Individual at Full Sutton

Investigation into the circumstances surrounding the
death of a male prisoner at HMP Full Sutton
in May 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2010
This is an investigation into the circumstances surrounding the death of a man
who died at HMP Full Sutton on 26 May 2009. The man died of ischaemic
heart disease. I would like to extend my condolences to the man’s mother for
her loss. I apologise for the delay in issuing this report and any additional
distress this may have caused.
The man had suffered from mental health problems for many years but he
died, unexpectedly and at an early age, from ischaemic heart disease (heart
disease caused by a reduced blood supply).
This investigation was carried out on my behalf by two of my colleagues. An
independent review of the man’s clinical care was conducted by a Clinical
Reviewer from East Riding Primary Care Trust. I am grateful for her
assistance.
I would like to thank the Governor and his staff at Full Sutton for their full and
ready cooperation during the course of my investigation. I am particularly
grateful to the Liaison Officer for his assistance.
I make one recommendation in regard to adhering to the principles and spirit
of Prison Service Order 2710 (Follow Up to Deaths in Custody) when Full
Sutton informs the next of kin following a death in custody. I am pleased to
see that Full Sutton has accepted my recommendation in full.
This version of my report, published on my website, has been amended to
remove the names of the man who died and those of staff and prisoners
involved in my investigation.
Jane Webb
Acting Prisons and Probation Ombudsman June 2010
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CONTENTS
Summary 4
The investigation process 5
HMP Full Sutton 6
Key events 9
Issues 13
Conclusions 17
Recommendation 18
3
SUMMARY
The man was convicted of manslaughter and sentenced to two life sentences
on 30 July 1992. He had a troubled youth and suffered from mental health
and substance misuse problems for many years, both before coming into
prison and during his time in prison.
During the man’s 18 years in prison he was frequently of concern to prison
staff. He struggled to cope because of his mental health problems and self
harming behaviour. The man’s mental health deteriorated to such a degree
that on two occasions he was transferred from prison to hospital under the
Mental Health Act 1983.
The man had no medical history of significance apart from his long psychiatric
history. He smoked a great deal. The forensic pathologist, said in his report
that “death resulted from the effects of ischaemic heart disease” and that “the
degree of heart disease was such that death could have occurred suddenly at
any time”.
Early on the morning of 26 May 2009, the man was found slumped in a chair
in his cell by prison staff who were conducting their routine check at the end of
a night shift. The staff went into his cell and tried to help him by placing him
on the floor and attempting emergency aid. Healthcare staff were called and
arrived promptly. They immediately commenced cardio pulmonary
resuscitation (CPR) and defibrillation (electric shock given by a defibrillation
machine to attempt to start the heart). They also tried to administer oxygen,
but all without success.
The staff called an emergency ambulance while they continued with their life
saving attempts, but sadly the man had already died. The paramedics soon
arrived and, at 7.30am, confirmed that he had died.
I make one recommendation to the Governor about the need to ensure that
the principles and spirit of Prison Service Order 2710 Follow Up to Deaths in
Custody, specifically the supplementary guidance 4.13 which states “using the
telephone is too impersonal to use in delivering news of a death to the family
and should be used only as a last resort” are adhered to by his prison family
liaison officers. I am pleased to see that the Governor has accepted my
recommendation in full.
.
4
THE INVESTIGATION PROCESS
1. The investigation was opened on 27 May 2009. The investigator
issued notices announcing the investigation to the staff and prisoners
of HMP Full Sutton. The notices included an invitation to those who
wished to contribute to the investigation to make themselves known.
2. The Investigator visited the prison and met the Governor, the Chair of
the local branch of the Prison Officers’ Association, and the Chair of
the Independent Monitoring Board. The Head of Business Change
assisted the Investigator as his liaison officer.
3. The Investigator made a tour of the prison and visited B wing to see
cell B1-32, which had been the man’s room. He talked to a number of
staff and prisoners who had known him.
4. The man’s prison and health records were made available to the
Investigator. He reviewed all relevant documents, which included the
man’s core record, clinical record, wing documentation, care plans, lifer
review reports and other custodial and clinical documents.
5. East Riding of Yorkshire Primary Care Trust (PCT) was asked to
organise a clinical review of the healthcare the man had received whilst
in prison. The PCT commissioned the Assistant Director of Clinical
Governance to carry out the review. I am grateful to her for completing
her work expeditiously.
6. One of the Ombudsman’s Family Liaison Officers contacted the man’s
mother to explain the investigation process and to offer an opportunity
for her to be involved in the investigation.
7. The man’s mother did not have any specific concerns about the
investigation but asked to receive the draft report when it was ready.
She also asked to see copies of the man’s psychiatric reports from the
Hospital and HMP Wakefield. The Family Liaison Officer facilitated this
process and offered support to the man’s mother as she was
concerned that reading the reports might be upsetting. The man’s
mother also asked if he had received regular medical checks whilst in
prison.
8. The Investigator went on sick leave in late 2009 so I asked another of
my colleagues to take over the investigation. The second Investigator
constructed a chronology of significant events from his review of the
man’s case files and reviewed all relevant records. He considered that
it was not necessary to interview staff or prisoners. He followed up the
enquiries that had already been commenced and drafted this report.
9. After seeing the draft report, the man’s mother provided a number of
comments about the report. As a consequence, I have made some
revisions to the chronology of events.
5
HMP FULL SUTTON
10. HMP Full Sutton is one of five dispersal prisons in England. It holds
prisoners who have committed serious offences resulting in lengthy
sentences and who need to be held in conditions of high security.
11. Full Sutton is a purpose built, high security prison for Category A and
Category B male offenders situated a few miles outside the city of
York. It was opened in 1987 and holds 595 men. It comprises three
wings for mainstream prisoners and three wings for vulnerable
prisoners.
12. Healthcare services at Full Sutton are commissioned by East Riding of
Yorkshire Primary Care Trust. Services are classified as Type 4
Healthcare, which means that there is provision for 24 hour access to
healthcare services within the establishment. Healthcare recently
introduced an electronic clinical information system, called SystemOne,
which records and manages prisoners’ clinical information.
HM Chief Inspector of Prisons’ inspection in 2007
13. HM Chief Inspector of Prisons last inspected Full Sutton in an
announced inspection in November 2007. In her report she
commented:
“This inspection charts considerable progress at Full Sutton
since the last inspection, particularly in the areas of activity and
resettlement. Given its population, the prison had remained a
commendably stable and largely safe environment. There is still
work to be done to ensure more positive and proactive staff-
prisoner relationships as an essential part of dynamic security.
In addition, the forthcoming cuts to prisoners’ regime, as part of
the Prison Service’s overall efficiency cuts, will be a significant
challenge to managers and staff seeking to maintain stability
and activity levels.”
14. HM Chief Inspector of Prisons also wrote:
“Recent changes in the delivery of health services to reflect
provision in the outside community had not been well received
by prisoners, who felt they had less access to the healthcare
team. The introduction of some in-possession painkillers had
not been well explained to prisoners, who could wait up to a
week for a supply. There were reasonable clinical governance
arrangements, and good staffing levels with some excellent
skills, knowledge and competences. The new clinical IT system
was well used. There was a range of primary care clinics, but
these were not regular. The care of older prisoners was
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managed innovatively, combining social care with physical and
mental healthcare. Dental services were clinically sound, but
the management of applications and the waiting lists was poor.
Inpatient beds were used to accommodate prisoners with
disabilities. Primary and secondary mental health services were
integrated, which appeared to work well.
“The health services department had introduced an electronic
clinical information system in the previous month, SystemOne.
This system managed all prisoners’ clinical interventions, waiting
lists and arrangements for clinics, but prisoners’ previous clinical
records had yet to be added. Staff were enthusiastic about the
new system, which still had a few minor problems with the
management of caseloads and waiting lists.
“There were nurse-led clinics for lifelong conditions and
vaccinations, and sessions for allied health professionals, such
as the dentist, optician and physiotherapist. While the latter
sessions were on fixed days, the nurse-led clinics were only
arranged when a clinical room was available and the relevant
nurse was on duty. Nursing staff followed national service
frameworks and National Institute for Health and Clinical
Excellence (NICE) guidance for prisoners with lifelong
conditions, although some diabetic patients had not had
retinopathy screening.”
The Independent Monitoring Board (IMB) Annual Report 2007/08
15. The Prisons Act 1952 requires every prison to be monitored by an
independent board appointed by the Secretary of State for Justice from
members of the community in which the prison is situated. The Board
must satisfy itself as to the humane and just treatment of those held in
the prison it monitors.
16. Full Sutton IMB’s most recent annual report was published in April
2009. The executive summary contains the following remarks:
“The Director General is asked to note the Board’s concern
relating to the Primary Care Trust’s (PCT’s) involvement in the
delivery of healthcare in Full Sutton prison. The Board
recognises the very pro-active and conscientious healthcare
support provided by the prison’s healthcare team which
continues to evolve and improve. The proposal to channel the
Prison’s healthcare requirements and funding through the local
PCT was implemented in recognition that there would be the
opportunities for healthcare improvements within the Prison
through an economy of scale and good practice as well as the
opportunity for further efficiencies and possible savings. With
the exception of the MRI scanner initiative, the Board is not
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aware that the PCT linkage is providing any dividends in the
form of healthcare improvements and savings.
“Healthcare staff are to be commended for the increased use of
the telemedicine link with Airedale Hospital and for acting as
consultants to another High Security prison in the installation
and effective use of this complex equipment.
“Full Sutton’s staff have performed well and have built on the
very positive HMCIP Inspection report from last year with some
very commendable progress in the key areas of Diversity, Safer
Custody and in the Segregation unit.”
Previous deaths in custody at Full Sutton
17. Since 2004, the Ombudsman’s office has investigated eight deaths at
Full Sutton, which have included seven deaths by natural causes and
one homicide. One of the deaths occurred after that of the man who is
the subject of this report. I am satisfied that there is no link between
the circumstances surrounding this investigation and the other deaths,
although a number of the deaths by natural causes were also
associated with chronic disease and long term medical conditions.
18. The Ombudsman investigated a death by natural causes in February
2009 at Full Sutton. The clinical review found that there was some
difficulty in identifying healthcare staff who had made entries in the
clinical record and that healthcare interventions and care plans were
not always clearly documented. The recommendation arising from that
investigation was that there should be a review of documentation to
ensure that evidence of care planning and designation of staff making
the entries would be clearly evident. Much of the problem was that the
use of SystemOne was still in its infancy and there had been some
initial technical difficulties at the time. The prison’s healthcare team
accepted the recommendation with the response:
“This is a systems error on the SystemOne clinical record
system, which has been reported. Until the fault is resolved staff
will enter information manually.”
8
KEY EVENTS
19. The man was remanded into custody at HMP Lincoln on 19 July 1991
charged with murder. Following conviction of manslaughter in 1992, he
was sentenced to two life sentences and sent to HMP Wakefield. On 5
August 1992, his Category A status was confirmed, which meant that
he was assessed as a risk to the public if he escaped.
20. On 7 September 1999, he transferred to HMP Full Sutton. He was
seen by healthcare staff on reception where a health assessment was
undertaken. Healthcare staff noted that he was in good physical health
although he was overweight and a heavy smoker.
21. In late 2000, healthcare staff wanted to carry out some clinical
diagnostic tests due to concerns about the man’s weight, excessive
smoking and eating habits. He would not cooperate and discussion
with a visiting psychiatrist on 4 January 2001 indicated that at that time
he was refusing any clinical tests regarding his physical health.
22. However, five days later on 9 January 2001, he relented and had a
cholesterol investigation. The subsequent biochemistry result indicated
he had a high level of cholesterol. Clinical details at the time indicated
that the man showed symptoms of depression and a suspected thyroid
problem which was contributing to his weight problem. He was
scheduled for an ECG test (electro cardiogram records and measures
the functioning of the heart) but he declined to comply. His blood test
for a thyroid function test showed the results as normal.
23. On 25 May 2002, healthcare staff called to see the man in his cell
because he was complaining of feeling unwell. They carried out a
clinical assessment but found there was nothing of concern. He was
advised to rest and inform the staff if he became any worse.
24. Healthcare staff maintained their contact with the man, particularly to
monitor his mental health. On 4 March 2005, he was reviewed by a
senior registrar in psychiatry who noted that he was “emotionally flat
and with poor hygiene”. The man’s long standing mental health
problems were still an ongoing concern for both clinical and custodial
staff. Concerns about his mental health and lack of insight in regard to
his offending behaviour had been noted by a number of discretionary
lifer panels (DLPs). Regrettably, the man’s mental health and
behavioural difficulties hindered his progress through his life sentence.
At the time of his death, he had served nine years more than his tariff
(the part of the life sentence a prisoner must serve before being
considered eligible for release on licence).
25. More than a year later, on 4 June 2006, the man went to the healthcare
centre after complaining of dizziness and nausea. He was assessed
by healthcare staff who observed that he smelt strongly of alcohol but
no medical intervention was required.
9
26. The man did not cooperate very well with advice from healthcare. On 9
June, he failed to attend the Practice Nurse Clinic. Failing to attend for
healthcare appointments or to comply with healthcare advice was a
common feature with him.
27. Two days later, on 11 June, he was seen after he complained of feeling
“depressed and being stressed with pain in his chest”. Healthcare staff
examined him but were not unduly concerned as their clinical
observations showed that there was “no sweating, pallor or vomiting”
(these are signs of acute heart problems). He was asked to attend
healthcare later that day to see the doctor.
28. The man did not return to healthcare that day but he was seen the
following day. He said that he felt “much brighter and no longer felt
depressed” and, when healthcare staff examined him, the pain in his
chest and abdomen had gone.
29. On 11 November, he was seen in healthcare at the request of wing
staff due to increasing concerns over his physical health. He reported
to staff that he had not eaten for a week due to nausea and vomiting
and felt light headed. Healthcare staff examined him and advised him
to drink more fluids. He was placed on the doctor’s list for a full
medical review.
30. He complained of a chest infection on 25 January 2008 and was given
antibiotics by healthcare staff.
31. A substance misuse assessment took place on 5 February 2009. The
assessment showed that the man had a history of drug or alcohol
misuse or was known to have taken medication from others. He had a
history of storing up or overdosing on medication although the
assessment acknowledged that this had not happened during the
previous five years. Also of concern was that the assessment
identified that he was a target for bullying and self harming behaviour.
He was not placed on Assessment, Care in Custody and Teamwork
monitoring (the Prison Service system to identify and support those
prisoners at risk of self harm or suicide). The risk assessment
concluded the man was at “moderate risk of substance misuse so
would have weekly drug assessments”.
32. Prison staff observed the man talking loudly to himself, possibly
responding to hallucinations, during the night of 11 May. He was
subsequently referred to healthcare for mental health assessment. A
few days later on 15 May, he was assessed by a psychiatrist who
thought he was suffering a possible relapse of his mental illness. The
psychiatrist treated the man’s psychotic symptoms with anti-psychotic
medication (for treatment of serious mental illness).
10
33. On the morning of 26 May, Officer A was conducting his final roll check
on B wing at the end of the night shift and went to check the man.
Officer A opened the observation panel of cell B1-32 at approximately
6.47am and saw the man slumped on his chair. The officer called out
to him but there was no response. A member of Night Patrol came to
assist and also called out to the man but again got no response. At
that point Officer A raised an emergency code blue alarm on his radio
(Bravo 2 – radio call sign).
34. At approximately 6.49am Officer A decided to go into the man’s cell, at
which point a prison officer dog handler arrived to assist him. Officer A
tried again to gain a response from the man but to no avail. He could
see no sign that the man was breathing. The Night Orderly Officer,
Officer A and a Prison Officer with training in healthcare went into the
man’s cell at 6.50am and saw him slumped in a chair. They placed
him on the floor and examined him, but could not find a pulse (which
would indicate his heart was beating) or respirations (which would
indicate he was breathing).
35. The staff immediately started cardio pulmonary resuscitation (CPR)
and defibrillation (electric shock given by a defibrillation machine to
attempt to start the heart) and tried to administer oxygen, but with no
success. At 7.10am a Nurse arrived and CPR was attempted again.
Healthcare staff were unable to insert an airway (a tube to clear the
patient’s airway to aid breathing) because, as the Nurse observed, “the
man’s jaw was locked and his body in a state of rigor”. (Rigor mortis
occurs after death and renders the body rigid.) They also observed
that there was pooling of blood (haemostasis after death) on the right
side of the man’s face and body and he was cold to the touch. An
emergency ambulance was summoned. The paramedics arrived and
verified that the man was dead at 7.30am.
36. The prison’s Family Liaison Officer telephoned the man’s mother at
9.00am to establish if she would be available for a home visit that day.
He broke the news that her son had died earlier that morning,
apparently from natural causes. The man’s mother accepted his offer
to visit her at home.
37. That afternoon the prison’s Family Liaison Officer, accompanied by the
duty governor and a representative from the chaplaincy, visited the
man’s mother at home. The prison’s Family Liaison Officer provided
the man’s mother with a letter of condolence from the prison and also
an information booklet containing contact numbers, relevant
procedures and other information.
38. The man’s mother told the prison’s Family Liaison Officer how she had
had a good relationship with her son and regular contact over the
years. She agreed that the man’s funeral would take place near Full
Sutton, rather than in his home area. The prison’s Family Liaison
11
Officer assured her that he would be in contact regarding funeral
arrangements.
39. The prison’s Family Liaison Officer told the investigator that the man’s
mother seemed concerned that he had “died so young” but expressed
the view that “after 17 years in prison he may just have given up”.
40. The Forensic Pathologist wrote in his post mortem report that the man
had “no medical history of significance apart from a psychiatric history
and that the man’s death was from natural causes”. His death resulted
from the “physiological effects of ischaemic heart disease and the
degree of heart disease was such that death could have occurred
suddenly at any time”. The Forensic Pathologist added that
“hypercholesterolaemia (high levels of cholesterol) and hypertension
(high blood pressure) would have been contributing factors” to the
development of the man’s heart disease.
12
ISSUES
Clinical care
41. A Clinical Reviewer from East Riding PCT conducted a review of the
man’s clinical care in accordance with the PCT’s Serious Untoward
Incident procedure. She identified that there was a failure to undertake
note summarisation of manually written clinical records onto the
electronic SystemOne which resulted in the information about the
man’s raised cholesterol levels not being readily available to healthcare
staff.
42. The clinical reviewer notes that there was poor record keeping until
computerised records were introduced. Some earlier entries were
illegible, or untimed, and the designation of the person making the
entry was not always clear. She wrote that there was:
“… poor clinical record documentation (prior to electronic health
records being implemented in 2007); some healthcare staff
signatures and parts of their entries in the clinical record are
illegible; entries seldom timed and the professional status of the
individual making the entry not always documented.”
43. However, she noted an improvement in the man’s records in that later
entries were eligible and the name and designation of the staff member
making the entry is apparent. The Clinical Reviewer viewed a number
of recent clinical assessments in a random sample of clinical records
complied by staff who looked after the man and was satisfied that the
recording of clinical assessments had improved.
44. The Clinical Reviewer identified in her clinical review report that until
note summarisation is undertaken the
“probability that someone with a long term health condition can
be lost in the system and is thereby not offered the opportunity
to participate in a clinical management programme remains.”
45. The clinical reviewer also identified the absence of a plan to address
the man’s cholesterol levels:
“There was no documented management plan supported by a
systematic approach to the management of his high cholesterol
to ensure he was reminded to attend for his blood tests and
given appropriate health promotion advice and support
When paper healthcare records were changed to electronic
records this was not supported with a process of note
summarisation to ensure key previous health information was
inputted onto the new electronic heath record.”
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46. The Clinical Reviewer adds:
“Prior to the move to electronic health records in 2007 the
system in place to ensure patients who required management of
a long term health condition relied in part upon the patient
presenting to healthcare rather than being called in for a review.
It appeared from the records that the man was reluctant to
attend healthcare for blood tests which could be the reason why
there are no further entries in relation to management of his high
cholesterol after 2006.
“Had note summarisation been undertaken when electronic
health records were introduced it is likely that the man’s
previous raised cholesterol levels would have been identified
and this information could have been transferred to his
electronic records prompting healthcare to request that he
attended for a blood test.”
47. She concludes in her clinical review:
“(There was) no systematic approach to the management of
patients with a long term health condition prior to 2007. Had
there been a systematic approach it is highly likely that this
would have resulted in the information being automatically
entered onto the electronic patient record when it was
introduced.
“There is no documented evidence to suggest that the man was
experiencing chest pains which could have alerted healthcare
staff to his coronary heart disease and led to his subsequent
management. (The man’s mother has, however, reminded me
of references to chest pain in June 2006 which I made at
paragraphs 27 and 28 of this report.)
“The man’s reluctance to communicate and comply at times with
the proposed management plan in terms of monitoring his
cholesterol levels will have impacted on the ability of the prison
healthcare team to appropriately and systematically monitor and
manage his raised cholesterol level. Had the man’s raised
cholesterol been known to the healthcare staff he would have
been identified and thereby managed by the ‘Long Term
Conditions’ prison nursing team which was established in 2006.
He would have had a Coronary Heart Disease (CHD)
management plan in place and would have automatically been
called for an annual review and offered health promotion advice
and information.
“In the man’s case although it is probable that he would not have
engaged with any active management of his raised cholesterol
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the opportunity to participate was unable to be offered as the
information relating to his raised cholesterol was not readily
available for healthcare staff.”
48. The Clinical Reviewer made the following recommendations, which I
am pleased to report have already been addressed by the Primary
Care Trust and Full Sutton:
“A plan for the summarisation of paper based patient notes is
developed and implemented with the information being entered
onto the electronic health record without delay.
“The Prison Healthcare staff should mitigate against this risk
until note summarisation has been undertaken by exercising
increased vigilance when taking medical histories from prisoners
in conjunction with a review of their paper held records where
this is reasonably practicable.”
49. Full Sutton’s Head of Healthcare has since responded that the project
to summarise the clinical records is underway and ongoing but is likely
to take a few months to complete.
First on the scene and emergency response
50. When the man was found in his cell, the response by discipline and
healthcare staff was timely, efficient and professional. A healthcare
officer quickly arrived to help him. Sadly, it appears that the man had
already died some time earlier.
Contact with the man’s mother
51. The Prison’s Family Liaison Officer telephoned the man’s mother at
9.00am to inform her of her son’s death earlier that morning. Later that
afternoon he visited the man’s mother at her home with the prison’s
condolences and to offer support. The Prison Family Liaison Officer
told the investigator that he recognised the need to inform the man’s
mother at the earliest opportunity and was keen to make a home visit
on the day of the man’s death. He said that the purpose of telephoning
the man’s mother was to establish whether she would be at home.
52. Prison Service Order 2710 (Follow Up to Deaths in Custody) states in
Supplementary Guidance on liaison with bereaved families at section
4.13:
“Using the telephone is too impersonal to use in delivering news
of a death to the family and should be used only as a last resort.
There may be no one nearby to support the family. If the family
lives abroad, the consulate may be able to assist in breaking the
news. However the news is broken and especially if this is not
15
done face to face by the prison, there should be an early follow
up by the prison.”
53. It is clearly best practice for either local prison staff or staff from a
nearby establishment to inform the next of kin on a face-to-face basis
of the death of their relative. The Prison Family Liaison Officer told the
investigator that, in this case, he considered his options. He concluded
that he should first establish whether the man’s mother would be at
home and available for him to visit. However he went on to notify her
of her son’s death during the telephone conversation.
54. The man’s mother told the Family Liaison Officer from my office that
although the Prison Family Liaison Officer had been supportive, she
also found it “difficult to get hold of him and had given up trying”
because the staff operating the prison switchboard never connected
her to the Prison Family Liaison Officer or took any messages. It is
most important that family members have confidence that they will
receive a timely response to questions and messages left following the
death of a loved one. I appreciate that because of shift working this
can be difficult, but nevertheless the perception of the man’s mother
was that it was difficult to maintain contact with the prison, which is
regrettable.
The Governor should ensure that the principles and spirit of
Prison Service Order 2710 Follow Up to Deaths in Custody
(particularly the supplementary guidance which states “using the
telephone is too impersonal to use in delivering news of a death
to the family and should be used only as a last resort”) are
adhered to by the prison’s family liaison officers.
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CONCLUSION
55. The man suffered from serious mental health problems for much of his
life and they continued to hamper his progress whilst in prison. There
is strong evidence which indicates that he frequently neglected his
health and did not take heed of advice from healthcare staff which
might have helped prevent his premature death. His mental health
difficulties made it difficult for him to have good awareness of his
problems.
56. The investigator found no substantial evidence to suggest that the man
had experienced any regular symptoms of ischaemic heart disease,
such as chest pains, which healthcare staff might have missed. This
meant that healthcare staff were not alerted to his underlying and
unknown coronary heart disease, which could have enabled them to
intervene with preventative clinical measures.
57. The man had no medical history of significance apart from his long
psychiatric history. He smoked a great deal which is likely to have had
a deleterious effect on his health. The forensic pathologist said that
“death resulted from the effects of ischaemic heart disease” and that
“the degree of heart disease was such that death could have occurred
suddenly at any time.”
58. The man died unexpectedly and at a relatively young age. He had a
close relationship with his mother who had visited him regularly in
prison over the years. Under the circumstances, I would have hoped
that the prison family liaison officer would inform the man’s mother of
her son’s death face-to-face rather than by telephone, although I
appreciate he followed up his call with a personal visit the same day.
The man’s mother lives less than an hour’s drive away from Full Sutton
and I feel that a prompt home visit, whether she proved to be at home
or not, would not have been onerous for the prison.
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RECOMMENDATION
1. The Governor should ensure that the principles and spirit of Prison
Service Order 2710 Follow Up to Deaths in Custody (particularly the
supplementary guidance which states “using the telephone is too
impersonal to use in delivering news of a death to the family and
should be used only as a last resort”) are adhered to by the prison’s
family liaison officers.
Full Sutton’s response was:
All operational managers and Family Liaison Officers will be advised
that delivering news of the death of a prisoner to family members
should be made in person. If this poses problems due to long
distances then the assistance of a FLO in another establishment shall
be utilised. Wherever possible the use of a telephone for passing such
news should not be used.
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