Individual at Wakefield

Investigation into the circumstances surrounding the
death of a man at HMP Wakefield in June 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2009
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This is a report into the death of a man in June 2008 at HMP Wakefield. He
was found hanging in his cell at 6.07am. The man was six and a half years
into a life sentence and had been transferred to Wakefield from HMP
Whitemoor in February 2008.
The investigation was led by one of my senior investigators. Her inquiries
were extensive and conducted over several months, and she was assisted by
my colleagues. My sympathies go to the man’s family and I must apologise
for the delay in issuing this report.
My investigator received excellent support from the Governor and his team in
the Offender Management Unit. I would also like to thank the Governor of
Wakefield for the time and resources that she and her staff gave to my
investigation.
I am also grateful to the local Primary Care Trust for their appointment of the
clinical reviewer to examine the medical care that the man received while he
was at Wakefield. The clinical review is attached as the first annex.
The man had spent his six and a half years in custody moving around the
Prison Service estate. He frequently made allegations that he was the subject
of racism. I examine the way in which these allegations were investigated
and am critical of the handling of some of his complaints.
The man received treatment for his mental health throughout his time in
prison. At the time of his death, he was subject to an Appropriate Behaviour
Compact (an agreement between staff and prisoners to manage disruptive
conduct). As part of this investigation, I explore the management of the
man’s behaviour and the impact that this had on his mental health. I look at
the decision to reduce the man’s Incentives and Earned Privileges regime to
basic, and criticise the process that led to that decision.
I make nine recommendations.
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.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2009
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CONTENTS
Summary
The Investigation Process
HMP Wakefield
Key Events
Issues
Conclusion
Recommendations
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SUMMARY
The man was serving a life sentence for a violent sexual offence. He
struggled to adjust to a prison environment and was transferred between
prisons 12 times during the six and a half years he was in custody. He was
subject to suicide prevention measures on four separate occasions, the last
time in 2006.
When the man was transferred from Whitemoor to Wakefield in February
2008, he was returned to a wing he had originally been on between 2003 and
2005. He became abusive to staff and was identified as a prisoner with
challenging behaviour. Staff observed that the man would often speak to
female staff in preference to male staff and female officers allegedly reported
that he could be intimidating. An agreement was drawn up (known as an
Appropriate Behaviour Compact) whereby the man was not permitted to
approach female staff members. A daily record was kept of the man’s
conduct, with the aim of encouraging positive behaviour.
In the meantime, the man was seen by a mental health worker who spoke to
him about the importance of taking his medication. (The man was taking anti-
psychotic and anti-depressant medication.) The inreach worker understood
that the man was not complying with wing rules and recommended that he be
assessed by a consultant psychiatrist. The psychiatrist found no evidence
that the man was at risk of self harm or suicide and did not adjust his
medication.
The man reportedly found the terms of the compact difficult to stick to. Some
staff and prisoners said that he was confused about when he was allowed to
interact with female staff. His actions towards one female member of staff
became “bizarre” and highly abusive. Other female staff were relaxed about
speaking to him and did not challenge him when he approached them.
However, the man’s behaviour deteriorated and his privileges were eventually
reduced to the basic level of the Incentives and Earned Privileges Scheme,
but without the attendance of his personal officer at the review board.
While on the lowest level of privileges (which included loss of his television),
the man became isolated and staff worried about his lack of interaction.
Unbeknown to staff, he had ceased contact with his family. The acting wing
manager contacted the mental health team and asked for their view on
whether the man’s television should be returned to him. An officer also asked
the mental health team to consider whether the man should be supervised
when taking his medication because she was concerned he was not taking
the required dose. A different mental health worker visited the man and
agreed that he should have his television given back to him. The mental
health worker also felt that he had sufficient insight into the importance of
taking his medication that he need not be supervised when taking it.
The man made one of many complaints on 28 May 2008. Although difficult to
follow, he wrote “suicide is an option!” Two days later, the man returned to
the standard level of privileges. As part of the response to his complaint, a
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senior officer spoke to him on 31 May, but did not refer to his written suicide
threat. He spoke to the man about general matters and concluded that he
was not at risk of suicide or self harm. The senior officer’s written response to
the complaint was general and mentioned none of the specific issues that the
man had raised. The senior officer did not consider initiating formal suicide
prevention measures.
In the days before he died, two prisoners reported hearing the man shouting
at officers that he was going to kill himself. The officers did not recollect this,
and said in interview that they would have immediately spoken to him about
any such threat and considered whether suicide prevention measures were
necessary.
At the end of a night shift, at 6.07am in June, the man was found hanging in
his cell. An urgent call for medical assistance was made over the radio and
officers entered the cell and cut the ligature. The man’s body was lowered to
the ground but resuscitation was not possible due to the onset of rigor mortis.
Paramedics arrived 20 minutes later and confirmed that the man had died.
In this report, I consider how the man’s behaviour was managed at Wakefield
and the decision to put him on the basic regime. I also examine his
allegations of racism among staff at Wakefield (allegations that were echoed
by other prisoners to whom the investigation team spoke, but which in
aggregate terms have not been substantiated in an inspection by HM Chief
Inspector of Prisons). I look at how the man’s complaints were handled, and
especially how the last complaint made on 28 May was dealt with.
The man’s family raised a number of concerns about family liaison following
his death, and I trust that these are also appropriately dealt with in the report.
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THE INVESTIGATION PROCESS
1. I appointed my investigator to lead the investigation into the man’s
death. A Governor arranged for the man’s records to be copied and
sent to her. My investigator sent notices to the prison, inviting staff and
prisoners to contact her with information that they felt was relevant to
the investigation. There were two responses from prisoners, both of
whom my investigator contacted and interviewed.
2. My investigator and one of my Family Liaison Officers arranged to visit
the man’s family in London. I would like to thank the man’s family for
their valuable contribution to the investigation process. Among other
things, they discussed their concerns about the contact they had with
the prison after his death. I trust that I have addressed their concerns
in my report. My investigator was also contacted by the family’s legal
representatives, who requested full disclosure of all documentation. In
accordance with our disclosure policy, this was arranged.
3. My investigator went to Wakefield in August 2008 and met the clinical
review team to conduct joint healthcare interviews. In October, my
investigator was joined by the clinical reviewer and three other
colleagues from my office to conduct further interviews. Investigators
from my office conducted interviews with prisoners who had asked to
speak to us in connection with the man’s death. They also spoke to a
prisoner who was subject to a basic regime. In total, the investigation
team interviewed 24 members of staff and 13 prisoners. Notes of
these interviews are annexed to the investigation report.
4. An Assistant Ombudsman joined my investigator and the clinical
reviewer to interview staff over these three days in October. My
investigator fed back her preliminary findings to the Governor of
Wakefield after that visit. After further consideration of the evidence,
my investigator returned to Wakefield at the end of November to carry
out more staff interviews.
5. As part of the investigation, my investigator wrote to the Chair of the
Independent Monitoring Board (IMB) to discuss their involvement in the
man’s care and their understanding of diversity at Wakefield. I am
grateful for their response. She also spoke with another of my
Assistant Ombudsmen who manages complaints from prisoners at
Wakefield. My investigator also met and subsequently liaised with the
lead of the team from Her Majesty’s Inspectorate of Prisons who
carried out a full announced inspection of Wakefield in December
2008.
6. My investigator returned to Wakefield for a final interview in February
2009. I am grateful to the Head of Offender Management and his team
for providing my investigation team with excellent liaison throughout a
complex investigation process.
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HMP WAKEFIELD
7. Wakefield is one of eight high security prisons in England and Wales.
It accommodates up to 751 prisoners on four main wings. At the time
of the most recently published report from HM Chief Inspector of
Prisons (April 2005), 51 per cent of prisoners at Wakefield were
accused or convicted of a sexual offence, making up the largest
section of the population. Black or minority ethnic prisoners made up
about 16 per cent of Wakefield’s population at that time.
8. HM Chief Inspector further inspected Wakefield in December 2008,
during the course of this investigation. My investigation team met with
the Inspectorate to share findings. The Inspectorate report is not
published at the time of issuing this draft so it cannot be explicitly
referred to, but I am grateful to the Chief Inspector for her team’s
valuable contribution to my own investigation.
9. The Chief Inspector’s 2005 report followed an unannounced inspection.
She found that staff-prisoner relations still needed some development.
However, the inspection team judged that the Governor at the time
“demonstrated a commitment to promoting good race relations and
tackling racist behaviour”. Complaints about racist incidents were well
investigated. But despite a significant population of black or minority
ethnic prisoners, the inspection team found that “almost all staff were
white” and “there was relatively little evidence of active, positive,
promotion of cultural diversity”. Three and a half years later, my
investigation team were also concerned to find that there are almost no
black or minority ethnic officers working on the wings at Wakefield. I
will discuss this in more detail later in the report.
10. During the course of her investigation, my investigator was told that
approximately 35 per cent of staff on the wing where the man was
allocated were female. At that time, there was only one female senior
officer on the wing. My investigator spoke to that senior officer and she
acknowledged that her relationship with the man was difficult as the
only female wing manager.
11. The Wakefield Independent Monitoring Board’s (IMB’s) annual report
for 2008 found that there had been “excellent progress for all aspects
of diversity, not just race equality”. (Every prison has an IMB made up
of members of the local community who monitor day-to-day life for
prisoners and ensure that proper standards of care and decency are
maintained.) The IMB raised no concerns about safer custody, and
reported a “relaxed but secure relationship between staff and offenders
throughout the establishment”. My investigator wrote to the IMB to ask
if there had been any contact between the man and any of its members
and they confirmed that there had not.
12. In 2008, there were six deaths at Wakefield, four from natural causes
and two apparently self-inflicted. Each death is investigated
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separately, and there are few similarities between the circumstances of
the man’s death and those of the other prisoners.
Appropriate Behaviour Compact (ABC)
13. An appropriate behaviour compact (known as an ABC) is a security
strategy particular to Wakefield, designed to provide additional support
to prisoners who have challenging behaviour that affects life on the
wings. The prisoner and staff agree the aim of the ABC. Staff monitor
the prisoner’s behaviour, keeping an ongoing record of whether they
are meeting the ABC’s requirements. The ABC is reviewed at least
monthly at a multi-disciplinary meeting attended by the Head of
Residence. The man was subject to an ABC at the time of his death.
Incentives and Earned Privileges (IEP) scheme
14. The Prison Service’s Incentives and Earned Privilege (IEP) scheme is
designed to encourage and reward positive behaviour. The scheme
has three levels: standard, basic and enhanced. All prisoners have
access to the standard regime when they first arrive at a prison. If a
prisoner complies with the prison’s regime and uses his time
productively, he will earn extra privileges and become an enhanced
prisoner. Basic is the most restricted regime and means less time out
of cell and no television, among other restrictions. The man was on the
basic regime between the end of April and the end of May 2008.
15. As a prisoner on the basic regime, the man was released from his cell
for 20 minutes three times a day to collect his meal, make telephone
calls and use the shower. He was entitled to two periods of association
a week. The basic regime does not restrict access to education or
employment, but the man attended neither and so spent long periods
of time alone in his cell.
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KEY EVENTS
16. The man was remanded to HMP Pentonville at the end of January
2002. He moved to HMP Belmarsh just over a week later, where he
stayed for two and a half months before he moved to HMP Brixton. In
June the man was convicted and he was sentenced to life in prison two
months later. He remained at Brixton for one and a half years.
Between December 2002 and February 2003, the man was made
subject to a F2052SH. (An F2052SH was the term used to describe
suicide prevention measures that were used by the Prison Service
before a new system, ACCT, was introduced in April 2005.) He told
staff that “his long sentence causes him to have ups and downs he still
gets depressed and feels at times he could be suicidal”. By February
2003, he reported feeling “well within himself” and the decision was
made that he was no longer at risk and it was agreed to close the
F2052SH.
17. When the man was first transferred to HMP Wakefield on 20 November
2003, he assaulted staff in reception. He remained at Wakefield on
this occasion for about two years, apart from a one month period in
HMP Whitemoor around July 2005. His time at Wakefield was marked
by episodes of violent behaviour and accusations of racism against
staff. A second F2052SH was put in place for a month between
October and November 2004 after the man was allegedly racially
abused by a prisoner on the wing. By November, the man was
recorded as “forward looking and gave positive ideas”. The
multidisciplinary review board agreed that the man was no longer at
risk and closed the F2052SH.
18. Shortly after the man was moved to Frankland in November 2005, he
asked to be permanently transferred to Whitemoor. The application
was forwarded to the Population Management Unit for consideration.
19. The man told a nurse that he wanted to talk about his “funeral
arrangements” on 27 May 2006. When challenged, he was confused
about what his problems were, but they included not getting along with
staff, lack of visits and lack of funds. An ACCT document was opened
and remained open for two months. (Assessment, Care in Custody
and Teamwork, or ACCT, is the system now used to identify, support
and monitor prisoners at risk of self harm or suicide, and which
replaced F2052SH.) It was closed on 26 June.
20. Three days later, the man rang his cell bell and told the officer who
responded that he was suicidal because he was likely to be segregated
the following morning. Another ACCT document was opened and
remained open for one and a half months. The man was moved from
the segregation unit to the healthcare centre where he remained for
much of this time. He told staff that he did not want to be in Frankland
because it was so far north and his family could not visit him easily.
During his ACCT case reviews, he admitted that he was “probably
9
worrying too much about the adjudication”. (An adjudication is a
disciplinary hearing run by an independent adjudicator or a governor
when a prisoner is alleged to have broken prison rules.) On 18 August,
the man “categorically denied having any suicidal thoughts or
intentions”. He told staff that he felt “safe and secure on the wing” and
the decision was taken to close his ACCT document. This was the last
time that he was subject to suicide prevention monitoring.
21. After a year at Frankland, the man was transferred to Whitemoor in
November 2006. In January 2007, he was assaulted by three
prisoners and sustained a hand injury. Following the news of a close
relative’s death shortly afterwards, the man told staff that he could not
sleep. When he was seen by a doctor from the mental health inreach
team in March 2007, he said that he thought he had between six and
seven breakdowns while he was in prison. He complained that the loss
of his employment due to his hand injury meant that he had nothing to
do, and the doctor agreed to speak to the physical education
department to help him occupy his time. The man assured the doctor
that he had no thoughts of harming himself at that time. He settled
back into life at Whitemoor. The prison was closer to his friends and
family and the man enjoyed more visits. However, the Vulnerable
Prisoner Unit (VPU) closed and its prisoners were transferred to other
high security prisons. (Some prisons have a VPU for prisoners who
struggle to adapt to life on the wing, or who may be victimised. It is
often the case that such units accommodate prisoners with a history of
sexual offences.)
22. The man arrived at Wakefield for the second time on 15 February
2008. After the draft report was issued, the family asked my
investigator to check whether his records arrived with him, and the
prison said “to the best of our knowledge, all documentation arrived
with the man on transfer”. My investigator found no evidence to
suggest that his records, including his previous ACCT documentation,
did not come with him to Wakefield on that occasion. His Prisoner
Escort Record (PER) indicated that he was a violent prisoner who had
committed a sex offence, and also that he was vulnerable. (A Prisoner
Escort Record is opened every time a prisoner is taken into custody to
communicate the prisoner’s level of risk between custodial agencies.)
The following warning was recorded:
“The man is serving LIFE for RAPE, extreme violence was used,
he is a volatile prisoner who is abusive to staff and prisoners, he
especially singles out female staff. Racially abusive to staff and
is deemed as a real threat to females … Permanent transfer to
Wakefield.”
23. His cell sharing risk assessment was completed and the man was
assessed as “low risk” of harming other prisoners. When he was
located in his cell, he refused to speak with staff and prisoners and
blocked his door with a cardboard box to prevent others from coming
10
into the cell. He told staff that he would go to the segregation unit and
would respond to staff there. An Officer made an entry on the man’s
wing history sheet: “been on previous ABC compact, danger to staff.
Previous ACCT documents. Mental health issues.”
24. The next day, the man had an interview with a first night officer which
was designed to identify any immediate needs. He told a second
Officer that his next of kin was a girlfriend. (The woman was contacted
by my Family Liaison Officer at the beginning of my investigation and
she confirmed that she had only exchanged letters with the man.)
During the reception procedures, he went on to say that he had no
thoughts of suicide or self harm. He was told who his personal officers
were at that time and he said he had no concerns about being at
Wakefield. Although the man borrowed a Muslim prayer mat and
headwear, there is no record of whether or not he was a Muslim in the
records from his time at Whitemoor.
25. The man’s first reception healthscreen was entered on his electronic
record two days after it was carried out. The entry reads as follows:
“He has reportedly self harmed in the past although I am unable to
locate details of same and he states he has no history of self harming.”
As a result of the first reception healthscreen, he was referred for a
mental health assessment.
26. The same day this entry was made (17 February 2008), the man
approached a third Officer and asked whether the same female staff
worked on B wing (the man was located on B wing on both occasions
he was at Wakefield). The following day, the man had an altercation
when he was collecting his food. His television was later found
smashed on the floor of his cell. He told staff that it had fallen off the
shelf. There is an unsigned entry in his clinical record from the same
day, recording his allegation that he had been attacked in Whitemoor in
January 2007 and that he was also “beaten” in Frankland. The entry
also recorded that he had no thoughts of suicide at that time.
27. The man completed a self-referral for the disability department on 21
February. He was a diet-controlled diabetic and was signed up to the
diabetes clinic. He was also recognised as having mental health
problems. A Senior Officer (SO), the Disability Liaison Officer,
explained in interview that there are no strict criteria for prisoners to
qualify for support from the disability liaison team. Prisoners must
identify themselves as disabled and will be offered additional support
from her and her team on that basis.
28. On 26 February, the man told staff that “he wanted to go to the
seg[regation] block because he was fed up with males sucking up to
female [officers].” He was advised against this course of action. The
same day, he made a complaint about female officers organising fights
between staff and prisoners “using professionals and sports men”. He
wrote that he wanted “to stop the Irish mentality, to stop using me as a
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meal ticket”. He requested a transfer to Full Sutton. An SO received
the complaint and referred the man to the mental health team.
29. The next day, the man asked a female officer if he had “come to bed
eyes”, which was recorded as a security matter. The senior officer on
the wing was made aware and female staff were asked to be careful of
the man approaching them. A fourth Officer wrote in the man’s security
record the following day:
“The man chooses only to speak to female staff. There can be
any number of male staff, however, he chooses to bypass them
and speak to females.”
30. That same day (28 February), a mental health worker from the mental
health inreach team made his initial assessment of the man’s mental
health needs. He recorded that he found the man to be orientated.
The man told the nurse that he was only taking half of the Risperidone
(an anti-psychotic) but, after an altercation with a member of staff, he
resumed his full dosage. The mental health worker was told by staff
that the altercation occurred when a male officer asked the man to stop
following a female member of staff. The mental health assessment
concluded that the man needed psychiatric input “as soon as possible”.
During interview, the mental health worker told my investigator that,
given the man’s presentation, it was routine for him to need to see a
psychiatrist as soon as reasonably possible, but it was not a matter of
special urgency:
“… obviously if he was having altercations with staff on the wing
about following females, he had shown some non-compliance
with his medication, that in itself would make me want to get him
to come down and discuss whatever was happening with a
consultant forensic psychiatrist as quickly as possible.”
31. The man was placed on an ABC the following day. As the senior
officer managing the wing that day, a second SO explained the
decision to open the compact. She said that staff had complained to
her that the man was watching a female Officer. The second SO told
my investigators that, as a senior officer on the wing, she is responsible
for the management of staff and the female Officer was not comfortable
with the situation. During interview with the investigation team, the
second SO recalled:
“… he would speak to her, he would probably home in on her,
go past other staff to speak to her or he’d speak to, if she was
on another landing, he would still go and speak to her, it was like
… unhealthy, and staff had raised concerns that they weren’t
comfortable …”
32. In her interview, the female Officer did not recall speaking to any
members of staff about concerns with the man’s behaviour before his
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ABC was put in place. She remembered, “he would approach me over
staff that were in the nearer vicinity to him”, but thought that the ABC
was opened because of more general concerns about his behaviour
with female staff, rather than just with her.
33. The man was told that his behaviour towards female officers was
inappropriate. The first target of the ABC was not to approach female
officers at all. Once the man had achieved this target, the aim was to
improve his behaviour so that appropriate interaction could take place.
When the second SO was explaining the terms of his ABC to the man,
he did not accept that he had acted inappropriately towards female
members of staff. She made the following entry in his wing history:
“While being placed on ABC compact he refused to accept that
his behaviour was not appropriate. When challenged he
became bizarre to myself and I felt he was trying to intimidate
me. He was showing inappropriate behaviour.”
34. The second SO explained to my investigation team what she meant by
“bizarre” behaviour. She said that, during this exchange, the man leant
over to her and stuck his tongue out at her while shouting. She said
that a third SO was in the room so she did not feel threatened, but she
perceived it as intimidating behaviour. The man was removed to the
segregation unit for adjudication for his threats to the second SO.
35. While the man was in the segregation unit, security intelligence came
to light suggesting that prisoners were scared of being assaulted by
him. The intelligence also highlighted a risk that the man would be
assaulted by other prisoners because of “his attitude towards some of
the other prisoners”. The man returned from the segregation unit
following his adjudication. His behaviour was monitored through the
ABC and he had no difficulties complying with the terms of the
compact. There were no recorded assaults involving the man.
36. On 12 March, the man approached the SO about his property at
Whitemoor. The SO observed that he could get confused at times
about where he was. The next day the SO reviewed the man’s ABC
with him. The document was to stay open with the same restrictions.
37. The third SO intervened when he saw the man speaking to two female
members of staff from another department on 15 March. The senior
officer reminded him of the restrictions on his compact and he
apologised for breaching those restrictions. The third SO then
mediated between the man and the female members of staff.
38. Following the mental health worker’s recommendation that the man
should be assessed by a psychiatrist, the psychiatrist had his first
appointment with him on 18 March. During the review, the psychiatrist
noted that the man was upset about the outcome of his recent appeal
and that he had a “normal mental state”. He prescribed 37.5 milligrams
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(mg) Venlafaxine (an anti-depressant) twice daily and three mg of
Risperidone to be taken daily. The psychiatrist was aware that the
man was on an ABC “not to speak to female officers”. He found no
evidence of acute mood disorder or psychosis.
39. The next day, a fifth Officer spoke to the man. During interview, the
fifth Officer said that she had not experienced the man’s inappropriate
behaviour personally. She said that he would become very angry, but
when challenged would quickly calm down. She was happy to speak
to him without a male member of staff around, and often did so.
40. A sixth Officer observed the man watching a second female Officer on
21 March. He described the man as “not taking his eyes off” her.
During interview, the sixth Officer said that he did not challenge the
man about this behaviour or speak to the second female Officer about
it. He explained that the ABC records intelligence about a prisoner’s
unacceptable behaviour so that staff can work with the prisoner to
encourage appropriate conduct.
41. A fourth SO had to remind the man of the terms of his compact two
weeks later. The fourth SO did not normally work on the man’s landing
but he was aware of the terms of his compact. The man told the fourth
SO that he often spoke to female staff, and could not always find any
male officers to speak to. The fourth SO encouraged him to try to find
male officers to speak to. (The fourth SO estimated that about 35 per
cent of officers on the wing are female, but with shift patterns it is
difficult to guarantee that there will always be a male officer on duty.)
42. On 9 April, the man approached a female member of staff who did not
work on the wing. He asked where she worked in the prison and she
responded before going into the staff office. Other staff told her about
his ABC, so she was then accompanied by a male officer off the wing,
avoiding him. He was not spoken to about this incident and his
reaction was not recorded.
43. The second SO had to reiterate the terms of the man’s compact again
on 10 April. She told my investigators that she shared other officers’
concerns that he was using the compact to avoid going to education.
Staff told him that this was “not good enough and he was to attend
regardless”, saying that they would facilitate his attendance. The man
asked to be moved to the segregation unit because he was concerned
about his treatment on B wing.
44. The man repeated his request on 11 April to a seventh Officer, who
made the following entry in his wing history:
“The man has requested to go to [the segregation unit] as he
believes it is a black environment and that he was being
hounded by homosexuals. At one point he followed a member
of staff around and continually went into the wing office until he
14
was warned if he continued to follow this individual he would be
placed behind his door.”
45. My investigation team spoke to the seventh Officer who said that, while
there were no black or minority ethnic officers on B wing, there are
none on the segregation unit either. My investigation team studied
statistics of the prisoners who were segregated and found no statistical
over-representation of black or minority ethnic prisoners. (I examine
the issue of the man’s allegations of racism later in this report.) The
fifth Officer spoke to him later that day and the man admitted that he
had “behaved badly” and “did not do well under certain circumstances”.
46. The man’s medication was reviewed on 13 April and his anti-
depressant was reduced. The following day, the prison doctor
contacted the hepatology unit at St James’ Hospital to discuss the
treatment of the man’s Hepatitis C. Arrangements were made for a
hospital doctor to visit on 5 May. The man did not attend this medical
appointment.
47. Smoking on a residential wing has been prohibited since a ban came
into force in July 2007, although prisoners are still allowed to smoke in
their cells. An eighth Officer found the man smoking on the wing on 19
April and she gave him a verbal warning, telling him that his IEP level
would be reviewed. The eighth Officer challenged the man and
thought that the matter was been dealt with, but he continued to speak
with her. She reminded him that he should not speak to her because
of the terms of his compact.
48. The Acting Principal Officer (PO) went over the restrictions of the
man’s compact with him that afternoon. He told him that he could
speak to female staff if he had their permission, but that he must not
approach them. The man reacted by telling the Acting PO that “he is
terminally ill, as he has Hepatitis C and he also came out with a
statement that he is a good looking black man and I know what is
happening”. The Acting PO asked the mental health team if the man’s
behaviour was a symptom of mental illness. If not, staff were going to
consider reducing his IEP status to basic.
49. In interview, a Nurse said that she was allocated the wing staff request
for someone to speak to the man about his mental health. She said
that she is not a mental health specialist but often dealt with primary
mental health care needs. She made the following entry in his medical
record:
“[Staff] were wishing to review his IEP status because he keeps
breaching his compact expectations and approaching female
staff. The wing staff wanted to know whether his behaviours
were influenced by mental illness … there appear to be a
paranoid element to his pattern of thinking, though I do not think
this would impact/impede on his ability to comply with the
15
compact. The wing staff are going to pursue the privilege being
reduced.”
50. On 26 April, a PO was asked by the second SO to conduct an IEP
board review of the man’s status. The second SO told the PO that she
thought the man’s privilege level should be reduced to basic. My
investigator spoke to the PO who recalled speaking to the second SO
and reviewing the man’s ABC. He said that he was satisfied that the
second SO was a responsible senior officer and he trusted her
judgement. He also thought that entries in the man’s ABC sufficiently
demonstrated that he was not complying with its terms.
51. Three Officers recall the PO asking whether they thought that the
man’s regime should be reduced to basic. The officers said that they
did not think that he should be on the basic regime, and they were
worried that reducing his incentives level would have an impact on his
behaviour. (When he spoke to my investigation team, the PO could not
recall this conversation.)
52. The PO, second SO and a ninth Officer carried out the IEP review. A
tenth Officer was working on the wing that day and was the man’s
personal officer at the time, but he did not go to the board. The tenth
Officer told my investigation team that he knew the man from his time
at Frankland between 2005 and 2006, when he worked there as an
officer. He said that he did not have many dealings with him at
Wakefield. The PO said that the tenth Officer was asked to join the
board as he was working on the landing where the board took place.
53. The PO did not remember the board very well, but he recalled that the
man did not deny breaching his compact. The PO said that the man
was upset at the outcome but seemed to understand the reasons his
IEP status was being reduced to basic. The fifth Officer remembered
that the man was angry when he returned to his cell after the board.
However, once he had calmed down, he handed staff his personal
belongings, including his television, and co-operated with the compact
and regime. He was only released from his cell at meal times for 20
minutes at a time and had two periods of association each week. He
could attend education, but refused because he was unsure whether
he would breach his ABC in doing so. This meant that he spent a good
deal of time alone in his cell.
54. Apart from a written warning about smoking on the wing, the man
complied with his compact and the basic regime during the following
few days. On 2 May, the IEP review concerning the man’s smoking
was held and the disability liaison officer attended at his request. She
said that she had a good relationship with him and spoke to him daily
without male officers present. She never experienced any
inappropriate behaviour in her dealings with him. After the IEP review,
the disability liaison officer made the following entry in his disability file:
16
“Today I attended an IEP review on the man. He is subject of
an ABC compact and is also a basic prisoner. I have concerns
about his mental state which appears unstable. Long periods
locked in his cell is impounding [sic] the problem and he stated
that he couldn’t cope.”
55. The fourth SO chaired the review and acknowledged the positive
comments about the man’s behaviour in the ABC. However, the fourth
SO said he had no choice but to keep him on the basic regime. He
explained to my investigator that the review was in response to the
man smoking on the wing. As smoking is prohibited, the fourth SO
said it “would send the wrong message” to have been lenient under the
circumstances.
56. Later that day, the man made two complaints about the second SO of a
homophobic and racist nature. The second SO’s colleague, the first
SO, dealt with the complaint but found no evidence to support his
allegation.
57. As noted above, the man did not attend the appointment arranged on 5
May to discuss his hepatitis. The disability liaison officer spoke to the
man as promised and he told her that he was finding it “hard going”
without a television. He said he was trying to improve his IEP status
and looked forward to working because “being locked up for long
periods makes him feel stressed”.
58. The man expected a further IEP review to be held on 9 May. The third
SO explained to my investigator that, when the man was at Wakefield,
basic prisoners had their first IEP review within seven days and the
next review 28 days later, unless there was significant evidence that
the status needed to be changed in the meantime. (This is in line with
the requirements of Prison Service Order 4000 – Incentives and
Earned Privileges. Prison Service Orders, or PSOs, are national
instructions.)
59. The man was therefore not due an IEP review on 9 May. He was
angry that a review was not going to be held and became abusive
towards the third SO. He turned over a football table and threw a cup
of tea across the landing before returning to his cell. He asked to
speak to the fifth Officer about why his status had not been reviewed,
although another prisoner’s status had been upgraded from basic to
standard. The fifth Officer said that he responded well when staff
pointed out that he was being unreasonable. He calmed down, and
she said that he understood that an IEP review was not due and
apologised for his outburst.
60. The disability liaison officer spoke to the second SO that day about the
man’s request that she be invited to his next IEP review. The second
SO questioned the logic of the senior disability liaison officer’s
attendance but the senior disability liaison officer reminded her that the
17
man had a clinical condition that meant he was disabled. When asked
why she insisted on attending the review, the disability liaison officer
explained to my investigator that she was “concerned” about him and
he had asked her to help him. As she had known him “many years”,
she was in a good position to contribute to the review and to support
him.
61. The man saw the psychiatrist again on 10 May to discuss his ongoing
mental health needs. During the psychiatric review, he told the
psychiatrist that he felt singled out by staff, particularly a female officer,
although he had no problems with other prisoners. He told the
psychiatrist that it was “worth being alive”. The man’s medication was
adjusted and the psychiatrist planned to see him within a month.
62. The fifth Officer had worked as a mental health nurse before being
employed as a prison officer. She told my investigator that, due to his
erratic presentation, she was concerned that the man was not taking
his prescribed medication. On 11 May, she referred him to the mental
health team to consider whether he should be supervised when taking
his medication. The fifth Officer’s concerns were discussed the next
day between the mental health team and wing staff and it was
suggested that he might be “misusing his medication”.
63. An IEP review was held on 12 May. The third SO said that more
reviews took place, although the man was not strictly entitled to them.
The third SO chaired the review and decided that the man should
remain on basic. He told my investigation team that he was aware of
the man’s mental health issues. He explained that it is a difficult
balance to judge whether to keep someone on the basic regime. When
asked whether he thought that the man’s mental health was adversely
affected by being on the basic regime, he told my investigator: “…
maybe, but I think it would affect anybody’s mental state, wouldn’t it?
You know, being locked up in their cells all the time.” The man
attended the review but made no representations. According to the
record of the review, he agreed with the outcome but refused to sign
the document. There is no record that the disability liaison officer
attended the IEP review on this occasion, despite her request to the
second SO.
64. A second mental health worker carried out a mental health assessment
on 13 May. According to his record, the man “did appear quite bored
on the wing and admitted to finding it difficult to get on with certain staff
members. Some paranoia evident.” He told the mental health nurse
that he felt his “mental state deteriorated slightly due to his lack of
activity since being placed on basic and a compact”. Although the
man said that he had no thoughts of self harm, the second mental
health worker recognised that the measures taken to improve his
behaviour were not “conducive to his mental health at the moment
though the need for it acknowledged”. As a result of the second mental
health worker’s conversation with the man and wing staff, his television
18
was returned. An entry was made in the man’s case history that he
had been given his television “as long as he adheres to the compact”.
65. Following the fifth Officer’s communication with the healthcare
department about supervised medication, the second mental health
worker also spoke to the man about whether he was taking his
medication. The man said that he did not think he needed to take it, so
he had only been taking half the prescribed dose. The man told the
second mental health worker that he just realised that taking the
medication meant he was less angry, so he had started to take the full
dose again. The second mental health worker was satisfied that the
man had sufficient insight into the need to take his medication and its
relation to his moods. They agreed that he could continue to take his
medication unsupervised for the time being, although the situation
would be reviewed. The second mental health worker arranged for an
appointment with the psychiatrist for the following week.
66. After attending a diabetes clinic on 15 May, the man’s diabetes
medication was restarted.
67. Two days later, the man asked the eighth Officer whether he could be
subject to ACCT measures so that “staff would watch him more”,
although he told her he had no intention of harming himself. The
eighth Officer explained to him that increased supervision without any
risk of suicide or self harm was not the purpose of the suicide
prevention measures. In interview with my investigator, she said that
she did not think that he was was at any risk of suicide or harming
himself, but was just trying to get more attention from staff.
68. The psychiatrist assessed the man on 21 May and recommended a
change in medication. He told the psychiatrist that he was being
targeted by one member of staff. A record of their meeting was written
in his paper medical file, but was not copied in the electronic medical
records used by the rest of the healthcare department.
69. The man made more complaints containing allegations of racism.
Copies of all such complaints are passed to the Race Equality Principal
Officer and she spoke to the man on 23 May. She noted his
“perception that staff are racist as other offenders have told him that.
The man was polite throughout the interview.” The Race Equality
Principal Officer held the meeting in an office on B wing and a male
officer accompanied her because of the terms of the man’s ABC.
70. A further complaint was submitted by the man on 28 May. It said:
“I have been convicted on circumstantial evidence. All my
efforts to prove my innocence have failed. I was at the time a
drug addict. I have not used in six years, but to no avail. I cope
each day by begging. It’s the joke of the prison. I want to leave
and work and enjoy sporting activity while I still can. I am
19
terminally ill. I don’t want treatment. I would like people to talk
to me as someone, and not written off as mentally ill. I would
like the Governor to stop laughing in my face, suicide is an
option! I am only human; please stop treating me like an
animal.”
71. The man indicated that he had spoken to the third SO about the
matters raised in his complaint. However, the third SO told my
investigator that he had not seen the complaint before being
interviewed after the man’s death. He said that the man had spoken to
him about his offence and appeal process, but they had not discussed
anything else and he was not aware of his threat of suicide.
72. The prison doctor wrote to Leeds General Infirmary the following day to
refer the man for “hepatitic surveillance”. The doctor explained to my
investigator that the man’s condition was not serious at the time but
could that it be fatal if left untreated. The man continued to refuse
treatment for hepatitis, and so the prison doctor was concerned that he
should be referred to the hospital and his condition monitored.
73. On 30 May, the third SO revised the man’s ABC. The requirement of
“no approach to any female member of staff” was amended to read that
the man could approach female staff “to ask permission” and should be
polite at all times. When asked about the alteration at interview, the
third SO explained that he wanted to give the man more opportunity to
talk to staff, although he believed that there was usually a male
member of staff on duty. At the same time, the third SO reviewed the
man’s IEP status and increased it to standard. There is no formal
record of the review, but the third SO made an entry in the wing history
sheet. It is not possible to determine who else attended the review.
When asked by my investigator about the decision to reinstate the
man’s standard regime, the third SO explained that it was difficult to
balance the fact that he was no threat to staff with prisoners’
complaints about his behaviour.
74. The man’s complaint of 28 May was answered by a fifth SO on 31 May.
The fifth SO normally works on A wing, but was covering B wing over a
weekend. In interview, he said that he knew the man in passing. The
fifth SO saw the complaint in the senior officer’s office but was
originally not going to deal with it as he saw the reference to the
Governor and so thought that it was outside his own powers. The man
then came into the office and spoke to the fifth SO about his canteen.
(Canteen is the term for the prison shop where prisoners can spend
their private cash.) His IEP status had been reviewed and he had been
made a standard prisoner a few days earlier, but his income had not
been altered. The senior officer looked at the man’s canteen sheet,
and agreed that he was entitled to more purchases and made the
appropriate adjustment.
20
75. Following their brief conversation about his canteen, the fifth SO felt
confident that he could deal with some elements of the man’s
complaint. The fifth SO thought that the man was happy about their
exchange and he “did not register” the sentence “suicide is an option!”.
Even in retrospect, during interview for my investigation, he did not
think he would have approached the complaint differently because he
did not judge that the man was at risk of suicide or self harm. As a
result, the fifth SO did not open an ACCT document. The fifth SO told
my investigator that he thought that the allegation about the Governor
would be raised automatically with the Head of Residence, as part of
the complaint sifting system. The fifth SO’s written response to the
complaint was as follows:
“HM Prison Service has a duty of care to all offenders and am
confident that your well being is being maintained. If you have
any concerns over your mental health you should apply to see
the mental health team.”
76. Just before prisoners were locked in their cells for the lunchtime period
on 2 June, the man approached the female Officer to ask for
envelopes. The female Officer was assisting the sixth Officer and an
eleventh Officer to lock prisoners in their cells. In interview, she said
that the man was closer to the eleventh Officer and the sixth Officer
(both male officers), but walked to the other end of the wing to speak to
her. She asked the man to wait until the afternoon as she was in the
middle of locking prisoners in their cells. He walked away and then
returned with the same request and so she told him that he was in
breach of his compact. The man called the female Officer a “racist
bitch” and the other officers came to her support. The female Officer
made an IEP referral following this episode.
77. The man went back to his cell but was angry and continued to shout
through the cell door. One of the prisoners who spoke to my
investigation team alleged that the man shouted through the cell door
that he was going to kill himself. The prisoner said that the eleventh
Officer told the man to “do it then”. When my investigation team put
this allegation to the eleventh Officer, he was adamant that this
exchange had not taken place. He said that he would have taken such
threats seriously and spoken to the man about it. The prisoner also
said that the eighth Officer was present during the exchange. Again,
the eighth Officer said that she had no recollection of hearing the man
threaten to kill himself. She also said that, had she heard any such
threat, she would have spoken to him about what he meant.
78. The next day, the man made a complaint about the female Officer’s
treatment. He alleged that her reply was “racist” and that she made the
sixth Officer threaten him through his door. He went on to say, “I would
like you to stop these staff having racist fun at my expense”. The
complaint was answered by the second SO, as follows:
21
“After speaking with all staff involved in the incident and found
that you were in breach of your compact. Not allowed to
approach female staff without permission. The sixth Officer
challenged you appropriately and at no stage threatened you. I
feel no necessity to take this any further.”
79. The sixth Officer told my investigation team that he had not been asked
about the episode. The second SO said that she reviewed the
paperwork and was satisfied that staff had acted appropriately. She
did not speak to the man expressly about the complaint.
80. Another prisoner on the wing remembered seeing the man collect his
dinner on the evening of 5 June. He said that the man seemed
“stressed” about going back on the basic regime, but “otherwise he
seemed okay”. A further prisoner also remembered speaking to the
man that evening, and said he could tell something was wrong. He did
not alert staff to his concerns.
June 2008
81. In June, a Night Officer was coming to the end of his first week of
nights at Wakefield. An experienced officer from HMP Leeds, he had
been working at Wakefield for 18 months. The Night Officer received a
hand-over from staff on evening duty and began his shift. He counted
all the prisoners in their cells before the evening staff went off duty. In
order to perform a roll count, the Night Officer walked around every cell
and looked through the observation panel. He said that, if he could not
see the prisoner because the cell was too dark, he would use the night
light. (The switch for a night light is located on the wall outside the cell
and the light is dimmer than the normal cell light.) Once he was
satisfied that all the prisoners were accounted for, his roll check was
complete and the evening staff went off duty. He was the only officer
on B wing for the night shift, in line with normal staffing patterns.
82. Throughout the night, the Night Officer patrolled the landing. He
responded to cell bells and checked category A prisoners (the highest
security prisoners) and made the required ACCT checks on those
identified as at risk of suicide or self harm. The man fell into neither
category and so the Night Officer did not open his observation panel
after the evening roll count.
83. At about 5.45am, the Night Officer started his morning roll count on the
fourth landing. He arrived at the man’s cell at 6.04am. He looked
through the observation panel. The Night Officer could only see the
bottom of the man’s body. His upper body was behind a drawn curtain.
He noticed that the man’s legs were at an angle and that his feet were
not carrying his weight, so he realised that he was hanging. He made
a radio call for immediate medical assistance, before shouting at staff
in the area to help. The assist night orderly officer was working on the
22
centre (a small office based in the middle of the wings) and arrived
within seconds. A second Night Officer was shortly behind him.
84. At night, only the most senior officers in charge of the prison carry a full
set of keys. Officers carry a cell key in a sealed pouch for use in
emergencies. The Night Officer broke his sealed pouch and unlocked
the door. He had to kick it open because items (such as paper and a
plastic knife) had been wedged in the frame. The Night Officer moved
to the side and the assist night orderly officer went into the cell. He
moved the curtain to reach the man’s head and the ligature. The
officers noticed that his tongue was swollen and his eyes were
enlarged. The assist night orderly officer used his ligature knife to cut
the bed sheet that was around the man’s neck and attached to the
window. The officers lowered him to the floor. The Night Officer
explained to my investigation team that, due to the confined space, the
man’s body was too large to lay out completely with the three officers in
the room. The assist night orderly officer checked the man for a pulse
and found that there was none. He was not breathing and he was cold
to the touch.
85. A Healthcare Senior Officer (HCSO) was in the healthcare centre at the
time of the Night Officer’s emergency call. He had no keys to get to B
wing because the prison was still in a more secure night patrol state
(where there are fewer staff and only the orderly officer in charge of the
prison and dog handlers carry keys to main gates). The night orderly
officer therefore collected the HCSO from the healthcare centre. The
HCSO carried the defibrillator and emergency grab bag to the wing.
He estimated that about three minutes had elapsed since the
emergency call was raised. He found the man still leaning against the
wall. He cradled the man’s head and was assisted by the assist night
orderly officer to lower his body to the floor. By this time, the Night
Officer and the assist night orderly officer had left the cell. It was the
HCSO’s impression that the man had been dead for some time. He
requested an ambulance and was told that one had already been
called. The HCSO did not attempt resuscitation. He told my
investigator that he was unable to insert an airway into the man’s
mouth.
86. When the Night Officer reported the medical emergency on B wing, the
communications office automatically called an ambulance. The
ambulance arrived and paramedics made their way to the man’s cell.
They searched for signs of life but found none. He was pronounced
dead by the paramedics at 6.23am.
87. The prison chaplain was informed of the man’s death. He was
concerned because he believed the man was a Muslim and requested
the prison imam go to his cell to carry out the appropriate rites. When
the prison chaplain and the imam arrived at the man’s cell, they found it
was locked. The man was laid out on the floor with his hands by his
23
side. The imam said nothing else needed to be done with respect to
his faith.
Family support
88. A member of staff was appointed as the prison’s family liaison officer
and was telephoned on her way to work with the news that the man
had died. When she arrived at the prison, the family liaison officer
checked details of his latest correspondence and visits and noticed that
he was most recently in touch with his mother. (In fact, he had listed
another person as his next of kin.) Nevertheless, the family liaison
officer telephoned the man’s mother to break the news of his death.
When asked by my investigator why she had chosen to break the news
of his death over the telephone, she explained that the distance from
London to Wakefield would have caused an unreasonable delay in
notifying the man’s family. I will examine the decision to break the
news over the telephone later in this report.
89. The man’s family were understandably upset by the news of his death,
and the family liaison officer explained that she would contact them at a
later time to arrange for them to visit the prison and look around his
cell, if that was something they would find useful. She explained that
the Governor had offered to pay for his funeral expenses, in
accordance with national policy. The family were concerned with some
aspects of this arrangement, which I also consider in more detail
below.
90. The man’s mother agreed to pass the news of his death on to the listed
next of kin. In line with my procedure, my own Family Liaison Officer
contacted the person listed as next of kin but, as noted earlier, she
explained that she did not know the man very well, although she was
sad to hear of his death from his mother. The person the man listed as
his next of kin did not want to be involved any further with my
investigation.
Support for prisoners
91. The prisoners on B wing were told about the man’s death a morning in
June and Listeners were asked to make themselves available.
(Listeners are prisoners trained by Samaritans to provide confidential
emotional support to fellow prisoners in distress.) Staff told my
investigation team that there was a lot of tension on the wing that day.
The chaplaincy also arranged for at least two members of their team to
be present to support the prisoners.
92. A collection was arranged so that prisoners could send flowers to the
man’s funeral. Originally, prisoners wanted to send flowers that spelled
his name. However, insufficient money was raised and a bouquet of
flowers was sent instead. Regrettably, this caused the family some
anxiety. They had understood that the flower arrangement would be
24
sent by the prison and so had not arranged for flowers spelling the
man’s name themselves. They were disappointed to find that an
arrangement with his name was not sent.
93. A memorial service was held in the prison chapel on 8 August. It was
attended by 21 prisoners.
25
ISSUES
Clinical Care
94. I am grateful to Wakefield PCT for appointing a clinical reviewer to
conduct the clinical review of the man’s care. He attended the prison
with my investigation team for three days in total and was present for
all of the clinical interviews. He also visited the prison independently to
speak to the psychology department about their input into ABCs. His
review can be found at the first annex to this investigation report.
95. In his clinical review, the clinical reviewer finds that the man’s physical
health needs were dealt with appropriately while he was at Wakefield,
including his diabetes. His mental health needs were dealt with by the
mental health team promptly, and there was evidence of good liaison
with residential staff. Despite the man’s refusal to engage with
treatment for hepatitis C, the clinical reviewer notes the prison doctor’s
continued efforts to refer him for treatment.
96. The man’s family were particularly concerned about whether he was
taking his medication. When he was in touch with them, they thought
he was sometimes incoherent and were worried that he was not taking
the required medication to manage his mental health. The fifth Officer,
previously a mental health nurse, was concerned that some of his
behaviour indicated that he was not taking his medication, and asked
the mental health team to consider whether he could be supervised
when he took it. The second mental health inreach worker assessed
the man on 13 May. The man explained that he had reduced the
amount of medication that he took, but then realised that it helped him
and began to take it again. The second mental health inreach worker
decided that the man had sufficient insight into the effects of his
medication and did not require supervised medication. The second
mental health inreach worker asked wing staff to let him know if they
had further concerns and he would review the decision.
97. It may have been that the man was not taking his medication when his
family last had contact with him in April 2008. However, the man
assured the second mental health inreach worker that he was taking
his medication properly again in May. In his clinical review, the clinical
reviewer raises no concerns about the second mental health inreach
worker’s decision, and describes his assessment as “thorough”.
98. The clinical reviewer makes three recommendations. One relates to
mental health input in the ABC process and will be discussed below.
The clinical reviewer also recommends that there should be an audit of
mental health assessments at reception and improvements to the
recording of mental health assessments on the electronic medical
system. I endorse both his review and his recommendations.
26
Appropriate Behaviour Compacts
99. According to PSO 1810 – Maintaining Order in Prisons:
“Governors must develop a Local Security Strategy for the
management of prisoners whose behaviour is difficult or
disruptive. Local strategies are to be agreed with Area Managers
and must provide individual case management, the aim being that
prisoners achieve an acceptable level of behaviour within the
holding establishment.”
100. The ABC system is classified as a local security strategy and falls
within the terms of this order. The system was developed by Wakefield
in 2007. The Head of Residence explained its origins. Originally, the
compact was called an Inappropriate Behaviour Compact and was to
manage prisoners who proved particularly difficult and who did not
respond to the IEP system. The Head of Residence explained that,
when he took over the role of Head of Residence, such compacts were
already in use. He “wanted to turn it round” and renamed the
compacts Appropriate Behaviour Compacts to emphasise the
encouragement of positive behaviour.
101. The Head of Residence outlined the system that underpins the use of
the ABC. It is the wing manager’s responsibility to ensure the
effectiveness of an ABC. The officers use the ABC to manage the
prisoner on a day to day basis and contribute to it by monitoring and
recording positive and negative behaviour. A multi-disciplinary review
is held on the first Thursday of every month to discuss each of the
open ABCs. The review should be attended by representatives of
offender management, security, wing staff, safer prisons, healthcare,
and the mental health inreach team if a prisoner has a mental health
condition. As Head of Residence, he always attends the monthly
reviews. The man was put on an ABC within two weeks of his arrival at
Wakefield. The mental health team were invited to attend his reviews
but could not do so due to workload pressures.
102. In his clinical review, the clinical reviewer acknowledges that the
inreach team only had one member of staff for some of the time the
man was at Wakefield. The second mental health inreach worker
joined him at the beginning of May 2008. With such low staffing levels,
it is not surprising that workload pressure prevented them attending the
multi-disciplinary reviews. During a meeting with the Acting Healthcare
Manager and the Head of Healthcare, the clinical reviewer was told
that from June 2008 steps were being taken to increase the number of
Registered Mental Nurses in employment at Wakefield. With this in
mind, he makes the following recommendation, which I endorse:
27
The Head of Healthcare and the Head of Residence should work
together to ensure that, when a prisoner is on the caseload of the
mental health inreach team, they should attend the initial review
meeting to set up an ABC and also attend subsequent reviews.
103. The circumstances surrounding the opening of the man’s ABC are
confusing. The second SO understood from other staff that the female
Officer was uncomfortable with the man’s dealings with her. The
female Officer told my investigator that she had no problem with the
man until he was on his compact. She understood that it was his more
general behaviour towards female staff that was the problem.
The Head of Residence should ensure that the reason for starting
an ABC is clearly and specifically stated on the document and the
reason is effectively communicated with the prisoner.
104. For over a month of the ABC, the man was instructed not to approach
female officers under any circumstance. Despite this strict condition,
the disability liaison officer and fifth Officer were two of a number of
female members of staff who spoke to the man without a male officer
present. The fourth SO said that he could not guarantee that male
officers would always be on duty, given the shift arrangements at
Wakefield.
105. The eighth Officer breached the man for speaking back to her after she
challenged him about smoking. During interview, she told my
investigator that he started a conversation after she approached him
about smoking on the landing. The female Officer also challenged him
about asking for envelopes on the landing when two male officers were
closer and could have been asked. She explained to the man that he
had breached his compact yet he persisted in speaking to her.
106. Not only was the man’s compact opened for unclear reasons, it was
also applied inconsistently by staff members. Many of the prisoners
interviewed by the investigation team were concerned that the ABC
was being used by staff to control him. Staff told my investigator about
the difficulty enforcing the terms of his compact. The eighth Officer told
my investigator that she did not think that the man understood the
terms of his compact. She said it was difficult for him to “differentiate”
between female officers approaching him as opposed to him
approaching a female officer. On receipt of the draft report, the family
asked my investigator to clarify with the eighth Officer why she did not
raise her concern about the man’s confusion with another member of
staff. In her written response, the eighth Officer said:
“At no time did I raise this issue with another member of staff as
this was a personal opinion that I held. I felt and still feel that as
I did interact with the man it may have added to his confusion.”
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107. The Governor explained that the ABC system provides flexibility when
dealing with prisoners who are unable to cope with the strict discipline
required on the wing. Rather than reducing their IEP status, she
explained that staff are empowered to manage a prisoner’s behaviour
without depriving them of access to the regime.
108. However, the Head of Residence confirmed that a prisoner’s IEP status
is linked to their ABC because both relate to challenging negative
behaviour. PSO 4000 – Incentives and Earned Privileges sets out how
compacts should relate to the IEP scheme: ”failure to comply with the
terms of a compact does not constitute a disciplinary offence, unless it
stems from behaviour that is in itself a breach of discipline.” The Head
of Residence said the man was abusive towards staff which constituted
a breach of discipline, but merely talking to female staff rather than
male staff would not constitute a breach of discipline.
109. I appreciate the principle behind the ABC but I am concerned about its
application in the man’s case. Staff told my investigation team that
they were confused about how to enforce the terms of the compact.
Prisoners and staff all thought that the man struggled to understand the
terms of his compact. Some female staff strictly enforced the terms of
the compact, but others happily spoke to him without a male member
of staff being present. It is difficult to believe that such an inconsistent
approach would best encourage him to interact appropriately with
female staff. Although the third SO changed the terms of the man’s
compact on 30 May, by then he had experienced more than a month of
being prevented from speaking to female officers.
110. In response to the draft report, the family asked whether there is a
training package for ABCs. My investigator asked the prison how staff
were trained in the use of ABCs and received the following response:
“ … there is no formal training package as it is not a national
product but a local HMP Wakefield tool used to manage
unacceptable behaviour. Staff on the wings become familiar with
the documentation via the safer prisons team who oversee the
process and terms of the compact. They are used in a very similar
way to a national programme of security monitoring for some
individuals and as such all residential staff are aware of their
purpose and how to record information in them. The compact itself
also has a clear description of why it is applicable to that particular
offender at the front for all staff to read and discuss with the
offender if required.”
In their response, the prison also explained that the ABC system builds
on staff’s existing skills so no further training should be necessary. I
appreciate staff learn the ABC process through its use, but I am
surprised that there is no formal training package.
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111. Although the ABC was subject to monthly discussions at the multi-
disciplinary meetings, I am concerned that it was not working to
encourage appropriate behaviour as intended. Consistency of
approach and achievable aims must be central to the management of
challenging behaviour.
The Governor and the Head of Residence should consider
introducing an audit and training package to accompany the ABC
system.
Basic regime
112. The decision to reduce the man’s IEP status was taken by the PO, the
second SO King and ninth Officer. The PO told my investigator that he
had no reason not to trust the second SO’s opinion that the man’s
status should be reduced to basic. He could not remember speaking to
other officers, including the man’s personal officer, for their views. The
second SO had experienced abuse from the man personally and said
that she had a problematic relationship with him as she was the only
female senior officer on the wing.
113. The disability liaison officer for B wing, and tenth Officer, the man’s
personal officer, remembered that the PO asked their views about
whether he should be on the basic regime. They said that, in their
view, he responded well when challenged and reducing his IEP status
would not improve his behaviour. They did not think that his IEP status
should be reduced. Despite the fifth and tenth Officers having a good
deal of contact with the man, neither was invited to attend the review.
The ninth Officer was asked to attend with the PO and the second SO
because he happened to be on the landing when the review was
convened. In interview, he acknowledged that he knew little of the
man.
114. I understand the man’s perception, with that of other prisoners on the
wing, that the decision about his IEP status was unfairly taken. As
discussed above, the terms of his ABC were not consistently applied.
The second SO opened the ABC and was also instrumental in the
decision to place the man on the basic regime. Not all the officers
agreed with the decision to reduce his IEP status, but it seems that
their views were not considered during the review.
115. PSO 4000 requires that “the decision making mechanism must operate
consistently and fairly” and “ideally this will be a formal board which
includes the personal officer”. I am surprised that the PO went to the
trouble of consulting the man’s personal officer but did not ensure that
he attended. The PO was not usually based on B wing, but the second
SO should have known that the tenth Officer was the man’s personal
officer and could have expressly invited him to the review.
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116. I have no reason to distrust the view of the second SO that the man’s
behaviour was disruptive and that her experience of him was difficult.
However, it is clear from conversations with other officers that there
was a difference of opinion about whether the man should have been
on the basic regime. I am concerned that the decision was made at a
review without his personal officer or the disability liaison officer, both
of whom were available and knew the man well. I understand the
second SO’s concerns about the man’s poor behaviour towards her
and persistent breaching of his compact. I do not conclude that the
decision to reduce his IEP level was unreasonable (although others
might equally reasonably have concluded that it should not be
changed), but I am concerned about the way that it was reached.
The Governor should remind staff that personal officers should be
involved in IEP reviews when available.
117. Following a consultation with the second mental health inreach worker,
the man was given back his television as officers were concerned
about the impact of the basic regime on his mental health. I am
pleased that the mental health team were actively involved in the man’s
care and that staff were prepared to be flexible to safeguard his mental
health.
118. The third SO returned the man’s status to standard on 30 May. The
investigation team have not seen a formal record of the review but
there is a note in the man’s wing history sheet to that effect. As there
is no formal record, there is no way to determine who was involved in
the decision to reinstate the standard regime. The third SO explained
that the decision was a difficult balance. After a review of the ABC, the
decision to reinstate the man to the standard regime fairly reflected the
staff’s overwhelmingly positive comments about his behaviour.
119. The man was on the basic regime from 26 April until 30 May.
Following the draft report, his family told my investigator that they were
concerned about the frequency with which his basic status was
reviewed. The requirements for IEP reviews are set out in 4000. The
man’s IEP status was reduced on 26 April and a review was held within
the required seven days, on 2 May. He was expecting a review a
further seven days from that point, but he was mistaken to expect a
second review so quickly. After the first IEP review, there does not
have to be a review of a prisoner’s IEP status for 28 days, as set out in
PSO 4000. Staff responded to the man’s concern and held an early
review on 12 May, ten days after his previous review. A further IEP
review was held on 30 May, 28 days after his first IEP review, in line
with Wakefield’s procedure. The investigation found that IEP reviews
were held with the required regularity.
120. I am concerned at the impact of the basic regime on the man’s mental
state. He was on the basic regime from 26 April until 30 May, over a
month of his time at Wakefield. Being on basic meant that he had 20
31
minutes every meal time to make a telephone call, collect a meal and
take a shower. He was allowed association twice weekly, but
otherwise spent his day alone in his cell. He elected not to go to
education because he thought it might breach the terms of his ABC,
despite staff assurance that it would not. My investigation team spoke
to a fourth prisoner on the same wing as the man who was also subject
to the basic regime. The fourth prisoner said that he too was allowed
out of his cell for around half an hour three times a day and had two
periods of association a week.
121. The man’s last telephone contact with his family was 24 April. No staff
were aware that he had stopped making calls. They reassured my
investigator that he would have had the opportunity to use the
telephone every day and that he must have chosen not to use it.
Contact with friends and family is critical when a prisoner is otherwise
isolated by being on basic. I accept that the man may have had the
opportunity to use the telephone, and it may well be coincidental that
he stopped contacting his family at the same time that his regime was
reduced to basic. I trust that the Governor will reinforce the importance
of prisoners on the basic regime maintaining contact with friends and
family.
Racism
122. The man made many allegations of racism against prison staff, not just
at Wakefield, but at other prisons as well. Other prisoners alleged to
my investigation team that there was a racist culture at Wakefield, and
they were concerned that the man’s treatment was affected because
he was a black prisoner. On one occasion, the man asked to go to the
segregation unit because it was a “black environment”. When asked
about this during interview, the seventh Officer was surprised that he
thought that the segregation unit was a black environment. Although
no black or minority ethnic officers worked on the wing, neither did any
work in the segregation unit.
123. My investigation team spoke to the PO about her role as Race Equality
Officer. She told the team that she was well supported and brought her
concerns directly to the Deputy Governor or Governor who promoted
the diversity agenda. Race equality meetings were held every month
and were well attended. They were chaired by the Deputy Governor.
(Although the IMB’s role is to observe rather than participate in prison
meetings, I was disappointed to discover that the Wakefield IMB had
not attended any of the race equality meetings for which my
investigation team were given minutes, in spite of being invited. I am
assured that the appointment of another member of the IMB has
reinforced their own commitment to the diversity agenda and they now
attend every meeting.)
124. The Race Equality Officer explained the process by which she
investigates allegations of racism. She explained that all complaints
32
with a racist element or marked by the prisoner as racist are brought to
her attention. She said that each allegation is investigated: “it’s a
conversation, then you look for documented evidence and then
formulate a recommendation or an outcome from the enquiries”. I am
reassured that, at the inspection in April 2005, HM Chief Inspector
found that the process for investigating racist allegations was sound.
125. My own investigation team were also satisfied that the procedure for
investigating complaints of racism was theoretically robust. However,
as a consequence of the man’s ABC, he could not speak with the Race
Equality Principal Officer, a female member of staff, alone. A male
member of staff had to be present, so that he did not breach of the
conditions of his compact. The man’s allegations were sensitive in
nature and were about B wing officers. His meeting with the Race
Equality Principal Officer took place in an office on B wing. Although
she could not explicitly remember which male member of staff was
present, and there is no record of his identity, I am concerned that it
was likely to be a B wing officer. The Race Equality Principal Officer
said that the man did not seem to be intimidated by the officer’s
presence and she believed that he spoke candidly about his perceived
racial treatment.
The Head of Residence should ensure that, where on rare
occasions it is necessary for a racial investigation to be observed,
it should be observed by someone independent, for example the
IMB, and not by an officer from the same wing.
126. The man said that he was frustrated he could not speak to a black
officer about the racism he felt he was experiencing. In fact, he did
speak once to a Diversity Officer who is himself black. However, he
accused the Diversity Officer of being racist as well and would not
speak to him again. When my investigation team asked the Race
Equality Principal Officer about BME representation among the
workforce at Wakefield, she said that the Prison Service’s minimum
required ethnic mix had been achieved. However, she acknowledged
that almost all of the black or minority ethnic members of staff worked
in roles without access to prisoners. In fact, she could only name two
officers at Wakefield who were of a black or minority ethnic
background. I am extremely concerned about the impact that this
continues to have on a prison with a significant proportion of BME
prisoners.
127. The Chief Inspector’s report from April 2005 showed that 16 per cent of
prisoners at Wakefield were black or minority ethnic. I do not
underestimate the difficulty of recruiting a representative ethnic mix of
officers and ensuring that they are front line staff. Indeed, when my
investigation team put these findings to the Governor, she shared the
concern. The Governor of Wakefield explained that there are a
number of Operational Support Grades (OSGs – a grade below an
officer and a non-contact grade) who are black or minority ethnic.
33
Additional support has been provided to help them through the required
examination process to become officers.
128. My investigation team analysed figures for segregation, control and
restraint and basic regime broken down by ethnic origin. From this
crude assessment, they did not find an over-representation of BME
prisoners. They also noticed that these figures were provided and
discussed at every race equality meeting. The man told the
psychiatrist that he felt “singled out” by staff and he alleged that staff
were racist on many occasions. My investigation found no evidence of
overt racism at Wakefield. However, it is difficult to rebut the man’s
perception, shared by others, that the needs of BME prisoners are not
sufficiently appreciated by an overwhelmingly white workforce.
The Prison Service should ensure as far as possible that there is
an appropriate ethnic mix of staff working with prisoners at
Wakefield.
129. During the investigation process, my investigator met the team from
HM Inspectorate of Prisons carrying out a further inspection in
December 2008. By this time, my investigator was concerned about
the number of allegations of racism she had received from prisoners at
Wakefield, in addition to those made by the man. The inspection team
routinely looks at the treatment of black and other minority ethnic
prisoners and their perception of that treatment. Although the
inspection report remains unpublished at the time of issuing this draft,
my investigator has received informal feedback of the outcome. The
inspectorate has indeed found that black or minority ethnic prisoners
perceive that they are treated unfairly as a result of their race.
However, the inspectorate’s own examination of the treatment of
prisoners broken down by race (for example, access to courses, IEP
status, likelihood of segregation, use of restraint) found no discernible
differences.
130. I understand that black and other minority ethnic prisoners may feel
that they are unfairly treated as a result of their ethnicity. I am
concerned that there are insufficient role models on the wing to
promote cultural diversity. However, I am confident that the systems in
place to investigate allegations of racism are robust when appropriately
employed. I am also pleased to learn that HM Inspectorate of Prisons
has not found that prisoners are not treated differently according to
their ethnicity. Nevertheless, the Governor will wish to improve BME
prisoners’ perception of their treatment at Wakefield, and I suggest that
a better balanced staffing mix would be an important step in achieving
that aim.
Complaints procedure
131. I am concerned about the man’s experience of the complaints
procedure. My role as Prisons and Probation Ombudsman is to
34
investigate prisoners’ complaints that cannot be resolved under the
internal procedures. I maintain a good working relationship with
Wakefield while dealing with such complaints. I cannot sensibly
compare one prison’s handling of complaints with another because
there are too many varying factors, such as the make-up of the each
prison’s population. However, I can say that I have had no reason to
doubt the effectiveness of Wakefield’s complaints structure in general,
and I only examine the man’s own experience.
132. PSO 2510 – Prisoner’s Request and Complaints Procedure governs
the way that Prison Service staff answer complaints made by
prisoners. There are three stages to escalate a complaint. First, the
complaint goes to a frontline officer. The PSO suggests that most
complaints should be resolved at this stage. Secondly, if the prisoner
is not content with the response received after the first stage, they can
submit the complaint to a Governor for consideration. The final stage
within the establishment is for the complaint to be submitted to the
Governing Governor for consideration. If the complaint cannot be
resolved after the third stage, the prisoner may approach my office. In
total, the man made eight complaints during his last time at Wakefield,
some of which remained unanswered when he died. Of those that
were answered, he received an initial reply within the required three
working days.
133. According to Chapter 11 of PSO 2510, “any written allegation against a
member of staff must be investigated”. The matter must first be
referred to the staff member’s line manager and an investigation
conducted. The PSO goes on to say:
“A prisoner who has made an allegation against a member of
staff which, on investigation, has been deemed to be unfounded
should be given a written warning not to repeat the allegation,
followed where necessary by a formal order.”
134. All of the man’s complaints made during his most recent time at
Wakefield were allegations about members of staff. The first mentions
“female officers” and then he moves on to being more specific,
repeatedly complaining about the second SO and also the Governor
and the female Officer. When my investigation team spoke to the
Governor about how complaints of this nature are dealt with at
Wakefield, she explained that she expected complaints to be dealt with
at the lowest possible level. That would mean that a complaint about a
senior officer should be dealt with by a principal officer, and so on.
135. In fact, most of the man’s complaints were dealt with by staff senior to
those named in the complaint. However, he made a complaint on 26
April when he accused the second SO of being “racist” and stopping
his wages “without good reason”. The SO responded to that complaint,
as follows: “in relation to the issue of pay, you were not and will not be
paid for periods where you have failed to attend for labour”. During
35
interview with my investigation team, the second SO could not recall
whether the SO spoke to her about this complaint. Due to the
allegation of racism, the complaint was also referred to the Race
Equality Principal Officer and dealt with under the prison’s race equality
procedures, as explained above. Again, the second SO did not
specifically remember speaking to the race equality team in relation to
this complaint.
136. The man’s complaints were not always coherent. Staff responses were
brief and frequently asked him to be clearer about what he was
complaining about. After the man’s exchange with the female Officer
on 2 June, he made a complaint abut her, alleging that she was racist.
The second SO responded, without recording that she had spoken to
the staff involved or to the man about what had happened. The second
SO said that staff may not recall her speaking to them about the
complaint because she did not do so formally, but discussed matters
raised in the complaint in a general way.
137. I have been disappointed to learn of the lack of contact between the
IMB and a prisoner of the man’s profile. He was well known to staff
and routinely complained about his treatment at Wakefield. Despite his
mental health problems, he was subject to an ABC and placed on the
basic regime. However, the only complaint that the IMB responded to
involved them speaking to staff and not seeking out the man. When
the man was complaining about his treatment by staff, it is surprising
that the IMB did not speak to him as well as to the staff involved. I
have chosen not to make a formal recommendation but will send a
copy of my report to the Chair of the Board for their consideration.
138. When my investigation team asked the Governor about the operational
level at which complaints are routinely dealt with at Wakefield, she said
it was to empower wing staff to resolve matters locally. In this way, the
Governor hopes to promote communication among staff and prisoners.
This is laudable, and I share the view that grievances should wherever
possible be resolved at the lowest level possible. However, I am
concerned that, in practice, staff dealing with matters in which they or
their close colleagues are involved may not approach their task with
the appropriate degree of rigour and detachment. There is more than
one example of the man’s complaints being answered without staff
speaking either to him or to the staff mentioned in the complaint.
The Governor should review the operation of the complaints
system to ensure that responses to complaints are sufficiently
rigorous and evidence-based.
The man’s complaint of 28 May
139. The man’s complaint written on 28 May was answered by the fifth SO
three days later. The complaint mentioned the Governor, who the man
accused of “laughing in his face”. When my investigation team spoke
36
to the fifth SO, he explained that, when he first looked at the complaint,
he did not think he could deal with it because it was about a governor
and it would have to be referred to someone more senior.
140. In this complaint, the man also asked that “someone independent” deal
with the matter. The fifth SO was not intending to deal with the
complaint, but the man came into the wing office while he was there.
The fifth SO spoke to him about another matter, which he resolved.
After that conversation, the fifth SO thought that he was in a position to
deal with the issues the man had brought up in the complaint. In fact,
he had not spoken to him about anything contained in the complaint.
He told my investigators that he was worried that, by asking the man
about his complaint, the conversation would last a long time.
141. The complaint contained two possible warnings of the man’s thoughts
of self harm. He wrote “suicide is an option!” and that he was dying
and did not want treatment. I accept that the wording of the complaint
was confused, but it is disappointing that the fifth SO did not recognise
either indication of possible suicidal ideation. When asked during
interview, the fifth SO said that he “did not register” the sentence about
suicide being an option. When offered the opportunity to review the
complaint and his response by my investigator during interview, the
fifth SO remained of the view that he would not have handled it
differently even with the benefit of hindsight. He told my investigator
that he had assessed the man’s presentation during their conversation
and had not judged that he was at risk of self harm. The fifth SO said
he was confident in ACCT procedures and would have opened one if
he felt it was necessary.
142. My investigator was sufficiently concerned about the fifth SO’s
approach to this complaint that she brought it to the attention of the
Governor following his interview. The Governor took a copy of the
complaint and agreed to take the matter forward. Nevertheless, I make
the following recommendation:
The Governor should remind all staff that, if a complaint mentions
thoughts of suicide or self harm, staff must speak to the prisoner
as a matter of urgency and consider opening an ACCT document.
Suicide threat
143. Staff and prisoners told my investigation team that they were surprised
that the man took his life. So far as I have discovered, he had not
spoken to any prisoner about suicide or self harm. Moreover, the fifth
SO did not register his written threat, judging it as a manifestation of
the man’s frustration rather than as a serious intent to kill himself.
144. One prisoner recalled overhearing the man shouting at the eleventh
Officer that he wanted to kill himself the night before he took his life.
However, the eleventh Officer was not actually working on B wing that
37
evening. He was involved in the incident with the man on 2 June,
when he shouted through his door following his altercation with the
female Officer. The prisoner alleged that the eleventh Officer
responded to the man’s suicide threat by telling him to “do it then”. My
investigation team put the allegation to the eleventh Officer. The
eleventh Officer said that he would have taken any threat from the man
seriously and would not have responded in such a way. He said that
he might have waited until he calmed down, but would have spoken to
him about any such statement to establish whether it was true.
145. My investigation team could not discover any more evidence either to
support or refute the allegation. During the eleventh Officer’s interview,
there was good evidence that he had built up a rapport with the man.
There is also evidence that the man was a challenging prisoner and
would have been frustrating for staff to deal with. I trust that the
exchange did not take place as the prisoner recalled it, and I trust that
the Governor will remind her staff to take every suicide threat seriously.
Emergency response
146. The man was found during the morning roll check. A radio call was
made and an ambulance called without delay. As the prison was in a
night patrol state, the healthcare response had to wait to be collected
from the healthcare centre. Nevertheless, the HCSO estimated he
took only three minutes to reach the cell.
147. After consideration of the emergency medical response on the morning
of 6 June in his clinical review, the clinical reviewer concludes:
“The nurse responded quickly and appropriately. There were
no life signs and very clear signs of rigor mortis and therefore
quite rightly no resuscitation was attempted as the man
appears to have been dead for some time.”
148. The HCSO remembered that, when he reached the cell, the man was
still in a seated position leaning against the wall. The Night Duty
Officer recalled that the man’s size and the stiffness of his condition
meant that there was some difficulty lowering him to the ground. The
Night Officer explained that the dimensions of the cell made it hard to
find the space, and they may have still been trying to lay the man down
ready for resuscitation when the HCSO arrived. I am bound to say that
I am surprised it took more than the three minutes before the HCSO’s
arrival to move the man into an appropriate position for resuscitation.
However, if there was a delay it would plainly not have changed the
outcome given the onset of rigor mortis.
149. The family were concerned whether the man sustained a head injury
as part of the resuscitation efforts. The HCSO remembered taking
over lowering the man’s body and described “cradling” his head as he
was brought to the ground. I trust that such care was taken and the
38
resuscitation was carried out in an appropriately respectful manner.
Certainly the staff interviewed spoke respectfully about the man and
seem to have had regard for his dignity.
Family liaison concerns
150. During my investigator’s meeting with the family, they raised several
concerns about their liaison with the prison in the weeks following the
man’s death. I have dealt with their concerns about his care in the
previous sections. Here, I consider the problems they described with
the family liaison arrangements.
151. The officer who was appointed as family liaison officer by the prison is
one of five family liaison officers at Wakefield. She undertook the
Prison Service Family Liaison Officer training in November 2004 and
has been the appointed family liaison officer for other families following
deaths of Wakefield prisoners.
152. The family asked the family liaison officer whether the man was
receiving his medication. The family liaison officer knew that he was
on medication for diabetes because she saw the medication being
removed from his cell by the police. However, the family liaison officer
did not know that the man had a mental health condition. During
interview, she said she would not expect wing staff to know whether he
was on medication for his mental health:
“No, it’s medical in confidence. The wing staff might be aware
that the man goes to the medical hatch to collect his medication,
but that would be the only thing they know.”
153. The family liaison officer also mentioned a previous self harm attempt
to the family during their visit to the prison. From their discussion that
day, the family understood the man’s attempt to harm himself had
taken place not long before his death. They were concerned that they
had not been told of this previously. My investigator asked the family
liaison officer which self harm incident she was referring to in their
discussion, and she responded that she mentioned when the man
harmed himself in 2006, while he was at Whitemoor. When asked
whether she knew of any later attempts to harm himself, she
responded, “None whatsoever, not while he was within our prison.”
154. Every prisoner arriving in custody nominates who they consider to be
next of kin. The details are recorded in the prisoner’s core record and
on a national computer system. The man did not name a relative, but
nominated someone he was corresponding with. Strictly speaking, the
family liaison officer should have contacted the listed next of kin before
consulting the man’s telephone and visits records to determine who he
appeared to be in contact with. However, on this occasion, the family
liaison officer contacted those closest to the man and appropriately
maintained contact with them.
39
155. PSO 2710 - Follow up to Deaths in Custody governs the Prison
Service’s obligations to family after a prisoner has died in their custody.
It requires that the prison:
“Arrange notification to the next-of-kin and any other person
reasonably nominated by the prisoner as soon as possible in a
suitable manner giving an accurate factual account of what has
happened.”
156. The related guidance to family liaison officers has more detail of what
is expected following a death in custody and suggests that face-to-face
notification is best. The family liaison officer explained to my
investigator that she wanted to break the news of the man’s death to
his family by telephone because they lived over 180 miles from the
prison. She said that she thought the family should know as soon as
possible, and to tell them in person would have meant hours of delay.
The guidance in fact suggests that the “using the telephone is too
impersonal to use in delivering news of a death to the family and
should be used only as a last resort”. When distance is a problem, the
guidance suggests, “a dedicated Family Liaison Officer or chaplain
based in the area nearest the family home could inform the family face
to face.” I understand that the family liaison officer made the decision
to break the news to the family over the telephone with their best
interests in mind, but she was not working within Prison Service
guidelines.
The Head of Safer Custody should remind all family liaison
officers at Wakefield of the contents of Prison Service guidance
for liaison with bereaved families.
157. In accordance with the guidance, the man’s family was invited to visit
Wakefield and look around the cell where he died. PSO 2710 also
requires the prison to “hand over personal possessions and monies to
the appropriate person in a suitable manner”. The family told my
investigator that they were invited to Wakefield and were grateful to the
prison for arranging their transport. However, they were concerned
that the man’s cell had been “staged” for their benefit. They described
shower gel in his cell that was not his, and bedding that did not belong
to him. My investigator put their concerns to the family liaison officer
who explained:
“I mean I feel quite upset that the family have actually said that,
they felt it was staged, it sort of took me a bit by surprise really.
The property that was left in the cell was toiletries and other bits
and pieces that were actually, belonged to the prison, that we
give out to offenders in prison, sort of bars of soap, flask, the
television. The cell when the man died was sealed obviously
until [the police] said we could have the cell back. When I knew
the family were coming I asked the wing staff to do a cell
40
clearance which they did and take out the man’s personal
belongings, and I asked them to leave the cell as it was found
on the morning … I didn’t want the cell to look bare and empty, I
wanted them to leave some things in that were in the cell, but
take out the man’s personal belongings so I could give them
back to the family on the day, and as far as I understood it,
that’s what they’d done. When I went into the cell with the
family, there was still bits and pieces, like his flask in the cell,
and the bed was made on the day when he died anyway, so
nothing was changed, the cell had not been altered at any
stage, as far as I’m concerned, it was as it was when the man
died apart from his personal belongings taken out.”
158. The man used a bed sheet to make the ligature that he used to
suspend himself. The family were concerned that they could not then
understand how his bed was made when they visited the cell,
especially as the family liaison officer told them that the bed was left as
it was from when he was discovered. Upon questioning by my
investigator, the family liaison officer explained that a prisoner could
have a spare set of sheets in their cells. Therefore, she thought that
the man must have used the second set of sheets to make the ligature.
(I cannot confirm or deny this.)
159. During the family’s visit to his cell, they also noticed that the cell next
door had been taped, using yellow and black stripy tape across the
observation panel and on the door of the cell, as if it were a scene of
crime. The family were worried that, given their other concerns about
the “staging” of the cell, the cell next door was actually the cell where
the man died and they were being misled by the prison. My
investigator asked the family liaison officer about this matter in
interview, but she could not recall the tape on the door. When she
visited the wing, my investigator noticed that the tape was still on the
neighbouring cell. An officer explained that a prisoner had set a fire in
that cell and it was yet to be released for use by other prisoners. I trust
that this allays the family’s suspicions.
160. The family told my investigator that the prison had offered to pay for the
funeral but that they felt they had no control over the funeral
arrangements. They said that the prison had selected cheaper options,
for example a lower standard of coffin. When my investigator asked
the family liaison officer to explain the prison’s involvement in funeral
arrangements during interview, she said:
“I’ve contacted the Funeral Directors and they’ve sent the bill
directly to us, so the bill wouldn’t go to the family, the bill is on
my desk at this moment in time … Any arrangements to do with
the funeral is done by the family. All I ask for is the bill and say
you know, as long as it’s reasonable you know, we will pay the
cost, that’s all …”
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161. Clearly, the Prison Service must not restrict what the family may
arrange for the funeral of someone who has died in their custody.
However, if these arrangements result in costs beyond those
reasonably incurred, the family should pay the balance. The man’s
family told my investigator that they would have been happy to do this.
The family liaison officer assured my investigator that the prison gave
the funeral director no specification for the funeral but simply arranged
for payment to go through the prison. Supplementary guidance to
family liaison officers alongside PSO 2710 suggests that the prison
should offer to pay a reasonable sum, around £3,000, and should liaise
directly with the funeral director to arrange payment. The family liaison
officer discharged the prison’s obligation in this respect. However,
there seems to have been some miscommunication between the
family, the funeral director and the prison. This is most regrettable, and
I hope that the Governor will work with the appointed family liaison
officers to ensure that such a misunderstanding does not arise in the
future.
162. Following receipt of the draft report, the man’s family were concerned
that suicide prevention measures were not put in place before he died.
The investigation team considered the assessment of his risk
throughout the process. I am careful not to apply the benefit of
hindsight in my investigations. In interviews, staff assured my
investigator that that they were trained and confident in ACCT
procedures and would have opened an ACCT document if they thought
that the man was at risk of self harm. The man’s behaviour and mood
was being monitored through the ABC. Any concerns about risk of self
harm or suicide would have been recorded in that ongoing record and
checked by duty governors. There is no evidence of any such concern.
Staff told my investigation team that they did not think that the man was
at risk of self harm. All staff were surprised by his death. His low
mood was attributed to being on the basic regime, and staff took
measures to improve his wellbeing. Still, they did not think that he was
at risk of self harm. Given the information available to staff at the time
of their judgements, I do not think it was unreasonable for staff not to
have opened an ACCT document.
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CONCLUSION
163. The man was not alone amongst BME prisoners in his view that he
was being treated unfairly at Wakefield. However, as HM Inspectorate
of Prisons has found in its most recent inspection, this perception of
unfair treatment is not borne out by an analysis of access to courses,
IEP status, likelihood of segregation, use of restraint, etc.
Nevertheless, it is clear that more must be done to improve the
persuade BME prisoners that Wakefield lives up to the Prison Service’s
vision of treating all prisoners fairly and with respect for their diversity.
I have suggested that an important step would be by increasing the
proportion of frontline staff from a BME background.
164. While the decision to place the man on an ABC was not improper,
staff’s use of the compact was flawed. Neither the man nor officers
fully understood the reason the ABC was opened and the terms of the
ABC were difficult to enforce. They were also ignored by some female
staff, which undoubtedly added to the man’s confusion.
165. Equally, given his abusive behaviour and apparent targeting of staff,
the decision to reduce the man to the basic regime may not have been
unreasonable. However, the process followed was not satisfactory,
and this investigation has revealed that some staff thought the decision
itself was wrong. In practice, the man responded badly to the
downgrading and isolated himself from his family.
166. The man made numerous complaints about how staff treated him. The
complaints were ‘investigated’ without speaking to the people involved.
This did nothing to reassure him that his treatment at Wakefield was
fair.
167. The man was undoubtedly both a challenging prisoner and a
vulnerable man himself. However, while I have criticised aspects of his
treatment, I also wish to acknowledge that many staff appear to have
worked well with him.
168. I agree with the clinical reviewer that the actions taken on the morning
that he was discovered were appropriate and timely.
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RECOMMENDATIONS
1. The Head of Healthcare and the Head of Residence should work
together to ensure that, when a prisoner is on the caseload of the
mental health inreach team, they should attend the initial review
meeting to set up an ABC and also attend subsequent reviews.
The prison accepted this recommendation, with the following response:
“Mental Health team to be invited as regular attendee to ABC
meetings. Mental Health Team co-ordinator to be informed of
anyone being considered for ABC before meeting to ensure
current caseload offenders are flagged up as such.”
2. The Head of Residence should ensure that the reason for starting an
ABC is clearly and specifically stated on the document and the reason
is effectively communicated with the prisoner.
Following the issue of the draft report, the prison accepted this
recommendation. In response, they wrote:
“ABC document to be reviewed at next ABC meeting (November
09) to ensure reasons are clear and written document is given to
all offenders subject to ABC outlining why the document has
been opened and ensure wing rep attending meeting or wing
manager/safer prisons manager speaks directly to offenders to
explain the process and outcome when they are placed on
ABC.”
3. The Governor and the Head of Residence should consider introducing
an audit and training package to accompany the ABC system.
The prison only partially accepted this recommendation.
“Safer Prisons awareness package can be altered to include
ABC awareness. Performance unit to be asked to look at
feasibility of an internal audit protocol for ABCs.”
4. The Governor should remind staff that personal officers should be
involved in IEP reviews when available.
The prison accepted this recommendation and issued a notice to staff
to remind them of the involvement of personal officers in IEP reviews.
5. The Head of Residence should ensure that, where on rare occasions it
is necessary for a racial investigation to be observed, it should be
observed by someone independent, for example the IMB, and not by
an officer from the same wing.
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The prison accepted this recommendation, with the following response:
“Any investigations such as this go via Race Equality Officer
who may task their assist staff to pursue the enquiry. To discuss
with REO using staff from wings/areas other then originating unit
to carry out this work. IMB to be invited to discuss this proposal
with REO and Residential manager with oversight for equalities
issues.”
6. The Prison Service should ensure as far as possible that there is an
appropriate ethnic mix of staff working with prisoners at Wakefield.
The Prison Service is yet to respond to this recommendation.
7. The Governor should review the operation of the complaints system to
ensure that responses to complaints are sufficiently rigorous and
evidence-based.
The prison accepted this recommendation and undertook to take the
following action:
“An advice document will be compiled and made available to all
staff, with particular focus on managers. This will include clear
guidance on how to respond to a complaint that has an inclusion
of suicidal or self harm related issues, as well as general
guidance on making through and evidence based responses.”
8. The Governor should remind all staff that, if a complaint mentions
thoughts of suicide or self harm, staff must speak to the prisoner as a
matter of urgency and consider opening an ACCT document.
The Governor accepted this recommendation and reissued a notice to
remind staff of their obligations following any threat of self harm.
9. The Head of Healthcare and the Chaplain should remind all family
liaison officers at Wakefield of the contents of Prison Service guidance
for liaison with bereaved families.
The prison accepted this recommendation and reminded all FLOs at
Wakefield of the importance of the Prison Service guidance for liaison
with bereaved families.
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