Individual at Bullingdon

Investigation into the circumstances surrounding the death
of a man at HMP Bullingdon in September 2006
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2007
This is the report of an investigation into the death of a man at HMP
Bullingdon in September 2006. The man was found hanging in his cell. He
was a foreign national by birth and was 31 years of age.
My colleagues and I offer sincere condolences to the man’s family and friends
for their sad loss.
This investigation has been undertaken by two of my colleagues. I would like
to thank the Governor of HMP Bullingdon, and his staff for their participation in
the investigation. Particular thanks go to the officer who acted as the
establishment’s Liaison Officer.
A medical practitioner of Oxfordshire Primary Care Trust (PCT) undertook a
review of the man’s clinical care and I also greatly appreciate his assistance.
When he first arrived at Bulingdon, the man was subject to suicide and self
harm monitoring and support procedures and was located in the Healthcare
Centre in a ligature free cell. This was because he was upset and appeared
to be having trouble coping with being in prison. However, he maintained he
did not have any suicidal or self-harm intentions, and after just over a week he
was taken off the monitoring and support. After that, it seems the long period
he spent on remand facing serious charges did cause him unhappiness.
However, there is no evidence that he confided in staff any intention to harm
himself and concerns raised by his solicitors were properly explored. His
death came as a great surprise to his cellmate and other prisoners. I do not
think the circumstances were such that staff could reasonably have predicted
that the man would attempt to kill himself.
The clinical review has raised as a matter of concern that the member of staff
who performed the initial mouth to mouth resuscitation did not have a barrier
mask (albeit the resuscitation attempt on the man was appropriately and
efficiently carried out). My report includes one recommendation relating to
that matter and I draw two other issues to the Governor’s attention.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2007
CONTENTS
Summary
The Investigation Process
HMP Bullingdon
Key Events
18 September 2006
Issues
Family concerns
Clinical review
Conclusion
Recommendation
SUMMARY
The man was remanded in custody at HMP Bullingdon on 21 November 2005
to await trial for a number of offences, including two of a serious sexual
nature. This was his first time in custody. During his induction, he was very
upset and, because of concerns about potential mental health problems and
his ability to cope in prison, he was immediately located in the Healthcare
Centre in a ligature free cell. He was placed on an ACCT (Assessment, Care
in Custody Teamwork) form and staff checked him hourly. (ACCT is the
system used by HM Prison Service to monitor and support a person at risk of
suicide or self-harm.)
On the next day, the man was relocated from the Healthcare Centre to E
wing, a unit for vulnerable prisoners, because of the nature of his alleged
crimes. He continued to be monitored under the ACCT system until 29
November 2005 when the form was closed. There was nothing in his mood or
behaviour that caused concern and he said he had no thoughts of suicide or
self-harm. The man was interviewed on 10 December, as appropriate when
an ACCT form is closed, and again no concerns were raised.
The man settled on E wing and knew some of the prisoners there from
outside prison. He mixed well with a small group of prisoners, but officers
tried to discourage this as they felt that these prisoners were not always a
good influence on him and sometimes ‘led him astray’.
There were no significant events until 15 May 2006 when his solicitors sent a
fax to the prison saying that they were concerned that he might be depressed
and inclined to suicidal thoughts. They asked that he be ‘appropriately
supervised’. It is unclear when this information was passed on to E wing, but
the man was seen by an officer on 16 May. She noted that she had spoken to
him and he had assured her he was alright and had no thoughts of suicide or
self-harm. She said she explained the support mechanisms available for him
and he seemed content with that. The officer did not consider it necessary to
open an ACCT form.
The man had a meeting with his legal representative, during the late morning
of 18 September. The solicitor said that the man’s trial date had been set and
most of the meeting was spent discussing that. They also briefly discussed
him having access to his son, as his partner had stopped allowing their son to
visit him. The man’s legal representative assured him that legal aid could be
obtained to hire a solicitor specialising in family law. He had no concerns
about the man’s wellbeing after their meeting.
The man’s cellmate went to the gym on the evening of 18 September. The
man declined to go. When his cellmate returned at around 7.27pm, the
escorting officer found the man suspended from a ligature made from his
shoelaces attached to the top bunk. She called for immediate assistance and,
with the help of a Physical Education Officer (PEO), secured the rest of the
prisoners returning from the gym in their cells. Other staff arrived and
commenced Cardiopulmonary Resuscitation (CPR) at around 7.30pm. Mouth
to mouth resuscitation was commenced without a barrier mask as no member
of staff had one. Nursing staff arrived at around 7.35pm. They administered
oxygen and attached an automatic defibrillator. The defibrillator did not
advise to shock the man at any time. Resuscitation continued until
paramedics arrived and pronounced the man dead soon after.
Two prisoners who knew the man well described him as being a little
despondent and feeling fed up with the length of time his trial was taking.
However, they did not feel his behaviour or mood indicated he was going to
commit suicide and his death came as a shock to both of them.
My report contains just one recommendation.
THE INVESTIGATION PROCESS
1. My investigators studied all relevant prison records relating to the man.
These included his main prison record, medical record and statements
made by prison staff.
2. The Clinical Governance Lead for Oxfordshire PCT was asked to carry
out a review of the man’s clinical care. I am grateful for this review
being undertaken in a timely manner.
3. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of my investigation, and to request a copy of the Post
Mortem report. Upon completion, this report will be sent to the Coroner
to assist him in his enquiries into the man’s death.
4. One of the investigators and one of my Family Liaison Officers met with
the man’s family. His sister was unhappy with the contact from the
prison after her brother’s death. She asked what had been done to risk
assess her brother’s cell. She also believed her brother’s work
applications had been refused, and she questioned why prison officers
would not provide him with reasons for this. She said that her brother
had not gone out for association for two weeks prior to his death and
questioned why this was not picked up by staff.
5. The man’s sister felt her brother was sometimes singled out at the
prison and said he was strip searched before all his visits. She asked
whether it was usual for prison officers to know about prisoners’
medical conditions and for prisoners on remand to share cells with
those already sentenced.
6. The sister spoke about her brother’s concern about receiving a long
sentence. She asked for clarification about her brother banging on his
cell wall calling out for another prisoner who was in the cell next to him
on the day he died. She also asked for further information about what
was discussed at her brother’s meeting with his solicitor on the same
day. These concerns are fully discussed in a later section of my report.
7. My investigators discussed aspects of the man’s treatment with both
staff at Bullingdon and the clinical reviewer. Notices were issued to
staff and prisoners telling them of the investigation and offering them
the opportunity of contributing. During the course of the investigation
three members of staff were interviewed. My investigators spoke with
Bullingdon’s police liaison officer and the man’s solicitor. They also
met with two prisoners and a prison chaplain.
HMP BULLINGDON
8. HMP Bullingdon operates jointly as a local and category B training
prison for adult males. The primary catchment area is the Crown
Courts at Oxford and Reading as well as the local Magistrates’ Courts.
9. Bullingdon was opened in 1992. It has four main houseblocks, which
have been supplemented by a fifth since 1998, and the prison can
currently accommodate 963 prisoners. Edgcott wing (E Wing)
accommodates those prisoners defined as vulnerable because of the
nature of the offences they have committed or are accused of.
10. Provision of healthcare within Bullingdon is the responsibility of the
North Oxfordshire Primary Care Trust. Overnight and weekend cover
is provided by local GPs who are on call. There is also a clinically
qualified member of healthcare staff on duty at these times. There is
an in-patient unit with 24 beds, and all cells have integral sanitation.
The unit is staffed by discipline and clinical staff who provide health
and social care for patients with mental health needs, and for some
with physical needs who require a 24 hour nursing presence.
11. The most recent report by HM Chief Inspector of Prisons was
published in August 2004 following an unannounced short inspection
conducted in June 2004. HMCIP report noted that, ‘There were no
specific recommendations on the protection of vulnerable prisoners in
our previous report (full unannounced inspection September 2002).
However, we noted that the Edgcott Wing was now entirely for sex
offenders and operated as a vulnerable prisoner unit. Prisoners on this
wing raised few issues about their protection and the prison had
addressed some particular concerns, such as procedures for visits.’
KEY EVENTS
12. On 21 November 2005, the man was remanded in custody at HMP
Bullingdon. He was assessed as a low risk for sharing a cell with other
prisoners and was said to be upset. It was his first time in prison. The
First Reception Healthscreen noted his GP’s name and that the man
had some outstanding clinical appointments. He said he had suffered
from TB two and a half years previously and had been treated at the
specialist hospital. There were no concerns about his health. The man
said he had not taken any drugs in a month.
13. The man was admitted from reception to healthcare because of
possible mental health problems and poor coping. It was noted he was
crying. An ACCT form was opened by a senior nurse. According to
the ACCT care plan, the man was located overnight in Healthcare, in a
ligature free cell, and was observed hourly.
14. A Secondary Healthscreen was completed on 22 November by the
prison doctor. An initial questionnaire completed by a student nurse
noted that the man was depressed and wanted to give up smoking. In
terms of his physical health, he wanted a hepatitis B vaccine and was
HIV positive. It does not appear that he needed any antiviral
medication but regularly attended the specialist clinic at the local
hospital. The prison doctor noted that the man was ‘calm and rational,
not depressed, not suicidal and fit for ordinary location.‘ He was also
seen by a chaplain who did not note any concerns. The man was
located on E wing at 3.30pm and seemed to settle in quickly. There
was no indication he was contemplating suicide or at immediate risk of
self-harm.
15. On 28 November 2005, the man went to the Crown Court. On return
he was seen by a member of healthcare and deemed 'fit'. On 29
November 2005, the ACCT form was closed and it was noted that he
had no thoughts of deliberate self-harm, was more settled and had
good family support.
16. On 30 November 2005, a member of the public protection unit
interviewed him and noted he smelt strongly of cannabis. This was
also recorded in a Security Information Report.
17. The man’s personal officer and he made various notes in his core
record which are referred to in my report. On 1 December 2005, the
officer noted that the man had settled on E wing and was friends with
prisoner A.
18. On 10 December 2005, the personal officer noted that the man had
become an industrial cleaner and had no issues. The man’s post
ACCT closure interview on 10 December 2005 noted that he got on
well with his cellmate, was receiving letters and had put in an
application for work.
19. On 22 December 2005, the personal officer noted that the man was
having trouble making international telephone calls. This was
addressed as the man later applied to use an official telephone to
make an international telephone call which was allowed. Records
show that the man then spoke to his parents in his home country for
five minutes on 20 February 2006. Through the same procedure he
also telephoned his parents on 16 May and 4 August.
20. On 3 January 2006, the personal officer noted that the man had settled
and made friends with a select few prisoners on E wing. On 11
January, the man was seen by a doctor as he said he was feeling tired
and having problems sleeping. He was examined and the diagnosis
was given as ‘insomniac’. He was issued a seven day prescription of
what was possibly Trazodone, but the entry is not legible. (Trazodone
is an antidepressant used to treat depression when accompanied by
anxiety, insomnia or both.) No follow up consultation is recorded.
During his time at Bullingdon, the man was seen in the GUM clinic
(Genito-urinary medicine or sexual health clinic) on 24 January, 11
April, 27 June and 4 July.
21. On 3 February, the senior officer (SO) noted that the man demanded to
go back to the wing after his legal visit finished early. On 8 February,
he refused to move to the top bunk to accommodate an elderly
prisoner in the cell. The man said he did not think he would get on with
the prisoner because of the age difference. The prisoner was located
in a different cell. His personal officer did not identify that the man had
any other concerns or issues.
22. On 22 February 2006, the man was remanded for trial at the Crown
Court on 21 November 2006. On return to Bullingdon he was seen by
a member of healthcare staff and deemed 'fit'.
23. On 5 March, his personal officer noted that he had not been at work for
three weeks and in that time the man had remained quiet and
compliant with no concerns or issues raised with staff. On 11 March,
an entry in his core record by the SO notes that he warned the man
about his behaviour as he had been absent from work. The man
complained of being ‘poorly’.
24. On 1 April, the man spoke to his personal officer at length about his
trial and general wellbeing whilst the officer was escorting him back
from reception. The officer noted, ‘It seems that it may be a long drawn
out process, although he seems quite positive about everything. He is,
however, mixing with the wrong crowd on the spur and they are leading
him astray without him knowing it.’
25. On 4 April, the man’s cellmate asked to move cells due to possible
intimidation by the man. On 10 April, there is another record of a
complaint from the cellmate of possible intimidation/bullying by the man
and his friends. The man’s cellmate was moved out of the cell and no
further action was required. Some time in April, prisoner A moved into
the cell with the man.
26. There is a security report about an incident on 21 April when the man
was involved in an argument with three prisoners, including prisoner A.
It appears from the security report that the man then pushed one of
these prisoners in the gym on 23 April. The security report noted that,
on 24 April, two of the prisoners had ‘kept the argument going.’ Staff
were concerned that the dispute was in danger of spilling over into the
work area and gym as all four prisoners involved were industrial
cleaners. The Wing SO was told and a note was made for staff to keep
an eye on the situation.
27. On 25 April, the man put in a formal complaint about missing tobacco.
The response from the Acting Governor said that the man should not
have used the confidential access system to lodge his complaint as
such complaints have to go to the governor in charge. The acting
governor explained the issue had been passed to another governor to
look into. In future the man should use the open access complaints
system (not in a sealed envelope) or address concerns through senior
wing officers. There is no evidence of any further action being taken
on this issue.
28. On 9 May, the man appeared at the Crown Court and was remanded in
custody until 24 November 2006. On 12 May, the personal officer
recorded that the man had returned from court: ‘Long time to wait until
his next appearance, not entirely happy but seems to be taking it quite
well.’
29. On 14 May, the personal officer was informed by Physical Education
Officer (PEO) that, due to poor attendance, the man was off the gym
list and would need to reapply if he wanted to use the gym.
30. On 15 May, a letter addressed to the Governor was faxed to the prison
by the man’s solicitors. This said the man was depressed and had
suicidal thoughts. The letter said that the man was ‘suffering from a
depressive state of mind and has shown an inclination to suicidal
thoughts.’ The solicitors asked the prison ‘for appropriate supervision’
for the man ‘to avoid any unforeseen events.’ The fax is timed at
4.16pm.
31. On 16 May, there is an entry in the Wing Observation log noting the
concern from the man’s solicitors regarding his intention to self-harm:
‘Received phone call from the prison officer (legal visits) who received
a fax from said prisoner’s solicitors. Stated that prisoner said he felt
suicidal. Asked the officer to send copy of the fax to E wing. The man
could not be interviewed because he was on Alpha course this a.m.
Needs interviewing this afternoon.’ The man made a five minute
telephone call to his parents in his home country that afternoon and the
wing officer spoke to him after that. He noted in the man’s core record,
and said in interview, that the man told him he was not suicidal and
was ‘ok’. He wrote, ‘I explained the support mechanisms that we have
in place in Bullingdon, ie Chaplaincy, Listeners, Samaritans phone,
staff support. He said he will be ok and thank you for the phone call.’
The wing officer did not consider it necessary to open an ACCT form
for the man. (It is not clear whether the wing officer was aware of the
concerns raised when the man had arrived at Bullingdon six months
previously.) There is a note by the wing SO, dated 17 May, on the
letter from the solicitors indicating that staff had spoken to the man.
32. On 21 May, the second wing officer noted in the man’s core record that
he had introduced himself as the man’s new personal officer. The
officer wrote that the man was trying to improve himself and his general
attitude after he had addressed him about the previous entries. The
officer also noted that he had started to let the man help wing cleaners
and that he had regular visits from his family and associated with a
small group of prisoners. There were no current issues.
33. On 1 June, the man’s personal officer recorded that there were still no
problems with the man. He also said that the man was continuing to try
to get on the wing cleaners list and had offered to help out in the
mornings and afternoons. He said that the man was still associating
with the same prisoners and in his opinion was being influenced by
others in the group. The officer was going to try to encourage him to
break away from this crowd and make his own choices.
34. On 2 June, the man appeared again at the Crown Court. He returned
to the prison and was seen in reception and said he was fit. On the
same day, there is a note in his core record that he went to the visits
hall as he had a visit booked. However, he asked to leave shortly after
as his visitor did not turn up and he said the children in the visits hall
were bothering him. It is not clear what he meant by this and there is
no visit listed in his visits record for 2 June.
35. On 6 June, the man changed the next of kin details he had given to the
prison from his partner to his sisters. On 12 June, the man again
appeared at the Crown Court and his case was adjourned for trial.
36. On 15 July, the personal officer noted, ‘Remains a quiet lad but still
hangs around with the wrong crowd. Gets on ok with staff and other
peers, no issues.’ On 28 July, the officer again noted that the man did
not have any issues.
37. On 4 August, the man made a five minute telephone call to his parents
in his home country and was said to be in good spirits after the call.
On 12 August, the personal officer noted that the man was still a fairly
passive member of the wing and that his regular visits from his family
and friends were his highlights. He recorded that the man was
currently an unemployed industrial cleaner but that would soon be
rectified. When interviewed, his personal officer said the man would
have applied to become an industrial cleaner and part of the
application process involves getting security clearance. He was not
sure how far his application had progressed, but he explained that he
always encouraged him to help out with the wing cleaning.
38. On 8 September, the man appeared at the Crown Court and the date
of his trial was to be fixed. On 16 September, he had visits from his
brother-in-law, and his sister. Prisoner A said he was aware that the
man spoke about his ex-partner to his brother-in-law but he was not
aware of the details of the conversation.
18 SEPTEMBER 2006
39. In interview, the man’s solicitors recalled that he saw the man in the
late morning of 18 September. He said the man was concerned that
he was no longer able to see his child and felt let down by his ex-
partner. The solicitor said that he explained to him that legal aid could
be obtained for a solicitor specialising in family law, but the focus for
most of the meeting was the forthcoming trial. He said the man
seemed to accept this, and acknowledged that this was the priority.
The legal visit lasted for approximately 90 minutes, of which ten
minutes was spent talking about access to the man’s son. The solicitor
did not have any concerns about the man’s state of mind when the
legal visit concluded in the early part of the afternoon.
40. The wing officer escorted the man to the legal visit. She recalled in
interview that he did not talk to her, but did chat with another prisoner
as he was being escorted to the Healthcare Centre at the same time.
Prisoner B was located in the cell next to the man and spoke regularly
to him. Prisoner B has told police and my investigators that he saw the
man in the afternoon when they were both being escorted by the wing
officer. He said the man told him he was frustrated at the length of
time he had been on remand and told him he was generally fed up with
everything. He said the man appeared to be more open than usual
when they were talking. In his opinion, the man’s talk about being fed
up was the usual talk from prisoners and he did not think it was said
seriously. He said the man mentioned he was upset with people
outside the prison, perhaps with his family, but he was not sure. The
man complained that his trial was taking a long time. He said that the
man was fed up and said things like ‘you feel like ending it here’. He
thought this was out of character but was not concerned about him
after their conversation and did not tell any members of staff.
(Information from others indicates that the man met his legal
representative late in the morning.)
41. Prisoner B told my investigators he saw the man again in the evening
when they were in the queue for food. He said the man looked jolly,
although he could see in his eyes that he wanted to talk but it was too
public an area to engage to do so. The PEO2 escorted some prisoners
to the gym. She remembered the man using the gym on previous
occasions.
42. The wing officer opened the cell door to let prisoner A, the man’s
cellmate, go to the gym at around 6.00pm. Prisoner A recalled that,
when it was announced over the tannoy that it was time for the gym,
the man pressed the cell bell to let staff know prisoner A wanted to go.
In hindsight, prisoner A considered this was unusual and out of
character for the man. The man said ‘see you later’. Prisoner A
recalled that the man had been ‘a little despondent’ and had been
having trouble sleeping for a few months.
43. Prisoner B did not go to the gym. He said he realised that the man was
on his own in the cell when he heard banging coming from his cell next
door. He explained to my investigators that this was not unusual as
prisoners often do this to let each other know if there is anything
interesting on television. There is no evidence that prisoner B spoke to
any member of staff about this.
44. At around 7.25pm, the wing officer and PEO2 were locking prisoners
back in their cells after gym. The wing officer was locking up cells 132-
148 on the left and the PEO2 was locking up cells 162-149 on the right.
The wing officer arrived at the man’s cell at around 7.27pm. She
opened the observation flap on the cell door and looked in. The wing
officer described what happened in interview, in her incident report and
in her police statement. In her police statement, she said that it was
getting dark and the lights were off and she saw a white shoe lace
coming from the top bunk and down at an angle. She unlocked the cell
door (E145), and called to the PEO2 there was a level 1 emergency.
(A Level 1 emergency is a call for medical assistance and indicates a
serious medical emergency.) She removed prisoner A, the man’s
cellmate, from the area and asked him to wait upstairs. Again in her
police interview, she said ‘it went through my mind that the man had
hung himself.’ She recalled the man had his back to her and it looked
like he was crouched down. She did not go in as there were other
prisoners who still had not been secured in their cells. She said she
was ‘very conscious for everybody’s safety’. She locked the other
prisoners up, with the help of the PEO2.
45. Prisoner A recalled that he returned from gym and waited outside the
cell. He spoke briefly to prisoner B through his cell door. He was
taken to healthcare and was later told the sad news of the man’s death.
46. PEO2 said in her incident report and police statement that she
responded to the wing officer’s call for help and, after she had looked in
the cell, she called the Level 1 emergency over the radio. With the
wing officer, she continued to lock up other prisoners who had returned
from the gym. She also helped to move prisoner A away from the
area.
47. PEO3 heard the emergency call and arrived at the cell at around
7.30pm. The wing officer returned and gave PEO3 her anti-ligature
knife. He cut the ligature (white shoe laces) from around the man’s
neck and unravelled it. He said he checked for but could not detect
any pulse. PEO3 opened an airway to check for breathing but could
not detect any breath present. He asked for a barrier mask to
commence Cardiopulmonary Resuscitation (CPR) but no member of
staff had one. He began CPR without a barrier mask and gave him two
rescue breaths. He checked for circulation but noticed that the man
was cold to touch. The wing officer cut the shoelaces from around the
man’s ankles then left the cell.
48. The principal officer (PO) arrived and assisted PEO3 with CPR. Three
nurses arrived around 7.35pm. Nurse1 saw the PO and PEO3
performing CPR and took over with Nurse2. Nurse2 asked PEO3 how
long he had been doing CPR, and he replied approximately five
minutes. Nurse3 saw Nurse2 apply the oxygen mask and airway. The
duty SO responded to the emergency call and arrived with the Duty
Governor. The three nurses were in the cell. An ambulance was called
around 7.31pm. The PEO3 re-entered the cell to take over chest
compressions from Nurse2 until the paramedics arrived in the cell at
around 8.00pm and pronounced the man dead.
49. The duty SO spoke to prisoner B, who was distressed, and the
prisoner then spoke to a Listener. The cell was sealed following the
arrival of the police and the removal of the man’s body at around
8.37pm.
ISSUES
Family concerns
50. The man’s sister was concerned about the contact from the prison after
her brother’s death, and was very upset by the way in which her family
were notified. She told my family liaison officer that a police officer was
sent to her home to break the news on 19 September at around
9:30am. However, she was at work so, unable to inform her in person,
the officer contacted her elderly parents in their home country. The
sister had by this time sought permission to leave work early. On
arriving home she was presented with a number for the police officer
who had seen her younger sister. However, she explained that despite
numerous attempts she was unable to contact him. By this time, her
family abroad had contacted her and confirmed her brother had died.
She said she then telephoned the prison but they would not give her
any information and were insistent that she speak with the police.
51. The man’s sister said that she did not receive any further contact on 18
September or the next day, from either the police or the prison. She
said she has since found out that the police initially called at her home
at midnight on Monday 18 September to notify her. However, when no
one answered, they left. She said that on 20 September an article
appeared in the local paper about her brother’s death which reported
that he had died on 19 September, not 18 September. She said she
contacted the paper that day to ask for information.
52. The sister told my family liaison officer that she spoke to the Deputy
Governor and family liaison officer at Bullingdon, on 21 September and
was anxious to establish the circumstances surrounding her brother’s
death. She said he confirmed that her brother had died on Monday 18
June. However she did not feel she was given even basic information.
The sister felt generally that all subsequent contact with the prison was
largely initiated by her. She said the prison was not forthcoming either
in providing information or in making arrangements such as for her to
view her brother’s body or see his cell. Finally, she said she was not
invited to meet the governing Governor of Bullingdon, and was upset
that no member of the Prison Service visited her at home.
53. Prison Service Order (PSO) 2710 provides guidance on liaison with
bereaved families. The guidance provides a recommended option for
delivering the news of a prisoner’s death and explores the issues to be
considered when taking the decision on how to do this (paragraphs 4.7
to 4.14). The PSO recommends that the news is broken to a family as
soon as possible after the death, face to face, by a dedicated Family
Liaison Officer along with the Chaplain, Governor or most senior
individual available. The PSO indicates that asking the police to break
the news of a death is, generally speaking, poor practice although it
does explain that in certain circumstances this may be necessary. In
deciding whether the police should be asked to break the news of a
prisoner’s death, the PSO encourages Governors to consider the
following (paragraph 4.12):
(cid:127) The prison should demonstrate its duty of care and show that it
is taking the death seriously by making a personal visit.
(cid:127) Failure to make a personal visit can sour the prison’s entire
future relationship with the family.
(cid:127) Families who have experienced deaths in custody say they
prefer a personal visit and regard anything less as a shirking of
responsibility.
(cid:127) The police officer deployed to speak to the family may not be
trained in breaking bad news or know anything about prisons.
Many police forces have dedicated trained family liaison officers
but it is likely that an untrained local police constable will be
tasked with visiting the family, especially at night.
(cid:127) The police officer will have limited information about the incident and it
is frustrating for families not to have access to all the information they
want.
54. The duty governor at the time of the man’s death said she was told by
the officer in charge of the police investigation not to speak to the
man’s family until the police had done so. The police told the prison
they would contact them when they had spoken to the man’s family.
The duty governor passed that information on to Governor of
Bullingdon. The duty governor explained that the police had not
telephoned Bullingdon by the morning of 19 September, despite efforts
by the prison to contact them.
55. The duty governor said that a governor spoke with the man’s sister on
19 September after she had contacted the prison. A second governor
spoke with the man’s sister on 20 September and took a message after
which the first governor returned her telephone call. The duty governor
spoke to the sister on 21 September, again after she had contacted the
prison. The man’s sister went to Bullingdon on 26 September
accompanied by other family members. Before the family went to the
cell they visited the chapel where they prayed for the deceased. The
family then visited the man’s cell and his sister spoke to his cellmate,
prisoner A. After visiting the cell the family returned to the chapel.
56. The prison provided financial assistance towards the funeral costs.
They contributed towards repatriating the man’s body to his home
country and towards a plane ticket for one family member. They also
contributed towards the cost of the wake.
57. There is some inconsistency in the accounts given of contact between
the man’s family and the prison which I simply report. Clearly the
man’s sister has found her contact with the prison frustrating, and I do
feel the prison could have been more proactive in their contact with the
family. In any event, I am firmly of the view that the police should only
be asked to break the news of the death, without prison staff in
attendance, when distance and the time of night make this truly
necessary. In addition to assessing the practical difficulties of asking
staff from another prison to deliver the news of a death, the decision
over whether to ask police to break the news of the death should take
into account the way this may be perceived by the family. (This is a
point made in the PSO and perhaps borne out by what I have recorded
here.) While I do not make a formal recommendation, the Governor
should ensure that the guidance on liaison with bereaved families in
PSO 2710 is followed in all cases.
58. The man’s sister asked what had been done to risk assess her
brother’s cell. She also believed her brother’s work applications had
been refused and she questioned why prison officers would not provide
him with reasons for this.
59. My investigators found that the man was appropriately placed overnight
in a ligature free cell when he first arrived at Bullingdon. There was no
subsequent indication that he was at special risk by being located in an
ordinary cell. An appropriate cell share risk assessment was
completed and the man was then properly located in a shared cell on E
wing.
60. The man completed an Industrial Cleaning course between December
2005 and April 2006. Work activity for this takes place in the visits hall
during the morning. As a remand prisoner after completion of the
industrial cleaning course he would only be required to work if he
completed an application for employment. My investigator has not
been able to discover why he stopped working. The prison does not
have any information either on his apparent outstanding work
application as they only keep records of work applications for six
months.
61. The personal officer entry in the man’s core record on 21 May clearly
says that he had started to let him help out wing cleaners. The officer
said in interview, “I tried to get him out of his cell to make him feel
worthwhile by encouraging him to do the cleaning. After his training to
become an industrial cleaner I let him help cleaning on the wing,
needed to get him security cleared for him to be further employed.
There are 8 or 9 cleaners on the wing. I am not sure how far he got
with the security clearance. He would have put an application in to do
the job. In the meantime I always encouraged him to help with the
cleaning on the wing.”
62. The man’s sister felt her brother was sometimes singled out at the
prison. She questioned why he was always strip searched before
prison visits. The sister asked whether it was usual for prison officers
to know about prisoners’ medical conditions. I have found no evidence
that the man was singled out at the prison or that he was strip
searched before prison visits. This would have been recorded in
security records and in the man’s core record. There is no evidence
either that prison officers were aware of any medical conditions that the
man had or that the confidentiality of his medical record was breached.
63. On the day of her brother’s death, the sister understood that he had
been banging on his cell wall, calling out for prisoner B who was in the
cell next to him. She believes prison officers spoke with prisoner B.
However, she questioned why they did not talk to her brother directly
about the incident. Prisoner B explained in interview that prisoners
often bang on their cell walls usually to alert each other about an
interesting programme on television. There is no evidence that prison
officers spoke to prisoner B about this before the man’s death.
64. The man’s sister mentioned that her brother had not gone out for
association for two weeks prior to his death and questioned why this
was not picked up by staff. Again, I have found no evidence to
substantiate that the man had not gone out for association for two
weeks before his death. Certainly, there is nothing noted in his core
record to that effect.
65. The sister asked whether it was normal practice for prisoners on
remand to share cells with those already sentenced. If a prisoner on
remand shares a cell with a sentenced prisoner the remand prisoner
has to sign a disclaimer form. In this case the man shared a cell with
prisoner A, a sentenced prisoner, between April and September 2006.
There is no evidence that the man signed a disclaimer form. I draw
this to the Governor’s attention.
66. The man’s solicitor told my investigators about the meeting he had with
the man on 18 September. He recalled that the man was upset that he
was no longer allowed to see his son. The solicitor said he explained
to him that legal aid could be obtained for a solicitor specialising in
family law, and the focus of the meeting was on his impending trial.
The solicitor said the visit lasted for approximately 90 minutes. Ten
minutes were spent talking about access to the man’s son, the rest of
the time being devoted to discussing the trial. He did not have any
concerns about the man’s state of mind when the legal visit concluded.
Clinical review
67. On 25 September 2006, my investigator asked North Oxfordshire
Primary Care Trust to conduct a clinical review of the man’s treatment
in custody.
68. In his review, the clinical reviewer says, ‘full and appropriate
resuscitation was implemented. Whilst the risk of serious infection
being transmitted by mouth-to-mouth resuscitation is low, it would have
been prudent for all attending staff to have had a resuscitation mask
immediately available.’
69. Prison Service Order (PSO) 3845, Blood Borne and Related
Communicable Diseases, Chapter 2 section 6 ‘Resuscitation’ states:
‘Existing standards of good practice are designed to protect both the
giver and receiver of resuscitation. It would be unethical to refuse
resuscitation to anyone on the grounds that they may be infected with
HIV, hepatitis B or C, or tuberculosis, and the best precaution against
infection is to follow procedures correctly. Prison healthcare staff must
be trained in the use of resuscitation aids for use in mouth to mouth
resuscitation, as must any staff who carry them. Brookes airways or
similar resuscitation aids are included in first aid packs widely available
in all establishments, but must only be used by those trained to do so.’
70. In this case, staff who were immediately involved did not have barrier
masks. As staff may be called on to perform mouth to mouth
resuscitation, they must have immediate access to barrier masks. This
is to reduce the chance of transmission of infectious disease from the
victim to the person attempting resuscitation. There are a number of
small systems that are available that could be carried unobtrusively on
officers’ belts. I believe masks are not issued to all staff.
The Governor should ensure that staff who may be called on to
perform mouth to mouth resuscitation have immediate access to
barrier masks.
71. The clinical review considered whether an ACCT should have been
opened on 16 May following the concerns raised by the man’s
solicitors. I agree with the conclusion reached by the clinical reviewer:
‘The documented response to concerns raised by the deceased’s
solicitors is brief, and no new ACCT plan was instituted then. The tone
of the solicitor’s letter is sufficiently strong that a Medical/Psychiatric
assessment might have been felt to be appropriate. It seems however
that the conversation that took place as soon as possible between the
PO and the deceased was reassuring, and indeed no untoward
incident followed at that time to suggest there had been an error in
judgement in not requesting a further opinion.’
72. I have reflected on whether it was correct for the officers who
discovered the man hanging to continue to lock prisoners up rather
than immediately entering the cell. Bullingdon’s Contingency plan for
dealing with a death in custody instructs the first person on the scene:
‘You may enter a cell alone, your priority is to preserve life. However,
you need to balance this against any security or safety concerns.’ I
suggest that consideration should have been given to one of the
officers locking up the remaining prisoners while the other attended to
the man. However, I appreciate that the officers had to make an
instant assessment of a very difficult situation. They decided that the
appropriate course of action was to finish locking up the remaining
prisoners. I feel this was a not unreasonable course of action in the
circumstances described.
Conclusion
73. In retrospect, it may now seem apparent that the man was in distress
over the long period he had spent on remand and the pressure of his
impending trial. However, neither staff nor prisoners believed he was
at special risk. In the circumstances, I do not believe that his actions
could have been predicted.
RECOMMENDATION
The Governor should ensure that staff who may be called on to
perform mouth to mouth resuscitation have immediate access to
barrier masks.
The Prison Service response to the recommendation:
‘Barrier masks are available for staff to carry if they wish. There are
grab boxes on each residential unit held in the unit office to be used in
such instances which contain a barrier mask. In light of this
recommendation the Governor will review the system and reinforce the
availability of resuscitation.’