Individual at Belmarsh

Investigation into the circumstances surrounding
the death of a man, a prisoner at
HMP Belmarsh, in February 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2007
This is the report of my investigation into the death of a man on 10 February 2007.
The man was found hanging in his cell at HMP Belmarsh in the early hours of the
morning. He was aged 22.
I wish to offer my sincere condolences to the man’s family and friends for their loss.
The investigation was conducted on my behalf by two of my investigators. I would
like to extend my thanks to the Governor and her staff at Belmarsh for their help and
co-operation.
In addition to my investigation, a clinical review was undertaken by the Greenwich
Primary Care Trust into the medical care that the man received in custody. I am
grateful to the clinical reviewer and his panel for that review.
This young man was charged with a number of serious offences including murder.
According to a letter he left for his parents, the shame he felt for his crimes
apparently led to a decision to end his own life.
I have made three recommendations in addition to the learning points emanating
from the clinical review panel all of which have been accepted by the Prison service.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2007
CONTENTS PAGE NO.
Summary 1
The investigation process 2
HMP Belmarsh 4
Key events 5
Issues considered during the investigation 9
Recommendations 12
SUMMARY
1. In November 2006, the man was arrested and charged with a number of
serious offences, including murder. He was remanded into custody on 27
November to await his trial.
2. The man was initially sent to HMP Wandsworth, but as a potential category A
prisoner he was transferred to HMP Belmarsh on 30 November. He was
described as a ‘model prisoner’, well behaved, quiet and polite. None of the
staff, nor other prisoners nor members of his family noticed any change in his
mood over the next two months. His sister visited him the day before his
death and later said that he appeared to be his normal self.
3. However, in a letter dated 9 February 2007 and timed at 11.00 pm, the man
wrote to his parents about his shame for what he had done and his feelings
about ending his life. At about 5.15 am on the morning of 10 February, he
was discovered hanging from the window bars of his cell. Despite the efforts
of staff and paramedics, he was pronounced dead at 5.44 am. The man was
just 22 years old.
1
THE INVESTIGATION PROCESS
4. My investigators opened this investigation at Belmarsh on 19 February 2007.
The Governor and her staff produced the man’s core record and a number of
other documents for examination. Notices were distributed around the
establishment notifying staff and prisoners of the investigation. As part of the
investigation process, a number of staff were formally interviewed.
5. Her Majesty’s Coroner was contacted to inform him of the nature and scope of
my investigation and to request a copy of the post mortem report. Upon
completion, this report will be sent to the Coroner to assist with his enquiries
into the man’s death.
6. A clinical review of the man’s treatment in custody was undertaken on behalf
of the Greenwich Primary Care Trust.
7. One of my Family Liaison Officers contacted the man’s family to inform them
about my investigation and to offer the opportunity to raise any concerns and
questions that they would like explored and addressed. They chose not to
meet with my investigator or Family Liaison Officer at that time. The family
felt the prison had been open and honest with them about what had happened
and did not have any significant matters to raise. However, they were
concerned that, where possible, lessons should be learned to prevent the
same thing happening in the future. Members of the family had spoken with
prisoners who had known the man. The prisoners raised an issue about
potentially vulnerable category A prisoners being allocated a single cell.
8. The man’s sister told the family liaison officer that she and her son had visited
the man on his birthday (the day before his death). The man had seemed his
normal self and had not given any indication of feeling low or depressed. The
family felt, although it was incredibly difficult, it was important to recognise that
ultimately this was the man’s decision.
2
HMP BELMARSH
9. HMP Belmarsh opened in 1991. It is a local prison within the high security
estate and can hold category A prisoners.
10. In common with many other prisons, Belmarsh is overcrowded. Most of the
prison’s population are accommodated on four residential houseblocks.
11. In the introduction to an unannounced follow-up inspection report published in
December 2005, Ms Anne Owers, Her Majesty’s Chief Inspector of Prisons,
writes:
12. ‘Belmarsh is a complex prison. Most of its prisoners are short-term, relatively
low-risk prisoners who could be found in any local prison; but it also holds
higher-risk prisoners in security category A, some within the main prison and
some in its special and high security units. In addition, it has a significant
population of young adults and life-sentenced prisoners.
13. At our last inspection, we described Belmarsh as “struggling to provide a
regime and an environment that met the basic needs of its prisoners”. Since
then, the complexity of its task had, if anything, increased. The number of
category A prisoners and of young adults had grown. Life-sentenced
prisoners were spending longer in Belmarsh because of difficulties in
transferring them within an overcrowded system. And the prison’s high
security and special security units were at full stretch, holding, among others,
those suspected of the failed suicide bomb attempts of July.
14. There had undoubtedly been progress since the last inspection. This was
most marked in relation to resettlement, which had been reorganised and
coordinated. Drug treatment services had developed, and there was an
excellent visitors’ centre. There were still, however, no effective custody or
rehabilitation plans for the short-term and remanded prisoners who formed the
bulk of the population.’
15. Shortly after the man’s death, the Governor introduced a new regime at
Belmarsh. One of its aims is to reduce the period of time prisoners spend in
their cell.
16. In April 2005, Greenwich Teaching PCT assumed responsibility for
commissioning healthcare services in the prison. The Head of Healthcare
leads a multi-disciplinary team of nurses, healthcare officers, discipline
officers and nursing assistants, and there is input from a Mental Health In-
reach Team (MHIRT), visiting GPs and a consultant forensic psychiatrist.
17. The man’s death was the third apparently self-inflicted death to have occurred
in Belmarsh since I began investigating fatal incidents in April 2004. (There
has since been one other apparently self-inflicted death at the prison.) I have
made recommendations in two other investigation reports regarding record
keeping training for staff.
3
KEY EVENTS
18. During the night of 5/6 November 2006, two very serious offences were
committed - one of which resulted in the death of a woman. The man was
first arrested on 18 November on suspicion of being involved in those
offences. He was released after interview but re-arrested on 23 November as
the result of DNA evidence. The man was charged with the murder and other
serious offences.
19. The man appeared at the City of Westminster Magistrates’ Court on 27
November. He was remanded into custody at HMP Wandsworth and
committed to the Central Criminal Court with a trial date of 5 March 2007.
20. The man arrived at Wandsworth and underwent the standard reception
procedures. He was considered a low risk to others during the cell sharing
risk assessment. However, he was identified as a potential category A
prisoner due to the nature of the charges he was facing. (A category A
prisoner is someone whose escape would be highly dangerous to the public
or the police or the security of the State and for whom the aim must be to
make escape impossible.)
21. The first reception health screen was completed and the man told the nurse
that he had seen a doctor recently for a groin abscess. He had been given
antibiotics to treat the abscess whilst at the police station. No other medical
or mental problems were identified other than ongoing treatment for his acne.
However, due to the nature of the crime that the man was charged with, he
should have been referred for further psychiatric assessment. That was not
done.
22. The man was transferred to HMP Belmarsh on 30 November due to his
potential category A status. On 1 December, a secondary health assessment
was completed. Again, no medical or mental health problems other than the
abscess and acne were either mentioned or indicated. The man said that he
was emotionally ‘ok’ and that he was aware of the Listeners service and the
Samaritans. (The Listeners are volunteer prisoners who are trained by the
Samaritans to perform a similar role within prison.)
23. A prison officer conducted a one to one induction interview with the man the
same day. He confirmed the low risk cell sharing risk assessment, and
explained the procedures at Belmarsh for visits and telephone calls for
potential category A prisoners. The prison officer also gave the man literature
explaining life sentences. When asked how he was managing with being in
prison, the man said that he was coping at present but finding it hard. He
confirmed that he did not have any suicidal or self-harm thoughts. The prison
officer completed the ‘Identification of Potential Life Sentence Prisoner’ form.
In the section entitled ‘What is the prisoner’s initial reaction to his/her remand
in custody?’ The prison officer wrote, ‘Coping at present, but finding it hard.
Aware that the charge of murder can result in a mandatory life sentence.
Accepts move to Belmarsh, but it may cause problems with visits.’
4
24. The man was allocated a single cell on houseblock 3. It is normal for
category A prisoners to be allocated a single cell for reasons of security. An
exception to the rule is sometimes made if there are concerns about the
prisoner self-harming. There were no such concerns raised in relation to the
man and therefore the allocation of a single cell was in accordance with the
local policy.
25. The man did not come to notice of staff during the remainder of his time at
Belmarsh. He was polite and complied with any instructions he was given.
Neither staff nor prisoners saw any change in his mood or behaviour which
would indicate potential self-harming thoughts or behaviour.
26. The man was seen by healthcare staff on 1 December, 12 December, 4
January 2007 and 8 February, when he was prescribed various medications
for his abscess and his acne. However, there are no entries in his continuous
medical record relating to these dates.
27. The man’s sister visited him on his 22nd birthday (9 February 2007), and later
said that he appeared to be his normal self and had not given any indication
of feeling low or depressed. At interview with my investigators, the night duty
officer said that he had spoken with a prisoner in the next cell to the man who
had been talking with him that evening. The prisoner said that the man did
not ‘give anything away’.
28. The night duty officer was on duty on houseblock 3 that night. Part of his duty
was to check the category A prisoners four times during the night. There
were 18 such prisoners (including the man) on spur one, and he checked
them all at around 10.30pm, 1.30am and 3.30am. The night duty officer did
not notice anything untoward during his checks.
29. At about 5.00am, the night duty officer began his final count, making sure that
all of the prisoners in houseblock 3 were still in their cells. When he got to cell
36 on spur one (the man’s cell), he switched on the night light. He could not
see the man in his bed or in the toilet area. He saw that the table and chair
had been moved to the middle of the cell and it was then he noticed the man.
The man had apparently tied a ligature made from his bed sheet to the
window bars and around his neck. He was slumped down as if sitting on the
heating pipes underneath the window.
30. The night duty officer kicked the door several times to get a response, but
without success. He radioed a ‘level one’ emergency call to the control room,
and then ran to the office (referred to as ‘the bubble’) to contact the control
room again by telephone. He told them that he had a level one emergency,
gave the details, and then returned to the cell. The call was logged at 5.15
am. (A level one call indicates a serious medical emergency.) The control
room called for an ambulance at 5.17 am.
31. A second prison officer was the first to arrive. He opened the cell door and he
and the night duty officer entered. The second prison officer immediately
supported the man to relieve the pressure on his neck, while the night duty
5
officer returned to the ‘bubble’ to get the cut down scissors. The night duty
officer cut the ligature and the officers laid the man down on the cell floor.
The second prison officer then cut the ligature from around the man’s neck.
The ligature was thin and had left a deep mark in the man’s neck. It was so
deep that some officers who arrived later thought it was the ligature itself.
32. The second prison officer noticed that there was a quantity of toilet paper in
the man’s throat and he had difficulty removing it. The night orderly officer
arrived as the second prison officer began Cardio Pulmonary Resuscitation
(CPR). Other staff arrived. They included a healthcare worker who also
attempted to remove paper from the man’s airway. The healthcare worker
applied the ambu-bag to introduce air into the man’s lungs and the second
prison officer continued with the chest compressions.
33. An automatic external defibrillator was applied to the man’s chest but it
indicated not to shock. CPR was continued by the staff until the ambulance
crew arrived and took over at 5.27am. Sadly, despite the efforts of staff and
paramedics, at 5.44am the ambulance crew confirmed to the control room
that the man had died. At 8.26am, the prison doctor, who had been called in
from home, certified that the man was dead.
34. When the cell was searched, a letter written by the man was found dated 9
February and timed at 11.00pm. In the letter the man talks about his shame
for his offence and says goodbye to his family. Towards the end of the letter
there is a passage which reads, ‘It’s meant to be my birthday, but all I can
think about is ending my life!’ A diary was also found in the cell. The head of
healthcare at Belmarsh, saw the printed proverb for the 10 February which
read ‘man shall not live by bread alone’. The head of healthcare noted that
the words ‘shall not live’ had been highlighted.
35. The man’s family was informed of his death by the police and a member of
the prison chaplaincy. They have since had the opportunity to visit the prison,
see the man’s cell and speak to staff and prisoners who knew him. I was
pleased to learn that, in line with Prison Service policy, the Governor provided
a contribution towards the funeral costs.
36. On 13 February, an officer put in a Security Information Report relating to the
man’s death. Having heard about the particular circumstances of how the
man had apparently ended his life, in particular the use of toilet paper, the
officer recalled an interview with another prisoner. Whilst sitting in on a
medical interview he had heard the prisoner, who had recently transferred in
from another prison, almost boasting about the way he had tried to kill himself.
The prisoner had said that he tried to hang himself after stuffing toilet paper in
his mouth. The officer was struck by the similarity with the way that the man
had died.
37. The prisoner concerned had been on the same houseblock as the man for a
few days, so it is possible that he heard the man’s story and decided to use
that method. Unfortunately, like other prisoners my investigators wished to
speak to, this prisoner declined to be interviewed for my investigation. (Under
6
my current non-statutory Terms of reference, I have no power to compel
potential witnesses to assist my inquiries.)
7
ISSUES CONSIDERED DURING THE INVESTIGATION
Clinical Review
38. The panel concluded that:
(cid:127) the medical record appeared to be incomplete
(cid:127) the level of care the man received whilst in custody was comparable to
the care he could have expected in the community
(cid:127) no suicide or self-harm indicators were identified prior to his death
(cid:127) the clinical response to the emergency call appeared appropriate.
39. The panel has identified a few learning points that the Prison Health
Partnership may wish to consider for future service improvement. A copy of
the full clinical review is included in the annexes to this report.
Record keeping
40. Upon arrival at Wandsworth, the man went through the standard Reception
procedures which included a First Reception Health Screen. The form was
completed by a reception nurse. After the section on the form that asks
questions about the prisoner’s past and present mental health, there is a
paragraph in underlined capital letters which reads: ‘If yes to questions 12-14
or charged with homicide, refer to CPN for further psychiatric assessment and
record details in IMR’.
41. During his interview with my investigator, the reception nurse said that the
man was not referred as required due to an oversight, even though the
reception nurse was aware of the charges that the man faced. The reception
nurse is a registered CPN (Community Psychiatric Nurse) and said that the
man’s presentation on the 27 November did not give him any cause for
concern. Whilst I do not feel it would have altered the outcome in this case,
healthcare staff at Wandsworth should be reminded of the importance of
completing the reception procedures correctly.
42. The Prison Health Partnership at HMP Wandsworth should remind all
healthcare staff of the importance of correctly completing the reception
procedures and ensuring the timely referral of prisoners when required.
43. The prisoner’s medical record should contain a chronology of interactions with
healthcare staff, treatments and medication prescribed. There were no
entries on the man’s continuous medical record by Belmarsh staff until the
day of his death.
44. A Secondary Health Assessment form was completed the day after the man
arrived at Belmarsh (1 December) when he said that he felt emotionally ok.
The prescription chart shows entries on 1 December and 12 December 2006
and 4 January and 8 February 2007. There should be entries on the
continuous medical record to document the prescribing of this medication.
8
Poorly completed or incomplete medical records are highlighted in a
significant number of my reports and accompanying Clinical Reviews.
45. Healthcare staff should take steps to ensure they adhere to the guidance
on records and record keeping issued variously by the General Medical
Council, the Nursing and Midwifery Council and the Royal
Pharmaceutical Society of Great Britain.
Anti-ligature knives
46. When the officers entered the man’s cell they had no means of cutting the bed
sheet ligature. The night duty officer returned to the ‘bubble’ to get the cut-
down scissors from the emergency box. The time delay in this case was
minimal. Nevertheless, Prison Service Instruction (PSI) 32/2006, issued on
20 November 2006, introduced the personal issue of cut down tools. All
establishments are required to have a local protocol on the procurement,
issuing, carrying and use of cut down tools. The PSI says:
47. ‘All unified and uniformed staff in closed and semi-open establishments must
be provided with and carry on duty their own personal issue cut-down tool. It
is not sufficient for cut-down tools to be held in a box in the office for ‘grab-
and-go’ purposes, nor for staff to collect ‘any’ cut-down tool upon
commencement of duty.’ (Emphasis in original.)
48. The Governor must ensure local compliance with Prison Service
Instruction 32/2006.
Prisoner/staff interaction
49. A copy of the relevant section of the Staff Observation Book for houseblock 3
was given to my investigators at the start of their investigation. My
investigators were impressed with the quality of the entries made by staff,
particularly with regard to any concerns they had about prisoners self-
harming. The quality of these entries demonstrates a good level of interaction
between staff and prisoners, enabling changes in an individual’s behaviour or
emotional state to be recognised. Furthermore, such entries enable effective
continuity of care and safety of individuals who may be at risk.
9
Conclusion
50. The man was a young man with no experience of adult prison life. Because
of the nature of the charges against him, he faced a very long custodial
sentence if convicted.
51. It is clear from the letter the man wrote to his parents on the late evening
before his death that he felt ashamed of what he had done, and he appears to
have taken a decision to end his own life.
52. During his two months in custody the man was seen both by medical and
uniformed staff. Neither the staff nor fellow prisoners noticed any
deterioration in his mood. It is also telling that the man’s sister, who visited
him on his birthday the day before he died, also saw no signs that he intended
to take his own life.
10
RECOMMENDATIONS
HMP Wandsworth
(cid:1) The Prison Health Partnership at HMP Wandsworth should remind all
healthcare staff of the importance of correctly completing the reception
procedures and ensuring the timely referral of prisoners when required.
HMP Belmarsh
(cid:1) Healthcare staff should take steps to ensure they adhere to the guidance on
records and record keeping issued variously by the General Medical
Council, the Nursing and Midwifery Council and the Royal Pharmaceutical
Society of Great Britain.
(cid:1) The Governor must ensure local compliance with Prison Service Instruction
32/2006
11