Individual at Isle of Wight

Investigation into the circumstances surrounding the
death of the man at HMP Albany
in October 2008
Report by the Prisons and Probation Ombudsman for
England and Wales
August 2009
This is the report of an investigation into the death of a man. He was found
hanging in his cell at HMP Albany on 27 October 2008 and was pronounced
dead by the prison doctor shortly afterwards. He had been in custody for six
months.
I would like to offer my personal condolences to the man’s family, friends and
everyone affected by his death.
The investigation was undertaken by my colleague. In addition, a doctor was
appointed by the Primary Care Trust to undertake a review of the man’s
clinical care, and I am grateful for his contribution to my investigation. I must
also thank the Governor of Albany and his staff for their participation.
Having received a 15 year sentence for sexual offences, the man transferred
from HMP Winchester to Albany to commence a Sex Offender Treatment
Programme (SOTP). He was described by staff as a quiet individual who
gave them no concern. However, in August 2008 a fellow prisoner became
anxious about the possibility of the man harming himself and alerted prison
staff. Yet when staff spoke to him, he denied having any thoughts of self-
harm. He was reminded that support was available from staff and Listeners
should he ever wish to talk. He was also provided with an appointment slip to
complete to see the prison doctor as he said he was not sleeping well. After
this, he raised no issues or concerns, and staff did not detect any signs that
he intended to harm himself.
On the evening of 26 October 2008, there were no problems noted about the
man when he was checked upon during the evening roll check. The next
morning, he was discovered hanging by a member of staff conducting the
subsequent roll check. Letters were found in his cell, the content of which
clearly indicates his intention to take his own life.
My report includes four recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2009
CONTENTS
Summary 4
The Investigation Process 5
HMP Albany 6
Key Findings 9
Issues 16
Recommendations 20
SUMMARY
The man was arrested in March 2008 for serious sexual offences. Two days
later, he appeared at the Magistrates Court and was remanded into custody
and transferred to HMP Bullingdon. In April, after pleading guilty, he was
convicted. He was transferred to HMP Winchester before later being
sentenced to 15 years imprisonment. The court recommended that he
undergo a Sex Offender Treatment Programme (SOTP) whilst in custody.
The man was then transferred to HMP Albany on 28 July, as a space on the
SOTP had become available. From the time of his arrival in Albany he was
described by staff as a quiet individual who gave them no concern. He
completed his prison induction without any problems.
During August 2008, the man had a number of conversations with a fellow
prisoner in which he talked about harming himself. The prisoner became
concerned and told staff that he was worried about him. However, when staff
spoke to the man about his well-being, he said that he had no problems
except that he had not been sleeping properly. Staff reminded him of the
support networks available to him, and gave him an appointment application
so that he could ask to see the doctor. He gave no indication of wanting to
harm himself.
The man was seen by the prison doctor approximately three weeks after he
submitted his appointment request. During this time, no concerns had been
raised about him by wing staff. The doctor prescribed medication for his
sleeping problem and for back pain, but raised no concerns about his mental
state.
On the morning of 27 October, the man failed to respond to the officer
conducting the morning roll check. Staff entered his cell to discover him
sitting by the window with the curtain covering the top half of his body. When
the curtain was pulled back, he was found hanging from the window. He was
lowered to the floor where staff examined him but found no signs of life. As
his body was cold and rigor mortis was present, they rightly decided that
cardio pulmonary resuscitation (CPR) would not be attempted.
This report includes four recommendations.
THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened by one of my
investigators, on 29 October 2008 when he visited Albany. He met the
Governor and some of his staff. Notices of the investigation and terms of
reference had already been sent to the prison, and these invited anyone
with any information to contact my investigator. As a result, my
investigator interviewed one prisoner.
2. My investigator also met the Head of Healthcare and representatives of
the Prison Officers’ Association. He visited all parts of the prison
including the wing where the man had lived, and met the Chair of the
prison’s Independent Monitoring Board.
3. The man’s prison records, including his medical record, were made
available to my investigator during his initial visit to the prison. A full set
of documents were given to him, already clearly ordered and filed in a
ring binder, which he found extremely helpful. Additional documents
were made available when he returned to conduct interviews.
4. A clinical review was commissioned from the local Primary Care Trust
(PCT) to assess the man’s medical care. I am grateful to their consultant
for his review.
5. One of my family liaison officers (FLOs) made contact with the man’s ex-
wife, informing her of the investigation. His brother and his wife also
took an active role in dealing with the prison in the immediate aftermath
of the man’s death. They were out of the country for much of the
investigation but will be given an opportunity to comment on the draft
report. The man’s family provided my FLO with some further insight into
how he felt whilst in prison:
(cid:127) The family described the man as a very sociable, gregarious man
who was extremely popular in his local community before going into
prison. They believe he realised that he could never really return,
and this would have weighed heavily on his mind. He had begun to
feel the burden of his offending and was thinking rationally about a
bleak future.
(cid:127) Compared to previous prisons the man had been in, the family
believed that he had completely changed when he moved to
Albany. They had visited him on at least three occasions and said
he had settled well and was in a more relaxed and constructive
environment.
(cid:127) The man had spoken to family members by telephone a few days
before he died but gave no indication of wanting to harm himself.
(cid:127) The family felt the man chose to take his life in a planned and
deliberate way. He left letters in his cell for his son, his brother and
his girlfriend in which they felt he clearly said goodbye. They
wished to know how he had learnt how to take his life in the manner
that he did.
HMP ALBANY
6. Albany is a category B training prison situated near Newport on the Isle
of Wight. It opened in 1967 on the site of a former military barracks.
Albany offers a varied regime with education and several offending
behaviour programmes.
7. At the time of the man’s arrival, the prison could hold up to 567 adult
male prisoners. The average age of Albany’s population is high when
compared to most jails.
8. There are five wings (A – E) which are almost identical. Each wing holds
between 94 and 96 prisoners in single cells with in-cell power and
access to electronic night sanitation (the cell door unlocks for a limited
time to allow the prisoner to go to the toilet). There are three small
‘spurs' on each landing, with communal recesses containing showers,
toilets and wash basins. There are also two 40 bed units (F and G)
which comprise single cell accommodation with en-suite facilities.
9. Health services at Albany and at the other two prisons on the Isle of
Wight are commissioned by the local NHS Primary Care Trust. The
prison’s healthcare is clustered with Camp Hill and provided by
Parkhurst. In total, Parkhurst provides healthcare to 1,500 or so
prisoners on the island. Prisoners’ daily medical needs at Albany are
met by way of out-patient clinics and core day primary nursing cover.
There are three nurses on duty from 7:30am to 5.30pm during the week.
At weekends and during evenings, one member of healthcare staff is on
duty. GPs from Medina Healthcare, a local community practice, attend
Albany for three-hour sessions four times each week. Evenings and
weekends are covered by on-call GPs from the local PCT. There is no
nursing or healthcare cover based at Albany during the night.
10. Since April 2004, when my office became responsible for investigating all
deaths in prison custody, there had been no previous self inflicted deaths
at Albany.
11. From 1 April 2009, the Prison Service officially launched HMP Isle of
Wight, clustering Albany, Camp Hill, and Parkhurst. The amalgamated
prison holds approximately 1,700 prisoners on the three sites with a
central administration.
HM Chief Inspector of Prisons’s report
12. The most recent report on Albany by HM Chief Inspector of Prisons
followed a full announced inspection in November 2007. The Chief
Inspector noted that public protection and the range of activities provided
were good. Offending programmes were also of a very high standard.
However, the Chief Inspector noted that relationships between staff and
prisoners were distant and mistrustful. There were insufficient work
places, and systems to protect prisoners against bullying and self-harm
were not sufficiently robust.
Independent Monitoring Board (IMB) report
13. IMB members are lay people appointed to each prison by the Secretary
of State for Justice to monitor the treatment of prisoners. They are not
members of the Prison Service, nor are they part of the prison’s
management team. They are required to report annually to the
Secretary of State, highlighting good practice and any areas of concern.
14. The IMB report for HMP Albany for the period 2007-08 said that existing
healthcare services within the prison were stretched to capacity, largely
due to the age of the prison’s population. This could at times lead to
missed hospital appointments, and delays in issuing medication from the
pharmacy in Parkhurst. The report said that Albany had a very pro-
active Safer Custody and Suicide Awareness policy in place with strong
prisoner involvement.
Assessment, Care in Custody and Teamwork (ACCT)
15. As at all prisons, ACCT has been introduced at Albany to monitor and support
prisoners assessed as being at risk of suicide or self harm. (The previous
system was known as the F2052SH procedure.) Once placed on ACCT, the
prisoner is observed at pre-determined intervals according to the perceived
level of risk. At ACCT plan review meetings, a prisoner’s level of risk can be
reviewed and noted as either ‘Low, Raised or High’ depending on the level of
concern.
Cell Sharing Risk Assessment (CSRA)
16. In order to make sure that unsuitable prisoners do not share cells (for example,
locating a racist prisoner together with one from a visible ethnic minority, or a
mentally disturbed prisoner with a violent one), a cell sharing risk assessment
form is completed by reception when a prisoner is first admitted.
Induction
17. Induction is the process of introducing new prisoners or newly sentenced
prisoners into custody. It is designed to explain the immediate consequences
of being in custody. Staff will also explain the routines and procedures of the
prison, and any rules and regulations that must be observed. The induction
period includes sessions with various agencies such as Mental Health In-
Reach Team, the chaplain, probation and CARATS. Staff check that prisoners
understand what is going to happen to them and attempt to deal with any
immediate problems.
Listeners
18. Listeners are prisoners trained by the Samaritans to provide a listening ear for
their peers. Like Samaritans, they do not offer counselling but are there to offer
support particularly for prisoners at risk of self harm. The service is
confidential.
National Offender Management Information System (C-NOMIS)
19. This is a national computer database introduced in prisons to improve data
holding, and sharing of information. The first release (and pilot) of C-Nomis
took place at HMP Albany.
Personal officer
20. Although the personal officer scheme in operation at Albany is not
mandatory, every prisoner is normally assigned a personal officer. Their
role is to meet the prisoner on a regular basis and to discuss any issues
or concerns the prisoner may have.
KEY FINDINGS
Prior to the man’s arrival at HMP Albany
21. Following the man’s arrest on 26 March 2008, he was held in police
custody for two days when he appeared at the Magistrates Court,
charged with serious sexual offences. He was remanded into custody
and transferred to HMP Bullingdon, arriving there at 5.41pm. He
received a full prison induction and was assessed by prison and
healthcare staff. A cell sharing risk assessment (CSRA) was completed
and he was assessed as a “low” risk. (He remained a “low” risk
throughout his imprisonment.)
22. The man remained at Bullingdon for ten days. No concerns were raised
about his well-being during his time there.
23. On 7 April, the man was convicted after entering a guilty plea. He was
transferred to HMP Winchester to await sentencing. When he arrived at
Winchester, he repeated the prison reception process. Due to the nature
of his offences, he requested vulnerable prisoner (VP) status and was
duly located to the VP wing. He received his induction into the prison
regime and procedures and appeared to settle into prison life.
Comments in his wing history sheet ranged from “a quiet individual who
is polite, no concerns with this prisoner” to “prisoner has no issues to
raise, stated fine no problems”.
24. At the Crown Court on 19 May, the man was sentenced to 15 years
imprisonment. The court also recommended that, while in custody, he
should undergo a Sex Offender Treatment Programme (SOTP). He was
transferred from Winchester to HMP Albany on 28 July as a space had
become available for him on the SOTP.
The man’s arrival at HMP Albany
25. The man arrived at Albany around 2.41pm. When he was handed over
by the escort staff to Albany reception, no concerns were raised about
his well-being. He went through the reception process again and was
seen by reception officers who explained Albany’s procedures and rules.
A senior officer (SO) was on duty the day that the man arrived. He told
my investigator that he would interview all prisoners for approximately 25
minutes when they first arrived to obtain their details and confirm their
well-being. The man denied that he had any history of harming himself
and, in response to a standard question, said that he had no thought of
harming himself. The reception SO assessed him as a low risk prisoner
and his cell sharing risk assessment document was noted accordingly.
26. Later that day, the man was also assessed by a healthcare officer. His
blood pressure and weight details were checked and the man said that
he was moderate smoker. On the ‘Physical activity readiness
questionnaire’, he said he suffered from slight back pain. No other
concerns were noted by reception staff. He was located onto A wing, to
receive his prison induction.
27. At interview with my investigators, an officer confirmed that he worked on
A wing when the man arrived at Albany. The A wing officer described
him as “very quiet, kept himself to himself and was polite”. He gave staff
no cause for concern.
28. A fellow prisoner told my investigator he had several conversations with
the man as their cells were close together on the same spur on A wing.
The man often ate his meals in his cell with him. He described him as a
quiet man, but one who had talked about killing himself - specifically by
hanging. At first, the fellow prisoner had no great concern about him,
saying that many prisoners would talk about such things but not actually
carry out the act. However, as the man spoke more about harming
himself, the detail of how he would do it became more specific. As a
consequence, the prisoners concerns for the man’s well-being
increased, and on 20 August he reported them to the man’s personal
officer.
29. The same day, at the request of the personal officer, the prisoner’s
concerns were followed up by another senior officer (SO) accompanied
by an officer. The SO told my investigator that his conversation with the
man was quite in-depth, and he reminded him of the support of staff and
the Listeners. The man explained that he had good and bad days, and
was not sleeping very well. However, he said that he was okay: he had
a son and partner and was looking forward to them visiting him in prison.
30. The SO said that he “felt confident” having spoken to the man that there
was no need to open an ACCT document. He did, however, provide him
with a healthcare application form to complete to see the doctor
regarding his sleeping problem.
31. The prisoner told my investigators that the man knew what to say to the
officers to allay any concerns they might have had about him. He said
the man felt as if there was nothing left for him, and had said he was
having sleeping problems and “could not cope”. The prisoner told him to
see the prison doctor.
32. According to the medical appointments database records, the following
day (21 August) the man submitted his healthcare application form to the
healthcare department to request a doctor’s appointment. In general, if a
prisoner says their need is urgent or important, they are seen quickly.
Otherwise, appointments are treated as routine, with a delay at the time
of approximately three weeks.
33. On 12 September, the man attended a doctor’s appointment. He was
examined by the primary care consultant, who was a locum doctor who
did not permanently work at the prison. His assessment of the man was
recorded on the computerised medical record system (known as
VISION).
34. In a statement provided as part of the clinical review for this
investigation, the primary care consultant said that he examined the man
in an out-patient clinic at the prison. He told him that he had a history of
back pain. He also complained of not sleeping properly (insomnia)
because of issues with his partner, although when asked he gave no
further information. The doctor prescribed zoplicone (commonly used for
insomnia) and ibuprofen and anusol cream. The primary care consultant
said that the man maintained good a rapport during the consultation and
he had no cause for concern about his mental state.
35. The man was moved to B wing (B3 -13), a normal residential wing, on 20
September. A B wing officer told my investigator that he was the wing
officer in charge of movements and, if a prisoner had a problem, he was
often their first point of call. When the man arrived on the wing, he
welcomed him and went through the wing induction procedures. The B
wing officer described him as a mature man who was compliant, polite
and respectful. He never approached the B wing officer to raise any
concerns.
36. According to C-NOMIS, the man was allocated an SO as his personal
officer when he was transferred to B wing. The B wing SO said he was
unaware of this as it was not brought to his attention. He also said that
senior officers were not allocated personal officer duties so he was
unsure why his name was entered on the computer system.
37. The B wing officer told my investigator that the system on B wing for
allocating personal officers used to be based on cell numbers, so each
officer knew they were the personal officers for specific cells. However,
the system was being revised at the time of the man’s arrival and was in
some confusion. Personal officers were allocated to prisoners and not
cells, so wherever they moved the personal officer stayed the same.
Although the prison has now reverted back to the old system (so
personal officers are allocated by cell number), at the time he was not
allocated a personal officer.
38. My investigator found very few entries on the man’s computer wing
history sheet (C-NOMIS) referring to his well-being. The B wing officer
said the man worked in the woodwork workshop in the mornings and
afternoons every week day. No concerns had been raised by staff in the
workshop.
39. Prison records made available to my investigator show that the man
made a telephone call to a friend on 24 October, and then to his sister-
in-law on 25 October. He did not suggest in either call that he intended
to harm himself. In fact, as his telephone conversation with his sister-in-
law came to a close, he told her he would ring in a week’s time. (The
content of these telephone calls only became known to the Prison
Service after the man’s death.)
Events on 26 - 27 October
40. Another prisoner provided my investigator with a statement about a
conversation he had with the man on Sunday evening (26 October). He
said that the man approached him around 3.00pm in the communal area
of their wing. They chatted for while and he asked the other prisoner if
he had any puzzles. Although he did not have any, they continued to
talk for a few minutes before he returned to his cell. The other prisoner
said that the man was “quiet and did not seem distressed in any way”.
41. Later that evening, an operational support grade (OSG) arrived to
commence his night duty shift. At interview with my investigator, he
explained that staff would rotate approximately every eight weeks onto a
different wing. On this particular set of nights, he was on B wing and
started his night duty shortly before 8.00pm.
42. The OSG said that, after collecting his radio and receiving a handover
from the day staff, he commenced his roll check of B wing (all single
occupancy cells). He said he did this by “rattling the door” to get a
response. The OSG explained that 90 per cent of the time the prisoner
would respond, and he always also checked the cell by looking through
the cell observation flap. However, he said that the man was the kind of
prisoner who did not respond. He would just turn his head and look at
the officer conducting the check to acknowledge him.
43. The OSG said this was exactly what the man did on this night. He was
in his cell standing up watching television. When the cell flap opened, he
turned his head, glanced at him, and then turned his head back to the
television. The OSG said he had no concerns about him at the time.
44. The following morning, the OSG began the morning roll check at around
5.30am. He started by checking prisoners on the fourth landing and
made his way to the third and second until he arrived at his cell at
around 5.40am.
45. The OSG said that, given the time of morning that the roll check takes
place, staff generally try not to make too much noise. As he looked
through the spy observation hole of the man’s cell, he noticed a curtain
or sheet hanging down from the window. He also thought he could see
him sitting behind the curtain with his face obscured. The OSG
immediately turned on the cell light and looked through the observation
panel of the cell door to gain a better view. He saw that the man’s feet
were on the floor, the bottom part of his chest was showing and his left
arm appeared to be inside his tee shirt. He called his name, flicked the
cell light on and off and rattled the door to get a response. He did not
respond. Wanting to be discreet, the OSG then proceeded to the wing
office (which was only seconds away) to telephone the Control Room to
tell the SO in charge of the prison, what he had seen.
46. The SO in charge of the prison told my investigators that no concerns
had been raised during the night shift and he visited A wing at around
10.00pm as part of his routine check. When he was contacted by the
Control Room in the morning, he was at the furthest point in the prison
away from B wing. He asked what type of incident had occurred. After
being told that it was an emergency, he asked the Control Room to send
two officers to B wing immediately, and said that he would follow as soon
as possible.
47. At interview with my investigator, the duty governor confirmed that
Albany did not use any specific codes in emergencies. He explained
that it could be difficult to use an open communication device like a radio
without giving too much information to any nearby prisoners. If an alarm
needed to be raised, the expectation was that an officer would use the
office telephone to contact the Communications Unit if they were in an
area with other prisoners. Otherwise, staff would use their radios.
48. The A wing officer told my investigator that he begun his night duty
around at 8.30pm. The following morning (Monday 27 October), the A
wing officer commenced his roll check at around 5.30am. Soon
afterwards, he heard the Control Room relay information regarding an
unresponsive prisoner on B wing. After a couple of minutes, the A wing
officer received a call for him to attend B wing, which he did immediately.
He was aware that it might have been necessary because, if a prisoner
needed to be unlocked at night, three members of staff are required to
be present.
49. When the A wing officer arrived on B wing, another officer and the OSG
were outside the man’s cell. The two officers updated him on the
situation and, having looked through the cell observation panel, the A
wing officer immediately told the other officer to contact the Control
Room to unlock the cell (which was secured with a remote electronic
locking system) and call the SO in charge of the prison.
50. The officers went in the cell. The television was on and the man was
sitting by the window. The curtain was covering the top half of his body.
The A wing officer pulled the curtain back and saw the man hanging from
the window. He had ripped strips of bed sheet to use as a ligature. The
A wing officer raised the man’s body to release some of the tension on
the ligature whilst the other officer used his cut down tool to cut the
ligature. He was then put in the recovery position. The A wing officer
checked for any signs of life, but could not find a pulse. He said that the
man’s eyes were glazed, he was cold and stiff, and rigor mortis had set
in. Although not being first aid trained, the A wing officer said that he
thought the man appeared to be dead. He said that the OSG and other
officer concurred and therefore cardio pulmonary resuscitation (CPR)
was not attempted.
51. The SO in charge of the prison arrived at B wing within minutes of being
notified, and was briefed by the staff who had gone in the man’s cell.
Although he himself did not enter the cell, he looked in and, in interview,
described him as being colourless. He believed that he had been in the
same position for some time. The SO ensured that the cell was sealed
to preserve evidence and contacted the Control Room to instigate the
death in custody contingency plans. An ambulance was requested
immediately. While he awaited the arrival of the ambulance, the SO
checked on the welfare of those staff present.
52. The paramedics arrived at 5.50am and were escorted to the man’s cell.
They examined him for signs of life but found none. Although they
confirmed his death, they did not have the authority to pronounce death
and so the prison duty doctor was contacted and asked to attend the
prison. The A wing officer said the paramedics believed the man had
been dead for at least five hours.
53. Having been contacted by the Communications Room, the duty governor
arrived at the prison at 6.25am, together with the police. They were
briefed and attended the man’s cell. ‘Suicide notes’ were discovered in
the cell and handed to the police, who also interviewed the officers who
had responded to the emergency.
54. Arrangements were made to identify the man’s next of kin. Shortly
afterwards, the duty governor held a Hot Debrief meeting with all staff
who had been involved in discovering the man, and officers completed
incident statements. The Care Team were notified and offered support
to staff.
55. The prison doctor arrived soon afterwards and, following an examination,
the man’s death was pronounced at 7.17am. The doctor told the duty
governor that, given the condition of the man’s body, he had been dead
for a number of hours. At 7.37am, the duty governor spoke to all the
prisoners on B wing, offering support and reminding them of the services
of the Listeners. The Samaritans were also informed of his death.
56. The man’s next of kin was identified as his brother. After discussions
with the Governing Governor and duty governor, a principal officer and a
reverend were appointed as the family liaison officers (FLOs). They
travelled to the man’s brother’s home area, arriving at 11.30am.
Although they discovered that he was out of the country, they were able
to contact and meet with his ex-wife, his son and his sister-in-law, who
were in turn able to contact his brother. The man’s brother told his family
that he would return to the United Kingdom to deal with matters
surrounding the death. In his absence, the family were given all the
necessary information from the FLOs. This included contact details and
the offer of financial assistance with the funeral arrangements. The
FLOs offered to visit the family again when the man’s brother was
present.
57. The following day (28 October 2008), the Governing Governor sent a
letter of condolence to the man’s family. The family later asked the
revered to conduct his funeral, which was also attended by the duty
governor.
58. Some weeks after the incident, a Critical Debrief meeting was held to
discuss the man’s death. The duty governor told my investigators that it
was well attended by staff who thought it was a useful process. Prior to
this, he had also sent each member of staff involved a letter reminding
them of available support should they require it.
Post Mortem
59. The post mortem report has confirmed that the man’s death was caused
by “hanging”. He was not under the influence of any drugs or alcohol.
The report commented that there was no opportunity for active treatment
to save him as his body was cold when discovered.
60. The pathologist described the ligature found in the man’s cell as a folded
piece of green fabric, the folds held in place with multiple irregularly
spaced single threads tied with multiple turns and then knotted around
the ligature. The pathologist comments that the ligature appears to have
been fashioned with some attention and its appearance was similar to
that used by fishermen when tying nets.
61. The man’s ex-wife told my FLO that the prison had been very helpful and
supportive to the family since the man’s death and they appreciated the
support they had been given.
ISSUES RAISED IN THE INVESTIGATION
Clinical Review
62. In his report, the clinical reviewer comments that the healthcare given to
the man whilst in Albany was good and equivalent to the care he would
have received in the community. Although the clinical reviewer makes
three recommendations which will be shared with the PCT, I have not
specifically referred to them in my findings here as they do not contain
any factors relating to the man’s death.
The doctors appointment system
63. There was a period of approximately three weeks between the man
submitting an application to see a doctor and the actual appointment.
The Head of Healthcare told the clinical reviewer that, at this particular
time, there were delays in booking routine appointments. Ways of
reducing delays were being considered. Healthcare were exploring the
use of Pin Phones for patients to book their own appointments. This
would ensure confidentiality and direct access to healthcare clinics,
which could also reduce delays.
64. I do not believe that the time it took for the man to be seen by the doctor
was relevant to his decision to take his own life. When he did see the
doctor, he did not express any concerns about his mental health. The
man was aware of the support networks available to him and raised no
concerns with staff about his feelings.
65. I am pleased that the Healthcare Department are taking steps to improve
prisoner access to the doctors’ surgery, as it is important that even
routine appointments are dealt with as quickly as possible.
Personal officer scheme
66. The man was not assigned a personal officer. This reduced the
opportunity for staff to interact with him and be alert to any concerns or
thoughts of harming himself that he might have had. It also meant that
no regular comments about his well-being were noted in his prison
records. The personal officer scheme, although not mandatory, is a
fundamental part of caring for prisoners, and every training prison should
be able to provide properly functioning arrangements.
The Governor should ensure that the Personal Officer Scheme is
operational throughout the prison.
C-Nomis
67. Albany had been a pilot site for C-Nomis for approximately 12 months
when the man died. It appears that the transition from recording
observations on paper to computer was difficult for some staff to
manage. My investigator found that his wing history sheet contained
very little information. It is very difficult therefore for anyone now to gain
a true picture of the man and how he was, or was not, conforming to life
in prison.
68. The B wing officer told my investigator that staff found C-Nomis time
consuming, and described the initial training as inadequate. The B wing
SO concurred with this view, and felt that the introduction of C-NOMIS
had affected the operation of the personal officer scheme.
69. C-Nomis has great potential as a tool to record information and assist in
all aspects of prisoner care. It is now in the process of being rolled out to
other prison establishments, and I am aware that the pilot programme at
Albany is regarded as having been a success. This investigation has
shown that this success was not an unbridled one, and for that reason it
would be sensible if the Governor took stock once more. My
recommendation is made with that end in mind.
The Governor should remind staff of the use and purpose of use of
C-NOMIS and where necessary provide further staff training.
Use of emergency codes
70. At the time of the man’s death, Albany did not use any specific codes in
emergencies. This contrasts with most prisons and with the experience
of this office that the use of codes can quickly relay very specific
information to the recipient and ensure a prompt and full response with
the right equipment. This can especially be useful during night state
when staffing levels are reduced. Although the use of a code in this
instance would not have saved his life, I recommend that Albany
introduces such a system into their emergency contingency plans as
soon as possible.
The Governor should review all relevant contingency plans and
consider the introduction and use of emergency codes when
alerting staff to such incidents.
Radio ear piece
71. When the man was discovered, the officer on duty raised the alarm by
returning to the wing office to use the telephone. He did this despite
having a radio, so that he could talk freely without other prisoners then
becoming aware of what was going on. I do not criticise the officer’s
actions, which only took him seconds as he was very close to the wing
office. However, it is important to reduce any delays when a possible
emergency or life threatening situation has arisen.
72. My investigator raised this issue with the Governing Governor. He told
my investigator that the prison had purchased radio ear pieces to be
used with radios so staff could discreetly pass on information about
incidents they were involved with. Ear pieces had been made available
to staff some time prior to the man’s death, and the Governing Governor
said that he would reissue a note to staff reminding them of its use. I
therefore need do no more than bring this matter to the Governor’s
attention again.
First aid training
73. The first officers to arrive at the man’s cell were confident that there were
no signs of life. He was cold and rigor mortis had set in. When the
paramedics arrived, they confirmed that he had probably been dead for
several hours. Two of the officers who attended the cell, however, were
not first aid trained. I have previously recommended in other
investigations that first aid training is provided for all staff in contact with
prisoners. I suggest that basic life support or first aid training should be
reviewed for frontline staff at Albany to ensure that they are fully up to
date with resuscitation procedures. Although sadly it would not have
made a difference in this case, I believe this to be even more important
for Albany because, during the night period, they do not have any
healthcare staff on duty within the prison.
The Governor should review the need for first aid or basic life
support training for staff on frontline duties.
CONCLUSION
74. The man had received a long prison sentence for very serious offences.
He had been in custody for just over six months when he took his own
life.
75. Whilst serving his sentence, the man was a quiet man and his
interactions with staff were low key. I understand that these
characteristics were in some contrast to how his family knew him when
he was in the community.
76. Whilst at Albany, the man expressed no concern or distress to the staff.
He did, however, confide in a fellow prisoner about possible ways he
would harm himself. The prisoner rightly drew his concerns to the
attention of staff who, in turn, responded appropriately. However, it
would appear that he was intent on concealing his feelings from staff,
and was successful in doing so.
77. I do not believe that staff at Albany could have predicted that the man
had any intention of taking his life when he did.
RECOMMENDATIONS
1. The Governor should ensure that the Personal Officer Scheme is
operational throughout the prison.
The Prison Service has accepted this recommendation.
2. The Governor should remind staff of the use and purpose of use of C-
NOMIS and where necessary provide further staff training.
The Prison Service has accepted this recommendation.
3. The Governor should review all relevant contingency plans and consider
the introduction and use of emergency codes when alerting staff to such
incidents
The Prison Service has accepted this recommendation.
4. The Governor should review the need for first aid or basic life support
training for staff on frontline duties.
The Prison Service has accepted this recommendation.