Individual at William Collier House

Investigation into the circumstances surrounding
the death of a woman in July 2009
following her release from HMP Bronzefield
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2010
This is the report of the investigation into the death of a woman in July 2009. She
had been released from HMP Bronzefield the previous day, having served ten days
of a 21 day sentence imposed following breach of a previously suspended sentence.
She was found dead in her hostel bedroom from a methadone overdose. This
investigation has been carried out under the Ombudsman’s discretionary power to
consider deaths following release from custody.
The woman was 40 years old when she died. I offer my sincere condolences to her
partner and all those who knew her and are touched by her loss.
The investigation was conducted by one of the Ombudsman’s investigators. I would
like to thank the Director of Bronzefield and her staff for their assistance.
The woman had been dependent on alcohol for a number of years. More recently,
however, she had managed to significantly reduce her daily intake. She worked well
with her community alcohol support worker and was waiting for a place in an alcohol
detoxification centre. She had used drugs in the past and still did so occasionally,
although she did not mention using methadone.
While at Bronzefield, the woman completed an alcohol detoxification course but
there was little time to address any other resettlement needs. She said she did not
need any help with her drug use and so did not receive any. Fortunately, she was
able to return to her room at a hostel in Brighton on release and, by all accounts, this
came as a relief to her.
In my view, the shortness of the woman’s sentence has been central to the
investigation. It is clear that short sentences cause difficulties for both the prisoners
and the prisons that receive them. A 2007 review of women with vulnerabilities in
the criminal justice system said that women “must never be sent to prison for their
own good, to teach them a lesson, for their own safety or to access such services as
detoxification”. Although I appreciate the challenge presented if suspended
sentences are breached by those who lead disorganised lives, it is difficult to see
what practical purpose the woman’s sentence served.
I believe that staff at Bronzefield did all they could to support the woman during her
very short time with them. I make only one recommendation, relating to the
provision of information to prisoners being released. I conclude, however, that her
death was neither foreseeable nor preventable.
This version of my report, published on my website, has been amended to remove
the names of the woman who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Acting Prisons and Probation Ombudsman January 2010
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CONTENTS
Summary
The investigation process
HMP Bronzefield
Key findings
Issues identified during the investigation
Conclusion
Recommendations
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SUMMARY
On 4 June 2009, the woman appeared in court and was sentenced to five days
imprisonment. She served her sentence at HMP Bronzefield, being automatically
released at the half way point of the sentence, two days later.
Six weeks later, on 20 July, she returned to court having breached the terms of an
earlier suspended sentence and was sentenced to 21 days in prison. On her arrival
at Bronzefield, she told staff that she was dependent on alcohol. She also said that
she used heroin occasionally. She underwent a drugs test, which showed that she
had not taken any drugs. She was prescribed medication to relieve the symptoms of
alcohol withdrawal that night and an appointment with the doctor was made for the
following day.
The woman completed the induction questionnaire, noting that she had no
accommodation concerns or financial worries. She said that she wanted help with
her alcohol use and with education. She wrote that she did not use drugs and did
not, therefore, need any help with this.
The next morning, she was assessed by the doctor. He noted her history of heavy
drinking and placed her on a ten day alcohol detoxification programme.
During her induction, she received information from the prison substance misuse
team about the dangers of using drugs after release and particularly the risk of
overdose due to lower tolerance levels. She had no further contact with the
substance misuse team.
The woman’s accommodation provider in the community had agreed to reserve her
room while she was in prison. The prison housing officer liaised with hostel staff
prior to her release.
After serving ten days of her sentence, the woman was due to be automatically
released. At the time, the prison ran pre-release courses (which include repeating
the information about the risks of returning to drug use on release) every other week.
During the ten days she spent at the prison, no pre-release courses were held and
so she did not receive any further information prior to her release.
The woman left Bronzefield at 8.30am on 30 July and returned to her hostel in
Brighton. She went out for the evening, returning in the early hours of the morning.
Night staff saw her and had no concerns about her. Later that morning, hostel staff
checked and found that she had died. The post mortem concluded that she had died
of a methadone overdose.
This investigation has highlighted the real difficulties caused by very short
sentences. I believe that staff at Bronzefield did their best to help the woman but
were constrained by time limits. I make only one recommendation, which concerns
the provision of pre-release information to prisoners.
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THE INVESTIGATION PROCESS
1. The Ombudsman’s office was notified of the death of the woman on 31 July 2009.
The investigation was allocated to an investigator on 6 August 2009. The
investigator visited HMP Bronzefield on 1 October when she met the Director and
conducted informal interviews with members of staff.
2. Notices were issued inviting staff and prisoners to contact the investigator with
any information they felt might be relevant to the investigation. There was no
response to the notices. The investigator was provided with copies of the prison
records relating to the woman’s two recent periods at Bronzefield.
3. During the investigation, the investigator visited William Collier House in Brighton,
where the woman died, and spoke to staff there. She also made telephone
contact with the woman’s community alcohol worker.
4. HM Coroner was contacted and informed of the scope of the investigation. She
provided the investigator with the results of the post mortem. A copy of this
report will be sent to the Coroner to assist with her enquiries.
5. The woman gave no next of kin details when she arrived at Bronzefield. HM
Coroner could not trace any members of her family, but was able to give the
investigator details for her partner. One of the Ombudsman’s family liaison
officers contacted him through his community support worker and invited him to
be involved in the investigation. While he had no specific questions or concerns
about the woman’s time at Bronzefield or her release, I hope this report provides
him with a better understanding of her time in prison and the events of 30 and 31
July.
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HMP BRONZEFIELD
6. HMP Bronzefield is a contracted local prison for women, run by the private
company Kalyx. The prison, in Ashford, Middlesex, opened in 2004 and
accommodates up to 465 prisoners on remand or sentenced. There are currently
three houseblocks holding 137 prisoners each, with a fourth due to open shortly.
The prison offers 24 hour healthcare and has an 18 bed inpatient unit. Figures
supplied by the prison indicate that between April and September 2009, 168
newly arrived prisoners had received sentences of six months or less (78 were
serving less than three months).
7. Each prison in England and Wales is subject to performance monitoring by the
National Offender Management Service (NOMS). NOMS produces quarterly
performance ratings, compiled using an agreed framework. Bronzefield’s
performance has been rated as “good” (the second best rating available) for the
past four quarters.
HM Inspectorate of Prisons
8. HM Inspectorate of Prisons conducted an unannounced short follow-up
inspection at Bronzefield in October 2007, following a full inspection in June
2005. The report concluded that Bronzefield provided a “reasonably safe and
respectful environment for its needy and challenging population”. The
Inspectorate noted improvements in detoxification arrangements and
resettlement. However, the lack of custody plans for those prisoners serving
short sentences was highlighted.
9. At the time of the inspection, prisoners with substance misuse problems were
“mostly” treated in line with national clinical management protocols. The
detoxification service was described as “flexible and needs based”. Services for
drug users were found to have “improved considerably” and a monthly alcohol
awareness group had been set up. However, one to one work with primary
alcohol users was “limited”.
10. The prison’s work on resettlement, including carrying out a needs analysis, was
recognised. However, the Inspectorate concluded that the needs of particular
groups, including short-sentenced women, were not covered.
Independent Monitoring Board
11. Each prison in England and Wales is monitored by an Independent Monitoring
Board (IMB), formed of volunteers from the local community. IMB members have
access to every prisoner and each part of the prison. The Board produces an
annual report, the latest available for Bronzefield covering the period August
2007 to July 2008.
12. The Board concluded that “Bronzefield is a decent, safe prison, staffed for the
most part by caring, if inexperienced officers”. The report highlighted the ethos of
the prison being “one of respect for the individual”.
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The Corston Report
13. In 2007, Baroness Jean Corston published her review of women with
vulnerabilities in the criminal justice system in which she called for a “woman
centred approach”. Baroness Corston wrote that she was:
“… dismayed to see so many women frequently sentenced for short periods
of time for very minor offences, causing chaos and disruption to their lives and
families, without any realistic chance of addressing the causes of their
criminality.”
14. The review highlighted the overuse of custody for women and the need for
alternative sanctions and disposals. Baroness Corston called for criminal justice
agencies to work together to divert low-level offending women away from the
courts and prosecution.
Counselling, Assessment, Referral, Advice and Throughcare service
15. Counselling, Assessment, Referral, Advice and Throughcare services (CARATs)
are available in all prisons in England and Wales offering non-clinical treatment to
prisoners who use drugs. Under Prison Service Order (PSO) 3630, CARATs
should not provide a service to prisoners who only use alcohol. They may,
however, offer a service to prisoners who use drugs and alcohol.
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KEY FINDINGS
16. On 4 June 2009, the woman appeared at a local magistrates’ court charged with
failing to surrender to the court on a previous matter. She was sentenced to five
days imprisonment, to be served at HMP Bronzefield. Prisoners sentenced to
less than four years imprisonment are automatically released after they have
served half their sentence and so she was released two days later, on 6 June.
17. The woman appeared in court again on 24 June charged with theft. While at
court she was assessed by a community psychiatric nurse. She told the nurse
that she drank three cans of strong lager every day and that she had been
waiting for a place at an inpatient alcohol detoxification centre for over a month.
She said that she used heroin in the past but had not used it regularly for three
and a half years, although she admitted to “two minor slip ups”. The nurse
recorded that she was not mentally unwell and posed a low risk to herself and
others. She received a 28 day sentence, suspended for six months.
18. Less than a month later, on 20 July, the woman appeared in court once again,
having breached the terms of her suspended sentence. She was sentenced to
21 days imprisonment, to be served at Bronzefield. She arrived at the prison at
7.15pm. While in reception, she underwent the first reception healthscreen with a
nurse. (The healthscreen is designed to identify any immediate physical or
mental health concerns requiring referral to the doctor or other specialist service.)
19. The woman told the nurse that she had been at Bronzefield recently. She said
that she drank three or four cans of Special Brew (a strong lager with an alcohol
by volume measure of eight per cent) every day and used heroin and cannabis
occasionally. She said she spent about £10 a month on heroin and had last used
it four days previously. Following her admission, the nurse carried out a drugs
test, which was negative and indicated that she currently had no drugs in her
body.
20. The nurse noted that the woman had no history of mental health problems but
had tried to harm herself in the past. She wrote that six months previously, the
woman had cut her legs using a knife and had received hospital treatment for the
cuts. However, she said that she did not currently feel like harming herself. The
woman said that she had seen her doctor in the last few months “for a sick note”.
She had no concerns about her physical health, although she said she had
suffered fits due to her alcohol use. She was not prescribed any medication and
she asked to be referred to the doctor because of her alcohol problem.
21. Following the first reception healthscreen, the nurse prescribed chlordiazepoxide
(used to treat the symptoms of alcohol withdrawal), Buscopan (for stomach
cramps) and paracetamol because the woman was complaining of a headache.
An appointment with the doctor was made for the following morning.
22. While in reception, the nurse and an officer completed the Cell Sharing Risk
Assessment. (This assesses the risk the prisoner poses to other prisoners and
whether they are suitable for sharing a cell.) The officer recorded that the woman
was dependent on alcohol. She said she would prefer not to share a cell as she
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“got frustrated”. The officer assessed her as posing a low risk to other prisoners
and suitable for sharing a cell and the nurse agreed with this assessment. In the
event, because of her alcohol dependence and the likelihood that withdrawal
symptoms would make her feel unwell, she spent her first night in the healthcare
centre where she occupied a single cell.
23. The Head of Healthcare was interviewed during the investigation. She said that
healthcare staff had noted how much better the woman looked this time
compared with her stay at Bronzefield in June. She said that the woman had
managed to significantly reduce her alcohol intake and, as a result, staff were
much less concerned about her physical and mental health.
24. The woman completed the induction questionnaire that evening. She said that
she had no accommodation concerns but did want help with education and her
alcohol use while she was in prison. She wrote that she did not use drugs and so
did not need any drug related support. While she had no rent arrears or money
worries, she said that she had outstanding court fines. She confirmed that six
months previously she had harmed herself by cutting her leg and jumping from
the pier into the sea. She said she had no concerns about being in prison.
25. The following day, 21 July, the woman was examined by the prison doctor. The
doctor recorded in the medical record that she had been a “heavy drinker” for four
years, and normally drank about four cans of Special Brew every day. He noted
that she used to drink more than this. He wrote that she “had shakes/sweats” if
she did not drink and that she had a fit two months previously as a result of
alcohol withdrawal. She told the doctor that she currently felt “shaky and
clammy”. She also said she had a history of anxiety and depression and had
been prescribed medication in the past as a result. The doctor noted that she
currently had no thoughts of harming herself.
26. The doctor placed the woman on a short alcohol detoxification course. He
prescribed her a reducing dose of chlordiazepoxide over eight days, ten days of
carbamazepine (an anticonvulsant) and Calms tablets, for anxiety. He also
prescribed vitamin B and Thiamine (both commonly prescribed to patients
dependent on alcohol). (The woman completed the courses of chlordiazepoxide
and carbamazepine but decided not to take any Calms tablets after a week.) The
doctor decided that she was well enough to leave healthcare and so she moved
to D spur, the substance support wing on Houseblock 1. The Head of Healthcare
explained that because the woman’s alcohol intake had reduced so much whilst
she was in the community, she was able to detoxify more quickly and with fewer
side effects.
27. Over the next two days, during induction sessions, the woman received
information on a range of services available at Bronzefield. This included
information on the library, the gym, the programmes available and a talk from
CARATs. The investigator was told that the CARATs staff always include
messages about the risks of overdose and that prisoners may have a lower
tolerance to drugs following a prison sentence. However, as she had said she
was dependent on alcohol and did not need any help with her drug use, she was
not allocated a CARATs worker.
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28. On 26 July, an officer made an entry in the woman’s file, noting that she had
been on D wing for almost a week and that there were “no issues”. A second
officer also made an entry the next day, writing that she had “been very quiet on
the spur, has not raised any issues”.
29. The prison housing officer was also interviewed during the investigation. She
said that the woman was more fortunate that many women in the prison as she
had accommodation arranged for her release. (Staff at William Collier House
were prepared to keep her room while she was in prison.) However, to ensure
this was the case, the housing officer spoke to hostel staff when the woman
arrived at Bronzefield and again shortly before her release. She also made sure
that the woman would be able to claim her benefits on release. She said that the
woman was clearly pleased to be able to keep her room at the hostel and that
she had no concerns about her.
30. The doctor who delivers the substance misuse clinic saw the woman on 28 July.
She had been referred automatically to the clinic because of her dependence on
alcohol and previous use of heroin. However, during her appointment, she told
the doctor that she was being released two days later and that there was nothing
else she needed.
31. The woman was released on 30 July, having served half of her sentence.
Prisoners who are being released “automatically” (because they have reached
the midway point of their sentence) must be released before 9.00am. A senior
prison custody officer (SPCO) was responsible for carrying out the final checks
before release. She told the investigator that on the morning of 30 July, the
woman had seemed “fine” and appeared not to have any concerns. The SPCO
confirmed that she had been given a travel warrant to take her to Brighton and
her discharge grant.
32. Before leaving the prison, the woman was assessed by a nurse, who noted no
concerns. Frequently, prisoners are being prescribed medication by prison
healthcare staff and need further treatment in the community. In this case,
healthcare staff will normally issue three days’ worth of medication and a letter to
be given to the community doctor. The woman was no longer being prescribed
any medication, having completed her detoxification. She was given a letter to
pass to her doctor, explaining the treatment she had received.
33. The investigator spoke to a second SPCO, the senior officer in reception. She
explained that prisoners being released were not routinely given advice on the
risk of overdose if they returned to drug use, or that their tolerance levels might
have changed after a period in prison. She said that this information was given
by CARATs staff during the pre-release courses. At the time the woman was at
Bronzefield, the pre-release courses were held every other Friday. None took
place during her ten days at the prison and so she did not have the opportunity to
attend prior to her release. (Pre-release courses now take place at Bronzefield
every Friday.)
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34. The woman left Bronzefield at 8.30am. Later that day, she arrived at William
Collier House in Brighton. She went out for the evening, returning to the hostel at
about 2.30am. The night porter on duty saw her as she returned and told staff
that she seemed fine. There were no obvious signs that she was unwell or had
taken drugs. The following morning, 31 July, her partner rang William Collier
House and asked staff to check her as she had bought methadone the night
before. She was found in her room, and it was apparent that she had been dead
for some time.
35. The post mortem revealed that the woman died from a methadone overdose. All
those spoken to as part of the investigation said they were very shocked to learn
she had died and particularly the cause of her death.
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ISSUES IDENTIFIED DURING THE INVESTIGATION
The woman’s short sentence
36. In the two months before her death, the woman received two short prison
sentences, of five days and 21 days, and spent both at Bronzefield. In reality,
these sentences meant that she spent two days in prison in June and ten days in
July. On both occasions she told staff that she was dependent on alcohol and
underwent alcohol detoxification, but in July she also said that she would like help
with education. During her ten days at the prison, she completed the alcohol
detoxification course but this left no time to begin to address her educational
needs, or to carry out work which might have helped her avoid a return to prison
in the future.
37. This investigation necessarily raises issues about the appropriateness and
effectiveness of short sentences. Staff interviewed explained the difficulties they
faced working with women serving very short sentences. The Head of
Healthcare explained that after a ten day alcohol detoxification, the woman
would, most probably, have conquered her physical dependence on alcohol.
However, she suggested that breaking the psychological dependence that comes
with years of substance use takes far longer. The likelihood of her remaining
abstinent after such a short sentence was slim. The Head of Healthcare also
highlighted the practical difficulties of managing prisoners with short sentences.
She said that healthcare staff run pre-release clinics once a week, which focus on
any outstanding health needs. Some prisoners serving short sentences arrive
and leave again before the clinic has been held.
38. The Head of Resettlement explained that providing a resettlement service to
prisoners serving short sentences was also difficult. She said that staff work hard
to maintain tenancies and benefits arrangements – two of the biggest problems
facing the women there. The housing officer explained that it could be very
difficult to find accommodation for women serving short sentences in time for
their release, particularly as there were far fewer vacancies for women in
temporary accommodation. Currently, work is in progress to target prisoners with
short sentences at Bronzefield and quickly assess their resettlement needs.
39. In many ways, the woman was more fortunate than other women serving short
sentences. The hostel where she lived (and where she felt safe and settled) in
Brighton was prepared to keep her room for the duration of her sentence. Staff at
Bronzefield contacted the hostel during her brief stay with them. She was
registered with a doctor in the community and had a community alcohol support
worker, with whom she was engaging well and would have continued to work with
after her release. He told the investigator that she had begun to see her short
sentences as “almost funny”. However, he was clear that they caused disruption
and uncertainty and that, for a recovering alcoholic, routine is vital.
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Addressing the woman’s drug use
40. On her arrival at the prison in July, the woman told healthcare staff that she
sometimes used heroin, although she was primarily an alcohol user. She did not
mention using methadone. The nurse referred her to the doctor but not to drug
services in the prison. On her induction questionnaire, the woman wrote that she
did not use drugs and therefore needed no targeted support. During her first
appointment with the doctor, he noted that she had tested negative for all drugs.
41. As mentioned earlier, CARAT teams work within the parameters set out in PSO
3630 and may only work with primary alcohol users if they also use drugs. On
the information staff had about the woman’s drug use it is reasonable that they
did not refer her to CARATs. However, she did attend the CARATs induction and
would, therefore, have received information about the risks of returning to drug
use after a period of abstinence.
42. Staff interviewed said that prisoners attend a pre-release course, during which
CARATs remind them of the risks of using drugs on release. Prisoners who
attend are given a pre-release pack, containing a range of written material,
including information about drug use. The investigator was told that reception
staff do not reiterate such messages to prisoners on the day of release.
However, while the woman was at Bronzefield, the pre-release course was held
every other Friday. No courses took place during her stay and so she did not
receive any pre-release information. The Head of Resettlement said that the
course is now run every week – but there is still a chance that women given very
short sentences will not be at the prison for long enough to attend. She also said
that the pre-release packs were available in reception and should be given to
every prisoner on release. Reception staff appeared unaware that this was the
case. With that in mind I make the following recommendation:
The Director will wish to assure herself that pre-release packs are given to
each prisoner on release.
43. The Head of Resettlement told the investigator that an A4 size leaflet containing
information relevant to some of the most common destinations for released
prisoners was also being considered. She said that such a leaflet could also
repeat warnings about tolerance levels and the risks of overdose. I would
welcome such an initiative. That said, as the woman’s drug use remains
something of a mystery, I am not certain whether receiving such warnings on
release would have altered the choices she made subsequently.
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CONCLUSION
44. In June 2009, the woman spent two days at Bronzefield. The following month
she was sentenced to imprisonment again and spent ten days there. She had a
history of alcohol dependence and had used drugs in the past but had managed
to reduce her intake of both significantly. She told staff that she wanted help
addressing her alcohol use, but said she did not need any help with her drug use.
During her ten days at the prison she underwent an alcohol detoxification, which
she successfully completed.
45. Prior to coming to prison, the woman lived in a hostel in Brighton. She told her
community alcohol support worker that she felt safe and settled there.
Fortunately, the hostel agreed to keep her room while she was in prison and so
she knew that she was able to return there on release. In many ways, she was
more fortunate than other prisoners serving short sentences. She was already
engaging well with community services and was returning to a life that she was
comfortable with.
46. I believe that staff at Bronzefield did all they could to assist the woman during her
very short time with them. Sadly, the day after her release, she was found dead
in her room from a methadone overdose. I am satisfied that her death was
neither foreseeable nor preventable and make only one recommendation to the
prison.
47. However, the investigation has also highlighted the real difficulties caused, both
to prisoners and the prisons that hold them, by very short sentences. Although
the courts are faced with an evident dilemma when a suspended sentence is
breached less than a month after it is imposed, it is difficult to see what practical
purpose could have been served by sending the woman to prison for ten days. A
copy of my report will be sent to the minister responsible for the Government
response to her recommendations and to Baroness Corston for their
consideration.
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RECOMMENDATIONS
1. The Director will wish to assure herself that pre-release packs are given to each
prisoner on release.
The Prison Service accepted this recommendation noting that:
“In the short term the resettlement manager and CARATs team have compiled a
release pack which contains harm minimisation information: ‘Staying Alive and
Saving a Life’. The release pack will be issued to each prisoner on release by
reception officers. There are longer term plans for a hard cover ‘filofax’ style release
pack which will cover geographical areas with relevant local information; it will also
include harm minimisation information. Prisoners are helping with the design.”
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