Individual at Doncaster

Investigation into the death of a man whilst in the
custody of HMP & YOI Doncaster in February 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2011
This is the report of an investigation into the circumstances surrounding the
death of the man at HMP & YOI Doncaster in February 2010. The man was
an Iranian national on remand for the murder of his ex-girlfriend. He had been
in the prison for just six days when he was found hanging in his cell. I would
like to offer my condolences to his family and friends.
The man’s death was investigated by one of my senior investigators and my
senior family liaison officer contacted the man’s cousin and offered him the
opportunity to tell us about any questions or concerns he had about his
cousin’s death. At a late stage my family liaison officer was also contacted by
solicitors representing the man’s mother. A copy of the draft report was sent
to both. I received final comments from the family on 22 September 2011.
A clinical review was commissioned by a clinical reviewer at HMP Durham and
HMP Frankland. Because Doncaster is a privately run prison I have no formal
agreement with the PCT to provide a clinical review and rely on the
Department of Health to assist me to identify a suitable reviewer.
Unfortunately, the clinical reviewer was not appointed until some six weeks
after the man’s death. I did not receive his final report until 9 December 2010.
I offer my sincere apologies to the man’s family and to all interested parties for
the long delay in issuing this report.
I am grateful to the Director and staff of HMP Doncaster for their co-operation
with this investigation. I would also like to thank the senior investigations
officer for Serco, for sharing his findings with my investigator.
This investigation raises concerns about the reception procedures at
Doncaster and the ability of staff to appropriately identify prisoners at risk. I
am alarmed that staff do not refer prisoners for mental health assessments
when prompted by the reception screening tool, particularly as we made a
recommendation on this issue in a previous investigation. In a report into a
subsequent apparently self-inflicted death at Doncaster I raise a concern that
a risk identified at reception was not passed on to other staff at the prison.
This version of my report, published on my website, has been amended to
remove the names of the man who died and those of staff and prisoners
involved in my investigation.
Nigel Newcomen
Prisons and Probation Ombudsman September 2011
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CONTENTS
Summary
The investigation process
The Man
HMP Doncaster
Key events
Issues considered
Conclusion
Recommendations
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SUMMARY
The man was charged with the murder of his ex-girlfriend on 3 February 2010.
He appeared at Rotherham Magistrates Court on the same day and was
remanded into custody at HMP Doncaster. He had not been in prison before.
The police informed G4S court custody staff that the man was at risk of
suicide/self harm. The police wrote in the risk indicator table on his Person
Escort Form (PER) that he had attempted to take his own life in December
2009. The G4S court custody records show that a suicide/self harm warning
form (SSHWF) was opened.
When the man arrived at HMP Doncaster the SSHWF was not in his PER.
The receiving officer did not notice the entry in the risk indicator column. He
was the only person to look at the man’s PER.
The nurse who completed the man’s first reception health screen was aware
that prisoners charged with the homicide of a partner or family member are
considered to be at exceptionally high risk of suicide/self harm. Nevertheless
she did not refer the man to the mental health team when prompted to do so
by the health screen form.
The man presented as quiet and polite to staff and prisoners. He seems to
have mixed well with a small group of prisoners and, for the most part, did not
appear to be under stress. He had two family visits on 4 and 9 February.
Following the visit on 9 February, he appeared very stressed and told his
cellmate that he wanted to kill himself. His cellmate tried to reassure him and
thought that he had calmed him down. The man’s cellmate did not tell anyone
what the man had said.
The cellmate returned to his cell at the end of afternoon association and found
the man hanging from the bunk bed. He raised the alarm and three prisoners
and a member of staff cut the ligature. Two prisoners began Cardio
Pulmonary Resuscitation (CPR) and were relieved by nursing staff after a
minute. The man was pronounced dead by paramedics after 20 minutes.
I am critical of the risk assessment and reception process at Doncaster and of
the actions of two members of staff. I also note the prompt response of staff
and prisoners, their wholehearted attempt to save the man’s life and the
excellent care offered to staff and prisoners in the aftermath of his death.
I make seven recommendations including one to formally recognise the efforts
made by the four prisoners involved in the attempt to save the man’s life.
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THE INVESTIGATION PROCESS
1. I was notified of the man's death. The case was allocated to my
investigator on 11 February. My Assistant Ombudsman visited HMP
Doncaster on 15 February. He met with the Head of Internal Affairs,
collected the relevant documents, visited the wing where the man died
and spoke informally to the prisoner who was second on the scene. He
also spoke to the Ministry of Justice Controller.
2. Notices of investigation were issued and put up around the prison,
inviting staff and prisoners who wished to contribute to contact the
investigator. No responses were received.
3. My investigator visited Doncaster three times during February and
March 2010 and interviewed eight staff and five prisoners. She also
met the Ministry of Justice Controller, the Deputy Controller, and the
Senior Investigations Officer for Serco. My investigator visited
Rotherham Magistrates Court in April 2010 and interviewed three
members of the custody staff and copied relevant documents. She also
spoke by telephone to the G4S Custody Manager for court custody
suites in South Yorkshire. My investigator viewed Closed Circuit TV
(CCTV) footage from Houseblock 3 recorded on 9 February 2010.
Regular feed back on the progress of the investigation was provided to
the Head of Internal Affairs.
4. The clinical reviewer wrote a clinical review of the medical care
received by the man in Doncaster. The clinical reviewer was
commissioned by the Department of Health and agreed to undertake
the review on 25 March 2010. I received his final report on 9 December
and it appears at Annex 1.
5. My senior Family Liaison Officer, spoke to the man’s cousin by
telephone. She asked him for any questions and concerns he had
about his cousin’s time in Doncaster. He was concerned that the man
had been isolated in Doncaster and had not had visits or access to
monies that he had on him when he was arrested. He thought that the
man should have had a mental health assessment because he had
previously attempted to take his own life. He was concerned that there
was sufficient television cable in the man’s cell to allow him to hang
himself in the way that he did. He added that Doncaster had offered
financial and practical assistance with the repatriation of his cousin’s
body to Iran which had been helpful.
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The man
6. The man was born in Iran and moved to the United Kingdom in 2005.
He lived in Rotherham and, together with a business partner, ran a
pizza and kebab shop. Apart from one cousin, all of the man’s family
live in Iran.
7. According to the police report, the man began a relationship with a
woman in Rotherham and moved into her flat in 2008. The relationship
ended in late 2009. The man found the break up difficult and, on 25
December 2009, he took an overdose of alcohol and tablets. He was
taken to hospital and recovered.
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HMP & YOI DONCASTER
8. HMP Doncaster is a purpose built prison holding remand and
sentenced adult males and young offenders. It opened in 1994 and is
privately managed under contract by Serco Home Affairs. It is a local
prison serving the courts of South Yorkshire and has a maximum
overcrowded capacity of 1,145 prisoners.
9. Every privately operated prison has a Controller appointed by the
Ministry of Justice. The Controller is responsible for monitoring the
contractor’s compliance with the contract. The prison is required to
follow the operational guidance contained in the Prison Service Orders
(PSOs) and Prison Service Instructions (PSIs) that apply to public
sector prisons. In addition, private prisons have their own set of
procedural Director’s Rules specific to each prison.
10. An unannounced inspection by Her Majesty’s Inspector of Prisons
(HMCIP) took place in the week beginning 8 November 2010. The
prison was previously inspected in an unannounced follow-up
inspection in February 2008. HMCIP found the arrangements to
receive, settle and induct newly arriving prisoners operated well. At the
time there was an average of 600 new prisoners per month. Reception
was found to be well organised with staff taking steps to minimise
delays during the busiest periods. HMCIP found the induction
procedure to be thorough, with the appropriate involvement of
specialist departments. At the time of writing the average number of
new prisoners per month was 466.
11. The latest available annual report of the Doncaster Independent
Monitoring Board (IMB – independent volunteers who monitor the day
to day life in prisons) for 2008/2009 did not raise any concerns about
issues that are relevant to this investigation.
12. There have been 14 deaths at Doncaster since the Ombudsman took
responsibility for investigating deaths in custody in April 2004. Two of
these were apparently self-inflicted. I draw some parallels between the
man’s first reception health screen process and that of a prisoner who
died apparently by his own hand in 2006. There have been three
apparently self-inflicted deaths since the man died, three natural cause
deaths and from methadone toxicity. In the only report into these
published at the time of writing I raise a concern that a risk identified in
reception was not passed on to other staff.
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KEY EVENTS
13. On 28 January 2010, the man's ex-girlfriend was found dead in her flat.
He was arrested by police in Rotherham on 31 January. He was held
in police custody until 3 February when he was charged with her
murder. He appeared at Rotherham Magistrates Court the same day
and was remanded into custody in Doncaster.
14. The custody suite and escort services at Rotherham MC are run by the
private company G4S. Senior custody officer told my investigator that,
at 7.10am on 3 February, he collected the PER forms and property of
the prisoners who were due in court. He was briefed by the police that
the man had been charged with murder and had an indicator on his
PER that he was at risk of suicide or self harm. The G4S, senior
custody officer said he passed this information to his colleagues at the
morning briefing at 8.53am and made an entry on the daily briefing
sheet highlighting the man as a risk.
15. The court occurrence book for 3 February shows that the man was
collected from the police by a member of court custody staff at 9.20am.
All prisoners transferring between police, court and prison custody
have a person escort record (PER) form. The PER is in the form of a
booklet. Page two lists any indications that the prisoner may be at risk.
In the suicide/self harm column of the man’s form the police wrote
“Attempt overdose Dec 2009.” At 9.26am custody staff opened a
suicide/self-harm warning form (SSHWF). This is recorded in both the
court occurrence book and part B of the PER form. The SSHWF is a
separate document that should be placed inside the PER and travel
with the prisoner wherever they go. It consists of a front page and two
different coloured carbon copy sheets. Its existence should also be
recorded on the front cover of the PER. The front cover of the man’s
PER and the SSHWF have not been found.
16. Court custody staff told my investigator that the man was allocated cell
number seven because it was near to the custody office and therefore
made it easier for staff to make regular checks on him. Part B of the
PER shows that checks were made at 9.37am and 9.56am and that the
man was called to court at 10.05am. He was remanded into custody
pending trial at Sheffield Crown Court. He was returned to his cell at
10.11am and four more checks were made before escort staff took
over his care at 11.04am.
17. The man arrived in reception at Doncaster at 12.19pm. Prisoner
Custody Officer (PCO) was the receiving officer. The receiving officer
is responsible for checking the prisoner’s PER form for a SSHWF and
indications of any risk and passing them on to the nurse who interviews
the prisoner and completes the first reception health screen. At
Doncaster, the receiving officer is the only person who reads the
prisoner’s PER before it is placed in his custodial documents file. The
receiving officer is also responsible for completing the first and second
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parts of the Cell Sharing Risk Assessment (CSRA) form (those that
deal with indications of violent and anti-social behaviour, drug use and
whether the prisoner has a SSHWF).
18. The receiving told my investigator at interview that he did not notice the
suicide/self harm risk indicator on the man’s PER. He said that he had
forgotten his reading glasses that day. He said there was no SSHWF
in the PER. He added that it is his usual practice to ask the escort staff
whether there is anyone who is deemed to be a risk and the G4S
escort officer usually tells him anyway. The escort officer did not tell
him either that the man had a SSHWF or that he had an indication to
that effect on his PER.
19. The receiving officer explained that his first concern when looking at a
PER is to check the page that lists the property and valuables
belonging to each prisoner. Once it has been confirmed that the PER
tallies with the property that has arrived in the van, the prisoner can be
brought into reception. He said he remembered the man because he
had a significant amount of money. He recalled that he was polite,
confident and made good eye contact with him throughout the
reception process.
20. The receiving officer said that, at the time, it was the practice at
Doncaster that the third part of the CSRA (the medical assessment)
was completed first by the nurse during the first reception health
screen. He thought he might have put the man’s name, date of birth,
reception date and offence on the CSRA before he passed it to the
nurse but he did not complete sections one and two. He completed the
rest of the CSRA later before the man transferred to the first night
centre.
21. The nurse who completed the man’s first reception health screen. All
prisoners have their health screen interview in a separate room with
the nurse and, usually, a health care assistant (HCA). The nurse goes
though the screening process and enters the information onto the
prisoner’s electronic medical record and the HCA completes the paper
first reception health screen. The only paperwork that the nurse sees
is the part-completed CSRA and a SSHWF (if there is one). At
interview the nurse said she remembered the man. She said he was
polite, spoke good English and appeared fit and healthy. Nothing in his
demeanour gave her any cause for concern.
22. The nurse said she was aware of the nature of the charge against the
man. She said that when she asked him what his offence was, he had
replied, “they say allegedly I killed my ex-girlfriend”. At the end of the
first section of page two of the health screen it says in bold type, “if
charged with murder or manslaughter, refer for mental health
assessment”. At interview the nurse said she had not referred the man
for an assessment. She said she had either forgotten to refer him or
had gone though a conscious process and decided he did not merit a
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referral. When asked in the section on mental health whether he had
tried to harm himself in the past, the man replied that he had not.
Question 11 asks the nurse to record their impression of the prisoner’s
behaviour and mental state. The nurse did not complete this section.
23. The nurse also completed the second reception health screen. At
interview she said that ideally this form should be completed at a later
date and within the first 72 hours of custody. She thought for practical
reasons it was completed in reception at Doncaster. Finally the nurse
completed section three of the CSRA. She ticked the form to indicate
that the man was suitable for sharing a cell and that no concerns had
been raised about self harm. She wrote on the form “Nil issues” and
“NOC” (nature of charge).
24. The man returned to the main part of reception. The receiving officer
completed sections one and two of the CSRA. He ticked to indicate
that he had received the man’s PER and warrant. He wrote in the
additional important information section that the man was charged with
murder. He ticked ‘no’ in answer to the question of whether the man
had an open 2052SH (a form no longer in use indicating a prisoner is
subject to self harm monitoring) and gave the source of this information
as ‘I’ (for inmate). The receiving officer completed the man’s personal
summary sheet. The man told him that his next of kin was a friend who
lived in Doncaster.
25. Once the reception process was complete, the man was taken to the
first night centre on Houseblock 3. A Senior Prisoner Custody Officer
(SPCO) took him through the induction process. The purpose of the
induction process is to introduce the prisoner to the wing regime and
facilities and establish whether they have any issues from their lives
outside prison such as housing and employment. The induction officer
will confirm whether the prisoner is suitable to share a cell.
26. The induction officer told my investigator that he remembered the man
as respectful, well educated and able to speak good English. The
induction officer said that he had sight of the man’s CSRA but not his
PER or warrant as these were in his custodial documents file held in
the discipline office (administration centre of the prison). He knew that
the man was charged with murder but was not aware who the victim
was. He was unaware that people charged with domestic murder are
statistically at higher risk of harming themselves. Based on the CSRA
completed in reception, the induction officer confirmed that the man
could share a cell. The man was allocated cell 3D-48 (Houseblock 3,
D wing, cell number 48 – on the upstairs landing).
27. The induction officer said that the man had appeared fine when he
spoke to him. He had shown a little concern about how his business
partner would cope without him but the he said he had no concerns
about the man after speaking to him.
10
28. The following day, on 4 February, the man received a visit from his
cousin and his friend. Later that afternoon he was taken to reception
by the induction officer to witness two officers from Doncaster CID
remove money and a set of keys that he had in his possession when
he was arrested on 31 January. The induction officer said he asked
the man how he was getting on and he replied that he had slept well.
He said the man was obviously not overjoyed to find himself in prison
but had been quite sociable.
29. On 5 February, the man attended Sheffield Crown Court. The
accompanying PER showed no indications of risk. The man returned
to Doncaster the same day. There are no entries on his record
between the court appearance and 8 February.
30. The second prisoner on the scene, who worked as a wing painter on
Houseblock 3, told my investigator that he first spoke to the man on the
night he arrived. He said the man appeared to be fine and he also saw
him the next morning at breakfast. The man usually sat with him and
his friends at mealtimes. He recalled that in his first few days on the
Houseblock, the man said on several occasions that the police did not
have a case and he was innocent of the charge against him. After
about three days, the man appeared to withdraw more. He said he
tried to encourage the man to tell him why he was quieter but he did
not respond.
31. Two other prisoners said they spoke to the man at mealtimes. Both
described him as quiet and polite. The first prisoner said that everyone
was aware of the nature of the charge against the man but that he had
not come under pressure from other prisoners. The second prisoner
said that the man had not shown any outward signs of stress about his
situation.
32. On 8 February, the man was referred to the Immigration and
Nationality Department (IND) Criminal Casework Team in the Home
Office. All foreign national prisoners are automatically referred to IND
for consideration for deportation. On the same day the foreign national
prisoner representative, spoke to the man and completed an internal
foreign national referral form. The man said that all of his family lived
in Iran. He also completed an international call form in order to
telephone his mother in Tehran. The foreign national prisoner’s
representative told my investigator that the man had seemed relaxed
when he spoke with him.
33. On the same day a prisoner arrived at Doncaster and became the
man’s cell mate. The man’s cellmate told my investigator that the man
had seemed calm when he first talked to him in their cell. However,
after talking about the charge against him, the man became stressed.
The man’s cellmate said the man kept repeating that he had not killed
his ex-girlfriend. The man said he tried to reassure the man that if he
11
was innocent he would not stay in prison. He said the man kept
repeating, “I can’t be here now, I don’t want to be here.”
34. The next day the man received a telephone card that would enable him
to call his mother in Iran. He also received a visit from his cousin at
about 9.30am. The man’s cellmate said that the man was “very
stressed” after this visit. He said he thought that the man had received
some bad news about what evidence the police might have against
him. The man’s cellmate said that the man had told him that he was
going to kill himself. The cellmate said he tried to reassure the man.
He told him that suicide was against their religion (they were both
Muslims) and he should keep praying. The cellmate said the man
talked about his family in Iran. He said they did not know he was in
prison and other family members had told them that he was away. The
man said that if he killed himself then at least they could tell his family
that he was dead.
35. The man’s cellmate said the man appeared to calm down after he
talked to him and they even laughed about something. A third prisoner
said in a statement that the man had sat next to him at lunch. He said
that that the man had seemed happy. He spoke to his cellmate in a
different language. When he had finished eating he smiled at the third
prisoner and then went back to his cell. At about 2.10pm, the man’s
cellmate said their cell was unlocked for afternoon association and he
went for a shower. When he returned to the cell he could see that the
door was locked so he went down to the main association area. He did
not see the man there as he expected but did not think anything of it.
36. The man’s cellmate said that, towards the end of the association
period, he saw an officer unlocking the cell doors and returned to his
cell. He pushed the door open and saw the man hanging from the end
of the bunk beds. The man’s cellmate said he shouted for help and
three prisoners ran past him into his cell.
37. The first PCO on the scene was on duty on Houseblock 3 and had
unlocked the man’s cell at about 3.20pm. He did not look into any of
the cells but unlocked the doors and moved on to the next one. Once
he had unlocked the cells on the upstairs landing he returned to the
lower level. He heard the man’s cellmate raise the alarm and ran back
upstairs followed by a second PCO. On the way to the cell, the second
PCO used her radio to call for assistance. The radio operator’s
monitoring log shows that the call was made at 3.23pm.
38. The first prisoner on the scene told my investigator that he was in his
cell on Houseblock 3 when he heard the man’s cellmate shout that the
man was hanging. He ran to the cell and arrived a step ahead of the
second prisoner on the scene. The first prisoner on the scene said he
thought that the man was dead. He was blue in colour and cold to the
touch. His eyes were white and he had congealed blood and saliva
hanging from his mouth. He noticed that the ligature was a television
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cable that had been tied in such a way that the plug prevented the
cable from slipping from the frame of the bed. The first prisoner on the
scene said he and the second prisoner on the scene held the man up.
There was a lot of shouting and several people in the cell. A third
prisoner on the scene tried to undo the cable but it was too tight so he
shouted for the first PCO on the scene to cut it and the man landed in
his arms. The man was lowered to the floor and then a fifth prisoner on
the scene arrived and pulled the man out on to the landing where there
was more space.
39. The second prisoner on the scene told my investigator that he too was
in his cell on Houseblock 3 when he heard the man’s cellmate shout,
“he’s hanging”. He said he immediately ran to the cellmate’s cell,
arriving just after the first prisoner on the scene who went into the cell
first. The second prisoner on the scene saw the man was hanging
from the frame of the bunk beds with his knees touching the floor. The
man had used the cable from his television to hang himself. He had
also tied his hands together across his chest. The second prisoner on
the scene said that his first impression was that the man was dead. He
touched his neck and could not feel a pulse. He and the first prisoner
on the scene lifted the man up and a fourth prisoner on the scene tried
to undo he television cable but was unable to. The first PCO on the
scene used his personal issue cut down tool to cut through the
television cable.
40. When he arrived at the man’s cell, the first PCO on the scene said he
saw a group of prisoners holding him up. He saw that the man had the
television cable around his neck which was attached to the frame of the
bunk beds. He confirmed that he used his personal issue cut down
tool to cut the cable in two places. The prisoners put the man on the
floor and a fifth prisoner on the scene began giving him rescue breaths.
The first PCO on the scene said that other staff had arrived and the
SPCO, the unit manager, directed him to begin locking the other
prisoners in their cells.
41. The fifth prisoner on the scene said he was standing with the first
prisoner on the scene and the third prisoner on the scene when he saw
the man’s cellmate go to his cell. He did not hear what the man’s
cellmate shouted and assumed it was a fight. The first prisoner on the
scene and the third prisoner on the scene ran to the cell but he “stayed
put”. The fifth prisoner on the scene said he then heard someone
shout, “he’s hanging” and immediately ran over to the cell. He saw the
first prisoner on the scene, the second prisoner on the scene and the
first PCO on the scene laying the man on the floor. The fifth prisoner
on the scene said he had been in the army and knew how to administer
Cardio Pulmonary Resuscitation (CPR). He had also recently attended
a CPR course at HMP Everthorpe.
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42. The fifth prisoner on the scene said that he shouted to everyone
present to move out of the way and pulled the man out on to the
landing where there was more space. He checked the man’s mouth for
obstructions. The man was not breathing so he tipped his head back
and began rescue breaths. The first prisoner on the scene began
chest compressions. They worked at the rate of 30 compressions to
two breaths. The fifth prisoner on the scene said the man was grey in
colour and cold. He had blood and mucus coming from his mouth and
a severe indentation around his neck. The fifth prisoner on the scene
said he thought there was a faint sign that the man was breathing for
himself but it was not strong so he continued rescue breaths. He was
then told to move away and nursing staff moved the man into the
recovery position.
43. The unit manager told my investigator that he heard a medical
emergency called over the radio at the end of afternoon association.
He said that no code was given (Doncaster operates an emergency
code system - code blue means a person is not breathing, code red
means there is a blood injury). When he arrived at the man’s cell he
realised the nature of the emergency and used his radio to call for the
orderly officer (the officer responsible for the day to day running of the
prison) and for an ambulance. The radio operators’ monitoring log
shows that this call was made at 3.25pm. The unit manager then
directed staff to begin locking the prisoners in their cells.
44. The first nurse on the scene said she was in the nurse’s room on
Houseblock 3 with the second nurse on the scene when they heard a
call for emergency response on “3D” (D wing on Houseblock 3).
Neither of them heard an emergency code called so they were
unaware of the nature of the incident. The first nurse on the scene said
that, although neither of them was designated as an emergency
response nurse that day, they went to D wing anyway. They arrived at
the man’s cell at the same time as the unit manager and the induction
officer. She said she saw a group of prisoners performing CPR.
45. The first nurse on the scene said that the man appeared to be
breathing and she thought she felt a faint pulse in his neck. She, the
second nurse on the scene and the SPCO put the man in the recovery
position. The SPCO felt the man’s wrist for a pulse and said it was
getting fainter so they put him back on his back and she inserted a
geudel airway (a medical device that prevents an unconscious patient’s
tongue from blocking their windpipe).
46. The SPCO began rescue breaths and the first nurse on the scene did
chest compressions. The second nurse on the scene used her radio to
call for a defibrillator. The incident log records this call was made at
3.25pm. She let the fifth prisoner on the scene into the shower area so
that he could wash blood from his mouth. The defibrillator arrived very
quickly and she attached it to the man’s chest. It advised not to shock
(a sign that there is no electrical activity in the heart) and so they
14
continued CPR. The second nurse on the scene said she thought that
the man was already dead as he had changed colour and was cold to
the touch. The second nurse on the scene noticed that the man’s
hands were tied with a shoelace and his legs were also bound below
the knee with an article of clothing. He had deep ligature marks around
his neck.
47. Three other nurses went to Houseblock 3 after hearing a call on the
radio for a defibrillator to be brought there. A sixth nurse collected the
defibrillator from the adjacent Houseblock. The third nurse on the
scene and fourth nurse on the scene relieved the SPCO and the first
nurse on the scene. CPR continued until the prison medical officer,
arrived. He checked the man for signs of life and then told nurses to
continue CPR.
48. The incident log records that the ambulance arrived at the prison gate
at 3.30pm. At 3.35pm paramedics were directed from healthcare to
Houseblock 3. The paramedics took over CPR from staff. The prison
medical officer assisted them by giving the man adrenalin. At 3.50pm
the paramedics stopped CPR and the prison medical officer
pronounced the man dead.
49. A hot debrief was held in the prison at 5.40pm the same afternoon. (A
hot debrief takes place straight after an emergency. It allows staff to
discuss the effect the incident has had on them and to identify any
immediate lessons which need to be learnt.) The Director led it and the
first nurse on the scene, the SPCO on the scene, the first PCO on the
scene and the second PCO attended.
50. The assistant director, the reverend, the prison chaplain, the prison
Imam, and a police officer went to the man’s friend’s address in
Doncaster at 7.15pm to break the news of the man’s death.
Unfortunately the friend was not at home. The police subsequently
contacted him at 9.40pm. They also contacted the man’s cousin the
same evening.
51. A Critical Incident Debrief was held the following day on 10 February.
(This is a meeting held in the days after a serious incident to review
procedures and also to offer support to staff.) A trained counsellor was
present to offer support. The assistant director sent a hand written
letter of condolence to the man’s friend. The five prisoners who
attempted to resuscitate the man were taken to the prison chapel for
their own debrief with the chaplain.
15
CCTV footage
52. The clock on the CCTV footage viewed by my investigator did not show
the correct time compared to the prison incident logs (the clock on the
CCTV being some ten minutes fast). I am satisfied that the timings of
the incident logs are correct. The incident logs and the statements
from staff and prisoners are borne out by the CCTV pictures. The
following is a summary of events on Houseblock 3 D wing on the
afternoon of 9 February. The timings are taken from the CCTV tape.
53. The first PCO on the scene is seen unlocking the cells on the upper
landing for the afternoon association period. The man and the man’s
cellmate come out of their cell. The man walks around the landing and
then goes down to the lower level. The man’s cellmate talks to the
PCO and appears to show him some paperwork. The man’s cellmate
returns to the cell and comes out with a towel. He then disappears
from view. The man comes back up the stairs and goes into the cell.
A minute later he comes out of the cell and walks along the landing
looking around before going back inside. A couple of minutes later he
is seen in the cell doorway. He looks down to the lower level and
walks around the upper landing looking around. There is no one else
in the picture. He goes back in but comes out almost immediately
looks around again and then goes back in at 2.28pm.
54. Two minutes later a PCO and a prisoner are seen walking along the
landing. Eighteen minutes after that, another PCO comes up the stairs
following a prisoner and lets him in to the cell three doors down from
the man. A further 43 minutes later, at 3.30pm, the first PCO on the
scene unlocks the cells on the upper landing. He does not look into
any of the cells.
55. Three minutes after the cell has been unlocked and an hour and five
minutes after the man has last been seen, the man’s cellmate returns
to the cell at 3.33pm. The man’s cellmate goes into the cell and comes
out immediately, waving to attract attention. Prisoners run from the
other side of the landing and into the cell followed by the first PCO on
the scene. The pictures show the man being brought out onto the
landing within a minute and CPR being started. The unit manager
arrives within a minute of the alarm being raised. The first and second
nurses on the scene arrive within two minutes of the man coming out of
the cell.
56. It is then difficult to distinguish exactly what happens but emergency
bags arrive within two minutes of the first and second nurses on the
scene. The paramedics arrive 11 minutes after the man’s cellmate
raised the alarm.
16
ISSUES CONSIDERED
The assessment of the man’s risk
The suicide/self harm warning form
57. On the morning of 3 February, the police briefed the G4S senior
custody officer at Rotherham Magistrates Court that the man was
charged with murder and they had written on his PER form that he was
at risk of suicide/self harm. The court occurrence book (an electronic
record) and part B of the PER form record that a suicide self harm
warning form (SSHWF) was opened at the court. SSHWFs should be
placed in the relevant PER with the prisoner’s other documents in trays
in the court custody office. Escort staff collect the paperwork and put it
in the van. They pass the pink and yellow carbon copies of the
SSHWF to reception staff at the receiving prison and retain the original
white copy. The white copy is bundled together with copies of all the
paperwork that has travelled with that van and sent to the G4S archive.
Neither my investigator nor the Serco investigator, have been able to
find any part of this form. The G4S custody manager in South
Yorkshire told my investigator that the white copy was not in the G4S
archive.
58. I do not know what happened to the missing SSHWF. It does not
appear to have arrived at Doncaster. The front cover of the PER has a
box for escort contract staff to indicate whether there is a SSHWF
inside the PER. My investigator was told that staff in reception in
Doncaster could not find this cover. Inside the PER there is a section
listing other the forms enclosed. None of the entries are marked in the
man’s PER, including that for a SSHWF. The receiving officer said
there was no SSHWF in the PER when it arrived at Doncaster. I have
seen no evidence that the SSHWF left the court with the escort staff.
59. The absence of the SSHWF was the first step in a chain of events that
meant that the man’s risk of suicide/self harm was not adequately
appreciated until he was found hanging in his cell. The chain of
custody in communicating risk between the police, the court custody
and escort service and prison is crucial. If one link in the chain is
broken it can greatly undermine the ability of those further up the line to
exercise their duty of care.
60. In terms of an audit trail I am greatly concerned that no one in G4S can
show me physical evidence that such an important form ever existed.
I recommend that G4S instruct their custody suite staff to make a
copy of all suicide/self harm warning forms opened by their staff
and keep the copy in a file in each custody suite.
Initial reception and the first reception health screen
17
61. The receiving officer told my investigator that, when he looks at a
prisoner’s PER, he always looks for the pink slip of a SSHWF because
they are immediately obvious. He also said that it is his practice to ask
the escort staff whether anyone is at risk that he needs to be aware of.
He said that escort staff are usually proactive about warning him of
such prisoners. The escort staff did not mention the man to him on
3 February.
62. Nevertheless, it is the responsibility of the receiving officer to check the
prisoner’s PER form. By his own admission, the receiving officer did
not notice the entry on the risk indicator page of the man’s PER where
the police had marked in the suicide/self harm box, “attempt overdose
Dec 2009”. He told my investigator that he had left his reading glasses
at home that day. He also told my investigator that it is his practice to
turn immediately to the page listing the prisoner’s property and cash
because his first task is to make sure that the entries on the PER
correspond with what has arrived at the prison.
63. Unfortunately the information on the PER was perhaps the most
important information of all - the fact that the man had attempted to kill
himself in December 2009, just a few weeks before his remand. The
single biggest indicator that a person will attempt to kill themselves is if
they have tried to do it before. This omission was the second step in
the chain of events that meant that the man’s risk of suicide was not
recognised.
64. Because there was no SSHWF and because the receiving officer did
not notice the risk indicator on the PER, the nurse who completed the
first reception screen was not immediately prompted that the man
might be at risk of suicide/self harm. However, during the course of the
first reception health screen the man told her that he had been charged
with murdering his ex-girlfriend. The nurse told my investigator that
she was aware that persons charged with domestic homicide are
statistically at high risk of suicide/self harm. She said however that
nothing in his presentation indicated that he was at risk if suicide/self
harm and she did not take any further steps to assess the risk.
65. The nurse who completed the first reception screen did not refer the
man for a mental health assessment when prompted to by the first
reception health screen. At interview she told my investigator that she
either forgot or that she had decided from the man’s presentation that
he did not need to be referred. Neither did she record her impression
of the man’s mental state at question 11 on the first reception health
screen. In the clinical review, the clinical reviewer says:
“It is most unfortunate that an entry was not made here as the
failure to refer for formal mental health assessment could only
really be justified if a clear description of the current mental state
was given and it was not.”
18
66. Prison Service Order 2700 Suicide Prevention and Self Harm
Management chapter four paragraph 10 parts one and two say:
“Prisoners charged with homicide are a particularly high risk
group, and within this prisoners charged with homicide against a
partner or family member are at an exceptionally high risk of
suicide. Reception/first night staff must be made aware of the
suicide and self harm risks associated with prisoners who are
charged with offences related to violence against a family
member and/or homicide. [italics in original] …
“Establishments must make provision for additional risk
assessments and care to keep safe prisoners who have been
charged with domestic violence and/or domestic murder of a
family member. Such provision must include ensuring a record
is maintained to show what action has been undertaken [italics
in original].”
67. It is alarming that none of the discipline staff interviewed by my
investigator – all of them based either in reception or on the first night
centre and some of them very experienced - were aware that prisoners
charged with the murder of a partner or relative presented a particularly
high risk of suicide. The procedural failures in this case - the absence
of the SSHWF and the receiving officer’s failure to see the PER
indicator – could have been mitigated had staff been aware of this fact.
At the time there was no provision at Doncaster for the additional risk
assessments referenced in PSO 2700.
68. I am also concerned that the nurse who completed the first reception
screen, despite being aware of the heightened risk of someone
charged with domestic murder, did not highlight this to staff on the first
night centre. Even if she did not think that the man presented as being
at risk of suicide /self harm, I consider that this is important information
that should have been passed on. The nurse wrote ‘NOC’ (for nature
of charge) in the issues section of the CSRA, but I do not consider this
was sufficient, especially as she wrote above it “Nil issues”.
69. Neither did the nurse who did the first reception screen refer the man
for a mental health assessment when prompted by the first reception
health screen. She told my investigator that she was not sure whether
she had forgotten to do this or had gone through a conscious risk
assessment and decided the man did not require a referral. Whichever
is the case the prompt to refer a prisoner charged with murder for a
mental health assessment is mandatory and does not give the nurse
discretion.
70. In a previous death in custody at Doncaster in 2006 a different nurse
also failed to refer the prisoner for a mandatory mental health
assessment when prompted by the first reception health screen. In
that case I made a recommendation in July 2009 that “The Director and
19
Head of Healthcare must ensure that all staff make the referral required
by the first reception health screen.” The recommendation was
accepted. I am disappointed to discover that this omission has been
repeated. I consider that mandatory prompts to refer prisoners for
assessment if they fit known high risk categories (in the man’s case
because he was charged with domestic murder and in the 2006 case
because the prisoner had previously attempted suicide) are an
excellent idea. If there are gaps in knowledge about the nature of risk,
these prompts act as a failsafe. If they are not followed however, the
system fails.
71. There are other factors too that should have led to further consideration
of the man’s risk. Paragraph 6.16 of PSO 0500 Reception (in force at
the time the man arrived in Doncaster but since replaced by PSI
52/2010) lists prisoners who may be more prone to suicide/self harm.
The list includes: those in prison for the first time; those accused of
particularly violent offences, especially those against a family member;
and potential deportees. It was the man’s first time in prison and he
was a foreign national prisoner. This, like the nature of his offence,
was information which was known to staff at Doncaster.
72. I accept that throughout the reception process, the man appeared calm
and confident and gave no outward appearance of stress about finding
himself in prison in a foreign country. However, the guidance in PSO
2700, PSO 0500 and the prompts on the first reception health screen
are there for very good reason. In this case there was both a lack of
awareness amongst staff about the nature of risk and a failure to follow
procedures properly.
73. Immediately after the man’s death, the Director amended Director’s
Rule 18.1 (the local suicide and self harm strategy) as follows:
“14.9 PSO 2700 4.10 to 4.10.2 provides information on
prisoners charged with violence against a family member or
homicide. Establishments must make provision for additional
risk assessments and care to keep safe prisoners who have
been charged with domestic violence and/or domestic
murder/murder of a family member. Such provision must
include ensuring a record is maintained to show what action has
been undertaken. Doncaster’s policy is that all prisoners
charged with domestic murder, extreme violence including
that of a sexual nature against family members will be
placed on an ACCT plan. All prisoners charged with
murder who are also first time in prison will also have an
ACCT [the process used in prison to monitor prisoners thought
to be at risk of harming themselves] plan opened. [emphasis in
original]”
20
I am satisfied that the Director took prompt action in response to the
man’s death and I consider that the changes brought in via DR18.1
above tighten procedure at Doncaster. Nevertheless, I will send a copy
of my report to the Controller of HMP Doncaster so that she can
monitor the implementation of the Director’s Rule. The following
recommendations are intended to fill an apparent training need and to
ensure that the reception process in general is working as it should.
I recommend that the Director provides reception staff and
healthcare staff who complete first reception health screens with
refresher training on the provisions of chapter four of PSO 2700.
I further recommend that the Director of Offender Management for
Yorkshire and Humberside in consultation with the Ministry of
Justice Controller satisfies himself that the reception process at
Doncaster, including completion of the first reception health
screen, complies with PSI 52/2010 and Director’s Rule 18.1.
Completion of the man’s CSRA
74. PSO 2750 Violence Reduction deals with the cell sharing risk
assessment process. The purpose of the CSRA is to draw together
information about the risk a prisoner might pose to his peers in a
locked cell and to make the best use of documentary evidence.
Paragraph 15 provides that, if available, the PER and warrant must be
consulted when the CSRA is being completed.
75. According to the receiving officer, the practice in reception at
Doncaster in February 2010 was that the receiving officer put the name
and number of the prisoner, and sometimes also the offence, at the top
of the CSRA before passing it to the nurse. This information was
gathered from the PER and the warrant and then those documents
were placed in the prisoner’s custodial documents file. The nurse
completed the third part of the CSRA (the medical assessment) during
the first reception health screen. Reception staff completed the first
and second parts of the CSRA when they had time. These sections
deal with indications of violent and anti-social behaviour, drug use and
whether the prisoner has a SSHWF. It is my understanding that the
PER and the warrant are not looked at again once they have been
placed in the custodial documents file and are therefore not used to
complete any of the first three sections of the CSRA.
76. PSO 2750 does not prescribe in what order the CSRA should be
completed. However, I consider that if they are routinely completed in
the way described by the receiving officer, then the opportunity to use
the PER and the warrant to help identify risk is being missed. This is
contrary to the guidance in PSO 2750. Furthermore the nurse is
potentially also starved of important information that would inform the
first reception health screen. In the man’s case another opportunity to
notice the vital risk indicator on the PER was thereby missed.
21
I recommend that the Director of Doncaster issues a new
Director’s Rule to ensure that both the receiving officer and the
nurse complete their part of the CSRA with reference to the PER
and the warrant and any other available documents.
Other reception matters
77. Lastly I note that paragraph 10 of Director’s Rule 17.1 (which covers
the reception process at Doncaster) says:
“All new prisoners received at HMP&YOI Doncaster will be
immediately assessed by a qualified nurse and within a 24 hour
period by a qualified medical practitioner.”
I have seen no evidence that the man was seen by any member of
healthcare staff other than by the nurse who completed the first
reception screen.
78. My investigator raised this with the clinical reviewer but he was not
unduly concerned by this because the man did not appear to have any
reason to see a doctor. Nevertheless I draw it to the attention of the
Director and the Head of Healthcare.
The prison’s response to finding the man hanging
79. The response from both staff and prisoners was swift. The prisoners
were proactive in putting the man on the floor and giving him CPR.
The fifth prisoner had received CPR training in the Army and also while
he was a prisoner at HMP Everthorpe. The first prisoner on the scene
had also received training through working previously as a gym
instructor. At interview the fifth prisoner on the scene described a
textbook response to finding a person unconscious and administering
first aid. The first and second PCOs were on the scene immediately.
The first PCO on the scene used his cut down tool to cut the ligature
and the second PCO on the scene used her radio to call for emergency
assistance.
80. The first and second nurses on the scene arrived within two minutes of
the man being found. They were not the designated emergency
response nurses and carried no emergency equipment. Both had
received recent refresher training in emergency aid. The emergency
equipment arrived with the other nurses very soon afterwards. The
SPCO on the scene is a qualified first aid instructor.
81. When the nurses and the SPCO arrived, the fifth prisoner on the scene
told them he thought the man had started breathing faintly.
Accordingly they did not immediately take over CPR but moved him
into the recovery position while they checked his breathing and pulse.
When they were satisfied that the man was not breathing sufficiently
22
well they returned him to his back and started CPR. This is consistent
with best practice. Paramedics were on the landing within ten minutes
of the ambulance being called.
82. In the clinical review, the clinical reviewer concludes that the
emergency aid offered to the man was timely and in accordance with
the latest Resuscitation Council guidelines. The necessary equipment
was brought but he notes that a connection was found to be missing
from the ventilation bag. He did not feel that this contributed to the
man’s death but it is clearly extremely important that emergency
equipment is in full working order at all times.
I recommend that the Head of Healthcare review the procedures
for checking emergency equipment to ensure they are satisfied
that regular checks are made.
83. I am very impressed with the response of the prisoners in this case.
They acted swiftly and provided a professional level of first aid. They
also went back to their cells when asked to by staff. I note particularly
that the fifth prisoner on the scene performed rescue breaths on the
man without a mask and despite the presence of blood.
I recommend that the Director should formally commend the
prisoners for their committed attempts to save the man’s life.
84. The prison’s death in custody contingency plan was followed. An
incident log was kept at the scene and all appropriate agencies were
contacted in a timely manner.
85. At interview none of the staff who heard the call for emergency
assistance over the radio could recall hearing a code. They were
therefore unaware of the nature of the emergency to which they were
responding. A code system is in operation at Doncaster but does not
appear to have been used in this case.
I recommend that the Director issues a notice to staff reminding
them of the importance of using emergency codes when using
their radios to ask for emergency assistance.
Support for staff and prisoners
86. All the staff interviewed by my investigator told her that they had felt
very well supported in the aftermath of the man’s death. There was a
hot debrief on the same afternoon and a critical incident debrief the
following day. All staff were offered a session with a trained counsellor
and were visited by the staff care team. The counsellor proactively
approached staff and asked them if they wanted to see the counsellor.
87. Immediately after the man’s death all the prisoners involved in the
attempt to save his life plus another prisoner and the man’s cellmate
23
were taken to a separate room away from the wing and given hot
drinks and cigarettes. Security staff took their statements and they
were given a meal. They were all allowed to use the telephone in the
room to call home. They were also spoken to by the staff care team.
The next morning the same prisoners were taken to the Chapel to have
their own critical incident debrief with the chaplain. The second officer
on the scene told my investigator that he had also subsequently been
visited by members of the mental health team and the staff care team.
The first officer on the scene told my investigator that he had been,
“brilliantly well looked after”.
88. The man’s cellmate said that he had been visited by the care team, the
Imam, the chaplain and by healthcare staff. The prison doctor gave
him some medication to help him cope with anxiety. He had been
moved to another Houseblock and was obviously still struggling to
come to terms with what had happened. Houseblock staff were aware
that he was being interviewed by my investigator. Staff had opened
suicide monitoring procedures on the man’s cellmate following the
man’s death. He told my investigator that staff on his new Houseblock
checked on him regularly.
89. Staff and prisoners were all looked after well. I am particularly
impressed with the sensitive way in which the prisoners were treated.
Family liaison
90. The prison chaplain and the prison Imam travelled with the Assistant
Director to inform the man’s next of kin personally of his death.
Unfortunately the man’s friend was out and he was told by the police
later the same evening. I am pleased that prison staff attempted to
break the news of the man’s death in person. The next day the imam
left a message for the man’s cousin and also contacted the Doncaster
Coroner to help arrange a Muslim funeral at Doncaster Mosque.
91. The reverend subsequently spoke to the man’s cousin and it was
agreed that his body would be sent back to Iran for the funeral. The
reverend and the imam kept in touch with him and the prison offered
financial assistance. The man’s cousin also visited the prison. He told
my senior family liaison officer that the prison had been very helpful
about arranging for the man’s body to be flown to Iran.
92. On 10 February, the director wrote a handwritten letter of condolence
to the man’s cousin. The letter was sensitively written and offered the
family appropriate assistance.
93. The man’s cousin raised some concerns with my family liaison officer.
He was concerned that the man had been isolated in Doncaster and
had not had visits or access to money. Evidence from the five
prisoners spoken to by my investigator shows that the man formed part
of their group at mealtimes. There was another prisoner who spoke his
24
first language (he was transferred to another prison before my
investigator could interview him) with whom the man appears to have
got on well. The man also appears to have been able to talk freely to
his cellmate who shares his faith. I am satisfied that he was not
isolated or withdrawn in the short time that he spent in prison.
94. The man was in Doncaster for six days only. During that time his visits
record shows that he received two visits – on 4 and 9 February. He
arrived at Doncaster with a considerable amount of money in his
possession. This was seized by the police the following day as
evidence. When a remand prisoner arrives in a prison with no money,
he is given an advance of his unemployed basic prison wage in order
that he can make purchases at the prison canteen. The man’s canteen
record shows that he made several purchases from the canteen on 4
February and was not without money.
95. The man’s cousin was concerned that the man should have had a
mental health assessment because he had attempted suicide in
December 2009. I have dealt with concerns about the man’s risk
assessment above. Clearly he should have been referred for a mental
health assessment. He was also concerned that the man had access
to sufficient television cable in his cell to be able to hang himself. It is
my understanding that at the time my senior family liaison officer spoke
to him, the information received from the police was that the man had
used the cable as a ligature and also tied it around his arms and
hands. In fact the cable was of standard length. From the accounts of
the staff and prisoners present I believe that the man used a shoelace
to bind his hands and an item of clothing to tie his legs. Because the
man was not recognised as presenting a risk of suicide there were no
extra restrictions on what he could have in his possession.
25
CONCLUSION
96. The man appears to have made a determined effort to kill himself when
he knew he would be alone in his cell for sufficient time. The CCTV
footage shows him looking around the wing a few times before
returning to his cell for the last time. In all his dealings with staff and his
peers, the man presented as a confident and calm person. The only
person to whom he revealed that he was struggling to cope and
considering suicide was his cellmate. The man’s cellmate did not
believe that the man was serious about taking his own life and did not
tell anyone else. The man did not display any overt signs that he
presented a risk of harming himself.
97. Nevertheless, there is compelling statistical evidence that people
charged with the murder of a partner or family member are at increased
risk of attempting suicide. The man was also a member of another
particularly high risk group – those who have previously attempted to
take their own lives. The latter fact was missed during the reception
process at Doncaster and the former, though known, was not given the
recognition that the guidance in PSO 2700 requires. There is no
guarantee that the man’s death would have been prevented had his
potential risk been identified during the reception process or by the
mental health referral that should have been made. However, the
chances of staff being able to exercise their duty of care and keep him
safe were seriously undermined as a result.
98. I am pleased to note the prompt response of staff and prisoners, their
wholehearted attempt to save the man’s life and the excellent care
offered to staff and prisoners in the aftermath of the man’s death.
26
RECOMMENDATIONS
For G4S
1. I recommend that G4S instruct their custody suite staff to make a copy
of all suicide/self harm warning forms opened by their staff and keep
the copy in a file in each custody suite.
Accepted: “G4S operating procedures have been amended to instruct staff to
retain a copy of suicide self-harm warning forms opened by G4S staff in the
custody suite.”
Local and Area recommendations
2. I recommend that the Director provides reception staff and healthcare
staff who complete first reception health screens with refresher training
on the provisions of chapter four of PSO 2700.
Accepted: “Director’s Rule 18.1 section 14 and the appendix to Director’s
Rule 18.1 Reception Local rules on page 5 paragraph g was amended
immediately after the death of the man to read:
‘Prisoners charged with domestic violence. Action PSO 2700 4.10 to 4.10.2
provides information on prisoners charge with violence against a family
member or homicide. Doncaster’s policy is that all prisoners charged with
murder, extreme violence including that of a sexual nature against family
members will be placed on an ACCT plan. All prisoners charged with murder
who are also first time in prison will also have an ACCT plan opened.’
The introduction of PSI 09/2011 will also result in refresher training for
reception staff and HCC staff.”
3. I further recommend that the Director of Offender Management for
Yorkshire and Humberside in consultation with the Ministry of Justice
Controller satisfies himself that the reception process at Doncaster,
including completion of the first reception health screen, complies with
PSI 52/2010 and Director’s Rule 18.1.
Accepted.
4. I recommend that the Director of Doncaster issues a new Director’s
Rule to ensure that both the receiving officer and the nurse complete
their part of the CSRA with reference to the PER and the warrant and
any other available documents.
Accepted.
27
5. I recommend that the Head of Healthcare review the procedures for
checking emergency equipment to ensure they are satisfied that
regular checks are made.
Accepted.
6. I recommend that the Director should formally commend the prisoners
for their committed attempts to save the man’s life.
Accepted: “All prisoners to be contacted in writing by the Director and
commended on their actions.”
7. I recommend that the Director issues a notice to staff reminding them
of the importance of using emergency codes when using their radios to
ask for emergency assistance.
Accepted: “Staff will be reminded via note on the daily morning meeting
notes. The communication room will report any issues of wrong codes or no
code called when staff request support to the Assistant Director Security.
They will ensure the information is passed to the respective area and the
member of staff made aware of the correct procedure.”
28