Individual at Leeds

Investigation into the circumstances surrounding the
death of a man at HMP Leeds in April 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
April 2008
This is the report of an investigation into the death of a man that was found
hanging in his cell at HMP Leeds on 19 April 2006. The man was 25 years of
age.
I would like to express my condolences to the man’s family and friends for
their loss. I hope that my report addresses any concerns they may have. I
must also offer my apologies for the delay in completing this report.
The investigation into the man’s death was carried out on my behalf by one of
my investigators. A clinical review was conducted by Leeds West Primary
Care Trust. I would like to thank the then Governor of Leeds, and his staff, in
particular the principal officer, for their co-operation and assistance with my
investigation.
The man was received into custody at HMP Leeds on 8 February 2006. On
18 April, he was located in the segregation unit for disobeying an order to
transfer to HMP Ranby. The man self harmed but, although attended to by
healthcare staff, he was not placed on an Assessment, Care in Custody
Teamwork (ACCT) document. The man was found hanging by a ligature the
following evening.
My report highlights a number of concerns with regard to the segregation unit
at Leeds and the care that was afforded to the man whilst there, and I have
made a significant number of recommendations. I would add that I have
raised some of these concerns in previous investigation reports.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2008
2
CONTENTS
Summary 4
The Investigation Process 7
HMP Leeds 10
Key Findings 14
Background 14
Events of 18 and 19 April 2006 20
The man’s refusal to transfer and return to his cell 20
The man’s location in the segregation unit
20
Events during the evening of 18 April 23
Events of 19 April 27
Events leading to the man’s discovery 32
Events after The man’s death 35
Toxicology, Post Mortem and Clinical Review 36
Issues 40
The man’s movement to the segregation unit 40
Conditions of cell 41
The man’s attempt at self harm on 18 April 42
Staff handover 44
Adjudication 44
Discovery of The man
45
Communication 46
Action taken after the man’s death
47
Recommendations 48
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SUMMARY
The man had served a number of custodial sentences before being received
into HMP Lincoln in October 2003. The man’s long history of self harm was
recorded by staff. In November, the man was transferred to HMP Hull,
returning to Lincoln later that month. In December, the man was moved to
HMP Durham, before being transferred back to Lincoln. Healthcare staff at
the prisons recorded his history of deliberate self harm and he was assessed
on several occasions by a psychiatric nurse. Whilst at Lincoln, the man’s
medication was reviewed by the prison doctor.
In May 2004, the man was transferred to HMP Stocken where he became
more settled. In March 2005, he was released on licence but was breached
and recalled to HMP Doncaster in May. Staff at Doncaster recorded that the
man was a prolific self harmer and he was placed on an F2052SH. (The
F2052SH was a document which was used to assess and observe prisoners
at risk of self harm. This has now been replaced by the Assessment, Care in
Custody Teamwork (ACCT) process.)
In June 2005, the man was transferred to HMP Ranby. Staff at the prison
recorded that the man had used threats of self harm to manipulate staff and
had no qualms about carrying out such threats. During January 2006, the
man was again released on licence from HMP Stocken. However, the next
month he was arrested and was received at HMP Leeds on 8 February.
At Leeds, the man was assessed by nursing staff. They recorded that he
suffered from depression. An ACCT booklet was opened to monitor and
support his self-harm risk. The man’s history of drug and alcohol abuse was
recorded and he was put on the drug detoxification programme. Over the
subsequent weeks the man continued to be monitored by healthcare staff.
The man’s behaviour deteriorated towards the end of February and he
smashed his in-cell television. He was placed in the segregation unit, but
was moved back to his own cell the following day.
On 18 April, the man was told that he would be transferred to HMP Ranby.
He told staff that he would not transfer as he was in debt. He refused to
return to his cell and told staff to take him to the segregation unit. On arrival
in the segregation unit the man was placed in a cell with little furniture and
with no personal possessions. He was seen later that day by healthcare
staff and a member of the Independent Monitoring Board (IMB).
That afternoon the man was charged with disobeying an order, and told that
he would be adjudicated upon the following morning. The man was given his
evening meal and staff reported that he had little to say. At around 9.30pm,
the man asked an OSG for a newspaper. The OSG told the man that none
was available. However, an hour later he gave the man a supplement from
his own paper. The man then asked the OSG to see the nurse, explaining
that he had made cuts to his arms.
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At around 10.30pm, the man was seen by a nurse who treated the wounds.
The nurse recorded that the man had made approximately 20 superficial
scratches to both of his arms. The OSG and the nurse completed an
F213SH (a form on which any act of self harm is reported). None of the staff
present that evening opened an ACCT document. The nurse made a record
of the man’s self harm in the healthcare observation book. No record was
made by the OSG in the segregation unit observation book.
On the morning of 19 April, at the daily briefing of staff in the segregation
unit, the man’s act of self harm was not discussed. Applications in the
segregation unit were taken from prisoners at the regular time of 7.30am
during the governor’s rounds. The man refused to talk with staff at this time.
The man was seen by a mental health nurse, as a consequence of a referral
made by nursing staff the previous day. Although the mental health nurse
was aware of the man’s actions the previous evening, she said that the man
had no signs of mental illness. The mental health nurse did not open an
ACCT booklet.
The man was considered fit for adjudication and this took place later that
morning in front of a governor. The governor was not aware that the man
had self harmed the previous evening. The man refused to attend the
adjudication and the governor proceeded in the man’s absence. Finding him
guilty, the governor gave the man a punishment of 20 days cellular
confinement.
That afternoon the man was notified of the adjudication’s outcome. A
second nurse saw him and passed him fit for cellular confinement. The
second nurse said that she noticed the scratches to the man’s arms, but said
that he did not appear to be withdrawn or depressed at the time. That
evening the man was given his tea and was later heard throwing his plastics
(eating utensils) around his cell. Soon afterwards, staff removed his cup and
bowl from his cell but appear to have left his plate and a fork.
Two of the three officers on duty in the segregation unit that afternoon were
called to other areas of the prison in order to assist with other discipline
duties. A prison officer was left in charge of the unit. The prison officer
started his final check of prisoners and equipment on the unit at about
7.55pm. The prison officer said he completed the checks at 8.00pm,
although he did not sign the man’s hourly cellular confinement log. The
prison officer reported the prisoner numbers for the final roll check and then
left the prison.
At about 8.30pm, the OSG began his first check of the segregation unit. The
last cell to be checked was the man’s. Failing to obtain a response, the OSG
raised the alarm. Discipline and healthcare staff responded and on entering
the cell they found the man hanging. They removed the ligature and
commenced cardio pulmonary resuscitation (CPR) immediately. Staff
continued to give CPR to the man until instructed to stop by the prison’s
Medical Officer. Paramedics from West Yorkshire Ambulance Service
5
attended and the man was pronounced dead.
In the early hours of 20 April, staff from Leeds informed the man’s mother,
and then father, of their son’s death. A Family Liaison Officer from the
prison, represented the Prison Service at The man’s funeral.
6
THE INVESTIGATION PROCESS
1. The investigation was opened by one of my Deputy Ombudsmen but
then conducted by an investigator from my office. My investigator was
assisted by two further colleagues when interviewing staff at Leeds.
Notices were issued to staff and prisoners informing them of the
investigation and inviting them to contact the investigators should they
wish.
2. The investigators visited Leeds and were given full access to the
segregation unit and the cell in which the man apparently took his life.
They met with the Governor as well as representatives of the
Independent Monitoring Board (IMB) and with the Police Liaison
Officer. They also made themselves known to a representative of the
local branch of the Prison Officers’ Association.
3. The investigators reviewed the man’s prison and health records in
addition to other documentation. Interviews were conducted with a
number of staff who had had contact with the man. I would also like to
thank the Police Liaison Officer at Leeds and the principal officer, for
their assistance to my investigators.
4. I commissioned a clinical review from the Leeds West Primary Care
Trust (PCT). A Doctor completed this on behalf of the PCT.
5. West Yorkshire police confirmed that they had no concerns with regard
to the circumstances of the man’s death.
6. One of my Family Liaison Officers made contact with the man’s family
to explain the purpose of my investigation and invite them to raise any
concerns they wish to be considered and addressed as part of the
investigation. The family chose not to engage in this process at this
time.
7. However, in early 2007, the family contacted another of my Family
Liaison Officers and requested a visit from my office. My family liaison
officer and my investigator visited the family at their home in Hull on 28
February 2007. During the visit the family raised a number of issues,
some of which the family liaison officer and my investigator were able
to address during their meeting.
8. Other issues raised by the family are addressed within this report and
include:
(cid:127) Why was the man in the segregation unit?
(cid:127) Was the man on ‘suicide watch’ around the time of his death?
(cid:127) What time had the man apparently taken his life and could
this have been a cry for help, had it happened around unlock
time?
7
(cid:127) Was the man tested regularly for drugs?
(cid:127) When the family saw the man at the funeral directors he
appeared to have some bruising in the middle of his
forehead. (My investigation has been unable to establish
why this was.)
I hope this report helps his family better understand what happened to
the man in the time leading up to his death.
8
HMP LEEDS
9. HMP Leeds is predominantly a Victorian prison. The four original
wings (A, B, C and D) were built in 1847. Two more wings (E and F)
were opened in 1994, together with new kitchens, gymnasium and
healthcare centre. It is a category B local prison for adult male
prisoners from West Yorkshire.
Segregation
10. The segregation unit at Leeds is known as S1. It has 22 single cells.
These include two special cells and two cells equipped to deal with
prisoners on dirty protest. The first of the special cells is used as a
holding cell. Prisoners are first located here when transferred to the
segregation unit. Here they are searched and asked to change into
standard issue prison clothing. The second special cell is a normal
cell. This cell, along with the holding cell and the two dirty protest cells,
is fitted with closed circuit television. Twelve additional cameras
continuously film the landing and are monitored in the segregation unit
office. At the time of the man’s death there were no segregation unit
cells which met the Prison Service’s definition of a safer cell. However,
steps were being taken for some to be altered to meet this standard.
11. None of the cameras in the segregation unit at Leeds, either in the
special cells or on the landing, were in operation at the time of the
man’s death. Although my investigators enquired on a number of
occasions why the cameras on the unit were not working, they were
unable to establish precise details.
12. When prisoners are first located in the segregation unit they should be
given an information booklet about the unit’s rules, the daily regime,
and how to make applications or a complaint. The booklet also acts as
a compact between them and the unit staff. This sets out the agreed
and accepted levels of behaviour and entitlements. The booklet should
be given to prisoners within 24 hours of their arrival on the unit.
13. It is a mandatory requirement of the Prison Service that all prisoners
held in a segregation unit are visited daily by the duty governor,
chaplain and doctor. The visits are to ensure that prisoners are being
treated fairly and decently, and to give them an opportunity to raise any
concerns.
14. In Leeds, prisoners in the segregation unit are expected to be up and
dressed by 7.30am when they are unlocked briefly and are allowed to
make applications. (Applications are written requests by prisoners to
access services or an item.) Prisoners not adhering to this rule are
unable to make applications later in the day. Those in the segregation
unit have to apply for items available as a right for other prisoners,
including telephone calls, showers and exercise. Prisoners who arrive
on the unit half way through the day are not formally given the chance
9
to make an application until the following day.
15. Whilst in the segregation unit, prisoners can ask to talk to the Listeners
(selected prisoners trained by Samaritans to offer support for prisoners
at risk of self harm.) and use the Samaritans mobile telephone at any
time. This applies to all prisoners regardless of their reason for being
on the unit.
16. Meals are brought to prisoners in the segregation unit at midday and
during the early evening. Food is left at the cell door, together with a
flask of hot drinking water. Each door is opened in turn to permit the
prisoner to collect his meal tray, and the routine is repeated when the
used plates and flasks are removed. Prisoners are given a breakfast
pack at the same time as they are given their evening meal.
17. During the night, as in other parts of the prison, staff have a routine
known as pegging which requires them to go to pre-determined parts
of their wing at pre-set times to log their presence. The purpose of the
pegging routine is to ensure that all parts of the wings are patrolled
regularly through the night. There are two pegging points in the
segregation unit.
18. The staffing levels in the segregation unit remain the same regardless
of the number of prisoners in the unit. During the day, the unit is
managed by a senior officer and six prison officers who are all
specialist staff and have been through a selection interview. At the
time of the man’s death, at night time, unlike other wings which are
staffed by prison officers, the segregation unit was staffed by an
operational support grade (OSG) rather than a specialist on the unit.
The OSGs do not have specialist knowledge of the requirements for a
segregation unit and are not selected for the role. During the day their
duties are often in other parts of the prison and the only time they work
on the wings is at night. Their knowledge of the prisoners and what
has been happening in the unit that day is obtained from the wing staff
when the OSGs take over.
19. As well as looking after prisoners in the unit, segregation staff are
responsible for the administration of adjudication hearings including
preparation of paperwork, collecting and returning prisoners to and
from cells, and being in attendance throughout the process.
Inspection
20. Leeds was last inspected by Ms Anne Owers, HM Chief Inspector of
Prisons, in August 2005. She identified that the prison faced a number
of difficult challenges because of chronic overcrowding and a high
turnover of prisoners. Ms Owers said in her report that:
“We also had concerns about the management of the
segregation unit, and the support and management of prisoners
10
at risk. The unit was run in a militaristic fashion: there was an
over use of the special cell, without proper recording, and
sometimes as a punishment for relatively minor disciplinary
offences by prisoners already segregated.”
21. Ms Owers also reported that segregation unit staff made three written
entries, on average, in the prisoner’s history sheets. She said that:
“These were extremely superficial and usually consisted of single lines
merely stating that the prisoner was ok…”
Suicide and self-harm
22. Prisoners who are considered to be at risk of self-harm whilst in prison
are placed on an Assessment, Care in Custody and Teamwork (ACCT)
document. This is used to assess and observe and support prisoners.
It highlights the problems and possible trigger points of a prisoner at
risk of self harm and delivers a multidisciplinary plan to give support
and help through a period of crisis.
23. Before the introduction of ACCT, staff used a booklet called the
F2052SH to monitor those prisoners at risk of self harm.
The adjudication process
24. An adjudication is a prison disciplinary hearing. It is a requirement of
Prison Service Order 2000 that healthcare staff are given sufficient
time to raise any concerns with regard to a prisoner’s fitness to attend
an adjudication. However, the final decision as to whether or not the
accused is fit to face the hearing rests with the adjudicating governor.
If a prisoner is found guilty a range of punishments can be given.
25. Examples of punishments that can be given at adjudication include the
forfeiture of particular privileges, lost earnings, and cellular
confinement. (Cellular confinement is a punishment whereby a
prisoner is locked in a cell for most of the day and, apart from exercise,
is not allowed to mix with others. Prisoners who serve a period of
cellular confinement are sometimes not allowed access to radio,
television or to some or all of their own belongings as an additional part
of the punishment.)
Incentives and earned privileges (IEP)
26. The IEPS scheme is intended to encourage and reward good
behaviour by allowing prisoners access to such privileges as in-cell
television, wearing of own clothes and more time out of cell. There are
three levels: basic, standard and enhanced, dependent on behaviour.
The scheme continues when prisoners are located in the segregation
unit. As a standard regime prisoner, the man would have been entitled
to the same regime as he had whilst on normal location and was
11
permitted personal possessions in his cell subject to security
clearance.
12
KEY FINDINGS
Background
27. The man’s antecedents (police records) show that he received
numerous custodial sentences. His final period of custody began in
August 2003. In March 2004 he was released on licence only to be
recalled to prison two months later. The man was released on licence
for the second time in January 2006, before being arrested for a
burglary in Leeds. He was received into custody at Leeds on 8
February.
28. The man was received at HMP Lincoln on 15 October 2003 as a
convicted un-sentenced prisoner. During the reception process his
long history of self harm was immediately recorded by staff and as a
consequence he was placed on an F2052SH. The man was seen by
the prison doctor and put on the prison detoxification programme. On
27 October, his F2052SH was reviewed and closed.
29. The man remained at Lincoln until a court hearing at York Magistrates’
Court on 7 November. Due to an adjournment the man was told that
he would be sent to HMP Hull. The man told staff that he was known
to other prisoners at Hull and would self harm if he was sent there.
However, the man was in fact transferred to Hull and staff opened an
F2052SH.
30. On 19 November 2003, the man returned to Lincoln. During reception
it was again recorded that he had a history of self harm, but no
F2052SH was opened. The man was assessed by the prison doctor.
He reported that the man was suffering from depression, but did not
appear depressed in mood. The doctor noted that the man had
apparently been on the antipsychotic drug chlorpromazine, but
questioned the need for this medication.
31. On 1 December, the man was transferred to HMP Durham. He told
staff that he had been waiting for a mental health assessment. The
man’s medical record said that he had a history of deliberate self harm
and a mental health referral was made. On 9 December, the man
received a mental health assessment by a community psychiatric
nurse (CPN) from the Mental Health in Reach Team (MHIRT).
32. On 10 December 2003, the man was transferred back to Lincoln and
healthcare staff recorded that he should be seen by a CPN. On 6
January 2004, he was assessed by a nurse from the MHIRT. She
recorded that the man had no evidence of an enduring mental illness
and that his desire to receive the antidepressant amitriptyline instead of
venlafaxine was perhaps in order to obtain a “buzz”. On 30 January,
the doctor at Lincoln agreed to stop the man’s prescription of
venlafaxine and begin a course of amitriptyline.
13
33. On 28 April 2004, there is an entry in the man’s medical record
recording that the effects of his amitriptyline had begun to wane and
that he had been adding extra doses (up to 250mg) from other
prisoners.
34. On 20 May 2004, the man was transferred to HMP Stocken. The man
continued to be prescribed amitriptyline. In an entry dated 14 June, the
prison doctor noted that the man was very talkative, even charming,
but said that he was a skilled manipulator who only wanted drugs. He
added that the man wanted to come off amitriptyline.
35. On 21 July, The man indicated to staff that he wished to address
issues connected with his drug taking and offending. However, on 11
October he was removed from the drug treatment programme due to
non attendance. On 10 December, it was reported in his medical
record that his prescription of amitriptyline should be reviewed with a
view to it stopping.
36. On 24 March 2005, the man was released on licence. However, he
was breached and recalled to prison on 16 May. The man was sent to
HMP Doncaster. During the reception process a member of healthcare
staff recorded on his Cell Sharing Risk Assessment (CSRA - a form
used to assess the risk that a prisoner would present to others when
sharing cells) that he was a prolific self harmer, and that he felt he
would self harm if not given detoxification and protection. Due to these
concerns staff, immediately opened an F2052SH. A note on his
medical record says that he told healthcare staff that he did not feel like
self harming that night, but would if not given detoxification medication
or a television. Later that evening, the man was taken to the
healthcare centre after making a number of superficial cuts to his left
forearm.
37. During an F2052SH review on 17 May, The man told staff that he had
self harmed because his detoxification was not working. He said that
he wanted to be signed off his detoxification programme and to be put
on amitriptyline. The reviewer recorded that the man was:
“… tearful at times, asking why he cannot have a new cell mate
or television. He implied that this is stressing him and therefore
would cause self harm.”
38. On 19 May, the man’s medical notes record some confusion with
regard to his prescription of amitriptyline. He had a “temper tantrum” at
not receiving it. He was prescribed the drug later that day.
39. The man’s F2052SH was reviewed before being closed on 31 May.
The reviewers recorded that he had no further thoughts of self harming
now that his detoxification had been completed and his medication had
been sorted out.
14
40. On 21 June 2005, the man was transferred to HMP Ranby. The CSRA
recorded that he was a prolific self harmer and that he:
“Had used threat of self harm to manipulate staff, nevertheless
has no qualms about carrying out these threats.”
Entries in the man’s wing history sheets indicate that over the coming
months he settled into the regime at Ranby, although his behaviour
deteriorated towards the end of his time at the prison.
41. The man was transferred to HMP Stocken on 5 December 2005. The
healthscreen indicated that the man was currently receiving
amitriptyline for his depression. On 14 December, the man submitted
a complaint form saying that he had been given no reason by the
prison doctor for having his amitriptyline stopped. In response, the
practice manager wrote that the amitriptyline had been withdrawn as it
was not on Stocken’s list of approved medicines. The practice
manager told the man that a period of one week must elapse before
another anti-depressant could be given. He advised him to make an
appointment with the doctor in order to discuss an alternative
treatment. No notes about the withdrawal of the man’s medication at
Stocken were made in his medical records.
42. On 13 January 2006, the man was released on licence from Stocken.
However, he was arrested for offences of robbery and burglary in the
Leeds area and remanded into HMP Leeds on 8 February. It was later
learnt by the prison that the man was a recalled prisoner, and his
licence was revoked on 23 February.
43. On 8 February, a reception officer at Leeds completed the CSRA. The
man told the officer that he had a history of drug and alcohol abuse
and had previously been placed on an F2052SH.
44. A reception nurse carried out a first night reception healthscreen on the
man. The reception nurse noted that he consumed three litres of
strong cider a day, took cocaine, heroin and cannabis daily, and
amphetamines “now and again”. The reception nurse indicated that
the man suffered from depression, had previously seen a psychiatrist
and had been prescribed amitriptyline from 2002 to December 2005.
The man said that he had self harmed in the past by cutting both
wrists.
45. Part of the man’s healthscreen involved him giving a urine sample for
drug testing. The sample tested positive for opiates, benzodiazepines
and amphetamines.
46. The man was received at Leeds while the Leeds West PCT and Leeds
University were conducting a trial which involved researching the
effectiveness of buprenorphine, more commonly known as Subutex,
and Methadone. The man met the criteria for taking part in the trial.
15
He was, at random, prescribed Subutex as opposed to Methadone in
order to detoxify from opiates over a 20 day period. The man received
his first dose of Subutex on 9 February and attended daily for the
medication. However, he failed to collect his last two doses. This non
attendance was not followed up by staff.
47. The urine of a participant in the trial was sampled, confidentially, eight
days, one month, three months and six months after the last dose of
Subutex had been administered. No referral to discipline staff was
made should prisoners test positive for opiates. Nursing staff not
involved in the trial would also be unaware if prisoners returned
positive urine samples.
48. The man was given his first post trial test on 7 March, eight days after
the trial had ended. The Drug Therapist and Evaluation Co-ordinator
of the trial at Leeds, explained to my investigators that at this point he
should have tested negative for all drugs including Subutex. However,
the man’s sample was positive. The Drug Therapist and Evaluation
Co-ordinator confirmed that the sample taken a month later, around 8
April, also tested positive, suggesting that the man may have been
obtaining the drug illegally from the wing. At the time of the man’s
death, the toxicology results from the post mortem were negative.
49. As well as the healthscreen, the reception nurse also completed a self
harm assessment. This is done by scoring prisoners by asking a
number of questions. If a prisoner scores more than ten out of a total
of 22, he is considered to be at risk of self harm and an ACCT
document is opened. During the assessment the man scored ten
points and the reception nurse opened an ACCT booklet. The man
was placed on hourly observations. The reception nurse told my
investigators that, because of his history of depression, she referred
the man to the mental health clinic.
50. On 9 February, as part of the ACCT process, an assessment interview
was completed by an assessment officer. The assessment officer said
that when the man was told of the assessment, he swore at the officer,
saying that he would not talk to anybody until seen by the doctor. The
assessment officer recorded that the man’s only problem was that he
had not received his detoxification, but would be seeing the doctor that
morning. He added that the man had last self harmed two years
previously as a coping mechanism, and had no suicidal intent at that
time. It was recorded that the man had a supportive family and friends
with whom he said he would keep in contact.
51. After the man’s assessment interview, a senior officer chaired the initial
case review along with the assessment officer. The man was also
present. The senior officer recorded that the man was:
“…not suicidal or feeling like self harming. Has now been
written up for a detox and has now settled into prison regime. In
16
our opinion this ACCT now has served its purpose and can now
be closed.”
The date of the post closure interview was set for 16 February but this
never took place.
52. On the morning of 9 February, the prison doctor saw the man. He
recorded his history of drug and alcohol abuse and that he had been
accepted onto the detoxification trial. The prison doctor recorded that
there was no deliberate self harm or intention, and that the man had a
history of depression and amitriptyline prescription. The prison doctor
noted that the man would require a mental health evaluation.
53. Whilst on the first night induction centre, the man was given a short
induction to prison life at Leeds. He was seen by a member of the
chaplaincy team, education department, and by a Counselling,
Assessment, Referral, Advice and Throughcare worker. (The CARAT
team deal with prisoners with drug problems and can offer counselling,
support and referrals to rehabilitation centres during sentence and on
release.) A referral was made for the man to attend a Drug
Intervention Programme in York on his release. On 16 February, the
man’s CARAT worker undertook a substance misuse assessment.
54. On 18 February, an unidentified officer introduced himself to the man
as his personal officer. On 20 February, another officer also
introduced himself as the man’s personal officer and recorded in his
wing history sheets that the man had no problems to date.
55. On 20 February, the man was adjudicated upon for refusing to obey a
lawful order. A note in his medical record by the mental health nurse
indicates that he was fit to attend the adjudication.
56. On 28 February, the man was seen at the mental health clinic by the
mental health nurse . She recorded in his medical record that the man
had:
“No evidence of mental illness present. Does have issues with
low mood, this appears to be related to his drug abuse and
alcohol abuse. Advised he will be seen in the substance misuse
clinic.”
57. On 1 March, the man was sentenced to two years and four months
imprisonment at Leeds Crown Court.
58. On the evening of 5 March, the man smashed his TV and was placed
on report (a process which marks the start of the adjudication process),
and was removed to the segregation unit. It is a Prison Service
requirement that all prisoners who are moved to the segregation unit
must been seen by a registered nurse within two hours of their arrival.
The assessment is recorded on a Segregation Safety Algorithm which
17
is intended to be a ‘snapshot’ of the prisoner’s condition at the time of
the screen.
59. The algorithm was completed by a third nurse. She advised that there
were no healthcare reasons why the man could not be segregated. A
second governor authorised the man’s segregation at 8.30pm.
60. On 6 March, The prison doctor visited the man in the segregation unit
and noted “no probs” in his medical record. Officers on the unit
recorded in the man’s segregation history sheets that he had a poor
attitude and could not be bothered to get out of bed for lunch. The
man appeared to be in a much better mood that evening.
61. On the morning of 7 March, after visiting the man in the segregation
unit, the prison doctor again recorded that there were “no probs” in his
medical record. Staff in the segregation unit that day noted that the
man was seen by the second governor for applications. The man was
reported as having no issues. It was recorded later that day that the
man was moved to C wing.
62. My investigator failed to find any documentation informing the man why
he had been located in the segregation unit from 5 to 7 March.
Although this period of time in the segregation unit had no bearing
upon the man’s death some weeks later, this lack of paperwork is
raised again later in my report.
63. On 8 March, the man made an application to work in the prison’s
clothing exchange store. However, an officer noted in his wing sheets
that he would not be suitable at that time.
64. The last entry in the man’s wing history sheets was made on 23 March.
It said that the man had been issued with a warning for refusing to
attend work because he had a headache. The officer added that the
man lay in bed ignoring him and that he had a surly attitude.
18
Events of 18 and 19 April 2006
The man’s refusal to transfer and return to his cell
65. At approximately 9.30am on 18 April, the man was taken from his cell
to see a member of staff from the Observation, Allocation and
Categorisation unit (OCA) on B1 Landing. (Staff who works in OCA
are primarily responsible for the categorisation and allocation of
prisoners. They have responsibility for assessing the needs and
requirements of prisoners, and establishing which prison would be
most appropriate for them to be transferred to). The man was advised
by OCA staff that he would be transferred to Ranby the following day.
66. Before a transfer can take place a prisoner is ‘fitted’ for travel by a
member of healthcare staff who has access to the medical record. A
fourth nurse who ‘fitted’ the man for travel that day, explained that
prisoners are informed of their transfer before being assessed by
healthcare staff. The fourth nurse said that prisoners were assessed
behind a screen, but in the same room that they are seen by OCA
staff. The fourth nurse said when the man was told of his transfer to
Ranby, the man told the officer that he did not want to go because of
debt. The man told him that he could not go, and would not go.
However, because there was no medical reason preventing the man’s
transfer, the fourth nurse recorded in the man’s medical record: “Seen
prior to transfer, fit and well. No medical issues. Fit to travel.”
67. At approximately 9.50am, after being seen by allocation staff, a second
prison officer asked the man to return to B1 holding room. The second
prison officer said that the man refused to go, saying: “I’m staying here,
I’m not going to Ranby, you’d better get me down the block.” The
second prison officer contacted a second principal officer who told him
to take the man straight to the segregation unit.
The man’s location in the segregation unit
68. The man walked to the segregation unit, escorted by the second prison
officer. An entry in the man’s Record of Events, F2052A, on the
segregation unit (more commonly known as prisoner history sheets)
records that he:
“Walked to Seg from B1 after refusing to return to his wing due
to debt. Very obnoxious refused to talk with nurse or staff a very
angry young man.”
The man’s segregation unit history sheets record that he was placed in
the segregation unit under Prison Rule 55 (the rule that allows staff to
keep a prisoner located in the segregation unit in order to serve a
punishment of cellular confinement).
19
69. Although there is no written record of what exactly happened to the
man when he arrived in the segregation unit, staff confirmed that he
would have been placed in the “strip cell” and searched before being
moved to a normal cell on the unit.
70. During interview, a fifth nurse explained that, at about the time the man
was being brought to the segregation unit, she had been asked to
attend the unit to see two other prisoners. She said that whilst there
she was told that the man was on his way. The fifth nurse was asked if
she would mind waiting so that she could carry out the required
Segregation Safety Algorithm assessment.
71. At 10.10am, the fifth nurse completed the man’s assessment. She
indicated on the form that the man had not self harmed in the current
period of custody, was not taking any psychotic medication and was
not showing signs of being acutely unwell. She concluded that the
man would be able to cope with a period of segregation. The fifth
nurse also recorded: “Will refer to RMN [mental health clinic] re
antidepressants but not acutely unwell.”
72. In her police statement, The fifth nurse said that she had asked the
man if he had any injuries, to which he said no. She added that none
was visible. During interview with my investigators, the fifth nurse said
that when she saw the man in his cell he did not look at her and came
across as very angry. During her medical assessment the man had
complained that he should have been prescribed amitriptyline as he
had been prescribed the drug before coming into prison. The man
denied any suicidal or self harm intent and, with his agreement, she
referred him for an assessment with an RMN. The fifth nurse
confirmed with my investigators that when completing the segregation
safety algorithm in the segregation unit, nursing staff would not always
have access to either the prisoner’s medical record or to their
electronic medical record (EMIS).
73. The man was placed in cell S1.31, a regular cell on the segregation
unit. The cell had integral sanitation and contained a standard single
iron bed with mattress, sheets and blanket. The only other furniture
was a cardboard chair.
74. An entry by a segregation officer in the segregation observation book
(a book in which all major movements and incidents on the unit are
recorded) says that the man was held in the segregation unit under
rule 53. (Rule 53 allows the Prison Service to hold prisoners in the
segregation unit who have been charged for breaking a prison rule and
who are pending an adjudication.)
75. At around this time the man was also seen by the prison doctor. He
again recorded in the man’s medical notes that there were “no probs”.
The prison doctor told my investigators that part of his job as a medical
officer was to visit all the prisoners in the segregation unit at about
20
11.00am each day to establish if they required his services or not. The
prison doctor said that:
“it is a brief ‘good morning’, how are you today, how you feeling
today, any medical problems and that is it.”
He said that he very rarely entered a prisoner’s cell due to the strict
security on the unit. The prison doctor told my investigators that he did
not really look at the prisoners’ medical records before attending the
unit, adding, “I don’t know who I am going to see until I get there”.
76. At 10.15am, a third governor approved the man’s segregation under
Rule 53. At 11.00am, as required, the Independent Monitoring Board
was informed of the man’s location on the segregation unit.
77. At some point that morning, the man signed the segregation unit
compact. On the second page of the compact prisoners are informed
what prison rule they are being held under and an explanation of the
rule is provided. The last page of the compact is where the prisoner
signs indicating that they agree to the unit’s rules and what is expected
of them. Although staff at Leeds were able to provide my investigators
with the back page of the man’s compact, they were unable to provide
the front page which would have informed the man of the reason for his
location on the unit.
78. Applications in the segregation unit are made at 7.30am. The man
arrived in the segregation unit at approximately 10.00am and therefore
missed the governor’s daily round at which applications are made.
Staff explained that it was still possible for prisoners located on the unit
after 7.30am to make applications, although this was dependent on the
type of request and other factors such as time and staffing levels.
There is no record that the man made any applications or requests on
18 April, or that he was invited by staff to make any.
79. A request was made by segregation unit staff for the man’s property to
be removed from his cell on C wing. At 11.05am, officers removed a
number of items. These included letters and cards, playing cards,
legal papers and toiletries. Although these items were removed at the
request of the segregation unit staff, they were not taken to the unit to
be given to the man. Segregation unit staff did not follow up the
request when the man’s property failed to appear. A second senior
officer confirmed that, as a prisoner on the standard regime, the man
would have been entitled to personal possessions in his cell, subject to
security clearance. The first governor said that prisoners would
normally let staff know that they wanted their property.
80. An entry in the Segregation Observation book states that the man put
his “plastics” (eating utensils) out after lunch. When asked by a third
prison officer, the man said that he was ok.
21
81. At 2.35pm, the man was seen by the IMB. The IMB recorded that the
man was:
“In bed. Either ½ (or ¾) asleep or feigning well. Grunts for
replies to questions and on 3rd turned over & covered himself &
back to sleep.”
82. At approximately 4.30pm, the man was given his evening meal and
breakfast pack for the following morning. The third officer recorded:
“he didn’t really have nothing to say when asked if ok.”
83. The third officer issued the man with his adjudication charge
sheet at 4.47pm. The charge sheet informed the man of the charges
laid against him, for refusing to return to his cell earlier in the day, and
told him that the adjudication would be heard by the adjudicating
governor at 9.30am the following morning.
Events during the evening of 18 April
84. On the evening of 18 April, The OSG commenced work as usual at
about 7.30pm, although his night shift duties did not officially start until
about 8.15pm. The OSG explained that he would start early in order to
get ready for the night ahead and to be briefed by other staff. In his
police statement The OSG said that he recalled checking the man
some time between 8.00pm and 8.30pm as the man “… was subject to
cellular confinement”. However, the man had not been adjudicated
upon and therefore was not subject to any punishment at this time,
including cellular confinement.
85. The OSG said in his police statement that the man had first
asked for a newspaper at about 9.30pm. He said that the man was still
“ok” when he checked again at 10.00pm. At about 10.30pm, The OSG
gave the man a supplement from his newspaper along with a pen. He
told my investigators that:
“I think he was banging on his door, you know, asking for a
paper, and I explained to him that I couldn’t give him a paper
because there were none there to give him. So he kept
banging, banging, then he sort of settled down. A bit later on I
noticed that I had a supplement in my paper, so I offered him
that, it was crosswords and things like that he could do. So I
went to his cell door, called him, no reply, I called him again,
without any reply and so I just said to him, ‘well you don’t want
this then’, then he replied to me, ‘well what is it?’ I said, well I
have got a supplement you can have, it’s crosswords, I will give
you a pen you can, he reacted to me then, you know and he
said, ‘oh yes please’, he put on his light and I gave him the
paper and he was actually quite happy.”
The OSG said that before giving the man the crosswords he had had
22
nothing else in his cell. He added:
“…once I gave him the paper he said to me, ‘can I see the
nurse’, so I asked why, and he said, ‘well I have been cutting
myself’, so when I looked there was no blood there or anything
like that.”
The OSG explained that the man had a number of wounds. He did not
know which were fresh and which were old.
86. At around 10.30pm, the OSG summoned assistance from a nurse, who
was based on A wing, the landing above the segregation unit. He said
that she requested the night orderly officer who carried keys to also
attend the segregation unit. (During the night neither OSGs nor
Nurses hold an emergency cell key.) However, the night orderly officer
said that he believed the call to attend the segregation unit came from
The OSG himself. The OSG told my investigators that the night orderly
officer and the nurse:
“… opened the door and asked the man to come out onto the
landing so they could see properly and the nurse said, ‘well
there is nothing there, there is nothing to dress’. You know.
There was no blood; there was no weeping skin or anything like
that. She just said, ‘I can’t dress anything that you haven’t
hurt.’”
87. The night orderly officer said he had been told that a prisoner had self-
harmed or threatened to self-harm if he did not get some reading
material. On attending the segregation unit The OSG told the night
orderly officer that the man had now been given something to read and
appeared to be okay. The night orderly officer said that the man’s
arms “didn’t look too bad at all”. He said that the nurse applied some
antiseptic spray and the man was allowed to go back into his cell.
88. The OSG said that the nurse asked the man what he wanted her to do.
The man asked for a couple of Paracetamol tablets to take the pain
away. The nurse gave the man the tablets and he “was quite happy”.
89. The nurse told my investigators that she was alerted by an officer that
she was required in the segregation unit as a prisoner had made cuts
to his arms. She first went to A wing to collect a dressing pack. In her
statement to police she said that she arrived on the segregation unit at
10.35pm. The nurse said that when the man was unlocked he came to
the cell door. She asked him what he had done and it was then that he
showed her his arms. The nurse said:
“There were scratches on his arms, not consistent with, I
thought at the time, well it is not consistent with a razor blade,
because they were not really cuts, they were more like raised
red areas across his arm, I could see old scarring from other
23
marks that had been made previously, how old, I don’t know, I
couldn’t really say accurately. There was no blood coming from
his arms at all, wounds weren’t bleeding, they were more like
raised welts …”
In her statement to police the nurse said that the marks on the man’s
arms were “numerous but very minor”. She believed that it was not a
serious attempt by the man to self harm, but a protest about not getting
a newspaper.
90. The OSG told my investigators that the nurse asked the man why he
had cut himself. The OSG thought the man said that he had only done
it because he could not get a newspaper. During her interview the
nurse said she had asked the man:
“…’well, what is wrong, what have you done it for.’ He said,
‘well I wanted a newspaper.’ I said, ‘well I can’t help you with
that either.”
The OSG said he visited the man on a couple of further occasions that
night to check on the man’s welfare.
91. The night orderly officer was asked if he was sure whether the man
had self harmed or not. He said:
“Me personally I am not sure whether he did or he didn’t, it
looked to me as though he hadn’t because there was no fresh
marks there at all.”
The night orderly officer went on to say :
“I believe the officer down there filled in a 213SH, but as far as I
could see there was no evidence as to any self harm at all, it
seemed as though the self harm threat had been taken care of
by handing over the reading material.”
92. The OSG completed a Report of Injury to Inmate Form F213 and
recorded that:
“This inmate requested to see the nurse after he scratched both
his forearms. The nurse attended at 22.30hrs along with Oscar
1 and the inmate requested he just wanted painkillers.”
The nurse wrote on the form that she had examined the man at
10.35pm:
“Many (approx 20) superficial scratches seen on both arms – not
bleeding, dressing inappropriate as they were very small and
hardly broke skin surface.”
24
93. The OSG also opened an F213SH, Self-Harm / Attempted Suicide
Form. (This is a form on which any act of self harm must be reported.
It is set out in a questionnaire format and, as with the F213, part of it is
completed by the medical officer.) The OSG left both forms on the
nurse’s desk for completion.
94. The nurse told my investigators that she did not feel the man was at all
suicidal. (As noted above, she told the police that it was a protest
about a newspaper.) She told us that a prisoner’s location in the
segregation unit would not influence her decision on whether to open
an ACCT document or not.
95. When asked if he had considered opening an ACCT document, the
night orderly officer said:
“…the reason he said he was going to self-harm was because of
the reading material and when I went down there and got an
overview of all of the picture and he had been given the reading
material … there was no problem, he had got his material
whatever it was, magazine, there was no reason to open an
ACCT document.”
96. During interview, The OSG said that the man’s injuries were minor and
were not a serious attempt at self harm. He had accepted the nurse’s
decision not to open an ACCT document.
97. The OSG said that, although he would normally have expected to
record the attendance of the nurse and orderly officer in the
observation book, on this occasion he had not. No entry was made in
the man’s history sheets either.
98. The nurse was asked whether a note of her attendance was made on
EMIS, the electronic medical record. The nurse said that it was not
because “the injuries were exceptionally minor.” She said:
“…I could spend my entire night putting on EMIS that, ‘oh he
has cut his finger with a razor blade [or] while sharpening a
pencil’, I could spend my entire night doing that and some nights
it could be exceptionally busy.”
Although no entry of the man’s injuries was made in his medical
record, the nurse did make an entry in the healthcare observation book
before going off duty. She wrote that the man had: “made superficial
scratches to both arms – no dressing required”.
99. In his police statement, the OSG said that he checked the man again
at 11.00pm. He asked him what had caused the injury. The man
passed him a small piece of black plastic which he put in the bin. The
OSG said that he checked the man during the rest of the night. At
25
some point during the night the man smashed his hot water flask.
100. The nurse was asked by my investigators about nurses on night duty
handing over healthcare responsibilities to nurses coming on duty the
following morning. The nurse said that the fourth nurse would have
been there. She said that during the handover everything that had
happened through the night and was in the observation book was
explained.
101. The fourth nurse told my investigators that he started work on 19 April
at approximately 6.30am. He said that as part of the handover routine
he would have gone straight to A wing, where the nurses base
themselves at night, to see if there were any problems. The fourth
nurse said that the handover involved reading any notes made in the
healthcare observation book. When asked if he was aware of the
“superficial scratches” that The man had made to his arms The fourth
nurse said:
“I was aware of that when I spoke to [the nurse], it was made clear that
he had done it because he wanted a newspaper overnight. Therefore
it was not a deliberate self harm, to kill himself, it was not manipulated
but a way of getting something from somebody.”
102. In his police statement, the fourth nurse said: “I did not see the nurse
who had been on nights. I did however receive a ‘handover’ from
another nurse. I can’t recall who.”
Events of 19 April
103. At 7.30am, the second senior officer led the daily staff briefing in the
segregation unit. The OSG told my investigators that told staff that the
man had been seen by a nurse during the night after having made
scratches to his arms. He could not remember whom he told.
However, from interviews with segregation unit staff who were on duty
that morning, I know that the man’s self harming was not discussed at
the segregation unit morning meeting.
104. The first governor told my investigators that at 7.30am on the morning
of 19 April she did her usual morning rounds with the chaplain. She
said that the man’s cell was opened up for daily prisoner applications
and the governor’s check at approximately 7.45am. The governor said
that the man refused to speak to her. On completion of her rounds she
left the unit, not returning until about 9.30am to start adjudications.
105. It was at this time that the man handed back the damaged flask. The
third prison officer wrote in the man’s history sheet, “handed his flask
back which he had smashed up. Placed on report.” A fourth prison
officer told my investigators that, “during applications, first thing in the
morning, the man did not get out of his bed, or want to have any
26
interaction with staff.”
106. The prison doctor also visited the man in the segregation unit that
morning, noting once again in his written medical record that there
were “no probs”.
107. At approximately 10.00am the mental health nurse and healthcare
manager at the prison, saw the man in the segregation unit as a
consequence of the referral made by the fifth nurse the previous day.
The mental health nurse recorded in his medical record:
“… denies any suicidal intent at this time. No evidence of any
florid psychotic symptoms at this time. Will see again for
assessment. Located in the seg unit at present time. Made
superficial scratches to both his arms last night. No treatment
required. He needs to be advised to request to see the doctor
regarding a medication review.”
The mental health nurse completed a Mental Health Referral Form,
noting that the man had previously been treated for depression and
that he had said he had been on amitriptyline.
108. In her statement to police, the mental health nurse said that she was
aware from the entry by the first nurse in the healthcare observation
book that the man had been seen in the night following an act of self
harm. She said that she “knew that neither the first nurse nor the fifth
nurse had seen fit to open one [an ACCT booklet].”
109. The mental health nurse said that she believed the man was not
suicidal when she saw him at that time. She told my investigators that,
when she asked the man why he had scratched his arms, he said it
was because he had not been given a newspaper. She said that the
man had no signs of mental illness at all and had “laughed” the incident
off. The mental health nurse described the scratches on the man’s
arms as like those from a bramble or a cat. She said she did not bring
the scratches to the attention of staff as they had happened the night
before and she presumed the issue had been dealt with. The mental
health nurse said she did not consider opening an ACCT because
there were no obvious signs of self-harm or suicidal ideation.
However, had she been the first to attend the man the previous
evening, she probably would have done so.
110. In her statement to police, the mental health nurse said she told the
man that she:
“… would see him again after he came out of the segregation
unit to do a full assessment of his mental state and medication.”
She was not aware that the man had been given 20 days cellular
confinement. In her opinion:
27
“… the self harm incident[s] of the previous night were token
gestures, made in an effort to get his own way.”
111. The first governor said that two of the adjudications that morning
involved prisoners who were in the segregation unit. The man was one
of them and his adjudication was one of the last to be held although it
was completed before lunch time. (All adjudications at Leeds take
place in the segregation unit.)
112. The fourth nurse explained to my investigators that since the
introduction of PSO 2000, The Prison Discipline Manual, a new
screening tool had been devised for medical staff to fit prisoners for
adjudication. At Leeds this information is recorded on a document
called Adjudication Concern Screening. He said that staff in the
segregation unit send the medical clerk a list of all prisoners who are to
be adjudicated on that day. Nurses check the medical records of
prisoners to see if there were any concerns. He said that, although he
noted the entry by the fifth nurse the previous day entitled mental and
behavioural problems, he believed the man would have understood the
adjudication process. The fourth nurse recorded that there were no
concerns which the adjudicator should be aware of before the start of
the hearing.
113. The fourth nurse confirmed that he had not seen the entry by the
mental health nurse, made that day. He said he did not record the
scratches the man had made to his arms the previous evening on the
adjudication screening form because:
“Personally I had no issue because one, he didn’t show that he
was going to try and kill himself and two, he was fit to sit in front
of the Governor to be adjudicated.”
In his police statement, the fourth nurse said:
“I collected all the inmate medical records in respect of inmates
located on the segregation unit from the medical records office
together with a list of names. I then checked all the records with
regard to any mental or medical issues each individual might
have. I ticked the form ‘no’ on each name which indicated that
there were no issues of note. I then went to the segregation unit
with the completed form. Which I signed and gave it to an
officer on the unit. I had no knowledge of any incidents that
occurred through the night in respect of any names on the list.”
He also said in this statement:
“I did not know the man had self harmed. Even if I had, I
would not have altered my opinion that he was fit for
adjudication. But I would have documented the brief details of
28
the incident on the column marked ‘details’.”
114. The fourth prison officer and a fifth prison officer had been assigned
adjudication duties that morning. The fourth prison officer told my
investigators that he went to collect the man for the adjudication but the
man said he did not want to attend.
115. In her police statement, the first governor explained that the
adjudication proceeded without the man. She said that she read out
the evidence of the second prison officer as recorded on the Notice of
Report. The second senior officer read out the man’s conduct report.
It is unclear whether the charge against the man was for refusing to
transfer to Ranby or for refusing to return to his cell. However, the
governor said that it was clear in her mind that the charge stood as the
man had refused to transfer to Ranby. This conclusion was drawn
from the officer’s evidence and what she had been told about the
reasons for the man’s presence in the segregation unit. The governor
found the charge proved and the man was given a punishment of 14
days cellular confinement. A previously suspended punishment of six
days cellular confinement was added, giving the man 20 days cellular
confinement.
116. The governor told my investigators that this was only the second time
she had carried out adjudications. She was not aware that the man
had self-harmed the previous evening. The governor thought none of
the segregation unit staff knew either, as nothing had been entered in
the unit observation book. The governor explained that she would not
necessarily know if a prisoner was on an ACCT before an adjudication.
However, she said that she would check before sanctioning the use of
cellular confinement, expecting to have been informed by the nurse
who carried out the algorithm.
117. The fourth prison officer took the paperwork informing the man of the
outcome of the adjudication and punishment to his cell. In his police
statement, the fourth prison officer said that the man said nothing. He
believed the man remained in his bed and appeared not to be bothered
by the punishment. It was at this point that the fourth prison officer
noticed a number of superficial marks on the man’s arms that
appeared to have been self inflicted.
118. At 12.10pm, the second nurse was called to the segregation unit in
order to assess the man’s fitness for cellular confinement. (A
punishment of cellular confinement cannot be imposed unless a
medical practitioner or nurse has completed an assessment.) The
second nurse told my investigators that when she saw the man she
noticed the scratches that he had made to his arms and asked him
about them. The marks appeared to be consistent with self-harm. The
man confirmed that he had self-harmed. She recalled that the man did
not really want to talk. He was “stroppy” and in quite a “bad mood”, but
was not personally abusive. The second nurse said that when she left
29
the man:
“…he turned over on his bed, he was resting on his bed, turned
over on his bed with his back to me, which was kind of like,
‘yeah I don’t want to talk to you anymore’.”
The second nurse said that when she saw the man he did not appear
to be “…withdrawn or depressed or acutely unwell…” Although she
could not remember telling any one specifically about the scratches to
the man’s arms, there were two officers present who would have heard
her conversation. The second nurse recorded on the algorithm that the
man had self harmed during his current period of custody. She added
that his mental state would not deteriorate significantly if segregated
and that he showed no signs of being acutely unwell at the present
time. She said at interview:
“… his behaviour seemed normal to me, as a Registered
General Nurse, there was nothing about his behaviour that
struck me as abnormal or unusual … [He] also denied to me,
having any further wishes to self-harm or commit suicide, so
from that point of view I was satisfied”.
The second nurse told my investigators that she was not aware that a
period of segregation should be noted in the prisoner’s medical record
or that an ACCT booklet should be opened after an act of self harm.
119. The first governor signed the segregation safety algorithm at 12.20 am.
She recorded that the man was suitable for cellular confinement and
should be segregated as per the adjudication punishment. In her
police statement, the first governor said she only became aware that
the man had self harmed after he had died.
120. In his police statement, the fourth prison officer said that the nurse did
not mention anything about the marks on the man’s arms which could
be clearly seen. The fourth prison officer said that he was “quite
disturbed by this”. The second nurse told the police she did not make
any entry on the man’s medical record as she felt that the algorithm
explained it all.
121. That afternoon, an officer wrote in The man’s history sheet that he:
“Got out of bed to put his plastics out, wouldn’t speak to staff
when asked if ok.”
122. At 5.00pm, the first prison officer had issued the man with an F1127B,
Notice of Report form, for having “smashed” up his flask the previous
evening.
123. The fourth prison officer told the police there were no incidents of note
that afternoon. The man was on hourly checks because of his cellular
30
confinement. At about 5.30pm, the man was heard to be kicking or
throwing his cup and bowl around his cell so they were removed. The
fourth prison officer told my investigators that the man seemed a very
angry person. The fourth prison officer said he was later asked to give
assistance to colleagues on D wing.
124. In his statement to police, the first prison officer said the man’s cell
door was opened at about 5.30pm and he was given his tea. The man
asked about having a flask of hot water for the night but was told there
was not one to give him because he had smashed his previous flask
the night before. The first prison officer said that the man swore at
staff, and began to shout and make a lot of noise. The man’s cup and
bowl, which he was throwing around, were then removed. I note that
although these items were apparently removed from the man’s cell, at
the time of his death a plastic plate and fork were present.
125. The last entry in the man’s history sheets was made by the first prison
officer. He recorded that the man:
“Took tea meal, [the man] became abusive to staff because he
had not been given a flask.”
During his interview with my investigators, the first prison officer was
unable to recall the exact details of the contact he had with the man
that afternoon. He could remember that he had given the man the
notice of report and that the man had been abusive when not given his
flask.
126. In his police statement, the first prison officer said that he believed that
he had done the evening checks, but did not sign the entry for 8.00pm
on the man’s hourly watch cellular confinement record. However, the
first prison officer said he did check the man’s cell and recalled that he
saw him lying on his bed. The man was on his side and just looked at
the first prison officer before looking away. The man did not give him
any cause for concern at that moment.
Events leading to the man’s discovery
127. The fourth prison officer told my investigators that it was probably
between 6.15pm and 6.30pm when he left the segregation unit to
assist other staff on D Wing. At about the same time the sixth prison
officer was ordered to assist with a hospital escort. The first prison
officer was left working alone in the segregation unit.
128. At about 7.30pm, The OSG arrived in the segregation unit to prepare
for his nightshift. Only the first prison officer was on duty when he
arrived. The first prison officer briefed him that, if the man asked why
he did not have a flask, it was because he had broken one the previous
day. Apart from this, the first prison officer said that it had been a quiet
day. The OSG told police that after telling him about the smashed
31
flask, “the first prison officer then went and opened the fire hydrants
and relevant gates as per night patrol conditions.” The OSG said, “I
don’t know whether he did his last checks of the prisoners as I didn’t
see him do it.”
129. The OSG said that after the first prison officer did his final round he
returned to the office at about 8.00pm. The first prison officer told the
OSG that he was going to the centre of the prison in order to report
segregation unit numbers for the final roll call. After giving in the
numbers, the first prison officer returned to the segregation unit,
collected his things and left.
130. The first prison officer told my investigators that he commenced his
final checks of the segregation unit at around 7.55pm. This included
opening gates, unlocking the fire hydrants and counting the prisoners.
The first prison officer said that he gave his numbers for the final roll
check just after 8.00pm, before returning to the segregation unit,
collecting his bag and leaving via the First Night Centre.
131. The OSG told my investigators that, once the day staff had left, he
would check the doors and locks to the cells himself, as well as
checking the number of prisoners on the unit. The OSG began his
checks at 8.05pm. The last cell he checked was the man’s. Although
the cell light was off, The OSG could see a silhouette at the back of the
man’s cell. He tried to get the man to respond.
132. Failing to get any response, The OSG tried to summon Oscar 1 on his
radio, but the battery was dead. He then went to the office to get a
spare battery, but that too was flat. (My investigators were told by the
OSG that he would often have to change the batteries in his radio two
or three times a night.) He then phoned the control room and asked for
Oscar 1 (the orderly officer) to attend the segregation unit immediately.
133. The Duty Governor, and the principal officer attended. The OSG
shouted to the officers congregating at the centre of the prison waiting
to go home for further assistance. The OSG then went to the office,
collected the ligature scissors and returned to the man’s cell. The man
had already been cut down. The OSG took no further part in the
efforts to revive him.
134. At 8.00pm, the principal officer was located on the prison centre to start
the process of confirming the prison roll. This takes 10 to 15 minutes.
the principal officer said that, at about 8.10pm when the roll call was
still in progress, the alarm was raised over the radio for Oscar 1 to
attend the segregation unit. He and the duty governor who was
standing behind him at the time, immediately walked down the stairs
leading from the centre to the segregation unit. The principal officer
said he was told by the OSG that he could get no response from the
prisoner in cell S1 31, and that he was unable to turn the light on. The
principal officer checked and saw that the man was motionless at the
32
back of his cell.
135. The principal officer immediately opened the cell door. He described
the cell as being, “… a very sparse cell, nothing much in there at all”.
He said that the man was hanging with a ligature around his neck, and
was suspended from the window bars. The duty governor then
activated his personal alarm.
136. The principal officer took the weight of the man’s body by lifting him
and shouted for a pair of ligature scissors. The fourth prison officer,
the second person to enter the cell, assisted in supporting the man.
The ligature was then cut by the seventh prison officer. The principal
officer said that the man was still warm and flaccid when he was
placed on the bed. The Fourth prison officer immediately checked for
a pulse and chest compressions were started. The principal officer
said that a nurse quickly attended and checked the man’s airways
before commencing full cardio pulmonary resuscitation (CPR). The
principal officer said that there were a number of nurses in attendance
at this point. An automatic external defibrillator (a machine used to
assist in restarting the heart) was attached to The man, but it advised
not to shock.
137. In his police statement, the fourth prison officer said that whilst on the
centre at about 8.05pm he heard the call for assistance from the duty
governor. He said he ran down to the segregation unit and saw the
duty governor and the principal officer standing outside the man’s cell.
The fourth prison officer said that he followed the principal officer into
the cell and assisted him in taking the man’s weight. The seventh
prison officer cut the ligature from around the man’s neck with a
ligature knife (a safety blade used to cut ligatures quickly), and the man
was placed on the bed. The seventh prison officer took no further part.
The fourth prison officer said that he continued to assist nursing staff
with CPR until told to stop by the prison doctor.
138. The fifth nurse was cleaning the medical centre when the alarm was
raised. The fifth nurse and the sixth nurse were told by an officer that a
prisoner had been found hanging in the segregation unit. The fifth
nurse attended immediately. On her arrival at the cell she found an
officer giving the man cardiac massage. The fifth nurse checked for
vital signs and prepared to carry out mouth to mouth resuscitation.
She said that the man’s body was still warm to the touch.
139. At this point, three other nurses attended, bringing with them
emergency equipment. Chest compressions continued whilst staff
attempted to get air into the man. One of the nurses said that CPR
had commenced by the time of her arrival. She said a defibrillator had
been attached to the man and that the third nurse was trying to fit an
airway. Another nurse also assisted the nursing team with CPR.
33
140. The prison doctor told my investigators that at 8.17pm he was informed
by an officer that he was required urgently in the segregation unit. The
prison doctor arrived on the unit at about 8.20pm to 8.25pm. He said
he found members of medical staff and non medical staff in
attendance, administering CPR to the man. The prison doctor said he
felt the man had been dead for some time as he was not warm to the
touch. However, he let staff continue to administer CPR. This was
confirmed by the principal officer who told police that the prison doctor
entered the cell when staff were administering CPR to the man. He
said that the prison doctor had said the man was dead, but to carry on
with CPR until the paramedics had confirmed death. However, shortly
before the arrival of paramedics, the prison doctor told staff to
discontinue.
141. Paramedics arrived at 8.30pm. One of the Yorkshire Ambulance
Service paramedics, confirmed that CPR had ceased when he arrived
at the man’s cell. The paramedics left the prison when it was clear that
death had occurred.
142. The first prison officer told my investigators that he had gone off duty
by the time the man was found in his cell. The first prison officer said
the man “was fine” when he left the unit at 8.00pm. He said:
“… I was there ‘till eight o’clock, I went down, I checked on
everybody before I left, looked through to make sure, obviously
for the roll count and everything and put the numbers in and
left.”
143. When the night orderly officer came on duty around 8.20pm, staff were
still waiting to be released from the centre. He said that Oscar 1 would
give permission for staff to leave early if they had good reason.
Events after the man’s death
144. The OSG remained on duty in the segregation unit and was not asked
to complete a report about his involvement or to attend the hot debrief.
Incident reports from a number of healthcare and discipline staff were
also not completed.
145. A second Family Liaison Officer at Leeds, was contacted and informed
of the man’s death at 9.00pm. Accompanied by four police officers, the
second Family Liaison Officer and the duty governor and Sister from
the chaplaincy visited the man’s mother at about 2.15am on the
morning of 20 April to inform her of her son’s death. The man’s father
was told at 3.00am.
146. The Family Liaison Officer, attended the man’s funeral on behalf of the
prison. Leeds made a contribution of £1,000 to the costs of the man’s
funeral. However, it was a number of months before the funeral
34
expenses were finally settled by the prison.
147. West Yorkshire Police attended the prison. The Scenes of Crime
Officer took photographs of the man and the cell in which he had died.
A number of photographs show around 20 cuts to each of his forearms.
Some of the cuts are up to four centimetres in length and indicate a
recent act of self harm.
Toxicology, Post Mortem and Clinical Review
148. The post mortem report completed by a forensic pathologist, recorded
that the man had:
“...multiple recent superficial parallel incised wounds on the
back of the right forearm extending down from the elbow
towards the wrist, and there were a couple of marks also on the
back of the wrist. Much older scars were present on the inner
aspect of the forearm extending down from the ante cubital
fossa to the wrist, again parallel marks. All these appear to be
marks of self harm.”
149. The forensic pathologist noted that on the man’s left arm there was:
“… virtually exactly the same pattern of distribution of self harm
marks with much more recent ones present on the outer aspect
of the forearm and older ones present on the inner aspect”.
150. He concluded:
“The pathological findings are those of hanging, consistent with
the bed sheets used. The appearance and distribution of the
ligature mark are typical of being self inflicted. There was
evidence on the deceased of previous attempts at self harm.”
151. Toxicology tests completed on the man returned a negative
toxicological screen.
152. A Clinical Review was conducted by a Director of Public Health at
Leeds West Primary Care Trust. In his review, the doctor concludes
that both written and electronic medical notes relating to the man were
clearly recorded.
153. The clinical reviewer draws attention to the difference in timings
recorded by different participants. He comments that timings in such
situations should be recorded as carefully as possible. The clinical
reviewer judges that the medical care provided during the attempted
resuscitation of the man was entirely appropriate.
154. With regard to the injuries the man inflicted on himself, the clinical
reviewer says:
35
“The man was seen by a nurse in segregation after he had
superficially injured his arms. Although this was recorded on
an F213SH no entry was made in the IMR or EMIS [The man’s
medical records]. It is important that all clinical interactions are
recorded in the clinical records. However, there is no evidence
to suggest that failure to record some information led to
inappropriate care.”
155. The clinical reviewer observes that the man was seen by the doctor on
each occasion he was admitted to the segregation unit. However, he
highlights that the recording of such contact was not particularly clear
and that EMIS was not used. The clinical reviewer says:
“The GP is required by Prison regulations to see a prisoner in
segregation every 72 hours. Segregation is a difficult
environment within which to work and a ’superficial chat‘ from
the cell door is not a particularly effective means of assessing a
prisoner. It could provide false re-assurance and is not an
effective use of medical time. All interactions by healthcare staff
with prisoners must have a clear context in terms of identifying
and meeting needs. A more systematic assessment of physical
and mental health needs could be undertaken and recorded in
EMIS by the nurses and referral made to the GP if necessary.
This should include unwillingness of the prisoner to take part in
the assessment as well as describe constraints on the
assessment process.”
The clinical reviewer makes two recommendations:
Healthcare staff should review the purpose of assessing
prisoners in segregation. A more systematic process of
assessment and recording of results needs to be developed. This
should be done on the basis of the most effective use of staff
skills and competencies.
Healthcare staff should be reminded that all clinical interactions
with prisoners must be recorded in the IMR and preferably on the
EMIS system.
156. I concur fully with the clinical reviewer’s recommendations. However, it
is apparent from my investigation that on many occasions healthcare
staff are asked to attend the segregation unit at short notice. As a
consequence, they appear not to have access to prisoner’s health
records when completing assessments. The man had significant
contact with healthcare staff when in the segregation unit. However,
most was never formally recorded on his medical records, either
electronically on EMIS or manually. The lack of access to the EMIS
system by healthcare staff would be one contributing factor. I make
the following recommendation in respect of access to medical records:
36
The Prison Health Partnership should consider the possibility of
providing a terminal linked to the EMIS system either in the
segregation unit or nursing station in the main prison.
157. The clinical reviewer says that the man’s assessments by medical staff
were mindful of his needs and he concludes there were no significant
omissions in his care. The clinical reviewer notes that it is not possible
to say if the man’s behaviour was related to the illicit use of
Buprenorphine (Subutex) and the potential transfer to Ranby.
158. During the investigation, my investigator contacted the clinical reviewer
on a number of occasions. He asked the clinical reviewer to look at the
man’s prescription of amitriptyline over the previous five years, and the
effect this may have had upon him. In response, the clinical reviewer
said that the man was not on amitriptyline when he went to Leeds and
there was nothing in his clinical assessment to suggest that he should
have been. He said that the policy at Leeds was not to use the drug
because of its toxic profile in overdose situations. The clinical reviewer
said that the man’s main concern at this stage was to get on the detox
regime.
159. My investigator asked the clinical reviewer to look at what action staff
took when the man missed the last two doses of Subutex which he was
receiving as part of his detox programme. The clinical reviewer said
that missing the final treatments of his detox regime was unlikely to
have had a significant impact on the man. Prisoners had a personal
responsibility for their health. Failure to turn up for medication usually
did not warrant follow up unless staff had particular concerns. The
clinical reviewer said that this had to be seen in the context of some
7,000 prescribing interactions per week.
160. The clinical reviewer was asked to explore healthcare staff’s
awareness of the man’s history of self harm and depression and the
RMN screening on the day of the man’s death. My investigator asked
the clinical reviewer whether adequate consideration had been made
with regard to the man’s suitability to remain in the segregation unit on
19 April. The clinical reviewer said that the mental health assessments
of the man were undertaken by a qualified and experienced member of
staff. The recording of information was sufficient to convey the
outcome of the assessment undertaken. The clinical reviewer noted
that:
“Delay of 20 days between closure of the ACCT on the 9th and
being seen in the review clinic is longer than staff would like but
not inappropriate in a routine situation. It compares well against
NHS waiting times.”.
The clinical reviewer concluded that the review and suggested follow
37
up were not inappropriate.
161. The clinical reviewer was asked to comment with regard to the
considerations taken by healthcare staff in deciding whether to open an
ACCT after the man’s self harm on the evening of 18 April. Although
not included in his initial report, in his e-mail response to my
investigator on 22 August, the clinical reviewer said:
“I agree an ACCT should have been started on the 18th but my
understanding is that this should [have] been undertaken by the
person finding the injuries. This has to be seen in the context of
on average 2 episodes of self harm per day in the prison
(inflicted for a variety of reasons).”
162. I am very grateful to the clinical reviewer for his assistance. However, I
recall that following the death of another prisoner at Leeds in August
2004.he wrote to me saying that his investigation into clinical care
could not be independent as Leeds West Primary Care Trust employed
a number of staff at HMP Leeds and he was the line manager of the
Head of Healthcare at the prison. I drew this concern to the attention
of the PCT at the time and must repeat it here.
Leeds West Primary Care Trust should ensure that any apparent
conflict of interest is minimised when appointing a clinical
reviewer.
38
ISSUES
The man’s movement to the segregation unit
163. On the morning of 18 April 2006, the man refused to return to his cell
on C wing, having explained to officers that he would not transfer to
Ranby because of debt. The man told staff they should take him to the
segregation unit.
164. Given the man’s refusal, staff had little choice but to escort him to the
segregation unit. The segregation unit observation book and
segregation safety algorithm record that the man was located in the
segregation unit under Prison Rule 53, pending adjudication. Staff
recorded in his history sheet that it was under Rule 55, cellular
confinement.
165. The man’s history sheet records that he was placed in the segregation
unit under Rule 55, cellular confinement. It is possible that Rule 55
was recorded by staff in error. However, on 18 April, the OSG appears
to have been under the impression that the man was serving a period
of cellular confinement. He told police that he had checked the man
between 8.00pm and 8.30pm as the man was subject to cellular
confinement.
166. The reason for the man’s transfer to the segregation unit had no direct
bearing on his death. However, it is of concern that some staff at
Leeds were uncertain as to which prison rule applied. It is also
disappointing that, for both occasions that the man was segregated,
staff have been unable to provide my investigators with the paperwork
informing him of the reason.
The Governor should ensure that all staff and governors, in
particular those working in the segregation unit, are aware of the
prison rules which relate to the authorisation of a prisoner’s
transfer to the segregation unit, ensuring that the correct and
appropriate rule is applied to individuals.
167. The man arrived in the segregation unit at approx 11.00am.
Applications by prisoners on the unit had already been made at
7.30am. As already explained, this is the one time each day when
prisoners can formally make applications on the unit.
168. I draw attention to the inspection report on Leeds by HM Chief
Inspector of Prisons. Ms Owers describes the segregation unit as
being “run in a militaristic fashion…” and the applications process may
provide an example of this. However, I do note that the first governor
told my investigators that staff had discretion whether or not prisoners
were allowed to make applications after 7.30am. She added that the
ability to make applications was dependent on the individual’s
39
circumstances and the time he arrived.
169. Staff in the segregation unit at Leeds were unable to provide my
investigators with any record that the man either made any applications
during his first day on the unit, or that he was invited by staff to do so. I
appreciate that, subject to staff discretion, prisoners are able to make
applications in the segregation unit after formal applications are made
at 7.30am. However, I make the following recommendations.
The Governor should review the way in which applications are
made by prisoners in the segregation unit and consider
introducing formal procedures which allow prisoners, when
appropriate, to make applications after 7.30am.
Conditions of cell
170. On 18 April, the man was placed in a regular cell in the segregation
unit. This contained nothing more than a bed and a cardboard chair.
PSO 1700 on Segregation states that normal cells in segregation units
should be:
“… well lit and equipped to a standard similar to that found on
normal location within the prison (this includes integral
sanitation, in-cell electrics and TV aerial points). Any restriction
of facilities (e.g. cardboard furniture, no in possession lighter) is
supported by a risk assessment.”
Staff at Leeds were unable to provide a risk assessment outlining the
justification for there being just one cardboard chair in the man’s cell.
171. At the time of the man’s death, nearly all the furniture contained within
the cells in the segregation unit at Leeds was cardboard. However, my
investigators told me that, when they visited Leeds during the course of
their investigation, cell furniture on the unit was gradually being
replaced by furniture similar to that found in other areas of the prison.
172. When the man was moved to the segregation unit he had not been
charged with breaking any prison rules. As such, he was entitled to the
same level of privileges as he was whilst located on C wing. The man
was not treated in this way.
173. The cell the man occupied on C wing had been cleared of his
possessions as the consequence of a request by staff in the
segregation unit. However, the few possessions that the man had
were not passed onto him. He had nothing to occupy him in his cell in
the segregation unit. He was given no TV or radio (to which he would
have been entitled as a standard prisoner), no reading material, pen,
paper or indeed any of his own possessions. At the time of his death,
there was nothing in the man’s cell other than his bed, cardboard chair,
plastic plate and what appears to have been the remainder of his
40
breakfast pack.
174. It is clear to me that on 18 April, the day on which the man self harmed,
he was serving what can only be described as a period of cellular
confinement without privileges. This is very disturbing.
The Governor should ensure that all cell furniture in the
segregation unit is comparable with that found in cells on normal
location. Cardboard furniture should only be used when
supported by a risk assessment in line with PSO 1700.
The Governor should ensure that those prisoners transferred to
the segregation unit are provided with any possessions and
activities to which their privilege level entitles them.
The man’s attempt at self harm on 18 April
175. As noted, on the evening of 18 April, the man was located in a cell
containing only a bed and cardboard chair. It may be that in order to
alleviate the boredom that he requested a newspaper. The OSG
advised the man that there was none to give him, although I
understand that a small library is available to prisoners on the
segregation unit. At 10.30pm, The OSG gave the man a supplement
from his own newspaper. It was at this time that the man drew the
OSG’s attention to the marks he had made to his arms.
176. The nurse was called to see the man. She said that the man’s injuries
were “numerous but very minor”. As there was no blood or weeping
skin, she advised the man that she was unable to dress his wounds.
The nurse told my investigators that she could see on the man’s arms,
“… old scarring from other marks that he had made …” the night
orderly officer said that he had been called to the segregation unit
because a prisoner had self harmed or had threatened to self harm.
177. Given the evidence presented to my investigators, and having had the
opportunity to view photographic evidence from West Yorkshire Police,
it is clear to me that the man had self harmed on the evening of 18
April. This had been acknowledged by staff themselves in the
completion of an F213SH. I am therefore very surprised that not one
of the three members of staff, one a trained ACCT manager, opened
an ACCT document. This was despite the fact that the man had made
many cuts to both his arms, was to all intents and purposes serving a
period of cellular confinement, had a history of self harm and was
located in the segregation unit.
178. I am also troubled by some of the responses of the nurse to my
investigator’s questioning. I believe they may reveal insufficient
understanding of the needs of prisoners in vulnerable situations. In
one response she said that the man’s attempt to self harm was not
serious but a protest about not getting a newspaper. I believe that the
41
night orderly officer also showed a lack of judgement in believing that
the man had not self harmed.
179. The Prison Service definition of self harm as outlined in PSO 2700
Suicide and Self Harm Prevention, 3.1.1 is that:
“… ’self harm’ is any act where a prisoner deliberately harms
themselves irrespective of the method, intent or severity of any
injury”.
Paragraph 3.1.2 goes on to say:
“An act of self harm should always be taken seriously. Even if
the prisoner appears to be using self harm as a means of
gaining something, it is still a desperate act and the prisoner
should be helped to find constructive ways to meet the
underlying need.”
180. Prison Service Instruction 18/2005, says at appendix C, section 2:
“In the event of any incident of self-harm, or whenever a
member of staff believes a prisoner/trainee is at risk of suicide or
self-harm, they must (where there is not one open already) open
an ACCT plan.”
Leeds’s own policy document on self harm clearly reflects this
guidance. It says, “An ACCT will be opened in respect of any prisoner
who self-harms.”
181. I believe that the staff who responded to the man on the evening of 18
April made a serious misjudgement in not opening an ACCT document.
182. I would add that the man was seen by a number of staff the following
day. These included the prison doctor, nurses and discipline staff.
Some were aware of the man’s self harming or had been informed of it
by the man himself. Although some gave consideration to opening an
ACCT, none thought it necessary.
The Governor of Leeds should remind all staff of their obligations
under PSO 2700 to open an ACCT on any prisoner who self
harms.
183. I draw attention to my report into the death of a prisoner in the Leeds
segregation unit in August 2005. In that report my investigators
established that the ability of staff to detect those prisoners at risk of
self harm was limited because of the nature and restrictions imposed
by the unit. I said that staff had few meaningful interactions with
prisoners and recommended that the Governor should take advice
from the Prison Service’s Safer Custody Group (the part of the National
Offender Management Service (NOMS)). This was to ensure that self
42
harm training included awareness of issues arising from an individual’s
circumstances and location especially in the segregation unit. Whilst I
make no formal recommendation, I draw this to the attention of the
current Governor.
Staff Handover
184. The nurse said that, during her handover to nursing staff on the day
shift, she had explained everything that had happened through the
night, making reference to the healthcare observation book. The nurse
said that the fourth nurse would have been present at the handover.
185. The fourth nurse said that he was aware of the ‘superficial scratches’
that the man had made. In his police statement, he said that he did not
see the nurse who had been on nights, but received the handover from
another nurse whose name he could not recall.
186. My investigators have been unable to establish conclusively who was
present during the healthcare handover, or what information was
provided to nursing staff on the morning of 19 April.
The Prison Health Partnership must ensure that nursing staff are
aware of their duties during shift handovers. When nursing staff
hand over a shift, a record of the handover should be made in the
healthcare observation book.
187. Additionally, no record was made by the OSG in the segregation
observation book, or in the man’s history sheets, that the man had self
harmed or that an F213SH had been completed. The OSG said that
he did tell staff that the man had been seen by a nurse in the night, but
could not recall to whom he spoke. Staff told my investigators that the
man’s attempt to self harm was not discussed at the segregation unit
morning meeting on 19 April.
188. It was unsatisfactory that the man’s actions were not recorded
appropriately by discipline staff. Significant events, such as attempts
of self harm, must be discussed and recorded appropriately.
The Governor should remind segregation unit staff of the need to
keep accurate and comprehensive records. Additionally, the
Governor should remind night staff of the importance of providing
staff coming on duty with significant information.
Adjudication
189. The man was fitted for adjudication by healthcare staff in accordance
with Prison Service instructions and guidance. However, the fourth
nurse did not record that he had self harmed the previous evening. He
wrote that he did not know of any reason why the man’s adjudication
should not proceed. He did not draw to the governor’s attention the
43
man’s act of self harm the previous evening despite having been made
aware of this during the shift handover.
190. The man’s adjudication took place late on the morning of 19 April. The
first governor told my investigators that she had been unaware of the
man’s actions the previous evening. She said that, had she been
aware of the man’s attempt to self harm, she would have considered it
prior to the adjudication. The first governor agreed that the man’s
adjudication had not been conducted in the appropriate manner.
191. The first governor told my investigators that 19 April was only the
second time that she had conducted adjudications. I have studied the
adjudication record made by the first governor and note that there are
some significant procedural flaws. These include not completing
section 12 of the record indicating the man’s plea, and not adhering to
the guidance laid out in chapter 4.3 of PSO 2000 on how to conduct an
adjudication in a prisoner’s absence. Additionally, the officer who had
laid the charge was not summoned to give evidence in person.
192. None of us is on top of any task the second time we carry it out. And I
intend no personal criticism of the first governor. However, the
evidence may indicate that she had not received adequate training in
order to conduct adjudications. I recommend that:
The Governor should satisfy himself that all governors have
received adequate training before conducting adjudications.
Discovery of the man
193. After his adjudication on 19 April, the man was checked hourly by
segregation unit staff because he was on cellular confinement. These
checks were recorded by staff on a cellular confinement watch sheet.
At about 6.30pm, two of the three officers remaining in the segregation
unit were asked to complete alternative duties elsewhere. The first
prison officer was left alone in charge of the segregation unit. At
7.30pm, the OSG arrived. At around 7.55pm, the first prison officer
commenced his final checks of the unit and reported his final numbers
for the roll call just after 8.00pm, before returning to the unit to collect
his bag and leave. The first prison officer did not sign the man’s hourly
watch sheet confirming that he had checked the man at 8.00pm.
However, he did tell the police and my investigators that the man was
fine when he left the unit at that time.
194. The OSG did not see the first prison officer make the final checks on
the segregation unit. However, The OSG conducted his own check at
8.05pm during which he discovered the man hanging in his cell. At this
time, the first prison officer was leaving the prison although the final roll
had not been confirmed.
The Governor should remind all staff that, unless given the
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authority to do so, no member of staff should leave the
establishment until the final roll has been confirmed.
195. I concur with the clinical reviewer’s finding that the medical care
provided during the attempt to resuscitate the man was entirely
appropriate.
Communication
196. My investigators have reported to me on the quality of record keeping
in the segregation unit. Entries on the wing history sheets were
generally of a poor quality. It would also appear that only the required
standard three entries are being entered on a daily basis. As
mentioned, staff were unable to provide my investigators with
requested information. I also understand that staff visiting the unit are
not regularly signing in and out as required by PSO 1700.
The Governor should remind segregation unit staff of PSO 1700
and the importance of keeping auditable, accurate and
comprehensive prisoner and unit records.
197. My investigators were frustrated by the lack of information provided by
Leeds as to why the CCTV cameras in the segregation unit were not in
operation at the time of the man’s death. Staff were unable to clarify
when the camera’s had stopped working. They were unable to say
why this had occurred or confirm when the cameras were reinstated.
The CCTV cameras should be checked by a governor on a regular
basis. A record of these checks should be kept and entries made
if the cameras are not operating.
198. Upon discovering the man, the OSG went to use his radio to summon
assistance. The batteries were flat, as was a second set he tried to
use. The first governor told my investigators that she was not aware of
the problems with regard to flat radio batteries. Neither had any staff
drawn the problem to her attention.
199. During my investigation into the death of a prisoner who died in the
segregation unit at Leeds in August 2004, I was told that the failure of
officers’ radios was a regular occurrence. I understood that the matter
was being discussed at a high level within the prison. In my report I
recommended the Governor ensure that staff have functioning radios.
I repeat that recommendation.
The Governor should review procedures to ensure staff have fully
functioning radios in all parts of the prison.
200. Staff in the segregation unit said that, because the man had been
kicking his plastics around his cell, they were removed on the
afternoon of 19 April. It would appear that some plastics were
45
removed. However, photographs indicate that a plate, and what
appears to be a fork, were left in the cell. However, what is certain is
that the man was left with nothing from which to drink.
201. At the time of the man’s death, the segregation unit was patrolled by an
OSG who was based solely on the unit. When necessary, support was
sought from other officers in the prison. The OSG told my investigators
that this had now changed, and that for most of the time during nights
an officer is on duty in the segregation unit in addition to having
responsibility for A wing. This issue was also raised in my report into
the segregation unit death in August 2004.
The Governor should ensure that at least one officer is routinely
detailed to work and is based in the segregation unit at night.
202. I also note that during the early evening on 19 April one officer was left
in charge of the segregation unit. I appreciate there are times when
officers have to be redeployed to other areas of the prison. However, I
would ask the Governor to give careful consideration when redeploying
staff from the segregation unit.
Action taken after the man’s death
203. The second prison family liaison officer, the Sister from the chaplaincy,
and the duty governor broke the news of the man’s death to his mother
at her home in Hull. During her meeting with my staff, the man’s
mother explained that being told of the man’s death was obviously
upsetting and had not been helped by having four police officers
present in addition to Prison Service staff,.
204. The OSG remained on duty after the man was discovered and he was
not asked either to attend the hot debrief or to submit an incident
report. In my report into another death in August 2004, I reminded the
Governor that all staff should be seen for a hot debrief before going off
duty.
The Governor should ensure all staff involved in the death of a
prisoner submit an incident report form, and should attend the hot
debrief before going off duty.
205. Although the majority of staff felt that their welfare needs had been
addressed, a number said that approaches from the staff welfare team
had been unsatisfactory, and that management at the prison had not
thanked them for their efforts. I draw this to the Governor’s attention.
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RECOMMENDATIONS
Healthcare staff should review the purpose of assessing prisoners in
segregation. A more systematic process of assessment and recording
of results needs to be developed. This should be done on the basis of
the most effective use of staff skills and competencies.
No Response - Response from HMP Leeds to follow.
Healthcare staff should be reminded that all clinical interactions with
prisoners must be recorded in the IMR and preferably on the EMIS
system.
Accepted – Full response from HMP Leeds to follow.
The Prison Health Partnership should consider the possibility of
providing a terminal linked to the EMIS system either in the
segregation unit or nursing station in the main prison.
Accepted – Full response from HMP Leeds to follow.
Leeds West Primary Care Trust should ensure that any apparent
conflict of interest is minimised when appointing a clinical reviewer.
No Response - Response from HMP Leeds to follow.
The Governor should ensure that all staff and governors, in particular
those working in the segregation unit, are aware of the prison rules
which relate to the authorisation of a prisoner’s transfer to the
segregation unit, ensuring that the correct and appropriate rule is
applied to individuals.
Partially Accepted – HMP Leeds responded that PSO 1700 and PSO 2000
authorised segregation under Rule 53 from the time of the offence pending
adjudication. A copy of each PSO is held in the segregation unit. The
principal officer in charge of the unit will affix posters to remind staff of
relevant rules and paragraphs for segregation.
The Governor should review the way in which applications are made
by prisoners in the segregation unit and consider introducing formal
procedures which allow prisoners, when appropriate, to make
applications after 7.30am.
Accepted – Full response from HMP Leeds to follow.
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The Governor should ensure that all cell furniture in the segregation
unit is comparable with that found in cells on normal location.
Cardboard furniture should only be used when supported by a risk
assessment in line with PSO 1700.
Accepted – Full response from HMP Leeds to follow.
The Governor should ensure that those prisoners transferred to the
segregation unit are provided with any possessions and activities to
which their privilege level entitles them.
Accepted – Full response from HMP Leeds to follow.
The Governor of Leeds should remind all staff of their obligations
under PSO 2700 to open an ACCT on any prisoner who self harms.
Accepted – Full response from HMP Leeds to follow.
The Prison Health Partnership must ensure that nursing staff are
aware of their duties during shift handovers. When nursing staff hand
over a shift, a record of the handover should be made in the
healthcare observation book.
Accepted – Full response from HMP Leeds to follow.
The Governor should remind segregation unit staff of the need to keep
accurate and comprehensive records. Additionally, the Governor
should remind night staff of the importance of providing staff coming
on duty with significant information.
Accepted – Full response from HMP Leeds to follow.
The Governor should satisfy himself that all governors have received
adequate training before conducting adjudications.
Accepted – HMP Leeds responded that no adjudicator is allowed to
undertake adjudications without having attended the relevant course.
However, arrangements are being put in place to better support
adjudicators new to the role by shadowing more experienced members of
staff as part of their induction.
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The Governor should remind all staff that, unless given the authority
to do so, no member of staff should leave the establishment until the
final roll has been confirmed.
Accepted – Full response from HMP Leeds to follow.
The Governor should remind segregation unit staff of PSO 1700 and
the importance of keeping auditable, accurate and comprehensive
prisoner and unit records.
Accepted – HMP Leeds say that a copy of each PSO is held in the
segregation unit. The principal officer in charge of the segregation unit will
affix posters to remind staff of relevant rules and paragraphs for
segregation.
The CCTV cameras should be checked by a governor on a regular
basis. A record of these checks should be kept and entries made if
the cameras are not operating.
Not Accepted – HMP Leeds propose that a manager checks the CCTV,
and not specifically a governor grade.
The Governor should review procedures to ensure staff have fully
functioning radios in all parts of the prison.
Accepted – Full response from HMP Leeds to follow.
The Governor should ensure that at least one officer is routinely
detailed to work and is based in the segregation unit at night.
Accepted for Review – HMP Leeds said that an exercise is underway to
identify the resource implications of this recommendation.
The Governor should ensure all staff involved in the death of a
prisoner submit an incident report form, and should attend the hot
debrief before going off duty.
1. Accepted
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