Individual at Holme House

Investigation into the circumstances surrounding the
death of a man at HMP Holme House on 7 January 2006
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2007
This is the report of an investigation into the death of man at HMP Holme House on
7 January 2006. Just after 5.00 am that morning, the man was found with a ligature
tied around his neck and attached to the top of the bedstead in his cell in the
healthcare centre. The man had been sentenced to eight years imprisonment on 16
December 2005. He was 67 years old.
I took over responsibility for investigating deaths in prison custody in April 2004 and
this was the third apparently self inflicted death that I have investigated at Holme
House. 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. The investigation was led by Two investigators from my office. I
commissioned a clinical review from North Tees Primary Care Trust and I am most
grateful to the clinical governance lead at the Trust, for supplying a detailed medical
report.
I thank the Governor of Holme House and his staff for the co-operation my
investigators received at all stages of the investigation. They were greatly assisted
by the prompt way in which the liaison officer carried out his duties. I also thank the
Detective Sergeant of Cleveland Police for the assistance he gave to my
investigators.
One of my investigators and one of my Family Liaison Officers, met with the man’s
son and daughter-in-law. They asked for a number of questions to be addressed in
the course of the investigation. The family liaison officer spoke on the telephone to
the man’s partner and she also raised concerns for me to consider. I have
endeavoured to deal comprehensively with all their questions in my report. I offer my
sincere condolences to the man’s family and friends.
The man had never been in prison before. In the documents annexed to my report
there are numerous references to ‘bizarre’, ‘distressed’ and ‘challenging’ behaviour.
It appears that the man’s acute distress was attributed to manipulation or his
withdrawal from the large amounts of alcohol he had drunk over decades. He was
not seen by nurses from the prison’s integrated mental health service until the day
before his death, by which time he had been held at Holme House for three weeks. I
have made a number of recommendations designed to improve systems and
procedures at Holme House but I also comment on some highly commendable staff
responses and behaviour. I am pleased that all the recommendations made in my
draft report and in the clinical review have been accepted.
Stephen Shaw CBE
Prisons and Probations Ombudsman March 2007
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Contents:
Summary 4
The investigation process 6
The man 7
HMP Holme House 8
The man’s initial health screen on 16 December 2005 9
The man’s ‘confused and bizarre’ behaviour 12
The man’s location in the segregation unit on 1 and 2 January 17
The man’s time in Houseblock 3 21
The man’s mental health assessment on 6 January 25
The night and early morning of 6 and 7 January 29
Contact with the man’s family 33
Contact between Holme House and his partner
(i) Contact between Holme House and his son
Consideration and Conclusions 39
(i) The man’s medical care while at Holme House
(ii) Training for healthcare staff
(iii) Camera cells in the healthcare centre
(iv) Medical fitting for adjudication
(v) The man’s location in the special cell
(vi) Contact with the man’s family
(vii) Good practice and commendable staff actions
Recommendations 49
ANNEXES
List of Annexes
(i) Reference documents referred to in the investigation
(ii) Reference documents consulted but not included in
the report.
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Summary
A man was found hanging in cell HA1-5 in the healthcare centre at HMP Holme
House at approximately 5.00 am on 7 January 2006. The man had never been in
prison before but was sentenced to eight years imprisonment on 16 December 2005
for serious sexual and violent offences. On arrival at Holme House that afternoon,
he was located in the healthcare centre overnight then started an alcohol
detoxification programme the next day.
During the three weeks the man spent at Holme House, he had numerous cell
changes and his behaviour was described as disturbed and bizarre by many
observers.
On 29 December, the clinical nurse manager at Holme House contacted
the man’s GP in relation to his “recent strange behaviour.” The nurse manager told
the GP that the man could appear to be quite lucid but then his behaviour would
change and he would become rude and abusive. The nurse manager recorded in
the man’s clinical record that the GP told her that this behaviour was quite usual for
the man and he would use “any means to manipulate to get what he wants.”
The man flooded his cell in the healthcare centre on an almost nightly basis. On 1
January 2006, control and restraint techniques were used to transfer him from the
healthcare centre to a special cell in the segregation unit because the man had
flooded and smashed up his healthcare cell. At a disciplinary hearing on 2 January,
the man was accused of offending against Prison Rules by intentionally endangering
the health and safety of himself and others. It was alleged that he had flooded,
urinated and defecated on the floor of his cell.
On 3 January 2006, the man was transferred to Houseblock 3 which is used to
house vulnerable prisoners and new receptions. The man had already applied to be
segregated from other prisoners due to the nature of his offences.
Soon after the man’s arrival on Houseblock 3, an officer wrote in the record of events
section of the man’s prison record that he was agitated when unlocked for teatime.
He said that people were in the exercise yard wanting to kill him and shouting at him.
At 6.00 pm the same afternoon, a regular landing officer on Houseblock 3, noted
continued bizarre behaviour. He answered the man’s cell bell and the man asked
the officer for help because ‘’them on the yard were going to get him.’’ The regular
landing officer recorded that there were no prisoners on the yard at that time.
On the morning of 6 January, the regular landing officer urgently referred the man to
the mental health team at the prison. Two experienced mental health nurses saw
the man the very same morning and decided that he should be seen by a visiting
psychiatrist three days later. The man was transferred from the segregation unit to
cell HA1-5 in the healthcare centre. That was a camera cell but during the night of 6
to 7 January the camera did not work effectively until approximately 5.00 am. At that
time an Operational Support Grade (OSG) who was on night duty in the healthcare
centre with a Nurse, noticed that the man seemed to be “a funny colour.” He was
lying on his bed but had attached a ligature made from a sweatshirt to the headboard
4
of his bed. The two women were joined by two male colleagues and strenuous
efforts were made to revive the man, but without success.
The prison sent a recently trained Family Liaison Officer (FLO) to inform the man’s
partner and her family of his death. The man’s son, a serving officer at a prison near
London, rang Holme House during the afternoon of 7 January to obtain more
information about his father’s death. Regrettably, the son was given no additional
information about his father or the circumstances of his death until two days later.
I make several recommendations and attach particular importance to the
recommendation relating to a more robust FLO system in the North Eastern prisons.
I am very disappointed that the man was not referred to the mental health team at
Holme House until the day before his death despite the high levels of confusion and
distress that he had been displaying for many days before then.
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The investigation process
1. This investigation was undertaken by two investigators from my office. They
issued notices to staff and prisoners, telling them of the investigation and its
term of reference and offering them the opportunity to participate.
2. They visited Holme House on a number of occasions and interviewed staff
who had especially significant relationships with the man. They reviewed all
relevant documentation and visited cells where the man had been held, both
in the healthcare centre and segregation unit. They met with the detective
from Cleveland police leading the investigation into the man’s death.
3. My Family Liaison Officer arranged a meeting with the man’s son and
daughter in-law which was attended by herself and one of my investigators.
My investigators conducted interviews both at Holme House and the prison in
which the son worked. This was in response to his complaints about the
treatment he received when he rang Holme House, on the afternoon of 7
January, to obtain information about his father’s death. The family liaison
officer spoke to the man’s partner, on the phone. The partner said she was
concerned about the man’s alcohol detoxification programme, the healthcare
he received in prison and that his victim had been told of his death before the
family.
4. I commissioned a clinical review about the circumstances of the man’s death
from North Tees Primary Care Trust. The review was undertaken by a clinical
reviewer.
5. No pre-sentence report was written at the time the man was sentenced and
my investigators endeavoured to obtain reliable information about his life in
the community. They made telephone contact with the experienced criminal
lawyer who had represented the man at his trial and I am most grateful for the
information he supplied. They also wrote to the Crown Prosecution Service in
Middlesbrough but received no response. A response to The clinical
reviewer’s report was invited and received from the locum medical officer at
Holme House.
6. My investigators studied the reports on previous self inflicted deaths at Holme
House in 2002, 2004 and on 5 March 2005. They obtained advice on the
medical fitting of prisoners for adjudications from the policy lead on this
subject at the Offender Policy and Rights Unit in the National Offender
Management Service.
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The man
7. The man was 67 years old at the time of his death. Although he was
sentenced to eight years imprisonment at Teesside Crown Court on 16
December 2005, no pre-sentence report was written at the time. There is,
therefore, only a limited amount of documented biographical information about
him.
8. Some information about the man’s life in the community before his sentence
is contained in the mental health assessment report written by two Nurses on
the morning of 6 January 2006. They wrote that the man had drunk heavily
for many years and that his wife had died 20 years previously after 30 years
of marriage. The man told the nurses that he had worked as a crane driver
but stopped working when his wife died. He was described as retired on his
core prison record.
9. My investigator spoke to the experienced criminal lawyer who represented the
man at his trial. The lawyer explained that, if he has concerns about the
possibility that one of his clients will self harm, it is his practice to warn the
staff who are escorting his client to prison. The lawyer had no concerns at all
that the man would self harm and thought he would settle well in prison once
his alcohol detoxification was complete.
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HMP Holme House
10. Holme House is situated in Stockton on Tees, Cleveland, and is a category B
local prison for unconvicted, convicted and sentenced male adults. The
prison primarily serves the communities of Tees Valley, South West Durham,
East Durham and North Yorkshire. The prison opened in May 1992 and its
operational capacity (the maximum number of prisoners who can be held
there) is 994.
11. Her Majesty’s Chief Inspector of Prisons, inspected Holme House in April
2005 and issued her report three months later. In the introduction to her
report, she wrote that her inspection recorded some extremely good work in
detoxification and healthcare. She added that “suicide and self harm
prevention was well managed; and more prisoners told us that they felt safe in
Holme House than in comparable establishments. They also reported better
than average relationships with the staff.”
12. In the section of her report dealing with self harm and suicide, The inspector
wrote that five prisoners committed suicide at Holme House in 2002. She
noted that Holme House had been one of the pilot sites for the Prison
Service’s new Assessment, Care in Custody and Teamwork (ACCT)
approach to managing prisoners at risk of self harm. The inspector observed
approvingly that the mental health in-reach team had run sessions for staff
and Listeners (prisoners trained to assist their fellow prisoners at times of
crisis) to raise awareness of mental health issues.
13. Soon after my investigation began, the Governor transferred from a nearby
young offenders’ establishment to become governing Governor at Holme
House.
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The man’s initial health screen on 16 December 2005
14. On the afternoon of Friday 16 December 2005, the man was sentenced to
eight years imprisonment at Teesside Crown Court for offences of rape and
assault. The man had been on bail until the time of his sentence and he had
not been to prison previously. He was escorted from court to Holme House
by staff working for Global Solutions Limited, a private escort company. The
front page of his Prisoner Escort Record (PER) highlighted his medical
condition and his conviction for a sexual offence. Escort staff wrote at section
5 of the PER form “DP (detained person) states that he has a heart condition
– medication with DP.”
15. Section 4 of the PER form has a column devoted to risk categories other than
medical and security. This column includes ‘drugs/alcohol issues’ and the
perceived risk of suicide or self harm. Neither of these categories were
thought to be relevant in the man’s case and at the foot of the column the
heading ‘no known risk’ was ticked.
16. During the reception process at Holme House a number of personal details
about the man were recorded on the first page of his core prison record. He
indicated that he had been living at an address in Hartlepool. He stated that
his next of kin was his partner who lived at the same address. The man told
prison reception staff that she was the person to be contacted in an
emergency.
17. The health of all newly received prisoners at Holme House is screened and
the information obtained during that process is recorded on a first reception
health screen form. In the man’s case, the nurse who carried out the
reception health screen was an experienced Registered Nurse. The man told
the nurse the name, address and telephone number of his GP in Hartlepool.
He said he had not been in prison before and that he had seen a doctor in the
last few months due to his high blood pressure. He said that he was receiving
medication for hypertension and his only other physical health concern at the
time was an ingrowing toenail on his right big toe.
18. In answer to questions about alcohol use the man said that he drank socially,
consuming six to seven pints of beer daily. When asked about the timing of
his most recent drink, he replied that it had been the same morning.
19. On arrival at a local prison such as Holme House all prisoners are asked a
series of questions about mental health. The man told the nurse that he had
never received treatment for any form of mental health problem. He said he
had never received medication for his nerves and had never tried to harm
himself. As is routine, the nurse explained that coming into prison can be
difficult for some people, with a few finding it so hard that they may consider
harming themselves. The man was asked if he felt like that or even suicidal
and he answered no to both questions.
20. At the end of the first section of the form, the nurse wrote that because of the
man’s length of sentence and his age he should be placed in the healthcare
9
centre overnight. In the second part of the form, headed ‘secondary health
assessment’, the nurse recorded the man’s blood pressure and in the
‘planned action’ section, at the end of the form, she recorded her decision that
the man should be referred to the prison doctor.
21. My investigator interviewed the nurse and discovered that she had qualified
as a Registered Nurse in 1977 and had practised continuously as a nurse
since that date. She worked as a sister on the Accident and Emergency (A
and E) ward at North Tees Hospital for about 25 years, and then started
working at Holme House about 18 months before the man’s death.
22. The first reception health screen form states that, if a new prisoner has been
drinking more than about 20 units daily (the equivalent of ten pints of beer or
cider or half a bottle of spirits) or is showing signs of withdrawal, the nurse
should hold a discussion with the doctor and consider admission to healthcare
for observation. The man was underneath that threshold as he told the nurse
that he drank six to seven pints each day. My investigator asked if the nurse
had concerns about the way the man was presenting or about possible
alcohol withdrawal. She replied that she had no alcohol related concerns at
all about him.
23. My investigator asked the nurse if the man seemed low or depressed in view
of the lengthy prison sentence he had just received. She replied that he had
said “I don’t suppose I’ll ever get out of here” but, to her, he seemed “quite
chirpy, quite intelligent and he didn’t seem depressed.” The nurse explained
that she put him in the healthcare centre that evening “because of his age and
because of the length of his sentence, not because I was worried about him.”
Later in the interview, the nurse added that she expected the man to remain in
the healthcare centre for just one night so that he could see the doctor. She
anticipated that he would then be moved to another houseblock.
24. The nurse told my investigator that the man was not the usual type of prisoner
she encountered because “he was intelligent, he was easy to talk to, he spoke
quite well and he just seemed a very nice gentleman.”
25. The nurse emphasised that there were no signals whatsoever that made her
concerned about the man in relation to alcohol detoxification and withdrawal.
She confirmed that, as a result of her long experience in A and E medicine
she was very familiar indeed with people presenting in front of her who had
significant alcohol problems. My investigator asked the nurse a number of
questions about the possible risk that the man would self harm. She
answered that she had no concerns at all and, when asked to explain why,
she said:
“He was calm, spoke very intelligently, came across as a very
intelligent gentleman. First time in prison but no concerns whatsoever
about him at all. Between the two of us, the relation was quite good,
his communication was very good, he didn’t stammer, stumble,
anything all his questions were answered clearly and concisely and he
just came across as a very intelligent man.”
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26. On 16 December, the man also completed a form requesting that he be
located on the vulnerable prisoner unit on Houseblock 3. The form indicated
that his offence was rape and he wrote that he wanted protection “for my own
safety.” The man was not actually transferred to Houseblock 3 until 3 January
2006 as his stay in the healthcare centre turned out to be much longer than
the nurse had predicted.
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The man’s ‘confused and bizarre’ behaviour
27. Although there were no concerns about the man on Friday 16 December, that
situation began to change as soon as the following day. For the last three
weeks of the man’s life there were numerous expressions of concern about
him, recorded in a number of different documents. He was frequently very
noisy and staff used adjectives such as “strange”, “bizarre” and “confused” to
describe his behaviour.
28. On 17 December, the medical officer noted in the man’s clinical record that it
was his first time in prison and that he had received an unexpectedly heavy
sentence. He was feeling a bit low but had no past history of depression or
self harm and denied any thoughts of self harm. The next entry in the clinical
record, also dated 17 December, stated that the man was found to be
tremulous and very anxious. He was now giving information that he drank
quite heavily, consuming two and a half bottles of cider daily. In response to
his alcohol withdrawal, the doctor prescribed a reducing daily dose of
chlordiazepoxide (brand name Librium – used to treat anxiety) which began at
noon on 17 December and ran until 27 December 2005.
29. On Sunday 18 December, a further entry in the clinical record referred to a
review that morning. The notes continued:
“Claims he heard women singing last night - that unsettled him. Found
to be a little paranoid this morning – refused to take his medication.
Was eventually convinced to take his Librium.”
30. A lengthy entry on a care plan/pathway continuation sheet also dated 18
December states:
“Appeared confused and deluded at beginning of duty today thinking
people were drilling into his cell from adjacent cells and that a woman
was singing in his cell… Seen by MO (medical officer) mid-morning
and was less confused. Medication changed… Staff to monitor for any
disorganised behaviour/ paranoia / hallucinations.”
31. The man had initially been located in cell HA1-5 which is on the ground floor
in the inpatient section of the prison’s healthcare centre. At 11.00 pm on the
evening of 18 December, a Nurse recorded in the clinical record that the man
had been relocated to cell H1-23 after smashing all the furniture in cell HA1-5
and setting fire to his bedding. The man told staff he was about to be
murdered and that they needed to send for the police and the doctor. He
refused to take his chlordiazepoxide “as it is poison.” One of the prison
doctors was contacted and expressed concerns that the man might fit due to
his alcohol detoxification. He was “to be on constant obvs (observation) in
camera cell”. (Some of the cells in the inpatients unit have camera cover with
pictures being transmitted to a screen in the nurses’ office.)
32. Cell H1-23 is a camera cell but the man was not put on constant observations
as Holme House does not have a policy for constant observation.
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I recommend that the Governor should consider whether a policy on constant
observations, especially in camera cells, should be drawn up.
33. Two other entries were made by a nurse in the clinical record during the early
hours of Monday 19 December. The entry at 2.00 am notes that the man:
“Continues to shout, scream and bang. Cell flooded with water – same
turned off by Orderly Officer. Constant use of cell bell, but does not
want anything.”
34. A further entry at 3.10 am observed that the constant banging and shouting
was continuing. The man was now shouting that he had been murdered by
“four security officers, three nurses, a journalist and Santa Claus.” His
mattress looked as though it had been ripped in half.
35. On 21 December, entries in the man’s prison record (F2052A, record of
events booklet) state that he was lying on the cell floor behind his cell door.
He had excrement all over his lower body and excrement could be seen on
the walls and table. The man did not respond when staff spoke to him but he
was moving around the floor, “spreading his bedding about.” At 11.00 am that
morning, he was moved to cell number 1 after having a bath.
36. The next entry in the record of events booklet, also known by the staff as the
history sheet, was made by an Operational Support Grade (OSG) on 23
December. She wrote:
“A settled day, polite to staff but remains paranoid thinking someone
can get into his cell to abduct him. Have assured him this cannot
happen.”
37. On the morning of 24 December yet another cell change took place, with the
man being moved to H1-5, the camera cell he occupied when he first arrived
at Holme House. The entry in his clinical record states that he was relocated
after smashing a table in his cell overnight. He walked to the new cell without
any difficulty or problems and accepted his morning medication, again without
any problems. At 10.00 am on 24 December he was seen in the camera cell
by the medical officer who wrote “appears confused and complaining of
hallucinations. Has infected toe … to remain in safety cell.”
38. The OSG undertook a week of night duties in the healthcare centre beginning
on Monday 19 December and she was again on night duties on the inpatients
landing during the week beginning Monday 2 January 2006. On 19
December, when she first saw the man, she said he did not know where he
was or what was happening to him. She said she stood and talked to him for
quite a while, trying to explain to him how to work his taps, and she gave him
regular cups of water while he was awake. She explained that he did not go
to sleep but used to sit on his bed or lie on the floor. He had his mattress and
possessions on the floor. The OSG said she spent quite a lot of time with the
man that week “because I thought he was poorly off the alcohol” and she was
13
endeavouring to reassure him. She recalled that he warned her he would
blow the television up if she tried to enter his cell. By the end of the seven
nights the OSG thought that the man was coming round to realising that he
was in prison. She thought he understood that she and her nursing colleague
that week were keeping him safe and no one was going to get him. Her
recollection was that on seven nights out of seven he flooded his cell. She
would then call for the night orderly officer (the officer in charge of the prison
during the night) to come in order to turn off the water and electricity supply to
his cell. This could be done from a panel in the corridor just outside the man’s
door.
39. The OSG made some long entries in the hospital observation book about the
man’s behaviour on 24 and 25 December. At 11.00 pm on 24 December, the
OSG wrote:
“For approx 2 hours the man has had his TV on very loud. He has
water over the door and floor. He says if anyone goes in to kill him he
will blow the place up. He says that I am a witch and wouldn’t turn the
TV down until he had a note saying he will be safe until 7 am.”
40. An entry at 2.30 am on Christmas Day noted that the TV was back on loud
and the observation window in the cell door was covered in soggy bread. The
man started to throw water around his cell and the night orderly officer turned
off the water and electricity. The man was “playing the drums with broken
table legs.”
41. A further entry by the OSG on Christmas Day says:
“The man has had his water turned off as he started to flood the cell
again. He has handed over 3 cups which he was using to bang on
pipes. Has not slept at all and at approximately 4.00 am started to
bang on the door with his shoes claiming someone wants to kill him
and will break in his cell by drilling from next door.”
42. On 28 December, an Officer made an entry in the record of events booklet.
The officer wrote that he had interviewed the man as part of an attempt to
deliver an induction package. As he was located in the healthcare centre, the
man had missed out on the induction package routinely delivered to prisoners
who transfer directly to a residential houseblock. The officer declared he was
happy with the man’s general well-being but:
“Could not really make any progress re induction package due to
apparent mental health issues and delusional behaviour.”
43. Again on 28 December, the following entry was made in the care plan/
pathway continuation sheet:
“Confused at tea-time, put his tea in the sink. Praying to a cross he
made on the floor. Convinced the staff are going to hurt him,
reassured and he stated thank you for helping and talking to him.
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Denied any thoughts of self harm, remains on frequent/irregular
observations.”
44. On 29 December the clinical nurse manager at Holme House, contacted the
man’s GP in Hartlepool by telephone. The clinical nurse manager made a
lengthy entry in the clinical record at 9.00 am:
“GP contacted today regarding the man’s recent strange behaviour.
Explained how he appeared to be quite lucid but then behaviour would
change where he became rude and abusive. I also informed him that
he had undergone an alcohol detox regime. GP explained to me that
this was normal behaviour for the man to use any means to manipulate
to get what he wants. States he can be very charming when things
were going his way. The man was prescribed Temazepam by his GP
but it was suspected that he was selling them. I explained that we
were concerned that there could have been something underlying but
GP assured me that this was the man’s normal behaviour.”
45. In interview the clinical nurse manager said she had been a Registered
Mental Nurse (RMN) for 30 years and had worked at Holme House for 12
years. She had recently completed a forensic mental health degree at the
University of Teesside. Her work at the prison was mainly with patients who
had mental health and substance misuse problems. Her concern about the
man was triggered because:
‘’He’d gone through the detox, seemed as if he was doing fine, really
well, then all of a sudden he’d start displaying signs as if he was having
DTs again.’’
46. Healthcare colleagues had reported to her that the man seemed to be in
(alcohol) withdrawal again. She was surprised because ‘’ you don’t normally
come out of withdrawal and then go back in it.’’ She observed the man
carefully and on the basis of that close observation decided to phone his GP.
47. When the GP told the clinical nurse manager that the man’s behaviour was
‘’normal’’ she decided to find out if there was any underlying organic reason
for his abrupt behaviour changes. She instructed her colleagues to take blood
samples so that Liver Function Tests could be conducted at North Tees
Hospital. The clinical nurse manager wanted to know if the man had liver
damage and wondered if he had an infection causing all his confusion. A Full
Blood Count would establish whether the man was anaemic and fasting blood
sugar would indicate whether he had diabetes. (Raised or low blood sugar
levels, according to the clinical nurse manager, could have caused his
confusion.)
48. A note in the care plan sheet for the same date stated that the man would be
transferred to a residential houseblock the following day.
49. On Friday 30 December, an entry in the clinical record stated:
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“The man’s GP says he is faking his condition. To stay in HC
(healthcare centre) over weekend – transferred to HB (houseblock) on
Tuesday.”
50. A more detailed account of the clinical response to the man on 30 December
is set out on the care plan sheet. There a nurse made an untimed entry on 30
December:
“Seen by MO and nursing staff. Continues to present as confused.
Quite agitated and confrontational when challenged re-confusion.
Remains in camera cell on frequent and regular observations. His
Doctor feels that sending him to the houseblock would be a problem
over the weekend/bank holiday period – due to his behaviour he would
return very quickly to healthcare. He has been told he will be going to
the houseblock first thing Tuesday 3 January.”
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The man’s location in the segregation unit on 1 and 2 January
51. The man did indeed move to Houseblock 3 on 3 January 2006 but before he
did so he was held in the segregation unit on 1 and 2 January. Through the
night of 31 December to 1 January, the man was again very noisy and
disruptive and there were fears that he would use violence against staff. A
Nurse’s note in the care sheet about the nightshift is untimed but it is likely
that she wrote her account around breakfast time on New Year’s Day. She
observed:
“Shouting his name, address and prison number. He is aware that he
is in prison, and stated that it was New Year’s Day. He has covered
his face in faeces, and has made a weapon by placing his belongings
in his pillowcase which he is swinging towards the staff when
approached. He also has what looks like a crushed Marvel tin which
he is using to try and hit staff on the hands when hatch is opened. He
has upset all the other patients in healthcare with his incessant
shouting and banging.”
52. In her account in the record of events booklet, the Nurse added that the
orderly officer (the officer in charge of the operational running of the prison
during the day) was aware of the situation. In her entry in the hospital
observation book, she also indicated that the man was hiding his pillowcase,
with personal belongings inside, down the side of his toilet.
53. At approximately 8.30 am on the morning of 1 January, force was used to
transfer the man from his hospital cell to the segregation unit. When
authorised force is used, as in this particular movement, the staff involved are
required to complete use of force forms. Five staff in total were involved in
the use of force and each of these men completed the necessary statement.
54. The staff team was led by a Senior Officer (SO) from the security department
at Holme House. In his statement on 1 January, the SO wrote that on the
instructions of the orderly officer he attended the hospital and spoke to the
man. He was flooding his cell and blocking his toilet and hand basin. He had
a pillowcase in his hand with unknown items inside. The works department
turned the water supply off and SO Dempsey then spoke to the man, who
refused to comply with orders he was given. The SO’s statement continues:
“For his and staff safety he was removed and relocated to cell SA1-27.
He was seen by the healthcare and reported no injuries. No injuries
were sustained by any staff.”
55. During the man’s removal to the segregation unit, control and restraint (C and
R) techniques were used. These are techniques, approved by the Prison
Service, which staff are permitted to use in carefully limited circumstances
where a prisoner has to be restrained or transferred from one location to
another. During the man’s removal, officers used approved techniques to
control his head and each arm. An Officer wrote in his statement that he was
part of the team involved in the man’s planned removal. He said the man had
17
to be removed from cell HA1-5 due to the fact that he had flooded his cell,
covered himself in excrement and was holding a pillowcase with unknown
items inside and threatening to assault any member of staff who entered the
cell. The officer took charge of the man’s head and observed that the man
“was at times non-compliant and a full relocation was required.”
56. A Staff Nurse observed the planned move to the segregation unit and
afterwards duly completed form 213 entitled Report of Injury to Inmate. At
section 2b of the form the staff nurse reported that the man sustained no
serious injuries during his planned removal from healthcare to the segregation
unit using C and R methods. At section 3 of the form the medical officer wrote
that no injuries were reported or seen when the man was examined at 9.30
am on 1 January.
57. When the man arrived at the segregation unit he was located in special cell
SA1-27. A special cell is a cell in the segregation unit from which the usual
items of furniture have been removed.
58. The man was the first prisoner at Holme House to be located in a special cell
in 2006. The register of the use of special accommodation and mechanical
restraints at Holme House indicates that they were deployed on just 15
occasions throughout the whole of 2005.
59. Form 2323, the form used when a prisoner is located in a special cell, shows
that the man was located in cell SA1-27 at 8.30 am and removed from that
cell at 2.35 pm on the same day. At 9.30 am the medical officer signed to
confirm there was no medical reason why the man could not be located in the
special cell.
60. At 9.45 am, the Governor authorised the man’s location in the special cell.
The reason given for this decision was:
“Due to violent and abusive nature, normal clothing removed and to
remain in current location. Clothing wet due to smashing up of cell and
flooding of HA1-5.”
61. The Governor instructed that the man must be observed every 15 minutes
while he remained in SA1-27. On the reverse of the form, two Officers have
made entries at 15 minutes intervals in the records of actions and
observations. Many of these entries refer to the man pacing the cell and lying
or standing on the plinth on the cell floor. The last entry in the record of
actions and observations was made at 2.35 pm and comments on the man’s
removal from the special cell due to improved behaviour. He was given a
shower.
62. The computerised record of the man’s cell changes during his time at Holme
House is inaccurate because it states that he remained in cell SA1-27 until
11.00 am on 2 January. A more reliable source of information is the
segregation unit history sheet which comments at regular intervals on the 26
hours that the man spent in the unit. The history sheet shows that, at 2.30 pm
18
on 1 January, the man was given a shower then relocated to SA2-25 where
he was given cardboard furniture. The night patrol officer commenced his
duty at 7.30 pm on 1 January, and then made an entry at 1.00 am on the
morning of 2 January. At that time the man “pressed the cell bell, asked when
he could come out of his cell for association! Informed about seg routine.” At
3.00 am, the man pressed his cell bell again and asked the officer how the
radio worked in his cell. The man appeared to think that the air vent in the cell
window was a radio. In the morning the man had breakfast and a shower.
The last entry on the history sheet was made at 10.30 am. The man was
seen at that time by a Governor and a Doctor. The decision was taken that
he should return to the healthcare centre and the segregation history sheet
was closed.
63. A segregation safety algorithm must be completed by a registered nurse or a
doctor within two hours of a prisoner being placed in the segregation unit.
Part A of the algorithm appears to have been completed by a doctor. The
third question asks if the prisoner shows signs of being acutely unwell (for
example psychotic). The answer given was ‘yes’ and, confusingly, both yes
and no were ticked in response to the fourth question ‘Do you think that the
prisoner will be unable to cope with a period of segregation?’ The Governor
completed the form at 9.50 am and wrote that the man’s removal had been
planned due to a ‘smash up’ and attempted assault on staff. The Governor
decided that the man was suitable for segregation and he supplied the
necessary authorising signature.
64. On New Year’s Day, the man had been charged by the Staff Nurse with
intentionally endangering the health and safety of himself and others by
flooding, urinating and defecating in his cell at approximately 8.00 am the
previous morning. He appeared at adjudication on 2 January but no formal
consideration seems to have been given to his medical fitness for adjudication
as section 4 of the adjudication form (F256 record of hearing and
adjudication) is blank.
65. The man pleaded not guilty to the charge and said he had not urinated or
defecated on the floor though he had flooded the cell in an attempt to get out.
The record of hearing does not clearly indicate whether the man made his
points in response to the charge against him on 2 or 3 January nor does the
record show whether the Nurse, who made the allegation against the man,
was required to give evidence in person. The charge was found proved by a
Governor on 3 January, with the man’s punishment being stoppage of 50% of
his earnings for a period of five days and forfeiture of a number of privileges
for three days.
66. The man’s clinical record refers to him being seen in the segregation unit on 2
January by a doctor. The doctor wrote that the man answered the questions
coherently but then ‘wandered’ into a story about being captured by Scots and
how they imprisoned him. The doctor ordered that the man should be
observed for the present on the hospital wing. He noted that blood test
results, commissioned by the clinical nurse manager, were due back on the
19
following day. Information supplied to me by Holme House is that these blood
test results were never received.
20
The man’s time in Houseblock 3
67. On 3 January, a doctor declared that the man was fit for adjudication that
morning and also asked for an assessment by the ‘dementia team’ to be
arranged. There is no signature by the medical officer at section 4 of the
record of hearing and there is no written record of any communication
between the medical officer and the adjudicating officer. An entry by a nurse
on the care plan sheet reads:
“Adjudication this morning, MO “fitted” on return may go to houseblock
same done.”
68. In a letter dated 6 June 2006 the doctor explained that he did not see the man
during the two weeks between 18 December 2005 and 3 January 2006. On
the latter date, he had a general discussion with the nurses and ‘’I felt he was
fit for adjudication.’’ It has not been possible to interview the doctor as he no
longer works at Holme House.
69. The computerised record of cell moves indicates that the man spent two and
a half hours in cell HA1-2 (in the healthcare centre) around lunchtime on 2
January before being transferred to cell HA1-5 for the next 24 hours. HA1-5
is the camera cell from which the man had been forcibly removed on the
morning of 1 January. The computer record shows that he transferred from
the healthcare centre to Houseblock 3 at 2.50 pm on 3 January.
70. As soon as the man arrived on Houseblock 3 he was located in cell B3-2 by
the regular landing officer. The regular landing officer had contact with the
man on a number of occasions on both 3 and 6 January and my investigators
interviewed him at some length. The regular landing officer explained that he
has been a prison officer for ten years and has been a landing officer on B
wing in Houseblock 3 for the last year. He was the first point of contact the
man had when he left the hospital and came to the houseblock. The regular
landing officer explained what the wing routine would be but he felt the man
“seemed a little bit vague as if he didn’t really understand what I was saying.”
71. Once the man was located in his cell, the regular landing officer recollected
that he constantly rang his cell bell. The man was unlocked for the teatime
meal by another Officer and the other officer made an entry about this in the
man’s record of events booklet. He said:
“I unlocked this inmate for his teatime meal. He was a bit agitated
saying people were in the exercise yard wanting to kill him, shouting at
him and that he did not want to come out for his meal.”
72. The regular landing officer said that, after the staff had served the teatime
meal, the man constantly rang his cell bell “asking for strange, trivial things.”
Around 6.00 pm, the regular landing officer made an entry in the history
booklet which reads:
21
“Continued bizarre behaviour from this man, I answered his cell bell
and he asked me to help him because “them on the yard” were “going
to get him” (it is 6.00 pm and there is nobody on the yard) warned
verbally about misuse of cell bells. I have contacted healthcare and
spoken to the clinical nurse manager about the man. She told me that
he has (emphasis in original) been referred to mental health services
already. His behaviour needs to be monitored and recorded.”
73. In interview, the regular landing officer explained that although he is not
medically trained he had concerns about the man’s mental health. He was
asked by my investigator how many times in a ten year career he had been
sufficiently concerned about a new prisoner to ring up healthcare. He
estimated he had done this just six times in his career to date. He was asked
what made him sufficiently concerned to ring healthcare and replied:
“It was his behaviour, it was bizarre, the things he was saying didn’t
make sense. Obviously I am his landing officer so I was responsible
for him and that was the reason that I phoned the hospital.”
74. The regular landing officer recalled that the clinical nurse manager told him
that the man had already been referred to the mental health services and his
behaviour needed to be monitored and recorded.
75. When interviewed in February 2007, the clinical nurse manager was asked if
she could recall why she told the regular landing officer that the man had
been referred to mental health services. She agreed that she had not been
looking at a document or a piece of paper which led her to say that the man
had already been referred. The clinical nurse manager said:
‘’There was something in my head that said he’d been referred. I didn’t
have it in front of us, no.’’
76. Earlier in the interview, the clinical nurse manager said she assumed that the
man had been referred to her mental health colleagues. She added:
‘’For somebody with behaviour like that, I’d already seen him and done
everything else, rightly or wrongly I’ve maybe assumed that it’s been
done. But that is the way it should have happened.’’
77. In an email exchange with my investigator in July 2006, the clinical nurse
manager wrote that on 3 January she was informed that the man had been
referred already by the staff that were on duty. She was later informed that
another Nurse was the referrer but it has not been possible to arrange an
interview as the other Nurse no longer works at the prison nor indeed for
North Tees PCT.
78. The regular landing officer went off duty at 7.45 pm on 3 January and his next
duty on B wing was not until the morning of 6 January. In the intervening
period, several different staff made entries about the man’s bizarre and
disruptive behaviour in the Houseblock 3 observations book, the record of
22
events booklet and a history sheet headed ‘Induction/Resettlement interview’
sheet.
79. The next entry in the record of events booklet was made by the OSG on 4
January 2006. The regular landing officer explained that the OSG was a night
patrol officer who came on duty at 8.45 pm on 3 January. His entry reads:
“This prisoner continues with his bizarre behaviour, constantly on his
cell bell, banging his cell door, shouting at the top of his voice “stop
them in the yard, they are going to kill me”. A very disruptive prisoner,
tried to speak to the man but he refused to speak.”
80. A further entry made in the record of events booklet around breakfast time on
4 January states:
“This prisoner is very disruptive to the wing routine. He has kept
everyone up during nights and has received various threats to his
safety. In my opinion he is not fit to be on any normal (emphasis in
original) location within the prison.”
81. When the SO came on duty on the morning of 4 January, he spoke to the
man about his behaviour during the night. The man said he could not
remember anything, but the SO warned him that if his disruptive behaviour
continued he would be segregated. Later the same day, the man was again
charged with an offence against the Prison Rules. In his report about the
alleged offence, an Officer wrote that, at 8.00 am on 4 January, he recovered
a torn bed sheet from the man’s cell. It had been made into a ‘line’ which was
attached to the window bars of the cell. Such ‘lines’ are often used by
prisoners to transfer items to and from their cells during the times of the day
when they are locked in. On 5 January, the hearing of the charge was
adjourned until the following day because the man entered a plea of not guilty
and the Officer was not on duty to give his evidence in person.
82. The single entry for 5 January in the man’s history sheet was made by an
Officer who said that, during the teatime patrol; the man had pressed his cell
bell numerous times, often making bizarre statements. He appeared to the
officer to be unaware of where he was and what he was doing.
83. The regular landing officer returned to duty on the wing on the morning of 6
January. The first entry in the man’s history sheet that day was made by an
Officer at 7.40 am. In interview, the regular landing officer explained that
prisoners collect their medication first thing in the morning before breakfast is
served. The Officer’s entry reads:
“Unlocked the man and told him to go down to the two’s for his
treatment. He kept repeating “You are releasing me? I don’t believe
it!” I tried to get him to go for his treatment but he kept talking and
making no sense at all. He appears to be very mixed up and
confused.”
23
84. The regular landing officer had read the history sheet and wing observation
book and was aware that entries about the man had continued in the same
vein as the written remarks he made on the evening of 3 January. On 4
January,
85. The same officer who placed the man on report for possessing a line, wrote a
Security Information Report (SIR). The SIR said that, when the officer was
unlocking B wing at breakfast time on 4 January, various prisoners made
veiled threats to harm the man due to his erratic behaviour during the
previous night. According to the other prisoners, the man had banged his
door and shouted out throughout the night.
86. In similar fashion, on the morning of 6 January a number of prisoners on B
wing told the regular landing officer that they were ‘sick’ of the man ‘ranting
and raving’ throughout the night. The regular landing officer wrote in the
observation book and history sheet at 8.35 am of his fear that there might be
repercussions. He also submitted a SIR about his fears but this SIR could not
be traced while my investigators were at Holme House.
87. The regular landing officer explained that SIRs are sent to the prison’s
security department and are used to report any incident that a member of staff
feels could have security implications. The regular landing officer’s fear was
that there would be an assault on the man by other prisoners. Five or six
prisoners, all from the same landing as the man or the cells directly beneath
him, went to the officer and said that he needed to get the man off the wing
because he had kept them up all night.
88. The regular landing officer went to the Senior Officer (SO) with his concerns.
The SO wrote in the observation book that he was confronted by numerous
prisoners during breakfast. They complained about the man. The SO knew
that the man was on report that morning. He said he would suggest at the
morning meeting that “he remains in the segregation unit or be located in the
hospital. He is clearly not fit for normal location.” In the history sheet Tte SO
made a second entry stating that he had spoken to the man and told him that
his behaviour was not acceptable for normal location. The SO wrote that the
man “needs to be assessed by a psychiatrist or that type of person, ASAP.”
The regular landing officer sat in during the meeting between the senior officer
and the man. He was asked by my investigators how the man came across at
that time. The regular landing officer’s assessment was that the man did not
seem to know where he was, “he thought we were going to release him, just
bizarre, confused behaviour.”
24
The man’s mental health assessment on 6 January
89. The regular landing officer and another officer escorted the man from
Houseblock 3 to the segregation unit for his resumed adjudication. The
regular landing officer and the Senior Officer had agreed that the regular
landing officer should check with the mental health in-reach team (MHIT) that
the man had been referred to them. The regular landing officer rang his
colleagues in mental health from the houseblock phone. He then escorted the
man to the segregation unit and immediately afterwards visited the mental
health team in the healthcare centre.
90. The regular landing officer confirmed he was aware that any member of staff
at Holme House who is concerned about any prisoner can complete a mental
health referral form.
91. There are two Registered Mental Health Nurses (RMNs) working in Holme
House. The first RMN remembered receiving a phone call from the regular
landing officer just after 9.00 am on 6 January asking if she had received a
referral for the man. She said she would check her records. When she did
so, she established that a referral for the man had definitely not been received
before that time. She recollected that the regular landing officer was adamant
that he wanted to know if the man had been referred previously. Within about
ten minutes, before she could ring the regular landing officer back on the
houseblock, he appeared in her office. He told the nurse that he was
extremely concerned about the man and that he was displaying bizarre
behaviour. The first RMN told him that they had not received a referral form.
She gave him a blank form and he sat down and filled it in immediately.
92. The regular landing officer wrote that the reason for referral was “needs to be
assessed because of his continued bizarre/paranoid behaviour.” The next
question asked him to indicate areas of concern, for example, unusual or
bizarre behaviour, high risk of suicide or risk of self neglect. The regular
landing officer described the man’s behaviour whilst located on Houseblock 3.
93. The two RMNs said in interview that they decided they would assess the man
immediately in the segregation unit. Normal procedure at Holme House was
that allocation meetings were held on Monday, Wednesday and Friday
lunchtimes and new cases would be allocated, if appropriate, at those
meetings. The two women decided that, given the circumstances and the
level of concern that the regular landing officer was displaying, they did not
wish to wait until the allocation meeting later that day with the danger that the
man would not be seen until after the weekend. They went to the segregation
unit and saw the man at 9.50 am, before his adjudication was resumed. The
two nurses confirmed that the man had not been drawn to their attention
either by healthcare colleagues or by any prison officers prior to the morning
of 6 January.
94. During the assessment of the man, which took approximately an hour to
complete, the first RMN asked most of the questions and the second RMN
recorded the necessary information on a screening assessment document.
25
She wrote that the reason for referral was the man’s bizarre behaviour on the
houseblock. He said he believed he was going to be killed and was spending
all night shouting from his cell and disturbing other prisoners. The man told
the nurses that he had no previous contact with the mental health services.
He said there was no family history of psychiatric problems. He told them he
had been on a detoxification programme for his alcohol abuse since coming
into custody. He said he was a heavy drinker, drinking two and a half bottles
of cider a day and having his first drink when he got up in the morning.
95. The second RMN noted that the man was dressed in his prison clothes. She
said he sat on the bed in his cell in the segregation unit and was quite
relaxed. He maintained quite good eye contact with both nurses and his
speech was fairly normal in weight and tone. There was no evidence of
distress while he talked. There was no evidence of any depression or
depressive type symptoms. Nor was there any evidence of pressure of
speech or elation in his moods.
96. The man described some paranoid symptoms. He believed that people were
out to kill him and said he knew this through hearing it on the prison tannoy
system. The man stated he had met a gangster two months previously and,
because he would not do as the gangster wanted, there was a contract out on
him. The nurses asked the man if they could see him again in a week or two
but he said he would be dead because the gangster would have killed him.
The nurses thought he was quite frightened about all of this. At one point he
told them that he had flooded his cell because he wanted people to come and
help him.
97. The man described visual hallucinations and spoke of having seen women
dancing on the walls outside his cell. My investigators asked the nurses
about the man’s tone of voice as he described these frightening
hallucinations. They replied that the man remained relaxed throughout. His
voice was not raised and he did not become distressed in any way.
98. The nurses asked the man about thoughts of suicide or harming himself. The
second RMN said “he adamantly denied that he had any of those thoughts or
any plans or anything like that. He also denied any history of having ever
tried to harm himself or kill himself.” He talked about having paper in his ears
which he said “was to cut out the noise of the Irish singing which has been
going on for three days.” The nurses confirmed that the man took toilet roll
paper out of his ears, showed it to them and then put it straight back in his
ears again.
99. When talking about his family, the man said that his wife had died 20 years
previously after 30 years of marriage. He said he had worked as a crane
driver but had stopped when his wife died because he did not feel he could
cope with working. He said his second son was a prison officer but he was
not really sure where he lived. He thought it was in the Kent area.
26
100. The nurses wrote that the man’s concentration seemed quite poor at times
and he was confused about his current location because he had moved
several times within the prison.
101. At the end of the document the nurses wrote a summary of their assessment.
They referred to evidence of confusion and to auditory and visual
hallucinations although they added that the presentation was inconsistent.
They felt that the man needed further assessment. They agreed that they
would refer him to see a psychiatrist as soon as possible. They expected that
he would be seen by a visiting forensic psychiatrist, on the afternoon of the
following Monday, 9 January 2006.
102. The last part of the action plan that the nurses agreed after seeing the man
was that they should discuss with the prison medical officer whether he
should be transferred to the healthcare centre. The first RMN explained that
their joint view was that the number of moves which the man had already
made might have contributed to his confusion and disorientation. They were
unsure about whether he was suffering from psychosis or not and they felt the
healthcare centre was the best place for him because there is usually a
Registered Mental Nurse (RMN) on duty there. They had decided he should
be assessed by the psychiatrist the following Monday and hoped that even
more information would be obtained during the intervening weekend. The first
RMN told my investigators that, by observing and communicating with a
patient, staff hoped to obtain “a much bigger, clearer picture.”
103. In interview, the first RMN explained that she was a gateway worker at Holme
House, which was a role entirely new to the Prison Service. A pilot scheme
had been introduced at Holme House on 30 August 2005, just over four
months before the man’s death. The first RMN explained that normal practice
in the community is for a gateway worker to be based within a GP practice. If
a GP saw a patient who was displaying any mental health problems he or she
would refer the patient to the gateway service. The gateway worker sees the
patient and might then take that person onto their own caseload or refer the
patient to the most relevant service. They were concerned that the man had
not been drawn to their attention before 6 January, either by healthcare
colleagues or by any prison officers.
104. In interview, the first RMN emphasised that referrals to the mental health team
can be made by anyone at all. They can be made by healthcare
professionals or prison staff or may even take the form of self referrals. The
first RMN said that the people they see may not have been previously known
by psychiatric services and they did not have to be on a care programme
approach (CPA) in the outside community. There was no indication, for
example, that the man had had any previous contact with community
psychiatric services.
105. The first RMN told my investigators that there were 17 referrals to mental
health services in the three months before the pilot programme began. In the
first three months of the new programme, there had been an 11 fold increase
in the number of referrals to 186. The first RMN was eager to deliver mental
health training at Holme House and had already done so at HMP Durham.
27
My investigators asked her what sort of education was required and she
replied:
“Right across the board, through healthcare, the officers, probation
[need to know] about what is mental health, what is mental illness,
what’s an appropriate referral, what isn’t an appropriate referral …
there is a big need to drive that forward.”
106. The nurses in the mental health team told my investigators that they wanted
the man to be observed in the healthcare centre during the weekend after
they had assessed him on 6 January. They said that they never worked in the
inpatient part of the healthcare centre and that they did not attend handover
meetings between shifts of nurses in the healthcare centre.
107. After the man had been seen by the RMNs, the Governor completed the
adjudication started by one of his colleagues the previous day. The man
pleaded guilty to the charge against him and told the Governor that he had
made the line by tearing his bed sheets. When asked for what purpose, he
replied that it was to try and get some food. The punishment selected by the
Governor was a caution, the lowest possible punishment he could administer.
There is no indication at section 4 of the initial record of hearing that the
question of the man’s fitness for adjudication was formally considered on
either 5 or 6 January.
108. A lengthy but untimed entry was made in the clinical record on 6 January by
the Doctor. The previous entry in the record is timed at 1.50 pm and was
made by the second RMN so my assumption is that the doctor’s entry was
made some time during the afternoon of 6 January. The entry states that the
doctor saw the man in the segregation unit after he had caused disruption on
the houseblock again. Erratic behaviour was observed and the man kept
making reference to “the Gangster”, who wanted to kill him. He said he felt as
though the gangster would come into the prison to kill him. He also spoke of
hearing music and seeing women dancing. The doctor recorded that the man
was currently orientated to time, person and place. He recorded that the man
should remain in the healthcare centre over the weekend and be seen by the
other doctor on Monday 9 January.
109. The prison’s computer record on the Inmate Information System (IIS) shows
that the man was located in cell HA1-5 for the fourth and last time at 12.03 pm
on the afternoon of 6 January. The man remained in that cell until his death
the following morning.
28
The night and early morning of 6 and 7 January
110. There are no recorded entries documenting the man’s behaviour during the
afternoon and early evening of 6 January. During the night, two members of
staff were on duty in the healthcare centre. They were an RMN and an OSG.
111. The OSG recalled that on the night of 6 January the man’s behaviour was not
as challenging as it had been previously. He was, however, still walking up
and down, shouting out of the window because he thought someone was
drilling in the cell next door to him.
112. The RMN made an entry in the man’s clinical record at 11.15 pm. She wrote
that he had flooded his cell using a cup to pour water over himself. She went
to his cell and asked him to stop throwing water over himself as he was
flooding the cell. She said he swore at her and told her that he was cooling
himself down. She phoned the night orderly officer and asked him to turn the
man’s water supply off. The man was in a cell with camera cover and the
nurse noted that, while he was being observed on camera, the man began to
use his dirty clothing to dry the water up. She noted that “he then tried to
obtain water from the toilet and seemed to be examining this for some time.
Observation maintained.”
113. The RMN recalled that the night orderly officer, an SO came at about midnight
to turn off the water supply. The OSG remembered that at the time the man
had put his jumper on the radiator so that it would not get wet. He was
standing at the sink in his boxer shorts pouring cups and cups of water over
himself. Once the water had been turned off the man still did not settle down.
The OSG said he spent some time kicking the water around his cell but then
began cleaning the walls
“which he often did, after he’d done something in his cell, in the
morning it would be spick and span again, there’d be no water on the
floor anyway. He mopped up the water using his clothes.”
114. The man was in a camera cell but he was not on an open Assessment, Care
in Custody and Teamwork document (ACCT - the Prison Service system of
monitoring and supporting prisoners thought to be at risk of suicide or self
harm) because he was not perceived as being at risk of self harm. The RMN
told my investigators there were two men on ACCT documents during the
night and this meant they were subject to enhanced observations, requiring
staff to attend their cell and physically interact with them. As far as the man
was concerned she had been given no instructions, either on the board in the
nurse’s office or in the handover book, about how frequently he was to be
observed during the night. The nurse’s office, where the two women were
based, was in a corridor at right angles to the cells where the man and other
inpatients were held so they could not see directly into his cell from the office.
The cameras in the man’s cell, and those containing the men on enhanced
observation, were supposed to transmit pictures to the monitor screen in the
nurse’s office but both women drew attention to the fact that the quality of the
CCTV system was poor and sometimes it failed completely.
29
115. In interview, the RMN said that the man took some time to settle after his
water was turned off. She looked through the hatch in his cell door to begin
with and then she and the OSG watched his behaviour on the camera screen.
Her memory was that between 1.30 and 1.45 am he was lying on the base of
his bed. He had thrown his mattress onto the floor earlier in the morning. My
investigators asked the RMN if it was easy or difficult at this time to see what
the man was doing inside the cell. She replied that it was easy to see what
was going on when he was actively doing things. She said that when he was
lying on his bed it was not possible to identify by looking at the screen
whether he was breathing or not.
116. The two women first became aware that something was seriously wrong with
the man at almost exactly 5.00 am. In her statement to the Governor, the
OSG wrote that, at 5.00 am, she was changing the monitors for the camera
cells because she could not get a clear picture when HA1-5 came onto the big
television. She noticed that the man was “a funny colour”. In her interview
the RMN explained that
“because there was a bit of camera failure she [the OSG] was trying to
get the imaging right because of the men they had on observations.”
117. Unusually, a large colour picture of the man’s cell came up on the screen,
compared to the poor quality black and white split screen images on which
they normally had to rely. Both women agreed that the man did not look well
so the RMN went to the man’s cell. She looked through the observation panel
then shouted to OSG to get help. The RMN ran to the clinic room to fetch the
emergency bag.
118. The OSG went towards the man’s cell, calling on her radio for Oscar 1.
(Oscar 1 is the radio call sign for the night orderly officer.) He and his assist,
were about to leave their office in order to remove the double locks which
provide additional security in a prison during the night time period. Their
office is adjacent to the healthcare centre and therefore the two men arrived
at the man’s cell within seconds of the alarm being raised. The night orderly
manager arrived so quickly that he used his own cell key to unlock the man’s
cell before the OSG was able to break the sealed packet in which she carried
a cell key for emergency use.
119. The assist said in his statement that, when he and the night orderly manager
entered the cell, they observed the man lying on his right side with a
sweatshirt forming a ligature tied to the top of his bedstead. The assist took
the ligature knife that the OSG was carrying and, assisted by the night orderly
manager, cut the ligature around the man’s neck. The OSG had asked for an
ambulance over the radio at the same time as she summoned Oscar 1. She
recalled that the radio signal was not very good and, because she feared that
the control room might not have received her message, she ran to a
telephone to double check that an ambulance had been summoned.
30
120. The log kept by the control room at Holme House records the first radio
message at 5.05 am. At that time, call sign Hotel 1 (a healthcare centre call
sign) asked for Oscar 1 to attend the hospital immediately because there was
a ‘code blue’. (Code blue is a signal that a prisoner is hanging.) The next
entry in the control room log was at 5.06 am and recorded a request from
Hotel 1 for an ambulance. Two entries at 5.07 am indicate that an ambulance
was en route to the prison and that the prisoner in the cell was the man. At
5.17 am, the ambulance arrived at the prison and the crew made their way to
the healthcare centre.
121. At interview the OSG described the man when staff first went into his cell:
“The man was lying on the bed and the bed didn’t have a mattress on.
He was lying on his right-hand side with his shoulders raised up so you
couldn’t actually see his head, just the bulk of his body. His arms were
down by his side and he was like in the foetal position like he was
lying.”
122. The assist explained in interview that he had worked at Holme House for 13
years. For his first two years he was a nurse employed in the healthcare
centre. For the next nine years he worked as a healthcare officer then, for the
two years prior to the man’s death, he worked in the therapeutic community
located on Houseblock 5. The assist qualified as a Registered General Nurse
at Hartlepool in 1988. At the time of the man’s death, he retained his
professional nursing registration although he was then working as a prison
officer. When the assist, the night orderly manager and the RMN first entered
the cell the floor was wet. The assist went to the mattress store directly
across the corridor from the man’s cell and brought back a brand new
mattress. He put it down on the cell floor then he and his two colleagues lifted
the man onto the mattress. He said he felt for a pulse but could not find one.
He said that the man was obviously not breathing. The emergency equipment
that the RMN had brought to the cell earlier included an oxygen cylinder and
an Ambu-bag (the brand name of a bag which is placed over a patient’s face
and used to administer oxygen).
123. Once the man had been placed on the new mattress, the night orderly
manager said he realised immediately that he had blocked his airways with
putty. The night orderly manager said that the man had made some sort of
putty out of toilet roll and water and had then pushed it very hard up both
nostrils. The night orderly manager realised that staff would not get an airway
until the putty had been removed. He managed to do this although it was
quite deep in the man’s nostrils. Once the putty was removed the staff got
him into a position where they could tilt the man’s head back and open his
airway. The night orderly manager recalled that the assist started to give the
man oxygen with the bag. Almost immediately, he swapped with the RMN
who took over on the bag while the assist attempted cardio pulmonary
resuscitation (CPR).
124. The assist estimated that they carried on trying to resuscitate the man for ten
to 15 minutes until the ambulance crew arrived. The RMN was trained in first
31
aid at the time of the man’s death and, although the assist ’s first aid
qualification had expired, he said that he had administered CPR many times
in hospital and had also done it in the street a couple of times. My
investigators asked the assist if he was offered any relief once he had started
working on the chest compressions along with Nurse Fortune. The assist
replied that he and the nurse had got into a good working rhythm so that,
although the night orderly manager offered to take over the bagging, they
were able to keep going without a break until the paramedics arrived.
125. The control room log has an entry at 5.25 am recording information from the
night orderly manager that the man had died. The RMN recalls that when the
two paramedics arrived they entered the man’s cell and attached defibrillation
pads to him. They said that there was nothing else that could be done and at
that point efforts to revive the man ceased. The assist was of the opinion that
the man was probably already dead at the time when prison staff first entered
his cell just after 5.00 am. The ambulance was escorted from the main prison
gate to the healthcare centre by an Officer. Both the night orderly manager
and the officer had the foresight to unlock gates through which the ambulance
would have to pass in order to make a quick passage to the healthcare
centre.
126. The control room log indicates that a doctor was informed of the man’s death
at 5.48 am. The same log shows that he arrived at the prison at 6.17 am.
The doctor is a partner in a general medical practice in Middlesbrough and he
has also been a part-time medical officer at Holme House since 1992. He
saw no signs of life in the man and pronounced him dead at 6.35 am.
127. A post-mortem was conducted later on the morning of 7 January by one of the
Home Office pathologists for the North East of England. In the summary and
conclusions section of his report to the Coroner, the pathologist wrote that:
“The post-mortem examination has shown that the deceased had
significant enlargement of the heart and significant coronary artery
disease such that it could have brought about death at any time.
Although this condition could have accelerated death during an
asphyxial process due to pre-disposition of a fatal arrhythmia, there is
no indication that it did so in this case.”
128. In the pathologist’s opinion, death was due to hanging and he added that the
mode of death was asphyxia, brought about by pressure to the neck as a
result of a ligature.
32
Contact with the man’s family
(i) Contact between Holme House and the man’s partner
129. When the man arrived at Holme House on 16 December, he was asked a
number of personal questions which were recorded on the personal summary
sheet of his core prison record. He indicated at that time that he had been
living at an address in Hartlepool and that his partner lived at the same
address. On 16 December, the man had indicated that the person to be
notified in an emergency was his partner. No additional information had been
recorded about the man’s next of kin or other people who should be contacted
in an emergency.
130. During the weekend of 7 and 8 January, there were two Governor grades on
duty. The first Governor was in charge of the prison during the weekend and
the second Governor was the duty Governor on 7 January. The acting
Governor of the prison was a third Governor. She was not scheduled to be on
duty that weekend but came into the prison later in the morning in response to
the man’s death.
131. Holme House had two trained Family Liaison Officers but neither officer was
on duty during the weekend. The third Governor told the first Governor that, if
necessary, she would go to Hartlepool herself in order to break the news of
the man’s death to his partner. The first Governor managed to make contact
with a Principal Officer (PO) who was one of the FLOs. Although it was his
rest day, the FLO offered to come into the prison in order to see the man’s
family. The FLO duly attended the prison during the morning. In accordance
with the prison’s protocol with Cleveland Police, the FLO made arrangements
that he and the Governor would be escorted to the home address of the
man’s partner by the local police in Hartlepool. To their surprise it was clear
to them when they arrived at the man’s partner’s home that she and her family
were already aware of the death. It appeared they had found out from a
friend of the man’s victim. The third Governor was extremely concerned to
hear this and asked the Assistant Chief Constable of Cleveland Police, to
make some enquiries.
132. On 19 January, The Assistant Chief Constable telephoned the third Governor
with the results of his enquiries. Apparently the telephone call from the prison
to Hartlepool police requesting an escort to the family home was taken by an
officer who had been involved in the man’s case. This officer told the victim of
the offence. He visited the victim’s flat, where it seems that a relative of the
man was also present. This relative then informed the man’s partner’s family.
The Assistant Chief Constable was most apologetic to the third Governor
about this train of events. He informed her that the officer concerned had
been advised about his actions, as had the officer’s superiors, and that a
senior police officer would be visiting the family to apologise formally.
33
(ii) Contact between Holme House and the man’s son
133. On Tuesday 10 January 2006, three days after his father’s death, the man’s
son wrote to the Director General of the Prison Service. He said that he
wished to lodge a formal complaint against the first Governor of HMP Holme
House. On 13 January, the Director General forwarded a copy of the man’s
letter to me, explaining in his covering letter to the man that I normally deal
with the way in which contact with relatives after a death is handled.
134. In his letter of 10 January, the man explained that he had received a
telephone call on 17 December from an aunt in which she informed him that
his father had been found guilty of rape and sentenced to eight years in
prison. The man said he made vigorous efforts to establish whether the
information was true and to locate his father. He made telephone calls to
Holme House but the phone was never answered. On 18 December, he
contacted the Prisoner Location Service and gave them a number of factual
details about his father. On 21 December, he received a reply stating that
they could trace no one in the prison system with those details.
135. By 7 January 2006, the man’s son had still not received formal confirmation
about his father’s status or where he was being held. At approximately 3.45
pm on the afternoon of 7 January, the man’s aunt rang again and broke the
news that his father had taken his own life at Holme House.
136. The man’s son was himself a Senior Officer at a prison near London, although
he was not working at the time of his father’s death. He immediately rang
Holme House and asked to speak to the orderly officer about the death of the
man. At Holme House, the orderly officer is a Principal Officer (PO) whose
task is to ensure the smooth daily running of the prison and to respond to
incidents and emergencies. The orderly officer asked for the man’s phone
number so that the duty Governor could call him back.
137. According to the man’s letter to the Director General, the first Governor called
back approximately five minutes later. The first Governor told the man’s son
that there was no mention of him as next of kin. This upset the man’s son but
he accepted that his father might not have put him down as next of kin
because of the sensitivity of the man’s son’s occupation. The man’s son
asked the first Governor what Holme House was going to do with the body but
the first Governor would not say. The man’s son said he put down the
telephone until he had gathered his thoughts. The man’s son alleged that the
first Governor did not treat him with decency and respect and further alleged
that the first Governor discriminated against him “because he understood
himself to be speaking to the son of a rapist.” During the rest of the weekend
the man’s son received no contact from anyone in the Prison Service.
138. The man also wrote that, at 10.00 am on Monday 9 January, he telephoned
the Governor’s secretary at Holme House asking that someone inform him of
the location of his father’s body. Approximately five minutes later, the first
Governor phoned him. There was some discussion between the two men as
to whether their previous conversation had been on the Saturday or Sunday
34
of the weekend. The first Governor allegedly told the man’s son that he did
not like his attitude and the man’s son in turn said that he did not like the first
Governor’s “because he demonstrated no respect for me, for my situation or
my father’s death. I put the phone down.”
139. Immediately afterwards, the man’s son again rang the Governor’s secretary
who put him through to the third Governor. (As noted, at the time of the man’s
death the third Governor was the acting Governor at Holme House.) The third
Governor spoke to the man in a manner he described as clear, calm and
courteous. He felt she demonstrated understanding of his very difficult and
traumatic situation. She offered him the services of a Family Liaison Officer
but the man declined the offer as his home is so far away from Holme House.
140. The third Governor herself carried out an investigation into the complaints
made by the man’s son to the Director General. For the purposes of her
inquiry, the third Governor interviewed the first Governor, the second
Governor and the orderly officer on the afternoon of the man’s death. I am
very grateful to the third Governor for making all the relevant papers available
to me. At the close of her enquiry, the third Governor made two
recommendations. The first was:
“The first Governor has been advised that his comment “I don’t care for
your attitude” was inappropriate. He has accepted that advice. I do
not recommend any further action in relation to this.”
141. The third Governor also recommended that the man should receive a further
letter of apology from the new Governor. The new Governor wrote a detailed
letter of apology to the man’s son on 14 February, with copies going to the
Director General and the Prison Service’s North East Area Manager.
142. I am pleased that the Prison Service mounted its own investigation so rapidly
into the complaints made by the man’s son. I have, of course, made my own
independent enquiries into the serious issues raised by the man’s son. As
The Director General said in his immediate response, I pay very close
attention to the way in which contact with relatives is handled in the immediate
aftermath of a death in prison. At the beginning of February, two of my
colleagues, an investigator and an FLO, visited the man’s son and his wife in
their home near London where the man’s son explained the matters that were
troubling him. He asked my colleagues why no one from Holme House had
called him back after his initial conversation with the first Governor on the
afternoon of 7 January. He also asked why he had to wait until Monday 9
January before someone from the prison where he was employed came to
speak to him. My investigators then carried out lengthy interviews with both
the first Governor and the Head of Residence at the prison where the man’s
son worked, in order to establish what had taken place in the first 72 hours
after the man’s death.
143. On 9 January, the first Governor wrote a memorandum to the third Governor
detailing his contacts with the man’s son. In his memo, he explained that he
was given a telephone number by a PO. After his briefing from the PO, the
35
first Governor said he reassessed the information available in the man’s core
record. He said he discovered, in a report completed by the mental health in-
reach team, a reference to a son of the man possibly living in the Kent area
and employed within the Prison Service.
144. The first Governor then rang the man’s son and endeavoured to explain to
him that he needed to verify his identity before he could release any details
about the death that morning. According to the first Governor, the man’s son
put the phone down before he could establish any facts.
145. In an effort to ascertain if the man’s son was the son of the man who had
died, the first Governor compared the telephone number given to him by the
PO against the list of people sharing the man’s surname in the Prison
Service’s computerised staff directory and established “a tenuous link” to a
prison near London. He contacted the duty Governor at that prison and she
confirmed the telephone number as that of the man’s son who was currently
employed there. The first Governor requested that a manager make contact
with the man’s son to inform him of the situation.
146. The first Governor confirmed that he had telephoned the man’s son a second
time on the morning of 9 January after the man’s son contacted the
Governor’s secretary at Holme House. The first Governor wrote that he
endeavoured to calm the man’s son and to engage in meaningful dialogue but
the man’s son terminated the call.
147. At the time of the man’s death, the first Governor was the Head of Security at
Holme House. In interview, he emphasised that he did not wish to release
confidential information to a person about whose identity he was not certain.
The possibility that the man might have a son who was a serving prison officer
was first discovered on 7 January by the third Governor, not by the first
Governor or the second Governor. At the time, the two men were dealing with
the many actions that had to be taken after the man’s death and they also had
to maintain safety, order and activity in a large local prison. The first
Governor chaired a debrief around 9.00 am for staff who had been intimately
involved in responding to the emergency and he then conducted adjudications
on prisoners who had allegedly broken prison rules. The Governor went to
Hartlepool with The FLO to break the news of the man’s death to his family.
When the third Governor arrived at the prison later in the morning she had
time to study the man’s prison record carefully and it was she who noticed the
reference to as son in the notes of the mental health assessment conducted
the previous day by the two RMNs. She was not able to alert the first
Governor directly to this information as he was conducting adjudications at the
time. The first Governor felt that, even if he had received the information
about the man’s son’s occupation before talking to him, he would still have
wished to establish very carefully who the man’s son was. The first Governor
said “my fear was just willy nilly give information to somebody then what are
they going to use that information to do and then I could be accused of giving
confidential information about a prisoner to some stranger.”
36
148. My investigator asked the first Governor about the length of the first
conversation with the man’s son and he estimated it was a minute or a minute
and a half. The first Governor said that the man’s son slammed the phone
down on him and he vehemently refuted the man’s contention that he had
been treated inhumanely and unfairly.
149. The first Governor then rang his colleague at the prison near London to ask if
a Senior Officer who was the man’s son was employed there. The first
Governor was concerned that the man’s son was under duress and asked his
colleague if it would be possible for somebody to visit the man’s son at his
home address and explain the situation to him. (The man’s son and his wife
lived close to the prison where he was employed.) The first Governor said in
interview that his colleague “assured me that she would endeavour to have
somebody visit if not that day certainly in the next two days.”
150. My investigator put it to the first Governor that this seemed a rather leisurely
response to the absolutely critical information he was giving. In reply the first
Governor said that he did not know whether the man who worked at the
prison near London was indeed the son of the man who had died at Holme
House and what he wanted to happen was:
“I wanted them to go round and establish by speaking to the individual
directly, is the man the deceased’s son, and then explain the situation
to him.”
151. The first Governor was asked what he was going to do next after the
conversation with his colleague and he replied:
“I left the circumstances as they were, on the understanding that [the
prison near London] would come back to me, they still hadn’t confirmed
that there was a son for the man.”
152. The first Governor agreed with my investigator that the telephone call
between himself and the man’s son had ended rather abruptly but said he had
not given any thought on the Saturday afternoon to the possibility of someone
else making an attempt to re-establish contact.
153. The first Governor estimated that his second telephone call with the man’s
son, on the morning of 9 January, lasted no longer than the first. He thought
the two men had spoken for 30 seconds or a minute at most. The first
Governor recollected that the second conversation moved almost immediately
from a calm level to again becoming rather irate. He said he was trying to
assist the man’s son but admitted he had said that he did not like the man’s
son’s attitude. He said he had not chosen the expression vindictively and “it
wasn’t said with any malice, or any intent or any view to cause any damage to
any individuals or distress.”
154. My investigators asked the first Governor if he or other senior managers at
Holme House had given any thought between the late afternoon of 7 January
and the morning of 9 January to the possibility of making renewed contact
37
with the man’s son. The first Governor replied that he was awaiting
information from the other prison because, he said, “I hadn’t established at
that stage whether the man’s son was the son of the man.”
155. My investigator went to the prison where the man’s son worked in order to
interview the Governor. In interview, the Governor confirmed that she
received a phone call from the first Governor at Holme House at
approximately 5.00 pm on the afternoon of 7 January. It was the end of her
duty period and she was in the communications room collating the roll before
going home. When the first Governor unexpectedly telephoned her at that
time, she confirmed that the telephone number he had been given by the man
was the home telephone number for the man’s son who worked at her prison.
The Governor said that the first Governor asked if she could arrange for
someone to speak to the man’s son to assist in confirming his relationship
with the deceased man. She “advised that I would do that but it wouldn’t
happen until Monday 9 January.”
156. My investigator asked the Governor why it would not be possible for
somebody to speak to the man’s son before Monday 9 January. She replied
that the man’s son’s line manager was not on duty during the weekend and
she “thought it was appropriate that whoever went round was a line manager
and was in a position to be able to deal with this matter sensitively.”
157. The Governor added that she was conscious the man’s son had already
spoken to the first Governor and “if indeed it was his father then he [the man’s
son] was obviously aware of what had actually happened.”
158. My investigator asked if any thought was given to someone other then the
man’s son’s immediate line manager going to see him during the weekend.
The Governor replied that the man’s son was obviously aware of the man’s
death at Holme House and she “didn’t believe that he would want to know that
we [senior management at his place of employment] were involved in this in
any way really at that time.”
159. On the morning of Monday 9 January the man’s son’s immediate line
manager, returned to duty after his weekend off. He was instructed by the
Governor to visit the man’s son at his home address and duly did so. At this
point it was finally established that the man’s son was the man’s son and he
was formally told of his father’s death in Holme House on Saturday 7 January.
38
Consideration and Conclusions
(i) The man’s medical care while at Holme House
160. At my request a clinical governance lead for North Tees PCT, undertook a
clinical review and wrote a detailed medical report. The first three and a half
pages of the clinical reviewer’s report set out a day by day chronology of what
the man did and what happened to him. It is very striking in the chronology to
see the numerous references to the man smashing all his furniture, continuing
to shout, scream and bang, flooding his cell, appearing confused and
complaining of hallucinations, being agitated and confrontational, being noisy
and disruptive or presenting “bizarre” and “paranoid” behaviour.
161. In the discussion section of his document, the clinical reviewer writes that the
man was rightly placed in the healthcare unit when he arrived at the prison on
16 December. The following day he was diagnosed as having alcohol
withdrawal syndrome and was correctly, according to the clinical reviewer,
placed on a detoxification regime which was to last about ten days. The
clinical reviewer writes that, from 18 December, the records show that the
man exhibited “unusual” and sometimes “bizarre” behaviour. The clinical
reviewer :
“Finds it difficult to understand why more medication was not offered
when the notes record shouting, screaming, confusion, disorientation,
hallucinations and violent behaviour when the man smashed a table in
his cell during the period 18.12.05 – 27.12.05.”
162. The clinical reviewer discusses the contact with the man’s GP on 29
December 2005 and notes the GP’s comment that bizarre behaviour was
“normal behaviour for the man to use any means to manipulate to get what he
wants.” The clinical reviewer’s assessment of the telephone conversation
with the man’s GP is that, while it provided good background information, it
did not preclude the attending doctor from forming an assessment of the
patient in his care. The clinical reviewer’s discussion continues:
“If the doctor was concerned, why did he not arrange a mental health
assessment of the patient to address his concerns? It appears that too
much reliance was given to the GP’s opinion of the man’s past
behaviour rather than assessing the patient’s presenting behaviour and
condition at the time.”
163. The clinical reviewer expresses surprise about two decisions on 3 January
2006 when the man was both considered fit for adjudication and referred for
an assessment by the dementia team. The clinical reviewer writes:
“This decision seems unusual, when the prisoner is deemed to be fit to
understand adjudication but is in need of a possible dementia referral,
which may mean that he would find it difficult to understand an
adjudication process.”
39
164. The clinical reviewer notes that the man was assessed by the community
mental health team on 6 January, when the nurses decided that he should be
urgently assessed by a psychiatrist at the beginning of the following week.
The clinical reviewer wonders why no further medication was offered to the
man at that time in order to deal with his “bizarre/paranoid behaviour.”
165. At the end of his report the clinical reviewer makes three recommendations.
These are:
1. I feel that it is good practice on reception to the prison to contact
the prisoner’s GP to get a full past medical history and a list of
their current and past medication.
2. Patients who show signs of hallucinations and paranoid ideation
should be offered urgent assessment of their mental state and be
given medication in the interim to deal with their presenting
behaviour.
3. Not all entries in the record had a time and name attached. I feel
that doing so should be standard practice.
I endorse all three recommendations made by the clinical reviewer.
167. I note that his first recommendation corresponds closely with instructions
contained in Prison Service Order (PSO) 3050 on the continuity of healthcare
for prisoners which was issued a month after the man’s death.
168. A copy of the clinical reviewer’s clinical review was made available to the
locum medical officer. On 6 June, the locum medical officer wrote to my
investigator and said there was no evidence of mental disturbance when he
saw the man on 17 December. The locum medical officer saw the man again
on the afternoon of 17 December when the man volunteered information to
the doctor that he drank quite excessively. The doctor assessed him as
suffering from alcohol withdrawal syndrome and started him on treatment with
chlordiazepoxide. The locum medical officer reviewed the man in the hospital
wing on the morning of 18 December. The locum medical officer did not see
the man again for two weeks until 3 January 2006. On that date, based on
the information that had been received from the man’s GP and his
presentation that day, the doctor felt he was fit for adjudication. After a
general discussion between the doctor and nurses a referral to a dementia
team was made by one of the nurses.
169. On 6 January, the locum medical officer saw the man for the last time
following his assessment by the second RMN. The doctor and the second
RMN agreed that it would be best to locate the man in the hospital wing until
he had been fully assessed by a psychiatrist. The locum medical officer felt at
the time he should wait for a full assessment and recommendation by the
psychiatrist before starting on any treatment.
40
170. I am extremely concerned that the man was not brought to the attention of the
mental health team until the day before his death. The clinical reviewer’s
medical report strongly suggests that the man’s mental health should have
been assessed at an early stage. The delay would appear to suggest that the
identification and referral of prisoners who need, or may need, to be seen by
mental health staff at Holme House may not be happening as quickly or
smoothly as it should be.
171. The system at Holme House provides that any member of staff is able to
complete a referral to the mental health team using the gateway process. The
man consistently displayed extremely disturbed and confused behaviour
during his three weeks in prison. Indeed, several staff made entries on
various documents testifying to the bizarre nature of his behaviour. Despite
this and the open access nature of the referral system, no member of staff
saw fit to refer the man to the mental health team until the regular landing
officer commendably did so on 6 January. There may have been an
opportunity to obtain a deeper understanding of the man’s bizarre behaviour
on 29 December 2005, when the clinical nurse manager telephoned the
man’s GP in Hartlepool. I share the clinical reviewer’s concern that too much
reliance was placed on the GP’s opinion that the man could be manipulative.
An entry in his medical notes translated this opinion into an assumption that
txamination of his disturbing behaviour.
172. I note too that RMNs do not attend the handover meetings with staff who work
directly with the inpatients in the healthcare centre. It appears to me that their
attendance at such meetings may help to identify prisoners with mental health
needs.
I recommend that urgent management attention should be paid by the
Governor, healthcare manager, Primary Care Trust and local Mental Health
Trust to the integration of the expanded mental health team at Holme House
within existing clinical services so that the best possible value (both clinical
and financial) is obtained from their skills and expertise.
Staff in the mental health team have enormous and critical skills to place at the
prison’s disposal. I recommend that the Governor makes use of the readily
available talent within the mental health team to deliver a programme of
training on mental health issues to selected staff as soon as possible.
(ii) Training for healthcare staff
173. A point of good practice at Holme House is that all nurses have been trained
in first aid. However the nurse on duty during the night of 6 to 7 January
when the man died told me that she had not been trained to use a defibrillator.
In this case I do not think that the man’s chances of survival were adversely
affected by the fact that the RMN had not received defibrillator training.
However, the nurse on night duty at Holme House is the first line medical
response for nearly one thousand prisoners. It is clearly essential that such a
critical member of staff should receive training in equipment that may help to
save a life.
41
I recommend to the Governor and PCT that a programme of defibrillator
training for staff in the healthcare centre should be introduced without delay.
(iii) Camera cells in the healthcare centre
174. When my investigators first went to Holme House in January 2006, a number
of staff expressed anger and frustration about the poor quality of the close
circuit television (CCTV) system in the healthcare centre. The night orderly
officer on the night when the man died said that the quality of the pictures on
the monitor screen in the nurses’ office was often “deplorable.” My
investigators examined the CCTV pictures and agreed that it was extremely
difficult to make out any detail on the screens. There are a number of cells in
the inpatient part of the healthcare centre with camera cover and pictures
from these cells are beamed to the monitor screen in the nurses’ office. The
prison’s policy statement for the temporary use of safer cells and camera cells
was written in March 2005 and reviewed in November 2005. According to the
policy statement, the aim of these cells is “to provide a safe and secure
environment for those individuals deemed to be at high risk of suicide or self
harm.”
175. At the time of his death, the man was not thought to be at risk of suicide or
self harm but he was located in cell 5 on the inpatient unit which did have a
camera. My investigators were told that cell number 2, which was
theoretically to be used for prisoners at risk of suicide, provided such low
picture quality that it was akin to “looking into a sauna.” The pictures from cell
2 were indeed of abysmal quality when my investigators saw them on the
monitor in the nurses’ office in January 2006. When my investigators returned
to Holme House in April 2006 they discovered that thousands of pounds had
been spent on the supply and installation of a digital recorder and flat screen
monitors in the healthcare centre. Regrettably, the quality of picture being fed
from cell number 2 to the monitor was still completely unacceptable.
176. There is no point whatsoever in having camera cells if the quality of the
pictures from these cells is so poor that staff cannot actually see what is going
on inside them.
I recommend that the Governor ensures the CCTV equipment in the healthcare
centre is fit for purpose and that staff have been adequately trained in how to
use it.
177. The policy statement of March 2005 is rather confusing. It says that safer
cells or ligature free rooms are used as a last resort when the individual has
been deemed at high risk of suicide, self harm or harm to others. The fifth key
principle in the policy statement is that any person placed in these safer
rooms will be on camera observation and a sixth key principle is that staff on
duty will observe the individual at frequent irregular intervals and during this
time allow the individual to ventilate their feelings. The policy statement does
not say whether staff observation is direct observation at the cell door or
observation on the monitor in the nurses’ office. The staff on duty in the
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healthcare centre at the time of the man’s death did not think he was subject
to frequent irregular observation, and it is difficult to establish from the policy
statement whether the arrangements for prisoners liable to cause harm to
others are exactly the same as for prisoners at risk of suicide or self harm.
I recommend that the policy statement be reviewed, especially if the intention
at Holme House is to continue locating prisoners at risk of harm to others in
camera cells.
(iv) Medical Fitting for Adjudications
178. I was surprised to see that the records of the two adjudications the man
attended on 2 and 5 January 2006 contain no reference to his fitness for
adjudication. The fourth section of the record of hearing contains a space for
any relevant medical or psychiatric observations, including an opinion on the
prisoner’s mental condition at the time of the alleged offence. That section of
the document is blank in both cases. This is especially surprising for charge
number 0001/06 in view of the nature and location of the alleged offence. The
man was charged with intentionally endangering the health and safety of
himself and others by flooding, urinating and defecating in his cell in the
healthcare centre on New Year’s Day. Before the adjudication took place, the
man had spent a number of hours in the special cell in the segregation unit, in
itself an unusual and noteworthy occurrence.
179. My investigators obtained guidance on medical fitting for adjudication from the
policy lead in the Offender Policy and Rights Unit at the National Offender
Management Service in London. The policy lead referred to policy guidance
issued in November 2003 which said that “the final decision as to whether or
not the accused is fit for the hearing rests with the adjudicator.” These
instructions remained in force until 23 January 2006, just a fortnight after the
man’s death, when the Prison Service published PSO 2000 “The Prison
Discipline Manual – Adjudications.”
180. The new PSO confirms that the final decision as to whether or not an accused
is fit to face a disciplinary hearing rests with the adjudicator. The new PSO
states at chapter 2.25 that “a list of all those appearing before the adjudicator
must be passed to the healthcare unit in sufficient time to enable any relevant
concerns about individual prisoners to be given to the adjudicator before the
start of the prisoner’s adjudication.” My comments about medical fitting for
adjudications are not made in a spirit of bureaucratic box ticking but because
it is fundamental that due process is observed, especially when the prisoner
attending the adjudication is vulnerable or may have significant health
problems.
I recommend that the Governor reviews arrangements at Holme House for
ensuring that accused prisoners are fit to face disciplinary hearings.
(v) The man’s location in the special cell on 2 January
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181. Policy on the circumstances in which special cells and mechanical restraints
may be used in prison is set out in Prison Service Order (PSO) 1600 on the
Use of Force. Chapter 4 of the PSO states that special accommodation may
be used for the temporary confinement of a violent or refractory prisoner but
only if its use is necessary in order to prevent the prisoner causing self injury,
injuring another prisoner or staff, or damaging property or creating a
disturbance. The prisoner must not be confined in special accommodation as
a punishment and, as soon as the original justification for the use of the
special accommodation has ceased, the prisoner must be moved from that
accommodation. (I may say in passing that I think the use of the word
‘refractory’ is very old-fashioned. It is not a word most staff could define.)
182. Chapter 4.6 of the PSO states that no prisoner shall be placed in special
accommodation except on the prior authority of the Governor in charge. If he
or she cannot be contacted the decision may be taken by the officer for the
time being in charge of the prison. The decision to use a special cell must be
recorded at once on form 2323 and the form must be signed by the duty
Governor or by the officer taking the decision. If the decision has been taken
by a person other than the duty Governor, the matter must be referred to him
or her for consideration at the earliest opportunity.
183. Chapter 4.8 of the Order states that where special accommodation has been
used the prison doctor must be notified as soon as possible and must
examine the prisoner as soon as practicable. Where the doctor is satisfied
there are no clinical contra–indications, he or she must certify accordingly by
signing and returning form 2323.
184. Chapter 4.12 of the Order deals with monitoring, and states that the use of
special accommodation must be discontinued immediately it is no longer
necessary. The Governor in charge must personally observe any prisoner
who is confined in special accommodation at least twice in every 24 hours. A
prison doctor must personally visit any prisoner who is confined in special
accommodation at least twice in every 24 hour period.
185. I have examined form 2323 relating to the man in the light of the stringent
safeguards set out in PSO 1600. The form does indeed appear to show that
the necessary actions were taken. That said, I am concerned by the quality of
the decision making. It seems to me that the man’s behaviour was treated
solely as a disciplinary matter to be managed punitively. In addition to his
location in the special cell and segregation unit on 1 and 2 January, he was
twice placed on report and appeared at adjudication and he was later
threatened with transfer to the segregation unit because he had disturbed
other prisoners on Houseblock 3. Yet the man was a 67 year old man who
had not experienced prison before. He was undergoing detoxification from
chronic alcohol abuse and was demonstrably unfit for location on a regular
wing. I accept that he proved extremely challenging to manage.
Nevertheless, I consider that the first and most appropriate action would have
been to ensure he received a proper mental health assessment.
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(vi) The prison’s contact with the man’s family
186. It is very unfortunate that, despite the efforts of staff at the prison to inform the
family of the man’s death promptly, they in fact heard from a friend of the
man’s victim. It has become clear that a police officer was responsible for
‘leaking’ the news of the man’s death to his victim, and I attach no blame to
staff at the prison for what could only have been an extremely upsetting way
for the family to hear the sad news. Indeed, I consider that the prison’s
contact with the man’s partner and her family was unusually good. I
particularly commend the FLO for his devotion to duty on 7 January. He
came into the prison although it was his weekend off so that he could give
support and reliable information to the man’s family in Hartlepool. During
subsequent days the prison provided a great deal of practical support to the
Hartlepool family. On 9 January, the FLO arranged for a taxi to collect the
man’s partner and her sisters so that they could come to the prison and see
the cell where the man had died, go to the undertakers to view the man’s
body and then have a taxi home again. The prison agreed to meet the cost of
the man’s funeral and the FLO attended the Coroner’s Court with two
members of the family when the inquest on the man’s death was opened and
adjourned. The family in Hartlepool expressed appreciation for the humane
treatment they received from the prison in the days following the man’s death.
My investigators met with the FLO and were impressed by the qualities of
sensitivity and empathy that he clearly brings to his new role.
187. The story of the man’s son’s contact with the prison does not make such
happy reading. I am strongly of the view that further contact with the man’s
son should have been made during the late afternoon or early evening of 7
January after he had terminated his first telephone conversation with the first
Governor. The Governor of the London prison said that when the first
Governor telephoned her “he wanted to know if we had the man’s son working
here as an officer and if the number he’d been given actually coincided with
the man that had contacted him.” The answer to both questions was very
clearly in the affirmative. At this point, the first Governor should have
accepted the man’s son’s word when he said the man who had died at Holme
House was his father. In any event, I do not consider that staff at either prison
placed sufficient urgency on the matter of establishing whether the man’s son
was related to the man.
188. It is not surprising that the man may not have behaved in a calm and
composed fashion during his first telephone conversation with the first
Governor. The man had just been told by his aunt that his father had taken
his own life in prison, and I can only imagine the shock and grief this must
bring. The first Governor and senior colleagues at the prison should have
immediately considered strategies to re-establish contact. I consider that the
onus was on Holme House to make contact with the man’s son because it
was in Holme House that his father had died.
189. If the relationship between the first Governor and the man’s son was strained,
then consideration should have been given to finding another member of staff
at Holme House who would be able to deal promptly with the man’s son’s
45
questions. It seems that consideration of security unduly outweighed
consideration of humanity in the response to the man’s son during the first
weekend after his father’s death. It is a great shame that the FLOs were not
made aware of the existence of the man’s son on the day his father died.
190. The man’s son was so angry after his two telephone conversations with the
first Governor that he wrote immediately to the Director General of the Prison
Service. I have uncovered no evidence that the first Governor treated the
man’s son inappropriately because of the nature of the crime his father had
committed. I agree with the third Governor that he should not have told the
man’s son that he did not care for his attitude. The third Governor observes in
her report that in ideal circumstances it would have been a Family Liaison
Officer who made contact with the man’s son. There is no doubt that the
death of the man emphasises the crucial role that FLOs can and should play
in establishing and maintaining contact with bereaved families.
191. The newly revised Prison Service Order on follow-up to deaths in custody
became operational on 4 January, just three days before the man’s death.
Chapter 4 of the PSO deals with support for the family and contains a
hyperlink to additional guidance on Family Liaison following a death in
custody which is available on the Prison Service’s intranet. The
supplementary guidance indicates that the Prison Service has decided to
follow a very broad definition of a family, as developed by the Metropolitan
Police. In answer to the question ‘who are the family?’ the highlighted
guidance responds:
“The term “family” can include “chosen” as well as “biological” and can
include: husbands, wives, partners, significant others, parents, siblings,
children, guardians and others who have had a direct and close
relationship with the deceased.”
192. The guidance adds that every family is different and has its own dynamics. It
notes that many modern families are split by divorce or separation and:
“there may be several branches all with equal rights to information…
The Family Liaison Officer should be prepared to deal with different
sections of one family if necessary.”
193. The supplementary guidance recommends at section 4.9 that the family
should be informed face-to-face as soon as possible after the death. In the
following paragraph the guidance given is as follows:
“If the distance from the prison presents a problem, a dedicated Family
Liaison Officer or chaplain based in the area nearest to the family
home could inform the family face-to-face… this individual must give
the family contact details at the establishment where the death
occurred and the visit should be followed up by that establishment as
soon as possible.”
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194. During my investigation I was heartened to discover how determined the
Family Liaison Officers in the North East area are to provide an excellent
service. The third Governor is the operational link to these FLOs and
attended a meeting with them at Holme House in July 2005. At the meeting
an important discussion took place about the possibility of having an “on call”
trained FLO on duty at all times. The on call FLO would be an additional
resource to all prisons in the North East. Those attending the meeting
thought the best option was:
(cid:127) Each establishment would try to contact their own trained FLO in the first
instance when a death has taken place.
(cid:127) If that person was not available, the on call FLO could be contacted to
provide the initial service.
(cid:127) This person would attend the establishment (where the death has occurred)
and start/complete the risk assessment prior to delivering the death
message.
(cid:127) They would then be deployed with a senior manager from the establishment
to deliver the death message to the next of kin, if establishment FLO was
still not available.
195. In August 2005, the third Governor wrote to the then North East Area
Manager, telling him of the clear enthusiasm and commitment of the trained
FLOs in the North East, and asking for his approval of the suggestion that
there should be an on call FLO who would carry a pager at all times.
196. The man’s death clearly underlines the point that the death of a prisoner may
occur at any time of the day or night and not necessarily when a FLO is
available. Holme House had two trained FLOs at the time but that resource
was not sufficient to cope with the complexity of the situation. The prison
needs to be able to liaise almost simultaneously with family members in quite
separate parts of the country. Some imaginative thinking had already been
devoted to this very issue by the third Governor and her FLO colleagues in
the North East. I commend them for their foresight.
I recommend, as a matter of urgency, that the Governor and Area Manager
review arrangements at Holme House and other North East prisons for timely
liaison with family members in the immediate aftermath of a prison death.
197. The man’s son was visited by his line manager on 9 January 2006, two days
after his father’s death. It was Holme House’s responsibility to ensure that
news of the man’s death was conveyed to his son but the prison near London
where the man’s son worked at the time should not have delayed contacting
him for two days. The Prison Service’s own guidance refers to the possibility
of a dedicated FLO or chaplain based in the area nearest to the family home
informing the family face to face but this sensible alternative was not adopted
by the prison near London.
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The Governor at the prison where the man’s son formerly worked should
review arrangements at that prison for timely liaison with family members in
the immediate aftermath of a prison death.
(vii) Good practice and commendable staff behaviour
198. The response by night staff to the emergency discovered just after 5.00 am on
7 January was excellent. The Senior Officer and his assist were in the orderly
office adjacent to the healthcare centre when the alarm was first raised. They
arrived at the man’s cell just a few seconds later and immediately entered it.
The four members of staff who were then present, the two men, the RMN and
the OSG worked as an effective and disciplined team. The night orderly
manager ensured that the blockages to the man’s airway were removed and
that staff were despatched to unlock gates which would have hindered the
swift arrival of an ambulance. The assist and the RMN administered CPR to
the man but regrettably their valiant efforts to revive him were to no avail. The
OSG made sure that an ambulance was swiftly summoned and she had the
presence of mind to make a telephone call to the control room in case her
initial radio message had not been safely received.
199. The OSG had already had a great deal of contact with the man during her
week of nights that began on 19 December. The man was evidently in great
distress that week and there is evidence that she tried to reassure him and
help him come to terms with a situation and location that was completely alien
to him.
200. Another notable contribution was made by the regular landing Officer. When
the man arrived on Houseblock 3 for the first time on 3 January, after being
held in the healthcare centre and segregation unit, the regular landing officer
made things happen. He was concerned by the man’s bizarre behaviour on
Houseblock 3 and made a careful written record of what he saw and heard.
He rang the healthcare centre on the evening of 3 January and was assured
by the clinical nurse manager that a mental health assessment of the man
was already in hand. On the morning of 6 January, the regular landing officer
rang the mental health team to find out what could be done for the man. After
he had dropped the man off in the segregation unit for his resumed
adjudication, the regular landing officer went in person to the healthcare
centre and completed a mental health referral form at the request of his
colleagues there. The regular landing officer might claim that he was merely
doing his job but he used existing systems at Holme House to great effect for
the man’s benefit. Had it not been for the energy, determination and concern
that the regular landing officer displayed, I think it most unlikely that any
mental health assessment would have taken place before the man’s death.
As a housekeeping point I note in passing that Holme House were unable to
retrieve the SIR that the regular landing officer wrote when my investigators
requested it.
I recommend that the five members of staff whom I have named should receive
formal commendation from their Governor or the North East Area Manager.
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Recommendations
I recommend that the Governor should consider whether a policy on constant
observations, especially in camera cells, should be drawn up.
I recommend that urgent management attention should be paid by the
Governor, healthcare manager, Primary Care Trust and local Mental Health
Trust to the integration of the expanded mental health team at Holme House
within existing clinical services so that the best possible value (both clinical
and financial) is obtained from their skills and expertise.
Staff in the mental health team have enormous and critical skills to place at the
prison’s disposal. I recommend that the Governor makes use of the readily
available talent within the mental health team to deliver a programme of
training on mental health issues to selected staff as soon as possible.
I recommend to the Governor and PCT that a programme of defibrillator
training for staff in the healthcare centre should be introduced without delay.
I recommend that the Governor ensures the CCTV equipment in the healthcare
centre is fit for purpose and that staff have been adequately trained in how to
use it.
I recommend that the policy statement (on Healthcare temporary use of safer
cells and camera cells) be reviewed, especially if the intention at Holme House
is to continue locating prisoners at risk of harm to others in camera cells.
I recommend that the Governor reviews arrangements at Holme House for
ensuring that accused prisoners are fit to face disciplinary hearings.
I recommend, as a matter of urgency, that the Governor and Area Manager
review arrangements at Holme House and other North East prisons for timely
liaison with family members in the immediate aftermath of a prison death.
The Governor at the prison where the man’s son formerly worked should
review arrangements at that prison for timely liaison with family members in
the immediate aftermath of a prison death.
I recommend that the five members of staff whom I have named should receive
formal commendation from their Governor or the North East Area Manager.
From the clinical review:
I feel that it is good practice on reception to the prison to contact the
prisoner’s GP to get a full past medical history and a list of their current and
past medication.
Patients who show signs of hallucinations and paranoid ideation should be
offered urgent assessment of their mental state and be given medication in the
interim to deal with their presenting behaviour.
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Not all entries in the record had a time and name attached. I feel that doing so
should be standard practice.
50