Individual at Gloucester

The circumstances surrounding the death of a prisoner at
HMP Gloucester in April 2005
Report by the Prisons and Probation Ombudsman for England
and Wales
February 2006
This is the report of an investigation into the circumstances surrounding the
death of a prisoner at HMP Gloucester at the end of April 2005. He died by
hanging. At the time of his death, the man was 37 years old.
My colleagues and I would like to extend our condolences to the man’s family
and to all those touched by his death. His family has raised a number of
specific points in relation to his drug use, mental health and transfer from
HMP Blakenhurst to HMP Gloucester. I hope this investigation goes some
way to answering their questions.
Two of my colleagues, carried out the investigation on my behalf. One of my
family liaison officers, visited the man’s family and remained in contact with
them. A clinical review of his health care and treatment at Gloucester was
conducted by a doctor on behalf of West Gloucester Primary Care Trust
(PCT). His review is annexed to this report.
I would like to thank the Governor of HMP Gloucester and his staff for their
ready co-operation and assistance with this investigation.
The man’s death was one of four apparently self inflicted deaths to have
occurred in Gloucester during 2005. However, my investigators did not
discern common factors with these other tragedies.
This report makes a number of recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2006
ii
Contents
Summary ...........................................................................................................
Investigation Process .......................................................................................1
BACKGROUND INFORMATION........................................................................................................
HMP Gloucester
Events leading up to the man's death…………..........…………………………..4
Events up to the man's death
The day and early evening prior to his death
The night period prior to his death and the day of his death
Contact with the family …… ……………………………………………………16
Issues considered..........................................................................................17
The man's drug use
The transfer from Blakenhurst to Gloucester
The man's escape attempt
Elist procedures
Events during the evening prior to his death
Incident reports
Record keeping
The man's assault allegation
Conclusions...................................................................................................21
Recommendations, housekeeping points and good practice.........................22
iii
Summary
The man was initially remanded to HMP Blakenhurst on 4 April 2005, after
spending four days in police custody. Having been given medication for
heroin withdrawal during this time, he declined to undertake a detoxification
regime upon his arrival at Blakenhurst.
On 12 April, he was transferred to HMP Gloucester on security grounds.
These related to events that had occurred during a previous period in custody.
Once at Gloucester, the man shared a cell with an old acquaintance.
The man was taken from Gloucester prison on a police production order to
Rugby Police Station on 26 April. During the return car journey to Gloucester,
he attempted to escape but was unsuccessful. Evidence suggests that this
was a planned attempt which the man had believed would succeed.
However, its failure led to him being placed on the escape list and thereby
being subject to the E list regime. This included being located in a single cell,
wearing distinctive clothing, and being checked once an hour when locked in
his cell.
During the morning prior to the man’s death, his ex cell mate found him to be
upset and he spent some time talking with him. His ex cell mate thought that,
by the time he left the man, his mood had lifted. However, that evening, whilst
locked up for the night, the man passed a note to his ex cell mate that
indicated his intention to end his life.
The man’s ex cell mate, and his cell mate, rang their cell bell several times
and asked to be able to go to see him. An officer responded but what
happened next remains uncertain. Both prisoners have said that they were
explicit in stating their concerns about the man’s intention to take his own life
and their need to see him. The officer refutes this and says they gave no
reason for wanting to see the man. However, he did check on the man and
his demeanour gave him no cause for concern.
At 1:10 am, whilst doing an hourly check, the OSG found the man hanging.
The alarm was raised and staff attended immediately. Resuscitation was
attempted, but sadly was unsuccessful. He was declared dead at 2:30am.
The post mortem indicated that the cause of death was hanging consistent
with a ligature tightened during life. No illicit drugs or alcohol were found in
the man’s body.
My investigators have been unable to determine the exact events that took
place during the evening prior to the man’s death. Differing accounts are
given by two prisoners and two members of staff. Nonetheless, my report
makes recommendations in relation to the need to document and record
security decisions made about a prisoner’s transfer to a different
establishment, and in the day to day files and paperwork held about prisoners.
iv
I also propose that procedures in relation to prisoners being placed on the
escape list are reviewed so that issues concerning the risk of self harm and
suicide are considered as part of the risk assessment.
v
Investigation Process
Two of my colleagues conducted a preliminary visit to HMP Gloucester on 3
May 2005, and returned on three subsequent occasions. During the course of
initial inquiries, the investigation team were shown around the prison and
visited the cell where the man died. They reviewed all the relevant
documentation and established a chronology of events.
Notices were issued to staff and prisoners telling them of the investigation and
offering them the opportunity to speak with my colleagues. A number of
prisoners and staff were interviewed. A prison officer, an OSG and a prisoner
were interviewed twice.
My investigators met with representatives of the local branch of the Prison
Officers’ Association (POA) and the Chair of the Independent Monitoring
Board (IMB). No specific concerns were raised by either body.
The man’s family were offered, and accepted, the opportunity to meet with
one of my family liaison officers and an investigator. They raised a number of
concerns relating to his possible drug use and the escape list regime. In
addition, my investigators spoke with the man’s probation officer and his legal
representative.
The investigating team also visited HMP Leyhill to speak to a prisoner who
had moved there from Gloucester. They also made enquiries at HMP
Blakenhurst and spoke with a number of staff.
1
Background Information
HMP Gloucester
HMP Gloucester is a category B adult local prison and young offender remand
centre, situated in the centre of the city. The prison is made up of three
wings, each with three landings holding 90-100 prisoners.
The man who died was on A wing throughout his time at Gloucester. The
cells for prisoners on the escape list (E list) are located on the two’s landing
(on the second floor) of A wing.
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Events leading up to the man’s death
Events up to the end of April 2005
On Friday 1 April, at 3:25 pm, the man was arrested under warrant at the
family home and taken to a Police Station. According to the detention record,
he told an officer that he was a heroin user and had smoked half a bag that
day. He requested to see a doctor and at 7:08 pm he was seen by the
Forensic Medical Examiner (FME). The FME report indicated that the man
stated that he smoked 3-4 bags daily and had last used that morning. The
FME prescribed a standard Dihydrocodeine and Diazepam regime. According
to the form, the FME classed the man as ‘no known risk’ of self-harm. There
is no medication form with the medical report, but the custody record indicates
that he was given his medication at 7:10 pm that night and then four times the
next day.
At 6:06 pm on 2 April, the man was taken to another Police Station for
identification procedures in relation to another robbery offence and remained
in custody there. On 3 April, he saw the FME at the Police Station at 11:50
am and complained of feeling cold due to the heroin withdrawal. He was
further prescribed Dihydrocodeine and Diazepam. The FME recommended
half hour checks, but did not record whether or not he viewed the man as a
risk of self-harm. The medication form is attached and shows he was given
medication at 9:00 am, 5:55 pm, and 10:00 pm that day. On the morning of
the 4 April, he was given his medication before being taken to a Magistrates’
Court at 8:15 am.
Following his court appearance, the man was remanded to HMP Blakenhurst,
until 12 April 2005. His Prisoner Escort Record (PER), which had been
completed at the Police Station on 1 April 2005, highlighted the man’s risk
area as ‘drugs’. In another section about risk issues, it states ‘DNA confirmed,
firearms, escaper, drugs, offends on bail’.
Upon reception at Blakenhurst, a Cell Sharing Risk Assessment form was
completed. This form is used to assess if the prisoner is a risk to themselves
or others. Using the man’s warrant and Prisoner Escort Record (PER) for
information, Section 2 of the form notes that he had previous convictions for
firearms offences. When asked about his use of alcohol and drugs, the man
said he had neither abused or was dependent on either. He also said he had
not been subject to any self-harm observational procedures (F2052SH) and
did not have any concerns about sharing a cell. The officer notes ‘previously
been in BTBM [Blakenhurst] before, no problems’.
As part of the reception process, prisoners who request help for their drug
abuse are required to take a urine test to establish that they are drug users
and therefore eligible for the detoxification programme. The officer, who was
working in reception that day, recognised the man as he had been at school
with the man’s brother. They chatted for a while about school days and the
officer observed that the man seemed ‘annoyed at having been caught’. He
then asked, ‘I think I know what the answer is, but do you do drugs? (meaning
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do you need to have your urine tested?)’, the man replied no. The officer then
completed the Reception Clinical Urine Drug Test proforma writing, ‘States
does not take drugs’.
The man was then seen by a nurse who carried out a First Reception Health
Screen. It was noted that he was on remand, had been in Blakenhurst before,
had no health concerns and was not taking any medication. When asked
about his drug use, he said he used heroin and cannabis daily and had last
used on 31 March 2005. He was then asked about his mental health and
reported no concerns. The man was referred to the drugs service (CARATs)
and to see the doctor.
He was later seen by the doctor who noted ‘states he would like to try to de-
tox without medication. But has requested that if this proves too hard to start
a Cofexadine detox.’(sic). The man was located on Houseblock 6 and
completed his induction on 9 April 2005. His regime review on that date
remarked ‘compliant and polite, no problems’.
On 12 April, he appeared at the Crown Court charged with robbery and
possession of a firearm. His PER, completed by staff at Blakenhurst indicated
that he had ‘no known risks’, despite the information which had been
previously given to Blakenhurst on the PER by the police. The man was
further remanded and returned to Blakenhurst.
On Wednesday 13 April, an officer in the security department received a
request from the Governor to arrange a transfer for the man from Blakenhurst
to HMP Gloucester on security grounds. In interview, the officer confirmed
that he was aware that the man had been moved to Gloucester before on
security grounds. Information supplied on the inter-prison transfer document
reads:
“Resides in the same street as … [members of staff] – one of which is his
next door neighbour. History of conflict and he has slashed her car tyres.
The man cannot be located on Houseblocks 1 and 3 as there are inmates
against which and their families he has made threats to kill” (sic).
The officer phoned the Observation, Categorisation and Allocation (OCA)
department of Gloucester. He spoke to an officer over there, explaining the
situation and the officer at the OCA department said he would look into the
matter. On Monday 18 April, the Governor asked if the transfer had been
agreed. The officer from Blakenhurst had not by this time had a response
from Gloucester. He phoned the OCA department there again. On this
occasion he spoke to a senior officer in the security department who agreed
the move.
At this juncture it is necessary to understand the nature of these security
concerns. The man had been in Blakenhurst on a number of previous
occasions. In 2003, officers on his wing reported that he was making threats
against an officer. It seemed that the man lived in the same area as the
officer and at one point it was believed he was responsible for writing her
4
address on the wall of the houseblock. Security reports were submitted at the
time, even though there was no proof he was responsible. The officer also
said the man made direct threats to her about damaging her car, and again
security reports were raised in relation to this.
The officer’s car was damaged after the man had been released and she
believed he was responsible as he had seen her at a local garage. All four of
her tyres had been slashed and she reported it to the Police. On another
occasion, she said the man passed by her house as she was cleaning her car
and she then realised that he lived just a few doors away from her. She
contacted the Police for a second time as she said he was making threats to
her and her family. She was advised to use extra security and was given a
mobile phone to contact the police should something happen.
A few weeks later, the officer discovered that her daughter’s car had been
damaged. She said she felt the threat was becoming more serious and
decided to sell her house and move, which she eventually did in August 2004.
During this time, the officer said she had spoken to her Senior Officer at
Blakenhurst and eventually the man, by now back in custody, was transferred
out. She expressed great shock when he arrived back there in April 2005 and
again had to request his transfer because of their history. My investigators
visited Blakenhurst but, although the security manager confirmed these
incidents, there were no reports available.
On 18 April 2005, the man was transferred from Blakenhurst to Gloucester. A
Security Information Report (SIR) submitted by one of the escorting officers
indicated that he was very angry during the journey. According to the report,
he did not want to be moved and blamed the officer from Blakenhurst for his
transfer each time he arrived at Blakenhurst. He said he had been blamed for
vandalising her car and made threats about what he would do when he saw
her next. The PER completed on 18 April at Blakenhurst again indicated no
areas of concern, with none of the risk sections highlighted.
Upon arrival at Gloucester, the man went through the reception process. His
Cell Sharing Risk Assessment (CSRA) indicated firearms as a risk area. On
this occasion, when he was asked about his alcohol and drug use he reported
that he had abused both in the past but was not currently addicted. A nurse
completed the Health Check paperwork and observed ‘states fit and well.
Declined MO [medical officer].’
He was located on A wing and began his induction the next day, 19 April. The
programmes were completed on the same day. This was quicker than usual,
but a note explains that he had been at Gloucester in August the previous
year and was therefore familiar with the prison processes and procedure.
There is only one entry in his’s wing history sheet whilst at Gloucester and
that is ‘standard’, which related to his level of privileges on 23 April. The man
seemed to settle well on the wing and nothing of significance came to the
attention of the officers during this time. In interviews with staff, he was
5
described by officers as ‘mild mannered, polite, not a management problem
etc’. According to the officer in charge of the cleaners, the man had asked
about getting a job and had put his name on the waiting list.
It appears that the man and an old acquaintance bumped into each other
during induction and agreed that they would like to share a cell together. In
interview, the man’s acquaintance explained they had served sentences at
similar times in other prisons and also were in contact in the community. They
were located in a double cell (cell 24) on the second landing (the twos) of A
wing. His acquaintance said that they talked a lot and the man had been
concerned about the number of charges he was facing and the sentence that
could result from them.
On 19 April, the Police faxed Gloucester a request for a police production
order for 26 April. They requested that the man be collected by police officers
and taken to the Police Station for the making of an identification video. The
police liaison officer recommended and signed the form on 20 April and the
Governor gave signed authority on 22 April. The prison received a second fax
from the police on 21 April: the Prisoner Production Risk Assessment form.
The form identified the man as a risk due to ‘firearms, escaper, drugs’. The
prison had to complete its own security form, the Police Productions Security
form, and under the security section a senior officer has written ‘no issues at
this prison’. The form is dated 26 April. The man has one entry on his own
security record from 22 April: it says information had been received from a
prisoner that he and his cell mate were expecting to receive heroin in a
greetings card.
According to his cell mate, the man was planning an escape. He was aware
that the police were wanting to question him further and would therefore be
taken out on a police production order. It was during this trip that the man
was allegedly planning to escape. The man’s cell mate explained that the
man had sharpened down a plastic prison knife and hidden it in his cell. He
also said that the man, with his help, rehearsed certain scenarios: going
through what was likely to happen and how he was going to effect his escape.
According to his cell mate, the man was expecting the police to take him out
for further questioning on Thursday 27 April, but they turned up on
Wednesday 26 April. His cell mate said he saw the man briefly before he left,
when he went into the cell to retrieve his hidden knife and to get some
tobacco. The security senior officer, explained to my investigators that during
random monitoring of the phone calls they had heard his cell mate talking
about planning an escape. A security incident report was generated and the
cell, which he was sharing with the man who died, was searched on 21 April.
Nothing was found. They realised later that he been talking about the man
who died and not himself.
In preparation for going out on the police production order on 26 April, the
man was taken to reception. The senior officer on duty that day in reception,
was responsible for preparing the man for discharge into police custody. The
man was given a full search including undergoing a full strip search, which
involves the prisoner taking off the top half of his clothes, which are searched,
6
putting these back on and then removing the bottom half. His mouth would
also have been examined. All this would have taken place in the presence of
two officers. At this juncture, it is worth noting that the officer was not aware
that the man was deemed an escape risk. But in the interview he stated that,
even if he had been, the search would have been the same. The PER form
which would have been prepared by the prison the day before does indicate
that the man was an escape risk. However, it is clear that this information
was completed by someone other than the original author. My investigators
have been unable to ascertain when and who added this piece of information.
At 9:05 am, he was released into the custody of three police officers from the
Police Station.
He arrived at the Police Station at 11:10 am. He was met there by an agent
for his solicitor, who described the man as relaxed and in high spirits. During
the course of the day, a video was made of the man for use in an identification
parade. According to the agent for his solicitor, the man was unperturbed by
the process and was confident that he would not face any charges in relation
to the offences. The purpose of the day had been to make the video and he
was not charged with any offence. The agent from his solicitors said he was
in the man’s presence for the whole time until he left the station, at which point
he was being booked out to return to prison.
The PER form does not indicate what time the police left the station with the
man who died. The same senior officer was still on duty when they arrived
back at the reception gate at Gloucester at 3:25 pm. The senior officer stated
in the interview that, as soon as he ‘got out of the car it was very relevant to
me that the man had been involved in a confrontation of some sort, it was
obvious that he had, for want of a better word, had been in a fight, that
something had taken place with him because he was in an agitated state. He
immediately was complaining to me that the police had beaten him up.’
However, according to the senior officer, the police did not give any account of
what had happened. It was not until they had actually left the reception area
that the police officers then returned and said that they needed to let the
prison know what had happened. The senior officer found this very strange
and asked them to complete the PER form to reflect what had happened
during the journey back to the prison. The police officer wrote in the PER that:
“Whilst travelling along M5 motorway the man produced plastic knife (burnt
handle) moved forwards placing hands (handcuffed) round front nearside
passenger’s neck shouting ‘I’ve got a knife, I’ve got a knife, I’ve got a knife at
his throat.’ Had to be forcefully restrained resulting in minor injuries to his
wrists. Immediately apologised, knife seized. Was searched on arrival at
police station and knife not found. The knife was handed to prison staff.”
The senior officer described the knife as the blade part of a prison plastic
knife, three to four inches long, which had been sharpened down to a point.
The man told the senior officer that he had found it in the footwell of the car.
A senior officer from the security department attended reception and spoke
with the man. He said that he had found the knife under the seat in the police
7
car and that he picked it up on impulse. According to the senior officer from
security, the man told a number of different stories to different people, but it
was the senior officer’s view that the knife appeared to be from the prison and
it had been sharpened. According to one story he heard, the man had said
that he had had it in his training shoe when he went out in the morning. The
senior officer said he only saw the man briefly, but that he had his head in his
hands and appeared regretful of what he had done.
A principal officer and the Police Liaison Officer went to reception to see the
man. The PO described him as ‘quite hyped up’. A decision was made with
the duty manager to place him on the escape list. This meant that the man
would be subject to a number of additional security restrictions. Primarily, he
would be located into a single cell, would have to wear special clothing so that
everyone would know he was an escape risk, and he would be checked
hourly. Additionally, all in-cell possessions would have to be authorised by
prison management on the advice of the security department. His case would
be reviewed at the following monthly review meeting. The principal officer
informed the man about the escape list regime and expectations which he
appeared to accept without question.
In reception the man was also seen by a nurse and a F213 form (report of
injury to prisoner) was completed detailing the extent of his injuries. The
injuries were described as ‘bruising back of hand, wrist abrasions, thumb
injury’. The prescription chart indicated he was given a dose of Brufen. He
was also referred to the see the doctor the next day.
An officer collected the man from reception and escorted him back to the
wing. By this time he had already changed into the E list clothes (known as
‘patches’) and signed the form outlining the process. The officer knew the
man from the wing, as well as his ex cell mate. The man asked for a shower,
which was granted, and an officer accompanied the man and his ex cell mate
to the shower. Whilst there, the officer recalls the man chatting about general
things and his family. He was taken back to the wing, collected his meal and
the officer recalls sitting with him in his cell for about 20 minutes. The man’s
ex cell mate was also present for some time. As part of the E list conditions,
the man would not have been allowed to keep any cutlery in his room and the
officer removed these when he left. He recalled that the man thanked him
when he left and made a comment that he was going to be nailed for twenty
years and had one chance and missed it. The officer said he got the
impression that the man had thought his escape attempt was going to be
successful and was disappointed when he had not succeeded. However, the
officer did not think that there was anything worrying about the man’s
demeanour and was very shocked when he heard about his death.
In interview, a senior officer, who had no previous knowledge of the man,
remembered him coming back in ‘patches’. He gave permission for him to
have a shower. He recalled sitting with the man in his cell and going through
the E list procedures. He said the man said that he supposed he ‘would not
get anything, that he had really done it now and that the prison would be right
8
on top of him’. The senior officer tried to reassure him and explained that they
would give him as much leeway as possible. He felt that the man was fine.
An officer who had chatted with the man previously, also spoke to him whilst
he was being located into the escape list cell. Seeing him in the escape strip
clothing, the officer asked what had happened and the man said that he had
been beaten him up whilst in the police cells. He described him as being
flustered at what had happened and ‘focused’ but did not give him any cause
for concern.
The officer, who had no previous knowledge of the man, signed the E book
between 7:30 – 8:55 pm. He took his trainers and clothes from him and said
he seemed fine. An OSG took over from 8:55 pm until 8.00 am the following
morning and checked on him throughout the night. The man gave him no
cause for concern.
The day and early evening of 27 April 2005
A Senior Officer from C wing was helping out on A wing on 27 April. He
explained that he recognised the man as someone he had known from a
previous establishment. He said the man was wearing E list clothing. The
man recognised him and they spoke for a while. He said the man appeared
fine. He had asked him how he was in light of the E list clothing and because
it was his practice to check that new prisoners were settling in alright. The
man said that he was fine.
Another prisoner had been in Gloucester a few weeks and had been located
in the cell next door to the man and his cell mate. On the morning of 27 April,
following the man’s move to the escape list cell, the new prisoner started to
share the cell with the man’s ex cell mate. He did not know his new cell mate,
although he was friendly with the man who died. He said that when the man
came back into Gloucester in the ‘banana suit’ everyone had a laugh, but that
the man seemed to take this well. He said he saw the man who died on 27
April, but was not sure if it was on the exercise yard or on the wing. He said,
‘he seemed the same, although he thought he had been upset about his
girlfriend’. According to the Coroner’s officer, a letter from his partner was
found in the man’s cell following his death. The letter appears to have
indicated that she was ending their relationship and the postmark suggests it
would have been given to him that day.
The man’s ex cell mate said he saw him about 11:10 am on 27 April and
described him as tearful. The man’s ex cell mate was on his way back from
education and the man who died was locked in his cell. He said he went and
spoke to a senior officer as he was a bit concerned about him. The senior
officer agreed for an officer to open up the man’s cell and allowed him in to
speak with him. The man’s ex cell mate said he and the man who died were
together for about an hour speaking about his worries about the escape and
the sentence he thought he might receive for that offence, and the other
charges he faced. He was worried that he would receive another long
sentence and would be separated from his children. The man’s ex cell mate
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told him to pull himself together and said he appeared to perk up and they
went down to collect their lunch together about 11:40 am. They returned with
their lunches and again talked in his cell. The man’s ex cell mate said that,
when he finally came out of the man’s cell, an officer asked him how the man
was and he replied that he was okay. He also told the senior officer that the
man was alright.
An officer collected the man from his cell and took him to see the doctor and
then back to the wing. He did not have previous knowledge of the man. He
was seen by a GP covering shifts at the prison, some time between 1:35 pm
and 2:00 pm as a result of the injuries he had sustained the day before. (It is
standard process to be referred to the GP within 24 hours.) The doctor felt he
presented as a little bit disappointed, a bit down in the mouth. He was sore
from the wrist and head injuries, but nothing very serious and the doctor
advised him to come back in a week if they were not healing properly.
According to the doctor, there was nothing worrying about the man’s
demeanour and he did not give concern about self-harm.
The man’s ex cell mate saw him again later at about 4:30 pm and asked him if
he was okay. He gave him some shaving foam and the man said he was
alright.
The regime at Gloucester means that only one landing per evening has
association. It was not the turn of the two’s landing which meant that neither
the man who died nor his ex cell mate were on association. The ex cell mate
explained that at about 7:00 pm the landing cleaner came to his cell door and
slid a folded piece of paper under it. He described it as folded like an
envelope and he immediately noticed it contained tobacco. He said he knew
it was from the man who died because no one else would be sending him
tobacco. He opened up the envelope and it contained a note from him and
some tobacco. The ex cell mate said it was a very down letter and described
it as ‘basically a suicide note’. In it the man had asked him to look after his
partner and to keep the note confidential. He said in interview that he did not
initially know what to do. The man had asked him not to tell anyone and he
spent 15 minutes thinking about it. He spoke with his cell mate who
persuaded him to ring the cell bell and to tell an officer. By now the time was
about 7:15 pm and an officer answered the bell. What happened next is
unclear as the accounts given by those interviewed differ. According to the
man’s ex cell mate, he said that his friend was ‘not right’ and that he ‘was
feeling a bit down’ and that he needed to go over and speak to his mate.
According to him, the officer said he could not come out of the cell.
The ex cell mate rang his cell bell for the second time and, when the officer
attended again, he explained that a senior officer had said the he could go
over and speak to the man. According to the man’s ex cell mate, he
explained that he had ‘got a suicide note’ and that the man would not speak to
a Listener but he would talk to him. According to the ex cell mate, the officer
then asked what cell he was in and he told him. He said the officer then left
and he assumed he was going to check on the man. Looking through the gap
in the door, he said that the officer did not check on him. Another officer, who
10
had no previous knowledge of the man who died, checked on him at around
8:30 pm, she was monitoring him as he was on the E list. She did not speak
with him as there was no requirement to do so.
The man’s ex cell mate then said that he rang his buzzer again and started to
bang and kick the door. The glass panel in the door cracked and he was
expecting to be placed on a disciplinary report the next morning. He
described himself as ‘very hostile and aggressive’ at this point. He estimated
the time now to be about 8:55 pm. At this point, another officer was locking
up the prisoners who had been on association that night and the man’s ex cell
mate said he was ignored.
He then said he waited until 9 pm when the night officer came on duty.
According to the ex cell mate, when the night officer came round doing the roll
check, the ex cell mate spoke to him, told him he was a bit worried about his
friend and the night officer agreed to check on him. The ex cell mate said, on
each occasion the night officer passed his cell, he asked how the man was
and the night officer replied he was fine, he did this a few times during the
night. At about midnight, he said that he was still awake. By standing on a
chair in his cell he could see the door to the man’s cell at an angle and noticed
that the light was on. He said that the man did not like light and so he was
worried about this. He said he again spoke to the night officer and asked him
to check on the man. The night officer did so, and reported back that the man
was making toast (by removing the mattress from the bed and putting the
toast on the wire frame and burning it from underneath). The ex cell mate
said he checked and saw that the man’s light was now off. He got undressed
and into bed himself at about 12:30 am.
In his interview, the night officer explained that he was checking the man
regularly not because his ex cell mate had alerted him, but because of the E
list procedures. In fact, the night officer was adamant that he did not have
any conversation with the man’s ex cell mate or his cell mate regarding the
man who died.
The other cell mate said a note came under the cell door at association time.
He said he and the man’s ex cell mate got on the buzzer and shouted at the
officer something like ‘he’s going to kill himself, get him in a strip cell’ or ‘get a
watch, he’s doing himself in’. He said they passed the note out to the officer
under the door or through the gap in the side. He said the officer looked at it
for five or six seconds and returned it saying, ‘get your heads down’.
According to the other cell mate, the officer did not go and check on the man.
He said the man’s ex cell mate kept ringing the cell bell, but it was turned off.
He described how the officer, whom he did not know, was standing a few
doors down from their cell and they shouted at him, ‘he does what he says’,
meaning the man would go through with it. However, the other cell mate said
the officer did not react.
Later, he said he and the man’s ex cell mate talked to the night officer who
was more helpful and they asked him to keep an eye on the man. He said
they went to bed about 12:30am.
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The officer’s account of the evening differs somewhat from the versions given
by the man’s ex cell mate and his cell mate. He agrees that the man’s ex cell
mate rang his cell bell several times that evening. In interview, he said that
both the prisoners in the cell asked to be let out to use the toilet and the officer
decided to let one prisoner out to use the toilet on the wing and suggested the
other used the facilities in the cell. The second time the cell bell was rung, he
said they asked him to go over to the man’s cell and check on him. When he
did this, he said the man was lying on his bed watching TV. He explained that
he went back over to the man’s ex cell mate’s cell and let them know that the
man was okay. The escape list log for that evening shows that the officer
signed it for the hours 5:30 to 6:30pm and again 7:30 to 8:30pm, thus
indicating that he had checked on the man in his cell twice that evening.
The officer said the man’s ex cell mate then wanted to go across to the man
himself and he had told him this was not allowed. In interview, he
remembered that the ex cell mate had repeatedly asked, stating that one of
the SOs who had been on duty earlier that day had agreed to it. The officer
then went and spoke to the SO who was in charge of the wing that night to
check the position. The SO had confirmed what the officer thought.
The officer said that, at this point, the ex cell mate lost his temper and they
exchanged words. However, he said he did check on the man a couple of
times that evening. On the last occasion, just before he went off duty at 9pm,
he spoke to the man asking him if he was all right and the man said he was.
In the interview, the officer was asked if he had been shown a suicide note or
if either of the two other prisoners involved had said that the man was suicidal.
The officer was unequivocal and said that neither had happened. The officer
said, ‘he just said that he wanted to go over and he didn’t give me no reason
why he wanted to go over there’. He was confident that he would have acted
in quite another way if they had. The officer did not make any entry in the
Wing Observation Book about his discussions with the two prisoners.
Another prisoner in a nearby cell, also saw the man on 27 April in the exercise
yard. He said they spoke briefly and he described the man as ‘walking around
like a zombie, you could see he wasn’t right, he wasn’t the person he came in
as’. Later that evening, the other prisoner heard the man’s ex cell mate
‘shouting a lot and banging the door of his cell’. He said the officer was
responding to the cell bell and he and others asked him to keep the noise
down. He said he then heard the man’s ex cell mate shout ‘let me out’ and
‘could someone go and speak to him’.
(During the course of this investigation, the team were given a copy of the
note passed between the man who died and his ex cell mate.)
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The night period of 27/28 April 2005
A night orderly officer was the Principal Officer in charge on the night of before
the man died. He came on shift at 8:30 pm and was aware there was an ‘E’
man and that he was on hourly checks. An OSG came on duty about the
same time and was in charge of A Wing that night. The night orderly officer
checked with him that he knew that there was an E man and which cell he
was in. The OSG confirmed that he did.
The OSG explained that during the night he was checking the man once every
hour, as well as doing his 2052SH checks on other prisoners and other duties.
He said he spoke to the man at about 11:20 pm as he was doing his rounds.
He said that at this time the man was watching television and the OSG had
asked if he was alright. He said the man replied, ‘yes, I am fine boss’. OSG
again checked the man at 12:20 am and said he appeared to be asleep on his
bed.
At 1:20 am, the OSG checked on the man and found him hanging with a
bedsheet from the window bars. He immediately radioed for help and spoke
to the control room. At that time, two officers, another OSG and a nurse were
involved in a serious self-harm incident on B2 landing when they heard the
call over the radio. They all responded to the call. The two cells are very
close together and staff only needed to travel 30 metres to get from one cell to
the other.
One of the officers said he could also hear the OSG on duty shouting that the
‘E man was hanging’ as they made their way across the bridge that connected
A and B wings. When they arrived, the OSG was opening the cell door with
his key from his emergency pouch. He entered, followed by the two other
officers and the nurse. By this time, a further officer had also arrived at the
cell.
The OGS on duty at the time cut the ligature with his emergency pack
scissors and the three officers lowered the man to the floor. The nurse said
she immediately started cardiopulmonary resuscitation (CPR) and, under her
instruction, the OSG assisted her by doing the compressions while another of
the OSG’s went downstairs to collect the defibrillator and emergency bag
which was in the nursing station on the one’s landing. She said she then
instructed the Night Orderly Officer to call an ambulance and a doctor. When
the OSG returned with the defibrillator, they put it on the man. However, the
reading indicated that there were no signs of life and not to shock. She could
not find a pulse, so continued with CPR assisted by the OSG. The nurse
observed that the man’s body was still warm and she had thought they might
have been able to save him.
The Principal Officer explained that he cleared the scene to allow the others to
work on the man. He then called the control room and asked for an
ambulance; he thought it was about eight minutes before they arrived. The
control room log shows the ambulance was requested at 1:23 am and arrived
at the prison gate 1:27am and was on the wing at 1:30. At one point, the
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Principal Officer said that he took over the chest compression from the OSG
while he fetched a piece of equipment. Then the ambulance crew arrived. He
said he sent one of the officer’s back to his duties on B wing. As the Night
Orderly Officer, he stayed in control of the scene, working over the radio
issuing instructions through the control room.
The night incident log shows that a doctor was called to the prison at 2:10am.
A Doctor is recorded as entering the prison at 2:20 am. He pronounced the
man dead at 2:30am.
The contingency plans for a death in custody were then put into effect.
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Contact with the family
Upon reception, the man had named his partner as his next of kin. At 5:15
am, the Governor contacted the Police and asked them to break the news to
the family. He also requested that they stay with them while the family
phoned the prison and spoke with the Governor.
There was some delay in contacting the man’s partner as there was a
problem with the phone number that the man had supplied. When the police
later visited her home, she was not there. She eventually contacted the
prison at 11 am, having just been told about the man’s death by the police.
The man’s mother was then informed and she contacted the prison at noon.
The following day, the Governor, the deputy governor, the family liaison officer
and the chaplain met with the man’s partner, his mother and his brother.
Members of the family were offered the opportunity to visit the cell but
declined. However, they did ask for a prayer to be led by the chaplain and
this was done.
The Governor issued notices to staff. He also arranged for a notice to be put
into each cell on A wing to inform prisoners that the man had died during the
night.
The family said they had no concerns about the way the prison had treated
them. In fact, they found all the staff they met to have been sensitive to their
situation.
At Gloucester police station, the family had been given the blanket the man
had used as a ligature but not his personal effects. The man’s partner and
brother then went to the prison. They were seen immediately by the deputy
governor. The Governor, who was not on duty at the time, came to the prison
immediately.
I am pleased to commend the actions of the Governor and his colleagues.
15
Issues considered during the investigation
The man’s drug use
The man who died found himself arrested after a significant period out of
custody. His family had noticed a clear deterioration in him in the previous six
months, and they were concerned that his mood was related to drug use.
It would seem that the man had a heroin problem that he sought to keep
hidden from key people in his life: his family, his cellmate and his probation
officer. At the police station on 4 April, he disclosed that he used heroin and
asked for medication to deal with withdrawal. However, upon reception at
HMP Blakenhurst, he denied using drugs. The officer to whom he was talking
mentioned to the man that he recognised him and knew his brother. We
cannot know whether this played any part in his decision not to undertake a
urine test (thereby making him ineligible for detoxification, something he had
gone through on at least one previous period on remand in Blakenhurst).
Whether the man experienced any withdrawal symptoms is uncertain. He did
not subsequently complain to the doctor or nursing team that he was suffering
from withdrawal.
The transfer from Blakenhurst to Gloucester
It is clear that the man had a history at Blakenhurst and there were particular
difficulties concerning one of the female officer’s. While allegations are not
the same thing as proven truth, Blakenhurst owes a duty of care to its staff.
That said, there is no paper trail showing what decisions were taken regarding
the man’s original transfer and the reasons they were taken. Moreover, it
appears as though the second transfer may have happened just because the
officer suggested it. The man’s current file showed no concerns of a risk
against staff. Paradoxically, his paperwork described him as ’not a problem’.
Prison staff, like everyone else, should be able to go about their work without
fear of intimidation or threat. I think it was right that, each time the man
arrived at Blakenhurst, he was transferred out. However, a record of the
decisions would have made it much easier to piece his story together.
The man’s escape attempt
The man had an offence of ‘escape from lawful custody’ amongst his previous
convictions. According to the senior officer in the security department, this
might have been known by the security department at Gloucester when they
drew up their risk assessment for his police production request. The senior
officer completed the form and wrote, ‘no issues at this prison’. The form is
dated 26 April, although it is not clear who dated it as the form also had to go
to two other departments in the prison before being completed.
As a result of random phone monitoring, the security department had
suspected that the man’s cell mate was planning an escape. On 21 April, the
senior officer had conducted a search of their cell and found nothing. This is
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the same day the prison received the risk assessment form from the police
stating that the man was an ‘escaper’. It would have been prudent for the SO
completing the police production security form to have informed the police
about the current information about his cell mate. This might have led the
police to treat the man differently.
His family were clear that the imposition of E list restrictions on him would
have affected his mood. The man had been on the E list on a previous
sentence, and his family described him as very down during that period which
they attributed to the restrictions he was living under. He had been subject to
closed visits previously, but this would most likely have been as a result of
receiving drugs during a visit rather than being on the E list.
Each establishment operates the E list guidelines according to what is
appropriate to that prison. The man’s previous experience of the E list was at
Whitemoor, a high security establishment. It is possible that the E list
procedures there were implemented differently. This may have been difficult
for him to deal with, particularly as his family believe he was subject to them
for about seven months. However, at Gloucester the E list restrictions were
not unduly restrictive and wing staff had sought to reassure the man that he
would be fairly treated.
E list procedures
The guidelines for monitoring those on the E list stipulate that, ‘The wing
manager MUST IDENTIFY a member of staff on a daily basis to be
responsible for observations and movements of the inmate and the updating
of the F1352, designated cover for the member of staff’s meal breaks must
also be assigned’. At Gloucester, this was not done for the practical reason
that no single officer remained on the wing for the duration of a shift.
However, this did not have any impact on the supervision of the man and he
was always monitored appropriately.
One of the rules for an E list prisoner is that ‘no prisoner is allowed in the cell’.
My investigators asked a number of officers, at all grades, how they
interpreted this rule and varied answers were given. My investigators were
led to believe that no in-cell association after lock-up would be allowed for any
prisoner without prior arrangement. Having said that, it would seem that the
man’s ex cell mate had been allowed into his cell, albeit with an officer posted
outside the door, when he had been distressed earlier in the day. This
seems an entirely reasonable decision by the Senior Officer, given that he had
been reported as upset.
The E list is, of course, primarily concerned with the risk of the prisoner
escaping. However, it would be prudent to consider the placing of someone
on the E list as a ‘change in circumstances’ and that the prisoner should be
monitored accordingly - including an explicit consideration of welfare and risk
of self-harm. All staff who saw the man who died felt that he was not at risk of
self harm or suicide, and he presented as a very strong character. However,
more specific questions such as why was he trying to escape, how did he feel
17
about being caught, how desperate he might have been to try, and then how
he felt when he failed, might have uncovered different feelings.
Events during the evening before the man died
The accounts of the discussions between the officer on duty, the OSG and the
two prisoners during the early evening of are conflicting. The two prisoners
both say they were explicit about their concerns for the man and that they said
he was suicidal. The officer is adamant that the prisoners did not say that the
man was suicidal or that they had received a suicide note from him. If they
had, the officer was clear that he would have acted differently. As far as he
was concerned, the prisoners had just said he was upset and he thought this
was because he was ‘in patches’. As it was, he went to the man’s cell to ask
him if he was okay, and was reassured that he was. At 9 pm, the officer went
off duty. The OSG is equally adamant that he did not have any involvement
with the two prisoners regarding the man who died during that evening.
The exchanges with the officer took place in a very heated atmosphere and
what was said may have been understood differently. In interview, the
prisoners believed they were clear about their worries. However, while the
officer clearly heard and understood that the man was thought to be upset and
went to check on him, he interpreted the concern in a different way.
The senior officer said that, during a conversation with one of the prisoners
the morning after the man was found, the prisoner blamed the officer on duty
for not allowing him over to speak to the man the night before. The senior
officer said he explained to the prisoner that this was not permitted and he
agreed that this was the rule. However, in interview, the senior officer
observed that he had relaxed the rules the day before, allowing the cell mate
into the man’s cell. He remarked that, at the time he thought this was
important, as the man was reported to be feeling down. However, he
recognised this might have set a precedent, leading the cell mate to believe
he could go and see the man at any time despite the rules. The SO also
acknowledged his action might have put the Officer in a difficult position in
trying to work according to the rules.
Record Keeping
There are very limited entries in the man’s core record, including his wing
history sheet. Although some staff interacted with the man quite extensively,
this was not reflected in the entries. Even when the man returned to the
prison on 26 April and was placed on the escape list, this was not put in the
wing observation book until the next day and was not written in his wing
history sheet. There is only one entry in his wing history sheet during the
duration of his time in Gloucester. The core records during his time at
Blakenhurst are equally limited.
Simon’s assault allegation
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My investigators contacted the Independent Police Complaints Commission
(IPCC) on a number of occasions in an attempt to establish the nature of their
investigation into the man’s assault allegation and his attempted escape.
They have been unable to establish the outcome of these investigations or
whether the police had intended to charge the man with an offence in relation
to the attempted escape and assault on the police officer.
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Conclusions
The man’s drug use, and his decision to keep it a secret, may have meant that
he did not seek help whilst in custody. Whether this impacted on his state of
mind is unknown. Having planned an escape which he believed he could pull
off, the man found himself back at Gloucester prison in escape ‘patches’.
Whilst the man was spoken to by several staff about being on the E list and
the implications of this, he was not specifically asked questions in relation to
his risk of self harm or suicide.
It seems likely that his failed escape attempt did affect the man’s state of
mind. We also know from conversations that he had with his cell mate that he
felt concerned about the prospect of serving another long term prison
sentence. The man may also have been upset on 27 April because of the
letter from his partner questioning the future of their relationship.
With regard to the escape, a more thorough security intelligence check might
have established a link with the cell mate’s telephone calls apparently
planning an escape. Passing on all the information might have led the police
to handle the man’s security requirements differently.
Blakenhurst were unable to provide any audit trail in relation to security
information regarding the man’s alleged threats to prison staff and his
consequent transfer to a different prison. They also failed to record
information provided on PER forms in relation to him being an escape risk.
The most contentious issue in this case concerns the conversations that
allegedly took place between the officer on duty, the man’s ex cell mate and
his cell mate during the evening of 27 April and the conversations between the
OSG and the same two cell mates, later on that evening. It is not clear to me
or to my investigators what the true version of events is.
The Clinical Review found no omissions in the healthcare received by the man
who died while in custody. The post mortem found that he died from
strangulation, consistent with hanging.
The staff involved at the time of discovering the man’s body did all they could
to revive him. They are to be commended for their actions.
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Recommendations, housekeeping points and good practice
Local recommendation 1: The governor of Gloucester should consider
reviewing the local E list guidelines with the aim of ensuring that specific
consideration is given to a prisoner’s risk of self harm or suicide after being
placed on the escape list.
Local recommendation 2: I recommend that that the security department at
Gloucester examine their methods for drawing together information in relation
to risk assessments for a prisoner going on escort.
Local recommendation 3: I recommend that HMP Blakenhust review their
systems for recording PER information and for handling security intelligence
information.
Housekeeping point a: The governors of both Gloucester and Blakenhurst
prison should remind their staff of the importance of detailed and regular
written entries in all prison records, particularly wing history files.
Housekeeping point b: Staff should be reminded to write incident reports
that contain as much detail as possible, as soon after the event as they are
able to. The duty governor should also ask wing staff to write a statement if
they had significant contact with the person who died in the day prior to their
death.
Good practice
The staff involved at the time of discovering the man’s body are to be
commended for their efforts in attempting to save his life.
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