Individual at Parc

Investigation into the circumstances surrounding the
death of a man
at HMP Parc in August 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2009
This is the report of an investigation into the death of a man at HMP Parc. On a
morning in August 2008, an officer who was carrying out his morning roll check
found the man hanging in his cell. It seems the man had used a canvas strap, which
he had taken from his workplace, and tied it around the hinges of his toilet door. The
officer and several of his colleagues responded quickly but their attempts at
resuscitation were not successful. The man, who had been remanded to HMP
Cardiff in February 2008, charged with the murder of one of his sons and the neglect
of the other, had transferred to HMP Parc on 13 June. He was 35 years old.
My colleagues and I would like to extend our condolences to the man’s family and all
those affected by his loss.
The investigation was carried out on my behalf by two of my investigators. A review
of the man’s clinical care in prison was carried out by a clinical reviewer on behalf of
the Healthcare Inspectorate Wales. I am very grateful to the clinical reviewer for her
assistance. I also thank the Director of Parc for the co-operation of her staff, several
of whom came in on their day off to be interviewed by my investigators.
I make seven recommendations: one each to Parc and Cardiff in relation to
transferring medical information, two to Parc regarding healthcare, two in relation to
emergency responses, and one regarding security procedures. My own
recommendations incorporate two made by the clinical reviewer. I also note one
area of good practice.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw
Prisons and Probation Ombudsman May 2009
2
CONTENTS
Summary 4
The Investigation Process 5
HMP Parc 6
Key Findings 7
Issues Considered 18
Recommendations 22
3
SUMMARY
The man had been remanded in custody in February 2008, charged with the murder
of one of his sons and neglect of the other. He was held at HMP Cardiff, where after
a month he asked to go onto Rule 45.1 Cardiff does not have a separate unit for
vulnerable prisoners so the man was held in the segregation unit. This was clearly
not satisfactory and, after some negotiation between the heads of establishment at
Cardiff and HMP Parc, the man was transferred to Parc in June 2008.
Throughout the six months he was held in custody, the man maintained he was
innocent of the charges against him. He spent considerable amounts of time
researching medical information to prove he had not murdered his son, and those
who met him at the time have described him as ‘obsessed’ with the research. As
part of his court proceedings, the man had been assessed by a Specialist Registrar
in Forensic Psychiatry. The Specialist Registrar wanted the man to be assessed in a
secure unit under section 35 of the Mental Health Act 1983 for a more thorough
mental health assessment. The man initially co-operated but later refused to
communicate with staff from the secure unit. At the time of his death he had not yet
received the recommended full assessment.
There was an inadequate handover when the man transferred from Cardiff to Parc,
and his records do not appear to have been adequately reviewed at Parc to ensure a
follow up of his mental health assessments. Staff from the secure unit had been to
see the man two days before his death, but he had apparently refused to speak to
them. The visit was not logged in his medical record at the time.
The man’s wife was in the process of divorcing him. He was aware of the
proceedings but from telephone conversations with his friends he appeared to want
to re-establish their relationship. On 15 August 2008, the man received further
paperwork regarding his divorce. After he died, this paperwork was found in his cell
with the message ‘my death sentence’ written on it.
Staff to whom my investigators spoke were unaware of the man’s marital problems.
However, they were aware that he was consumed by his court case and maintained
his innocence. He was otherwise described as a private person. Nobody my
investigators spoke to had any indication that the man was suicidal, and his death
came as a shock to everyone.
The clinical reviewer also found that there should have been a better handover when
the man transferred prisons. The clinical reviewer believes that, because the follow
up at Parc was inadequate, his mental state might have deteriorated unnoticed.
However, she could not judge whether any admission, assessment and treatment, if
necessary in a secure unit, would have prevented the man taking his own life when
discharged back to prison.
1Rule 45 is a means by which vulnerable prisoners may be segregated from the mainstream.
Vulnerable prisoners include those at risk of harm from others because of the nature of their offence
or for other reasons.
4
INVESTIGATION PROCESS
1. My investigators requested all the relevant prison documentation including the
man’s medical and core prison records. My investigators also visited Parc to
interview staff and prisoners who had dealings with the man. One member of
healthcare who had assisted in attempts to resuscitate the man was on long
term sick absence when my investigators visited the prison and he has not
therefore been interviewed. The information regarding his involvement has
been taken from his ‘incident statement’ and the statements of other staff.
2. Notices to staff and prisoners were sent to the prison to be displayed. They
invited anybody with information to talk to my investigators. In this instance
only one person, other than those identified by my investigators, wished to be
interviewed. That person was another prisoner on Delta (D) wing who
sometimes played chess with the man. He wanted to tell my investigators
about the man’s research for his court case and the time he spent in the
library.
3. A clinical review into the man’s clinical care in prison was carried out by the
clinical reviewer for the Healthcare Inspectorate Wales. Additionally, my
investigator corresponded with the Specialist Registrar in Forensic Psychiatry
who carried was wrote a psychiatric report on the man for his court
proceedings.
4. HM Coroner for Bridgend and Glamorgan Valleys was informed of my
investigation. The Coroner will receive a copy of this report.
5. My Senior Family Liaison Officer has been in contact with the man’s
estranged wife and his father to offer them both the opportunity to be involved
in this investigation and to raise any concerns they might have. The man’s
wife has not raised any queries for my investigation. His father has asked
why prison staff did not read the letter from his solicitors enclosing paperwork
relating to his divorce and take some action to monitor him. I will endeavour
to address this question in my report.
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HMP PARC
6. Opened in 1997, HMP Parc, in Bridgend, is a category B male prison
managed by Group 4 Securicor (G4S). It is a modern building, constructed to
an American design. Parc holds up to 1,126 remand and convicted juveniles
and young offenders and sentenced adult males, and includes a unit for
vulnerable adult prisoners.
7. Healthcare services in Parc are provided under contract by Primecare
Forensic Medical Services (Primecare). There is 24 hour primary care and an
in-patient facility with 24 spaces. Clinical care is provided by doctors,
registered general nurses, and registered mental health nurses employed by
Primecare. Additionally, there are links with the local NHS Trust and other
medical staff who visit the prison to provide services (for example, a
psychiatrist, dentist and optician). There is also a mental health in-reach
team.
8. The last full inspection by Her Majesty’s Chief Inspector of Prisons was in
January 2006. Although the Chief Inspector found it to be a disappointing
inspection in many respects, she noted that the prison was moving forward
under a new Director and a clear management strategy. I do not go into the
details of the Chief Inspector’s’ report given the length of time since it was
issued. (The full report can be found on the Chief Inspector’s website.)
9. Since my own office took over responsibility for investigating all deaths in
prison custody in 2004, there have been 14 deaths at Parc. There were
seven natural cause deaths and two apparently self-inflicted prior to the man.
There have been four apparently natural cause deaths since.
10. In its report for the year 2007-08, the prison’s Independent Monitoring Board
wrote as follows with regard to safer custody:
“Members of the Board regularly attended Safer Custody meetings during
the current reporting period. Staff changes led, regrettably, to the late
cancellation of meetings, a cause of concern to the Board in view of the
crucial importance to prisoner welfare of these multi-disciplinary meetings
… There were no self-inflicted deaths during the reporting period. There
was one near-fatality, following which the Safer Custody team worked
successfully to reintegrate the prisoner with his hitherto estranged family.
The Samaritan trained Listener scheme continued to be widely used
throughout the prison …
“During the reporting period the ACCT (Assessment, Care in Custody and
Teamwork) scheme, fully implemented at Parc in the autumn of 2006, was
continuously updated. Staff worked increasingly confidently with what had
initially appeared an onerous scheme. ACCT folders were regularly
opened as a support mechanism for troubled prisoners; the folders were
managed by Wing officers and monitored by the Safer Custody Manager.
Board rota members regularly checked on ACCT folders, recoding entries
where they had concerns.”
6
KEY FINDINGS
11. The man was remanded to HMP Cardiff in February 2008. He made several
court appearances prior to this death. His trial was due to commence in
January 2009.
12. On 12 February, the escorting services officer at court completed a
suicide/self harm warning form, noting that the man appeared depressed and
had taken an overdose two years previously which he had told the officer was
“… a cry for help”. The officer’s observation was that the man appeared “very
calm and couldn’t care less attitude …” However, she noted that, if he was
convicted, the man might face a life sentence which could possibly lead him to
harm himself. It was also recorded that there were “family matters,” but there
is no further explanation regarding this.
13. A First Reception Health Screen was completed by a nurse. The man was
described as physically “fit and well”. It was noted that he had taken an
overdose of sleeping tablets 18 months previously (this differs slightly from
the court form). He had been prescribed anti-depressants (Citalopram)
between September 2006 and February 2007, but had stopped taking them
as he felt they did not help him. The nurse wrote in the medical record that
the man was “very focused on the details of his case [trial] and somewhat
detached. Little emotion expressed. Says he has lost everything.” The
nurse decided that the man needed a further mental health assessment and
he was referred to the doctor. A Cell Sharing Risk Assessment (CSRA) was
completed to determine the man’s suitability to share a cell with another
prisoner. He was found to be low risk of harm to others or himself at that
time, although his overdose attempt was noted. It was suggested that he be
regularly reviewed, particularly in relation to the nature of his alleged offence.
The man remained in healthcare to allow for a mental health assessment to
be carried out.
14. On 14 February, the man had a formal mental health assessment although
the records do not clearly show who undertook it. At the end of the
assessment, the assessor described the man as having:
“Bizarre presentation. Detached. Aloof. Intellectual. Attention to detail.
Totally preoccupied with finding out case of son’s death. A few tears at
end of interview. Described hopelessness / helplessness, despair.”
The assessor determined however that there was no evidence of a “major
affective2/psychotic disorder”.
15. The man remained in healthcare and was reviewed on several occasions. On
19 February 2008, he told healthcare staff that he had no suicidal thoughts
and had “everything to live for”, referring to his son and wife. Later that day
he was assessed as fit to be discharged to a residential wing. This did not
happen but the reasons are not recorded. Three days later a prison doctor
2Refers to a person’s mood.
7
reviewed the man and noted that he had “an odd affect [mood]” and “seems
preoccupied with the detail of case”.
16. The Specialist Registrar in Forensic Psychiatry employed by the Caswell
Clinic, interviewed the man on 6 March (although some paperwork shows this
to have been on 5 March) in the court cells. The Specialist Registrar found
that the man had no thoughts of self-harm or suicide, but was obsessed by
the details of his son’s death and might have been suffering from delusional
beliefs. It was the Specialist Registrar’s opinion that the man needed a full
and thorough assessment in appropriate conditions. A place at the Caswell
Clinic was applied for. The prison doctor reviewed the man again on 10
March, following a court appearance. She noted that she was still waiting for
his psychiatric report, and that the man was “emotionally detached”. The
prison doctor added in the medical notes that the man had told her he was
“coping well with his imprisonment physically and mentally – some low days”.
Again, it is documented that the man was preoccupied with proving his
innocence and maintaining contact with his surviving son.
17. During March, the man appears to have had problems accessing his
telephone credit and numbers. On 11 March, solicitors acting for the man’s
wife asked the prison to prevent all correspondence and telephone calls from
the man to his wife. The security department at Cardiff actioned this request
the following day (12 March). Also that day, the man was allegedly assaulted
by a nurse, but he did not report the incident until 14 March.
18. The man’s next court appearance was also on 14 March. On his return to the
prison he was interviewed in reception and applied for Rule 45. It is not clear
whether the man initially returned to healthcare or if he was seen by the
prison doctor in Reception, but when the prison doctor saw him on 14 March
he told her about the allegation of assault. He would not allow the prison
doctor to give him a full examination, only to observe the bruises on his arm.
The prison doctor noted in the medical record that the man would be moved
out of healthcare to the segregation unit as a vulnerable prisoner.
19. A governor at Cardiff went to talk to the man about the alleged assault. The
man had a bruise (approximately 4cm x 5 cm) on his upper right arm.
Photographs were taken to record it and the man was moved from healthcare
to the segregation unit under Rule 45. (Cardiff does not have properly
designated facilities for prisoners on Rule 45. Vulnerable prisoners are either
placed in the healthcare centre or the segregation unit. Neither area,
particularly the segregation unit, is suitable for long term residence for
someone segregated for their own protection.)
20. In the prison records, there is a partially completed interview log regarding the
alleged assault. The man completed the interview section and said that he
had been trying to discuss an ongoing query about his telephone credit with
the nurse. He alleged that the nurse had pushed him back from the cell
entrance and that he fell onto his bed, bruising his right arm. The man was
undecided about whether or not to report the incident to police and was going
to take advice from his legal team.
8
21. This appears to be the last action taken by any party in relation to the
allegation of assault. There is no recorded follow up and the forms were filed.
The forms did not accompany the man’s transfer to Parc, where they were
unaware of the allegation. My investigators asked the Deputy Governor at
Cardiff what the outcome of the allegation was. The Deputy Governor had not
been directly involved with the matter but had learnt that, because the man
had not pursued the matter within the prison, it was never dealt with. The
Deputy Governor also told my investigators that the nurse alleged to have
assaulted the man no longer works in the Prison Service.
22. The man remained in the segregation unit over the next three months. It is a
mandatory requirement for prisoners in segregation to be seen by a member
of healthcare every day. The man was seen by healthcare and was treated
for palpitations which were thought to be triggered by anxiety or stress. The
man also had three more reviews with the Specialist Registrar, but his
interaction appears to have lessened on each visit. The man was still waiting
for a place at the Caswell Clinic. Also during this period, although I do not
have a specific date, the man received notification that his wife was issuing
divorce proceedings.
23. On 1 June, the prison doctor saw the man but noted that he would not
communicate with her and appeared detached. She also noted that his
personal hygiene was poor and he did not undertake exercise. The
segregation daily notes also show little interaction with staff. Three days later
(4 June), a charge nurse from the Caswell Clinic visited to assess the man.
The nurse noted in the medical record that the man declined to be interviewed
until he had consulted his legal team. She also wrote that the man had told
her he was already supposed to be in the Caswell Clinic and that the
Specialist Registrar had told him “a pack of lies back in March saying he’d be
in Caswell by now…” At that point, the interview was terminated.
24. The residential governor in charge of the segregation unit compiled an update
for other staff of the situation in the unit and the prisoners on Rule 45. The
summary describes efforts being made by the OCA3 department at Cardiff to
move the man to HMP Parc. Staff at Cardiff believed, rightly, that it was not
appropriate for the man to remain in the segregation unit for a lengthy time.
He did not have a full activity regime and slept most of the day. However,
whilst Parc has a vulnerable prisoners unit, it is currently only for vulnerable
sex offenders. The man was not a sex offender and did not therefore meet
Parc’s criteria.
25. After some liaison, the Governor and Director4 of both prisons became
involved. The Director of Parc agreed to take the man until a more suitable
alternative could be found, as everyone was in agreement that a segregation
unit was not appropriate.
3OCA – Observation, Classification and Allocation. One of the functions of the department is to
arrange prisoner transfers where appropriate.
4In public prisons the head of the establishment is referred to as the Governor. In contracted prisons
they are referred to as the Director.
9
26. The man transferred to Parc on 13 June. Not all of the man’s paperwork
followed him, and (as noted above) Parc were unaware of the allegation of
assault by the nurse. Parc only completed a short medical ‘transfer in
checklist’ and, even though this checklist was completed by a Registered
Mental Health Nurse (RMN), the man’s history of mental health assessments
at Cardiff was not followed up. An entry in the medical notes on 13 June by
the RMN records that the man had “no physical or mental health problems”. It
also noted that the man said he had no substance misuse problems but
recorded his previous self-harm attempt. When asked about this attempt, the
man told the RMN that he currently felt fine. In interview, the RMN told my
investigators that he did not follow up any mental health referrals or
information because the man had been deemed ‘fit for transfer’. The RMN
was of the view that, if there had been any concerns by the previous
establishment, it would have been written in the medical record for a follow
up. He believed that ‘fit for transfer’ meant the previous establishment had no
concerns.
27. A Prison Custody Officer (PCO) was the man’s personal officer. (She has
since left G4S and has not been interviewed as part of my investigation.) The
PCO introduced herself to the man as his personal officer on 21 June. She
wrote in his wing history sheet that he appeared to have settled onto the unit
and was mixing well. Three days later, the personal officer made another
entry after a conversation with the man. She wrote that he had told her he
was coping well with the new routines, and had spoken openly about his
offence and the length of time he was facing on remand (his trial was
scheduled for January 2009). The personal officer added that the man had
told her he had no thoughts of suicide or self harm.
28. The man took employment in the workshop just over a week after arriving at
Parc. Shortly afterwards, the prison took on a contract for preparing canvas
straps which are used by supermarkets for pulling trolleys. It was the man’s
job to assemble them.
29. The Industries Instructor, a civilian member of staff, told my investigators that
the man was a good worker. He would reach his target for a day and then
enjoy some ‘down time’. The Industries Instructor explained that prisoners
who had completed their allocated work would occasionally do some
education homework or sit and speak to him. The Industries Instructor also
told my investigators that he sometimes saw the man with his head in his
hands, but he was unaware of any reason. The Industries Instructor said that
his “door was open” to prisoners if they wanted to talk about anything, and the
man was aware that he could do this if he so chose.
30. According to the local security strategy, prisoners should be searched when
leaving their place of work. My investigators asked the Industries Instructor
about the searching procedure in the workshop. Whilst the Industries
Instructor, as a civilian member of staff, is not responsible for carrying out the
searches, he said he was aware that the searching procedures in place prior
10
to the man’s death were not followed by officers. I am unable to determine
what action any staff or managers took to address this at the time.
31. On 5 July, the personal officer made an entry noting that the man was working
in the industries workshop and that he had told her he was “enjoying the
distraction from constantly being in his cell”. It was also noted that he
“continues to work hard gathering information for his court case in his spare
time”. Just over a week later, on 16 July, the personal officer recorded that
the man was receiving numerous legal visits and was to attend court the next
day. She wrote that the man had told her he was feeling confident that the
case would go in his favour and prove that he was not guilty of the shaken
baby syndrome or the neglect of his other son. The personal officer and the
man had two more similar conversations over the next three weeks. The
entries in the wing history sheet show that the man was spending a lot of time
preparing for his impending court case and that he now had medical
information which he believed would prove his innocence.
32. The last entry made by the personal officer in the man’s wing history sheet
was on 11 August. She wrote that there were no changes to note and no
concerns. The man had told his personal officer that he had no issues to
raise with her.
33. The telephone records show that the man telephoned a friend on 11 August.5
The conversation started by the man telling his friend that he was doing “not
too bad” and was keeping his strength up. He said he was having problems
with the Pinphones,6 and then went on to talk about wanting to fire his legal
team. Later in the call the records show that he was upset about not knowing
how his wife felt about him, and he wanted to “try and pick up his marriage
next year”. He then said that he had lost everything including his son, and
would probably emigrate and start a new life with a new family, but then spoke
about how he loved and missed his wife and would cry at night thinking about
her. His friend told him to remain positive and think of winning his court case.
She also tried to dissuade him from firing his legal team.
34. The following day (12 August), the man telephoned another friend. They
talked about the man’s upcoming trial in January 2009 and how he hoped to
get justice, presumably relating to some new evidence he had come across.
They also talked about the man’s son being returned to his wife (it appears
that there had been Social Services involvement between the man and his
wife and their surviving son), and how he took comfort in one of them getting
justice. His friend said he was waiting to find out when he could visit, and the
man replied that he could come whenever he wanted. He added that he
would get his friend’s address when they spoke again as he did not have a
pen with him. The man told his friend that he would write with dates and
times for a visit.
5Telephone conversations are digitally recorded and listened to either randomly or if intelligence
suggests they should be. There was no specific reason to monitor the man’s calls. After his death
the prison retrieved the digital recording and provided my investigator with a written summary.
6The telephone system used by prisoners.
11
35. Two staff from the Caswell Clinic visited the prison on 14 August to interview
the man. (The clinical reviewer has noted that the visit was not logged in the
medical record at the time). On the day that the man died, the RMN wrote a
retrospective entry to say that the nurses had attended but that he did not
know, at the time, if the man was actually seen. The clinical reviewer has
noted that, from information received from the Caswell Clinic, the man refused
to be interviewed by the nurses. The reason he gave was that he had been
told not to by his legal team.
36. A PCO on D wing remembers speaking to the man on Thursday 14 August
about access on his telephone account. He was unhappy because he had
been trying to get two friends’ numbers on his list since he was at Cardiff.
The PCO took the numbers to the security department to be checked, and
then to the Pinphone department to add them to the man’s Pinphone list. The
security form only shows one number but the man never used it. It might
have been that the man did not have sufficient credit on the Pinphone system
at the time he tried to make the calls.
37. The man did, however, manage to make a telephone call to his legal team on
the Thursday and Friday before his death (14 and 15 August). Legal calls are
not monitored, but my investigator spoke to the solicitor acting in the man’s
criminal case. She remembers that they spoke about an expert evidence
report from Australia in relation to immunisation jabs, which the solicitor
expected to receive the following week. The man asked his solicitor about
arranging a visit with him when she received the report.
38. Also on the Friday before his death, the man received a letter dated 13
August from the solicitor dealing with his family care proceedings. (This was
a solicitor from the same company as his criminal case solicitor.) Enclosed
with the letter was some court paperwork which his solicitor had received in
relation to the man’s divorce case. Although the family care proceedings
solicitor was not acting for him with regard to his divorce proceedings, he
thought it appropriate to enclose a court order which had been forwarded to
their office. The letter explained what the order meant, and that the solicitor
would be happy to discuss this issue with the man at their forthcoming
meeting (scheduled for 26 August).
39. Although the solicitor to whom my investigator spoke was not the one dealing
with his family care proceedings case, she was able to provide information.
The letter was not from her, but she said that the man’s divorce proceedings
were not a surprise to him, and he had been aware of them since earlier in the
year. The firm of solicitors did not therefore feel the need to raise any
concerns when forwarding to him the information that had been sent to them.
(Prison staff do not monitor any mail that arrives under legal privilege (Rule
43) and therefore they would not have read the solicitor’s letter.)
40. A menu choice was delivered to all prisoners that Friday (15 August) as usual.
The man completed his choice of meals for two weeks commencing 18
August. The menu list was found in his cell after his death.
12
41. That evening, the man declined to come out for association. The PCO, who
was on duty that evening, said at interview that prisoners are unlocked for
association at about 6.00pm when they can play cards or chess together or
just talk to one another or to staff. The PCO had unlocked the man for
association, but he said he did not want to come out and so his door was
locked again. She did not think that there was anything untoward when the
man did not want to come out because prisoners can choose whether or not
they want to be out for association. The PCO added that the man did not give
a reason why he did not want to come out. She said that, in hindsight and
following a conversation with other prisoners after the man’s death, he did
usually come out for association to play cards and chess and so it was out of
the ordinary that he chose to stay in his cell. Since the man’s death, my
investigators have had sight of a letter he left for his son. He wrote that he
was starting the letter at 6.30pm that night.
42. At approximately 7.45pm, prisoners on the wing were allowed showers or a
last game of pool etc before being locked up for the night. The prisoner in the
cell next to the man remembers speaking to him approximately ten minutes
before being locked up. They spoke about a television programme which was
on later that night. Everybody was then locked in their cells shortly after
8.00pm, and staff carried out a roll check. The PCO carried out the check for
the man’s landing. She remembers that his cell door was open and that he
was looking out of the window. The PCO thinks that she just said “Good
night”, but remembers that there was nothing that gave her any concern. That
was the last time she saw the man.
43. Two different PCOs came on duty at approximately 8.00pm. They were
detailed to work on D wing and C wing respectively. The two wings are
connected by interlocking doors. As part of their duties the officers would
check any prisoners on an ACCT7 form at the given intervals through the
night. There are no other mandatory requirements to check prisoners through
the night, but officers can use their discretion. For instance, if during the shift
handover the night officer is told that somebody has had an upsetting
telephone call they might check periodically through the night. My
investigators asked the D Wing PCO if he had any reason to check on the
man during his shift. The D Wing PCO could not recall any concerns being
reported to him that night.
44. Parc has an electronic printout of ACCT visit checks as well as a pegging
report.8 The printouts show that the D Wing PCO checked the six prisoners
who were on ACCT at the time, and pegged regularly throughout the night.
The records show that the PCO completed ACCT checks between 5.35am
and 5.42am as he started carrying out the morning roll check.
7Assessment, Care in Custody and Teamwork (ACCT). The Prison Service’s monitoring form and
process for supporting prisoners at risk of harming themselves.
8Pegging is an expression used by the Prison Service to describe a security procedure for accounting
that an area has been visited by an officer. The system records the date and time, and can be
monitored as necessary.
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45. At 5.43am, the PCO arrived at the man’s cell. At interview, the PCO said that
he opened the cell observation panel and saw the man. At first he thought the
man was standing or going to the toilet or basin. The PCO said that some
prisoners are awake at that time of the morning, getting washed or dressed.
As he was closing the panel he felt that something was not right. He looked
back into the cell and saw that the man was hanging from his toilet door. The
PCO pressed the personal alarm button on his prison radio. He also asked
the control room to open the cell door electronically.9
46. At the same time, the C Wing PCO had returned to C Wing to start his own
roll count. He had just entered the wing when he heard the personal alarm
call. He responded straightaway and asked the control room to open the
interlocking door for him (electronically).
47. A member of staff was designated Oscar 1 (the senior member of staff in
charge at night), and was in the healthcare centre as part of his rounds when
he heard the alarm. The centre is only a few yards from D Wing. A
Healthcare Nurse (HCN) and a Healthcare Assistant (HCA) were also on duty
in the centre. An additional PCO was working an extra shift, carrying out
constant observations on a prisoner on ACCT in the healthcare centre.
48. When the D Wing PCO pressed his personal alarm, Oscar 1, the additional
PCO and the HCN responded, the HCN taking an emergency equipment bag
(excluding the defibrillator) with him. The HCA had to remain in the
healthcare centre on standby because they could not leave healthcare
unstaffed especially with prisoners on ACCT. The staff then ran to D Wing,
asking the control room to electronically unlock the doors for quicker access.
49. As they entered the wing, the D and C Wing PCOs were already in the man’s
cell. They had lifted the man to take his weight off the ligature. The additional
PCO entered shortly behind them and cut the ligature, which was attached to
a hinge on the toilet door, with his fishknife.10 The ligature was one of the
canvas straps prepared in the workshops. The officers then lay the man on
the floor. The staff could not detect a pulse and so the HCN and the D Wing
PCO began cardiopulmonary resuscitation (CPR). The additional PCO was
sent back to healthcare so that the HCA could collect the defibrillator. He
arrived and took over the D Wing PCO’s role in the resuscitation attempts.
Whilst all this was happening, Oscar 1 asked the control room to call an
ambulance. The defibrillator, which can restart the heart if it detects a
shockable rhythm, was applied. It did not advise any shocks and so CPR was
continued.
50. The ambulance arrived at 6.00am (although this entry is written
retrospectively in the control room ledger). Paramedics attempted
resuscitation but were unsuccessful. The prison doctor arrived and
pronounced the man dead at 7.15am. A member of the chaplaincy team went
to the man’s cell and said prayers for him. Oscar 1 arranged for the prisoner
9In Parc, the cell doors and wing gates can be operated electronically.
10 Also referred to as a ‘cut down’ or ‘anti-ligature’ knife. It is a knife designed make the cutting of a
ligature easier.
14
in the cell next door to be moved and for the area to be sealed off to provide
privacy and decency.
Events after the man’s death
51. The staff involved in responding to the man’s cell, with the exception of Oscar
1 who remained on the wing, attended a debrief. (A debrief gives staff the
opportunity to talk through an incident or traumatic event.) All staff were
offered support by the care and welfare team should they wish.
52. The Houseblock Manager had arrived at the prison soon after the man was
found. She unlocked some Listeners11 and went round to all prisoners to
explain what had happened. A death in custody can be a vulnerable time for
other prisoners. I acknowledge the efforts of the Houseblock Manager who
ensured that all prisoners were informed of the man’s death and were given
the opportunity to speak to a Listener.
53. The PCO who had been on duty during association the previous evening,
came on duty later that morning and was told that there had been a death in
custody. She initially assumed it was one of the older prisoners. She said in
interview that, when she discovered it was the man, she was shocked and
frustrated that she had not asked him if everything was alright the night
before. However, there had been no indication that anything was wrong.
54. A prisoner on D Wing, asked to speak to my investigators. The prisoner
sometimes played chess with the man and also used to see him in the library.
The prisoner wanted to give my investigators some background information
about the man. He said that the man would regularly play cards and chess
and that he was very good with numbers (in relation to the games). The
prisoner said that the man would also regularly visit the library, and it would
sometimes be difficult to persuade him to leave when the allocated time of 45
minutes was over.
55. The man was researching prescription drug compositions and spoke about
‘medical negligence’. The prisoner said that the man was a very secretive
person but that it was known he was carrying out research with regard to his
court case. The prisoner said that, approximately a fortnight before his death,
it had been a particular struggle to get the man out of the library. One of the
books he was looking at was a reference book so he could not remove it and
the photocopier was not working. The man had also told the prisoner that “it
was all over” and that he was going to sack his legal team and represent
himself. He had apparently had an argument with his legal team.
56. According to the prisoner, approximately a week before his death the man
was not concentrating on his card games. The prisoner said that other
prisoners also noticed that he was not playing cards as well as usual. The
prisoner told my investigators that this was the only noticeable change. He
11 Like most jails, Parc has a Listener Scheme under which the Samaritans train selected prisoners to
be the first contact for any prisoner who is feeling vulnerable and at risk.
15
did not think that the man looked depressed or different in any way. When my
investigators asked the prisoner how he felt about the man’s death he said:
“He gave no indication, he didn’t look depressed or in need. You do find
on this wing a lot of the guys look out for each other, if somebody starts
sitting on their own we’d go up and have a talk with them and find out you
know what’s, you know what’s going on or are you okay? We’ve got the
Listeners, they are pretty keen as well and the staff. The staff are pretty
good at noticing somebody going off on their own or they start getting
depressed, you know they jump on that straightaway. When I did find out
in the morning there was an incident I was guessing about other people
…”
57. My investigators asked to speak to other prisoners who knew the man and
those who had cells close by. Only one other prisoner agreed to give
information. The second prisoner was in the cell next to the man. The
second prisoner remembered seeing the man earlier in the day on Friday 15
August. He said that the man was “down” because of his Pinphone problems.
The second prisoner then spoke about seeing the man about ten minutes
before the night lock up. He said that they had spoken about the television
programme, Big Brother, which was on that evening. The second prisoner
said that the man was generally not a happy person, but he did not notice
anything different that night.
58. The second prisoner said that he was aware that the man had marital
problems and knew that he had received a letter. He did not see the letter,
but the man had shown him the envelope. The second prisoner told my
investigators that, if he had thought the man was depressed, he would have
alerted staff. He added that when staff found the man they tried hard to revive
him. He had heard the paramedics through the door asking how long staff
had been attempting resuscitation. He had heard them say “16 minutes”. He
also told how the Houseblock Manager had informed everybody what had
happened and why there were delays unlocking the other prisoners out for
breakfast.
59. After the man’s death, the court paperwork regarding his divorce was found
with the words “my death sentence” written across it. Also found was the
letter the man had written to his second child. The police took possession of
the documents when they attended the prison following the man’s death. In
the letter, the man asked for forgiveness if he was emotional because “these
are the last moments of my life as I have gone through so much pain,
heartache and persecution over the last 3½ years since the loss of your
brother…” He told his son why he was in prison but that it was all a “lie” and
he had proof of his innocence, going on to explain the medical evidence he
felt he had. He added:
“I know that if and when I die I know how my son and your brother died
and I can have a clear conscience because after all this time I finally have
the truth … unfortunately the truth has come too late for me as I am in too
much pain to go on with this harrowing nightmare as today I received the
16
divorce papers by letter from my solicitor who in turn got them from your
mother so today is judgement day for me by my hand…”
The rest of the letter talks about his son’s future, with the man wondering what
he will do with his life. He told his son that he and his brother were the most
special gifts in his life, but that he did not have the mental strength to go on.
60. The man’s father has expressed concern that nobody read the solicitor’s letter
and thus was unable to ensure his son was monitored. As I have explained in
my report, any legal mail that is marked as Rule 43 and any legal telephone
calls are not permitted to be monitored by prison staff. This is an essential
safeguard that guarantees prisoners’ access to legal advice and support.
However, it may mean that information relevant to risk of suicide or self-harm
is not known. The man’s solicitors said that he was aware of the divorce
proceedings, and that they did not consider there was any need to alert the
prison of the documentation being sent to him.
17
ISSUES CONSIDERED
Clinical Care
61. The prison doctor reviewed the man in HMP Cardiff on 1 June. She noted
that he appeared detached and would not interact with her or other staff. The
prison doctor wrote that the man had poor personal hygiene and was
declining exercise. The clinical reviewer has commented that, with hindsight,
the man might have been suffering from a depressive illness. However, the
man had been seen by the Specialist Registrar on a number of occasions and
the clinical reviewer has concluded that the man might not have been
suffering from a treatable psychiatric illness. The full assessment had not
been carried out as recommended by the Specialist Registrar in March 2008,
so a firm diagnosis cannot be made.
62. The clinical reviewer says it is surprising that a prisoner who was regularly
seen by psychiatric staff at Cardiff was assessed as having “no physical or
mental health problems” on transfer to Parc on 13 June 2008. She believes
that there should have been a more comprehensive handover from Cardiff to
Parc. Once the man transferred to Parc, he was not seen by the Specialist
Registrar again. When staff from the Caswell Clinic came to see him two
days before his death, he is reported to have declined to speak to them. The
clinical reviewer has noted that any deterioration in the man’s mood might
have gone unnoticed in the two months he was at Parc. The medical record
only shows two occasions when the man was seen by the healthcare team at
Parc. These were on 16 and 17 July and were in relation to his fitness for a
court appearance and return from court.
63. I have already commented that the RMN did not believe there were any
concerns regarding the man’s health because he had been assessed as “fit
for transfer”. The RMN believed that, if the Caswell Clinic were working with
the man, they would be in touch with staff at Parc. It is of concern that
healthcare staff accepts ‘fit for transfer’ as meaning there are no medical
issues. ‘Fit for transfer’ simply means that a prisoner is able to undertake a
move to another prison and the journey, in the same way s/he might be fit to
attend court.
The Head of Healthcare at Parc should ensure that healthcare staff are
aware of the meaning of ‘fit to transfer’ and that staff do not use this as
a reason not to check historical entries.
64. Reviewing the man’s medical record and noting the comments of the clinical
reviewer, I am concerned that full information was not clearly handed over to
Parc. However, I am also concerned that the man’s medical notes were not
fully reviewed by healthcare staff at Parc. If they had been, it would have
been clear that there were ongoing assessments, and outstanding
appointments, to determine the man’s mental health state. Additionally, had
wing staff been made aware of this, they might have monitored the man more
closely.
18
The Head of Healthcare at Cardiff should ensure that proper written
handovers are given to any receiving prison especially when a prisoner
has ongoing medical issues.
The Head of Healthcare at Parc should remind staff to review a
prisoner’s medical record on reception or within 24 hours if no handover
is given from the sending prison.
65. At the time of his death, the man was still waiting for admission to a medium
secure unit for an assessment of his mental health. The Caswell Clinic is the
only NHS medium secure unit in South Wales. The man was on a waiting list
but a space had not become available. The services provided by the Caswell
Clinic are for tertiary assessments for those who are likely to transfer to a
secure unit, and the clinic is not contracted to provide day-to-day psychiatric
care to prisoners. That said, the staff at the Caswell Clinic made efforts to
support the man when he was at Cardiff but he would not co-operate fully with
them. The clinical reviewer is unable to judge whether or not the man would
still have taken his life had he been admitted, assessed, and treated if
necessary.
66. There were no records made when staff from the Caswell Clinic visited the
man on 14 August. After the man’s death, the RMN was asked to make a
note of the visit. This was inappropriate and an entry should have been made
either by the Caswell Clinic staff or by a member of healthcare on the day.
The Head of Healthcare at Parc should ensure that any medical contact
made with a prisoner, either by internal or external staff, is recorded in
his medical notes according to best practice guidelines. This should be
audited regularly.
Searching prisoners as they leave work areas
67. When leaving their place of work, prisoners should be searched according to
the local security strategy. The risk assessment for the workshop which was
in place at the time of the man’s death instructed that all prisoners leaving the
workshop should have a hand held metal detector search and a rub down
search. (This is carried out by placing hands on the prisoners’ clothing and
then moving the hands across the material to check for concealed items). My
investigators were told that the searching policy was not being carried out
properly in the workshop prior to the man’s death. This meant that he was
easily able to take the canvas strap from the workshop back to his cell.
68. Given the type of strap, I am aware that, even if searching had taken place
properly, there is the possibility it could still have been removed from the
workshop. I am also mindful that there are other materials which could be
used as ligatures which are readily available in cells (for example, bedsheets,
clothing or shoelaces).
69. However, my investigators found that the risk assessment for materials in the
workshop was out of date and inadequate. I have been pleased to learn that,
19
since the man’s death, searching procedures in the workshop are being
implemented properly. However, I highlight the point to the Director so that
she can satisfy herself that the searching and risk assessments across the
prison are adequate.
The Director should satisfy herself that the establishment complies with
its local security strategy in relation to activity exit searching and that all
activity risk assessments are updated when the operation of an activity
area changes.
Emergency Response
70. Director’s order 1.196.2006 outlines the codewords for events requiring
emergency response from healthcare. It states, “… it is the responsibility of
the officer at the scene to decide which code the medical assistance is and to
inform the Control Room accordingly.” The order goes on to describe the
codes as:
(cid:127) “Code red
This is a major event, which requires IMMEDIATE nurse response and
the examples of this could be: -
(cid:1) A loss of consciousness (by any means)
(cid:1) Hanging
(cid:1) Collapse
(cid:1) Serious self harm
(cid:127) Code blue
A nurse is required urgently and the prisoner is too ill to walk to
Healthcare”.
71. The prison’s death in custody contingency plan slightly contradicts the order
and states that the personal alarm could be used. The code system requires
the member of staff to talk over the radio to raise the alarm, hence being able
to say what is required. The personal alarm is a button which is pressed on
the radio to alert other staff that there is a problem, but which gives no
indication of what it is for - a fight between prisoners or with staff or a medical
emergency, for example.
72. The second PCO pressed his personal alarm when he discovered the man
hanging. By doing so, other staff knew to respond quickly but did not know
what they were responding to (although, due to the time, several staff had
guessed). However, the proximity of staff when help was summoned on this
occasion was largely down to chance. In the event of a similar situation, staff
might not be as nearby and would take longer to respond, losing precious
minutes trying to obtain the right equipment.
73. Although the code system was not applied, I make no criticism of the second
PCO who responded quickly and helped with resuscitation attempts. Indeed,
the efforts by staff responding to the man should be commended.
20
The Director should ensure that the instructions in all emergency
response documents and control room procedures are consistent, and
that staff are aware of the correct procedures.
74. During interviews it became clear that not all staff were aware of the
requirement to replace the blade in the fishknife if it has been used. Staff on
night duties also have difficulty replenishing their first aid kit because the
supplies are kept by staff working on day shifts.
The Director should ensure that all staff are aware of the need to replace
emergency equipment and that there is an easy way to do this.
Conclusion
75. Whenever a person takes his or her own life in prison, my investigators will
check if they were on an ACCT and if not what the reasons were. From the
documentation and interviews, it is clear that nobody was aware of the man’s
thoughts and feelings and more specifically that he was intending to take his
own life. My investigators found that there were six prisoners on open ACCTs
on D Wing the night the man died. I believe that had the man approached
staff, or if staff had had concerns over his welfare, he would also have been
placed on an ACCT.
76. Intra-familial violence is an acknowledged risk factor for suicide. Family
breakdown is another. Previous self-harm is another. However, given that
the man had been in custody for six months and that he had given neither
staff nor fellow prisoners any particular reason for concern, I do not believe
his death could reasonably have been predicted.
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RECOMMENDATIONS
HMP Cardiff
1. The Head of Healthcare at Cardiff should ensure that proper written
handovers are given to any receiving prison especially when a prisoner has
ongoing medical issues.
A response to this recommendation is still to follow.
HMP Parc
2. The Head of Healthcare at Parc should ensure that healthcare staff are aware
of the meaning of ‘fit to transfer’ and that staff do not use this as a reason not
to check historical entries.
This recommendation has been accepted.
3. The Head of Healthcare at Parc should remind staff to review a prisoner’s
medical record on reception or within 24 hours if no handover is given from
the sending prison.
This recommendation has been accepted.
4. The Head of Healthcare at Parc should ensure that any medical contact made
with a prisoner, either by internal or external staff, is recorded in his medical
notes according to best practice guidelines. This should be audited regularly.
This recommendation has been accepted.
5. The Director should satisfy herself that the establishment complies with its
local security strategy in relation to activity exit searching and that all activity
risk assessments are updated when the operation of an activity area changes.
This recommendation has been accepted.
6. The Director should ensure that the instructions in all emergency response
documents and control room procedures are consistent and that staff are
aware of the correct procedures.
This recommendation has been accepted.
7. The Director should ensure that all staff are aware of the need to replace
emergency equipment and that there is an easy way to do this.
This recommendation has been accepted.
Good Practice
The third PCO said that, when patrolling the landings, he checks anything which
may be out of the ordinary, for example lights on after a certain hour. Although it
is not a mandatory requirement, it is good practice which should be shared with
other staff.
This has been noted and the good practice shared.
22