Individual at Erlestoke House

Investigation into the circumstances surrounding the
death of a man
at HMP Erlestoke in February 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2010
This report considers the circumstances of the death of a man, a prisoner at HMP
Erlestoke. The man was found hanging in his cell during a routine check at 2.12am
on 4 February 2010. Staff went into his cell and, after removing the ligature,
administered cardio pulmonary resuscitation (CPR). This continued until the arrival
of paramedics who continued the resuscitation attempts. Despite their best efforts,
the man did not regain consciousness and was pronounced dead by paramedics at
3.18am. He was 25 years old.
I would like to take this opportunity to offer my sincere condolences to the man’s
family and friends for their sad loss. The man’s family asked a lot of questions which
I attempt to address in my report.
One of my colleagues conducted the investigation on my behalf. I would like to
thank the Governor of HMP Erlestoke and his staff for their co-operation and
assistance with the investigation. A Medical Director of an NHS conducted a review
of the medical care given to the man in custody. I thank him for his report.
The man was serving an indeterminate sentence. He was clearly keen to meet the
requirements for parole and tried to pursue the relevant courses. However, it seems
that the availability and temptation of drugs got in the way of his efforts. There were
opportunities to help the man, but his denial of his problems prevented staff from
fully intervening. Nevertheless, given the information presented, I judge that a more
pro active approach could have been taken to tackle the problems on Imber Unit.
I make seven recommendations, but I also acknowledge the positive actions being
taken by the prison to improve facilities for drug treatment and in identifying the use
of illicit drugs. The recommendations relate to sharing of information, applying good
practice in the Twelve Steps, improving the anti-bullying and ACCT procedures and
taking appropriate action on security information. Following the issue of the draft
version of this report, the Prison Service said that they accepted all but one of the
recommendations. In relation to the analyses of security information and follow up
actions, they considered the systems were already appropriate. The responses to all
recommendations are recorded under the recommendations section of this final
report.
Jane Webb
Acting Prisons and Probation Ombudsman October 2010
2
CONTENTS
Summary 4
Investigation process 6
HMP Erlestoke 8
Key findings 10
Issues 40
Recommendations 51
Annexes
3
SUMMARY
The man had been in custody since December 2006. He was given an
indeterminate sentence (with no automatic date of release), and spent the first part
of his custody at HMP Lewes, before transferring to Erlestoke in August 2008. There
is information to suggest that the man began using illicit drugs at Erlestoke. It was
also reported that he had been using drugs at Lewes, although there is no evidence
to support this. The man had moved to Erlestoke to complete an Enhanced Thinking
Skills (ETS) course, but following an assessment, was considered unsuitable. The
man was disappointed as he felt that, without completing the course, he was unlikely
to be granted parole. However, staff encouraged him to enrol in the Twelve Steps
drug and alcohol programme and he subsequently moved to Imber Unit where those
taking part in the programme are located.
Despite the man’s concerns about working in a group environment, he initially
progressed well. However, he developed a friendship with another prisoner and
once again began using illicit drugs. In January 2010, during a group meeting, the
man confessed to having used heroin over the Christmas period. As a result, he
was moved back to the preparation stage of the programme. Interaction from
programme facilitators and his offender supervisor followed and he was encouraged
to re-dedicate himself to the programme. On 25 January, the programme manager
de-selected the man from the programme as she considered he was not committed
and would benefit from more one to one work. He was relocated from Imber to
Wessex Unit the same day. During the man’s stay in Imber, concerns were raised
about the possibility that he was being bullied by other prisoners in connection with
drug dealing.
Little is documented about the man’s time on Wessex Unit, but his mother did
contact the prison to express her concerns about his de-selection and the effect it
might have on him. Staff said they were unaware of any anxieties about the man
harming himself and so no special monitoring was put in place.
In the early hours of 4 February, the man was discovered hanging in his cell by an
officer conducting a routine check. Staff went into the cell, where they attempted to
resuscitate the man until the arrival of ambulance and paramedic staff. Sadly, all
their efforts failed and the man was pronounced dead by the paramedics at 3.18am.
After the man’s death, prison staff went to his mother’s home to break the news to
her. The man left a note for his family. Prisoners and staff were offered support,
and reviews were held for those subject to suicide and self-harm procedures.
I conclude that the man’s decision to take his own life was likely to have been
influenced by feelings of hopelessness about his sentence, compounded by his
continued struggle to overcome his addiction. I am satisfied that, when he was
discovered, staff took appropriate steps to resuscitate him. However, I consider
there is scope to enhance some of the procedures relating to the management of
prisoners at Erlestoke. I therefore make seven recommendations relating to anti-
bullying procedures and Assessment, Care, Custody and Teamwork (ACCT), (ACCT
documents are used to identify prisoners who may be at risk of suicide and/or self-
harm, and provide regular monitoring and interaction to assist them over their period
4
of crisis.) sharing security and other information, and following good practice on the
Twelve Steps drug and alcohol programme. (Twelve Steps is a set of guiding
principles outlining a course of action for recovery from addiction, compulsion, or
other behavioural problems.)
5
THE INVESTIGATION PROCESS
1. My colleague initially telephoned the prison on 4 February. He spoke with the
Deputy Governor to arrange for the man’s prison and medical records to be
made available. Notices informing both staff and prisoners of the
investigation were issued that day. They invited anyone who had information
about the man’s death to contact the investigator. A number of prisoners
contacted my colleague and were interviewed as part of the investigation.
2. My colleague visited Erlestoke to formally open the investigation on 9
February and met the clinical reviewer. He also viewed the documentation
and arranged to return to conduct interviews with staff.
3. My colleague visited Erlestoke again on 7, 8, 28 and 29 April. He conducted
interviews with seven members of staff who had been in regular contact with
the man or involved with him during his time at Erlestoke, and seven prisoners
who had known him.
4. The man had fairly regular contact with the healthcare department while in
custody. Wiltshire Primary Care Trust (PCT) was commissioned to conduct a
review of the medical care that he received at Erlestoke. The clinical reviewer
carried out this review. I would like to thank the reviewer for his report.
5. One of my family liaison officers contacted the man’s mother as his next of
kin. This was to explain the purpose of my investigation and to provide the
man’s family with an opportunity to ask any questions or raise any concerns
for consideration as part of my investigation. At the family’s request, my
family liaison officer and my colleague visited the man’s mother and sister at
their home on 30 March, to discuss their concerns about his time in custody
and the events leading to his death. Their concerns are listed here:
• The reasons for the man’s deselection from Twelve Steps programme.
The family were particularly concerned given close proximity of the man’s
parole hearing. They asked how the decision was communicated to the
man and what the likely impact would have been on his state of mind.
• Why did the man not attend medical appointments on Monday and
Tuesday prior to his death, and why was his non-attendance not followed
up?
• What medication had been prescribed to the man and had this been
changed or stopped at any time?
• The man’s mother had spoken to him on the Wednesday before his death
when he was tearful. She telephoned the prison as she was concerned
and was assured by a member of staff on Imber Unit that he would speak
with the man. The family asked why the officer did not speak to the man
and why an ACCT document was not opened.
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• Why was it considered appropriate for the man to do Twelve Steps
programme given his difficulties with group work?
• Why did it take seven months following the man's transfer to Erlestoke to
determine that he was not suitable for the Enhanced Thinking Skills?
• Whether the man was being bullied and if this was connected to drug use
or debt. How was the prison tackling this and any drug issues?
• Another prisoner was in possession of a number of the man's belongings
such as clothes and a Chelsea mug/clock. What action was taken by staff
to challenge this?
• Were prisoners suspected of dealing drugs on Imber Unit using positions
of trust to do so?
• The family consider that the man's state of mind declined rapidly in the
week before his death. Following contact with the prison, his mother was
told the man would be checked on and spoken to. Did this happen and
what level of monitoring was the man on when he died?
• After an officer raised concerns with the Deputy Governor about the man
just days before his death, what action was taken?
6. My colleague has investigated these and other issues. I hope that my report
provides the family with more clarity of the time the man spent in prison and
the events leading up to his death.
7. My colleague also contacted the Coroner to inform him of the nature and
scope of the investigation. He requested that a copy of the post mortem
report be made available when completed. The Coroner very kindly provided
this and the report concludes that the cause of the man’s death was
“compression of the neck structures by a ligature”. The toxicology tests
conducted after his death have indicated that there had been no overdose of
either prescribed medication or illicit substances.
7
HMP ERLESTOKE
8. HMP Erlestoke is set on the former grounds of Erlestoke Manor House in rural
Wiltshire. It is a category C adult male training prison and the only prison in
the county. It has an operational capacity of 470 prisoners located across
nine residential units.
9. The healthcare department of Erlestoke does not have an inpatient facility.
Doctors from the Adcroft surgery in Trowbridge provide medical cover during
the day from 8.00am to 6.30pm. Evening and weekend cover is provided by
the out of hours service in the community.
10. HM Chief Inspector of Prisons published her most recent report on Erlestoke
in 2008. The report said that the prison could be commended overall for
purposeful activities and resettlement. However, at the time of the inspection,
a serious drug problem was highlighted. Healthcare provision and
accommodation had improved since the previous inspection. My investigation
has found that illicit drug use remains a problem at the prison.
11. During the investigation, my colleague spoke with the Governor who said that
while the prison was committed to reducing the amount of illicit drugs entering
the prison, its rural location meant that items could often be thrown over the
perimeter fences. He also explained that a new unit would be opening that
would allow the drug treatment unit to be more self-contained.
12. The Prisons Act 1952 and the Immigration and Asylum Act 1999 require every
prison to be monitored by an independent board appointed by the Home
Secretary from members of the community from which the prison or centre is
situated. This is known as the Independent Monitoring Board (IMB). The
Board is also required to produce an annual report on the prison to the
Secretary of State, highlighting good practice and flagging up areas of
concern. The Erlestoke IMB report in 2008 noted a number of concerns that
mirror issues which arose in this investigation:
• “The very high level (approximately 100) of life and IPP sentenced
prisoners and the lack of resources to address their needs, which
creates angst and friction in the community.
• “The continuing drug culture in the prison, although there are
encouraging signs that this is improving.
• “Offending behaviour courses are oversubscribed and this particularly
impacts on many IPP prisoners whose release depends on completion
of the course.”
13. This is the fourth death investigated at Erlestoke since 2004 when the
Ombudsman’s office was given responsibility for investigating deaths in
custody, and the first self-inflicted death. Recommendations were made in
the previous investigations, but none are relevant to this death.
8
KEY FINDINGS
14. The man had been on bail, having been charged with criminal offences. He
attended court in December 2006, where he was convicted. Sentencing was
deferred for psychiatric assessment and pre-sentence reports to be
completed. The psychiatric report mentioned that he had harmed himself
previously by banging his head and had past thought of suicide, particularly
when he felt stressed. It was recorded during the assessment that the man
had not indicated any suicidal motivation, but that he would revert to harming
himself if stressed. The pre-sentence report completed by the Probation
Service concluded that a period of custody would provide the man with the
opportunity to reflect on his behaviour linked to violence, and serve to break
his pattern of binge drinking, whilst offering protection to the public.
15. Following his conviction, the man was taken to HMP Lewes. This was his first
time in prison custody. The man’s solicitor had raised concerns about his
welfare before he left court and a suicide and self-harm form was completed
by the escort service and passed to reception staff at the prison. While in
reception, the man had a health screening that took account of the warning
form received from court. It was recorded that the man was currently
receiving medication for anxiety and depression and that he did not drink
alcohol or take drugs. However, this entry is partly contradicted by a further
comment that he had seen a counsellor for alcohol problems. A referral was
made for him to be seen by a doctor and have a mental health assessment.
16. Nurse A completed a further health screen and recorded that the man was a
recovering alcoholic who had been free from alcohol for the last two months.
She wrote that although a warning form had been received, the man denied
any thoughts of self-harm and had no history of harming himself. A referral
was made to the Mental Health In-Reach Team (MHIRT). The day after the
man’s arrival at Lewes, staff requested his medical history from his community
general practitioner (GP) and a response was received the same day. The
GP informed the prison that the man was a very anxious young man with
serious alcohol problems but he had recently been abstinent and attended
Alcoholics Anonymous regularly. His GP also said that the man had a history
of overdosing and was taking medication regularly.
17. On 13 December, a prison GP assessed the man again and recorded that he
had been taking diazepam before he went into prison and was now
withdrawing. (Diazepam is commonly used to treat anxiety.) As a result, the
GP arranged for the diazepam to be re-started.
18. Following the referral to MHIRT, a community psychiatric nurse (CPN), Nurse
B, assessed the man on 14 December. Nurse B recorded that the man
showed no signs of severe or enduring mental illness and indicated that it
would be more appropriate for him to receive primary care support. (Primary
care relates to the type of treatment available within a community GP
surgery.)
9
19. Throughout the man’s time in custody, his mother was concerned about his
welfare and keen to ensure that his needs were being met. She wrote to the
prison on 28 December to raise concerns about plans to reduce his
diazepam, as he felt anxious about his impending court case. The deputy
head of healthcare at Lewes responded to the letter and assured the man’s
mother that he would receive appropriate medical treatment while in custody.
No concerns about the man were raised on the residential wing and he
appeared to settle well. He was seen by healthcare staff on 22 January, four
days before his court case, and complained of anxiety and sweating which
had become worse since his diazepam had been reduced. He said that he
had no suicidal thoughts and it was decided that he should continue taking
diazepam for a further two months.
20. The man returned to court on 26 January, where he was sentenced to IPP,
with a tariff of two years. He had not been given a prison sentence before,
having previously been given community supervision. He and his family were
therefore shocked at the sentence. It is not clear whether the significance of
the IPP sentence was explained to the man at court. However, as he was
unfamiliar with the significance of the IPP sentence it is likely that the man
returned to Lewes with little understanding of what it meant.
21. On his return to Lewes, a nurse assessed the man in reception, as is normal
for those returning from court after being sentenced. The nurse recorded that
the man was “shaken” and “quite anxious” as he had not been expecting such
a sentence. The nurse contacted the GP who prescribed the man 7.5mg of
zopiclone. (Zopiclone is a mild sleeping tablet used for the short-term
treatment of insomnia.) The following day, Dr A prescribed a further three
days zopiclone. On 29 January, Nurse C spoke with the man and recorded
that he remained very anxious and had been worse since receiving his
sentence. The psychiatric report completed before the man was sentenced
does not appear to have been considered by healthcare staff. A further
referral was made to the MHIRT.
22. Nurse B, who had previously seen the man, assessed him on the day of the
referral. She wrote on the assessment form:
” … Been living with father prior to custody. In contact with both
parents and sister. Father has alcohol problems and attempted suicide
in 2005. No mental health problems in family. Depression last 4 years.
History of anxiety and panic attacks. Denies taking illicit drugs. Severe
alcohol problems, has been sober/abstinent 60 days prior to charges.
No psychosis, paranoia, suicidal ideation. Difficulty sleeping. Eating
well. Extremely anxious, shaking and trembling, not psychotic,
traumatised at receiving life sentence but sensible and realistic. Plans
for the future, planning to attend AA [Alcoholics Anonymous]. His mum
had always been concerned at his lack of confidence and he saw a
psychologist as a child. Always been nervous, low self esteem, lacking
in confidence, depressed, loner …”
10
23. Nurse B then completed a care plan for the man and contacted his community
GP to obtain any previous psychiatric notes. A referral was made for the man
to be assessed by a psychiatrist and for a review of his medication. Nurse B
also decided to supply one to one support for the man.
24. Sadly, the day after this review, the prison was told that the man’s father had
died. The man’s mother and sister visited the prison and, along with Nurse B,
Senior Officer A and the chaplain, they broke the news to the man. As
expected, the man was extremely distressed and he was given time with his
family before returning to the wing. Nurse B continued to offer him support
and recorded that during the tea period that day, the man had a severe panic
attack and was given advice on breathing techniques. The man told Nurse B
that he felt safe with his cellmate and had no intention of harming himself. Dr
B conducted a follow up review the next day, when it was recorded that the
man was receiving support from his mother and sister.
25. Nurse B continued to see the man weekly for one to one meetings. On
6 February, she recorded that the man was coping appropriately with his
father’s death, and was engaging with wing activities and attending education.
They discussed ways of coping with the man’s panic attacks and he asked for
his anti-depressant medication to be changed. Nurse B referred this request
to Dr B. Nurse D accompanied Nurse B when she saw the man again on 13
February. He told them that he was having difficulty coping with his father’s
death, and appeared depressed and anxious. Nurse B recorded that he was
still awaiting a date for the funeral and that he found it helpful to talk one to
one to air his feelings. Nurse D saw the man three days later on the wing. He
told her that he had been told the cause of his father’s death and felt some
relief that the funeral could now go ahead. He also said that he was still
feeling low and asked to resume his course of Citalopram. (Citalopram is an
anti-depressant drug that can be used in the treatment of anxiety.)
26. Contact with healthcare continued over the following two weeks leading up to
his father’s funeral. One to one sessions with Nurse B also continued and
gave the man the opportunity to talk about the feelings he had about his
father’s death. He told her that he continued to feel anxious and was not
coping particularly well with prison life. However, during this time he attended
a drug and alcohol course, which he found useful. Nurse D assessed the
man before he left the prison on 26 February to attend his father’s funeral and
recorded that he appeared calm and relaxed.
27. The day after the funeral, the man decided to leave the Prisons Addressing
Substance Related Offending (PASRO) course that he had begun, as he felt
he could not cope with it at the time. However, he resumed the course shortly
afterwards. A comment in his wing history book on 5 March recorded that he
was settling down after his father’s funeral, had re-engaged with the course
and was attending the gymnasium regularly.
28. The man’s problems coping with the death of his father continued and his
anxiety led to him being admitted to the healthcare centre on 14 March. He
had asked to speak with Nurse B and told her that he felt as though he was
11
falling apart and could not cope on the wing. On his admission to healthcare,
two razor blades were found in his property. When asked about them he said
that he was not suicidal and used the blades to cut his tablets before taking
them. Staff referred him to a bereavement counsellor.
29. A visiting psychiatrist assessed the man on 27 March and recorded that he
was very anxious, had a long history of alcohol dependence, and had relied
on diazepam in the past to manage his anxiety. The man said that the anxiety
had been worse since the death of his father and he felt as though life was not
worth living. Despite these feelings, he denied any thoughts of self-harm, and
told the psychiatrist that he knew that such action would hurt his family.
30. The man was discharged from the healthcare centre on 1 May. He completed
the PASRO course in June and a restorative justice, Sycamore Tree course.
(The aims of the course are to enable prisoners to understand the impact of
crime on victims and accept responsibility for their actions and responses.)
The bereavement counselling also continued. A progress report by the man’s
seconded probation officer on 30 August says:
‘ … It appears that the man has done everything asked of him while in
custody at Lewes and he is now working with CARATS and probation
to put things in place for his possible release. From the evidence of
recent information he is likely to be co-operative with conditions
attached to any licence conditions imposed … ’
31. A further progress report completed by Officer A, lifer manager, recorded on
19 September:
‘ … the man is a shy quiet man who does not appear very confident.
Has suffered from anxiety in the past and spent time in HCC
[Healthcare Centre]. The man has worked hard to address his
offending behaviour completing both PASRO and Sycamore Tree
courses with positive results. I have witnessed a positive change in the
man and feel able to support the view that he should be released on
licence with the correct support package …’
32. In October, a nurse was called to see the man on the wing. The nurse
recorded that his anxiety had increased and he said that he felt vulnerable,
but no reason for his feelings was noted. The nurse decided that a period of
respite in the healthcare centre would be appropriate and arranged for the
man to be moved. It is known that he moved on 30 October, but there is no
record of when he was discharged back to the wing. On the wing, the man
continued to be polite to staff. He is recorded as keeping himself to himself
and was happy to spend the majority of his time in cell. He continued to
attend education regularly.
33. The next significant interaction with healthcare staff was on 19 December,
when the man said that he did not want to live anymore. He denied any plans
or attempts to harm himself at that time, but said that he could not be sure
that this would not change if he remained on the wing. Nurse E, a community
12
psychiatric nurse, who saw him on the wing recorded that he had a poor
appetite and was “flat in mood”. He was not motivated to attend education.
She opened an Assessment, Care, Custody and Teamwork (ACCT)
document, and discussed with other nursing staff whether the man should be
admitted to the healthcare centre. They decided to avoid doing so if possible.
34. When opening the ACCT document, Nurse E, wrote that the man’s mood was
low due to a delay in his parole hearing scheduled for November and the
forthcoming anniversary of his father’s death. The ACCT monitoring process
requires an assessment to be conducted by a trained assessor. Officer B
conducted the assessment with the man on 19 December. When asked
about the perception of his current problems, the man said that with the
approaching anniversary of his father’s death, his mood was becoming lower.
He had hoped to be released by the time this came around but had
discovered that the parole review would not take place until February 2008.
The man said that he had not attempted suicide but had thought about it and
felt that he would be better off dead. He had also previously accidentally
overdosed. When asked about his reasons for living or ways of coping, the
man said that his mother and sister were supportive and he was getting close
to the end of his tariff.
35. The man remained on the wing and continued to be monitored under the
ACCT self-harm and suicide prevention measures. A review carried out on 24
December indicated that the man wanted the ACCT document to be closed.
Staff considered that this had more to do with his belief that there was stigma
attached to being monitored. The review team recorded that he attended
work and associated on the wing, although not as much as he had done
previously. They decided to continue monitoring under the ACCT provisions.
Staff commented in his wing history file on 24 December that the man was
very quiet which was not unusual. The man told staff that he was only a bit
depressed and not suicidal. He liked to keep himself to himself and was
always polite and respectful.
36. The next review took place on 7 January 2008, and recorded that the man
was no longer considering harming himself and had no thoughts of suicide.
He was attending work regularly and had arranged to go to the chapel on the
anniversary of his father’s death. The review team telephoned Nurse B who
confirmed that the man had not been diagnosed with any mental illness. The
decision was taken to stop the ACCT monitoring.
37. The man’s first parole review was due on 15 February and he was confident
that he would be granted release. However, the hearing was adjourned for
three months. The man told Nurse B on 18 February that he was very
disappointed and was only sleeping for four hours per night. He continued to
receive support from medical staff and his medication was reviewed and
changed as required.
38. On 2 March, the man’s mother telephoned wing staff. She told them that
following a visit earlier that day she was concerned about her son, and asked
staff to keep an eye on him. Staff spoke with the man in response and again
13
the following day after another call from his mother. The man said that he
was having a good day and felt better than the previous day.
39. The man was advised by staff that the Parole Board might expect him to have
completed further courses to reduce his level of risk of reoffending before
release. On 4 April, he told Nurse F that he was worried about having to
spend a further two years in custody. Nurse F recorded her concern that this
would lead to a deterioration in the man’s mental state, as he did not know
when he would be released. She added that she planned to write to the
Secretary of State to support the man completing courses in the community
while on Home Detention Curfew (HDC). (HDC allows prisoners early release
from prison to live in the community wearing an electronic tag, which must not
be removed, and while subject to a curfew.)
40. Wing staff recorded on 17 April that the man continued to be very quiet and
kept to himself. The only purposeful activity that the man took part in was
education, which he was not enjoying. He had also applied for Release on
Temporary Licence (ROTL) to visit his father’s grave, and waiting to hear
whether he had been accepted onto an Enhanced Thinking Skills (ETS)
course. (ROTL is granted either for compassionate reasons or to help the
prisoner improve their chances of resettlement after their release. Prisoners
are only released on temporary licence after they have been rigorously
assessed and approved by an authorised senior manager.) The man also
requested a Listener and was recorded as being tearful and shaky and said
that he felt more isolated. (Listeners are prisoners trained by the Samaritans
to provide confidential support to fellow prisoners during periods of crisis.)
41. An entry in the man’s wing history file on 25 April, commented that he
remained quiet, kept to himself and at times appeared very down. However,
he went to education regularly and staff had allowed him to help with the
landing cleaning in an attempt to bring him out of his shell. The man’s parole
hearing was due to begin again. He told staff that he was worried that his
sentence would be extended, as he had not completed all the courses he was
expected to do. Staff told the man that he should bring to the Board’s
attention that the two courses he needed to do were not run at Lewes and he
had received no reply to his application for a transfer.
42. Nurse F sent a letter supporting the man’s release as agreed during her
earlier assessment. The Briefing and Casework Unit of the National Offender
Management Service (NOMS) responded on 13 May. They advised that, if
the Parole Board recommended that the man needed to complete further
courses, these would have to be completed in custody.
43. The man’s Parole Board hearing took place on 4 July. He remained very
anxious while awaiting the decision, which was expected on 11 July. The
Board’s decision was communicated on 14 July. They concluded:
“ … The man should be commended for his behaviour in prison and for
the commitment he had shown in undertaking offender behaviour work
on substance abuse and use of alcohol. It was acknowledged that his
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index offence had not been as grave as most that lead to IPP
sentences but was a pattern of escalating violent behaviour. The panel
felt that his good progress could be reversed if not underpinned with
further courses, as it was felt there were doubts about his insight into
the use of alcohol and anger. The board commented that the man was
unable to explain why he started drinking or why he became angry
when drunk. The panel felt that the man would benefit from completing
further coping and thinking skills before being released. A further
review date was set for January 2010 … “
44. The courses highlighted were ETS and Controlling Anger and Learning to
Manage it (CALM). As neither are run at Lewes, this meant that the man
would need to transfer in order to meet the targets of his sentence plan.
HMP Erlestoke
45. The man transferred to HMP Erlestoke on 8 August to complete the ETS
course. On arrival, a nurse completed a health screen. No referrals were
made to either the GP or any other agencies. Following the reception
process, Officer B escorted the man to Wren Unit where he was to be located.
Officer B recorded in the man’s wing history file that during the walk to the
wing, he was sick several times. My investigator asked Officer B about this.
Officer B said that when she collected the man from reception he was very
quiet, very pale and said that he felt sick. Officer B asked the man whether
the travelling had made him feel ill, but could not recall his response. When
asked whether she had considered asking a nurse or doctor to examine the
man, Officer B said that he was keen to go straight to his cell.
46. Two prisoners already located on Wren were friends with the man and they
told staff that he was a quiet and timid person. Officer B made a further entry
in the wing history file to record that the man had not eaten his evening meal,
and sat on the chair in his cell, saying he continued to feel sick. Officer B also
wrote “… bed has not been covered in his gear”. My colleague asked Officer
B to explain what she meant by this comment. She replied that when the man
went to the Wren Unit, he placed his bags of belongings on his bed, and they
remained packed in bags. She found this unusual as most prisoners unpack
and spread their things about the cell.
47. During the next week, the man took part in the induction (the process of
introducing new prisoners or newly-sentenced prisoners into custody) and
was introduced to his personal officer, Officer C. (The personal officer
scheme is run in most prisons and provides a prisoner with a named officer
who will act as their initial point of contact for any problems. The personal
officer will also write reports on a prisoner as required.) Officer C spoke with
the man on 15 August and recorded that the man was finding it hard to settle
in, and was feeling down. Officer C told the man that the regime on Wren did
not represent the rest of Erlestoke and it would be better as he started to
progress through the units, and he must be focused on his ETS course. The
man said that he would pull himself through his feelings of unhappiness.
15
48. On 27 August, Ms A, who works as part of the Counselling, Assessment,
Referral Advice, and Throughcare service (CARATs) team at Erlestoke,
conducted a one to one interview with the man. (CARATs workers can run
programmes, offer counselling, support and referral to rehabilitation centres to
prisoners and on release into the community. Access to CARATs is
voluntary, by application.) My colleague asked Ms A if she could recall her
first meeting with the man. She said that the man was a very quiet person
with very poor eye contact and over the couple of years that she had known
him, having a conversation could be quite difficult. She said that he was quite
limited in his words. He would talk, but it was difficult to get information from
him. Ms A said that the man was very much of the mind that parole was
coming, his first parole hearing had gone badly, and he knew he had to do
specific programmes, namely ETS and CALM. (The CALM course is not run
at Erlestoke.)
49. Ms A said that during her first conversation her impression was that the man
would struggle with the ETS course. She explained that ETS includes a lot of
role play, and on her first conversation she could tell from her experience that
there was going to be some difficulty because of his shyness. Ms A told my
colleague that she did not share her views with the man at that time.
50. Ms A, whose background is in mental health, went on to say that she was not
sure if the man had any underlying mental health problems. She explained to
my colleague that this would be termed dual diagnosis. She considered
whether the substance misuse had caused mental health problems or if the
man had mental health problems for which he was taking the drugs. Ms A
said that during the first meeting she considered there was a need to link with
other departments at Erlestoke, such as the mental health nurse, the man’s
offender supervisor and then potentially a counsellor. The man was very
keen to complete the work to gain parole, and it was clear to her that his
indeterminate sentence weighed heavily on his mind.
51. On 1 September, the man told Officer C that he was not feeling well and felt
on edge most of the time, as he was spending so much time locked in his cell.
He said that he had made a number of job applications, but had not yet been
allocated work. Officer C told the man that he would speak with the cleaning
officer and ask him to unlock the man to help with the wing cleaning, but it
would be unpaid. The man’s feelings continued and Nurse G, a mental health
nurse, assessed him on 11 September due to worsening symptoms of anxiety
and panic attacks. Nurse G recorded in the man’s medical record that he was
preoccupied with doing ETS, due to his fear of speaking in groups. Nurse G
also recorded that the man was depressed because of his father’s death and
having been refused release on temporary licence to visit his grave. The man
also reported to Nurse G that he had some Obsessive Compulsive Disorder
(OCD) symptoms.
52. Over the next two weeks, the man failed to attend appointments with both
Nurse H, Mental Health nurse and Ms A. He also received two warnings for
not attending work. A Security Information Report (SIR) was submitted on 30
September. (SIRs can be completed by anyone working in a prison to raise
16
concerns about a threat to security, or behaviour that might affect the good
order and running of the prison.) The SIR indicated that the man and another
prisoner had requested “rest in cell”, a term used for a prisoner who has been
excused work due to a medical condition. The SIR noted that neither prisoner
had any sign of illness, and were both considered vulnerable, therefore
concerns about bullying were raised. Principal Officer B, Security Manager,
commented on the SIR that the unit manager should interview both prisoners
and support them under the anti-bullying measures, if appropriate. There is
no information to suggest that these actions were carried out.
53. On 3 October, the man had a one to one meeting with Ms A. My colleague
asked Ms A about the appointment that the man had failed to attend. She
explained that prisoners sometimes fail to attend appointments because they
do not receive an appointment slip. She said that with the man would
sometimes say that he could not attend or that it conflicted with other
appointments. In Ms A’s opinion, the man was not the type of person to just
not turn up. My colleague asked Ms A about her appointment with the man
on 3 October and the fact that they discussed the Twelve Steps programme
when he had yet to be fully assessed for ETS. She said they discussed group
work as he had previously completed a PASRO course, but he felt very
uncomfortable in a group setting.
54. Ms A explained that group work was very informal with participants learning
from each other. The man always found group work difficult. Twelve Steps
was discussed as it used thinking skills a lot more, rather than doing separate
programmes. However, the man’s view at that time was that he was not
prepared to undertake Twelve Steps, so they agreed to continue one to one
work and build up from there. Ms A said that the fact the man had previously
completed the PASRO course indicated that he knew he could do course
work. (The PASRO course is six weeks long and looks at relapse prevention,
and motivations to change, consisting of a couple of hours a day. Both
Twelve Steps and ETS are much more intense.) Ms A said that she tried to
discuss the PASRO course with the man and how much he had learnt from it,
but he could only ever remember “snippets”.
55. Due to the warnings for not attending work, the man was reduced to the
standard regime as part of the Incentives and Earned Privileges (IEP) scheme
on 12 October. (IEP is a scheme to encourage and reward good behaviour.
It consists of three tiers, enhanced, standard and basic. The highest level is
enhanced and prisoners move between the various levels depending on their
behaviour and engagement with offending behaviour courses.)
56. On 16 October, Officer D introduced himself to the man as his new personal
officer. My colleague asked Officer D about an entry he had made in the
man’s wing history file about him mixing with individuals who could exploit
him. Officer D said that at the time that the man was on Wren Unit there was
a group of prisoners who were bullying and exploiting those who were more
vulnerable. Officer D considered that the man could be vulnerable. Although
the man was friends with the group who were bullying others, Officer D felt he
17
was also being exploited. The officer believed that when the man moved to
Sarum Unit, a couple of these prisoners were also located there.
57. My colleague asked Officer D if staff had concerns that the man was using
drugs or being encouraged to do so on Wren Unit. Officer D explained that
the concerns about the group the man was associating with concerned the
use of mobile telephones. (Mobile telephones are banned items within
prisons. They are smuggled into prisons in various ways and are known to be
used for criminal activity.) Officer D believed that the man had been
approached to hold a mobile telephone. He was not aware of the man being
involved with drugs, but he was always trying to obtain tobacco. Officer D
believed the man was getting into debt, and paying it off by holding banned
items for other prisoners.
58. On 3 November, Nurse H assessed the man’s mental health. The nurse
recorded that the man was concerned about his weight and was struggling
with anxiety over forthcoming courses. She advised him to complete the
course as his fears were exaggerated. Nurse H wrote that the man’s mood
remained low and had asked for a change of medication once he completed
his course. The nurse agreed to support the man whilst he completed the
course and arranged to see him again in two weeks.
59. An entry made by Officer D in the man’s wing history file on 9 November,
read:
“ … The man is a very quiet individual who keeps himself to himself.
He is currently a wing cleaner doing a good job. He is an IPP who is
due for parole hearing in 2010. He is currently in mid-progress on a
cleaning course. No positive results for drugs. He was struck off the
education list for failing to attend. For his sentence planning, he is
waiting for a date for ETS, which precedes him starting the CALMS
course. Mother and sister visit regularly which keeps his spirits up.
Have discussed his release and what he would like to do, says he is
interested in bricklaying …”
60. When the man met Ms A again on 24 October he told her that he was unsure
whether he would do the next ETS course. My colleague asked her to explain
what the man meant by this. She said that there could have been various
reasons. She explained that the ETS staff tended to prioritise people who
were due to be released, so indeterminate prisoners like the man would not
be included.
61. On 1 December, the man asked the practice nurse, Nurse J, if he could see
someone from the mental health team. This request was passed to Dr C, who
saw the man on 3 December. Dr C asked Nurse K, a mental health nurse to
assess his mental health.
62. An SIR submitted on 3 December contained a statement from a prisoner who
alleged he had been the victim of bullying by a number of prisoners. The
prisoner said that he had agreed to make and supply ‘hooch’ in attempt to win
18
favour with other prisoners. (Hooch is the term given to a fermenting alcoholic
liquid made by prisoners from fruit, bread and sugar.) He also said that he
was buying ‘puff’ (cannabis) and heroin from a number of prisoners, whom he
named. These prisoners were also selling other pills and Subutex. The
prisoner said that the bullying started when the ‘hooch’ was not made
correctly. Staff asked if he was aware of any other prisoners who might be
targets of the bullies and he named the man, saying he believed him to be at
risk. The security senior officer, Senior Officer B, commented on the SIR that
the prisoner who had made the statement was now located in the segregation
unit for his own protection, and the others named should be monitored. The
investigator was unable to establish what that monitoring consisted of, or what
action was taken in relation to the man.
63. Nurse K assessed the man on 5 December and wrote in his medical record:
“ … Seen today following referral from GP. the man is an IPP who has
already served double his sentence. Very anxious about the course he
has to do. Feels unable to switch of his thoughts and spends a lot of
time ruminating about things inside and outside prison. Especially
worried about his weight loss even though he says he eats well.
Appears very anxious with possible borderline learning difficulties,
which may be why he is anxious about the courses. Review in two
weeks, refer to ‘Ms C’ and ‘Dr D’ … “
64. A meeting between Ms A, Ms B (The man’s Offender Supervisor) and ETS
staff took place on 10 December. Ms A told my colleague that the purpose of
the meeting was to decide how best to move the man forward. She said that
ETS staff were of the view that the man would be unable to complete the
course due to his problems with group work and perceived learning
difficulties. She asked whether the work could be completed on a one to one
basis, but was told that at that time there was no suitable provision. Ms A
spoke with Ms B about working with the man on improving his social skills,
building his assertiveness and communication skills, and completing other
courses. Ms A told my colleague that she was advised that the man had to
complete ETS and CALM, as set out in his sentence plan. She said it was
difficult to see how he could do this.
65. The man had regained enhanced IEP level on the Wren Unit, and was due to
move to Sarum Unit, which is the enhanced wing. However, Officer D wrote
in his wing file that the man had declined a move, as he owed tobacco and
wished to remain on Wren so he could pay people back before moving.
Officer D said that the man was placed on anti-bullying measures at this stage
and staff monitored who he was associating with. He told my colleague that
he advised him to move to Sarum, but the man was adamant that he should
pay off his debt. The man re-applied for Sarum on 4 January, and an
unsigned entry in his wing history file reads:
” … The man has re-applied for Sarum Unit and I will be trying to move
him up as soon as possible, as he is becoming a target for bullies. Still
19
a very quiet individual on the wing has regular visits from family, which
keeps spirits high. Still awaiting confirmation on ETS course …”
66. During the routine monitoring of mail on 23 December, a letter sent out by the
man was intercepted. In the letter, he said that he was getting “two boots” of
heroin per week and the odd Valium. The officer submitting the SIR also
wrote “from the smell of the unit, heroin is very available on the east side of
the unit”. Senior Officer B commented on the SIR that a target mandatory
drug test (MDT) was authorised. It was mentioned that monitoring of the
man’s post should be considered. There is no evidence to suggest that either
of these proposals was put in place. Although the SIR was submitted by a
member of staff on Wren Unit, other staff working there told the investigator
that they had no concerns that the man was involved with drugs.
67. Ms C, a counsellor, met the man for the first time on 14 January 2009,
following the referral by Nurse K on 5 December. Ms C recorded that the man
was experiencing feelings of anxiety related to group work and being
evaluated by others. They also looked at experiences and relationships and
planned to continue the work during their next session.
68. The man’s mother contacted the prison on 27 January. She left a message at
the gate saying that she was concerned that he had not telephoned her and it
was approaching the second anniversary of his father’s death. Officer B
recorded that the information was placed in the unit observation book to be
shared with other staff. At interview, she could not recall any other special
measures being put in place for monitoring the man at that time.
69. On 30 January, Officer E, submitted an SIR about two prisoners paying
regular visits to the man’s cell. He wrote that the man had bought a new
alarm clock a while ago, and the power pack for it had been taken. One of the
prisoners visiting the man’s cell told the officer that the man had asked him to
get the power pack for him, and the officer questioned whether that now
meant the man owed a favour in return. Both the prisoners mentioned in the
SIR were recorded as having known involvement in the drug culture within the
prison. Principal Officer B commented on the SIR that staff should monitor
and raise any further concerns.
70. The man moved to Sarum Unit for enhanced prisoners on 24 February.
Another meeting between the man and Ms C took place on 25 February, and
they continued to work on areas discussed in the previous session. Ms C
recorded that she would provide the man with self-help information.
71. On 4 March, the man was told that following a recent assessment of his
learning needs, it had been decided that the ETS course would be unsuitable
for him at that time, and he had been removed from the list. By that time, it
was around seven months since the man came to Erlestoke specifically to
complete ETS.
72. My colleague interviewed Ms D who had sent the memo to the man and was
the ETS facilitator. He asked about the process for accepting prisoners onto
20
ETS. She explained that referrals were accepted from a prisoner’s offender
supervisor. The individual’s OASys (Offender Assessment System) scores for
thinking and offending were considered to see if they were suitable, which Ms
D believed was around 70. (OASys is a risk assessment tool to assess a
prisoner’s needs and to help select an appropriate prison for a sentenced
prisoner. The aim of the system is to improve the consistency of offender
assessment, provide courts with better informed sentencing advice, and
support informed decisions on release and interventions.) A one to one
interview would then be completed to assess for suitability for the course.
Those who are suitable are then placed on a waiting list, prioritised in order of
their tariff expiry, or release date if a determinate sentence prisoner. Ms D
confirmed that the man would have been a priority given that he was already
over his tariff.
73. My colleague asked Ms D whether it was normal for a prisoner at Erlestoke to
wait seven months to be assessed. She said that seven months was a long
time, but there had been a stage where the waiting list was quite long. She
added that the man had been subject to further assessments to test his IQ
due to concerns about his learning ability, and this may have delayed matters.
Ms D conducted the Wechsler Adult Intelligence Scale (WAIS) test. (WAIS is
used to test a person’s intelligence, and defines intelligence as “the global
capacity of a person to act purposefully, to think rationally, and to deal
effectively with his/her environment”.) This is not a standard test before ETS,
but would be conducted if concerns had been raised. Ms D said it consists of
four tests divided into two different areas. The man’s overall score was 77,
and the average is 100 to 110. The guidance for ETS was that a score below
80 would indicate that the individual would struggle with the course.
74. Officer F, an officer working on Sarum Unit, was approached on 1 May, by a
prisoner who told him that the man was being bullied by other prisoners, but
he would not say who they were. Later the same day, the prisoner
approached the officer again and said that he had not wanted to reveal the
identity of the bullies in front of others. He then gave the names of those
involved. Given this information, anti-bullying documents were opened and
the man was spoken to by unit staff, but denied that he was being bullied.
Officer F submitted an SIR. In addition, prisoners’ cells, including the man’s,
were searched the same day using the drug dog. On searching the man’s
cell, nothing was found, but it is recorded that the dog gave a strong indication
of the presence of drugs.
75. The man had been found in possession of hooch during an earlier routine cell
search, and placed on report for a breach of discipline. (When a prisoner is
placed on report an adjudication hearing will take place. The adjudicator is
generally a governor. The prisoner is given the opportunity to explain events
and can ask for legal advice, legal representation or a friend or call witnesses.
Once the evidence has been heard, the governor will decide whether the
prisoner is guilty. If found guilty, the governor can give a number of
punishments such as loss of privileges, cellular confinement or a suspended
award depending on the seriousness of the charge. If it is a serious offence,
the adjudication can also be referred to an independent adjudicator. These
21
are serving judges who have the power to add time to a prisoner’s sentence.)
76. During the subsequent adjudication, the man told the governor that he had
been asked to hold the item for other prisoners and it did not belong to him.
The man also told the security senior officer, Senior Officer B, and said that
he had been forced to hold the hooch, but was not willing to name the
prisoners who had threatened him. Senior Officer B completed an SIR and
commented that the information should be shared with the unit manager so
that staff could continue to monitor the man’s movements and those with
whom he associated.
77. As a further consequence of being placed on report, the man’s IEP level was
reviewed. He was again downgraded to standard, and moved back to Wren
Unit on 5 May. The man met with the counsellor, Ms C, the day after arriving
back on Wren and told her that he was feeling stressed. He also said that he
had experienced some problems on Sarum Unit, which had contributed to his
low mood, but did not specify what they were.
78. Officer B, who had known the man previously on Wren, was assigned as his
personal officer. My colleague asked her whether she noticed any changes in
the man when he returned from Sarum. Officer B said that she felt that she
needed to re-establish trust with the man again. She constantly asked him if
he was all right and told him that if he had any problems he could speak to
her. Officer B recalled having concerns that the man was being bullied, which
she recorded and kept a close eye on him. She said that although it was
clear to her that the man had problems communicating, he had many friends
on the unit, and did not stay in his cell, but associated quite well with other
prisoners. He was also employed as a unit cleaner, which meant that he
spent more time out of his cell.
79. Over the next few weeks, the man met Ms C for further one to one sessions,
and continued to work on behavioural exercises. Officer B recorded that the
man continued to have very little conversation with staff, but she would
continue to encourage him to do so.
80. Although the man had been removed from the list for the ETS course, his
solicitor wrote to Ms E, who had taken over as his offender supervisor on 5
June. The solicitor asked when he was likely to start the course. An entry on
the Offender Management Unit contact log on the same day in response to
the letter reads:
“ … Ms F (ETS) has said that the man is working one to one with
CARAT worker Ms A for work on assertiveness and cognitive skills.
The man has a very poor memory because of alcohol use and would
not at present seem able to retain information on ETS course. The
man is seeing Ms C who could get someone in to do a memory
assessment to confirm whether he is suitable for ETS …”
81. Ms E told my colleague that she took over as the man’s offender supervisor at
the beginning of June, and had spoken to Ms F about his suitability for ETS.
22
On 7 June, the man submitted an application for a transfer. Officer B said that
the man had asked her about a transfer, as he was frustrated at not being
able to complete the ETS course. She completed all the necessary
paperwork and told the man that a transfer would not take place immediately
and he needed to be patient. In the meantime, Officer B told the man that she
would look at the Twelve Steps course to see if that would be suitable and
give him something to aim for.
82. Ms G, the healthcare practice manager at Erlestoke, made an entry on the
man’s medical record on 8 June. She wrote that the man needed to complete
ETS as part of his sentence plan, but concerns had been raised by both
CARATs and the counsellor about his capability to complete it. Ms G referred
to the test carried out by Ms D. She commented that the man had a parole
review coming up. She thought that a further assessment of his IQ and
memory should be conducted beforehand, so he could be provided with
assistance to meet his targets and receive ongoing care, if he was found to
have learning difficulties. In spite of Ms G’s referral, no further tests were
conducted.
83. The man continued to attend sessions with Ms C and worked on coping
strategies. Following their session on 10 June, Ms C wrote that he required a
follow up mental health review. Officer B submitted the man’s application for
a transfer on 20 June. On 3 July, a meeting took place between the man, Ms
A and Ms E. Ms E told my colleague that the Twelve Steps course was
discussed as it was felt that this would be a better route for him rather than
ETS. She said that both she and Ms A were worried that the man might panic
if there was a change that he did not understand and he would think it was
going to go against him. She explained that the man believed that he had to
do ETS to have any chance of parole, and the purpose of the meeting was to
reassure him that changes to his sentence plan would not disadvantage him.
Following the meeting, Ms A submitted an application to Twelve Steps on the
man’s behalf.
84. At his next meeting with Ms C, on 8 July, the man told her that he had been
accepted for Twelve Steps, and she wrote that he appeared quite positive,
which reflected in his general mood. The man’s IEP status was restored on
23 July but, during the next week, he was given a warning for failing to attend
work, and reminded that his enhanced status could be removed. The man
also failed to attend a number of appointments with healthcare staff and Ms C
during the next month. No explanation was provided by the man or sought by
staff.
85. A further three way meeting took place on 3 September, this time with the
man, Ms E and Ms H, the Twelve Steps manager. It was agreed that the man
should attend an Alcoholics Anonymous meeting during the next week to see
how he felt about this approach. However, when he was unlocked to attend
the meeting on 7 September, he told Officer B that he did not know why he
had to attend and did not go. He later told Officer B that he had not been
prepared for the meeting and had not realised it would be so soon. The man
23
finally moved to Imber unit on 24 September 2009, to begin the Twelve Steps
programme.
Imber Unit – Twelve Steps
86. Given that the man had been deemed unsuitable for the ETS course, my
colleague asked Ms H to explain the difference between that and the group
work required on Twelve Steps. She said that the background information on
the man showed that he had completed the PASRO programme and that he
had also been part of some group work with CARATs. One of the criteria
considered for Twelve Steps is the ability to function well in groups or the
ability to undertake group-based learning. Ms H said that she had consulted
the man’s offender supervisor and, together with Ms E, met the man twice
before deeming him suitable for Twelve Steps. They talked to the man about
the community based self-help aspect of Twelve Steps and believed they
would be able to support him with the group, because it is based on peer
support.
87. Ms H suggested that this support might not have been prevalent in previous
group work assessments or referrals. This was one of the reasons why they
decided to let the man try the Twelve Step programme. She added that there
were no concerns about the man’s written work, his literacy levels or his ability
to articulate through written work. There were some concerns about his ability
to work within the groups. It was important that he spent longer than usual in
the preparation stage, in order to assess whether he was suitable to move
into a larger group.
88. My colleague asked Ms H about her first impressions of the man and whether
she had any concerns about drug use at that time or previously. She said that
he was nervous. She got the impression that he liked being sociable and
enjoyed being part of a social group. Maybe it was not a large one, but she
thought he had an identity on the unit and people warmed to him immediately
within the community. Ms H said that she did have concerns about drug use
and he presented as someone who was possibly using on a regular basis.
89. My colleague asked Ms H to explain her concerns. She explained that she
had observed him as being very watchful, perhaps waiting to be caught out
and identified for a voluntary drug test (VDT), and somebody who was
“struggling to be spontaneous”. She considered that some of what she
described was the man’s natural state. However it appeared that he had
something to hide which she considered to be the extent of his drug use. In
addition, he presented as somebody whose concentration was limited, and
who was lethargic. Ms H said it was difficult to identify if his medication was
causing that, although he was always reported to take his medication. She
thought there were signs of opiate use.
90. Officer G was on Imber Unit the day that the man arrived and is a regular
member of staff there. She said that the man appeared quite quiet and
seemed to find verbal communication difficult. When he spoke to her he
would not make eye contact and appeared to be quite shy. She wrote a
24
comment in his history file on 12 October that described the man as “needy”.
My colleague asked her to explain what she meant by this. She replied that
when the man wanted something he was quite adamant about it. She also
said that at times his reasoning skills were not the best. For example, he
would ask her to do something. If she replied “I can’t do that right now, but I’ll
do it and I will let you know”, a couple of minutes later he would come back
and ask the same question. Therefore, she considered him to be quite needy
in that respect.
91. The man appeared to settle in well on the Twelve Step course, but once on
Imber Unit he stopped attending his counselling appointments with Ms C. His
personal officer was Officer J, with Officer G acting as support in Officer J’s
absence. Ms H told my colleague that, when asked questions in the group,
the man would always offer his experience and opinions, although staff had to
prompt him rather than him volunteering. She said that it was obvious that the
man took a lot in through listening in the group sessions. One of the main
parts of the group sessions involves developing active listening skills (active
listening intentionally focuses on who you are listening to, whether in a group
or one-on-one, in order to understand what he or she is saying. As the
listener, you should then be able to repeat back in your own words what they
have said to their satisfaction,) and it was evident that the man would listen
well. Verbally, he was not as animated as most of the other members, but
when asked questions or for his opinion, he was able to volunteer feedback.
92. The man returned to Imber Unit at the same time as another prisoner with
whom he developed a close friendship. My colleague interviewed this
prisoner, who told him that he and the man had started the Twelve Steps
programme together. He realised the man was quite a vulnerable person
from the beginning and described him as “a lovely guy”. He said that the man
struggled on the programme so he did his best to help him and they became
close. For example, he helped him to write assignments, and gave him ideas.
He told my colleague that the man was probably his “best and closest mate”.
He told the man things that he had never told anyone and the man did the
same as well as offering advice. He explained that during the programme
“you have to look right back into your past” in terms of what led to the
addiction. In spite of the man’s initial struggle, he began to do well and
started “getting the hang of it”. His confidence increased and for the first time
he would sit in the group with his head held up high rather than slouched
down to the floor.
93. The man’s friend told my colleague that the prisoners on the unit changed all
the time and there were always people using drugs. He mentioned one
prisoner who regularly used drugs and began doing so with the man. The
prisoner started giving the man drugs for nothing. His friend said that the man
had confided in him because of their friendship and would tell him everything.
The other prisoner gave the man drugs to give him the taste of it. The man
wanted more and the prisoner then began to make money out of him. The
man had asked his friend whether he thought he should say anything in the
group. He told the man that he could not continue to use drugs all the way
through the programme, and he was going to have to try and stop. He told
25
the man to “stick with the winners”, it is felt that he was advising the man to
stay away from those prisoners that may encourage him to use drugs and
distract him from the course.
94. The man’s friend told my colleague that the man used to visit his cell to play
his PlayStation with him, but then he asked him to hold some heroin for him.
From that from that point on, his friend felt he had to “take a back seat” for his
own recovery and safety. He told my colleague that things became so bad
that the man had to “sell t-shirts, his alarm clock, cups, everything” and had
got into debt because of his drug use. He explained that he knew it was
linked to the other prisoner because he saw things in his cell that belonged to
the man. When he asked the man, he would just say he owed him a certain
amount. The man’s friend also believed he was trying to send money to
outside accounts for the other prisoner in order to pay for drugs. At this point,
he had a word with the other prisoner and told him to leave the man alone but
he took no notice.
95. My colleague also asked Officer G if she or other staff were concerned about
the man’s relationship with the prisoner alleged to be supplying drugs. She
was aware that the man was interacting a lot with this prisoner, and they
would often be messing around with each other, like child’s play. For
example, she recalled an incident where the man and the other prisoner were
throwing talcum powder under other people’s doors and they had to be
warned about this. Officer G said that at that time no concerns had been
raised with her or other staff about the man using drugs. Other prisoners
interviewed by my colleague supported the officer’s assertion that the man’s
drug use had not been reported to staff.
96. During the interview, Officer G explained the procedures for cell searching,
and whether staff obtained a prisoner’s property card before conducting a
search. (The property card identifies the items that a prisoner is supposed to
have in their possession.) Officer G said that staff would obtain the property
card. She also said that prisoners would realise that searching was taking
place when they saw staff entering a cell and have time to hide items that they
were not supposed to have.
97. Seven prisoners were interviewed during the investigation, including the
man’s close friend. Transcripts of their interviews are attached to this report.
They all said that they were aware that the man was using drugs and that the
prisoner mentioned by the man’s friend was supplying them. However, while
they told my colleague that they tried to support the man, they also said that
they did not wish to be labelled as a “grass” and so nothing was mentioned to
staff.
98. Another prisoner who had been a peer supporter on Imber Unit and knew the
man previously on Wren Unit, told my colleague that he had tried to raise
concerns about him being bullied during a group session (peer supporters are
prisoners that have completed the course and remain on the unit to offer
support to those who are new to the programme.) He was told by other
prisoners that he should not do that. He also said that the man had denied
26
that there was a problem although it was common knowledge amongst
prisoners on Imber that the man was “using drugs” and who the drug dealers
were.
99. My colleague asked the prisoner if he thought that the man was using drugs
when he knew him on Wren Unit. The prisoner replied that he believed that
the man was using drugs then, mostly due to his appearance. However, he
added that he believed the man was “clean” when he arrived onto Imber, as
his appearance had changed, he was much brighter, had his hair cut and was
more positive. He said that appearance is one of the things those using drugs
are not too bothered about. The prisoner explained that he had also become
aware that the man was being bullied for his canteen, just before Christmas.
When he spoke to him about it, the man denied that there was any problem.
(Canteen is the term used in prisons for personal items bought weekly by
prisoners such as food, toiletries and tobacco.) Prisoners interviewed also
mentioned that the original reason the man had not wished to move from
Wren to Sarum was because he was comfortable there and had a good
supply of drugs.
100. Ms H, the Twelve Steps manager, told my colleague that the facilitators on the
groups were aware of some of the man’s interactions with others. She said
that during community meetings one of the areas of concern raised by older
peers, senior peers, and peer supporters was the man’s welfare. They made
comments about people that needed to “back off”, leave the man alone, and
not put him under any pressure. Ms H said that she spoke to Officer G, and
was told that an anti-bullying document had been opened. She was aware
that the man had been warned at one point about a relationship with another
prisoner who at times was quite playful, but at other times appeared to be
quite intimidating.
101. In view of the comments, Ms H had spoken to the man. She found it very
difficult to identify exactly what was happening, so staff needed to observe
him on the landing, and look for any cliques forming. She considered that
there were people who wanted to protect the man and others who appeared
to want to move away from him. It was quite difficult to read who was an “ally
and who was a foe”. She thought there were dynamics within the community
where fellow members appeared to be influencing the man in a negative way.
102. Over the Christmas period, concerns were raised about drugs being available
on Imber Unit. An SIR was submitted by Officer J, the man’s personal officer
on 25 December. A prisoner had told staff that another prisoner on Imber had
brought back lots of heroin from a period of temporary release. The person
with the heroin was reported to be using peer supporters from the Twelve
Steps course to “traffic” (pass) the drugs to prisoners on the course. The
prisoner said that the man was in debt to the person with the drugs and was
worried about how he was going to pay him back. He added that there had
been threats of violence if the debts were not paid off. Despite the
significance of the information, the security department took no action on the
SIR until 4 January, but this may have been due to the Christmas period. The
27
security department recorded that the information should be passed to the
prison’s head of drug strategy. No action relating to the man was recorded.
103. Officer J also submitted another SIR on 25 December, regarding prisoners on
Imber Unit “bottling up”. (Bottling up is the term used when a prisoner
attempts to use urine they have passed earlier or from someone else when
providing a sample for a drugs test.) This practice suggests that drugs were
being used on the unit. Officer J’s SIR also referred to the man having
purchased a large amount of tobacco on 24 December but had nothing left
the following day. He confirmed in the SIR that he had spoken to the man
about this. The man told him that it was because the canteen was on the
wrong day and he had borrowed some which he had then paid back. The
security department recorded that the head of drug strategy was aware of the
claims of “bottling up”.
104. My colleague asked Officer G about her concerns regarding allegations that
the man was being bullied. Around Christmas time, she placed the man on
anti-bullying monitoring as it had been noticed that items on his canteen order
were different to what he usually ordered. She knew what the man generally
ordered every week and gradually different things appeared. Officer G said
that she and other staff on Imber spoke to the man about their concerns and
he told them that he was paying back what he had borrowed. A couple of
weeks later, she asked the man about it again and he admited he was paying
back a debt. He said that it was almost paid which would be the end of it.
105. In early January, the man admitted during a group meeting to having used
drugs over Christmas. Other prisoners also admitted using. The man
attempted to have money sent out at the end of December to an address in
Wales. He said that the money was to go to his daughter, but staff were
aware that he had no children, and Ms H spoke to him about it. Although he
maintained initially that the money was for a daughter, on further questioning
he confessed that he was sending the money out to pay for drugs.
106. Ms H said that, due to the man’s admission to using drugs, he was removed
from that stage of the course and put back to the preparation stage. A
prisoner who had admitted to using drugs would normally be removed from
the entire course, but they considered that the man should be given the
opportunity to re-dedicate himself to the programme. My colleague asked Ms
H about the man’s reaction after he admitted using drugs. She said that he
was pleased that he had not been removed from the programme and seemed
to be relieved. He did not express any particular gratitude but he seemed to
understand the reasoning. She explained that the man and another prisoner
were given the same sanction at the same time. The other prisoner did not
respond particularly well and saw it as punitive. Ms H thought this had
influenced the man slightly. His initial relief and pleasure at remaining on the
unit rather than being de-selected turned into a little bit of resistance, but this
seemed to be influenced by the other prisoner.
107. The man submitted two applications to see his offender supervisor, Ms E,
following his removal from the programme, and she spoke to him on 7
28
January. Ms E said that they talked about why he had used and why he
chose to use drugs at that moment. The man told her he was craving drugs
and gave in to temptation. They discussed what the man could have done
instead, which he identified as ”I could have gone to some of the other lads on
the programme and got some support and I didn’t”.
108. Ms E summarised her meeting with the man as having looked at his lapse and
seeing how he could have done things differently. It was evident that the man
did not want to give up the programme and he was willing to do it all again.
She told him that he had a positive attitude. Ms E also said that the man had
more to say than he had previously, as it was usually very difficult to get much
out of him at all. She confirmed that they would meet in a couple of weeks to
look over his assignments and encouraged him that this was “not the end of
the road”. She agreed to advise his solicitor about the delay finishing the
programme.
109. The anti-bullying measures were stopped on 11 January, following a review.
On 15 January, Officer J spoke to the man prior to starting a period of night
duties. The man told Officer J that he had informed the Twelve Step staff that
he had used drugs while on the programme, and he was annoyed with
himself. However, he had since re-dedicated himself to the programme.
Officer J recorded that the man told him that he had not used drugs for the
past eight days. The officer told the man that he would not be back on day
shifts until 8 February, and that he should speak with Officer G if he had any
problems.
110. Ms E went to speak with the man on Imber Unit on 22 January, as she had
previously arranged. On arriving on the unit, she spoke briefly with Ms H, and
asked her how the man was getting on. Ms H replied that the man was likely
to be de-selected from the programme within the next week for a variety of
reasons, which included his lack of motivation.
111. My colleague asked Ms E about this conversation. She said that she had not
planned to see Ms H and it was just a chance meeting. It came as a surprise
to her when Ms H mentioned the man being de-selected from the course, as
he had seemed positive when she spoke with him a fortnight before. When
she spoke with the man she did not mention de-selection to him.
112. My colleague asked Ms E how the man appeared and if she had noticed any
change in his motivation to complete the programme. She said that, in her
opinion, what she had been told was not consistent with her own impression.
She said that the man impressed her as working very hard with his
assignments and appeared to be no less motivated. Ms E considered it to be
a very tricky area, she was aware of the man’s vulnerability, and did not want
to mention de-selection to him at that time.
113. Three days after Ms E met the man, the decision was taken to de-select him
from the Twelve Steps programme. My colleague asked Ms H about the
decision and the reasoning behind it. She referred firstly to her conversation
with Ms E. Ms H explained what was meant by the man’s lack of motivation.
29
Staff had spoken to the man after a period of reflection. They needed to see
more evidence of him becoming more engaged and talking more about his
drug and alcohol use. They heard the man relate his feelings, but he did not
say the types of things they expected. Ms H said that, because the man was
now in the therapeutic phase, or would be going back into the therapeutic
phase, they needed to be sure that he would increase his involvement.
114. Ms H said that there had never been any concerns about his written work or
assignments and the man appeared to be able to do “beautiful, fantastic”
assignments. Staff were concerned that the man was moving into a phase
where he would need to be verbally explaining his index offence, his alcohol
use, and his behaviour under the influence of alcohol.
115. Ms H said that the final decision to de-select the man was not made quickly or
easily. The man had been “a client of concern” for weeks and monitored
during the morning meeting and in the debrief process. One of the important
parts of de-selection is an individual’s alleged abstinence and the integrity of
the programme. There was a dilemma about the man’s and staff questioned
whether the intervention was working for him. Ms H said that, on asking the
man “are you abstinent, or have you lapsed?” there was always a blanket
response “no I have not”. Ms H said that there were no avenues of discussion
around that which was very difficult.
116. One of the prisoners interviewed alleged that the man had told him that he did
not know why he had been de-selected. He said that Ms H had challenged
him and said “I know that you are still using, and we are going to get rid of
you.” My colleague shared this allegation with Ms H and asked for her views.
She explained that she would have said to the man,
“ …. you appear to be still finding it difficult to come out of yourself, to
be spontaneous. You have a history of having used substances and
I’ve got concerns, I have concerns about why there’s this difficulty in
what’s blocking you. Something seems to be blocking you”.
Ms H said that would be the normal type of approach and facilitators would
not overtly make an accusation without any grounds.
117. My colleague asked Ms H whether the de-selection process was the same for
everybody, or if the man had been given more opportunities to engage with
the programme than the norm. Ms H said there had been sanctions and
interventions, key work and care plan objectives. When staff reach the point
of a de-selection interview, it is not a discussion about further outcomes as
the decision has already been made. Although two members of staff would
usually hold the meeting, on this occasion it was just Ms H and the man. She
said that even though a decision had been made on Friday, staff decided to
wait until Monday and she felt “uncomfortable doing it” (de-selecting the man).
118. My colleague asked about the man’s reaction to being told that he was to be
de-selected. Ms H said that the man was confused. She spent time
describing the programme to date and explained the rationale behind the
30
decision. Ms H said that she explained what staff would look for at a second
attempt. They were for the man to remain substance free, be able to take
“more risks”, (this is by talking openly), make his vocal commitment more
animated and come out of himself.
119. Ms H said that every now and again the man had been “quite free” and had
been able to be open during the programme. She did not know what
prompted those moments but staff saw evidence of it and then the man would
retreat. Ms H tried to explain to the man that they needed to see more of this
type of engagement and she thought that he fully understood that he could re-
apply for the programme after 28 days.
120. Following his de-selection, the man moved to Wessex Unit on 25 January.
Officer K, who had known the man previously on other units, was working on
Imber Unit at that time and escorted the man across to Wessex. The officer
later raised concerns about the man with the deputy governor, and my
colleague asked him about these.
121. Officer K explained that on the morning that the man was de-selected he was
working on Wessex Unit. Other officers mentioned that a prisoner was
moving across from Imber that afternoon. He asked which prisoner and was
told that it was the man. He said that the man’s name “rang a bell” with him
as he recalled that the man had to complete Twelve Steps for his parole.
122. Officer K said that, when he accompanied the man from Imber to Wessex,
another prisoner was with him pulling the trolley. On the way to the unit,
Officer K asked the man “what’s going on?” The man said he had failed a re-
test, it had come back positive, and that it’s only 28 days. Officer K said that
the other prisoner also told the man that it was only for 28 days and he would
be all right. Officer K asked the man if there was anything else he wanted to
tell him, but the man did not say anything. The investigator was told that the
28 days referred to how long it would be before the man could re-apply for
Twelve Steps.
123. When Officer K went back to Imber Unit, he asked the regular staff what was
happening on the unit, and whether there was any bullying. He was told that
several SIRs had been put in recently. When asked why he was concerned
about the man, Officer K said that it did not seem right to him that someone
who had to complete that programme, and knew it would affect their parole,
would allow themselves to be de-selected. It had bothered him overnight and,
the next day, he went to see the deputy governor. He told the governor of his
concerns about the man’s de-selection and that he had heard allegations of
bullying. The deputy governor asked whether the man had said anything and
that, unless he was willing to speak out, it would be difficult to take action. He
advised Officer K to get in touch with Ms J, one of the CARATs team to see if
the man would interact with civilian, non-uniformed staff.
124. Officer K emailed Ms J. She, in turn, spoke with Ms H who said that she was
aware of recent problems on the unit which were being dealt with. Officer K
told my colleague that he was not concerned about the man harming himself,
31
and his concerns were more about what was happening on Imber Unit. He
did not see the man for a couple of days after taking him to Wessex. The next
time he saw him he asked whether he was all right and the man replied “yes
I’m all right guv”.
125. On his arrival on Wessex, the man was told that his personal officer would be
Officer L. There is little information recorded in his wing history file about his
movements or behaviour on Wessex.
126. On 26 January, the day after he moved to Wessex, the man’s mother
contacted the prison and spoke with Ms K. His mother expressed concern
about her son’s removal from Imber Unit. She told Ms K that she was aware
that the man had been de-selected due to his drug use. Ms K confirmed that
she believed that the correct procedures had been followed. The man’s
mother expressed concern about how the de-selection might impact on his
forthcoming parole hearing, as he had also been unable to complete ETS,
both of which were sentence planning requirements. During the telephone
conversation, she told Ms K that the coming weekend would be the third
anniversary of the death of the man’s father.
127. Following the telephone call, Ms K contacted Wessex Unit. She told the staff
about the anniversary of the death and asked the staff to keep a closer eye on
the man, checking that he was all right given his recent move from Imber Unit.
The staff told Ms K that an entry would be made in the unit observation book
to alert staff. (The observation book is used on all units to record important
information about individual prisoners or events that is then shared with staff
as part of a briefing.) Despite their assurances, my colleague found no
evidence that staff had recorded the concerns relayed by Ms K or listed any
follow up action.
128. Ms K also contacted Ms E and Ms H regarding the concerns raised by the
man’s mother. Ms E responded to Ms K on 28 January to tell her that she
had seen the man. Arrangements were in place for him to be seen the
following week by staff from other departments to discuss further actions. Ms
H also responded and explained the de-selection process as well as the
follow up action taken since the man’s de-selection.
129. As part of the follow up action, the man asked to speak with Ms A from the
CARATs team. She went to see him on 27 January, just before she went on
leave. She asked the man what had gone wrong and all that he would say is
“why have I been de-selected”.
130. Ms A wanted to have a meeting with the man and Ms H, but was aware that
this would not happen until she returned to work. Her immediate thought was
how to keep the man focused until the meeting could be arranged, as his
parole hearing was quite close. Ms A told my colleague that she advised the
man to continue attending Narcotics Anonymous (NA) meetings, which he
had been doing while on the programme, as well as other meetings. She also
gave him some work to complete in his cell on substance misuse. She told
the man that, on her return to work, she would meet him and Ms E to discuss
32
a plan that they could take to the Parole Board. Alternatively she would try to
have the hearing suspended to allow time for the man to resume the Twelve
Steps course.
131. To try and ensure that the man had support in place while she was on leave,
Ms A spoke to Ms C, who had previously held regular counselling sessions
with him. Ms C worked at the prison for one and a half days per week, and
Ms A was keen for her to support the man straight away. My colleague asked
Ms A whether in her opinion, removal from the Twelve Step programme and
possibly being in debt were things that would have weighed heavily on the
man’s mind. She felt that they were. She considered that if you did not have
sufficient communication skills, it is likely that prisoners would keep things to
themselves. Being on a wing with limited support and a drug problem and
impending parole hearing, are “big stones” (meaning burdens) stacking up
against you.
132. After being told by Ms K of the concerns raised by the man’s mother, Ms E
arranged to see him the next day (27 January). She said that during the
meeting, the man said he could not understand why he had been de-selected
as he thought he had been doing his best. Ms E said this fitted with her
previous meeting with the man when he had done all his written work. He told
her that he was stressed about his sentence, and had been given a date for
his parole hearing. Ms E said that she tried to reassure the man that although
the Twelve Steps had ended, it was “not the end of the world”, and there was
going to be another focus. She tried to contain his worries by suggesting a
meeting with his offender manager and CARATs worker to look at a new
approach. The man suggested that he could attend AA meetings, and she
was impressed by his positive suggestion.
133. My colleague asked Ms E whether she had any concerns about the man’s
welfare, given the anxieties raised by his mother. She said that the man was
a vulnerable individual and she would always be concerned. She set
concrete and constructive tasks which she hoped would contain his anxiety
and not leave him feeling that he was “just sinking”.
134. In one of their previous meetings, the man had mentioned to Ms E that he
was doing the “Path to Happiness” course “off his own bat”. The man did not
elaborate much on the course which was something that he had applied for
and he was working on. During what was to be their last meeting, the man
again said that he was still doing the “Path to Happiness”. She encouraged
him to remain focused on positive things and to continue with the course as
well as attending AA. She also told the man to do some writing, telling him
that he was good, so he should try and write his thoughts down. Ms E said
that there was nothing in their conversation that made her feel the man was in
a really critical state.
135. It is clear that from the investigation that “The Path to Happiness” is a course
that is available in many guises, and there are a number of publications
available. Although it is not clear which one the man was pursuing, the aims
are the same. They are to make participants aware of what is not working for
33
them, and change the way that this is interpreted. The man may have learnt
about the course during AA or other meetings.
136. As previously mentioned, there is little recorded information about the man’s
interaction with staff or other prisoners during his relatively short time on
Wessex Unit. One entry in his wing history file on 29 January says that he
had asked for a move to a warmer cell. When Officer L told the man that a
cell was available and he could move during the association period, he
declined, and was told that he would have to stay in his existing cell.
137. My colleague asked Officer L whether any concerns had been raised by staff
about the man using drugs on the unit. He responded that the man was
associating with some known drug users but, in his opinion, a high proportion
of the unit would have been considered users at that time. He did not
necessarily assume that the man must be using because he was associating
with them and was unaware of any information to suggest he was using
drugs.
138. My colleague asked Officer L’s view about an allegation regarding his
interactions with the man, and whether he could recall anything that might
have been perceived as bullying. Officer L said that he could not. He
explained that, a few days before the man’s death, he had gone to healthcare
to speak to another officer about something else that was going on. He then
went to see the man to tell him that he had to go somewhere else from
healthcare. Officer L explained that the man thought that he was talking
about him to the other officer. He told him that was not the case and he was
talking to the officer about something completely different. He put the man’s
response down to the fact he was quite a nervous individual who had read
more into the situation than actually happened. Officer L explained that he is
the type of officer who challenges poor behaviour from all prisoners if they are
not conforming. He said that perhaps that could be perceived as bullying by
those he challenged.
139. As a regular member of staff on Wessex Unit, Officer L was asked about the
information from the man’s mother that had been passed to the unit by Ms K.
He had not been aware of any information relating to the man and would
expect such information to be recorded in the unit observation book and his
wing history file. However, he was aware of the anniversary, as the man had
mentioned it during a conversation. When asked whether the man had
mentioned the anniversary specifically, Officer L said that it was part of
general “chit-chat”. The man had just said, “I’ve got this anniversary coming
up and I’m feeling a little bit on edge” but that was about it. When asked if he
had concerns about him, Officer L said that the man always looked as though
he was “on edge” so he did not feel it was anything out of the ordinary.
140. Despite the lack of information about the man’s week on Wessex Unit, a
number of prisoners my colleague interviewed said that they had heard that
the man was telling prisoners on Wessex that “it was all messed up and I am
never going to get out of prison”. However, none of the prisoners could
substantiate this.
34
141. It is known that the man failed to attend doctors’ appointments on 2 and 3
February. It is not clear what the appointments were for and may have been
to review his medication. The man had been taking medication for his anxiety
since arriving into custody. When he failed to attend the appointments,
healthcare staff booked him on the next one.
142. The man sent a card to his mother and sister for the anniversary of his
father’s death. His mother told my colleague that the man wrote in the card
that “his life had no purpose without his mum or sister”. The man had also
telephoned his mother on Wednesday 3 February. She said that he had been
tearful and anxious. She asked whether he had been to see the doctor and
the man said that he had. Following the telephone call, she contacted Senior
Officer C on Imber Unit, who she had dealt with before, and had built up a
rapport. She told Senior Officer C about the man’s telephone call and that
she was worried about him. She asked the SO if he could go and see the
man and make sure that he was all right, and Senior Officer C said that he
would. She told the SO that she and the man’s sister were planning to visit
him on the Saturday.
143. Senior Officer C said that he took the call just before he was due to go off duty
and had spoken with the man’s mother on many occasions before. He did not
get the impression that the man’s mother was concerned about the man
actually harming himself, but it was more about how he was coping on
Wessex. Senior Officer C said that he did not identify any sense of urgency
and the man’s mother told him that she would be visiting on the coming
Saturday. Although he intended to see the man before going off duty, he
decided to do so the following day instead.
144. On 3 February, the man also contacted CARATs and asked to speak with Ms
A, but was told that she was on holiday and would not return to work until after
the weekend. Ms J, the CARATs manager, told my colleague that the man
was asked if he wished to speak to anyone else. He said that he did not,
giving no indication what his problems were.
145. My colleague was also told that the telephones used by prisoners were not
working on Wessex Unit for a few days. It was claimed by a fellow prisoner
that on the evening of 3 February, the man had asked to use the office
telephone to contact his mother, but was told by staff that he could not.
Officer L said that there was a period around that time when the telephones
were not available for a few days, and there was a delay in them being
repaired. He was not aware of the man asking to use an office telephone. As
mentioned in a previous paragraph, the man’s mother said that she had
spoken to him on 3 February, which indicates that the telephones had actually
been repaired by this time.
Events during the evening of 3 February and morning of 4 February
146. During the evening of 3 February, Operational Support Grade (OSG) A
started his night duty on Wessex Unit at around 8.30pm. He carried out a
35
physical check of all the prisoners on the unit to confirm that the correct
number were in the cells. He then spoke to Officer M who gave him a
handover regarding a prisoner subject to the suicide and self-harm prevention
monitoring. He went to see the prisoner and then conducted a number of
administrative tasks.
147. During the evening, OSG A patrolled the wing regularly and tended to various
requests from prisoners. At 2.00am, he began to complete another physical
count of the prisoners on the unit. He reached the man’s cell at around
2.12am, and saw that the light was on. As OSG A looked into the cell through
the observation panel, he noticed the man at the back of the cell behind his
curtain and initially thought he was looking out of the window. However, he
then noticed that the man’s feet were facing into the cell and his legs
appeared to be bent at the knees. OSG A immediately radioed for urgent
assistance. At the same time, the night orderly officer, Officer N, arrived at
Wessex Unit for a routine visit. (The night orderly officer is in charge of the
prison during the night.)
148. Officer N went immediately up to the man’s cell. OSG A began to open the
sealed pouch that he carried containing a cell key. (During the night, for
security reasons, staff other than the duty manager do not carry keys.
However, they are provided with a sealed pouch that contains a single cell
key, to be used in an emergency.) However, around the same time, Senior
Officer D, duty night manager and a trained first aider, arrived and used her
cell key to gain entry. When she went into the cell, OSG A pulled away the
curtain covering the man and staff could see that he had a ligature around his
neck made from bedding.
149. While OSG A and Senior Officer D supported the man, Officer N attempted to
cut the ligature. Unfortunately, it was too thick and tight to be cut. She
therefore took over supporting the man and OSG A removed the ligature from
where it had been tied to the window frame. They laid the man onto the floor,
loosened the ligature and removed it from his neck. The man did not respond
and Senior Officer D could not feel a pulse or any signs of life. She told
Officer N to instruct the control room that an ambulance was required, and the
officer left the cell at 2.15am to go to the unit office. On her way, she passed
Officer G who was responding to the initial call for assistance. When he
realised the nature of the problem, Officer G collected the first aid box from
the unit office and returned to the cell.
150. Along with Senior Officer D, Officer G began carrying out cardio pulmonary
resuscitation (CPR) at 2.16am. Officer N later returned to the cell and took
the man’s hand to feel for a pulse while the others continued CPR. A short
while passed and Senior Officer D was called to the main gate as the
ambulance had arrived. Officer G took over in administering breaths and
OSG A continued chest compressions. Both staff continued CPR until the
first response paramedic arrived in the cell at 2.35am. The paramedic and
ambulance staff took over CPR at 2.40am. Attempts to resuscitate the man
continued, but he failed to respond. Sadly, at 3.18am, he was pronounced
dead by the paramedics.
36
151. Following the man’s death, the police attended the prison, as is normal
practice after any death in custody. A note left by the man intended for his
mother and sister was found in his cell. It said that he just wanted to be at
peace, and he did not want his mother and sister to think he was selfish. It
suggested that he could not see an end to things and it had all got too much.
The police took the letter and a copy was made available for the man’s family.
The governing governor came to the prison and along with members of the
staff care team spoke to all the staff, before they went off duty and held a de-
brief for the staff involved.
152. Arrangements were also made for the man’s family to be notified. Ms L, Head
of Community and Ms M, prison chaplain, left Erlestoke at around 5.30am, to
travel to the home of the man’s mother to break the news of his death. The
prison appointed Ms N as their family liaison officer. The family visited
Erlestoke a few days after the man’s death and met the Governor. They were
given the opportunity to see the man’s cell. Staff told them about
arrangements following a prisoner’s death, including the Ombudsman’s
investigation. The family were also advised that the prison would contribute to
the funeral costs. The man’s family later returned to the prison, where a
memorial service was held, attended by both staff and prisoners.
153. Ms N remained in contact with the family to answer any questions that they
had. All the staff involved on the morning of 4 February, as well as staff who
had known the man or worked with him, were offered ongoing support from
the staff care team. Other prisoners who were subject to monitoring under the
suicide and self-harm prevention measures were also reviewed and offered
additional support as required.
154. The post mortem concluded that the man had died from compression on the
neck caused by a ligature. Further toxicology tests indicated that at the time
of his death, no drugs were present at a level that might be considered
dangerous.
37
ISSUES
Clinical care
155. A review of the man’s clinical care in custody was conducted by the clinical
reviewer, on behalf of the Primary Care Trust. The clinical reviewer found the
following:
“ … The man was a patient with longstanding problems with mental
health and addiction. His major diagnoses were anxiety and
depression. His vulnerability was regularly monitored, and while in
prison had always denied suicidal intention. He also was suspected to
have a low IQ, and to be suffering the effects of severe alcohol abuse
in the past.
“Sadly, his death is not unusual in such a patient, as suicidal intent is
often covert even in the face of questioning; and in a vulnerable
individual, suicide may be an impulsive act in reaction to
circumstances, rather than as a direct result of a serious depressive
illness. The writing of a note to his family demonstrates that this was a
premeditated act.
“ From my review of his medical records, it appears that his medical
care was at least as good as would have been available to him if the
man had been at liberty during the period of his illness:
• He had access to specialist mental health supervision, and regular
counselling and general practitioner appointments if he chose to
attend them.
• He was on antidepressant medication confirmed as suitable by a
Consultant Psychiatrist.
• The issue of his learning disability might have contributed at a
future Parole Board hearing, but would not have affected his short-
term situation.
• His involvement with illicit opiate drugs may have complicated his
mental health problems, perhaps mainly in terms of social stress.”
156. The clinical reviewer pointed out that, although the man had been moved from
the Twelve Steps programme after admitting to heroin use, there is no
mention of this in the medical record. However, he does highlight that during
the post mortem examination needle marks were noted on the man’s left hand
and arm. No intravenous drugs had been used during the resuscitation
process or prescribed. The toxicology tests did not identify heroin in the
man’s blood, but did indicate the presence of tramadol, a prescription drug.
The pathologist noted that the levels shown would not have contributed to the
man’s death.
38
157. The clinical reviewer also said that the man had not been prescribed
tramadol, which would suggest it had been used illicitly, and the levels in his
blood would indicate that it had been taken within 24 hours of his death. He
noted that tramadol is not a controlled drug, but has some of the same effects
as the morphine and heroin group of drugs. Controlled drugs have special
storage and recording requirements, which do not apply to tramadol. The
clinical reviewer says that if the drug is stocked in the prison, the prison health
authorities may wish to review the storage of tramadol ampoules and tablets
to ensure that there is no risk of diversion of prescription drugs for illicit use.
158. The clinical reviewer concludes “there are sadly no recommendations to
make about this patient’s medical management, which could be expected to
avert a similar situation in future … ”
159. Ms G, the healthcare manager at Erlestoke, responded to the clinical reviewer
’s comments regarding tramadol:
“ … With regards to the tramadol situation, they are most definitely
secured within healthcare safely and appropriately and issued only to
the prisoners that they are prescribed for. We do not keep tramadol as
stock at all. However it is a known fact, backed up by prison
intelligence, that prisoners will see the GPs with problems that require
an opiate based medication, sometimes tramadol, and as we have to
offer an equivalent service to that received in the community, the GPs
and the healthcare team are no longer allowed to say that opiate based
medication cannot be prescribed, and thus prisoners receive tramadol
which they may or possibly may not clinically need. There is therefore
a black market within the prison for various medications, not just
tramadol, and this is almost certainly how Dan had managed to procure
some tramadol. I can be 100% sure that the tramadol the man had
used was not "acquired" from the healthcare department direct …”
Drug use at Erlestoke
160. The problem of prisoners obtaining and using illicit drugs while in custody is
not one that is exclusive to Erlestoke. It was clear from the investigation that
the prison was making progress in identifying those prisoners using drugs and
taking steps to stem the flow of dugs into the prison. The Governor told my
colleague that Erlestoke had recently been below the target figure for those
prisoners proving positive on Mandatory Drug Tests (MDTs) for the first time
in seven years. I agree that this indicates that the prison is making progress
in this area.
161. My colleague spoke with a number of prisoners who had known the man in
the various units where he had lived. Some of them said that their impression
of him was that he was using illicit drugs from the time he arrived at Erlestoke.
The man’s application to take part in the Twelve Steps programme
demonstrates that he wanted to try and free himself from his addiction. The
early feedback he received from facilitators indicates that he was beginning to
achieve this. However, when another prisoner who was still using drugs
39
arrived on the unit and became friends with the man, it placed temptation in
his path. From information received from his friends, the man also began
using drugs again.
162. The extent of the man’s drug use is unclear, but one of his close friends said
that he would not be using continuously but he was “well into it”. The
availability of drugs on the unit was well known amongst prisoners. Security
information reports by staff raised concerns, but there is no indication that any
particular action was taken by the security department, other than passing on
the information to the prison’s drug strategy coordinator.
163. As with other units, prisoners on Imber Unit are subject to Voluntary Drug
Testing (VDT) as part of an agreed compact. However, during the
investigation my colleague was told that the room used on the unit for
conducting these tests was such that it was difficult for staff to observe
prisoners actually providing the sample, and therefore it is possible for it to be
adulterated. This is significant given the concerns that were raised via an SIR
about prisoners on the unit “bottling up”.
164. The man never failed a drugs test while on the unit and his drug use was only
discovered as a result of his admission during a group session. The man had
been having regular meetings with Ms A from the CARATs team before going
onto Twelve Steps. However, the information that the man had been using
drugs was not immediately shared with her and no referral was made.
165. The location of Imber Unit means that prisoners not undergoing the Twelve
Steps programme are able to approach the unit. Equally those on the course
are still able to associate with prisoners from other units during exercise and
when attending the healthcare centre. This makes it difficult to ensure that
access to drugs is removed from those on the programme.
166. The Governor told my colleague that a plan is underway to move the Twelve
Steps programme into new purpose-built accommodation, which would
include its own treatment room and make it unnecessary for prisoners to go
off the unit. He also explained that the programme had been moved several
times to different accommodation, to make it more of a separate community,
and the latest plans are the final part of that process. I suggest that the
provision of a more user-friendly room for conducting VDTs should be part of
the plans for the new building.
167. It was evident during the investigation that the prison is addressing the
problem of drugs and positive results are being achieved. In terms of Imber
Unit, it is also clear that the new accommodation will help in creating a more
drug-free environment and improve the integrity of the programme. Due to
the progress already made and the actions that are ongoing, I make no formal
recommendations in this area.
40
Anti-bullying procedures
168. The investigation found that Erlestoke has anti-bullying procedures in place
that are understood by staff, and are regularly initiated. As with most cases of
alleged bullying, information from the perceived victim is important as is staff
awareness of other factors that may indicate that an individual is being bullied.
169. During the investigation, my colleague was told that staff were concerned
about the man’s vulnerability quite soon after he arrived at Erlestoke. It was
said that he was a quiet individual, who would keep himself to himself and
staff felt this could make him a target for prisoners who would take advantage
of him. Anti-bullying procedures were put in place on a number of occasions
due to concerns raised by staff or indeed information from other prisoners.
However, on each occasion, the man maintained that there was no problem.
This made it difficult for them to take further action, although they continued to
monitor the people that the man associated with. The reasons that he denied
he was bullied is unclear, and it may have been that he did not see the
behaviour of other prisoners as bullying. I accept that, without further
information, it would have been difficult for staff to intervene or challenge
particular prisoners. I am satisfied that the staff monitored the people who
might have been bullies and also that the man received a lot of support from a
range of staff.
170. Prisoners on Imber Unit were concerned that the man had been targeted and
had given away personal items. However, they did not share their concerns
openly with staff, and tried to deal with the situation themselves. Security
information submitted later suggested that the man was in debt and that
violence might be used against him. On this occasion, no anti-bullying
monitoring appears to have been opened, and no staff approached the man
about the particular concerns that had been raised.
171. Items kept in prisoners’ possession are signed for and recorded on their
property cards, and guidance says that the cards should be checked by staff
when carrying out a cell search. When questioned about this, Officer G said
that it would be normal practice. However, because of the design of the unit,
prisoners could see staff when they began searching and they then had time
to hide items. This is a matter of concern as the purpose of a cell search is to
discover hidden items.
172. I am also concerned that despite numerous fears about the man’s
vulnerability, and staff responsibility to check property cards, no one noticed
or enquired about the missing items. It is possible that some of these items
may have been given away freely by the man before he arrived onto Imber
Unit as payment for drugs. Staff did speak to the man about discrepancies on
his canteen sheet, but again seemed to be happy to accept his reasons for
buying items and giving them away. Anti-bullying measures were initiated on
this occasion and the man told staff that he was in debt and had to pay the
items back. Again, it is a concern that although the man freely admitted to
being in debt, no further enquiries were made and the anti-bullying document
was closed.
41
173. Some of the items that had either been taken from the man or given away
were returned to Imber Unit staff by prisoners after his death. This indicates
to me that the property had remained on the unit and could have been found
by staff. It also indicates to me that the prisoners no longer wanted to keep
what were the man’s belongings. If these items had been discovered or
identified during cell searches, it would have provided staff with further
evidence to help ensure that the man was not the victim of bullying.
174. As mentioned above, Erlestoke has an anti-bullying policy that is understood
by staff and the procedures are easy to follow. However, the Governor may
wish to remind staff that the process should not stop when a prisoner denies
being bullied. Staff should continue to monitor those prisoners considered to
be at risk. Particular attention should also be paid to those prisoners
considered ‘at risk’ when staff are conducting routine cell searches and
discrepancies in their property should be followed up. Equally, prisoners
identified as having other prisoners’ belongings should also be subject to anti-
bullying monitoring. In view of these concerns I make the following
recommendation:
The Governor should issue a Notice to Staff reminding them of the anti-
bullying procedures and the importance of using other resources such
as cell searching to identify possible bullying activity.
Security information
175. I have mentioned earlier in this report that numerous security information
reports concerning the man were submitted when he was at Erlestoke. Some
were specifically about him and he was mentioned in others. The subject was
mostly potential bullying, with some indicating concerns about drug use.
Despite the amount of information submitted, there is no evidence that staff
action took account of previous intelligence or that the bigger picture was
being considered. One such report on Imber highlighted that a prisoner had
brought drugs into the prison after a period of temporary release. The report
also indicated the possibility of the man being at risk of violence if he was
unable to pay for them. Despite the potential seriousness of the information,
the only action recorded was to pass on the information to the drug strategy
coordinator. I consider that the prison was not sufficiently proactive in
challenging the prisoner concerned or in ensuring the safety of other
prisoners, including the man. I therefore make the following
recommendations:
The Governor should ensure that security information is analysed
appropriately and any actions recommended by the security managers
is followed up, with outcomes being recorded.
The Governor should ensure that, where necessary, information relating
to a particular unit is shared with the staff so that all prisoners or others
that may be at risk can be monitored and supported.
42
Twelve Steps programme and de-selection
176. When the man began the Twelve Steps programme he spent longer in the
preparation stage to ensure that he was ready for the group work. Despite his
difficulties engaging in a group setting, Ms H, the manager of the programme,
said that the man coped well with the written work and before Christmas had
been engaging more in groups.
177. After the Christmas period, a number of prisoners confessed to using drugs
and the facilitators took action against each of them. The man was told that
he would return to the preparation stage of the programme, and be given time
to re-dedicate himself to the aims of Twelve Steps. Ms H said that the man
initially welcomed the opportunity of a second chance, but owing to the
influence of other prisoners, he then viewed the sanctions imposed on him as
unfair. Ms H said that staff were aware from the start of the man’s particular
problems engaging in a group setting. Therefore, extra measures were put in
place to support him, including the opportunity to return to the preparation
stage rather than being immediately de-selected.
178. The man’s admission to using drugs was not shared with his CARATs worker
or Ms E, his Offender Supervisor. Although Ms E went to see the man prior to
his de-selection, this was in response to an application he had submitted.
When she returned two weeks later, Ms H told her in a chance meeting that it
was likely the man would be de-selected within the next week. Ms H gave the
reason as his lack of motivation, something that Ms E said she had not
noticed.
179. It is clear from the investigation that Twelve Steps staff supported the man
while he was on the programme and extra measures were taken to enable
him to engage fully with the group sessions. However, the decision to de-
select the man appears to have been made in isolation. The views or
opinions of his CARATs worker, Ms A or his Offender Supervisor, Ms E were
not sought and neither was notified of the final decision until after the man had
left Imber Unit.
180. During the investigation, my colleague was told that there is a protocol that
sets out the requirements for de-selecting a prisoner from the Twelve Steps
programme. He has since found that there is no such a protocol, although
there are guidelines that set out good practice. The guidelines suggest that
good practice is to involve as many people as possible who have input into an
individual from outside of the programme when making a decision about de-
selection. The decision should not be made in isolation, and the prisoner
should be involved. The guidelines also indicate that the exception to this is
where there is enough documented evidence to support the decision.
181. When interviewed, both Ms A and Ms E said that after the man’s de-selection
they told him that the aim was to arrange a meeting and for Ms H to discuss a
way of moving forward. If the suggested good practice had been followed,
43
then such a meeting would have taken place before the decision was made.
This would have allowed all parties, including the man, to discuss the issues
and provide him with a clearer picture of how he could progress with his
sentence plan targets and allay possible concerns about his forthcoming
parole.
182. Given that the Twelve Steps programme is designed to treat those with
addiction, it is unfortunate that when a prisoner admits to using drugs they are
de-selected with no follow-up support in place. Ms H said that since the
man’s death, she has been more aware that extra support for de-selected
prisoners needs to be in place. This is being discussed, in partnership with
the CARATs team. In view of these concerns, I make the following
recommendations:
When a prisoner is considered for de-selection from the Twelve Steps
programme, staff should follow the good practice guidelines and
involve both CARATs workers and offender supervisors in the decision-
making process. This will also ensure that a de-selected prisoner is
supported as soon as they leave the unit.
The CARATs team should be made aware of any concerns about a
prisoner’s continued drug or alcohol use while on the Twelve Steps
programme.
Information sharing
183. During the man’s time at Erlestoke, numerous reports were submitted which
mentioned him in relation to suspected drug use and potential bullying. The
investigation has revealed that it was common knowledge amongst his fellow
prisoners on Imber Unit that the man was both using drugs and getting in debt
to pay for them, but they chose not to share this information with staff.
184. My colleague asked the prisoners concerned why they chose not to say
anything to staff, despite knowing the effect it was having on the man and that
it could result in his de-selection. The majority of them said that it would be
seen as “grassing”, which is something that they would not do. Instead, they
tried to deal with the problems themselves. There were a few prisoners who
said that they had tried to bring up the concerns about the man during
community meetings, but were told to keep quiet by other prisoners. Although
there is no evidence to support this opinion, my colleague got the impression
that the reason some prisoners were not willing to bring the problems to the
attention of staff was that they had their own interest in drugs being available
on the unit.
185. Further information and worries about the man were raised by his mother and
the family solicitor, who wrote to the prison to draw attention to their concerns
and enquire about his progress. On each occasion, the prison responded in
writing. The man’s mother also spoke with staff on Imber Unit and built up a
rapport with them. After the man’s de-selection, she telephoned the prison
about her anxieties and spoke at length to Ms K. Ms K responded to the
44
man’s mother’s concerns and followed this up with a letter. She also
contacted Wessex Unit to inform staff that the anniversary of his father’s
death was the following weekend and his mother had asked staff to keep an
eye on him. Ms K was told that staff would speak to the man. Information
such as that passed to Wessex by Ms K, should be considered significant. A
record of the concern should be made in the unit observation book, prisoners
wing history file, and passed on to the staff on duty.
186. With regards to Senior Officer C and his actions following the conversation
with the man’s mother. I am satisfied that Senior Officer C acted with the best
intentions based on his perception of the problems and his knowledge of the
man. During the conversation with Senior Officer C, it was evident that he
had been supportive of the man, but he could never have foreseen the actions
the man would take before he returned to duty.
187. The man’s family asked why the ACCT procedures had not been put in place
despite their raising concerns and making the prison aware of the anniversary
of his father’s death. Staff told the investigator that the man did not present to
them as having any problems, had not mentioned being depressed or
concerned about the impending anniversary. However, good practice would
be for staff to initiate the suicide and self-harm procedures where serious
concerns about a prisoner’s welfare are raised by friends or family, and
particularly where a significant anniversary is pending. This would allow a
formal assessment to be conducted and an informed opinion made on their
potential level of risk of self-harm. I make the following recommendations:
The ACCT process should be opened in all cases when a family raises
serious concerns about a prisoner’s welfare so that a full assessment
can be conducted. Those opened due to a significant anniversary that
might potentially cause the prisoner distress should put in place
enhanced monitoring in the days leading up to the anniversary, as well
as on the day, and should not be closed before the date has passed.
188. Ms K was unable to remember the name of the member of staff that she had
spoken to, but my colleague found that no entry had been made in the wing
observation book or the man’s wing history file. There was also no evidence
that the information had been shared verbally with unit staff and the man had
not been spoken to in relation to these concerns. Staff failed to follow
procedures and I therefore make the following recommendations:
The Governor should issue a notice to remind staff of the importance of
recording information. This should include a requirement that anyone
passing on information should obtain and record the name of the
person spoken to so that follow-up action can be monitored.
45
CONCLUSION
189. There are numerous accounts from prisoners who knew the man of his
struggle to overcome his drug use. His well documented desire to do all he
could to achieve a positive result from the Parole Board would clearly have
been affected by this continued drug use and almost certainly resulted in a
negative outcome. The man would have been aware of this.
190. While the investigation found that information about drug use on Imber Unit
did not appear to have been acted upon, anti-bullying procedures had been
started on more than one occasion. However, when staff spoke to the man,
he always maintained that there were no problems, and this may have been
because he was concerned about his own drug use being discovered.
191. Although the use of illicit drugs was the catalyst for the man’s removal from
the Twelve Steps programme, the IPP sentence and the failure to address his
offending behaviour would be likely to have weighed heavily on his mind. He
would have understood that his de-selection would have been likely to lead to
another period in custody and give him no definite end to his sentence.
Despite the reassurance of both Ms A and Ms E, it seems that the man felt
that his addiction would keep him in custody indefinitely and possibly
influenced his decision to take his own life.
Family response to draft report
192. Following sight of the draft report my colleague and one of my office family
liaison officers met with the man’s mother and sister on 9 September, to
discuss the investigation findings. The man’s family further reiterated
concerns that they had about access to dugs on Imber unit, given its role as a
rehabilitation unit. They were also concerned to learn about the apparent
failure of security staff to act on information relating to the man and welcomed
the two recommendations made to improve practice in this area. The family
remained particularly concerned that the man was deselected from 12 Steps
programme without any input from his CARAT’s worker or Offender
Supervisor and that little reassurance or explanation was offered about the
likely impact this would have on his parole application. The family believe that
this would have played heavily on the man’s mind at a time when he was
already feeling vulnerable due to the anniversary of his father’s death.
46
RECOMMENDATIONS
1. The Governor should issue a Notice to Staff reminding them of the anti-bullying
procedures and the importance of using other resources such as cell searching
to identify possible bullying activity.
Following the issue of the draft report the Prison Service accepted this
recommendation and said:
‘… A Notice To Staff (NTS) is awaiting approval from the Governor, with a
target date of 30 September 2010 …’
2. The Governor should ensure that security information is analysed appropriately
and any actions recommended by the security managers is followed up, with
outcomes being recorded.
Following the issue of the draft report the Prison Service did not accept
this recommendation, saying:
‘… The establishment analyses security information appropriately
however, a spot check will be completed by 30 September 2010 …’
3. The Governor should ensure that, where necessary, information relating to a
particular unit is shared with the staff so that all prisoners or others that may be
at risk can be monitored and supported.
Following the issue of the draft report the Prison Service accepted this
recommendation and said:
‘… A process is being compiled with a completion date of 30 September
2010 …’
4. When a prisoner is considered for de-selection from the Twelve Steps
programme, staff should follow the good practice guidelines and involve both
CARATs workers and offender supervisors in the decision-making process.
This will also ensure that a de-selected prisoner is supported as soon as they
leave the unit.
Following the issue of the draft report the Prison Service accepted this
recommendation, and said:
‘… Recommendation implemented in accordance with the clinical good
practise guidelines of the 12 Step Programme.
When a decision is made concerning the de-selection of an individual
from the programme it involves Treatment Manager, Programmes
Manager or Governor Drug Strategy Unit in his absence and CARAT Case
Manager or the Senior Practitioner in her absence.
47
On finalising an Individuals de-selection a confirmation email is sent to
CARATS and arrangements are then made to hold a 3 Way.
The 3 Way is organised by CARATS and will involve 12 Steps
representative, CARAT representative and the individual concerned in
order to establish the interventions that can be offered following de-
selection.
Following De-Selection the 12 Step Treatment Manager (or representative
in her absence) contacts the individuals Offender Supervisor in order to
inform them of the situation.
It is also standard practise to inform the individual that they are able to re-
apply for the programme after 28 days regardless of reason for discharge.
A copy of the updated policy for information sharing between 12 Steps
and CARATS has been produced and presented as evidence for part of
this action plan …’
5. The CARATs team should be made aware of any concerns about a prisoner’s
continued drug or alcohol use while on the Twelve Steps programme.
Following the issue of the draft report the Prison Service accepted this
recommendation and said:
‘… This process is now in place …’
6. The ACCT process should be opened in all cases when a family raises serious
concerns about a prisoner’s welfare so that a full assessment can be
conducted. Those opened due to a significant anniversary that might
potentially cause the prisoner distress should put in place enhanced monitoring
in the days leading up to the anniversary, as well as on the day, and should not
be closed before the date has passed.
Following the issue of the draft report the Prison Service responded to
this recommendation, saying:
‘… A Safer Communities Email address, phone and log will be
implemented by 30 Sept 2010.
Implementation of Safe Communities Phone Line with log and email
address by end September 2010 in order for families, friends, legal
representatives to report dates of anniversaries or concerns direct to the
Safe Communities Team in order for ACCT to be implemented.
Information about how families use the phone line and email along with
contact details are situated in public areas of the establishment (EG:
Visits centre, visits hall, 12 step public areas, legal visits waiting room
etc) and information is also included on Visiting Orders and Legal Visit
confirmation issued by OMU …’
48
7. The Governor should issue a notice to remind staff of the importance of
recording information. This should include a requirement that anyone passing
on information should obtain and record the name of the person spoken to so
that follow-up action can be monitored.
Following the issue of the draft report the Prison service accepted this
recommendation and said:
‘… A Notice To Staff (NTS) has been drafted and is awaiting approval from
Governor, target date of 30 September 2010 …’
49