Individual at Isleworth Crown Court

Investigation into the death of a man in hospital
following an appearance at Crown Court
in June 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2008
This is the report of an investigation into the circumstances surrounding the death of
a man who died in hospital after taking an overdose of anti-histamine tablets in the
dock at a Crown Court. He was 40 years old and had been on bail. He was
attending a re-trial on 28 June 2007 on charges of cruelty and grievous bodily harm
committed in 2002.
The investigation was led by one of my investigators. My senior family liaison officer
contacted the man’s cousin and she and my investigator visited her. I offer her, and
all those affected by his death, my sincere condolences.
The circumstances of this case are highly unusual, and may indeed be unique. I
have only investigated one previous death at a Crown Court, and I believe that the
manner in which the man took his own life may be without precedent among deaths
in custody in the UK. These highly unusual circumstances mean that my
investigation has a necessarily narrow focus. He was in the custody of the court
escort services for less than two hours between being found guilty and being
pronounced dead.
I am grateful to the Senior Investigations Officer for SERCO Home Affairs for sight of
his report into the man’s death. I am also grateful to the Metropolitan Police for sight
of the witness statements gathered as part of the police investigation.
This is a very sad story. I conclude that the man’s death could not reasonably have
been foreseen by the court escort and custody services. I make two formal
recommendations designed to improve guidance to staff. I have also suggested that
there might be benefits if the lessons from this report were to be shared more widely
amongst court administrators.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2008
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CONTENTS
Summary
The investigation process
The events leading up to the man’s death
Issues considered during the investigation
Conclusion and Recommendations
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SUMMARY
The man suffered from epilepsy and autistic spectrum disorder. In 2004, he was
found guilty of cruelty and grievous bodily harm to his three month old daughter and
sentenced to five years in prison. He was released on appeal in December 2006
pending a re-trial. During his time in prison he said that he was badly bullied and
told his family on numerous occasions that he would rather die than return to jail.
The man’s re-trial began on 5 June 2007. The Tamil interpreter employed by the
court to translate for him during his trial, said that part way through the proceedings
the man had told him that he had 200 tablets which he intended to take if he were
found guilty. The interpreter said he did not believe that the man meant what he
said.
Immediately after the jury returned a verdict of guilty at about 4.30pm on 28 June
2007, the interpreter said he saw the man add a powdered substance to a bottle of
clear liquid which he had with him in the dock. He then drank some of the liquid
before the dock officer removed the bottle from him.
Counsel for the defence told the judge that the man appeared to have drunk
something that he should not have and the judge directed that a doctor should be
called immediately. He was taken to the custody area and an ambulance was called
at 4.40pm. He refused to say what substance he had taken and said that he wanted
to die.
Paramedics arrived at 4.50pm. The man was handcuffed, escorted to the
ambulance and taken to the local hospital. At the hospital he had a number of fits
and went into cardiac arrest. He was pronounced dead at 6.14pm. A post mortem
and toxicology report showed he had died from an overdose of anti-histamine.
I conclude that the manner of the man’s death could not have been reasonably
foreseen by any of the employees of the court escort and custody service. I also
conclude that the circumstances are extremely unlikely to occur again. I make a
local recommendation to amend Director’s Rule 15.5 to give advice to staff at the
Crown Court about what prisoners off bail should be allowed to take into the dock. I
make a national recommendation that guidance is issued to all court escort staff on
their responsibilities to prisoners who refuse emergency medical treatment.
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THE INVESTIGATION PROCESS
1. I was notified of the man’s death on 29 June 2007. After some discussion it was
decided that the case was within my remit to investigate and I appointed one of
my investigators. She obtained further information from the court escort services
contract manager for the Crown Court.
2. My investigator also contacted the senior investigations officer for SERCO (the
company who provide escort services at the Crown Court), and obtained a copy
of his report into the man’s death. She spoke to the deputy court manager at the
Crown Court to explain that an investigation would be taking place. My
investigator spoke at length with a Detective Inspector from the police and he
agreed to provide her with copies of the witness statements taken during the
police investigation. She spoke to the contract compliance manager for the
Crown Court and obtained a copy of the Director’s Rules for prisoners appearing
off bail (the rules by which court escort staff operate). My investigator remained
in regular contact with the Coroner’s Officer throughout the investigation.
3. My senior family liaison officer wrote to the family offering them the opportunity to
be involved in my investigation. The man’s cousin contacted my senior family
liaison officer to say that she would like to be involved in our investigation. My
senior family liaison officer and investigator visited her to explain the nature and
purpose of the investigation and to hear her particular concerns.
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THE EVENTS LEADING UP TO THE MAN’S DEATH
4. On 29 April 2004, the man was convicted of cruelty and grievous bodily harm
and sentenced to five years in prison. He lodged an appeal against his
conviction and was released in December 2006 pending a re-trial. During his
time in prison he regularly complained to his family that he was the victim of
bullying. He expressed a desire to end his life on many occasions and said that
he was only awaiting the outcome of his appeal before doing so.
5. A psychology report prepared for the Crown Prosecution Service in June 2006 as
part of the appeal process said:
“Should [the man’s] [sic] appeal be rejected, consideration should be made
regarding the appropriateness of his disposal to prison. In my view he is
inappropriately placed in prison due to his psychological and practical needs
relating to ASD. He will continue to remain extremely vulnerable to bullying
and exploitation from others in prison and his risk of suicide is, and will
continue to be, high.”
6. The man’s re-trial started on 5 June 2007. The court security officer who was
responsible for searching people’s bags as they entered the court building said
that he remembered the man asking him on 24 June whether he would be
searched if he left the court building and came back in. The court security officer
said he told him that he would be searched on each occasion that he entered the
court building.
7. A Tamil interpreter employed by the court to translate for the man said that part
of the way through his trial the man had told him that he had 200 tablets, which
he intended to take if he was found guilty. He told the interpreter that, if the
judge told him to go home to get his belongings to prepare for prison, he would
take the tablets. The interpreter said that he thought that this statement was
“part of his autism”.
8. The interpreter said that, on 28 June 2007, the jury retired to consider their
verdict at about 1.20pm. He said he, the man and his solicitors waited in the
court waiting room. At about 2.00pm, the man told him again that he would take
the tablets if the verdict went against him. At about 4.20pm, they were called
back into the court and the jury returned a verdict of guilty. The interpreter said
that he was sitting on his right-hand side and noticed that he had a Coca-Cola
bottle half filled with a clear liquid. The interpreter said this was not unusual as
the man had brought one with him every day of the trial. He said he saw him
produce a powdered substance from a bag and add it to the liquid in the bottle.
He then began to shake the bottle. The interpreter said he presumed from what
the man had said previously that the substance was tablets in a powdered form.
He tried to pull his hand away to prevent him from adding more powder to the
bottle and tried to get the attention of the dock officer using sign language. The
interpreter said he did not get any response from the dock officer. He said the
man then started drinking from the bottle. He tried to grab his right hand to stop
him and screamed “Stop it.”
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9. The interpreter said the dock officer then came over and between them they
managed to remove the bottle from the man. The interpreter said he managed to
convey to the defence team what had happened and they told the judge. The
judge requested probation reports and advised the court officers that the man
should be seen by a doctor.
10. The dock officer for the week commencing 25 June 2007 said that prisoners who
appear in court off bail and their bags are searched before they enter the court.
He said that, on 28 June 2007, he looked into the man’s bag before he first
entered the dock and saw papers, a photograph and a bottle containing clear
liquid. The dock officer said he asked the interpreter to tell the man not to take
the bottle out of the bag. He said the judge summed the case up and sent the
jury out to consider their verdict. At about 4.25pm, he was told that the jury had
returned. He returned to the court and again looked into the man’s bag before
he entered the dock. He said he saw the same contents in the bag as he had
seen that morning.
11. The dock officer said that after the judge returned to the court, the junior defence
barrister approached the dock and asked the man how long he had spent in
prison. He said he appeared agitated and upset. After the verdict was given, the
man slumped in his seat and looked depressed. The defence barrister began to
tell the judge what the man’s original sentence had been and at this point the
dock officer heard the interpreter say, “You can’t drink that!” The dock officer
said he looked up and saw the man drinking as quickly as possible from his
bottle. He said he “rushed” over and grabbed the bottle from him and put it on
the floor near his seat. He heard the defence counsel tell the judge that the man
appeared to have drunk something he should not have. The judge remanded
him into custody pending reports, and asked the dock officer to make sure that
he saw a doctor immediately. The dock officer took the man to the cells and an
ambulance was called. He then returned to the court to retrieve the bottle. As
he got back to the custody area the ambulance crew arrived.
12. The SERCO court manager said that he was in the custody area when the dock
officer returned with the man from the court. He said the dock officer told him
that the judge had said that the man should see a doctor because he might have
swallowed something he should not have. The SERCO court manager said he
asked for an ambulance to be called. The entry in the occurrence book showed
that this was at 4.40pm. The SERCO court manager said that the man appeared
steady on his feet and was able to walk. The SERCO court manager began
making plans for a hospital bedwatch and contacted court security to warn them
of the imminent arrival of an ambulance. He said the man appeared placid and
calm. A barrister brought the bottle to the custody area and told the SERCO
court manager that it was the one the man had drunk from. The SERCO court
manager said that it was about a third full with a cloudy liquid. He said the man
appeared slightly restless and he heard him say, “I want to die. I don’t want to go
to hospital. I want to kill myself.”
13. The SERCO court manager said the ambulance arrived and the man’s barrister
tried to persuade him to go to hospital. He again heard him say, “I don’t want to
go to hospital. I want to die.” The SERCO court manager said that his first
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response was that the man was in custody and he had to go to hospital. He tried
to confirm this with his supervisor but she was unsure of the exact position. He
said the ambulance crew told him that they could not force the man to accept
treatment. The SERCO court manager said that he impressed upon them that
the man had to go to hospital and two prisoner custody officers guided him to the
ambulance. He said he did not resist.
14. A prisoner custody officer said she was sitting at the desk in the custody area
when the man was brought down from the court. She said she asked him what
he had drunk and he said he would not tell her. She asked him to empty his
pockets and noticed a plastic bag containing a blue box of ‘Sleepeasy’ tablets.
She asked him if he had taken any of the tablets and he again replied that he
would not tell her. The prison custody officer said she heard the man say, “I
want to die.” She said he seemed agitated and would not stand still. She said
he refused medical assistance. She noticed his legs begin to give way and two
officers supported him under the arms. He was then handcuffed to one of the
officers and led into the ambulance.
15. A paramedic arrived at the court at 4.50pm. He said that he was met by a
security guard who told him that the man had swallowed some liquid and showed
him some milky fluid in a bottle. He said the man was alert and walking about
the room. He said the man told him that he did not want any treatment. A man
dressed in robes and a wig then said to the paramedic, “You’ve got to take him.”
The paramedic said he explained that he had no powers to force the man to
receive treatment. He said a debate ensued and eventually the security guards
handcuffed the man and took him to the ambulance.
16. The paramedic said that when he got into the ambulance the man vomited twice.
His heart was found to be beating very fast and a priority call was put through to
the hospital. The ambulance arrived at the local hospital at 5.11pm. They were
met by a doctor and taken directly to the resuscitation room. By this time he was
having seizures. He was pronounced dead at 6.14pm.
17. A post-mortem examination and toxicology report showed that the man had died
as a result of consuming a fatal dose of anti-histamine.
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ISSUES CONSIDERED
The man’s risk
18. Ordinarily persons who have been remanded into custody are taken to the
custody area of the court and pages one and two of form F2050F (Prison Service
Record) are completed. At this point a Prisoner Escort Record (PER) is also
completed. The prisoner is assessed and one of the questions addressed is
whether they pose a risk of self-harm or suicide. In this case I would have
expected the man to have been deemed a high risk of self-harm or suicide but
the risk assessment process was overtaken by events. I do not consider that
these events could have been foreseen by anyone other than the interpreter
(who had been told by the man on more than one occasion, the most recent at
2.00pm that afternoon, that he had tablets and intended to take them if he were
found guilty).
19. The interpreter had vital information that he shared with no one and about which
he made his own judgement. He is not employed by the court escort and
custody service and I am unable to make any recommendations in his regard.
The court may wish to consider whether interpreters need further guidance on
what to do when they receive such information from defendants.
Did the dock officer respond appropriately?
20. The dock officer said in his statement that, on the morning of 28 June, he warned
the man not to take his bottle out of his bag after he had done so once. One of
his duties as dock officer is to make sure that the person in the dock does not do
anything untoward to himself or others. The man sat in the front row of seats in
the dock next to a wall, with the interpreter on his other side. The dock officer
was stationed in a row of seats behind him and to the side. It is clear that in a
very short space of time, the man removed the bottle from his bag, put powder in
it and began drinking from it. At the same time the dock officer was making a
phone call to the SERCO court manager and there was a certain amount of
activity in the room. I believe there was enough to distract the dock officer
legitimately from his duty to observe the prisoner in the dock and make sure
nothing untoward happened. It seems clear that as soon as the dock officer
became aware that the man was drinking from his bottle he reacted quickly (and
to greater effect than the interpreter, who was sitting next to him and watched
him put the powder in the bottle).
21. I do not take issue with the dock officer decision to allow the man to take the
bottle into the dock or with the search process. He had no reason to believe that
the man presented a risk to himself and I do not believe it can have been
reasonably foreseen that he would take an overdose while still in the dock.
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The response of the court escort and custody service staff
22. Once it had been established that the man had consumed something he should
not have done, the judge directed that a doctor should be called immediately.
The SERCO court manager took the decision to call an ambulance because it
would be quicker than calling a doctor. The paramedics were at the court within
about 20 minutes of the man having drunk from the bottle and 10 minutes after
being called. I consider that the court manager was absolutely right to call an
ambulance and the response of the court escort and custody service staff was
appropriate.
23. The circumstances of the man’s death were extremely unusual, but the issue of a
prisoner refusing medical treatment in an emergency is one that may arise again.
In this case, I believe that the staff acted in his best interests and according to
the duty of care they have towards those in their custody. Nevertheless, I
believe they would benefit from clear guidance about their role and
responsibilities in such situations because prompt treatment is crucial to
preserving life in a medical emergency.
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CONCLUSION AND RECOMMENDATIONS
24. The man’s experience of prison seems to have left him with a dread of returning
there and a determination not to do so at whatever cost. Although he appears to
have formed a clear plan to take an overdose if found guilty, I do not believe his
death could reasonably have been foreseen by any member of the court escort
and custody service.
25. I believe the manner of the man’s death – an overdose taken in the dock – may
have been unique among deaths in custody in England and Wales and may
never be repeated. Nevertheless I believe it would be sensible for guidance to be
given to staff about what they can allow defendants off bail to take with them into
the dock. The current Director’s Rule (number 15.5) does not appear to cover
this question. Given that water is available to defendants if they ask for it, it may
be sensible to prevent them from taking unsealed bottles into the dock with them.
I recommend that the contract manager for the Crown Court amends
Director’s Rule 15.5 to include advice on what prisoners off bail may take
with them into the dock. This should include a consideration of whether
prisoners should be allowed to take only unsealed bottles into the dock.
This recommendation was accepted by the Prisoner Escort and Custody
Services (PECS) at draft report stage. They said:
“It is considered that on this occasion that stopping the man taking a
bottle of liquid into the dock may not have prevented him taking an
overdose. PECS will issue a notice to all escort contractors that any
liquid refreshment sealed or not will not be allowed in the possession of
the prisoner. If liquid refreshment is required then this will be provided
by the court.”
26. I also believe it would be sensible for all court escort staff to have guidance on
their responsibilities to prisoners who refuse emergency medical treatment.
I recommend that the Head of the Prisoner Escort and Custody Services
(PECS) directs all his contract managers to inform the relevant
contractors to issue guidance to staff on their responsibilities to
prisoners who refuse emergency medical treatment.
This recommendation was partially accepted by PECS at draft stage. They
said:
“Escort contractors will seek medical assistance in all cases where it is
thought necessary or requested by a prisoner, including the calling of
the emergency services. In this case the emergency services were
called and the prisoner continued to refuse medical assistance and on
this basis the paramedics were unable to try and treat him. However,
the escort contractor was able to persuade the prisoner to eventually
go to hospital. Further guidance is being sought from the Dept of
Health to establish what else may be done under these
circumstances.”
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27. The Head of the Prisoner Escort and Custody Services may also wish to consider
if copies of this report should be sent to all senior court administrators. Given the
highly unusual nature of the circumstances described in this report, I make no
formal recommendation to this effect. Nevertheless, I think that there is some
important learning that it would be beneficial to share.
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