Individual at Leeds

Investigation into the circumstances surrounding the
death of a man at HMP Leeds
in September 2007
Report by the Prison and Probation Ombudsman
for England and Wales
May 2009
This is the report of an investigation into the circumstances surrounding the death of
a man at HMP Leeds on 28 September 2007. The man was found hanging in his
cell shortly before 5.00am. At the time of his death the man was a remand prisoner
awaiting trial for the murder of his wife. He was originally from Ethiopia and came to
this country in 2003. At his death, the man was 30 years old.
I offer my sincere condolences to the man’s relatives and friends for their loss. I am
aware that difficulties were experienced in tracing family members, and that this
resulted in a significant delay before his funeral could be held.
This investigation has been undertaken by one of my colleagues. I would like to
thank the Governor of Leeds, and his staff for their participation. Particular thanks
go to the Principal Officer who facilitating interviews and made all the practical
arrangements. A clinical review was carried out and I must also thank the reviewer
for his contribution.
The man had two young children who one day may read this report. I have to tell
them and others that I have been unable to say conclusively why the man apparently
took his own life. However, he had expressed a number of anxieties to prison staff
particularly about the welfare of his children. Additionally, fellow prisoners have
reported that he might have been subject to bullying.
My report also includes allegations that staff may have had a part to play in the
bullying of the man by other prisoners. The contents of my draft report into the
man’s death were brought to the personal attention of the Director General of the
National Offender Management Service. I am now content that these complaints
have been enquired into by the appropriate authority.
Minor amendments were made to my draft report after comments were received by
the Prison Service. I have made no amendments to recommendations.
I make two recommendations to the Prison Service in respect of monitoring
prisoners following closure of ACCT documents, and providing information on
incidents in single cells. I make a further five recommendations for the Governor
regarding the provision of information, recording contact, monitoring procedures and
cell sharing risk assessments. I note one example of good practice.
Finally, I must apologise for the delay in issuing this report. This was due, in part, to
the time needed by the police to investigate some of the issues uncovered by my
investigator.
Stephen Shaw CBE
Prisons and Probation Ombudsman May 2009
2
CONTENTS
Summary 4
The investigation process 5
HMP Leeds 7
Key events 8
Issues 13
Conclusion 20
Recommendations 21
Good practice 23
3
SUMMARY
The man was born in Ethiopia in May 1977. He moved to the United Kingdom with
his family in 2003 to seek asylum and settled in Bradford. On 30 June 2007, the
man was arrested and charged with the murder of his wife. He was found hanging in
his cell at HMP Leeds shortly before 5.00am on 28 September 2007, little more than
two months after his arrest.
When he arrived at Leeds, the man had numerous wounds to his hands that required
surgery. These injuries were possibly sustained during the attack on his wife.
Although he initially refused treatment for his injuries, the man eventually had the
necessary surgery. As a result, he was located in the prison’s healthcare centre
during the early weeks of his time in custody. I believe the period in healthcare, with
support from the healthcare team, helped him come to terms with the early stages of
his imprisonment. However, he was anxious about the welfare and whereabouts of
his children and his legal representation. In addition, the man spoke little English.
The man moved to C wing on 27 July. At about 4.55am on the morning of 28
September, a prison officer discovered the man hanging from the window bars in his
cell. The officer raised the alarm and waited for colleagues to arrive before he went
into the cell. Several staff responded. The night orderly officer and a second officer
removed the ligature and lowered the man to the ground. The night orderly officer, a
staff nurse, the second officer and a healthcare officer attempted cardio pulmonary
rescuscitation (CPR) until paramedics arrived at about 5.10am. The man was
assessed by the paramedics and CPR ceased at about 5.15am.
On 29 September, a complaint was submitted by a prisoner who was located in the
cell next door to the man at the time of his death. The prisoner claimed that
prisoners had been bullying the man because officers had told them that he was a
sex offender. The prisoner believed the man had killed himself due to intimidation.
The prisoner told my investigator that the man had visited him in his cell on the
morning before his death. He added the man had been distressed and crying and
insisted that he was not a sex offender.
I have not been able to determine why the man took his life. However, if the
prisoner’s account is accurate, the man must have believed that other prisoners
thought he was a sex offender. Coping with imprisonment for the first time in the
man’s circumstances must have been extremely difficult. The concern he had for his
children may also have added to his distress. To be wrongly accused of being a sex
offender, and bullied by other prisoners, might well have been too great a
psychological and emotional burden for the man to bear.
I have made five recommendations to the Governor of Leeds and two to the Prison
Service. I have also identified an instance of good practice in which officers on night
duty make a point of checking prisoners in single cells when they carry out
monitoring on other prisoners at risk of self-harm or suicide.
4
THE INVESTIGATION PROCESS
1. My investigator made initial contact with the Governor at Leeds on 1 October
2007, and formally opened the investigation during a visit on 3 October. All
available documents likely to be required for the investigation were collected or
requested at this time.
2. Before my investigator’s visit, notices were issued to staff and prisoners. They
announced the investigation and invited anyone who had information about the
man to make themself known. One prisoner came forward.
3. My investigator carried out 12 interviews with staff and three with prisoners.
Interviews with staff were recorded and copies of the transcripts are attached
as annexes to this report. Notes were taken of interviews with prisoners. A
clinical review of the man’s clinical care whilst in custody was conducted on
behalf of Leeds Primary Care Trust.
4. My investigator considered the reports of other death in custody investigations I
have undertaken at Leeds, and the recent reports by the Independent
Monitoring Board (IMB) and HM Chief Inspector of Prisons, Dame Anne Owers,
were also considered. My investigator also contacted HM Coroner to inform
him of the nature and scope of the investigation and to request a copy of the
post mortem report. Upon completion, my report will be sent to the Coroner to
assist in his enquiries.
5. One of my Family Liaison Officers attempted to contact the man’s next-of-kin to
offer them the opportunity to participate in the investigation. Unfortunately, she
was unable to do so.
6. My investigator was made aware of serious allegations against members of
staff when he interviewed prisoners in December 2007. Two of the prisoners
said they would be concerned for their own safety if the information provided
became known whilst they were still in Leeds. The Governor was informed
informally and plans were put in place to move the individuals concerned.
7. In January 2008, I wrote more formally to the Governor outlining the
allegations. The matter was referred to the police. The police found insufficient
evidence to warrant a full investigation.
5
HMP LEEDS
8. HMP Leeds is category B local prison built in 1847. It is located approximately
two miles from Leeds city centre. The prison serves magistrates’ and crown
courts in the West Yorkshire area. Up to 1,000 prisoners are held on six wings
and in the healthcare centre in accommodation that is certified to hold 824
prisoners. (It is common practice in Victorian local prisons for prisoners to
share cells originally designed for one person. This is known colloquially as
doubling.)
9. During her inspection of Leeds in August 2005, Dame Anne Owers, HM Chief
Inspector of Prisons, found a negative culture among some staff. Relationships
between staff and prisoners had deteriorated, and this was particularly evident
among black and minority ethnic prisoners. The Chief Inspector carried out a
further unannounced inspection of Leeds in December 2007. She found that,
although there were still considerable problems in the prison, there had
nevertheless been progress in all areas. However, a survey carried out by
Dame Anne’s researchers at the time of the inspection found that black and
minority ethnic prisoners felt significantly less safe than other prisoners at
Leeds.
10. The latest Independent Monitoring Board (IMB) annual report does not identify
any particular concerns relating to suicide prevention, violence reduction or
diversity. The report describes a prison that is making progress in all these
areas. In particular, the IMB note a reduction in the number of self-inflicted
deaths in 2007 compared to the previous year.
11. The prison’s healthcare centre has 20 in-patient beds. There is a wide mix of
medical needs and each patient has an individualised care plan during their
time in healthcare.
12. There have been 13 previous self-inflicted deaths at Leeds since I took on
responsibility for undertaking all death in prison custody investigations in 2004.
Numerous recommendations have been made covering a wide range of issues.
There are no similarities between my findings in earlier investigations and my
recommendations in the man’s case.
13. Approximately five per cent of the prisoners at Leeds are foreign nationals. My
investigator reports that there are few special arrangements for these prisoners,
who are dispersed throughout the prison.
6
KEY EVENTS
14. On 30 June 2007, the man was arrested and charged with the murder of his
wife. Whilst he was in police custody, West Yorkshire police completed a
medical record sheet. The doctor who examined the man noted that he had no
history of mental illness and showed no signs of acute mental illness. The
record sheet also included information relating to injuries to his hands that were
likely to have been received when the alleged offence was committed. The
man initially refused hospital treatment to his hands. A comment entered by a
nurse on page two of the record noted that the man ran and head butted a wall
after she had re-dressed his hands. The police medical record and a risk
assessment report accompanied the man when he left police custody.
15. The man appeared at Bradford Magistrates’ Court on 4 July and was remanded
into custody at Leeds. The Prisoner Escort Record (PER) that accompanied
the man includes an entry on the front cover that states he was a suicide risk.
It goes on to say that he was the subject of constant supervision whilst in police
and escort contractor custody. (The PER is a form that accompanies prisoners
during journeys to and from prison. It provides a chronological record of events
such as meals served and journey times and serves as a communication tool
about risks a prisoner poses on escort or transfer.) A suicide/self-harm warning
form was completed by a Senior Custody Officer. A recommendation was
made that the man should be re-assessed when he arrived in prison custody.
16. When the man arrived at Leeds, routine reception procedures were carried out.
The PER was checked and signed by an officer. A Cell Sharing Risk
Assessment (CSRA) was completed in which the man was identified as at high
risk of harming a cell mate if located in a shared cell. This was based on
information received from the police and escort staff. (A CSRA is completed
when a prisoner is admitted to prison to assess whether he is suitable to share
a cell or poses a risk to other prisoners.) It was therefore recommended that
the man should be located in a single cell. An entry was also made on the
CSRA that said the man would harm himself at the earliest opportunity. The
duty manager completed the section of the CSRA. She noted that he appeared
to be agitated and possibly in shock. The duty manager confirmed that the
man should be held in a single cell and should be subject to self-harm
monitoring.
17. An Assessment, Care in Custody and Teamwork (ACCT) document was
opened during the evening of the man’s reception into prison. The immediate
action plan section was completed by a Principal Officer (PO) at 8.20pm. He
instructed that the man should be monitored every 30 minutes until a full review
could be carried out the following day. (The ACCT procedure provides
additional monitoring and personalised support for prisoners considered to be
at risk of self-harm or suicide.)
18. The man was placed in a single cell on D wing, the induction unit. (Induction is
the process of introducing new prisoners into custody. It is designed to explain
the immediate consequences of being in custody, the routines of the prison,
and the rules and regulations prisoners must observe.) The first night induction
7
procedures were completed and the man signed two compacts agreeing to
abide by the rules and regulations of the unit. During his induction interview,
the man expressed concern about his children. This information was also
noted as part of his caremap in the ACCT document.
19. On 5 July, the ACCT assessment interview took place and a caremap was
prepared. Lack of contact with his children and problems finding a solicitor
were the two issues identified. An entry in the caremap notes that the man’s
children were safe but added that he was not to be informed of their
whereabouts. An officer made an entry in the ongoing record confirming that
she had told the man this information. Another officer interviewed the man and
completed a foreign nationals referral form. (This form is used to collect basic
information about a foreign national prisoner which is forwarded to the UK
Border Agency.) The man answered most of the questions and the majority of
the form was completed. Chambers of Bradford were identified on the form as
the man’s solicitors.
20. The man received a letter from his solicitors on 10 July. An entry in the ACCT
ongoing record, at 11.15 am, says that staff tried to explain the contents but
found it difficult due to the man’s limited ability to speak English. The entry
goes on to say the man was very distressed and could not understand why he
could not see his children, or be told where they were. At 3.50pm that day, the
man became tearful and chanted, “My kids, my kids”. When the staff member
present tried to talk to the man, he said he was sorry and ended the
conversation. On the same day, the man requested treatment to the injuries he
had received before he came into custody on his hands. He was admitted to
Leeds General Infirmary (LGI) that evening to undergo surgery.
21. An ACCT case review was carried out at LGI during the morning of 11 July.
The summary of this review says that the man remained anxious and
concerned about the welfare of his children. An entry in the ongoing record
made at 1.10pm the same day by the second principal officer says that the man
was asking about his children. The second principal officer explained that they
were in a place of safety and told the man that investigations could be made on
his return to prison. Several other entries were made the same day relating to
the man’s concern for his children.
22. Later that evening, the man’s solicitor visited him in hospital. An entry in the
ACCT ongoing record says he became distressed when his children were
discussed. There are no further entries relating to this subject during his time
at the hospital.
23. During the afternoon of 13 July, the man returned to HMP Leeds. His injured
hands had been heavily bandaged, and he therefore required assistance to
carry out basic activities. Consequently, he was located in the healthcare
centre. An entry in the ACCT ongoing record, made during the afternoon of 15
July, noted that the man had many concerns. Three worries were listed in the
record. The man was still concerned about his children; he did not feel he was
being represented well by his solicitor; and he was unsure of his legal status in
the UK. The person who made the entry explained to the man that they would
8
try and answer some of his concerns the following day. An entry the following
day says that a senior officer would visit the man that day to discuss these
issues. However, there is no written evidence that this visit took place and the
senior officer told my investigator that he did not recollect meeting the man.
24. At 7.15pm on the evening of 17 July, an officer from the healthcare centre,
spoke to the man. An entry in the ACCT ongoing record notes that he was still
very upset at not being able to see his children. He did not understand why he
could not see them. The member of staff said he would make enquiries the
following day. At 9.15am the following day, an entry in the ongoing record
shows that the man had used the telephone to try to contact his family, but had
been unable to get a reply. The entry also notes that the man was very content
and had no serious problems. There was no reference to the entry the
previous evening or any indication that enquiries had been made about the
man getting access to his children. Following a review later that day, the ACCT
was closed. The summary of the review recorded that the man denied any
intentions to self-harm. It was agreed that staff would look at his legal issues
and childcare concerns. A post closure interview was planned for 25 July.
There is no documentary evidence that this review ever took place.
25. On 27 July, a second nurse spoke to the prison’s police liaison officer about the
possibility of the man having access to his children. The nurse was advised to
contact Bradford Social Services and, on doing so, was informed that the man
could not see his children under any circumstances. The man was informed
and an entry to that effect was made in the man’s history sheet. Later that day,
he was discharged from the healthcare centre and located on C wing. A
careplan was put in place and follow up medical appointments were made. The
nurse completed a healthcare advice and information sheet for wing staff. This
summary highlighted that an ACCT had been closed on 25 July and that the
man was not to have contact with his children. (The ACCT document was
actually closed on 18 July. The date of 25 July was in fact when the post
closure review was due to take place.)
26. In the period between the man’s discharge from the healthcare centre on 27
July and his death two months later, only two entries were made in his wing
history sheet. Both related to an incident in an education class (described
below). As part of the personal officer scheme within a prison, prisoners are
given a named officer who they can approach for advice or to resolve
complaints. There is no evidence of any significant contact between the man
and his personal officer. The man’s personal officer told my investigator that he
knew very little about the man.
27. On 5 September, a member of staff from Bradford Social Services visited the
man. The staff member told my investigator that she had been accompanied
by an interpreter who, unfortunately, had refused to enter the prison. The staff
member therefore saw the man alone to discuss possible contact with his
children. The staff member said the man had been prevented from seeing his
children as they had been clearly traumatised by the events on the night of their
mother’s death. The staff member said that, in spite of this, she considered
that the man would be able to see his children in the future. She told my
9
investigator that she thought that the man had understood details of the
conversation.
28. The man was allocated to an ongoing basic English class. During one of these
classes on 17 September, the man became aggressive towards his teacher.
The man did not want to participate in the class and was therefore removed.
Staff issued a warning under the Incentives and Earned Privileges (IEP)
scheme. (IEP is a system to reward and encourage good behaviour in prison.
The scheme has three levels - basic, standard and enhanced. Incentives
include access to in-cell television, a higher allowance of private cash, wearing
own clothes, increased time out of cell and community visits.) An entry
confirming the warning was made on the man’s history sheet the following day.
This was the only entry on the history sheet following his discharge from
healthcare and the last before his death 11 days later.
29. At about 4.55am on the morning of 28 September, a prison officer discovered
the man hanging from the window bars in his cell, C3-41. The man was the
only occupant of the cell. The discovery was approximately 45 minutes before
a scheduled roll check. The officer told my investigator he checked the man as
he was checking prisoners who were on ACCT documents. The prison officer
raised the alarm and waited for fellow staff to arrive before he went into the cell.
(Staff on residential units do not routinely carry keys at night. They carry a
sealed pouch containing a cell key to be used in an emergency). An
ambulance was called immediately by the prison radio operator. Several staff
responded. The Night Orderly Officer and the second officer removed the
ligature and lowered the man to the ground. The night orderly officer, the staff
nurse, the second officer and the healthcare officer attempted cardio pulmonary
rescuscitation (CPR) as soon as they arrived at the cell. The second officer
said in interview that he held the man whilst the night orderly officer removed
the ligature. The man was lowered to the floor and chest compressions were
started by the night orderly officer whilst the staff nurse undertook breathing.
The second officer said he left the cell to collect CPR equipment, returning a
few minutes later. The staff nurse said in interview that the man was cold,
clammy and failed to respond. Another nurse arrived at the cell and helped
with CPR. He told my investigator that they continued to attempt resuscitation
until paramedics arrived at about 5.10am. Shortly after this time, at about
5.15pm, it was concluded that the man had died. The other prisoner, in cell C3-
42 said he thought he heard someone say “He’s gone” about thirty minutes
after the alarm was raised.
30. The duty governor arrived at the prison at about 5.15am. He ensured the cell
was sealed and that death in custody contingency plans were put in place. The
duty governor held a “hot debrief” for staff who had responded to the man’s
death. (Hot debriefs are primarily carried out to ensure staff have the
opportunity to discuss emotive issues relating to incidents. Minutes are not
normally taken at these meetings.) Staff completed the appropriate incident
report forms before they went off duty. They were offered the services of the
staff care and welfare team when they attended the hot debrief. Most staff told
my investigator they felt supported after the man’s death. Some said that
members of the care team spoke to them a few days afterwards and I judge
10
that the support offered to staff was appropriate. However, none of the
prisoners interviewed mentioned any support being offered to them by prison
staff.
31. The duty manager was appointed as the prison’s Family Liaison Officer (FLO).
The man’s children were informed of their father’s death by the foster parents
who had been appointed by Social Services. Numerous attempts to contact
other family members were made by the prison and Social Services, but
without success.
32. A post-mortem was carried out during the afternoon of 28 September by a
doctor at Pinderfields Hospital, Wakefield. The doctor concluded that the man’s
death was due to hanging. A toxicology screen to determine whether the man
had taken any legal or illegal drugs was negative.
33. On 29 September 2007, a complaint was submitted by the other prisoner. The
prisoner was located in cell C3-42, next door to the man, at the time of his
death. The other prisoner told my investigator that the man had visited him in
his cell on the morning before his death. He said the man was crying and had
asserted that he was not a sex offender. The other prisoner’s complaint
claimed that prisoners had been bullying the man because officers had told
them that he was a sex offender. The other prisoner believed the man had
killed himself due to intimidation.
34. A principal officer and a senior officer interviewed the other prisoner and gave
him a written response on 2 October. In the response, the principal officer
noted that the complaint could not be pursued as the other prisoner had
refused to name any staff who he alleged had behaved in an unprofessional
way. My investigator interviewed the other prisoner and two other prisoners
who had been in the cells next to the man when he died. They all spoke of
inappropriate behaviour by more than one member of staff. I deal with this
matter below.
11
ISSUES
Allegations of bullying
35. The complaint submitted by the other prisoner on 29 September 2007 led to
him being called to a meeting with a Principal Officer. The other prisoner told
my investigator that a Senior Officer was also present and that the complaint
was discussed. The other prisoner alleged to my investigator that the PO had
said to him, “I can make people’s life hell.” He added that he was encouraged
to withdraw his complaint. He said he was told that, in return, he would be
given a job as a cleaner as well as enhanced status under the Incentives and
Earned Privileges (IEP) scheme. At the end of the meeting, the other prisoner
said he saw the PO turn to another member of staff and raise his thumb. He
interpreted that to mean, “It has been sorted.” The other prisoner said he sent
a copy of his complaint to the Governor several days after he received the
formal response as he felt he should be aware of the contents. He told my
investigator that about a week later he received the complaint back in a plain
envelope with his name written on the outside of the envelope. There was no
written response from the Governor included. My investigator could find no
evidence that the complaint had been registered or sent to the Governor.
When my investigator showed the complaint to the Governor he said he had
never seen it before.
36. The other prisoner told my investigator that he knew the identity of the staff
member who had told prisoners that the man was a sex offender. He added he
would not name him as he was afraid that he would be assaulted if he did. He
believed the officer concerned had allowed two cleaners to enter a cell to
assault an Asian prisoner about six months before the man’s death. The other
prisoner said he was hoping to be released in early January 2008 and he would
then be safe.
37. My investigator also interviewed a prisoner who shared a cell with the other
prisoner at the time of the man’s death. He told my investigator that he was not
afraid to talk as he was serving a life sentence and was not afraid of staff. The
other prisoners cellmate alleged that an officer had told him that the man was a
sex offender. He added that after the man’s death the other prisoner was very
upset and told him that it was not correct what staff had done. The cellmate
added that he encouraged the other prisoner to submit a complaint. The
cellmate moved cells shortly afterwards and alleges that the same officer came
to his new cell and tried to provoke his new cellmate, a black prisoner. The
cellmate also told my investigator that, the day before the interview, this officer
approached him and tried to be very friendly and appeared to be worried. The
cellmate believed it was because the officer knew he was due to be interviewed
by my investigator the following day.
38. Another prisoner was located in cell C3-40 at the time of the man’s death. He
told my investigator that he did not know the man very well, only that he spoke
little English. When asked if he was aware of any issues related to bullying, the
prisoner told my investigator that he also had problems with one particular
member of staff. He went on to say that a female officer had a problem with
12
sex offenders. He alleged that she had told prisoners that he was a sex
offender and, as a result, he had felt afraid to go out on exercise for several
months. He added that he had told an SO and she replied, “She wouldn’t do
that.” The prisoner said he submitted a complaint but the response was that
the officer he complained about could not have made the comments as she had
been on two weeks annual leave. The prisoner said he felt this was a cover up
as clearly she could have made the comments before her leave. The prisoner
also told my investigator that, in about June 2007, another officer had told
cleaners that a stocky foreign national prisoner was a sex offender, this was the
same officer named by the other prisoner’s cellmate. This prisoner requested
protection and moved to A wing (the vulnerable prisoner unit). The prisoner
added that the officer concerned had approached him before his interview with
my investigator in what he believed was an attempt to influence what he would
say. He said that he feared for his safety if staff became aware of the
information he had provided. My investigator discussed the matter with the
Governor and agreed to wait until the prisoner had transferred to another prison
and the other prisoner had been discharged before formally raising the issues
outlined above.
39. In mid-January 2008, my investigator formally informed the Governor of the
allegations outlined above and provided the names of staff against whom the
allegations had been made. As a result, the Governor reported the matter to
the police and informed my investigator that an enquiry would be conducted.
The police enquiry resulted in no criminal charges against any member of staff.
Be that as it may, I am very concerned about allegations that prisoners who are
from a minority ethnic background or have committed offences of a sexual
nature might have been targeted by a small number of staff at Leeds. It is of
equal concern if, as alleged, wing managers cover up for staff when a prisoner
does choose to make a complaint. There are numerous issues that arise from
the allegations outlined above.
The Governor should undertake a formal internal investigation into the
allegations of staff malpractice outlined in this report.
Support for the man
40. A prison officer interviewed the man on 5 July 2007. He completed a foreign
nationals referral form the same day. The role of foreign nationals co-ordinator
involves gathering information for the UK Border Agency. It does not include
helping to deal with day to day problems faced by foreign prisoners on arrival in
prison custody. Nor does it involve maintaining contact with foreign national
prisoners after the initial meeting. The man was clearly anxious about the
whereabouts of his children and had concerns about his solicitors. He also had
difficulty understanding English. I believe the issues faced by the man in
respect of his children and legal representation could be experienced by any
prisoner, regardless of their nationality. However language barriers are likely to
have made resolution of the issues more difficult. These issues should have
been brought to the attention of the man’s personal officer. This could be
achieved by providing the personal officer with a copy of the referral form
supported by a note of the interview from the foreign nationals co-ordinator.
13
The Governor should ensure that the foreign national co-ordinator
provides information for personal officers on any prisoner who is likely to
have difficulty communicating with staff as a result of language barriers.
41. Whilst the ACCT document was open, and throughout his time in the
healthcare centre, staff attempted to help the man. He had daily contact with
staff in the healthcare centre and numerous entries were made in either his
medical record or on the ACCT document itself. The ACCT document was
closed on 18 July 2007. A week later, the man moved to C wing. There is no
evidence that he was offered any subsequent support or had any constructive
contact with staff. The personal officer should be the first point of contact for a
prisoner. There is no evidence that the man approached his personal officer or
that the personal officer spoke to him. Indeed, the man’s personal officer, told
my investigator that he knew very little about the man. He acknowledged in
interview that language barriers were an issue. There is no documentary
evidence that attempts were made to communicate effectively with the man
after he left the healthcare centre. Translation services such as Bigword and
Language Line might have helped. Language Line was contacted when the
man was in healthcare and interpreters were used when he was in LGI. It is
possible that Bigword and Language Line were contacted after his move to the
wing but, if that is the case, no records were kept.
42. The man was charged with the murder of his wife. His young children may
have been present at the time the offence was committed. This must have
been a very traumatic time for all the family members. The correlation between
intra-familial homicide and suicide is well known. However, this does not
appear to have been considered in respect of the man. Had the man been
eventually convicted of murder, he would have received a life sentence. He
would then have been seen by the prison’s lifer team, and it is likely that
support would have been provided at that time. However, this would have been
several months away. I have decided not to make a formal recommendation on
this matter. However, the Governor may wish to consider ensuring that any
prisoner who is likely to receive a life sentence is seen shortly after their initial
reception by a member of the lifer team.
43. With the exception of two entries relating to the incident in the education
department, no entries were made on the man’s wing history sheet after he left
healthcare until his death. This was a period of just over two months. While I
understand the pressures that exist in busy local prisons like Leeds, in my
opinion this level of reporting is wholly unacceptable. Ideally, all prisoners
should have regular meaningful contact with staff and detailed entries should
then be made on their wing history sheets. It was particularly important in this
case as the man had made threats to self-harm and had difficulty speaking
English.
The Governor should ensure that contact is made with all prisoners at
least monthly, and that details of the contact are recorded in the
prisoner’s history sheet.
14
Assessment, Care in Custody and Teamwork
44. All appropriate initial actions were completed when the ACCT document was
opened on 4 July 2007. However, there was very little information documented
in the assessment interview, possibly due to language difficulties. The
caremap identifies lack of contact with the man’s children and problems with his
solicitor as the two issues that needed to be addressed. Any efforts made to try
to resolve these issues do not appear to have been successful at this time.
The summary notes of the case review carried out on 11 July stated that the
man remained anxious and concerned about his children. They also said he
was crying and visibly upset when discussing the death of his wife. At the next
case review, held on 18 July, it was acknowledged that the man remained
emotional about his circumstances. The review panel agreed to look at his
legal issues and childcare concerns. Several entries were made in the ACCT
document and medical record to confirm that these concerns were followed up.
The man was adamant that he was not at risk of deliberate self-harm. The
ACCT document was therefore closed. It appears that the underlying issues
were identified and appropriately addressed whist the man was subject to
ACCT procedures. However, a post closure review was scheduled for 25 July
and I have found no evidence within the ACCT document that this review took
place.
The Governor should ensure that all ACCT post closure reviews take
place on the scheduled date and the ACCT document is updated.
45. The ongoing record section of the ACCT document should provide a record of
significant events, conversations linked to the caremap, and observations as
specified in the introduction to the section. I consider that the number of entries
in this section might confuse staff. For prisoners on half hourly checks, there
could be over 50 entries per day recording routine observations such as
“asleep on left side”. It might become difficult for staff to identify key issues
amongst so many routine entries. I believe this section should be reserved for
significant contributions linked to the issues identified in the caremap. The
recording of uneventful observations during regular checks might sensibly be
entered elsewhere in the ACCT document. Some establishments choose to
put routine observations on a separate document. The Governor may wish to
consider a way that key information is not missed when staff view the ACCT
form.
46. The man’s ACCT document was closed a week before he left healthcare.
Having spent around three weeks in the healthcare centre soon after he went
into prison, the move to a large residential wing would have represented a
considerable change in the man’s circumstances. The apparent lack of contact
on the wing might have had a significant effect on him. The man had been
identified as at risk of attempting suicide and as at risk of self-harm. I believe it
is essential for staff to have regular contact with prisoners who have recently
been subject to ACCT monitoring. For prisoners in this category, I believe
meaningful contact should be made at least weekly. Detailed entries of the
contact should be entered on the wing history sheet. The contact and entries
should be made for a considerable period after ACCT documents have been
15
closed. Had a member of staff looked at the man’s history sheet, they would
not have got any idea of how he was coping with prison life or any other issues.
This is clearly unacceptable. There is no current policy on this issue. I believe
that such a policy should be developed.
The Prison Service should consider developing a policy that ensures
detailed entries of weekly contact with prisoners who have been identified
as at risk of suicide are made in the individual’s history sheet for a period
of three months after the ACCT document has been closed.
Cell Sharing Risk Assessment
47. Following a brief period in police custody, the man was remanded into prison
custody on 4 July 2007. All the necessary documentation accompanied him
into custody. This included information on the PER relating to threats to self-
harm and the police medical record that noted the man had deliberately banged
his head on a wall and had been subject to constant supervision. When the
man arrived at Leeds, reception and induction procedures were completed and
a CSRA was carried out. The CSRA recommended that the man should be
located in a single cell. Given the level of risk indicated, I believe the single cell
recommendation was appropriate at that time. However, at a later stage it
might have been more appropriate and of some benefit to the man to move him
to a shared cell. Prison Service Order (PSO) 2750, Violence Reduction,
outlines the requirement for regular reviews of prisoners initially identified as
high risk. I can find no evidence that any CSRA reviews took place.
The Governor should ensure that Cell Sharing Risk Assessment reviews
take place in accordance with the requirements of PSO 2750.
The events of 28 September
48. The prison officer discovered the man hanging in his cell at about 4.55am. The
time of discovery is somewhat unusual as there was no formal requirement to
check on the man at this time. The prisoner who was in the cell next door to
the man, told my investigator that he thought the man had been checked
several times during the night. When my investigator asked the prison officer
why he had checked the man he replied that he had been carrying out checks
on prisoners who were on ACCT documents. He had been told by more
experienced staff in the prison that it was good practice to check prisoners in
single cells at the same time. He added that he had no specific concerns about
the man. Ideally, I believe this procedure should be carried out in all prisons.
However, I accept that given resource constraints it might be extremely difficult
to adopt this practice in prisons that have large numbers of prisoners who do
not share cells. I therefore do not make a formal recommendation on this
matter, but I note the prison officer’s actions, and the advice on which they
were based, as an example of good practice.
At prisons where it is normal for prisoners to share cells, I believe that
checking prisoners in single cells during the night to be an example of
good practice.
16
49. When the man was found, the alarm was raised via the prison radio net. The
night orderly officer was in charge of the prison at the time. He told my
investigator that he was on D wing when the alarm was raised and responded
immediately. He said he was at the man’s cell within about one minute. He
added that as he approached the cell he shouted to the prison officer to break
into his sealed pouch and open the cell door. The second officer arrived at
about the same time as the night orderly officer. He told my investigator that
the prison officer was still outside the cell at that time. He added that when he
spoke to the officer he appeared shaken. The prisoner in cell C3-40, said he
thought it was about five minutes after the alarm was raised before staff went
into the cell, but it is impossible to say exactly how long it took for staff to arrive.
I have found no other evidence to suggest that their response was in any way
delayed.
50. In interview, the night orderly officer told my investigator that he would not
expect any member of staff to enter a cell on their own at night. He added that
officers are expected to wait for another member of staff to arrive. The Prison
Officers’ Association (POA) representative who accompanied the night orderly
officer advised at the interview that, “It’s down to the individual person’s
discretion, as long as they don’t think it’s a set up, I mean if there’s only one
person in the cell it’s a bit clearer.” Prison Service policy leaves it to the
discretion of the individual member of staff whether to enter a cell on their own.
Staff may enter a cell in an emergency if they feel it is safe to do so.
51. It is impossible to say whether an immediate entry into the cell would have
helped to save the man’s life, but it is unlikely given that other staff arrived at
soon after. Nevertheless, it is self-evident that the swifter the response to a
prisoner who has seriously harmed the more likely it is that his or her life will be
saved. A delay of just a few minutes whilst waiting for support to arrive could
mean that all subsequent efforts might fail, no matter how professionally
undertaken. It is difficult to say authoritatively when staff should use their
discretion to enter a cell because circumstances will differ. However, if prison
staff lack confidence to enter a single cell when a prisoner is clearly hanging, it
is difficult to imagine any circumstances when they would feel safe to go inside.
I acknowledge that some staff may be reluctant to enter a cell alone for fear
that the prisoner might attempt to overpower them. But it would be interesting
to know just how often such an event has taken place. If the actual level of risk
is very low (as I suspect), a more balanced and informed judgement could be
made.
The Prison Service should provide further information about the number
of prisoners in single cells who have apparently attempted suicide at
night and then tried to overpower staff who went into the cell alone. The
information should be used to advise staff when to use the sealed pouch.
52. Once staff went into the man’s cell, all actions taken seem to have been
appropriate and in line with Prison Service policy. I have found no evidence to
suggest that staff who attended did not make every effort to resuscitate the
man.
17
53. Support provided to staff following the man’s death also seems to have been
appropriate. Prisoners interviewed appeared to have concerns about the
treatment of the man rather than needing support themselves. Nevertheless, I
take this opportunity to remind the Governor that appropriate support should be
offered to prisoners as well as staff following any death in custody.
Clinical Care
54. A review of the man’s clinical care was undertaken at my request. He
concludes that the man’s medical problems were dealt with promptly and
appropriately. He also finds that all actions taken at the time of the man’s death
were appropriate. The clinical reviewer has made no recommendations.
18
CONCLUSION
55. The man arrived in prison custody in a distressed and emotional state. I
believe the period he spent in healthcare helped him come to terms with the
early stages of his imprisonment. His period of supervision under the ACCT
procedures also seems to have been a success and it may have prevented him
self-harming or attempting to take his own life.
56. Having spent several weeks in the relatively safe environment in healthcare
and under ACCT supervision, the man transferred to C wing. Following this
move, there is little evidence of contact with staff or that their support was
available. It seems likely that this sudden reduction in supervision and support
from staff made it difficult for the man to cope.
57. It is impossible to determine exactly what caused the man apparently to take
his own life. It is said that he went into the cell occupied by the other prisoner
and his cellmate on the day before his death in a very distressed state and
insisted that he was not a sex offender. If so, he clearly believed that other
prisoners thought he was. Coping with imprisonment for the first time under the
circumstances in this case must have been extremely difficult. Concerns about
the safety of and access to his children may have added to his distress. If it is
true that he was wrongly accused of being a sex offender and bullied by other
prisoners, that may well have proved too great a psychological and emotional
burden for the man to bear.
58. I am obviously very concerned by the allegations that staff may have
contributed to the bullying of the man. I emphasise that these are allegations
only, and that the passage of time will make their investigation all the more
difficult. Nevertheless, I have no doubt that the Governor and the Prison
Service will wish to ensure that they are examined as thoroughly as possible.
19
RECOMMENDATIONS
1. The Governor should undertake a formal internal investigation into the allegations
of staff malpractice outlined in this report.
Prison Service response
Partially accepted. A review by West Yorkshire Police and the Governor concluded
that there was insufficient evidence to initiate a formal investigation.
2. The Governor should ensure that the foreign national co-ordinator provides
information for personal officers on any prisoner who is likely to have difficulty
communicating with staff as a result of language barriers.
Prison Service response
Accepted. All prisoners identified as foreign nationals will have relevant information
attached to their wing history sheet.
3. The Governor should ensure that contact is made with all prisoners at least
monthly, and that details of the contact are recorded in the prisoner’s history sheet.
Prison Service response
Accepted. In place. The new personal officer scheme requires weekly contact with
prisoners.
4. The Governor should ensure that all ACCT post closure reviews take place on the
scheduled date and the ACCT document is updated.
Prison Service response
Accepted. In place. A new system to ensure compliance was put in place in April
2008.
5. The Prison Service should consider developing a policy that ensures detailed
entries of weekly contact with prisoners who have been identified as at risk of suicide
are made in the individual’s history sheet for a period of three months after the ACCT
document has been closed.
Prison Service response
Accepted. Scope currently exists within PSO 2700
6. The Governor should ensure that Cell Sharing Risk Assessment reviews take
place in accordance with the requirements of PSO 2750.
Prison Service response
Accepted. Ongoing. A new system is in place maintained by the Violence
Reduction co-ordinator.
7. The Prison Service should provide further information about the number of
prisoners in single cells who have apparently attempted suicide at night and then
tried to overpower staff who went into the cell alone. The information should be used
to advise staff when to use the sealed pouch.
20
Prison Service response
Accepted. PSO 2710 contains mandatory instructions about immediate actions
following an apparent death. SCOP will consider reiterating these in the Safer
Custody News.
21
GOOD PRACTICE
At prisons where it is normal for prisoners to share cells, I believe checking prisoners
located in single cells during the night to be an example of good practice.
22