Individual at Holme House

Investigation into the circumstances surrounding the
death of a prisoner at HM Prison Holme House on 5 March 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
December 2005
This is the report of an investigation into the death of a prisoner on 5 March
2005. The prisoner was a remand prisoner at HM Prison Holme House.
According to the post mortem, the cause of death was hanging.
My Deputy Ombudsman and one of my investigators conducted this
investigation. The North Tees Primary Care Trust also conducted a clinical
review into the prisoner’s care and treatment whilst at Holme House.
The prisoner appeared to have settled into the prison routine well, and was
polite and compliant. There was no indication to staff, as a result of his
actions or demeanour, that he was at risk of suicide or self-harm. However,
the prisoner’s brother, solicitor and his cellmate were allegedly aware of his
intentions, but no one alerted the prison.
I would like to extend my condolences to the man’s family for their loss. I
would also like to thank the Governor of HMP Holme House, and his staff for
their help and co-operation during this investigation. I would like to extend my
thanks to Cleveland Police and Durham Constabulary for their assistance in
this matter.
This final version of my report has been amended in a number of places to
take account of comments from the prisoner’s widow.
Stephen Shaw CBE
Prisons and Probation Ombudsman December 2005
CONTENTS
Summary
Investigation methodology
The prisoner
HMP Holme House
Events prior to the prisoner’s death
Events after the prisoner’s death
Clinical Review
Post Mortem report and Post Mortem report
Findings and conclusions
Recommendations
Summary
At approximately 7.50pm on Saturday 5 March, prison staff at HMP Holme
House were alerted to the fact that a prisoner had been found suspended
from the cell window by a ligature around his neck. He was unconscious and
not breathing. Assistance was sought from a member of the prison nursing
staff who happened to be on the wing at the time when the prisoner was
discovered. There was no effort to resuscitate the prisoner, as it was obvious
to staff that he had been dead for some time. Paramedics also attended and
concurred with the nurse’s findings. The post mortem report indicates that he
died as a result of hanging. The clinical review concludes that, whilst in
custody, there was no deterioration in the prisoner’s physical health although
the acute problem with his diabetes probably deflected attention away from
his psychiatric condition.
At the time of his death, the prisoner was sharing a cell with a fellow prisoner.
During the course of our investigation, it became apparent that the prisoner,
who could not read or write, had sent letters to his son and his solicitor in
respect of his affairs. It transpired that the prisoner’s cellmate had written
these letters on the prisoner’s behalf.
The prisoner’s brother was not surprised on learning of his brother’s fate and
confirmed to the police that he often spoke about killing himself. The brother
also said that he told the prisoner’s solicitor about the prisoner’s feelings.
Unfortunately, no one alerted the prison. The prisoner had found his feet in
prison and was polite and co-operative. There was therefore no reason for
staff to believe he was at risk of suicide or self-harm.
To date, the police do not suspect foul play in this sad story. The prisoner’s
cell mate says he simply did not notice what the prisoner was doing.
This report makes two recommendations and identifies two areas of good
practice.
The Investigation process
1. The investigation was opened at HM Holme House on 31 March when the
Deputy Ombudsman visited Holme House on a preliminary visit. The
investigation proper took place on 4-5 May. The Governor and his staff
produced the prisoner’s core record and a number of other documents for
examination. Notices were issued to staff and prisoners telling them of the
investigation. My investigators were able to speak to members of staff
who knew the man or who were on duty at the time of his death. The
investigators were also able to speak with Cleveland Police in relation to
issues of common interest.
2. The North Tees Primary Care Trust conducted a clinical review of the
prisoner’s care and treatment. A representative from the Trust also took
the opportunity of visiting Holme House with the investigation team and
participating in the investigation process.
3. A Family Liaison Officer from my office, Lucy Phelan, wrote to the
prisoner’s family on 11 May informing them of my investigation and
whether there were any concerns that they wanted to raise. A response
was not received from the prisoner’s widow until after a copy of the draft
report had been circulated. In a letter, dated 18 August, the widow stated
that she had handed in her husband’s prescription to police on the day of
his arrest and said that he had not received his prescribed medication for
his mental condition whilst in custody. Without medication, the prisoner’s
wife stated that her husband was liable to take his own life. My Family
Liaison Officer and my investigator met with the prisoner’s wife on 14
November to discuss the draft report with her.
4. My investigators contacted and met with Mr Sheffield, HM Coroner, to
inform him of the nature and scope of my investigation and to request a
copy of the Post Mortem report. Upon completion, this report will be sent
to the Coroner to assist him in his enquiries into the prisoner’s death.
The prisoner
5. The prisoner was, according to the arrest warrants issued by the court,
born on 1 April 1947. However, the available documentation also gives
dates of birth as 1 April 1945 and 12 September 1945. We have not been
able to confirm with the police whether the prisoner had any previous
convictions, due to these discrepancies.
6. The prisoner was a tenant farmer at the time of his arrest. He lived on the
farm with his wife and their five children. The prisoner had been married
for approximately 27 years. The prisoner’s brother also lived on the farm.
It is believed that the prisoner was unable to read or write. It is also
reported that he did not take alcohol or drugs.
7. On 4 February 2005, the prisoner was involved in an incident at a local
garage with his eldest son whom he threatened to kill. He was arrested
and taken to a local police station. During the course of police
investigations, a number of other alleged offences came to light from
family members. These included prolonged and sustained mental and
physical abuse against members of the family. Following the circulation of
my draft report, the prisoner’s widow said in a letter dated 18 August, and
during a meeting with my Family Liaison Officer and my investigator, that
on the day of his arrest she handed her husband’s prescription to police
emphasising that, without his medication, the prisoner’s mental condition
would deteriorate. The prisoner’s wife also said that whilst at the police
station she arranged for a police officer on duty to speak with the
prisoner’s GP over the telephone in order to confirm her husband’s mental
status. A copy of the prisoner’s custody record obtained from Durham
Constabulary did not indicate that the prisoner had any mental health
issues. Durham Constabulary has confirmed that on the day of his arrest
the police surgeon did speak to the prisoner’s GP by telephone. The
conversation was noted in the police surgeon’s notes. However, it would
appear from the police custody record that the main concern at the time
was controlling the prisoner’s diabetes.
8. According to the prisoner’s GP, he last saw the psychiatrist on 2 April
2004. At the time of his arrest he was prescribed Trazadone, Epilim and
Olanzapine.
9. On 5 February, The prisoner was charged with a total of eight offences.
These included two sexual offences and one of actual bodily harm. He
remained in police custody that weekend.
10. On 7 February, The prisoner appeared before the North Durham
Magistrates Court sitting at Newton Aycliffe. Initially, following a bail
application, bail was granted to the prisoner with specific conditions.
However, there was an appeal from the prosecution and he was remanded
into custody to HMP Holme House. This appears to have been the
prisoner’s first term in prison custody.
11. The prisoner arrived at Holme House with over £2,200 in his possession.
This was later paid by cheque to his brother via a letter sent from prison.
12. On reception at Holme House, the prisoner was channelled through the
various aspects of the reception process. This included an induction
interview. The prisoner stated that he was worried about his children.
Due to the nature of the charges against him, the prisoner received an
explanation of the opportunity for segregation under Rule 45 of the Prison
Rules. Because of his illiteracy, a member of staff gave the prisoner
assistance in completing the appropriate application forms. The prisoner
was then seen by a duty governor and his request to be placed on the
vulnerable prisoner’s unit was approved.
13. It was noted at the time of his reception to Holme House that the prisoner
stated that he had suffered a nervous breakdown in 2001, and that he had
then tried to hang himself. On 7 February, the medical record indicated
that the prisoner was not showing any obvious signs of mental illness. His
mood was acceptable and his behaviour was appropriate. When
questioned about his mental health and prescribed medication, the
prisoner could not elaborate any further.
14. Throughout his period in custody, the prisoner did not give any indication
to staff that he was contemplating any form of self-harm. As a result, the
prison did not feel it necessary to implement the Assessment, Care in
Custody and Teamwork (ACCT) procedure. It should be noted that the
prison knew that he suffered from a number of physical conditions that
included insulin controlled diabetes, epilepsy and a heart condition for
which he had been taking medication.
15. On completion of the reception process, the prisoner was moved to the
Health Care Centre for a period of assessment due to his physical health
needs. The prisoner had suffered with diabetes for approximately 20
years. His brother used to administer the treatment, although his widow
later stated that she used to try to administer medication to her husband.
It was also established that the prisoner did not always adhere to the
treatment regime for his diabetes and consequently it was uncontrolled.
16. On 8 February, the Health Care Centre sent an urgent faxed request to the
prisoner’s GP asking for the dosage of insulin that he was on. A response
was received the same day and included Epilim, Olanzapine and
Trazadone. However, this did not prompt any further investigation into his
mental health status at that time. Indeed, the prisoner did not present a
mental health problem to healthcare staff. The prisoner was kept in the
Health Care Centre for observation that night.
17. On 9 February, following a consultation with the doctor, the prisoner was
considered to be fit to be relocated to a normal residential unit. He was
identified as being of ‘medium’ risk for cell sharing and, because of his
vulnerable prisoner status, was moved to a block that accommodates
vulnerable prisoners (houseblock three).
18. On 14 February, the prisoner returned to Holme House from Court having
been again remanded into custody. His case had been adjourned for trial
at Crown Court.
19. On 3 March, it is recorded that the prisoner was finding his feet in prison
and describing him as being polite and compliant. It is also noted from
interviews with staff that he had developed a good relationship with his
cellmate. The cell mate was also identified as a medium risk in terms of
sharing a cell, although he had stated on the assessment that he was
homophobic. The cellmate had been placed on the vulnerable prisoners’
unit because of perceived threats from other prisoners. The cellmate was
serving a one-year sentence for affray. The two men had been sharing
cell A2 (11) since 28 February. The cellmate has been described as an
individual who found it difficult to cope and who may have learning
difficulties. He is also described as having a manipulative nature. The
cellmate had found it hard to settle down with previous cellmates. Staff
recall that the prisoner tended to follow in his cellmate’s shadow.
20. On the afternoon of 4 March, the prisoner’s continuous medical record
indicated that health care staff were not able to locate his treatment card
or medical record. However, he was given medication for his diabetes and
epilepsy.
HMP Holme House
21. Holme House is a category B prison for adult males, opened in May 1992.
The prison primarily serves the communities of the Tees valley, South
West Durham, East Durham and North Yorkshire. The prison was
inspected in April 2005 by HM Chief Inspector of Prisons and her report
will be published shortly.
22. The establishment expanded in the late 1990s, and currently has a
capacity for 994 prisoners who are accommodated in six self-contained
house blocks with a mixture of single and double cells. Block three
accommodates vulnerable prisoners and those prisoners on induction.
23. Holme House offers a variety of employment opportunities within its
modern workshop complex. These are complemented and supported by a
purpose built education department that offers both part time and full time
classes.
24. It was also identified during our investigation that Holme House was in the
process of implementing community based primary care on each wing.
This is seen as good practice and this development should be supported
and encouraged across the whole prison. It was also evident from our
investigation that health care staff were professional, mutually supportive
and treated prisoners with a high degree of care and compassion.
Events prior to the prisoner’s death
25. On 9 February, the prisoner was moved from the Health Care Centre to
house block 3, B wing. Up to his death, the prisoner was accommodated
in various other cells on the wing. On 28 February, the prisoner was
moved into cell number 3A2 (11) which he shared with a cellmate.
26. Whilst in prison, the prisoner received domestic visits on 19 February, 22
February and 2 March from his brother, his sister and a friend. He did not
receive any visits from his wife or children. They had moved away at the
time of his arrest. The prisoner was scheduled to have another visit on 6
March 2005 from his brother and a friend. The prisoner also received
legal visits on 16 February and 1 March.
27. A Senior Officer remembers seeing the prisoner at breakfast time
(approximately 7.30am) on Saturday 5 March with his cellmate. The
Senior Officer remembers yawning in the presence of the two prisoners
and that a light hearted banter followed that was initiated by the prisoner’s
cellmate with the prisoner joining in. The prisoner appeared to be in a
good mood.
28. During the course of the day, nothing untoward was noted and prisoners
and staff complied with the schedule of core activities for the day.
29. At 5.45pm, prisoners were locked in their cells after association time. The
cellmate and the prisoner lay on their respective bunk beds watching
television. The cellmate stated to the police that he fell asleep watching
the television and did not wake up until shortly before 7.50pm. The
cellmate said that he lay asleep with his back to the television and did not
hear or see anything as the cell was in relative darkness. The television
remained on.
30. At 7.20pm, an officer checked the cells through the door flap as part of the
standard prison roll call. He noted that the cell light was turned off and
that the prisoner appeared to be asleep on the top bunk bed with his head
facing the cell window, whilst his cellmate appeared to be asleep on the
bottom bunk with his back to the television facing the cell wall. The cell is
a single cell that is used to accommodate two persons and is small. At
7.30pm, the officer phoned through the roll call to the control room.
31. At approximately 7.50pm, a nurse was on her routine round on the wing in
order to administer medication to prisoners. Two officers escorted the
nurse. At about the same time, the officer was alerted by the cell buzzer
on A2 landing. It was quickly established that the cell bell for cell A2 (11)
had been activated. The officer attended the cell and opened the cell door
flap. He noted that the prisoner’s cellmate was directly on the other side of
the flap and seemed to be very agitated and asking for a cigarette. The
cellmate stated that, when he awoke from a deep sleep, he did not notice
that the prisoner was hanging from the cell window because of the poor
light. On seeing the prisoner, he had tried to get a response by talking to
him and touching his arms but a response was not forthcoming. The
cellmate turned on the cell light. The prisoner had a ligature tied around
his neck that was made from a piece of bedsheet. The other end of the
ligature was tied around the cell window. The prisoner appeared to be
lifeless and ashen in colour and his eyes were fixed and dilated.
32. The officer summoned assistance and opened the cell door. The
prisoner’s cellmate was taken immediately to a crisis cell further along the
landing and a prison Listener was asked to sit with him. The officer, along
with another officer, took the prisoner’s body weight and snapped the
ligature. The prisoner was placed in the recovery position on the cell floor
and attempts were made to find a pulse. A pulse could not be detected.
At 7.52pm, an ambulance was called. The governor and duty governor
were also informed of the situation.
33. The nurse, who was on the residential unit at the time, attended the cell.
She noted the prisoner’s pallor and also attempted to find signs of life. A
pulse could not be detected and the nurse and the officers at the scene
concluded that the prisoner had been dead for some while. In light of the
clinical condition of the prisoner, it was decided that resuscitation would
not be appropriate and therefore it was not started.
34. The nurse left the cell and the officers moved the prisoner onto his back.
The cell door was shut until the arrival of the police and the Coroner’s
Officer. The prison initiated and acted in compliance with their
contingency plan in the event of a death in custody. The paramedics
arrived at the prison at 8pm. The prisoner was pronounced dead at
8.34pm. At 8.30pm, the police arrived to begin their investigation into the
circumstances of the prisoner’s death. The Prison Service National
Operations Unit was told of the prisoner’s death at 9.38pm.
35. A hot debrief for staff directly involved took place later on that night. Staff
stated that they had received an appropriate level of care and support from
management since the prisoner’s death. The governor also sent a letter of
thanks to staff for their efforts in dealing with the tragedy. This is seen as
good practice, conveying a strong message of support and gratitude as
well as compassion to junior members of staff who have dealt with a
traumatic incident.
Events after the prisoner’s death
36. Cleveland police took a statement from the prisoner’s cellmate
immediately following the discovery of the prisoner’s death. The cellmate
is described by staff as a man with learning difficulties. In his statement to
the police, the cellmate recounts that the prisoner had frequently talked
about suicide, but that he did not think of alerting staff because he had
been successful in dissuading the prisoner from this course of action. Mr
Bailey states that the prisoner was feeling down but that his efforts to
cheer him up appeared to be working.
37. The cellmate claims that he did not see or hear the prisoner hang himself,
as he was asleep on the lower bunk bed with his back to the television.
The cell was in relative darkness although the television remained on.
Indeed, the cellmate has maintained to police on two occasions that he
was in a deep sleep, with his back to the prisoner when he hung himself.
He therefore, did not see or hear anything suspicious. The cellmate has
been contacted by the Ombudsman’s office at his forwarding address. To
date, the cellmate has not responded to our communications and it is felt
that he is unlikely to assist with our enquiries into the death of the prisoner.
38. A search of the cell revealed a letter, purportedly written by the prisoner to
his youngest son, that appeared to be settling his affairs. It was strongly
suspected that the prisoner was illiterate. During the course of the police
enquiry, it was soon established that the cellmate had written several
letters over the preceding week for the prisoner who dictated the content.
A letter had also been sent to the prisoner’s solicitor detailing what should
happen to his estate in the event of his death. The solicitor acting on
behalf of the prisoner does not appear to have interpreted the letter as
indicating anything untoward nor to have alerted the prison as to the
prisoner’s possible intentions.
39. Police also took a statement from the prisoner’s brother who had visited
him whilst he was in prison. His brother said that during the visits the
prisoner had spoken to him about taking his own life because of his
situation. On 28 February, his brother was so concerned that he
contacted the prisoner’s solicitor to voice his concerns. The prison was
not made aware of his intentions either through the solicitor or the brother
and therefore did not take any action. The prisoner’s brother is upset that
the solicitor did not inform the prison of the prisoner’s threats to self-harm.
40. The prisoner had also told his brother that he had attempted suicide by
electrocution in his cell. The prisoner had spilt water by his feet and had
attempted to use the kettle lead to conduct electricity. The attempt failed.
The prison was unaware that this was a serious attempt at self-harm. The
incident was reported to staff, and subsequently recorded, as accidental
damage to the equipment.
41. Following the discovery of the prisoner’s body, the cellmate was moved
from the crisis cell to the healthcare centre for observation. His behaviour
was deemed strange in that he wanted to return to the cell he shared with
the prisoner to obtain a bottle of Radox that belonged to the prisoner. He
was also seen to be in a jovial mood by staff working in the Health Care
Centre. This was also considered to be strange under the circumstances.
42. The cellmate served out the remainder of his custody in the Health Care
Centre and was subsequently released from Holme House on 9 March to
a probation hostel (approved premises) in York. The police were able to
interview the cellmate at this location on 12 April on the direction of the
Coroner. At interview, the cellmate maintained that although he was
aware of the prisoner’s intentions, and that he had written letters on his
cellmate’s behalf, he did not see, hear or assist in the prisoner’s death. At
interview, he was described as co-operative.
43. Following the prisoner’s death, efforts were made to contact the prisoner’s
brother, the nominated next of kin, but this proved to be unsuccessful.
However, senior managers were aware that he was due to have been
visited the next day by friends. The decision was therefore made to delay
informing the next of kin until contact details could be obtained the
following day from the visitors.
44. On 6 March, the prisoner’s visitors were seen by the Governor and deputy
governor and informed of the prisoner’s death. A contact number was
obtained for the prisoner’s family to inform them officially of the death. In
the meantime, the prisoner’s friends had already contacted the prisoner’s
brother and told him the death. The prisoner’s widow stated that on the
day of her husband’s arrest she had moved away from the area. The
prisoner’s widow was told of her husband’s death through an acquaintance
of her husband’s by telephone. She then contacted the police who were
able to confirm it.
45. Prisoners and staff were informed of the prisoner’s death on 6 March. The
mood of the wing was described as sombre.
46. The prisoner’s widow visited the prison and spoke to a governor about her
husband’s death. During the visit she asked whether her husband had
been receiving his medication. The widow was told that he had been
receiving treatment for his diabetic condition, but was not able to confirm
that he had received any appropriate treatment for his mental illness. The
prisoner’s widow was adamant that without medication her husband was
likely to self-harm. She remains very upset that his mental condition was
not detected or treated.
47. The prison sent a letter to the prisoner’s widow offering their condolences
and financial support towards the funeral. She claimed that she had never
received the letter. However, it is noted she moved away shortly after the
prisoner’s arrest. Following a visit to the widow by my Family Liaison
Officer and the investigator, a copy of the invoice for the prisoner’s funeral
has been forwarded to the Governor for his consideration.
48. The prison informed the Prison Service’s National Operations Unit (NOU)
of the death of the prisoner on the night it occurred. Unfortunately, the
NOU failed to inform the Prisons and Probation Ombudsman of the death.
It was only after a call to our office on 29 March, requesting to know the
lead investigator, that we were alerted to the case.
Clinical Review and Post Mortem report
49. North Tees Primary Care Trust undertook a clinical review of the prisoner’s
care and treatment whilst he was at Holme House. The review confirms
that the prisoner had a history of unbalanced diabetes, epilepsy and
coronary heart disease, and that prescribed medication also indicated he
had mental health problems and depression. Indeed, the review suggests
that the acute problem with the prisoner’s diabetes probably deflected the
attention away from his past history of psychiatric illness. At the time of
his admission to Holme House, there was no indication that the prisoner
had a psychiatric condition. This condition would have been known had
the prison been able to obtain the prisoner’s previous medical history from
his GP or hospital.
50. The post mortem report indicates that the prisoner was suffering from a
number of medical problems consistent with his age. However, the report
concludes that he died simply as a result of hanging. There was no
evidence that he was restrained or the victim of assault and thus foul play
was not suspected.
Findings and conclusions
51. The prisoner was treated properly on reception at Holme House and
received the appropriate care and treatment for his known medical
conditions whilst in custody. Although the prison was aware that the
prisoner tried to hang himself in 2001 as a result of a nervous breakdown,
there was no indication given to staff that he intended to harm himself
again. However, the prisoner’s solicitor, the prisoner’s brother and his
cellmate were all apparently aware of his threats but failed to alert the
prison. In respect of the apparent failure by the prisoner’s solicitor to alert
the prison to the prisoner’s intention, despite the receipt of a letter and
concerns voiced by his brother, the police have asked the solicitors to
comment. To date, the solicitors have refused to co-operate with the
police and this remains the subject of an on-going enquiry.
52. In response to my draft report, the prisoner’s widow said that she passed
the prisoner’s prescription to police on the day of his arrest. She added
that she told police that, without his medication, the prisoner’s mental
condition would deteriorate, implying that he might attempt self harm. A
copy of the prisoner’s police custody record was obtained, but does not
indicate any mental health issues or any medication that was handed to
police.
53. On reception at Holme House, the prisoner’s past medical record,
including his past psychiatric history, was not made available.
Consequently, a full and proper assessment of his mental state could not
have been made. However, the Health Care Centre was made aware by
his GP of the medication that the prisoner was in receipt of at the time of
his arrest. This included, Epilim, Olanzapine and Trazadone. However,
this knowledge did not prompt further investigation by health care into the
prisoner’s mental health status, although the medical record indicated that
medication was administered.
54. Police enquiries to date have not identified anything suspicious
surrounding the circumstances of the prisoner’s death that would warrant
further investigation. The prisoner’s cellmate claims that he was asleep at
the time and therefore did not see the prisoner hang himself. The
cellmate’s strange behaviour was noted but was seen as symptomatic of
his character.
55. Although it is evident that the prison took the appropriate and timely action
in informing the National Operations Unit of the death of the prisoner, it is
unfortunate that the Prisons and Probation Ombudsman’s office was not
notified promptly. Regrettably, this has occurred on a number of
occasions and NOU will wish to review its procedures to ensure they are
robust.
Recommendations
The National Operations Unit (NOU) should review its procedures for
informing the Prisons & Probation Ombudsman of deaths in custody to
ensure that the investigation process can be started in a timely manner.
The Governor of Holme House should remind healthcare staff that, where
prisoners have significant medical or psychiatric conditions, their GP or
hospital doctor should be contacted to provide details of the patient’s
previous medical history as well as their present medications. Access to
this information may give the prison a more comprehensive medical and
mental state of the prisoner and thus allow the prison to take timely,
effective and appropriate action and treatment. In instances where it is
known where a prisoner is in receipt of anti-psychotic or anti-depressant
medication, this should prompt further investigation, irrespective of the
patient’s presentation.
Good Practice
The development of primary care clinics on the residential units at Holme
House echoes the concept of primary care delivered in the wider
community, and its continued expansion to the whole prison should be
encouraged and supported.
The personalised letters from the Governor thanking staff for their efforts in
responding to the finding of the prisoner’s body are an example of good
practice.