Individual at Reading

Investigation into the circumstances surrounding the
death of a young man
at HMP & YOI Reading in December 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2009
This is the report of an investigation into the circumstances of the death of a
young man who was found hanging in his cell on A wing at HMP & YOI
Reading on 19 December 2007. He had been in Reading for just two weeks.
I extend my sincere condolences to the man’s family and friends for their loss.
The investigation was carried out by my colleague. The local Primary Care
Trust carried out a review of the man’s clinical care and treatment while at
Reading.
I would like to thank the Governor of Reading, and her staff for their help.
The man was remanded into Reading in December 2007 having been charged
with a public order offence and with breaching an anti-social behaviour order
(ASBO). He hoped to obtain bail before Christmas but, to his annoyance, his
application was refused.
On 18 December, the man had three telephone conversations with his mother
and four with his girlfriend. In addition, he wrote two letters to his mother and
another to his girlfriend. Two of the letters indicate that he believed his
relationship with his girlfriend was over. Staff at Reading would not have been
aware of these conversations and letters at the time.
After his death a letter was found on his bed indicating that it was his intention
to end his life. The letter contains no explanation of the man’s reasoning.
Neither staff nor friends of his observed anything about his demeanour to cause
them to fear for his safety. The death of a young person is always especially
sad. However, I have found nothing to suggest that he should have been
identified as especially at risk relative to the other young people held at
Reading.
I have made one recommendation about provision of bedding material and one
about cell sharing risk assessments. Additional recommendations are made in
the clinical review. Other recommendations are made in an internal review
commissioned by the Specialist Services Manager for Children’s Services.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2009
CONTENTS
Summary
The investigation process
HMP & YOI Reading
Key events
Issues
Conclusion
Recommendations
SUMMARY
The man had spent time in a number of children’s homes and Young Offender
Institutions (YOIs). His disruptive behaviour at home and at school was first
recognised by outside agencies when he was nine years old. His treatment
from that time included referral to child and adolescent psychiatric services and
his clinical diagnoses included anxiety and depression.
The man had been released from YOI Feltham in November 2007. Less than a
month later he was rearrested for a public order offence and breach of an
ASBO. He was remanded into HMP & YOI Reading, arriving there on 3
December.
His brief time in Reading was largely uneventful. However, he was involved in
an incident on 15 December that resulted in him being charged under the
Prison Rules with use of abusive and insulting words. Later that day, the man
apologised to the officer involved and it seems that he did so entirely of his own
volition. At an adjudication hearing two days later, he was found guilty of the
offence.
The man had been hoping to obtain bail, but his application was refused on 17
December. In a letter to his mother, he wrote about his frustration at the
decision, particularly because it meant that he would be in prison for the
Christmas celebrations.
In the early afternoon of 18 December, the man had a total of seven telephone
conversations within a period of little more than an hour. The first three calls
were to his mother, during which he expressed great anger towards his
girlfriend (or ex-girlfriend). It seems that he blamed her either wholly or in part
for his arrest and imprisonment. All four remaining conversations were with his
girlfriend. In the first two, he was extremely angry and threatening. In the third
conversation he apologised for things he had done in the past and told his
girlfriend several times that he loved her. The conversation ended with them
agreeing to speak again the following week. The fourth conversation was brief,
his telephone credit was running out and he asked his girlfriend to pass a
message to his mother.
The man wrote three letters that afternoon. The evidence indicates that they
were written after the telephone conversations. One letter was to his mother
and it included criticism of his girlfriend. Another letter was to his girlfriend in
which he repeated his apologies for his previous behaviour. He again told his
girlfriend that he loved her while making a comment about his regret that their
relationship had ended ‘like this’. The third letter was found on top of his bed
after his death in which he indicated his intention to take his own life (although
he gave no explanation for his reasons). He was found hanged in his cell
during the early morning roll check on 19 December 2007.
Nothing occurred during the man’s time in Reading for staff to suspect that he
might have been at risk. His death came as a complete surprise both to staff
and to the two friends of his who agreed to speak with my investigator.
THE INVESTIGATION PROCESS
1. The investigation was opened on 27 December 2007 when my colleague
visited Reading and met a number of prison staff, including the Governor,
the duty governor on the day of the man’s death, and a representative
from the Prison Officers’ Association. My investigator informed the staff of
the nature and scope of the investigation. Notices were issued to staff
and prisoners notifying them of the investigation.
2. Nine members of staff and two prisoners were interviewed. No additional
prisoners came forward to give evidence directly in response to the
published notices.
3. The local Primary Care Trust agreed to carry out a review of the man’s
clinical care and treatment while at Reading.
4. One of my family liaison officers (FLO) contacted the man’s mother who
was listed as his next-of-kin. The FLO informed the man’s mother of the
scope of the investigation and gave her the opportunity to ask any
questions or to raise any concerns she wished to be considered as part of
the investigation. She and my investigator subsequently met the man’s
mother, his grandfather and his aunt. His mother said that her son had a
history of mental health and psychiatric problems and been treated for
depression from a young age. She said that his mental health problems
included Seasonal Affective Disorder (SAD). She understood that her son
had been on suicide watch at both Feltham and Huntercombe but it
seemed few of the records were transferred to Reading. She said that her
son had complained to her that the prison was cold and that his cell
window was broken, but staff refused to give him additional blankets. She
thought this would have added to any feelings of depression he might
have been suffering – as would the fact that he would be parted from his
family over Christmas. She thought it incomprehensible that her son was
not being closely monitored.
5. His mother commented that the healthcare questionnaire completed by
prisoners on arrival is an ineffective way to collect medical information,
particularly about the person’s mental health. She thought that a
telephone call to the family could have clarified a lot of matters about her
son.
6. The way in which the news was broken about the man’s death caused the
family great distress. The two police officers who visited the house did not
say why they were there and, in order to provoke a response from them,
his mother put it to them that they were there to tell her that her son had
taken his life. The family visited the prison the following day but they were
given no information about the time of death, nor about the precise
circumstances. Further contact with the prison had been primarily
instigated by the family and they were not allocated a dedicated family
liaison officer or single point of contact. The man’s mother also said that
his trainers had gone missing.
7. His mother said that she thought her son had been let down by ‘the
system’ from a young age. She felt that his psychiatric history had been
overlooked for years and there had been significant failings across a
number of key agencies in sharing this information. She also said that as
her son was still under licence (subject to a Supervision Order) when he
went to Reading, he would still have come under the care of the Youth
Offending Service and should still have been considered a youth offender.
This should have given him better rights and, perhaps, better support.
8. An internal management review was carried out to consider the delivery of
care to the man through Local Authority Children’s Services and the Youth
Justice Service (YJS). Some of the findings of that review are referred to
in this report.
9. In their response to the draft report the solicitors acting for the man’s
family made a number of comments. Some of these have resulted in
amendments to this version of the report; most notably, paragraphs 82
and 83.
HMP & YOI READING
10. HMP & YOI Reading is a small prison of Victorian design. It was built in
1844 on the site of a former jail. In 1973 Reading was designated as a
local prison and in 1992 was re-roled as a Remand Centre and Young
Offenders Institution, holding male prisoners between the ages of 18 and
21 years. Its operational capacity is around 300. The accommodation
comprises a mixture of single and double cells.
11. Reading has an average of 10 to 12 Listeners available. Listeners play an
active part in the prison reception process meeting and greeting new
arrivals. There is always a Listener1 based on the induction landing. A
direct telephone line to the Samaritans is available 24 hours a day.
12. In May 2007, Reading received an unannounced inspection from Her
Majesty’s Chief Inspector of Prisons. In the introduction to her report the
Chief Inspector wrote:
“The busy reception facility was much brighter and better decorated
than when we last visited, but the accommodation remained limited
and staff struggled to manage safely all the young men who had to be
dealt with. First night procedures were basic, while induction was
brief and needed to be improved.
“In the aftermath of three tragic deaths in 2005, much greater
attention had been paid to suicide and self-harm prevention, and a
small team of energetic and innovative staff had made significant
progress in improving procedures.
“The quality of accommodation at Reading varied … Staff-prisoner
relationships also varied, with excellent interactions on two units, but
much less interaction elsewhere in the prison. Consistency was not
assisted by the lack of a functioning personal officer scheme and little
use of the incentives and earned privileges scheme to challenge and
motivate young prisoners.
“Food was much improved and there were now two hot meals a day,
as we had previously recommended. Most other services had also
improved … Healthcare provided a reasonable service in poor
surroundings …
“Like many Victorian city centre local prisons, Reading had
insufficient education, training and work places. This left too many
young prisoners unemployed and locked in their cells for most of the
day.
1Listeners are prisoners trained by the Samaritans to provide the same confidential service
as Samaritans offer in the community.
“Staff at Reading have the difficult task of managing a challenging
and volatile population of young prisoners … some with serious
mental and behavioural problems. The prison itself is old and has
limited space, and too few resources, to provide the purposeful
activity that they need. There were pockets of excellence, but this
inspection also exposed some serious concerns about safety, which
appeared to have deteriorated since our last inspection.”
13. Later on in her report Her Majesty’s Chief Inspector of Prisons talked more
about the availability of purposeful activity. She reported on
improvements to the physical education department with a significant
increase in time available for access to physical education. The Chief
Inspector repeated her concerns about the limited places for work and
education. She reported on improved landing association since the
previous inspection while adding that the vast majority of prisoners had no
access to evening association, and that weekend association was often
cancelled.
14. In their report for the year April 2007 to March 2008, the prison’s
Independent Monitoring Board (IMB) remarked on the fact that the year
was one marked by the man’s death, the first at Reading since 2005. In
its executive summary the IMB said:
“The year has seen changes at Reading to the management structure
and staffing; to the regime; and to the expansion of resettlement
opportunities. The Governor, and her staff, have managed the
pressures to overcrowded Reading Prison extremely well.
“The Board has reported and praised many good initiative and
practices, and also commented where there might be improvements.”
15. The man’s was the fourth death at Reading since I took on the
responsibility for the investigation of all deaths in prison custody in April
2004. There appear to be no significant similarities between his
circumstances and those of the other three cases.
KEY EVENTS
16. The man had had contact with children’s services from a comparatively
young age and spent time both in children’s homes and in young offender
institutions. This included time in Feltham YOI in early 2006 when he was
subject to special monitoring under the Assessment, Care in Custody and
Teamwork (ACCT)2 process after he had threatened to kill himself. He did
not harm himself while being monitored and he later said that he only
made the threat in the hope that he would be moved to the same wing
where his younger brother was being held.
17. On 19 June 2006, the man was received into Huntercombe YOI on an 18
month detention and training order. He was discharged from
Huntercombe on 19 March 2007, having served nine months of the
sentence. For the remaining nine months of the sentence he was subject
to a supervision order. (A supervision order requires that the young
person be supervised by a youth offending team. The young person is
required to take part in activities such as reparation to the victim of the
crime and tackling offending behaviour.)
18. On 26 June 2007, the man reached the age of 18. Just before this, the
leaving care services split into what were termed a ‘16+ service’ and an
‘18+ service.’ The latter team were now responsible for his ongoing
support.
19. On 8 August, the man attended court for breaching his licence in three
respects:
(cid:127) leaving home without a secure alternative address and not
informing his supervisor where he was living,
(cid:127) failure to co-operate with his supervisor and making threats to
him,
(cid:127) failure to attend specified supervision sessions.
20. The man was taken into Feltham where he remained for three months.
He was released from Feltham in November and on that day he was seen
by his new 18+ key worker. The key worker informed him that he was still
under licence and the conditions were explained to him. After his release
from Feltham, he initially stayed at his girlfriend’s home before later
moving into his mother’s home.
21. He was arrested on 3 December for a public order offence and for breach
of an ASBO. He was remanded into custody at HMP & YOI Reading.
Upon arrival, the man was seen by a nurse for a standard first reception
health screen assessment. The nurse told my investigator that the first
reception health screen is used to explore any matters surrounding the
person’s general, mental and social health. He said that these interviews
2 ACCT is the process used for monitoring and supporting prisoners who have been
identified at possible risk of self-harm or suicide.
usually last between 10 to 20 minutes depending on the issues raised,
and also on how talkative the person happens to be. The first reception
nurse added that he tries to establish a friendly relationship with prisoners
which he finds allows him to better assess their mental health.
22. In the man’s case, he reported having previously been in Feltham and, as
the first reception nurse had previously worked there, they spoke about
that establishment. The first reception nurse said that the man was fit,
healthy and co-operative so it was a straightforward consultation.
However, the time they spent chatting about Feltham meant that the
consultation probably lasted around 15 minutes. The information he gave
included that he had not seen a doctor in the last few months, nor was he
receiving any prescribed medication. He reported having no concerns
about his physical health and the first reception nurse’s observation of his
physical appearance was that he appeared fit. The screening also
explores mental health. The man denied any mental health history,
denied ever trying to harm himself in the past, and said that he had no
present thoughts of doing so. After completing the reception process he
was allocated a cell on C wing. This was a double cell which he shared
with another prisoner.
23. Reading contacted Feltham to ask for the man’s records to be forwarded
by them. The records were subsequently examined by my investigator
and he found that they included records for his earlier time at Feltham, but
not for his final time at that establishment (from 8 August 2007 to 7
November 2007). My investigator made enquiries of both establishments
but neither was able to locate the missing records.
24. Prisoners at Reading receive a detailed follow-up assessment of their
mental state on their second day in the establishment. It was the first
reception nurse once more who saw the man for this assessment, which
uses a ‘depression scale’ to help establish the individual’s state of mind
including any thoughts of self-harm. The clinician undertaking the
assessment asks the patient a series of questions which are rated using a
scoring system. The over all assessment of the patient’s mental health is
based upon their cumulative score and not upon the answer to any single
question. The only negative answer that he gave was to say that his
appetite was not as good as it used to be. The first reception nurse told
my investigator that the man was again very co-operative and gave no
indication that he could be at risk. He was also seen by one of Reading’s
doctors that day who noted that he was displaying no signs of mental
health problems.
25. The man was moved into a new cell at some time on 4 December. The
new cell was again a double cell which he again shared with another
prisoner.
26. The prison reception process includes a cell sharing risk assessment to
determine if a prisoner poses a risk to other prisoners with whom they
might share a cell. The assessment includes the identification of racist,
homophobic or violent prisoners to ensure protection of potential victims.
In the man’s case he was initially classed as low risk for cell sharing.
However, on 5 December, a note was made on his cell sharing risk
assessment form that he had been charged with a racially motivated
offence. As a result his level of risk for cell sharing was raised to medium
and a note was made that he should be located into a single cell. It is
unclear why the information about the racial aspect of his offence was not
identified during his initial reception. Nor was he moved immediately from
his shared cell when his risk assessment was raised.
27. The prison induction process also includes provision of information about
religious services and support. The man gave his religion as Roman
Catholic. One of Reading’s chaplains has the same surname as the man.
Because of their common surname the Reverend went to see the man on
5 December to find out if they were related (they were not). The
Reverend told my investigator that the man was pleasant but did not fully
engage with him. He did not express any issues or concerns. The
Reverend told my investigator that Roman Catholic mass is held on
Saturdays with an average congregation of around 20. No record is made
of the names of those who attend mass so it is not known whether the
man attended on either 8 or 15 December. He did not speak directly to
Reading’s Roman Catholic chaplain.
28. On 7 December, the man moved from C wing, the induction wing, to A
wing, which is a residential wing. He was located into a cell on the third
landing and this time he was the sole occupant of the cell. (From this time
onwards, he did not share a cell again.)
29. The man seems to have settled into the regime on A wing. He attended
the gym and associated with other prisoners. He would have had around
five hours out of his cell each day and he had a television in his cell.
Nevertheless, he wrote to his mother on 14 December saying that he was
very bored as there was nothing to do. He also wrote that he was hoping
to obtain bail the following Monday (17 December), but if he failed he
would want a transfer to Feltham. The man also wrote that the worst
aspect of all was the prospect of being in prison for the Christmas and
New Year celebrations.
30. By 15 December, the man was occupying a cell on the second landing on
A wing. At lunchtime he came down to the first landing, went to one of the
locked cells, and began talking to one of his friends through the cell door
hatch. The first officer told my investigator that he asked the man to
return to his own landing as staff were in the midst of serving lunch. The
first officer said that he became rude and abusive but eventually began to
walk away when the first officer repeated his instruction that he should
leave the landing.
31. The second officer told my investigator that she was in the A wing landing
office when she heard a bit of a commotion. She noticed the first officer
having words with a prisoner who was talking to another prisoner through
the cell door hatch. The second officer did not recognise the prisoner so
she knew he was from a different landing. She went to assist. She told
the man to leave the landing. He responded with abuse. He began to
walk away from the cell but he continued making abusive comments so
the second officer told him that she would place him on report for his
behaviour. He was charged under Prison Rule 51, paragraph 20: “uses
threatening, abusive or insulting words or behaviour”.
32. That afternoon the second officer spoke to an officer from the second
landing to see if they had capacity to take one of the prisoners from the
first landing who had asked for a move. The second landing officer said
that they in turn had a prisoner who wanted to move to the first landing so
they agreed a swap. It was the man she had placed on report who turned
out to be the prisoner who wanted to move down to the first landing. The
second officer told my investigator that she unlocked the cell when the
man came down to the first landing and the first thing he did was
apologise for his earlier behaviour. She told my investigator that it was a
genuine apology on his part and, in their few further contacts he was
always polite and compliant with the prison regime.
33. The first officer told my investigator that he only had minimal contact with
the man after his move down to the first landing. He also described him
as being very polite after his move.
34. The man’s friend told my investigator that they knew each other from
before arriving in Reading. The friend said that on 15 December the man
came to his cell on the first landing to ask for a cigarette and they began
chatting. He heard staff telling the man to go back to his own landing.
Later that day the man moved into the cell next to his. The friend said that
the man was always laughing and joking. He mentioned that he had a
girlfriend although he did not talk about her nor did they speak about
important issues.
35. Allegations that prisoners have transgressed Prison Rules or have
behaved inappropriately are dealt with at adjudication hearings. If the
charges are proved, certain punishments can be applied. The allegation
that the man had been rude and abusive to the second officer was
considered at an adjudication hearing on 17 December. The man was
given a copy of the second officer’s report in which she set out her
account of the event and of the language that the man had used. He
declined to attend the hearing but pleaded guilty to the charge. The
charge was proved and he was punished with five days loss of access to
the prison shop and reduced time out of cell for three days. These
penalties would not commence until the following week.
36. The man’s hope that he would obtain bail on 17 December was dashed
when bail was refused. His friend told my investigator that the man was
initially angry about this outcome but he calmed down as the day wore on.
37. My investigator spoke to another prisoner who knew the man. He said
that he had not known the man previously but met him when he came to
Reading. He said that they chatted a few times, and played a few games
of pool and table tennis. This prisoner said that the man never spoke
about anything important, but he was always chirpy and never gave any
signs that he was miserable. The last time this prisoner saw him was on
17 December when he thought that the man seemed his usual self.
38. On Tuesday 18 December, the man wrote a letter to his mother indicating
his frustration that he would be in prison over Christmas. In the next
sentence he indicated that it did not matter as the next Christmas would
be ‘the big one’. He complained in the letter that Reading was the worst
prison he had been in. He complained about the quality of the food and
that the prison was very cold. He also mentioned that he had placed
money on his telephone account and he would telephone her as soon as
the account was activated.
39. The man had been booked in to visit the doctor at 1.30pm that day. The
reason for the consultation was not recorded. The man did not attend the
appointment and nothing is known about why he failed to do so. (He had
missed two previous appointments to visit a doctor. There is again
nothing recorded about his reason for missing those appointments.)
40. After his telephone credit was activated, the man made a series of seven
calls between around 2.00pm and around 3.20pm. The first three calls
were to his mother during which he expressed great anger towards his
girlfriend saying that he would assault her when he came out of prison.
The next four calls were to his girlfriend (although the evidence is that
their relationship might have ended, at least temporarily, before he arrived
in Reading). In the first two calls the man told his girlfriend that both she
and her family were going to be assaulted. About ten minutes later he
telephoned her again telling her that he was sorry and that he loved her.
At times he can be heard crying. This conversation ends with their
agreement that he would telephone her again the following week. The
final call is a very brief one. The man telephoned his girlfriend asking her
to pass a message to his mother to say that he would not be able to
telephone her until the following week as he had used up all of his
telephone credit.
41. The man wrote to his girlfriend some time that afternoon in which he
referred to having just come off the telephone to her. He apologised for
the way he had behaved towards her in the past and wrote that he was
‘sorry it had to end like this’. On the reverse of the letter he wrote a
heading that included the word exit, followed by the date 2007. The letter
appears too long for the man to have written it between his first and
second conversations with his girlfriend or between their second and third
conversations. I assume it was written after the third conversation or after
the fourth, very brief and last, conversation.
42. The man also wrote another letter to his mother that afternoon which
seems to have been written after the series of telephone calls as he
mentions having used up all his telephone credit through speaking with his
girlfriend. The man again mentions his regret at missing Christmas as he
wished to have been at home for the celebrations.
43. One of Reading’s physical education (PE) instructors told my investigator
that he had met the man two or three years previously when he was 15 or
16 years old and a prisoner in Feltham YOI. The PE Instructor said that
when he met the man again on arriving in Reading, he found that he had
matured both physically and emotionally. At Feltham, he had been
involved in a lot of incidents with staff and other offenders but whenever
he came to the gym at Reading he was well behaved and always laughing
and joking. The man told the PE Instructor that out of prison he had a job
and a girlfriend.
44. The last time that the PE Instructor saw the man was just after 5.00pm on
18 December when prisoners were collecting their evening meal. He
seemed in good spirits and was joking with other prisoners. The PE
Instructor knew that the man had been refused bail so he asked him about
that. He did not seem upset and said that he hoped to get bail after
Christmas. After he had collected his meal he would have been locked in
his cell for the remainder of the evening.
45. The man’s friend told my investigator that the man had been quiet during
the evening of 18 December. Ordinarily, he would have banged on the
wall between their cells to have a chat but he did not do so that evening.
The friend said that he was shocked that it seemed the man had taken his
life as he never showed any signs that he would do such a thing.
46. Evening staff carried out a roll count at just after 8.00pm and a further
count was carried out just after that by the on-coming night staff. The
night officer counted the prisoners on the first landing and he signed the
records to show that he had completed his count by 8.20pm. He told my
investigator that he had no recollection of seeing anything untoward when
he checked the man’s cell. Through the night the landings would have
been checked twice per hour at irregular intervals. Cell checks would also
be made through the night on individual prisoners subject to monitoring
through the ACCT process. This, of course, did not apply to this man.
47. In the early morning of 19 December, the night staff began to count the
prisoners ahead of the arrival of the day staff. It was again the night
officer who counted the prisoners on the first landing. As it is dark at that
time of the morning in the winter months, the night officer switched on the
in-cell lights so he could see the prisoners. When he reached the man’s
cell at around 5.40am he found the observation panel covered on the
inside with toilet paper.
48. The night officer shook the door and the toilet paper slipped down. He
looked into the cell and saw the man hanging from a ligature tied to the
window frame. The night officer said that it took him a few seconds to
take stock of the situation and he then called for assistance from his two
colleagues who were checking the other two landings. The night officer
also sent a radio call to the communications room. This resulted in the
Night Orderly Officer being called as well as a 999 call for an emergency
ambulance.
49. Two officers responded to the night officer’s shout for help. The night
officer’s set of keys were in a sealed pouch and he was trying to break the
seal when the assistant night orderly officer arrived with open keys and
unlocked the door. The officers went into the cell and cut the ligature with
an anti-ligature knife. One of the officers checked for a pulse and found
none. This officer told my investigator that the man’s body was cold and
blue in colour and it was obvious to him that he was dead. The assistant
night orderly officer gave similar evidence about the appearance of the
man’s body and the clear signs that he was already dead. The assistant
night orderly officer told his colleagues that attempting cardio pulmonary
resuscitation would be futile so they should leave the cell.
50. Ambulance paramedics arrived within ten minutes of being called. They
examined the man and confirmed his death.
After the man’s death
51. To help decide the arrangements for breaking the news to the man’s
family, Reading’s police liaison officer telephoned the police force local to
the family home. The police informed Reading that there were potential
concerns with the estate where the home is located and also concern
about how the man’s brother might react. The police advised that if staff
from the prison were to visit, they should be supported by police officers.
In the light of that advice, Reading’s Governor decided that it would be
better for the police to break the news alone and give contact details of
appropriate staff at the prison. The police visited the family home at just
after 11.00am and informed the man’s mother of the death of her son.
52. The man’s mother visited the prison the following day with her sister and
was able to go to her son’s cell. It was also arranged that the PE
Instructor would speak to her about how her son had been getting on in
the prison.
53. Reading instructed a funeral director to deal with the arrangements and
asked that they send their bill directly to the prison. Representatives from
the prison attended the man’s funeral.
54. A hot debrief was held on the morning of the man’s death before the night
staff went off duty. However, my investigator received mixed responses
from staff about the support offered to them. Staff said that members of
the care team were available on the morning of the death but none was
available that night when the same staff were on duty again. One officer
thought that an extra member of staff should have been on duty in case
one of the officers found it too difficult and wanted to go home.
55. The second officer was on leave for several days after the man’s death.
Upon her return she made a point of speaking to the man’s friend to check
that he was okay.
The letter found in the man’s cell
56. After his death a letter was found on the man’s bed indicating that it was
his intention to take his life, although he did not give an explanation for his
decision. A date on the letter suggests that the man’s life might have
ended on 18 December rather than on 19 December when his body was
found. All of the other letters that the man wrote on 18 December were
recovered from the landing post-box where he would have deposited them
before he was locked in his cell for the night. Neither of the letters that he
wrote to his mother contain anything to suggest that the man might have
been contemplating taking his life. However, in his letter to his girlfriend
the man included the ambiguous remark about him being ‘sorry it had to
end like this’. The second page of the letter was also headed ‘exit’ which
was followed by the year 2007.
ISSUES
The decision to allocate the man to a single cell
57. When the man arrived at Reading on 3 December it was not noticed that
there was a racial aspect to the offences with which he had been charged.
At that stage he was deemed suitable to share a cell. It is not clear why
the information about his offences was not recognised. In other cases I
have investigated there have been tragic outcomes when the cell sharing
risk assessment has failed to identify such issues. Two days later, the
information about the man’s offences was acted on and it was then
deemed that he should be allocated to a single cell (despite this, he
continued to share a cell until 7 December). However, Prison Service
Order 2750 which deals with reduction of violence in prisons advises that
a prisoner who is understood to hold racist views can be allocated to a
shared cell provided that the cell mate is from a non-targeted group.
There is no reason therefore why the man could not have shared with a
prisoner of the same ethnic origin.
58. Having said that, there was no obvious reason for there to have been any
concern with placing the man in a single cell. He was not deemed to be at
risk of self-harm, nor had he expressed a particular desire to share.
I recommend that the Governor reminds staff of the importance of
the cell sharing risk assessment both in terms of factors that mean
a prisoner should not share a cell as well as situations where they
can.
The adjudication decision
59. At an adjudication hearing on 17 December, the man was found to have
contravened paragraph 20 of Prison Service Rule 51. Specifically, two
days previously he had used abusive and insulting words towards the
second officer. The man pleaded guilty to the charge and was punished
through five days loss of access to canteen and three days loss of
association. I do not consider this to have been an unreasonable
punishment.
60. Nor is there any evidence to indicate that the man considered himself to
have been treated harshly. He made no mention of the adjudication
decision during his telephone conversations on 18 December.
Significantly, in one of his two letters to his mother written that day, he
complained about the food and that the prison was very cold. He made
no complaint, however, about the adjudication or about the staff.
The man’s complaints about HMP & YOI Reading
61. The man’s mother told my staff that her son complained to her that he was
very cold and that his cell window was broken but his request for extra
blankets had been refused. In one of the letters he wrote to his mother on
18 December he complained that he was so cold he was sleeping in his
clothes. He also complained about the food.
62. My investigator made enquiries of Reading about the provision of bedding
material. He was told that prisoners are given two sheets and one
blanket. If a prisoner complains that he is cold a check will first be made
that the cell window closes properly. Any defects with the window will be
corrected but if there are no problems with the window the prisoner will be
told to submit an application (a written request). The claim for an
additional blanket will then be considered.
63. My investigator spoke with Reading’s complaints clerk who informed him
that the man submitted no applications while in the prison. My
investigator was also told that there was no record that any of the
windows in any of the cells occupied by the man were broken.
64. I understand that at some prisons it is standard for prisoners to be issued
with two blankets during the winter months. It might well be that the
majority of prisoners at Reading find one blanket sufficient even in winter.
However, even if that is so, it is self-evident that some prisoners will feel
the cold more than others. I do not see why it should be necessary for
prisoners to have to submit a formal application in order to obtain an
additional blanket.
I recommend that the Governor should allow prisoners to obtain an
additional blanket on a simple oral request.
Letters and phone calls on 18 December
65. The man made seven telephone calls between 1.58pm and 3.18pm on the
day before his death. My investigator listened to all of these calls. The
first three calls were to his mother and, during one of them he spoke
briefly to his grandfather. He was very angry during these conversations,
appearing to blame his girlfriend for his being in prison.
66. The remaining four telephone calls were to his girlfriend. The man was
again very angry and agitated in the first two calls. However, during the
penultimate call they discussed some of the problems that had occurred in
their relationship. The man apologised for his past behaviour and told his
girlfriend that he still loved her. She did not return his expressions of love.
Even so, the conversation ended with them agreeing to speak again the
following week once he had re-credited his telephone account. Their final
conversation was very brief. The man asked his girlfriend to pass a
message to his mother. He said that he had tried to telephone her direct
but it seemed that she was not at home when he rang.
67. The man wrote two letters to his mother that day. The first was written
before any of the telephone calls as he said that he was still waiting for
credit to be put on his telephone account. He wrote of his regret about
being refused bail meaning that he would miss Christmas at home.
However, the very next sentence appears to anticipate Christmas 2008.
The second letter was clearly written after the telephone calls as the man
referred to using up his telephone credit. In the letter he indicated that his
relationship with his girlfriend was at an end.
68. The man also wrote to his girlfriend after either the third telephone
conversation or after the fourth. The evidence shows that he and his
girlfriend had a fairly volatile relationship. It seems that they had
separated and been reconciled on a number of occasions in the past. He
wrote in the letter that he was ‘sorry it had to end like this’. It could be
understood that he was referring to the end of the relationship, rather than
the end of his life. However, the letter also contains the word ‘exit’
followed by the year 2007.
69. The man wrote one further letter some time in the next few hours. This
was the one found on top of his bed the following morning in which he
indicated his intention to take his life.
Continuity of care
70. Following the man’s death, the Specialist Services Manager for Children’s
Services, commissioned a confidential internal review to consider his
involvement from 2005 with the Local Authority Children’s Services, with
the local service provider of 16+ Services and with the Youth Justice
Services (YJS). My investigator obtained a copy of this report to help him
consider the man’s mother’s belief that her son had been let down over a
number of years by a number of agencies involved in his care. The
relevant services granted me permission to summarise the main findings
of the review.
71. The review found that the level of multi-agency communication and joint
working was very variable and it was questionable whether it was
particularly effective. It was found that in the two and a half years after
June 2005 no individual professional took on the role of key worker and
there was no discussion by any agency that one was needed. The result
was that individual professionals worked within their own remit and with
limited knowledge of and concerns for the remit of others. Nor was there
any thought that other colleagues might have information that would
provide a more complete picture of the situation.
72. It was also found that the quality of assessment and planning by the 16+
Service in 2006 and 2007 was not adequate. However, the quality of
assessment and intervention by the YJS was considered to have been
sound, with the only exception being the number of different officers
involved with the man in the final two year period.
73. Neither the 16+ Service nor the new 18+ Service visited the man while he
was in Reading, but the review concluded that it would be harsh to be
critical of that fact. The 18+ Service depends on the young person
wanting support and the man had previously indicated that he could look
after himself. It was also unclear who the key contacts would be as the
YJS involvement was due to end in December 2007 at the end of the
licence period.
74. The review also found no indication in the man’s records that he would
treat this last period in custody any differently to his previous ones. Nor
was there any such indication from interviews with staff.
75. The review included three recommendations for changes to processes
and procedures. (At the time of the issue of this report the
recommendations were yet to be adopted by the relevant services.)
Main findings from clinical review
76. The main findings of the clinical review include the need to improve
management of the doctors’ clinic. This relates to the fact that the man
missed three appointments to see the doctor but nothing was recorded
about why he missed the appointments nor about the original reasons for
the consultations. The review team add that they do not believe that this
issue contributed to the man’s death.
77. The clinical review team found deficiencies and inconsistencies in record
keeping. This included the omissions set out above as well as other
deficiencies such as a failure to enter in the man’s records that he had
been dispensed a skin moisturiser and a failure to record the timing for a
consultation about a headache. Another finding linked to record keeping
was Reading’s failure to obtain the clinical records from the man’s time at
Feltham.
78. Based on their consideration of all the evidence the clinical review team
conclude that on the occasions the man presented to the healthcare team
he appeared to be coping well and no concerns were raised about his
mental health. They also note, however, that his community medical
records show that he was prone as a child and as a young man to
impulsive behaviour.
Should HMP & YOI Reading have realised that the man might have been
at risk?
79. No one who encountered the man during his brief time in Reading noticed
anything about his demeanour to suggest that he might have been at risk.
Apart from the one incident when he used abusive language towards the
second officer he otherwise seems to have complied with the prison
regime. The second officer’s evidence included that the man went out of
his way to apologise to her for his behaviour on 15 December and
thereafter he was always polite and well behaved. The first officer, who
was also involved in the incident that led to the adjudication hearing,
agreed that the man was polite thereafter. As has already been
discussed, there is no evidence to indicate that he was upset at the
punishment imposed at the hearing.
80. The physical education instructor first met the man at Feltham when he
was around 15 or 16 years of age. It would seem that he was quite
volatile at that time but the PE Instructor told my investigator that he had
matured in the two or three years since they last met. He said that the
man was always laughing and joking but was also well behaved. He
mentioned that he had a job and a girlfriend. The last time the PE
Instructor saw the man was on the afternoon of 18 December 2007. He
asked him how he was feeling about being refused bail the previous day.
The PE Instructor did not think that he seemed upset; he said he would
reapply after Christmas.
81. My investigator spoke to two prisoners who were on friendly terms with
the man. One of whom knew him from outside prison. Neither noticed
any signs that he might be at risk.
82. In response to the draft report the solicitors acting for the man’s family
raised a number of matters that they consider might have alerted staff to
the possibility that he was at risk. They consider that there is an evident
contradiction between the staff’s impression as to how he was coping and
the fact that he had a history of ADHD, OCD, anxiety and depression.
Although it is true that the man had been diagnosed with these conditions
in the past, there is no evidence that any of these conditions were active
at the time of his arrival into Reading. At that time he denied having any
physical or mental health problems and he was not in receipt of any
prescribed medication. ADHD is usually diagnosed in childhood and is a
condition that many children simply grow out of. The PE Instructor’s
evidence, as already mentioned, was that the man had matured since he
had last seen him. In addition, there are entries in his clinical records from
2006 indicating that he considered some of his past clinical diagnoses to
be behind him.
83. Another matter raised by the family’s solicitor was whether the man should
have been more closely monitored given that this was his first time in an
adult prison. There is no such provision in place. It should be borne in
mind, however, that for many of the young men in Reading at any time
this will be their first time in an adult prison. It should also be borne in
mind that although Reading is an adult prison, none of the men there are
older than 21. Thus, for this man, he was still among what could be
termed, a peer group.
The way the man’s mother was informed of her son’s death
84. Prison Service Order (PSO) 2710 provides guidance and instruction on
notification to families following a death in custody. The only mandatory
requirement is for the notification to be made as soon as possible and in a
suitable manner, giving an accurate factual account of what has
happened. In general, face to face notification by staff from the prison is
considered to be the preferred option. However, Governors are also
advised that they should be mindful of the safety of their staff so advice
should be sought from the local police force on the level of likely hostility
in the neighbourhood and at the family home. The guidance goes on to
say that, if judged necessary, the police should be asked to escort the
team or to remain nearby.
85. The guidance acknowledges that asking the police to inform the family
may sometimes be necessary, and that the police should be asked to
break the news if there is a risk to staff going into the neighbourhood or
family home. The guidance warns, however, that if the police are asked to
break the news, it should not be assumed that the officer deployed to visit
the family will have been trained to break bad news.
86. When my family liaison officer and investigator visited the man’s mother at
her home she expressed great anger about the way the news was broken
to her. She was angry that the risk assessment indicated the apparent
necessity of a police presence as it might not be safe for prison staff to
visit alone. She also said that the two police officers who visited her home
handled matters extremely poorly.
87. I can understand why the man’s mother felt affronted that the risk
assessment advised that it might not be safe for prison staff to visit the
family home. I can certainly place on record that my staff were made very
welcome when they visited the family home where they met his mother,
her sister and their father (the man’s grandfather). I also understand from
my staff that they felt no concern about the neighbourhood in general.
Having said that, Reading were adhering to protocol in contacting the
police for their advice on security issues. When the advice came back
that a police presence was advisable it would have been unreasonable to
have expected staff to visit the home unaccompanied. In my view the
most appropriate option would have been for Reading’s Governor to
arrange for her staff to make the visit with the support of the local police.
88. Once the police were tasked to make the visit the prison was no longer in
control of the situation. The man’s mother’s evidence indicates that the
police officers who visited were either untrained or unskilled in dealing
with the extremely sensitive task of delivering the news of the death of a
family member. That can only serve to intensify any family’s distress. I
am certain that Reading’s Governor will be sorry to learn of the family’s
experience. This is a matter on which she will wish to reflect to see what
lessons can be learned for any future tragedy.
Liaison between HMP & YOI Reading and the man’s family
89. The man’s mother complained that most of the contact with the prison had
to be instigated by the family and she also complained that there seemed
to be no single point of contact at the prison.
90. One of Reading’s governors, who no longer works at the prison, was the
intended family contact person for the man’s family. I do not know
whether or to what extent this arrangement broke down. Nor do I know
the reasons why it might have broken down. However, prison governors
are extremely busy people and, in a small prison such as Reading, will
have many different tasks to carry out every day. It is probably not
practical therefore to allocate family liaison work to a governor grade. I
understand from Reading that one of its officers has recently received
family liaison officer training and that she will carry out this important role
in the case of any future deaths. I am pleased to learn of this
development.
The man’s training shoes
91. At some stage after the man’s death his training shoes went missing. It is
unclear when they went missing although I presume that his body
remained fully clothed until reaching the mortuary where all clothing would
have been removed for post mortem. His body would have subsequently
been released to funeral directors, but they deny receiving the shoes. I
sympathise with his mother for the distress caused through the loss of
some of her son’s belongings. Unfortunately, I cannot say how the shoes
came to be lost.
CONCLUSION
92. Nothing occurred during the man’s brief time in Reading for staff to
suspect that he might have been at risk. He had had something of a
troubled past, but that could probably be said of most, if not all, of the
young men at Reading. Two matters that troubled him around 18
December were the prospect of being in prison over Christmas and the
seeming end of his relationship with his girlfriend. However, most of the
other prisoners still in Reading by 19 December would be there for
Christmas and I am certain that he would not have been the only one
experiencing the end of a relationship.
93. It was written of the man that he was prone to impulsive behaviour – that,
of course, might equally be said of a great number of young people who
are to be found in custody. Although he left behind a letter indicating that
he was planning to take his life, he gave no explanation why he was
intending to do so.
RECOMMENDATIONS
I make the following recommendations and I note the Prison Service’s
responses to date in italics following each recommendation. I invite the
Service to respond to the first recommendation:
1. I recommend that the Governor reminds staff of the importance of the
cell sharing risk assessment process.
2. I recommend that the Governor should allow prisoners to obtain an
additional blanket on a simple oral request.
Prison Service response: Recommendation accepted. There never has been
any local policy stating that request for a blanket has to be through a formal
written application. However, a Governors Order has been issued advising staff
that a formal written application is not required to request an additional blanket.
If a prisoner makes any such request verbal or otherwise a blanket will be
issued to the prisoner concerned. Action completed.
I also endorse the following recommendations which appear in the clinical
review:
3. A clear clinic protocol should be developed supported by the prison
governor so that prisoners are enabled to see the doctor when
requested.
Prison Service response: Recommendation accepted. Protocol now in place
and a dedicated officer is funded by the PCT to escort prisoners who need to
see the GP on a daily basis. An audit trail is in place to record the outcome.
Action completed.
4. A clear protocol for the management of prisoner requests to see the
doctor should be developed which includes how prisoners get
rescheduled for appointments if appropriate.
Prison Service response: As above.
5. Record keeping must be improved in line with Nursing and Midwifery
Council guidelines and should form part of regular supervision of staff.
Sharing best practice with Feltham is recommended.
Prison Service response: Recommendation accepted. Record keeping was
audited on 26 January 2009. PCT staff will be attending PCT record keeping
training through Feb 2009 and training will be on going for new staff. Record
keeping is discussed as part of personal development plans. A number of
protocols have been obtained from Feltham and are now in place. Target for
completion: March 2009 and ongoing.
6. All relevant communications and interventions should be written in the
relevant record/s and signed. The name should also be printed under
the signature.
Prison Service response: Recommendation accepted. As above. This will
continue to be reinforced by weekly audits by the Primary Care Lead. Target
for completion: March 2009 and ongoing.
7. Medication given to prisoners within the treatment room must include a
time on the prescription chart.
Prison Service response: Recommendation accepted. For those on regular
prescribed medication the timings are recorded as am, pm or night based on
current set treatment room times. Whilst those that report sick have date,
complaints, dosage, complaint and signature. There is no box to record time
on the national prescription chart used. However, primary care lead will direct
nurses in the treatment room to record time in the date box. Target for
completion: February 2009.
8. A records audit should be completed to establish a baseline and then
repeated in six months to measure improvement
Prison Service response: Recommendation partially accepted. Annual record
keeping audits are carried out. The last one on took place on 26 January 2009,
actions are implemented and discussed in team meetings. Target for
completion: February 2009 and ongoing.
9. We recommend that at a local level previous prison and community
healthcare records be sought. At national level we would request the
Ombudsman to alert authorities to the need to integrate community and
prison records to ensure that prisoners have the same lifelong records
as those in the community.
Prison Service response: Recommendation partially accepted. Prison records
are sought. In the man’s case they had been requested but not arrived. In
relation to health care records, locally, these are requested if a prisoner self
reports concerns or concerns are identified by health care staff as part of the
health care assessment. These include Mental Health records. In this case no
such concerns were raised. Action completed.
10. There should be urgent consideration of the early implementation of an
integrated and comprehensive IT system to replace hand written
records, similar to those systems within GP surgeries. This would
enable all healthcare information to be made available between HMP
YOI institutions.
Prison Service response: Recommendation accepted. Locally agreed and
HMP Reading identified as a pilot for the introduction of System One as part of
the existing phased introduction across establishments. National
Implementation was due in April 2009 but has been delayed until Sept 2009.
Once in place this will enable Reading to obtain information from other
establishments, but only those that take part in the national programme. Target
for completion: September 2009.