Individual at Whatton

Investigation into the circumstances surrounding the
death of a man at HMP Whatton in August 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2013
This is the report of an investigation into the death of a man at HMP Whatton in
August 2008. His cellmate has since been convicted of his murder. On the night of
the incident he called staff to the cell he shared with the man at about 12.30am.
Nearly 25 minutes later, once staff had removed him from the cell, they checked the
man’s vital signs and found none. Nevertheless, resuscitation was attempted until
he was pronounced dead at 1.35am.
Regrettably the investigation has been delayed primarily because of the criminal
prosecution and conviction of the man, and his subsequent appeal. Further matters
were raised with the Crown Prosecution Service, which prevented my office from
pursuing enquiries until last year. I am sincerely sorry for the delay in investigating
the serious circumstances of his death and for the distress this must have caused his
family.
The investigation examines whether it was reasonable for someone with the
cellmate’s custodial history and index offence to be sharing a cell. He had been
convicted of raping a man and was accused of serious sexual assault against other
prisoners on two occasions while he was in custody. Neither accusation resulted in
a criminal charge.
The investigation found systemic failures in the risk assessment processes which
suggest this death should have been preventable. Although key security information
was eventually transferred with the cellmate as he moved between prisons, it was
not always acted on promptly or properly considered. Some of it should have rung
alarm bells about whether he was in the appropriate security category. Important
information about his risk when he transferred from Manchester prison to Wymott
seems not to have accompanied him or was lost. Poor communication of relevant
risk information between and within prisons he was held in is a recurrent theme and
decisions about his risk were taken without reference to structured risk assessments
within the offender management system.
Cell sharing risk assessment procedures have improved and strengthened since the
man’s death, but like all such guidance it is only as good as it is applied on the
ground and requires careful consideration of all the relevant information.
Finally, the report considers the actions of staff on the night of the incident to
determine whether they struck the appropriate balance between security and the
preservation of life.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Nigel Newcomen CBE
Prisons and Probation Ombudsman October 2013
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CONTENTS
Summary
The investigation process
HMP Whatton, HMYOI Doncaster, HMP Manchester, HMP Wymott
Glossary
Key Events
Issues
Conclusion
Recommendations
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SUMMARY
1. The man was murdered by his cell mate in August 2008. The pair had shared
a cell for less than a week. Neither was regarded by the prison as a particular
risk to other prisoners at the time of the murder.
2. The man was serving an indeterminate sentence for public protection, with a
minimum tariff of three and a half years. He had spent more than three years
at HMP and YOI Doncaster, where there were no appropriate courses for him
to address his offending behaviour and demonstrate he was suitable for
release. He was eventually transferred to HMP Whatton in July 2008 and was
on the waiting list for the Sex Offender Treatment Programme at the time of his
death.
3. The cellmate began his period of imprisonment at HMP Manchester. As soon
as HMP Manchester discovered that he was charged with the rape of an adult
male, his cell sharing risk assessment (CSRA) was reviewed to recognise that
he posed a high risk to other prisoners. He remained high risk for the duration
of his time at Manchester. Security information indicated that he had been
reported to the police on two separate occasions, following allegations of
serious sexual assaults of fellow prisoners. After a year and a half of
deliberation by the police and the Crown Prosecution Service (CPS), there was
found to be too little evidence to proceed to charge for the first allegation.
There was no record of the second matter being referred to the police, apart
from some observations by prison staff on his records. Adjudications were not
completed for either alleged attacks but both incidents were recorded in his
security file.
4. Convicted of rape, the cellmate was assessed as a medium risk security
Category C prisoner offender, following the strict algorithm of categorisation
used in the prison service which did not take into account the security
information about the alleged sexual assaults. He was transferred to HMP
Wymott, a Category C prison, to complete the Sex Offender Treatment
Programme (SOTP).
5. On arrival at Wymott the cellmate was assessed as “low/medium” risk to other
prisoners for cell sharing despite having been identified as a high risk at
Manchester. There is no evidence to explain why his risk had altered with his
transfer. He remained at Wymott for six months, but did not complete the sex
offender treatment programme because concerns about his risk meant he was
not held on the vulnerable prisoners unit. His security file also logged
allegations that he was grooming new prisoners on the induction wing, at
Wymott. (The VPU is mainly used to accommodate prisoners with a sexual
offending history.) He and his legal representatives corresponded with the
prison to request he attend the sex offender treatment programme but he
transferred from Wymott in December 2007 to Whatton without doing so.
6. The cellmate was assessed as at medium/low risk to other prisoners when he
first arrived at Whatton. For the first month he shared cells and a dormitory
with other prisoners without incident. Security information including the
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allegations of sexually assaulting other prisoners was received and discussed
at a risk management meeting in December 2007 but no action was taken. The
security information was discussed again at a similar meeting in January 2008
and this time his CSRA assessment was changed to high risk to reflect the
danger he posed to other prisoners. The CSRA was subject to regular reviews,
in line with the prison’s policy, and by February 2008, staff felt that his risk had
reduced and he was assessed as a medium risk to others. This judgement was
revisited monthly and, even taking the allegations into account, his risk to
others when sharing a cell remained assessed as medium until June 2008,
when it was reduced to low.
7. The cellmate was made subject to Violence Reduction Strategy (VRS)
monitoring on three occasions at Whatton and was subject to such monitoring
when he murdered the man. On the first two occasions, his cell sharing risk
assessment was reviewed and his risk level was considered appropriate. The
last Violence Reduction Strategy document was opened in the week before the
man’s death and no cell sharing risk review was completed, in apparent
contravention of the national guidance which required a re-assessment if there
is a significant event that triggers concern.
8. The cellmate started the SOTP course in May 2008, and was said to have
struggled to adapt to the challenges of the course. SOTP facilitators did not
know about the information on his security file, nor were they aware that he was
subject to VRS monitoring. There was some communication between
facilitators and wing staff as his attendance was erratic and the two areas
worked together to enforce a compact designed to improve his compliance with
the SOTP.
9. In July, the cellmate approached officers and volunteered to share a cell.
Officers agreed with the Principal Officer managing the wing that “it would be
inappropriate in view of recent [allegations] and this current VRS document” but
his CSRA was not reviewed. Two weeks later, after the VRS document had
been closed, he moved into a dormitory cell, shared with two other prisoners.
On 16 August, he was moved to the cell he was to share with the man. The
man moved into the cell on 22 August 2008.
10. According to prisoners’ accounts, the cellmate indicated to other prisoners on
the wing on the afternoon of 22 August that he intended to have sex with his
cellmate ‘no mater what’. None of the prisoners suggested that staff were
aware of these remarks and there were no security incident reports about this
until after the man’s death.
11. On the night of the incident the cellmate rang his cell bell and told the
Operational Support Grade (OSG) on night duty that he needed to speak to the
Night Orderly Officer. The OSG contacted the manager. He rang his cell bell
again and told the OSG that he thought he had killed his cellmate. Another
OSG contacted the Orderly Officer and asked for her urgent attendance. Staff
could not clearly see the man in the cell. Twenty one minutes elapsed between
the time he told the OSG that he had killed the man and the cell door being
opened. Once the cell door was opened and he was searched and removed to
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another cell, a further three minutes elapsed before the man was seen. An
ambulance was not called until staff had assessed his condition.
12. Since the man’s death there has been a significant change in the CSRA
process but there is little doubt that the way the CSRA procedures in place at
that time were implemented did not adequately protect other prisoners from the
risk the cellmate presented. Had the processes operated in the way they were
intended the man’s death should have been preventable. The precautions
taken to ensure the safety of the prison on the night when he was killed were
not effectively balanced against the possibility of preserving him and he ought
to have been attended to earlier by staff.
13. The investigation was suspended for the ongoing criminal investigation by the
police and subsequent appeal and it was not until August 2011 that the coroner
gave the go ahead for the investigation to proceed.
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THE INVESTIGATION PROCESS
14. A senior investigator was originally appointed to lead the investigation into the
man’s death. She visited Whatton on 27 August 2008 and met staff, the
Governor and reviewed the man’s and the cellmate’s records.
15. The Prisons and Probation Ombudsman is obliged to investigate all deaths in
custody, but investigations must not compromise any ongoing criminal matters.
The investigator met Nottinghamshire police and the Coroner in the month after
the man’s death and was asked to suspend the investigation until the resolution
of criminal matters.
16. A family liaison officer was appointed and contacted the man’s family at the
beginning of the investigation to explain the process. She also explained that
our investigation was suspended so as not to compromise the criminal
investigation ongoing at the time.
17. The cellmate was convicted of murder and sentenced to life in prison in May
2009. He unsuccessfully appealed his conviction. Throughout this time the
investigation team kept in touch with Nottinghamshire police. The police
provided documents and statements gathered during the course of their
criminal investigation. In May 2010, the investigator’s colleague took over the
investigation from her and met Nottinghamshire police. They agreed that she
should proceed with the Ombudsman’s investigation, in liaison with the police
and the Coroner, although requested that she concentrate her enquiries at
Manchester and Wymott until further notice because the police were conducting
further enquiries at Whatton.
18. The family liaison officer wrote to the man’s family to explain that our
investigation had started again. The family replied through their solicitor, listing
concerns that they wanted to be considered as part of the investigation.
19. After reviewing the paperwork, the investigator met the police again and visited
Whatton for two days with a senior investigator. The team interviewed staff and
spoke to the Governor, the Independent Monitoring Board (IMB) and the Prison
Officers’ Association. Both investigators were shown around the induction unit,
looked around the prison, and visited the cell where the man was murdered.
20. Following the visit to Whatton, both investigators went to HMP Woodhill where
the cellmate was now held to review his security file. The team spoke to the
police liaison officer there and the security department to clarify details of
outstanding allegations against him from his time at Manchester prison at the
beginning of his sentence.
21. In October 2010, the investigator went to HMP Manchester to conduct four
interviews about the cellmate’s categorisation and security information. She
reviewed his core records and tried to establish the conditions of his transfer
between Manchester and Wymott. Later that month, she visited Wymott to
interview four members of staff about his cell sharing risk assessments,
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participation in the sex offender treatment programme and categorisation. She
also established how security information is used in the prison.
22. The family liaison officer and the investigator visited the man’s family in January
2011 to explain the progress of the investigation to date and what the next
steps were.
23. Later in January 2011 the investigator met the Coroner and the Deputy
Coroner, who was leading the inquiry into the man’s death on her behalf, and
the police acting on behalf of the Coroner. They updated each other on the
respective progress of their investigations and the investigator agreed to share
her provisional findings to date with the Coroner and police to assist their
enquiries.
24. In May 2011, the investigator arranged to visit West Bridgford Homicide Unit.
She met HM Deputy Coroner and the police and viewed the Closed Circuit
Television footage (CCTV) of the afternoon before the man died and the night
he was discovered in his cell. At that stage she was also given copies of all of
the statements taken by police and a log of the evidence the police had
gathered as part of their investigation.
25. In March 2011, in a letter to the police leading the investigation on behalf of the
Coroner, the investigator explained the progress of her investigation to date
and what steps she needed to conclude the investigation. Although there was
no formal correspondence to allow her to conclude the investigation, in August
2011 she was told by the Deputy Coroner that the police enquiries were
drawing to a conclusion and she could now proceed.
26. The investigator returned to HMP Whatton in September 2011 and interviewed
ten members of staff. She also spoke to a representative of the POA and the
IMB to update them on the investigation. She fed back her preliminary findings
to the Governor for her consideration during her visit and followed this up in
writing.
27. It is usual in the Ombudsman’s fatal incident investigation for a clinical review to
be commissioned by the local Primary Care Trust (PCT) to examine the clinical
care that the deceased received in custody. In this case, the clinical care that
the man received while in prison is unrelated to the cause of his death. The
PCT agreed to review the care that the cellmate received, especially in relation
to his mental health, but he withheld his permission to consider his clinical
records and there is therefore no clinical review in this case.
28. The man’s family asked the investigator to explore the following areas as part
of the investigation:
• Would the Ombudsman be able to interview people that had already
been interviewed by the police?
The investigator had access to comprehensive police statements.
Nevertheless, she was also able to interview people that had been
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interviewed by the police to address some issues that the police had not
pursued, as they were not relevant to the police investigation.
• Could the investigation set out how staff were first called to the man’s
cell on the night of the incident?
The investigator describes the response to the cell bell in the
investigation report. She subsequently considers the appropriateness of
the response.
• Will the investigator have access to the transcripts of evidence given by
prisoners who were part of the cellmate’s criminal proceedings, for
consideration in the investigation?
The investigator requested copies of the transcripts to consider but the
cost of obtaining the transcripts was prohibitive but we have seen the
prisoners’ statements to the police.
• Can the investigator confirm whether there was any population pressure
that resulted in prisoners having to share cells at the time that the man
moved into the cell?
It was not possible to establish the exact population pressures at
Whatton at the time of his death so long after the event and whether
these directly contributed to cell sharing but all sharing of cells originally
designed for one are as a result of general population pressures in the
prison estate. The investigator explores fully the reason that the
cellmate was allowed to share a cell. There is little to suggest that this
was associated with shortage of spaces.
• Would the investigator have access to the cellmate’s medical record as
part of the investigation process?
His medical record is a confidential document and even as a convicted
murderer the law requires his consent before it could be considered as
part of the investigation. Regrettably, he did not give his consent for his
medical record to be used in this way.
• Were the cellmate’s or the man’s telephone calls monitored? If so, would
they be considered as part of the investigation process?
As with all prisons, telephone calls at Whatton are recorded
automatically under the PIN phone system but only a proportion are
monitored on a random basis unless there are specific grounds for
suspicion. Legally privileged and other confidential calls are not
recorded. The investigator did not have access to transcripts of their
telephone conversations.
• Can the man’s movements be confirmed for the afternoon of the day of
the incident, particularly whether he was playing pool at that time?
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As part of their investigation, the police gathered CCTV footage of the
landing outside the man’s cell from 12.43pm on the afternoon of the day
of the incident. The pool table was not covered by the CCTV footage.
The police arranged for the investigator to review all of the CCTV
footage available, and she has set out the movements.
The family responded to the findings of the investigation. They raised a
number of concerns, and the final report has been amended to reflect the
inaccuracies identified. While some concerns did not result in changes to the
report, we have addressed them in separate correspondence.
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HMP WHATTON
29. HMP Whatton is a Category C prison that accommodates adult male prisoners
convicted of sexual offences. The prison expanded considerably in 2006 and
holds over 800 prisoners mainly in single cells. Prisoners transferring to
Whatton are expected not to be in denial of their offence or maintaining their
innocence, so that they are ready to address their offending behaviour.
Her Majesty’s Chief Inspector of Prisons
30. The last announced inspection of Whatton was in January 2007, before either
the cellmate or the man arrived at the prison. There was a full unannounced
inspection in March 2010, a year and a half after the man’s death.
31. At the time of the announced inspection in 2007, the Inspectorate reported that
Whatton was still adjusting to almost doubling its capacity and despite a rapid
period of change”, concluded that Whatton was “a reasonably safe prison”
although there was concern that the comprehensive violence reduction policy
was not being used by staff. No one had been trained in the requirements of
managing violence reduction and there were a significant number of new
officers that did not feel confident about how best to challenge inappropriate
behaviour.
32. In 2010, the Inspectorate also found that Whatton was a “reasonably safe”
prison that had made “commendable progress”. However, some incidents of
bullying were not being reported to the offender management unit or the
psychology team, a matter which will be considered in relation to the cellmate’s
time at Whatton
B wing
33. The man and the cellmate shared a cell on B wing at the time of the murder.
This is the oldest part of the prison and the central staff office is on the ground
floor, although each landing has its own office. B wing is also where the
majority of offending behaviour programmes take place and most of the
population walk through the wing on weekdays. In 2006, B wing was identified
as a fire hazard with significant health and safety concerns for the prisoners
accommodated there. Since then a significant refurbishment programme has
updated the wing although the 2010 inspection noted that there were still
problems with the plumbing system and a lack of privacy screens for showers
and toilets.
34. The Inspectorate noticed “positive examples of staff-prisoner relationships” in
2007, although reported that “this was not universal and more formal
interactions were the norm”. In the later, unannounced inspection, staff-
prisoner relationships were described as “reasonable” across the prison, but
better on B wing.
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The Independent Monitoring Board (IMB)
35. The Independent Monitoring Board (IMB) is made up of volunteers from the
community who visit the prison frequently to monitor fairness and respect for
people in custody, and ensure that proper standards of care and decency are
maintained. The IMB produce an annual report for the Justice Secretary, which
is published on their website, with recommendations for improvements.
36. The investigator met the Chair of the IMB and his team on several occasions
throughout the investigation process. They provided a copy of correspondence
with the then Justice Secretary outlining their concern about cell sharing with a
population of prisoners with a history of sexual offending. The Chair was
worried that the continued use of shared cells constituted a breach of the duty
of care to prisoners, as the risk they may present to one another cannot be
effectively managed.
37. The Chair showed a response he received from a copy recipient, then the
Shadow Justice Secretary. (He has since assumed the role of Justice
Secretary substantively.) At the time the Shadow Justice Secretary shared the
IMB’s concern about the practice of sex offenders sharing cells and suggested
that an inquiry into this matter was warranted. The Justice Secretary did not
share the IMB’s concerns that cell sharing was inappropriate for sex offenders
and did not propose an inquiry. No further correspondence has been
exchanged relating to this matter.
HMP & YOI Doncaster
38. HMP and YOI Doncaster is a local Category B prison which accommodates up
to 1,145 male prisoners. The man was at Doncaster from August 2005 where
he was held when he received his indeterminate sentence. At an inspection in
2008 the inspectorate noted that ‘As at other local prisons, we found a number
of indeterminate sentenced prisoners who had not been moved on quickly
enough to appropriate training prisons where they could address their risks’.
The Inspectorate noted that this was a national problem. The sex offender
treatment programme was not offered at Doncaster and he waited until July
2008 to transfer from Doncaster to Whatton to complete the programme.
HMP Manchester
39. HMP Manchester holds nearly 1,300 prisoners. It serves local courts, but also
has a high security unit for prisoners who have been assessed as the most
likely to escape and pose a high risk to the public. The cellmate served
previous sentences at Manchester. It was while he was serving a different
sentence at Manchester for driving offences in December 2006, that he was
charged and subsequently convicted of the sexual offence that brought him to
Whatton a year and a half later.
40. It was at Manchester that the cellmate was assessed as being a Category C
prisoner, and he was transferred from Manchester to Wymott to complete the
sex offender treatment programme.
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HMP Wymott
41. HMP Wymott is a Category C prison near Preston, which accommodates 1,144
prisoners. The prison is comprised of two parts: one side of the prison
accommodates only sex offenders and the other side of the prison is described
as ‘integrated’, which means that it accommodates sex offenders and prisoners
with other types of offence together. When the cellmate arrived at Wymott in
June 2007, he was accommodated on the integrated side of the prison, where
he remained until he was transferred to Whatton six months later.
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GLOSSARY
Cell Sharing Risk Assessments (CSRA)
42. A Cell Sharing Risk Assessment (CSRA) is a form used by prison staff to
assess the suitability of individual prisoners to share a cell with another
prisoner. It should be completed each time a prisoner arrives at a new
establishment, as soon as possible after arrival.
43. At the time of the man’s death, instructions about the CSRA were set out in
Prison Service Order (PSO – a national instruction for prisons) 2750 - Violence
Reduction. The purpose of the cell sharing risk assessment tool was described
in the PSO was to:
• “draw together information about risk
• make best use of documentary evidence;
• support staff judgement about allocation to cells and risk
management;
• record additional operational precautionary measures for a prisoner
identified as a potential risk, where cell sharing is unavoidable;
• provide a record about risk of harm to others as a prisoner moves
between wings/prisons, or needs peer support;
• to enable early identification of racist, homophobic, or violent
prisoners;
• to ensure that other Prison Service procedures to protect potential
victims are followed.”
44. In April 2011, Prison Service Instruction amended the original order and
replaced it with a new system outlined in PSI 09/2011 - The cell sharing risk
assessment. The new instruction is aimed at improving the CSRA process, by
ensuring that “an evidence based check of specified sources is carried out on
the day prisoners are received into custody, or the next working day”.
Categorisation
45. There are four categories for sentenced prisoners: A, B, C and D, with category
A prisoners requiring the highest level of security and category D prisoners the
lowest level of security. The category is determined by the likelihood that the
prisoner will try to escape and the risk that the pose should they do so.
Previous custodial behaviour can be taken into account, if a prisoner requires a
higher security prison to address the risk they pose to control.
46. The man and his cellmate were both Category C prisoners at the time of the
man’s death. According to PSO 0900 – Categorisation and Allocation,
Category C prisoners are “Prisoners who cannot be trusted in open conditions,
but do not have the resources and will to make a determined escape attempt”.
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Indeterminate Sentences for Public Protection (IPPs)
47. Indeterminate sentences for public protection set a minimum period to be
served before a prisoner can be considered for release. After this the prisoner
must satisfy the Parole Board that he is no longer a risk to the public before he
can be released.
Assessment, Care in Custody and Teamwork (ACCT)
48. Assessment, Care in Custody and Teamwork (known as ACCT) is the principal
tool for assessing, monitoring and managing any prisoner thought to present a
risk of self-harm or suicide.
Sex Offender Treatment Programme (SOTP)
49. Sex offenders are usually expected to complete the sex offender treatment
programme (SOTP) as part of their sentence plan. The programme aims to
give prisoners insight into their behaviour and the means to prevent them from
re-offending in the future.
50. There are three main types of sex offender treatment programmes, core,
adapted or rolling. Most prisoners will undertake the core programme, if
prisoners are in need of extra learning support they will attend the adapted
programme and the less structured rolling programme is usually used for lower
risk prisoners.
Person Escort Record (PER)
51. A Person Escort Record (PER) is a form that accompanies prisoners on all
journeys from and between prisons. It is a means to share information
between prisons and escorting agencies about a prisoner’s risks and custodial
history. It includes information about a prisoner’s risk to themselves and
others. Until May 2009 the PER was known as the prisoner escort record.
The Incentive and Earned Privileges Scheme (IEPS)
52. The Incentive and Earned Privileges Scheme (IEPS) is designed to encourage
prisoners to progress through their sentence plan, to undertake work or other
purposeful activity and create a better and safer environment for prisoners and
staff. There are three levels under IEPS – basic, standard and enhanced – with
all new prisoners initially being on standard level. Changes to that level will
then depend on their conduct and progress through their sentence plan.
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KEY EVENTS
The man’s time in HMP and YOI Doncaster
53. The man was released on licence from HMP Acklington in December 2004
after serving six months for indecent assault. Eight months later, he was
accused of further sexual offences and he was recalled to custody on 15
August 2005. On arrival at Doncaster, he was assessed as a low risk to share
a cell with another prisoner, although he told staff that he had concerns about
sharing a cell.
54. In line with national policy, the man received a notice explaining his right to
appeal his recall, although he waived this right. He was identified as a potential
life sentence prisoner on 16 August and given information about the
indeterminate sentence for public protection (IPP).
55. On 5 September, the man was convicted of two counts of sexual assault of a
female minor. Two days later, he was sentenced to an IPP with a minimum
tariff of three years. The probation officer who completed his pre-sentence
report noted his dangerousness and the likelihood of his re-offending and
suggested he needed to attend the sex offender treatment programme while
serving the custodial part of your sentence”. At the time all prisoners with an
IPP sentence were initially categorised as security category B – for whom high
security conditions are not necessary, but escape needs to be made very
difficult.
56. The man settled into life at Doncaster. He became the prisoner representative
for IPP sentenced prisoners and worked as a cleaner, a trusted position. Due
to continued excellent behaviour, he gained enhanced status on the Incentives
and Earned Privilege (IEP) Scheme and gained additional privileges such as
more visits and a higher allowance of private cash.
57. The man’s first annual sentence review took place on 21 August 2006. He was
recorded as “very polite and helpful to staff”. He continued as a wing cleaner
and undertook courses, although the sex offender treatment programme,
central to his sentence plan, was not available at Doncaster. His next annual
review took place on 6 September 2007, when his behaviour was described as
“very good”. However, he could not progress until he had completed the sex
offender treatment programme, because he was still considered at risk of
reoffending.
58. On 7 February 2008, the Prison Service issued a national instruction
concerning prisoners who were sentenced to an IPP, with a tariff of three years
or less. Due to an unexpected level in the use of the IPP sentence, access to
courses had prevented many prisoners from progressing their sentence and
being released on tariff. The instruction required that all IPP prisoners with a
tariff of three years or under should be considered for re-categorisation to
Category C, and transferred to corresponding prisons to complete offending
behaviour work.
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59. Following this instruction, the man was re-categorised as Category C on 20
February 2008. In a sentence planning and review report completed on 18
March, the lifer manager at Doncaster reflected his exemplary behaviour in
custody:
“I can report that he has acted as the Indeterminate Sentences
representative for his wing since the scheme began in March 2007,
and he has always carried out his duties diligently.”
60. In the review board meeting, the man made his frustration about his lack of
progress known, “he is willing to undertake the work and is unhappy that the
system has held him back”. While being assessed by a psychologist for a
progress report, he told the psychologist that he understood he would not be
considered for parole “as he believed he would be required to attend a sex
offender treatment programme”.
61. On 2 May 2008, at a sentence plan review meeting held at Whatton (although
the man had not yet transferred from Doncaster) it was noted that a transfer
could be facilitated, but the parole board were still awaiting his ‘parole dossier’
(various assessments and documents from professionals for consideration for
parole) before he could transfer. After correspondence over the next month
and a half between offender supervisors in prison and his community offender
manager (probation officer) a Parole Assessment report was carried out. He
said he broadly agreed with the assessment, requiring him to do further
offending behaviour work, specifically the sex offender treatment programme.
The parole dossier was sent to the parole board on 2 July and he was
eventually transferred to Whatton on 17 July 2008, nearly three years after
receiving his indeterminate sentence, and less than a month before his
minimum tariff was due to expire.
The man’s time at HMP Whatton
62. The man’s Prisoner Escort Record (PER) detailed that he was assessed as a
risk to children and that he was vulnerable (this may have referred to the nature
of his offence, although there is no explanation on the PER). An officer carried
out his cell sharing risk assessment in the reception area of the prison. He
noted that he was a smoker and he had been an enhanced prisoner. He told
the officer that “he can get frustrated but is ok to share”. The officer assessed
that he was a low risk to other prisoners and could therefore share a cell.
63. The man remained on the first night centre and underwent the induction
programme, which he completed on 24 July. On 1 August, he met his offender
supervisor, who followed the meeting up with an email to confirm their
discussion with relevant prison departments. She acknowledged that he had
“been unable to complete any offence focussed work due to the lack of
programmes at Doncaster despite being very motivated” and that the delay in
his parole dossier being prepared “set him back even further”.
64. According to the risk assessment completed by the psychologist for his parole
dossier, the man had been assessed as “medium risk for sexual recidivism
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[repeat offending], he is also a medium risk for violent offending giving him a
combined risk rating of medium”. Once his offender supervisor had outlined his
risk assessment, she concluded that he would be put on the waiting list for the
sex offender treatment programme, but he would be unlikely to begin the core
programme until October 2008.
65. In line with national policy, the man’s cell sharing risk assessment was
reviewed after three weeks, on 5 August. Nothing had altered staff’s perception
that he posed a low risk to other prisoners and another officer confirmed the
earlier assessment.
66. On 12 August, the man’s minimum tariff expired. He moved wings on 18
August, and was then asked if he would mind moving to share a cell with
another prisoner. Although he preferred not to share a cell, he agreed to move
to a double cell to co-operate with the officer’s request.
The cellmate’s custodial history
67. The cellmate was convicted of driving offences, theft and criminal offences on
20 February 2006. Just after receiving his sentence, he told the judge that he
wanted to kill himself and suicide prevention measures were opened. He was
taken to HMP Manchester to await sentencing. When he arrived at
Manchester, he asked for protection because on previous sentence he had
received threats because he was gay.
The cellmate’s time at HMP Manchester
68. Less than two weeks after arriving at Manchester, an officer wrote about “an
alleged incident on a previous sentence”, involving a “sexual attack in the
showers” in the cellmate’s ongoing suicide prevention record. The source of
that information is not clear from the records and neither is when the attack
took place or whether he was the alleged victim or attacker. Nevertheless, the
officer recorded, “it would be advisable to allow him time to shower when no
other prisoners in the vicinity”.
69. On 8 March, the cellmate was escorted to a police station where he was
charged with rape of an adult man in the community. The offence was alleged
to have taken place in the short time between his release from his previous
sentence at Manchester in December 2005 and his current sentence. When he
returned to the prison, he was assessed as high risk to share a cell as a result
of the new charge and was located in a single cell. Less than a week later, on
14 March, he received a 20 week sentence for criminal damage, driving
offences and theft.
70. The cellmate’s first security categorisation form was completed on 15 March.
Due to the nature of the offences of which he was convicted, he was assessed
as a category C prisoner. However, as there was an outstanding charge of
rape by this time, he remained in Manchester, a category B local prison, as an
uncategorised prisoner.
18
71. The cellmate settled into the unit and the suicide prevention measures opened
at court were closed on 27 March. Four days later, another prisoner alleged
that he had carried out a serious sexual assault on him when they were in
prison together in December 2005 (this is possibly the incident referred to by
the officer earlier that month). A Senior Officer (SO) recorded the allegation in
his wing history and reported it to the police. The SO carried out a cell sharing
risk review and concluded that he was to remain high risk and should be
located in a single cell. He noted on the cell sharing risk review that “the
cellmate totally denies any allegation of a serious sexual assault”.
72. The next day, on 2 April, a governor spoke to the cellmate and they agreed that
he should not go into other prisoners’ cells or have any prisoner in his own cell
while the rape charge was outstanding. According to his security record, he
was adjudicated the following day for seriously sexually assaulting a prisoner
between 9 December and 30 December 2005. The security record is likely to
be referring to the opening of an adjudication, but there is no record of the
eventual outcome.
73. The cellmate was reported to respond badly to “the prospect of a second rape
charge”, and another Assessment Care in Custody and Teamwork (ACCT)
document was opened to monitor the risk he presented to himself. His risk to
other prisoners was still assessed as high and therefore he was not able to
share a cell as part of his support plan. (In PSO 2700 – suicide and self-harm
management, cell sharing is recognised as a way of reducing loneliness and
giving an at-risk prisoner someone to talk to.)
74. Over the next month, the cellmate wrote to a friend in another prison. His
letters were intercepted because they contained inappropriately threatening
remarks, directed primarily at another prisoner, for example:
“How dare he call me a rapist when he’s been done for fiddling with
little girls. HE WILL DIE.”
75. In other letters written at the same time, the cellmate described his frustration at
being described as a bully, and his difficulty in dealing with anger without
resorting to violent thoughts. In one such letter, he wrote about his plans to
murder people when he was released. A note was made in his ACCT ongoing
record and his security file was updated.
76. The cellmate was due to appear at Crown Court but his warrant was not
forwarded by the magistrates’ court in time and he was released for one day.
When he was brought back into custody on 29 April on remand for the rape
charge officers recorded that he had to be kept separate from three prisoners.
He was to be kept separate from the prisoner who he was alleged to have
sexually assaulted, the prisoner who he wrote about threateningly and a further
prisoner who is not mentioned elsewhere on the files reviewed by the
investigation team, so the reason for not allowing contact is unknown.
77. The cellmate was still assessed as at risk of harming himself and an ACCT
document was opened. On 12 June 2006, he asked to speak to a mental
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health nurse. According to the ACCT document, he told a Registered Mental
Health Nurse (RMN) that he was “experiencing constant thoughts/urges to cut a
male’s throat”, particularly another nurse at the prison. He said that he felt
“sexually excited” at the thought and went into detail, “showing no empathy with
the intended victim”. Ten days after this interview, he was assessed by a
psychiatrist, who determined that he should be referred to a Personality
Disorder Unit. Otherwise, the psychiatrist found that he was fit to be located on
a residential unit (rather than in the healthcare centre) and was suitable to
share a cell “from a psychiatric point of view”. (There is no further mention of
the referral in the records reviewed by the investigation team and as explained,
unfortunately we did not have the right of access to his medical records.)
78. The cellmate remained a high risk on his cell sharing risk assessment and
stayed in a single cell throughout the summer of 2006. On routine cell sharing
risk reviews in September and October, it was noted that he “tended to be
friendly with vulnerable prisoners”. Despite his high risk, no risk minimisation
plan was completed as was required. In October, he alleged that a prisoner
had sexually assaulted him on a number of different occasions and asked for
that prisoner to be moved. Less than a week later, he was moved wings and
became the cleaner, a responsible job reserved for prisoners who have built
trust with staff through good behaviour. It enabled him to move around the
prison with less supervision. His ACCT document was closed because he was
no longer considered at risk of harming himself.
79. On 1 November 2006, the cellmate was segregated for allegedly attempting to
rape another prisoner “at blade point”. A security incident report was
completed. According to prison records, the allegation was referred to the
police. An adjudication was opened and adjourned, pending the outcome of
the police investigation. The investigator liaised with the police liaison unit at
HMP Woodhill, where he was being held at the time of the investigation. They
contacted Manchester police to clarify their response to this incident.
Manchester police advised the investigation that they had not been notified
about this incident according to their records, and therefore there was no
evidence of any subsequent police investigation. The adjudication was not
resumed so he was neither prosecuted nor adjudicated following this allegation.
80. An ACCT document was opened by the senior manager on the segregation
unit. During the cellmate’s ACCT assessment, it was noted that the first charge
of sexual assault against a prisoner (dating from December 2005) had been
dropped due to a lack of evidence. There is no other record of this outcome in
his files.
81. On 2 November, a risk assessment meeting was held to discuss whether to
continue to accommodate the cellmate on the segregation unit. (A prisoner
who has been identified as at risk of self harm should only be segregated in
exceptional circumstances because of the restricted regime and support
available in a segregation unit.) He acknowledged that he was “shocked” at his
own behaviour and said that he “does not have control over his other irrational
side”. It was agreed that his situation constituted exceptional circumstances
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because he posed such a high risk to other prisoners and he continued to be
accommodated in the segregation unit.
82. A cell sharing risk review was carried out on 8 November, where it was
acknowledged in capital letters, that the cellmate had sexually assaulted a
prisoner on the wing. The officer also recorded that he had made threats of a
sexual nature to other prisoners and that he “continued to befriend vulnerable
prisoners”. He remained on the segregation unit. On the record of the cell
sharing risk review completed one month later, “sexual assault on cellmate”
was noted. It was not clear from his records whether this related to the assault
on 1 November or whether there was another incident. This comment was
repeated in the cell sharing risk reviews on 8 January 2007.
83. An OASys risk review was completed on 19 January 2007. It noted that the
cellmate had been “diagnosed with schizophrenia and personality disorder”. A
worker from community supervision group recognised that he posed a risk to
male members of the public and himself. However, she found that his risk to a
known adult while he was in custody was low and the risk he posed to
prisoners was medium. Nevertheless, the prison rightly continued to regard
him as a high risk to other prisoners and he was accommodated in the
segregation unit.
84. The cellmate’s last cell sharing risk assessment before his conviction on 8 April
2007 recorded that he was a high risk to other prisoners. The following was
noted on the form:
“Alleged sexual assault on cell mate.
Never self-harmed while on the seg unit.
Alleged weapon used on sexual assault on cell mate.
In daily contact with [mental health in-reach team].”
85. On 12 April 2007, the cellmate received a six and a half year sentence for male
rape. It was still recorded on his prison escort record used when escorted to
and from court, that he should be kept separate from the three prisoners
identified the previous year and that he was convicted of a sexual offence. He
was identified as “vulnerable”.
86. According to Prison Service Instruction (PSI) 32/2005 which governed cell
sharing risk assessments at the time, there was no absolute requirement to
review a prisoner’s cell sharing risk assessment upon conviction although the
instruction required a re-assessment ‘if there is a significant event which
triggers concern.’ The cellmate’s next cell sharing risk review took place on 8
May and exactly the same wording was used on the form, as used on the form
dated 8 April and set out above.
87. Also on 8 May, Officer A completed the cellmate’s security categorisation,
which was signed off by a SO. An “Initial Categorisation of Adult Male
Prisoners” (ICA1) form, is completed when a prisoner is sentenced. An officer
fills in the details of the form based on a prisoner’s pre-convictions and
information available in the core record. The officer explained:
21
“When a prisoner is actually sentenced we collect all the core records,
which is everything, all information that’s out together about a prisoner.
We get information from the courts, we get previous convictions and
we … took them all to the OCA unit.”
The officer who completes it does not meet the prisoner unless they are being
considered for a category D prison.
88. Officer A completed the provisional categorisation algorithm, noting that the
cellmate was convicted of a sex offence and had previously been convicted of
failure to surrender and breach of bail. Following the algorithm, the officer
determined that he should be considered a category C prisoner.
89. The next page of the categorisation form invites officers to record any
circumstances which indicate a prisoner should be placed in a higher security
category than that suggested by the algorithm. It cites the following examples:
“security information, significant control problem, circumstances of offence,
pattern of offending or facing further charges of a serious nature”. Officer A
ticked that no such circumstances applied in the cellmate’s case. He
explained:
“If there was security information sent to us by the police or our
Security Department saying he’s a risk to certain groups or individuals,
that would be things you would actually put in there.”
90. The investigator asked Officer A whether the allegations that the cellmate had
sexually assaulted prisoners on two occasions in custody would have been
taken into consideration. He explained that as the cellmate had not been
convicted of the offence, and neither had it be proven at adjudication:
“That wouldn’t affect him whatsoever.”
91. By contrast, the Head of Security at Manchester told the investigator that he
would have expected the two allegations to have had a bearing on the
categorisation assessment. However, the possibility of overriding the
algorithm, allowed for in the form seems not to have been considered and the
outcome of the categorisation assessment was that the cellmate was a
category C prisoner, as defined by PSO 0900 – Categorisation and Allocation,
“Prisoners who cannot be trusted in open conditions, but who do not have the
resources and the will to make a determined escape attempt”.
92. The process of allocation is distinct from categorisation and takes into account
the prisoner’s suitability for certain types of accommodation, for example if he is
a vulnerable prisoner, medical needs, sentence plan and his home area,
among other factors. As a convicted sex offender, Officer A recommended that
the cellmate be allocated to the vulnerable prisoner unit at HMP Wymott.
Around half of the population in Wymott are sex offenders.
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93. Despite the investigator’s request, Manchester could not confirm whether the
cellmate was still in the segregation unit, the healthcare centre or on a
residential wing at the time of his transfer. There was no PER for the journey to
Wymott on 14 June, in the copied files received by the investigator and no
reference to it at Wymott.
The cellmate’s time at HMP Wymott
94. Just over a month after his categorisation and allocation was complete, the
cellmate was transferred to HMP Wymott, a Category C prison near Preston.
Despite his offence, and Manchester’s recommendation he was not
accommodated on the vulnerable prisoner unit used for prisoners who are at
risk from other members of the prison population such as those convicted of a
sexual offence.
95. A cell sharing risk assessment was completed on the same day, 14 June 2007,
by an officer. For the first time since the cellmate was charged with rape of an
adult male in March 2006, he was not assessed as high risk to other prisoners.
The officer noted that he was a smoker and that he “prefers own cell”. In
another section, the officer recorded that he was “afraid of cell sharing as he is
gay. Will cell share with non-homophobic prisoner”. He was assessed as a low
to medium risk despite his offence and with no apparent reference to the
security information and allegations against him.
96. On 12 July 2007, an entry was made in the cellmate’s security file, as follows:
“Intel from previous establishment, complaint from other prisoner that
he had been raped by him and was facing charge in April 2006.
Suspicion that he will try and groom vulnerable prisoners, and is open
about his homosexuality. He was placed with health care due to his
constant urges to cut a member of staff’s throat and become sexually
excited by the thought. Has no victim empathy. Wing informed.”
97. The investigation team saw no other entry relating to this information in the
cellmate’s wing history record. It did not trigger a cell sharing risk review.
There was no updated security information.
98. On 13 July, the cellmate told staff that he had swallowed two razor blades. He
was taken to the local accident and emergency department for follow up, after
an initial examination at the prison. An ACCT document was opened when he
returned to the prison later that day. During the case review the next day, he
told staff that he would “slash up to get a move to the VP side of the jail or the
CSU”, (CSU stands for Care and Separation Unit as the prison’s segregation
unit was known). He was told that he might have to go to another prison to
complete the sex offender treatment programme (SOTP), identified as part of
the sentence plan that he had to complete prior to being considered for release.
Another entry was made on the security file, recording that “concerns about
[his] threat to wreak havoc when released if he didn’t get help logged on
security file”. He was identified as raised risk to himself and his ACCT
remained open. He was referred to the mental health in reach team.
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99. At the next ACCT case review on 23 July, the cellmate asked to go to Whatton
or Stafford. He told staff that he felt he was being ignored by them. The ACCT
document remained open following this case review, although it is not possible
to determine when it was closed, because despite her request the investigator
has not seen the record of the closing case review (although there was a post-
closure review on 11 August).
100. A further security matter was logged on 10 August when staff received a letter
addressed to the cellmate as the ‘induction officer’ about adoption. At the time
the letter was received, he was running a drop-in centre for prisoners
undergoing induction and was also an Insider. (Insiders are prisoners who
usually work on first night and induction centres and offer guidance and
information to new prisoners.) As well as possibly impersonating an officer,
staff had observed him closing the door when speaking to several prisoners
and was thought to be taking advantage of his position. He was removed from
his post.
101. On 14 August, another ACCT document was opened after the cellmate cut his
right leg. He was admitted to the healthcare centre where he underwent a
mental health assessment. Over the following month, he was subject to ACCT
monitoring following his self harm.
102. As part of his support plan, officers looked into why he was not located on the
vulnerable prisoner unit at Wymott, which would enable him to complete the
SOTP and advance in his sentence plans. Because Wymott was concerned
about the risk that the cellmate posed, he was assessed as “not suitable” for
the vulnerable prisoner unit and therefore had to be transferred to another
prison to complete the programme. Had he remained at Wymott to do the
SOTP outcomes might have been very different.
103. Although he had the support of staff to transfer to another prison, the cellmate
needed a psychological assessment to determine which type of sex offender
treatment programme would be most suitable. He continued to ask staff why
he could not move to the vulnerable prisoner unit in Wymott to complete the
SOTP, and there is no record of him being given an explanation. His solicitor
wrote to the Offender Management Unit on 19 September to complain about
their client’s lack of sentence progression. By the time his ACCT was closed
on 30 September, he had been assessed by the psychology department as
suitable to complete the core SOTP programme and it was recommended that
he to go to Stafford.
104. Towards the end of November, the cellmate told staff that he was suffering from
seasonal depression and that he might harm himself. An ACCT document was
opened and it was noted that he was to be accommodated in a single cell. The
ACCT remained open for the rest of his time at Wymott.
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The cellmate’s time at HMP Whatton
105. The cellmate remained at Wymott until his transfer to Whatton on 5 December
2007. The nature of his offence and his vulnerability were indicated on his
PER, although there was no mention of the two allegations of sexual assaults
against prisoners. Neither was there any mention of the security matters that
prevented him from being accommodated in the vulnerable prisoner unit at
Wymott but allowed him to be held in Whatton a prison populated only with sex
offenders. There was no further reference to a transfer to Stafford which had
previously been suggested.
106. Although we found no evidence that the cellmate’s cell sharing risk assessment
was reviewed during his time at Wymott, “*High Risk CSRA* was recorded in
the ‘Additional Information’ section of the PER which suggests it had been
changed at some stage. On arrival at Whatton a cell sharing risk assessment
was completed. The majority of the form was left blank and, despite the high
risk indicator on the CSRA, he was recorded as a low risk to other prisoners.
107. The PER indicated that the cellmate’s ACCT document was closed, although
he was transferred on an open ACCT. Nevertheless, the ACCT document
transferred with him and the Whatton induction senior officer conducted a case
review on 6 December, the day after his arrival at the prison. The senior officer
recorded that he was “still a little anxious while he was settling in” and kept the
ACCT document open. The day after this first case review, another review was
held following a death in custody. (All prisoners on open ACCT documents
should be reviewed following any death in custody.) The review noted that he
was settling in and “is now sharing and is happy to have someone to speak to”.
The ACCT document was closed a week later.
108. A Safeguarding Children meeting was held on 12 December. At that time, all
new prisoners were discussed at this meeting to determine if there were any
risk factors which required additional security or public protection measures.
The cellmate was discussed at the meeting on 12 December, as a new arrival.
The meeting noted details of his index offence, his removal from the job of
induction orderly at Wymott and the fact that there was an ongoing allegation of
rape against a prisoner. It was also recorded that “he has urges to cut people’s
throats for sexual pleasure”. The conclusion of that meeting was that he should
be subject to monitoring as a risk to prisoners and staff and that his CSRA
should be reviewed. (In fact, there was no evidence that his CSRA was
reviewed as a result of this meeting.)
109. The cellmate’s risk management was also referred for further consideration at
the Interdepartmental Risk Management Team (IRMT) meeting, which also
assessed how to best manage the risk every new prisoner presented. (The
Safeguarding Children and the IRMT meetings have now been merged into one
fortnightly meeting, designed to communicate and manage risk posed by
prisoners.)
110. In line with Whatton’s CSRA policy at the time, the cellmate’s cell sharing risk
assessment was reviewed on 29 December because he moved wings. His
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wing move is noted on the form, but nothing else was written. No outcome of
the review was recorded, and he continued to live in a double cell. Just two
days after this review, a security report was submitted alleging that he was
involved in dealing medication for sexual favours. There was no evidence that
he was spoken to about this by staff or that any action was taken following this
allegation.
111. The cellmate’s cell sharing risk assessment was again reviewed on 3 January
because he was moving cells. He continued to be assessed as a low risk. He
was moved to share a dormitory cell on B wing with two other prisoners.
112. The IRMT meeting was held on 8 January. As the cellmate had been referred
by the Chair of the Safeguarding Children meeting two weeks earlier, his risk
factors were discussed, including that he “was investigated while at HMP
Manchester over rape of another prisoner, no results of the investigation
known”. The police liaison officer at Whatton was asked to check the status of
the police enquiry. As a result of his risk factors, it was decided to alter his
CSRA to high and relocate him into a single cell.
113. That same day, the cellmate’s cell sharing risk assessment was revisited by an
officer and he was considered a high risk to other prisoners. The following note
was made on the cell sharing risk assessment:
“The prisoner has been accused of raping two male prisoners in
previous establishment.
Has made threats to cut people’s throats and especially a member of
staff.”
114. The cellmate was moved into a single cell on A wing. Also on 8 January, he
had his first interview with the Offender Management Unit who noted that he
had been sectioned three times, but had no other issues.
115. The cellmate took an overdose of 20 tablets on 28 January. An ACCT
document was opened and a mental health referral was made. He gave staff a
“cast iron guarantee” that he would not self harm, but described suffering from
“bouts of depression”. He told the mental health nurse that he took all his
tablets when he received them at the beginning of the week and bought more
medication from other prisoners. He claimed he did not suffer from withdrawal.
The ACCT document was closed seven days later, when he was described as
“buoyant and optimistic”.
116. On 10 February 2008, the cellmate was interviewed for his cell sharing risk
review. He said he did not know that he had been assessed as a high risk to
share a cell because he had been cell sharing for some time. A SO carried out
the interview. He recorded:
“The information noted is for an allegation of rape on two males at
Manchester.
I have asked for his security file to be checked before a thorough,
informed review can take place”.
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117. A SO carried out a further cell sharing risk review the following day. He noted
the following in the cellmate’s ongoing record after their discussion:
“He accepts that his history could be seen as a potential risk but he has
been sharing cells without any problems for over a year. [He was rated
as medium risk with three reviews a year.] He is happy with this
decision as he is very confident he will not pose a risk at all.”
This was not the case as in February 2007 a year previously he was assessed
as high risk at Manchester and held in a single cell during his time there. He
also spent time at Wymott in a single cell.
118. The SO completed the cell sharing risk assessment form, indicating that he had
spoken to the security department. The senior officer was advised by the
security department that all intelligence about the cellmate’s risk to other
prisoners was more than two years old. They told the SO that there was
nothing in his records over the last two years to suggest that he was a risk. HE
continued to be in a single cell, although his risk was reduced to medium.
119. The cellmate completed a standard pre-SOTP assessment on 16 February.
Among other questions, he was asked whether there was anything about his
offending that he had not yet disclosed. He responded: “I also fantasise about
being raped and acting out rape scene with sexual partners”. In her report for
Nottinghamshire police, the then Clinical Lead, commented on this extract as
follows:
“This information was shared in the context of the Sex Offender
Treatment Programme, and does not necessarily indicate imminent
risk. Indeed, honest disclosure such as this is encouraged in
treatment, so that men can address their risk factors appropriately.”
120. On 16 March, the cellmate asked his personal officer to be considered for
enhanced status. The officer explained that his behaviour had been “too
unsettled” for consideration of enhanced status, and that he needed to
demonstrate positive behaviour for at least a month before he would be eligible.
The officer explained in interview that the cellmate often had disagreements
with other prisoners and was “immature”.
121. A group worker who facilitated SOTP interviewed the cellmate on 29 April as
part of the assessment process. He discussed his background and his attitude
towards men and women. She also asked him about his sexual history and he
told her that he had had a lot of sexual partners. He said that he had “acted out
rape scenes – both consenting”. When asked what was “the most sexually
satisfying” parts of his offence, he said that “the act, in a way I had the control
over him”. He went on to acknowledge that before the index offence he “had
fantasies of people being asleep and them not knowing”. Finally, he told her
that he was attracted to “straight men”.
27
122. In a further assessment two days later, the cellmate recalled the circumstances
of his offence and reflected what he could have done differently. He explained
that he acted on the “spur of the moment” and told the group worker that he
wanted to complete the SOTP course “to get an understanding of why I
committed the offence. To put things in place/change things so it doesn’t
happen again/don’t come back to jail”.
123. The cellmate attended chapel regularly throughout his time in custody. On 2
May, he was recorded as “displaying a poor attitude towards chaplaincy staff
and other prisoners”. He was restricted from attending all chaplaincy activities,
apart from services on a Sunday and Wednesday. He responded badly to the
restrictions and an ACCT document was opened.
124. In the following few days, the cellmate told staff that there had been some
issues in the chaplaincy but he “held his hands up” and said “he was in the
wrong”. He had acted inappropriately towards another prisoner. On 7 May, a
Violence Reduction Strategy (VRS) document was opened. The VRS has
three stages, the first of which is staff monitoring. He was placed on stage one
and, as part of his support plan, he was encouraged to talk to prisoners he liked
and think before talking.
125. Four days later, the personal officer recorded that the cellmate was upset to be
put on a VRS document. He said “he hates bullies and is shocked at the
suggestion that he is one”. The officer recorded that their conversation was a
“pleasing interview, filled with positive points”.
126. The cellmate’s ACCT document was closed on 14 May, less than two weeks
after it had been opened. He asked staff to be taken off the document,
because he did not feel in need of the additional support and he did not want it
to affect his chances of getting on the SOTP. The same day, he was sent an
invitation to attend the core sex offender treatment programme.
127. Just four days later, the cellmate started his sex offender treatment programme.
On the second day of the programme, he walked out of the course, but staff on
his wing were not informed. It was him who told his personal officer that he had
left the course. That day, he also saw a nurse, complaining of dizziness and
“stabbing in the left chest into the left arm”. The nurse speculated that the
symptoms might be related to the reduction in his mental health medication and
suggested monitoring for a week.
128. On 21 May, the VRS document was closed. It was noted that he had been “no
cause for concern over previous 14 days” and that he was speaking to the
prisoner who he disagreed with, thanks to mediation sessions co-ordinated by
the chaplaincy.
129. A forensic psychologist in training interviewed the cellmate on 4 June 2008 for
his suitability for the core SOTP. The aim of the interview was determine
whether he had any psychopathic traits and whether it would have an impact on
the SOTP. He was assessed as suitable to continue with the core SOTP.
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130. A scheduled review of the cellmate’s cell sharing risk assessment took place on
23 June. A SO recorded that there had been no information from the security
department in the previous three years. He went on to write in his wing history:
“CSRA assessment done. On reading last review when it was felt that
he should be dropped to low, I see no problems with this as there has
been no real concerns with him in the last three months. CSRA now
low.”
His risk to other prisoners was assessed as low. He was recorded as, “pleased
to be reviewed to low standard. To be reviewed in three months”.
131. On 25 June, the cellmate was challenged by an officer about why he had been
observed “hanging around” a particular landing “on a regular basis”. He told
the officer that he was waiting for chapel. The officer noted this exchange in his
wing history, recommending that staff remain “aware” of this behaviour.
However, there is no evidence that a security report was submitted.
132. A security report was made following an allegation made against the cellmate
by another prisoner on 1 July. The prisoner alleged that he made inappropriate
sexual comments to him. An equal opportunities form was submitted and the
information was added to his security file.
133. The cellmate’s personal officer spoke to him about the prisoner’s allegations
four days later, on 5 July. The officer recorded that he was “very upset” at the
possibility of being placed on another VRS. He said that “he was trying very
hard to get on with his sentence and coming to terms with doing the SOTP
course”. He told the officer that he did not deserve to be on the VRS document
again.
134. A VRS document was opened again on 8 July, in connection with the
allegations the previous week. In the VRS document, it was noted:
“Information received by a PO that he has previously raped three male
prisoners.
Accused of sexual assault of a prisoner in 2005.”
135. A SO sent the following email to staff on the cellmate’s wing:
“In order to comply with Whatton’s VRS procedures, I need to inform
you that he has been placed on Stage 1 VRS, after allegations of
inappropriate sexual comments were made against him by another
prisoner. As he is currently participating in SOTP and spends much of
his free time in the Chapel, could you inform staff of his conduct on a
daily basis, if staff in your department have contact with him.”
136. The cellmate appealed against the decision to open a VRS document, but it
was rejected. This is recorded in the VRS ongoing record. None of the
allegations or the fact that he was put on a VRS resulted in a review of his
CSRA.
29
137. On 14 July, SOTP facilitators visited the cellmate’s wing to establish why he
had missed about ten sessions. Officers investigated and discovered that there
was a healthcare related matter. The facilitators warned that he would be taken
off the course if he missed more sessions. Facilitators agreed to call the wing if
he missed another session. A compact was drawn up, whereby he agreed to
attend the SOTP course.
138. The same day, the cellmate approached an officer to volunteer to share a cell.
The officer recorded the following entry in his VRS document, following their
conversation:
“ … it has been agreed by myself, another officer and a PO that this
would be inappropriate in view of recent allegations and this current
VRS document.”
Although the officers recognised that it was inappropriate for him to share a cell
at this stage this did not trigger a review of his CSRA.
139. The next day, the cellmate asked his personal officer “to record the fact that he
wants more support from wing staff due to him struggling with the SOTP
course”. The officer recorded the conversation in his wing history.
140. On 16 July, the cellmate breached his compact by failing to attend the SOTP
course again. He assured staff that he was fully committed to the course and it
was agreed that the compact would be reviewed in six days.
141. Six days later, the cellmate walked out of the SOTP course again after a
disagreement in the class. He returned after five minutes. Despite the short
time away from the course, it was still considered to be a breach of his
compact. He was given one more week to demonstrate his commitment to
SOTP.
142. On 23 July, the day after the above incident, a SO closed the cellmate’s VRS
document with an officer. He recorded that there had been no repeat episodes
and that he had been polite and respectful when talking to staff.
143. The SOTP ‘block’ of work addressing patterns in offending behaviour
concluded on 24 July. According to his SOTP progress report, the cellmate
disclosed that he did not want to offend again in the future and that was his
motivation for staying on the course. However, he acknowledged that he
continued to have thoughts of “rough sex” and was encouraged to consider
how these patterns of thinking could be risky for him in the future.
144. The next ‘block’ concluded on 31 July and encouraged the cellmate to reflect
on social and emotional functioning, as well as self-management. He
discussed his “preoccupation with sex” and was recorded by the treatment
manager as having “a good grasp on the areas relevant to him”.
30
145. The cellmate made an application to move from A wing to the second or the
sixth landing on B wing on 1 August. The application was sent to the allocation
department. The next day, he told his personal officer that he had more
problems with prisoners in the chapel that morning. He told the officer that he
wanted to move wings to get away from a particular prisoner who was
accommodated on the same landing as him. Each time a prisoner moves cells,
his cell sharing risk is reviewed. An officer completed a cell sharing risk review
on 3 August and again assessed him as low risk to others.
146. The cellmate was moved to a dormitory cell on B wing, sharing with two other
prisoners on 4 August. A further cell sharing risk review was completed by an
officer and signed by a manager. It confirmed an officer’s assessment that he
was a low risk to other prisoners when sharing a cell.
147. The Clinical Lead of the SOTP at Whatton at the time of the investigation,
explained that one ‘block’ of the course concentrates on victim awareness. She
told the investigator that prisoners often find this element of the programme
difficult. As part of victim awareness, the prisoner writes a letter to their victim.
The letters are not sent, but are intended to promote understanding of the effect
of their actions on the victim. The cellmate wrote a letter to his victim on 9
August 2008. A report was prepared for Nottinghamshire police by the SOTP
Clinical Lead at the time of the man’s death, reviewing his interaction in the
SOTP course. The Clinical Lead described the letter to his victim as follows:
“This victim letter was a good one; he recognised the harm done to the
victim; he reassured the victim that he was getting help for his
offending behaviour; he recognised the harm done to the victim.
Indeed, this would be a good letter if it was the second victim letter
written by a group member.”
148. The cellmate approached a member of the Sentence Management team on the
12 August because he was concerned that he only had six weeks to complete
his sex offender treatment programme and still did not have a sentence plan.
An email was sent to his probation officer for an update. A Treatment Needs
Analysis was also begun that day, setting out a plan to addressing his offending
behaviour.
149. On 16 August, the cellmate was moved to a double cell on the third landing of B
wing. On 19 August, he was told that he would be having a telephone
conference with his Offender Manager in September.
150. The third VRS document was opened on 20 August by a SO after it was
suspected that the cellmate had “taken advantage of” another prisoner in the
chapel. The SO noted that he had been the subject of another VRS for
“attempted grooming”. The incident was documented in his IEP record, but
there was no corresponding Security Information Report. There is also no
evidence that his cell sharing risk assessment was reviewed on this occasion.
151. In the ongoing VRS document, Officer B recorded that he had a “good lengthy
chat” with the cellmate on the morning of 21 August. He said that they had
31
previously “not seen eye to eye”. He suggested that he might have turned over
“a new leaf”. Later that day, he approached the officer and asked whether he
could have a cellmate because “he is getting a bit stressed on SOTP and would
like the company”.
152. In his statement to the police after the man’s death, Officer B said that he did
not remember the first conversation he recorded with the cellmate. He went on
to say that he “could not recall whether he had such a conversation or not”.
The officer confirmed that he was not personally involved in relocating him into
a shared cell, but just recorded the conversation in the ongoing VRS document.
He told the police that he did not make recommendations about cell sharing but
“may have referred to a [senior officer] verbally that he was asking [to share a
cell]”.
153. An officer recorded a conversation with the cellmate the next morning at
9.30am. He said “he was happy at present, but just wondering when his cell is
being doubled up”. (‘Doubled up’ is an expression for turning a single cell into a
shared cell.) The officer reassured him that it would “probably take place soon”
and recorded that there were “no concerns seen at present”. At 12.15pm, he
added a further entry to the VRS, recording that a prisoner from induction had
moved into the cell. When he asked him about it, he assured him that he had
been wanting to share.
154. Over the next few days, the cellmate was observed associating well with
prisoners. Officer B described him as “his usual social self” and commented in
the VRS document that he “seemed to be getting on well with his new cell
mate”. The officer said he had no concerns at all and the “signs at this time are
very encouraging”. The officer confirmed in his police interview that “he had no
reason to suspect there was a problem between them”. He had a visit from his
family on 24 August, and a further visit was scheduled for the following day,
Bank Holiday Monday 25 August.
Events of the incident
155. The investigator reviewed the CCTV footage of the landing outside the
cellmate’s and the man’s cell in the afternoon and night of the incident. Staff
made statements to police in the days following the man’s death. Three years
later they were interviewed by the investigator. There are differences between
the accounts of staff, the CCTV and the evidence they recalled in interview for
this investigation. The CCTV footage has been set out in tables below,
followed by a summary of statements. There is no suggestion that staff have
been deliberately misleading to the police or the Ombudsman’s investigator.
The difference in accounts is more likely to reflect the traumatic nature of the
events of that night and the protracted nature of this investigation.
Afternoon of the incident
Time Event
3.00pm CCTV footage starts.
32
Cell door open but neither the man nor the cellmate are visible
on the footage.
Two prisoners are in the communal areas in front of the CCTV
camera.
3. 04:51 The man stands in doorway of cell wearing jumper.
3.05:20 The man comes out of the cell and closes the cell door behind
him.
Walks towards the CCTV camera and walks off screen.
Doors stays closed.
3.17:00 The man returns to his cell with a plastic bag.
Opens door and enters cell.
3.17:41 The man leaves the cell and waits in line to get water from the
tap next to his cell.
3.18:00 The man walks away from the water tap with a flask and returns
to his cell.
Door remain open.
3.18:24 The man leaves his cell with a kettle and gets more water.
3.18:49 The man returns to his own cell.
3.19:37 Leaves the cell with his kettle and again seems to go to the tap.
3.19:50 Returned to the cell and cell door remains open.
3.27:26 Door pushes to from the inside.
3.29:01 Door opens from the inside.
3.29:18 The man leaves cell and walks away from the CCTV camera.
He reads the noticeboard carefully.
3.29:49 The man returns to his cell and his door remains open.
4.04:56 The cellmate returns to cell.
4.05:09 Cell door pushes to from the inside.
4.06:35 Door opens from the inside.
The cellmate leaves the cell and the door stays open behind him.
Walks towards the CCTV camera and off camera.
4.07:00 CCTV stops.
4.27:00 CCTV starts again.
4.27:52 The cellmate walks back on camera and into cell.
4.28:22 Male member of staff leans into cell and closes the door.
Member of staff locks the door.
4.31:00 CCTV footage stops.
7.25:00pm CCTV footage resumes.
7.25:47 Female member of staff looks through observation hatch.
8.11:42 Male member of staff looks through observation hatch.
10.59:07 Male member of staff walks onto wing and walks to the other end
of the wing, away from the CCTV camera.
10.59:10 Another officer follows and wanders near the cell, opposite the
man’s cell.
10.59:37 Male member of staff walks off camera.
10.59:50 Other male member of staff walks back down wing corridor and
off camera.
11.01:00 CCTV summary stops.
156. The man spent more time in the cell, but the cellmate occasionally went back to
the cell throughout the afternoon. Both were locked in their cell at 4.28pm.
They were then checked again at 7.25pm by an officer during a roll count. (A
roll count is carried out by officers to check the number of prisoners on the
wing.) She told the police that she could not specifically remember looking
33
through the cell observation panel, but was confident that there was nothing out
of the ordinary at that time.
157. The closed circuit television camera (CCTV) footage showed a member of staff
looking through the observation panel of cell B3 33 at about 8.10pm. An
Operational Support Grade (OSG) 1 said in police statement that this was done
by OSG 2, who was also working on B wing that night. OSG 1 started the night
shift at 8.15pm. In a police statement, he described the duties as “checking on
the vulnerable prisoners, checking basic security and answering the cell
buzzers”. At the time of the man’s death, he explained that he only worked
night shifts and therefore did “not interact with the prisoners, unless [they press]
their cell buzzer”. He said that he did not carry any keys with him throughout
his shift. (It is possible that the OSG was referring to standard prison keys as
all night staff should have cell keys in sealed pouches for use in an
emergency.)
158. According to OSG 2’s police statement, he started his shift at 8.45pm.
However, in interview for this investigation, he clarified that his shift started at
8.45pm but he would often arrive earlier in order to receive a handover from the
staff on evening duty. OSG 1 remembered the other OSG was already in the
central office when he arrived on the wing at 8.15pm and did the roll count. At
the time of his interview, OSG 2 could not remember whether he had
completed the roll check that evening, but if anything had been a matter of
concern, he would have raised it with his manager and recorded it.
159. In line with their duties, both OSGs patrolled the units that make up B wing and
responded to cell buzzers. OSG 2 told the investigator that it was a quiet shift
that evening. He explained that he responded to cell buzzers around the wing
and completed a ‘pegging check’ (a patrol around the wing which is recorded
via electronic points stationed around the wing). At that time, he said that staff
on B wing at night would wait in the central office for cell buzzers to be
activated. The central office was located on a lower floor from the man’s cell,
down two flights of stairs.
160. The CCTV footage showed one male member of staff walking from one end of
the landing to the other at 11.00pm. In the meantime, OSG 2 walked into the
shot of the CCTV camera, and hovered at the end of the wing in the area of the
man and his cellmate’s cell. The investigator asked him if he could remember
hearing anything at that time. He said that he could hear television and parts of
conversations from inside cells. However, on that occasion, he could not
remember hearing anything that concerned him on the B3 landing.
Responding to the cellmate’s cell bell
Time Event
12.31am Two men walk to cell (not visibly carrying radios)
Look through hatch one at a time
12.31:58 Walk back towards the CCTV and off camera together
12.36:15 A man walks to the cell and talks through the observation panel.
34
12.36:50 Man closes the hatch but then reopens and continues to talk.
12.37:00 Another man walked into view towards the man’s cell stopped and
then walked off camera.
Other man remains at observation hatch apparently talking through
the observation hatch.
161. In his police statement, OSG 1 said that at around 12.34am, he responded to a
buzzer activated by someone in cell B3 33. In the statement, he said:
“I came back to the office and turned it off and then made my way to
cell B3 33 where the call had come from. I did not rush as usually it is
not an emergency, so I took a fast walk up the stairs to the cell.”
162. The OSG told the police that he went to the cell alone. OSG 2 remembered
being in the central office when the cell bell sounded. He said that a light
turned on and there is a sound when the cell bell is activated. He recalled
responding to the cell bell and said that OSG 1 followed him to the man’s cell.
OSG 2 estimated that it took about a minute to get from the central office to the
cell, up two flights of stairs.
163. Both OSGs remembered opening the observation panel and seeing the
cellmate’s face close to the window. He said, “I’m hearing voices, I can’t get
them to stop, I think I’m going to do something really bad”. OSG 1 said he
asked him to calm down, but he insisted that he wanted to see the night
manager. Throughout the exchange the OSG said that the cellmate’s face was
pressed up to the glass and he could not see into the cell. He described him as
“very distressed and on edge, his eyes were wide and he was very agitated”.
He assured him that he would get the manager and went to the landing office, a
few doors down from the cell on the same level.
164. In his statement, OSG 1 said that when he left the cell he went to the central
office and contacted the Night Orderly Officer (NOO), who was operationally
managing the prison overnight. He reflected to police that he was “not alarmed
to start with as many of the prisoners suffer from mental health issues”. The
senior officer said that she would be there as soon as she could with the
assistant orderly officer. Once he had spoken to her, he said that he went back
to the cell and continued to talk to the cellmate through the door. He estimated
that this was approximately 12.36am.
165. OSG 2’s recollection was that it was he who contacted the night orderly officer,
via the control room. He said that he then left OSG 1 talking to the cellmate
while he looked for his prison history file stored in the landing office. He
explained to the investigator that he was checking whether he had a history of
mental health problems. He said that he did not get an opportunity to look at
the file before the other OSG called him back to the cell.
166. OSG 1 told police that when he went back to the cell on the second occasion,
he asked the cellmate whether he was “okay”. He replied:
“I’ve done something really bad; I think I’ve killed my cell mate.”
35
167. In his statement, OSG 2 described the cellmate’s voice as “very panicky” and
said that he was pacing around his cell. He said that he had suffocated his cell
mate and confirmed that he was on the top bunk in the locked cell. It was at
that point, that he told his colleague about the claims. OSG 2 went back to the
landing office and telephoned the communications room to “explain what had
been said”.
168. OSG 1 remained at the cell, reassuring the cellmate that he would not be hurt
by staff and trying to help him remain calm. The cellmate asked him to stay
with him, and he continued to comfort him through the observational window.
Eventually, the OSG said that “His eyes were vacant, he was still on edge but
his body seemed quite relaxed. There was no anger in him at all”.
169. OSG 2 told the investigator that OSGs are not qualified to open a prisoner’s cell
at night. He explained that they are not trained in Control and Restraint (the
techniques used by the Prison Service to control refractory prisoners). He said
that they had to wait for their line manager to attend the cell before they door
could be opened. In fact all night staff, including OSGs, are provided with a cell
key in a sealed packet in order that they may enter a cell in the event of an
emergency. Prison Service guidance is that …’because of the security
implications of opening a cell at night when there are only a small number of
staff on duty, all night patrol staff are trained to radio for assistance from the
Night Orderly Officer in the event of discovering an incident. After assistance
has been summoned an operational judgement must be made by the patrolling
officer about whether to enter the cell or await assistance. This will depend
upon the nature of the incident, the circumstances in the cell and the need to
maintain safety and security whilst responding to the incident’.
The arrival of the orderly officer and her assistant
Time Event
12.41:50 Man still talking through obs hatch.
Two men and one woman return to the cell and look through the
panel.
12.42:50 All staff leave the cell locked and unattended.
170. The NOO was in the communications office when she received the OSGs’
messages about the cellmate. After the first message was relayed to her by
the communications OSG, she spoke to her assistant, who was in a
neighbouring office. She told the investigator that it was not unusual to be
called to a cell during a night shift and the reasons for her attending varied
greatly. She explained that even after the first message she treated the call as
urgent, because anything requiring her assistance during a night shift could be
an emergency situation. She did not remember being told that the cellmate had
claimed to kill his cellmate at that point. She told the police that OSG 1
sounded “stressed”, and she assured him that she was on her way with her
assist. (In interview for this investigation, she could not recall whether she
spoke to one of the OSGs directly or via the communications OSG.) The
36
assistant NOO remembered being told by the communications OSG that the
cellmate claimed to have killed his cellmate.
171. The NOO and her assistant made their way “at pace” to B3 landing. She said
that there were several locked doors between the communications department
(located above the staff entrance to the prison) and B wing, and both she and
her assistant carried keys. She said that they are not allowed to run for health
and safety reasons, but walked as quickly as they could. According to the
CCTV footage, nearly five minutes elapsed between OSG 2 walking off camera
towards the landing office and them arriving at the cell.
172. The NOO said in her police statement that when she arrived on the wing with
her assistant, she was told by OSG 1 that “the cellmate had said he was going
to kill him”. She said she understood that as “he was going to kill his cell mate”.
According to the CCTV footage, OSG 2 accompanied them to join OSG 1
outside the cell.
173. Each officer looked through the observation window. The assistant NOO
recalled in interview that the cellmate’s face was against the observation
window. The officer asked him what had happened and when he said he had
killed his cellmate, he said “What?” He told the investigator that he did not think
he had heard correctly. He asked him to move to the back of his cell so that he
could see the man. He said that he wanted to satisfy himself that it was “not a
decoy”. The officer told the police that he could see another man lying on the
top bunk completely covered by a sheet and asked the cellmate to remove it.
At that point he could see his:
“feet, the back of his legs, his bottom, his back and the top of his head,
I watched his feet, they had no colour to them and the male wasn’t
moving at all.”
While Orderly Officer collected additional staff
Time Event
12.43:20 Man returns to cell
12.43:50 Leave cell unattended
12.46:43 Man returns to cell, stays for two seconds and then leaves cell
unattended.
12.47:46 Man goes to the cell next door, closes observation hatch and
walks off camera.
12.48:30 Man walks past cell to the end of the corridor away from the CCTV
camera.
12.49:30 Man walks back to the cell carrying an object – possibly
defibrillator
12.49:50 Man leaves cell unattended.
174. The assistant NOO told the police that he stayed with the cellmate throughout
the time it took for the NOO to collect other staff. The NOO thought she had
asked him to remain at the cell until she returned. In fact, during the nine
minutes it took for two officers to be collected by the NOO, the cellmate was
37
largely left with the man on their own in the cell, unattended by officers. During
interview for this investigation, the assistant NOO was surprised that he had not
stayed with him, as he remembered having a long conversation with him. He
said that he would have had to check that there was an empty cell on the
landing for him to be moved to, in the event that his claims were true. He said
he would therefore have had to go to the landing office and see which cells
were available and then check that cell to make sure.
175. The NOO, in the meantime, contacted the control room to let officers know that
they would be needed for security purposes in advance of her getting to the
wing to collect them. She then walked to A wing and collected two officers and
returned to B wing at about 12.51am, nine minutes after she left B wing.
According to the officers, she was not sure about whether the cellmate had
claimed to kill his cellmate. She told the investigator that she explained to the
two officers why they were needed and the nature of the cellmate’s claims.
176. OSG 2 accompanied the NOO to A wing and was asked to cover officers’
duties on A wing. He therefore remained on A wing once all of the officers had
left. OSG 1 said that he “stood back” once the NOO had arrived, explaining
that as an OSG he was “not allowed to enter cells or deal physically with
prisoners”.
177. The NOO said that they needed five members of staff present to remove him
from his cell due to the cellmate’s “demeanour”. She explained to the
investigator that he seemed intimidating as he was striding around and she
needed to assure herself that her staff and the prison were not at risk before
the door was opened. She therefore required staff who were trained in Control
and Restraint.
Going into the cell
Time Event
12.49:50 Man leaves cell unattended.
12.50:16 One member of staff goes to the man’s cell door and speaks
through the hatch.
12.50:50 Joined by two more members of staff
12.50:57 Joined by two more members of staff
12.52:17 Five members of staff present. Cell door opened. Man walks out
calmly and is searched outside the cell. (The cellmate)
No one enters cell at this point.
12.53:20 Man walks down corridor, accompanied by members of staff.
One male member of staff remains at cell. Leans on door
12.54:16 Male member of staff goes into the cell
12.54:30 Male member of staff leaves cell
12.54:56 Male member of staff and a number of staff members go back into
cell.
12.56:40 Male member of staff picks up object (defibrillator?) from outside
cell.
38
178. At 12.52am, with five members of staff present, the cell door was opened.
Each member of staff recalled events differently in their police statements and
interview. According to the CCTV footage, the cellmate calmly walked out of
the cell and was searched by the assistant NOO. No-one went into the cell at
this point. A minute later he walked down the corridor to the new cell assigned
for him by the assistant NOO. He was accompanied by two officers and the
NOO.
179. The assistant NOO remained at the cell and lent on the door. He told the
investigator that he was trying to get a response from the man. He explained
that he was still not certain that he was dead, and this was not an attempt to
breach the prison’s night security. He shouted at him, but got no response. He
said that he went into the cell with an officer in order to make sure he had
assistance if the man tried to assault him. According to the CCTV footage, he
was alone when he went into the cell at 12.54am. In his police statement, the
officer said that he went into the cell and touched the man’s foot. He told police
“the male was cold and very stiff, there was no response”. In interview for this
investigation, he said he thought it likely that his condition was serious, but was
still unsure. Although he did not recall it in interview, the assistant NOO then
left the cell briefly and returned with an officer.
180. The assistant NOO continued to try and get a response from the man and
eventually he and an officer turned him over. He said that he wanted to move
the man to the floor because he understood that resuscitation is more effective
on a hard surface. However, due to the man’s weight and his position on the
top bunk, he was concerned that he risked losing control of him and causing
him further injury when lowering him to the floor. He decided to check his vital
signs and begin resuscitation on the top bunk. He said he climbed onto the top
bunk, where he lay to look at his face, check whether he was breathing and
check his pulse. He said his skin colour and appearance did not look good.
181. The NOO returned from relocating the cellmate and asked the assistant what
his impression of the man’s condition was. He told her that it was serious and
that the cellmate’s claims of murdering his cellmate may be true. They agreed
that she should contact the communications room to call the police, paramedics
and Duty Governor. She walked to the landing office and instructed the
communications OSG to do so. The assistant NOO started resuscitating the
man, using two breaths to 30 chest compressions (in line with Resuscitation
Council (UK) guidelines).
182. At 12.56am, an officer lent out of the cell and picked up the defibrillator from
where OSG 1 had left it earlier. The assistant NOO set up the defibrillator and
the officer left the cell to take over the log, which had been started by the NOO.
By this time, the NOO had left B wing to escort the paramedics from the gate to
the wing. During this time, the assistant NOO was continuing resuscitation on
his own. Both officers both told the investigator that they offered to help him,
but he refused their assistance. The assistant NOO told the investigator that he
was confident in resuscitation, there was restricted access to the man on the
top bunk of the bed and it would have been awkward for another officer to help
39
him. He was also conscious that he wanted to preserve evidence in the cell in
what was likely to be a crime scene.
183. A paramedic told the police that the ambulance received emergency response
call at 1.09am to attend a possible suffocation at HMP Whatton. No further
details were given. He said they arrived at the prison at 1.22am and a female
prison officer took them to the incident.
184. At 1.23am, the paramedics arrived and went into the cell. They applied their
own defibrillator, while the assistant NOO continued with chest compressions.
The paramedics’ defibrillator confirmed that the man had no heartbeat. In his
police statement, the paramedic said that because the alarm was raised at
12.34am and resuscitation did not start until 1.00am, and there had been no
change in condition in the meantime, the paramedics did not continue to
attempt resuscitation. The man was pronounced dead at 1.35am.
Prisoner support
185. The morning after the man’s death, prisoners were asked to remain in their
cells until the police had completed their evidence gathering procedures. The
cellmate was removed to the segregation unit and remained there until he was
taken into police custody. Once prisoners could leave their cells, staff spoke to
them about the events of the previous night. They were reminded that they
could speak to a Listener and members of the chaplaincy also made their
presence known. All prisoners subject to ACCT monitoring were reviewed to
determine whether their level of risk had been affected by the distressing
events of that night.
Family liaison
186. The man’s mother was listed as his next of kin. As there was to be a police
investigation into the circumstances of the death, the Governor and the family
liaison officer gave the family their contact details and asked them to call them
should they require anything. The police’s family liaison officer took over the
main liaison with the family, to ensure that they were kept up to date with the
progress of the criminal investigation.
Liaison with offender’s family
187. The cellmate’s parents had visited him the day before the murder. They lived
some distance from Whatton and had accumulated visiting orders. They were
due to visit him the day following the incident. They arrived at the prison to visit
their son, but were told that he was not available that morning. They were
asked to wait until someone was available to speak to them about the events of
the previous night.
188. The cellmate’s mother wrote to this office about the length of time that she and
her husband were left to wait in the car park of the visitors’ centre, until
someone came to explain that their son was believed to have killed his
cellmate. Such circumstances are thankfully incredibly rare, but the family
40
suffered real distress at the delay in providing an explanation as to why they
could not visit their son. Given the seriousness of the circumstances, it is more
surprising that they were not told immediately of their son’s situation.
Staff support
189. All staff except one interviewed by investigators said they were well supported
by the management team at Whatton in the aftermath of the man’s death. On
the morning of 25 August, the Governor held a hot debrief (a meeting of all the
staff who were involved in a major incident, which focuses on reassurance,
information sharing and how staff can support each other), which all present
found helpful. Most felt well supported throughout the protracted investigation
process following a homicide in custody except one who did not feel that she
had been supported by the Governor. She said she did not know how to
access staff care and welfare services, although we found that efforts were
made to give her such support.
41
ISSUES
190. The man was murdered by his cellmate in their shared cell. Accordingly, the
investigation examines whether it was reasonable for the cellmate to be sharing
a cell with another prisoner, taking into consideration cell sharing risk
assessments, violence reduction strategy, sharing of security information and
how serious allegations regarding prisoner on prisoner assaults are dealt with
in the prison system. His categorisation and the transfer of information
between prisons may also have had a bearing on the events of that evening
and merit consideration.
191. The cellmate did not comment throughout his interview with the police. He
refused access to his clinical records for the purpose of the Ombudsman’s
investigation. References are made in ACCT documents to his poor
compliance with mental health medication that he was prescribed in the months
before the man’s murder. Had the investigator had access to all of his medical
records, we would have commissioned a clinical review to reflect on whether
his non-compliance with his medication adversely affected his state of mind at
the time of the murder, and whether staff working with him, both on the wing
and on his sex offender treatment programme, were sufficiently aware of his
medical condition.
Should the cellmate have been in a shared cell?
The timeliness of cell sharing risk assessments
192. At the time of the man’s death, instructions about the purpose and operation of
cell sharing risk assessments were contained in Prison Service Order 2750 –
violence reduction. The purpose was set out as follows:
“The purpose of the risk assessment tool remains the same to:
• “draw together information about risk
• make best use of documentary evidence;
• support staff judgement about allocation to cells and risk management;
• record additional operational precautionary measures for a prisoner
identified as a potential risk, where cell sharing is unavoidable;
• provide a record about risk of harm to others as a prisoner moves between
wings/ prisons;
• to enable early identification of racist, homophobic or violent prisoners, to
ensure that other Prison Service procedures to protect potential victims
are followed.”
193. The cell sharing risk assessment system required that a CSRA was carried out
when a prisoner arrived at the prison, and was reviewed either at pre-determine
intervals, or in response to a wing move or other events that may have a
bearing on the assessment of risk that the prisoner posed to others. Some
examples of when a review might be triggered were listed such as ‘repeated or
escalated threats of violence, particularly towards cellmates; discharge from
segregation following violent or threatening behaviour; unexpected conviction
42
or harsh sentence’, but the instruction said that circumstances for triggering a
review were for local judgement. The instruction required prison staff to ensure
that the focus of cell sharing risk assessments – the ‘personal safety of
cellmate’ was maintained.
194. The instruction noted that ‘A prisoner with a history of violence in custody
(situational violence) presents a heightened risk’ and a prisoner ‘who is known
to have armed himself with a weapon whilst in custody should be managed with
extreme care.’ Over the course of his custody, the cellmate had been involved
in repeated incidents. On 1 November 2006, he admitted threatening his
cellmate with a razor blade and forcing him to perform a sexual act.
195. A review of the cellmate’s cell sharing risk assessments demonstrated that risk
reviews were held in response to the examples listed in PSI 32/2005 but it did
not appear that local judgement was used in other cases such as when he was
subject to VRS. There was a concerning lack of records from the six months
he spent at HMP Wymott.
The timeliness of the cellmate’s CSRAs at HMP Wymott
196. As soon as Manchester was notified of the cellmate’s charge of rape, he was
assessed as a high risk to share a cell. Despite monthly reviews in the 15
months he remained at Manchester, he was always considered high risk. On 6
November, he was segregated after allegedly attempting to sexually assault a
prisoner with a weapon. There is no record of whether he left the segregation
unit before his eventual transfer to Wymott on 14 June. What is clear from the
records is that he spent a number of months in the segregation unit following
this alleged assault.
197. On arrival at Wymott on 14 June, the cellmate was assessed as “low/medium
risk”. The apparent lack of a PER for the journey from Manchester to Wymott is
a major omission. The investigator spoke to the Safer Custody Manager about
the CSRA process. She explained that the senior reception officer received a
core file when a prisoner arrives at Wymott and looks through it to determine
ant relevant information for assessing risk to other prisoners. She
acknowledged that there is a time pressure when a prisoner is going through
the reception process. Nevertheless, she was confident that cell sharing risk
assessments were completed effectively. It is difficult to see how this could be
the case if a PER was not used for a new arrival.
198. The Safer Custody Manager told the investigator that a prisoner should not be
assessed as “low/medium” risk. The officer completing the form should have
judged whether that prisoner was “low” or “medium”. She said that she would
expect a cell sharing risk review to be held every three months if such a
judgement was made.
199. The investigator asked the Safer Custody Manager if she was surprised that
the cellmate’s risk had reduced so suddenly from “high” at Manchester, to
“low/medium” at Wymott. She agreed that she would expect a more gradual
reduction in the level of risk. The safer custody manager also explained the
43
reason for any CSRA judgement should be documented on the CSRA form,
especially when there has been such a dramatic reduction in risk. No manager
picked up on the fact that he was assessed as having reduced so suddenly.
There is no formal audit system in place to assess the effectiveness of the first
CSRA judgements.
200. There was no record that the cellmate had any further cell sharing risk
assessments at Wymott. The only indication that his risk was reviewed was
that his PER from Wymott to Whatton on 5 December indicated that he was a
“H [igh] CSRA”. While at Wymott, he was accused of grooming other
offenders, kept separate from vulnerable prisoners due to an unspecified
security risk and segregated. However, the investigator has not seen any
evidence of further cell sharing risk assessments, despite her requests and
these obvious triggers such as the security file entry on 12 July 2007 which
recorded concerns at Manchester about his alleged rape of another prisoner
and his urges to cut a staff member’s throat.
201. The lack of cell sharing risk reviews may have had a serious impact on the
subsequent assessment of the cellmate’s risk. It demonstrates that staff at
Wymott did not consider re-assessing his risk in light of the allegations of
grooming on the induction wing and the unspecified security threat he posed to
other prisoners on the vulnerable unit.
202. As the cell sharing risk assessment was noted as ‘High’ on the PER, on his
transfer from Wymott it is possible that reviews were conducted but not
appropriately filed with the cellmate’s records. Not only has that resulted in a
compromised audit trail for this investigation, but also undermined the
information available for those making subsequent assessments. The apparent
lack of a CSRA on transfer from Manchester is likely directly to have led to an
inaccurate assessment.
The cellmate’s CSRAs at HMP Whatton
203. The cellmate arrived at Whatton on 5 December, with a PER that noted his
“CSRA H” (‘H’ indicating High). The CSRA completed on 5 December by
reception staff at Whatton assessed that he presented a “low” risk to other
prisoners. The sparsely completed form suggested that there was “insufficient
information” to give a medical opinion about the risk that he presented, despite
having two years of custodial records. As a result of this judgement, he soon
found himself located in a dormitory cell with two other prisoners.
The governors of HMP Wymott and HMP Whatton should ensure that all
initial cell sharing risk assessments are based on information contained
in a person escort record (PER) and security and other information
available at the time of a prisoner’s arrival.
204. Once the security information was finally acted upon in January 2008, the
cellmate’s CSRA was reviewed to reflect that he presented a high risk to other
prisoners on the basis of his past behaviour in custody: his history of alleged
assault. In the light of serious security information, a cell sharing risk review
44
was appropriately triggered and his risk to other prisoners was appropriately
identified as high.
205. On 11 February 2008, a SO revisited this assessment. He recorded:
“[The cellmate] accepts that his history could be seen as a potential
risk but he has been sharing cells without any problems for over a
year.”
On the basis of his self report that he had been sharing a cell for over a year,
the SO adjusted his CSRA to reflect that he posed a medium risk to other
prisoners but this information was inaccurate and should not have been relied
on.
206. The cellmate’s CSRA was revisited when he moved cells or wings. It was
reviewed when he was put on the first two of his VRS documents. However,
when the third of the documents was opened on 20 August, no cell sharing risk
review was held. Whatton’s own VRS policy recognises the important link
between allegations of bullying and risk to other prisoners.
The Governor of HMP Whatton should ensure that staff review cell
sharing risk assessments when a VRS document is opened.
Were there indications that the cellmate was a risk to other prisoners?
207. When reviewing the risk a prisoner posed to others, officers were asked to
consider a certain set of questions. Below we have created a table listing those
questions, how they applied to the cellmate, where the evidence was recorded
in his file and any actions taken by staff as a result of the information. This
evidence was not taken from his cell sharing risk reviews.
Question Evidence in the Where recorded Actions taken at
cellmate’s file Whatton
Has there been The cellmate had been Security Incident The cellmate’s security
any new accused of raping Reports, Security File, record was discussed
information to another prisoner on a Adjudication Records, at the Safeguarding
link the previous sentence and ACCT documents, meeting, but no action
prisoner with had admitted to holding Safeguarding Meeting was taken. This was
violent another prisoner minutes, Cell sharing picked up in the next
offences? hostage with a razor risk assessments at meeting; his CSRA
blade on his current Whatton. was reviewed to high.
sentence.
Has the The cellmate’s three Violence Reduction The cellmate was
prisoner Violence Reduction records subject to Level One or
displayed any Strategy Documents Two monitoring three
homophobic were opened as a times as a result of
or racist result of his interaction allegations of
behaviour? with other gay inappropriate
prisoners but there was behaviour to other
no evidence he was homosexual prisoners.
homophobic. There There is no evidence
was evidence of sexual that this information
45
harassment and anti- was passed on to the
social behaviour. sex offender treatment
programme facilitators.
Has the The cellmate had been Security Incident The cellmate’s security
prisoner accused of two serious Reports, Security File, record was discussed
displayed any sexual assaults against Adjudication records, at the Safeguarding
anti-social other prisoners, and ACCT documents, meeting, but no action
behaviour, was subject to Violence Safeguarding meeting was taken. This was
bullying, Reduction Strategy minutes, Cell sharing picked up in the next
threats, Documents on three risk assessments, meeting; his CSRA
damage to occasions because of Violence Reduction was reviewed to high.
property, inappropriate records. He was subject to
aggression, behaviour to other Level One monitoring
hate-motivated prisoners. three times as a result
behaviour, of allegations of
assaults? inappropriate
behaviour to other
homosexual prisoners.
There is no evidence
that this information
was passed on to the
sex offender treatment
programme facilitators.
Is there a When he arrived in Prisoner Escort Recorded in Security
reason to custody, he was Records – including file, in-possession
suspect that assessed as having that on 5 December medication status
the prisoner is substance misuse when transferred to reviewed and ACCT
abusing drugs/ needs and it is Whatton, ACCT opened.
alcohol? indicated he was document, OASys,
referred to the Security file, ACCT
substance misuse documents.
team.
In December 2007 the
cellmate was
suspected of dealing
medication on the wing
while just after his
arrival at Whatton,
In January 2008, he
told staff that he had
taken 20 tablets and he
was no longer able to
have medication in
possession.
Does the The cellmate was ACCT documents, ACCT documents
prisoner have subject to nine ACCT Wing History Sheets opened at time of high
a history of documents while in risk, in possession
self-harm? custody on this medication was
occasion. He was revised, no evidence of
described as a “prolific input from sex offender
self-harmer” by officers treatment facilitators,
at Whatton. mental health team or
other healthcare staff
into ACCT document.
Does the The cellmate had been Security File, Wing Security Information
security accused of raping History Records Reports were raised
46
department another prisoner on a and recorded by the
have any previous sentence and security department but
information had admitted to holding evidence that wing staff
that may affect another prisoner were not aware of the
the risk hostage with a razor serious allegations
assessment – blade on his current made against him.
eg evidence of sentence. Violence Reduction
a weapon? He was suspected of Strategy Documents
grooming prisoners at were opened, but no
Wymott and his evidence that sex
inappropriate offender treatment
behaviour towards programme facilitators
other homosexual were informed or
prisoners was recorded contributed to process.
in his security file.
Does the No access to mental OASys, Prisoner No evidence of
Health Care health records, Escort Records, information sharing
team have any although other records Sentence Management between the mental
information indicate that he had documents health team and the
that may affect been diagnosed with sex offender treatment
the risk schizophrenia, was facilitators or wing staff.
assessment? taking medication that
transferred with him
between prisons, and
was in contact with the
Inreach team at the
time he was taking the
sex offender treatment
programme.
208. There were several occasions when staff were concerned about the cellmate’s
behaviour. There was sufficient information in his records to indicate that he
posed a risk to other prisoners and should not have been in a shared cell. The
information was recorded, although not all staff had access to all information.
209. On 11 February 2008, a SO judged that the cellmate’s risk had decreased. He
described the reason for that judgement as his behaviour over the previous
year. On 23 June, his cell sharing risk was reviewed and revised to low. A SO
recorded that his behaviour for the preceding three years gave him no cause to
believe he was a risk to other prisoners.
210. The previous CSRA system allowed decisions to be based on the behaviour of
an individual, taking into account all of the relevant information. In the
cellmate’s case extremely risky decisions were taken at a relatively low level
without reference to offender management assessments and other relevant
information about risk.
211. Subsequent to this tragic killing at Whatton the guidance on cell sharing risk
assessments has been revised. The new PSI 09/2011, sets out that prisoners
can only be assessed as ‘high’ or ‘standard’ risk to other prisoners. It also
recognises that there are circumstances when prisoners can be described as
“mandatory high risk prisoners”, as follows:
• Murder or manslaughter of another prisoner
• Assisting in the suicide of another prisoner
47
• Committing a life threatening assault on another prisoner
• Raping or committing a serious sexual assault on an adult victim of the
same sex. For Young People only (aged 15 – 17) the victim may be any
age and either male or female.
212. Although it does recognise that these risks can be subject to review:
“Decisions on when it might be safe to reduce the risk rating of these
prisoners to standard risk should be taken in the future based on
evidenced reduction of risk in all other risk areas from offender
management assessment.”
213. In the PSI, great emphasis is placed on the information available from the
police national computer (PNC) and the prisoner’s adjudication history.
However, those deciding whether a prisoner can safely share a cell are
required to ensure that :
“All information relevant to cell sharing risk held in NOMIS must be
used to carry out initial assessments and reviews.”
214. The cellmate had been convicted of the rape of an adult male. He would have
therefore met the requirements to be considered a mandatory high risk prisoner
under the new PSI. It is to be hoped that in future prisons will not reduce the
risk of such prisoners lightly without full information about the risk posed.
Nevertheless it is apparent that there were a series of failures in the
management of his risk assessments which ultimately failed to protect the man.
In the light of the failings at Wymott and Whatton to identify and review
risk appropriately, cell sharing risk assessments at all prisons should be
regularly checked by managers to ensure that they effectively identify
prisoners’ risks to others.
Should a prisoner convicted of a sexual offence share a cell?
215. In a letter to the then Justice Secretary, the Whatton IMB at were concerned
that any prisoner who had been convicted of a sexual offence should be
sharing a cell. At the time of the last inspection in 2010, sexual offending was
recorded as the main offence of nearly 92 per cent of the population at
Whatton. All of the prisoners were assessed as Category C or lower, so were
not the highest security risk. In her meeting with the investigator, the Governor
was confident that prisoners there could safely share cells, particularly with the
new cell sharing risk assessment.
216. As described by the instructions set out above, a prisoner’s index offence is
only part of the information that is considered when assessing their suitability to
share a cell. The type of sexual offence varies greatly and so therefore does
the associated risk. Those who have committed a sexual offence against a
victim of the same gender will now be considered a “mandatory high risk
prisoner”. However, it is not possible to determine that in all cases someone is
48
not safe to share a cell, solely because they have been convicted of a sexual
offence.
Should someone undertaking the SOTP share a cell?
217. When asked whether someone undertaking the sex offender treatment
programme should share a cell, the Clinical Lead of the SOTP at Whatton,
explained:
“It is discouraged unless of course there is a specific reason that we
would want them to share a cell, you know if they needed the extra
support. The main reason it is discouraged is because, is actually less
about threat to other prisoners, more about the homework and the out
of session reflection that might go on and needing that private space to
do those things.”
218. The cellmate asked to share a cell for additional support. His first request was
turned down on 14 July, because of “recent allegations” which resulted in a
VRS being opened. However, the VRS was closed on 23 July and he was
subsequently moved into a dormitory on 4 August with two other prisoners.
Despite having another VRS document opened on 20 August, his CSRA
remained assessed as low and he continued to share a cell.
219. The Clinical Lead recognised that prisoners undertaking SOTP may get
additional support from a cellmate, however, there is no record that SOTP
facilitators were consulted about his request. The Clinical Lead for SOTP
described “pressure points” in the SOTP course when some individuals might
struggle to cope with the demands of the course. One such pressure point was
when dealing with victim awareness, the stage that the cellmate had arrived at
with his SOTP group. Consultation with the SOTP facilitators would have
informed wing staff that he was undergoing a stressful part of the course.
SOTP facilitators would also have been aware of the VRS document being
opened.
Allegations of sexual assault
220. Two weeks after the cellmate arrived at HMP Manchester convicted of driving
and other offences, he was charged with the rape of an adult male in the
community. On 1 April, three and a half weeks later, another prisoner alleged
that he was raped by him in the showers in December 2005, while he was there
on a previous sentence.
221. An adjudication was opened, but was adjourned because the allegation had
“been referred to the police for further investigation which is currently pending”.
He remained on a residential wing, but was assessed as a high risk prisoner
and located in a single cell awaiting the outcome of the criminal investigation.
In July 2007, a year and four months after the allegation, the police concluded
that there was insufficient evidence to proceed. By this time, the cellmate had
been transferred to HMP Wymott. His adjudication was never revisited.
49
222. While police were still considering the first allegation, the cellmate was accused
of holding another prisoner hostage with a razor blade and trying to make him
perform a sexual act. Again, an adjudication was opened and “adjourned for
police action”. The investigator has not seen a record of the adjudication, but
reference is made to adjourned adjudication in his ongoing ACCT record.
There is no record that the matter was referred to the police, so it has not been
possible to confirm whether there was a criminal investigation following this
incident. Again, his adjudication was never revisited.
223. PSO 2000 – Adjudications set out the requirements for prisons dealing with
prisoners who are alleged to have offended against prison discipline. (The
guidance is now in PS1 47/2011.) The PSO instructs that “any serious criminal
offence … should be reported immediately to the Governor” who will decide
whether the matter is referred to the police. Regardless of that decision, a
“disciplinary charge must nevertheless be made within 48 hours of the
discovery of the alleged offence”. The PSO mandates that the adjudication
must be adjourned “pending the outcome of the police investigation”. From the
evidence available, it seems that a disciplinary charge was laid against the
cellmate within 48 hours of an allegation of sexual assault both in April 2006
and in November 2006.
224. Where the police or the Crown Prosecution Service decide there is insufficient
evidence to proceed to charge the prisoner with the alleged offence, and “the
disciplinary charge is similar to and relies on the same evidence as the
potential prosecution”, PSO 2000 instructs that “the adjudicator must dismiss
the disciplinary charge”. Although there need not be a hearing for this, the PSO
suggests that the prisoner must be told of the outcome of the adjudication and
the adjudication record should be updated. Although the police decided not to
proceed with the investigation relating to the allegations in April 2006, there
was no record that the cellmate was told of the outcome of the adjudication and
the record of his hearing was not updated.
225. It took the police and Crown Prosecution Service 16 months to reach a decision
about the alleged rape in December 2005. PSO 2000 recognises that
“unjustifiable delay” in adjudication processes could prevent a fair hearing. The
order suggests, “It may therefore be necessary for the Governor or Director to
press the Crown Prosecution Service for a rapid response as to the outcome of
any trial or decision on their part”. From the evidence available, it is not
possible to determine whether the delay in reaching a decision in this case was
justifiable or otherwise, or if the Governor did press for a speedy decision.
226. There was also no formal record of the outcome of the criminal investigation
relating to the first allegation. When considering the second allegation made
against the cellmate, an officer recorded that the first allegation was not being
pursued due to lack of evidence, but this reference is before the police have
made the decision. There is also no evidence that the associated adjudication
was formally dismissed. The allegation remained unresolved on his records.
227. While the incident on 1 November is well-documented in the cellmate’s files,
there is almost no information about the resultant adjudication or referral to the
50
police. At an ACCT case review, he admitted that he was “shocked that he
does not have control over the other side of his behaviour”. Despite this
acknowledgement on his part, there is no evidence that the matter was referred
to the police. The police liaison officer at Manchester reviewed his record at
the investigator’s request and has no record of any such incident. The
adjudication remained adjourned and the matter was never dealt with. The
allegation remained unproven on his security file.
228. It is a matter of concern that such a serious allegation was not followed up by
either a criminal investigation or a full adjudication hearing.
The Governor of HMP Manchester should ensure that the progress of
disciplinary charges which are referred to the police are monitored
regularly, relevant parties including prisoners are kept informed and that
the outcome is clearly recorded.
Categorisation
229. The cellmate arrived at Manchester charged with a driving offence. He was
assessed as a Category C prisoner, but by this time he was charged with
raping a man. He remained at Manchester and after he was convicted of rape
and sentenced on 12 April, his categorisation had to be determined again.
230. The SO, who signed off the categorisation decision, explained to the
investigator that this was not a review of the cellmate’s categorisation because
he was newly sentenced. If a prisoner’s categorisation is reviewed
contributions from other departments, for example education and security, must
be considered and it must be signed off by a governor grade member of staff.
However, the initial allocation of a prisoner after sentencing requires the
completion of an ICA1 form which only takes into account a prisoner’s pre-
convictions, offence and length of sentence and needs to be signed off by a
senior officer.
231. The first part of the ICA1 form, the provisional categorisation, which is an
algorithm to determine a prisoner’s category. Officer A noted that the cellmate
was charged with a sex offence, had failed to surrender and breached bail on
previous occasions. There were no outstanding charges noted and he was
assessed as a Category C prisoner.
232. A SO told the investigator that the ICA1 form is completed with access only to a
prisoner’s pre-convictions. Security information would not normally be
considered and neither would other information from the prisoner’s files. When
the investigator asked whether the SO would have expected the two serious
allegations of sexual assault made against the cellmate by other prisoners to be
included on the form, he said he would not. The SO explained that, as neither
of the charges had been proven, either by the police of through adjudication, it
would have been “prejudicial” to have considered tem as part of the
categorisation process.
51
233. Manchester’s Head of Residence, Governor Gregory, took a different view. He
understood that it was a mandatory requirement for a prisoner’s core record to
be consulted when determining that prisoner’s category. He said that if Officer
A had been aware of the two allegations of sexual assault against prisoners, he
should have taken them into consideration, despite neither allegation being
proven. He said that he believed if had been aware of the facts in such a case
he would have made a recommendation to upgrade.
234. The cellmate was not charged with either alleged assault by the police and had
not been subject to an adjudication by the prison on the matters. The officer
and senior officer had understandable concerns about prejudicing his sentence
progression based on the allegations. However, the Governor’s view that
security intelligence needs to be considered as apart of the categorisation
process is appropriate and an expected part of the categorisation procedures.
The Governor of HMP Manchester should ensure that initial
categorisation decisions take into account all relevant information.
Use of security information
Initial identification of risk at Whatton
235. On arrival at Whatton both the man and his cellmate were assessed as a low
risk to other prisoners despite the cellmate’s PER indicating that he was a high
risk and the serious allegations of sexual assault recorded on his security file.
236. Soon after his arrival on 5 December a Safeguarding Children meeting
discussed the cellmate’s case. The Head of Security at Whatton explained to
the investigator that there were two meetings at the time, run alternately, the
Safeguarding Children meeting and the Interdepartmental Risk Management
Team (IRMT). Staff at either meeting should have picked up and acted on the
information from his security record. The Safeguarding Children meeting that
took place in December discussed the allegations made about him assaulting
other prisoners, but failed to take any action. He continued to be considered a
low risk to other prisoners, until the security information was reconsidered by
IRMT and his risk was raised on 8 January.
237. Since 2008, the Safeguarding Children meeting and the IRMT meeting have
been combined and are held fortnightly. The Head of Security told the
investigator in interview that he was confident that such security information
would not have been overlooked as it was in December 2007. However, he
said that there was still work to do in disseminating risk information to staff on
the wing.
238. The cellmate’s personal officer told the investigator that he understood that he
was undertaking the sex offender treatment programme and was struggling
with it. He knew that he had been made subject to several violence reduction
strategy documents. However, he said he did not know, and routinely would
not know, the nature of his index offence. Neither was he aware that he had
allegedly assaulted two prisoners while in custody at another prison. He said
52
that he considered such information would have been relevant when trying to
manage him on the wing.
Sex Offender Treatment Programme facilitator’s knowledge of security
information
239. The Clinical Lead of the SOTP at Whatton at the time of the investigation told
the investigator that she was not confident that her team would always be
aware of significant security information regarding prisoners partaking in their
programme. She acknowledged that some information is shared with her
department from the security team, but believed that there was still room for
improvement.
240. The Clinical Lead told the investigator that security information is key for SOTP
facilitators to recognise behaviours that should be addressed as part of the
course. She also felt that SOTP facilitators should contribute to the
assessment of a prisoner’s risk while they participate in the course. She
explained that there are particularly difficult phases in the SOTP courses,
known as “pressure points, and prisoners’ behaviour can be affected at such
time. They might present a higher risk.
The Governor at HMP Whatton should ensure that the Interdepartmental
Risk Management Team appropriately identifies security risks posed by
individual prisoners, acts on the information without delay and that all
key security and risk information is shared with those who need to know
including staff delivering offender behaviour programmes.
The Emergency Response
Responding to the cell bell
241. OSG 2 could not specifically remember the start of his shift on 24 August. OSG
1 recalled that his colleague had carried out the roll count by 8.45pm, when he
arrived for duty and reported to the central office. OSG 2 could not recall
looking into the man’s and his cellmate’s cell, but told the investigator that he
would have raised the alarm if he had seen anything suspicious.
242. OSG 2 told the investigator that it was a quiet shift. He was not called to cell
B3 33 to his recollection throughout the evening. At 12.31am, the CCTV
footage showed both OSGs going to cell B3 33. OSG 2 remembered being in
the office at the time that the cell bell was activated. OSG 1 told the police that
he had just returned from another cell, and immediately left the staff office
again. He said that he did not rush to the cell. The central office where the two
OSGs were based was on another floor, and OSG 2 estimated that it took them
a minute to get to the cell. The footage showed both officers standing at the
cell for less than a minute and then, looking through the observation panel and
then walking back towards the direction they came.
243. The man’s family were concerned that staff did not respond to the cellmate’s
cell bell quickly. The OSGs were based in the staff office. When a cell bell is
53
rung, staff are alerted by a light indicator and an alarm in the central office,
which does not stop until a member of staff deactivates it outside the cell where
the bell was activated. The OSGs made their way directly to the cell, and could
be seen to spend a minute talking through the observation panel.
244. The CCTV footage gathered by the police did not cover the central office, or
other areas of the wing. The footage available to the investigator showed the
two officers walking directly to the cell together. During the investigation, staff
demonstrated the cell bell system to the investigator. The alarm and the light
were clear, persistent indicators that were difficult to ignore and there is no
evidence that there was undue delay in responding to the bell.
Opening the cell
245. PSO 2710 – follow up to deaths in custody, advises that, “if the apparent death
has taken place in a cell, the first person on scene must enter the cell as soon
as possible”.
246. According to their statements, the cellmate did not tell the OSGs what he had
done when he first called them to the cell, but said that he needed to see the
night orderly officer. (He did not make any comment in his statement to the
police.) Four minutes after the OSGs left the cell, OSG 1 walked back to the
cell and spoke through the observation panel. It was at this point (he told the
police) that the cellmate said that he had killed his cellmate. The NOO arrived
at the cell five minutes after he made this statement.
247. According to the National Security Framework (since overtaken by PSI
24/2011):
‘Under normal circumstances, authority to unlock a cell at night must
be given by the Night Orderly Officer (NOO) and no cell will be opened
unless a minimum of two/three (subject to local risk assessment
procedures) members of staff are present one of whom should be the
NOO.’
Guidance to staff clarifies that:
‘Staff have a duty of care to prisoners, to themselves and to other staff.
The preservation of life must take precedence over the directions….
above. Where there is, or appears to be, immediate danger to life,
then cells may be unlocked without the authority of the NOO (but
subject to the conditions set out in 5.19 below) and an individual
member of staff may enter the cell on their own. However, night staff
should not take action that they feel would put themselves or others in
unnecessary danger.’
248. The NOO said that she was in the security department when she received a
telephone call from the Communications Room. She said she was initially
advised that a prisoner was hearing voices and she was required to attend.
She recalled receiving a second telephone call, advising her that the situation
54
was urgent and she needed to get to B wing quickly. She asked her assistant
NOO to accompany her and they “proceeded with haste” to B wing. She told
the investigator that staff are “not allowed to run”, possibly for health and safety
reasons. In the meantime, OSG 1 had remained with the cellmate since he
said he had killed his cellmate. At the time he described him as ‘still on edge
but his body seemed quite relaxed. There was no anger in him at all’.
249. Once she arrived on the wing, the NOO and her assistant joined OSG 1 at the
observation panel. The NOO spoke to the cellmate through the panel. She
recalled that he was “pacing” and “quite frightening”.’ The officers and OSG
stayed at the cell for a minute and then the observation panel was closed and
they all left them alone in the cell.
250. Over the next eight minutes, the NOO went to another wing to collect two
officers. She said she had to ensure that she had sufficient staff to meet the
requirements of the local security strategy before the cell could be opened at
night. She explained that, although there were already four members of staff at
the cell when she first arrived on the wing, two were OSGs, who she described
as “non operational”. She said:
“ … they’re not supposed to have prisoner contact. Normally they’ll just
be patrolling and wouldn’t actually come into contact with prisoners,
other than perhaps through a cell door …’
251. The local security strategy does not specify the grades required to attend a cell
at night, before it can be unlocked. The requirements of an OSG are set out in
PSI 42/1997. While they are not strictly non-prisoner contact roles, they are not
routinely trained in Control and Restraint, the techniques used to physically
manage fractious or violent prisoners, when the situation cannot be de-
escalated through verbal reasoning. Nevertheless contrary to what the OSGs
said all such staff at night are issued with cell keys in a sealed pouch to open a
cell door in an emergency. It is a matter of concern that the OSGs appeared
not to be aware of this.
252. The NOO had to judge whether the situation was sufficiently serious as to
require officers trained to handle a violent prisoner. The cellmate had claimed
to kill his cellmate. He was in a shared cell. All of the officers and OSGs told
police or the investigation team that they did not have a clear enough view to
determine the man’s condition. The NOO could not have reasonably ruled out
the possibility that the man and his cellmate posed a threat to the security of
the prison. It is reasonable that she sought assistance from other officers in the
prison who were trained to deal with potentially dangerous prisoners.
Leaving the cell unattended
253. From the moment staff left, until the orderly officer returned eight minutes later,
the cell was checked twice, once for thirty seconds and once for two seconds.
The rest of the time, the cellmate and the man were left alone. When asked by
the investigator whether she had asked anyone to remain at the cell, the NOO
said:
55
“I think so, yes, but I can’t be 100% sure; but I am pretty sure that that
would have been the case, yes.”
254. The assistant NOO told the police that he remained at the cell talking to the
cellmate while the NOO left the wing. When the investigator asked him
whether he remained with him during that time, he responded:
“And I can’t exactly remember whether I stayed. I thought I’d stayed
with him, talking to him all the time. But if the CCTV footage shows I
didn’t, I didn’t.”
255. Incidents like this are extremely rare and there is a scarcity of guidance to staff
determining how they should respond. Although there are no requirements or
instructions, staff should have remained with the cellmate while the NOO left
the wing. While it was reasonable to delay opening the cell until more
appropriately trained staff were present, his claims were of such a serious
nature that ongoing monitoring was necessary, to determine the veracity of the
claims and manage any possible risk to safety or security.
Emergency response for the man
256. The NOO had ensured that sufficient staff were available to open the cell
safely. On leaving the cell the cellmate was compliant and did not pose any
threat and control and restraint techniques were not required. Nevertheless, it
took nearly two minutes after that for the assistant NOO to enter the cell and
check the man’s vital signs. He was alone at the cell when he entered. On the
CCTV footage, he clearly leans against the door for some time before finally
going into the cell. He explained why he did not go straight into the cell:
“I was like shouting his name and I was seeing if he’d respond. I didn’t
know whether he was going to still jump up or what; I don’t know why I
had that fixed in my mind. I just thought they’re messing about, I really
did think they were messing about.”
257. When asked during interview why staff did not go into the cell as soon as the
door was opened, the NOO explained:
“From memory everything was dealt with as quickly as possible. But
we just wanted to get the cellmate out of that cell and out of that
environment so the man could be tended to due to the state of [the
cellmate’s] mind and his demeanour.”
258. Despite his concern for security, the assistant NOO was not accompanied by
anyone when going into the cell and there was no one outside to assist him.
Neither did he enter the cell straight away to check the man’s vital signs and
begin resuscitation. None of the team that had gathered to open the cell safely
remained with him to manage the possible security risk or assist with the
emergency as it unfolded. As a result, valuable minutes were lost before the
man’s condition was confirmed and resuscitation begun. It is important for such
56
emergencies that there are always first aid trained staff on duty at night and the
Governor of Whatton has assured us that to ensure this is the case all night
orderly officers are first aid trained and that this was the case in 2008.
259. An ambulance was called once the assistant NOO had started resuscitation
efforts. The NOO explained that she did not request an ambulance earlier than
that because “we still had to rule out that it wasn’t a decoy or a hostage
situation”. The senior officer told the investigator that to call an ambulance
earlier could have undermined “the safety of the prisoners in the cell, the safety
of staff, and the security of the prison in general”. She said that she wanted to
be absolutely “clear of the situation and what I was dealing with to relay a
message to the Ambulance Service as to why they need to come in”.
260. The Prison Service and the Health Service have subsequently reinforced the
guidance in such situations. In a letter written jointly to all prison Governors
and Primary Care Trusts by the Director of Offender Health and the Director of
NOMS, dated 17 February 2011:
“Where there are concerns about the immediate health of a prisoner an
ambulance should be called without waiting for healthcare staff to
attend the scene. A follow up call can be made to cancel the request if
healthcare arrive and deem it unnecessary for an ambulance to
respond.”
261. The NOO was also under pressure because of the number of staff on duty at
night at Whatton. To have arranged for an ambulance to be effectively
accompanied from the entrance of the prison to B wing would have taken at
least one or two staff, and she required several to attend the cell before it could
be opened.
262. Nevertheless, an ambulance should have been called as soon as the man’s
health was in doubt. Despite there not being complete clarity about the
situation the NOO, or any other member of staff on duty, should have judged an
ambulance was needed as soon as the nature of the emergency became
apparent.
The Governor of HMP Whatton should ensure that all grades of staff
working at night understand the night procedures and their respective
responsibilities in an emergency including the need for constant
monitoring of emergency situations and the need to call an ambulance
immediately if there are urgent concerns about a prisoner’s health.
Measures for the cellmate
263. When the cell was finally opened, the cellmate was brought out of the cell,
searched and then relocated to another, empty cell. The NOO explained that
she and an officer removed all of the obvious ligature points from the cell
because, “if someone’s capable of doing something like that, then you’ve got to
question their state of mind”. Once he was in the cell, an officer was stationed
outside to monitor him.
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264. The Duty Governor requested that the cellmate was moved to the segregation
unit. From here he was taken by police into their custody for questioning.
Ultimately, he was moved into the Close Supervision Centre, at HMP Woodhill,
a national resource used to manage the most disruptive prisoners. The
management of his risk on that evening was appropriate.
Night time staffing levels at Whatton and on B wing
265. The man’s family were concerned that the cellmate’s supervision was
compromised by low staffing levels on B wing. The investigator reviewed
CCTV footage of the landing on the afternoon of the incident. Staff were visible
on the landing and could be seen interacting with prisoners, but the
Inspectorate commented in the 2007 report that staff did not always patrol
landings during association. There was also some concern in 2007 that there
had been an influx of new staff, many of whom had never previously worked
with sex offenders and lacked understanding of working with sex offenders and
the need to support treatment interventions. In the 2010 inspection they found
better levels of engagement and that staff interaction on B wing was particularly
good. None of the prisoners interviewed by police suggested that staff were
insufficiently present on the wing to pick up on the cellmate’s comments that
afternoon. Instead, they suggested that he spoke to other prisoners only.
266. The Head of Security at Whatton explained that staffing levels were risk
assessed, although it was not his responsibility to carry out the risk
assessment. When the investigator fed back to the Governor about the family’s
concern about staffing, she was confident that the staffing levels met the
minimum requirement and the needs of the prison population.
267. When asking for further information about staffing levels on B wing, the
investigator was provided with a document entitled, “HMP Whatton Placement
of Night Staff”, dated 7 September 2011. The document recorded that there
were 12 Operational Support Grades on the wings at night, and a minimum of
four officers in the prison. B wing was required to have a minimum of one
officer and one OSG, although according to a note at the end of the document,
“B wing has a minimum of an OSG and an Officer and any spare staff are
allocated to this wing by the [Night Orderly Officer – responsible for managing
the prison]. At the time of the man’s death there were only two OSGs on B
wing and we were informed that the increase to include officer presence was as
a direct result of his death.
268. The Governor is confident that her staffing levels meet the minimum
requirement set out by NOMS. However, it is a matter of concern that on the
night of the incident the orderly officer had to choose between managing the
threat that the cellmate posed to security and calling an ambulance to preserve
the man’s life.
269. It was not clear from the records whether the cellmate was transferred directly
from the segregation unit (where he was held following the serious sexual
assault on another prisoner on 1 November 2006), or whether he was
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transferred from the healthcare centre at Manchester. The significance of
these details are heightened by the apparent aberration in the cell sharing risk
assessment when he arrived at Wymott.
Family liaison
270. The annex to PSO 2710 – follow up to deaths in custody outlines guidance for
family liaison in the event of a death in custody. This guidance suggests that
“face to face notification is best” and “notification by the prison is best”. The
news of the man’s death was broken to his family by the police. Given the
extremely rare event of a homicide in prison, and the role of the police in the
subsequent investigation, it was appropriate for them to take the leading role in
family liaison. When the investigator and family liaison officer from this office
met the family, they had no complaint about the liaison from the prison. They
recalled that the Governor had visited them following his death. They had no
complaints about the prison’s dealings with them. The family understood why
the police took the leading role in family liaison, given the criminal investigation.
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CONCLUSION
271. The cellmate had allegedly sexually assaulted prisoners on two previous
occasions. He had been convicted of the rape of an adult male two years
before the man’s death. There were concerns that he was ‘grooming’ other
prisoners at Wymott. He was the subject of three Violence Reduction Strategy
documents, due to his inappropriate behaviour to other prisoners at Whatton,
the last of which was open at the time he murdered the man. Given the
security information available in his files, he should have been considered a risk
to other prisoners and not been sharing a cell. The lack of action on these
indicators of risk meant that there was a failure to protect the man.
272. At Manchester prison the cellmate was considered such a risk that he was held
separately in the segregation unit yet he was categorised as C and sent to
Wymott. At Wymott where he was considered too risky to go to the vulnerable
prisoner side of the prison where most sex offenders are held and could not
therefore take part in the sex offender treatment programme. Despite this
concern unaccountably his cell sharing risk assessment was reduced at
Wymott. Even more concerning is that Wymott then transferred him to Whatton
a category C prisoners for sex offenders. It is inexplicable why he was
considered suitable for Whatton when Wymott regarded him as too high a risk
to live with other sex offenders there. At no stage does anyone seem to have
considered whether he was appropriately categorised. When he transferred
from Wymott his PER indicated that he was a high risk for cell sharing.
273. Despite this information the cellmate was assessed as a low risk in August
2008. Under the new cell sharing risk assessment procedures, he would have
been considered a “mandatory high risk prisoner” which indicates there has
been some change since the man’s death, although most of the failures in this
case were the result of practice rather than poor guidance. Lessons should be
learned in the effective communication of security information to inform the
management of risky prisoners and to ensure that such information is acted on.
274. In the early hours of 25 August, staff responded quickly to the cellmate’s initial
emergency call. However, too much time elapsed before the cell was opened
and the man’s condition was assessed and the emergency services called.
Homicides in prison are thankfully rare, but the preservation of life in any
emergency should be a priority.
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RECOMMENDATIONS
National Recommendation
1. In the light of the failings at Wymott and Whatton to identify and review risk
appropriately, cell sharing risk assessments at all prisons should be regularly
checked by managers to ensure that they effectively identify prisoners’ risks to
others.
Accepted. Response as follows:
Governors and Directors of prisons have been instructed to use the guidance
detailed in PSI 09/2011 ‘Cell Sharing Risk Assessment’, reinforced in PSI
64/2011 ‘Safer Custody’, with regards to CSRA policy.
Within PSI 09/2011 it states that all CSRA reviews must be carried out by, or
subsequently approved by, a multi-disciplinary team to ensure that a balanced
and reasonable risk decision is taken. The authorisation section of the CSRA
should be signed by the chair of the multi-disciplinary team or the Duty
Governor or Manager.
Recommendations to HMP Wymott and HMP Whatton
2. The Governors of HMP Wymott and HMP Whatton should ensure that all
initial cell sharing risk assessments are based on information contained in a
person escort record (PER) and security and other information available at the
time of a prisoner’s arrival.
Accepted. Response as follows:
HMP Wymott
All prisoners on arrival in Wymott have their Cell sharing risk assessment
reviewed in line with PSI 09/2011 Section 6.
HMP Whatton
Reception CSRA procedures changed with the introduction of PSI 09/2011. It
is now the responsibility of the sending prison to complete a full CSRA. Local
procedures at HMP Whatton are that if any prisoner is transferred in using the
old format CSRA then a new one is completed immediately in reception with
the available information. The safer custody team provide a quality check of
all CSRAs within a week of reception and scan onto the shared electronic
drive.
Recommendations to HMP Whatton
3. The Governor of HMP Whatton should ensure that staff review cell sharing
risk assessments when a VRS document is opened.
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Partially Accepted. Response as follows:
CSRA reviews are conducted in accordance with national guidelines as per
PSI 09/2011.
4. The Governor at HMP Whatton should ensure that the Interdepartmental Risk
Management Team appropriately identifies security risks posed by individual
prisoners, acts on the information without delay and that all key security and
risk information is shared with those who need to know including staff
delivering offender behaviour programmes.
Accepted. Response as follows:
Risk information identified by IRMT is circulated appropriately and the
prisoner Prison-NOMIS record is flagged accordingly.
HMP Whatton maintains an electronic current concern board that is brought to
the attention of all staff. This holds the prisoner image, recent behaviour and
security concerns.
5. The Governor of HMP Whatton should ensure that all grades of staff working
at night understand the night procedures and their respective responsibilities
in an emergency including the need for constant monitoring of emergency
situations and the need to call an ambulance immediately if there are urgent
concerns about a prisoner’s health.
Accepted. Response as follows:
Night staff are fully aware of night procedures and their responsibilities
including what action to take to summon an ambulance.
Recommendations to HMP Manchester
6. The Governor of HMP Manchester should ensure that the progress of
disciplinary charges which are referred to the police are monitored regularly,
relevant parties including prisoners are kept informed and that the outcome is
clearly recorded.
Accepted. Response as follows:
The process by which disciplinary charges are referred to the police is
monitored and relevant parties are kept informed will be reviewed and
updated accordingly.
7. The Governor of HMP Manchester should ensure that initial categorisation
decisions take into account all relevant information.
Accepted. Response as follows:
All initial categorisations decisions take into account all relevant information.
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