisoner provided
informal counselling for the man after staff had gone off duty in the
evening. He taught the young man, whom he described as being like
a 13 year old, how to tie his shoe laces and he supplied the man with
extra clothing as best he could when he had soiled himself. Prison
staff on the man’s landing were not aware of his bowel problems.
8. The man initially denied his offences but then agreed to attend the
Adapted Sex Offender Treatment Programme (ASOTP). He first
attended an Enhanced Thinking Skills (ETS) course which concluded
in February 2005, but the tutors on that course only became aware of
his learning and developmental difficulties after it had ended.
9. The man and seven other men began ASOTP in June 2005.
Evidence from a number of sources indicates that the man found the
course a difficult and challenging experience. On the morning of his
death (14 September), he was in the ‘hot seat’ where he had to give
an account of his offences. However, he did not appear to be unduly
distressed at the end of the session and agreed to continue with his
account at the beginning of the next day.
10. Also on the morning of 14 September, an Officer, (Officer B) a regular
on B3 landing, received two significant pieces of information about
the man. Some prisoners complained about the smell coming from
his cell and Officer B received a phone call from the instructor in the
Weavers’ Shop. The instructor had been told by the older prisoner
that the man owed nearly 30 Mars Bars to a number of prisoners as a
result of bets he had made and lost. The instructor kept the man
back from work that afternoon so that he could discuss these matters.
The man told the officer about his bowel problem and Officer B
energetically set about obtaining practical support for him. He rang
the Healthcare Centre and arranged with the Clothing Store for extra
clothing to be delivered immediately to the wing.
11. At about 4.10pm, another prisoner looked into the man’s cell and saw
him hanging from the window bars. Staff ran to the scene when the
emergency bell was pressed and did their utmost to save the man,
but to no avail. The first three Prison Officers who arrived in his cell
struggled to loosen the ligature from around his neck as there was a
double knot and they had no anti-ligature knives.
12. The man was socially isolated as his family lived far away and he
received no visits. He had not made any phone calls home in the
weeks leading up to his death, although he did write letters. News of
his death was broken to the family by police in their home town.
13. The circumstances of the man’s selection for and ongoing
membership of, the ASOTP have been very closely scrutinised during
6
this investigation. I have made a number of recommendations about
the man’s involvement with the course which have both local and
national application.
7
THE INVESTIGATION
14. Since 1 April 2004, I have had responsibility for investigating all
deaths in prison custody in England and Wales. This investigation
was undertaken by two investigators from my office. They issued
notices to staff and prisoners, telling them of the investigation and its
terms of reference, and offering them the opportunity to participate.
15. My investigators visited Wymott on a number of occasions and
inspected the cell where the man was discovered hanging. They
interviewed both staff and prisoners who had had significant contact
with the man. They reviewed all relevant documentation and spoke
with the detective leading the Lancashire Police investigation into the
man’s death. They also met with the Chairman of the Independent
Monitoring Board at Wymott, who had arrived at the prison very
shortly after the man’s death.
16. One of my Family Liaison Officers spoke with the man’s grandmother
and his nominated next of kin. The man’s grandmother declined the
offer of a meeting with the Family Liaison Officer and an investigator,
but had a lengthy telephone conversation at a later date with one of
my investigators.
17. I commissioned a Clinical Review of the care the man received at
Wymott from Chorley and South Ribble PCT. I am most grateful to
Head of Service Development at the PCT for undertaking the review.
The investigator had a lengthy discussion with the Healthcare
Manager at Wymott, about the issues of confidentiality and
appropriate screening of potential ASOTP candidates.
18. Seven other prisoners were undertaking the ASOTP at the same time
as the man. My investigators visited the group and asked if any of
the men wanted to talk about the circumstances of the man’s death.
Two of them volunteered to do so and were interviewed on tape.
19. One of the facilitators who was leading the ASOTP on the morning of
the man’s death could not be interviewed as she was on maternity
leave. However, she kindly made contact with my investigators and
discussed a number of matters during a telephone conversation.
20. My investigators made early contact with the National Head of the
Sex Offender Treatment Programme. I am obliged to her for
providing a detailed letter about the circumstances of the man’s
death. She has given valued assistance throughout this investigation
and watched with one of my investigators the video tape of the
session on the morning of 14 September at which the man gave a
detailed account of his offences. My investigators have carefully
scrutinised national documents about the delivery of ASOTP,
8
including the 2003 Treatment Manual and the Accredited
Programmes Audit Document issued by the Offending Behaviour
Programmes Unit (OBPU) at Prison Service Headquarters.
9
HMP WYMOTT
21. Wymott is a Category C training prison for adult male prisoners. Over
half of the population are vulnerable prisoners, many of them sex
offenders. The prison is located on the outskirts of Leyland in
Lancashire. The maximum number of prisoners who can be held at
Wymott is 1046.
22. Responsibility for healthcare at Wymott transferred to the local PCT
in April 2005. The Healthcare Centre has a doctor available every
weekday. Overnight and weekend cover is provided by local GPs
who are on call. There is also a clinically qualified member of
healthcare staff on duty at these times.
23. There have been a number of natural cause deaths at Wymott since I
assumed responsibility for investigating prisoner deaths in 2004. In
addition, a prisoner was found hanging in his cell in the Segregation
Unit in February 2005, and another prisoner was found hanging in his
cell on a vulnerable prisoner wing (A Wing) on 21 June 2005.
Although this latter prisoner did not die, I understand that he
sustained permanent injuries and that he remains in hospital at the
time of writing this report. The Area Manager commissioned an
investigation and report from an experienced governor in another
prison.
24. The prison was last inspected by Her Majesty’s Chief Inspector of
Prisons in December 2003. Her report was published in March 2004.
Her overall judgment was that Wymott was a good and well-managed
prison which provided work for almost all its prisoners. However, she
noted that staff in general needed to be encouraged to engage more
positively with prisoners, two-thirds of whom said that staff rarely
spoke to them when they were out of their cells. The Healthy Prison
Summary at the beginning of the report stated that a new anti-bullying
policy was being rolled out but was not yet effective. The programme
was not supported by staff training and there were no interventions or
programmes for either bullies or victims. Most prisoners who claimed
they had been the victims of bullying stated that it had been largely in
the form of verbal intimidation.
25. In relation to health services, the report noted particular problems with
access to doctors and long waiting lists to see GPs. The Chief
Inspector stated that communication between the Healthcare Centre
and the rest of the prison was poor. At the time of her inspection,
there was little mental health service input for prisoners although
there were plans to improve this in 2004.
26. The Chief Inspector also reported that work in the area of offending
behaviour programmes had improved considerably and the prison
10
was on target to meet its required level of completions. She identified
a need to tackle robustly the high number of sex offenders who were
in denial of their offences. She added that the staff culture, which did
not prevent this level of denial, needed to be challenged.
27. In the current financial year (2005-2006), the Head of Psychology and
Programmes is the manager charged with the responsibility of
ensuring that at least 36 prisoners complete a SOTP.
11
The Man
28. A great deal of information about the man is contained in a number of
reports written before he was sentenced at Manchester Crown Court
in September 2003. The first of these is a Social Background Report
prepared in May 2003 by a social worker on behalf of Highland
Council Social Work Service. The report stated that the man was
born in 26 November 1982, and that during her pregnancy the man’s
mother was taking anticonvulsant medication. After his birth, both his
mother and grandmother observed symptoms that were similar to
common problems associated with foetal anticonvulsant syndrome
(FACS).
29. The report also lists a number of problems associated with FACS.
These include developmental delay, problems interacting with peers,
no sense of danger, poor fine motor control (holding a pen or knife)
and bowel problems (constipation and soiling). When the man was 10
months old, he moved with his parents to Salford and the family
remained there until after the death of the man’s father in 1998.
30. In June 1992, a Statement of Special Educational Needs was drawn
up for the man. The report refers to a Health Assessment drawn up in
1994 for problems associated with soiling and food intolerances.
31. The man was given a diagnosis of childhood dyspraxia (an
impairment or immaturity of the organisation of movement).
Developmental milestones may be delayed and dyspraxic children
have difficulty in planning and organising thoughts.
32. In 1998 and 1999, the man received support from the Salford
Families Project (SFP). He did well under the guidance of his key
support worker. He learned how to use public transport and go to the
cinema, as well as improving his independent living skills.
33. The man’s father died in January 1998, and his paternal grandfather
died in December of the same year. After the two deaths, the man
and his mother moved to a small village in northern Scotland and
then to a Scottish town in January 2001. His younger sister remained
in England.
34. The man enrolled at a Local College and he also attended the local
Day Resource Centre. Both the College and the Resource Centre
offered courses and activities for adults with special needs.
35. In March/April 2002, Greater Manchester Police contacted the social
work office in the man’s home town to arrange for him to be
interviewed by police officers at a later date. Some months later, the
man was taken to Carlisle for questioning about a number of serious
12
sexual offences which he had allegedly committed. On 26 March
2003, the man was found guilty on a number of counts at Manchester
Crown Court. He remained in custody until 12 September 2003 when
he was sentenced to six years detention in a Young Offender
Institution.
36. At the direction of the Trial Judge, a number of reports were written
between the man’s conviction and sentence. A Consultant Forensic
Psychiatrist at a hospital in Glasgow wrote his report on 6 May 2003.
The man told the psychiatrist that he could not read but was able to
write. The psychiatrist reported that “his handwriting was rather odd
and was confined to the extreme margin of the page which I had
given him”.
37. The psychiatrist’s view was that the man’s intellectual functioning was
significantly below average and he was probably “at least borderline
learning disabled”. The psychiatrist added that, when he was in the
community, the man “needed a considerable level of support from
Social Services and now that he has been convicted of serious sexual
offences his needs in terms of care and supervision are inevitably
more complex, both while he remains in secure custody and at
whatever point in the future he may be considered for return to the
community again”.
38. The psychiatrist considered that, by reason of the man’s mental
disorder, it might be appropriate to make a formal recommendation to
the court for a disposal under the Mental Health Act. The man told
the psychiatrist that, prior to being taken into prison, he had always
been under the care of a social worker and a keyworker.
39. A further psychiatric report on the man was prepared at the request of
Manchester Crown Court by a Consultant Forensic Psychiatrist at
Prestwich Hospital in Manchester.
40. In her report, the psychiatrist explained that she had interviewed a
man at HMP Altcourse on 13 June 2003. He told her that since being
in prison he had had boiling water thrown over his shoulders and he
had been punched in the arms and stomach. He showed the
psychiatrist a bruise on the inner aspect of his upper arm. At the
time, he was being detained on a special wing for vulnerable
prisoners. The man told the psychiatrist about two voices that were
always arguing in his head. One was a Scottish woman who told him
to do good things, the other was an English man who told him to do
bad things such as robbing Post Offices. The man said he had lost
three stones in weight, reducing from 23 stones to 20 stones. He
said he had the occasional suicidal thought, including hanging
himself. The man said that his family and his mates on the outside
kept him going, but if he received a ten year sentence he would kill
himself.
41. The Opinion Section at the end of her report said:
13
“Objectively he was not clinically depressed or demonstrating any
signs of a psychotic illness. However, I cannot exclude the possibility
of a psychotic illness, which may be depressive in nature. He would
benefit from further assessment by a psychiatrist and a mental health
team to assist in reaching a conclusion about diagnosis.”
42. In another paragraph, the psychiatrist explained that, had the man
been living in England, she would have been minded to recommend a
Section 38 Hospital Order so that he could be assessed in an
inpatient setting. She added that funding for such an assessment
would be very difficult to arrange and that, because of bed shortages,
it would take some considerable time before a bed could be located in
an appropriate hospital somewhere in the United Kingdom. For that
reason, she decided not to recommend a further adjournment to the
court.
43. In a significant paragraph the the psychiatrist wrote:
“The man presents as a young man with learning difficulties. He has
a long history of contact with Social Services and presents as
functioning within the learning disabled range in many spheres. In his
current environment he is very vulnerable and has been subjected to
a number of assaults. It is likely that he will continue to be vulnerable
from assault and abuse whilst in the prison system. The risk of self-
harm is also high. I think it is unlikely that he would be able to
undertake any meaningful offence related work in prison as he would
not be able to cope with regular Sex Offender Treatment Programme
groups being run in prison.
I believe there is also a risk of further deterioration of his mental
health whilst he is in prison. In the event that he is given a custodial
sentence, his mental health will need to be closely monitored and it is
possible that he would require transfer to hospital for assessment and
treatment of his mental health needs.”
44. A third psychiatric report on the man was prepared in August 2003 by
a Specialist Registrar in Forensic Psychiatry at a hospital in
Middlesbrough. This report was written at the request of the solicitors
acting for the man. The man told the registrar that he had not been
able to achieve total faecal continence and, later in his report, the
registrar wrote that the man had a long history of faecal incontinence
dating back to his childhood.
45. In the Discussion section of his report, the registrar noted that the
man presented as a young man with learning difficulties: “Prior to
being arrested, the man received a comprehensive care package
from a variety of agencies in his community. It is likely that the man
functioned at a reasonable level given the extensive supervision and
support. Furthermore, the man benefited from attending college
courses, specially designed for people with special needs … The man
did not cope well, both academically and socially, whilst attending
14
mainstream schooling. His functioning notably improved following his
transfer to special schools.”
46. In the Opinion and Recommendations section of his report, the
registrar expressed his opinion that the man did not suffer from a
major mental illness. The registrar repeated that the man had
previously depended (to a large extent) on extensive support and
supervision for his social functioning. He thought it very likely that the
man would find it difficult to cope in prison. He had been assaulted
by other prisoners and continued to be vulnerable. It was likely that
he would be bullied and abused by other prisoners. The registrar
thought the stressors in prison could negatively impact on his
emotional wellbeing. He recommended that measures should be
taken to ensure the man’s safety, especially should a custodial
sentence be considered.
47. The registrar recommended that:
“In the event of a custodial sentence, a copy of my report be sent to
the prison medical officer, so that he may be aware of the man’s
problems and address them as appropriate.”
48. On the last page of his report, the registrar addressed the question of
self-harm. The man informed the doctor that he had superficially cut
his wrists on two occasions as a coping mechanism to deal with the
voices in his head. The man did not perceive any benefit from doing
so and informed the doctor that he had stopped attempting to self-
harm.
49. The doctor suggested that the risk of self-harm could be increased by
the man’s perceived inability to deal with stresses such as being
bullied or assaulted whilst in prison. The risk of self-harm would be
reduced by strategies to deal with bullying and measures to ensure
the man’s safety.
50. The Trial Judge, made lengthy sentencing observations when the
man appeared before him for sentencing on 12 September 2003.
The judge said he had had particular regard to the psychiatric reports.
He said the reports did not disclose the existence of any disorder
within the meaning of the Mental Health Act but they referred to the
difficulties which the man might well experience whilst he was serving
his sentence. The judge observed that “those difficulties have to a
certain extent already manifested themselves. Those reports, in my
judgment, should accompany you throughout your sentence.”
There is no evidence that the judge’s remarks followed the man
around the prison system. There was no copy of the remarks in the
man’s prison record and they were obtained in this investigation only
because my investigator asked for a transcript to be prepared.
15
THE MAN’S TIME IN PRISON
51. The man spent a total of nearly two and a half years in a number of
prisons before his death. He arrived at HMP and YOI Forest Bank
from Manchester Crown Court on 26 March 2003. A First Reception
Healthscreen was conducted on that date and the man said he had
no worries about his general health. In the Mental Health section of
the reception screen, the man said he had never deliberately harmed
himself or attempted suicide. The man was recorded as saying it was
not his first time in prison, although in fact it was. The reception
screen also incorrectly stated that the man had not been charged with
sexual offences. Fortunately, in the additional information section of
the form, a more accurate record of the man’s situation appears
along with a decision that he should be admitted to the Healthcare
Centre due to his vulnerability and the fact that it was his first time in
prison. On 28 March the man was segregated from other prisoners
due to threats that had been made by other men on his wing. Shortly
afterwards, on 8 April 2003, the man was transferred to HMP
Altcourse in Liverpool.
52. The man was injured on a number of occasions during the time he
spent at Altcourse. On 24 April 2003, he was involved in a fight with
another prisoner on Reynoldstown Blue, a wing for vulnerable
prisoners. After the fight, the Medical Officer noted that the man had
redness to the right-side of his neck and a small cut to the right-side
of his nose. An Incident Report completed on 3 May 2003 stated that
the man was assaulted by another prisoner who threw a cup of boiling
water over him. On 12 May, another Incident Report form stated that
the man had been fighting with a prisoner on Reynoldstown Blue
wing. He sustained a cut lip and said that the other prisoner had
punched him.
53. On 18 June, a member of staff completed a Suicide and Self-Harm
Communication form because the man was distressed after a visit
from his mother. For the next few hours, the man was specially
watched at regular intervals by staff. However, by 10am the following
morning, he stated that he was feeling much better. He wanted to be
removed from the watch and that is what happened.
54. On 27 June, the man was transferred from Altcourse to HMYOI
Lancaster Farms. An entry in his Clinical Record on that date noted
that he had had diarrhoea in his trousers, though he seemed
unconcerned about it. The man showered and his clothes were
changed to aid his comfort, hygiene and dignity. He was admitted to
the Healthcare Centre at Lancaster Farms for assessment and also
due to his vulnerability.
16
55. On 18 July, the man was discharged from the Healthcare Centre to
Coniston Unit, a residential wing at Lancaster Farms. His Clinical
Record expressed concern that he might struggle to settle and
commented on the possibility that he would be bullied by other
prisoners. Healthcare staff had developed a six point plan to help in
the transition. Features of this plan included support in areas of
hygiene, strategies for dealing with bullying, arrangements to ensure
the man was seen daily by nursing staff, that he was to attend ward-
based education between Monday and Friday, and liaison with
discipline staff.
56. On the very next day, the nurse who had recorded the plan, made a
further entry in the man’s Clinical Record. She said that the man had
been seen on the wing as part of the discharge plan. He had settled
in well on his first night, had been out for breakfast with the other
prisoners and had attended a chapel service. He had been chatting
with the orderlies on the wing and stated that everything was okay
with no reported problems.
57. The man was sentenced to six years detention in a Young Offender
Institution on 15 September 2003. His Clinical Record states that he
was not expecting such a long sentence. On 1 October, there is an
impressively lengthy note in the Clinical Record of a visit made to the
man on Coniston 1 wing by the nurse who had recorded the plan.
Issues highlighted in this note include a programme of care to enable
the man to maintain his personal hygiene and to keep his cell clean to
a reasonable standard. The man agreed to come to Healthcare for
education and to cooperate with staff at all times. He also agreed
that he would shower on the hospital unit each day before attending
education, and would bring a clean set of clothes over from Coniston
Unit with him. The man also agreed to see the Medical Officer for a
review of his medication as he was very lethargic during the daytime,
and the possibility of reducing his promethazine (an oral
antihistamine) was discussed. Wing staff agreed to make bedding
and clothing available on a daily basis due to the soiling problem that
he had on occasions.
58. Despite the detailed support plan of 1 October to enable the man to
remain on residential accommodation, it proved necessary for him to
be admitted to the Healthcare Centre as an inpatient on 2 October.
The primary admission problems on the admissions sheet were
described as his learning disabilities and personal hygiene problems.
An inpatient nursing care plan was drawn up the same day. The
identified needs at the beginning of the plan were that the man’s
learning disabilities made it difficult for him to be housed on normal
location. His personal hygiene needed monitoring and his social skills
were lacking. He was due to be moved to an adult prison as he
would be 21 in late November. The desired outcome was that the
man would come to terms with being in prison, his level of personal
hygiene would become acceptable and he would build appropriate
social networks. The care plan added that the man should be housed
17
on the hospital wing because his “condition makes him vulnerable to
bullying if placed in normal location”. Other parts of the plan spelled
out the number of baths and showers the man would have each
week, the healthy diet he would be encouraged to eat. (The man
agreed that he needed to monitor his weight), and the
encouragement he would be given to attend to personal hygiene after
using the toilet.
59. The Record of Events section of the man’s prison record indicates
that he returned to Coniston Unit from the Healthcare Centre on 15
October. However, at lunchtime the same day, he self-harmed by
making a noose from a radio lead. The lunchtime patrolling officer
had gone to the man’s cell when he pressed the cell bell. He noticed
that the man had red marks on his neck. The man said he was
feeling suicidal and could hear voices in his head. The officer went to
get help. When he returned to the cell, the man had tied his radio
lead around his wrists and was pulling it. He was readmitted to the
Healthcare Centre and the officer opened a Self-Harm at Risk form
(F2052SH). The purpose of this form is to ensure that as much help
as possible is given to a prisoner during a difficult period when he
may be at risk of suicide or self-harm.
60. The man was immediately assessed by the nurse who knew of his
learning disabilities and poor coping skills. When the nurse asked the
man why he had tied the radio lead around his neck, he said he did
not know. The prison doctor saw the man next and decided that he
should be admitted to the Healthcare Centre. An informative entry
was made in the support record section of F2052SH at 9pm the same
evening. The writer had a chat with the man about the day’s events
and recorded that the man was frightened on the wing. He also
mentioned that he thought he would copy a suicide attempt made by
another prisoner. The writer counselled the man and explained that
this could have gone wrong and had serious consequences for him.
The man stated that he would not do it again and was sorry. The
entry concludes by noting that the man appeared relaxed and
confident back on the Healthcare Centre.
61. A case review was held on 20 October. Its purpose was to share
information on how the man was coping and to reach team decisions
on what further action needed to be taken. The review was chaired
by a different nurse and was also attended by a Senior Prison Officer
and a Probation Officer. The review summary stated that the man’s
case was discussed at length. The team now felt that he was not at
risk of self-harm, although he had complex needs which could best be
met in the Healthcare Centre. The team decided to close the man’s
F2052SH because they believed that the risk of self-harm had
declined. No further self-harm at risk forms were opened in the two
years before the man’s death.
62. A second Inpatient Nursing Care Plan was created for the man on 27
October. It stated that he had been admitted to the hospital wing
18
from reception due to a concern expressed regarding his vulnerability
whilst in prison. The desired outcome was for the man to be
accurately assessed and to have his needs met with a view to a
possible later transfer to normal residential accommodation. The
care plan set out four actions that would be taken:
(cid:127) The man would be placed in an ordinary cell on the Healthcare
Centre in order to reduce any risks of assaults by other
prisoners;
(cid:127) A F2052SH would not be opened because the man was “quite
a confident young man, who does not present with any self-
harm problems”;
(cid:127) The man would be allowed time to discuss his concerns on a
daily basis with his named nurse or an associated nurse.
These counselling sessions would provide an atmosphere of
acceptance for the man and give the opportunity for the nurse
and the man to discuss progress;
(cid:127) The man would be encouraged to attend education and gym
as soon as possible. The writer said it was fundamentally
important for the man to socialise with other prisoners, and
exercise was a contributory factor in his physical wellbeing.
(cid:127) The man remained in the Healthcare Centre at Lancaster
Farms from this time until his transfer to HMP Wymott on 7
January 2004.
63. Detailed information about the man’s progress and treatment in the
Healthcare Centre is contained in the daily nursing notes and in Care
Plan Evaluations which were conducted weekly. A particularly useful
summary of his conduct and behaviour in the late autumn of 2003 is
contained in a report written by his named nurse, on 16 November.
They wrote that the man was one of up to ten young men resident in
the Healthcare Centre at Lancaster Farms. At times the man’s
behaviour was childlike and stubborn, and at other times defiant and
unhelpful. The nurse said that the man did not present as particularly
challenging and was easily managed within the confines of set
boundaries.
64. The section on hygiene in the nurse’s report noted that the man’s
personal hygiene was very poor and resulted in nursing staff
spending extended periods of time with him in order to ensure a basic
level of socially acceptable cleanliness. The nurse noted that the
man had a long-standing problem with soiling his clothing and added
that “there may be deeper seated reasons for this behaviour, which
will take much specialised work over a number of years to resolve”.
65. The first of the weekly Care Plan Evaluations was completed on 26
October. It stated that the man’s major problems appeared to be
personal hygiene and bullying issues. The man told the writer that he
had no control over his faecal incontinence and revealed that he had
19
been supplied with incontinence pads when in the community. The
plan noted that these should again be given to him, and the next entry
on 1 November confirms that he had been given a supply of
incontinence pads as required.
66. The entry on 13 December was that the man had been compliant with
his hygiene needs. He had adapted well to the hospital environment
and his self-esteem and confidence were growing.
67. The entry for 27 December reads:
“Still requiring one-to-one observation and support with general
hygiene and cell cleanliness to maintain some level of hygiene.
Vulnerability issues continue and depend on what inmates are in his
peer group.”
68. At this time, the man was asking to be transferred to a prison in
Scotland and there are several documents in his record which discuss
the option of transfer to HMP Peterhead in North East Scotland.
However, the man remained in the English prison system and this
appears to have been at his own request.
69. The final Care Plan Evaluation was written on 3 January 2004. It said
that the man still required ongoing support to maintain a healthy level
of personal hygiene. He continued to reside in the Healthcare
Centre.
70. Once the man arrived at Wymott, there is no explicit recognition in his
clinical record that he had spent the previous three months as an
inpatient in the Healthcare Centre at Lancaster Farms. The first
Wymott entry was made on 7 January 2004 and notes that he was
not seen by the medical officer (MO). The signature next to the entry
is indecipherable. The next entry in the clinical record was made on
20 January and records the man’s statement that he was fit and well.
The unsigned entry adds that he needed to see an optician. On the
same date, an Inmate Medical Risk Assessment report was signed by
the doctor. The two pieces of information recorded on the form were
that the man was fit to go to the gym and that his labour classification
was I which meant that he was not excluded from any work areas.
71. On 13 February, the man complained of insomnia and asked for
sleeping tablets. The clinical record states, “advised that we don’t like
giving sleeping tablets. He was happy with the answer and left.”
72. On 1 May, a nurse was called to B wing and discovered that the man
had a severe laceration to his right upper side lip. The nurse’s
opinion was that the laceration required deep suturing (stitching) and
the man was consequently escorted to a nearby hospital. The
hospital’s diagnosis was that the man had sustained the laceration
after slipping on a wet floor. Three months later, a doctor specialising
in plastic surgery wrote to the prison’s medical officer informing him
20
that the scar following suturing of the man’s lip laceration had settled
very nicely. The plastic surgeon said it would not be necessary for
her to see the man again in her clinic.
73. The man’s clinical record shows that his weight had dropped to 91
kilograms by the end of November and then to 84 kilos by 13
February 2005.
74. There are two further entries in the man’s clinical record before the
date of his death. On 23 March 2005, a nurse was called to the man’s
workshop. He had collapsed, but by the time of the nurse’s arrival he
was conscious and had no dyspnoea (difficulty in breathing). The
man felt hot and clammy and had vomited several times. He stated
he was under a lot of stress at work related to his poor performance.
He was escorted back to his wing.
75. On 29 June, a nurse wrote of being called to a wing, though the wing
was not specified. An elderly prisoner had grabbed the man by the
neck and shaken him. No injuries were reported apart from some
redness around the man’s neck area and the entry ends “now feels
fine”.
21
THE MAN’S DAILY LIFE AT WYMOTT
76. Residential accommodation for vulnerable prisoners at Wymott is
available in A and B Houses, whereas prisoners who are not
identified as vulnerable are housed on C, D, E, F, G and H wings.
The man was a vulnerable prisoner who spent all of his 21 months at
Wymott on either A or B House (mostly referred to as wings by both
staff and prisoners). From November 2004 until the time of his death,
the man’s cell was continuously on B wing, first on B6 landing then on
B4 and finally, from 20 June until 14 September 2005, at B3-11. The
man was mainly employed in the Weavers’ Shop where he cleaned
machines and swept up. The man received few visits in prison, with
his visits record showing none at all in 2005.
77. Several witnesses told my investigators that the man was exploited
and verbally abused by some other prisoners.
78. The man began an intensive Sex Offender Treatment Programme
(SOTP) in mid June 2005 and was actively involved with the
programme on the day of his death. He was not due to conclude the
programme until February 2006. More detailed information about the
man’s time at Wymott is contained in his prison record and in a series
of interviews conducted by my investigators with both staff and
prisoners who knew him well.
79. Wymott operates a Personal Officer scheme, with an individual Prison
Officer being the Personal Officer for eight prisoners on a designated
landing. The same officer is reserve Personal Officer for prisoners in
a further eight cells. Many of the entries in the man’s wing file
(F2052A, Record of Events) are made by different officers who acted
as his Personal Officer, although of course there are entries made by
many other officers also. The first entry in the record on 9 January
2004 referred to his learning difficulties, but observed that he could
communicate very well if given the time to compose himself. Staff
were advised to be aware that he was vulnerable and “maybe
susceptible to bullying”. On 26 January, during his first Personal
Officer interview, the man completely denied that he had committed
any sexual offences. An entry on 2 May states that he injured his
upper lip after falling whilst cleaning his cell. A Senior Officer spoke to
the man about the injury. The man assured him that nothing sinister
had occurred and that the cause of the injury was genuine.
80. An entry on 7 June referred to an application for a move to a Scottish
prison. The man was told that Peterhead was the only Scottish
prison that accepted vulnerable prisoners. The man was not willing to
move to Peterhead and said that now he would like to remain at
Wymott.
22
81. In October 2004, the man told his then Personal Officer who was also
an experienced SOTP facilitator (tutor), that he was willing to join the
SOTP.
82. On 20 March 2005, an officer wrote after a Personal Officer interview
with the man that he had completed the Extended Enhanced Thinking
Skills (ETS) programme.
83. According to the man’s prison record, another five months passed
before his next Personal Officer interview was held on 29 August. On
20 June, the man moved from B4 landing to B3-11 and another
officer became his Personal Officer at that point. There are many
references in the man’s record to the untidiness of his cell and on 13
August an officer who was a former nurse, wrote that she had found
the man’s cell in a dirty state. She told him that if it was not cleaned
over the weekend he would be on Basic on Monday. (This was a
reference to reducing the man’s privileges on the National Incentives
and Earned Privileges Scheme to the Basic (lowest) level.) Another
officer made an entry on 15 August to say that she had checked the
cell and found it much cleaner, but warned the man about any future
decline. The next entry in the record on 17 August was again made
by the same Officer. She referred to the interception of a letter that
the man had written to his social worker. He told his social worker
that he had self-harmed. The man told the officer that the self-harm
was a very superficial scratch on his forearm which he had done
several days previously. He said that several staff were already
aware of it and that it was a “one off” because he did not feel suicidal.
84. My investigators interviewed the officer about the entries she had
made in the wing file. She had brought the man into the office and
chatted to him about the letter to his social worker. When she asked
the man about self-harm, he rolled up his sleeve and showed her his
forearm. It was clear to the officer that the injury was several days old
“because it had scabbed over, it was very superficial, it didn’t need a
dressing on it”. The officer asked the man why he had done it and
remembered him saying that it was because he was doing the SOTP
and that the SOTP tutors were aware of what he had done. The
officer said in interview that she wondered whether the man had
some sort of learning difficulties because he always walked about
very slowly, and was always very grubby looking despite being
encouraged with his personal hygiene. She recalled that he walked
around with his shoe laces undone and his shoulders hunched.
85. The next entry in the man’s wing file was made by an officer on 29
August after his Personal Officer interview with the man. He recorded
that he had been unable to write a report in July due to his annual
leave and night duties. He noted that the man still had problems with
his hygiene and cleanliness, even though other prisoners on the
landing were trying to help him. The man told the officer that he
would try harder. The officer recorded that he was attending the
SOTP “and appears to be coping”.
23
86. My investigators interviewed the officer,and discovered that he was a
very experienced officer who has worked at Wymott for the last 20
years. The officer described the man as a man with many problems.
He was very immature and was a difficult person to relate to because
he seemed to keep himself to himself in a lot of ways, and was not
willing to open himself up to other people. The officer knew that a
couple of prisoners on the man’s spur were willing to assist him and
tell him what he needed to do “and talking to him and if he was low at
any time just try to buck his spirits up”. The officer realised that the
SOTP was causing the man problems. In interview, and with the
benefit of hindsight after the man’s death, the officer said that:
“he was finding difficulty in accepting and once he had been actually
made to think about what he had done, to accept that he had actually
done that and it seemed to be on his mind and that was making him
more and more depressed and withdrawn.”
87. The officer felt that there were two sides to the man’s participation in
SOTP. On the one hand, he was getting something out of the
programme because it made him think about what had happened and
gave him an incentive to go one step further. On the other hand, “he
got more and more involved in what was happening and having to tell
the people what he had done, he went down and the two lads
seemed to be spending more time actually talking with him and trying
to bring his spirits up”.
88. The officer spoke of the man‘s incontinence coming to light after his
death. The officer was not sure whether the bowel problems were a
rumour or the truth. He added:
“… if that was the case, it would explain a lot of the problems we had
with him and perhaps if we had been aware of that at an earlier time,
we would have understood more about what was going on.”
89. When speaking in greater detail about his wing file reference to
hygiene and cleanliness on 29 August, the officer recalled that there
were a couple of times when wing staff found faeces in the man’s cell.
There was another occasion where the man put his kit or clothing to
the wing laundry to be washed and there was a smell. When the kit
was taken out, wing staff found that it was full of faeces. There is no
indication that healthcare staff were consulted at the time.
90. My investigators asked the Officer about the man’s behaviour in the
two weeks of September before his death. The officer recollected
that the man “seemed quite cheerful, talkative, laughing, little pranks
which is what he was good at doing. He did seem a lot better. I think
this [his death] actually came a little bit out of the blue.” With the
assistance of his friends, the man was keeping his cell reasonably
tidy and seemed to the officer to be coping a lot better.
24
91. My investigators asked the officer about the man’s relationship with
the other men on his spur. The officer said that prisoners did pick on
him, referring to his personal hygiene and “just telling him about how
dirty he was and intimidating with remarks”. The officer was not
aware that the man had been physically intimidated since his arrival
on the 3s landing. However, he spoke of being told that the man had
been assaulted and picked on and actually hit on a couple of
occasions during the six weeks he spent on the 4s landing before his
transfer to B3-11.
92. The officer said he was very surprised when he heard that the man
had committed suicide (the officer’s expression) because the man
seemed to have been much improved and less depressed. When
asked about any recommendations he would like to make, he said
that he did not think that the man should have been at Wymott: “I
don’t think we have the facilities he required due to his mental state,
his lack of education; I think he needed more attention and we were
not able to give him that.” In a later answer, the officer said he did
not think that Wymott had the facilities, the time or perhaps the
professional people within the prison who could have helped the man.
93. The prisoner at Wymott who knew most about the man was the older
prisoner. He was the man’s prisoner supervisor in the Weavers’
Shop and, during the last few months of his life, the man was housed
just across the landing from him. In interview, the older prisoner
recollected that he first met the man on A wing in January 2004 when
the man arrived at Wymott. He added it was quite clear after several
days that. “the boy could not really take care of himself … First of all
we had a job in teaching him how to put his shoes on, on the correct
feet and how to start tidying his cell.” The older prisoner did his
utmost to care for the man and to give him practical help with his daily
life at Wymott.
94. The older prisoner said that the man had a very difficult life in the
prison because he had bowel troubles and many prisoners on the
wing called him smelly. He added several times that the man was like
a boy of 13 in a man’s world. Prisoners took advantage of the man,
according to the older prisoner, and then he got into debt. The older
prisoner stated that there were one or two prisoners who did not really
understand the man and they used to hit him. The older prisoner
indicated that he put a stop to that and recalled that the man took a
few bangs to the head from other prisoners. The older man said the
blows were to the side of his jaw and his forehead in the smokers’
room of the Weavers’ Shop.
95. The older prisoner knew that the man was in debt to several prisoners
at the time of his death. He said the debt was 27 Mars Bars which
the man owed to about five different prisoners. The older prisoner
said the prisoners were reluctant to receive payment after the man’s
death, but he insisted on cancelling the debt.
25
96. The geography of the spurs at Wymott meant that the man had
unlimited opportunities to talk to the older prisoner, especially once
the staff had gone off duty at the end of each evening. There is a
locked gate at the top of the corridor leading to each spur in the
prison, but within the confines of the spur prisoners have free
movement and they also possess a key for their own cell door. He
explained that the only time the man would talk to him about his
personal problems was in the evening because then the man could
go into his older friend’s cell on his own. He recollected how the man
would come into his cell at teatime and say that he had to talk to him
later. He would never do so until the door at the end of the corridor
was locked, and the staff had gone home for the night.
97. The older prisoner spoke very matter-of-factly about the practical
assistance he gave to the man. When he first saw that the man’s
shoes were on the wrong feet, he would tell him to take his shoes off
and then put them back on again. They went through this procedure
for quite a period of time “but eventually he got the knack, then it
would be very rare you would see him with his shoes on the wrong
feet”.
98. As soon as the interview with my investigators began, the older
prisoner referred to the man’s bowel troubles. He explained that,
after lock-up in the evening, prisoners only have access to one night
toilet on the landing and they do not have access to showers. The
older prisoner said that, “if he was unfortunate and had an accident at
that time, well we had to try to use our own methods as best we
could. After his death, someone said that it [his bowel problem] was
not even entered on his medical record. This could be a possibility
because several times I would have to give him fresh underclothes
out of my own allocation. Fortunately, I could manage because I was
not ill.”
99. Towards the end of the interview, the older prisoner was asked to
speak about the man’s bowel problem in more detail. He said that, in
normal circumstances, if somebody has bowel troubles he is given a
mix of clothing and underclothes and the necessary bags to put his
stuff in. The man never had any of these. The older prisoner used to
give him some of his own clean clothes. He encouraged the man to
seek help for the problem himself because he felt it was no good if he
did everything for his friend, and he wanted the man to become self-
sufficient. The older prisoner used unofficial, as well as official,
means to try to preserve the man’s dignity. He sometimes asked
prisoners working in the stores to make additional sets of
underclothes available to him for the man’s benefit.
100. The older prisoner was very critical of the SOTP course and felt it
should be scrapped. He said that the man was a 13 year old boy who
was being mentally “hammered” by some of the other prisoners on
the course. The older prisoner claimed that the man slowly got more
and jittery as the course was going on, because he knew it was
26
coming closer and closer to the time when he must speak about the
circumstances of his offences. The older prisoner was not aware that
the man was to be on the ‘hot spot’ (as the older prisoner called it) on
the day of his death, and the older man was strongly of the view that
the man should have received treatment on a one-to-one basis rather
than in a group environment.
101. The man’s next door neighbour, in Cell B3-10, was another prisoner
who felt that the man was very confused, quite emotionally
unbalanced and needed a lot of help. The neighbour said that a
number of prisoners tried to wind him up and called him names. They
did not know the extent of his toiletry problems so they called him
smelly.
102. The man’s neighbour, said he was very insecure and needed a lot of
cuddles. He confirmed that the man was in debt at the time of his
death and that he had made up a list in preparation to pay the debts
off. He stated that he and the older prisoner had discussed the
matter at length with the man. He felt that the man made “the most
ludicrous bets, knowing full well that he would lose, maybe just to
gain a bit of attention, to gain people’s affection”.
103. My investigators asked the neighbour about the man’s behaviour in
the days and weeks leading up to his death. He felt his behaviour
had changed slightly, that he had become a little rowdy and he was
seeking attention a lot more. The neighbour said he was quite “down,
he voiced concerns about the SOTP course that he was attending
and he was quite down about that and really didn’t look forward to
going into any of his course days”. When he was reflecting at the end
of his interview the neighbour said that prisons are one size fits all,
which doesn’t work, “it should be judged on individuals rather than
inmates collectively. Everyone should be looked after individually. I
think somebody like the man with mental health issues really
shouldn’t have been in prison in the first place, he needed care. He
didn’t need to be put in here to be made ten times worse.”
104. Two prisoners who were attending the same SOTP course as the
man asked to see my investigators. One said, in a striking phrase,
that the man was “tormented by a lot of inmates” when he first arrived
at Wymott. He was asked what form the torment took and said he
saw the man having his trousers pulled down in front of everybody.
He added that the man was called names and he alleged that some
officers laughed at him.
105. The second prisoner said that sometimes the man had to be told to
pull his trousers up because they were around his ankles. He said
that the man was “like a young kid’’ who could not tie a knot and could
not even tie his own shoe lace. He suggested the investigators
should look at the question of whether the man killed himself or
whether he was helped.
27
106. A third prisoner spoke to my investigator just before being released at
the end of his sentence. He felt he had information about what might
have caused the man’s death. He spoke of a man on the wing who
was “taking coffee, biscuits, tea and sugar off the man. As he was a
bit slow in certain things, this bloke pestered him and he [the man] did
hand the stuff over.” The man in question was on I wing, a unit for
elderly prisoners, along with the third prisoner. The third prisoner said
he spoke to Mr W, the man allegedly pestering the man, and told him
to stop. He said that Mr W did stop but then in the last couple of
months before the man’s death it started up again. The man’s
motivation for handing over items he had purchased in the canteen to
Mr W seems to have been the mistaken belief that Mr W would help
him to move from B House onto I wing. The third prisoner explained
to the man that he had no chance of moving onto I wing and that Mr
W was robbing him.
28
14 SEPTEMBER 2005
107. The Adapted Sex Offender Treatment Programme (ASOTP) consists
of 13 blocks, and by the morning of 14 September the man and the
seven other prisoners in the group had reached block 7, which is
called ‘My Offence’. The treatment manual for the programme
explains that during the sessions in this block each group member
has to go through his offence. Other members of the group will ask a
lot of questions. The facilitators will be looking for individual prisoners
“to give an account which describes ‘how you made the offence
happen’”. The manual states quite clearly that:
“Most people find this difficult at first. It takes a lot of courage to be
honest about what you have done. Learning to take responsibility is
the first real step towards not reoffending”.
108. One of the facilitators wrote an account of the events of the morning.
The programme that day began at 9.15am with all group members,
except one, present. The session was No. 37 in the programme. The
first half of the session focussed on the offence account of another
prisoner. There was a coffee break at 10.20am and then the session
resumed at 10.40am with the man giving his offence account.
109. To the surprise of the facilitators, the man was very forthcoming in
relating the details of his offence. He had always been open in giving
details about his offence, but the facilitators felt he was particularly
honest in disclosing some very sensitive information on this occasion.
Fellow prisoners were invited to ask questions, but few did so since
the man was doing most of the work without any need for prompting.
Both facilitators wrote that the man seemed generally relaxed in
giving his account, even when disclosing sensitive information.
110. The session ended at 11.35am. The man was praised by group
members and facilitators for his efforts. He was asked if he would be
willing to resume his account for 20 minutes at the start of the next
session (there is just one session each day) and he said he was very
willing to do this.
111. A fellow course member said in interview that the man was very
truthful on 14 September about his offence. He added, “I think he
was more revealing than he had ever been and my own opinion was
that he wanted to get it all out there and then. But I think the stress of
the course didn’t help him.”
112. The fellow course member added that, being asked about the
circumstances of your offence by another prisoner, “was horrendous
to go through. In my opinion it is worse than being interrogated by
the police and that’s how bad it was.” He felt that the man had done
29
very well to give his account in the way he did: “I admired him for
bringing it all out as he did.”
113. After the other group members had left the group room, the man
came to see one of the facilitators and told her that his bowel problem
was getting worse. He said that he wanted to tell the group so that
they would understand his problem. She advised him to think about
the issue overnight and give it careful thought before he told the
group. He repeated that he wanted to tell his fellow group members
and that he felt comfortable in doing so. The facilitator told him that if
he still wanted to tell the other prisoners in the morning he would be
allowed some time to do so before the session began. This was the
last time that she saw or spoke to the man.
114. In her statement about 14 September, the facilitator also mentioned a
discussion with the man which had taken place several weeks earlier.
The man showed the officer a letter stating that his friend had been
moved to another wing. The man missed talking to him. The next
day the man came to see her again and said he had been advised by
another prisoner to tell someone that he had self-harmed. She asked
him why and he told her that it was because his friend had been
moved. He also told her he had harmed himself six days previously.
She looked at his arm and noticed a few superficial scratches. He
said that he did not wish to be placed on F2052SH and that the desire
to self-harm was no longer present.
115. The facilitator immediately went to speak to a Senior Officer (SO) on
B House. She told him that she did not consider the man to be a risk
to himself at that time. This was because the injuries had been
inflicted six days previously and “the reason for them was linked to
getting a prisoner back on to the same spur as the man”. The SO
said he trusted the facilitator’s judgment and was happy not to open a
Self-Harm at Risk form. She returned to speak to the man and
informed him that his friend could not be moved back on to the wing.
The man said “he understood and was fine with this. He reiterated
that he no longer felt like self-harming and I obtained an agreement
from him that if he experienced any further problems or he felt
depressed in any way to come and speak to one of the facilitators as
soon as possible.”
116. On the morning of 14 September, a regular officer (Officer A) on B3
landing but not the man’s Personal Officer received two pieces of
information about the man. Some prisoners from B3 landing
complained about the smell coming from the man’s cell and he
answered a telephone call from the instructor in the man’s workshop.
The older prisoner had told the instructor about the size of the man’s
debt and the instructor was sufficiently concerned to ring staff on the
man’s wing. Officer A decided he would keep the man back from
work during the afternoon so that he could talk to him about the two
separate matters that had just come to his attention.
30
117. The man’s next door neighbour saw him at lunchtime after he had
returned to the landing from his ASOTP course. When asked how
the man seemed to be, the neighbour replied:
“His behaviour was pretty much like the man’s, quite consistently
inconsistent really. One minute he was quite jovial and happy and the
next minute he was quite down.”
The neighbour added that another prisoner had upset the man after
his course and the neighbour had also heard that “an inmate had
threatened to stab him in the workshop or something”.
118. Officer A did indeed speak to the man on the afternoon of 14
September. He estimated that their conversation lasted for about 15
minutes. The man readily told him that he had a bowel problem and
about the debts that he owed. The Officer responded energetically to
the man’s disclosure about his bowel problem. He rang the
Healthcare Centre to find out if they already knew. In interview,
Officer A said that the lady in HCC to whom he spoke got the man’s
medical record out. He thought she must be a member of the
administrative staff in HCC because she could see no reference to a
bowel problem in the record but said that one of the nurses would call
the man back. He also rang the clothing exchange store to find out
the prison’s policy on help with incontinent prisoners. Officer A has
been an officer for 15 years and was well aware that I wing at Wymott
holds a number of elderly men, some of whom might also be
incontinent. Later in the afternoon, his colleague in the clothing store
sent over additional items of kit for the man to use in response to the
Officer’s initiative.
119. The last person to see the man alive appears to have been his
neighbour. In interview, he estimated that he last saw the man at
3.30pm. At that time, he complained to the man who was playing a
song at full blast on his stereo. He knocked on the man’s cell door,
they had a bit of a laugh together and a playful exchange, and then
the neighbour went back to his cell and carried on with his upper body
exercises.
120. At 4.10pm, the neighbour looked into the man’s cell and saw him
hanging from the bars on the window. The neighbour asked another
prisoner who was on the spur to come and verify what he was seeing,
and then the prisoners pressed the alarm bell situated towards the
gates at the end of the spur.
121. The first officer to reach the man’s cell in response to the alarm call
was Officer B. In interview, he explained that he was the cleaning
officer on B wing on the afternoon of the man’s death. He said that,
when a prisoner presses the alarm call bell on the landing, a light
lights up in every wing office and also in the Senior Officer’s office on
B House so that staff can determine from which landing the call has
been made. Officer B was sitting with some colleagues in the 1s and
31
4s wing office, which is on the same level as the man’s cell but at the
opposite end of the wing. Staff told my investigators that it was quite
rare for the alarm bell to sound during the afternoon, so they
responded rapidly when the panel in their office lit up to indicate a
possible problem on B3 landing. Officer B thought that the time when
the emergency began was approximately 4.10pm because he was
talking with his colleagues just shortly before going for his tea at
4.15pm. At the time, the majority of prisoners were still at work, but
there are always some other prisoners on the landings who either
work as cleaners or who have not gone to their normal jobs for a
variety of reasons.
122. When Officer B entered the man’s cell he saw him hanging by his
neck from the cell bars. The bars were at the rear of the cell as he
looked in at the doorway. Straightaway, Officer B could see a ligature
around the man’s neck. It appeared to him to be the blue belt of a
terylene dressing gown. The man was facing the door of the cell and
his feet were off the floor. Other Officers were immediately behind
Officer B. He climbed onto a table beside the man and tried to
remove the ligature from around his neck, while the other Officers
supported the man’s weight. Officers at Wymott do not carry ligature
knives and Officer B said in interview:
“We had a struggle to undo the knot initially, because of the man’s
weight. We changed round, I supported some of the weight and a
second officer undid the first of two knots and the second knot was
harder to remove. I removed that and then we placed the man on the
bed.”
123. Officer A ran to the landing office to obtain a set of scissors or a blade
to assist his colleagues. He also rang Wymott’s Control Room and
asked for immediate healthcare assistance for a Code Blue (hanging)
emergency on B3 landing. All three officers indicated in their
statements to the Governor that supporting the weight of the man’s
body before the ligature could be removed was physically very difficult
indeed. The man was described by the detective who led the police
investigation as a stocky prisoner. The third Officer wrote how he and
the second Officer struggled to lift the man higher so that the Officer
B could undo the second knot.
124. The Control Room Daily Log Sheet contains no significant entries on
14 September until 4.13pm when a phone call was made from B wing
to say that a prisoner was hanging. The Healthcare Centre was
informed at that time. At 4.14pm, the log sheet shows that the
Control Room received a Code Blue urgent message and at the same
time a nurse (H3) was on her way to the emergency. At 4.15pm, the
Control Room received a call to say that an ambulance was required.
The Control Room duly requested an ambulance and was told that
two vehicles were en route.
32
125. The first attempts to revive the man were made by Officer B. He
attempted to clear the man’s airway by tilting his head back so that
his tongue was not obstructing. He then started chest compressions,
although he thought that the man was already dead. He recalled that
his eyes were staring, there was no movement at all and there was
froth around his lips. In interview, Officer B remembered that a nurse
seemed to appear on the scene almost straightaway. The third
Officer helped healthcare staff by bringing their Code Blue bag from
the medication room and the Officer B assisted the nurse in the cell
while she gave the man oxygen.
126. Two Nurses made a joint entry in the man’s clinical record. (I
observe, in passing, that it would have been preferable for the nurses
to make an entry each, in order to acknowledge their individual
accountability.) They wrote that they arrived on the wing at 4.15pm
and found the man where wing staff had placed him on his bed.
There were no signs of life, they could feel no carotid pulse and he
was cyanosed. (Cyanosis is a medical term meaning a bluish
discoloration of the skin due to inadequate oxygenation of the blood.)
The man’s pupils were fixed and dilated. They began airway
management and cardiopulmonary resuscitation (CPR). Officer B’s
description of this part of the rescue attempt is that the nurse was
giving alternate mouth-to-mouth and chest compressions to the man.
127. The nurses wrote that a defibrillator was connected to the man. (This
is a piece of equipment with the ability to administer an electric shock
to a patient’s heart in a bid to restart it.) The machine advised the
nurses that the man should not be shocked. They continued with
CPR in response to instructions from the defibrillator until paramedics
arrived at the cell. At 4.35pm, a joint decision was made by the
nurses and paramedics to discontinue resuscitation attempts.
128. The Control Room log states that at 4.22pm a message was received
from B wing to say that the man was receiving CPR but there were no
respiratory signs. At 4.24pm, the first ambulance arrived at the prison
and at 4.26pm a second ambulance arrived. At 4.27pm, first
response personnel arrived at B wing and the log then records a
message from a Principal Officer at 4.32pm to say that the man had
died.
129. The last part of the nurses’ entry in the clinical record states that a
doctor was contacted but was unable to attend in order to confirm
formally that the man had died. Another doctor was then contacted
and said that he would attend the prison at approximately 6.30pm
following his surgery. The last entry in the man’s clinical record was
made by the second doctor. He wrote that he attended at the cell at
6.45pm and confirmed the man’s death at 6.51pm.
130. The man’s mother and grandmother live in a town hundreds of miles
to the north. Prison Service Order 2710 on Follow-up to Deaths in
Custody states that the news of a prisoner’s death should be
33
conveyed in person by a visit to the next of kin unless it is
inappropriate for geographical reasons. In this case, it was clearly not
feasible to break the news of the man’s death in person due to the
extremely long journey that would have been involved. The prison
therefore liaised with the local police force in Scotland and asked
them to pass the news of the man’s death to his next of kin.
131. In May 2005, the man had applied for his grandmother to be
recognised as his next of kin. The man’s prison record states that an
application was sent to Custody Admin on 3 May 2005 for his next of
kin details to be changed from his mother to his grandmother. There
is no further entry on the record to say what happened to the man’s
application. The necessary alteration appears to have been made at
this time to the prison’s computer record on the Local Inmate
Database System (LIDS). However, no manual change was made to
the first page of the man’s core prison record which continued at the
time of his death to show his mother at her own address as the man’s
next of kin.
132. The duty governor on the evening of the man’s death told my
investigator that he had considerable problems in making contact with
the man’s next of kin. He eventually managed to make telephone
contact with the man‘s grandfather and the man’s grandmother was
also at home at the time. They made their way to the home of their
daughter (the man’s mother) but, by the time they arrived, the news of
the man’s death had already been broken to her by a local police
officer. Scottish police records show that Lancashire Constabulary
made contact with them at 7.51 pm on 14 September. Three minutes
later, the message was passed to a local police officer to deal with. It
is extremely unfortunate that the man’s mother, who is herself a
vulnerable woman, did not receive the shocking news of her son’s
death from her own parents but from a policeman.
133. My investigator has discussed the man’s 3 May application to change
his next of kin details with the Executive Officer in charge of the
Custody Office at Wymott. She told him that prisoner requests to
change next of kin details are very rare indeed, with requests to
change religious affiliation being more common. When an
emergency arises, it is clearly essential that making contact with a
prisoner’s nominated next of kin can be done speedily and
straightforwardly.
I recommend that the Governor reviews what happened after the
man’s next of kin application of 3 May with a view to devising a
system that is efficient, reliable and as un-bureaucratic as
possible.
134. The arrangements for giving support to staff and prisoners after the
man’s death were very good. An important report on the aftermath
has been supplied to me by the Chairman of the Independent
Monitoring Board (IMB) for Wymott. (Each prison has an IMB
34
composed of local people, appointed by the Home Secretary, whose
task is to monitor the treatment of prisoners and the performance of
the prison.) The chairman’s report is an objective and credible
document because of his independence from the Prison Service, and
I am most grateful to him. He has written that he received news of
the man’s death at 4.45pm. By 5pm, he had arrived at the prison. At
5.15pm, he accompanied a Residential Governor, who visited each of
the landings on B wing to let prisoners and staff know what had
happened. The chairman has recorded: “He handled this sensitively
in an open but discreet manner … He advised prisoners of the
arrangements for additional chaplaincy and staff presence during
evening association; there was a good response from prisoners.”
After 6pm, the chairman’s report indicates that wing staff organised
the serving of the evening meal as normal. There followed normal
evening association (when prisoners are permitted to mix with each
other outside their cells) with appropriate restrictions on movement in
the vicinity of the 3s landing.
135. The chairman’s overall assessment at the conclusion of his report is
as follows:
“From my observations, the staff who were directly involved in the
incident and other wing staff responded sensitively and professionally
both to the requirements of the situation and to the needs of the other
prisoners on the wing.”
136. Since June 2005, there had been seven other prisoners on the
ASOTP group that the man had been attending. Detailed and
sensitive plans were drawn up to decide how the group of both
prisoners and staff should respond to the shocking event of his death.
137. On the morning after the man’s death, the Head of Psychology and
Programmes at Wymott, and a Senior Officer (Programmes Manager)
arranged to meet with three facilitators on the group in order to
provide support and to decide on the appropriate action for group
members. During the meeting, the three facilitators had an
opportunity to discuss what had happened and their responses to the
news. The three facilitators met with the group members on the
afternoon of 15 September and it was also agreed that the normal
session of the group would take place on Monday 19 September.
138. The statement written by one of the facilitators explains that the
purpose of the meeting was to give all the group members an
opportunity to talk about the man’s death the previous day. The
senior officer opened the meeting by telling the group exactly what
had happened from the moment the man was discovered hanging in
his cell, through to the removal of his body by undertakers at
approximately 7.45pm in the evening. The remainder of the
afternoon was spent by inviting everyone, including the facilitators, to
speak about how they felt regarding the man’s death.
35
CLINICAL REVIEW CARRIED OUT BY HEAD OF SERVICE
DEVELOPMENT AT THE PCT
139. I am most obliged to the Head of Service Development at Chorley
and South Ribble PCT for carrying out a comprehensive review of the
clinical care received by the man at Wymott and at other prisons. He
concludes that the man was a very vulnerable individual. He notes
that his vulnerability was further compounded by his apparent
learning disability and possible mental health condition, although the
latter was not confirmed. The clinical reviewer comments favourably
on the lengths to which nursing staff at Lancaster Farms went in order
to ensure that the man’s level of vulnerability was reduced. He
praises particularly the detailed Nursing Care Plans which were
developed and agreed. However, he is concerned that recognition of
the man’s vulnerable nature was not picked up at Wymott. He states
that, “there is no apparent recognition in the IMR following transfer to
Wymott of the level of input that had been provided by the healthcare
team at Lancaster Farms”. The reviewer is particularly forthright
when commenting on the quality of record keeping that he
encountered in reviewing the case. He states that the Inmate Medical
Record (IMR) is difficult to follow, with notes and reports filed in what
can only be described as a chaotic manner and out of sequence. He
adds that entries are often illegible and signatures are indecipherable.
It is very often impossible to ascertain to which prison a particular
form or entry relates as this is not identified on the form.
140. The reviewer includes a page on confidentiality in his review. He
observes that the overriding principle in relation to confidentiality
outside the prison environment is that of a “need to know basis”. He
explains that the issue of confidentiality is not as clear when it comes
to the passing of information within the prison setting. He suggests
that further work should be undertaken on a national basis to examine
the issues relating to confidentiality within the prison system.
141. The reviewer makes four sets of recommendations at the end of his
review. In relation to care planning, he notes that the process of care
planning at Wymott appears to be basic and to lack a clear
systematic approach. He recommends that a Senior Nurse be
responsible for the review of care plans and that minimum standards
for the completion of care plans be implemented and reviewed on a
regular basis.
36
142. In relation to the inadequate record keeping the clinical reviewer
encountered during the process of his review, the recommendations
he makes are:
(cid:3) all entries to the IMR should be signed and dated with a
signature printed overleaf;
(cid:3) the record should include all relevant Prescription and
Administration Record Charts with a note being made if a drug is
not administered;
(cid:3) all prison pre-printed documentation should include space for
the prison to identify itself on the form;
(cid:3) The quality of records should be subject to regular review and
audit, in line with current best practice and professional
standards.
143. In relation to risk assessment, the reviewer writes that there is no
evidence of a system of assessment of prisoners at risk upon arrival
at HMP Wymott. He recommends that:
(cid:3) a comprehensive mental health risk assessment of all
vulnerable prisoners should be implemented at Wymott;
(cid:3) a policy for the proactive follow-up of vulnerable at risk prisoners
should also be developed.
144. In relation to confidentiality, the reviewer recommends that a review of
confidentiality within Prison Healthcare should be undertaken, with a
particular and initial emphasis on those prisons providing SOTP.
145. I endorse all of the recommendations made by the reviewer.
37
THE ADAPTED SEX OFFENDER TREATMENT PROGRAMME
146. A central element in my investigation has been to examine whether
there was any link between the man’s involvement in ASOTP and his
death. My investigator has read the 78 page Treatment Manual for
ASOTP, which was issued in 2003 by the Offending Behaviour
Programmes Unit (OBPU) at Prison Service Headquarters. Early
pages of the manual explain that one of the main goals of the course
is that “low intellectually and socially functioning sex offenders”
should move from Old Me to New Me. ‘Old Me’ is the person they
were when they offended; ‘New Me’ is the person they are working
towards being, their ideal (but realistic) self. The programme is
divided into 14 blocks and a total of 89 sessions, each lasting for two
hours. Most of the blocks consist of just a few sessions, but there are
two blocks which are very much longer than any other. Block 7,
entitled My Offence, lasts for 32 sessions. Block 13, just before the
end of the course, lasts for 25 sessions and is entitled Introducing
‘New Me’ Tactics. There is a review in the middle of the programme
and a case conference at the end of the group, but the man’s death
came before either of those events.
147. The section of the manual dealing with Block 7, My Offence,
stipulates that each group member should have approximately three
sessions in the ‘Hot Seat’ where he has to give an active account of
the circumstances of his offence or offences. Page 41 of the manual
refers to this as a stressful block and the facilitator’s notes at the end
of the block say it is “extremely stressful and demanding; most of
them [the prisoners] will find it very difficult”.
148. Before the man attended ASOTP, he had already completed an ETS
programme in February 2005. This programme consists of 21 two-
hour sessions and is based on the premise that an individual’s ability
to achieve goals in a pro-social (rather than anti-social) manner is
improved by developing thinking skills. My investigator has examined
the post-programme progress review written on 18 March 2005 after
the man had completed ETS. The Summary of Progress section at
the beginning of the Progress Review commences thus:
“In preparing to write this report and therefore gathering information in
respect of the man, it has come to light that he experiences a number
of learning and developmental difficulties which we were unaware of
prior to his commencement of the course.”
149. Section 2 of the report states that: “The man’s seemingly erratic
contributions [to the course] appear to be systematic [(sic) I assume
this is a misprint for symptomatic] of his condition. Unfortunately
tutors did not have access to this information until after the course
was completed.”
38
150. The last part of Section 2 covers the application of skills learned on
the course to real life situations. The review’s conclusion is:
“… in the light of new information as detailed above, tutors are unable
to give an informed opinion regarding the man’s level of
understanding and application of skills. It would appear that further
intensive work tailored to meet the man’s individual needs would be
more appropriate.”
151. Section 3 is the final section of this review and lists recommendations
for the further development of skills. The recommendation of staff
attending the review was to:
“Formulate a care plan through a case conference to include multi-
disciplinary professionals in order to address the man’s outstanding
needs whilst in prison and upon release. Case conference to be held
within four weeks of the date of this report.”
152. I have been unable to find evidence that this recommendation was
heeded or actioned as the man was considered shortly afterwards for
participation in ASOTP. The document does not indicate that
recommendations and action points made at the review were to be
implemented by a named person or persons.
I recommend to the Governor that the action plans and
recommendations drawn up at reviews of offending behaviour
programmes should clearly indicate who is accountable for
implementing them.
153. At an early stage in this investigation, I decided to obtain expert
answers to a number of questions about the man’s involvement in
ASOTP from the highly qualified psychologist who is the Head of the
Sex Offender Treatment Programme at the OBPU. I am most
grateful to her for the detailed and candid information she has given
to my investigators at various stages of this inquiry. My investigator
wrote to her on 4 October and she replied to all the questions in that
letter on 14 October.
154. The psychologist was asked to comment on whether decisions taken
at all stages of the assessment and course delivery process were in
accordance with the arrangements set out in the SOTP manual. She
concluded that the decisions about the man were in accordance with
published standards. The man was fully assessed for intellectual
functioning and he signed all the relevant forms, such as consent
forms. Medical clearance was obtained in the usual way for SOTP.
The group was run by fully trained and experienced facilitators and
had an experienced supervisor. There is evidence, according to the
psychologist that at least some information about the man’s medical
and mental health was available to the facilitators. The psychologist
believes that best practice would additionally have included a fuller
account of the man’s medical history, including a more detailed
39
account of the symptoms associated with FACS and information
about the support plans that had been in place for him prior to coming
to Wymott. Ideally, a care and support plan would have been agreed
with residential and healthcare staff.
155. The second question answered by the psychologist was whether the
man should have been selected for ASOTP. She noted that the
majority of reports recommended ASOTP for him or referred to
ASOTP without any comment on suitability.
156. The psychologist thought that the decision to select the man for
ASOTP was reasonable in the light of the information available. She
said that: “in the same position, I would have made the same
decision”. However, she referred to the man’s needs outside the
group and added, “He was not receiving the level of professional day-
to-day support he was used to and obviously needed”.
157. The third question answered by the psychologist was whether the
facilitators and their supervisor were aware of any misgivings about
the man’s participation in SOTP. She said it would be important to
discuss whether the facilitators communicated the following
information to their supervisor:
(cid:3) that the man asked on several occasions to come off the group
(including by written note to his facilitators and verbally, as
recorded in his treatment diary);
(cid:3) that the man told several people he found the group "very hard”;
(cid:3) that the man told one of the facilitators that he had self-harmed.
158. The fourth question answered by the psychologist was whether the
Healthcare Centre at Wymott had disclosed sufficient information
about the man’s medical condition before he began ASOTP. The
psychologist wrote that the procedure followed in the man’s case was
in accordance with current national SOTP standards. A form was
submitted to the medical centre. However, the psychologist criticised
the fact that the date on the form was several months after the start of
the course as “not acceptable”. She said that medical clearance
should be obtained before a prisoner starts a course. I agree entirely.
159. The psychologist thought that some additional information was
available to the facilitators. She referred to the Progress Log
containing a short paragraph about the man’s diagnosis of dyspraxia
and the symptoms he had associated with FACS.
160. The psychologist was asked to comment on whether the
arrangements for supporting the man at the time he disclosed his
decision chain (the circumstances of his offences) were adequate.
She wrote that, with the benefit of hindsight, there were some
indicators that additional support would have been helpful for the
man. These indicators included:
40
(cid:3) The fact that the man had historically received very high levels
of personal support in his home town from carers in simple day-
to-day living.
(cid:3) The fact that the man had communicated to facilitators that he
found the group hard, wanted to come off the group and that he
had self-harmed.
(cid:3) The psychologist wrote that the SOTP was clearly going to be a
demanding enterprise in relation to the man’s life experience
and therefore it would have been appropriate to consider that he
might need some back-up support on a regular basis throughout
the programme
161. The psychologist noted that the man’s presentation in the session on
the morning of his death did not show signs of depression or distress.
In her view, the man spoke in a reasonably confident and forthcoming
way about the lead-up to his offence. He readily agreed to continue
talking about the offence at the beginning of the next day. The
psychologist wrote: “there is nothing about his presentation in the
session to indicate depression or suicidal intentions”.
162. Both the psychologist and my investigator have watched a videotape
of the session on the morning of 14 September where the man spoke
about his offences. The psychologist is therefore able to say in her
letter:
“I would like to stress that the session itself was run in a cheerful and
relaxed manner. There was no question that the man was badgered
or put under pressure by the facilitators or other group members. He
appeared comfortable talking about his offence and responding to
their questions. There are no moments of tension and the facilitators’
therapeutic style is warm and encouraging towards the man.”
163. My investigator shares the psychologist’s view about the videotape.
There are no signs on the tape that the man was in acute or undue
distress, or that he was contemplating a major act of self-harm just a
few hours later.
164. In the final section of her letter, the psychologist commented on
whether any changes should be made to delivery of SOTP locally or
nationally. She considered that there were two areas where delivery
of SOTP could be adjusted. The first is the communication system
between health and psychology departments about a prisoner’s
suitability for treatment. She felt that the medical clearance form
might be inadequate both in content and in process.
165. In this man’s case, the system for obtaining medical clearance was
that an exchange of forms took place between the Psychology and
Healthcare departments. A standard pro forma, headed Sex
Offender Treatment Programme, was sent from a Psychology
41
Assistant, to Healthcare on 6 September 2005 (the assistant had
taken up her post just a month previously). The form was not
addressed to a particular person in the Healthcare Centre, but
explained that eight prisoners were possible candidates for the
SOTP. It added that prisoners in five categories could not be
selected. The categories were 1 – an acute psychotic illness now or
at the time of the offence, 2 – those suffering from paranoid
personality disorder, 3 – those with chronic brain damage, 4 – those
who will miss more than three sessions due to health reasons, 5 –
those with any medical conditions which would prevent them from
participating in the course. The recipient was asked to tick the
appropriate box and return the form. The three possible boxes that
could be ticked were Medically Fit, Physically Unfit or Mentally Unfit.
166. It is manifest that prisoners with acute psychotic illnesses or chronic
brain damage are unsuitable candidates for SOTP. However,
prisoners not suffering from such serious disorders might also be
unsuitable candidates for a course as intensive as SOTP.
167. A related form is entitled Healthcheck – Information required and
states that the Medical File should be checked for the following:
(i) mental health issues either in community or while in prison;
(ii) heart conditions;
(iii) serious known medical conditions;
(iv) requires regular visits to outside hospital;
(v) requires regular visits to healthcare;
(vi) pending surgery;
(vii) any medication currently taking.
A handwritten note at the bottom of the man’s form states: “collapsed
in workshop – March 05. No further problems reported.”
168. My investigator was told by the psychology assistant that she made
this note herself. She had been told that Healthcare staff were too
busy to respond to the form she had sent them. She was invited to
attend the Healthcare Centre in order to study the clinical records of
the men identified on the form. She made no note of the man’s bowel
disorder or learning disabilities. Nor did she mention the misgivings in
relation to SOTP expressed by the psychiatrist in her psychiatric
report to the Crown Court written in June 2003.
169. The psychology assistant was placed in an intolerable situation and I
emphasise that I make no criticism whatsoever of her actions. She
was inexperienced and could not possibly have been expected to
have the expertise to extract the necessary information from the
records.
42
170. I am not convinced that the forms my investigator examined ask all
the right questions. I was also dismayed to discover that the form
was not sent to the Healthcare Centre until 6 September. That was
just over a week before the man’s death, and at a time when he and
the other named prisoners on the form had already completed two
and a half months of ASOTP. The psychology assistant assumed
that a similar form had been sent to the Healthcare Centre previously,
but there is no evidence that this happened.
171. The psychologist also suggests that the SOTP audit criteria could be
reviewed to give more encouragement and weight to assessment and
support. She suggests that WAIS assessments need to be fully
interpreted, with the interpretation and conclusions of this assessment
being communicated clearly to the group facilitators. (WAIS stands
for Wechsler Adult Intelligence Scale and is a tool used by
psychologists to assess intelligence.) She also refers to the support
needs of all ASOTP candidates, and the possibility of drawing up a
care plan for ASOTP group members that involves programme and
residential staff.
172. My investigator has studied the most recent Accredited Programmes
Audit Document issued by OBPU in May 2005. In the section of the
document headed Treatment Management and Integrity, there is an
audit requirement that “Prisoners are selected for an intervention
through assessments of need, risk and suitability.” The action
required by the Audit Document is that, for ASOTP candidates, a full
WAIS should be administered and fully interpreted for each group
member prior to the start of the programme. I agree with the
psychologist that it is vital for the conclusions of this assessment to
be communicated clearly to the group facilitators.
I recommend that OBPU reviews the Audit Document and ASOTP
Treatment Manual with a view to ensuring that the interpretation
and conclusions of WAIS assessments are communicated
clearly to group facilitators.
173. The psychologist’s letter refers to the support needs of all ASOTP
candidates. In her conclusion she refers to the need for “a greater
focus on monitoring out of group support”.
174. ASOTP is an arduous and very demanding programme for both the
facilitators and the prisoners who undergo it. At the time of his death,
the man was at block 7 of the programme and I note that that block is
described in the Treatment Manual as ‘’extremely stressful and
demanding”.
175. I was not able to see any references to support for prisoners in the
OBPU Audit Document. The “Old Me” block of the Treatment Manual
includes two paragraphs in a section entitled Other People Who Can
Help Me. In that section, the facilitators are advised to tell the group
that it is important to think about other people in their lives who can
43
help them. A list of possible helpers is set out, but all the people on
the list, such as Probation Officers, key family members, GP and
neighbour, are outside the prison. There is no discussion in this
section of the possibility that the prisoner will need help in the here
and now – and not just in the future when he is trying to apply the
learning from ASOTP treatment in the outside community.
176. The question of support for the man also came up in a supervision
session between the facilitators and Treatment Manager, on 15 July.
A requirement of the programme is that a Record of Supervision is
kept. The Audit Document explains that supervision has a number of
purposes - including the development of the tutors’ skills by providing
feedback from observations made by the Training Manager, and
allowing the tutors to raise questions or bring sections of videotape
along for review. (All sessions on ASOTP are video taped.)
177. The meeting on 15 July was attended by the treatment manager and
all three tutors on the man’s course. They talked about planning for
the forthcoming block 7. The facilitators were recorded as saying that
they were concerned the man might find the walk and talks difficult:
“The man may therefore need some further support out of the
sessions.”
178. In interview, one of the facilitators explained that he saw the
necessary support as coming from the tutors themselves at times
when the group was not meeting. I do not think it is fair or sensible
for the tutors to carry this heavy burden alone. The psychologist
suggests that the care plan for ASOTP group members should
involve both programme and residential staff, although there are
complex cultural issues which cannot be addressed simply by writing
a policy document.
I recommend that the Treatment Manual includes a section on
sources of support, not confined to the tutors, which can be
accessed inside the prison by prisoners doing ASOTP.
179. There is evidence that, on at least one occasion, the man wanted to
leave the programme. In interview, one of the facilitators
remembered a time when the man felt that confidentiality had been
breached on the course. Somebody who was not on the course had
been talking about his offences on the landings. The facilitator could
remember talking to the man about the problem. At the end of their
conversation, the man said that he would stay on the course. The
facilitator added that the man might even have put it in writing
because he “was a great one for sending us notes on various things”.
180. My investigators were given a note addressed To Whom it May
Concern in the man’s distinctive handwriting. The spelling mistakes
in the original have been corrected in the following extract:
44
“I, is currently doing SOTP AP5. I am wishing to come off the course
for a while as I fear for my safety and cannot sleep at night as people
who is not on my course are wishing to know why I am on the course
and are asking people who are on my course about my offences.”
181. In the same note, the man writes about self-harming in the past and
being “bollocked” by his best mates for hurting himself. The note also
refers to the man being “on his own” shortly when his best mate, was
due to be released from Wymott. The man’s mate was indeed
released from Wymott to a hostel in a nearby city exactly a week after
the man’s death.
182. The facilitator disclosed during his interview that the information about
the man’s medical condition contained at the beginning of his
Progress in Treatment Log may not have been included at the
beginning of the course. He said that the information would have
been typed in when it became available. He had not typed the entry
himself, “so I couldn’t say that it was actually written at the beginning
of the course. It could have been written in at any stage when we
found that out.”
183. At the end of his interview, the facilitator considered that the
pressures of SOTP might have been a contributory factor to what
happened on the afternoon of 14 September in the man’s cell. But
the officer added that he could not believe that SOTP was the sole
cause. He referred to the man’s debt problem and suspected there
was a lot of banter on the man’s landing that afternoon, “probably
taking the mick out of him because he was cleaning his cell, possibly
they had spotted his new laundry bags coming in.” The facilitator
named a particular prisoner with an extremely low IQ who might have
mocked the man.
184. The facilitator thought it was, “just a series of a number of things that
had come together on that afternoon that just tipped him over the
edge, and if somebody had only had the slightest idea and gone in
and talked to him that afternoon, I suspect by the evening he would
have been over the worst of it and able to cope again.”
185. A final SOTP issue worthy of note is that the Treatment Manager
received less information about the difficulties the man was
experiencing than the facilitator thought she did. My investigator
asked the facilitator if information about scratches the man had made
to his wrists was made available to the treatment manager. He replied
that he was pretty sure that she knew about them, and then added
that she would definitely have been informed. He was asked by
whom and replied, “I would have thought by one of the facilitators.”
186. In her interview, the treatment manager said that she could not recall
the facilitators discussing with her the man’s desire to come off the
course before his death. Shortly afterwards, she was asked if one of
the facilitators had told her about the scratches on the man’s arms.
45
She said that she had not been aware of the scratches before his
death. At the end of her interview, she spoke of the importance of
facilitators using supervision effectively. She explained that she is
“reliant on the facilitators approaching me with any issues and
problems and that means them coming prepared to supervision with
issues.”
187. Although the facilitator was ‘’pretty sure’’ that the treatment manager
had been informed of the scratches on the man’s arms, I think it is
likely that she had not been so informed. I cannot be certain about
this matter because it was not possible to interview the facilitator who
was on maternity leave. However, I emphasise the importance of
supervision sessions considering all information that suggests an
individual prisoner is in distress.
46
FINDINGS AND CONCLUSIONS
188. No note was found in the man’s cell after his death, but it is highly
probable that he took his own life. I have considered the claim made
by another prisoner in interview that the man would not have known
how to tie the ligature found around his neck. My investigator
discussed this question with the detective who led the police
investigation. I understand there are a number of factors that strongly
suggest to the police that the man was not attacked by another
prisoner or prisoners. He was described by the detective as a stocky
man and he was facing the cell door when he was discovered. The
police supposition is that the man would have struggled violently if
another prisoner or prisoners had attempted to harm him against his
will. As he was facing the cell door he would have been in a position
to see, and resist, any person who entered his cell with evil intent.
There were no signs of scrapes or scratches on his body and his next
door neighbour would surely have intervened if he had heard anything
amiss.
189. The man had committed a number of grave sexual offences, but he
was himself a very vulnerable young man who had previously
received significant levels of support, both in the community and at
Lancaster Farms. In terms of prisoner support, the man’s situation on
B3 landing was probably the best it had been during his time at
Wymott. I single out for particular praise the contribution to the man’s
welfare made by the older prisoner. I think that the older prisoner had
the man’s best interests at heart and that he gave the man quiet,
unspectacular assistance in areas that really mattered. He taught the
man to put his shoes on the correct feet, helped him to tidy his cell
and made unofficial arrangements for the man to have clean clothing
when he had soiled himself. He acted as a trustworthy confidant and
counsellor late in the evening when staff had gone home.
I recommend that the older prisoner receives a formal letter of
thanks from the Governor or Area Manager.
190. I conclude that the man received a high level of care and individual
attention during the time he spent at Lancaster Farms. There he was
located for many weeks in the Healthcare Centre, where weekly
reviews and personal care plans were drawn up. There was even a
straightforward list of things that the man had to do each day (the
man’s Daily Checklist).
I recommend that a copy of this report is sent to the Governor
of Lancaster Farms drawing attention to my comments on the
care the establishment offered to the man.
47
191. Although the man received excellent healthcare support while he was
at Lancaster Farms there is no evidence that his continuing
healthcare needs were adequately conveyed to Wymott. The Prison
Service’s performance Standard on Health Services for Prisoners
(Number 22) states at 22.2 that each prison must have written and
observed guidelines in place which set out the procedures for
transfer, ‘’ensuring information on continuing care is conveyed to
other establishments on transfer.’’
192. During the course of my investigation, on 10 February 2006, the
Prison Service issued Prison Service Order (PSO) 3050 on Continuity
of Healthcare for Prisoners. Chapter 5 of the new PSO deals with the
transfer of prisoners. Three paragraphs in the chapter are devoted to
the topic of continuity of care between establishments, with paragraph
12 being especially relevant:
‘’Patients with more complex health needs may require more detailed
planning such as communicating directly with the receiving health care
team in advance of transfer.’’
The last part of Chapter 5 deals with receiving transfers and ends with
the instruction:
‘’Each establishment must develop a local protocol and procedure for
the reception of transfers to its establishment that meets its local
needs and is responsive to any significant clinical events.’’
I recommend that the Governor of Lancaster Farms reviews the
arrangements for ensuring continuing healthcare for young men
transferring to other establishments I recommend that a local
protocol is drawn up urgently at Wymott for the reception of
transfers, especially those with significant health issues.
193. In his sentencing remarks on 12 September 2003, the Judge said that
he had had particular regard to the three psychiatric reports. He said
that those reports referred to the difficulties which the man might well
experience while serving his sentence and the Judge knew “from
what I have been told that those difficulties have to a certain extent
already manifested themselves”. The Judge indicated that all the
reports on the man should accompany him to where he serves his
sentence, “which I hope will be of some assistance”. There is no
evidence that the sentencing judge’s remarks followed the man
around the prison system. There was no copy of them in his prison
record and they were only obtained during the course of my
investigation. There is scant evidence that information about the
man’s vulnerability contained in the reports was widely known or used
to inform his treatment at Wymott. In response to my draft report
colleagues in SCG have informed me that a review of the Prisoner
Escort Record (PER) is currently being undertaken. PER is the
document used to record information of special importance as
prisoners are transferred from one criminal justice agency to another
48
and within the prison system. Another relevant initiative is the
Improvement and Implementation Project which is presently
scrutinising the work of the Prison Escort and Custody Service.
194. There is compelling evidence that the man was struck and called
names by other prisoners. One of the facilitators thought that the
man had suffered from bullies right through his sentence because of
the way he was, “because physically he wasn’t the most able of
people. He looked a little bit strange and, yes, he had been bullied,
he had come to us and said he had been bullied and we dealt with it.”
Prisoners told my investigators that the man was subjected to name
calling, tormented by some prisoners and told that he was smelly by
others. Such assaults on his dignity cannot have assisted his
psychological wellbeing.
195. I commend the Officer B highly for the energy, compassion,
determination and initiative he showed on the last afternoon of the
man’s life. The man told him openly about his bowel problem and
Officer B immediately set about trying to provide assistance. I
congratulate Officer B for what he did, but also express sadness that
it was left to a conscientious prison officer on the last afternoon of the
man’s life to come up with a decent solution to such a basic human
need. Officer B kept the man away from work on the afternoon of 14
September so that he could attend to the issues that had been
brought to his notice. (I think this was the right thing to do, although
keeping a prisoner away from work is a decision that should probably
have been agreed with the Senior Officer on the wing.)
The Governor should send a letter of commendation to Officer B.
196. There are constant references in the man’s prison record to the
untidiness of his cell. Just a month before his death, the wing
handover book contains a note as follows:
“The man warned re the state of his cell. It has been cleaned up and
looks OK but why does it still smell.”
197. Two immensely experienced officers did not know about the man’s
bowel problem before the last day of his life, although they worked
regularly on his landing. Staff on the wing were actively hindered
from giving the man appropriate care because they were not aware of
his bowel problem.
I recommend that the Governor and Primary Care Trust work
together to set up a system which will supply “need to know”
medical information to carefully identified non-clinical staff.
198. The young man who died badly needed a staff champion. Yet no
Personal Officer interview was held with him for the five month period
between the end of March and the end of August 2005. If Wymott is
to retain a Personal Officer system, then such gaps are highly
49
undesirable – even a very brief contact and entry in the wing file is
better than no entry at all. I think it is likely that Wymott’s anti-bullying
and violence reduction procedures would have operated more
successfully in the man’s case if there had been more regular contact
with a Personal Officer. Such contact would have given the man
further opportunities to raise any concerns that he had and given the
officer the chance to ask direct questions about the welfare of a
clearly vulnerable young man.
I recommend that the Governor considers whether there are
ways to make the Personal Officer scheme at Wymott work more
effectively.
199. I am extremely grateful to the psychologist who is the National Head
of the Sex Offender Treatment Programme, for the detailed response
she supplied in mid October to seven questions put to her. She
herself recognised that there were a number of areas where delivery
of SOTP might need to be adjusted “to reduce the likelihood of any
repetition of this kind of tragic outcome”. She highlighted the need to
review communications between Healthcare and Psychology
Departments regarding a prisoner’s suitability for sex offender
treatment. I have no doubt that the medical clearance arrangements
in place at the time of the man’s death need to be reviewed and
improved. I believe that pre-assessment scrutiny before a prisoner is
selected for a SOTP needs to be more rigorous. In particular, better
systems must be devised for supplying relevant medical information
to Programmes staff.
I recommend that OBPU and Prison Health jointly examine
communications between Healthcare and Psychology
Departments regarding a prisoner’s suitability for sex offender
treatment. Particular attention should be paid to medical
clearance arrangements and to the provision of relevant medical
information to Programmes staff.
200. The psychologist criticises the medical clearance form sent by the
Wymott’s Psychology Department on 6 September for listing only
narrow programme exclusion criteria and not allowing for other issues
to be communicated. The form was sent to the Healthcare Centre
when ASOTP5 was already far advanced. ASOTP is making a
critically important attempt to change the behaviour of sex offenders
for the better. The Treatment Manual announces that “one of the
main goals of the ASOTP is the identification and restructuring of pro-
offending beliefs into anti-offending beliefs”. In common parlance,
this means helping sex offenders to face up to making the change
from old me to new me. The process is lengthy and difficult but
potentially life changing. It is asking prisoners to talk about and to
renounce what the facilitator called probably the worst things they
have done in their lives. It is not acceptable to seek appropriate
medical clearance when participants have already been on the group
for many weeks.
50
I recommend that no prisoner at Wymott should begin SOTP or
ASOTP unless the necessary medical clearance has been
obtained. This recommendation may need to be repeated
nationally.
201. My investigators have discovered that the psychology assistant had to
write her own response to the questions posed in the form she sent to
the Healthcare Centre on 6 September. That situation should never
have arisen and must not be repeated. Information about clinical
factors which may prevent a man’s participation in SOTP must be
supplied in timely fashion by suitably competent people. I am very
encouraged to learn of the pre-assessment arrangements now being
developed at Wymott. These mean that senior professionals from the
Healthcare Centre and Psychology Department will sit down together
to assess possible candidates for courses so that informed decisions
on suitability are taken.
202. Neither the facilitators nor the Treatment Manager had seen the
psychiatric report, so they were not aware of her opinion that the man
would be unable to cope with regular SOTP groups in prison. There
is also evidence that staff at Wymott may not have seen relevant
information that was available before offending behaviour
programmes began. The psychologist wrote in good faith, at
paragraph 1.2 of her letter, of evidence that at least some information
about the man’s medical and mental health was available to the
facilitators before ASOTP began. She referred to the description of
FACS at the beginning of the Progress Log. However, information
that came to light after she wrote her letter suggests that the
facilitators may have had less information than she thought they had.
One of the facilitators explained in interview that information at the
beginning of the Progress Log could have been written in at any stage
when it actually became available. He added that, in some cases, the
facilitators have all the information they need on group members
before the course has started. But in other cases, “I have known to
almost complete a course when things like depositions, court
depositions have arrived.” He said it was very important to have that
kind of information “because then you know who you are dealing
with”.
203. It was only after the man had completed his ETS programme in
February 2005 that programmes staff became aware that he
experienced a number of learning and developmental difficulties.
These difficulties may well have explained, or partly explained, why
the man did not respond to parts of that course. There is no evidence
that the proposed multi-disciplinary case conference to address the
man’s outstanding needs whilst in prison, as suggested in the post-
ETS review, ever took place. There is no evidence that SOTP staff
were aware of such a recommendation. It is not possible to find out
exactly what information the facilitators did see before SOTP began:
51
I recommend that clear guidance is published for Programmes
staff and facilitators about the kinds of information they should
attempt to obtain before working with a prisoner in an offending
behaviour group.
I recommend that OBPU should consider issuing national
guidance on how staff are to obtain relevant prisoner information
before delivering accredited programmes.
204. The existing national Treatment Manual for ASOTP was issued in
September 2003. I suggest that it may be necessary to issue
amendments to the existing manual or to produce a revised version of
it. Page 41 of the manual refers to each group member having
approximately three sessions in the “hot seat”. This expression was
widely used at Wymott, but OBPU may wish to reflect on whether
such a term should continue to appear in the manual. The
psychologist also addressed in her letter the issue of out-of-group
support. The manual itself recognises that Block 7 is extremely
stressful and demanding and that most of the group members will find
it very difficult. It would be helpful for national SOTP managers to
reflect on questions such as who should give support to SOTP group
members and when it should be offered.
I recommend that the guidance on support in the Treatment
Manual (and other relevant documents such as the SOTP Audit
Criteria) should be urgently reviewed.
205. Although the OBPU Audit document states that all sessions on
ASOTP must be videoed, at the time of writing some videos of
individual sessions could not be found.
I recommend that a robust system is introduced without delay at
Wymott for storing videos of ASOTP sessions.
206. In the penultimate paragraph of her letter, the psychologist makes a
number of technical criticisms in relation to course delivery. She
highlights the importance of wind-down time at the end of a session,
the need to debrief and praise group members who have undertaken
difficult work during the session, and the importance of
communicating in a manner that will be easily understood by men
with intellectual difficulties. I draw these matters to the attention of
the Governor.
207. When the man was discovered hanging, Officer B went to find what
he called in interview a self-harm kit in the office. He could not find
one. The first staff to arrive in the man’s cell had great difficulty in
untying the double knot in the ligature. Staff suggested to my
investigators that they should be issued with ligature knives and that
more offices on the wing should hold emergency response kits. I do
not write of the Officer B’s difficulty in order to embarrass him, but to
52
emphasise the training point that front-line staff must be regularly
briefed on the location (and, ideally, use) of emergency equipment.
I recommend that anti-ligature knives be issued to all prison
officers at Wymott who have direct contact with prisoners.
208. When staff succeeded in removing the ligature from the man’s neck,
he was placed on the bed in his cell. The recommended action in
Prison Service Order 2700 on Suicide and Self-Harm Prevention is
that once a prisoner has been cut down, he should be placed on his
back on a flat, solid surface. I do not believe that the man’s death
would have been prevented if he had been placed on the cell floor,
but in a report on a prisoner’s death from natural causes at Wymott
on 8 June 2005 I also noted that CPR should ideally be carried out on
a hard surface, and highlighted the risks of staff not being properly
first aid trained.
I recommend that the Governor reminds all staff of the PSO
requirement to place a prisoner on his back on a flat, solid
surface if he is found hanging.
53
RECOMMENDATIONS
1. I recommend that the Governor reviews what happened after the
man’s next of kin application of 3 May with a view to devising a
system for making emergency contact with relatives that is
efficient, reliable and as un-bureaucratic as possible.
2. I recommend that OBPU reviews the Audit Document and ASOTP
Treatment Manual with a view to ensuring that the interpretation
and conclusions of WAIS assessments are communicated clearly
to group facilitators.
3. I recommend that the ASOTP Treatment Manual includes a
section on sources of support, not confined to the tutors, which
can be accessed inside the prison by prisoners doing ASOTP.
4. I recommend that the older prisoner receives a formal letter of
thanks from the Governor or Area Manager.
5. I recommend that a copy of this report is sent to the Governor of
Lancaster Farms drawing attention to my comments on the care
the establishment offered to the man.
6. I recommend that the Governor of Lancaster Farms reviews the
arrangements for ensuring continuing healthcare for young men
transferring to other establishments. I recommend that a local
protocol is drawn up urgently at Wymott for the reception of
transfers, especially those with significant health issues.
7. The Governor should send a letter of commendation to Officer B.
8. I recommend that the Governor and Primary Care Trust work
together to set up a system which will supply “need to know”
medical information to carefully identified non-clinical staff.
9. I recommend that the Governor considers whether there are ways
to make the Personal Officer scheme at Wymott work more
effectively
10. I recommend that OBPU and Prison Health jointly examine
communications between Healthcare and Psychology
Departments regarding a prisoner’s suitability for sex offender
treatment. Particular attention should be paid to medical
clearance arrangements and to the provision of relevant medical
information to Programmes staff.
11. I recommend that no prisoner at Wymott should begin SOTP or
ASOTP unless the necessary medical clearance has been
54
obtained. This recommendation may need to be repeated
nationally.
12. I recommend that clear guidance is published for Programmes
staff and facilitators about the kinds of information they should
attempt to obtain before working with a prisoner in an offending
behaviour group.
13. I recommend that OBPU should consider issuing national
guidance on how staff are to obtain relevant prisoner information
before delivering accredited programmes.
14. I recommend that the guidance on support for prisoners
undergoing ASOTP in the Treatment Manual (and other relevant
documents such as the SOTP Audit Criteria) should be urgently
reviewed.
15. I recommend that a robust system is introduced without delay at
Wymott for storing videos of ASOTP sessions.
16. I recommend to the Governor that the action plans and
recommendations drawn up at reviews following offending
behaviour programmes should clearly indicate who is accountable
for implementing them.
17. I recommend that anti-ligature knives be issued to all prison
officers at Wymott who have direct contact with prisoners.
18. I recommend that the Governor reminds all staff of the PSO 2700
requirement to place a prisoner on his back on a flat, solid surface
if he is found hanging.
19. I endorse all the recommendations made by the clinical reviewer
at the conclusion of his Clinical Review. These recommendations
are:
(cid:1) It is recommended that a senior nurse be responsible for
the review of care plans and that minimum standards for
the completion of care plans be implemented and reviewed
on a regular basis.
(cid:1) It is recommended that all entries to the Inmate Medical
Record be signed, the signature printed underneath and
clearly dated.
(cid:1) The Inmate Medical Record to include all relevant
Prescription and Administration Record Charts and a record
made if a drug is not administered.
(cid:1) It is also recommended that all prison pre-printed clinical
documentation includes space for the establishment to
identify itself on the form.
55
(cid:1) The quality of records should be subject to regular review
and audit in line with current best practice and professional
standards.
(cid:1) A comprehensive mental health risk assessment of all
vulnerable prisoners should be implemented at HMP
Wymott.
(cid:1) A policy for the pro-active follow up of vulnerable at risk
prisoners should also be developed.
(cid:1) It is recommended that a review of confidentiality within
Prison Healthcare be undertaken with a particular and initial
emphasis on those prisons providing SOTP.
56