Individual at Nottingham

Investigation into the circumstances surrounding the
death of a man on 30 September 2009, following his
release from HMP Nottingham
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2010
This is a report of an investigation into the death of a man, who died following
his release from HMP Nottingham on 30 September 2009. The man died less
than 12 hours after his release from prison. I have carried out this
investigation under my discretionary power to consider those deaths following
release from custody, where issues are raised about the care provided by the
Prison Service.
I would like to extend my condolences to the man’s family and to all those
affected by his death. I would also like to apologise for the delay issuing my
report, and for any additional distress this may have caused.
One of the Ombudsman’s investigators was appointed to carry out my
enquiries into the circumstances of the man’s death. In addition, a clinical
review was commissioned by Nottinghamshire Primary Care Trust, who
appointed a clinical reviewer to carry out the review. I am grateful for her
timely contribution to the investigation. I am also grateful to the Governor at
HMP Nottingham and his staff for their assistance during this investigation. In
particular, I would like to thank the prison’s liaison officer.
The man was released from Nottingham on 30 September. His death was
recorded at 9.38pm the same day. A post-mortem report concluded that the
man had taken heroin and died shortly afterwards, possibly as he had lost
tolerance to morphine.
I make one recommendation to the National Offender Management Service.
Jane Webb
Acting Prisons and Probation Ombudsman July 2010
CONTENTS
Summary 4
The investigation process 6
HMP Nottingham 7
Key findings 9
Issues 14
Conclusion 15
Recommendations 16
SUMMARY
The man was sentenced to 18 months imprisonment in September 2008 for
an alcohol related offence and was taken into custody at HMP Nottingham.
He was prescribed methadone daily (as he had been in the community) and
began attending a substance misuse programme. He also spent a short time
on Assessment, Care in Custody and Teamwork monitoring (ACCT, the
Prison Service monitoring system for those at risk of suicide or self harm) , as
he said he felt stressed and concerned about his housing situation.
The man remained at Nottingham for just over four months, after which he
was transferred to HMP Ranby and then on to HMP Stocken. Whilst at
Stocken, he was assessed by their Counselling, Assessment, Referral,
Advice and Throughcare (CARATs) Team. They identified that he had last
used heroin in November 2007 and had been on methadone for the last 18
months. The man said he did not want to work with the CARATs Team as he
was now free of drugs. On 16 June, he was released on licence.
On 30 July, the man committed a public order offence for which he was
recalled to prison. When he arrived back at Nottingham he told staff that he
had no fixed abode and no next of kin to record. He also said that he had no
problems with drugs or alcohol and had “been clean” for the last three
months. He said he did not want to be referred to the CARATs Team.
On 3 August, he was interviewed by a resettlement officer with a view to
discussing his offending behaviour and plans for his release. However, as the
man was due to be released on licence at the end of his sentence, the
responsibility for this fell to his probation officer. She carried out an Offender
Assessment System (OASys) review on the man the next day and noted that
being homeless was a major contributory factor in his offending behaviour.
She contacted Nacro (a charity which helps people find accommodation) on a
number of occasions, but was unable to get any reply (and still had not by the
time he was released).
A CARATs worker saw him on 23 September. She had only been alerted the
day before that he had previously had dealings with the CARATs team at
Stocken. The man told her that he did not want or need any support as he
had been drug free for some time.
The man was released on licence on 30 September. He met his probation
officer at 12.30pm that day. She had been unable to help him secure
accommodation and so he should report to the emergency accommodation
unit. He said he did not want to do this as it would be “full of drugs”. He was
disheartened and disappointed that he still had nowhere to live and said that it
had been pointless remaining free of drugs and alcohol. He said he intended
to drink later that day. He said he felt that if he committed a more serious
offence, his housing needs would be taken more seriously.
Police reports explain briefly what happened to the man later that day. It
seems that he did indeed drink some alcohol and at some point in the evening
became involved in a fight in the street. He sustained a head injury when he
fell to the pavement. Later that night he injected some heroin into his forearm
and fell asleep. His companion was unable to wake him and called for an
ambulance. The man was pronounced dead at 9.38pm, just 12 hours after he
was released from prison.
I make one recommendation to the National Offender Management Service.
This concerns communication between themselves, Nacro and other housing
organisations.
THE INVESTIGATION PROCESS
1. The Investigator was appointed to conduct this investigation after the
office was notified of the man’s death. She received all the necessary
paperwork shortly after he died and visited HMP Nottingham on 17
November 2009 to conduct recorded interviews with staff. One of the
people interviewed was the man’s Probation Officer. This was to find
out what happened to him after he left prison, and what support and
assistance he given to him.
2. Notices were issued to both prisoners and staff inviting anyone who
had information regarding the man to make themselves known to the
Investigator, no further witnesses came forward.
3. One of the Ombudsman’s Family Liaison Officers contacted the man’s
family to explain the role of the Prisons and Probation Ombudsman
and offer the opportunity to participate in the investigation. The man’s
family said they were frustrated at the lack of information they received
from the police surrounding his death. They were concerned about the
circumstances of his death and had not received all of his personal
effects either. The man’s mother also told the Family Liaison Officer
that the family had not been aware that the man had been in prison
prior to his death and did not know why he had been in custody. The
man’s mother spoke very positively about the contact she received
from the Governor at Nottingham. I hope this report answers any
questions the man’s family may have and helps them better
understand events leading up to the man’s death.
4. Nottinghamshire Primary Care Trust (PCT) were commissioned to
conduct a clinical review into the standard of care the man received.
The Clinical Reviewer led the review.
5. In response to the draft report, the man’s parents said it appeared that
their son was well looked after and treated fairly whilst at Nottingham.
They feel, however, that the man was let down by the Probation
Service who they believe did not do enough to support their son. They
feel strongly that had more been done to assist him in finding suitable
drug free accommodation on his release from prison, the outcome may
have been different.
HMP NOTTINGHAM
6. HMP Nottingham is a prison that serves the courts in the
Nottinghamshire area. The prison holds 550 prisoners. It has four
residential wings and a segregation unit. G wing is the first night centre
and induction unit which holds 130 prisoners. F wing is predominately
used as a drug treatment wing. Approximately 50 per cent of the
population are remanded by the courts, the remainder being convicted
prisoners either awaiting sentence or undergoing an initial assessment
of needs before transfer to a suitable prison.
7. Although there are full time healthcare staff, the prison does not have a
separate healthcare wing or area. A number of cells are allocated on a
wing which can accommodate prisoners with additional health needs.
This is known as ‘enhanced care’.
Her Majesty’s Chief Inspector of Prisons
8. Nottingham was most recently inspected by the HM Inspectorate of
Prisons in an unannounced short follow-up inspection in October 2007.
In her report, the Chief Inspector, said:
“Nottingham remained a generally safe prison, despite a
transient population with multiple needs. However, the
reception area was unchanged and remained unsuitable for its
task.
“Both detoxification and drug treatment arrangements had
improved with the introduction of the integrated drug treatment
system.
“Nottingham continues to provide reasonable resettlement
provision, although there was scope for improvement.”
Independent Monitoring Board (IMB)
9. An IMB is appointed to each prison by the Secretary of State for
Justice. Its members are made up from members of the local
community and are wholly independent of the Prison Service and the
prison’s management team. Each IMB is required to produce an
annual report to the Secretary of State about the prison, highlighting
good practice and areas of concern.
10. The latest report from the Nottingham IMB covers the period 1 March
to 28 February 2009. The IMB said:
“The strategic aim set out by National Offender Management
Service (NOMS) is ‘to increase the proportion of socially
excluded adults in settled accommodation and employment,
education or training’ and the harm caused by drugs alcohol
drives the resettlement work at the prison.”
“Referrals for accommodation within Nottingham City are made
through Gateway. This single point of access has cut down
options but HMP Nottingham prisoners are prioritised wherever
possible.”
Nacro
11. Nacro provides a range of services across England and Wales to help
people access basic services such as housing and education and
provide opportunities for re-habilitation.
Assessment, Care in Custody and Teamwork (ACCT)
12. ACCT is a care-planning system whereby staff can work together to
provide individual care to prisoners identified as being a risk of harming
themselves or of suicide. Any member of staff can open an ACCT on a
prisoner, and scheduled meetings are held to monitor and review the
prisoner’s care and progress.
Counselling, Assessment, Referral, Advice and Throughcare (CARATS)
13. There are drug workers in most prisons from organisations specialising
in the treatment of substance abuse. CARATS workers run
programmes, and offer counselling, support and referral to
rehabilitation centres to prisoners and on release. Access to CARATS
is voluntary.
Offender Assessment System (OASys)
14. The system is used as part of sentence planning. It is a risk
assessment tool to make a proper assessment of a prisoner’s needs
and to help select an appropriate prison for a sentenced prisoner.
KEY FINDINGS
15. The man arrived at HMP Nottingham on 17 September 2008 for an
alcohol related offence for which he was sentenced to 18 months
imprisionment. Upon his reception at Nottingham, he was seen by a
mental health nurse (RMN). He had been prescribed 60 millilitres of
methadone daily whilst in the community and it was noted that he took
drugs intravenously. The man was given one 20 mls dose of
methadone that evening with 40 mls prescribed daily from the following
day.
16. The man said he was concerned about housing issues and stress at
home so, after a week into his sentence the ACCT procedures were
opened. It was noted that he seemed very low and twice mentioned
the possibility of taking his own life. However, a day later, he said it
had all been a misunderstanding. He apologised for wasting time and
appeared happy and confident. The ACCT book was therefore closed.
17. On 8 October, the man refused his methadone treatment, as he said
he wanted to attend the gym instead. Staff were advised to withhold
treatment, although there is no further record to explain if this was done
and for how long.
18. It was noted in medical records on 2 January 2009 that the man was
attending a substance misuse programme. At some point his
methadone prescription had been reduced from 40 mls to 30 mls, but it
is not clear from the records when this happened.
19. He remained at Nottingham for just over four months when he
transferred to HMP Ranby. Three months later he moved to HMP
Stocken. On 20 April, the man was assessed by the CARATs team.
The CARATs worker identified that he had last used heroin in
November 2007 and had been taking methadone for the last 18
months. The man said he did not want to engage with the CARATs
team as he said that he knew what the triggers for a relapse were
(being homeless, bored and unemployed). He appeared to be free of
methadone, but was told that he could use the CARATs service if he
wanted to and his file would remain open. On 16 June 2009, he was
released on licence from Stocken.
20. On 30 July, the man committed a public order offence. The man’s
Probation Officer, thought the offence was serious enough for him to
be recalled to prison. In any event he was sentenced to four months
imprisonment and returned to Nottingham.
21. When he arrived back at Nottingham, it was noted at reception that he
said he had no next of kin and no fixed abode. He said at interview
that he had no problems with drugs or alcohol and no thoughts of
harming himself or of suicide. He said he had “been clean” for the last
three months. He did not identify himself as a drug user and, despite
being asked whether he had been referred to CARATs before, he did
not make himself known to staff. (Unless a prisoner is automatically
referred by staff because drug problems are evident or the prisoner
already has a prescription for methadone, it is for an individual to refer
themselves.)
22. However, all prisoners passing through reception are seen by a
CARATs team member. They explain what the service can offer,
reassure prisoners that the service is confidential, and mention the
assistance with alcohol issues and referrals that is available once a
prisoner is in the community. They also speak about harm reduction,
including the risks of injecting drugs and reduced intolerance following
abstinence. The man did not choose to speak to anyone from
CARATs.
23. On 3 August, he saw a Senior Officer (SO) (the Resettlement
Manager). The Resettlement Manager’s role is to interview all new
prisoners with regard to reducing offending and re-establishing
prisoners into the community.
24. The Resettlement Manager told the investigator that the purpose of the
interview is to discuss a prisoner’s accommodation issues, employment
training, education, finance and benefit problems and family issues.
On the day he saw the man, he had approximately 12 prisoners to
interview in an hour, so he was only able to spend about ten minutes
with him. The purpose was to gather information about the likelihood
of him re-offending. The Resettlement Manager added that, as the
man was due to be released on licence at the end of his sentence, his
probation officer, would be responsible for dealing with his
accommodation problems.
25. The probation officer carried out an OASys assessment for the man on
4 August. In the assessment she noted that, when he was previously
released from Nottingham, he did not have anywhere to live. She
believed that this was a factor in his offending behaviour. He had been
referred to a housing organisation, but did not attend. He had been
accepted on a Nacro housing list, to look at housing on release.
(Nacro housing in Derby and Staffordshire provides supported
accommodation for single homeless people in Derby and Stoke-on-
Trent. The probation officer contacted them on 3, 23, 24 and 28
September to check the status of the man’s application, but nobody
returned her messages. This matter was still outstanding when he was
released.)
26. The man told his probation officer that he had mainly lived on the
streets since 2001, although occasionally he was able to sleep at
friends’ houses. He said this would be the case when he was released
at the end of this sentence.
27. The man told his probation officer that he was drug free when he was
released from Stocken and had attended a detoxification programme
there. (The CARATs team at Nottingham later confirmed to his
probation officer that the man would not have a methadone prescription
on release and he had been free from methadone for eight weeks.)
The man told his probation officer that he had failed to attend a relapse
prevention session because he “couldn’t be bothered”. He said he did
not believe drugs were an issue for him anymore, but he had been
drinking alcohol which had led to his last offence. He said he tried to
take his own life a number of times over the last three or four years.
He had regularly thought about suicide, but these feelings had
diminished.
28. The man agreed on a plan of action with his probation officer. It
included remaining drug free, trying to reduce his alcohol consumption,
that he would attend any appointments with housing providers and
behave appropriately so as not to jeopardise his chances of obtaining
suitable accommodation.
29. On 10 September, the man was asked to supply a urine sample for a
drugs test. He failed to provide a sample. (The prison rules state that
prisoners are allowed to refuse to comply once, but will be tested within
a week.) He supplied a sample five days later. This was negative and
indicated that he was drug free.
30. Nearly a fortnight later, on 22 September, just over a week before he
was due for release, the man’s CARATs file arrived from Stocken. (It is
not clear why the file took so long to arrive at Nottingham, but it seems
likely that it was not known that the man had returned to prison.)
31. A CARATs worker, saw the man the next day. She told him she had
received a file from Stocken and wanted to know whether he had any
ongoing drug issues or needed any support. The man said that he did
not and that he had been drug free for some time. The CARATs
worker said that, as he was due for release in the next few days, she
could make an appointment with a local drugs intervention programme,
which he could visit after release. The man declined saying he was
fine. The man’s probation officer left him some harm reduction advice
(about the risk of taking drugs again and reduced level of tolerance to
drugs after abstaining) which is normal practice for prisoners due for
release. The probation officer told the investigator that, although they
obviously do not encourage drug use, if released prisoners do decide
to use then it is better to smoke, rather than inject, the drug. The man
signed to confirm that he had received the paperwork.
32. The man was released on licence from Nottingham on the morning of
30 September. The usual discharge checks were made but, as he had
not engaged with CARATs at the prison, he was not reminded about
the dangers of drug use after release.
33. The man’s Probation Officer completed a Form PD1 – Pre-Discharge
report (which she had faxed to the prison a few days before his
release). She confirmed that he did not have a discharge address.
She added that he had been accepted by Nacro, but they had not
confirmed whether a vacancy existed for him on 30 September. The
man was referred to emergency accommodation on release.
34. The man’s licence showed that his supervision began on 30
September and was due to expire on 16 March 2010. Conditions on
his licence included that he should be well behaved, not commit any
offence, keep in touch with his probation officer, and permanently
reside at an address approved by his probation officer.
35. A section on the need for additional licence conditions said:
“You are to comply with any requirements reasonably imposed
by your supervising officer for the purpose of ensuring that you
address your alcohol and drug offending behaviour problems,
including attendance at a substance misuse agency for an initial
assessment and support sessions if so required.”
36. The Probation Officer also requested that the man should be given a
higher discharge grant (£46 and an additional £5) payable to Derby
City Council. The man was offered overdose prevention information for
prisoners, but he wrote “N/A” when asked to sign for the paperwork.
37. The Senior Officer (SO) in reception recalled the man’s discharge. He
remembered asking about accommodation and whether anything had
been arranged. The SO in reception had no information about
accommodation, but he was to report to his probation officer as soon
as possible. The man told the Senior Officer that he did not normally
“do his full licence” and usually got recalled. He said “I’ll see you
before Christmas”. The SO in reception said the man seemed quite
happy, apart from the accommodation issue.
38. Although he was due to see his probation officer at 12.00pm, the man
arrived at 12.30pm. He said he did not know what time he had been
required to report, but just knew it was that day. The man’s probation
officer explained his licence conditions and what was expected from
him. They discussed his lack of accommodation. The probation officer
told him she had contacted Nacro, but had not heard back (she
contacted them again later that day, but still got no reply). She advised
the man to go to an organisation at Milestone House that provided
emergency accommodation in Derby. The man said he was not willing
to go there and saying that he did not want to live in a hostel because it
would be “full of drugs”. The probation officer said it was his best
option at that time, but he said he had a friend he could stay with. If he
was unable to stay there, he would remain homeless.
39. The man also said that he fully intended to drink alcohol that day and
would go back to prison because he had nowhere to live. He went on
to explain that he had friends who were a higher risk than him who had
been found accommodation on release. He said he may as well
commit a more serious offence, for example stabbing someone, as he
would then stand a better chance of finding somewhere to live in the
long run. The probation officer advised him against this. The man
added that as well as drink he might as well take drugs, as there was
no point in staying clean for so long. They discussed this at some
length and eventually his probation officer made another appointment
to see him on 1 October at 12.00pm. After the meeting, the probation
officer spoke to her supervisor about what the man had said about re-
offending and also spoke to the police. The police logged that these
threats had been made.
40. Reports from officers from Derbyshire Police explain what is known of
the man’s final hours. He had met another man, most likely the friend
he intended to stay with, who bought him a can of extra strong lager.
They went back to the man’s flat, where he fell asleep for
approximately half an hour. He got up to have a shower, although he
also fell asleep there. Finally he got up and went into town. He saw an
Asian man, and became verbally abusive towards him. The Asian man
made a telephone call, and two more men attended. One of the men
punched him in the face, he fell to the ground and hit his head. It is
possible there were additional blows. The men were eventually
separated and the man returned to his friend’s flat. Police visited the
flat, and were verbally abused by the man.
41. At some point later that night, he apparently had with him a bag of
heroin. It is not clear where or when he got this. It seems that he put
the heroin into a syringe and injected it into his right forearm. The
other man also took drugs. The man fell asleep on the bed, and his
friend on the floor. After a period of about 40 minutes, the man’s friend
noticed that he was lying face up on the bed and looked unwell. He
tried to wake him, but was unsuccessful. He rang for an ambulance
which attended at 9.10pm. The man was pronounced dead by
paramedics at 9.38pm.
42. A toxicology examination was held at the East Midlands Forensic
Pathology Unit at the University of Leicester the next day. The cause
of death was morphine and alcohol toxicity. The pathologist noted that:
“A period of incarceration within a prison would cause a loss of
tolerance. In addition to taking the morphine he has also in my
opinion imbibed alcohol ….. alcohol can potentiate the effects of
morphine and lower its minimal fatal concentration.”
43. Nottingham prison was informed of the man’s death the next day, when
police rang for any next of kin details. (They had noticed that he had
prison literature with him.) The prison did not have any information as
the man had not given any details on his reception into the prison.
44. The prison Governor wrote to the man’s family, which he passed to the
coroner to be forwarded. The letter expressed his condolences and
gave contact details, should the family wish to speak to him. A family
member did contact him and they had a long conversation about the
man. The Governor offered to pay for the man’s funeral, which the
family accepted. The Governor and the Liaison Officer attended the
funeral, on 3 November, and the Liaison Officer provided on-going
support to the family, helping to fill in the gaps since their last contact
with him. The family spoke very positively about help and support they
received from the prison which they should be commended for.
ISSUES
Records from previous prisons
45. It took at least eight weeks for the CARATs records from Stocken to
arrive at Nottingham. As the man did not make himself known to the
CARATs team at Nottingham, they were unaware of his previous
involvement until the files arrived. However, Stocken knew that he had
been released on licence and would not have immediately known that
he had been recalled to Nottingham. Whilst I make no formal
recommendation, I suggest that the system for ensuring that prison
records are forwarded between prisons is reviewed for its
effectiveness.
Drug tolerance advice
46. The man was again given advice by the CARATS team on his
reception into Nottingham and during his meeting with his probation
officer. He was warned that taking drugs again after a prolonged
period of abstinence could be dangerous. He was also offered leaflets
on his discharge from the prison which also explained this. However,
he signed a discharge form to say “N/A” meaning the forms were not
applicable to him.
Accommodation
47. It appears that the man’s concerns about his lack of accommodation
were a big factor in his attitude to offending and alcohol and drug
taking. The prison’s resettlement team were not responsible for
assisting him, as he was to be released on licence and the
responsibility therefore fell to his probation officer. She attempted to
secure somewhere for him to live via Nacro, whom she contacted on a
number of occasions. It seems that the probation officer never
received a reply from them and so could only refer him to emergency
accommodation on release, where he did not want to go. It is clear
from his discussion with the probation officer after his release, that he
was disheartened about the lack of help, and that he felt that avoiding
drugs and alcohol was pointless. It appears that his probation officer’s
help was limited and there was no other alternative that she could
suggest. Although I cannot be certain that this contributed to the man’s
decision to take drugs and drink later that day, it seems to have been a
major factor.
The National Offender Management Service should look at ways to
improve communication between Nacro and housing associations.
CONCLUSION
48. When the man was recalled to custody on 31 July and returned to
Nottingham prison, he said that he had no alcohol or drug problems.
Records from his time in other jails suggest otherwise but did not arrive
at the prison with him as he was a licence revokee who had been
released from another prison.
49. The man was offered the services of the CARATs team, but said he
was drug free and did not require any support. However, it seems that
an area where he did need support was to find him accommodation
upon his release. It appears that he attributed much of his offending
and lifestyle to the fact that he had nowhere to live.
50. The Resettlement Unit at the prison deal with prisoners who are not
released on licence, but leave the prison at the end of their sentence.
As he was released on licence, it fell to the probation officer to try to
help him secure accommodation.
51. His Probation Officer did try to help the man find somewhere to live, but
her attempts to contact Nacro proved fruitless. During his meeting with
his Probation Officer on 30 September, he seemed frustrated that he
remained homeless, thought he would be better off in prison, and
threatened to commit a more serious offence to stand a better chance
of accommodation.
52. It seems that the man met a friend who offered him somewhere to stay.
At some point during 30 September, he drank alcohol and injected
heroin. As he had been free from drugs for some time, it is likely that
his intolerance led to his death.
RECOMMENDATIONS
To the Probation Service:
1. The National Offender Management Service should look at ways to
improve communication between Nacro and housing associations.
This recommendation was accepted.