Individual at Leeds

Investigation into the circumstances surrounding
the death of a man at HMP Leeds, who died in Leeds
General Infirmary
in August 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2010
1
The man was just 21 years old when he died on 1 August 2009 in Leeds
General Infirmary. He had been transferred to hospital the previous day after
being found hanging in his cell at HMP Leeds. I offer my sincere condolences
to his family and friends for their sad loss.
I wish to thank the Governor of HMP Leeds for making the necessary facilities
and information available to my investigator. I am also grateful to the prison’s
liaison officer for his assistance.
In the course of the investigation, I asked for a clinical review to be carried out
into the medical care and treatment of the man received in custody. The
clinical reviewer appointed by West Yorkshire Primary Care Trust to
undertake a clinical review on my behalf. I am grateful for their assistance
and for the clinical reviewer’s report.
Since taking over responsibility in April 2004 for the investigation of all deaths
in prison custody, there have been 36 deaths at HMP Leeds, including that of
the man. Although I have made 137 recommendations in previous reports
relating to those deaths, I have not identified any matters that I have written
about before that also arise here. I concluded that the man’s actions in
apparently taking his own life could not reasonably have been anticipated by
prison staff.
I make two recommendations in this report.
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 July 2010
2
CONTENTS
Summary
The Investigation Process
HMP Leeds
Findings
Issues
Conclusion
Recommendations
3
SUMMARY
The man was arrested by officers from West Yorkshire Police on 24 June
2009 and taken to a police station for questioning. Whilst at the police station,
he was seen and assessed by a police doctor. After completing his
examination, the doctor told police officers that the man had attempted suicide
in 2007. He assessed the risk of suicide as high and recommended that the
man be placed into a police cell containing a video recording capability.
Following an appearance at a Magistrates’ Court on 26 June, the man was
remanded into prison custody. This was his first experience of imprisonment.
During the normal prison reception procedure, he was identified as being at
risk of suicide or self harm. A nurse decided to begin monitoring him under
the Prison Service suicide and self harm procedures known as Assessment,
Care in Custody and Treatment (ACCT). An ACCT document was opened,
and he was seen and assessed by prison staff and given advice on what
support was available to him. On 4 July, ACCT monitoring was deemed
unnecessary and the document was closed.
In the meantime, and due to the nature of the allegations made against him,
he asked to be regarded as a vulnerable prisoner. This was agreed and he
was treated as a vulnerable prisoner from then on. However, due to the main
vulnerable prisoner wing (A wing) being full, he was allocated to an overspill
cell in C wing, which he shared with another vulnerable prisoner.
The man appeared to have settled in reasonably well to prison life and gave
no cause for concern. The only time he did appear to show any visible signs
of being upset was following a visit from his family on 30 July. After returning
to his cell, he began writing a letter to his family as he wanted to express his
feelings for them.
On 31 July, the man declined an offer to join other vulnerable prisoners from
C wing who had gone to A wing for a period of association, preferring instead
to remain in his cell. However, his cellmate did go, and it was whilst he was
alone that the man took his own life. He was later discovered hanging by
another prisoner, who then raised the alarm. Despite extensive efforts to
resuscitate him both at the prison and in hospital, he was pronounced dead
the following day.
I make two recommendations which relate to ACCT procedures at HMP
Leeds. One refers to the use of untrained staff to carry out case management
tasks. The second refers to post closure interview procedures.
4
THE INVESTIGATION PROCESS
1. After receiving notification from the National Offender Management
Service (NOMS) Prison Service in August that the man had died, I
appointed one of my senior investigators to carry out the investigation
on my behalf. My senior investigator contacted the prison’s governor
and arranged to travel to the prison to meet him and his team for the
purpose of opening the investigation.
2. On 5 August, my senior investigator arrived at the prison where he
attended the opening meeting along with the prison’s governor. Also at
that meeting were prison liaison officer for my senior investigator, the
prison’s family liaison officer, a member of the local Independent
Monitoring Board (IMB), the senior manager, the Healthcare Manager
and the Primary Care Co-ordinator.
3. Following any death in prison, I publish a notice to staff and prisoners
inviting anyone with information and who wishes to contact me to make
themselves known to the investigator. There was no response to the
notices regarding the man.
4. On 24 August, my senior investigator returned to the prison to begin
the investigation. He interviewed a number of staff, some formally and
others informally. He also spoke to two prisoners whom he believed
might have been able to assist my investigation.
5. Four days later, my senior investigator met the deputy governor and
outlined his findings to that point. He explained the case was still
under investigation and the findings subject to change. Before leaving
the prison, my senior investigator arranged to return the following
month to continue his work.
6. In the meantime, one of my family liaison officers had been in contact
with the man’s family. She explained my role and offered the man’s
family the opportunity to meet her and the investigator. The purpose of
the meeting was for the man’s family to contribute towards this report
and ask any questions they would like examined.
7. On 22 September 2009, my senior investigator and my family liaison
officer met the man’s parents at their home address, where they were
made very welcome. The man’s parents were able to provide
background information about their son, which I have included within
the report. They asked a number of questions relating to the man’s
time in prison that I believe this report has been able to answer for
them.
8. The man’s family asked the following questions:
• What sort of Health and Safety Assessments are done in the
prison?
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• He had been termed a “vulnerable prisoner” (VP) and they
wanted to know what this meant. Additionally, they asked how
often he was being checked by prison staff.
• Would he have been able to use the same method of suicide if
he had been on the VP Wing?
• Did staff shortages prevent the man moving in with a more
supportive cell mate?
• Were there staff shortages at the time of his death due to swine
flu? Did this contribute to the length of time he was left before
he was found?
• What has been done at the prison following previous deaths?
9. After meeting the man’s family, my senior investigator returned to the
prison. The purpose of going back was to meet the clinical reviewer
who had been commissioned by the West Yorkshire Primary Care
Trust to examine the man’s medical care while he was at Leeds. They
interviewed two members of staff who had not been previously
available.
10. The clinical reviewer is a general practitioner in Leeds. He qualified in
1986, gaining an MB ChB from Sheffield University. Prior to this he
also gained a Bachelor of Medical Science degree at the same
university. The clinical reviewer passed the membership of the Royal
College of General Practitioners exam in 1990. The following year, he
was fully accredited for work in general practice. Between 1997 and
2005, he was chairman of the North East Leeds Primary Care Group
and subsequently chairman of the Professional Executive Committee
of the North East Leeds Primary Care Trust.
11. In October, the clinical reviewer submitted his clinical review. His
report does not include the findings of the post mortem, as it was not
available from the Coroner.
12. On 16 March, I received a response to the draft report from the
National Offender Management Service (NOMS). They did not identify
any factual inaccuracies and enclosed a copy of the prison action plan.
The action plan noted that the recommendations made had been
accepted and action taken to address them.
13. Two months later, after agreeing to a request from the man’s family to
an extension for them to comment on the draft report, my senior
investigator received the family feedback. In their feedback, the man’s
family asked my senior investigator to include further information about
their son. Specifically, they asked:
6
• Whether the vulnerable prisoner overspill on C wing had
been addressed by the prison
• That they receive a copy of the prison response to this report
• Whether there were any plans to reduce ligature points at the
prison.
14. I can confirm that the additional family comments about the man have
been included and that the prison response to the draft report is
included at the recommendations section. I understand that vulnerable
prisoners are no longer held on C wing and that they are located on A
wing. However, I am not aware of any plans to reduce ligature points.
7
HMP LEEDS
15. HMP Leeds is situated in Armley, close to Leeds city centre. Built in
1847, the prison has undergone a great deal of refurbishment and
extended from four to six wings. It has accommodation for up to 1,008
prisoners.
16. Leeds is a local prison. The majority of prisoners are unconvicted and
on remand or awaiting sentence. However, there are a number of
convicted prisoners.
17. The prison serves the courts of West Yorkshire and receives and
discharges a large number of prisoners each day. The prison has the
facility to provide video links directly into court. This helps reduce the
number of movements through the prison gate each day. Even so,
there were in excess of 20,000 movements in and out of the prison in
2009.
Her Majesty’s Chief Inspector of Prisons’ report
18. Her Majesty’s Chief Inspector of Prisons reports on all Prison Service
establishments. The majority of inspections are pre-announced and
allow the prison being reported on to prepare for inspection. However,
a small number are unannounced, meaning the prison concerned has
no prior knowledge that the Chief Inspector’s team is visiting until they
arrive.
19. In December 2007, the Chief Inspector carried out an unannounced
inspection of HMP Leeds. In the introduction to her report, the Chief
Inspector referred to her previous inspection carried out in August 2005
in which she focused on negative cultures amongst some staff. She
said the latest inspection found there were still considerable problems
in the prison, but that vigorous management attempts were being made
to deal with them. The Chief Inspector added that the prison was
failing to perform well in any of the key areas, with the exception of
resettlement. However, she acknowledged there had been progress in
all areas.
20. The Chief Inspector said that, between August 2005 and December
2007, there had been 12 self inflicted deaths. She added that the
safety of prisoners had been given considerable management
attention. She went on to say that a large proportion of prisoners (44
per cent) had felt unsafe, with anti bullying procedures being
underdeveloped, high incidence of drug use and vulnerable prisoners
not always held safely or decently. That said, she also reported that
her inspectors had found evidence of there being “extremely committed
individuals” at the prison.
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21. In closing her introduction, the Chief Inspector said the inspection
showed that there were still fundamental problems which needed to be
addressed at Leeds. She added that the management team were
working methodically and vigorously to tackle underlying causes as
well as the symptoms. She said it was not an easy task in a prison that
was “creaking at the seams…” Her final comment was to say that the
“… many good and committed staff in the prison … will need
considerable support.”
22. Under the report heading of “self harm and suicide”, the Chief Inspector
said:
“A senior level group had been established to examine how to
reduce the numbers of deaths in custody and, as well as
implementing practical changes, had identified cultural issues which
needed to be addressed. However, not enough was done to
ensure that lessons from death investigation reports were learned
quickly. Assessment, care in custody and teamwork (ACCT)
procedures were inadequate and the safer custody unit was not
sufficiently involved. The active group of Listeners largely felt
supported. Not enough attention was paid to basic emergency
procedures.”
The Chief Inspector made eight recommendations relating to suicide
and self harm.
23. In relation to safety, the Chief Inspector said:
“Vulnerable prisoners were held separately on A wing. Although
there was some concern about the mix of sex offenders and others,
such as those in debt, most said they felt relatively safe.
Arrangements for holding an overspill of vulnerable prisoners on
other wings were extremely poor. Some had spent some months in
conditions where they felt unsafe and had few, or even no,
opportunities for association or exercise.”
Independent Monitoring Board (IMB) report
24. Each prison has an Independent Monitoring Board (IMB). Their role is
to monitor the prison and to report any concerns that they have
regarding the prison or how prisoners are treated. Board members are
able to visit any area of the prison at any time, and have direct access
to any prisoner who they wish to see or who asks to see them. The
Board holds regular meetings in the prison, with the Governor
attending for part of the meeting. The Chair of the Board produces an
annual report to the Secretary of State for Justice.
25. In the latest report covering the period 2008/9, the IMB Chair, said in
the executive summary:
9
“The Board judge that, within the constraints of budgets and staff
selection and recruitment, HMP Leeds is providing a generally safe
environment for prisoners and slowly improving the respect shown
to them by staff.”
26. The member of the IMB who attended the investigation opening
meeting on 5 August, said she had noticed an improvement in how the
prison communicated with the IMB. She told my senior investigator
that, unlike previous occasions following a death in custody,
communication had been good and she and the Board had been kept
well informed.
Prison officer grades
27. There are three levels of uniformed prison officer grades. Prison
officers are the front-line supervisory staff and, in the majority of cases,
prisoners have first and most contact with them.
28. Senior Officers (SOs) are the first grade of managers and act as a
reference point for prison officers. SOs are responsible for the day-to-
day management of their area, supervising staff and dealing with
issues raised by prisoners.
29. Principal Officers (POs) are the highest rank of the uniformed staff.
They supervise other uniformed staff and have operational
responsibility for the prison.
30. In addition to prison officer grades, there is a group of staff known as
Officer Support Grades (OSGs). OSGs wear prison uniform and carry
keys but do not carry out the same function as prison officers. Their
role is to support the areas of the prison that have little or no prisoner
contact: for example, the gate.
First Night Centre
31. First night centres are intended to ensure the safety and well-being of
prisoners, particularly during their first night in prison. At Leeds, newly
received prisoners are allocated to the First Night Centre once they
have gone through the routine reception procedure.
Prison Service Orders (PSO)
32. Prison Service Orders are long term instructions that are intended to
last for an indefinite period. Any mandatory instructions to Governors
or Directors of contracted prisons are written in italics. Each PSO is
given a title and unique reference number.
PSO 2700 “Suicide and Self Harm Management” (Safer Cells)
33. PSO 2700 “Suicide and Self Harm Management” states:
10
“The design of safer cells has several features which can assist
staff in the task of managing those at risk from suicide, such as
specially designed furniture and fixtures which are manufactured
and installed to make the attachment of ligatures very difficult,
and access to window bars prevented via specialist approved
window design. Safer cells are designed not only to minimise
ligature points, but also to create a more normalising
environment. They have been found to be more durable, easier
to maintain and easier to search.
Safer cells cannot deal with the problems underlying a prisoner’s
self-harming/suicidal behaviours, and so safer cells can only
complement (i.e. not replace) a regime providing individualised
and multi-disciplinary care for at-risk prisoners. That said, it is
thought that removing or reducing access to means of harm can
be an effective way of preventing suicide in some people,
especially where suicidal behaviour is an impulsive act in
response to particular events or circumstances.”
Vulnerable prisoners
34. Under normal circumstances, vulnerable prisoners at Leeds are held in
A wing, holding about 190 similar prisoners. However, at the time of
the man’s death, A wing was full and a number of vulnerable prisoners
were routinely being allocated to a section of C wing on C4 landing. C
wing is part of what is commonly referred to as a “normal location
wing”. This means it holds those prisoners who do not need to be kept
separated from other prisoners. At the time, there was a mixture of
vulnerable and “normal location” prisoners on C4 landing. There were
approximately 30 vulnerable prisoners on C4 landing.
Assessment, Care in Custody and Teamwork (ACCT)
35. ACCT requires staff to identify any concerns, take action, and
document those actions for prisoners identified as at risk of suicide or
self-harm. The ACCT document should be available to all staff where
the prisoner is located. Within 24 hours of the document being
opened, the at-risk prisoner will be seen by a trained ACCT assessor
and have a case review meeting, which is a multi disciplinary meeting.
The meeting draws up a care and management plan, known as a
CAREMAP, and a member of staff is nominated as the case manager.
Wing managers are specifically trained to take on the role of case
manager, oversee the management of the ACCT document, and attend
case reviews.
Listeners
36. The prison has a “Listener Scheme”, under which the Samaritans train
selected prisoners to be the first contact for any prisoner who is feeling
11
vulnerable and at risk. The scheme is confidential and any prisoner
can ask to speak to a Listener at any time of the day or night.
Prisoners can access the scheme easily by speaking to a member of
staff who will then make the arrangements for a Listener to speak to
the prisoner concerned. During the hours that prisoners are locked in
their cells, anyone wishing to speak to a Listener can make the request
from the night staff on duty. The Night Orderly Officer has the authority
to unlock a Listener and to escort him to the cell of the prisoner who is
requesting assistance.
Anti-Ligature Knives
37. Staff in contact with prisoners are issued with specially designed anti-
ligature knives, commonly referred to as “fish knives” because of their
shape, which are used in an emergency to remove a ligature. The
knives have a concealed blade which is placed against a ligature and
which can be pushed forward to cut it without harming the prisoner.
Care Team
38. Each prison has its own care team. Care team staff are drawn from all
areas of the prison and trained specifically to help and support other
staff following a serious incident or in other circumstances.
Emergency response codes
39. In the event of urgent medical assistance being required, a number of
prisons have chosen to adopt codes to alert medical staff to particular
incidents. The most common codes are code red and code blue,
although some prisons have opted for code one and code two.
40. At Leeds, codes red and blue are in use. Code red tells medical staff
that the patient is bleeding and code blue alerts them that the patient is
in breathing difficulty. In prisons where codes are used, healthcare
departments have created emergency response bags that contain the
necessary equipment to deal with the particular incident. This ensures
that medical staff take the correct emergency equipment with them and
helps provide the necessary medical care as quickly as possible.
Police investigations of deaths in custody
41. With all deaths in prison custody, the police are notified by the prison
as soon as the death has been discovered. In the first instance, the
police treat the area where the person is found as a potential crime
scene and, as part of their investigation, note the names of everyone
involved and those who have been in contact with the body.
Additionally, they note the identity of all those entering and leaving the
cordoned area. It is only when the police are satisfied that the death is
not suspicious that the Ombudsman’s investigator can sensibly begin
their work.
12
FINDINGS
24 June 2009
42. On 24 June, the man was in the custody of West Yorkshire Police,
being interviewed in relation to a serious offence. As part of the normal
procedure for those remaining in police custody, he was interviewed by
police surgeon who then completed a risk assessment report. In his
report, the doctor warned police that the man had attempted suicide in
2007 by jumping from a bridge. (The man had told the police surgeon
this when asked if he had ever tried to harm himself.) The doctor gave
his medical opinion in the section of the report headed “Medical advice
for the attention of custody officer”, and wrote: “Fit and well.
Depression, self harm and overdose two weeks ago, now does not feel
suicidal.” Completing his report, the police surgeon assessed the
man’s risk of self harm to be high and recommended that he should be
located into a police cell with closed circuit television capability. This
meant the man would be kept under observation whilst in police
custody.
43. Two days later, on 26 June, the man appeared before Bradford
Magistrates’ Court having been charged with a number of serious
offences. During the hearing he was remanded into prison custody
and, following the court appearance, taken to HMP Leeds. This was
his first experience of prison.
44. When he arrived at Leeds, the man’s first contact with staff was when
he entered the reception department, where his personal details were
recorded. During that process, and as part of the normal procedure, he
was interviewed by a member of the healthcare staff.
45. The nurse in reception who carried out a medical health screen
assessment and recorded the man’s details in his medical record.
During that assessment, the nurse completed the suicide risk factor
section of the medical record. The section is designed to help identify
the level of suicide or self harm risk that a prisoner poses. There are
19 questions, each of which attracts a score of either one or two. Any
total score of ten or over means the prisoner is regarded as high risk.
46. After completing the form, the nurse recorded a score of ten for the
man. This prompted her to open an ACCT document. At interview, the
nurse said she explained the ACCT procedure and her reason for
opening it to the man, adding that he appeared to understand what was
happening. After completing her assessment, the nurse passed the
ACCT form to a member of prison staff for further action. The nurse
returned to her normal reception duties and had no further dealings
with the man.
47. Having completed the reception procedure, the man was taken by a
prison officer to the First Night Centre where he would be expected to
13
remain overnight. Because an ACCT document had been opened, and
in order to keep the man safe, the First Night Centre manager on duty
that afternoon, Acting Senior Officer (ASO), allocated him to what is
recorded in the ACCT document as a “safer cell”. The ASO wrote
instructions in the ACCT document for the man to be observed at least
two times per hour, and to be given access to a telephone and the
Samaritans. Additionally, he noted that the man had been given advice
on the Listener scheme and had been told how he could access a
Listener.
48. At about 9.10am the following day (27 June), and because of the open
ACCT document, the man was interviewed by one of the prison ACCT
assessors. In her summary, the officer said there were no outstanding
problems or issues affecting the man. She went on to say that he
appeared a little blasé about the alleged offence and that he had told
her he should not be in prison. He also told the ACCT assessor that he
was due to return to court in July and expected to be granted bail.
However, it would not be a problem if bail was not granted.
49. At interview, the ACCT assessor said the man appeared confident and
had denied the allegations made against him. She said he spoke in
depth about his parents and told her that he had spent a lot of time with
his father. He told her that he had briefly used cocaine, but had not
used unprescribed drugs for at least six months. The ACCT assessor
added that she had no concerns about him and repeated that he had
said he had not committed the offence.
50. My senior investigator asked the ACCT assessor if she thought the
offence was playing on the man’s mind. She said that she did not. My
senior investigator also asked whether there had been any discussion
about previous suicide or self harm attempts. She said he had told her
he had taken an overdose in 2007 after falling out with a girlfriend, but
there had been no similar event since.
51. Following the assessment, a case review meeting was held with both
the ACCT assessor and the man attending. That meeting was chaired
by the ASO. At interview, he said he had been temporarily promoted to
SO since March 2009. He told my investigator that he had not
received any specific training to be an SO, nor to undertake the role of
ACCT case manager. The ASO added that he was a trained ACCT
assessor and had sat in on a number of case reviews. He noted in the
ACCT document that the man had made good eye contact and that his
body language was open. The ASO also made a note that the man
had denied the offence for which he had been charged, and had told
them that he had no thoughts of harming himself. After discussing the
reason for opening the ACCT document, they all agreed that it could be
closed that day. This was the only occasion that the man was
monitored under ACCT. Before closing the document, and as part of
the normal ACCT procedure, a post closure interview was arranged for
14
seven days later, on 4 July. (In fact, the post closure interview did not
take place as scheduled and was not held until 7 July.)
52. In the meantime, and due to the nature of the allegations against him,
the man asked to be treated as a vulnerable prisoner and submitted a
written application. The application was assessed by an officer and
she approved the request. As the vulnerable prisoner wing was full,
the man was allocated to the overspill facility of C wing and allocated to
cell C4/15. Also allocated to the cell with another prisoner. They had
asked to share a cell as they had arrived in the prison at the same time
and were getting on well.
53. During an informal meeting with my senior investigator, the man’s
cellmate said he had been in prison a number of times and had
previously been a Listener. He said that although the man was often
quiet, he never talked about wanting to end his life, or gave him any
cause for concern. The cellmate added that he was aware of the man
being monitored under ACCT, but said the man told him it was
because it was his first time in prison.
54. On 7 July, the man’s application for bail was refused and once again
he was remanded into custody. There is nothing recorded to show
how the man reacted to the news.
55. Also on that day, some three days later than scheduled, the ACCT post
closure interview took place. A SO completed the review after which
the file was closed.
56. My senior investigator examined why the review was not carried out on
the correct date. He spoke to the prison ACCT clerk and asked
whether she could explain why the review had been delayed. She
could not. She said the ACCT document for the man was sent to C
wing on 3 July, but could not say why the review had not taken place
on the due date. She said it was unusual for ACCT reviews not to be
completed on the correct day. My senior investigator also asked the
Head of Performance if he could explain why there had been a delay.
In an email to my senior investigator, the Head of Performance said
there had been a problem at the prison regarding the timing of ACCT
reviews. He said the situation had since been resolved with the
responsibility for case management being restricted to fewer
managers.
57. Just over three weeks later, on 30 July, the man received a visit from
his family. Following the visit he returned to his cell and told his
cellmate that his father had cancer and that it had returned after a
period of remission. (When my senior investigator and my family
liaison officer visited the man’s family, they were told that the man’s
father was not aware at this time that the cancer had returned. His
parents left the prison unaware that the man was struggling to cope.
Unfortunately, I have been unable to resolve the discrepancy between
15
the accounts of the man’s family and the man’s cellmate although I
have no reason to doubt that both are an accurate reflection of events
at the time.) The cellmate said the man was quiet for a while and then
began crying. He told the man that he had previously been a Listener
and invited him to speak freely. The man asked him for help writing a
letter to his family, saying he wanted to express his feelings and tell
them that he loved them, but did not know how to. The prisoner said
they spoke about what type of things to write, but that he did not see
what was written.
31 July
58. The cellmate told my senior investigator that the following morning was
normal. He said the man collected his lunchtime meal and that he was
still writing his letter.
59. At about 2.00pm, prisoners on C4 landing were unlocked for
association and exercise and escorted to A wing. (Association allows
prisoners to mix freely with each other.) Because association and
exercise is voluntary, it is not unusual for some prisoners to choose to
remain in their cells on their own, or with the other occupant. For those
vulnerable prisoners being held on C4 landing, and for their own
protection, any prisoner choosing to remain in cell during this period
does so in the knowledge that the cell door will be closed and locked.
This means they are unable to leave the cell and other prisoners are
unable to enter it.
60. The officer who was unlocking prisoners on C4 landing that afternoon.
At interview, he said that when he unlocked cell C4/15, the man said
he wanted to remain in the cell, whilst the other occupant, decided to
leave. The officer said that, although the man had chosen not to go to
A wing, he was not concerned about his safety. He added that, as the
man was not being monitored for any special reason, there was no
expectation that he would be seen until the end of the association
period about one hour later.
61. The man’s cellmate told my senior investigator that the man said the
reason he wanted to remain in his cell was because he wanted to finish
writing the letter to his family, and to get it in the post box that
afternoon. He told my senior investigator that although it was unusual
for the man not to go to A wing, he had no concerns about him. Had
he been concerned about him, he felt confident that he would have
been able to speak to officers and that they would have taken action.
62. In the meantime, another prisoner had been unlocked to make a
telephone call. After completing his telephone call, he went to see a
friend on a section of C4 where prisoners who were not regarded as
vulnerable were held. He said the purpose of doing so was to ask for
tobacco. The other prisoner said he looked into a number of cells in
the hope that he would find someone who would share tobacco with
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him. When he looked into cell C4/15 he saw the man hanging from the
window frame. During an informal interview with my senior
investigator, he said the man’s feet were off the ground and he was
suspended by a piece of bed sheet. He banged on the cell door, but
did not obtain a response so ran to tell an officer.
63. One of three officers supervising prisoners on C3 landing that
afternoon at interview, said that at about 2.30pm the other prisoner
approached them and said there was a prisoner hanging in one of the
cells on C4 landing. The officer said that both he and a second officer
ran to the cell.
64. The first officer said he looked into the cell through the door
observation panel and saw the man hanging. He unlocked the door
and both he and the second officer went in. In the meantime, a third
officer had used his prison radio to ask for urgent medical assistance
using the code blue procedure.
65. The first officer said that, because the man was suspended above the
ground, he had to stand on the water pipes to reach the ligature before
being able to cut it. At the same time as he cut the ligature, the second
officer took hold of the man’s legs and lifted him up to take the
pressure from around his neck. Once the pressure was released, the
first officer used his anti-ligature knife to cut the ligature. The second
officer was still holding onto the man when the ligature was cut, but due
to the weight he was unable to support the man and unfortunately he
hit his head on a radiator as he went to the ground. The second said
he saw the man’s face twist slightly when he hit the radiator and
wondered if he was still alive.
66. As soon as the man was on the floor, the officers placed him into the
recovery position and began checking for signs of life, but did not
detect anything. The first officer said the man was warm. The second
officer said they were just about to turn him onto his back with the
intention of performing cardio pulmonary resuscitation (CPR) when
healthcare staff arrived and took over.
67. The first nurse on the scene who was on duty that afternoon said that
one of her duties that afternoon was to carry a prison radio, and to be
first response to any medical emergency. Her radio call sign was ‘hotel
three’. She told my senior investigator that in the event of a medical
emergency, the person carrying the radio is required to go direct to the
scene, whilst other medical staff collect emergency equipment and
follow on. She said there are specific types of equipment taken
depending on the emergency.
68. At interview, the first nurse on the scene said that she and one other
nurse were preparing medication prescriptions when she heard the
code blue radio message. When she heard the message at 2.31pm,
she went straightaway to the man’s cell. She said the second nurse on
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the scene, arrived at about the same time. The first nurse on the
scene told my investigator that when she looked into the cell she saw
the man on the floor on his left side. His skin colour was dark,
describing it as being almost purple (cyanosed, which is a blue tinge of
the skin and caused by a lack of oxygen). The nurse said the ligature
had been removed, but she could clearly see where it had marked the
man’s neck. The first nurse on the scene checked for signs of life but
could not detect any. The nurse said the man’s skin temperature was
warm, his eyes glazed and there was no evidence of rigor mortis.
During the brief time that the nurse was waiting for the emergency
equipment to arrive, she began CPR at the rate of two breaths to 30
compressions.
69. In the meantime, the emergency medical equipment arrived and the
first nurse on the scene attached the automated defibrillator pads to the
man’s body. (A defibrillator can restart the heart in some cases of
cardiac arrest by giving an electric shock. It detects the electrical
activity in the heart and gives automated instructions to the rescuer.)
The nurse said the automated system did not instruct her to shock, but
to continue CPR. (In his clinical review, the clinical reviewer said this
was due to a lack of heart rhythm, referred to as “asystole”.) She
inserted a plastic airway and began to administer oxygen, and also
inserted a tube into a vein to allow intravenous access. The two
nurses continued CPR until a paramedic first responder arrived at
2.40pm. He was followed a few minutes later by two more paramedics
and they took over CPR.
70. The first officer on the scene told my investigator that, when healthcare
pulled the man’s top up to allow the defibrillator pads to be attached,
there was a letter tucked into the top of the man’s trousers. The officer,
said he did not read the letter, and it was later taken away by police
officers carrying out their investigation. (My senior investigator has
obtained a copy of the letter. It is a personal note from the man to his
parents and explains his reason for ending his life. It is clear that the
man did not feel able to deal with prison.)
71. The clinical reviewer notes in his clinical review that paramedics
administered four doses of intravenous adrenaline to the man.
Additionally, a tube had been inserted to allow full ventilation of his
lungs. The first nurse on the scene said she had noticed an
improvement in the man’s colour and was under the impression that
paramedics had detected some sign of life.
72. At the same time as the man was being cared for, prison staff began
locking up those prisoners who hade been unlocked on C wing. The
other prisoner told my senior investigator that officers had been
concerned about him and had asked a Listener to join him in his cell to
provide support.
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73. At 3.06pm, paramedics transferred the man to Leeds General Infirmary
(LGI) by ambulance. The clinical reviewer records that CPR continued
throughout the resuscitation attempts and transfer to hospital.
74. The first nurse on the scene said that, under normal circumstances,
whenever a prisoner dies in custody, paramedics leave the body at the
prison until police have completed their enquiries. However, on this
occasion because they transferred the man to hospital, it led her to
believe he might still be alive.
75. The man arrived at hospital at 3.25pm and was taken to the
resuscitation area where his condition was assessed by doctors. The
assessment showed no cardiac output or spontaneous breathing.
However, after about 20 minutes the medical team managed to restart
the man’s heart. He was transferred to the intensive care unit, and still
required full airway and ventilatory support using a life support
machine.
76. Due to the seriousness of the man’s condition, the Governor was
asked by a member of hospital staff to contact his family to ask them to
go to the hospital as quickly as possible.
77. Under normal circumstances whenever there is such bad news to pass
onto a family, the Governor or a representative of the prison would be
expected to go to the next of kin and inform them in person. However,
because of the urgency of the hospital request, the Governor decided
to telephone the man’s family. At about the same time as the Governor
telephoned the man’s family, the Deputy Governor went to the hospital
to meet them as they arrived. She also spoke to and supported those
prison staff who had accompanied the man to LGI.
1 August
78. Sadly, the man did not regain consciousness. The clinical reviewer
says in his clinical review that, having been starved of oxygen for so
long, the damage to the man’s brain was deemed to be so severe that
he was pronounced dead. The time of death was recorded at 4.25pm.
Following the man’s death
79. Following the man’s death there was a review of all those prisoners
being monitored under ACCT to ensure there was no adverse reaction.
This was in line with normal procedure.
80. Additionally, there was a ‘hot debrief’ chaired by a senior manager who
met the staff involved. As well as the debrief, the prison staff care
team was made available to any member of staff wanting to see them.
The Governor arranged for a critical incident debrief to take place.
(This offers a more in depth level of support.)
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81. The other prisoner said the Governor came to see him personally to
thank him for raising the alarm. The Governor had given him a small
reward of tobacco, which he appreciated very much. He said a number
of officers had spoken to him after the death, wanting to make sure he
was okay. Similarly, the cellmate said a number of prison officers and
nurses had spoken to him, which he had found supportive.
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ISSUES
Assessment Care in Custody and Treatment (Case management)
82. One of the mandatory instructions of the ACCT procedure is that all
case managers are appropriately trained. PSO 2700, section 1.3.1,
states:
“All Senior Officers, Principal Officers and Operational Managers
(F and above), including Governors and Directors, must be
trained to at least ACCT Case Management level.”
83. On 27 June, although not trained, the ASO chaired a case review
meeting. This was contrary to the instructions. Whilst I have no
reason to believe that the ASO’s management of the case review was
in any way deficient, it is important that proper systems are in place
and are followed. I understand that, since the investigator pointed out
this finding, the Governor has taken steps to remedy the system.
Nevertheless, I think it sensible to make the following formal
recommendation.
The Governor should ensure that ACCT case managers have
received the necessary case management training and are
competent to act as case managers. This should include any
uniformed member of staff who is temporarily promoted or those
carrying out short term “acting up” duties.
Post closure review
84. After closing the ACCT document, a post closure interview was
scheduled for 4 July in line with requirements under PSO 2700.
However, as a result of what appears to have been an administrative
problem and a lack of available managers, the review did not take
place for a further three days until 7 July. After raising the finding with
the Governor, I understand the Governor has corrected the problem
and that there is a new system in place to ensure post closure
interviews take place on time.
The Governor should ensure that the mandatory instructions
contained within PSO 2700 are followed.
Vulnerable prisoners
85. As this report has shown, a number of cells on C4 landing are being
used as an overspill for vulnerable prisoners unable to be located into
A wing. This is clearly not ideal. It means that vulnerable prisoners,
although locked into their cells, are potentially liable to intimidation from
normal location prisoners able to access the C4 landing. Whilst I have
no evidence that the man was in any way subject to intimidation, it
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concerns me that the separation between vulnerable and normal
location prisoners is not sufficiently robust.
86. It is clear, for example, that the other prisoner was allowed to walk
freely to C4 landing and to come into direct contact with any vulnerable
prisoners who had decided to remain in their cells. Whilst I make no
formal recommendation, the Governor will wish to satisfy himself that
his systems for protecting vulnerable prisoners are robustly managed.
Care for prisoners
87. At a time when prison staff were dealing with an extremely difficult
situation in C wing, there was clear evidence of care and support being
shown towards the other prisoner. To ensure he was supported, a
Listener was asked to join him. This was a kind, thoughtful and
professional gesture, demonstrating good practice.
Clinical review
88. In his clinical review, the clinical reviewer comments as follows:
“The commonest method of attempted suicide in prison is one of
asphyxiation, as in this case. Unconsciousness occurs fairly
quickly and usually within several seconds. Brain death occurs
due to oxygen starvation within a few minutes, though the heart
can remain beating for several minutes longer (10-15 minutes in
total). It was likely that the man was discovered hanging from
his cell window just after this period since he was showing
minimal, if any, signs of life. Though his body was warm, he had
no discernible cardiac output or spontaneous breathing. The
cyanosis confirmed the lack of normal oxygenation of his body.
“The response to this situation appears to have been quick and
appropriate with medical support arriving promptly.
Cardiopulmonary resuscitation (CPR) was begun in a timely
manner and was continued throughout until his heart was
eventually fully restarted in the emergency department of the
hospital.
“From my assessment I would like to note that the man received
good quality resuscitation prior to the arrival of the paramedic
crews and then subsequently prior to hospital and that he was
given the best possible chance of survival from the emergency
care he received at this time. However in my opinion the
damage had already been done by the time the man was found
and so the outcome, despite the best efforts of the prison staff,
paramedics and hospital staff, was unfortunately inevitable.”
89. Concluding his clinical review, the clinical reviewer commends the
man’s family. He reports that, despite the tragedy that had befallen
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them, they had the fortitude and courage to contemplate and then
proceed to donate the man’s organs. Others will live as a
consequence of their kindness, and I add my own thanks to them here.
90. The clinical reviewer makes no recommendations.
Family concerns
91. As well as the matters raised above, the man’s family have asked me
to consider several other issues that I have set out in paragraph 8
above. My senior investigator has spoken to the prison and has
received the following answers.
92. Leeds have confirmed that swine flu was not affecting staff levels on C
wing on the day of the man’s death. In terms of risk assessments,
Health and Safety risk assessments are carried out whenever there are
changes made. The prison also conducts a daily fabric check to
ensure that the integrity of the cell is sound and secure and that the cell
is habitable. Finally, Leeds confirmed that the windows in C wing are a
different design to those on the vulnerable prisoner wing. However, the
design of the vulnerable prisoner wing windows does not make them
anti-ligature, and it is unlikely that this in itself would have been a factor
in the man’s death.
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CONCLUSION
93. I have considered carefully whether the matters I have discussed
relating to the ACCT process had any bearing on the man’s actions.
Although it is clear that the prison was not complying with the
instructions of PSO 2700, I do not feel that this meant the man was not
supported. In fact, there was every indication that he had settled in
reasonably well and was displaying a positive outlook. I am therefore
satisfied that the decision taken to close the ACCT document was
reasonable and would probably have been made whoever was the
case manager..
94. In relation to the man being a vulnerable prisoner, again I am satisfied
that he was given the appropriate support and that there were systems
in place to ensure he could feel safe. That said, I question the sense of
allowing normal location prisoners to gain access to vulnerable
prisoners. The issue of the use of overspill accommodation has also
been identified by the Chief Inspector of Prisons in her latest report.
95. Overall, I am satisfied that the man’s prison and medical care was
appropriate. He gave no indication of what it was he was planning to
do, but does appear to have given it some thought. He wrote to his
parents, setting out his final wishes in some detail, and then ensured
he would not be disturbed for a while. I conclude that the man took his
own life, but his actions could not reasonably have been anticipated by
prison staff.
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RECOMMENDATIONS
1. The Governor should ensure that ACCT case managers have received
the necessary case management training and are competent to act as
case managers. This should include any uniformed member of staff
who is temporarily promoted or those carrying out short term “acting
up” duties.
The recommendation has been accepted. The Governor said: “HMP
Leeds have moved to core group model* with three Safer Prison’s
Senior Officers completing the role of case managers”.
(*I understand the prison has developed a safer prison group and it is
they who are now responsible for ACCT case management.)
2. The Governor should ensure that the mandatory instructions contained
within PSO 2700 are followed.
The recommendation has been accepted. The Governor said: ”HMP
Leeds have just received a full PSO 2700 audit with the only area of
non compliance being put right during the audit.”
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