Individual at Leicester

Investigation into the circumstances surrounding the
death of a man at HMP Leicester
in November 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2010
This report considers the circumstances surrounding the death of a man at HMP
Leicester on 16 November 2007. The man, who had come to this country from India
in 2004, was found hanging in his cell at approximately 7.05pm. I offer my sincere
condolences to all those touched by his passing.
The investigation on which this report is based was conducted by two of my senior
investigators in succession to one another. I would like to thank the Governor and
the Deputy Governor (who was Acting Governor at the time of the man’s death) for
their cooperation, and that of their staff. I am also grateful to the clinical reviewer
from the local Primary Care Trust for a comprehensive and thorough clinical review
of the man’s care while in custody.
The man who died spoke Gujarati and had no command of English. This made his
time in prison difficult. Staff at Leicester experienced great difficulty in
communicating with him without the use of an interpreter. This is an increasingly
common problem within the prison system, and staff use interpretation services such
as Big Word or Language Line. However, these services are impersonal and
difficulties can arise when interpreters do not understand prison systems or
terminology. As a result, bilingual and multilingual prisoners are often asked to help
translate. Such informal arrangements can work well on day to day matters.
However, they can be problematic when confidential and medical matters need to be
discussed. There is no easy answer to this dilemma. The solution would require
language training for staff, increased resources, or a prison specific translation
service. In the meantime, staff depend on the goodwill of prisoners to provide
communication links.
The language barrier aside, the man did not appear to experience any problems at
HMP Leicester. Staff said that he did not seem depressed. He never spoke of
intending to harm himself to his peers, staff or his solicitor. It is clear from interviews
with his solicitor and his cellmate that his frustrations stemmed from his court case
and a deep sense of shame around his offence. Sadly, he hid the extent of these
feelings and appeared to be coping. Whether this was due to his sense of pride or
because he felt unable to communicate through informal or formal translators is
impossible to say.
Since April 2004, there have been nine self-inflicted deaths at HMP Leicester. As I
discuss in this report, the family liaison support in this case was not consistent in
dealing with next of kin. This issue also arose during my last investigation at
Leicester.
I must apologise for the time taken to issue this report. I have made seven
recommendations.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2010
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CONTENTS
Summary 4
The investigation process 6
HMP Leicester 7
Key findings 8
Issues:
Healthcare 19
Language barrier 21
Window bars 22
Literature for life sentence prisoners 22
Education 23
Food 23
Hot debrief and defibrillator 23
Family liaison 24
Post mortem 26
Conclusion 26
Recommendations 28
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SUMMARY
The man who is the subject of this report was arrested in connection with serious
offences on 6 August 2007. He was interviewed under caution through an
interpreter as he could not speak English, and was represented by a duty solicitor.
On 8 August, he appeared in court. He was remanded into custody at HMP
Leicester. This was his first time in prison.
The man’s family were present at court. He told them that he was unhappy with his
legal representation as the solicitor did not speak his native language, Gujarati. The
family arranged for him to be represented by another firm of solicitors. No problems
were foreseen because he had not yet given any instructions to the first solicitor.
On arrival at prison, the man was both medically and risk assessed. The
assessments took place with the assistance of prisoner who spoke Gujarati. The
man was happy with this arrangement and staff found it easier than using the
telephone translation service.
An officer in reception wrongly recorded the nature of one of his alleged offences.
This resulted in him being incorrectly identified as a potentially vulnerable prisoner.
The officer completed the process to segregate him from the main part of the prison
for his own safety. It is not clear whether he had requested this or if the decision had
been made on his behalf. The officer who started the process does not recall what
prompted it.
The mistake was quickly realised and the man was not segregated as planned.
However, he was still placed in a double cell with another prisoner. My investigator
was unable to determine whether his request to share a cell with a Gujarati speaker
was fulfilled.
The man spent four uneventful months in prison. He attended English language
evening classes and made friends with other Gujarati speaking prisoners. He
occasionally shared cells with English speaking prisoners. This made him unhappy.
With the help of his peers and his solicitor he asked to share a cell with someone he
could speak to. During October 2007, he was moved up to the enhanced prisoner
landing to share with a Gujarati speaker.
Aside from the language barrier, the man does not appear to have had any other
problems at the prison. He did speak to his peers and his solicitor about the
difficulties with his legal representation and the court case. In addition, he expressed
deep shame regarding his offence. He was worried about how he would be
perceived by his community and the effect it might have on his family.
Although he often spoke about these matters with his solicitor and his peers, it was
made clear to my investigator that no one found him to be depressed or suicidal.
Had he shown such feelings, his peers and solicitor assured my investigator that
they would have felt comfortable in approaching staff for help.
On 14 November, the man attended a court hearing. The issue of securing his
desired legal representation remained unresolved. As in previous hearings, the
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judge maintained that he should remain with his original solicitor. The man was
upset by this. On returning to prison, he spoke to his cellmate about the hearing and
reiterated that he was ashamed of his situation and how it was affecting his family.
The cellmate told my investigator that although he was upset he did not notice any
heightened cause for concern.
Two days later at 7.05pm on 16 November 2007, the man was discovered hanging
in his cell by two prisoners who were on the landing undertaking their cleaning
duties. He had been alone in the cell for approximately one hour as his cellmate was
working. The prisoners alerted staff by shouting. Two officers immediately entered
the cell, lifted him up, and cut down the ligature. The officers began cardio
pulmonary resuscitation. At 7:10pm, an ambulance was called and prison
healthcare staff attendance was requested. Nurse B arrived at the cell at 7.14pm
with the emergency response bag. She found that the man had no signs of life and
continued resuscitation.
The prison doctor arrived at the cell at 7.18pm. He requested that the defibrillator be
brought to the cell. As this request was made, the paramedics arrived. The
paramedics confirmed there were no signs of life and that the man had died.
The response to finding the man was quick. Staff acted appropriately and I make no
substantial criticism of their actions. However, I have commented on the fact that
there was only one defibrillator in the prison and on its location. I have also raised
concerns over events after the man’s death, namely the family liaison support and
the hot debrief held for staff later that evening.
Regarding events prior to his death, I have discussed the difficulties in providing care
for prisoners who do not speak English. Whilst he did not have any documented
problems with staff care at Leicester, it is clear that his period in custody would have
been easier if he had been able to speak directly to staff. Leicester provided an
appropriate standard of care within the resources available, and it is not possible to
say if events would have been different had he been able to fully communicate with
those around him.
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THE INVESTIGATION PROCESS
1. One of my Senior Investigators opened the investigation on 20 November 2007
and arranged to visit the prison the following day. During her visit she
discussed the issues surrounding the man’s death with the Acting Governor.
She was provided with all documentation relating to his time in custody. Whilst
at the prison, she spoke to the man’s cellmate but did not formally interview
him.
2. The investigator left my Fatal Incidents Team in February 2008 to take up
another post. Her investigation was passed to another of my Senior
Investigators in March 2008 for completion. I apologise for the delay this has
caused.
3. The investigator conducted interviews at HMP Leicester during May and June
2008. Healthcare related interviews were conducted with the clinical reviewer
from the local Primary Care Trust. He submitted his clinical review findings on
17 July 2008.
4. One of my family liaison officers (FLOs) contacted two branches of the man’s
family – his daughter and his second cousin’s family, who were listed as his
next of kin on his prison records. This was to explain the scope of the
investigation and provide the opportunity to ask any questions or raise
concerns for consideration.
5. It has become apparent during the course of the FLOs contact with the family
that the prison’s FLO has unintentionally given primacy to the second cousin
and his wife. The man’s daughter’s needs were not handled with the same
speed or courtesy. This has caused his daughter some distress. My
investigator and FLO have had numerous discussions with the prison’s family
liaison officer to try to make sure that both parties were treated equally. Whilst
there were some improvements, I do not believe the way the two branches of
the family have been treated was even-handed. This is an issue that I have
encountered during an earlier investigation at Leicester, and I have discussed
this at greater length in the Issues section of this report.
6. My investigator was asked by the family members to consider the following
questions during the course of her investigation:
(cid:127) How was the man able to secure a ligature to his cell window?
(cid:127) Did he attend education and was he learning the English language?
(cid:127) What kind of food did he eat during his time in Leicester?
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HMP LEICESTER
10. HMP Leicester is local prison situated in the centre of the city. (A local prison
serves the courts and predominantly holds prisoners who have been remanded
in custody pending their court cases or who are serving short sentences.) It
was built in the Victorian era and has an operational capacity of 385 prisoners.
11. The main residential unit is situated in one building. The first level comprises a
first night centre, segregation unit and violence reduction unit. The second
level has a self-contained detoxification landing and vulnerable prisoners unit.
The third and fourth levels are standard prison accommodation. The upper
third level has an allocated area of cells for prisoners who qualify for enhanced
status under the Incentives and Earned Privileges scheme (a process to
encourage and reward good behaviour in prison). Only prisoners who have
been at the establishment for over 12 weeks, and can demonstrate they have
earned enhanced privilege status, reside on this part of the landing.
12. The most recent published report (August 2006) by HM Chief Inspector of
Prisons comments on incidents of suicide and self-harm at Leicester. The
report states that by August 2006 there had been nine deaths in custody over a
period of 28 months. She found that the timescale for implementing
recommendations from the inquiries into these deaths was unacceptably long
and that the processes in place for preventing self-harm and suicide -
Assessment, Care in Custody and Teamwork (ACCT) - was not effectively
managed
13. HM Chief Inspector of Prisons report found that services to and for foreign
national prisoners remained underdeveloped. Although the race relations
officer (RRO) post had become full-time, there was still much to do in this area.
There was limited evidence that the telephone translation service was used and
no overarching policy to ensure that consistent support was available to foreign
national prisoners. However, she found the quality of investigation and
resolution of reported racist incidents was good. She recommended that a
clear foreign national prisoner policy be drawn up and implemented. Another
inspection took place in June 2008, but the report has not yet been published
and I am not acquainted with its findings.
14. The annual report of the prison’s Independent Monitoring Board’s for 1
February 2007 - 31 January 2008 found that the role of the RRO had now been
well established. At the time of this report, foreign nationals at Leicester made
up 24 per cent of the prison’s population. Since the beginning of the reporting
year, all new receptions had received an induction talk from the race equality
officer (REO), and information books were available in 12 different languages.
Software had been purchased to translate other documents issued to prisoners
into these languages. New staff are also given an induction talk from the REO.
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KEY FINDINGS
15. The man was arrested on 6 August 2007 and taken to a police station. At the
station, the police interviewed him with the assistance of an interpreter and
provided a duty solicitor. The man denied he had committed offences, declined
to answer any questions, and refused to give any account for his actions. He
was kept in police custody overnight.
16. During the evening, he was given a medical examination and deemed fit for
detention. Details of his previous medical history of heart problems, the
removal of his right kidney and ‘alcohol intoxication’ were recorded. He was
issued with his prescribed medications:
(cid:127) isosurbide mononitrate 60mg (to reduce or prevent angina)
(cid:127) atorvastatin 10mg (to lower blood cholesterol)
(cid:127) atenolol 25mg (to treat cardiovascular diseases such as hypertension,
angina, coronary heart disease)
(cid:127) aspirin 75mg (used in low doses over long period as part of managing
angina and preventing a heart attack).
17. At 5.15pm on 7 August, the man reported experiencing chest pains and
paramedics were called to attend to him. He did not require any further
emergency assistance and declined to go to hospital. (The paramedics’
paperwork is dated 7 July 2007, but this is incorrect as he was not in custody
during July.) The prisoner escort record (PER) form has an entry by escort
staff which confirms that the incident took place before his court appearance on
8 August.
18. During his court appearance, the man was charged with threats to kill and
attempted murder and remanded in custody. He was taken to HMP Leicester.
This was his first time in prison. He had told his family that he was unhappy
with his firm of solicitors, as they did not speak his language, and he did not
want them to represent him. Later that day, the man’s family contacted
solicitors that they were familiar with and asked them to provide representation.
The firm has a couple of solicitors who speak Gujarati. No problems were
expected in revoking the legal aid costs and changing solicitors, as the man
had not yet given instructions to the first solicitor.
19. On arrival at prison, a member of prison staff misinterpreted the man’s charge
and wrongly recorded his alleged offence as being against a child. He was
then risk assessed by reception staff. (This assessment is to determine
whether a prisoner is able to share a cell and if they have any immediate needs
such as medical or mental health concerns). It was noted that he could not
speak any English. Fortunately, one of the other prisoners returning from court
was a Gujarati speaker. He was able to act as a translator under the man’s
instruction. (If the other prisoner had not been present, I understand that
reception staff would have used a telephone translation service called Big
Word.) It was recorded on the man’s cell sharing risk assessment form (CSRA)
that he would prefer to share a cell with someone who could speak Gujarati.
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20. Part of the reception process is to have an initial health screen conducted by a
nurse. A second and more in-depth health screen follows the initial
assessment within 24 hours. At Leicester, the first and second health screens
are held in sequence, during the same sitting. A nurse conducts the first
screen followed by the prison doctor. Both are present in the room throughout
the two screens. In the man’s case, Nurse A and Dr C undertook the
assessments with the assistance of the other prisoner. Neither Nurse A nor Dr
C was given any documents (a prisoner escort record or police forensic medical
examination record) that accompanied the man into prison to inform their health
screens.
21. Nurse A stated at interview that the man appeared to be comfortable talking to
the other prisoner and that his presence was helpful. She told my investigator
and the clinical reviewer that she has used Big Word on a number of occasions.
However, she said she sometimes has problems with the interpreter
understanding what she is trying to ask the prisoner concerned. Dr C had had
no experience of using Big Word to interpret, but had occasionally used other
prisoners brought over from the wing.
22. During the health screens, Nurse A and Dr C made a record of the man’s
existing heart and kidney problems. Part of the health screen process is to
identify any mental health issues. He was assessed as having none and gave
a negative response to questions about self-harm. He was asked whether he
drank alcohol, to which he answered “no”. He answered “yes” to the question
“do you think there is any reason why you might need to see a doctor?” but did
not elaborate. It was concluded by the healthcare staff that no immediate
action was required.
23. It is good practice after the health screens take place for a prisoner’s
community general practitioner (GP) records to be obtained, particularly when
there is an existing medical history. The man signed a ‘Medical Information
Sharing Consent Form’, but there does not appear to be any record of contact
being made with his GP.
24. After the completion of the CSRA and health screens, the man was placed in a
cell in the first night area with another prisoner. My investigator was unable to
ascertain whether his cellmate spoke Gujarati. He was taken through the
induction process on the first night centre using the Big Word. The induction
paperwork relating to him does not indicate whether he received an information
pack. Induction officers told my investigator that the documentation is
translated into a large number of languages. The man had not signed to
confirm that a booklet had been issued to him, and therefore it was not possible
to determine whether he received one in his language or not.
25. The following day, based on the incorrect listing of the man’s offence, it was
decided that for his own safety he should be placed on Rule 45 – segregation
for his own safety. (Prisoners are segregated for two reasons, either for their
own interests/protection or as a matter of good order and discipline.) It was
decided that he should be segregated for his own safety based on the
incorrectly noted information that his offence was against a child. Such
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offences can attract abuse from other prisoners or lead to other vulnerabilities,
such as risk of self-harm. There was added concern over his potential
vulnerability due to his limited English language skills.
26. Governor D approved the application for segregation under Rule 45 processed
by wing staff. Officer E wrote in the man’s history sheet (a record of events
kept for each prisoner) that he had asked to apply for segregation. The
investigator interviewed Officer E but, due to the time lapsed between his
contact with the man and this investigation; he was unable to recall the incident
in any detail. Officer E told the investigator that he recognised the man on
being shown a photograph, but he did not remember how the application for
Rule 45 came about. It is not possible, therefore, to say with any certainty
whether staff suggested he should be placed on Rule 45 for his own safety, or
whether under guidance from staff he made the request himself. If he made
the request, it is probable that he did not fully understand the circumstances
surrounding the application as he would have known that his alleged offence
was not against a child. I cannot find any logical reason to suggest why he
would have made this request.
27. The Rule 45 application was signed and approved by Governor D at 9.20am on
9 August, with a review set for 72 hours later on 11 August. Nurse B completed
an initial segregation safety screen. She concluded that there was “no
apparent clinical reason to advise against segregation at this time.” The cell
sharing risk assessment indicated that there was ”reason to suspect that the
prisoner is abusing drugs/alcohol,” but it is not clear what information this was
based on because the man’s reception health screens make no reference to a
history of alcohol misuse. The only place this was recorded was on the police
forensic medical examination form, which the nurse and doctor both said they
had not seen.
28. Later that day, staff recognised that an error had been made when recording
the nature of the man’s alleged offence. The decision to segregate was
overturned and he was placed in a shared cell. Governor D said during
interview that, had he been segregated, he would not have been placed in the
segregation unit with prisoners subject to Rule 45 for discipline reasons. He
would have been placed briefly in a cell for Rule 45 prisoners in the first night
centre. Prisoners are located there if there are no spaces available in the
vulnerable prisoners unit. The man would have been placed in a cell with
another vulnerable prisoner under Rule 45. It is not known whether his
cellmate at this time was a fellow Gujarati speaker. However, Governor D was
told by staff that there were other speakers in the prison that the man socialised
with during association time.
29. Through access to the man’s prison records, the investigator and the clinical
reviewer had sight of a handwritten, undated note from the man’s solicitor. The
note requested “referral to see a Doctor” and notes the man’s inability to speak
English, his heart condition, high blood pressure and his need for medication.
On the note is an entry from prison staff recording cell number L2-06. The
investigator cross-referenced this location with his cell movements record. The
record does not indicate the date in which he moved into the cell (other than
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some time after 9 August), but does show that he moved out of that cell on 24
September.
30. My investigator was initially concerned that the need for a solicitor’s note to
explain his medical conditions meant there might have been a gap in the man’s
medication prescription. The investigator and clinical reviewer were told by Dr
C during interview that the man’s medication was issued after his health
screens. The man had a prescription slip on his person on entering prison,
which confirmed his medications. As evidenced by his prescription chart, he
did not go without medication at any stage.
31. The man was assigned a personal officer during August. (A personal officer is
a member of staff on the wing that a prisoner can approach if they have any
problems or concerns. In Leicester, personal officers are responsible for a set
number of prisoners, allocated by cell number. If a prisoner moves cell they
might find that their personal officer changes.) The first personal officer entry in
the man’s history sheet is by Officer F on 28 August. It reads:
“A quiet individual who cannot speak or understand English very well.
Has been told by other Asian lads the rules and regime and general
workings of the prison. No queries and no problems.”
32. Officer F made one other entry on 10 September which noted that the man was
polite, respectful and adhered to the rules and regimes. The investigator did
not interview Officer F, but did speak to two of his other personal officers who
said that conversations with the man were either limited to using gestures and
miming actions, or using a third party who could translate. This is clearly not an
ideal forum for discussing or raising potential concerns. Whether the man
genuinely had no concerns or queries at this stage is difficult to determine.
33. The man enrolled with the education department to help him learn English. My
investigator was unable to determine when his lessons started, but she did
speak to his teacher. The man attended her evening classes. These were held
on Monday and Thursday evenings. The class was to help non-English
speaking prisoners learn the language. She described the man’s English
language skills on entering the class as non-existent. She said that, as he
progressed, the man was able to give a basic greeting, but she was not
confident that he understood what he was saying. His teacher described him
as a very pleasant, kind and friendly man who was always smiling during class.
She said that he never appeared low in mood or depressed.
34. Although the man was on remand, due to the seriousness of the charges
against him he had been identified as a possible life sentence prisoner if
convicted. When a prisoner faces such serious charges, the implications of a
life sentence are explained in advance. Officer G, a lifer officer (an officer who
deals with the needs of life sentenced prisoners), held an initial interview with
the man on 1 October. With his agreement, another prisoner assisted Officer G
by translating. The prisoner was also a Listener. (Listeners are trained by the
Samaritans to offer emotional support to other prisoners.)
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35. The investigator asked Officer G about the potential stress caused to prisoners
when conducting interviews about life sentences. Officer G explained that
prisoners are often aware of the seriousness of their offence. The subject is
not, therefore, a surprise to them and it is helpful to talk through what it means.
In the man’s case, she said that he was a bit tearful during this interview.
However, his main concern was not his offence, but that he wanted to share a
cell with someone who could speak Gujarati. The investigator asked about the
availability of the life sentence information pack in languages other than
English. Officer G explained that, at the time of his interview, the material was
not available in Gujarati. Although the pack was available in some languages,
it had not been translated more widely as the document was being revised.
The finalised document was to be translated.
36. The issue of legal representation remained unresolved. The judge presiding
over the man’s case continued to disallow his appeal to transfer his to preferred
solicitor (both in writing and at two oral hearings), and this delayed his trial. No
reason was given for his ruling. The solicitor told my investigator that the man
became increasingly stressed and upset by the issue.
37. An oral hearing took place on 24 September. During the hearing, the judge
said that he did not want to hear from the solicitor. The interpreter provided by
the court for the hearing only spoke Punjabi and Hindi. The man could
understand a little Hindi, but not enough to fully comprehend what was
happening. The solicitor requested that a Gujarati interpreter be provided, but
this was not granted. The judge maintained his position on not acknowledging
the man’s preferred solicitor. (The investigator was given this information by
the solicitor and has had sight of documentation in relation to the hearing.)
38. On 5 October, a new prisoner who spoke Gujarati was moved into the man’s
cell. It was noted in his history sheet, “this should help him to settle as he now
has a cellmate who speaks the same language.” A week later (12 October
2007), his cellmate informed Officer F that the man wanted to move to the
enhanced prisoners landing. This was because he had become friends with
some of the Gujarati speaking prisoners on this landing. The man was not
strictly eligible to apply for the move because he had not been at the prison for
long enough. Prisoners are usually required to have demonstrated good and
compliant behaviour for up to 12 weeks as the enhanced status conveys a
number of privileges that should be earned.
39. The man’s cellmate moved on 25 October and was replaced with another.
Unfortunately, the new prisoner unsettled him and Officer I noted in his history
sheet that he was “very upset and disturbed and frightened of his pad mate … I
have sorted this out with Res S/O [residential senior officer] and moved the
man to L3:24.” (L3 is the enhanced landing and 24 the cell number.) The man
was granted an exceptional privilege in being allowed an early application to
move to this landing. The circumstances surrounding his move were not
mentioned to other prisoners on the landing so as not to create any undue
attention.
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40. The investigator asked Officer I about the man’s move and his problems with
his cellmate. She asked specifically if there was any indication of bullying.
Officer I told the investigator that the man had not given any indication of
bullying. He was upset because he was unable to understand or speak to his
cellmate and this caused him distress. The investigator asked Officer I why this
would cause the man to feel frightened. Officer I was unable to offer an
explanation, but did say that she acted as soon as his request came to her
attention and moved him out of the cell.
41. On moving cell and landing, the man was allocated a different personal officer –
Officer H. The first entry in his history sheet by Officer H was made on 4
November. Officer H noted that the man “has problems understanding English.
Going to try and move somebody in that speaks the same language.”
42. Two days later (6 November), Nurse A saw the man after he reported
experiencing chest pains. He communicated this to healthcare through a fellow
prisoner who was able to translate. Nurse A examined the man and concluded
that no immediate intervention was needed, but suggested a doctor’s
appointment. The man agreed and an appointment was made for 8 November.
With the man’s agreement, the prisoner acting as a translator offered to attend
the appointment with him. However, the man did not attend. There is no
record or evidence of any enquiries into why he did not attend. (I think that
making such enquiries would have been good practice. However, prisoners
can choose not to attend appointments, as can people in the community.)
43. During that week, the man moved cells on L3. He moved into cell 41 with a
Gujarati speaker who was employed as a staff tea orderly. The man appeared
happy with this move and reportedly got on well with his cellmate. The
investigator interviewed his cellmate. He told her that the man was a quiet and
very well respected man who was ashamed of his offence. The man had told
him that he was worried about the consequences of his actions upon his family,
and was concerned about his own reputation on release from prison. His
cellmate told the investigator that he would try to reassure the man and tell him
not to worry. He said that, although the man talked about being worried, he
never indicated that he felt depressed or intended to harm himself.
44. By moving cells, the man again had a change in personal officer to Officer J.
On 11 November, Officer J wrote the following entry – “Its hard to understand
the man, however he gave me a thumbs up and says is okay.” The investigator
asked Officer J about her difficulties speaking to the man. She also asked
whether, during her time as his personal officer, Officer J had felt concerned
about his wellbeing. Officer J told the investigator that, although she had
trouble verbally communicating, she had sufficient contact to gain an
impression that he was not low in mood. She added that he often looked a bit
lost and confused by his surroundings, but did not seem to be upset.
45. The man returned to court for his trial on 14 November. My investigator
interviewed his solicitor. The solicitor said that the man found the court hearing
very stressful. He was again told that he could not transfer his legal aid to his
preferred solicitor. The man was instructed to work with his original solicitor.
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The judge told him that he was causing a delay to his trial by refusing to comply
and asking for the transfer in representation. Subsequent to the hearing, The
man’s family and his solicitor submitted a complaint and requested a judicial
review on the basis of unfair treatment.
46. During this court appearance the man saw his family members. This was not
the first time that he had seen family members since being remanded into
custody, but he found the court setting distressing. On returning to prison he
told his cellmate that he felt saddened and ashamed that his family had seen
him this way. On speaking to his cellmate, my investigator found there was
nothing more significant about the man’s mood that evening or in the following
days. He spoke about his family and his worry about his position in the
community, but did not appear depressed or discuss self-harm or suicide.
47. The man made nine phone calls to family members, including his son, over the
next 24 hours. He spoke about the next court hearing that had been scheduled
for 28 November. He asked for a visit to be arranged with his solicitor. He also
wanted to talk to his daughter, but she was not at home when he called.
48. On Friday 16 November, Senior Officer (SO) L and Officer K were on evening
duty serving dinner. At 6.10pm, once the meal had been served, SO L went to
L3-44 to unlock the man’s cellmate for his tea orderly duties. His cellmate was
permitted to leave his cell to do his job before the evening association period
started. As he unlocked the cell, SO L joked with his cellmate that he had
almost forgotten all about him. As his cellmate laughed, SO L recalled seeing
the man also smiling. SO L told the investigator that the man appeared fine
and gave him no cause for concern.
49. At approximately 7.05pm, SO L was in the centre office (on Landing 2) with SO
M sorting out prisoners’ orders from the canteen in preparation for distribution.
(Canteen is the term used for the process by which prisoners are able to buy
items such as sweets, tobacco, biscuits, toiletries from their own funds on a
weekly basis.) SO L heard a shout out to staff and saw Officer K running along
Landing 3. He ran to join Officer K and at that point it became clear that there
had been an incident in the man’s cell. Two prisoners (cleaners that had also
been unlocked) who were friends of the man’s had looked into his cell to say
hello and had found him hanging by a ligature made from a bedsheet
suspended from the cell window. The prisoner started shouting, “Hurry, hurry,
suicide.”
50. Officer K arrived at the cell first with Officer N. They ran into the cell and Officer
K lifted the man up whilst Officer N cut through the bedsheet with his anti-
ligature knife. As they were laying the man down on the cell floor, SO M
entered. Officer K stepped out of the cell as more staff had arrived and were
beginning to try and resuscitate him.
51. Officer N checked the man for signs of life by trying to detect any breathing or
find a pulse. He noted that his chest was not moving and told other staff in the
cell that they needed to start cardio pulmonary resuscitation (CPR). Officer N is
trained in CPR and so started giving chest compressions (30 compressions to
14
every two breaths). As he started, Principal Officer (PO) O entered the cell and
instructed Officer P to start writing an incident log. The log was started at
7.07pm.
52. PO O radioed the healthcare centre for “code blue” assistance. (“Code blue”
indicates a medical emergency involving breathing difficulties. This signifies to
healthcare staff that the emergency response bag, including breathing
equipment, is required.) PO O requested that an ambulance be called and then
assisted Officer N with CPR until Nurse B arrived at the cell.
53. Nurse B had received the request for healthcare assistance at approximately
7.10pm. At the time, she had been dealing with another medical incident in the
first night centre but, confident that the situation was under control, she left to
attend the new emergency. The control room log shows that a call for the
ambulance was made at 7.12pm. Nurse B arrived at the cell at 7.14pm with the
emergency response bag. She checked the man for any pulse or signs of
breathing but found nothing. Nurse B noted that the man was cold to touch,
that his lips and fingers nails had turned blue (known as cyanosis), and he had
been incontinent of urine. These observations indicated to her that there was
no sign of life. SO M continued with chest compressions whilst Nurse B used
an ambu-bag and oxygen to aid breathing.
54. The prisoners who had discovered the man were both very upset. Whilst staff
were attempting to resuscitate him, SO Q took them aside and then to a
Listener’s cell so that they could be comforted.
55. The Head of Healthcare arrived at 7.15pm. He saw Nurse B and Officer N
continuing with CPR. Dr R (the prison doctor on duty) arrived at the cell at
7.18pm and requested that an automatic defibrillator, situated in healthcare, be
brought to the cell. In the meantime, the paramedics arrived (7.19pm) and
were directed straight to the man’s cell. Using their own defibrillator the
paramedics confirmed that the man had died. Dr R pronounced his death at
7.20pm.
56. A hot debrief with staff involved on the evening of the man’s death was held at
8.35pm that night. (A hot debrief is a meeting convened as soon as possible
after a death in custody, or any other significant event. The meeting is used to
reflect upon what has happened, staff involvement and whether anything could
have been done differently.)
Events after the man’s death
57. Reverend S (the coordinating chaplain at the prison) was informed of the man’s
death at 7.35pm. She arrived at the prison by 8.00pm and was given details of
what had happened. Reverend S confirmed the man’s religion and notified the
Hindu minister. At approximately 10.30pm, Reverend S, the minister and two
police officers went to the home of the man’s nominated next of kin to break the
news.
15
58. The following day, Governor D telephoned the man’s solicitor to notify him of
his client’s death. His solicitor told Governor D that the man’s nephew had
already notified him. The solicitor told Governor D that he had seen the man
approximately two to three times a week in relation to his court case and had
seen him recently. He said that there had been complications with the case,
which had unnecessarily drawn out the proceedings.
59. The solicitor had last seen the man during a legal visit on 15 November, the
day before his death. He told Governor D that there had been nothing out of
the ordinary regarding the man’s demeanour, and he had not said that he felt
suicidal. However, the man had said, “I’d rather be dead than had to deal with
all of this.” The solicitor did not register this as a serious risk of self-harm. He
told Governor D that the man had been dealing with some serious issues whilst
in prison – these being his problems with communicating due to limited English.
60. The solicitor said that since the man had moved into a cell with a Gujarati
speaker he had seemed a lot happier. He commented that there was no
indication that the man would take his life. The solicitor speculated that the
shock of being in prison, the seriousness of the charges against him, and the
stress of his court case, might have triggered his actions.
61. On reading Governor D’s record of this conversation, my investigator
interviewed the solicitor to further enquire about the man’s statement. The
solicitor told my investigator that he had never found the man to be depressed
or suicidal. Although the man had appeared upset at times, his solicitor said
that he did not get the impression this was depression or an indication of an
intention to harm himself. The solicitor did report that the man sometimes said,
“I’d rather be dead” when talking about his case or prison. My investigator
asked what he meant by this. The solicitor explained that this is a common
expression used by older members in his community to convey shame,
embarrassment or hardship. He further explained that it was to do with self-
respect. He said that it was not a literal statement and should not be
interpreted that way.
62. Governor D had also noted that the solicitor had said, “The man was facing
serious threats ...” My investigator asked the solicitor what he meant by this.
The solicitor explained that he had been misquoted and he had meant that the
man was facing serious charges.
63. The man’s funeral took place on 24 November. Ms T, family liaison officer, and
a chaplain attended on behalf of the prison.
64. Ms T liaised with the man’s second cousin’s family (whom he regarded as a
brother) and arranged for them to visit the prison on 26 November. The family
met with the Acting Governor and were briefed on the purpose of my
investigation and the inquest. They were then taken to the wing and met with
the family liaison team, the Hindu minister, and another chaplain who
welcomed them to the establishment. A meeting was held in the safer custody
suite with four of the prisoners who were close to the man, including his last
cellmate. Following this, the family was able to speak to a landing officer who
16
had daily contact with him, before visiting his cell. The Hindu minister led
prayers for the man. Flowers were given to the family on their departure.
65. On 27 November, the man’s daughter telephoned Principal Officer (PO) U and
asked if she could visit the prison as she had felt excluded from the visit on the
previous day. The investigator was made aware of the request by email. The
prison’s family liaison officer, Ms T, told my colleague that she was reluctant to
organise another visit because it would be too upsetting for the other prisoners
to witness another visit. My colleague reminded Ms T of the guidance on family
liaison (“who is the family?”) in Prison Service Order 2710 about equal
treatment of next of kin. She stressed that the man’s daughter should have a
visit arranged and that Ms T should enquire with the prisoners as to whether
they would be willing to meet her. Ms T said that she would organise this.
66. Section 3.4 of the guidance in PSO 2710 is clear that prisons should be
prepared to deal with more than one section of a family. It says:
“The family may be large, split geographically, at odds amongst
themselves. Many modern families are split by divorce or separation
and there may be several branches all with equal rights to information.
The Family Liaison Officer may be able to get the family to nominate a
single point of contact who undertakes to keep other family members
up to date. This may not always be possible, or may not work in
practice, so the Family Liaison Officer should be prepared to deal with
different sections of one family if necessary. The police sometimes
deploy more than one Family Liaison Officer to a family. This may be
an answer in extreme circumstances of family division.”
67. A visit was organised for the man’s daughter on 4 December 2007. She was
not taken into the prison and only met the family liaison team. This was
significantly different from the visit organised for the man’s second cousin and
his wife. The man’s daughter was upset that she had not had the opportunity to
visit inside the prison and see where her father had lived.
68. My own FLO remained in contact with both sets of next of kin. In May 2008,
the man’s daughter returned from a trip overseas and made contact with my
FLO. She said that she was still upset by the prison’s unequal treatment. My
investigator contacted Ms T on 9 May and asked her to facilitate a visit for the
man’s daughter in accordance with the PSO. My investigator was told that a
visit could be arranged, but that this might have a negative impact on the man’s
daughter and her father’s friends still at the prison. My investigator stressed
that if a visit was requested it should be facilitated in accordance with the
Prison Service guidance. Ms T agreed to make the arrangements.
69. By the end of May, a visit still had not been arranged. The man’s daughter told
my office that she had not heard from the prison. My investigator again asked
for a visit to be arranged. On 4 June, a visit was arranged for 13 July. The
man’s daughter was told that it would be very low key and she would only meet
Ms T. She would be taken into the prison but her request to meet the prisoners
who knew her father could not be met as it would be too upsetting for them to
17
talk about the events. Ms T said that she believed the man’s daughter
understood her concerns.
70. The man’s daughter contacted my FLO to say that she was disappointed at not
being allowed access to the one remaining friend of her father’s at the prison.
She said that she would have understood better if this was a choice made by
the prisoner, but felt this decision had been made without consulting him. Both
my FLO and my investigator contacted Ms T with concerns that she was taking
a decision on behalf of the prisoner without taking into account his views. The
visit took place without seeing the remaining prisoner.
71. Neither branch of next of kin had been given the belongings found in the man’s
cell after his death. This was not brought to my investigator’s attention until his
daughter asked whether her father had undertaken any English lessons. She
wanted any of his English work if it was available. My investigator enquired
with Ms T if there was any education work in his cell and whether this might
have been given to the other branch of the family. Ms T told my investigator
that all his belongings were still at the prison and that they included no
education paperwork. My investigator asked that the property be returned to
the family as soon as possible as this should have been done much sooner
after his death. His belongings were given to his family (but not his daughter)
on 27 June.
18
ISSUES
Healthcare
Reception health screens
72. During interviews with the Head of Healthcare, Dr C, and Nurse A, my
investigator and the clinical reviewer explored the reception health screening
process. At Leicester, both the first and second health screen are conducted in
one sitting. The doctor and nurse are both in the room with the prisoner. The
investigator and the clinical reviewer asked why this is done and were told it
was to save time. I acknowledge this is done for practical reasons, but in the
man’s case it meant that there had been four people in the room which is not
an ideal arrangement for a personal assessment. (The fourth person was the
prisoner the man met in reception who was present to act as a translator.)
Although the man asked the prisoner to come with him, it might have hindered
how honestly and thoroughly he answered questions, particularly those
regarding his state of mind.
73. Although this was not an ideal environment for a medical consultation, I
appreciate that it would have been impossible to conduct the health screens
without an interpreter. The man had said that he was comfortable with this
arrangement and so using Big Word (the telephone language service) was not
considered.
74. Prior to conducting the interviews with healthcare staff, my investigator
familiarised herself with other investigations undertaken by my office at HMP
Leicester. She noted a recommendation made in 2006 regarding nursing staff
having sight of prisoner escort forms (PERs) during health screens. The PER
should briefly detail any disclosed medical or mental health concerns made
known to escort staff by the service with previous custodial responsibility. For
example, the police, a court or another prison.
75. In response the Prison Service accepted this recommendation and said:
“Healthcare staff undertaking reception health screens have access to
the PER form, but will now be required to sign and date the PER form
for each prisoner seen in reception.”
76. It is clear from the man’s reception documents that this recommendation had
not been implemented. Not only did the nurse not sign the PER, but also
during interview she and her nursing colleague said that they were unaware
that this was a requirement. I restate this recommendation below, in a slightly
revised form, and ask that staff are informed of the requirement to sign the PER
once they have seen it.
I recommend that, as a matter of routine, the PER form should be seen by
healthcare staff undertaking reception health screens and should be
signed and dated.
19
77. Both Nurse A and Dr C were asked whether they had seen the forensic medical
examination record provided by the police. (This medical record would have
been with the PER and warrant when the man came into reception.) Both
Nurse A and Dr C said that they had not. My investigator showed them the
record (which notes that the man had been seen by paramedics for chest pains
in police custody) for clarification. They maintained they neither had seen it
before.
I recommend that, as a matter of routine, any paperwork containing a
medical reference received by staff on reception is made available to
healthcare at the earliest opportunity.
Obtaining GP records
78. It should be standard practice that, where details of a doctor in the community
are provided by a prisoner, the surgery is contacted and doctor’s notes
requested. The Head of Healthcare stated that normally the doctor would be
contacted by fax, within 24 hours of a health screen, using the standard
Information Release form. This would be particularly important to ascertain or
confirm whether a prisoner had any regular medication. In the man’s case
there is no record of any request being made for his GP records. The clinical
reviewer checked with his listed doctor and there was no evidence of any
request being made for his record or information about him from his GP
records.
79. The absence of GP records did not affect him receiving his prescribed
medications. When he came into prison he had a prescription counterfoil in his
pocket that listed his medications. This appears to have been available to
healthcare staff during the reception screens and he was issued with
appropriate drugs at the reception.
80. The clinical reviewer says in his clinical review that medical staff have a duty to
seek information on new patients as soon as reasonably possible after coming
into prison. Recent developments within the National Health Service have seen
the early roll-out of ‘GP2GP Transfer’ (doctor to doctor), enabling the electronic
component of patients’ records to be acquired within hours of registration at a
new practice. Paper records follow later, but the essential up to date
information should be readily available.
81. The clinical reviewer suggests that the extension of this facility to healthcare in
prison should be investigated nationwide. I think this is a very important
proposal and would ask the Department of Health to consider how this could be
implemented as a matter of urgency. All too often in my investigations I come
across occasions when outside clinical information is not available to prison
healthcare staff.
I recommend that the Department of Health consider using the ‘GP2GP
Transfer’ of electronic patients’ system in the provision of healthcare in
prisons.
20
Language barrier
82. As the man’s first language was Gujarati and he spoke no English, his time in
prison was stressful. He required an interpreter for information to be passed to
him and to communicate with anyone other than his Gujarati speaking peers.
Staff told my investigator that they were able to communicate on a basic level
with the man through miming actions or asking very basic questions to see how
he was. This was an obvious disadvantage to him, but he never complained
via his peers or to his solicitor about his treatment at the prison (apart from
when he was not in a cell with a Gujarati speaker). I am disappointed that, at
times, he shared cells with English speaking prisoners, particularly when there
was the possibility of sharing with those who could speak his language. He
could not speak or understand English and told his solicitor and staff, through
his peers, that he was upset and frustrated when sharing with someone he
could not talk to. Being in prison, particularly if it is a prisoner’s first time in
custody, can be frightening and upsetting. Where possible, every effort should
be made for prisoners to share a cell with people with whom they can converse.
83. It is normal practice across the prison estate for prisoners without English
language skills to be spoken to using an official translator or through bilingual
and multilingual prisoners. The latter is a quick and effective way of breaking
down any language barrier. However, translation is not a service that a
prisoner should be relied upon to provide. Any assistance given is a matter of
goodwill and should be commended.
84. During the course of this investigation, both healthcare and discipline staff have
expressed some frustration with the Big Word service. I am told that the
translators on the end of the line are not always familiar with prison or clinical
related questions being asked, and this can pose problems with obtaining
information from the prisoner. Staff prefer in the first instance to use other
prisoners to translate.
85. The number of foreign national and non-English speaking prisoners in custody
is growing. I would like to see the Prison Service tailoring its use of the official
translation services to reduce the reliance on prisoners for assistance. Perhaps
training or briefing could be offered to Big Word or Language Line staff to
familiarise them with prison terminology. If prison staff were more confident in
the effectiveness of the translation services in conducting interviews, they might
be more inclined to use the service rather than relying on other prisoners. I
appreciate that prison work may represent only a very small proportion of the
overall workload of the major translation services. Nevertheless, I believe it
would be worth exploring with them if there are ways of improving their
familiarity with Prison Service
I recommend that the Prison Service liaise with translation service providers to
improve familiarisation with prison terminology, which will in turn better assist
non-English speaking prisoners.
21
Window bars
86. The man’s family have asked why he was not in one of the safer custody cells.
(A safer custody cell is one which is constructed in a manner to reduce the risk
of self-harm. The fixtures and fittings, including windows, are designed to be
ligature-proof so far as this is possible.) The man was in an ordinary cell for
double occupancy. He had not presented as a risk to himself and, as far as
staff were concerned, he did not need to be placed in a safer custody cell. In
hindsight, this was of course mistaken. However, staff made appropriate
decisions at the time as there was no evidence to suggest that he was at risk.
87. His family have also asked how he was able to suspend a ligature from his
window. My investigator noted on seeing the cell that there are window bars on
the cell windows. He had tied a bed sheet to the bars and used them as a
ligature point. As this was not a safer custody cell, there were other points in
the cell that could also have been used as a ligature point. I have made
recommendations in the past to the Prison Service to replace accessible
window bars. I reiterate this important recommendation here. Whilst it is true
that no cell is ever entirely ligature-proof, it is part of the Prison Service’s duty
of care to reduce the number of ligature points in cells whenever it can.
Window bars are commonly used in deaths by hanging and the Prison Service
should have a programme for installing “safer windows” in all cells as quickly as
resources allow.
88. My investigator raised this issue with the Acting Governor. He told her that a
bid had been submitted at the beginning of 2008 to refit cell windows to bring
them in line with those used in safer cells. This is good news and I hope that
the bid is successful. I hope the inclusion of a recommendation in my report to
remove the bars will support the case for funding if it has not already been
made.
I recommend that the Governor installs the same windows used in safer
cells throughout the prison.
Literature for life sentenced prisoners
89. My investigator spoke to Officer G, a member of the Lifer Management team,
about the difficulties of communicating with the man. The man’s offence could
potentially have resulted in a life sentence and Officer G’s duty was to explain
what this meant and what it would involve. Officer G conducted her interview
with the man with the help of a prisoner who interpreted for her.
90. My investigator asked Officer G whether she had provided the man with the lifer
information pack in Gujarati. She explained that it was only available in English
and, that at the time, it was being updated. Given this, the Lifer Management
team were not issuing packs to anyone. My investigator asked whether, once
updated, the pack would be translated as are the induction packs available in
the first night centre. Officer G said that this would be possible. My
investigator later raised the issue with the Acting Governor who confirmed that
22
translations would be available. He said he would check the progress on the
draft information pack.
Education
91. The man attended English language evening classes every Monday and
Thursday. My investigator tried to retrieve the paperwork relating to his English
classes for his daughter. She was told that there was no paperwork amongst
his property. The belongings found in his cell after his death were returned to
his second cousin’s family on 27 June. It is good that his property was
eventually returned, but this should have been done at a much earlier stage in
the year.
Food
92. At Leicester, prisoners are provided with a weekly menu from which they are
invited to choose what food they want to eat. The menu is distributed to each
prisoner with their dinner on Wednesdays. There is a choice of five different
meals each day and prisoners can pick whichever meal they like. Within the
five are Halal, vegetarian and vegan options. If a prisoner comes into the
prison after a Wednesday evening they are automatically given the vegetarian
meal until the following week.
93. My investigator was unable to determine what kind of meals the man had
selected whilst in prison. His cellmate told my investigator that the man did not
like English food and that they both spent their money buying extra foodstuffs
from the canteen to compensate. It is not documented anywhere in his records
that he either refused his meals or did not eat any food he was given.
Hot debrief and defibrillator
94. The hot debrief meeting was held just over an hour after the man’s death. It
was good practice that the debrief was held so soon. However, not all staff
involved were present. Indeed, Nurse B (who performed CPR) was not invited
to attend the hot debrief despite still being in the prison at the time it took place.
During her interview with my investigator, Nurse B expressed concern about
being omitted and said that she would have welcomed the opportunity to
comment.
95. Nurse B said that, had she been present, she would have raised her concerns
about the defibrillator. First, there is only one defibrillator in the prison and on
the day of the man’s death it was in the treatment room. Nurse B explained
that retrieving the defibrillator, if it was not brought to the cell in the first
instance, would take approximately five minutes as there are a number of gates
to negotiate en route. The doctor who attended the man asked for the
defibrillator to be brought to the cell. It was fortunate that the paramedics
arrived at around the same time as the request was made and used their own
machine. Nurse B said that it would have been beneficial had a defibrillator
been located on the wing. This would have speeded up the response in the
absence of the paramedics.
23
96. My investigator and the clinical reviewer were told at the time of interview that
the defibrillator is located on the wing. However, should it be needed in
healthcare for an emergency response then the same time delay would apply.
A second concern raised by Nurse B was that she was aware that the pads on
the prison’s defibrillator had expired. (The conductive gel on the pads has an
expiry date.)
97. Both of these points were discussed with the Acting Governor. He told my
investigator that, if I made a formal recommendation, he would consider
purchasing a second machine as they are relatively inexpensive. The Acting
Governor said that he believed the existing defibrillator had been serviced.
However, he would check that the pads had been replaced and provide my
investigator with the date of the last service. (This has not been forthcoming.)
I recommend that the Primary Care Trust supply the prison with a second
defibrillator.
The Head of Healthcare should make sure that all emergency response
equipment is within expiry date and serviced regularly.
98. Nurse B made one further comment during her interview. She said that it would
be useful if discipline staff could be trained to use the defibrillator. The machine
at the prison is automated and user-friendly. As staff are already trained in first
aid, and some are trained in CPR, I think that this is a sensible suggestion
although I make no formal recommendation.
99. The clinical reviewer supports Nurse B’s comments that a second defibrillator
would be advantageous. Whilst the location of the prison’s current defibrillator
had no bearing on the outcome in the case of the man, if the paramedics’
arrival had not been so timely the healthcare staff’s response might have been
hindered. Despite this, the clinical reviewer does say that the resuscitation
measures initiated and coordinated by prison officers, and the response and
actions of healthcare staff, should be considered good practice.
Family liaison
100. As I have outlined earlier in this report, family liaison after the man’s death has
been complicated. The prison’s family liaison officer, Ms T, has undertaken her
duties in accordance with Prison Service guidance with some members of his
family. However, her liaison with his daughter was not equitable. Indeed, it
took six months of correspondence between his daughter and my office for a
visit inside the prison to be organised. Even then, the visit was not on the same
scale and did not entirely meet his daughter’s needs.
101. I appreciate that the Prison Service guidance on family liaison in the event of a
death in custody is not prescriptive and it should not be. As the guidance
states in section 3.2, “every family is different and has its own dynamics. A
family liaison officer needs to be flexible and open-minded and should
approach the family in accordance with its individual needs.” The guidelines
24
also say in section 3.4 that, while at times families will be divided, they will all
have equal rights to information. Where it is not possible to work with one
single point of contact in the family, the liaison officer should be prepared to
deal with different sections of the family. As each branch of next of kin is
entitled to equal information they should also be treated equally.
102. The guidance used by the Prison Service is based on that used by the
Metropolitan Police. Where there are instances of divided families the police
sometimes employ the services of more than one liaison officer. Perhaps a
similar practice could be adopted by the prison’s family liaison team if
difficulties were to arise in the future in addressing the needs of more than one
branch of a prisoner’s next of kin.
103. I ask the Governor to remind her family liaison team of these guidelines and
ensure that they are taken into full consideration in any future cases to prevent
further upset to next of kin.
The Governor should remind her family liaison team of the Prison Service
guidance regarding dealing with more than one branch of next of kin,
particularly drawing attention to the right of equal access to information
and extending this to equal treatment.
I understand that the Safer Custody and Offender Policy group are in
consultation with Area Safer Custody Advisors on introducing area meetings for
prison FLOs. These meetings will be used to discuss a range of family liaison
issues, including the importance of liaising, where required, with every branch
of next of kin.
104. My investigator has spoken to the Governor about the concerns surrounding
family liaison. The Governor was not at Leicester at the time of the man’s
death, but has spoken to the staff involved about the decisions made over
family liaison. The staff maintain that they followed the correct protocol by
dealing with the next of kin nominated by the man. Whilst it is true that his
named next of kin were supported in the correct manner, the Prison Service
FLO guidance expressly refers to the need to deal fairly with more than one
side of a family where necessary.
105. The Governor said that she was advised that the man’s death had a significant
impact on the Hindu community within the prison. When his daughter visited, a
decision was made by the prison managers that involving other prisoners would
risk the prison’s duty of care to them. Her staff maintained that they felt this
was the right decision at that time. Whilst I of course appreciate the duty of
care to prisoners, I do not agree that such a decision should be taken without
consultation. The man’s cellmate told my investigator that he would have been
happy to speak to his daughter.
106. The family liaison team told the Governor that an email had been sent to the
man’s daughter in December 2007 after her visit earlier that month. The
Governor told my investigator that his daughter did not respond until April 2008.
25
However, the prison’s FLO had been made aware that his daughter was out of
the country and was unable to respond.
107. The man’s daughter told my own FLO that it was she who initiated contact with
the prison in the days following her father’s death, and then again on her return
from India some months later. She said there was only one occasion when she
did not respond to an email from the prison’s FLO, as she felt their FLO had
betrayed her confidence in discussing details of her contact with other family
members. His daughter said that she was too angry to respond. Given the
prison’s lack of response to her requests for a visit, and the fact that these
frustrations were communicated by my FLO and both of my investigators to the
prison on a number of occasions, it is wholly understandable that the man’s
daughter asked for the assistance of this office in helping secure a visit that met
her needs. Although it could be said that the man’s daughter could have done
more to raise her concerns with the prison directly, I understand that it would be
difficult for anyone in this situation, given the perceived lack of ongoing support
from the establishment, to feel able to voice their dissatisfaction in such a way.
Post mortem
108. Professor V, a forensic pathologist, performed a post mortem on 20 November
2007. He confirmed the cause of death as hanging. The autopsy records refer
to the man having made eight telephone calls in the 24 hours prior to his death,
none of which contained any reference to suicide or death. My investigator has
read the translated telephone transcripts and confirms this that this is true. He
left no suicide note and there is no evidence of a history of bullying or pressure
from a third party.
109. Reference was made in the post mortem report to the man having told his
cellmate that he might want to take his life, but that this information was not
passed on to the prison authorities. During her interview with the man’s
cellmate, my investigator asked whether the man had said that he intended to
take his life. The man’s cellmate said with conviction that the man had never
spoken about suicide and he was deeply shocked by his death. My investigator
was unable to ascertain where the information in the post mortem report had
come from as the man’s cellmate was insistent that he had not said it.
Although this falls outside my remit, I am concerned that a factual report such
as a post mortem includes information that is unsubstantiated.
Conclusion
110. The reason why the man hanged himself remains unclear. His family, cellmate
and solicitor have all said that they believe the man’s motivation was linked to
his court case and the shame he felt regarding his offence. My investigator has
been unable to find any evidence to suggest that the man felt vulnerable or at
risk at Leicester prison, aside from his language difficulties. It is unlikely that
the inability of staff to speak Gujarati had any bearing on his decision to take
his life. Nevertheless, had he been able to express himself, his now apparent
vulnerability might have been more easily identified. That said, the fact that he
elected not to discuss these feelings with the Gujarati speakers he did have
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contact with (that is, his cellmate, family and solicitor) indicates that he found it
difficult to communicate his problems regardless of language.
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RECOMMENDATIONS
Healthcare
1. I recommend that the Department of Health consider using the ‘GP2GP Transfer’
of electronic patients’ records system in the provision of healthcare in prisons.
This recommendation was partially accepted. The response states:
“The ‘GP2GP’ electronic patient record system is not currently available within
Leicestershire however the Department of Health has commissioned NHS
Connecting for Health to deliver the first national clinical IT system across the
entire Prison Service estate.
The infrastructure project is almost complete and talks are currently underway
with CSC Alliance to deliver TTP System one.”
2. I recommend that the Primary Care Trust supply the prison with a second
defibrillator.
This recommendation has been accepted. A second defibrillator has been
purchased and is available with emergency response equipment.
3. The Head of Healthcare should make sure that all emergency response
equipment is within expiry date and serviced regularly.
This recommendation has been accepted. All emergency response equipment at
the prison is within expiry date and is service as part of a regular contract.
Prison Service
4. I recommend that, as a matter of routine, the PER form should be seen by
healthcare staff undertaking reception health screens and should be signed and
dated.
This recommendation has been accepted. All incoming PER forms are routinely
seen by healthcare screening staff, who will sign and date the document.
5. I recommend that, as a matter of routine, any paperwork containing a medical
reference received by staff on reception is made available to healthcare at the
earliest opportunity.
This recommendation has been accepted. Any paperwork containing a medical
reference that is received by reception staff is made available to healthcare at the
earliest opportunity.
6. I recommend that the Governor installs the same windows used in safer cells in
all cells at Leicester.
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This recommendation has been partially accepted. A cell strengthening programme,
which includes replacing the windows of all cells in the main wing at HMP Leicester,
is planned with a start date of June 2010. This will be a two year project.
7. The Governor should remind her family liaison team of the Prison Service
guidance regarding dealing with more than one branch of next of kin, particularly
drawing attention to the right of equal access to information and extending this to
equal treatment.
This recommendation has been accepted. A newly trained family liaison officer is
now in place. The right of equally access to information and treatment forms part of
the training.
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Response to the draft report
The Prison Service’s response has been included in the Recommendations section.
The man’s daughter has raised a number of concerns regarding the translation
services and literature available at HMP Leicester.
She asked why the prison did not consider providing an official translator to assist
her father’s interview with the lifer officer, particularly given that the life sentence
information pack was not available in Gujarati. She said that it is unacceptable that
other prisoners are called upon to translate. It should not be acceptable to rely upon
another prisoner to relay serious information. His daughter said that her father would
have found it difficult to talk about personal and confidential matters in front of
another prisoner. She said that conducting an interview or conversation in this way
would not afford a prisoner the same confidentiality as anyone who did not require a
translator. Of most concern was the fact that healthcare assessments were
conducted using a prisoner as a translator.
I refer to my comments in paragraphs 82 to 85 regarding the issue of language and
translation in response to these concerns. As discussed, I am concerned about the
provision of translation services across the prison estate and would like to see a
more sensitive, confidential and professional approach to communicating with non-
English speaking prisoners. I have strengthened my point in paragraph 85 by adding
a recommendation that the Prison Service explore this possibility by liaising with
official translation services it uses. The paragraph now reads:
“The number of foreign national and non-English speaking prisoners in
custody is growing. I would like to see the Prison Service tailoring its use of
the official translation services to reduce the reliance on prisoners for
assistance. Perhaps training or briefing could be offered to Big Word or
Language Line staff to familiarise them with prison terminology. If prison staff
were more confident in the effectiveness of the translation services in
conducting interviews, they might be more inclined to use the service rather
than relying on other prisoners. I appreciate that prison work may represent
only a very small proportion of the overall workload of the major translation
services. Nevertheless, I believe it would be worth exploring with them if
there are ways of improving their familiarity with Prison Service
I recommend that the Prison Service liaise with translation service
providers to improve familiarisation with prison terminology, which will
in turn better assist non-English speaking prisoners.”
The man’s daughter asked whether publicity material in the prison promoting Big
Word was available in languages other than English. My investigator confirmed with
the prison that the poster promoting the service is multi-lingual. My investigator also
established that the life sentence information pack has been updated by the Prison
Reform Trust and is in the process of being translated. It will be available in Gujarati.
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The man’s daughter found it unacceptable that healthcare staff did not follow up with
her father when he failed to attend a doctor’s appointment. I appreciate why this of
concern given the language barrier; however it is not required of healthcare staff to
pursue a prisoner if they do not attend an appointment. As I said in the key findings
(paragraph 42), whilst I think that enquiring as to why he did not attend would have
been good practice, it was his choice not to attend. The system works in much the
same way as a doctor’s surgery in the community, it is a patient’s prerogative
whether or not they choose to seek and receive medical attention.
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