Individual at Gartree

Investigation into the circumstances surrounding the
death of a man in June 2009,
in hospital whilst in the custody
of HMP Gartree
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2010
This is the report of an investigation into the death of a man who died in June 2009,
in hospital, whilst in the custody of HMP Gartree. The man became unwell in March
2008, and was admitted to hospital with suspected pleurisy. He was discharged
three days later and returned to the prison. In May 2009, the man’s mobility and
general health was seen to be deteriorating and he was taken to the healthcare unit
for observation and treatment. On 9 June, he was admitted to hospital and died two
days later. The man was 69 years old.
The investigation into his death was undertaken by one of my colleagues. A post
mortem was not held into the man’s death at the request of HM Coroner for
Leicestershire and South District. It was noted that the man died of natural causes
as a result of bronchial pneumonia. I extend my sincere condolences to the man’s
family and friends.
A review of the man’s medical care was commissioned with Leicestershire Primary
Care Trust (PCT). I am grateful to a doctor for his timely review. I would like to
thank the then Acting Governor of Gartree and his staff for the help and assistance
with this investigation. I would also like to thank the liaison officer for her help.
I make one recommendation for the attention of the Governor in commending the
man’s personal officer for his professional support to the man. I acknowledge the
three recommendations held in the clinical review.
In this final report, the Governor of Gartree has written to the man’s personal officer
acknowledging the Ombudsman’s recommendation. Some minor amendments have
been made. The man’s family still had concerns over their brother’s decision not to
have family contact. My colleague made contact with his home probation officer and
her response is noted. I have dealt with further family responses on page 16 of this
report.
Jane Webb
Deputy Prisons and Probation Ombudsman January 2010
2
CONTENTS
Summary
The Investigation Process
HMP Gartree
Key Findings
Issues
Conclusion
Recommendations
Annexes
3
SUMMARY
The man was convicted of murder in 1986 and received a life sentence. In 1987 he
was transferred to Gartree and later received into a secure hospital, a high security
psychiatric facility in1995. Two years later, the man returned to Gartree. He did not
participate in any offending behaviour programmes or regime activities. The man
had also told his personal officer that he did not wish to have any family contact.
In December 2007, the man had a chest x-ray after complaining of shortness of
breath. The x-ray did not show any problems with his heart or lungs. Four months
later, the man was admitted to hospital as an emergency because of chest pain and
breathing problems. He remained as an in patient for three days transferring back to
Gartree after being diagnosed with suspected pleurisy.
On 10 November 2008, the man was seen in the healthcare unit with pain to his
thigh muscle. He was prescribed pain relief medication and given a walking stick.
Three days later the man was examined by a doctor, who diagnosed a hamstring
injury and anti- inflammatory medication was prescribed, together with physiotherapy
The man was examined by a doctor on 2 June and his thigh pain was still present.
The doctor asked for blood tests and referred him for further physiotherapy. Two
days later, the man was seen in the healthcare unit. He was losing weight and his
mobility greatly reduced. He was persuaded by wing staff to transfer to the
healthcare unit where he could receive supportive nursing care.
On 9 June, he was found on the floor of his healthcare cell. He was assisted back to
his bed and made comfortable. At about 1.00pm, following an examination by a
doctor, the man was admitted to hospital for treatment and assessment. The man
was escorted to hospital by two officers, one of whom was secured to him using an
escort chain (a chain with handcuffs at one end).
The following day, hospital staff contacted the head of healthcare and told her that
the man’s condition was serious and his next of kin should be informed. Prison staff
contacted the man’s brother and passed on details of his medical condition and
hospital information. At 8.20pm restraints were removed on the authorisation of the
duty governor.
At 9.04am on 11 June, a nurse told the escort staff that the man had died. Very
shortly afterwards, a bed watch escort officer spoke to the man’s brother by
telephone and passed on the news of his brother’s death.
The man had been a prisoner at Gartree for many years. He did not wish to
participate in the prison regime and preferred his own company. In 2006, he told his
personal officer that he was adamant he did not want family contact. I make one
recommendation to commend his personal officer for his efforts to build a meaningful
relationship with the man.
4
THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened on 23 June when my
colleague visited Gartree. She reviewed the man’s prison and medical files
and asked for copies of those documents to be sent to her. The
Ombudsman’s terms of reference and notices of the investigation had been
sent in advance of my colleague’s visit.
2. Members of the Independent Monitoring Board. and Prison Officer’s
Association did not ask to see my colleague. (IMB members are independent
and unpaid. They monitor the day-to-day life in their local prison.) Gartree
has previous experiences of death in custody investigations. Up to the
circulation of this report there has not been any response to the notices of
investigation from staff or prisoners.
3. A review of the man’s medical care was commissioned with Leicestershire
PCT. A general practitioner, carried out that review from medical records and
documents held in the man’s prison file.
4. On 14 July, my colleague interviewed prison staff and one prisoner at Gartree
Returning two weeks later to interview another officer.
5. One of the family liaison officers contacted the man’s brother, who was his
next of kin. This was to inform him of my investigation and to offer the
opportunity to raise any concerns or questions that he would like addressed.
the man’s brother raised the following issues:
 How long had he been unwell before he was admitted to hospital?
 What medication was the man being prescribed?
 Why had he not been notified sooner of the man’s ill health?
 The man’s brother felt that valuable time was lost by this delay,
particularly given his distance from the hospital and the difficulties he
faced in arranging transport.
These issues are addressed on pages 15 and 16 of my report. I hope the
findings of my investigation help the man’s family better understand the
events leading to his death.
5
HMP GARTREE
6. HMP Gartree opened in 1966, originally as a category C prison (category C is
a training prison). It was converted, within a year, to a high security dispersal
prison and maintained this function for approximately 25 years. In the early
1990s, Gartree was re-categorised to a B category training prison for adult
male life sentenced, and now indeterminate sentenced, prisoners. Typically,
it holds prisoners in the early stages of their sentence for up to five years with
an operational capacity of 575.
7. The prison’s purpose is to help prisoners come to terms with their sentences,
assess their individual needs and provide specific interventions, such as
offending behaviour programmes, until they can move through the prison
system.
8. Gartree has four residential wings (A to D) with B wing being the induction
unit. There is a therapeutic community unit, a healthcare unit and a
supervision and assessment unit.
9. Her Majesty’s Chief Inspector of Prisons carried out an unannounced
inspection at Gartree in April 2008 as a follow up to a full inspection in. August
2005. The inspector noted that a healthcare recommendation made in 2005
had been achieved. The recommendation said:
“The healthcare staff skill mix should be reviewed to ensure appropriately
qualified and graded staff are available to meet the clinical needs of
patients, particularly those with mental health problems.”
10. This had been achieved by:
“The skill mix had been reviewed in February 2007 and several changes
had been made. Nursing staff were appropriately qualified with a good
range of skills, including in mental health. There were two full-time on-
site pharmacy technicians. GPs from a local practice ran morning
surgeries every weekday. The healthcare team was almost at full
strength and offered a comprehensive service to prisoners.”
11. In her summary of the unannounced inspection, the inspector commented:
“Of the 49 recommendations in this area, 15 had been achieved, 12
partially achieved and 22 not achieved. We have made 33 further
recommendations. On the basis of this short follow-up inspection, we
considered that the prison continued to perform reasonably well against
this healthy prison test.”
Healthcare centre
6
12. The Health Care Centre is a type 3 Health Care Centre i.e. a registered nurse
is on duty 24 hours a day, but does not offer a secondary care service. Its
inpatient wing has 14 cells, 12 of which are on the operational capacity.
(Primary care services are delivered by doctors, nursing staff and other health
professionals, secondary care services are specialist medical services usually
provided in hospital.) The healthcare centre is over 40 years old and
somewhat tired in appearance. The IMB commented in 2006/07 that
refurbishment plans were currently under discussion at senior and area
management level. Despite appearances, the IMB report said that the
healthcare centre delivered an ‘excellent service’.
13. There have been seven previous natural cause deaths at Gartree since 2004.
Some of those deaths are similar to the man’s by the fact that they were
elderly prisoners with chronic disease illnesses.
14. This is the second recent death investigated by my colleague at Gartree and
she notes that in both cases healthcare staff acted professionally in the
provision of care and support in the previous death, and that of the man.
7
KEY FINDINGS
15. The man was received into Gartree in October 1987. In January 1995, he
was sent to a secure hospital, a high security psychiatric facility, after being
referred there under section 47 of the Mental Health Act. (Section 47 is a
directive from the Home Office to treat and house prisoners with a severe
mental disorder.) The man was diagnosed with chronic paranoid psychosis.
Despite intensive psychiatric care he did not progress as well as expected at
the hospital. Nevertheless, there was some improvement in his mental health
and he returned to Gartree in May 1997.
16. The man settled on a wing and became a compliant prisoner with a
reasonable standard of behaviour. He did not want to participate in his
sentence planning and had not undertaken any courses to address his
offending behaviour, despite encouragement from his personal officer.
17. On 10 February 2007, an entry in the man’s wing file, written by the man’s
personal officer, noted that his next of kin, his brother, had contacted the
man’s home probation officer asking about visiting him in prison. The man
said he did not wish to have any contact with his family. An entry on 20 May,
by the man’s personal officer, again noted that he did not wish to have any
contact with his family.
18. The man’s health issues mainly focused on his mental wellbeing. In
September he failed to attended the healthcare unit for an over forties health
promotion session. The man’s last Parole Board hearing was in November
which deemed him not ready for release.
19. On 6 December 2008, the man saw a nurse in the healthcare unit. He was
complaining of shortness of breath on exertion. He told the nurse that he
smoked about 20 cigarettes a day but had recently cut that down to ten per
day. The nurse referred the man to the doctor.
20. The following day, a doctor saw the man and examined his chest and lungs.
The man told the doctor that his hearing was becoming a problem. The
doctor referred him for a chest x-ray and a hospital appointment for hearing
tests. On 14 December, a chest x-ray indicated no heart or lung problems.
The following day, a nurse made a follow up visit to the man on the wing to
check on his breathing. The man told the nurse that he felt much better.
21. The man was next seen in the healthcare unit on 22 March 2008 by a nurse.
He complained of shortness of breath and pain in the right side of his chest.
The nurse noted his previous history of breathing problems. An ambulance
was called so that the paramedics could assess the man and he was given
oxygen to aid his breathing. The paramedics decided that he should be taken
to hospital. The man was escorted to hospital and admitted to a ward for
observation. Three days later, the man was discharged from hospital with
antibiotic medication and diagnosed with suspected pleurisy.
8
22. The man’s hospital appointment at the audiology clinic was cancelled on 30
May, due to operational problems. (Operational problems could range from
insufficient officers to provide an escort to security issues within the prison.)
The hospital was contacted to re-arrange the appointment. He saw a doctor
on 18 June, as he was still experiencing chest pain. The doctor examined the
man’s chest and there was no signs of a cough or shortness of breath. The
doctor thought the pain might be muscular.
23. The man went to the healthcare unit on 10 November and saw a nurse. He
complained of a pain in his thigh muscle which had been present for several
days. He was prescribed ibuprophen and paracetamol and given a walking
stick. The nurse told him to return to healthcare if the pain did not settle.
24. Two days later, the man returned to healthcare and saw a Healthcare Senior
Officer (HCSO). He told the HCSO that the pain in his thigh had not improved
and he thought he might have injured himself four days earlier whilst bending
down. He was advised to carry on taking the pain relief and an appointment
was made for him to see the doctor the following day.
25. The man went to see a doctor on 13 November. The doctor noted that he had
a tender hamstring in his left thigh. He advised the man to take his pain relief
and do some hamstring stretching exercises. Two days later, a nurse saw the
man on the wing for a follow up appointment. He told the nurse that the pain
was not getting any better and an appointment was made for him to be
reviewed by the doctor.
26. A doctor saw the man on 17 November and examined his hamstring injury.
The doctor wrote that the injury was still tender to the touch and prescribed
Naproxen, (an anti inflammatory medication). The doctor also referred him for
physiotherapy.
27. Five days later, the man saw a nurse. He told the nurse that the Naproxen
was helping to reduce the pain and he was prescribed more paracetamol.
Later, the man had a mental health review with a Registered Mental Health
Nurse (RMN). The RMN wrote that the man was more concerned about his
physical health than any mental health issues he might have. The RMN
added that there were no reasons to intervene with the man at the present
time and that wing staff did not report any behavioural issues.
28. On 24 December, a nurse reviewed the man’s hamstring injury and whilst the
pain was improving, further pain relief medication was prescribed. The
problem seemed to improve and from his medical record he was not seen by
a doctor again until 27 April 2009, when he saw a doctor. The doctor wrote in
his medical notes that the man had dermatitis (a skin condition) on his scalp
and face and there was a re-occurrence of his thigh pain. The doctor
prescribed medication for his dermatitis and pain relief.
29. The man was examined by a doctor on 2 June. The doctor noted the man’s
thigh pain, and that he was using a single crutch as his mobility had reduced.
9
30. Two days later, the man was seen in the healthcare unit by a physiotherapist.
He told the nurse that he was losing weight and his mobility was reduced with
ongoing pain. The man had a blood sample taken and was offered a place in
the unit as an inpatient.
31. A Senior Officer (SO) spoke to the man when he returned from the healthcare
unit. Whilst the man wanted to remain on the wing, the SO persuaded him to
move to the healthcare unit where he could be cared for in a more appropriate
environment. Later, the man was admitted to the healthcare unit and a care
plan opened to assess his mobility and general health needs.
32. A doctor noted on 5 June that the man’s blood test indicated an infection and
a course of antibiotic was prescribed. The man was given daily assistance
from nursing staff for his personal hygiene and immobility. Two days later, it
was written that the man had vomited and refused his breakfast. However, he
appeared to improve during the day and ate his lunch and tea meals.
33. A nurse assisted the man the following day with his personal hygiene. He
took a blood sample for testing and encouraged him to take more fluid. It was
also noted that his blood pressure was 118/58 (a normal blood pressure is
130/80), his pulse rate 100 beats per minute (a normal pulse rate is 60-100)
and his temperature was normal at 36.4 degrees. The nurse concluded his
entry by writing that if the man’s health did not improve, staff should liaise with
a doctor so that transfer to hospital could be arranged.
34. On 9 June at 3.00am, a nurse noted that the man had fallen to the floor in his
cell and was incontinent of urine and faeces. The cell was unlocked and he
was helped to bed, cleaned and given a cup of tea. The man told staff that he
was fine and had not hurt himself. At 6.00am, the man rang his cell bell for
help to use the toilet. A nurse noted that he was very unsteady on his feet
and needed full nursing care.
35. The HCSO wrote that the man had again been incontinent and needed
washing and his bed changing. His scalp was very sore and red and his
mouth was dry. There was a break in his skin at the base of his spine and
the HCSO referred him to the doctor. The doctor examined the man at
11.53am, and noted his deteriorating condition and arranged for him to be
admitted to hospital. Two and half hours later, the man was escorted to
hospital by two officers and restrained by an escort chain and admitted to a
ward. (An escort chain is a restraint that is a 1.8 metre length of chain with
one cuff attached to the prisoner and the other to an officer, thereby allowing
nursing staff to deliver treatment.)
36. The following morning the hospital made contact with the head of healthcare.
The man’s condition was serious and his next of kin should be informed. The
prison contacted the man’s brother to inform him of his brother’s ill health and
asked if they wished to visit him in hospital. Later, the head of healthcare and
10
37. At 8.00pm the man’s sister rang the hospital from her home in Scotland to
pass on her regards to her brother. She told staff that the man’s brother was
trying to arrange a visit to the hospital. A bed watch escort officer re-applied
the escort chain at 8.20pm, as the man became abusive towards hospital staff
and tried to disconnect the tubes attached to his body. Hospital staff
administered morphine which calmed him. Following contact with a governor
the escort chain was then removed again.
38. An officer wrote in the bed watch notes that the man was still agitated at
9.40pm and refusing treatment. Staff gave an injection of Haloperidol, an anti
psychotic medication, and he settled. Further medication was administered
around 3.50am on 11 June, when he again became restless. The officer
noted that the man was unresponsive to his surroundings and drifted in and
out of sleep.
39. An entry in the bed watch notes by the officer at 6.45am, showed that the man
would not be resuscitated should he go into cardiac arrest. The Do Not
Resuscitate directive had been made at 11.45pm, the previous day by the
hospital doctor. (This was also recorded in his prison medical notes.) The
man still intermittently showed signs of distress and escort officers assisted
nursing staff by holding his hands when the nurses changed his bedding.
40. An officer wrote in the bed watch notes that at 8.45am, the man was showing
signs of agitation despite being unconscious. About 10 minutes later, a nurse
examined the man and told the officer that he had died at 9.04am. His
brother rang hospital very shortly after the man died and an officer passed on
the sad news. The officer advised the man’s brother to make contact with
Gartree. A doctor confirmed the man’s death at 9.25am.
41. The man’s brother contacted a governor by telephone on 12 June. The man’s
brother was upset that he was unaware of how ill his brother had been. He
wanted more information as they had been isolated from him for many years.
The governor gave assurances that the man had been well cared for. He said
that the family liaison officer would contact them after the weekend. On 15
June, the liaison officer visited the man’s brother at his home and spoke to
them about funeral arrangements and the prison offered financial support
towards this.
42. The Acting Governor wrote a letter of condolence to the man’s family.
Prayers were said for him in the chapel which was followed by a memorial
service for prisoners.
11
ISSUES
Clinical care
43. A review of the man’s healthcare was commissioned with Leicestershire and
Rutland PCT. A doctor undertook that review on behalf of the PCT.
44. The doctor noted that the man suffered in a chronic psychotic illness and
declined to take antipsychotic medication which the doctor described as
‘regrettable’. The doctor further commented that the man’s medical notes did
not detail the amount of mental health contribution from 2003 to 2008, which
he felt was disappointing. Nevertheless, there was evidence of ongoing
medical care including vaccinations for influenza, blood tests and x rays. The
doctor said:
“The care in the man’s last month of life seems to have been entirely
appropriate with suitable assessment, diagnostic tests and prescribing,
together with supportive medical care. The decision to transfer the man to
hospital was an appropriate and timely one.”
45. As part of his review the man explored examples of good practice relating to
The man’s healthcare these were noted as:
 “Chronic Disease Management: There is evidence in the clinical
records that the man was seen for appropriate influenza vaccination.”
 “Collaborative working: The documentation within the man’s notes
indicated that he received appropriate care on arrival at HMP Gartree.
There was clear evidence of partnership working between the prison
healthcare team and the visiting forensic psychiatrists.”
 “Record keeping: The recording of history and examination findings
was clear and evidence of good quality of care particularly during the
last month of the man’s life.”
46. The doctor made three recommendations within the clinical review. He notes
areas of chronic disease and mental health management, revaluation of
healthcare issues for documentation and smoking cessation advice. I
acknowledge the recommendations held in the clinical review. They are:
 All prisoners with chronic mental health problems should be placed on
a chronic disease register to ensure regular follow-up to reassess
mental and physical symptoms and review healthcare needs including
compliance with medication.
 Prison healthcare teams should ensure that re-evaluation of healthcare
issues take place where appropriate and that this is documented.
12
 Smoking cessation advice should be a fundamental part of primary
care services within prisons especially for those with a history of
respiratory disease. Prison healthcare teams should develop a clear
strategy for health promotion.
Contact with personal officer
47. The man spent all his time on the wing or in his cell and passed retirement
age. During association time (free time on the wing when prisoners are
unlocked and able to access communal areas) he walked on the landings and
never went outside. He enjoyed reading a newspaper and was in reasonable
health until late 2008.
48. An officer was the man’s personal officer for four years. The officer made
regular and meaningful entries in the man’s wing file. From those entries it is
evident that the officer built up a relationship with the man which was
courteous whilst trying to encourage him to participate in the prison regime.
By his own choice the man did not have close friends in Gartree, and it seems
that his personal officer became his closest confidant.
49. An acquaintance of the man spoke of the support offered to the man by his
personal officer. The acquaintance said that the officer, showed respect to
the man and supported him as far as he would allow personal contact.
I commend the personal officer for his professional care and support to
the man.
Family issues
50. The man’s brother was concerned that he was unaware of his brother’s failing
health and wanted to know whether his brother had received proper
healthcare and treatment prior to his admission to hospital. Although suffering
from suspected pleurisy in March 2008, the man remained in reasonable
health until his hamstring injury in November. The injury did cause him some
pain and difficultly with walking, however he managed to remain on the wing
and was seen regularly by healthcare staff.
51. In May 2009, the man’s injury worsened and he was moved to the healthcare
unit on 5 June. Blood tests indicated that he had an infection and anti biotic
medication was started. Nevertheless he continued to deteriorate and was
taken to hospital on 9 June. The doctor in his clinical review noted that the
man received appropriate healthcare whilst at Gartree.
52. The man chose not to have contact with his family. His brother contacted the
home probation officer in 2006, asking if they could mediate to arrange
contact with the man. On receipt of this information, the man declined any
contact and discussed this with his personal officer. The officer told my
colleague that the man did not want any family contact and never wanted to
discuss this issue even when he became unwell.
13
53. Whilst the news of the man’s serious illness must have been a shock and
distressing for his family, their brother declined all family contact as a result
the prison would not have been able to disclose his poor health until he was
admitted to hospital. (Patient confidentiality means that information on a
patient’s medical history cannot be told to other people without their consent.)
It is not known whether the man was aware that his family had been
contacted when he was in hospital, as he was drifting in and out of
consciousness.
54. The man’s brother was contacted by the prison and told of his admission to
hospital. He was in the process of arranging transport to visit him. (He lives
some distance from the hospital, does not have a car and is retired.) The
man’s health deteriorated quickly after he was admitted to hospital and his
brother was unable to make the trip before he died.
55. This was a difficult time for the man’s family, but also a dilemma for Gartree
as they were aware of the man’s previous wishes not to have family contact.
Nevertheless, it may have been thoughtful of the prison to have considered
arranging transport for the man’s brother to visit him soon after he was
admitted to hospital.
Family response to draft report
56. Following the circulation of the draft report, the man’s brother raised several
points, some I deal with here, and some in separate correspondence with the
family. The man’s brother was still concerned about his brother’s decision not
to have any family contact. My colleague spoke to the man’s home probation
officer.
57. The probation officer told my colleague that the man’s brother had visited her
office on 3 January 2007. He was anxious to have contact with his brother
and any information that could be passed to him regarding his brother’s
health. The probation officer telephoned Gartree and followed the call up with
a letter, for prison staff to approach the man and ask him if he would like to
have any family contact or visits.
58. A short while later, the probation officer was told by prison staff that they had
spoken to the man and he had said he did not wish to have any family
contact. The probation officer further noted that the man did not wish to
participate in any parole board reports or have any direct contact with her,
despite being encouraged to by prison and prison based probation staff.
59. In response to the families’ concerns about their brother not wishing to receive
any contact with them, it is evident that this was his decision. I do empathise
with the man’s family and hope that they are re-assured that opportunities
were offered to their brother to have that contact. Furthermore, when the man
became ill, medical in confidence meant that information could not be passed
to his family without his consent.
14
60. The man’s family were concerned that a decision was made that should their
brother go into cardiac arrest he would not be resuscitated. On 9 June, a
doctor had noted that the man had a history of many medical conditions which
included alcohol abuse. The man’s family were concerned that their brother
had been taking alcohol whilst in custody.
61. The decision to not resuscitate was made by a hospital doctor on 10 June. I
am unable to comment on judgements made by hospital staff which is beyond
the remit of this investigation. However, the man’s family may like to raise this
issue at his inquest.
62. In relation to the medical history as detailed by the doctor. This doctor was
not employed in Gartree, I can only presume is employed at the hosptial.
Again, I am unable to comment on the documentation of hospital staff. The
medical conditions may well have included history from the man’s passed
medical notes, even before he was taken into custody. However, I did not find
any evidence that the man had consumed, or found to be in possession of
alcohol, whilst at Gartree and this was confirmed by an officer whom my
investigator spoke to for a second time on 5 January 2010.
63. The man’s family wished to thank their brother’s personal officer for the
relationship he built up with his brother and for this they are truly grateful.
Furthermore, they wish to thank the SO for encouraging their brother to go to
healthcare and to their brother’s acquaintance for his support.
15
CONCLUSION
64. The man received support by both prison and healthcare staff at Gartree
when he became ill. This was reiterated by the doctor, in his clinical review,
who noted that the man was well cared for in the last month of life.
65. He did not want any family contact and was prepared to accept that he would
stay in until his death. The man’s personal officer managed to build a down-
to-earth relationship with the man, who by his own choice did not reveal his
thoughts or feelings to others.
66. I believe that the care the man received from healthcare staff was equitable to
what he would have had in the community. The obituary written by a fellow
prisoner is testimony to the man’s independence, and also the role of the
staff.
16
RECOMMENDATIONS
For the Acting Governor of Gartree
1. I commend the man’s personal officer for his professional care and support to
the man.
17
ANNEXES
1. Documents considered during the investigation
18