Individual at Cardiff

Investigation into the circumstances surrounding
the death of a man at HMP Cardiff
in March 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2009
December 2009
This is the report of an investigation into the circumstances surrounding the death of
a man who took his own life using a ligature whilst alone in his cell at HMP Cardiff
during the early hours of 10 March 2009. He had been in custody for just 12 days.
The man arrived at Cardiff from a local magistrates’ court on 26 February. Prison
staff did not consider that he represented a risk to himself. He was not made the
subject of an Assessment, Care in Custody and Teamwork (ACCT) document
(intended to monitor those individuals thought to be at risk of harming themselves).
He took his own life in the early hours of 10 March.
I would like to extend my sincere condolences to the man’s family. In particular, I
think of his mother (who worked with her son to overcome his drug use) and his
fiancée (who he planned to marry later in the year). I recognise that his death was
both unexpected and deeply shocking for them. To lose a loved one under these
circumstances is especially difficult to come to terms with.
The investigation was conducted by two of my colleagues. One of the Family
Liaison Team contacted the man’s family to discuss my investigation and the
questions which they had about his death.
A clinical review of the healthcare which the man received in Cardiff was undertaken
by a doctor from the Healthcare Inspectorate Wales on behalf of the Cardiff Local
Health Board. She assessed whether the care which the man received in custody
was comparable with that which he would have been offered in the community. I am
grateful for her assistance.
I would also like to thank the Governor of Cardiff, as well as the staff and prisoners
for offering their full cooperation whilst my investigation took place. In particular, I
am grateful to the Safer Custody Manager, who liaised with my colleagues and
organised the interviews.
The man did not voice suicidal thoughts to staff before he took his own life. There
had not been concerns in this regard during previous custodial sentences. With the
benefit of hindsight, his behaviour on 9 March was erratic and he appears to have
become anxious and irrational as the day progressed. The investigators are
satisfied that a number of staff took the time to speak to him and check on him. I
believe that their decisions were reasonable and well intended.
I express concern with regard to failures in communication which meant that staff
were not equipped with useful knowledge which could potentially have influenced the
decisions they made with regard to the man’s care. I make seven recommendations
and repeat a recommendation from an earlier investigation regarding the possibility
of testing prisoners to confirm suspicions that they are withdrawing from drugs. I
also endorse two recommendations made by the clinical reviewer.
Jane Webb
Deputy Prisons and Probation Ombudsman December 2009
December 2009 2
CONTENTS
Summary
The Investigation Process
HMP Cardiff
Key Findings
Issues
Conclusion
Recommendations
December 2009 3
SUMMARY
The man appeared at a local Magistrates’ Court in February 2009. His Community
Order was revoked and he received a short custodial sentence instead. He arrived
at HMP Cardiff later that day. He was placed on the detoxification unit and shared a
cell with another man who had appeared at the same court. The next day he was
found with a significant quantity of illegal drugs and taken to the segregation unit.
Two different assessments were completed by healthcare staff during this time to
ensure that it was appropriate for him to remain on this unit. On 1 March, he
returned to the main part of the prison. He shared a cell with the same prisoner, and
they were located on A wing.
On the morning of 9 March, the man was assessed by a substance misuse worker
from the Counselling, Assessment, Referral, Advice and Throughcare Services
(CARATS) team. She found him to be optimistic and chatty. At about 2.00pm the
same day, he told his personal officer that he was being bullied and wanted to be
moved off A wing for his own protection. The officer acted quickly to remove him
from the wing and, following consultation with other staff, placed him on the
therapeutic unit on B1 landing as a temporary measure. The man seemed to calm
down once he had left A wing.
The safer custody manager was asked to come to B1 landing and speak to the man.
He confirmed that the man was not voicing any suicidal thoughts and was satisfied
that the correct decision had been made to temporarily relocate him. The man did
not say anything further about the allegations of bullying. The safer custody
manager arranged for the violence reduction manager, who was not in the prison
that day, to interview the man the following day.
Shortly before 5.00pm, an officer became concerned about the man after he started
claiming that both prisoners and staff were calling him names. The officer could not
hear anybody doing this. A senior officer (SO) then arrived on B1 landing and
agreed to speak to the man. She knew him and thought that his irrational anxiety
was caused by drug misuse. The man did not want to associate with the other
prisoners and so stayed in his cell.
Concerned by the man’s paranoid thoughts, the SO called the healthcare
department. She spoke to a doctor and they agreed that he would be examined by a
psychiatric nurse the next day. The SO told the doctor that she did not need to visit
the man on the wing that night. The SO felt that an assessment could wait until the
morning. She was satisfied that he was not giving any indication that he might harm
himself. She knew that he had never been considered to be at risk of taking his own
life in the past. He had no history of significant mental health problems.
The man was locked up for the night on his own in a double cell. The SO checked
on him before she left at 7.15pm, and the officer also looked in on him at 7.45pm.
Both were satisfied that the man had calmed down and would be examined in the
morning. At about 11.00pm, the orderly officer went to speak to the man after he
rang his cell bell. The man had an unfounded fear that the IRA would harm his
family. To put his mind at rest, the orderly officer decided to give the man the
impression that he had contacted his family. He went away, returned about ten
December 2009 4
minutes later and told the man that he had made a telephone call to his mother. The
orderly officer thought that the man calmed down as a result.
The man took his own life using two ligatures in the early hours of the morning. One
was tied around his neck, the other around his knees. An officer glanced into the
man’s cell whilst he was counting the prisoners at the start of the day shift, but had
thought in the half-light that he was sitting up in bed.
At 7.45am, a second B1 officer unlocked the man’s cell door and raised the alarm.
Two officers removed the ligatures and lowered the man down to the ground.
Healthcare staff attended but did not attempt to resuscitate the man, as rigor mortis
had set in and they thought he had been dead for several hours. When the
paramedics attended, they attached a monitor to the man, which malfunctioned and
incorrectly indicated that a heart rate could be detected. As a consequence, they
decided to wait for a doctor to arrive. The doctor confirmed death at 9.15am.
The man had never been considered to represent a risk of harm to himself. He did
not voice any suicidal thoughts to staff during the 12 days he was held at Cardiff. He
did become tearful on 9 March, but spoke to two members of staff who found him to
be optimistic and calm. I am satisfied that staff made reasonable decisions and
acted in his best interests. I am concerned that they were not all equipped with
relevant information, and I make five recommendations to improve communication
amongst healthcare staff, substance misuse workers and prison officers. I make
three other recommendations and endorse two made by the clinical reviewer.
December 2009 5
THE INVESTIGATION PROCESS
1. My colleague was formally notified of the man’s death on 11 March 2009.
Notices were subsequently issued to both staff and prisoners at HMP Cardiff,
informing them of the investigation process and giving them the opportunity to
contact the investigators with any relevant information. During his opening
visit on 16 March, my colleague spoke with two prisoners.
2. My colleague made contact with the Safer Custody Manager at Cardiff who
acted as the liaison officer throughout the investigation. During the opening
visit, he provided all of the relevant paperwork relating to the man’s time in
custody. My colleague also met the Governing Governor on 16 March.
3. Having examined the man’s prison record and medical file, my colleagues
returned to Cardiff on 14, 15 and 20 April and 5 and 6 May. They conducted
16 interviews with staff. They also spoke to another prisoner. My colleague
conducted one interview by telephone when a doctor was unable to attend the
prison. My colleagues returned to Cardiff on 14 July to interview a prison
officer for a second time to obtain greater clarity.
4. My colleague wrote to the local Coroner’s office to inform them of the nature
and scope of my investigation. He obtained a copy of the post mortem report
and the results of toxicology tests. HM Coroner has been provided with a
copy of my report.
5. My colleague contacted Cardiff’s Local Health Board and asked that a clinical
review be carried out with regard to the medical treatment which the man
received in Cardiff. The purpose of this review is to establish whether the
care which he was offered in prison was comparable with that he would have
received in the community.
6. On 6 April, one of the Family Liaison Team contacted the man’s mother and
fiancée by telephone. The family liaison officer, along with the investigators,
visited both women and the man’s brother at the family home on 5 May. The
investigators explained the progress they had made. The Family Liaison
Officer talked about the investigation process and gave the family the
opportunity to express any concerns which they wished the investigators to
address during the investigation.
7. The man’s mother wanted to know why her son was placed in a cell on his
own on the afternoon before he died. She knew that his behaviour had
changed during 9 March and she wanted to know more about this. She was
concerned that her son had been bullied and she asked my colleagues to
explore this issue. When she viewed her son’s body, she observed what
appeared to be bruises on his hand and asked for them to be explained. Both
the man’s mother and fiancée wanted to find out more about the drugs that he
had brought into the prison. The man’s brother wanted to know the outcome
of the toxicology report. I hope that this report provides the family with a
better understanding of what happened to the man whilst he was held in
Cardiff.
December 2009 6
HMP CARDIFF
8. HMP Cardiff is a category B local prison with a maximum population of 784
adult men. It is located very close to the city centre and was originally built in
1827. As a local prison, the majority of the prisoners have arrived at Cardiff
after making court appearances in South East Wales. As well as prisoners
remanded into custody and those serving short sentences, a significant
number are serving life sentences.
9. Whilst at Cardiff, the man stayed in the detoxification unit (where drug users
can withdraw under supervision), before moving to the segregation unit
(effectively a completely separate part of the prison for those who have not
complied with the rules). He returned to a mainstream prison wing and was
then taken to the therapeutic unit (intended for those prisoners who do not
cope well with normal prison life) for his own protection.
10. The Local Health Board commissions Serco (a private company) to provide
primary healthcare to prisoners in Cardiff. The prison has 24 hour nursing
cover and 16 inpatient beds. During weekdays the core healthcare staff work
until 5.00pm. Four nurses continue to work between 5.00pm and 8.00pm.
Two nurses then work between 8.00pm and 9.00pm and from 9.00pm
overnight one nurse remains in the healthcare centre with a member of the
prison staff. That nurse will respond to emergencies and can contact the
healthcare manager out of hours if need be. Using an out of hours telephone
service, they can obtain medical advice, ask a doctor from a local surgery to
attend or summon an ambulance if they have serious concerns about a
patient.
11. All prisoners undergo a health screening during the first night reception
process upon arrival at Cardiff. Doctors from a city centre practice come into
the prison seven days a week to hold surgeries. There is a dedicated
healthcare team on the detoxification unit consisting of three full time and two
part time nurses. A mental health in-reach team is provided by Cardiff and
Vale NHS Trust.
12. HM Chief Inspector of Prisons, completed an inspection of Cardiff in January
2008. She found that prisoners were ‘much more likely to report feeling safe
than at other local prisons’, in the most part due to ‘good relationships
between staff and prisoners’. The support offered to newly arrived prisoners
was praised and the healthcare offered to prisoners was thought to generally
be of a good standard. Detoxification procedures were found to be working
well and the Inspectorate had no concerns about either the working of the
segregation unit or the use of force by discipline staff. Of particular note, HM
Chief Inspector of Prisons commented that:
‘Anti-bullying procedures had improved since the last inspection, but it
was disappointing that the enthusiasm of the safer custody manager
had not communicated itself to those staff responsible on a day-to-day
basis for supporting those at risk of self harm.’
December 2009 7
13. HM Chief Inspector of Prisons found that not all staff had been trained in the
use of the ACCT document, and she recommended that this training be fully
implemented. Similarly, she recommended that all staff receive anti-bullying
training. In general, the quality of completed ACCT documents was good.
14. During the inspection the relationships between black and minority ethnic
prisoners and staff were found to be less successful and it was considered
that complaints of racist incidents were not always effectively dealt with.
15. The most recent annual report published by the Independent Monitoring
Board (IMB) at Cardiff covers the year from September 2007 to August 2008.
(The IMB at each prison is made up of members of the public who are both
independent and unpaid. They monitor the day-to-day life in their local prison
and ensure that proper standards of care and decency are maintained.)
16. The IMB report commends the work of staff on the therapeutic landing, who
‘show a great degree of patience and understanding’. Similarly, the IMB
describes how staff working on the segregation unit ‘maintain their
commitment to the prisoners in their care’. The segregation unit was found to
be ‘always clean and tidy’ and ‘well managed by dedicated staff’. Adjudication
hearings were found to be ‘professionally conducted’. The IMB expressed
concern that the new healthcare centre was not yet being fully utilised. When
the investigators visited the prison, this remained the case.
17. The IMB considered that ACCT documents were being used appropriately to
help prisoners who were thought to be at risk of harming themselves. The
Board noted that a member of the Safer Custody team was available seven
days a week to offer advice to staff. 304 incidents of bullying were reported in
the year from September 2007 to August 2008.
Previous deaths in custody
18. Since 2004, the Ombudsman’s office has investigated nine previous deaths at
Cardiff, five of which were self-inflicted. Two of the previous investigations
have relevance to the circumstances in which the man died.
19. The Ombudsman investigated the self inflicted death of a prisoner in June
2007 and found that either a drug test or a mental health assessment would
have helped staff in determining how to help the man. In the event, staff
thought he might have been withdrawing from drugs. A very similar situation
occurred on the evening before the man took his own life, when a member of
staff thought he was under the influence of drugs and agreed with the doctor
that he should undergo an assessment with a psychiatric nurse. Toxicology
results have since shown that he had almost certainly not used drugs that
day. Again, as was the case during the earlier investigation, staff were unable
to accurately identify why his mood had altered. This has prompted me to
repeat the earlier recommendation regarding the need for urine testing when
staff wish to confirm that a prisoner is withdrawing from drugs.
December 2009 8
20. In relation to another prisoner who also took his own life in June 2007, the
Ombudsman recommended that the Governor and the safer custody team
consider how best to increase the trust between staff and prisoners and thus
the likelihood of incidents of bullying being reported. Staff had been unaware
that the man was being bullied because it did not seem that he had felt able to
tell them. Although the scenario is similar, the man was able to tell staff he
was being bullied and steps were quickly taken to move him to another unit.
December 2009 9
KEY FINDINGS
26 February – 8 March 2009
21. The man appeared at a local Magistrates’ Court on 26 February 2009. He
was under the supervision of the Probation Service, having been made the
subject of a Community Order on 7 July 2008. The Order required him to
complete 24 months of supervision and 12 months of drug treatment. It was
no longer considered to be workable after the man became verbally
aggressive to probation staff and damaged office property. He did not attend
a review relating to his drug treatment on 9 February, as well as five other
appointments arranged with his probation officer.
22. The court revoked the Order and resentenced the man for the original
offences of theft committed in February and May 2008. He received a 77 day
custodial sentence, comprising 63 days for theft and 14 days for the non-
payment of fines.
23. The supervising probation officer had completed an OASys document relating
to the man before the Order was revoked. (An OASys assessment examines
the individual’s likelihood of committing further offences and the risk of serious
harm which they represent to themselves and others.) The officer recorded in
the assessment that the man did not have any history of either self harm or
suicidal thoughts.
24. The man arrived at HMP Cardiff at about 4.00pm on 26 February and
underwent a first reception healthcare screening. Neither mental health
concerns nor a history of self harm were identified when he spoke with the
nurse. He had no history of psychiatric treatment.
25. A cell sharing risk assessment was completed before the man was placed on
a wing. (This document explores a prisoner’s potential vulnerability or the
possible harm they might do to other prisoners.) The officer who completed
the form recorded no particular concerns and noted that the man had never
been the subject of the Assessment, Care in Custody, and Teamwork (ACCT)
process. (An ACCT document is opened when staff have reason to believe
that a prisoner may be thinking of harming themselves or taking their own life.
The prisoner is kept under observation and their case is regularly reviewed to
monitor the risk they present to themselves.) The man shared a cell with
another prisoner who appeared at the Magistrates’ Court that day and arrived
at Cardiff with him.
26. During the reception process, the man’s alcohol and drug misuse were
assessed. As part of his drug treatment whilst working with the Probation
Service, he began a methadone treatment programme and was prescribed
65mg per day of this heroin substitute. The man said he had been misusing
alcohol before coming into custody. His community doctor was contacted and
confirmed that the man was prescribed 20mg daily of diazepam (a
benzodiazepine often referred to as Valium used to treat alcohol withdrawal)
at a reducing dose twice daily until 4 March. He had also been prescribed this
December 2009 10
medication in the community. It was agreed with his treatment provider in the
community that the man would continue to be given the same ‘maintenance’
dosage of methadone whilst he was in prison. This prescription would stop
him from suffering withdrawal symptoms and ensure that he could resume
treatment in the community upon his release.
27. The man was placed on the first floor landing of G wing, in the detoxification
unit. A six day course of diazepam on a reducing dose began on 26 February
and was completed on 4 March. He was also prescribed 14 day courses of
carbamazepine (to prevent epileptic fits, which can occur during alcohol
detoxification) and thiamine (a vitamin B supplement). The man collected the
medication from 26 February until 6 March, but did not complete the full 14
day schedule.
28. At 9.00am the following morning, 27 February, staff on G wing thought that
they could smell fumes coming from the cell the man and other prisoner
shared. When officers went into the cell, both prisoners seemed to be under
the influence of drugs. Although an initial search did not produce any illegal
substances, the man’s cellmate was then found with a small packet in his
hand. Staff went on to discover a significant quantity of drugs when they
searched the cell. The man told them that the drugs belonged to him,
although his cellmate was also implicated.
29. A little while later, at 10.50am, two officers began a full search of the man in
his cell. They wanted to find out if he had concealed any more drugs. He
started to remove his clothes and it was suspected that he had a small
package of drugs underneath the foreskin of his penis. He wanted a member
of healthcare staff present before the officers took any further action. They
agreed, but before this could happen the man took the package and tried to
swallow it. The officers used authorised control and restraint procedures to
restrain the man and prevent him from doing so. Another officer, who was
standing outside the cell, overheard the commotion and assisted his
colleagues.
30. One of the officers took hold of the man’s right arm, the second officer the left
arm and the third officer his head. He was taken out onto the landing and
forced to the ground on the third officer’s instructions (using restraint
procedures approved by the Prison Service) when he did not comply with the
staff. An SO arrived and supervised the control and restraint.
31. The man was brought to his feet and the SO placed him in handcuffs. He
stopped resisting and complied with the officers so the restraint applied to his
arms and head was released. He was supported by the officers as they
walked from G wing to the segregation unit (where prisoners who have broken
the prison’s rules are held). When they arrived in the unit, the handcuffs were
removed and the man was taken into cell P1-03. Another SO and officer
oversaw a full search of the man and instructed him to remove his clothes.
32. As he did so, the man was seen trying to reach down the back of his boxer
shorts. He was instructed to crouch down and another package fell onto the
December 2009 11
floor as he lowered his underwear. Once the search was finished and he was
locked in his cell, the officers involved completed the appropriate ‘Use of
Force’ documents at about 11.00am.
33. When my colleagues spoke to an SO who knew the man from previous
custodial sentences and was working on the segregation unit that day, she
said that he was not aggressive once he arrived on the unit, and accepted the
reason for his relocation. She remembered that the man’s mood seemed
noticeably heightened by drugs and that he was beginning to withdraw from
whatever he had been using. She thought that the man was quite heavily
under the influence of drugs and remembered that he asked for cold food
because he did not feel able to eat a hot meal.
34. A nurse visited the man to complete an Initial Segregation Safety Algorithm as
required by Prison Service Order 1700 (this process assesses whether the
prisoner is fit to be held in segregation). She had no concerns about the
man’s mental health. As regards his physical health, she recorded that he
had grazed knees and a sore wrist following the control and restraint, but no
significant injuries. The man subsequently asked to speak to a Listener (a
prisoner who is trained by the Samaritans to speak confidentially with others
who might be distressed). The Listener was provided but it emerged
afterwards that the man had only wanted to ask for tobacco.
35. The man was placed on report. At 9.30am the following day, 28 February, he
was subject to the adjudication process (a disciplinary hearing in front of a
governor). The SO remembered in interview that the man’s mood was still
altered and that he spoke to the governor quite flippantly, albeit in a friendly
manner. The outcome of the adjudication and any punishment were
postponed whilst the police investigated the matter. Because the amount of
drugs was of a significant value, the man faced the prospect of being charged
with bringing the drugs into prison with the intention of supplying them to other
prisoners. (Such an offence carries a substantial penalty.)
36. The man remained in the segregation unit (where he was monitored with a
camera in case he had any more drugs secreted on his person) on 28
February. The prison doctor was working that day and completed a second
Segregation Safety Algorithm. (She was not asked to check the man, but told
the investigators that she always visits the prisoners on the segregation unit
as a matter of routine when she works on a Saturday.)
37. The prison doctor confirmed that the man was suitable to stay on the unit.
They discussed his tinnitus, a problem with his hearing which he had had for
about three years. She offered to refer him for further treatment, but he told
her not to bother, as he was being released soon. Instead, she advised the
man to make an appointment with his doctor after he was released. The
prison doctor found the man relaxed and good natured and later recalled that
he had joked with her. She thought that he looked well. She was unaware of
the reason the man was being held in the segregation unit and did not have
access to his medical record when she assessed him.
December 2009 12
38. The same day the man spoke with the Samaritans on the telephone, was
visited by the chaplain and telephoned his mother. He returned to the main
prison population the next day, 1 March. The man was placed in a cell on the
first landing of A wing and continued to share with his cellmate, who had also
been released from the segregation unit following the drugs find. The
movements officer on A wing that day agreed to their request to share a cell.
He was unaware that both men had been implicated in the significant drugs
find two days earlier.
39. The man’s stay in the segregation unit had interrupted his initial placement on
the detoxification unit. Had he remained on the detoxification unit, he would
have been assessed by a substance misuse worker from the Counselling,
Assessment, Referral, Advice and Throughcare Services (CARATS) team
within 48 hours. Instead, a member of the healthcare team made a referral to
the CARATS team on 2 March.
40. Three days later, on 5 March, the man’s fiancée visited him. The next day he
was moved to the fourth landing on A wing, and continued to share a cell with
the same cellmate. The man was assigned a personal officer. The officer
spoke with him and remembered him being in a quiet mood but happy to
share a cell with his the same cellmate. The personal officer was aware of
the drugs find which was still being investigated by the police. He thought the
man was adapting well to life on the landing and had no cause to be
concerned about him. The same day, 6 March, the CARATS team received
the referral from the healthcare team. It had been sent via the internal post
system.
41. A prisoner who was a good friend of the man told my colleagues that the man
continued to promise drugs to other prisoners in the days after his supply was
confiscated even though there was no prospect of him being able to honour
his promise.
9 March
42. A member of the CARATS team interviewed the man and completed an initial
assessment of his substance misuse at about 9.45am on 9 March. They
spoke for about 45 minutes and she confirmed that he was being prescribed
methadone and diazepam. The man did not report any physical or mental
health concerns to her. They discussed the issue of self harm and the man
told her that he had no problems in this regard.
43. During their interview the CARATS worker found the man to be motivated,
optimistic and ‘chatty’. She told my colleagues that he had a ‘very positive’
attitude. The man did not report any significant worries and spoke about the
future and his forthcoming marriage. He told her that he was coping with his
sentence and expected to be released in a matter of weeks. The CARATS
worker completed a care plan to treat the man’s drug dependency. She did
not know about the large quantity of drugs which the man was thought to have
brought into Cardiff and which had been confiscated.
December 2009 13
44. The man collected his daily prescription of methadone at midday. At about
2.00pm, he asked his personal officer if they could speak in his cell. The man
was upset and said that he was being bullied by another prisoner. He alleged
that one particular prisoner was spreading rumours that he had made racist
remarks out of his cell window. The man did not explain why other prisoners
might be doing this. When he spoke to the investigators, the personal officer
remembered that the man was tearful and frightened of going back onto the
landing. He feared for his safety. The personal officer told the man that he
could stay and try to deal with the problem on the landing. Alternatively, he
could apply for vulnerable prisoner status under Prison Rule 45 (meaning that
he would be removed from the mainstream prison population for his own
protection). The man chose to apply for rule 45 and move off A wing.
45. The personal officer locked the man in his cell to keep him safe and went to
collect the necessary rule 45 paperwork. He returned and helped the man to
complete the form and pack his belongings. They then went to the wing
office, where an SO gave the man the option of moving temporarily to the
therapeutic unit on B1 landing as an alternative to asking for ‘rule 45’
protection and the stigma which can be associated with this.
46. The man chose to move to the therapeutic unit on B wing. He was moved
within 20 minutes of speaking to his personal officer. It was felt by staff that
this was a safe environment until the specific allegations of threats could be
explored. (Had the man chosen vulnerable prisoner status, he would have
been moved back to the segregation unit and then most likely transferred to
another prison.)
47. His personal officer took the man down to the therapeutic unit on B1 landing,
where he was temporarily allocated an empty cell. (The therapeutic unit takes
vulnerable prisoners who struggle to cope with prison life or who have mental
health concerns.) The man did not fit the profile of the usual prisoner found
on the unit but it was not intended that he stay there in the longer term. He
was placed there solely for his own protection.
48. On the way to B1 landing, his personal officer discussed the issue of self
harm with the man, who told him that he was not having suicidal thoughts and
expressed his relief at leaving A wing. His personal officer noticed that the
man immediately became more relaxed and stopped crying. His attitude
changed and he became happier.
49. When they arrived an officer on the landing had a conversation with the man,
explaining the rules of the therapeutic unit. A second officer told my
colleagues that the man asked not to share with anybody else. Space was
available and the officer placed the man on his own in a double cell. They did
not discuss the reasons he had come to the therapeutic unit, but the second
officer observed that the man was ‘fine’ and seemed relieved to have been
moved. (The second officer finished his shift shortly afterwards, at 4.30pm.)
50. After he returned to A wing, the man’s personal officer decided to call the
violence reduction manager. However, the violence reduction manager was
December 2009 14
off duty and instead he spoke with the safer custody manager. In the
absence of the violence reduction manager (who would normally address
issues of bullying), the safer custody manager agreed to interview the man.
The purpose of the interview was to address the alleged bullying, rather than
the risk of self harm.
51. When they spoke in his cell on B1 landing at about 3.20pm, the man told the
safer custody manager that he had reconsidered asking for rule 45 protection
because of the negative associations this can have amongst other prisoners.
He was reluctant to open up to the safer custody manager or elaborate on the
nature of the bullying. The safer custody manager perceived that the man
was content to have been moved from A wing and no longer wished to get
another prisoner into trouble, for fear of potential repercussions. He admitted
that he had problems to deal with both inside and outside the prison and had
been misusing illegal drugs in custody on top of his daily methadone
prescription.
52. The Safer Custody Manager touched upon the issues of self harm and suicide
during the interview. The safer custody manager knew that the man had not
previously been subject to the ACCT process. The man told him that he had
not self-harmed in the past and had never considered taking his own life. The
man seemed optimistic and spoke about his fiancée, his forthcoming
marriage, his family and his imminent release.
53. The man expressed a preference for a single cell. The safer custody
manager checked that the man’s pupils were not dilated and satisfied himself
that he was not currently under the influence of drugs. He remembered the
man speaking coherently and appearing calm. The man seemed more
relaxed than the safer custody manager expected him to be following the
rapid move from A wing.
54. The safer custody manager organised for the man to speak about the alleged
bullying with the violence reduction manager the following day when he was
back on duty. He was satisfied that the man had been moved away from the
wing which was causing him anxiety and he thought that the therapeutic unit
was an appropriate place for the man to be held temporarily whilst the bullying
allegations were explored. Their interview lasted about 25 minutes.
55. Between approximately 4.30pm and 5.00pm, the prisoners on the therapeutic
unit were locked in their cells whilst other prisoners returning from workshops
to the main part of the prison went through the landing. During this period, the
man rang his cell bell twice. An officer went to his cell and spoke to him on
both occasions. The man was anxious that other prisoners were shouting and
calling him a ‘nonce’ (a slang term for a sex offender) because he had
considered asking for rule 45 protection.
56. The man was agitated and his behaviour concerned the officer, who tried to
reassure him that nobody was calling him names. The officer could not hear
any shouting and promised to have a chat with the man once the cells were
unlocked again. The man was convinced that other prisoners were talking
December 2009 15
about him and that he could hear a female voice, although there were no
female staff on the wing at the time. The officer thought the man’s anxiety
was not that unusual in a prisoner who had just moved to the therapeutic unit.
57. Just before 5.00pm, an SO came onto the wing. The officer told her that the
man had been behaving oddly since he arrived on the therapeutic unit. The
SO told the officer that she would talk to the man to try and resolve the
problem.
58. The SO told my investigators that the man appeared tearful, anxious and
paranoid. She spent several minutes chatting to him. He kept repeating his
concerns about being labelled a sex offender by the other prisoners. Because
of his agitated behaviour and irrational worries, the SO thought that the man
had probably been using drugs. His speech was rambling and she did not
feel that he was fully aware of his surroundings. He sat curled up on the
bottom bunk with his back against the wall and a blanket wrapped around
him.
59. Shortly afterwards, dinner was served and the man was the last to emerge
from his cell. He went to the back of the queue and then became agitated
and upset. He went back to his cell and slammed the door. The SO went to
speak to him and he told her that the other prisoners were calling him a
‘nonce’. She had watched him join the queue and told him that she had not
seen anybody speak to him. She expressed her concerns to the man that
drugs were affecting his behaviour. She offered to fetch his dinner for him
and he accepted. She gave him his meal on a tray and collected an empty
plate 15 minutes later. She was concerned that the man should eat and was
relieved to see that he seemed to have done so.
60. The SO noticed that the man seemed to be feeling cold and was shivering,
which she attributed to drug withdrawal. He told her that ‘it’s not the drugs
this time’, but the SO was sure that he was under the influence of something.
She told my colleagues that he ‘wasn’t making much sense’ and was
‘completely paranoid’. The man was confused and preoccupied with what
others were saying about him. She tried to reassure him and remind him that
there was absolutely no reason for other prisoners to imply he was a sex
offender. After speaking with the man for about another 15 minutes, she
offered to telephone the healthcare team to organise for a member of staff to
assess him in the morning and he agreed.
61. During interview, the SO said that she was not overly concerned about the
man when she telephoned the healthcare department and spoke to the doctor
shortly after 5.30pm. She knew that he had eaten and thought it would be
best if he got some sleep before being assessed by healthcare staff in the
morning. She did not think that the man needed to be assessed by the
healthcare team that evening. The SO told the doctor that the man was
tearful, ‘extremely paranoid’ and believed irrationally that the other prisoners
were implying that he was a sex offender.
December 2009 16
62. The prison doctor was writing up her notes in the healthcare department when
the SO telephoned. She recalled in interview that the SO told her that the
man needed to be assessed, but that it was not urgent. The doctor offered to
visit him immediately, but the SO told her that this was not necessary, and
that an assessment in the next couple of days would be sufficient.
63. They discussed the possibility of self harm, and the SO told the doctor that the
man was not expressing suicidal thoughts. The doctor remembered the SO
telling her that she knew the man quite well, that he had no history of self
harm and that he was ‘not that sort of [prisoner]’. The doctor was satisfied
that the SO’s opinion was valid and based on prior knowledge of the man.
She did not recall the SO suggesting that the man might be under the
influence of drugs. When the SO spoke to the investigators, she could not
remember if she mentioned her suspicions about drug use to the doctor.
64. When she was interviewed, the prison doctor remembered the SO saying that
the man needed to talk to somebody in the next few days to relieve his
anxiety. (The SO thought that she had asked for the man to be assessed the
following day.) The doctor knew that the man was in a single cell, and
thought this was probably the correct decision because of his anxiety about
the other men on the unit. She knew about the drugs find on 27 February,
and thought that this explained the man’s anxiety.
65. Because of the anxiety the man was experiencing, the doctor and the SO
agreed that he should be examined by a psychiatric nurse, who would be able
to spend more time with him. At the suggestion of the safer custody manager,
the prison doctor made a note in the ‘Patients’ Treatment and Appointment
Diary’ on 10 March stating that the man needed an urgent referral to a
psychiatric nurse. (Routine referrals can take up to three weeks, but the
doctor prioritised the man’s appointment to ensure that it took place within
three days.) She added in her diary entry that ‘wing staff were concerned’
about him. The doctor recorded that the man was in a single cell but was not
suicidal. She completed a ‘Crisis Intervention Request Form’ to make the
referral, marking ‘CPN’ (Community Psychiatric Nurse) at the top of it. (This
was not the correct form, but she knew that it would achieve the desired
outcome.) The doctor felt that the SO was satisfied with the outcome of their
conversation.
66. When talking to the SO on the telephone, the prison doctor did not realise that
the man was the same prisoner she had assessed in the segregation unit on
28 February. Had she made the connection, she told my colleagues that with
the benefit of hindsight, she might have been more alarmed about the
situation. There was a stark contrast in mood between the prisoner described
to her on the telephone and the man she met two weeks earlier.
67. Following her conversation with the SO, the doctor went to check the man’s
medical record for any history of self harm. She could not find the records.
(She told my investigators that the file had not followed the man as he had
moved around the prison, and was probably still on the detoxification unit,
where he spent his first couple of days. Prisoners’ medical records are
December 2009 17
supposed to remain in the healthcare centre, but can be taken away if, for
example, a referral is made. A tracer card should be placed in the filing
cabinet to indicate where the file has been taken.)
68. Because the man denied having suicidal thoughts, the SO did not open an
ACCT document. She went to tell him that he would be assessed by the
healthcare team the following day, and he seemed calmer. She told my
colleagues that nothing about the man’s behaviour suggested that he was
thinking of harming himself. She thought that his anxiety was related to drug
misuse.
69. Towards the end of the association period the man had blocked the
observation panel in his cell door with toilet paper. The SO told him that the
obstruction would have to be removed and he agreed. At about 7.15pm, all
the prisoners including the man were locked in their cells for the night. The
SO suggested that the man give his decision to move to the therapeutic unit
some thought overnight, and they would discuss it again in the morning. She
told him that the officers would make sure that the healthcare staff came to
assess him the next day. She advised the man to speak to one of her
colleagues if he had any further worries. The man seemed less distressed
and frantic and she considered that he had calmed down. He was still
wrapped in a blanket and shivering and the SO assumed that he was
detoxifying. During the late afternoon and early evening, she did not make
any entries in the wing observation book about her concerns.
70. Before he finished his shift, one of the officers also checked on the man at
about 7.45pm. The man was calm and the officer told him not to worry and
that he would see him the following morning. He would make sure that a
psychiatric nurse came over to assess the man. The man thanked him and
they said goodnight. The officer had no other concerns about the man when
he left for the night.
71. Another officer was responsible overnight for the four landings on B wing,
including B1. He was based in an office on the second landing where the cell
bell indicator panel is located. At the start of his shift, shortly after 7.45pm, he
completed a count of all the prisoners he was responsible for, looking through
the observation flap on each cell door. He told the investigators that he would
have checked on the man during the count. He said that the impression he
gained during the handover from the day shift was that there was ‘nothing to
be concerned about’ with regard to the man.
72. The officer responsible overnight said at interview that he knew the SO had
spent time with the man before the cells were locked and that he had been
anxious earlier in the day. (The officer said that the SO had passed this
information onto the orderly officer in charge of the running of the prison
overnight, who then told him.) However, the officer responsible overnight was
not aware that the man had been referred to a psychiatric nurse.
73. The orderly officer started his shift at 8.45pm. As part of his duties, he visited
each wing at various stages throughout the night to check on the staff. The
December 2009 18
orderly officer was visiting B1 landing at about 11.00pm when he noticed on
the indicator panel that the man had pressed his cell bell. Because the officer
responsible overnight was on another landing the orderly officer went to the
man’s cell and spoke to him through the observation flap.
74. During interview, the orderly officer remembered that the man was agitated
about the safety of his mother and girlfriend, who he thought might be in
danger. He was standing in his cell with the light on and seemed panicky and
tearful. He was worried that his family were being targeted by the IRA. The
orderly officer thought this unlikely and that his fear might have resulted from
recent television news coverage of a terrorist incident in Northern Ireland.
75. The man asked if he could telephone his mother’s address to check that she
and his fiancée were safe. During the night, prisoners cannot be unlocked
except in the event of an emergency. The orderly officer therefore told the
man that this was not possible. The man asked the orderly officer if he could
make the call on his behalf. Wanting to calm the man and reassure him, the
orderly officer said he would contact his mother for him. The man gave his
mother’s contact details.
76. Attempting to reassure him, the orderly officer told the man that he would be
gone for about ten minutes. He went away and did not actually make the
telephone call, because he did not wish to disturb the man’s mother very late
at night and unnecessarily worry her. He believed that the man’s anxiety was
not connected to any genuine threat to his family. Instead, he returned to the
man’s cell a few minutes later and told him that he had spoken with his
mother and that she was safe and well. Feeling that this news had calmed
him ‘right down’, he told the man to settle, get some sleep and call his mother
after unlock in the morning. The man thanked him.
77. The orderly officer felt that he had resolved the man’s anxiety. The man
seemed happier and so the orderly officer did not call the member of the
healthcare team working the night shift to assess him. The orderly officer told
the officer responsible overnight about his conversation with the man, but did
not record the incident in the wing observation book. Contrary to what the
officer responsible overnight told my colleagues, when the orderly officer
spoke to the man during the night, he said he was unaware of the concerns
the SO had had about the man’s state of mind in the early evening. The
orderly officer had no further dealings with the man during the night.
78. One of the prisoners in the cell opposite recalled the man repeatedly
activating his cell bell between 11.00pm and midnight and speaking with the
member of staff who responded. He remembered the man sobbing loudly,
but also recalled the efforts that the officer went to to calmly reassure him. (I
assume that the prisoner opposite witnessed the orderly officer checking on
the man.)
79. When he spoke to the investigators, the officer responsible overnight told
them that he had no contact with the man during the night and did not go to
his cell again after the initial count. He did not make any entries in the wing
December 2009 19
observation book about the man. He said the orderly officer had told him
shortly after 11.00pm that he had spoken to the man, but that the problem
was resolved, he was now fine and ‘there was nothing to worry about and no
need to check him’.
80. The officer responsible overnight did not believe that there was any reason to
make further checks on the man during the night. He said the man did not
activate his cell bell again after the orderly officer left the wing. He continued
to make regular checks on prisoners subject to ACCT documents, but did not
make random checks on other prisoners. The man was not checked again
after about 11.00pm.
10 March
81. At some stage in the early morning, the man hanged himself. He tied a
ligature made from a bed sheet around his neck and attached it to the slats of
the bunk above him. He tied a blanket around his knees and also attached it
to the bunk above. The officers who found him later that morning thought that
he had shuffled off the mattress, causing his body to bow, his weight to drop
and his windpipe to be crushed.
82. The officer who had left the previous evening returned for his next shift at
around 6.50am on 10 March. He arrived on B wing at about 7.00am and
spoke with the officer responsible overnight, who told him there had been no
problems during the night. Before the officer responsible overnight left, the
other officer began the day shift by accounting for all the prisoners, looking
briefly through the observation flap in each cell door.
83. Between 7.00am and 7.30am, the officer looked in on the man, believed him
to be sitting up in bed and said, ‘Morning, everything alright’. Glancing into
the dimly lit cell very quickly, the officer mistakenly thought that he was alive.
The unusual method the man had used to hang himself meant that he was
facing the door and appeared to be sitting on the bed. (His head was near the
window and his feet towards the door.) The man had hung a sheet over the
back of the bunk nearest the window, which prisoners often do to stop
daylight from waking them too early.
84. Returning to the B wing office, the officer met the orderly officer, who told him
about his discussion with the man during the night and the action he had
taken to calm him down. They confirmed that the man was due to be
assessed by a CPN later that morning. Because officers cannot unlock cells
on the unit without a colleague being present, the officer then waited for his
colleague to begin his shift. Once his colleague arrived as scheduled at about
7.30am, they began the process of unlocking the landing cleaners. The
cleaners placed a carton of milk outside each cell and then the two officers
began opening the other cells, with each officer taking one side of the landing.
85. At about 7.45am, the newly arrived officer unlocked the man’s cell to give him
his milk. He switched the light on as he opened the door and immediately
realised that something was wrong. He saw the ligature around the man’s
December 2009 20
neck and blood around his mouth. He sprang the lock on the door and raised
the alarm, calling to the other officer for immediate assistance. The newly
arrived officer went to the bed and supported the man’s weight whilst the
other officer untied the ligature around his neck. (The material was too thick
for the officers to attempt to use their ligature knives.) The other officer used
his radio to inform the control room of the emergency. Once he had helped
the newly arrived officer to untie the blanket from the man’s feet, they moved
the man from the bunk onto the floor of the cell.
86. The healthcare team, led by the practice nurse, rapidly responded to the ‘code
blue’ request sent over the radio. The practice nurse was allocated the call
sign ‘Hotel 3’, meaning that he was the designated first responder in the event
of a medical emergency. He brought the emergency response bag with him
and, upon arrival, asked for an ambulance to be called. Resuscitation was
not attempted. The man was cold and rigor mortis had set in, meaning that
his body had stiffened in the seated position in which he was found. (If rigor
mortis is evident prison staff are not expected to start resuscitation.) Blood
had drained to the base of the man’s body (this condition is known as
hypostasis). These observations allowed the safer custody manager and the
practice nurse to agree that the man had died earlier that night and they could
do nothing to save him. The man did not leave a suicide note.
87. The movements officer contacted the control room by radio at about 7.47am
to ask for an ambulance. The Ambulance Service records show that they
received a call from the prison at about 7.50am. The ambulance was mobile
at 7.52am, reached the prison at 7.56am and the paramedics arrived on B1
landing at 8.00am. They agreed that resuscitation should not be attempted
and attached an electrocardiogram (ECG) monitor to the man in order to
certify death.
88. The machine gave a false reading suggesting that a heart rate was present.
(My colleagues spoke to a variety of members of staff who attended the
emergency, and all concurred that the man died well before the officers found
him. He was cold, and could not be moved from the seated position the rigor
mortis had left him in.) In the circumstances, the paramedics were unwilling
to certify death without a doctor, given the confusing readings provided by the
ECG monitor. The readings were thought to be caused by the amount of
metal fixtures and fittings in close proximity to the man, which interfered with
the device. The healthcare principal officer (PO) offered to provide the
paramedics with the prison’s own ECG monitor, but it was felt that the best
option was to await the expert opinion of a doctor.
89. The head of healthcare contacted the control room and asked for the duty
doctor to be notified. She also asked staff to contact another doctor, who was
in any case due to come to the prison to hold a surgery at 9.00am.
90. The prison doctor does not carry a pager. She left home at 8.20am and
arrived at her practice at 8.30am. She did not receive a telephone call either
on her landline number before she left home or on her mobile telephone
before she went straight into a meeting at 8.30am. (When she returned to her
December 2009 21
mobile phone at about 10.30am, she noticed that she had missed calls from
the healthcare PO and immediately contacted the prison. She subsequently
went to the prison later that day to support staff members.) The doctor due to
hold a surgery told the investigators that she did not receive a telephone call
before she arrived at the prison at about 9.00am to begin her normal shift.
91. The Governor of Cardiff had reached B1 landing ten minutes after the man
was found. Another governor had arrived on the landing and agreed with the
duty governor that he would open the command suite (a designated office
next to the prison’s control room from where staff coordinate the response to
an emergency). When he arrived in the suite, the governor who had agreed
to open the suite found that the room was not ready for use. The ‘wipe clean’
wall boards were covered in writing from a previous emergency exercise. He
also found that the three keys used to open cabinets where emergency
materials are kept were not clearly labelled.
92. The two officers who found the man were both sent to a quiet room as soon
as healthcare staff arrived in the cell. At about 8.40am, one of the officers
was spoken to by the care team and then he and the other officer were sent
home by the duty governor at about 9.30am.
93. When the doctor who was due to hold a surgery reached the prison gate, the
head of healthcare had left a message for her and she was instructed to go
directly to B1 landing. Arriving on the unit, she looked at the ECG printout
and then went into the cell to examine the man. She was accompanied and
supported by the head of healthcare. The doctor checked for heart sounds
and breathing, and confirmed rigor mortis and hypostasis. She thought that
the man had been dead for several hours and certified death at 9.14am, an
hour and a half after he was found. The paramedics then left the prison.
94. Having identified the man’s next of kin, the Governor, the safer custody
manager and the prison chaplain left Cardiff at about 9.00am to break the
news to his family. They arrived at his mother’s house at 9.40am. Having
visited her, they then tried to telephone the man’s fiancée. Because they
were initially unable to contact her, they began the return journey to Cardiff.
However, they then managed to get in touch with the man’s fiancee and
retraced their steps to visit her immediately.
95. The man’s personal officer was asked by the police to identify his body later
that morning. A hot debrief meeting involving staff members present during
the emergency was held at 2.30pm that day. (This meeting allows staff to
discuss the effect the death has had on them and to identify any immediate
lessons which need to be learnt from the emergency.) At 3.30pm, the
Governor and a colleague visited the family again.
96. A confidential critical incident debrief arranged by the staff care and welfare
service was conducted over 17 and 18 March. Staff were provided with the
appropriate support following the man’s death and were offered the chance to
speak with the care team if they felt the need. The man’s funeral, paid for by
December 2009 22
the Prison Service in accordance with national instructions, was held on 24
March.
December 2009 23
ISSUES
Substance misuse
97. Before he entered prison, the man misused drugs (including heroin) and
alcohol. When he arrived at Cardiff, it was agreed that his prescription for
methadone would continue. He was maintained on the same daily dose of
65mg of methadone until 9 March.
98. The clinical reviewer is satisfied that the man was prescribed the appropriate
medication to assist a managed withdrawal from alcohol misuse. He
completed the main part of the detoxification process (a course of diazepam
on a reducing dose from 26 February to 4 March) but did not complete the full
14 day courses of carbmazapine and thiamine (intended to help with the side
effects of detoxification). The man appears to have chosen not to collect this
medication after 6 March. The reason he did not complete the detoxification
process was not recorded in his medical file. The clinical reviewer makes the
following recommendation, which I endorse.
If a prisoner does not complete the detoxification process, the Head of
Healthcare should ensure that staff note the reason why in their medical
record.
99. The man was referred to the CARATS team by a member of healthcare staff
on 2 March. The CARATS team received the referral on Friday 6 March and
arranged an assessment on the next working day, Monday 9 March. A
CARATS worker assessed the man. Normally, she said that prisoners with a
drug problem would be seen by her team within 48 hours of their arrival on the
detoxification unit. However, because the man was found with drugs on 27
February and taken to the segregation unit, the normal referral process was
interrupted. The man did not return to the detoxification unit and instead
moved onto A wing.
100. Given that the usual referral process was interrupted, I consider that the delay
in the assessment taking place was understandable. However, I am
concerned that the apparently slow internal postal system meant that the
referral took four days to reach the CARATS team. In order to avoid a similar
delay in future, sending referrals to the CARATS team electronically could be
explored by the management team.
101. When he spoke to the safer custody manager on 9 March, the man admitted
that he had been misusing illegal drugs as well as taking his methadone
prescription. He was found with a significant quantity of different illegal drugs
in his cell on his second day in Cardiff, and it was thought that he had brought
them into the prison from court. The man also had a number of small
packages secreted in his body which were confiscated. He seemed to have
used some of the drugs when he came to the attention of staff. The SO
noticed that his behaviour was odd when he was in the segregation unit
between 27 February and 1 March. He was disoriented and giggly and it was
thought that he was under the influence of drugs.
December 2009 24
102. The SO also thought that the man was under the influence of drugs a week
later in the afternoon and early evening of 9 March. She saw him shivering
and thought he showed signs of paranoia. However, the toxicology report
showed that the only substances present after death were methadone,
diazepam and carbmazapine. In other words, prescribed drugs in quantities
that were to be expected. The results confirmed that the man had not
misused illegal drugs before he died, although the toxicologist stressed at the
end of her report that,
‘In cases involving hanging, death may have occurred before any
ingested drug could be absorbed into the blood. Hence, it is difficult to
determine whether excessive ingestion of drugs has occurred
immediately prior to death.’
103. However, the clinical reviewer told my colleagues that, if the man had been
under the influence of drugs at about 5.00pm on 9 March (when the SO
became concerned about him), there would have been enough time (prior to
the orderly officers final conversation with the man at about 11.00pm) for them
to be absorbed into his blood stream and show up on the test results. (At the
earliest the man died around midnight.) The man’s stomach was empty,
indicating that he had not eaten his meal either, as the SO thought he had. It
seems almost certain that the man was not under the influence of additional
illegal substances during the afternoon and evening before his death.
104. As I have noted, the orderly officer spoke to the man around 11.00pm and
noticed that he was agitated and tearful. He was making baffling claims about
the IRA harming his family. It may be that he had taken an illegal drug at this
stage, and took his own life impulsively immediately afterwards. In these
circumstances, there is a remote possibility that the drugs had not been
absorbed into his system and therefore did not register in the blood and urine
tests completed by the toxicologist. However, I note that the orderly officer
thought that the man calmed down once he was told that his mother was safe,
which seems to indicate that his anxiety was not connected to drug use.
Bullying
105. When the man asked to be moved to the therapeutic unit on 9 March, he told
the personal officer that he was being bullied. He named a specific prisoner
and said that he was being accused of making racist remarks from his cell
window. (I note that staff told my investigators that the prisoner concerned is
white. The man was also white.) The man wanted to be moved for his own
protection. This happened unexpectedly and he had not given any indication
previously to staff that he was the subject of bullying. The personal officer
acted swiftly and appropriately by removing the man from A wing.
106. Once the man had been moved to B1 landing, his personal officer thought he
should be assessed by the violence reduction coordinator (who is responsible
for exploring allegations of bullying). However, the violence reduction
coordinator was not working that day, and in his place the safer custody
December 2009 25
manager, who works alongside him, conducted an interview with the man.
The man was reluctant to disclose any further details with regard to the
bullying. The safer custody manager arranged for the violence reduction
coordinator to interview the man the next day.
107. After the man died, two prisoners made claims regarding the allegation of
bullying. One wrote to his partner stating that the man had been threatened
by three black prisoners who accused him of being racist. Staff intercepted
this letter and this prisoner was interviewed by a governor and the violence
reduction coordinator on 11 March. He declined to elaborate on the allegation
during that interview.
108. On 12 March, the prisoner who shared a cell with the man told a member of
the CARATS team that he had heard about three black prisoners going into
the man’s cell. He implied that these prisoners were upset after rumours had
circulated about the man using racist language. This CARATs worker did not
find the cellmate’s account particularly credible. She submitted a Security
Incident Report.
109. Later that month, on 23 March, the safer custody manager and the violence
reduction coordinator interviewed the prisoner who the man had named when
he asked to be moved from A wing on 9 March. This prisoner denied knowing
the man well or having any significant interaction with him. Without
prompting, he alluded to drugs and said he had nothing to do with them,
which confused his interviewers.
110. After the man died, the cellmate asked to share a cell with the prisoner the
man had named on 9 March. Both men were subsequently monitored
covertly by staff. The cellmate transferred to HMP Shrewsbury on 31 March
and was later released, whilst the other prisoner was released from Cardiff on
7 April. (The cellmate has yet to be either questioned or charged in
connection with his alleged role in bringing drugs into Cardiff.)
111. My colleague interviewed the cellmate when he visited Cardiff on 16 March.
The cellmate said that he was not aware of any particular person bullying the
man. He confirmed that he had heard allegations of racism against the man
from other prisoners.
112. It was difficult for prison staff to substantiate the rumours that circulated after
the man died. Steps were taken to interview the prisoners who it was thought
might provide more detailed information, but they were reluctant to discuss
the matter any further. Their subsequent departures from Cardiff stymied
further lines of enquiry and meant that the investigators did not speak to them.
113. The prisoner who the man identified on 9 March alluded to drugs. Whatever
difficulties the man might have encountered were quite possibly linked to the
significant quantity of drugs he was alleged to have brought into the prison on
26 February. They were all confiscated the next day. Both the police and
prison staff suspected (with good reason) that the man had agreed to bring
December 2009 26
the drugs into custody to supply them to other prisoners. There were too
many drugs of different kinds to have been solely for his personal use.
114. The man presumably planned to take the drugs into Cardiff before he was
resentenced and secreted them on his person prior to arriving at court. The
drugs would have been worth a great deal more in prison than in the
community.
115. When the man returned from the segregation unit on 1 March, it seems likely
that he would have had to explain to other prisoners what had happened to
the drugs they were supposed to receive from him. A prisoner who was a
good friend of his told my colleagues that the man continued to promise drugs
to other prisoners after his supply was confiscated even though there was no
prospect of him being able to honour his promise. When the other prisoners
realised this, it seems safe to presume that they would have been displeased.
116. The investigators have been unable to substantiate either the claims of racist
remarks said to have been made by the man or the subsequent reprisals by
prisoners from a black or minority ethnic background. There is no evidence
that the man held racist beliefs or that he was involved in any previous racially
motivated incidents in custody.
117. It can be unhelpful to speculate on what often amounts to hearsay. The facts
tell us that the man arrived at Cardiff with a large amount of drugs on his
person. They were confiscated, which would almost certainly have had
consequences for him. The man told his personal officer that he was being
bullied and the personal officer acted quickly in removing him from A wing.
He was taken to the therapeutic unit for his own protection and was no longer
the subject of bullying. This was the appropriate measure for prison staff to
take at the time. The matter was followed up by the safer custody manager
and the violence reduction coordinator planned to meet the man on 10 March.
118. We cannot know what impact this stress had on the man. He did not leave a
suicide note. He does seem to have been worried about his family’s safety in
the hours before he died, albeit he was making irrational claims about the IRA
targeting them. It is possible that the man feared that they would be
victimised if he did not repay the debt he might have owed.
The Governor should remind staff of the importance of assessing the
vulnerability of any prisoner alleged to have committed a serious
offence within the prison.
Communication
119. A number of failures to communicate information may also have had an
impact on the man’s situation. When the CARATS worker interviewed him on
9 March, she had not been told about the significant amount of drugs which
the man was alleged to have brought into custody. She told my colleagues
that the information would have affected her assessment of the man’s drug
misuse and caused her to ask him different questions. The referral to the
December 2009 27
CARATS team came from the healthcare team after the man was released
from the segregation unit, rather than from the detoxification unit where the
drugs were found, which perhaps explains why the breakdown in
communication occurred.
The CARATS team should be informed when a prisoner is alleged to
have illegal drugs.
120. Similarly, the movements officer did not know about the adjudication
regarding the drugs find when he allowed the man to share a cell with his
cellmate when they left the segregation unit. Both men were alleged to have
brought drugs into prison, and both faced being charged with the serious
offence of possessing drugs with intent to supply them to other prisoners. In
these circumstances, allowing the men to continue sharing a cell was
something that should have been considered carefully. Whilst it was not
obligatory to separate the two men, it would have been good practice to avoid
the possibility of the two co-defendants influencing or interfering with each
other, and separate wings would have been more appropriate. The
movements officer was not privy to the relevant information, although he told
the investigators that it would not have affected his decision.
The Governor should consider whether it is wise for prisoners who are
jointly implicated in committing an offence in custody to share a cell.
Staff asked to locate the prisoners should be told the facts of the alleged
offence before they make the decision.
121. The prison doctor did not know the reason the man was held in the
segregation unit when she completed a Segregation Safety Algorithm on 28
February. She was unable to locate his medical record either, as it had not
followed him from the detoxification unit. She therefore made her assessment
without access to all of the pertinent information.
122. No history of suicidal thoughts or self harm was detailed in the medical record,
but the prison doctor would not have been able to know this. Although the
doctor’s dedication in checking the prisoners in the segregation unit and her
concern for the man are to be commended, healthcare staff should check the
prisoner’s medical record for relevant information before the algorithm is
completed. Prison Service Order 1700 requires the member of staff to record
their findings in the medical record after they have completed the assessment.
123. When she spoke to the SO on the telephone on 9 March, the prison doctor
was again unable to refer to the man’s medical record, which had still not
been returned to the central filing system in the healthcare centre.
The Head of Healthcare should review the movement of prisoners’
medical records to ensure that staff can promptly locate them.
The Head of Healthcare should ensure that all healthcare staff who carry
out Segregation Safety Algorithms consult the prisoner’s medical record
and make an entry about their findings.
December 2009 28
124. Late in the evening on 9 March, the orderly officer spoke to the man, who was
agitated and expressed an irrational fear about his family being targeted by
the IRA. The orderly officer dealt with the situation, tried to reassure the man
and left the therapeutic unit thinking that he had calmed him down. He told
my colleagues that he was unaware of the SO’s earlier interaction with the
man and the decision to refer him to a psychiatric nurse. (The officer
responsible overnight thought he had been told about the SO’s earlier
dealings with the man by the orderly officer, but the latter did not think he
knew the information when he spoke to the man.)
125. It is difficult to know whether the orderly officer would have made a different
decision (such as calling a healthcare worker across to examine the man) had
he been aware of similar concerns earlier that day and identified a pattern of
anxious behaviour. The SO had not noted her concerns in the wing
observation book on B1 landing, and the orderly officer did not make a note of
his later interaction either.
Staff should make clear entries in the wing observation book and the
prisoner’s wing history sheet when they have concerns about an
individual’s state of mind.
Whether an Assessment, Care in Custody, and Teamwork (ACCT)
document should have been opened
126. The investigators spoke to a considerable number of staff who met the man at
various times between 26 February and 9 March. None of them ever felt that
he was at risk of harming himself or taking his own life. At no stage was a
member of staff sufficiently worried about him to consider opening an ACCT
document. Throughout the man’s time in Cardiff, he was asked a number of
times whether he had considered harming himself, and on each occasion he
said ‘no’.
127. The man’s decision to take his own life was unexpected. This was not his first
time in custody. He had not been the subject of an ACCT document during
previous custodial sentences. There was no history of deliberate self harm
other than apparently accidental overdoses from misusing drugs. The man
was described as a good natured prisoner who fitted in with the prison regime.
He did not present as somebody who was particularly depressed or chaotic.
He knew that he would be released within a matter of weeks and he talked
about his forthcoming marriage.
128. However, as I have considered in the section titled ‘Bullying’, the man may
have had significant anxieties about the drugs confiscated from him on his
second day in custody. It seems likely that he brought the drugs into Cardiff
to sell them on to other prisoners. Even when he no longer had the drugs, it
appears that he continued (perhaps unwisely) to tell prisoners that he could
supply them. It is possible that he was trying to repay a debt by smuggling
drugs into Cardiff. If this was the case then his predicament may have been
aggravated when the drugs were taken off him.
December 2009 29
129. The man faced the prospect of a much longer prison sentence if he was
convicted of possessing drugs with the intent of supplying them to other
prisoners. He might not have been released as he hoped, within a couple of
weeks, but could instead have been remanded into custody until a trial was
held.
130. On 9 March, the man was interviewed by the CARATs worker in the morning
and the safer custody manager in the afternoon. Neither was given any
reason to believe that the man was thinking of taking his own life. The
CARATs worker remembered the man being optimistic and having a positive
attitude.
131. The safer custody manager assessed the man after he transferred to B1
landing. He had calmed down after being brought to the therapeutic unit by
his personal officer. The safer custody manager asked the man about any
suicidal thoughts, as did his personal officer when he escorted the man
across from A wing. (The personal officer noticed that the man’s mood
improved after he was removed from A wing.)
132. One of the officers noticed that the man became agitated later in the
afternoon after he settled onto B1 landing. He became anxious that the other
prisoners were labelling him as a sex offender even though they were not. He
continued to behave unusually, refusing to come out for dinner and sitting
shivering in a blanket on his bed.
133. From about 4.30pm on 9 March, the man’s state of mind seemed to
deteriorate. Having spoken to all four members of staff, my colleagues
consider that the officer, the SO, the prison doctor and the orderly officer
acted with the best of intentions. I do not believe they could realistically have
predicted that the man might harm himself. On balance, I am satisfied that it
is not reasonable to have expected them to open an ACCT document and
keep the man under additional observation.
134. All four staff were required to make difficult judgement calls. There were
certainly indicators that all might not be well, and the man presented as
irrational and agitated. However, he did not voice suicidal thoughts and there
was no supporting history of self harm. Staff showed considerable concern
when the man’s mood altered and took the action they thought appropriate at
the time.
135. An SO was sure that the man was under the influence of drugs in the late
afternoon and early evening. This seems to have been a reasonable
assumption given his history of substance misuse and his presentation on the
day. However, the toxicology report appears to disprove this assertion.
Although the man was experiencing feelings of paranoia and anxiety he had
not used drugs. The SO knew the man quite well from his previous stays in
Cardiff. She spent a considerable amount of time chatting with him, fetching
his meal and then calling the doctor.
December 2009 30
136. It certainly seems to have been an appropriate decision by the SO and the
prison doctor to refer the man to a psychiatric nurse the next day. He was
presenting with anxiety and seemed to be behaving oddly. The doctor offered
to visit him at the time, but the SO thought this was unnecessary. I consider
that this was a reasonable decision. The SO had spent time talking to the
man and knew that he had not been the subject of an ACCT document in the
past. She satisfied herself that the man was not having suicidal thoughts after
his arrival on B1 landing. Because there was no perceived risk of him
harming himself, the decision not to have him assessed by the doctor
immediately, but to book a less urgent appointment, was understandable.
137. In the Ombudsman’s report of an investigation of the self-inflicted death of
another prisoner at Cardiff in June 2007, I commented on a similar set of
circumstances:
‘Although his behaviour was bizarre, [the man] did not present as
suicidal. It was … reasonable for staff to consider him as non-urgent.’
138. The Ombudsman’s report of the earlier investigation commented on the
difficulties staff had in understanding whether the man’s symptoms of anxiety
and odd behaviour were due to drug withdrawal or mental health problems. I
suggested that a urine test or mental health assessment would have clarified
the situation. Whilst the SO arranged for a psychiatric assessment, there
does not seem to have been a facility available to dismiss or confirm her
suspicions about the man’s drug misuse. I therefore amend my
recommendation from the earlier report in the hope that it assists staff identify
why a prisoner’s mood has altered:
The Governor should consider whether urine drug tests could be carried
out on prisoners (with their consent) if they are behaving unusually and
staff suspect that they are experiencing serious withdrawal symptoms
or are under the influence of drugs.
139. The SO told the man about the appointment with the psychiatric nurse the
next day and checked that he had calmed down before she finished her shift.
An officer also checked that the man was calmer before he left for the night.
140. The orderly officer was the only other member of staff to have any contact
with the man that night. He took time to speak to the man more than once,
something confirmed by a fellow prisoner who was awake in a nearby cell.
The orderly officer listened to the man’s concerns and dealt with them calmly.
He offered reassurance and felt that he had reduced the man’s agitation.
141. It does not seem that the orderly officer was fully aware of the SO’s dealings
with the man earlier that evening (as I have already highlighted). Had the
orderly officer known that the man’s agitation was part of a pattern, it might
have affected his decision about what to do. The orderly officer told the
investigators that he would have taken the man over to the healthcare centre
and placed him in a cell with a camera if he thought there was a possibility of
December 2009 31
him taking his life. However, the man did not express any suicidal thoughts to
him.
142. The man’s death was unexpected and would seem to have been a very
sudden and impulsive decision. He never voiced his intention to any staff. He
planned for the morning by hanging a sheet over the back of his bunk to block
the sunlight coming through the cell window and stop himself being woken
early.
143. The man took deliberate actions to kill himself in the early hours of the
morning. He used an unusual method, tying two ligatures to the top bunk
and, I assume, shuffling his weight off the lower bunk. This meant that the
officer mistakenly thought that the man was sitting up in bed when he glanced
through the observation flap.
144. On balance, I am satisfied that reasonable decisions were made by staff
based on what the man told them. He did present as anxious and tearful on 9
March, but they took steps to help and reassure him, for example by moving
him onto a different wing, interviewing him, ringing the doctor and offering to
contact his family. I consider that the decision to refer him for psychiatric
assessment, but not to open an ACCT document, was justified based on the
fact that the man had never previously spoken about suicidal thoughts. For
the same reasons as I have just discussed, it was also not unreasonable for
staff to place him in a single cell for the night.
Confirmation of death
145. The man was found in his cell at 7.45am. My colleagues spoke to a number
of staff who attended the emergency, and there was no doubt in their minds
that the man had died several hours earlier. He was cold, his body was stiff
and fixed in a seated position. It is clear that rigor mortis had set in by the
time the man was found. In this situation, staff are not expected to start
resuscitation, as it is an indication that death has occurred.
146. The paramedics were called and reached the therapeutic unit at 8.00am.
They agreed that the man had died and attached an ECG machine for official
confirmation. Unfortunately, due to a fault, the monitor gave a false reading
and indicated a heart rate. Although all the healthcare staff knew the man
had died, the paramedics wanted a doctor to confirm death and override the
erroneous reading provided by their equipment.
147. The head of healthcare asked the control room to contact the duty doctor and
the doctor who was due to begin a surgery in the prison at 9.00am. The duty
doctor was available on her home landline until 8.20am, and on her mobile
phone until 8.30am. After this she went into another room at her surgery
away from her mobile phone. When she returned to it later in the morning,
she found messages from the healthcare PO.
148. The doctor who was due to begin a surgery did not receive a telephone call.
She arrived as normal at 9.00am at the prison gate, where the head of
December 2009 32
healthcare had left a message directing her to B1 landing and informing her
that there had been a death in custody. The doctor who was due to begin a
surgery made her way promptly to the therapeutic unit and, accompanied by
the head of healthcare, carried out the appropriate checks and certified death
at 9.14am.
149. It is unfortunate that the ECG monitor did not work as it should have done. It
is also regrettable that, despite the head of healthcare’s instructions, neither
doctor could be contacted earlier to avoid a delay of over an hour in
confirming death. Nonetheless, it is clear from the interviews that the man
died before his cell was unlocked. I am satisfied that all of the appropriate
measures were taken, and the paramedics acted with the best of intentions in
waiting for the doctor. The clinical reviewer makes the following
recommendation, which I endorse. (However, I note that the remit of the
Ombudsman’s investigation does not extend to the Ambulance Service, and
therefore I can only draw their attention to the recommendation.)
The Welsh Ambulance Service should satisfy themselves that their ECG
monitors are functioning correctly.
Post mortem results
150. Having viewed her son’s body, the man’s mother was concerned that it
seemed as if his fingers were broken. The post-mortem report concluded
that the man died as a result of hanging, after tying a ligature around his neck.
The author found that the man’s fingers were not broken but were bruised.
He commented,
‘There were a few marks of blunt force trauma, particularly bruises, on
other parts of the body, specifically two knuckles of the right hand.
None of these injuries were characteristic of ‘restraint’.’
151. The post mortem makes it clear that the man took his own life and there is no
evidence of any other person restraining him. The police investigation
similarly concluded that this was a self inflicted death. I hope that the
pathologist’s conclusion puts the man’s mother’s mind at rest.
Cell bell recording
152. The cell bell records for B1 landing on the night of 9 and 10 March could not
be retrieved after the man died, as the computer had developed a serious
fault. The prison was not able to say precisely when the computer developed
the error but staff said that it probably occurred at some point in the preceding
two or three weeks. The machine was corrupted beyond repair and had to be
replaced, leaving the prison without a cell bell recording system for over a
month afterwards. The data relating to cell bell records was initially retrieved
onto a CD-Rom, but was corrupted and could not be recovered.
The Governor should remind staff of the importance of regular checks to
ensure that the cell bell recording system is functioning correctly.
December 2009 33
Command suite
153. After the man was found, a governor went to open the command suite. (This
is located next to the control room and is the focus of communication whilst an
emergency is ongoing.). He discovered that the room was not ready for
immediate use. The ‘wipe clean’ wall boards were still covered in writing from
a previous emergency. The keys used to open cabinets where emergency
materials are kept were not clearly labelled.
154. I am pleased to learn that, when the governor spoke to my colleagues, he told
them that both problems were swiftly rectified. He said that new electronic
interactive wipe boards have been installed. They were used during a
subsequent emergency and found to be very effective. The keys and
cabinets in the command suite have now been clearly labelled to avoid any
further confusion.
Use of mobile phones during an emergency
155. When the investigators spoke to some members of staff, they expressed their
frustration at not being able to carry a mobile telephone during the
emergency. (In order to reduce the likelihood of prisoners gaining access to
mobile telephones, it is now an offence for staff or visitors to carry one inside
a prison.) On the morning the man was found, it was felt that the limited
communication afforded by landline telephones was insufficient for the
amount of communication required with external agencies such as the
coroner, police and doctors.
156. Since 10 March, it has been decided that, in the event of an emergency, staff
will be able to use six mobile telephones located in the command suite. They
are normally reserved for officers escorting a sick prisoner to hospital or the
unlikely event of both the radio net and landline telephones failing.
December 2009 34
CONCLUSION
157. I consider that the man’s death could not realistically have been predicted or
therefore prevented. A number of different staff showed appropriate concern
for him on 9 March and acted reasonably based on the information available
to them at the time. Their actions were well intentioned. Their judgement in
not opening an ACCT document was understandable. The man’s decision to
take his own life seems to have been both unexpected and impulsive. My
investigation has drawn particular attention to a number of failings to
effectively communicate information within Cardiff, and I hope that some
lessons can be learned in this regard.
December 2009 35
RECOMMENDATIONS
1. If a prisoner does not complete the detoxification process, the Head of
Healthcare should ensure that staff note the reason why in their medical
record.
The prison accepted this recommendation. The Head of Healthcare agreed
that nursing staff would provide the reason for a prisoner not completing a
prescribed detoxification process in their medical record.
2. The Governor should remind staff of the importance of assessing the
vulnerability of any prisoner alleged to have committed a serious offence
within the prison.
The prison accepted this recommendation, replying as follows:
‘Any prisoner who is alleged to have committed a serious disciplinary offence
is assessed, this is achieved by the completion of the Segregation algorithm
and the judgement of the adjudicating Governor.’
3. The CARATS team should be informed when a prisoner is alleged to have
illegal drugs.
The prison partially accepted this recommendation, replying as follows:
‘The CARATS Team will be informed once a prisoner is proven to have been
in possession of illegal drugs. There is a concern, especially for life sentence
prisoners who are subject to parole hearings, that if a CARATS File is initiated
on suspicion only, this might influence a decision regarding an individual’s
release by the panel.’
4. The Governor should consider whether it is wise for prisoners who are jointly
implicated in committing an offence in custody to share a cell. Staff asked to
locate the prisoners should be told the facts of the alleged offence before they
make the decision.
The prison partially accepted this recommendation, replying as follows:
‘Individuals can be located together if they are co-defendants of a crime in the
community. Once an offence is committed in custody this should not
automatically stop two prisoners sharing a cell as they may be a support to
each other. All facts should be provided to wing staff of the offence committed
within custody and a risk based decision can then be made regarding
location.’
5. The Head of Healthcare should review the movement of prisoners’ medical
records to ensure that staff can promptly locate them.
The prison accepted this recommendation. The Head of Healthcare has
issued a notice to healthcare staff regarding this matter.
December 2009 36
6. The Head of Healthcare should ensure that all healthcare staff who carry out
Segregation Safety Algorithms consult the prisoner’s medical record and
make an entry about their findings.
The prison accepted this recommendation. The Head of Healthcare has
issued a notice to healthcare staff regarding this issue and agreed to regularly
monitor compliance.
7. Staff should make clear entries in the wing observation book and the
prisoner’s wing history sheet when they have concerns about an individual’s
state of mind.
The prison accepted this recommendation. The Governor indicated that
quality control checks of personal officer scheme files and wing observation
books will be carried out.
8. The Governor should consider whether urine drug tests could be carried out
on prisoners (with their consent) if they are behaving unusually and staff
suspect that they are experiencing serious withdrawal symptoms or are under
the influence of drugs.
The prison accepted this recommendation. The Governor confirmed that
Cardiff conduct regular mandatory and voluntary drug testing.
9. The Welsh Ambulance Service should satisfy themselves that their ECG
monitors are functioning correctly.
No response had been received from the Welsh Ambulance Service at the
time the final report was published.
10. The Governor should remind staff of the importance of regular checks to
ensure that the cell bell recording system is functioning correctly.
The prison accepted this recommendation. The Governor has asked the
works department to remind staff of the importance of regular checks to
ensure that the cell bell recording system is functioning correctly.
THE FAMILY’S RESPONSE TO THE DRAFT REPORT
The Family Liaison Officer spoke to the man’s brother towards the end of
November 2009. He told her that the family did not wish to make any
comments about the draft report.
December 2009 37