Individual at Pentonville

Investigation into the circumstances surrounding the
death of a man at HMP Pentonville
in March 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2009
This is a report into the death of a man at HMP Pentonville in March 2008. A
sentenced prisoner awaiting trial on a further charge, he was found hanging in his
cell around 5.15am. He was 24 years old. The man was held in custody under
another name and claimed to be an American citizen. Only after his death was his
real identity discovered along with the fact that he was a Ghanaian national.
I offer my sincere condolences to the man’s family and friends for their loss. The
death of a loved one in these circumstances, so far away from home, must add to
their sorrow. I regret the delay in issuing my report and the additional distress that
this may have caused.
The investigation was led by my one of my investigators. He was assisted by an
Assistant Ombudsman. I thank the local Primary Care Trust for appointing an
independent clinical reviewer. I am also grateful to the Governor and staff of HMP
Pentonville, especially the Governor whose assistance was a great help to my
investigators. My Senior Family Liaison Officer liaised with the man’s fiancée
throughout the investigation.
The man’s immigration status and his false identity seem to be at the heart of this
tragic story. However, while I am critical of aspects of the ACCT process at
Pentonville, I do not believe that the staff charged with his care could reasonably
have predicted his actions.
I make eight recommendations and one commendation.
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 CBE
Prisons and Probation Ombudsman December 2009
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CONTENTS
Summary
The Investigation Process
HMP Pentonville
Key Findings
Issues raised in the investigation
Recommendations
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SUMMARY
The man was first detained under immigration powers on 26 August 2007, having
arrived at Holyhead in North Wales from the Republic of Ireland. He was carrying a
United States passport with a forged bio data page in another name. He was
detained and eventually sentenced in this name, and maintained throughout that it
was his true identity and that he was a United States citizen. His fiancée told my
team that she knew him by the same name and nationality. It was only after his
death that his true identity and nationality as a Ghanaian citizen were established.
He appeared in court on 27 August, charged with possession of a false passport,
and was remanded into custody at HMP Liverpool. He was assessed by reception
staff as being of low risk of self harm.
After his committal on 7 September to the Crown Court for trial, he transferred to
HMP Altcourse. Assessment, Care in Custody and Teamwork (ACCT) procedures
to reduce risk of self-harm and suicide were opened on 11 November because
monitoring of his letters found references to killing himself. He was concerned that
the court case questioned his identity, that his fiancée might not believe him and that
he would suffer a legal injustice. An immediate ACCT action plan was put in place
which included frequent observations by officers and regular conversations. The
support of his fiancée and his thoughts about the child they were expecting were
recognised as factors that should protect him from harming himself. His ACCT
document was closed five days later.
The man was convicted for possessing the forged passport and sentenced to 12
months imprisonment. The judge made no recommendation about deportation
although this could reasonably have been anticipated. On 4 December, he was
notified of his conditional release date of 25 February 2008 and sentence expiry date
of 26 August 2008.
Altcourse transferred him as a sentenced prisoner to HMP Bullingdon on 10
December. Transfer and reception assessments indicated that he was again judged
to be low risk of self harm.
The Border and Immigration Agency (BIA) (now UK Border Agency) served the man
with a notice of the liability to deport on 16 January 2008. He indicated his intention
to appeal against the deportation. He was served with the notice of the decision to
deport him on 18 February, together with the reasons and his right of appeal. In
response, he wrote a letter in which he said he had decided to take his own life as he
refused to be in prison after 25 February and that, “I cannot continue living in prison
after my sentence.” In another letter to BIA, he asked for release from Bullingdon,
quoting immigration law and human rights rulings that immigration detainees should
be held in immigration removal centres after the expiry of their sentence.
That same day, the man threatened to hang himself if he was not released or
deported on 25 February. A senior officer immediately opened another ACCT
document. Records indicate that he was depressed by the problems stemming from
his immigration status. He was seen by the prison’s doctor the following day, by
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which time he said that he was no longer suicidal. The doctor indicated that he
would need more support around his conditional release date.
Further correspondence from BIA informed the man that permission to enter the
country under bail conditions would not be granted, but that he could appeal to an
immigration tribunal. On 27 February 2008, the Asylum Immigration Tribunal notified
him that the appeal hearing would be on 27 March. On 29 February, the ACCT was
closed.
On 1 March, an ACCT was opened immediately after the man’s cell mate found him
with a bed sheet ligature around his neck attempting to hang himself. He was
admitted to the healthcare centre and placed in a reduced risk cell, with frequent
observations by officers. Immigration issues were identified as the main reason why
he had harmed himself. He was given an international telephone call, recorded as to
his family in America, and was described as feeling better afterwards. He said that
his fiancée and child were his reasons for coping, and that he did not want to stay in
prison but to go to America. The ACCT action plan was due for review on 7 March.
The man was taken to Stratford Magistrates Court on 7 March to answer a further
charge of conspiracy to defraud. He was remanded into custody to appear before
the Inner London Crown Court in May. Instead of returning to Bullingdon, he was
transferred to HMP Pentonville afterwards. He remained on an open ACCT and
hourly observations continued. He was described on the first night as settling in well
with his new cell mate, although a little tearful.
On 9 March, the man was allowed a telephone call to his fiancée by the senior officer
who later undertook the ACCT review. The senior officer recorded that he was more
positive, that he intended to speak to his solicitor, and that he had settled into the
wing regime and wanted to start education. The ACCT was closed without a post-
closure review being arranged.
Further correspondence from BIA on 25 March refused the man’s temporary release
to the UK and indicated that he would remain in custody at Pentonville until the
Crown Court hearing on 7 May. Correspondence from the Immigration Appellate
Authority indicated that the appeal hearing scheduled for 27 March was adjourned
until April. In a letter to BIA, the man referred to a visit from the US Citizens Service
on 25 March.
A fellow prisoner told the investigation that he saw the man in reception on 28
March. He said that he had been expecting a visit from the immigration authorities,
but that they had not arrived and he was very frustrated that the meeting did not take
place. However, this prisoner did not think he was at risk of harming himself.
The man wrote three letters. One was to the BIA official dealing with his case, and
another to the US Citizens Service asking that they inform his aunt of his death. The
last was to his fiancée and to unborn daughter, apologising and saying he could not
go on in prison as he was suffering too much.
One morning in March, a uniformed member of staff made a routine check and
looked into the man’s cell. He was hanging from a ligature tied to the window bars.
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Staff responded quickly to the call for emergency assistance. Cardio pulmonary
resuscitation (CPR) was carried out until the paramedics arrived some 20 minutes
later. The paramedics pronounced that he had died at 5.47am.
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THE INVESTIGATION PROCESS
1. My investigators visited HMP Pentonville and spoke to staff who knew the
man. They interviewed 18 members of staff and one prisoner. Notices were
posted to staff and prisoners inviting contributions to the investigation. The
investigators studied all relevant prison records including his main prison
record, medical records and the statements made by staff.
2. The local Primary Care Trust identified a medical practitioner to carry out a
review of his clinical care. I am grateful to the Senior Practitioner-Practice
Nurse for undertaking the review. My investigators discussed aspects of his
treatment with both healthcare staff at HMP Pentonville and with the clinical
reviewer.
3. My investigators contacted HM Coroner for St Pancras to inform him of the
nature and scope of my investigation and to request a copy of the Post
Mortem report which was made available. Upon completion, my report will be
sent to the Coroner to assist his enquiries into the man’s death.
4. My Senior Family Liaison Officer contacted the man’s fiancée to inform her of
my investigation. The Senior Family Liaison Officer has spoken to her on a
number of occasions throughout this process. The man’s fiancée raised a
number of issues she wished to be considered by my investigators, and I
hope that my report provides answers for her.
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HMP PENTONVILLE
5. Pentonville is a local prison serving the London courts. Built over 150 years
ago, it has an operational capacity of 1,150 prisoners. Around a quarter of the
population are foreign national prisoners.
Healthcare
6. Pentonville has a new purpose-built healthcare centre offering both inpatient
beds and a day care facility for prisoners with mental health problems. There
are primary care facilities on the wings, including a consulting and dispensary
area. Healthcare staff are available 24 hours a day. Doctors, mental health
and nurse-led clinics are available, as well as a range of other more
specialised services. The prison’s clinical governance board has a strategy to
improve assessment and delivery of treatment to prisoners within their first 48
hours of arrival.
Previous deaths at HMP Pentonville
7. This is the 12th death at Pentonville that my office has investigated since I
became responsible for investigating all deaths in prison custody in April
2004. The main issues raised by the circumstances of the man’s death are
different from those raised in my previous investigation reports.
Night state
8. At night, when the prison is locked up, the number of staff on duty is much
lower than during the day and only one of the prison gates may be opened for
emergency access. The Night Orderly Officer (NOO) is in overall charge of
the prison and visits each wing at intervals. The wings are in the care of night
patrol officers who are responsible for monitoring security and safety. The
number of officers on patrol varies from wing to wing and includes prison
officers and operational support grade (OSG) staff. The NOO carries cell
keys but the wing officers carry only cell keys in a sealed pouch for
emergency use only.
Assessment, Care in Custody and Teamwork
9. ACCT has been introduced at all prisons. It is a care-planning system
whereby staff can work together to provide individual care to prisoners
identified as being at-risk in order to help defuse a potentially suicidal crisis or
to help individuals with long-term needs (such as those with a pattern of
repetitive self-injury) to better manage and reduce their distress.
Samaritans and Listeners
10. The Samaritans is a national voluntary organisation that provides a
confidential telephone support service for people in distress or at risk of
harming themselves. Listeners are prisoners selected, trained and supported
by the Samaritans to provide a similar service in custody.
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Conditional Release, Licence and Sentence Expiry Dates
11. All prisoners given sentences of between 12 months and four years
imprisonment are released automatically, but conditionally, at the half way
point of their sentence, unless they are subject to other periods of remand in
custody or lawful detention. A prisoner released on their conditional release
date is subject to licence conditions that require, among other things, their
supervision in the community by the probation service. The period of
supervision extends to the licence expiry date, and in the meantime the
prisoner may be recalled into custody. Some prisoners may be released
earlier than their conditional release date on home detention curfew and are
subject to electronic monitoring. Foreign national prisoners are not eligible for
release on home detention curfew.
12. The sentence expiry date is the date when the whole period of the sentence is
complete. A 12 month sentence expires when the whole period has been
served.
Her Majesty’s Chief Inspector of Prisons
13. The most recent inspection of Pentonville by HM Chief Inspector of Prisons
was unannounced and took place in June 2006. Some of the issues raised in
her report are pertinent to the circumstances of the man’s death. The
inspection found that work with foreign nationals had improved. However, HM
Chief Inspector reported that there was a group of foreign national detainees
who were frustrated by the lack of information and advice about their
immigration and detention status.
14. HM Chief Inspector commended the establishment of a foreign nationals
committee which had drawn up a new policy for working with foreign national
prisoners. She recommended more regular meetings and an action plan to
oversee the development of provision. She said that the foreign nationals co-
ordinator should organise regular information and support groups for
detainees, to be attended by an independent immigration advice agency.
15. HM Chief Inspector repeated an earlier recommendation that ACCT reviews
should be multi-disciplinary, noting that some were only attended by a senior
officer and the prisoner. She particularly mentioned that the foreign nationals
coordinator had not been invited to ACCT reviews of foreign national
prisoners.
Independent Monitoring Board (IMB)
16. The IMB annual report on Pentonville for the year ending 31 March 2008
noted some progress but reported that “a comprehensive regime for foreign
nationals is still lacking”. The IMB said that the foreign nationals coordinator
still worked largely alone and focussed mainly on individual immigration
matters. It welcomed plans to increase the number of officers which it was
hoped would enable the re-establishment of foreign national support groups.
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17. The IMB noted that United Kingdom Border Agency (UKBA) immigration
caseworkers visit Pentonville on two days each week to hold surgeries on
each wing, and that the independent Detention Advice Service visits regularly.
Additionally, the IMB commended the presence of foreign national liaison
officers on each wing, supported by a dedicated team of prisoners working as
foreign national orderlies.
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KEY FINDINGS
18. On 25 August 2007, the man was arrested at Holyhead, North Wales,
travelling from the Republic of Ireland into the United Kingdom on a United
States passport in an assumed name. He was arrested as the passport had a
forged bio data page. He was served with an immigration detention document
(IS91) following interview under caution as a suspected illegal entrant.
19. Subsequently, the man was charged with deception, specifically “possessing
a false identity document with intent to establish registrable facts” (i.e
possession of the passport). He appeared at Ynys Mon/Anglesey Magistrates
Court on 27 August and was committed in custody to appear before Mold
Crown Court for trial. He was taken from court to HMP Liverpool.
20. On reception at Liverpool, the man gave his address as Upminster, Essex,
where he said that he lived with his fiancée, who he identified as his next of
kin. A cell sharing risk assessment (CSRA) to assess his suitability for
sharing a cell with another prisoner was undertaken and identified him as low
risk.
21. At a Crown Court appearance on 7 September 2007, the man was remanded
in custody and transferred to HMP Altcourse. The Prisoner Escort Record
(PER) is a record of all escorted journeys made by a prisoner. It includes a
section highlighting any known risks including potential self-harm and medical
issues. The PER for his journey to Altcourse identified no risks, and the
CSRA completed in reception assessed him as low risk and suitable for
sharing a cell, preferably with a non-smoker. Between September and early
November, the records show that the man had settled and scored well on the
incentives and earned privileges scheme (IEP). He was described as
generally co-operative and helpful.
22. However, monitoring of the man’s letters revealed references to him taking his
life and to his fiancée not believing who he was. Consequently, on 11
November, an Assessment, Care in Custody and Teamwork document
(ACCT) was opened. During the initial ACCT interview, he said he had
thought of suicide in the previous weeks and especially that day, although he
emphasised that things were “fine” between him and his fiancée. He said he
had thought of jumping from an upstairs landing onto his head. He was
described as withdrawn and it was noted that he did not come out of his cell
very often.
23. The immediate ACCT action plan to reduce his risk included five observations
per hour, with three significant conversations per shift, living in a shared cell,
and telephone access to the Samaritans and contact with a Listener.
24. The ACCT assessment the following day recorded that the likely triggers of
self-harm were the man’s communications with the court, with his solicitor and
with his family. The assessment identified that he was concerned that he had
been wrongly accused and did not want to suffer an injustice in the court. He
expressed concerns that the court said he was a different person to who he
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said he was and that he felt “torment” in prison but did not want to kill himself.
The support of his fiancée and his thoughts about his unborn child were
expected to help to protect him from harming himself. The man was
assessed as more positive with no thoughts of self-harm, and he was
encouraged to maintain good contact with his fiancée and his solicitor. The
ACCT observations were suspended and the significant conversations
reduced to twice a day.
25. The ACCT was reviewed with the man on 16 November. Due to his level
headed approach to his problems, it was closed with a post-closure review set
for 23 November. The post-closure meeting was actually undertaken on 24
November. It recorded his plans for beginning education classes. He was
looking forward to a visit from his fiancée, and was settled with his cell mate.
He was aware of the availability of Listeners and the Samaritans should he
need them.
26. The man appeared before Mold Crown Court on 22 November, and was
found guilty of possession of a forged passport. On 30 November, the same
court sentenced him to 12 months imprisonment. The judge ordered that the
95 days he had spent on remand should be taken into account. There was no
recommendation from the judge regarding deportation and the man returned
to Altcourse.
27. On 4 December, the man was given his sentence calculation dates. His
conditional release date was set at 25 February 2008, and his licence and
sentence expiry dates as 26 August 2008. There is no record of his reaction
to the information.
28. As Altcourse is primarily a remand prison holding only a few sentenced
prisoners, the man was transferred to HMP Bullingdon on 10 December. The
Prisoner Escort Record (PER) document prepared for his transfer identifies no
risks. At the CSRA undertaken on reception at Bullingdon, he was recorded
as not being on an open ACCT, and was deemed to be low risk and suitable
for sharing a cell. The induction healthscreen noted that he was not having
any thoughts of deliberate self harm.
29. There is a record that the man was taken to Milton Keynes Magistrates Court
on 18 December but no indication as to why this happened.
30. The man applied on 7 January 2008 to leave the UK under the Facilitated
Return Scheme (FRS). (The FRS is a voluntary scheme run by the UK
Border Agency to help prisoners from outside the European Economic Area to
return home. It pays for travel and provides some financial assistance.)
However, he withdrew his application on 10 January following advice from his
solicitors.
31. On 16 January, the man was served with a notice of liability to deport by the
Border and Immigration Agency. Prison records show that he was given the
notice on 17 January. He completed the attached questionnaire which he
returned on 6 February. While the prison record does not clearly indicate his
12
response, it is clear from later documentation that he appealed against
deportation. A subsequent letter from BIA indicates that he also wrote on 4
February asking to be released on bail at the discretion of the Chief
Immigration Officer (referred to as CIO bail).
32. On 18 February, BIA served the man with a notice of the decision to deport.
The reasons given included that he had been convicted of possessing a
forged passport that he gave a false identity, and had failed to substantiate
any of his history within the UK. Furthermore, the notice letter noted that he
was not “asking for residency, citizenship or seeking asylum”. It concluded
that it was appropriate to deport him to the USA. At the same time, he was
served with further IS91 detention documentation authorising his continued
detention beyond his conditional release date of 25 February.
33. The man wrote a long letter, dated 18 February, in reply to the notice. It was
headlined with the request ‘please release my corpse to my family’. He wrote:
”I have decided to take my own life. Because I refuse to be in prison after
25 February 2008. It is better to die than continue suffering for a crime I
did not commit … I cannot continue living in prison after my sentence.”
34. In a further undated letter around the same time, again in response to the
deportation notice, the man asked for a transfer to an immigration removal
centre following his conditional release date of 25 February. He supported his
request by quoting from the Nationality, Immigration and Asylum Act 2002 and
European Court of Human Rights rulings, and argued that detainees should
be held in immigration centres after the expiry of their sentence. He said that
his human rights would be breached if he remained in prison after his
conditional release date.
35. There is no record that the man was given an explanation for his continued
prison detention beyond 25 February. However, the BIA letter to him dated
18 February made clear that he had impending prosecutions for other
offences. Furthermore, in a letter dated 26 February declining his request for
CIO bail, BIA specifically mentioned that he had a pending prosecution for
fraud for which he would be appearing at Stratford Magistrates Court on 7
March.
36. The man made a noose and threatened to hang himself on 18 February. The
wing senior officer opened an ACCT document. The document was not found
amongst the records provided by Pentonville for this investigation.
37. The medical records show that the senior officer telephoned a Staff Nurse to
ask a nurse to assess the man as part of the ACCT process. She responded
that, due to a staff shortage, it was impossible for her to go to the wing to see
him. She offered advice over the telephone instead. It was agreed to place
him on frequent observations and that healthcare would be kept informed.
The Staff Nurse subsequently spoke with a Senior Officer (SO) who said that
the man was worried about immigration issues and wanted to be deported or
bailed on 25 February. She described him as depressed but able to remain
13
on the unit, and asked for him to see the doctor the following day. He was
placed on the doctor’s list.
38. A prison doctor saw the man on 19 February and confirmed that the main
issue was his immigration status, as he did not want to be held longer than his
sentence. She recorded that he said he did not want to kill himself and had
no active plans to do so. She assessed his current situation and did not
consider that any medication was necessary. She identified that his situation
might deteriorate the following week when his sentence expired, and he might
need further support at the time.
39. A memorandum was sent to the discipline office at Bullingdon from the wing
senior officer on 19 February. It advised that BIA needed to be informed in
line with mandatory requirements that the man, as a potential deportee, had
been placed on an ACCT document. The memorandum said that he wanted
his letters of 18 February faxed to BIA, and had said he would kill himself if he
was not deported or released on 25 February. The records indicate the
information was faxed as the man had asked. A fax was also sent to BIA
containing the IS91RA risk factor checklist which details any risks presented
by a person subject to detention and potential deportation. The checklist had
initially been completed indicating that the man was low risk, but was
amended with the comment that he had since threatened to harm himself and
was now on an open ACCT.
40. There is a copy of a letter dated 20 February which the man wrote to his
solicitor. The letter referred to the BIA letter of 18 February noting that he had
impending prosecutions, and that he had written requesting transfer from
Bullingdon on 25 February. He wrote, “I am innocent of the allegation and
nobody believes me but God knows.” He continued, “The criminal charge
against me is damaging to my soul and reputation.” He asked his solicitor to
let him know the date and venue of the court and wrote, “I need to be home
before my daughter is born.”
41. During the next week, the man received a letter dated 26 February from BIA
refusing his release on CIO bail. The letter specifically identified that he
would be taken to Stratford Magistrates Court on 7 March.
42. Bullingdon received a fax on 27 February from the Asylum Immigration
Tribunal (AIT). It confirmed the man’s appeal hearing at Birmingham on 27
March and asked for escorts to be arranged. A note on the fax indicated that
the date should be entered on the Local Inmate Database System (LIDS, the
Prison Service database), with a note that escorts should only be arranged
following the outcome of the court hearing on 7 March.
43. Subsequent records indicate that the man’s ACCT document was closed on
29 February. The circumstances are not known as the ACCT document is not
on file.
44. The following day (1 March 2008 at 4.30am), the man’s cell mate heard a
noise and found him attempting to hang himself. He had used a bed sheet
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ligature tied to the bed. The cell mate freed him from the ligature. An ACCT
was re-opened immediately. He was assessed by a Nurse and a SO, who
found him aware and oriented. He was immediately moved to a reduced risk
cell in the healthcare centre. He told the staff that he wanted to go home as
all his friends had been removed to immigration centres and he had been left
behind. Initially he was placed on frequent observations, which were reduced
later in the day to five per hour. He was informed about the support available
from the Samaritans and Listeners. He was seen by a second prison doctor
and said he was no longer suicidal. He wanted to go back to the wing, and
asked for an international telephone call.
45. The full ACCT assessment interview took place on 2 March. The triggers
were identified as immigration issues. The man said his problems were that
he had pleaded guilty even though he was not, and he would not get a fair
trial. He was appealing against deportation and hoped to delay it until his
child was born. He wanted to go back to America, but not whilst his fiancée
was pregnant. He said he thought that hanging himself was the only way to
deal with his problems. However, he said he was no longer suicidal and he
could cope because of his fiancée, his unborn child, and his wish to return to
America. The review decided to keep his observations to hourly, move him to
an ordinary cell with a television, and encourage him to talk to staff. The next
ACCT review was set for 7 March.
46. On 3 March, the man was given an international telephone call, which was
recorded as to his family in America. He was noted as being more positive
afterwards, having sorted out a lot of his immigration problems.
47. Over the next few days, the man was recorded as dealing well with the
paperwork relating to his refused bail application and with other immigration
issues. He was admitted to the healthcare centre for an unrelated matter and
the medical record entries indicate he repeatedly denied having suicidal
thoughts. On one occasion, he mentioned looking forward to the birth of his
daughter.
48. On 7 March, the man was taken to Stratford Magistrates Court to answer the
charge of conspiracy to defraud. The record does not show whether he
expected to return to Bullingdon. Stratford Magistrates Court remanded him
in custody to appear before Inner London Crown Court on 7 May.
49. The man was transferred to Pentonville after the court hearing. The PER
record showed indicators for a ‘mental condition’ and ‘suicide/self-harm’. It
recorded that he was on an open ACCT document, and subject to hourly
observations. The open ACCT document travelled with him in line with
requirements.
50. The cell sharing risk assessment undertaken at reception at Pentonville
recorded the man as a remand prisoner and a detainee charged with
deception. It assessed him as being a low risk, and on an open ACCT. A
Nurse undertook the initial health screening and assessed him as showing no
mental health problems, with no deliberate thoughts of self-harm, and with a
15
normal mental state. She told my investigators that she signed the CSRA
before seeing the ACCT document due to the procedure then in place in
reception. The CSRA was signed off by a SO, who also undertook the first
night interview with him and concluded that he was suitable to share a cell.
51. The ACCT record of observations for 7 March described the man as “seems
ok, although a bit tearful” following his arrival at Pentonville. Later in the
evening, the wing Officer recorded him as settling in well with his new cell
mate having been moved from a smoker’s cell. The man was chatting and
writing letters.
52. On 7 March, a letter from the Asylum Immigration Tribunal was faxed to
Bullingdon (it was faxed to Pentonville on 10 March). It said that the man’s
appeal hearing, which had been due on 27 March, was now adjourned until
17 April in Birmingham. The letter asked that escorts be arranged for the new
date. The records do not show clearly if and when the man was informed of
the adjournment.
53. The ACCT document was due for review on 7 March but, due to the man’s
production at court and transfer to Pentonville, this did not happen until 9
March. The hourly observations continued until the review. An SO undertook
the review alone with him. He recorded that he was more positive. The man
had accepted that he might not get bail, but would see his solicitor the
following day. The ACCT assessor described the man as settled into the wing
regime and wanting to start education as he had at Bullingdon.
54. The ACCT assessor closed the ACCT document on 9 March, two days after
the man’s arrival at Pentonville, and without setting a date for a post-closure
interview. He told my investigators that closed ACCTs would be given to the
Safer Custody Co-ordinator who would then organise the reviews.
55. The ACCT assessor allowed the man two telephone calls to his fiancée, one
before the ACCT review and another on 10 March, as well as a call to his
solicitor the same day.
56. A letter from the fiancée’s Member of Parliament was faxed to the prison on
19 March. It followed representations from the fiancée and requested
confirmation of the man’s status as a detainee. There is no record of a
response to the letter.
57. On 22 March, the man was given his secondary health screen check by a
Nurse. It was late - some two weeks after his reception into Pentonville - but
did not record anything of concern. There are few other records involving him
over the next days. He was recorded on 23 March as a man who “complies
with the regime and causes no problems”.
58. A further letter dated 25 March from BIA was faxed to Pentonville. It was in
response to a request made by the man on 18 March, requesting release on
Home Detention Curfew. The letter reiterated the reasons why BIA refused
temporary admission on bail. They included the judge’s refusal of bail in
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respect of the fraud charge, and the letter concluded that he would remain in
Pentonville until the Crown Court hearing on 7 May. The letter did not explain
that foreign national detainees are not eligible for release on home detention
curfew.
59. It is not clear when the letter from BIA was given to the man. However an
Officer told my investigators he remembered giving it to him on or around the
day it arrived, at the request of one of the immigration officials working in the
prison. He recalled that the man said he had received the information before,
and did not appear shocked, although he had not read all the details. The
foreign national coordinator also recalled giving him some other immigration
related paperwork, but could not recall when that was.
60. In a subsequent letter, the man said that he had received a visit from a
representative of the Citizens Services at the United States Embassy on 25
March. There are no details of the substance of the visit.
61. There is a copy of a letter dated 27 March written by the man to the
Independent Police Complaints Commission (IPCC). He asked the IPCC to
investigate what he described as a false claim about his DNA data. It is not
clear whether the letter was actually sent.
62. A fellow prisoner (who is trained as a Listener, but did not know the man in
this capacity), told my investigators that he saw him in reception on 28 March.
He understood that he was there as he was expecting a visit from the
immigration authorities but they had not arrived. He said that the man was
very frustrated as he had been building himself up for the meeting. It is not
clear, either from the records or from interviews with my investigators, why he
was taken to reception on at least one occasion on 28 March.
63. The Listener knew that the man’s fiancée was due to give birth, and that he
wanted to be released before the baby was born. He did not think that the
man was at risk of harming himself. He thought that he was not well known
on the wing as he had only been there a short time. He could speak English
well enough to make himself understood.
64. In March, the man was locked in his cell as usual. He had been sharing a
cell, but was alone that night as his cell mate had been moved. He wrote
three letters during the night which were found after his death. The first was
to the BIA caseworker saying that his dead soul would have vengeance. A
second was addressed to the US Embassy representative, asking him to
inform his aunt in America of his death. The final letter was to his fiancée and
unborn daughter, apologising as he was suffering too much in prison and
could not go on.
Events in March
65. At 5.15am, the night patrol officer, Operational Support Grade (OSG), was
carrying out routine cell checks when he looked through the door flap of the
man’s cell. He saw him hanging by a ligature tied to the window bars, with his
17
feet on the floor. He rapidly called for help from a night Officer, who
immediately called communications over his radio to raise the alarm. The
night Officer broke open his sealed keys, quickly opened the door and went
into the cell. Several other officers arrived within a minute or so, and the man
was released from the ligature and placed on the floor.
66. The SO (Night Orderly Officer in charge of prison) had commenced unlocking
the prison around 5.00am. As he approached the centre office, a member of
staff shouted at him and said there had been an incident on G wing. Staff had
apparently tried to contact him via his radio. The SO told my investigators
that he then discovered the batteries in his radio were dead. He made his
way immediately to G Wing to find healthcare staff trying to resuscitate the
man.
67. The night Staff Nurse arrived rapidly. She examined the man but was unable
to find a pulse or signs of life. She immediately began cardio pulmonary
resuscitation (CPR), and called for a defibrillator (a machine that applies
electrical impulses to the heart and advises whether there is any rhythm which
might be stimulated). It arrived quickly and, once applied, advised to continue
with CPR. A second night Officer took over applying CPR for some 15 to 20
minutes before the paramedics arrived. This must have been physically and
emotionally draining.
68. An ambulance was called at 5.25am. It arrived at 5.35am, but at the wrong
prison gate entrance. A second ambulance arrived at 5.38am, and at 5.40am,
the paramedics arrived at the cell. They took over CPR from the prison staff
and examined the man. At 5.47am, the paramedics confirmed that he was
dead.
69. Staff found the letters the man had written. They were laid neatly on the table
under a covering piece of paper asking that they be posted. The cell was
sealed to await the arrival of the police.
70. The prison’s action plan in the event of a death in custody was initiated by the
Duty Governor. The governing Governor, chaplain, head of healthcare, and
safer custody co-ordinator were all informed. The police were called and
arrived at 6.15am. The Coroner’s officer arrived at 7.28am. The police
forensic medical examiner subsequently confirmed that the man had died.
The undertakers left the prison with his body at 1.10pm.
71. A ‘hot debrief’ meeting was convened by the Governor attended by the staff
who had been involved. It gave the staff some immediate support and
opportunity for reflection. Staff told my investigators that a critical incident
debrief was held subsequently, and was also well attended. However, the
second night Officer, who had been so intimately involved in giving CPR, was
unable to attend that debrief and had no further contact or offer of support for
some six weeks.
18
72. A notice to prisoners was issued informing them of the man’s death, advising
of support available and offering the opportunity of support from the chaplain if
they wished.
73. The Duty Governor was appointed as the prison’s Family Liaison Officer. He
told my investigators that normally he would have gone personally to the
man’s nominated next of kin, his fiancée, but because of the pressures at the
prison he arranged instead for the police to inform her of his death. This was
done around 9.30am. The Duty Governor spoke with her by telephone at
about the same time.
74. The Duty Governor maintained regular telephone contact with the man’s
fiancée up to the end of April, except during the period when she gave birth to
her daughter. He was able to give her a copy of the letter the man had left
her. The Duty Governor also offered to meet with her if she had any concerns
that she wished to raise. The fiancée told my Senior Family Liaison Officer
that she felt that the prison had been very helpful to her.
75. The post mortem was carried out by the Consultant Forensic Pathologist on
31 March. He concluded that the cause of the man’s death was hanging,
consistent with self suspension.
76. The man’s identity was established by the police and Coroner after his death.
His fiancée was then able to contact his father in Ghana. She told the Duty
Governor that the family would like to be involved in the funeral arrangements,
and have him flown back to Ghana for burial. Subsequently, the Duty
Governor liaised with the man’s parents and solicitor in Ghana, and arranged
for his body to be repatriated to Ghana. Later, he had a telephone call from
the family solicitor confirming that the funeral had taken place.
19
ISSUES RAISED IN THE INVESTIGATION
Clinical Care
77. I am grateful to the clinical reviewer for undertaking a clinical review on behalf
of the local Primary Care Trust. The clinical reviewer makes 11
recommendations which I fully endorse. I emphasise two here for
consideration by the Governor and the Prison Service.
78. The clinical reviewer observes that there were some clinical procedural errors
on the man’s arrival at Pentonville. She highlights that, had his medical
record arrived with him and been assessed by the reception nurse, he would
have been seen by the doctor that evening and should have been referred for
a mental health assessment. Nevertheless, it is impossible to say whether,
had these errors not occurred, his suicide would have been prevented.
79. The clinical reviewer indicates that the small delay in the paramedics’ arrival
caused by the ambulance attending the wrong gate was not significant. On
this occasion I agree, although such delays must be prevented in future. The
clinical reviewer has recommended that the prison communications team and
London Ambulance Service should liaise to ensure that ambulances go to the
correct gate. I bring the matter to the attention of the Governor. It is self-
evidently of great importance that the prison and London Ambulance Service
find a solution to this problem.
The Governor should review the procedure for the attendance of
ambulances at the prison to ensure that a system is in place that clearly
directs ambulances to the correct prison gate.
80. The clinical reviewer concludes that the nurse, prison officers and ambulance
paramedics made appropriate interventions when the man was found hanging
and that resuscitation was not going to be successful. I agree with her
commendation of the second night Officer, who continued resuscitation for a
long period, sadly without success, before the paramedics took over. It is
important that such staff receive a proper standard of aftercare.
The actions of the second night Officer should be commended.
81. My investigators found that a significant number of uniformed staff at
Pentonville had either not had training in first aid and cardio pulmonary
resuscitation or it was out of date. I agree that the prison should ensure that
uniformed staff have up to date basic life support skills, which the clinical
reviewer says should be revised at least every five years. It should be
undertaken as part of a strategy which also ensures there is a sufficient
number of trained staff on duty, particularly when the prison is in night state.
The Governor should ensure that uniformed prison staff receive basic
life support skills refresher training at least every five years.
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82. Many receptions at Pentonville are a consequence of contracted prison
escorts not being able to return a prisoner to an out of London prison at the
end of the court day. Such unplanned transfers can cause problems for the
communication of critical information about prisoners, including their medical
records.
The Prison Service should ensure that, where possible, the prisoner’s
medical record accompanies them during production at court and on
transfer between prisons.
Assessment, Care in Custody, and Teamwork
83. My investigators found that ACCT procedures were opened three times: once
when the man was at Altcourse and twice when he was at Bullingdon. This
final ACCT remaining open when he transferred to Pentonville. There is
some evidence of good teamwork undertaken to support him and that he
benefited on several occasions.
84. At Bullingdon, ACCT procedures were opened for a second time on 18
February 2008. This followed his response to the notice of deportation,
including writing a letter threatening suicide and making a noose and
threatening to hang himself. Prison records show that the wing senior officer
asked the nurse in healthcare to attend and make an assessment. The nurse
said that she was unable to do so due to staff shortages, but gave telephone
support to the wing senior officer instead. She also ensured that the man had
an appointment with the doctor the following day. It is manifest that,
telephone support is not as useful as an initial face to face interview to inform
the healthcare contribution to the immediate ACCT action plan.
85. Whether there was sufficient multi-disciplinary contribution during the course
of the man’s ACCT plan is unknown as, but for a one page document that
informs BIA of the ACCT plan, no other records were included in the file at
Pentonville.
86. The ACCT document opened on 1 March at Bullingdon was sent with the man
when he went to court and they were available when he arrived at Pentonville.
However, the reception nurse did not read them before she assessed him.
Her failure is dealt with in the clinical reviewer’s clinical review. I am pleased
to learn that the system has now changed and healthcare staff should have
access to ACCT documents before undertaking their assessment.
87. Had the nurse seen the ACCT documents, the man might well have been
seen by the doctor on his first evening. PSO 2700 clarifies the responsibilities
for sending and receiving prisons when prisoners on ACCTs are transferred.
The PSO assumes that such transfers are mainly planned, and allow time for
proper communication to occur. Pentonville has problems of prisoners who
are unexpectedly remanded in custody by the courts. Nevertheless, the
prison should ensure that staff speak with the sending prison as soon as
practicable after a prisoner arrives on an open ACCT.
21
The Governor should ensure that, in line with Prison Service Order 2700,
there is a system in place to communicate with the sending prison when
a prisoner on ACCT is received into custody.
The Governor, in liaison with the healthcare manager at Pentonville,
should ensure that all prisoners received on an open ACCT are
assessed by the prison doctor on their first night.
88. An ACCT review was arranged for 7 March at Bullingdon but, unsurprisingly
given that this was the day of his court appearance and the man’s transfer to
Pentonville, it did not actually take place until two days later. When it did
happen, only a single senior officer and the man were present. The senior
officer told my investigators of the pressures to close ACCT documents, and
the difficulties organising reviews because of the high numbers of ACCT
prisoners at any one time.
89. I have every sympathy with the prison’s pressures. I also recognise that the
man presented himself positively in the review in March, three weeks before
he took his life. Nevertheless, I consider that closing the ACCT was
precipitate given that the man had been in Pentonville for less than two whole
days, and that there was no multi-disciplinary representation. I also note that
the post-closure review, which would have been an opportunity to reconsider
the decision, did not in fact take place.
90. PSO 2700 recommends a graduated closure of ACCT plans, and requires a
post-closure interview. Neither the closure of the man’s ACCT, nor the
system to organise post-closure interviews, met these standards.
The Governor should ensure that ACCT closures are carried out by a
multi-disciplinary team and are planned, graduated, and followed by a
post-closure review.
91. The foreign national coordinator told my investigators that she did not know
that the man had previously been on an ACCT when she served him with
some sensitive immigration papers. Serving immigration papers is likely to
increase the risk for prisoners. The coordinator relied on wing staff to inform
her of prisoners who were at risk of suicide and self harm. The new
arrangements which store current and closed ACCTs on the wing may
overcome the problem. I also advise foreign national coordinators to refer to
a list of the foreign national prisoners who are currently or recently subject to
ACCT before serving immigration papers. The coordinators should also
ensure that wing staff are asked to monitor any consequent reactions.
Working with Foreign National Prisoners
92. Pentonville has a large proportion of foreign national prisoners, and working
with them effectively requires specialist knowledge and training. Much of the
necessary information may be provided through the specialist foreign national
22
coordinators who are supported by BIA (now UKBA) staff who work in the
prison. However, my investigators found that weaknesses surrounding the
service of immigration papers, and a letter from a Member of Parliament
appears to have gone unanswered. Whilst I make no formal
recommendation in regard to either matter, I bring them to the attention of the
Governor who will wish to improve recording and to arrange for MPs’ letters to
be answered promptly.
93. Effective management of foreign national prisoners also requires additional
knowledge and skills amongst wing uniformed staff. My investigators found
that staff had insufficient training. Some progress has been made in response
to the recommendations from HM Chief Inspector and the IMB, and thus I do
not repeat their recommendations here.
94. The man was plainly distressed by being held in prison beyond his conditional
release date, without either transfer to an immigration removal centre or
release on bail. He thought that he might be transferred to an immigration
removal centre between 25 February and 7 March. He was also distressed at
the prospect of his impending trial for a further criminal charge. He had
appealed to the immigration tribunal and hoped for bail. It is not clear whether
he knew that his immigration appeal was adjourned from 27 March. However,
it is clear that, even if the hearing proceeded in late March, he would have still
been held in prison custody due to his remand on a fresh criminal charge.
95. PSO 4630 describes the requirements for prisons regarding immigration and
foreign national issues. Whilst the prisons holding the man worked within the
guidelines, it is not clear that he fully understood the various implications of
conditional release dates, licence and sentence expiry dates, eligibility for
home detention curfew, and the extent to which further prosecutions affect
immigration decisions. Nor is it clear that he understood that his transfer to an
immigration removal centre would be a decision for BIA, and that removal
centres do not hold prisoners who are on remand on criminal charges.
The Prison Service should review its guidance for working with foreign
national prisoners to ensure that the implications of outstanding
criminal prosecutions are explained to prisoners who are also held
under immigration law.
Prison radio batteries
96. The night orderly officer on duty told my investigators that his prison radio was
not working as the battery was not fully charged. Whilst this did not affect the
response to the call for assistance for the man, I am concerned that the night
orderly officer did not have a fully functioning radio. This is frankly rather
shoddy.
The Governor should ensure that prison radios are equipped with fully
charged and functioning batteries.
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Critical Incident debrief and employee support
97. Following the man’s death, the prison organised both a hot debrief and, later,
a critical incident debrief for the support of the staff who found him and came
to his assistance. However, the second night Officer who undertook CPR on
the man was unable to attend the critical incident debrief and was not
contacted for some six weeks. I have already commended him for his care of
the man, and am disappointed to learn that he felt that he was insufficiently
supported afterwards.
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CONCLUSION
98. Now that the man’s true identity has come to light after his death, there can be
no doubt that he must have had many things on his mind. However, at the
time he was in custody, he did not speak openly about who he was or how he
had come into the UK.
99. We do know that his immigration status caused worry and anxiety from the
start of his imprisonment. To add to this, his fiancée was expecting their first
child. His anxiety was acknowledged by the opening of an ACCT document
at Bullingdon, and he appeared to benefit from the extra support this offered.
However, the ACCT was closed two days after arriving at Pentonville. In my
view, this was premature as I do not believe staff had had sufficient time to
assess and observe him in his new surroundings. The process for closing the
ACCT was also flawed. Having said that, he appeared to have settled at
Pentonville during his short time there.
100. It seems highly likely that the man’s growing concern about his immigration
status, the fear that he might not see his child, and the inevitable pressures of
living with a false identity, combined to cause him to take the actions he did.
However, I do not believe his actions could reasonably have been predicted
by those staff charged with his care.
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RECOMMENDATIONS
1. The Governor should review the procedure for the attendance of ambulances at
the prison to ensure prison communications team and London Ambulance
Service have a system in place that clearly directs ambulances to the correct
prison gate.
2. The Governor should ensure that uniformed prison staff receive basic life
support skills refresher training at least every five years.
3. The Prison Service should ensure that, where possible, the prisoner’s medical
record accompanies them during production at court and on transfer between
prisons.
4. The Governor should ensure that, in line with Prison Service Order 2700, there
is a system in place to communicate with the sending prison when a prisoner
on ACCT is received into custody.
5. The Governor, in liaison with the healthcare manager at Pentonville, should
ensure that all prisoners received on an open ACCT are assessed by the prison
doctor on their first night.
6. The Governor should ensure that ACCT closures are carried out by a
multidisciplinary team and are planned, graduated, and followed by a post-
closure review.
7. The Prison Service should review its guidance for working with foreign national
prisoners to ensure that the implications of outstanding criminal prosecutions
are explained to prisoners who are also held under immigration law.
8. The Governor should ensure that prison radios are equipped with fully charged
and functioning batteries.
The prison Service have accepted all the recommendations
Commendation
1. The actions of the second night Officer should be commended.
26