Individual at Acklington

Investigation into the circumstances surrounding the
death of a man
at HMP Acklington in August 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2008
This report considers the circumstances surrounding the death of a man. The man
was found hanging in his cell at HMP Acklington at 9.20am on the morning of 29
August 2007, the day of a strike by the Prison Officers’ Association. He had last
been seen alive at 7.30am. The man was 39 years old.
The man had been released on licence from a four and half year sentence in March
2006. He was recalled for breaching the conditions of his licence in October 2006,
but did not in fact return to prison until July 2007. The man was not typically a
troubled or depressed man during his periods in custody. His death could not have
been predicted and his actions are regarded as totally out of character. His death
came as a great shock to the man’s friends and family, to whom I would like to offer
my sincere condolences.
My colleague led the investigation with an assistant. I would like to thank the
Governors of HMP Acklington and Durham, and their staff for their cooperation. I am
also grateful to the Northumberland Primary Care Trust who produced a clinical
review of the care that the man received. I must apologise for the delay in issuing
this report.
I have not been able to judge with any certainty whether the man’s actions were a
cry for help or if he intended to take his life. However, I am confident that staff in
both Acklington and Durham acted appropriately in meeting his immediate needs.
Nevertheless, I have found areas for improvement in the healthcare screening
process and the G3 unit at Acklington. I have also made a recommendation
regarding the transfer process from Durham (this has already been accepted and put
in place by the Governor).
I have been particularly concerned whether the fact of the POA industrial action
could in any way be related to the man’s death. I cannot discount that possibility, but
neither have I found any evidence to show that the two things were linked.
During 2007, the number of apparently self-inflicted deaths in prison custody
increased by 37 per cent (92 deaths, compared to 67 in 2006). Thirteen prisons had
three or more such deaths, one of them being Acklington, a category C training
prison. Although self-inflicted deaths are more likely to occur in local prisons, it is
simply not the case that training estate is immune. Deaths in category C prisons
seem to be on the increase, a reminder of the title of a major study conducted by the
former Chief Inspector of Prisons: suicide is everyone’s concern.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2008
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CONTENTS
Summary 4
The investigation process 6
Establishments
HMP Acklington 9
HMP Durham 10
Key findings
HMP Durham 12
HMP Acklington 14
Issues
Clinical 20
General 21
Conclusion 29
Response to the draft report 30
Recommendations 33
3
SUMMARY
This man was released from custody in March 2006 after serving 22 months of a four
and half year sentence. He was recalled to prison on 10 October 2006 for breaching
the conditions of his licence. Despite his recall, the man absconded and was not
brought back into custody until 7 July 2007. He was required to serve a further 19
months in custody.
On recall, the man was taken to HMP Durham. He was allocated a cell in C wing,
one of the smaller residential wings at Durham, where prisoners benefit from an
active regime and have up to eight hours out of their cells on weekdays. He quickly
adjusted to being back in prison and mixed well with other prisoners.
After spending six weeks at Durham, the man was transferred to Acklington. He was
told about his transfer the day before moving during a short assessment with a
member of healthcare. During the assessment he told the nurse that he was “happy”
to go.
As the man was a licence recall prisoner, the Observation, Categorisation and
Allocations Unit (OCA Unit) did not directly inform him of the transfer. At this time it
was not the policy to do so, whereas the OCA Unit would inform all other types of
prisoner. As a result, licence recall prisoners did not have the opportunity to raise
any security concerns about moving – unless they were aware that this could be
done by submitting an application request form. My investigator discussed this with
the Governor of Durham, his Deputy and the OCA Unit. During the meeting my
investigator made a recommendation based on the OCA Unit’s advice to revise the
practice and routinely issue a paper slip to licence recall prisoners. The slip would
inform the prisoner of the transfer and indicate that any concerns about moving for
security reasons would be investigated by the safer custody or security departments.
The Governor implemented this immediately. I commend his positive and speedy
response to feedback.
On arrival at Acklington, the man appeared anxious and said he was unhappy to be
at the prison. He said he was scared of unfounded rumours spread whilst he was at
Durham that he was a sex offender. He was not clear where the rumour had started
or of whom he was afraid.
The man only mentioned his anxieties once – during his initial assessment in
reception. The officer noted his concerns but did not record them in detail. A
member of healthcare recorded that the man was unhappy with his transfer, but no
further comments were noted. I have recommended that the reception healthscreen
assessment form be revised to make it mandatory for further comments to be
provided when concerns are raised by prisoners. I also recommend that officers are
reminded of the importance of keeping comprehensive and explicit records.
In acknowledgement of the man’s concern for his safety, he was immediately
allocated to the G3 unit. G3 unit is informally known as a ‘poor copers’ unit for
prisoners who feel at risk in the main prison area. The unit is based on the third floor
of G wing – a normal location wing. The unit has a very restricted regime and
prisoners regularly spend up to 22 hours in their cells. Prisoners are not routinely
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given a mental health screen on allocation to the wing despite being identified as
‘poor copers’. I have made a recommendation about revising the regime to make it
more purposeful and inclusive. I also recommend routinely giving prisoners new to
G3 a mental heath screen.
New receptions to Acklington usually go to the induction wing on their first night.
However, the man’s level of anxiety and concern was such that he bypassed the
induction wing and went straight to G3. He received his induction on the unit.
Although staff on G3 were aware that the man was worried about “bother” they were
unaware of the full extent of his concerns. The documentation completed by
reception staff indicated a level of genuine concern and anxiety, but did not go into
any further detail.
The man’s anxiety was considered great enough to segregate him in a safe
environment within the prison. Staff stressed to my investigator that the man did not
appear depressed or at risk of self-harm at any point whilst on G3. I believe that
staff on G3 cared for the man appropriately according to his presentation. Staff
quickly recognised the man’s wish to transfer and assured him that they would help
with his application to do so. One officer in particular was very helpful and said that
he would personally speak to the OCA Unit when he returned from four days of
leave. The man had been allocated a personal officer, but there had been little
interaction between them. I have commented on the ineffectiveness of the personal
officer scheme at Acklington and recommended that it is revised so that officers are
allocated to prisoners, and not cell numbers. Unfortunately, the man died before the
Officer returned from leave.
The man’s death occurred on the morning of the Prison Officers’ Association (POA)
strike. The impact of the strike on resources and the response has been taken into
consideration in this report. I have found no evidence of a link between the man’s
actions and the strike. Although prisoners were unlocked considerably later that
morning, it is not possible to say whether unlocking the man any earlier would have
prevented his death. In the event, despite there being only a skeleton staff, there
was an adequate number of people on the wing to respond to the situation.
I have not been able to say with any certainty whether the man's course of action
was a cry for help or intentional. Staff acted appropriately in meeting his immediate
needs on arrival at Acklington and they had no reason to believe that he would
attempt to harm himself.
I conclude that the prison’s response to the man’s death was good, given the
unusual circumstances. I have commended the actions of those staff who remained
in the prison whilst the strike took place and who carried out their duties under
extreme pressure and in unfamiliar circumstances.
5
THE INVESTIGATION PROCESS
1. The investigation was opened on 30 August 2007 by one of my investigators.
She discussed the circumstances surrounding the man’s death with the liaison
officer at HMP Acklington. Due to the POA strike the previous day, only limited
information was then available. My investigator agreed to return to the prison
on 3 September to collect the papers relating to the man’s time in custody and
to receive a full briefing from the Governor.
2. The briefing on 3 September was attended by my investigator, the Governor,
liaison officer, and a representative from the Independent Monitoring Board
(IMB). Although invited, the POA did not attend. My investigator was given an
overview of Mr the man’s custodial history, the impact of the POA strike, and
the events on the morning of 29 August.
3. Interviews were held at both HMP Acklington and HMP Durham. An assistant
was with my investigator with her enquiries at HMP Acklington. The interviews
at HMP Durham were carried out by my investigator only.
4. A clinical review of the man’s care in custody was undertaken by
Northumberland Primary Care Trust (PCT). An extensive review was not
required as the man had minimal contact with healthcare, primary or
secondary, whilst in custody. The clinical reviewer based this on
documentation provided by the prison, transcripts of interviews carried out by
my investigator, and his own telephone enquiries.
5. One of my family liaison officers contacted the man’s family. She was directed
to speak with the man’s listed next of kin, a close family friend. Confirmation of
the family’s desire for the listed next of kin to be the primary point of contact
was provided by her solicitors.
6. My investigator and family liaison officer met with the man’s next of kin, her
daughter, and a solicitor on 10 December 2007. The man’s next of kin asked
for the following questions to be answered:
(cid:127) What were the full conditions of the man’s licence?
(cid:127) What were the circumstances of his return to prison?
(cid:127) Why was the man moved from Durham?
(cid:127) How soon would the man have been able to contact friends/family
once he had arrived at Acklington?
(cid:127) Did he make any applications for visiting orders? How many
prisoners were on G3? What is the prisoner/staff ratio on a normal
shift?
(cid:127) Did the man have a personal officer?
(cid:127) Was the man seen by a doctor at Acklington?
(cid:127) How many hours a day would the man have been in his cell?
All of these questions have been addressed within this report.
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7. During the investigation process it was brought to my investigator’s attention
that another prisoner who had died in custody at HMP Frankland the previous
year, was the man’s second cousin. The family’s solicitors questioned whether
there was a link between the cases. The man had said he was concerned
about (mistaken) rumours of being a sex offender. The man’s second cousin
had wrongly been placed in a vulnerable prisoner wing (used to accommodate
sex offenders). When he was relocated to the correct wing the move was
announced over the radio network and some prisoners in the vicinity heard
what was happening. The solicitor questioned whether this resulted in the
man’s second cousin being labelled a sex offender by other prisoners. Such
stigma can lead to bullying.
8. On reception to Acklington, the man told an officer that he was worried about
rumours that he was a sex offender. He did not explain how the rumours
originated, but did say that he felt it would cause him trouble with other
prisoners at Acklington. The solicitors asked my investigator to explore the
potential connection between the deaths of the two cousins.
9. My investigator spoke to her colleague, who had investigated the
circumstances surrounding the man’s second cousin death. This investigator
provided the following summary:
“This man was transferred from Durham to Frankland on 17 July 2006.
On reception he was placed mistakenly on D wing (for vulnerable
prisoners) for a matter of hours. The mistake was realised and he was
moved from D to G wing on the same day. A message was broadcast
over the radio system, not a tannoy or any other public address
system, advising staff that the move was taking place. It was thought
by a member of staff that prisoners had overheard the broadcast …
recognising the potential of that mistake [they] reported the matter via a
security incident report (SIR) to the Security Unit.
“On the following day (18 July) as a result of the SIR an intelligence
assessment was made and the Security Manager and the responsible
Governor assessed the matter. There were no indications of any
problem rising from or related to this incident.
“On 2 August a Senior Officer from the Safer Custody Unit checked on
this man and noted that no repercussions had taken place and that he
was settled and remained on G wing.
“This man died during the night of 7/8 September in a single cell by
hanging. No mention was made during any of the interviews [this
investigator] had with this man’s friends, fellow prisoners or staff that
knew him, that this incident had taken place or that it had affected this
man in any way.”
In light of this information, my investigator was satisfied that there was no way
to determine whether the man’s second cousin experience had impacted on the
man’s time at Acklington. There is one suggestion (see paragraph 45 below)
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that the man was concerned because a member of his family had been
(wrongly) identified as a sex offender. Beyond that, there is no known link
between what happened to the man’s second cousin and the rumours about
the man.
8
ESTABLISHMENTS
HMP Acklington
12. HMP Acklington opened in 1972 as a category C prison. The prison is situated
on a former RAF station near Amble in Northumberland. It has the capacity to
house 882 prisoners.
Accommodation
13. The prison is split into two sites – the main site and vulnerable prisoners unit
(VPU). The VPU is separated from the main site by a natural fence line and is
populated only by sex offenders. The main site comprises five wings:
(cid:127) D wing – induction
(cid:127) E wing – main residential unit
(cid:127) F wing – main residential unit, plus drug strategy wing
(cid:127) G wing – main residential unit, with a landing cordoned off for prisoners
requiring protection (G3).
(cid:127) K wing – super enhanced
14. D, E, F and G have four enclosed landings each holding 28 prisoners. A senior
officer and five officers are allocated to a wing. Each landing has one member
of staff on duty. The staff to prisoner ratio is one officer to 28 prisoners.
15. G3 is a landing on G wing that is specifically cordoned off for prisoners who
require protection from the main wing but do not fit into the criteria for the VPU,
i.e. they are not sex offenders. It is unofficially referred to as the ‘poor copers’
wing. Reasons for seeking a safe environment away from the main prison
include debts and bullying. If a prisoner asks to stay in G3 he is encouraged to
apply for a transfer to another prison. However, pressures on the prison
population often prevent a quick transfer. In some circumstances prisoners are
content to remain in G3, but due to the restricted regime this is not ideal.
Healthcare
16. Northumberland Care Trust provides healthcare to the prison. Nurses and a
medical officer are employed to deliver primary healthcare during the daytime,
seven days a week. The healthcare team is also responsible for the
administration of medication, either weekly or monthly, to prisoners who have
been assessed as capable of keeping it in their own possession. Prisoners
who require in-patient nursing care are transferred to an outside hospital or
another prison with 24 hour healthcare facilities.
HM Chief Inspector of Prisons’ report
17. HM Chief Inspector of Prisons carried out an announced inspection of
Acklington in December 2006. The inspection found that the prison failed to
provide sufficient purposeful activity and also struggled to sustain a safe and
decent environment.
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18. The Chief Inspector’s report highlights that time out of cells is poor and there is
insufficient purposeful activity for a training prison. During the inspection, less
than half the prisoners were off the wings and engaged in activity. Limited
training and education was available. What was on offer was of a satisfactory
standard, but considered to be poorly managed.
19. The Governor of Acklington, was invited by my investigator to comment on the
inspectorate’s findings. I understand the prison is to be further expanded by 64
places from April 2008. The National Offender Management Service has also
ensured that activity spaces are sufficient to at least meet the additional need.
The expansion will also, for the first time, allow full-time access to learning and
skills to both sides of the prison through one centre. A range of in-cell learning
packs is available for prisoners who are unable to access learning and skills at
any particular time.
20. An Adult Learning Inspectorate inspection in February 2008 graded the prison
as “satisfactory”. This was an improvement on the 2006 grading of
“inadequate”. The inspection found that the prison “[had] demonstrated that it
is in a good position to make improvements. The early signs of improvements
identified at the previous inspection have continued. Many effective actions
have improved the quality and range of provision.”
21. With regard to time out of cell, the above measures are an indication of
increased and improved quality of provision. Further options are being
explored to increase purposeful activity.
22. According to the Chief Inspector of Prisons’ 2006 report, drugs and bullying
were rife in the main prison. Since that report, Acklington’s Violence Reduction
Strategy has been re-launched, with a local Violence Reduction Information
Report (VRIR) system introduced. This is linked to security intelligence and
has enabled better identification and control of bullies. There have also been
improvements in supply reduction of illegal drugs. Overall, for the last three
years the prison has come within its target for mandatory drug testing. There is
also an accredited drugs programme running three times a year, and a
Counselling, Assessment, Referral, Advisory and Throughcare (CARATs) team
in place.
23. The Chief Inspector’s report found reception and first night arrangements to be
weak. However there were few incidents of self-harm and some commendable
examples of care for those at risk.
HMP Durham
24. HMP Durham was built in the early nineteenth century and has been
undergoing a major refurbishment programme during the last ten years.
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Accommodation
25. Durham is a category B local prison serving the courts in the area. Category C
prisoners from the North East region are usually transferred from Durham to
Acklington, although transfer is also dependent on population pressure and
available spaces. Prisoners remain at Durham until a space at a training prison
becomes available. The average stay for a new prisoner is two months.
Prisoners on licence recall stay for approximately one month before moving to
a training prison.
26. There are seven wings plus a segregation unit and healthcare. The operational
capacity is 981 prisoners. The main residential wings (B and D) can
accommodate 200 prisoners each and C wing holds an additional 93.
Regime
27. The prison has what it terms a non-collusive regime. This means that prisoners
are not segregated from the main prison area due to the nature of their offence.
For example, sex offenders are not housed separately and there is no
vulnerable prisoner unit. All prisoners associate and work together.
11
KEY FINDINGS
HMP Durham
28. As noted, the man was recalled to prison on 10 October 2006 after breaching
the conditions of his licence. He disappeared for a period of nine months, but
was spotted in Newcastle in July 2007. He was taken into custody at HMP
Durham on Friday 7 July 2007.
29. On arriving at Durham, the man was taken through the reception process.
Every prisoner coming into custody, whether they are a new prisoner or on
licence recall, is subject to a cell sharing risk assessment (CSRA) and health
screen. This assessment uses a series of questions to determine whether a
person is either at risk to themselves or others. The assessment is based on
documentation accompanying the prisoner (prisoner escort forms or suicide
and self-harm warning documents provided by the police), information given by
the person themself, and staff observations. In the section for recording any
observations, the CSRA referring to the man states “no immediate concerns”.
He was declared fit to be on a normal location and able to share a cell if
required.
30. The second part of the reception process is the health screen. This was
conducted by a reception nurse. During the screen this nurse asked the man
about his physical and mental health. No concerns were raised and the man
was declared “fit and well” with no further action required. He was taken from
reception to the first night centre.
31. At the first night centre on the induction wing the man was given a telephone
PIN number and sufficient credit to make a call. The prison regime was
explained to him. Although this was not his first time in custody at Durham he
underwent the same process as any new prisoner.
32. From Monday to Thursday each week, new receptions have an immediate
needs assessment within 24 hours of coming into the prison. (If they arrive on
a Friday, it takes place the following Monday.) The assessment determines
any immediate needs or concerns regarding housing, benefits, family,
employment or legal support. The man’s immediate needs assessment took
place on 9 July.
33. An officer conducted the man’s assessment. She explained the assessment
process to my investigator. As part of the assessment, the officer contacts the
prisoner’s offender manager (probation officer) to let them know which prison
they are in. In the event that the prisoner is unsure why they have been
recalled, the officer will, where possible, provide them with more information. In
the comments and observations box at the foot of the assessment paperwork
for the man, she has written “outside probation notified. Licence recall
procedures explained.”
34. My investigator asked this officer if she could remember her interview with the
man. The officer could not and asked to see his photograph in case this
12
prompted any specific recollection. It did not. She explained that she conducts
hundreds of interviews and, unless prisoners present as being particularly
problematic or vulnerable, they do not stand out from the crowd. The officer
went on to say that, had the man raised any concerns or if she herself had
been worried about him, she would have noted it on the form and discussed her
concerns with induction wing staff.
35. On 11 July 2007, the man was moved from the induction wing to C wing. This
is a voluntary drug testing wing that is half the size of the other wings in the
prison. At maximum capacity the wing holds 93 prisoners over four landings.
Due to the smaller numbers, prisoners receive more staff attention. Prisoners
go to this wing for three reasons:
(cid:127) It is guaranteed to be free of any illegal substances.
(cid:127) They have been identified as “good candidates” whilst on the
induction wing (meaning not likely to cause any trouble for staff).
(cid:127) They would fair better on a quieter and smaller wing.
36. Despite the vulnerability of some of the prisoners it would be unfair to label it a
‘poor copers’ wing (a term that, in any case, I dislike). It is not clear why the
man came to the wing but, given no concerns or risks were raised, my
investigator believes he might have been placed on this wing for good
behaviour.
37. The regime on C wing is very structured. All prisoners are expected to take
part in purposeful activity every day. This means employment in the workshops
or wings, education, association or gym. An average week day allows for at
least eight hours of activity and association. During the weekend, there are two
periods of association, one in the morning and one in the afternoon. Prisoners
attend one session each day and attendance is established by rota. Being
based on C wing will have meant that, whilst at Durham, the man was in a safe
environment with an acceptable amount of time out of his cell.
38. It is documented in the man’s history sheet that he quickly settled in C wing and
had no concerns or problems. An officer on this wing noted that the man is a
“mature individual who keeps himself to himself”. A second entry on 28 July by
the same officer noted that the man had begun to mix with his peers, “but
needs to be careful who he mixes with”. It is not clear from the entry what this
officer meant by this. My investigator was unable to interview the officer as he
was on long term sick leave and none of the other officers interviewed knew
what this officer meant. As far as staff were aware, the man was not involved
in any trouble on the wing or was the victim of any bullying. There are no
further entries in his history sheet to suggest that anything sinister was meant
by the comment. My investigator did not speak to any prisoners at Durham.
None had asked to speak to her about the investigation, and when she visited
there were no prisoners on C wing who had been there at the same time as the
man. However, my investigator was satisfied from talking to a cross-section of
staff (including the chaplain) that there were no indications that the man had
suffered any bullying.
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39. On 16 August, the man was seen by a nurse from healthcare to ascertain
whether he was “fit to transfer” to another prison. Transferring from a local
prison to a training prison once a space becomes available is part of normal
progression through the prison system. The “fit for transfer” interview with a
member of healthcare is a pretty cursory assessment. It comprises a list of
basic questions covering whether the person has any medical problems, or
needs any medications dispensed to take with them on transferring. The man
was noted to have no medical needs. He was also asked how he felt about
transferring. The reply recorded was “happy”.
HMP Acklington
40. The following day the man moved to HMP Acklington. On arrival he went
through the same reception process as he had at Durham. However, on this
occasion when he was asked how he felt about coming to Acklington, he
appeared concerned and anxious. An officer completed the initial risk
assessment interview with the man. The first question on the form is, “Have
you any immediate concerns/worries about being at Acklington?” The man said
he had. The officer wrote, “Knows for a fact that he will have ‘bother’ here.
Unknown persons. Has requested G3.”
41. As noted earlier, G3 is a landing in G wing that offers security for prisoners who
feel they cannot cope in the main part of the prison. The vulnerable prisoners
unit at Acklington is used solely for accommodating sex offenders. Any
vulnerable prisoner who is not a sex offender can request a placement on G3.
42. The landing is split into two spurs. The regime on both spurs is limited as the
prisoners are kept separate from both the rest of the wing and the main prison.
There is no employment or education on offer, and association is limited to a
couple of hours per day. There are two association periods of one half hour
session in the morning and a couple of hours during the evening. Spurs take
association periods in turn. As a result, on alternate days each prisoner only
receives 30 minutes association time. The rest of the time (aside from
collecting meals) is spent in their cells. Residing in G3 is a voluntary decision
and prisoners can move back to the main prison on request. They can also be
moved for negative behaviour.
43. The officer asked the man if he felt staff should be concerned about his well-
being. He responded “yes”, but no specific details were documented. In
response to the question, “Do you feel depressed or suicidal in any way or have
you previously committed any act of self-harm?” the officer ticked the ‘yes’ box.
He wrote, “Very anxious ref above comments.” Although it is not recorded on
the form, the officer recalled in interview that the man said he felt unsafe as
rumours were allegedly spread at HMP Durham that he or a member of his
family was a sex offender. The man believed that this would cause him some
trouble. The officer recorded part of this information in the man’s history sheet:
“Appears genuinely concerned for his safety. Rumours were being
spread at Durham he knows there will be ‘bother’ here from unknown
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persons. He appears very concerned about any abuse he will get from
the ‘windows’. G3 explained to him and offered.”
44. The man appeared genuinely anxious. The officer felt that he was presenting
as paranoid. The man did not provide any concrete information as to why he
was so concerned. However, he did tell the officer that he believed an
application for transfer from Durham had been submitted on his behalf under
false pretences by another prisoner. My investigator did not find any substance
to this claim. His transfer was a routine procedure and there was no evidence
of bullying or rumour spreading found in Durham.
45. My investigator asked this officer about his interview with the man, particularly
with regard to evidence of depression, self-harm or suicide. Although the man
had admitted to self-harming in the past and appeared anxious and concerned
for his safety, the officer did not feel that he presented as a risk to himself at
that time. The officer stressed that, if he had thought the man’s concern went
beyond paranoid anxiety, and there had been signs of depression or risk of
self-harm, he would have opened an Assessment, Care in Custody and
Teamwork (ACCT) form. (ACCT is the Prison Service’s process for monitoring
and supporting prisoners believed to be at risk of suicide or self-harm.)
Nevertheless, he treated the man’s concern as genuine and allocated him a
space in the G3 unit. He said that the man was very relieved and thanked him.
It is important to note that this was the only time that the man mentioned his
concerns about the sex offender rumour to anyone.
46. Before being moved to a wing, prisoners are routinely issued with a reception
pack (containing tobacco, chocolate, drinks, breakfast items etc) and £2
telephone credit. The man did not make any telephone calls. A second officer
escorted the man to G3. He knew that the man was going to G3 for his own
protection, but no more than this. The assessment officer had not discussed
the reason with him. The documents that went with the man to G3 contained a
cursory reference to him being worried about “bother” but gave no further
explanation.
47. An officer on G3 spoke to the man the next morning. The man explained that
he was expecting trouble at Acklington, but did not go into any detail. This
officer noted that the man was “very vague” about why he was on G3. Aside
from saying he felt he should not be at Acklington, he would not elaborate. This
officer told my investigator that every time he spoke to the man he would say, “I
need to get away from this jail.” He tried to reassure the man, telling him he
was safe on G3. However, the man continued to talk about wanting to transfer
out of the prison. He never referred to specific prisoners and never detailed
any particular problems.
48. Apart from not wanting to be at Acklington, the man seemed fine. As the days
passed he became more sociable and spent association periods out of his cell.
Although settled he did not make any contact with his friends or family; neither
did he send out any visiting orders. The personal officer scheme provides
prisoners with a specific officer with whom they can raise issues or ask
questions. At Acklington, personal officers are allocated seven cells each,
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rather than specific prisoners. The cells allocated remain fixed, so if a prisoner
moves cell (which can be a frequent occurrence) they also move personal
officer. This makes building personal officer relations difficult. Personal officer
interactions are recorded on a prisoner’s history sheet.
49. The officer on G3 spoke to the man again on 23 August about a transfer.
Prisoners are usually required to say which prison they would like to move to
and the application is then processed by the OCA Unit. The officer asked the
man where he would like to go. The man confirmed that he would be happy to
move anywhere in the country. The officer told the man he would help him
submit a transfer application, but that the two senior officers (SO) in the OCA
unit were both off duty and he was himself due to go on leave for the next four
days. He said if the man was happy to wait until 29 August, he would
personally speak to a particular SO on his return. The officer also explained to
the man that his willingness to go to any establishment would make the process
quicker and easier, and that the SO would be able to advise which prisons had
spaces available. My investigator asked this officer whether he felt the man
was accepting of this help and willing to wait until his return. The officer
confirmed that he was, and said that the man appeared calmer as a result of
their discussion.
50. Approximately three days later, the man spoke to the same officer as previously
about transferring to another prison but did not explain the reason. The officer
gave him a transfer application form and offered to pass it to the OCA Unit once
completed. Again, the man appeared content with this although he did not
complete or submit the transfer application form.
51. At 6.00pm on 28 August, the man was out for evening association. One of the
officers on duty, locked the spur gate (access to cells is restricted during
association period) for an hour. At approximately 6.30pm, the man approached
him and asked to be taken back to his cell early. He gave no reason for the
request. This officer stressed to my investigator that the man did not appear
troubled or distressed. On returning to his cell the man made no further
requests. This officer last saw the man at approximately 7.20pm as he
performed the evening roll check. (This is a procedure when officers look
through the observation panel in the cell door to make sure that the right
number of prisoners are present, located in the correct cell, and that there are
no obvious problems.) At this time the man was sitting on his bed and
appeared fine. This officer finished his shift at 8.30pm.
52. During the handover to night staff, no issues or concerns were flagged
regarding any of the prisoners on G3. An operational support grade (OSG)
came on duty at 8.45pm. At night, an OSG is responsible for patrolling all the
prison wings and performing checks on prisoners. Night roll checks are
performed at approximately 9.00pm, 10.30pm and 5.30am. During the night
there is no requirement for verbal interaction, the checks are purely visual
unless the prisoner is at risk of self harm or suicide. The OSG told my
investigator that on all three roll checks the man appeared fine, and there was
nothing noteworthy about his behaviour or appearance.
16
53. The following morning day staff arrived at the prison from 7.00am for a 7.30am
start. Circumstances on the morning of 29 August were highly unusual. At
7.00am, the POA announced an unofficial countrywide strike. No prior warning
had been given to governors. Acklington’s Governor informed his managers of
the situation at 7.15am and an emergency contingency plan was put into
action. The Governor’s office became a command suite and all governors
arriving at the prison were called to the office for a briefing, to establish how
many staff were remaining in the prison, and to assign roles. By 7.30am, day
time operational staff were remaining outside the prison gate and not taking
over from night staff. Simultaneously, night staff were leaving the prison and
joining the picket line, leaving only a skeleton staff in the prison.
54. At 7.20am, an officer arrived at the gate and picked up his radio and a set of
keys before heading to G3 at 7.25am to begin his shift. At this time the night
staff were leaving the wing and one or two members of day staff were already
present. After a handover, this officer performed a roll check on the landing.
He checked all 28 cells, noted that everything appeared normal, and signed the
log sheet. To his recollection, the man was lying on his bed. After signing the
roll check log, the officer recalls being informed of the strike. All officers on the
wing apart from the officer who had just arrived left to join the strike.
55. The remaining officer noted that the roll check for G4 landing had not taken
place. He performed the roll check and gave the final figure for G wing to the
control room. On return to the office he received a telephone call from a POA
member who instructed him to tell a governor that he felt unsafe on the unit with
depleted staff and wanted to join the others at the gate.
56. At approximately 8.15am, the deputy governor, three other governor grades,
and two principal officers (PO) arrived on G wing to assist with unlocking for
breakfast. The remaining told the deputy governor, that he was unhappy and
wanted to leave the prison. The deputy governor sought advice from incident
command at national level (called Gold Command). The response was that the
officer should be given a direct order to remain in post.
57. The deputy governor told the officer to unlock two prison orderlies from F wing
to assist with breakfast. The total number of staff on patrol for the wing was
eight. The decision was taken to perform a controlled unlock. This meant
unlocking a maximum of four prisoners at a time to retrieve their breakfast from
the servery and return to their cells. Two cells from either side of the landing
were unlocked at the same time. The process began on G1 landing. Two
governors staffed the servery with the orderlies, whilst another two governors
unlocked the cells. The officer stood downstairs at the end of the G4 landing
watching the prisoners go to and from the servery. As soon as prisoners
returned to their cells, the next four were unlocked.
58. At approximately 9.30am, prisoners in G3 were being unlocked. The man was
in cell number six. It was around 9.40am when the first four prisoners from the
landing had picked up their breakfast. One governor opened the observation
panel on the man’s door and saw him in a kneeling position with his head bent
forward. A ligature made from a strip of bed sheet was tied around his neck
17
and suspended from the strip light fitting. This governor immediately shouted
“Code blue, we’ve got a person hanging” to the second governor. (“Code blue”
is the name given to an emergency situation involving hanging or breathing
difficulties.) The first governor then opened the cell door and rushed in to
support the man’s body. The second governor ran into the cell and stood on
the bed to try and pull down the ligature. Neither governor was carrying an
anti-ligature knife, a piece of equipment that all frontline operational staff are
required to carry on their belts.
59. The first governor loosened the ligature in a matter of seconds. The second
governor lifted and supported the man’s weight whilst the first governor tugged
at the bed sheet by the light fighting until it snapped. They placed the man on
the floor and loosened the sheet around his neck. The second governor then
left the cell and made sure that the prisoners collecting breakfast went back to
their cells.
60. The first governor’s assessment was that the man had been dead for some
time. His arms were blue and legs mottled (cyanosed), rigor mortis had started
to set in, and he had urinated. Despite this, the governor placed the man in the
recovery position and was about to commence cardio pulmonary resuscitation
(CPR) when a nurse reached the cell. She had arrived very quickly as she was
already on the wing having been instructed to help with general duties. She
had heard the “code blue” call and rushed to the cell. The nurse did not bring
the emergency response bag to the cell although it was easily accessible (the
bag is located between F and G wing in the healthcare dispensary). Before the
governor had the opportunity to start mouth to mouth resuscitation she told him
to stop. The nurse told my investigator, “My initial reaction was to jump in and
start CPR, but after stepping back and looking at the situation it seemed that
would be a very futile exercise because it was very clear that the man was
dead.” She said that if she had required the emergency response bag, she
would have started CPR, used the radio to call “code blue”, and asked for the
bag to be brought to the cell.
61. A prison doctor was asked to come to the cell and certify death. He arrived at
approximately 9.50am. The governor and nurse then left the cell. Due to the
exceptional circumstances of the day, it was impossible to implement the
routine death in custody contingency plan. Instead, advice was sought from
Gold Command on how to proceed.
62. The deputy governor spoke to Gold Command. He was told to block off the
observation panel, close the cell and continue unlocking for breakfast. A
Principal Officer (PO) remained outside the cell door. It was a delicate situation
as staff had to complete the breakfast unlock without drawing attention to the
fact there had been a death. As soon as breakfast was over, prisoners were
properly informed. A notice was also distributed for those in other wings. The
chaplain, who was already in the wing, provided immediate support and
counselling to anyone who required it. All those prisoners with open ACCT
forms were reviewed by the duty community psychiatric nurse (CPN).
18
Events after the man’s death
63. Although some support was offered to the staff involved, the usual protocol for
relieving staff of duties was not possible given the circumstances of the POA
strike. There were also other incidents during the day that took precedence.
However, counselling and support was offered the next day once the strike had
ended and the normal regime resumed.
64. The man’s next of kin was listed as a family friend and neighbour. The prison
informed her of the man’s death. The family friend relayed the news to the
man’s uncle and the prison chaplain, and the deputy governor later visited him.
The prison chaplain told the man’s uncle that the prison would assist with the
funeral service and meet the expenses. The man’s belongings were returned
to his aunt to be passed on to his son. The prison chaplain provided continuing
support to the man’s family and friends for which she was grateful. The man’s
funeral took place on 7 September 2007. The prison chaplain conducted the
service at the family’s request. The liaison officer attended representing the
Governor of Acklington, along with a SO, the prison’s family liaison officer.
19
ISSUES
Clinical
65. Northumberland Primary Care Trust (PCT) undertook the clinical review.
Summary
66. The man was admitted to HMP Acklington on 17 August 2007 and died by
hanging 12 days later. At no time was there any indication during routine
healthcare assessment that he had current mental health problems.
Areas considered
Were mental health issues adequately screened in the initial healthcare assessment
on 17 August 2007?
67. The clinical reviewer says the screening was carried out by an experienced and
appropriately trained member of healthcare staff. On progressing through the
screening no mental health issues, past or present, were identified. This
reflected the results of many previous assessments conducted during the
man’s time in custody.
68. During the reception healthscreen, a nurse asked the man whether he was
happy to be at Acklington. Although the nurse ticked the ‘no’ box, the adjacent
box that could be used for further comments was not completed. The nurse
told the clinical reviewer that the man did not want to discuss his reasons for
not being happy and she thought his response to the question was typical of
most new receptions. She concluded, therefore, that there was nothing
untoward about his comment. The next set of questions related to mental
health. The man told the nurse that he had no history of mental health
problems, including depression or self-harm. Based on this information, the
nurse decided that no further action or intervention was required.
69. The clinical reviewer concludes that the absence of follow up questions to elicit
further information when prisoners say they are unhappy to be at the prison
was inadequate. I agree. Further to this, the box adjacent to the question that
could be used for comments is not clearly labeled. I suggest that the
healthscreen form is amended to label the box clearly and indicate that it is
mandatory to record further information in the event of a prisoner being
unhappy. If the prisoner refuses to elaborate or discuss his concerns, it is
equally important to note this. It would demonstrate that at least one follow-up
question had been asked in relation to a negative answer.
I recommend that the Head of Healthcare at HMP Acklington, with the
Primary Care Trust, revises the initial reception healthscreen assessment
form to make it mandatory for further information to be recorded if a
prisoner expresses concerns about being transferred to the prison.
20
Was resuscitation appropriately withheld?
70. This content that, in the circumstances, the decision not to attempt resuscitation
was correct. An experienced nurse and doctor separately concluded that
attempts to resuscitate would be futile.
Was the unusual circumstance caused by the strike on that day of any relevance?
71. The clinical reviewer says the circumstances meant that the normal routine (for
discipline and healthcare staff) was disrupted. As a result of the strike,
prisoners were left locked in cells for longer than usual as staffing levels were
critically reduced and a different strategy for unlock had to be employed. It is
not possible to say with certainty that unlocking the man’s cell at the earlier
usual time would have prevented his death. The man had concealed any
intention to take his life from staff and fellow prisoners.
Evidence of Good Practice
72. Under the Northumberland PCT verification of death policy, nurses are
permitted to use their judgement in deciding if CPR is necessary. Where
experienced clinical staff judge that attempts at resuscitation would be futile,
this is both humane and respectful to the deceased person and to the staff
themselves. In the man’s case, the nurse at the time decided against CPR.
However, she did not exercise the verification policy as she knew there was a
doctor on site who could attend within minutes to pronounce death.
General
Impact of the POA Industrial Action
73. The POA held an unannounced strike on 29 August 2007. The High Court
declared the industrial action unlawful, stating that any officer not returning to
work would be in contempt of court. This was ignored by most officers
belonging to the union. As a consequence, prisons all over England and Wales
were left with only a skeleton staff, largely comprising governor grades. The
aim was to provide prisoners with meals and emergency medical attention for
as long as the strike lasted. Prisoners were made aware of the situation by
staff as the morning unfolded and through watching or hearing the news on
their radios and televisions.
74. The impact of the strike was felt at all prisons. The industrial action was called
at 7.00am. Night staff left prisons and were not relieved by day staff. Governor
grade staff were called upon to perform operational duties such as serving
meals, with the help of the few officers not members of the POA or who
declined to join the strike. Prison orderlies were also tasked to assist.
75. At Acklington, The Governor began informing his governor grade colleagues
from 7.00am. He asked them to arrive for duty as soon as possible. After
approximately 40 minutes the situation was under control with night staff
relieved at around 8.15am. The governors and any staff who decided to stay
21
and help were allocated responsibilities in accordance with the contingency
plan.
76. By this time, patrols had been assigned to wings and they had begun
organising how to manage the day, starting with serving breakfast. This would
normally have been served from 7.45am with whole landings being unlocked
for prisoners to collect their breakfast from the servery. Given the very limited
numbers of staff and the importance of maintaining security, this was not
possible on 29 August. It was decided to unlock four to six prisoners at a time.
This was a time consuming process and meant that serving breakfast took over
two hours. It also meant that no prisoner was seen by a member of staff from
the point of roll check (between 7.00-7.30am) until they were unlocked to
collect their breakfast.
77. Given the exceptional circumstances, the fact that the man was not seen from
approximately 7.30am until his cell was unlocked at 9.20am was not
unreasonable. The man was not treated differently to any other prisoner and
he had not presented as a risk to himself. The staff tasked to run the prison
that morning worked hard and to the best of their ability given the difficulties.
Despite the fact that they were working under pressure and performing tasks
they would not usually do, the staff to prisoner ratio for each landing was higher
than it would be on a normal day. The normal ratio is one officer to each
landing (28 prisoners). On that morning there were eight members of staff
managing the regime.
78. I have no evidence that the strike contributed directly to the man’s death. His
actions took staff and prisoners alike by surprise. I am unable to judge whether
being unlocked earlier for breakfast would have made any difference to the
outcome.
Contingency plan
79. The senior management team held an initial debrief followed by a contingency
planning exercise a few days after the strike to reflect on the existing plan and
incorporate lessons learned. The nurse who came to the man’s cell was not
aware of the debrief and was not invited to contribute retrospectively.
80. My investigator discussed the contingency plan for industrial action with
another governor. She asked whether after the debrief any inadequacies in the
plan had been identified. This governor said that with hindsight a less cautious
approach could have been adopted in unlocking for breakfast on the vulnerable
prisoners unit. The vulnerable prisoner population present fewer control
problems, and the process could have been made quicker by unlocking more
prisoners at a time. This would have left more resources for the main prison
and meant unlock in other areas could have been slightly quicker. Another
possible time saving measure identified was the use self-heating foods which
could be distributed to cells and reduce the time taken to serve meals. It is
impossible to say whether either approach would have made any difference to
the man’s situation.
22
81. A further lesson learned was that governors did not carry anti-ligature knives.
The contingency plan has since been amended to read that governors carrying
out operational duties should carry the same equipment as that which discipline
staff are expected to carry. Whilst access to an anti-ligature knife would not
have made any difference as the man had been dead for some time when he
was discovered, it might be critical in the future.
82. I have been pleased to learn that the senior management team took the
opportunity to reflect on the effectiveness of Acklington’s contingency plan.
This is good practice. However, I am disappointed that not all staff involved in
the emergency were invited to the debrief. The nurse told my investigator that
she would have found it useful to have attended and heard the discussion that
took place.
Reception interviews and paperwork
83. During his reception interview at Acklington, the man told the assessment
officer that he was worried about rumours originating from his time at Durham
about being a sex offender. Although this officer had made reference to the
man’s concerns in the induction paperwork and on his history sheet, he did not
record them explicitly. No other member of staff interviewed knew the precise
nature of the man’s concern. The reception interview and induction paperwork
are intended to make sure that a prisoner is appropriately supported and
managed, and that needs are met at the earliest point. Reception staff come
into contact with prisoners only infrequently once they have moved into the
main prison. For this reason, it is important that as much information as
possible moves with a prisoner, particularly when the prisoner is identified as
being vulnerable.
84. The man never spoke fully about his concerns after the reception interview. It
would have been useful to staff on G3 to have had sight of all information that
had been made available to the assessment officer. However, given my
investigator was unable to find any evidence to explain why the man had
expressed the concern he did, it is debatable whether it would have made any
difference to the outcome. Despite this, I strongly recommend that when and
where possible staff should provide a comprehensive record of issues and
concerns in all paperwork. This is a recommendation that I have previously
made to the Governor in the case of a prisoner who died at Acklington on 17
September 2004 and wish to restate.
The Governor of HMP Acklington should remind staff of the importance of
comprehensive record keeping and information sharing.
Personal officer scheme
85. The personal officer scheme at Acklington was re-launched in 2006. However,
during an inspection in 2006 HM Chief Inspector of Prisons found little evidence
of active personal officer work. Staff received little or no training in personal
officer duties and some had insufficient time to fulfil the role. Many prisoners
did not know who their personal officer is as personal officers were allocated to
23
cells rather than to individual prisoners. My investigator found this remained
the case.
86. I support the Chief Inspector’s recommendation that:
“… personal officers should introduce themselves to prisoners, get to know
their personal circumstances and record contact in wing files to build up an
accurate chronological account of their time at Acklington and any significant
events.”
I would add to this by suggesting that personal officers be allocated to
individual prisoners rather than to cell numbers. This would foster better
continuity of care and make it easier for personal officers to keep track of a
prisoner’s progress.
I recommend that the Governor revises the personal officer scheme at
Acklington to allocate officer responsibility by prisoner and not cell
number.
Access to telephones
87. The man’s next of kin asked whether he would have had access to a telephone
on arriving at Acklington. She told my investigator that she found it odd that he
had not made contact.
88. On reception into prison, prisoners are entitled to a free telephone call. All new
arrivals at Acklington are given a £2.00 telephone credit, but not all receive a
free telephone call during the first few days at prison. The man’s credit was
available from 20 August. He tried to make three telephone calls on 23 August.
The first two were at 10.49am and 10.59am; however the PIN system was not
switched on at this time. He tried again at 11.01am (when the system was on)
but his called was disallowed as he had no active telephone numbers on his
account. All three calls were to the same number. The prison has confirmed
that the man had £3.36 on his PIN account at the time of his death. There is no
evidence of any recorded approved telephone numbers.
89. The 2006 report by the Chief Inspector of Prisons noted that a number of
prisoners complained about delays in activating the telephone numbers they
wished to call and that the procedure could be lengthy. Prisoners record their
telephone numbers in reception and the security department makes sure they
are allowed to contact the people on the list. This can take a few days. Once
cleared the numbers are registered on to the personal identification number
(PIN) system.
90. G wing has five telephones for 112 prisoners. This is one extra phone
compared to the similar sized wings (E and F). Prisoners on G3 have some
difficulty in accessing the phones as they are locked in their cells during the day
and only receive a short association period every other day. Morning
association is between 10.45am and 11.15am and from 5.00pm to 7.00pm
during the evening. There is also opportunity for prisoners to use the telephone
24
when collecting lunch. Under some circumstances staff on G3 will allow calls
outside of these times.
I reiterate HM Chief Inspector of Prisons’ recommendation that all
prisoners should have daily access to a telephone.
G3 Unit regime
91. The HM Chief Inspector of Prisons report referred to G3 as offering an
“impoverished regime” for prisoners who through debt or personality clashes
needed protection from other prisoners. Lack of regime, in particular lack of
access to education and courses to address offending behaviour, meant that
prisoners on G3 stagnated. It made progression through the prison system
difficult and prisoners on the wing either had to transfer out or move back to the
main prison.
92. I agree that the regime on G3 unit is very limited. Prisoners spend an
unhealthy amount of time on their own in their cells with little stimulating
activity. Due to the positioning of the unit (a cordoned off unit in the middle of a
normal functioning prison wing), it is difficult to provide a more purposeful
regime. The prisoners in G3 need to be kept separate from other prisoners in
the wing and the rest of the prison for their own safety. To manage this they
are unlocked at different times for short intervals. Whilst this does mean that
prisoners are safeguarded, it does not help address the reasons why they are
in G3 in the first place. There appears to be little done to progress prisoners
out of G3 aside from transferring them to another prison.
93. I am concerned about the lack of follow-up support that the man received on
moving to G3. Although care had been taken to ensure he was situated in an
area where he would feel safer, no structured support appears to have been
provided beyond this. I appreciate that the man was not known to have any
mental health or self-harm problems, but consideration could have been given
to offering some support given his initial anxiety and his placement on a so-
called ‘poor copers’ unit. For example, he could have been offered an initial
session with the mental health in-reach team or, if available, another
counselling service. Such intervention might have helped bring out any deep-
rooted issues regarding his vulnerability that he might not have felt comfortable
talking about to an officer or fellow prisoner. G3 is an isolated environment,
and more needs to be done to foster an inclusive regime with a view to helping
prisoners move on or cope better.
I recommend that all prisoners allocated to G3 at Acklington are routinely
offered an initial session with the mental health in-reach team or another
counselling service, regardless of their perceived self-harm or mental
health problems.
94. Although G3 serves an important purpose, I consider that it compartmentalises
problems rather than solving them. However, I accept that G3 needs to be
sustained. What I would like to see is serious consideration taken to moving
the unit and developing a more inclusive and purposeful regime.
25
I recommend that the Governor of HMP Acklington moves G3 unit to an
area of the prison where a more inclusive and purposeful regime can be
provided.
Transfer and application process at HMP Durham
95. During her interviews at Durham, my investigator asked a number of officers
who work on C wing about the administration of applications for transfer. An
officer was asked whether it would be possible for a prisoner to submit an
application on behalf of another prisoner without their knowledge. He said that
this would only be possible if officers were particularly busy or if a high number
of applications was submitted on any one day. There is no limit to how many
applications a prisoner can submit in one go. Applications are handed in once
a day at a set time. If the officer who records the applications had a high
number to process, he or she might have difficulty identifying which prisoner
handed in a particular application. However, the officer stressed that if the
application was for an important request, such as a prison transfer, then the
prisoner would be approached by an officer to discuss it. Under no
circumstances would a request for transfer be submitted and processed without
the prisoner concerned being aware of what was happening. If an application
was submitted under false pretences and was not of a trivial matter (particularly
if the perpetrator was identifiable), a security information report (SIR) would be
raised.
96. My investigator asked the officer how far in advance of transfer a prisoner
would be told that they were moving. The officer replied that they would know
the day before they leave as a member of the healthcare team would have to
declare them “fit for transfer”. He also said that night duty staff would be aware
of any move as they would be required to prepare prisoners for leaving the
following morning. However, it is unlikely that officers would be aware of which
prison they would move to.
97. The transfer process is handled by the Observation, Categorisation and
Allocations Unit (OCA Unit) in the prison. A senior officer (SO) in Durham’s
OCA Unit, explained the transfer process to my investigator. All prisoners with
a long sentence can expect to be transferred from a local prison to a training
prison. (A long sentence is regarded as more than 12 months.) Transfers can
also be dictated by population pressures. A prisoner is transferred to a prison
consistent with their security categorisation, i.e. category A, B, C or D.
Acklington is a category C prison that holds some life sentence prisoners.
Another training prison in the north east is Kirklevington Grange. This is a semi
open prison. Reception to Kirklevington Grange follows an extensive
application process for category C or D prisoners. All applicants must
demonstrate the following:
(cid:127) Evidence of a desire to change
(cid:127) Evidence of need for resettlement
(cid:127) Evidence of ability to be granted temporary release on licence.
26
A prisoner on licence recall in the North East could not expect to be transferred
from Durham to Kirklevington. They would transfer to Acklington.
98. The average stay for a prisoner at Durham is approximately two months after
categorisation. A prisoner who is on licence recall would remain at Durham for
at least a month before transferring to allow time to establish whether any new
charges would be brought against them. Any additional charges would require
a court appearance so they would not transfer until the hearing was over.
99. Like other licence recall prisoners, the man would have been placed on a
waiting list to transfer to Acklington once the initial month had passed and a
space became available. As mentioned above, before a transfer can occur a
healthcare member must declare the prisoner ‘fit’ (meaning clinically well).
100. In addition to the healthcare assessment, all prisoners at Durham except for
those on licence recall are personally informed by a member of staff from the
OCA Unit. The member of staff explains that a transfer will happen and offers
the opportunity to the prisoner to cite any security reasons for not going to a
particular prison. Any such reason must be supported by evidence as well as
the names of prisoners they might have trouble with. The SO explained that
prisoners will often say that they do not want to go to a particular prison
because it is far from home and difficult for visitors, rather than for security
reasons. This is why sufficient reasons need to be given and confirmed prior to
the transfer.
101. At the time that the man moved from Durham, a licence recall prisoner would
not have received any contact from the OCA Unit. Licence recall prisoners
would still have had the opportunity to appeal against the transfer (by
submitting an application and statement to the OCA clearly stating the reason
for appeal). It was assumed that licence recall prisoners were familiar with the
process and therefore did not require a specific meeting/interview with the OCA
Unit.
102. This means that the man would have had contact with healthcare, but not with
the OCA Unit. The healthcare assessment records that he was “happy” to
transfer. It was open to him to submit an application asking not to transfer to
Acklington for security reasons, but he would have to have known about this
procedure and have asked wing staff for an application. There is no record of
the man submitting an application appealing against the move. The first
mention of his concern is recorded during the reception process on arrival at
Acklington. Either he did not consider the possibility of going to Acklington
when he was asked if he was happy to transfer, or the reason he gave when he
arrived was not genuine. It is impossible for me to comment with any certainty.
103. My investigator identified the disadvantage to licence recall prisoners and
discussed it with this senior officer, and with the Governor and Deputy
Governor of HMP Durham. She pointed out that, whilst licence recall prisoners
might be familiar with the system, they were not given the opportunity to
discuss any potential problems directly with the OCA Unit. The process heavily
27
relied on a prisoner being pro-active and more importantly knowing that they
had to be pro-active.
104. My investigator asked the SO whether it would be problematic or time
consuming for the OCA Unit to extend the ‘transfer interview’ to prisoners on
licence recall. He said that, if they were instructed to do so by management,
the OCA Unit could do this. However, he recommended that a more efficient
and effective way (given that licence recall prisoners are likely to be familiar
with transferring between establishments) would be to issue a simple slip to
prisoners informing them that they could be transferred at short notice. The slip
would highlight the opportunity for raising any concerns or submit a statement
to the OCA Unit in time for consideration before a transfer. He showed my
investigator an example of a slip already in use for new prisoners (except
licence recall prisoners). The Governor and deputy governor were receptive to
this idea, and said they would immediately implement a new system for
advising licence recall prisoners of transfers. I welcome and commend this
prompt response to feedback from my investigation.
28
Conclusion
108. It is not clear why this man took the actions he did on 29 August 2007. He left
no note and gave no indication of vulnerability or risk to himself. It was very
clear that he wanted to leave Acklington, but after his reception interview with
the assessment officer he never discussed the reasons. My investigator found
no evidence to suggest that the man was bullied at either Durham or
Acklington. He rarely came to staff attention and was a relatively quiet prisoner
who did not present as a cause for concern. He ‘kept himself to himself’ and
was happy to spend time ‘behind his door’.
109. The man’s initial anxiety on coming to Acklington was noted and handled
appropriately (and swiftly) by placing him on G3. The man was made aware of
the implications of being in the G3 unit (the limited regime) and nevertheless
appeared content to go there. His desire to transfer to another prison was also
dealt with appropriately. The officer on G3 told the man that he would handle
his transfer application as soon as he returned to work. Unfortunately, the man
hanged himself the day that this officer was due back from leave.
110. Staff who remained in the prison on the morning of the strike were faced with
the difficult task of maintaining security whilst trying to provide a limited regime.
Good teamwork was demonstrated and problems were tackled head on with as
little disruption as possible. The response to discovering the man was calm,
quick and appropriate. The two governors on scene were faced with a difficult
situation that neither would have encountered since working as officers. I
commend them for their swift, professional and sensitive handling of the
situation. It cannot have been easy for any of the staff involved, particularly as
there was no opportunity for staff to be relieved of their duties due to the
pressures caused by the strike.
111. I have been particularly concerned to see whether the fact of the POA industrial
action could in any way be related to the man’s death. I cannot discount that
possibility, but neither have I found any evidence to show that the two things
were connected in any way.
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RESPONSE TO THE DRAFT REPORT
112. The man’s family asked for clarification on the following points.
Self-harm and suicide risk
113. The man’s family remain concerned about staff at Acklington not identifying his
risk of self-harm. In their response to the draft report the family highlight:
(cid:127) his change in attitude to transferring prisons, and ask why it was not
further explored
(cid:127) the fact that an ACCT document was not opened
(cid:127) little support for the man
All of these issues have been dealt with during my investigation and explored at
length.
114. It was noted by the assessment officer during the reception process that the
man was unhappy and concerned to be at Acklington and he was moved
straight to unit G3. The man did not discuss his concerns any further with the
assessment officer. Despite the fact that the man said that he had self-harmed
in the past, this officer did not find him to be a current risk to himself. Decisions
to open an ACCT document are made by trained staff who consider a
prisoner’s presentation, recent events and information provided, i.e. police
records, information given by the prisoners. The decision is a judgement call
by staff. An ACCT form is not opened based on past events. If an ACCT
document was opened for every prisoner who had self-harmed in the past there
would be a danger of devaluing the process. The number of ACCT documents
would be very high and the process would be difficult to manage with purpose.
115. As previously stated, this issue was considered during the course of the
investigation and I have already highlighted my concerns. I remain content that
the assessment officer acted appropriately given that the man did not actively
present as a risk to himself. I have however recommended that all prisoners
allocated to G3 are routinely offered an initial session with the mental health in-
reach team or another counselling service, regardless of self-harm or mental
health issues. This has been accepted by the Prison Service.
116. There is no evidence that the man did not have access to Listeners or the
Samaritans telephone line. Both of these services should have been available
to the man if he had requested them. I have already commented on the
personal officer scheme and made a recommendation.
The strike
117. I have taken note of the fact that the family disagree with my statement that it
was not unreasonable that given the exceptional circumstances on the day of
the strike the man, along with all other prisoners on G unit were not seen until
after 9.00am. As explained in my report, prisoners on G3 are informally
labelled as ‘poor copers’. ‘Poor coper’ does not mean that the prisoner is at
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risk to themselves, it means that the prisoner requires protection from the main
wing. Reasons for seeking a safer environment include debts and bullying.
There is no reason why a prisoner would be checked more frequently if they
are not on an open ACCT.
118. The regime on the day of the strike was extraordinary. Staff followed the
prison’s contingency plan for industrial action. It would be an unfair statement
to say that staff were operating without a “well considered contingency plan”.
The events of the morning have been considered as part of the investigation
and I conclude it is not possible to discount the possibility that the strike is
related to the man’s death, but neither has any evidence demonstrated that the
two were linked.
Telephones
119. The man’s family were concerned that he did not contact them whilst he was at
Acklington. Specifically, they ask:
(cid:127) whether he had access to a telephone
(cid:127) whether he asked for any telephone numbers to be registered on the
PIN system
(cid:127) if so, when the numbers were added to the system
(cid:127) where the telephones are located for G3 prisoners
(cid:127) would the man have encountered any other prisoners not from G3 if he
used the telephone.
120. On 18 August 2007, the man agreed and signed his PIN phone contract to
indicate that he understood the system. The contract was returned to the PIN
phone clerk. Any phone numbers that a prisoner wants approved and placed
on the system would be attached to the contract for the clerk. Telephone calls
cannot be made unless approved numbers are entered on to the system. A list
of numbers was not submitted and so nothing was placed on the PIN system
for him.
121. On 20 August, the standard £2.00 reception account was opened to allow the
man access to the PIN phones. His account to date identifies that £3.36
remained in his account and there is no evidence of approved telephone
numbers recorded.
122. A BT statement records that on 23 August, the man attempted to make two
telephone calls at 10.49am and 10.59am. However, the PIN system was not
switched on at this time so no outgoing calls could be made. He later tried to
make a further call at 11.01am (when the system was on) however the number
dialled was not allowed as it had not been approved and added to the system.
Each of these calls was to the same number.
123. There are telephones located on G3 for use only by those prisoners on the unit.
Prisoners have access to these between 10.45am and 11.15 each morning
during association. They also have access whilst collecting lunch and between
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5.00pm and 7.00pm each evening. Under certain circumstances unit staff will
allow calls outside of these times.
Other
124. I have taken note of the family’s disagreement with the assertion that the man
concealed an intention to take his life from staff or prisoners. My investigator
was unable to find any evidence that the man gave staff or prisoners any cause
for concern that he was a risk to himself. He did make it clear that he did not
want to be at Acklington and that he required a safe environment due to
potential trouble. However, this did not translate as being at risk of self-harm.
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RECOMMENDATIONS
I recommend that the Head of Healthcare at HMP Acklington, with the Primary
Care Trust, revises the initial reception healthscreen assessment form to make
it mandatory for further information to be recorded if a prisoner expresses
concerns about being transferred to the prison.
The Prison Service has accepted the recommendation. The healthcare department
at Acklington will revise the initial health screen assessment to take account of
concerns raised by any prisoners on their first entry to the prison. Any concerns will
be recorded and information passed to Induction staff. The target date for
implementation is September 2008.
The Governor of HMP Acklington should remind staff of the importance of
comprehensive record keeping and information sharing.
The Prison Service has accepted the recommendation. A “Governor’s Order” will be
issued reminding staff of the importance of recording information passed to induction
staff. Target date for completion is September 2008.
I recommend that the Governor revises the personal officer scheme at
Acklington to allocate officer responsibility by prisoner and not cell number.
The Prison Service has accepted the recommendation. A revised personal officer
scheme has been written and will be implemented when the revised core day
attendance patterns are in place. Target date for completion is July 2008.
I reiterate HM Chief Inspector of Prisons’ recommendation that all prisoners
should have daily access to a telephone.
The Prison Service accepts this recommendation.
I recommend that all prisoners allocated to G3 at Acklington are routinely
offered an initial session with the mental health in-reach team or another
counselling service, regardless of their perceived self-harm or mental health
problems.
The Prison Service accepts this recommendation. Healthcare at Acklington will look
at the possibility of providing routine mental health in-reach or other counselling
services to prisoners located on G3 landing. Target date for implementation is
August 2008.
I recommend that the Governor of HMP Acklington moves G3 unit to an area of
the prison where a more inclusive and purposeful regime can be managed.
The Prison Service accepts this recommendation. The Governor of Acklington has
commissioned a review of the regime and level of purposeful activity provided on G3
landing. The target date for completion is August 2008.
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