Individual at Peterborough

Investigation into the circumstances surrounding
the death of a man
at HMP Peterborough in September 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2011
This is the report of an investigation into the circumstances surrounding the death
of a man at HMP Peterborough in September 2008. He was found collapsed and
dying in his cell shortly before 9.00pm that day. Attempts at resuscitation by prison
staff and paramedics failed to save his life.
I extend my condolences to the man’s family and all those touched by his death. I
am grateful to staff at HMP Peterborough for their assistance during my
investigation.
Following post mortem examination, a consultant pathologist found evidence of
blunt force injuries to the man’s head and face (as well as to other parts of the
body). The pathologist also found that the man had pre-existing ischaemic heart
disease. The pathologist concluded that the most likely explanation was that the
stress of an assault had precipitated a fatal cardiac dysrthythmia in the face of
significant underlying heart disease.
Cambridgeshire Constabulary identified six prisoners whom they considered to
have been involved in a concerted assault on the man. One of the six admitted his
involvement and pleaded guilty to a charge of manslaughter. The other five
denied involvement and were put on trial, also for manslaughter. At Crown Court
on 23 December 2009, three of the co-defendants were acquitted, while two were
found guilty.
The Prisons and Probation Ombudsman’s investigation was suspended pending
the criminal investigation and proceedings. At the conclusion of the criminal
proceedings, one of my colleagues carried out an investigation for this office. His
investigation focused on events prior to the man’s death, in particular, whether
sufficient action was taken in response to information suggesting that he might
have been at risk from other prisoners.
I apologise for the delay in issuing my report and for any additional distress this
may have caused.
I make five recommendations. Two relate to the way staff record and address
inappropriate and potentially violent behaviour. One is about taking account of
security information when allocating prison jobs. Another is about dealing with
prisoners who might be involved in the buying and selling of goods. The last is
about the need to conduct an audit of the cell alarm system.
This version of my report, published on my website, has been amended to remove
the name of the man who died and those of staff and prisoners involved in my
investigation.
Thea Walton
Deputy Ombudsman October 2011
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CONTENTS
Summary 4
The Investigation Process 5
HMP Peterborough 6
Key Events 8
Issues 18
Conclusion 23
Recommendations 24
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SUMMARY
1. The man was 33 years old, dying in unusual circumstances in HMP
Peterborough in September 2008. His cause of death was blunt force injury
to his head and face in association with underlying ischaemic heart disease.
2. The event that precipitated the man’s death was an assault made upon him
while in his cell. Several prisoners were arrested and initially charged with
murder. These charges were later reduced to manslaughter following the
post mortem examination. The pathologist’s findings included evidence of
blows to the man’s face, head and torso, but the injuries were not so serious
as would ordinarily result in death. The pathologist also found that the man
had an underlying heart condition and that the stress of the assault caused
cardiac arrest. At court, three prisoners were convicted of manslaughter.
The jury accepted that it had not been their intention to take the man’s life,
but had instead intended to issue him a “violent warning”.
3. This investigation has found no evidence indicating that either the man, his
friends or staff realised that other prisoners were planning an assault.
However, there was evidence that the man was alienating some of the other
prisoners through some of his behaviour. This evidence was captured in
security information reports, but little action was taken to deal with what might
be considered a ‘pattern’ of unacceptable behaviour.
4. An unfortunate aspect of the events occurring on the evening of the man’s
death was that when the other prisoners launched their assault, the man
pressed his cell alarm, as did a friend of his who was in the cell at the time.
Unfortunately, the alarm failed to activate; seemingly through an unexplained
technical problem. Part of the pathologist’s evidence, however, was that
even with early medical intervention his chances of survival would still have
been very poor.
5. My report focuses on potential learning for Peterborough. The direct cause of
the man’s death was established during the criminal trial following his death. I
make five recommendations. Four of these relate to the management of
prisoners who engage in violent behaviour or in the buying and selling of
goods. The other relates to the prison’s cell bell system.
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INVESTIGATION PROCESS
6. Following the man’s death my office made contact with HMP Peterborough
and also made contact with the Cambridgeshire Constabulary. The police
provided copies of CCTV recordings from the prison wing and also copies of
witness statements. In adherence to a protocol existing between my office
and the Association of Chief Police Officers, this office agreed to suspend its
investigation pending the outcome of the police investigation. .
7. Upon the conviction of three prisoners charged with involvement in the events
leading to the man’s death, one of my investigators attended a meeting with
the Cambridgeshire Constabulary to further discuss the evidence they had
collected. The investigator also visited HMP Peterborough to see the man’s
cell and to observe the wing. The investigator obtained an explanation about
the operation of the cell alarm system. The investigator explained the extent
and scope of the Ombudsman’s investigation.
8. The investigator subsequently interviewed six members of staff and spoke to
nine prisoners. One of the prisoners was a friend of the man’s who was in his
cell at the time he was assaulted.
9. The investigator contacted the Coroner, to whom a copy of this report will be
sent. However, there will be no inquest into the man’s death as the
circumstances directly leading to his death have already been considered at
Crown Court.
10. My Senior Family Liaison Officer wrote to the man’s wife, father and two ex-
partners to explain about the Ombudsman’s investigation. The family were
interested in receiving a copy of my report but did not raise any particular
issues that they wanted to be considered during this investigation. I hope that
my report offers further explanation into the events leading up to his death.
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HMP PETERBOROUGH
11. HMP Peterborough is a privately run prison, operated by Kalyx, under a 25
year contract to the Home Office. Opened in March 2005, it is the country's
only purpose-built prison for men and women, who are kept separate at all
times.
12. The operational capacity for male residence is 480. There are eight wings on
the male side radiating from a central hub and cellular accommodation
comprises both single and double cells. The residential area is on two levels.
13. Her Majesty’s Chief Inspector of Prisons conducted a short follow-up
inspection of Peterborough in June/July 2008. Following the previous
inspection, the Chief Inspector made a recommendation about the need for
improvements in the process for investigations into allegations of bullying. In
considering the action taken by Peterborough the Chief Inspector wrote in the
follow-up report that:
“A violence reduction referral form was usually completed following [an
incident] and prisoners were placed on the first stage of the violence
reduction strategy. The high number of prisoners automatically placed on
the strategy risked masking the extent and focus on bullying and did not
sufficiently distinguish behaviours … Few investigations included
supporting statements from victims. There were often delays between the
incident, investigation and subsequent action taken … Delays could result
in staff and victims losing confidence in the system. No prisoners were
currently [being] monitored through the violence reduction strategy, which
was unlikely to reflect the true situation …
“There were no effective interventions for bullies. Plans to introduce … a
course for prisoners with challenging behaviour had not materialised ...
Weekly reviews were held for any prisoner monitored as a suspected bully,
but the records did not suggest there had been any real challenge about
bullying behaviour. Only eight prisoners had been placed on stage two [of
the violence reduction strategy] in 2008.
“There was no evidence that bullying was a major problem or that the
prison was generally unsafe ... although [when compared to the last
review] there was now a better analysis of indicators of violence, there
were some discrepancies between sources including the number of
prisoner on prisoner assaults recorded through the incident reporting
system and through the violence reduction database.”
14. Peterborough’s anti-bullying policy comprises three stages. Stage 1 can be
instigated if any member of staff who witnesses any inappropriate anti-social
behaviour. The prisoner will suffer no loss of rights or privileges but their
behaviour will be monitored for between seven to 28 days. A prisoner will be
placed on to stage 2 if found guilty at an adjudication of fighting or committing
an assault or if is where there is a clear pattern of anti-social behaviour. In
this case the prisoner is likely to lose for a time some of his rights and
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privileges and the prison will implement a plan to help him address his
inappropriate behaviour. Moving a prisoner to stage 3 of the procedure will
be considered in the case of some combination of behaviours such as
repeated intimidation, continued aggression or a failure to respond to stage 2.
Sanctions in this case include a reduction in entitlement to privileges and
consideration of moving the prisoner to the segregation unit.
15. My office took over responsibility for investigating deaths in prison custody in
2004. Since that time there had been only three deaths of male prisoners
before that of the man’s. All three prisoners died from natural causes and no
issues arose during the investigations of those cases that were relevant to the
circumstances surrounding his death.
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KEY EVENTS
16. The man was born in March 1975. He had one brother. He spent most of his
working life as a taxi driver but later established a chauffering firm.
17. On 12 October 2007, the man was remanded into HMP Woodhill near Milton
Keynes, having been charged on a count of grievous bodily harm and a
number of linked offences.
18. During a standard first reception health screening assessment at Woodhill,
the man was asked whether he suffered with a number of specific illnesses,
including heart problems or chest pain. He denied having any of the listed
conditions and when asked if he had any other concerns about his physical
health, replied that he had none.
19. On 17 October, he transferred to HMP Peterborough and later that month
was convicted of the offences with which he had been charged. He was
subsequently sentenced to four years imprisonment.
20. Having completed the reception and induction processes, the man was
initially allocated to a cell on Y2 wing.
21. The Prison Service uses a variety of forms to record the large amount of
information that is collected about prisoners. One of the forms is the F2052A
form, which is commonly referred to as the “record of events” or “history
sheet”. This is the document used to note much of a prisoner’s day to day
activity. Entries made in the man’s history sheet during his first weeks in
Peterborough were positive, although one entry made at the end of
November included the comment that he “can still be a drain on staff at times
but behaves well.” That same entry also reported that he started working as
a wing cleaner that day.
22. Further entries in the man’s history sheet during December and early January
2008 again reflected that he was working well and was complying with the
prison’s regime.
23. All prisons have a system for dealing with any information or intelligence that
might affect the security of the prison, the security of its staff or the security of
prisoners. Any member of staff who identifies any matter that might
compromise safety should complete a security information report (SIR). The
SIR is then passed to the prison’s security team. The security team will rate
the information received in order to assess various matters such as the
reliability of the information, the potential risks and the action that should be
taken. On 14 January 2008, a member of staff wrote an SIR after witnessing
a suspicious incident where two prisoners appeared to exchange an item
which they each took pains to conceal. The prisoners involved were the man
and one of the prisoners later involved in the assault on him. This information
was not copied into his history sheet. Nor was it copied into the wing
observation book (in which observations about individual prisoners or general
comments about the wing might be recorded).
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24. At some time in January, the man stopped working as a wing cleaner and
instead became a servery worker (which meant that he gave out food at meal
times). An entry in his history sheet made on 27 January referred to him
having an argument with another of the servery workers about the running of
the servery. The man changed jobs a few days later, this time taking the role
of a Connexions worker. (This entails helping other prisoners with paperwork
relating to housing problems and other social issues.) Nothing is recorded
about whether it was the argument with the other prisoner that led to him
changing jobs.
25. As with all prisons, Peterborough operates an Incentives and Earned
Privileges (IEP) scheme. (Prison IEP schemes aim to encourage and reward
responsible behaviour through the award of greater privileges where a
prisoner has been compliant with the prison regime and has engaged in work
or other constructive activity. Enhanced status is the highest level within the
scheme.) Five separate entries in his history sheet through January all refer
positively to the man’s behaviour. He was noted to be polite to staff and
prisoners and compliant with the regime. As a result, an application was put
forward for him to be raised to enhanced status within Peterborough’s IEP
scheme. The wing officer’s comments in support of his application said that:
“[This man] is a good worker … a trusted worker who is polite to staff and
mixes well with other prisoners.” He was raised to enhanced status.
26. Positive entries about the man’s behaviour continued to be made in his
history sheet through the month of March, during which time he moved to Z2
wing. A few days later an officer submitted an SIR to say that he overheard
the man call out to another prisoner asking for a message to be passed to a
third prisoner reminding him that if he did not repay a certain debt he would
“get a smack”. The report was noted with the action to be taken: that wing
managers were to be advised of the incident and that the man was to be
monitored for three days. This information was not included in the man’s
history sheet, nor was it included in the wing observation book.
27. On 5 April, the man’s history sheet was noted to say that he had settled well
onto Z2 wing. Later on in the month, an officer recorded some apparent
concern for the man as it seems he was thought to be too quiet. The officer
noted asking him if he had “any issues” to which he answered that he had
none.
28. On 21 May, an officer submitted an SIR after a prisoner told him that the man
was threatening another prisoner and attempting to take items from that
prisoner. The officer added into his report that he had seen no evidence to
substantiate the allegation, and the prisoner who made the allegation was not
willing to say anything further. Again, this information was not included in his
history sheet, nor in the wing observation book.
29. A week later, the man was involved in an altercation with another prisoner. It
would seem that an argument arose following a misunderstanding about the
lending and borrowing of a computer game console. The man would seem to
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have exchanged blows with the other prisoner, although neither was injured.
When questioned, each blamed the other for the misunderstanding. Later on
that day, the man showed an officer a note that had been pushed under his
door that said “you’re a dead man”. Also on that day, the prisoner with whom
he had had a fight, told staff that he had been bullying servery workers for
extra food.
30. Peterborough’s response to the incident was to move the man to X2 wing and
to monitor him for a period of time under the local anti-bullying procedures.
Before he moved to his new wing, two prisoners told an officer that it was not
wise for the man to remain on Z2 wing as there was “bad feeling towards him
on the wing”.
31. The only entry made in the man’s history sheet about the events of these few
days was one referring to the confrontation with the other prisoner and that
anti-bullying paperwork had been started.
32. Two more reports about the man were submitted on 2 June. In a Violence
Reduction Referral Form, a prisoner was noted to have reported the man
asking him to pass a message to the prisoner with whom he had had a fight.
The message was that if the other prisoner “wants to call it quits and shake
hands then all will be left but if I get in trouble for hitting him he’s …dead”.
33. The other report was an SIR raised when a prisoner who claimed he was
being bullied by the man who thought him a “grass”, was arranging for the
man to be “sorted out”.
34. Both of the reports were considered under Peterborough’s violence reduction
measures. It was decided that no further action needed to be taken for the
moment as the man had been transferred to a different wing and he was
being monitored under stage 1 of the local anti-bullying procedure. A note
was made that if any further incidents were to arise, that the man would be
raised to stage 2 of the anti-bullying procedure. Neither of the two incidents
of 2 June were recorded in the man’s “history sheet”.
35. Monitoring of the man’s behaviour continued from 5 June to 12 June when it
ceased as no further concerns or incidents had arisen in that time
36. The man consulted one of Peterborough’s doctors on 19 June complaining
about chest pains. On examination, the doctor detected no sign of chest
wheezes. The doctor measured the man’s “peak flow” (his ability to blow air
from his lungs, a way of diagnosing asthma). The doctor recorded that the
had achieved a “perfect score” and that he had no history of asthma.
37. Also in June, the man failed a mandatory drug test, showing that he had
taken an opiate based drug. He was tested periodically for presence of drugs
in his system and it seems that this was the only occasion that he failed a
test.
10
38. Another SIR made on 10 July indicates that the man was making threats to a
prisoner on another wing about unpaid debts. No mention of this incident
was recorded on the man’s history sheet nor in the wing observation book.
39. The man started a new job as the principal servery worker on X wing on 14
July. An entry in his records this day said “… works well, no issues from him.
Compliant with officers and regime”.
40. On 23 July, the prisoner with whom the man had had a fight in May
complained that the man was regularly sending him threatening messages.
The prisoner said that although he was on a different wing, he was avoiding
going to the gym or anywhere else where he might encounter the man.
Consideration was given to placing the man on “stage 2” of the anti-bullying
procedure although it does not seem that this actually happened. No mention
of the incident was recorded in the man’s history sheet, nor in the wing
observation book.
41. Two entries in the man’s history sheet in early August each contained both
positive and negative comments. The positive comments were about him
being a hard worker who was polite to staff and generally compliant with the
prison regime. The negative comments included reference to him having an
“issue” with another prisoner (no detail was included about this “issue”) and
that he needed to be reminded about maintaining the boundaries between
officers and prisoners.
42. On 13 August an officer on X2 wing submitted a SIR about the man which
said:
“[The man] seems to believe that he has the right to question officers’
judgement. He seems to feel superior and is using his size/reputation to
intimidate staff/inmates.”
43. The officer who wrote the above report also made an entry in the man’s
“history sheet” to say:
“Has had an issue with myself. Interfering with wing discipline. It seems
the line between officer and prisoner is “blurred” with [the man].”
44. On the same day, another prisoner complained to staff about the man. He
said that he was stealing from the servery by giving out “short servings”. The
prisoner also complained that he was intimidating smaller/younger prisoners.
The security information form on which this incident was recorded was noted
to say that there had been previous complaints about the man threatening
and intimidating other prisoners. The planned action for dealing with the
matter was to inform the wing managers and for him to be interviewed (there
is no evidence that this happened).
45. A positive entry made about the man in his “history sheet” on 17 August said:
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“No issues, polite to staff and compliant with regime. Good [principal
worker] in servery, keeps it moving very quickly, always knows what’s
going on.”
46. Two days later a prisoner complained that the man became confrontational
about the music he was playing. This information was recorded in both a
security information report and in the man’s “history sheet”.
47. An entry made in the man’s records on 8 September was positive. It referred
to him being in good spirits, that he was working well in his job and was
compliant with the regime.
48. A prison custody officer (PCO) told my investigator that he first met the man
on Z wing not long after he first arrived at the prison. The PCO said that the
man tended to keep himself to himself, but he seemed “more or less happy”.
Referring to the man’s then role as a Connexions worker, the PCO said that
prisoners selected for this work will be those with a good grasp of spoken and
written English and who relate well to others. The PCO later transferred to X
wing and the man followed around two months later.
49. The PCO said that when he encountered the man again, this time on X wing,
he seemed much the same as he had been previously. He was by then
working as the principal servery worker. The PCO said that the man kept the
servery clean and he was quick and efficient at serving meals. No prisoners
complained about him as far as the PCO was aware. The PCO explained
that an officer always supervises the serving of meals. This means that any
issues about matters such as prisoners trying to jump the queue, or asking for
extra portions is handled by the officer and not by the servery workers. He
added that the man got on well with the other servery workers and they
tended to go to the gym together. Indeed, he seemed to get on with most of
the other prisoners and the PCO was unaware of any prisoner on the wing
being resentful of him. My investigator asked the PCO if he knew what was
meant by the entry in the man’s records made in August about him needing
reminding of the boundaries between officers and prisoners. The PCO said
that the man was very friendly but he needed to be reminded to be not so
familiar. He added that the man was not unique in behaving this way as most
prison wings had a prisoner who tended to blur boundaries.
50. Another PCO also first met the man when he was on Z wing. She told my
investigator that she always found the man to be a polite and compliant
prisoner. She told my investigator how the serving of meals is arranged. She
explained that every prisoner would have previously submitted their menu
options and their choices read out when they reach the servery. Officers,
however, are responsible for supervision of the process.
51. She told my investigator about an incident that occurred during the serving of
the evening meal on the day of the man’s death. He was working as the
principal servery worker as usual. One of the prisoners who was involved in
the later attack on him tried to push to the front of the queue. She stepped
forward and told him to go to the back of the queue and wait his turn. She
12
had to repeat the instruction before the prisoner complied. She said that
while she was speaking to the prisoner, the man did not say anything, he just
went on with serving the meals.
Events on the evening of 11 September
52. Three PCOs were on duty on X2 wing during evening association on 11
September. CCTV footage from just before 7.50pm shows a prisoner from
the upper landing walking down one of the two stairways leading to the lower
landing. This was the stairway at the end of the landing furthest away from
the man’s cell. When the prisoner reached the bottom of the stairs, he
collapsed, apparently suffering an epileptic fit. The first PCO was on the
lower landing closest to where the prisoner collapsed and she went to assist
him.
53. The first PCO told my investigator that she was dealing with paperwork in the
wing office when she was alerted by a prisoner that another prisoner had
collapsed to the floor. She went over to the collapsed prisoner and noted that
he was breathing, but thought that he should be checked by a nurse. She
had not been issued with a radio that evening as she was mainly dealing with
paperwork. The second PCO was at the other end of the lower landing and
she called out to him to contact healthcare.
54. The first PCO said that the two other PCOs came to the collapsed prisoner
while she radioed healthcare. A nurse arrived on the wing and began treating
the collapsed prisoner. At that point, the first PCO went back to the wing
office to continue with her paperwork and the other officers resumed
patrolling the wing.
55. The first and second PCOs’ evidence to my investigator was consistent.
56. My investigator was not able to speak to the third PCO as he has since left
the employment of Kalyx (the private company that runs HMP Peterborough).
His movements, however, were captured on CCTV. The footage shows that
he was on the upper landing when the prisoner collapsed on the opposite
lower landing. It would not seem that he realised at first what had happened.
It seems, instead, that it was when the first PCO began moving towards the
collapsed prisoner that he thought there might be an incident occurring where
his help was needed. At that point, he walked down the stairs and towards
the opposite end of the lower landing. This left the upper landing unstaffed.
57. Meanwhile, the CCTV footage shows several prisoners from the upper
landing leaning over the banister rails. At the point that all three of the PCOs
are attending to the collapsed prisoner, four of the prisoners from the upper
landing enter the man’s cell. One of the four leaves very soon after entering,
but the other three remain in the cell for several minutes. (Another prisoner, a
friend of the man’s, was in the cell when the other prisoners entered and he
remained in the cell throughout the time that they were in the cell.)
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58. At around 8.10pm staff began to lock-up prisoners for the night. The second
PCO was locking the upper landing. He told my investigator that one of the
duties of the principal servery worker is to prepare the meal total sheets for
the following day stating how many of each menu item is needed from the
kitchen for the wing. He said that the man was well organised and was
usually ready to pass over the sheets at lock-up time. This evening was
different as he was not standing by his door as usual. The second PCO said
that he pushed open the door and saw that the cell was in disarray. He said
that this also was unusual as the man kept his cell in well ordered condition.
He saw him slumped on the floor in a sitting position with his back against the
wall. He tried unsuccessfully to rouse him and then radioed for an
emergency medical response. He said that the third PCO came into the cell
and they both tried to find a pulse, but without success. He said that more
staff began to come into the cell at this point and he found himself being
pushed away from him.
59. A Senior Prison Custody Officer (SPCO) and another PCO arrived together at
the cell and both wrote statements about their involvement. Both report that
at the time of their arrival the man was in a seated position slumped against
the wall. The SPCO noticed some liquid coming from his mouth and, worried
that he might choke, moved him into the ‘recovery position’ (a lying position
on the side). She checked him for signs that he was breathing and, finding
that he was not, instructed her colleagues to move him onto his back. She
checked once more for signs of breathing. There were still no signs and at
that point staff started cardio pulmonary resuscitation (CPR).
60. A nurse arrived and she checked the man with a defibrillator1, which advised
that no shock be given but that efforts at CPR should continue. Staff
continued their efforts at CPR until ambulance paramedics arrived and took
over. Unfortunately, all attempts to revive the man proved unsuccessful and
he was pronounced dead at just before 9.00pm.
61. Most of the officers who entered the man’s cell noticed that there was a great
deal of mess, one officer described the cell as “trashed”. This was
particularly striking for the staff as the man was known for keeping his cell
clean and in good order. The second PCO had noticed some bumps and
bruises on the man’s face and the third PCO told the SPCO that he thought
the man had been beaten.
62. The local police force is routinely informed without delay about a death in
prison custody. The police will visit the prison and examine the scene where
the death occurred. In the vast majority of cases, there will be no evidence of
foul play or third party involvement in the death. However, with this death it
was apparent that something untoward had occurred.
63. When CCTV footage was viewed, it showed several prisoners entering the
man’s cell together at the point in time that the wing officers attended to the
1 A defibrillator checks for presence of electrical activity in the heart and emits audible instruction
about management of the patient.
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prisoner who had collapsed on the lower landing. Prison staff identified for
the police the prisoners apparently involved. The police interviewed those
prisoners as well as others who it was believed might be witnesses.
64. Peterborough’s then Director gave a briefing to staff that night. Two
members of the Samaritans were called into the prison the following day in
order to provide support to prisoners and staff. The Samaritans were briefed
on their arrival in the prison about the suspicious nature of the man’s death.
65. Because of the apparently suspicious circumstances surrounding the death,
the prison agreed that police officers should break the news to the man’s
family. A prison family liaison officer was appointed and he subsequently met
the man’s wife, his nominated next of kin. The prison held a memorial service
which his wife attended. Peterborough contributed to the funeral expenses.
66. The police investigation team took statements from various members of staff.
Most of those who expressed comments about the man described him as
polite and compliant with the prison regime and most seemed unaware of any
feelings of resentment towards him from other prisoners. However one
member of staff, a principal officer, wrote in his statement that the man was “a
bully … into the drug culture on the wing … a staff manipulator who tried to
get to no-go areas with staff on the wing.” Due to this staff member’s long
term absence from work through ill health, my investigator was not able to
interview him.
67. My investigator spoke with Peterborough’s Head of Male Residence at the
time the man was in the prison. My investigator asked about the use of SIRs
in managing prisoner behaviour. She said that any information highlighting a
prisoner as a potential bully would be discussed at the monthly safer custody
and violence reduction meeting. She said that a member of the security team
would also be a member of the violence reduction committee and that there is
regular liaison between the safer custody senior officer and security and a
monthly report is completed. That information is discussed at the violence
reduction meeting. If a pattern of inappropriate behaviour was highlighted a
decision would be made about how to deal with that. She said that If there is
corroborated evidence or continued evidence that some form of bullying is
taking place, the prisoner will be placed on “stage 2” of the anti-bullying
procedure. That could mean reducing the prisoner’s IEP level to “basic” for a
period of time, and the next stage would be a move the separation and care
(segregation) unit.
68. However, she could not recall the man being discussed at the safer custody
and violence reduction meetings and could not recall anything emerging to
suggest that he was involved either in bullying or being targeted by others.
69. My investigator spoke with a Principal Officer (PO) about the response by
officers to the apparent medical emergency that occurred on the lower
landing on X2 wing on the evening of 11 September which left the upper
landing unsupervised. My investigator asked whether one of the officers
should have continued to supervise the wings leaving the other two officers to
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deal with the emergency. The PO said that prisoners will use distraction
tactics to draw staff attention while other prisoners exchange forbidden items,
such as notes and drugs. However, staff are trained to respond to medical
emergencies and in the case of a person having a fit, the person can often be
violent during the fit and in danger of harming themselves as well as others.
He said that if an insufficient number of staff responded to such an incident,
Peterborough could be open to criticism.
The man’s cause of death
70. A Home Office consultant forensic pathologist was instructed to carry out a
post mortem examination on the man. He conducted preliminary and final
post mortem examinations and he wrote reports following each. He also
wrote two supplementary reports. His findings from his final post mortem
examination included that:
“There is evidence of significant natural disease in the heart with severely
stenotic coronary atherosclerosis in the left … coronary artery (narrowing
of the artery through a fatty build up). This would have made the deceased
potentially vulnerable to the development of sudden cardiac dysrhythmia
(abnormal electrical activity in the heart), particularly in circumstances of
stress …
“The findings in relation to the facial area and head are in keeping with
multiple blunt force impacts. There is also evidence of blunt force impacts
and/or gripping on the upper and the lower limbs as well as on the trunk.
These findings overall are consistent with multiple blunt impacts such as
from fists or mild to moderate force kicking. There is however no evidence
of any severe force kicking or other severe force blunt impact …
“On the basis of a lack of any fracturing or intracranial haemorrhage it
appears that the nature and extent of head and facial impacts falls short of
that normally associated directly with fatality. In my opinion the most likely
scenario is that the stress of an assault has precipitated a fatal cardiac
dysrhythmia in the face of significant underlying ischaemic heart disease ...”
71. The pathologist gave the cause of death as:
“1a Blunt force injury to head and face in association with underlying
ischaemic heart disease.”
72. In his first supplementary report, the pathologist wrote:
“There is a history of heavy smoking which would be a significant risk
factor for the development of coronary artery disease. In the [community
general practice] notes there is an entry [from 2003] when left sided chest
pain was complained of. In the prison records there is an entry dated 19
June 2008 … when chest pains were complained of. On neither occasion
was it suggested that these symptoms might have been related to
ischaemic heart disease and it does not appear that any further
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investigations were instigated. In retrospect it may be that the symptoms
complained of on either or both occasions were attributable to ischaemic
heart disease. However this would be to some extent speculative.
“Importantly, there is no evidence that the deceased was complaining of
any symptoms which in retrospect might be attributable to ischaemic heart
disease in the days leading up to his death … “
73. The pathologist produced a second supplementary report when asked to
consider the man’s chances of survival in the case that he had received
immediate medical attention. His opinion was that even in that situation, the
prognosis for him would still have been very poor with his chances of survival
probably being less than ten per cent.
74. Based upon all of the information before it the Crown Prosecution Service
decided that the prisoners apparently involved in the assault should be
prosecuted for manslaughter. One prisoner pleaded guilty and five others
were put on trial. Of these five, two were convicted of manslaughter and the
remaining three were acquitted.
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ISSUES
75. The prisoners directly involved in the attack upon the man that resulted in his
death were prosecuted, convicted of manslaughter and duly sentenced. This
report focuses on any potential areas of learning for Peterborough.
Security and other reports about the man’s behaviour
76. The man’s records indicate two distinct sides to his personality. In terms of
his interaction with staff, it seems that he was generally polite and compliant
with the prison rules and regime. It is also clear that he was a hard worker.
His final job was principal servery worker on X2 wing and several positive
entries were made in his records about his performance in this role. Other
entries in his records however refer to him sometimes interacting
inappropriately with staff. This, it seems, related to him being over familiar in
the sense of behaving towards staff more as would a peer, rather than as
should a prisoner.
77. With regard to his relationships with other prisoners, his records contain a
number of entries indicating that some prisoners considered him a bully or an
intimidating presence. On one documented occasion on Z2 wing he
exchanged blows with another prisoner. The two prisoners each blamed the
other for the incident so neither prisoner was deemed the guilty party. Even
so, the man was moved to X2 wing and for a seven day period and was
subject to anti-bullying monitoring. Immediately before his transfer two
prisoners reported to an officer that there was “bad feeling” towards him so
that it would not be wise for him to remain on the wing. This would seem to
be the only incident of potential bullying on the man’ part that was properly
investigated.
78. During the man’s time on X2 wing two separate reports were made about him
issuing threats to other prisoners about unpaid debts. One of these reports
led to him being monitored for three days. These were not the only reports
submitted about him. Another was about him giving out short servings on the
servery and stealing the surplus. One more was made by the prisoner with
whom he had had an altercation on Z2 wing. This prisoner complained that
he was continuing to send threats to him even though they were living on
different wings.
79. Prison Service Order (PSO) 2750 provides prisons with guidance and
instruction on the issue of violence reduction. PSO 2750 points out that staff
need to be aware that prisoners who are at risk of being victimised might be
tempted to use violence to defend their interests. PSO 2750 goes on to say
that prisoners involved in unacceptable behaviour must be challenged
through:
• staff intervention to resolve conflict in its early stages will reduce
likelihood of escalation to physical violence and need not always
necessitate disciplinary action.
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• constructive sanctions and incentives such as [the Incentives and
Earned Privileges scheme (IEP)] are appropriate for some prisoners,
but must be part of a package of measures which address the causes
and contributory factors.
80. PSO 2750 also instructs that any incidence or pattern of unacceptable
behaviour must be clearly recorded on the prisoner’s history sheet. Further
advice about managing unacceptable prisoner behaviour is contained
throughout the PSO.
81. The man’s history sheet was not used in the way required by PSO 2750.
There are sporadic entries about some of the incidents that occurred between
him and other prisoners, but an insufficient number are included to suggest
any pattern. The staff with whom my investigator spoke were essentially
unaware of any history of inappropriate behaviour on his part and unaware of
any feelings of resentment from other prisoners towards him.
82. Nothing is recorded to show whether thought was being given at any stage to
discussing with the man any pattern in his behaviour. Nor is anything
recorded about whether thought was ever given to reducing his IEP level.
83. In addition, the man was able to secure for himself the position of principal
servery worker. I understand this to be a coveted job and as such, I would
expect the person appointed to be among the more trusted and well behaved
of prisoners. I would question the process through which the man came to be
appointed to this position given his wing history.
I recommend that the Director remind staff about the guidance and
instruction in PSO 2750 in dealing with inappropriate behaviour and violence
reduction.
I recommend that the Director consider, and revise if necessary, procedures
for adequate copying into prisoner history sheets of relevant security
information.
I recommend that the Director consider, and revise if necessary, procedures
for proper use of security information when allocating jobs.
Possible motivation for the assault on the man
84. Despite the incidents that led to adverse reports being written about the man,
the precise motivation for the assault on him remains unclear. None of the
prisoners involved were among the number who had been threatened by him
or involved in any recorded altercation with him. Moreover, according to his
friend neither he nor the man suspected that an attack was being planned.
Indeed, a viewing of the CCTV recording for the evening of 11 September
shows the man walking about the wing in what appears a comfortable and
confident manner. His friend said that as the other prisoners came into the
cell they accused the man of being an informer. However, I have seen no
evidence to support such an accusation.
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85. Press reports of evidence that emerged at the trial of the three prisoners later
convicted of manslaughter referred to resentment of him due to a “reputation
for dealing in drugs and tobacco”. An SIR report in January 2008 detailed an
incident where he and another prisoner appeared to have exchanged an item
that each of them appeared to have taken pains to conceal. The implication
was that the item, if there was one, was a prohibited item, for instance drugs.
However, neither prisoner was searched it would seem so nothing was
proven. Five months later, the man failed a mandatory drug test. These two
incidents apart, there is no other evidence that he might have been involved
in the buying and selling of drugs.
86. There is some evidence that the man was involved in buying and selling
goods on the wing. This would probably have been the buying and selling of
prison canteen items such as cigarettes and foodstuffs. Two of the security
information reports about him allege that he was sending threats to other
prisoners about unpaid debts. These might have been debts about the failure
to pay for canteen items supplied by him, but this is speculation. The CCTV
recording from the night of the man’s death shows prisoners involved in the
assault walking out of his cell afterwards carrying items which presumably
belonged to him. These might have been items that he was planning on
selling on, but this again is speculation.
87. I accept that the buying and selling of goods probably goes on in all prisons
and is a difficult practice to control. Nevertheless, the practice is forbidden
within Peterborough’s wing rules, as it is in all prisons.
I recommend that the Director remind staff to be vigilant in identifying
prisoners involved in the buying and selling of goods.
Cell bell alarm system
88. All prison cells are fitted with cell alarms to allow prisoners to call for
assistance at times when they are locked in their cells. Prisoners are
instructed that cell alarms should only be used in the case of an emergency.
Consistently, however, most cell alarm use in most prisons are for reasons
other than an emergency. In Peterborough, the cell alarm system is
supported by the use of in-cell intercoms. When the prisoner activates the
cell alarm, the call goes to a central control point on the wing. An officer there
will speak to the prisoner via the intercom to find out the reason for the call.
The central control point will usually be staffed, but there will be times when
the staff might be elsewhere dealing with other matters. In that case, cell
alarms will be diverted to the main communications room if they remain
unanswered after 60 seconds. The main communications room is never left
unstaffed.
89. Cell alarm use by cell is recorded on an electronic system. The records show
that the man’s cell alarm was activated three times in quick succession on the
evening of 11 September, although the times recorded are around 20 minutes
earlier than the time of the assault. The recording sheet contains a column
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where the reason for the alarm call should be entered. For all three calls
“none” has been entered as the reason for the call. All calls were
disconnected in less than a second.
90. My investigator spoke to the prisoner who was in the man’s cell when the
other prisoners entered and carried out the assault. The prisoner said that he
had been chatting with the man, who was unaware that other prisoners were
planning to assault him. When the other prisoners came into the cell, one of
them accused him of being a “grass”, which he denied. The prisoner began
punching the man, who pressed the cell alarm button twice. The friend also
pressed the alarm button. None of the calls were answered. The friend said
that the assault was not very severe. After the others left the cell the friend
asked the man if he should call an officer or a nurse. The man replied that he
was fine and that he did not want anyone to be informed. The friend left the
cell to smoke a cigarette. Afterwards, he briefly returned to the cell and the
man still seemed fine. The friend left once more and did not see the man
again.
91. My investigator spoke to a number of other prisoners to ask about their
experiences of staff response when pressing cell bell buttons. Responses
were mixed. A minority of prisoners reported never having a problem in
obtaining a prompt response. The majority, however, reported problems from
time to time. This included instances when their calls appeared to be
immediately disconnected without anyone asking the nature of the problem.
I recommend that the Director should commission or conduct an audit of the
cell alarm system and to assure himself of its integrity.
Provision of radios
92. My investigator asked the Head of Male Residence about the number of
radios allocated to staff. In particular about the fact that one of the three
officers on duty on X2 wing on the evening of 11 September was not carrying
a radio. She said that the reason Peterborough restricted the number of
radios was to control the amount of radio traffic and to thereby lessen the
possibility of important calls being blocked.
93. At the point that one of the prisoners collapsed on the lower landing, the first
PCO was in the wing office dealing with paperwork. Another prisoner alerted
her to the fact that a prisoner had collapsed to the floor. She checked the
prisoner and decided that he should be examined by a nurse. However, she
had no radio. The reason for this was because only two radios were shared
between the three officers on duty. The other PCOs were patrolling the wing
so they each had a radio. As she was dealing with paperwork she was not
considered to have the same level of need for a radio so one was not
allocated to her.
94. I understand that radios are now carried by all officers on duty on a wing and
so I make no recommendation.
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Deployment of staff to stop assaults
95. The CCTV recording for the evening of 11 September would appear to
suggest that the timing of the assault on the man had been pre-planned. At
around 7.50pm a prisoner collapsed to the floor on the ground landing. All
three officers on the landing went to the aid of the prisoner and at that point
other prisoners entered the cell where they assaulted the man. My
investigator explored with senior staff at Peterborough the response by
officers to the apparent medical emergency when a prisoner collapsed to the
floor on the lower landing. All three officer on the wing responded to the
incident and this left the upper landing unsupervised. I accept the point made
by the PO about the need for a sufficient number of staff to be present in the
case of a possible medical emergency. In addition, in the case of a fight
between two prisoners, even three staff might prove insufficient to deal with
the situation. The inevitable consequence is that it is not possible for all
prisoners to be supervised at all times.
96. In a thematic review into “out of cell” activity, Her Majesty’s Chief Inspector of
Prisons commented that the amount of time that prisoners are able to spend
out of their cells is a key determinant in the overall health of a prison, is a
crucial part of rehabilitation, and critical to the mental health and wellbeing of
prisoners. Out of cell activity includes the amount of time that prisoners are
able to engage in purposeful activity, such as education, work and offending
behaviour programme, but also includes time spent in exercise, in association
with other prisoners, and in basic tasks such as showering and using the
telephone. The Chief Inspector goes on to say that these activities are part of
the “dynamic security” of a prison, which depends as much on activities and
relationships as it does on physical security.
97. I concur entirely with the Chief Inspector’s views on the benefits of out of cell
activity; however one effect is that during association periods a large number
of prisoners are moving freely around the prison wing while being supervised
by a small number of staff. The CCTV footage of the evening of 11
September shows that immediately before the attack on the man, the three
officers on duty had positioned themselves in a way that meant both landings
were well supervised. The officers then responded to the apparent medical
emergency and could not have been expected to anticipate that an attack on
another prisoner was about to be launched. I would not criticise the officers
for their actions, even so the Director might wish to remind staff about the
need for constant vigilance.
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CONCLUSION
98. The death of one prisoner at the hands of another is a rare event. The courts
have found that the prisoners who carried out the assault on the man had not
intended to bring about his death. Unfortunately he had an undiagnosed
heart condition and the stress of the assault resulted in him suffering a
cardiac arrest. The precise reason for the assault remains unclear. There
are several possibilities, such as his apparent involvement in the buying and
selling of goods and a suggestion that he might have been dealing in drugs.
What appears clear, however, is that he seemed unaware that he might be at
risk from other prisoners. Although it is clear that several prisoners had
alleged wrongdoing on his part, I do not believe that the assault could have
been predicted or prevented.
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RECOMMENDATIONS
The following recommendations were made in the draft report. The Prison Service’s
response to the recommendations appears in italics below each recommendation:
1. I recommend that the Director remind staff about the guidance and instruction
in PSO 2750 in dealing with inappropriate behaviour and violence reduction.
Prison Service response: Recommendation accepted. A review of inappropriate
behaviour and safety is underway to give strategic direction to the Safer Prison
agenda. A Notice to Staff highlighting the importance of dealing with inappropriate
behaviour will be issued. Target date for completion is the end of June 2011
2. I recommend that the Director consider, and revise if necessary, procedures
for adequate copying into prisoner history sheets of relevant security.
information
Prison Service response: Recommendation accepted. This will be discussed on
the monthly bi-lat with the Head of Security. Once completed instructions will be
given to all staff as to how this work will be managed while maintaining the
integrity of intelligence information. Target date for completion is the end of May
2011
3. I recommend that the Director consider, and revise if necessary, procedures
for proper use of security information when allocating jobs.
Prison Service response: Recommendation accepted and implemented. Security
information is considered when allocating all workplaces, and a full allocation
board is held weekly.
4. I recommend that the Director remind staff to be vigilant in identifying
prisoners involved in the buying and selling of goods.
Prison Service response: Recommendation accepted. To be discussed with the
Head of Male Services and the Stores/Shop Manager to introduce methods to
identify those prisoners suspected of dealing in goods. This will then be brought
to the attention of staff through the daily briefings. Target date for completion is
the end of May 2011
5. I recommend that the Director should commission or conduct an audit of the
cell alarm system and to assure himself of its integrity.
Prison Service response: Recommendation accepted. The IT department
through the Facilities Manager will conduct an audit of the cell alarm system and
report findings to the Director. Target date for completion is the end of May 2011
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