Individual at Wakefield

The death of a man at Wakefield prison on 13 January 2004
Report by the Prisons and Probation Ombudsman for England and
Wales.
March 2004
Preface to the published version
Although this case has been well publicised, and to most people in Britain the
identity of the man who died will be obvious, I have judged it right to publish
this report in an anonymised version. This is in line with the practice I am
required to follow in respect of all deaths in custody that have occurred since
April 2004 (when responsibility for the investigation of all such deaths passed
to my office). It is also consistent with the approach I have taken to the other
deaths I investigated before that date when – as in this case – I was acting on
behalf of a commissioning authority (the Minister or Director General).
With that exception and some very minor amendments, the text of the report
is as I submitted it in March 2004.
Stephen Shaw
Prisons and Probation Ombudsman for England and Wales
May 2005
1
Preface to the originally submitted version
I was invited by the Director General of the Prison Service to investigate the
death of a man on 13 January 2004 at Wakefield prison. This reports sets out
my findings.
It is hard to imagine just how difficult the weeks following the man’s death
must have been for his family. Losing someone while they are in custody is
traumatic in any circumstances. In the man’s case, the family has also had to
cope with intrusive and prurient media interest. I offer them my sincere
condolences.
I also offer my sympathies to management and staff at the prison. This was
the second death within a week at Wakefield, and will have had a profound
effect on everybody, especially those most closely involved with the man and
with trying to resuscitate him. Two such members of staff have themselves
suffered close family bereavements during recent weeks. They, in particular,
will need the continued support of their colleagues in the weeks and months
ahead.
I am grateful to the Governor for the help and hospitality we have received
during the investigation. Every assistance has been made available and all
staff have co-operated fully and readily with the inquiry.
I am grateful too to Dame Janet Smith, who chaired the independent public
inquiry into the issues arising from the case of the man, for offering to share
with me records in the inquiry’s possession.
I should also thank the Director General of the Prison Service and the
Governor at Whitemoor prison for seconding to me three members of Prison
Service staff to assist with the inquiry. Their knowledge, commitment and
hard work have been of immense value in expediting the investigation.
Finally, I should record my thanks to the typing pool at Whitemoor for their
excellent work typing up the interview transcripts.
Stephen Shaw
Prisons and Probation Ombudsman for England and Wales
March 2004
2
Contents Page No.
Glossary of terms 4
Executive summary 6
Background 8
Wakefield prison 8
Investigation 9
The man’s pre-Wakefield prison history 10
History at Wakefield 13
Discovery of the death 15
Examination of the issues
Medical care 19
IEPS 20
Views of prisoners and staff 22
Category A checks 24
Entering category A cells 24
Resuscitation 25
Emergency medical assistance 25
ECR 27
Ligature 28
Pension 28
Analysis of self-inflicted deaths 29
Consideration 31
Conclusion 37
Recommendations 37
3
Glossary of terms
Category A Prisoner for whom the highest level of security is
required
CPR Pertaining to Chest (Heart and Lung) resuscitation
DST Dedicated Search Team
ECR Emergency Control Room
ETS Enhanced Thinking Skills
F2050 Prisoner’s Main Core Record
F2052SH At Risk of Self Harm Record
FOCUS Drugs treatment course
Fish knife Knife which cannot be used as a weapon but is
designed specifically to cut through ligatures
Food boat Informal arrangement whereby a number of
prisoners each contributes an item towards a meal
Governor Senior Manager Graded A – F
HCC Healthcare centre
Hotel 5 Healthcare radio contact in an emergency
IEPS Incentives and Earned Privileges Scheme
IMB Independent Monitoring Board
IMR Inmate Medical Record
Lifer Prisoner serving a life sentence
LIDS Local Inmate Database System (computerised)
Listener Prisoner trained by Samaritans to support
prisoners at risk of self harm or suicide
NOU National Operations Unit
Oscar 1 Night Orderly Officer
Oscar 2 Assistant Night Orderly Officer
4
PDPR Personal development course
Peg Electronic keying in system for demonstrating that
staff have completed the requisite patrols
POA Prison Officers’ Association
Remand Prisoner held in custody before conviction
Safe Cell A cell from which ligature points have been
designed out or removed. The term ‘safer cell’ is
the more common usage. There are very few
‘safer cells’ in the older prisons like Wakefield.
SIR Security Information Report
SO Senior Officer
SO and three unlock A senior officer and three officers must be present
when the cell is unlocked
SOTP Sex Offender Treatment Programme
SPAB Suicide Prevention and Anti Bullying
Standard Audit Prison Service Internal Audit System
Visiting Order Form that enables someone to visit a prisoner
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Executive summary
1. This is the report of an investigation commissioned by the Director
General of the Prison Service into the death of a man on 13 January 2004 at
Wakefield prison.
2. The investigation team reviewed the man’s prison records and spoke to
a number of staff and prisoners. It also received correspondence from a
number of parties.
3. The man had been in prison custody since September 1998 and at
Wakefield since June 2003. Although considered a long-term suicide risk at
previous prisons, he was not considered to be at specific risk during his time
at Wakefield and was not subject to any special measures. He was found
hanging from the window of his cell at 6:10am during the morning roll count.
Extensive efforts to revive him proved fruitless and he was pronounced dead
at 8:10am.
4. The report reviews the man’s suicide ideation and care before his move
to Wakefield. It then explores in some detail events over the Christmas period
just before his death. This included him being downgraded to basic on the
Incentives and Earned Privileges Scheme (IEPS) and subsequently restored
to standard. I make criticisms of the operation of the IEPS and of the specific
decisions made relating to the man.
5. I also refer to a review of the man’s medical care whilst in prison
custody conducted on my behalf by the Northumberland Care Trust. This
concludes that his care was appropriate at all times and that staff do not
appear to have missed any warning signs. It also reports that the man was
not on any medication at the time of his death that would have caused him to
suffer depression. Having said that, I am critical of the fact that staff at
Wakefield do not appear to have been alerted to the man’s long-term risk of
suicide or what might finally trigger it.
6. I detail allegations by other prisoners that the man was pressurised by
staff generally and by a specific prison officer in particular. Prisoners alleged
that the prison officer told the man he should do them all a favour and that he
sang to taunt him. They also alleged that another prison officer told the man
he should kill himself. Both officers flatly denied the allegations and I found no
evidence to substantiate them.
7. The report describes in detail the actions taken by staff following
discovery of the death. The investigation was unable to establish exact
timings for the sequence of events. I am critical of Wakefield’s record keeping
in this respect and also suggest that local instructions on entering a category
A cell at night are not clearly understood by staff. Contrary to local guidance,
staff laid the man on a bed in order to carry out resuscitation. I have not
criticised them for this. Resuscitation was continued for approximately half an
hour, despite clear indications that the man was dead. I query the
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appropriateness of local guidance on when resuscitation should not be started
or should be discontinued. No ambulance was called and the doctor did not
arrive until almost two hours after the death was discovered. I am critical of
both the failure to call paramedics and the delay in contacting the doctor. I
have no reason to believe the doctor could have got to the prison any faster,
however, given that he lived on the far side of Leeds.
8. Both the National Operations Unit (NOU) and the police were put on
stand-by before the man was formally pronounced dead. I see nothing wrong
in this. Unfortunately, the address held on the prison’s computerised prisoner
records for the man’s next of kin was incorrect. This, together with a decision
by Home Office Press Office to issue an early press release and a possible
leak from the prison itself, resulted in the man’s wife learning of her husband’s
death from a family member who had heard about it on the radio before the
police were able to speak to her. This is extremely regrettable, but I can find
no fault by managers at Wakefield or staff in Press Office. I do, however,
query Wakefield’s policy which relies routinely upon the police to inform the
next of kin.
9. The report explores the source of the material used for the ligature but
draws no conclusions. It also describes the situation pertaining to the man’s
forfeited pension, as the man had said he would not kill himself until his
pension had been resolved. I could find nothing in relation to the man’s
pension which explained why he killed himself when he did.
10. The report also sets out some statistics relating to suicides by life
sentence prisoners. The man did not fit any profile. It also contains some
analysis by Safer Custody Group which suggests there may be a slightly
heightened risk of self inflicted death on or just before a birthday. The man
died the day before his birthday.
11. I conclude that, while there are procedural issues relating to the
management of the incident which should be addressed both locally and
nationally, from the evidence we have, the man’s death could not have been
predicted or prevented.
12. The report makes 17 recommendations.
7
Background
The man was remanded to Manchester prison on 8 September 1998, charged
with murder and forgery. He was transferred to Preston prison the next day
and to Liverpool prison on 14 October. He was returned to Manchester on 13
November, where he spent the rest of his time on remand.
The man was convicted on 31 January 2000 at Preston Crown Court of the
murder of 15 patients. He was sentenced to life imprisonment. The judge
recommended that he serve a minimum of 40 years for the purposes of
punishment and retribution. He was convicted simultaneously of the forgery
of the will of one of his victims and sentenced to four years imprisonment, to
be served concurrently. Further investigations have suggested he might have
been responsible for at least 215 murders.
Following conviction, the man moved to Frankland prison on 7 February 2000,
where he was accommodated in the healthcare centre. He remained there
until being transferred on 18 June 2003 to Wakefield. He had not undertaken
any offending behaviour work at Frankland and staff considered that a fresh
start might encourage him to do so.
The man was housed on normal location for the duration of his stay at
Wakefield, occupying, at different times, two cells on D wing. At 6:10am on
13 January 2004, he was found hanging in his cell. He had trapped a length
of material in his window and secured the other end round his neck. The
source of the material is not known. Staff tried for some considerable time to
resuscitate him, but were unsuccessful. A doctor pronounced him dead at
8:10am. He had not left a suicide note in his cell.
During the mid 1970s, the man had suffered a period of depression. He
apparently abused Pethidine, a controlled drug, and was convicted in 1976 of
possessing and misusing drugs, forgery and deception. He was fined a total
of £600. He was subsequently treated at The Retreat in York.
Wakefield prison
Wakefield started life as a House of Correction in the late 16th century. It
became a prison when it was taken over by the Prison Commission in 1887.
In 1966, it became a dispersal prison, and it remains within the high security
estate.
The establishment is a lifer main centre, focussing on sex offenders, who
comprise the majority of its population. Wakefield’s population profile is as
follows:
70% - lifers
34% - murderers
28% - over 50 years of age
86% - white
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As far as convicted prisoners are concerned, Wakefield takes only those
serving sentences of four years or more. Last year, however, it also took on a
remand function for potential category As. Despite additional funding being
made available as a result, the change of role has had a significant impact on
staffing. This has led to difficulties in escorting prisoners to work, resulting
frequently in prisoners being unable to work.
The prison has five or six workshops and an Education Department which
provides both full and part time education. Offending behaviour courses
include FOCUS, SOTP and ETS.
The population on 12 January 2004 was 563, five of whom were considered to
be at active risk of self-harm or suicide and subject to F2052SH (suicide and
self-harm prevention) procedures. Just over 100 were category A prisoners,
including around 20 remands. D wing, which housed the man, held 179
prisoners.
The last full inspection of the prison was in 1997, but an unannounced
inspection was conducted in October last year.
The last Security and Standards Audit was in May 2002. The prison achieved
a ‘Good’ rating for both.
Investigation
I formed a team comprising myself, the Deputy Governor of HMP Whitemoor,
one of my Assistant Ombudsmen, and a Manager and Principal Officer from
HMP Whitemoor.
I received a very helpful brief from the Governor before visiting the wing and
cell where the man died.
I agreed a protocol with the police and subsequently visited the local police
station to view some of the items that had been removed from the cell,
including the ligature. The police subsequently provided me with a summary
of everything they had removed, including some entries from the man’s diary
and other papers. I also listened to recordings of the man’s last seven
telephone conversations with his wife. The final one was on the evening
before he died.
I contacted the Coroner. I also spoke with the chair of the Independent
Monitoring Board (IMB) and the branch secretary of the Prison Officers’
Association (POA).
At the outset, we issued a notice to prisoners and staff inviting anyone with
information relating to the man’s death to make themselves known to the
inquiry. This resulted in a number of messages from prisoners asking to
speak to us. In the event, we spoke to about 20. We also received two notes
(one anonymous) apparently from members of staff.
9
Following the original submission of this report, I received an e-mail from
Home Office Press Office explaining the circumstances relating to the early
release of information about the man’s death to the media. I also received a
letter from a firm of solicitors asking me to speak to a number of prisoners
who apparently had information about staff entering the man’s cell during the
night of his death. In the event, only two would speak to my Assistant
Ombudsman. Neither suggested the man’s cell had been entered during the
night, but one, the man’s neighbour, said he heard a bang in the man’s cell
between 1 and 2am.
I read the, at the time unpublished, report on Wakefield by HM Chief Inspector
of Prisons and the most recent IMB annual report. I also received
correspondence from Dame Janet Smith, the chair of the independent public
enquiry, drawing my attention to the concerns of psychiatrists to the inquiry
that the man might become a suicide risk when the inquiry’s first report was
published on 19 July 2002, and from prisoners in other jails, ex-prisoners and
other members of the public.
We interviewed a number of staff who had been involved in the attempt to
revive the man and in the immediate period thereafter, and spoke to others
likely to be able to provide background information.
We reviewed the whole of the man’s prison file covering the duration of his
time in custody from his first remand on 8 September 1998. In addition, I
commissioned the Northumberland Care Trust to conduct a clinical audit of
the man’s care whilst in prison custody.
I have been in touch on several occasions with the man’s family, and
arrangements were made for us to meet. In the event, the family decided not
to go ahead at this time. Should they wish to meet, then I shall of course
make myself available to them. If matters emerge that are significant, I will
submit a further amended report.
The man’s pre-Wakefield prison history
Prior to his move to Wakefield, the man had been subject to F2052SH
procedures on four occasions. In each case, the procedures were instigated
as a result of external factors considered likely to place him at risk. These
were:
• his first remand to prison on a serious charge;
• his trial;
• bad news relating to his pension; and
• notification that he was to be stripped of his pension.
The most recent F2052SH was opened on 17 July 2002 and closed on 30
August 2002.
There are numerous references to suicide in the man’s files. In his first few
years in custody, he spoke apparently unemotionally about suicide as
10
something which he might consider in the future, should his appeal against
conviction fail and once he had ensured his wife was financially secure. A
Support and Supervision Record dated 23 September 1999 says:
“Although remains tearful says he will not commit suicide until after his
trial. Says he had discussed with his wife and he will take his own life if
faced with a life sentence.”
A case conference on 12 October 1999 noted:
“He is denying suicidal thoughts at the moment, but is giving the
impression that if he was found guilty, and after all appeals had been
heard, then he would consider suicide as a last resort, as he could not
bear to spend the rest of his life in prison. He is very close to his wife and
he could not see himself being without her for the rest of his life.”
On 23 January 2000, a summary of a review noted that the man was still
depressed, but “will not kill himself as will affect wife’s pension – if appeals
exhausted does want to die.”
On 1 February 2000, a case conference noted:
“[The man] had said that he would not take his life within the next five
years as his wife [ ] would then not get a pension.”
The report of the case conference added (probably quite presciently):
“It was generally felt by all at the case conference that if [the man] had
decided to take his life it would be ‘calculated’, he would ‘lull staff into a
false sense of security,’ showing no signs of depression or self harm
ideation, in fact, he would probably give the impression of being quite
settled, jovial in mood and planning activities for the future.”
On 7 February 2000:
“[The man] told [the SMO at Frankland] that his main concern was for his
family. He was especially concerned that his pension should not be
endangered. Apparently his family would forfeit the pension if he
committed suicide prior to its award or up to one year from the first
payment. The actuarial details are entirely based on [the man’s] account
and need to be confirmed. [The man] added that if the state withdrew the
pension, he would be taking legal action to recover his contributions.
“[The SMO at Frankland] felt that his very plausible testament about his
will to live could easily be constructed specifically for the authorities.”
An extract from his Inmate Medical Record (IMR) in February 2000 reads:
“Feels long term prisoners should be offered option of suicide every 5 years.”
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An F2052SH was opened on 9 May 2000. The initiating member of staff
commented:
“As a result of a taped telephone call, ECR informed us that he was very
upset over pension – states only two ways he can now collect his pension
– either he reaches 60 or he’s dead.”
A case review on the same date noted, “Adamant that he would not attempt
suicide until every last avenue had been exhausted.”
On 17 July 2002, a letter advising that the man was to forfeit his pension was
received, by prior arrangement, by the Governor and passed on to the man.
An F2052SH was opened immediately. On 15 August 2002, however, a note
of a case conference recorded that, “He has refused to take part in any
F2052SH reviews stating that staff are behaving in a ridiculous manner and
that he has no intention of committing suicide.” Nevertheless, the F2052SH
remained live for a further two weeks. During that time, healthcare staff
advised the correspondence office that:
“Following a recent case conference, it was agreed that it was imperative
[their emphasis] that all mail either incoming or outgoing relating to the
above inmate and his appeal against his pension being withheld be
monitored. Could you please advise us immediately [their emphasis] if
any mail indicates that the appeal has been unsuccessful.”
A Sentence Planning Review Board report dated 30 September 2002
commented that, “It is still a concern ref. [the man’s] threats of suicide/self
harm relating to his wife’s personal and financial well-being.”
Each F2052SH indicates a high level of care for the man during times at
which he was considered to be at risk of self-harm. Multi-disciplinary case
conferences were held on a regular basis. The records of meetings show that
considerable thought and insight was applied to his management.
The man’s diary also records his ideation at times during this period:
• 13/01/2001 - “So depressed. If ?[illegible] says no then that is it. There is
no possible way I can carry on, it would be a kindness to [ ].”
• 14/01/2001 - “[My wife] and the kids have to go on without me when it is
the right time. Got to keep the façade intact for the time being.”
• 27/03/2001 - “ … I’m looking at dying, the only question is when and can I
hide it from everyone?”
• 13/04/2001 (Good Friday) - “If I was dead they’d stop being in limbo and
get on with their life perhaps. I’ll think a bit more about it. I’m desperate,
no one to talk about it to who I can trust. Everyone will talk to the PO’s
then I’ll be watched 24hrs a day and I don’t want that.”
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• 26/06/2001 (Wednesday) - “ … As near suicide as can be, know how and
when just not yet.”
• 14/01/2002 (Monday) - “56 today, cards from everyone – very very sad
day, not what life is about at all. [ ] not very good, it must be dreadful for
her.”
I note that two of these entries were on the man’s 55th and 56th birthdays in
2001 and 2002 respectively. I discuss below the possible connection between
the timing of his death and his 58th birthday in 2004.
History at Wakefield
The man arrived at Wakefield on 18 June 2003. Records show that he was
not happy at the move and suggest that this might be because he had missed
a visit as a result. He was apparently aggressive and dismissive on reception,
refusing to engage in any of the procedures. There is no record in his IMR of
his being seen by a doctor at the time of his transfer. However, the Suicide
Prevention and Anti Bullying (SPAB) Officer completed a reception pro forma,
apparently after having spoken to the man. He noted that there was no live
F2052SH, no history of self-harm and no serious attempt on his own life.
Although the form refers to the likelihood of his being bullied because of his
high profile and records his “confrontational nature towards staff and inmates”,
there was no reference to previous F2052SHs, the possibility of suicide in the
future or what might trigger it.
There are just thirteen entries in the wing observation book relating to the
man. None of these suggests he gave staff any reason to believe he might kill
himself. The main issue was with his giving medical advice to other prisoners.
During autumn 2003, reports were prepared for the man’s sentence planning
review. A psychology report noted that, “Following sentence it is reported that
[the man] again voiced suicidal intentions stating that after he secured his
pension for his wife he would end his life and it is indicated that his wife was in
agreement that it was preferable to spending the rest of his life in prison.”
(This information was drawn from a post sentence report by a Probation
Officer, who had noted, “There is further concern with regard to [the man’s]
stated intentions to commit suicide in the future, therefore his mental health
and emotional well-being need to be assessed and monitored on a regular
basis.”)
The officer who completed the personal officer report, however, said simply in
relation to vulnerability, “There are no recorded events to date, he was
originally placed on a 2052SH after initial conviction but there have been no
further concerns at this establishment.”
On 11 December 2003, the man’s Incentives and Earned Privileges Scheme
(IEPS) level was reviewed as part of his annual sentence planning review. He
was reduced to basic. The principal consequences of this were that:
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• his in-cell TV was removed;
• he was not allowed to wear his own clothes;
• his visits were reduced to two ½ hour visits per 28 days;
• his access to cash was reduced (which impacted on his ability to make
phone calls); and
• he had to lock up 1½ hours before other prisoners.
He appealed, but was turned down on 17 December.
The man’s wife visited on 24 December and again on 28 December. Two
prisoners told us that a senior officer (SO) on one of the man’s last visits had
told him loudly beforehand that, because he was on basic, his visit would be
curtailed. One wrote to me:
“The effect of the basic regime created only one problem for [the man ....]
which was driven home in a cruel fashion a day or two before Christmas
… Whilst they counted in, the visits SO seemed to take great pleasure in
announcing that [the man’s] visiting time was reduced.”
This had apparently upset him deeply. (I note that in her report of the
unannounced inspection in October 2003, HM Chief Inspector of Prisons
recorded that prisoners on basic were restricted to half hour visits rather than
their statutory entitlement of one hour.) He sent out his last visiting order on
2 January 2004 – no date had been fixed for the visit at the time of his death.
The man had noted on a calendar in his cell that no work had been available
since 31 December. He also mentioned the non-availability of work in several
phone conversations with his wife.
On 8 January 2004, the man’s IEPS level was reviewed in line with standard
procedure. His interaction with officers was considered to have improved and
he had indicated his willingness to undertake non-offence related work. He
was awarded sufficient marks to enable him to return to standard.
At unlock on the morning of 9 January, another category A lifer was found
dead in his cell. He was 67 years old and had been suffering from major heart
problems.
Later that day, the man applied to be allowed to hand out on a visit from his
wife arranged for 14 January (his birthday) two calendars, one greetings card
“plus enclosed ‘confetti’” and magazines “sent in before being told that
Wakefield HMP has its policy of nothing being sent in.” The application was
referred (undated) to reception and again (undated) to visits. The man also
applied on 9 January for the return of his trainers (confiscated as a result of
his downgrade to basic – he always wore prison issue clothing but not
trainers). This was authorised on 12 January (presumably because the
weekend intervened). He does not seem to have asked for the return of his
television. Also on 9 January, the man ordered his canteen for the following
week – some phone credits, some small envelopes, a pepper and a potato
(he was apparently a member of the wing food boat).
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On 12 January, the man sent out five letters. These were to his wife, his
sister, his daughter, some friends and (so far as I can ascertain) his solicitors.
As a category A prisoner, all his mail was read before being sent out, but I
have not been able to establish who read it on this occasion. He also
requested a visiting order. In the evening, he phoned his wife as usual.
There did not appear to be anything out of the ordinary in their conversation.
He ended, as usual, by saying he would call her tomorrow.
No staff or prisoners had perceived anything different about the man on the
evening before his death (or the period leading up to it). One prisoner
suggested he might have been a little quieter than usual, but others said he
seemed quite cheerful and had played cards the evening before he died. One
prisoner commented that, unusually, the man had not returned to his cell until
the very last moment at lock up, returning instead for a further chat after he
had collected his water.
At the time of his death, the man was still appealing against the decision to
withdraw his pension and was pursuing an appeal against his conviction. The
man spoke to one prisoner for about 20 minutes on the evening before his
death. He referred to his pension. He was still waiting for information from
the British Medical Association, but he was apparently hopeful he would win
the appeal. Another prisoner confirmed that the man was still pursuing the
matter of his pension, although he said he did not go about it as vigorously as
he would have expected. He suggested the man might have been depressed.
I note that his last letter to the General Medical Council was on 19 November
2003. Another prisoner told us that a toxicologist was due to come over from
the USA within the next month. He was to provide advice in support of the
man’s appeal.
Discovery of the death
The prison officer who found the man apparently dead believes he last
checked the man at just a few minutes past five on the morning of 13 January.
Certainly, it would have been before 5:40am, since he told us that he carried
out his last peg at 5:40 or 5:45am and then immediately started his roll count.
It was during the roll check that he discovered the man’s apparent death. He
reached the man’s cell at approximately 6:10am. He looked in and saw the
man apparently looking out of the window. He was partially obscured by the
curtain, but the prison officer could see a shoulder and two legs. He
attempted to get a response from the man, by calling out his name half a
dozen times and kicking violently on the cell door. There was no response.
He therefore went for help.
The prison officer ran down to the next landing and summoned assistance
from the Assistant Night Orderly Officer on the Centre. He told us that he did
not use his radio as it would have been noisy and he did not want to alert the
whole wing to what was going on. The Assistant Night Orderly Officer
telephoned the Control Room and asked that the Night Orderly Officer be
informed, and that a nurse and dog handler also attend the scene. The
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Control Room asked the Night Orderly Officer to return to the Centre
immediately. The Night Orderly Officer was in healthcare at this point. He
rang the Centre and was informed by the Assistant Night Orderly Officer that
the man had been found hanging in his cell. The Night Orderly Officer asked
who was present at the Centre, and the Assistant Night Orderly Officer said
that the dog handler was present with him. (The dog handler had heard the
radio transmission to the Night Orderly Officer and had immediately gone to
the Centre.) The Night Orderly Officer instructed the Assistant Night Orderly
Officer to tell the night patrol officer on B wing and the prison officer who had
raised the alarm to enter the cell.
The Night Orderly Officer then set off for the Centre with a nurse, who
collected the resuscitation bag on the way. The healthcare centre is situated
some way from D wing and it therefore took a few minutes for the Night
Orderly Officer and the nurse to reach the incident scene.
The prison officer who raised the alarm collected the fish knife from the self-
harm box in the night office on D2 landing and went back to the cell with B
wing’s night patrol officer. They entered the cell, while the Assistant Night
Orderly Officer and the dog handler waited outside. They saw the man
hanging from the window area. The ligature was apparently made from
bedding sheets. The man’s legs were resting on the heating pipes, which
were situated below the window. A knot at one end of the ligature was
trapped between the window and the frame. (This was an obvious ligature
point – but there were many others in the cell. The man was not in a ‘safe
cell’.)
The man was not breathing and no pulse could be found. His legs were
purple while his upper body was white. He also had an injury just above his
left eyebrow where he had apparently hit his head against the window, and a
large blister or burn mark on one of his knees, apparently from the heating
pipes.
B wing’s night patrol officer lifted the man to ease the pressure from the
ligature while the officer who had raised the alarm cut through the ligature
above the man’s head using the fish knife. They then placed the man on the
bed. The officer who had raised the alarm cut the noose again to remove any
pressure from the neck and checked for a pulse but found none. He
commenced resuscitation while B wing’s night patrol officer performed chest
compressions.
The nurse and the Night Orderly Officer arrived shortly after (B wing’s night
patrol officer thought inside five or ten minutes later). The Night Orderly
Officer told the officer who had raised the alarm to leave the cell as he
seemed to be very shaken. The nurse saw that the man was not breathing
and found, on checking, no pulse. He was cold but his legs were slightly
warm. She placed an airway in his mouth. This was difficult as his teeth were
clenched very tight. She then placed a bag over the airway through which air
was pushed into the man’s lungs. B wing’s night patrol officer continued chest
16
compressions. The nurse asked whether paramedics were on the way, but
no-one knew.
Once he was satisfied everything possible was being done, the Night Orderly
Officer temporarily left the scene to check that adequate staffing
arrangements were in place elsewhere in the prison.
Resuscitation continued for approximately half an hour. The officer who had
raised the alarm went back in at one point to relieve B wing’s night patrol
officer. On a number of occasions during this period the nurse asked staff
outside the cell when the paramedics would be arriving, but no-one was sure.
At about 7:00am she left the cell to find out what was going on. The Night
Orderly Officer told her that no ambulance had been requested but that the
Control Room had contacted the Duty Doctor. She recommenced
resuscitation. About five minutes later she again went to the cell door. At this
point an officer told her she needed to write a statement. She became unsure
of what she should do – whether she should continue with resuscitation, write
a statement or contact healthcare. After thinking for a while, she telephoned
healthcare at approximately 7:15am. Five minutes later she was told she
would be relieved, and a second nurse duly arrived. The first nurse was then
directed to wait on her own in one of the Governor’s offices nearby for a
debrief.
The second nurse had been informed before she arrived at the scene that the
man had been found dead. When she arrived, she saw that resuscitation had
not been continuous as the first nurse was standing some way from the cell.
The first nurse had not told her at what point she had stopped administering
resuscitation, but had told her that the man had been found at about 6:20am.
With all this in mind, and seeing the man’s condition when she entered the
cell, she did not re-commence resuscitation.
The Duty Governor arrived on the scene a few minutes before 7:30am. He
was briefed by the Night Orderly Officer and entered the cell to assess the
situation. Resuscitation had stopped at this point and the doctor was awaited.
The Duty Governor then arranged for reliefs for those staff who had been
involved and posted an officer outside the cell to guard the integrity of the
scene. The governing Governor visited the site at approximately 7:50am.
The doctor arrived at about 8:00am – that is, some 77 minutes after he was
contacted. He examined the man and pronounced him dead at 8:10am.
After the doctor pronounced the man dead, the cell was sealed by the
establishment’s Dedicated Search Team.
The prison’s Head of Operations arrived in the establishment at approximately
7:15am. Shortly afterwards, he telephoned the Duty Governor to receive a
briefing. The Head of Operations then took over co-ordination of the incident,
principally in relation to dealing with outside parties.
17
The Head of Operations explained that staff were leaving the establishment at
the end of their shift. He said he knew from experience that some (and one in
particular) would give out information about the death straightaway. He
therefore decided to inform Headquarters immediately to put them on standby,
given the likely interest in the death. This was at approximately 7:45am. He
phoned the police soon after to put them on stand-by also. Once the doctor
had pronounced death, he phoned both parties again to confirm and to ask
the police to arrange for the man’s wife to be told. NOU in turn contacted
Press Office and the Deputy Director General.
The Head of Operations took the man’s wife’s address from LIDS. This
turned out to be wrong. The police did not inform the prison of the wrong
address until some time after 8:30am. By this time, the man’s wife had heard
the news from her family. The Head of Operations said that, had the police
got back to them earlier to say the man’s wife was not at the address given,
they would have phoned her. However, due to a bad experience several
months earlier, they did not routinely phone next-of-kin direct. The Head of
Operations explained that the difficulty with LIDS was that the prison could
only put on the system the information provided by records or by the prisoner
or his family.
The Head of News in the Home Office Communication Directorate understood
the message that the police were informing the man’s wife of the death to
mean that they were doing so at that moment. He therefore took the decision
to release information to the Press Association. He said he felt it was
important for the Home Office to take control of the flow of information, not
least to ensure that the public had an accurate picture of what had happened.
By the time he was informed that the police had gone to the wrong house, the
information about the death was in the public domain.
The Head of News at the Home Office has pointed out that news of this
magnitude can be difficult to contain and that he feared a ‘leak’ from
elsewhere. There was to be a shift change of prison officers within a few
minutes; prisoners were due to be released from their cells; the police and
Coroner’s office knew. Any of these might make a call to the media. The
Head of News said that all in all it seemed the correct thing to do at the time.
In the event, managers at the prison believe that there was a leak. Some of
the detailed information relayed by the media had not been made available to
the Home Office Press Office.
The Head of Operations also dealt with family liaison issues, asking the man’s
wife whether the prison could do anything to assist and whether she wanted to
visit the scene of her husband’s death. The Head of Operations kept the
man’s wife updated on arrangements the police were making in respect of her
husband’s body. The Governor sent a letter of condolence to the man’s wife.
The following were all contacted according to the establishment’s contingency
plans:
18
• The Chaplain
• The Police/Prison Liaison Officer
• The Care Team Leader
• The Suicide Prevention Team Leader (who arranged for a review of all
prisoners on an open F2052SH)
• The Independent Monitoring Board
• The Samaritans
• National Identification Bureau
• The man’s Supervising Probation Officer
The police (Coroner’s Officers) attended the establishment at 9:10am. At
10:43am, the man’s body was taken from the establishment by the
undertakers to Sheffield Mortuary to await a post mortem.
A debrief of staff was conducted following the incident and a notice to staff
and prisoners issued.
Examination of the issues
Medical care
A doctor from the Northumberland Care Trust reviewed the man’s IMR on my
behalf to determine whether his medical care whilst in custody was
appropriate. He noted without comment the man’s various ailments and the
treatments he had been given for them. He also commented that the man
was seen repeatedly by mental health professionals including several
Consultant Forensic Psychiatrists and was frequently reviewed by Prison
Medical Officers. All agreed that the man was not suffering from a delusional
state, nor was he clinically depressed. The man repeatedly denied feeling
suicidal or having any immediate suicidal intent, but equally made it clear that
he did not intend to serve a life sentence. Expert medical opinion indicated
that the man was, and would remain, a long-term suicide risk.
The doctor from the Northumberland Care Trust noted that procedures for
observation of potentially suicidal patients were implemented and carefully
reviewed at all times when the man’s clinical state appeared to merit it.
The doctor found nothing in the man’s IMR which indicated any significant
change in the man’s mental state, nor were there any changes in medication
which might have affected his state of mind. He could detect nothing which
might have alerted a member of the healthcare team to the man’s intention to
harm himself when he did. He concluded that the man was recognised as an
ongoing suicide risk but had no diagnosed serious mental health problems.
The medical record contained no observation that, if recognised, might have
led to preventative action by the healthcare team.
19
IEPS
During the initial review of his IEPS level, the man was given no marks for his
programmes report, as no sentence plan targets had been set. His work
supervisor noted that he always attended as required, was very polite and co-
operative and produced a high standard of work. She noted, however, that he
had not been in the shop very long and had not yet achieved the quantity he
needed to complete. She gave him three marks out of a possible four. His
wing report said the man kept himself and his cell clean and tidy and was
punctual at all times. He made correct use of the applications system and
complied with all instructions, although he only spoke when he was spoken to.
There were no concerns in relation to the keeping of inappropriate materials.
Under ‘Willingness to interact with all wing staff on a day to day basis and for
the purposes of formulating reports’, however, it was noted that, “He doesn’t
willingly interact with staff. He doesn’t participate with the formulation of
reports.” He was given four marks out of a possible eight.
The IEPS Board noted that the man did not accept full responsibility for his
offending behaviour and that both his wing and work reports were of average
standard. With just seven marks from a possible 16, two short of the mark
required for standard status, the man was reduced to basic.
Staff have reported that he did not seem unduly concerned by this
development. Prisoners, on the other hand, said he was deeply upset by the
ramifications for his contact with his family. One prisoner said that the full
implications had not hit him immediately, but it meant, for example, that he
only had 25p per day for phonecalls. Another wrote to me that, “the Wakefield
regime punished him for putting him on basic at the most difficult time of the
year for any inmate to cope with.” A note in the man’s IMR records, “It is
affecting him … can’t make much tel. call … Writing more letters to his wife …
depressed, emotional.”
The man appealed against the IEP decision on 15 December. He noted that
the problem with work was one of regular attendance. He had been available
for 92 sessions between September and 12 December, but had only attended
23 times. He suggested that his speed would only increase with regular
attendance. He considered he should have been given four marks until he
could be properly assessed. The man acknowledged that he did not attend
voluntary groups but said that, since he could not be a Listener or a wing
representative, he could only achieve a maximum of eight marks, rather than
ten [sic] for his wing report. He noted that he was otherwise considered fully
compliant in all respects, except in relation to his interaction with staff. Of this,
he said:
“It is agreed I interact with the staff. I do ask for information and that I am
polite. I have NEVER discussed family, the case, religion, politics or
current affairs with any staff. This is a voluntary exercise, unless HMP
Wakefield have unique rules in this matter.”
20
He therefore calculated that, “from the criteria laid down”, he should have
been awarded five or six marks for his wing report. He added:
“N.B. My personnel [sic] officer has made no contact since I sought him
out to introduce myself soon after my arrival here. No wing officer has
asked how I am settling in, coping or whether I have any problems (WCU
excepted).
“With the reduced level possible (10) it could be thought that the
assessment was less than sympathetic.”
A prison officer from the Sentence Planning Unit told us that the man spoke to
him about his intention to appeal against the decision. They spoke at length
about non-offence related work and the benefits the man might derive from
them, as well as the benefits which might accrue to other prisoners by having
him on the groups. The man apparently expressed his thanks to the
Sentence Planning Unit officer and said that nobody had ever explained what
was on offer before.
The man actually attended the appeal hearing on 17 December (this was
considered unusual in itself) and expressed a willingness to undertake non-
offence related work. The Sentence Planning Unit officer told us that he and
others on the board were really ‘excited’ and ‘chuffed’ at this development.
Nevertheless, the board upheld the original decision on the basis that it was
appropriate in light of the information available at that time. It noted, however,
his willingness to undertake some personal development work and that the
Sentence Planning Unit officer would see him about this the following week.
The interview took place on 23 December. The Sentence Planning Unit
officer told us that the man said he was very, very keen to do the work. He
said he (the officer) and his colleague felt ‘quite giddy’ as a result. The officer
thought the agreement to do personal development work was key to the man
being restored to standard. He spoke about his satisfaction when he and his
colleagues got prisoners off basic. He cited an example of another category A
prisoner who had finally agreed, after three years, to undertake some work.
The Sentence Planning Unit officer said:
“… but I emphasise there was no forcing him, at the end of the day I have
no vested interest in anybody who does or doesn’t do groups, it’s entirely
up to the individual but there was no, if you don’t get this you won't get
that, we never come at it from the slant that if you don’t do groups you can
expect to be on basic for a long time, none of that.”
During the weeks following the man’s reduction to basic, his conduct on the
wing was monitored closely, with entries being made on his history sheet at
least daily. These included references to contact the man had had with staff.
The Suicide Prevention strategy says, however, that the SPAB officer must
make and maintain regular contact with all prisoners on basic IEP level and
21
endorse the prisoner’s wing history sheet accordingly. This does not appear
to have happened.
The man’s IEPS status was reviewed on 8 January, in line with normal
procedure. The Sentence Planning Unit officer told us that he expressly
advised that one mark should be awarded on the programmes report in light
of the man’s agreement to do non-offence related work. His work report was
positive once again, this time noting that his output was increasing daily and
that he worked the whole time he was in the shop. He was awarded three out
of four once again. His wing report recorded that the man always kept himself
and his cell very clean and tidy, he was always punctual and conformed to all
rules and routines, with no instances of being late for labour or lock up. He
used the application system appropriately and complied with all requests
made of him by staff – “has made an effort to improve his relationship with
members of staff”. Under ‘Willingness to interact…’ was written:
“Has again made an effort to engage in conversations with staff, always
being polite and well mannered. These have been on general topics and
not centred around making requests. Has agreed to and been
interviewed by [the Sentence Planning Unit officer and another officer]
regarding sentence planning.”
He was awarded five marks, giving him a total of nine, and duly restored to
standard. The Board noted, “There have been improvements in your
relationship/communication with staff. You have agreed to undertake non-
offence focussed work, namely PDPR and stress management.”
The man apparently told a prisoner subsequently that the whole episode was
ridiculous and ‘beggared belief’. He sounded equally nonplussed when
speaking to his wife about his restoration to standard.
Views of prisoners and staff
The investigation team spoke to a number of staff and prisoners. All refuted
suggestions in the press that the man was being bullied by other prisoners.
Wakefield operates a scheme whereby two officers are allocated to each
prisoner as personal officers. This means that where the lead officer is not
available, the prisoner will be able to speak to the second personal officer.
Neither of the man’s personal officers, however, was able to offer any
information about him. They seem to have had little contact with him. (This
reinforces the man’s comments on his IEPS appeal.) One prisoner said the
man had been trying to see his personal officer, but had not been able to, and
no-one could tell him where he (the personal officer) was. He described the
man as going round in circles trying to sort things out.
Some prisoners on the wing described the man as a kind person who did not
make enemies. Others said he was a ‘very nice man’, who was amiable and
not arrogant as staff suggested. Many spoke of his devotion to his wife and
22
how he valued their visits and telephone contact. He apparently phoned her
every day.
One prisoner told us that the wing Principal Officer was not answering the
man’s applications and would not speak to him. He said the man had
resorted to writing via Royal Mail. This had led to a confrontation with the
Principal Officer. Other staff had also been confrontational, telling the man
that it was they who ran things. A number of prisoners told us that the man
was bullied by officers. They said staff were blackmailing the man via IEPS in
order to persuade him to undertake courses. They would not let the man
simply get on with his sentence. One prisoner wrote to me about “systematic
bullying by psychologists (programmes) and throughcare. Prisoners are
bullied and blackmailed into attending groups.” (I note that prisoners also
complained to HM Chief Inspector of Prisons during her unannounced
inspection in October 2003 of disrespectful and intimidatory behaviour by
staff.)
Other prisoners specifically named the Sentence Planning Unit officer as
putting pressure on the man. They said the officer wanted to get inside the
man’s head and to make him talk about his victims. One suggested that the
Sentence Planning Unit officer called the man to the office very frequently,
and that he and another officer always took the opportunity to ‘have a go’. He
was ‘on to him’ all the time. One prisoner suggested that the Sentence
Planning Unit officer asked the man why ‘he did not do them all a favour’ and
subsequently sang ‘Hi ho, hi ho, it’s off to basic we go’ to wind him up.
Another reported that the two men did not see eye to eye at all. Some said it
was entirely down to the Sentence Planning Unit officer that the man was
downgraded.
We put these allegations to the Sentence Planning Unit officer. He was not
surprised. He said a prisoner had tipped him off that a number of prisoners
were going to get together to tell the investigation team that he bullied them.
He suggested that a couple of prisoners who had previously been given
reports by him were trying to get even. The Sentence Planning Unit officer
had submitted an SIR about this at the time. (I have seen it.) He told us that,
because he prepared much of the IEPS paperwork, sat with the board and
relayed decisions to prisoners, he was generally perceived by prisoners to be
responsible for decisions to downgrade. He emphasised (as described
above) that he did not apply pressure on prisoners to engage with sentence
planning, but only explained to them the benefits. With regard to the
allegation about singing to wind up the man, the Sentence Planning Unit
officer said, “I can’t even comment on that, it’s just ridiculous.”
One prisoner alleged that another officer – the one who had raised the alarm
when the man was found - had told the man when he came to the prison that
he should kill himself and that he (the officer) would show him how to do it.
The officer flatly denied this, commenting that it would be a very
unprofessional thing to do.
23
Category A checks
National procedure is that standard risk category A prisoners need only be
checked once every two hours. The practice at Wakefield, however, is for
them to be checked during the course of every hour. The form recording
these checks is poorly designed. It simply lists all the category A prisoners on
the wing on one side and time slots of one hour on the other. The night patrol
officer simply has to tick each time slot to show that all the category A
prisoners have been checked within the timeframe. The form shows that
category A prisoners were last checked between 5 and 6am.
The man’s neighbour told us that he heard a bang in the man’s cell between 1
and 2am. He subsequently woke at 5:00am and watched television until he
heard the officer who raised the alarm banging on the man’s door. He had
heard nothing during this period.
A couple of prisoners suggested to the investigation team that category A
prisoners were not in fact checked hourly. One said that he was not checked
on most nights. An ex-prisoner wrote to tell me that the ex-wing tea boy used
to sort out clean blankets for night staff. (He also said that, while he was a
cleaner in Full Sutton prison segregation unit, he was required to ensure clean
sheets and blankets were provided for the night staff.) A member of staff also
wrote anonymously to me to suggest I might like to inquire how staff
positioned themselves during the night. The writer suggested, that although
one member of staff should be positioned in each wing, the practice was for
all wing-based staff to congregate on the Centre. S/he suggests that, while
this might not have had a bearing on the man’s death, the practice should
cease in order to ensure staff are on scene to respond to sounds or shouts.
The officer who raised the alarm confirmed that night patrol staff were not
necessarily walking the wings at all times, but explained that he was required
to follow a pegging rota at different points on the wing every 25 minutes. He
refuted the suggestion that category A prisoners were not checked every
hour, but added that staff usually wore soft soled shoes and tucked their
chains in their pockets to keep the noise to a minimum. Staff also used a
night-light which shone only dimly to avoid disturbing prisoners when looking
through the flap on the cell doors. He told us he thought he had last looked
into the man’s cell just after 5am.
Entering category A cells
The ‘Know Your Job Sheet’ for night patrol officers advises that staff will be
issued with a sealed packet containing a cell key which should be attached to
them by a chain. “If it is necessary to unlock a cell door the alarm must be
raised beforehand and a second Officer must be called to assist before the
door is opened.” The Head of Operations confirmed that the policy was that a
cell door should not be opened unless two officers are present. He added that
there was a prisoner in the segregation unit who was on SO and three unlock.
They had had prisoners who were on SO and five. In those cases, those
instructions must be followed to the letter because there was no way of
24
knowing, until the cell had been opened, whether the emergency was
genuine. However, “With the general run of the prison we say at nights not
less than two.”
The officer who raised the alarm referred during interview to the night patrol
instructions. He said, “obviously being a category A prisoner, you should not
enter the cell on your own anyway and there should be the Night Orderly
Officer Assist, another officer and also a dog handler.”
The Night Orderly Officer told us that the Contingency Plan said staff should
wait for his return before they enter the cell. He said, however, that, having
ascertained that there were three officers and a dog present, he “made a
judgement on that point because I thought we might have a chance, you know
we could have saved him and I must admit that was paramount in my
thoughts.” (Whether or not he was right about the procedure, I cannot fault
the Night Orderly Officer’s judgement.)
Resuscitation
The Intervention Plan in Wakefield’s Suicide Prevention Policy and Strategy
Document says that, in the case of hanging, the prisoner should be placed on
his back on a flat solid surface and that resuscitation should be attempted
“unless rigor mortis of the limbs has clearly set in [emphasis in the original]”.
The officer who raised the alarm told us that he had had no training on what to
do if he found a body. He had had basic training within the training
department, “but obviously that’s more to prevent suicide and things like that
happening rather than actually finding it.” He said placing the man on the bed
was simply the first thing that came to mind.
The B wing night patrol officer said he had not read the Safer Custody
document but was aware of the first on scene instructions. He believed he
had followed proper procedures. With regard to placing the body on the bed,
he simply said it was “just there”.
The Deputy Governor explained “it would be very difficult to do it on the floor
with its size and the state of room”.
When asked about carrying out CPR on a soft surface, the first nurse on the
scene said it was probably best not to move the person because, if he was all
right and survived and they had moved him, they could have damaged his
neck and paralysed him. “Things happened so fast, all I was considering was
getting some air into his lungs, to get his blood to circulate round his body.”
Emergency medical assistance
Wakefield’s contingency plans for the Control Room Senior Officer in the
event of a death in custody are as follows:
25
“When informed of a suspected inmate death you will: -
“Action:- 1 . Despatch Hotel 5 and the Medical Officer to the scene
2. Contact Duty Governor (to control room)
3. Inform Security and D.S.T. to cordon off the area, and
make prisoner’s record available to the Governor.”
It then lists the actions to be taken once death is confirmed by the doctor.
The Intervention Plan in Wakefield’s Suicide Prevention Policy & Strategy
Document (revised July 2003) says that upon discovery of attempted or actual
self-harm or suicide, the person making the discovery should:
1. Summon help and request emergency medical assistance and first aid
equipment.
2. Enter the cell as soon as possible, following the local strategy for safely
doing so.
3. Ensure a speedy access to the casualty by (A) the HCC staff and (B)
the external paramedics.
Nowhere does it appear to be set out whose responsibility it is to call the
paramedics – the officer making the discovery has only to request emergency
medical assistance while the ECR is instructed only to call the Medical Officer.
The ECR Senior Officer confirmed that, although the duty Medical Officer was
called, he did not make contact with paramedics - “none was requested”.
Subsequently, he said, “Had there been a request for any further assistance,
it’s a bit of a delicate line you draw between not wanting to interfere with
things that are going on or any need for any further assistance.” He told us
that it was not part of his contingency plans to call the paramedics. He said
he would, “expect to get a request by whatever means and as soon as we are
asked to call in the ambulance service, then we have a method of doing that
… so that’s normally done through the Control Room but, of course, we don’t
do it as a matter of course, we do it upon request.” He added that he would
expect such a request to come from healthcare staff.
The first nurse on the scene told us that, when she first arrived on the Centre,
there was no noise on the radio, so she thought everything was settled and
that the man could not be that bad. She therefore asked ‘them’ to contact the
doctor:
“I thought I’ll go up and assess the situation and if we need an ambulance
then we can get one. When I got up there I could see he was in a right
state but I assumed that whoever cut him down and when you realise
someone is not breathing, or having difficulty in breathing, I would assume
it was the responsibility of the people who were actually there. If you cut
somebody down and you see they’re not breathing, you need some sort of
assistance, you need some sort of help. I mean that’s my interpretation.”
26
The Head of Operations told us that the Contingency Plans did not say that
paramedics were to be called, but that they were to be called if necessary. He
continued:
“What happened is that the week before [the man’s] death we had a
category A prisoner died and we followed the protocol to the letter, so
naturally called out the paramedics. When the paramedics arrived, we got
quite a lambasting because our nurse had said that he was dead and they
said, ‘If you knew he was dead, why are you wasting our time? We do not
need to come out if people are dead. All you need to do is, if he is dead,
is to get your Doctor to come out and the Coroner.’ So bearing in mind
they knew early on that [the man] was dead, because they tried
resuscitation, and generally speaking for want of a better word, he was
actually dead. They knew at once, so I presume on that they didn’t call
the paramedics, particularly with the fact that we had problems the week
before, having called them out and then got this lambasting because he
was already dead.
“But if you look at the Contingency Plans, the Contingency Plans do not
say that on every incident you have to call out paramedics and we would
only call out paramedics to any kind of prisoner incident if one is having
breathing difficulties, blue light or if there is a bleeding difficulty, a red
light.”
(Wakefield has a code for identifying the type of medical emergency. There is
no indication that it was used at any stage during this incident.)
The ECR contingency plans do say, however, that in the event of the
discovery of an apparent death, the medical officer must be called. The first
nurse on the scene said she asked for the doctor to be called when she
arrived on the Centre (some time between 6:30 and 6:35am). The ECR log
shows that the doctor was called at 6:43am. This suggests that the ECR
waited to be specifically asked to call a doctor – that is, some 33 minutes after
the body was discovered – before doing so. The doctor said he was told only
that somebody had tried hanging himself. He phoned healthcare at the prison
and was told it was the man, but nothing else.
The doctor told us that he was asleep when he received the call and set off
immediately, without going through the normal getting up processes.
However, he lived on the far side of Leeds. He added that he was not, in fact,
the on-call doctor, as he did not do Mondays (which would have included
Monday night, into Tuesday morning).
ECR
Exact timings have been difficult to establish. None quite marries up with
another. In such cases, it would be usual to look to the ECR log for definitive
information, as the ECR should be at the centre of everything that happens
during an incident of any sort. There are, however, just three entries on the
Control Room Log relating to the man’s death. These are as follows:
27
“6:30 Informed by [Assistant Night Orderly Officer] (Oscar 2) [the man]
hanging in cell. Oscar 1 Hotel 1 to centre – Zulu rcve.
6:35 Duty Governor informed by phone – attending.
6:43 [Doctor] contacted to attend.”
We found out from the ECR Senior Officer that his involvement in the incident
had been minimal. He said he did not ‘particularly’ have any further contact
with those on the scene after the initial message from the Assistant Night
Orderly Officer. When pressed on this, he said he was aware medical
assistance was being given and that normal security precautions were in
place.
The ligature
Four separate torn-off lengths of linen were discovered in the man’s cell – one
formed the ligature he used to hang himself. This was actually made of two
pieces of cloth and had three knots in it – two were on either side of the man’s
neck while the other formed the ligature point. The other three strips were
found under the man’s pillow. One had knots in either end, one had one knot
and one none. This suggests that he had practised with various alternatives.
Although of a sheet type material, these lengths were not torn from the man’s
bedding. There was a suggestion that he might have secreted lengths of
material usually used for practising on from the workshop in which he worked.
This would have meant that he was preparing for his death nearly two weeks
before it occurred (as he last attended work on 31 December). However,
having examined the ‘practice’ material in the workshops, it is of a slightly
different shade from that used for the ligature. The ligature also seemed to be
from a more worn material. In light of this, I think it unlikely that the workshop
was the source for the material found in the cell.
We were advised that prisoners change their bed linen on Fridays. They strip
their own beds and take the bedding down to the orderly. The linen for the
whole wing is then sent off to Kirkham prison for laundering. From there, it
might be sent to any prison in the country. It is possible that the man tore the
strips off his own sheets before the Friday preceding his death - or even
earlier. The last search of his cell took place on 18 December 2003 (although
locks bars and bolt checks would have been carried out daily). In theory,
therefore, he could have had the lengths of material for quite some time. The
truth of the matter, however, is that we simply do not know from where he
obtained the material or how long he had had it. The fact that the material did
not properly belong in his cell, however, suggests that the man’s death was to
some extent planned rather than purely spontaneous.
Pension
We spoke to a member of staff at the Department of Health. She explained
that Regulation T6 of the NHS Pension Scheme Regulations provides for
forfeiture of pension benefits. The Regulation allows for forfeiture of all or part
28
of any benefits either payable to or in respect of the member. This includes
survivor benefits payable on the member’s death. The degree to which
forfeiture is applied is for the Secretary of State to decide, having regard to the
particular circumstances of each individual case. On 17 July 2002, the
Secretary of State decided to forfeit the man’s personal benefits. At the same
time, he decided to leave survivor benefits payable. The letter notifying the
man of the forfeiture decision clearly stated that forfeiture did not extend to the
benefits payable on his death. The result of this decision was that the man’s
wife would not be entitled to any payment from the pension until such time as
he died. In this case, ‘survivor benefits’ comprised a lump sum and annual
payment. Once the man had turned 60, the value of the lump sum payable
would have reduced year on year. Had he lived past 65, no lump sum would
have been payable. There had been no change regarding the man’s pension
position since he was advised in July 2002 that he was to forfeit it.
Some newspaper reporting has referred to the man’s wife’s financial
difficulties. One newspaper referred to her as living on benefits and unable to
afford to modernise her cottage. It also referred to crippling legal bills. The
man’s diary indicated his concern on this matter:
• 31/07/2002 (Wednesday) - “[Wife] – chat, no notes sent in yet. She’s
getting no money off the DHSS, supported by the kids. What a terrible set
up. How is she coping?”
• 17/10/2002 - “No money. [Wife] not able to get DHSS to see the poverty
she is in. Only the kids who have been absolutely brilliant – the pension
appeal.”
• 07/01/2003 - “A new year, a visit from [wife]. Still no money off DHSS … If
this year doesn’t get anywhere I know it is not worth the effort. I have to
lock down this overwhelming emotion or else I’d be on a suicide watch or
drugs.”
I do not know, and have not sought to discover, what the man’s wife’s
financial circumstances were at the time of the man’s death.
Analysis of self inflicted deaths
I understand that nine per cent of self-inflicted deaths occur in the high
security estate. Relatively few involve category A prisoners. (This is to be
expected given the small proportion of category A prisoners in the prison
population.) Safer Custody Group advises that there is about one category A
self-inflicted death per year, but that they do not routinely analyse statistics
because of the difficulty interpreting rates at such low numbers. Prior to the
man’s death, the most recent category A self-inflicted deaths were in May
2002 and September 2003 (both at Full Sutton.) Since the man’s death, a
category A prisoner at Woodhill prison killed himself on 22 January 2004.
The Prison Service’s Safer Custody News reported in February 2004 on a
study of 20 recent lifer self-inflicted deaths and trigger points. Warning signs
29
immediately before the death included refusing food, work or medication. In
contrast, mood and demeanour appeared to be unreliable indicators of risk.
In almost 50 per cent of cases, the prisoner was described:
“… as appearing happy, even unusually happy, just before they died,
despite showing behavioural warning signs immediately before death,
including:
• talking to a Listener or other prisoner about suicidal intent (six cases)
• food refusal (five cases)
• writing (two cases)
• refusing work or other activity (two cases)
• refusing medication
• agitated behaviour
• smashing property
• quiet and withdrawn.”
The study found that the group that died more than a year after conviction:
“… tended to have a previous history of self-harm or suicide attempts but
fewer signs of immediate risk. Problems in progressing through the lifer
system appeared to be a significant factor, including:
• hopelessness resulting from reduced status or failed appeal
• inability to adjust following transfer.
Other triggers included disrupted relationships in and out of prison.”
Safer Custody Group also provided me with some statistics related to self
inflicted deaths on or near birthdays. Since January 1978, six (0.46 per cent)
of 1,309 self inflicted deaths with a recorded date of birth occurred on the
prisoner’s birthday. This is apparently about two more (0.19 per cent) than
would be expected if the deaths had been evenly distributed. During the
week before a birthday, 33 (2.5 per cent) of prisoners killed themselves as
against an expectation of 25 (1.9 per cent). Self-inflicted deaths in the week
after a birthday are completely in line with what would be expected if there
was an even spread through the year. The Safer Custody Group concludes:
“There does appear to be a slightly raised risk of a self-inflicted death in
the week before and on an actual birthday. However the overall
proportion of self-inflicted deaths in which birthdays appear to be a major
factor is low and may well be explained by random variation. That said, if
we assume that only those deaths above the expected levels on a
birthday and during the week before should be counted then we have
about 0.79 per cent of all self-inflicted deaths in which birthdays appeared
to be a major factor. Although this figure is low it doesn’t, of course, rule
out birthdays as being an important factor in any individual self-inflicted
death.”
30
I note that an entry in the man’s IMR dated 12 January 1999 reads:
“… It’s his birthday tomorrow and he has received a lot of mail, feeling
very low and is finding the reduction in his anti-depressants too low …
states he’s not suicidal and would never commit suicide unless he was
sentenced to life.”
Two diary entries suggesting a very low state of mind were made on the
man’s 55th and 56th birthdays respectively.
I understand that, during 2003, only one prisoner older than the man killed
himself.
Consideration
The man was not on an open F2052SH at the time of his death and therefore
F2052SH procedures are not directly relevant in this case. However, it is
worth noting that the last Standards Audit conducted in May 2002 and
subsequent self-audits have resulted in the achievement of ‘Good’ ratings in
suicide prevention. In her report, HM Chief Inspector of Prisons also
describes an establishment performing well in the area of suicide prevention
and anti-bullying. She says that procedures are working effectively and that
the establishment gives due weight to the maintenance of a safe environment.
I have not spoken to the man’s wife and do not know, therefore, whether she
knew that her husband was going to kill himself or why. There is evidence,
however, that the man saw no point in spending the rest of his life in prison.
He was anguished by being apart from his wife and at times said he felt she
and the family would be better starting afresh. Financial considerations may
also have entered the equation. None of this – with the possible exception of
the last – explains why he chose to kill himself when he did.
I have noted the Safer Custody Group’s statistics on self inflicted deaths
before and on birthdays. It seems to me entirely possible that this was a
factor in the timing of the man’s suicide. An entry in his IMR for 12 January
1999 and two diary entries (13 January 2001 and 14 January 2002
respectively) indicate that he found it a very difficult time of year. There is no
reason to suppose that 2004 was any different. This may have been
exacerbated by events over the Christmas period, the fact that he had a very
bad cold and the unavailability of any work for a sustained period.
(I am concerned about the low expectations and low achievements at
Wakefield with regard to work for prisoners. The Governor told me that their
target was 19 hours per week. They achieved, on average, just 16. This is
poor and should be addressed as a matter of urgency.)
Other prisoners told us about alleged bullying by staff at the prison. I have not
investigated this, other than to put the two specific allegations to the officers
concerned. Nor have I investigated the allegation that the wing PO did not
31
deal with prisoner applications. These are, however, matters which the
Governor might like to consider further.
Prisoners also told us how hard the man took his reduction to basic. More
than one has made the point that the consequent reduced contact with his
family came at a period which is hard to bear in prisons at the best of times.
The man appears to have been mystified by the sequence of events over his
IEPS level, apparently saying that it ‘beggared belief’. The fact that he was
restored to standard would have done little to persuade him that the process
was in any way fair.
This, however, is no more than after the fact speculation. I do not consider
that staff at Wakefield had any reason to suspect what the man planned or
that his birthday would be any sort of trigger point. In addition, he appears
mostly to fall outside the findings of the Safer Custody Group’s analysis of self
inflicted deaths by lifers.
I am concerned, however, that Wakefield staff were inadequately informed
about the man’s suicide risk. While there is a wealth of information buried in
his records about the connection between his pension, his appeal against
conviction and his possible suicide, none of this appears to have been flagged
up for either wing staff or staff in the correspondence office at Wakefield. This
means that, had there been developments on either score, nobody would
have been aware of the likely implications. Frankland was well aware of the
nature of the risk. They should have taken steps to alert staff at Wakefield
rather than leaving them to discover it for themselves. In the event, this failure
was not an issue. But it could have been.
Notwithstanding the impact or otherwise of the IEPS saga on the man’s
apparent decision to kill himself, I have several concerns about it. In the first
place, it simply does not feel right that a prisoner universally acknowledged to
present no problem to staff or other prisoners, polite, clean and tidy, should be
on basic. This is not how the IEPS is supposed to work. Basic should be
reserved for those whose behaviour causes real problems.
However, I have more specific concerns. The first is the lack of direct
correlation between the published criteria for assessing a prisoner’s level and
that set out on the wing report. The IEPS document says:
“Placement on the appropriate level of the IEP scheme depends on a
number of factors and is measured against compliance and performance
with the following:
1. Rules and Regimes
• Following written and posted procedures
• Acceptable level of personal hygiene, including a clean and tidy cell
• Punctuality at lock up, labour and meals
• Sensible use of the application system
• Noise levels to an acceptable standard
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• Wearing appropriate clothing at the appropriate time
• Compliance with mandatory drug testing provisions
2. Relationship with Staff and Other Prisoners
• Treating staff, prisoners and visitors with respect, whatever their race,
religious belief or personal circumstances
• Co-operation with staff in the performance of their duties
• Absence of racist, obscene or other offensive remarks and gestures
• Appropriate attitude and behaviour to all staff and visitors
• Absence of bullying and intimidation
• Absence of bullying or threatening behaviour
• Interaction with other prisoners
• Wing representation e.g. lifestyle, Video rep, Listeners etc.”
Categories on the wing report form, however, are restricted to:
• Personal and cellular hygiene
• Punctuality in relation to the wing and prison regime
• Use of the application system
• Attitude towards staff and instructions
• Willingness to interact with all wing staff on a day to day basis for the
purposes of formulating reports; and
• Use or keeping of inappropriate materials, such as pornography.
This means that there is no room for following written and posted procedures,
acceptable noise levels, wearing appropriate clothing, compliance with drug
testing, treating others with respect, absence of racist etc remarks and
gestures, absence of bullying or threatening behaviour, interaction with other
prisoners and wing representation to be taken into account. The lack of
correlation between published standards and those actually taken into
consideration diminishes the transparency of the scheme and may well be
detrimental to perceptions of its fairness. Certainly, many prisoners have
spoken negatively about it. It is perhaps not without significance that, in all
but the last of these omitted criteria, the man would have scored positively.
I am also concerned by an element of double counting. The inclusion of
‘Willingness to interact with all wing staff on a day to day basis for the
purposes of formulating reports’ means that prisoners’ engagement or
otherwise with sentence planning can be taken into account on both the wing
report and the sentence planning report. Of course, this will work in the
compliant prisoner’s favour. For those not engaged with sentence planning,
however, there is scope to be marked down twice. It is clear that this was the
case with the man.
I also consider the actual marks given to the man to have been harsh. Eight
points were available for his conduct on the wing. According to the criteria on
both the IEPS document and the report form, he could only have lost marks
on wing representation and willingness to interact – and yet he lost half of the
33
marks potentially available. I have to agree with him when he suggested that,
“it could be thought that the assessment was less than sympathetic”.
Finally, I also agree with his comments about interaction with staff. I do not
see why he should be expected to be proactive in engaging with staff.
Provided he was polite and responsive and did as he was told, I believe he
was doing all that should have been required of him. He should not have to
engage in conversation with staff unless he chose to do so.
It is also somewhat ironic, in this respect, that the man complained of staff’s
unwillingness to engage with him. Interaction and communication must work
both ways. I am aware that HM Chief Inspector of Prisons also has concerns
about the absence of positive interaction between staff and prisoners.
I was disappointed too that neither of the man’s personal officers had had
much contact with him, and that they knew so little about him.
Turning to management of the incident itself, the investigation team would
have found it useful to have better documentary evidence on exactly when the
man was last seen by the Night Officer. The current category A check forms
are lacking in necessary detail. They do not tell us any more than that all
category As were last checked some time after 5:00am. Prisoners have
alleged that category A checks are not carried out as they should be. A better
designed form might also provide firmer evidence that they are. As to the
allegation that staff cluster in the Centre, it seems to me that so long as they
are doing their required patrols, this is not a heinous crime, and at least
means they are not, as has also been alleged, sleeping somewhere. I take
the point, though, about being readily available on the wing should anything
happen. The Governor might consider this matter worthy of further review.
It was evident during the course of interviews that staff were unclear on the
circumstances in which paramedics should be called, and equally unclear on
who should make the decision to call them. In this respect there are
discrepancies between the contingency plans for these types of incident on
the wings (which are primarily contained in the Suicide Prevention Policy
Document) and those in use in the Control Room. The failure to call
paramedics might, in other circumstances, have proved crucial – especially
given the distance the doctor had to travel. Notwithstanding the complaints
from the paramedics who attended the prison the previous week, I consider it
essential that a requirement immediately to call paramedics in the case of an
apparent suicide should be incorporated into the ECR contingency plans. The
ambulance can always be cancelled if a member of healthcare attends and
finds that the situation does not warrant its attendance.
It is also a matter of some concern that there was a delay in summoning a
doctor and that the doctor who was contacted was not actually on call. I do
not know if the doctor who should have been called could have reached the
prison any quicker. I do not believe, however, that it would have made any
material difference in the circumstances.
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The investigation team also found that there were many different
interpretations of the circumstances in which a cell should be entered in a
medical emergency, particularly in respect of how many staff should be
present. This may have led to some delay, although given the imprecise
timings of events, it is impossible to say with any certainty. (For what it is
worth, I do not consider it likely that this had any bearing on the man’s death,
given the condition of his body when staff got to him.)
The first on scene staff placed the man on the bed as opposed to a flat solid
surface. This is not in line with the correct procedure, but I would find it very
hard to criticise them for it. Otherwise they followed correct emergency aid
procedures and are to be commended for their actions. In line with
establishment policy, they administered resuscitation, as they could not be
sure that rigor mortis had clearly set in.
Indeed, the first nurse on the scene and the other staff present could not have
tried harder to revive the man. They are all to be commended. It is hard to
imagine just how distressing it must be to give resuscitation to someone who
is apparently clearly dead. The suicide prevention document refers to
carrying out resuscitation unless rigor mortis has clearly set in. We know that
the man’s jaw was tightly clenched, but it is not entirely clear whether rigor
mortis had set in. It does not seem likely that a trained nurse would attempt
resuscitation in a situation where it had. I wonder, though, whether the need
to be certain that rigor mortis has set in is too high a test in some instances,
even taking into account the need for absolute certainty of death. The first
nurse on the scene, a healthcare professional, seems to have doubted the
likely efficacy of continuing with resuscitation attempts but was unclear about
the length of time she should be expected to carry on. In this case, it appears
to me that resuscitation continued for longer than was necessary or than
should have been expected from staff. Given the condition in which the man
was found, and the lack of a response to emergency aid in the first few
minutes, a defensible judgement could have been made by the nurse, as a
healthcare professional, to discontinue resuscitation much earlier.
The establishment’s management acted appropriately in alerting
Headquarters as early as possible that the man was probably dead, even
though a doctor had not certified death. Furthermore, while it is very
regrettable that the man’s wife learned of her husband’s death in the way she
did, I do not criticise the Press Office for releasing information before she was
told. The decision to do so was clearly taken with the right intentions. That
said, it is extremely disappointing that someone else apparently acted outside
the proper channels.
Things might have been different had the police been given the correct
address (though given the timing of the shift change, they would have had to
move extremely quickly). The Head of Operations drew the address from
LIDS. This was entirely reasonable. Letters sheets (from which the correct
address was obtained) might have been used to corroborate the information,
but the Head of Operations had no reason to suppose the information was
wrong and was trying to act quickly. In any case, my limited experience of
35
deaths in custody shows that next of kin issues are extremely complex and
sensitive. He could have gone through this process only to find that the
elected next of kin had changed. As with most information systems, its
accuracy is entirely dependent on what is put into it. Responsibility for
ensuring information is correct and up to date must lie with the prisoner.
Prison Service Order 2710 says that next of kin should be informed before
anything is reported or confirmed to the media:
“The decision on how to inform next of kin should take into account
individual circumstances, especially the distance from the establishment.
Wherever possible, notification should be made by a governor grade and
chaplain from the appropriate denomination … In some instances
notification via the police will be preferable.”
Wakefield’s Suicide Prevention Strategy and Policy Document says only that,
“Wherever possible, the next-of-kin should be informed in person, not by
telephone.” I understand, however, that Wakefield routinely relies on the
police to make the first contact with the family.
I have given some thought to this issue. My preference is for contact to be
made in person by staff from the prison, assuming, of course, that this is
logistically possible. This means that the family gains immediate contact with
someone who can talk authoritatively about what happened, what happens
next, what the prison can offer the family etc. It is also important, it seems to
me, that the prison is not perceived to be hiding behind the police in any way.
Nevertheless, I am aware that Prison Service staff receive no training for this
type of (specialised) work and that the police do. I am also conscious of
safety issues. I consider that PSO 2710 is right in its presumption that Prison
Service personnel should normally inform the family, but staff undertaking this
work should be adequately trained and supported. Where it is not possible (or
not advisable) for staff to visit the next of kin, it might be possible to work out a
partnership arrangement with the police, whereby a visit by them is timed to
coincide with a call from the prison. Clearly, however, this would need very
careful management.
The investigation team looked at relevant recommendations from the report of
the last self-inflicted death in custody at Wakefield, in October 2002. These
included one relating to the need for staff to record accurate information when
dealing with incidents and another relating to the use of the establishment’s
Emergency Medical Response Protocol. With regard to the first of these, the
team found it difficult to establish a precise chronology of events due to
inconsistencies between the various accounts and the absence of clearly
organised incident paperwork. The former is, of course, understandable given
the pressure of the situation and that those involved do not check their
watches every two minutes. However, no log of events at the scene was
submitted to the investigation team and the Control Room record was
extremely poor, probably in part because of the very peripheral involvement it
had in the incident. We would have expected the Control Room to have a far
36
greater involvement in the incident, in a co-ordinating role, and therefore to be
continually aware of, and recording, developments at the scene. During any
incident the Control Room should be in overall charge until the arrival of the
Duty Governor or other more senior manager.
As far as using the establishment’s Emergency Medical Response protocol is
concerned, it was clear that some of the initial briefings about the incident
were sketchy. Had the specific codes referred to in the protocol been used (in
this case, Code Blue for unconsciousness due to asphyxia, hanging or
breathing difficulties), the picture might have been much clearer for all
concerned. The investigation team found no evidence that this code system
was used on this occasion.
On the whole, however, contingency plans were followed in respect of
management of the incident. The Prison Service Order on follow-up to deaths
in custody was implemented adequately. I particularly commend the efforts of
the Head of the Care Team in the prison. There are, however, some
important local and national issues requiring further consideration,
notwithstanding that they do not appear to have had any direct impact on the
man’s death or in any way affected the outcome of the incident. These
include arrangements for entering the cell of a category A prisoner during an
emergency and whether rigor mortis is too high a test for determining whether
resuscitation should be attempted or continued.
Conclusion
There is evidence that, during his first three or four years in custody, the man
frequently indicated an intention to take his life at some stage. Due to the
high profile nature of his crimes, he had been subject to close management in
the early part of his sentence. This included regular management reviews of
the way he was handling his situation and careful assessment of where he
should be located. He had for some periods been on an F2052SH following
concerns that he was intent on taking his life. I have been impressed by the
standard of care and supervision afforded to him during those periods.
It is worrying that not all the relevant information on his F2052SH history had
been passed to residential and correspondence staff at Wakefield. The man
had not, however, given staff any recent cause for concern over his welfare
and I can find nothing to suggest this failing in communication impacted on his
death.
Although the investigation team has found procedural issues relating to the
management of the incident which should be addressed both locally and
nationally, from the evidence we have they do not appear to have affected the
outcome.
Recommendations
I recommend that the Governor of Wakefield, in association – where
appropriate - with the Directorate of High Security Prisons:
37
• reviews the IEPS in respect of its transparency and fairness both in
principle and in practice;
• considers what changes are required to ensure that prisoners can attend
work regularly;
• reviews the effectiveness of the personal officer scheme and arranges
additional training as necessary;
• reviews the establishment’s death in custody contingency plans with a
view to eliminating any inconsistencies with the Suicide Prevention Policy
document and instructions to staff on the residential units;
• revises the establishment’s night state category A check forms to include a
record of the precise time each check is carried out on each prisoner;
• ensures all staff are aware of the circumstances in which they may enter a
cell in a medical emergency;
• reviews the instruction relating to when resuscitation need not be begun or
may be ended in the event of any delay in the arrival of the doctor or
paramedics. The onset or not of rigor mortis should not be the only test as
to whether resuscitation should be commenced or continued. A judgement
by a healthcare professional should be acceptable in some circumstances;
• incorporates in the revised contingency plans the code system for medical
emergencies (currently published as a separate instruction);
• incorporates in the ECR contingency plan relating to death in custody a
requirement to call paramedics unless explicitly advised not to do so by a
member of healthcare staff;
• ensures information about the on-call doctor rota is readily available in the
ECR;
• reviews the job specification of the Control Room Senior Officer to ensure
it describes in full his role during any incident; and
• reviews the establishment’s incident paperwork and ensure all staff are
aware of it. This should include a review of incident log paperwork in the
Control Room.
I recommend that the Prison Service’s Safer Custody Group:
• considers what arrangement could be put in place for ensuring that long
term, but dormant, suicide risk issues are communicated from one
establishment to another;
• disseminates to establishments statistics on self-inflicted deaths and
birthdays, perhaps via its newsletter;
• considers, together with the Department of Health, whether further
guidance should be issued relating to the circumstances in which
resuscitation need not be begun or may be terminated; and
• asks all establishments to remind prisoners during induction and via
notices that it is their responsibility to ensure their next of kin details are up
to date.
Finally, I recommend that DHSP:
38
• considers the appropriateness of existing guidance on entering category A
cells in a medical emergency.
STEPHEN SHAW
PRISONS AND PROBATION OMBUDSMAN FOR ENGLAND AND WALES
39