Individual at Garth

Investigation into the circumstances surrounding the
death of a man
at HMP Garth on 25 January 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2010
Ashley House, 2 Monck Street, London SW1P 2BQ Tel: 020 7035 2876 Fax: 020 7035 2012
E-mail: mail@ppo.gsi.gov.uk www.ppo.gov.uk
A man was found at just after 8.00am in his cell at HMP Garth, having covered his
head with a plastic bag and suffocated during the night of 24 and 25 January 2010.
He was found on the morning of his birthday. I offer my sincere sympathy and
condolences to those touched by his death.
The investigation was carried out on my behalf by two of my colleagues. A clinical
review of the man’s healthcare is being undertaken on behalf of Central Lancashire
Primary Care Trust. Unfortunately, the review is not yet available but I have decided
to issue my report without it. I would like to thank the Governor of Garth and her
staff for their co-operation and assistance. Particular thanks go to the Acting Deputy
Governor for his help throughout the investigation.
The man came into prison late in life, having been convicted of a murder committed
almost 30 years before. He was in HMP Manchester for two years before
transferring to Garth in 2007. The man did not talk freely with many officers or
prisoners but he only very rarely contravened prison discipline. He worked on the
gardens party and largely kept himself to himself. He had regular visits, through the
pastoral visits scheme, from a longstanding pastor in the community. The visits were
terminated by the prison (although the pastor could still visit under the normal visiting
arrangements) shortly before the man took his life.
Although the man was subject to suicide and self-harm management monitoring
procedures twice in 2008, there was no clear indication that he was preparing to take
his own life in early 2010. Staff responded quickly when he was found but he had
died during the night. I judge that the man’s death could not have been reasonably
predicted. There is some evidence that he planned his own death, but I am satisfied
that he did so in a way that did not draw him to the attention of staff or prisoners.
I make three recommendations in this report regarding pastoral visits and family
liaison issues. However, the recommendations are complemented by a number of
learning points, some of which the prison brought to the attention of the
investigators, and had already been addressed.
Jane Webb
Acting Prisons and Probation Ombudsman October 2010
2
CONTENTS
Summary 4
The investigation process 5
HMP Garth 6
Key findings 8
Issues 14
Conclusion 23
Recommendations 24
Annexes
3
SUMMARY
The man was born in 1944. He worked as a school teacher in the north of England.
He was convicted and sentenced to life imprisonment in 2005. The man was sent
initially to HMP Manchester, where he told staff that he was upset about his
conviction. During his time at Manchester, the man was visited by a pastor from a
church in Manchester who had befriended him during his trial. The visits were
conducted under the pastoral visits system, when a religious leader can meet a
prisoner in a confidential setting.
The man transferred to HMP Garth in September 2007. He told staff that he was
worried about being in prison, but did not want any support from the mental health
team. The pastor continued to visit the man at Garth until early 2008 when the
prison told him that they were withdrawing the visits. The pastor complained and the
visits resumed in April 2008.
Suicide and self-harm monitoring procedures were put in place in July 2008 when
prison staff realised that the man had been sent documents relating to the custody
and suicide of another prisoner. The man was adamant that it was unnecessary as
he was not going to harm himself. The procedures were ended later that month.
In late November, the man’s appeal against his conviction was rejected. He reacted
by complaining of feeling ill and vomiting. Other prisoners came forward to staff
concerned that he might harm himself. Suicide and self-harm monitoring procedures
were put in place again the following day and the man was moved into the
healthcare centre. The monitoring procedures were ended in mid-December.
The man did not often come to the attention of staff in 2009. He worked in the
gardens party and attended education classes. In December, the prison again
ended the pastoral visits the man had previously enjoyed. The pastor complained
but they had not been reinstated before the man’s death.
Following the man’s death, it became clear that he had given away a number of
items to other prisoners in the days leading up to death. Neither the man’s friends
nor officers were aware of this. On the morning of 25 January 2010, staff unlocked
the cells as usual at approximately 8.00am. The prisoner in the cell next to the man
was aware that he usually left his cell straight away to telephone his wife. When the
man did not appear, the prisoner went into the cell and found him on his bed with a
plastic bag over his head and a cord around his neck. Prison and healthcare staff
attended but the man had already died.
The prison telephoned the man’s wife to break the news and the chaplain visited her
later that day. Unfortunately, an offer of a contribution to the funeral expenses was
not made to the man’s wife although I understand that this has been rectified. My
report contains three recommendations regarding pastoral visits and liaison with the
man’s wife.
4
THE INVESTIGATION PROCESS
1. A colleague led the investigation assisted by another colleague. On their
initial visit to the prison, my two colleagues met the Governor and Deputy
Governor. They were also introduced to the Chairman of the Prison Officer’s
Association local branch. My colleagues were shown the F wing and the
man’s cell. Notices were issued to prisoners and staff to alert them to the
investigation. No-one came forward in response to the notices.
2. My colleague wrote to Central Lancashire Primary Care Trust to request a
review of the clinical care the man received while in prison custody. The
clinical reviewer, who conducted the clinical review, was provided with all of
the relevant documentation and transcripts of the interviews in order to assist
in her report. The clinical review has been delayed and, as the man had little
interaction with healthcare staff, I have decided to publish my draft report
without it. The final report will contain the findings of the clinical review.
3. The office’s Senior Family Liaison Officer contacted the man’s family to
discuss the investigation and any concerns they had. The family raised the
following issues:
(cid:127) They were concerned that the man was being verbally abused by other
prisoners while undertaking the gardening duty.
(cid:127) The man did not receive a hat that was sent in to him.
(cid:127) They were concerned that the man was ridiculed by prison officers for
wearing several layers of clothing when the weather was cold.
(cid:127) They wanted the ending of the man’s pastoral visits to be investigated.
(cid:127) The man’s wife said that she was unhappy about the manner in which
she was told of her husband’s death.
(cid:127) The man’s wife said that she was unhappy about the way in which her
husband’s property was returned to her.
4. The investigators conducted interviews with five prison staff and two prisoners
on 3 February 2010. The investigators returned to Garth on 6 May to meet
with the clinical reviewer and prison family liaison officer. They also fed back
the interim findings of the investigation to the Governor. Two further
interviews were conducted over the telephone with prison staff. They are
included with the final report in order to allow the interviewees the chance to
review them. The investigators also corresponded with the National Offender
Management Service headquarters chaplaincy team regarding the issue of
pastoral visits.
5. The National Offender Management Service and the man’s family commented
on the draft report, and I have included responses to their comments in this
report.
5
HMP GARTH
6. Garth is a category B training prison which was opened in October 1988. The
prison can hold 847 prisoners, and generally has approximately 550 prisoners
subject to indeterminate sentences for public protection (IPP) or life
sentences. On 25 January 2010, there were 835 prisoners in the prison.
Pastoral visits
7. Prison Service Order (PSO) 4550 (Religion manual) states:
“Prisoners are entitled to special visits from their local clergy or
religious leader.
(cid:127) One individual should be nominated, and security clearance
obtained in each case.
(cid:127) Where there is uncertainty about the standing of any individual
within their own faith, advice should be sought from Chaplaincy HQ
or Religious Consultative Services.
(cid:127) Visits should be supervised to take account of the need for privacy
and confidentiality.
(cid:127) Such visits should be in accordance with local procedures and at
intervals deemed by all parties to be reasonable. In the event of
disagreement, the Governor, in consultation with Chaplaincy HQ if
necessary, will decide what is reasonable.”
8. Pastoral visits are different from ordinary visits due to their private and
confidential setting, away from other visitors. The frequency of ordinary visit
is explained in PSO 4410 (Prisoner communication – visits) which says:
“Governors may organise visiting arrangements to accommodate the
particular needs of the establishment and the wishes expressed by
prisoners and visitors, subject to the following provisions:
a) Each unconvicted prisoner must be allowed visits on at least three
days a week, including the opportunity for a visit on Saturday or
Sunday, normally every weekend and at least once a fortnight;
b) Convicted prisoners, both adult and young offenders, should be
allowed a visit on reception after conviction and at least every two
weeks thereafter, including at least one weekend visit every four
weeks.”
9. Prisoners can gain extra visits as privileges under the Incentives and Earned
Privileges scheme. Prisoners at the standard level receive two privilege
visiting orders per month, enhanced prisoners receive three privilege visiting
orders per month.
Personal officers
10. Each prisoner is assigned a personal officer who acts as the officer that they
can turn to should they need help. The officer is also required to have regular
conversations with the prisoner and record these interactions.
6
Assessment, Care in Custody and Teamwork (ACCT)
11. Assessment, Care in Custody and Teamwork (ACCT) is a care planning tool
used by the Prison Service to help support and monitor those prisoners
identified as being at risk of suicide or self harm. The ACCT process
encourages staff to work together to provide individual care to prisoners in
distress and help to diffuse circumstances where self harm or suicide may
occur.
Listeners
12. A Listener is a prisoner trained by the Samaritans to provide emotional
support to other prisoners. It is a confidential service which provides support
but not counselling.
Independent Monitoring Board
13. Each prison has an Independent Monitoring Board (IMB) made up of
members of the community. The Board’s role is to ensure that the prison is
properly run and that prisoners are treated decently. Each Board produces an
annual report for the Secretary of State. The most recent report available
from the Garth IMB is that of December 2008 to November 2009. The report
stated that the prison is providing a safe environment where prisoners are
treated with decency and respect and have, currently, access to an extensive
programme of education and skills. The Board noted the increase in incidents
of self-harm but considered that the prison took the issue of safer custody
seriously.
Her Majesty’s Chief Inspector of Prisons
14. Her Majesty’s Chief Inspector of Prisons conducted an announced inspection
of Garth from 30 March to 3 April 2009. The report noted the difficulties
caused by the sudden increase in IPP prisoners but said that they “found
Garth to be one of the most effective and well-run adult prisons we have
inspected”. The report described the range of education and work as
‘outstanding’ and praise the collaboration between departments to meet the
needs of prisoners. Incidents of self-harm were reported to have increased,
but the suicide prevention strategies were described as effective.
Previous deaths at HMP Garth
15. The death of the man is the only self-inflicted death that Garth has
experienced since the Ombudsman’s office began investigating deaths in
custody in April 2004. However, one prisoner died from natural causes in
2009, and two more have died from natural causes in 2010.
7
KEY FINDINGS
16. The man was convicted of murder in 2005, and sentenced to life
imprisonment with a minimum tariff of 15 years. Upon his arrival at HMP
Manchester he told staff that he was “gutted” about his conviction, but said
that he would not deliberately harm himself. On 2 February, a post-conviction
immediate needs assessment was carried out. The man told staff that he had
begun to have thoughts of harming himself, but he would not act on them as
he needed to “stay strong” for his family.
17. The man saw a doctor on 19 March. He complained of heart palpitations and
lower back pain. The man explained that he had a history of irregular heart
beats and it was decided to undertake an electro-cardiogram (ECG). He went
to the healthcare unit on 27 March in order for this to be conducted.
18. During his time at Manchester, the man was visited by a pastor from an
evangelical church in the Manchester area, who had befriended him during
his trial. These meetings were conducted under the pastoral visits system.
19. On 12 September 2007, the man transferred to HMP Garth. His family history
of heart trouble was noted, as was the absence of self-harm or suicide
attempts. It was noted that he was anxious and depressed due to being in
prison, but he said he was coping and did not wish to see the mental health
team.
20. However, the man did see the mental health team two weeks later on 28
September following a referral from the reception staff. He stated again that,
although anxious about being in prison, he did not intend to harm himself. He
said that he did not want any support from the mental health team, although
they did discuss the option of counselling.
21. The pastor visited the man at the end of November. This was arranged
through the pastoral visits scheme. He arranged a further visit for December
but, when he arrived, he was refused access to the prison. The pastor said
that the prison mentioned concerns about security. In early 2008, the pastor
received a letter from the prison saying that they had decided to stop the
pastoral visits because they were able to fulfil the man’s spiritual needs within
the prison. The pastor questioned Garth’s decision and asked them to
reconsider. The visits resumed in April. The man was given leave to appeal
against his conviction on 30 April.
22. Staff began the Assessment, Care in Custody and Teamwork suicide and
self-harm monitoring procedures on 23 July. This was in response to the man
being sent documents in the mail relating to the self-inflicted death of a
prisoner. The document was the Ombudsman’s anonymised report into the
prisoner’s death which is published on the office’s website. The man denied
that the documents increased the risk of him harming himself but the staff
were sufficiently concerned to begin ACCT procedures.
8
23. Staff included details of the material in security information reports (SIRs).
The sections of the report included details of the method the prisoner used to
end his life, as well as quotes from the prisoner’s journal explaining his
determination to hide his plans to commit suicide and information about the
number of prisoners who committed suicide on their birthdays. I understand
that when the documents were removed from his cell, staff said that the man
told them something to the effect of “I know what I need to know now.”
24. The ACCT plan required staff to have a “meaningful conversation” with the
man at least once every morning, afternoon and evening. These are
supportive interactions when the member of staff talks with the prisoner.
Senior Officer A was his ACCT case manager and recalled the man’s
comments at the time:
“And he was in constant denial that he was going to do anything, he
wasn’t particularly talkative to anybody. … he just basically said that
that was between him and his wife and no one else, and it had nothing
to do with anyone else. It was basically nobody else’s business.”
25. The following day, a multi-disciplinary meeting was held to discuss the care of
the man. Staff were concerned that he was planning to harm himself, but he
repeatedly denied having any suicidal ideas. The man continued to be
monitored and, on 29 July, it was decided to close the ACCT. A post-closure
review was held on 24 September. The man stated that the ACCT had been
unnecessary as he had not intended to harm himself. Unusually, a further
post-closure review was held on 21 November. The man was described as
feeling positive, and looking forward to his appeal. It was also noted that he
was aware of the support available should he need it.
26. The man’s appeal was rejected on 27 November. He was described as
withdrawing into himself and complained of feeling ill and constant vomiting.
Other prisoners came forward to staff to express concerns that he might harm
himself as he was seen giving items away to other prisoners. (Giving away
personal items has sometimes indicated that someone is planning to commit
suicide.) ACCT procedures were begun the following day, and the man was
admitted to the healthcare unit on 29 November, where he was subject to the
constant watch procedures. (This is when a member of staff observes the
prisoner at all times. It is used when staff consider a prisoner to be at a very
high risk of harming themselves.) The man was unhappy about moving to
healthcare and said he had no intentions of taking his own life.
27. Staff noted that he had thrown out a lot of belongings from his cell but the
man explained that he had just been clearing it out. He said that he was in
shock following the failure of his appeal. The man was taken off constant
observation on 1 December, and intermittent observations were put in place.
On 4 December, during an ACCT review, the man said that, although he did
not need to be in the healthcare unit, he did not mind staying there for a while.
It was agreed that he would return to a normal wing the following Monday.
9
28. The man returned to his cell on F Wing on 8 December and appeared happier
having returned to normal location. The investigators were told by Officer A,
the man’s personal officer, that the man had moved to cell 30 at this point.
His previous cell was in the middle of the wing and the man had been
disturbed by the noise from the pool table. Cell 30 is close to the servery and,
other than at mealtimes, is in a quieter area of the wing. Cell 30 was one of
several safer cells on F wing. (A safer cell is specifically designed to reduce
the opportunity for someone to harm themselves. It has, for example,
reduced ligature points.) However, the man was not placed in that particular
cell for the purpose of safety. Had an at-risk prisoner needed it, the man
could have been moved to a different cell to accommodate them.
29. The ACCT was closed on 15 December. Staff wrote that he had suffered a
great shock with the failure of his appeal, but had now recovered. A post-
closure review was held a week later and the same impression was noted.
The man said that he now wished his case to be heard by the Criminal Cases
Review Commission, and would continue to fight to clear his name.
30. On 29 January 2009, the man was found guilty of attempting to pass an
envelope to a visitor the previous day. The prison were unable to tell the
investigators what was in the envelope. I understand that the visitor was the
pastor, the pastoral visitor. The security information report (SIR) regarding
this incident said that the pastoral visits should be withdrawn, and the pastor
should be written to informing him of this. It is unclear whether the letter was
sent, but the visits appear to have continued until December 2009.
31. The man worked in the prison gardens from March 2008 until his death. The
leader of the team that the man worked on told the investigators that the
working hours were 8.45am to 11.45am and 1.50pm to 4.30pm. He said that
the man enjoyed working outdoors and, although quiet, got on well with the
other prisoners. The leader of the team didn’t think there was any bullying or
intimidation on the gardens party and said he never saw the man being
abused by other prisoners. He worked part-time in the gardens so that he
could undertake IT courses and qualifications in the mornings.
32. On 16 December, Officer B telephoned the pastor to tell him that his pastoral
visits were being ended. It appears that the visits had taken place fairly
regularly each month. The pastor did not receive the message and arrived at
the prison the following day for the visit. He was allowed in but told that such
visits were no longer possible as the legal visits area, where they took place,
was becoming full.
33. The pastor wrote to the prison requesting a change in decision. Governor A,
Head of Security and Operations, replied explaining that the visits were being
stopped because the prison was capable of meeting the man’s spiritual
needs. The decision had been reached in collaboration with the chaplaincy
team who noted that the man went to the chapel regularly and took a full part
in their meetings and discussions. The pastor was told that he could continue
to visit the man, through a normal visiting order, in the main visits area. The
pastor continued to dispute this decision up to the man’s death. He was
10
adamant that he did not want the man to have to sacrifice a visiting order so
that he could visit him.
34. On one of days prior to his death, the man became involved in an argument
with another prisoner in the servery queue. Apparently, the man had
inadvertently bumped into another prisoner who began to verbally abuse him.
The investigators were told that this prisoner then became abusive to the
other prisoners and staff in the vicinity. One of the prisoners the investigators
spoke to said that the man was troubled by this altercation. However, he did
not raise it with his personal officer, and his friend, Mr A, did not tell the
investigators that the man seemed concerned. Rather, Mr A recollected that
he had told the man that he had friends on the wing. The man replied that he
realised this because of the number of prisoners who defended him during the
altercation.
35. The man gave away some personal items in the days leading up to 25
January 2010, but none of the prisoners involved raised the issue with staff.
Following his death, the prisoners said that they did not associate this
behaviour with the risk of the man harming himself. Mr A said that he seemed
to give the items away to people who would not raise any concerns, and, if
asked, the man had plausible explanations for what he had done. Mr A said
that if he had known about it he would have been concerned about the man’s
welfare.
36. During his interview with the investigators, Officer C said that the man did
nothing that attracted staff’s attention and had carried on in his usual manner
in the days leading up to 25 January.
37. The man spoke to Reverend A, a member of the chaplaincy team, on 21
January. Reverend A explained to the investigators that he was from a free
church background. There is national agreement from a number of
denominations to meet the pastoral needs of all free church Christians. The
chaplain saw the man frequently as the man regularly attended the chapel.
The man had asked Reverend A if he knew that his pastoral visits had been
cancelled. Reverend A confirmed that he knew the visits had been stopped.
He told the man that he believed it was connected to the man having, in the
past, attempted to pass mail to the pastor. The man was unhappy about the
decision, and warned Reverend A that he would bring “bad publicity” to the
prison. The chaplain told the investigators that he was aware that, when the
man was at HMP Manchester, protests had been conducted by his supporters
outside the prison. He thought that this was the type of bad publicity the man
was referring to. He did not consider that it referred to the man harming
himself.
25 January
38. On 25 January, the man’s birthday, the regular early morning roll check was
completed at approximately 6.00am. (A roll check involves counting the
prisoners to ensure that the correct number is in the prison.) The officer
completing this check saw the man in his bed, apparently asleep.
11
39. Officer C and his colleague, Officer D, began unlocking the cells on F wing at
approximately 8.00am. Officer C told the investigators that staff typically
unbolt the doors of the cells, without going in to wake each prisoner. Officer D
began with cell F1-30, the man’s cell, while Officer C proceeded with the rest
of the cells. Officer C described his reaction to not seeing the man:
“[The man was] Usually unlocked first, he came down and used the
phone, he phoned his wife every morning. He wasn’t there, so I recall
thinking well I wonder where he is, strange him not being there.”
40. Mr A, who occupied the cell next door to the man, was also aware that he was
generally already up and dressed when the doors were unlocked. Mr A was
so surprised to not see the man that he went into his cell. He found the man
in his bed, with the covers pulled over his head. He had a plastic bag over his
head with a cord tied around his neck.
41. Mr A left the cell and alerted Officer C. The officer went into the cell and
checked the man. The officer told the investigator that, in his opinion, the
man was dead as his body was beginning to stiffen, and his appearance was
waxen. Mr A had told him that the man had no detectable pulse. The cord
around the man’s neck was not immediately removed. Officer C told the
investigators:
“However in my own opinion, there was no life to preserve, it was
clearly evident that the man was deceased and had been for some
time. In my opinion, rigor mortis had set in. … it would have been a
futile attempt to try and administer any form of CPR [cardio-pulmonary
resuscitation].”
42. Mr A was taken from the wing and placed in a cell with a Listener on G wing.
Officer C left the cell and told Senior Officer (SO) A about the man. The
officer telephoned the communications room and the healthcare unit to ask for
their assistance. Senior Officer A went into the cell. He too judged that the
man was dead. He used the urgent message signal to alert the control room
and healthcare unit to the situation by radio. (Senior Officer A told the
investigators that he did so to ensure that the message was properly received
and understood, not because he thought the man could have been saved. He
agreed with Officer C that the man’s life could not have been saved.)
Nevertheless there was a delay calling the ambulance as communications
staff were not clear that it was necessary because the man was already dead.
43. Nurse A was alerted by radio to the situation and went to the man’s cell at
approximately 8.12am. He asked the communications room to alert the
healthcare member of staff carrying the radio ‘Hotel 2’ to come to the man’s
cell with the emergency bag, as he did not know what they would be dealing
with. (Hotel 2 is the call sign assigned to a radio held by a member of the
healthcare team.) Nurse A cut the cord around the man’s neck and moved
the bag to one side. Newspaper was covering the man’s mouth which was
12
also removed. Nurse A performed a series of checks but concluded that there
were no signs of life. He told the investigators:
“We checked for a carotid and radial pulse and then I asked for a
stethoscope to check for the apex pulse. It was at that point that there
was no obvious signs of life. The man’s chest was extremely hard, his
limbs were contracted and I asked my colleagues to double check for a
pulse. … There was no life to preserve unfortunately. His pallor was
very waxy, he was tepid and there was evidence of levidity [the pooling
of blood in the lowest parts of the body after death] within his limbs as
well, which would explain or indicate that death had taken place quite a
while ago.”
44. At 8.45am, the pastoral visitor telephoned the prison on behalf of the man’s
wife who was expecting her husband’s usual morning telephone call. The
man’s wife lives about two hours drive from the prison. As a result of the call,
and due to fears about the news reaching her by some other way, Deputy
Governor B decided unusually that the news of her husband’s death should
be broken to her by telephone. (Recommended practice is that the prison
should break the news in person.) Governor B is a trained family liaison
officer (FLO) and was asked to do this.
45. Reverend A suggested that Governor B might not be the best choice to be the
family liaison officer given his correspondence regarding the pastoral visits.
Reverend A was asked to be the FLO. He visited the man’s wife later that
day. Contrary to the Prison Service Order, an offer to contribute to the funeral
expenses was not made. The man’s wife telephoned Deputy Governor B
later that afternoon to discuss her immediate concerns. Reverend A, the
FLO, later visited the man’s wife and returned all of the man’s property to her.
46. Following the man’s death, Deputy Governor B wrote a letter in reply to the
pastor’s MP to apologise for the confusion over the visits, and to offer an
explanation to the pastor.
Support for prisoners and staff
47. Officer C explained that support was offered to the prisoners. Counselling
and the mental health in-reach team was offered to Mr A, and the others
involved in the events of 25 January. Any prisoners subject to suicide and
self-harm monitoring procedures were also re-assessed to ensure their well-
being.
48. After finding the man, the staff care and welfare team were immediately
deployed to support staff. A hot debrief was held at approximately 10.30am in
the boardroom. It was chaired by Deputy Governor B and included all those
involved in the events of the morning. A critical incident de-brief was held on
15 February. These meetings allowed staff to review the response and
express their views on it.
13
ISSUES
Whether the man was at risk?
49. The man had been subject to ACCT monitoring procedures on two separate
occasions in 2008. The first was begun due to the correspondence he had
received and the second was when he gave away items following the failure
of his appeal. In the first of these instances the man had documents that
concerned staff as they referred to the suicide of another prisoner. Staff were
concerned and I believe that they acted appropriately in beginning the ACCT
procedures.
50. The documents referred to the fact that the other prisoner died on his
birthday. The man took his own life on his birthday. Significant anniversaries
can increase the risk of suicide and self-harm. However, it is difficult to know
what dates are significant to the person concerned. Research undertaken by
the Prison Service indicates that there is a slightly increased risk of a self-
inflicted death in the week before and of the birthday. However the findings
reveal that the overall proportion of self-inflicted deaths in which birthdays
appear to be a major factor is low and may be explained by random variation.
This research was included in the Ombudsman’s report into the death of
another prisoner that the man had in his possession in 2008.
51. Although the documents read by the man could suggest an element of
planning, given that he had not attempted to harm himself on previous
birthdays, I do not think it reasonable for staff to have acted differently,
particularly in the absence of any other obvious risk factors. The most recent
of the ACCT procedures was closed in December 2008 and I consider both to
have been appropriately managed and closed.
52. With regard to the man’s actions immediately prior to his death, reports
emerged that he had been giving away items in the days leading up to 25
January. Officer C explained to the investigators that one of the prisoners
given items did question the man, but he convinced him that there was
nothing to worry about.
53. This account was confirmed by another prisoner who told the investigators
that the man had given him some packets of crisps in the days before his
death. The prisoner did not find this unusual and did not alert officers about it.
The man’s personal officer told the investigators that he had not known that
he had been giving away his belongings.
54. Mr A, the prisoner who found the man, told the investigators that he had not
known he was giving his things away, and would have told officers if he had
done. I am satisfied that staff were not aware of what the man was doing. If
they had known, I hope that they would have recognised that it could indicate
his intention to end his life.
55. Other than giving away his belongings (which staff were not aware of) the
man does not appear to shown any concerns in the period leading up to his
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death. The officers and prisoners who knew him said there was no change in
his demeanour. The leader of the gardens party confirmed that he was
unaware of any changes in the man’s attitude or behaviour. Reverend A,
from the chaplaincy department, saw the man regularly and said that he
wasn’t concerned about the man’s welfare. Although the man had been
involved in a brief altercation with another prisoner in the days leading up to
his death, his friends and the officers told the investigators that he did not
consider this to have been a cause of great distress to him. There was also
nothing in the man’s paperwork to suggest that it greatly concerned him.
56. When there are no apparent warning signs, it is very hard for staff to put in
place strategies to safeguard prisoners. I do not think that the staff could
realistically have predicted that the man would take his life. I believe that his
death was neither predictable nor preventable.
57. The man’s family responded to the draft report by saying that, in their view,
the reasons for the man’s death were clear, and listed a number of factors as
follows:
“1) His pastoral support was withdrawn
2) A hat which he requested twice was denied to him twice.
3) It was the coldest and longest winter in a long time.
4) He suffered from the cold as he was 65 years old and didn't carry
any body fat.
5) Exposure to cold over long periods causes depression
6) It was the anniversary of his conviction.
7) It was his birthday.
8) It was just after Christmas.
9) It was in the depths of winter.
10) Vindictive behaviour from certain prison staff.
11) A bullying incident from another prisoner.”
58. I have investigated whether there were signs that the man was intending to
end his life but there is no clear evidence why the man acted as he did. Of
course, the man’s family may be correct in the reasons they list but I must
limit myself to what evidence the investigation has established. The man
dissembled his intentions and did not give clear signs that he would take his
life. With regard to the potential significance of the timing of the man’s
actions, it is impossible to know if this was a factor but the man had been in
prison for several years and previous significant dates had passed without
incident.
59. The prison has a responsibility to support those prisoners who they have
reason to believe are at risk of harming themselves. They did not judge the
man to fit into this category and therefore did not begin ACCT procedures. I
do not criticise the prison in this regard due to the lack of clear signs that the
man was at risk of harming himself.
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Using a plastic bag
60. The man used a plastic bag to end his life. A plastic bag is something that
prisoners are ordinarily allowed to keep in their possession. It was, I
understand, used to line the rubbish bins in the cells. Staff would not routinely
remove objects from prisoners unless they had a specific reason to do so.
They did not take things from the man as they did not consider him to be at
risk of harming himself. Even if staff had considered him to be at risk the
plastic bag might have remained in his cell. PSO 2700 (Suicide prevention
and self-harm management) states:
“However, removing personal belongings from a person who is feeling
hopeless and depressed … can increase feelings of distress and
therefore increase the risk of suicide, self-harm or a higher risk method
of self-harm. Where possible, prisoners at risk should be allowed to
retain their belongings unless it is clearly unsafe to do so.”
61. I am satisfied that it was appropriate for the man to have the bag which is a
routine item in a prisoner’s possession. He was not judged to be at risk and
there was no reason to suspect that he would use it to end his life. Following
the publication of the draft report, the man’s family commented that they were
surprised that a vulnerable prisoner had access to a plastic bag. It is
important to note that because the man was not deemed to be vulnerable, his
access to items normally in his possession was unrestricted. As pointed out
above, even had the man been deemed to be at risk it is not certain that the
bag would have been removed from his cell.
Ending the pastoral visits
62. The man had been visited by a pastor from a local church during his time at
Manchester prison under the pastoral visits procedure. After the man moved
to Garth, the visits were ended, and then restarted. Garth again decided to
stop the visits in December 2009, and they had not resumed prior to the
man’s death.
63. Prison Service Order (PSO) 4550 (Religion manual) provides an opportunity
for the prisoner’s local clergy or religious leader to meet them in private. The
PSO does not lay down restrictions to these visits other than the visitor must
be security cleared and the visits should be conducted in accordance to local
procedures. This part of the PSO was included, according to the chaplaincy
team at the National Offender Management Service, to allow prisoners to
maintain links with their local faith groups to aid their resettlement after
release.
64. Garth stopped the visits twice and engaged in a long correspondence with the
pastor about them. The pastor said that the prison intimated that they were
concerned about the security of the visits. The prison became further
concerned when the man was seen attempting to pass an envelope to the
pastor during a visit. The SIR recommended that the pastoral visits
entitlement should be withdrawn. However, nothing appears to have been
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done until December, almost a year later. Although a security concern would
have been an appropriate reason to end the entitlement, it was not stated as
the reason why the prison wished to stop the visits in the letters to the pastor.
65. Instead, Garth used the man’s full and regular use of the prison’s chaplaincy
team as a reason to end the visits. While it is clear that the man did regularly
attend the chapel and did not claim that the chaplaincy team were unable to
meet his spiritual needs, this justification is irrelevant according to the PSO.
66. The decision to end the visits was a decision for Garth and, as noted, there
are several grounds for pastoral visits to end. However, the prison did not use
criteria set out in the PSO to make their decision. I have found that the issue
was not clearly handled by Garth as the visits were allowed, stopped, allowed
again before finally being stopped. Communication with the pastor was also
unhelpful as the responses often failed to answer the pastor’s questions. I am
pleased to hear that the Deputy Governor has written to the pastor’s MP
offering an apology for the tone of the correspondence. The Deputy Governor
has also offered to meet the pastor to explain the decisions taken by the
prison. This apology and offer is to be welcomed, although too late to benefit
the man. Nevertheless, the prison should consider how it would react to a
similar situation in the future.
The Governor should consider PSO 4550 and ensure that decisions are
consistent and clearly explained to prisoners and their faith leaders.
67. I understand that the headquarters chaplaincy team are available to help on
such matters, should they be required.
68. The man’s family responded to this section of the draft report by requesting
greater investigation into the details of the decision-making regarding the
ending of the pastoral visits. It is clear from their response that this issue has
caused the family a great deal of distress. However, I must distinguish
between the early incidents and communication and the final ending of the
pastoral visits. Although the report acknowledges the early decision making
and communication was flawed, the details of these early incidents fall outside
the remit of our investigation as they are not immediately relevant to the death
of the man.
69. The man’s family stated that they considered the ending of the pastoral visits
to be crucially important to understanding why he chose to take his life. The
only recorded evidence I have seen that the man was troubled by the issue
was on 21 January 2010 when he told Reverend A that he would bring bad
publicity onto the prison for ending the visits. Reverend A did not view this as
an indication that the man would harm himself, and I consider his response to
be understandable. There is no evidence of the man becoming upset on any
other occasion, threatening to harm himself or raising the issue with his
personal officer. My investigators have seen no evidence that the man at any
other point during his entire time at Garth complained about the issue of
pastoral visits at all.
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70. The man’s friends on the wings consistently said that the man did not appear
troubled in the days leading up to his death, and did not mention anything
regarding pastoral visits to the investigators. It is impossible to know what
was on the man’s mind at the time of his death. As there were no recorded
signs that the decision greatly upset him, I cannot be sure that the ending of
pastoral visits was an explicit reason for his death.
Clinical care
71. The man had very little significant contact with healthcare staff whilst he was
in prison, other than the time in healthcare following the first ACCT
procedures in 2008. The clinical reviewer described his overall medical
history in prison:
“The Clinical Review has highlighted that the man was generally in
good health and maintained his fitness by regular exercise. A health
screen conducted on reception to HMP Garth revealed that the man
had personal or family history of cardiac disease, asthma, hearing
difficulties and lower back pain. He received appropriate further
investigation and treatment and maintained his own stock of
medication. The man was reluctant to acknowledge any signs of
distress or accept mental health care.”
72. With regard to the man’s decision to take his life, the clinical reviewer wrote:
“In concluding the Clinical Review, I concur with the findings of the
Draft Report of the Investigation into the man’s death that the man’s
death could not have been reasonably predicted.”
73. Although there were no healthcare issues while the man was alive, two issues
were identified regarding the emergency response to his death.
Calling the ambulance
74. When the man was found, the officers and nurses agreed that the man had
died and there was no life to preserve. They did not attempt cardio-
pulmonary resuscitation (CPR) and I am satisfied that this was appropriate.
This is consistent with Annex 13A of PSO 2700 (Suicide prevention and self-
harm management) which states:
“If not breathing and/ or no pulse is present, clear airway and attempt
resuscitation, using a face mask with non-return valve, unless rigor
mortis of the limbs has clearly set in.” (Emphasis in original.)
75. An ambulance was requested but it did not arrive for some time. Nurse A told
the investigators that he asked on a number of occasions where the
ambulance was and was told that it was on its way. The investigators were
told that the delay calling the ambulance may have been caused by a lack of
certainty over whether it was necessary given the consensus that there was
no chance of reviving the man.
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76. I am satisfied that it was clear that when he was discovered, the man was
already dead and could not be resuscitated. However, this will not be so in
every case. The prison immediately raised this question with the investigators
when they opened the investigation. The Governor said that they had already
ensured that calling an ambulance is included in the contingency plans. The
staff in the communications room were now aware that it is their responsibility
to undertake this duty. Calling the ambulance had also been included in the
duty governor action sheet to ensure that they are aware of the importance of
the action. I am pleased that the Governor quickly recognised the confusion
about calling an ambulance and took immediate steps to issue clear guidance
to her staff. I have decided that a recommendation is not necessary as action
has already been taken to rectify the confusion.
The ligature
77. The ligature tied around the man’s neck was not immediately removed by the
staff who responded to the emergency. I understand that this was because it
was clear that the man had died and could not be resuscitated. The Governor
also brought this issue up with the investigators on their opening visit. She
realised that, in future situations, it may not be clear that the person cannot be
resuscitated. I am pleased to record that the Governor has now issued further
guidance to staff involved in responding to a suspected death in custody.
This guidance makes clear the importance of removing any ligature
immediately, and again I do not make a recommendation in this regard.
Liaison with the man’s family
Breaking the news to the man’s wife
78. The man’s wife was upset that the news of her husband’s death was broken
to her over the telephone whilst she was at work. She was then asked to
write down a telephone contact number. PSO 2710 (Follow-up to deaths in
custody) makes clear the recommended method of breaking the news:
“The family should be informed face to face as soon as possible after
the death.”
79. However, the PSO also acknowledges that this option is not always possible.
It does say that using the telephone should only be used as a last resort. The
investigators were told there were a number of reasons why the telephone
was used. Firstly, the pastor had already called the prison to enquire after the
man’s well-being as he had not made his regular morning call to his wife. The
prison realised she might already be worried. They thought that refusing to
confirm her concerns until someone could drive two hours to see her could be
seen as obstructive. The prison was also aware of the high profile nature of
the man’s offence and was concerned that the news would be leaked to the
media before she could be told in person. I understand that this belief was
well-founded as the news was leaked to the media within an hour of his death.
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80. I accept that using the telephone was the only reasonable thing for the prison
to do, albeit one that should be avoided wherever possible. However, the
manner of the telephone conversation was also troubling for the man’s wife.
She was not comfortable about being told to note down a telephone number
immediately after being told of her husband’s death. This illustrates that
telephone conversations are particularly prone to misinterpretation. Not
leaving a telephone number would have been equally neglectful. The manner
of such a conversation is important for the relationship with the bereaved
family and must be conducted carefully and respectfully.
The Governor and FLOs should review the sections of PSO 2710
regarding the breaking of the news to the family, particularly if the
telephone has to be used.
81. The National Offender Management Service (NOMS) suggested that this
recommendation be omitted since the report agrees that telephoning the
man’s wife was the only option in the circumstances. However, the
recommendation was made due to the tone and content of the telephone
conversation, and in order for such conversations to be carefully considered if
they are to be used in the future.
82. I understand that Reverend A took over the family liaison role from Governor
B following the telephone call. The chaplain correctly realised that Governor
B might be an inappropriate choice of FLO given his part in the decision about
ending the pastoral visits. This was important and prevented any further
erosion in the relationship with the man’s wife.
83. The PSO also says that:
“If face-to-face prison notification is not possible, there should be swift
face-to-face follow-up.”
84. It is reassuring that the prison went to visit the man’s wife later that day. A
personal visit is particularly necessary when the initial news has been broken
over the telephone.
The man’s property
85. The man’s wife wished to know what had happened to a hat that she had sent
to her husband. She said that, as it had not been delivered to the man, she
had sent a second hat, which had also gone missing. Officer C remembered
that the man had asked about the hat and the officer had been able to
establish that it had not been received into the establishment. Officer C told
my investigators that the man had told him that he was going to ask his wife to
send another. The investigators asked Garth for any further information
regarding the hats but have not been able to discover anything further. I am
sorry that I am unable to answer the man’s wife’s question.
86. The man’s family returned to the issue in their comments to the draft report,
saying that the unavailability of the hat may have been a factor in his death. I
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accept that the missing hat was frustrating for the man and his family, and
have attempted to discover how strongly the man felt about it. The
investigators have spoken to the prison and the man did not complain about
the hat, or do any more than mention it to his personal officer. Unfortunately, I
am limited to the evidence that available, although I acknowledge the
importance attached to the missing hat by the man’s family.
87. The man’s wife was also unhappy that the prison returned all of the man’s
belongings to her, without first checking what she actually wanted. She found
this upsetting. The investigators spoke to Reverend A, the family liaison
officer, who said that a form was given to the man’s wife listing all of the items
when he returned the property. I do not find anything untoward in the prison’s
actions but remind them of the sensitivity of handling the deceased’s property.
PSO 2710 includes a suggestion that the family is asked how they would like
to receive the property and this should be considered as families may react
differently when receiving the property.
Verbal abuse of the man
88. The man’s wife was also concerned that her husband may have been verbally
abused by other prisoners while working on the gardens and taunted by
officers for wearing several layers of clothing when it was cold. The
investigators asked prison staff if they were aware of such behaviour by
prisoners and other staff. They consistently said that they had never seen the
man being treated in such a way. It is worthy of note that the man’s personal
officer did not recall the man ever raising such a concern with him. The
investigators have also seen no record of such allegations in the man’s file. I
understand that this may be frustrating for the man’s wife but am unable to
provide any further information.
Funeral expenses
89. PSO 2710 (Follow-up to a death in custody – FLO guidance) says:
“Offer to pay reasonable funeral expenses or, if the family want
particularly expensive arrangements, offer a contribution. £3,000 is the
sort of figure considered reasonable in 2005-06 but do not quibble over
small sums.“
90. However, Garth did not make this offer to the man’s wife, although they did
arrange to pay to transport his body to his family. Although in previous deaths
the prison had contributed to the cost of the funerals, there appeared to be a
degree of confusion by staff about when a contribution should be offered to
bereaved families. It is disappointing to learn that an important aspect of the
prison’s assistance was managed poorly. The investigator, once he became
aware that the man’s wife had not been offered a contribution to the
expenses, spoke to the Governor about his concern. The Governor agreed to
make a contribution to the funeral costs.
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The Governor should review the requirements of PSO 2710 to ensure
that the offer to contribute towards funeral expenses is part of the family
liaison process.
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CONCLUSION
91. The man was, by all accounts, a private man. He did not share his feelings
with many staff or prisoners and there appears to have been no evidence in
late 2009 and early 2010 that he was planning to take his life. He did give
away items to other prisons but this did not arouse the suspicions of the
prisoners receiving the items. I cannot fault the prison for not recognising he
was a suicide risk. I believe that the care received by the man was of a good
standard, except that the prison did not manage the issue of the pastoral visits
well.
92. Following the man’s death, the prison engaged with the man’s wife although it
was disappointing to hear she had a number of issues regarding their liaison
with her. Most importantly, a contribution towards funeral expenses was not
immediately offered and paid. The prison must ensure that this does not
happen again.
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RECOMMENDATIONS
1. The Governor should consider PSO 4550 and ensure that decisions are
consistent and clearly explained to prisoners and their faith leaders.
The National Offender Management Service accepted this recommendation
and wrote:
“Functional Heads and Chaplaincy written to and advised that
PSO 4550 must be adhered to and decisions must be consistent.”
2. The Governor and FLOs should review the sections of PSO 2710 regarding
the breaking of the news to the family, particularly if the telephone has to be
used.
The National Offender Management Service suggested that the
recommendation be omitted since the report agrees that telephoning the
man’s wife was the only option in the circumstances. However, the
recommendation was made due to the tone and content of the telephone
conversation, and in order for such conversations to be carefully considered if
they are to be used in the future.
3. The Governor should review the requirements of PSO 2710 to ensure that the
offer to contribute towards funeral expenses is part of the family liaison
process.
The National Offender Management Service accepted this recommendation
and wrote:
“The Chaplaincy and FLO are now absolutely clear about the
requirement to pay funeral costs.”
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