Individual at Manchester

Investigation into the circumstances surrounding the
death of a man at HMP Manchester in
October 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2009
This is the report of an investigation into the death of a man. His cell mate found him
hanging in the bathroom of their shared cell at HMP Manchester in October 2008.
He had a ligature made from two shoelaces tied around his neck. Despite efforts to
resuscitate him, he was pronounced dead shortly after arrival at hospital. He was 46
years old.
I would like to extend my sincere condolences to the man’s family and to all those
touched by his passing. He was British, but had lived in Zimbabwe for much of his
life. His wife and daughters still reside there.
The investigation has been undertaken on my behalf by one of my senior
investigators. I am also very grateful to the clinical reviewer of the local Primary
Care Trust for carrying out a comprehensive clinical review of the healthcare the
man received whilst in custody. I would also like to thank the Governor of
Manchester and his staff for their help and co-operation.
From the time he came into custody, the man expressed concerns for the safety of
his family. However, it was only after he was sentenced to six years imprisonment
that he openly voiced his fears to his cell mate that he could not survive being parted
from them. His death, a week after being sentenced, appears to have been
meticulously planned. He left individual handwritten notes addressed to separate
family members expressing his love and affection for them and acknowledging the
heartache they would feel as a result of his death.
Manchester is formally recognised as a high performing prison. I am therefore both
surprised and dismayed that in what was otherwise exemplary management of the
events described in this report, the decision was taken to handcuff the man until the
moment of his death. This was frankly macabre. I am certain that the Governor and
his management team will wish to implement the lessons of this investigation as
quickly as possible.
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 August 2009
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CONTENTS
Summary
Investigation Process
HMP Manchester
Key Events
Issues
Recommendations
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SUMMARY
The man was born in Britain but had lived in Zimbabwe with his family for many
years. He regarded Zimbabwe as his home but he was worried about political unrest
there, particularly as a white former landowner. He wanted to accumulate as much
money as he could to enable his family to leave the country if it became necessary.
On 27 July 2008, he was arrested at Manchester Airport and charged with drug
importation and money laundering. After appearing in court the next day, he was
remanded in custody and taken to HMP Manchester. He was not regarded as a
foreign national by Manchester because he had the right to live in the United
Kingdom. This meant that the Foreign Nationals Officer was not aware of him and
his particular needs as a person living abroad were not recognised initially. After
leaving the induction unit (for prisoners new to Manchester), he moved to B wing.
Although he was allowed at least one telephone call to his wife on an ad hoc basis,
his application for extra telephone credit was turned down because he had received
visits in the previous month.
The man told the Healthy Prisons Co-ordinator that he was feeling under stress and
could not sleep because he was concerned about his family’s safety in Zimbabwe.
The Co-ordinator contacted the Foreign Nationals Officer on the man’s behalf and
urged him to make a healthcare appointment regarding his insomnia. He was given
an appointment to see a nurse specialising in insomnia on 13 October 2008.
In order to gauge how long his prison sentence was likely to be, the man canvassed
opinion from several prisoners who told him to expect around four years. However,
despite pleading guilty, he received a sentence of six years on 6 October. This left
him feeling stunned as it was longer than he had expected. Nevertheless, he told a
nurse on his return from court that he did not have any concerns. As there is no
specialised induction for convicted/sentenced prisoners, he returned to B wing. He
told the library orderlies that other prisoners had told him he would have to serve his
whole sentence in the United Kingdom instead of returning to Zimbabwe after the
custodial portion was served. The library workers asked him to go back when it was
less busy so they could explore what legal avenues were open to him but he did not
return. Instead, he asked the Foreign Nationals Officer, who told him that it was not
an automatic matter but one that could be explored.
Some prisoners described the man’s physical appearance after he was sentenced
as subdued, older and that he acquired a “lost look of desperation.” He told a couple
of fellow prisoners that he was annoyed that international telephone calls were so
expensive and that staff had ignored his queries about the cost. He told his cell
mate several times during the week after he was sentenced that he was at the end of
his tether. He could not survive his sentence and being apart from his family for so
long.
In October 2008 the man’s cell mate awoke and discovered him hanging from the
bathroom window. The ligature was cut and he was placed lying down by officers.
Efforts were made by the Senior Officer, healthcare staff and ambulance personnel
to resuscitate him and he was taken to hospital attached to an officer by an escort
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chain. He was pronounced dead shortly afterwards without regaining
consciousness.
I am acutely conscious of the fact that the man died just one week after he was
sentenced and have little doubt that his death was brought about in part as a
response to the length of his sentence. My report makes recommendations on the
lack of a structured induction process for convicted and sentenced prisoners. I also
consider whether there is scope for widening the definition of foreign national
prisoners at Manchester. Finally, I strongly criticise the use of handcuffs on an
unconscious man who has hanged himself.
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THE INVESTIGATION PROCESS
1. My investigator visited HMP Manchester three times. She was given access
to all prison records relating to the man. These included his clinical record,
initial statements from staff and his prison core record.
2. She met representatives from the Independent Monitoring Board and the
Prison Officers Association to offer them the opportunity to raise relevant
issues. Notices publicising the investigation were displayed around the
prison. Three prisoners and three members of staff were interviewed by my
investigator as a direct response to these notices. Contact was also made
with a Sergeant of Greater Manchester Police who confirmed that there was
no evidence of third party involvement in the man’s death.
3. The man’s family was offered and accepted the opportunity to contribute
towards the investigation process. One of my Family Liaison Officers
contacted his family to discuss the issues the family wished to raise. They
could not understand how he had managed to end his life using shoelaces
and they wanted to know whether anyone else, apart from his cell mate, had
picked up on how he was feeling.
4. The clinical reviewer from the local Primary Care Trust has provided a clinical
review which is annexed to this report. It examines whether the man’s
healthcare needs were met whilst he was in custody. I am grateful to him for
undertaking such a comprehensive review.
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HMP MANCHESTER
5. HMP Manchester is a large prison which holds up to 1,269 prisoners. It is
Victorian in external appearance but has been refurbished internally. Cells
have televisions, electric sockets and sanitary facilities. Manchester holds
both unconvicted and sentenced prisoners as well as a small number of high
security (category A) prisoners. For this latter reason, it is part of the high
security estate and security within the prison reflects this.
6. The prison is divided into two main blocks. The upper prison contains four
wings (G-K) which include the First Night Centre and the induction wing. The
lower prison has five wings (A-E). B wing, where the man spent most of his
time at Manchester, operates as a Voluntary Testing Unit for prisoners who
wish to live in a supportive environment away from drug use. Prisoners sign a
compact agreeing to be tested for drugs at random. The Voluntary Drug
Testing Unit has a reputation as a stable and quiet wing. Older first-time
offenders often find it a more suitable environment than the rest of the prison.
7. The man’s death was the second apparently self inflicted death to occur at
Manchester in 2008 and the fourteenth such death since I took over
responsibility for investigating all deaths in prisons in 2004. Few, if any, of my
recommendations in previous reports are relevant to the circumstances of his
death.
8. HM Chief Inspector of Prisons (HMCIP) carried out an unannounced
inspection of Manchester in May 2007 as a follow-up to her 2004 inspection.
Her report in 2007 said in relation to safety at Manchester that “the application
of category A procedures to the small number of category A prisoners had
implications for the quality of life for all prisoners, 630 of whom were merely
category C prisoners. Better and more equitable risk management was
required.” Her report spoke about the improvement in staff–prisoner
relationships, and in particular the impact of the group officer scheme which
meant that prisoners would be allocated a named officer who would be
responsible for engaging proactively with them. However, her report also
commented on suicide and self-harm procedures that required further work,
especially that insufficient profiled time had been allocated to staff involved in
safer custody. (I understand that the profile of safer custody issues has risen
markedly since 2007 and that improvement measures have been initiated on
many of the points raised in her report in this regard.)
9. The prison’s Independent Monitoring Board (IMB), is comprised of unpaid
members of the local community appointed by the Secretary of State for
Justice, and is required to satisfy themselves that prisoners are being treated
properly. In its most recent annual report covering the period 1 March 2007-
29 February 2008, the IMB said:
“Manchester is a well-run prison which is meeting most of its Key
Performance Targets … The Board has witnessed many occasions when
staff have demonstrated sensitivity to prisoners’ needs. e.g. in Reception
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on arrival at prison, officers giving information on what was happening and
answering any questions ..."
10. In relation to safer custody issues, the IMB commented that “staff do
everything they can to prevent prisoners harming themselves.” The First
Night Assessment and Induction form was described as “working well.”
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KEY EVENTS
11. The man was born in Sheffield in February 1962. He grew up in Zimbabwe,
married and had two daughters. He was arrested at Manchester Airport in
July 2008 after arriving on a flight from Zimbabwe. He was charged with drug
importation and money laundering. The next day, he was taken to
Manchester Magistrates Court where he was remanded in custody. He was
moved to HMP Manchester later that day.
12. On arrival at Manchester, the man was assessed by a Reception Officer using
a Cell Sharing Risk Assessment (CSRA). (This is a standard procedure to
assess a prisoner’s suitability to share a cell with another prisoner.) The man
was assessed as low risk. The Reception Officer told my investigator that he
regularly dealt with many prisoners coming through Reception so he could not
specifically remember him. However, he was confident that he would have
been able to spot signs of vulnerability if they had been evident at that time.
He told my investigator that he had been a Reception Officer for three and a
half years and had worked in the Prison Service for 16 years in several large,
busy urban prisons similar to Manchester. He said he had experience in
opening many Assessment Care in Custody Teamwork (ACCT) documents
on newly received prisoners. (ACCT is the Prison Service’s process for
supporting and monitoring prisoners who may be at risk of self-harm or
suicide.)
13. The man was also seen in Reception by a Healthcare Assistant (HCA) who
discussed his healthcare history by way of a First Reception Health Screen.
This is designed to find out whether a prisoner has medical needs and to
provide appropriate treatments. The HCA took the man’s medical history and
noted in his electronic clinical record that he had suffered a number of
fractures when he was younger, was a heavy smoker and had a family history
of cardiovascular disease. My investigator asked the HCA about spotting a
prisoner at risk and whether he would be able to detect signs of distress. He
said he would be confident about doing so.
14. The man was taken to H wing to spend the night as there were no spaces on
the First Night Assessment and Induction Centre on G wing (a specific
residential area set aside for prisoners who have newly arrived at
Manchester). Prisoners who have been to Manchester before usually follow a
fast-track process whereas first-time prisoners may remain in the induction
unit for up to two weeks. An Officer asked him a series of questions designed
to highlight if there were immediate concerns that needed to be addressed. In
response, he said that he was British and his family knew where he was as he
had been given the opportunity to telephone his brother-in-law whilst in
Reception. He said that it was his first time in prison. The Officer asked him
whether he had ever harmed himself, attempted to commit suicide or whether
he felt at risk of self-harm or suicide. The man replied “No” to these
questions.
15. The section in the booklet concerning foreign national prisoners was not
completed. At interview, the Officer said that he had not completed that
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section because the man held a British passport and thus according to his
understanding of Prison Service policy he was not a foreign national. In
section five of the First Night Assessment and Induction booklet he completed
on the man, the Officer described him as cheerful, co-operative and polite.
He added, “The man is a polite, well spoken individual, no issues or concerns
raised.” The Officer explained about Listeners (who are prisoners trained by
the Samaritans to support their peers experiencing anxiety or distress by
talking in confidence with them), the Samaritans telephone and the
emergency cell bell. He told my investigator that the man had chatted to him
about his work as a car mechanic and owning a garage.
16. The day after his arrival, the man moved to G wing. He was visited by a
minister from the chaplaincy team, as he was new to Manchester. He told the
minister that he was a British-born Zimbabwean and he was concerned about
his family in Zimbabwe as they did not know where he was. The minister
wrote in the man’s Record of Events, (where any significant occurrences or
observations are recorded), “Advised him to request international call from
officers. Agreed also to phone his solicitor to come in. No apparent risk of
self-harm but advised of support available. Not been in prison before. He’s
managing to cope, but finding it difficult.” The man was interviewed by an
Induction Officer as the second part of the induction process. He said he was
not concerned about being in Manchester and that he did not feel at risk of
harming himself.
17. On 31 July, the man attended the Education Department for induction. This
consisted of a basic skills assessment and information on services available.
An officer, who works in the Information Advice and Guidance section of the
Department, assessed him. At interview with my investigator, she described
him as willing to engage and complete the assignments he was given. He
told her of his fears for his family abroad and spoke of a time when he used to
sleep at night holding a gun in case his family was attacked. After being sent
to Manchester, he had told his wife to try and sell as many of their
possessions as she could in order to come to Britain. (He said his family were
all British citizens.) He asked the officer if she could assist him in retrieving
his wedding ring from Customs as it had been seized when he was arrested
at the airport.
18. An Information Technology trainer taught a class on the European Computer
Driving Licence which the man attended each weekday morning. He told my
investigator that the man had a very positive attitude, was keen and used to
be the first to arrive in class. Often they would chat for 5-10 minutes before
the lesson. The man would talk about his daughters and life in Zimbabwe.
19. The man kept appointments for hepatitis B vaccinations on 1 and 7 August.
Two of his brothers-in-law, who are resident in England, visited him on 2
August.
20. As noted above, B wing is a Voluntary Testing Unit for prisoners who wish to
be in a supportive environment away from drug use. Around 50 per cent of its
prisoners do not have a substance abuse history. It also welcomes older and
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first-time prisoners who may find the faster pace, turnover and activity on
other wings a more challenging experience. Prisoners on G wing may apply
to move to B wing or they may be recommended by staff. It is not clear by
which means the man heard of B wing but after spending eleven days on G
wing, he moved to B wing on 9 August.
21. A wing officer helped the man settle on to the wing and allocated him cell B3-
15 with another low risk prisoner. The Senior Officer (SO), one of three senior
officers on B wing, told my investigator that he got to know him well. On one
occasion, the SO arranged for him to telephone a friend in Zimbabwe to check
on his children’s safety when his wife was visiting South Africa. The man had
acknowledged that his lifestyle in Zimbabwe had been good but the political
difficulties white people were experiencing there made him increasingly
concerned about his family without him.
22. The SO described the man as being “perfect for B wing.” Asked why that was,
he replied: “He was of a middle age with a lot of sense, quite obviously he
wasn’t the type of character to cause any sort of disruption to the regime. And
in time it proved correct because you could see the possibility of him having a
positive impact on the regime as being a more mature character. Well
spoken, well educated guy, a likeable character.”
23. B wing practices Peer Group Induction which involves selected prisoners
(managed by a Senior Officer) introducing new arrivals to how it operates.
This includes the prison policies with particular relevance to B wing such as
Voluntary Drug Testing, alcohol awareness, where to seek help for issues of
substance misuse and how to make an application to access facilities and
services. My investigator interviewed a prisoner on B wing who is part of the
Peer Group. He described some of the tasks that the group undertakes. He
said that not only is peer support useful for those who may feel uncomfortable
talking to an officer about their personal issues but it also gives peer
supporters a feeling of self respect in being able to help others.
24. The prisoner said that he chatted with the man frequently. They became
friends on learning that they had a shared interest as ex-soldiers. They would
talk about military life and the man would paint mental pictures of Zimbabwe
which he described as a lovely country to see. However, he told the prisoner
of his safety fears for his family in Zimbabwe, whom he was very close to, and
he was concerned about violence towards white Zimbabweans. Asked by my
investigator about the man’s general demeanour, the prisoner said:
“He’d have a laugh and a joke like anyone else. Everyone, all the lads on
the wing thought he was a nice guy, he played pool with the lads and
things like that. But then you would notice every now and again he’d slip
into his own world … he’d walk up and down, not really going anywhere
but just walk up and down. And because I’ve done it myself, it’s when you
know someone’s got a lot on their mind … I try and grab his attention and
maybe occupy his mind in other ways.”
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25. The prisoner thought that the man was very upset at being in prison but he
never mentioned harming himself or taking his life. In interview, the prisoner
recalled the man describing imprisonment as “a walk in the park” compared to
their pasts as soldiers. The prisoner had agreed, saying that because they
had experienced active service they were probably more adaptable than most
people.
26. The man received visits from two friends from Derby. They saw him on 10
and 15 August and again on 3 September. His brothers-in-law arranged to
see him on 6 September but the visit did not take place.
27. The Healthy Prisons Co-ordinator told my investigator that he came into
contact with the man on four occasions in September. The Co-ordinator is
employed full-time by NHS Manchester (formerly Manchester Primary Care
Trust) to deliver health promotion programmes to HMP Manchester. He
explained that each session is on a different topic such as alcohol awareness,
smoking awareness, sexual health, testicular and prostate cancer, hepatitis
awareness and healthy eating. He also runs a course called the Campaign
Against Living Miserably (CALM) which was developed by a charity of the
same name and is a nationally recognised mental health intervention. It
encourages people to talk about the way they are feeling instead of bottling
themselves up, and to forge healthy friendships and offers general coping
mechanisms. CALM apparently found that 70 per cent of young men who
took their own lives did not talk to anyone about it.
28. The man attended a smoking awareness session on B wing at the beginning
of September. During a break in the smoking awareness session, he said
that he was smoking a lot due to the stress he was experiencing after leaving
his wife and children in Zimbabwe. He said he could not consider giving up
as he had a lot on his mind.
29. On 24 September, the man took part in CALM. After the session, the Co-
ordinator asked him how he was as he knew from previous conversations that
he had been feeling under stress. The man told him that he was not sleeping
and was still feeling stressed as his main focus was getting his family out of
Zimbabwe. The Co-ordinator said he would make an appointment for him to
see a doctor concerning his insomnia and he would refer him to the Foreign
Nationals Officer. He also thought that he would benefit from being able to
talk to others in a supportive setting so he referred him to the mental health
day centre. The man seemed receptive to the Co-ordinator’s suggestions.
The Co-ordinator told my investigator that he was struck by the man’s focus
on the future in terms of wanting to be sentenced so he could plan his future
and get his family out of Zimbabwe. He said he had no reason to consider
that he would take his life. The man attended four health promotion sessions
in total in September.
30. The Co-ordinator emailed the Foreign Nationals Officer on 24 September to
say that he had been working with the man. The man was worried about his
family’s safety in Zimbabwe and as a result he was not sleeping due to stress
and feeling powerless. He was concerned because it was expensive to ring
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Zimbabwe and he wanted to know whether there was a special rate available
for international telephone calls.
31. Manchester allows foreign national prisoners to apply for a telephone call up
to the value of £10 if they have not received a visit in the preceding month.
(UK citizens can make a call up to £5 under the same conditions if their family
lives 100 miles or more away.) The man had made an (undated) application
for a telephone call to his wife but was turned down on the grounds that he
had received visits on 2, 3 and 6 September. (In fact, the visits booked for 2
and 6 September did not take place.)
32. The man received a legal visit from his solicitor on 25 September and from
two investigation officers with HM Revenue and Customs on 26 September.
33. On 29 September, the man had an appointment with a prison doctor. She
noted in his electronic clinical record that he had seen her concerning after
effects of having fractured some bones when he was 20 years old. She
prescribed diclofenac, an anti-inflammatory medication. She noted that he
needed to see a physiotherapist for an assessment. She recorded his mood
as “euthymic but lots on his mind regarding family stuck in Zimbabwe.”
(Euthymic means a normal, non-depressed, reasonable mood.) The
prescription chart in his clinical record showed that she also prescribed seven
days of Zopiclone (a medication for insomnia) on the same day.
34. On 1 October, the man was seen by a physiotherapist. She wrote in his
clinical record that he had a chronic long-standing injury in his left knee which
would not improve with an exercise regime.
35. In the run up to the man’s appearance in court for sentencing, his cell mate
told the SO that the man was feeling down. The SO encouraged the man to
chat and share his problems which, as before, he expressed as concern for
his family’s welfare. The man told one of his teachers that the National
Probation Service had not yet prepared a Pre-Sentence Report but his
solicitor was encouraging him to be sentenced on 6 October as the judge
sitting in court that day was lenient.
36. A second prisoner on B wing told my investigator that he began to chat with
the man after another prisoner told him that the second prisoner had
committed a similar offence to his. According to the second prisoner, the man
would try and gauge from other prisoners the likely length of his prison
sentence. They told him he would get about four years and the second
prisoner thought the man had told him his solicitor had mentioned that figure.
He seemed to have it fixed in his head that he would receive four years. The
second prisoner thought this rather low and after reading (for his own case)
how the tariff was calculated, he felt that the man would receive seven years.
He told my investigator that he told the man “You need to get it in your head
that you’re getting six years so at least it doesn’t shock you when, if you do
get it.”
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37. On 6 October, the man was taken to Manchester Crown Court. He pleaded
guilty to the offences he had been charged with. In sentencing, the judge said
he acknowledged his personal circumstances, the failure of his business,
problems with his farm and anxieties over his family that had led him to
commit his offences. He also recognised that he had no previous convictions.
The judge explained that 12 years would have been an appropriate sentence
for both his offences but he would regard nine years as a starting point due to
his immediate co-operation after arrest. He would give a further one-third
credit for his guilty plea, leaving a sentence of six years on each offence to
run concurrently. The judge did not comment on whether he should face any
travel restrictions after serving the custodial part of his sentence.
38. On his return to Manchester, the man was seen in Reception by a nurse who
wrote in the healthcare reception book that he did not have any concerns.
Asked some time later by my investigator whether she recalled talking to the
man, she said she did not remember seeing him at all. She said that 12 new
prisoners had arrived at Manchester that afternoon and evening and her
priority would have been to interview them rather than deal with the 27
prisoners (like the man) who had returned from court that day. She added
that practice at Manchester had changed in the last couple of months and
Reception nurses were now required to speak to all returning prisoners. My
investigator asked a second (SO) for an overview of the systems to identify
issues with returning prisoners. The second SO said that there was not a
formal system in place but ideas were being discussed. I understand that a
Change of Status Identification Form devised by the Safer Custody Team is
now in place which requires various departments, starting with staff in
Reception, to make a record of any conversations they have had with a
prisoner whose circumstances have changed, bearing in mind the possible
risk of self harm and suicide.
39. The man returned to B wing as there is no formal induction for prisoners
returning from a court hearing where their status may have changed from
unconvicted to convicted and/or sentenced. He made a brief telephone call to
his family and another to his friends in Derby. He told the second prisoner
about his sentence and said he was thinking about appealing because he was
expecting less. He asked the second prisoner to show him the sentencing
guidelines and complained about his legal representation.
40. When the first SO was next on duty after the man was sentenced, on 7
October, he asked him how he was feeling. He replied that he was shocked
because he had expected a sentence of around four years. The SO sat down
with him and they looked at the computer breakdown of how much time he
would actually serve (three years including time spent on remand.) His
conditional release date would have been 28 July 2011. The SO told my
investigator that he tried to show him a positive way of looking at his time in
custody. He explained to him that by taking various courses and offending
behaviour programmes, he would soon reach a period when he could be
considered for a lower security category prison and that he could get through
the sentence.
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41. The man wondered whether he should try and encourage his family to move
to Britain as he wanted to see them regularly. On the other hand, he was
concerned that house prices had severely depreciated in Zimbabwe and, in
any event, it would be extremely difficult to get any money out of the country.
He also worried about the wisdom of having his children grow up in Britain,
which he thought might have a detrimental effect on them. He had told his
teacher that his daughters were in good schools and he wanted them to
continue their schooling. He made brief telephone calls to his family on 7 and
8 October. His telephone credit ran out after a call to his friend on 10
October.
42. The SO emailed the Foreign Nationals Officer asking him to see the man.
Also on 7 October, the process of deciding what category of prison he would
be sent to was started. According to form ICA1 in his custodial documents
file, the documents on which that decision would be based (such as previous
convictions and details of his offence) were requested on 7 October.
43. The Foreign Nationals Officer told my investigator that he met with the man
the day after receiving the SO’s email. The man said he wanted to be able to
access the foreign national telephone call scheme because it was expensive
for him to make calls otherwise. The Foreign Nationals Officer said he was
looking to amend the system so that prisoners who did not fall strictly within it
at the moment if they received the odd visit, could benefit on a discretionary
basis. He told the man to send his telephone call application directly to him
for it to be processed.
44. On 9 October, the man moved from B1-25 to B4-23 with the same cell mate
as they found the lower landing too noisy and preferred to be on an upper
level. As a result, another officer became his third personal officer on B wing
(the system allocates prisoners according to their cell location). He went to
the man’s cell and introduced himself to him and his cell mate. The man’s
teacher observed that he appeared very subdued as he entered class that
day. He told her that he had been sentenced to six years imprisonment and it
was his understanding that because he did not have a Pre-Sentence Report
he could not appeal against his sentence.
45. On 10 October, the Nurse Manager received a written application from the
man who said he was suffering from lack of sleep. An appointment was made
for him to see a Sister, a non-medical prescriber who is experienced in
working with prisoners who are suffering from insomnia, on 13 October.
46. On the same day, the man went to the library in the Education Department,
which he did two or three times a week, for the first time since he was
sentenced. Two prisoners who work in the library told my investigator that he
spoke of receiving a longer sentence than he was expecting. The first library
prisoner described his demeanour:” He was really down, really depressed, he
couldn’t see the light at the end of the tunnel. And we were trying to buck him
up and say ‘Look, come and see us when it is quiet and we’ll try and explore
the options’ … I tried to tell him to stay positive …” The first library prisoner
said he was concerned that the Prison Service does not do enough to help
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prisoners prepare for sentencing, doing a sentence or offer counselling to help
prisoners to deal with their circumstances. He said that in his case after he
was sentenced HMP Liverpool had a dedicated officer who spoke to him
about the appeals process. He added that prisoners had been telling the man
that he would have to serve both the custodial part and his release on licence
in Britain and would not be able to return to his family. He told him not to
listen to the “rumour mill” and that they would look at the legal literature in the
library to work out what actually would be the case.
47. The second library prisoner said that the physical change in the man after
returning from court was noticeable to him and his colleague. He had a
“look”, not that he was contemplating self-harm but more of feeling let down
and that the future was gloomy. As there were other people in the library, the
second library prisoner apologised for not being able to spend much time with
him but promised that the next time he visited, they would look at some law
books so he should not take his current situation as final.
48. The Foreign Nationals Officer met with the man on 10 October at about 10am.
The man told him that his application to make an international telephone call
had been returned to him. He was reminded that he needed to send it to the
Foreign Nationals Officer. He told the officer that he had been sentenced and
was feeling stunned and a bit shocked. He asked whether he would have to
spend his period of release on licence in the UK. The Foreign Nationals
Officer told him that when he was allocated a probation officer, he should
make them aware as soon as possible that he intended to return to Zimbabwe
on release. This would mean that the issue of a special dispensation on his
licence conditions could be explored. Whilst it was not an automatic right, it
would be on the agenda from the outset.
49. At lunchtime when the Foreign Nationals Officer happened to be on B wing,
the man gave him a copy of his turned down telephone application and a
fresh one. The Officer told him that he would be going home shortly so he
would deal with the forms when he returned to work on 13 October.
50. The second prisoner said that in the days after the man was sentenced, he
did not see much of him on B wing. One day, he went into his cell next door
to say hello but he was just sitting quietly on his bed. The man said that he
was “pissed off” that international telephone calls were so costly. The money
he had to make calls went in about two minutes and it left him annoyed. The
second prisoner suggested that he ask the SO to assist. A third prisoner who
was on B wing at the time of the man’s death, told my investigator that he
complained to him about staff ignoring his queries concerning the cost of
telephone calls to his wife. He was not sure exactly which officer the man had
been talking about nor what day he had said this but thought it might have
been 12 October.
16
The man’s life with his cell mate
51. The cellmate told my investigator that he had first met the man on G wing
during induction. He stayed for the full induction whereas the cellmate went
through the fast-track process as he had been in Manchester before. Once
on B wing, the man moved into his cell. Although they had moved cells twice
because of the cold or noise on the wing, they had remained together since
August and had got on very well. Once when the man was feeling down, the
cellmate had bought him a bar of Dairy Milk chocolate which lifted his spirits.
His main concern was his likely sentence and returning to Zimbabwe. He told
his cellmate at first that he was hoping for three years and remained quite
upbeat whilst he was on remand. The cellmate said the man was told by
prisoners he had sounded out that he was likely to get four years for a first
offence but the day he returned from court with a six year sentence, he was
devastated.
52. The cellmate said that, once sentenced, the man talked about suicide and
ending it all. He said he was at the end of his tether and he could not face the
thought of being without his family for three years. Asked whether what he
was saying surprised him, the cellmate replied “No, because I’ve heard it all
before. It just went in one ear and out the other.” He said that the man “kept
repeating it in different ways, I kept trying to talk him out of it.” Yet he also
insisted that “it was no hardship for him being in a British jail” and said it was
more comfortable in some respects than hotels where he had stayed in Africa.
However, he missed his family terribly and there was a marked physical
change in his appearance. The cellmate said the man “looked as if he was
bottling it up, his eyes were welling up, going red and more or less every day,
from his sentence, he looked older and older. He didn’t look like the man that
came in.”
53. My investigator asked the cellmate whether he had spoken to any of the
officers about the man saying that he could not handle imprisonment. He
replied “I told the SO about a month before he actually did anything … I went
to the SO on purpose to get searched [before work] and I said ‘You’re going to
have to sort him out because he’s climbing the walls, he needs one of your
chats’ and he got him in the office and he spent about an hour in there and
the SO gave him a few phone calls to Zimbabwe.” The cellmate thought that
the Healthy Prisons Co-ordinator had arranged for the man to have seven
days worth of sleeping tablets. (In fact, these had been prescribed by the
prison doctor, not the Co-ordinator.) They had worked but after seven days,
the insomnia returned.
The day of the man’s death
54. The cellmate told my investigator that he went to the gym. When he returned
to his cell at about 10.30am, the man was sitting on his bed with an A4 pad,
writing a letter. The cellmate saw this as a good sign. At lunchtime, the man
collected his lunch but when they returned to their cell he said he did not want
it and offered it to his cellmate, who ate the meat. The man then took three or
four spoonfuls of the dessert but left the rest. He told his cellmate “I really am
17
at the end of my tether” but his cellmate reminded him of his children and told
him to throw himself into his education classes.
55. At teatime at around 5pm, in contrast to the usual weekday routine, as it was
a Sunday, prisoners on B wing would remain locked in their cells after
collecting their evening meal until after breakfast the next morning. The
cellmate told my investigator that normally when he passed the man on the
stairs he would say “Hi” and they would have a little chat. That day, however,
he walked past him with just “a bit of a nod” and kept walking. Once he was
in his cell, he offered his cheese pie to his cellmate straightaway. The
cellmate declined, telling the man that he might want to eat it himself later on.
56. The cellmate kept flicking through the television channels during the evening
trying to find something that would cheer the man up. He recalled the man
laughing at a programme featuring the comedian, Peter Kay. However, at
about 9.20pm, there was a news item about political talks in Zimbabwe which
had stalled. The man had commented “That’s not good, that’s not good at
all.” It was at that point that the cellmate, who was also taking sleeping
tablets, said he offered him his last sleeping pill. The man refused it, insisting
that his cellmate should take it himself. About an hour later, he recalled the
man, who was on the top bunk, looking down at him and asking “Are you
watching this [television programme], are you still awake?”
57. The night officer who had been on night duty that week, looked into the man’s
cell whilst doing his rounds after the comedy programme had finished. He
told my investigator that the cellmate was in bed and the man was watching
television and had a cup with a drink in his hands.
58. The cellmate fell asleep. When he woke up about two hours later, he realised
that the television was still on and the sound had been turned up loud. He
went into the bathroom area to use the toilet and as he turned around, he saw
the man hanging from the window. This was at about 00:25 in the morning.
The cellmate pressed his cell bell, banged on the cell door and shouted for
help to the night officer.
59. The night officer had been patrolling B wing and was on the second landing
when he heard a cell bell begin to ring at about 00.25. He could see cell B4-
23 from where he was standing and as he went towards it, he heard its door
being kicked. The officer ran up the stairs and radioed for assistance from a
Principal Officer, the Night Orderly Officer, and an SO, the Assistant Night
Orderly Officer. Breaking open the sealed cell key pouch which is used in
emergencies, the night officer entered the man’s cell and was confronted by
an ashen-looking cellmate who said “He’s in the toilet.” The night officer went
to the toilet area and lifted the man up.
60. The Night Orderly Officer and Assistant Night Orderly Officer, who were
nearby, entered almost immediately afterwards. The Night Orderly Officer
guided the cellmate out of his cell and directed a second night officer to look
after him away from where the man was being cared for. The Assistant Night
Orderly Officer helped the night officer support the man whilst the Night
18
Orderly Officer cut the ligature (which consisted of two shoe laces tied
together) from around his neck with his ligature-cutting tool that all frontline
officers should carry on duty. He radioed for healthcare staff and an
ambulance to attend at 00.27. The Assistant Night Orderly Officer carrying
the radio call sign Oscar 2, transmitted that cardio-pulmonary resuscitation
(CPR) was being carried out and that the man did not have an obvious pulse.
A third night officer who was on night duty on C wing (which is next to B wing)
arrived and helped place the man on to the floor. The first night officer said
he had not been trained to carry out CPR whereas the Assistant Night Orderly
Officer had, so it was she who began efforts to resuscitate the man until
healthcare emergency response staff arrived.
61. A Registered General Nurse told my investigator that she was carrying the
healthcare emergency response radio whilst on duty in HMP Manchester that
night. She received a message over the radio that there was a medical
emergency on B wing. The RGN left the healthcare centre with a Healthcare
Officer (HCO) and they both ran to B wing, collecting the emergency bag and
defibrillator from F wing on the way. She estimated that it took them five
minutes to arrive at B wing but the records available do not note the actual
time they arrived.
62. The RGN administered breaths to the man using a pocket face mask. She
placed the pads of the defibrillator on his chest but the machine indicated that
a shock should not be administered. The RGN told my investigator that the
man did not show any reaction to the treatment he was receiving. She
described his body as being cold but not stiff. His skin was mottled. The third
night officer said that he had tried to feel his right wrist for a pulse but did not
detect one. He described him as looking dead and he felt cold but the
Assistant Night Orderly Officer and RGN continued with CPR until the
ambulance arrived at 00.36. The third night officer remained in the cell to
assist with CPR if he was needed. The Assistant Night Orderly Officer said at
interview that despite CPR, the man was unconscious and there were no
signs of life at all.
63. Paramedics arrived at the man’s cell at 00.45 and requested a second
ambulance to assist. They took over from the RGN, HCO and the Assistant
Night Orderly Officer. The RGN returned to the healthcare centre to prepare
a copy of the man’s clinical record for the officers who were preparing to take
him to hospital. The Assistant Night Orderly Officer went to the Security
Department (where she normally works as a manager when on day shifts) to
check whether there was any adverse security information about him. There
was nothing of note. She signed the escort route order form carried by the
officers taking him to hospital, that a single handcuff should be used. The
Assistant Night Orderly Officer told my investigator that whilst she felt the man
was dead, his death had not actually been pronounced. She recommended
that an escorting chain with a lighter type of handcuff (known as ratchet
handcuffs) rather than standard handcuffs should be used, although the final
decision would be for the Night Orderly Officer to make (as the more senior
member of staff). My investigator enquired why the man was not sent to
hospital without restraints as he was not a high security prisoner. The
19
Assistant Night Orderly Officer said that Manchester was a high security
prison and that prisoners on hospital escorts would normally be double cuffed
unless they were paraplegic. Double cuffing is where a pair of heavier
(standard) handcuffs are used to join both wrists of the prisoner together.
One wrist is then attached to one end of another pair of handcuffs and the
other handcuff is attached to an officer.
64. The Night Orderly Officer described the man as appearing “lifeless … his eyes
were closed, there were no pained expression, he looked to all intents and
purposes as if he was asleep.” As the ambulance staff prepared to take him
to hospital, the Night Orderly Officer arranged for two officers, the second
night officer and a fourth night officer, to accompany him. The man was
placed in a medical chair by the ambulance crew and carried down to an
ambulance.
65. The Night Orderly Officer decided that the man would be handcuffed to the
second night officer by an escort chain (a metal chain about six feet long with
a handcuff at either end. One handcuff was placed around one of the man’s
wrists and the other was attached to the second officer’s wrist. At interview,
she said that it was “daft” to handcuff the man and that she did not really feel
comfortable with the procedure. Nevertheless, she accepted the protocol that
he had to be handcuffed because he had not been pronounced dead and she
did not object.
66. My investigator asked the Night Orderly Officer why the man was handcuffed
given that he did not appear to be conscious. The Night Orderly Officer had
seen the man hanging and had cut off the ligature around his neck himself.
Moreover, he described him as looking lifeless. The Night Orderly Officer
replied “Nobody had stated to me that the man was dead; therefore until such
time as he is pronounced dead he is a prisoner going out on hospital
bedwatch and as such restraints have to be applied … All prisoners who go
out on escort will go out under Category B conditions, i.e handcuffed and with
escorting officers.” He was asked whether he would still handcuff a prisoner
that he himself had seen hanging and had cut down. He replied “Yes,
absolutely. Nobody had officially stated to me that the man was dead and
until such time that that is stated by somebody qualified to do so then he
would leave the prison under normal hospital escort conditions.”
67. The ambulance carrying the man left Manchester at 1.17am with the fourth
night officer and a paramedic at the front and the man at the rear with the
second night officer. The fourth officer told my investigator that when they
arrived at North Manchester General Hospital, the paramedics asked for the
handcuffs to be removed so that they could manoeuvre the man out of the
ambulance. The fourth night officer unlocked them as he was carrying the
key. He recalled them being standard rather than ratchet design.
68. The man was taken straight to the resuscitation area but sadly he was
pronounced dead at 1.30am.
20
Actions taken at Manchester after the man’s death
69. A minister, who is a member of Manchester’s chaplaincy team, telephoned
the man’s wife in Zimbabwe to break the news of his death. He also spoke to
the man’s brother-in-law who acted as a link between his family in Zimbabwe
and the prison. The minister has remained in touch with the family. Once the
necessary administrative procedures following the man’s death were
completed, a hot debrief, chaired by a governor was held at 6.00am. The
purpose of a hot debrief is to bring together all staff who have been involved
in the immediate aftermath of a serious event. It enabled the staff to discuss
how the aftermath of the man’s death had been handled and air any issues
that had arisen as a result.
70. A Notice to Prisoners was displayed around the prison to tell them of the
man’s death. Prisoners were reminded that they could speak to a Listener if
they were upset by what had occurred. The Samaritans visited Manchester
the day after his death and made themselves available to prisoners and staff.
71. The cellmate spent two days in the healthcare centre for observation. His
partner was allowed an additional visit to see him and the Samaritans visited
him. When he felt ready to return to B wing, after discussion with staff, he
moved back to another cell.
72. A Notice to Staff was also issued by the Governor expressing his
condolences. A number of prisoners and staff wished to talk about their
contact with the man. A teacher told my investigator that a Listener had told
her that he had spoken to the man four or five times but he had not given any
indication that he was intending to take his life. (I understand and respect the
rules governing Listener confidentiality which mean that the Listener would
not be able to divulge the contents of the conversation he had with the man
(or any prisoner). As a result, my investigator did not seek to interview him.)
73. As noted in para 3 above, one of my Family Liaison Officers contacted the
man’s wife and brother-in-law to let them know of my investigation and to find
out whether the family wished to contribute towards the investigation process.
74. A post mortem was conducted on the same day the man died. It gave his
cause of death as hanging and described the ligature as consisting of two
shoelaces.
75. Handwritten notes to individual members of the man’s family were found in a
locker in his cell. In addition, a note addressed “To whom it may concern” and
signed by him read “I have decided to take my own life. I have taken this
decision in an attempt to save my family the hardship that will face them if
they move to the UK with me. I cannot carry on in the state I am in. I
apologise for doing this as I was well treated here. Please ensure that my
family receive the letters I have left in a sealed envelope …”
76. An airmail letter from the man to his wife was found in B wing post box after
his death. It was dated 13 October, but made reference to it being Saturday
21
afternoon (11 October). He wrote of wanting his family to move to Britain
because he did not feel he could get through his sentence without seeing
them regularly. He wrote:
“I am ok but I have hit a real low spot. I am terribly depressed and a bit
worried about my state of mind but I am trying really hard to stay sane …”
“I have now been given the awful news that for the following 3 years after I
am released I will be under licence which means I may not leave the UK
so I am stuck here. I have spoke to the Foreign Nationals Officer and he
had told me that there is no way around it … I simply can’t face being
without you for so long ... 6 years is just not an option”
77. The man’s funeral was conducted by the minister. It was attended by his wife
and representatives from the prison. His wife was offered and accepted the
opportunity to visit Manchester to meet with staff and prisoners who knew
him. Officers spoke of him as a “really genuine” man. One prisoner
described him as “a fine, fine beautiful kindred spirit, he was a gentleman.” In
accordance with the man’s wish, his ashes were returned to Zimbabwe.
Clinical review
78. As noted, a clinical review into the healthcare the man received whilst he was
at Manchester was conducted by a clinical reviewer from the local NHS
Primary Care Trust. The clinical reviewer has found that he had received a
level and standard of mental health and physical care at Manchester
comparable to that he would have received if he had consulted a healthcare
professional in the community. The man had been screened for mental health
related issues on arrival at Manchester and had been assessed as low risk.
No factors were found that might have increased his risk of self harm or
suicide. His physical health issues had been addressed by the clinical team
referring him to a physiotherapist, he had been given advice on improving his
health and was vaccinated against the hepatitis B virus. The clinical reviewer
judges that “the man’s fatal attempt at self harm was not foreseeable and
therefore not preventable.”
79. In assessing whether Manchester met adequate standards of record keeping,
the clinical reviewer says that some entries in the man’s computerised record
fell short of the required standard. He gives the example of the entry on 6
October being made at 11.44pm with no explanation of why it was made at
that time when the man returned from court at around 4pm. In addition, in the
clinical record entry made by the RGN, there was no reference to the time
when the healthcare team arrived nor to the man’s vital signs. After seeing
the draft version of this report, the Prison Service commented that part of the
RGN’s entry in the clinical record on attending to him said “on examination, he
was cyanosed no pulse found … Defibrillator pads attached 3 cycles of CPR
continued, no shock advised CPR maintained until arrival of paramedics at
approx 00:40” which it took as reference to his vital signs.
22
80. The clinical reviewer refers to the NHS Standards for Better Health in force
from April 2005 which describe the level of quality that healthcare providers
are expected to meet in order to drive up standards by identifying areas for
improvement. He cannot find “convincing evidence” that Manchester’s
healthcare standards had been assessed against Standards for Better Health.
The clinical reviewer makes several recommendations to the PCT Board and
the Prison Health Partnership Board:
That the Board together with the Head of Healthcare team ensures that all
healthcare staff are aware of the standard they are required to attain when
they make entries on the patient record. The Board should set minimum
standards which it would expect all members of staff to achieve at all
times.
That the Board together with the Head of Healthcare team ensures that
there is an adequate record of all the observations made and interventions
undertaken by members of the healthcare team when attending
emergencies. The Head of Healthcare team should ensure that there is a
standard format for recording the said observations and interventions. The
head of Healthcare team should ensure that there is a regular audit of the
record keeping in relation to emergencies.
That the Board together with the Head of Healthcare team give careful
consideration to the capability of the health personnel who respond to
Hotel 1 calls with particular reference to being able to gain intravenous
access and to be able to administer cardiac stimulant drugs in appropriate
circumstances.
That the Board and Head of Healthcare ensure that healthcare at
Manchester is regularly assessed against Standards for Better Health.
That the Board and the Head of Healthcare ensure that assessment and
effective management of risk of self harm and suicide is part of the
mandatory training programme at HMP Manchester and that the said
training takes place at least on an annual basis.
That the Board and the Head of Healthcare ensure that all staff receive an
adequate and effective induction at the appropriate time in the course of
their employment.
That the Board and Head of Healthcare ensure that there is a fit for
purpose system for ensuring that staff are made aware of new NICE
[National Institute for Clinical Excellence] guidance which may be relevant
to patient care delivered at HMP Manchester.
That the PCT satisfies itself that its monitoring system for action plans in
response to recommendations from a clinical review is fit for purpose – in
that the system is capable of ensuring that fundamental issues identified in
a particular review do not repeatedly arise in subsequent clinical reviews in
relation to self harm and suicides.
23
81. My investigator discussed the promotion of self harm and suicide prevention
issues at Manchester with the Safer Prisons Co-ordinator and the Deputy
Safer Prisons Co-ordinator in October 2008. Following a recommendation in
the most recent report from HM Chief Inspector of Prisons in 2007 that safer
custody should be given a higher profile, it was decided to set up a full-time
dedicated Safer Prisons Team with five staff. The team works to improve
Manchester in suicide prevention, violence reduction and anti-bullying
spheres. Both Deputy and Safer Prisons Co-ordinators said that all new staff
received ACCT training so that suicide prevention and self harm issues
should be regarded as important and multi-disciplinary rather than the
responsibility of uniformed staff alone. Staff received regular refresher
training and they were pleased that Manchester had 35 trained ACCT
assessors. Setting up Listener suites, so that prisoners could see a Listener
in more relaxed and private surroundings, still remained to be achieved but
the Safer Prisons Co-ordinator said that funding had now been secured to
take that recommendation forward. After seeing a draft version of this report,
the Prison Service commented that two listener support suites were now in
place, with a third due to be completed this year.
82. My investigator discussed the organisation of prisoner induction with the
Acting Senior Officer. The Acting SO has worked on G wing, the Induction
Unit, for three years. He said he recognised that his unit operated a system
known as Triple A - Assisted Access and Advice - where staff would be
trained to identify specific needs of prisoners and deliver a more tailored
induction process for those newly received into Manchester. He emphasised
that he took his duty of care to provide excellent induction seriously and
feedback from prisoners on whether they found the induction process helpful
or whether they needed more time to understand prison life was acted on.
83. My investigator asked the Acting SO what arrangements were in place for the
induction of prisoners whose status had changed because of a court
appearance from unconvicted to convicted or sentenced. Although he
recognised that such a prisoner would have needs which meant that “he could
be a totally different prisoner”, G wing only dealt with prisoners new to
Manchester. Existing prisoners would return to the wing they had left that
morning and it was up to that wing to identify and speak to those prisoners
about their needs. He acknowledged that there was not a systematic
approach to picking up newly sentenced prisoners.
84. The first SO was asked about the induction arrangements for prisoners on B
wing. He said that he operated an open-door policy where prisoners could
feel comfortable to chat with him and vice versa. As a result, the SO and his
staff knew most of the prisoners well. He encouraged officers to interact. He
said he saw the man every day he was on duty and although the man had
said he was shocked by his sentence they had discussed how he could
progress through it. The SO had asked the Foreign Nationals Officer to see
the man to provide him with more specialised advice. Asked whether he had
considered opening an ACCT document on the man to provide support if he
was thought to be at risk of self harm, the SO replied that he would not have
24
had any hesitation but it was not necessary. The man had expressed
concerns for his family rather than for himself and he seemed to be
considering his situation in a logical way. The SO was proud of B wing’s
record in successfully supporting prisoners who self harmed.
85. The Foreign Nationals Officer was interviewed by my investigator regarding
facilities for foreign nationals. He said that he was the first link between
prisoners and the Immigration Service (UK Border Agency) so that any urgent
issues could be raised and resolved. He obtained details of foreign national
prisoners by obtaining lists of the birth place and nationality of prisoners and
new receptions from the computerised Local Inmate Data System (LIDS).
The man did not appear on any list he held regarding Foreign National
prisoners and he was not aware of him until the SO asked him to see the
man.
86. The man had asked the Foreign Nationals Officer whether he would have to
serve the whole six years of his sentence in Britain as this would put “stress
and strain” on his relationship. The Officer told him that he should speak to
his probation officer when he was allocated one to say that he wished to
return to Zimbabwe at the earliest opportunity. He continued “ … at some
point into his licence that they would possibly look into special dispensation of
his licence being ceased and for him to be allowed to return. I did make him
aware that it’s not an automatic right… but it’s not something that’s
impossible.” The Officer said that this had cheered the man up as his wife
had already said she would not come to Britain for the remaining period of his
sentence.
87. After learning of the man’s death, the Foreign Nationals Officer asked himself
whether there had been any indication when they met that the man was at risk
of harming himself but he had decided that there was not.
88. My investigator discussed the man’s circumstances with a member of the
Ministry of Justice’s Release Policy Team at the Sentencing Policy and
Penalties Unit. She asked whether the man would have had to serve his
whole sentence in England. He described the general process a prisoner in
the man’s position would have to go through. He said that the offender
manager (probation officer) in the Probation Area covering the prison the
man was being held in would need to carry out an assessment to verify
whether genuine ties existed in the country where he wished to reside (i.e
Zimbabwe). A risk assessment would have to be carried out to make sure
that allowing him to return would not pose an unacceptable risk. This would
depend, for example, on his criminal and offence history and progress in
custody. The criteria for considering whether to allow resettlement abroad
during the licence period are set out in Probation Circular 52/1997. If these
conditions were met, then the supervision requirements in his release licence
could be suspended to allow him to settle outside the UK. There are no
powers for licence provisions to be enforced outside the UK but the sentence
would remain and could be activated if the prisoner returned to this country
before the expiry of his sentence. There are no figures to indicate how many
prisoners would have similar circumstances to the man but the member of the
25
Release Policy Team estimated that the number would be very small. Asked
whether the process could only begin once a prisoner was released into the
community, he said that it could be started whilst the prisoner was still in
custody as part of his resettlement planning so that consideration could be
given as to whether or not it would be appropriate to allow the prisoner to
leave the country to live abroad as soon after release as practical.
26
ISSUES
89. The man was described by prisoners and staff who came across him as
family-minded, positive, pleasant to talk to and level-headed. His death left
those who knew him shocked and stunned. Even in retrospect, I have not
been able to find anyone at Manchester who had an indication that he
intended to harm himself. He spoke of his family with fondness. Any concern
he displayed was for their safety rather than his own. Unlike many prisoners
whose deaths I have investigated, his life had not been overshadowed by a
history of drug misuse, mental health problems, sexual abuse, physical
neglect or isolation.
90. The man was British by birth but had been resident in Zimbabwe for many
years and regarded Zimbabwe as his home. It was where he met his wife and
brought up his daughters. Even though it was his first time in custody and he
was based abroad, he did not appear especially vulnerable. He had strong
ties with his family. He telephoned his wife as often as his prison earnings
and saved money would allow, he wrote letters to his family, received letters
from his family and had visits from his brothers-in-law and two friends in the
United Kingdom.
91. The Prison Service defines a foreign national as a person who is not a British
citizen and who does not have the right of abode in Britain. Manchester’s
policy defines foreign nationals as prisoners who are not British citizens but
says prisoners with dual nationality can be regarded as foreign nationals.
Manchester allows Foreign National prisoners to spend up to £20 a week
extra of their own money on making international calls from their residential
wing. I do not know if the man had taken out Zimbabwean citizenship or
whether he was simply a permanent resident. Nevertheless, it is beyond
doubt that his links to Zimbabwe were solid, he spoke of Zimbabwe as his
home country and both staff and other prisoners accepted him on those
terms. Manchester’s foreign nationals policy acknowledges that such
prisoners may need help with immigration problems and are more likely to
face communication problems or need information about how the criminal
justice system works. The policy allows prisoners to apply for £10 telephone
credit if they have not received a visit in the previous month or a weekly
airmail letter in place of telephone credit. The policy states “International
telephone calls may also be granted on compassionate grounds or for urgent
legal reasons.”
92. When the man’s First Night Assessment and Induction booklet was completed
by the officer on his arrival in prison, the foreign nationals section was not
completed because although he lived abroad and spoke about Zimbabwe with
the officer, he was British born, was a British national and had a family contact
here. (The man also told the officer that he did not have any immediate
concerns.) Whilst this was understandable, it meant that he was not identified
quickly and assessed by the Foreign Nationals Officer as having some needs
of a foreign national prisoner such as extra telephone credit or a lack of
understanding of the criminal justice process. The SO allowed him to
telephone Zimbabwe at Manchester’s expense when he was worried about
27
his children but this was an exceptional rather than a regular arrangement,
although in accordance with Manchester’s Use of Telephones policy.
I recommend that where a prisoner is a British national but lives abroad,
the foreign nationals section of the First Night Assessment and
Induction booklet at Manchester should be completed and their details
passed to the Foreign Nationals Officer.
93. The man fostered good relationships in prison with staff and prisoners. It was
known that his family lived abroad, that he missed them and worried about
their safety in Zimbabwe. Nevertheless, he was not isolated in prison. He
attended education classes every day and built up supportive relationships
with teachers. He also attended health education courses on B wing and
spoke to the Healthy Prisons Co-ordinator about his concerns. The two
prisoners who worked in the library spoke of their friendship with him. His
cellmate and the two prisoners had frequent chats with him. The man was not
socially isolated but clearly felt the loss of physical proximity to his family very
keenly and feared the loss of emotional ties. Letters written to his family
members concerning his death were open, tender and loving. They indicated
what a wrench it was for him to be apart from them.
94. In the weeks leading up to his sentencing, the man asked various prisoners
about their court experiences to gauge his likely sentence. It is possible that,
as a consequence, he gained an over-optimistic picture. The consensus was
around four years but the prisoners he asked were not expert and did not
know of his particular circumstances. The second prisoner and a teacher had
a more realistic idea based on published sentencing guidelines but the man
did not appear to have seen them. Combined with his solicitor’s view that the
judge was known to be reasonable and the advice not to wait for a Pre-
Sentence Report, it may be that his hopes were raised unrealistically.
95. On returning to HMP Manchester having been sentenced to six years, higher
than the sentence he was expecting, the man passed through Reception.
The reception nurse spoke to him briefly but he said he did not have any
concerns. When he spoke to the SO the next day, however, he said he had
been stunned by the sentence. It would seem that once he had been
sentenced he entered an internal crisis period that he kept hidden. Whilst the
SO discussed with him the progression of his sentence and on the surface he
seemed to appreciate what was being said, in practice, he must have been
becoming more distressed.
96. The man seems to have felt badly served by his legal team and thought,
wrongly, that he was no longer able to appeal against his sentence because
he did not have a Pre Sentence Report. Much of his uncertainty and
frustration might have been alleviated if there was a more structured induction
for newly sentenced prisoners which gave reliable, factual and up-to-date
information on prisoners’ concerns. Prison Service Order 0550 on Induction
says in paragraph 4.7 “A change of status for example from unconvicted to
convicted, will require an induction process relevant to their individual
circumstances and to their previous experience and knowledge of custody.”
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97. Induction for prisoners new to Manchester seems to have been effective, and
indeed, G wing recently won an award within the high security prison estate
for the quality of its work. I have no doubt that the SO spoke with the man
about the issues raised and that he has played a significant role in creating a
positive ethos on B wing where staff are approachable and co-exist with
prisoners in an atmosphere of mutual respect. However, in relying on each
residential wing to provide its own informal induction on an ad hoc basis, there
is the danger that Manchester’s prisoners do not receive sufficiently robust
information about their circumstances to make informed choices. Although
the Foreign Nationals Officer told him that it was not impossible for his licence
after release to be suspended so that he could return to Zimbabwe, in the
unsent letter found in B wing’s post box the man wrote to his wife that he
would have to remain in Britain for the whole six years. The lack of written
information given to him about his situation might have meant that he
misunderstood or did not remember the details of what he was told.
98. The accuracy of the information given to the man about whether he would
have to remain in England after his release from prison seems to have been
at the crux of the matter. He was given conflicting advice from prisoners
about whether he would have to remain here. Despite the library prisoner
telling him not to listen to the “rumour mill”, he did not take up both library
prisoners’ offer to look at his legal options by using the legal library’s
resources. Nor did he seem to give weight to the Foreign Nationals Officer’s
advice that he should make enquiries when he was allocated a probation
officer (offender manager) instead of worrying about it at that time. The
member of the Release Policy Team was clear about the process the National
Probation Service would have to follow if the man wished to return to
Zimbabwe after serving three years in custody and that his release was
entirely possible. It would have been helpful (and might have made all the
difference) to the man if Manchester could have provided him with a written
fact sheet containing clear and unambiguous information to which he could
have referred. It is important that staff are able to give prisoners sound policy-
based advice so that uninformed “advice” from prisoners can be corrected.
I recommend that the Governor of Manchester creates a more
formalised induction for convicted and sentenced prisoners which takes
account of their legal and sentence planning needs and offers accurate
and timely information.
99. The man had complained of being unable to sleep. He made an application
to see a doctor concerning this and was due to attend an appointment on 13
October with a nurse-practitioner specialising in insomnia. According to his
cell mate, he had been given seven days worth of sleeping tablets which ran
out during the week of his death. He also made reference to the tablets in a
letter to his wife. However, there is no evidence in his clinical record that he
was prescribed any sleeping tablets.
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100. The clinical reviewer, who examined the healthcare that the man received
whilst in custody, judges that he had received a level of mental and physical
healthcare comparable to that in the community.
101. As I have said earlier, in relation to the standard of clinical record keeping at
Manchester, the clinical reviewer says that some of the entries in the man’s
clinical record fell short of the required standard. He notes that although the
man had returned from court on 6 October at about 4pm, the entry in his
record was made at 11.44pm and did not explain why it was entered out of
normal working hours. Although the clinical reviewer was later given an
explanation of the process for updating electronic clinical records, he says
that the fact that he had to seek an explanation illustrates his point about
ensuring the accuracy of the clinical record. Indeed, my investigator found
differences on at least two occasions when clinical entries by named
members of staff appeared to suggest that they had contact with the man,
which turned out not to be the case.
102. The clinical reviewer has made several recommendations to the Primary Care
Trust Board and the Prison Health Partnership Board that I have cited above
in paragraph 80 and which I endorse.
103. In his interview with my investigator, the man’s cell mate expressed the view
that the man who died encouraged him to take a sleeping tablet in the hope
that he would be able to harm himself in their shared cell without being
discovered. As we now know, the man spent some time drafting letters to his
family to explain his decision to take his life. He even wrote one to the prison
apologising for his actions and leaving instructions concerning his belongings.
104. After the man was discovered unconscious and attempts were made to
resuscitate him by healthcare staff and ambulance personnel, he was taken to
hospital handcuffed. The Night Orderly Officer and Assistant Night Orderly
Officer justified this on the grounds that Manchester is a high security prison,
the man had not been declared dead and he was leaving the prison so
mechanical restraint was required. Yet he had been seen hanging and
unconscious by those staff. Indeed, the Assistant Night Orderly Officer was
the first member of staff who attempted to resuscitate him by using CPR.
Words used by staff to describe his appearance were “lifeless”, “looking
dead”, “cold”, “mottled skin”. It is clear that the man’s risk of escape was
theoretical rather than actual. I have commented in several recent reports
(although none of them have involved Manchester) about prisoners being
handcuffed in circumstances that would be very difficult to justify and which
seem inconsistent with the Prison Service’s own ‘decency’ agenda. These
were mostly cases where the prisoner was elderly, serving a long sentence
and suffering from a chronic illness. I have never previously encountered a
man who has harmed himself by hanging to the point where he is about to
lose his life being handcuffed until his life has ended. I appreciate that he was
not double-cuffed and that ratchet rather than standard handcuffs were used
so some consideration of the circumstances was made. However, he was not
a high security prisoner and he was demonstrably unconscious. Current
policy in regard to escapes is extremely risk-averse. But even in the current
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climate, I am dismayed that he was subject to physical restraint. The escort
staff could simply have been told to re-apply restraints if he was successfully
revived until his situation could be properly assessed.
I recommend that the Governor reviews the security procedures for
escorting prisoners to hospital when they are found hanging and are
unconscious.
105. The man’s family wanted to know if he told anyone else apart from his cell
mate that he was feeling low. Sadly, I have not found any evidence to
suggest that he did. His sense of despair rose rapidly in the week between
receiving his sentence and his death. It is striking and all the more poignant
that such a short time elapsed between the two. His cell mate noticed that he
had changed visually after sentencing, and was talking of being at the end of
his tether and wanting to “end it all”. But his cellmate did not take this too
seriously as he had heard other prisoners say similar things in the past which
had come to nothing. (He did ask the SO to chat with the man, however.) In
retrospect, the first prisoner referred to his “lost look of desperation” and the
second library prisoner said he had a look of “feeling let down”. On the other
hand, no member of staff recalled the man giving cause for concern. All the
staff my investigator interviewed were knowledgeable about the actions to
take if they suspected a prisoner was at risk of self harm or suicide. Nothing
in his behaviour or conversations triggered their suspicions that he was at
risk. As I know from all too many investigations, it is all too possible that even
with a trained workforce with suicide prevention at the forefront of its mind –
for a prisoner who wishes to take his life to conceal his intentions from those
around him. All I can reasonably say is that his sense of despair seems to
have risen rapidly in the week between receiving his sentence and his death.
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RECOMMENDATIONS
I recommend that where a prisoner is a British national but lives abroad, the
foreign nationals section of the First Night Assessment and Induction booklet
should be completed and their details passed to the Foreign Nationals Officer.
After seeing the draft version of this report, the Prison Service accepted the
recommendation and said “The First Night Assessment and Induction process
will be reviewed by the Foreign Nationals Officer to advise on his input into
prisoners who are British nationals that live abroad. It gave the target date for
completion as 1 November 2009.
I recommend that the Governor of Manchester creates a more formalised
induction for convicted and sentenced prisoners which takes account of their
legal and sentence planning needs and offers accurate and timely information.
After considering the draft version of this report, the Prison Service said it
partially accepted the recommendation. It commented “This recommendation
will be reviewed by the Induction Wing manager to consider the implications
and the advantages of introducing a more formalised induction for newly
convicted and sentenced prisoners. The target date for completion was 1
November 2009.
I recommend that the Governor of Manchester reviews the security procedures
for escorting prisoners to hospital when they are found hanging and are
unconscious.
After considering the draft version of this report, the Prison Service accepted the
recommendation and said it was already in place. It commented “An individual risk
assessment will always take place at the time of an escort which takes into
consideration the circumstances of the individual involved. An option at the time of
the risk assessment could be an additional member of staff escorting the prisoner to
hospital rather than the use of handcuffs. However, this will be on an individual risk
assessment basis that is completed at the time of the escort.”
I endorse the recommendations made to the Primary Care Trust and the Prison
Health Partnership Board that:
- That the Board together with the Head of Healthcare team ensures that
all healthcare staff are aware of the standard they are required to attain
when they make entries on the patient record. The Board should set
minimum standards which it would expect all members of staff to
achieve at all times.
- The recommendation was accepted. “The PCT and the Head of Healthcare
will undertake an audit using the essence of care audit tool and address any
identified shortfalls.”
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- That the Board together with the Head of Healthcare team ensures that
there is an adequate record of all the observations made and
interventions undertaken by members of the healthcare team when
attending emergencies. The Head of Healthcare team should ensure
that there is a standard format for recording the said observations and
interventions. The Head of Healthcare team should ensure that there is
a regular audit of the record keeping in relation to emergencies.
- This recommendation was partially accepted. “The PCT and Head of
Healthcare will ascertain whether it is possible to obtain tracing from
defibrillator. The clinical observations were recorded on EMIS.”
- That the Board together with the Head of Healthcare team give careful
consideration to the capability of the health personnel who respond to
Hotel 1 calls with particular reference to being able to gain intravenous
access and to be able to administer cardiac stimulant drugs in
appropriate circumstances.
- This recommendation was partially accepted. “This is not in line with national
guidance. NICE guidelines states first response should be ILS trained and
not ALS. HMP Manchester will obtain Manchester PCT guidance on ILS
training.”
- That the Board and Head of Healthcare ensure that healthcare at
Manchester is regularly assessed against Standards for Better Health.
- This recommendation was accepted. “Standards for Better Health are
reviewed annually and are assessed internally and reviewed externally.”
- That the Board and the Head of Healthcare ensure that assessment and
effective management of risk of self harm and suicide is part of the
mandatory training programme for healthcare staff at HMP Manchester
and that the said training takes place at least on an annual basis.
- A response to this recommendation is not yet available.
- That the Board and the Head of Healthcare ensure that all staff receive
an adequate and effective induction at the appropriate time in the course
of their employment.
- “Already in place. All new employees at HMP Manchester are given a full
induction programme before they commence employment. Locum GPs have
written guidance and do not work alone.
- That the Board and Head of Healthcare ensure that there is a fit for
purpose system for ensuring that staff are made aware of new NICE
[National Institute for Clinical Excellence] guidance which may be
relevant to patient care delivered at HMP Manchester.
- This recommendation was accepted. “The head of Healthcare sits on the
Professional Advisory Group with the PCT and there is a system in place to
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ensure that staff are made aware of new NICE guidelines that are relevant to
HMP Manchester.”
- That the PCT satisfies itself that its monitoring system for action plans
in response to recommendations from a clinical review is fit for purpose
– in that the system is capable of ensuring that fundamental issues
identified in a particular review do not repeatedly arise in subsequent
clinical reviews in relation to self harm and suicides.
- “Already in place. The PCT Clinical Governance Committee reviewed the
monitoring system and is satisfied it is fit for purpose.”
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