Individual at Wellingborough

Investigation into the circumstances surrounding the
death of a man at HMP Wellingborough
in April 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2010
This is the report of an investigation into the death of a man at HMP Wellingborough
in April 2009. Just after 3.50pm that afternoon, he was found with a ligature tied
around his neck and attached to a pipe at ceiling level in his cell on C wing. He had
been sentenced to eight years imprisonment in December 2008. He was 34 years
old.
I took over responsibility for investigating deaths in prison custody in April 2004 and
this is the only apparently self-inflicted death I have investigated at Wellingborough
since then. (In November 2006, a Wellingborough prisoner died as a consequence
of long-standing health problems.)
The purpose of my investigation was to establish the circumstances and events
surrounding the man’s death, including the quality of care provided to him at the
prison. The investigation was led by two investigators from my office. I
commissioned a clinical review from the local Primary Care Trust and I am most
grateful to the clinical reviewer, who performed a similar role after the death in
November 2006, for working in close co-operation with my investigators and
supplying a detailed medical report.
I also thank the Governor of Wellingborough and his staff for the assistance my
investigators received at all stages of the investigation. I thank too the liaison officer
for the consistent help he gave with liaison arrangements during the investigation. I
am obliged to colleagues in Northamptonshire Police for all they have done to
support my enquiries.
My investigators and one of my Family Liaison Officers met at an early stage of the
investigation with the man’s parents and his partner. His parents in particular asked
for a large number of questions to be addressed in the course of this investigation. I
have endeavoured to deal comprehensively with these matters in my report. I offer
my sincere condolences to his family and his partner.
The man had never been in prison until he was 33 years old and he had an excellent
employment history. My investigation of his life and death at Wellingborough
emphasises the importance of having an effective applications and complaints
system that inspires confidence in the prisoners who use it. There were serious
defects in these processes at Wellingborough in the months leading up to his death,
and he felt that his voice was not being heard.
The man assumed that some of his applications and complaints were not being
answered in retaliation for a complaint he had made about a senior officer. I do not
believe there was a vindictive conspiracy against him. Nevertheless,
Wellingborough must ensure that just as much attention is given to supplying
answers to prisoners as goes into recording their applications and complaints in the
first place. Determined and consistent management attention must also be devoted
to guaranteeing that an interim response to any complaint, but particularly a serious
one, is swiftly followed by a substantive reply. This degree of organisation was
manifestly lacking in Wellingborough’s tardy response to the most serious complaint
lodged by him.
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The man was found hanging in his cell the same afternoon that he learned his
appeal against sentence had been rejected by a judge at the Royal Courts of
Justice. I am troubled by the circumstances in which he came to learn of this
decision. I trust that my report will be read with care, both within the National
Offender Management Service and the Criminal Appeal Office at the Royal Courts of
Justice, with a view to ensuring that major decisions such as the rejection of an
appeal are conveyed to prisoners swiftly and in a suitably supportive way.
Although I am critical of some systems deficiencies at Wellingborough, I am also
heartened by the contributions made by several members of staff, particularly after
the man was found hanging in his cell. The quality of the efforts to revive him was of
a very high order, and these efforts continued ceaselessly from 3.50pm until 4.40pm
when death was pronounced by a doctor who had arrived at the prison by helicopter.
(Outside the London area, I can think of only one other occasion in the last five and a
half years when a helicopter has been summoned as part of the effort to revive a
prisoner in mortal danger.) In what is necessarily a sad report, there is much to
admire in the compassion and energy shown by a number of staff.
I am sending copies of this report to the Governor of HMP Wormwood Scrubs, the
Registrar at the Royal Courts of Justice, and the Chaplain General and Principal
Roman Catholic Chaplain in the National Offender Management Service, in view of
recommendations that relate to their areas of responsibility.
I am pleased to report that all the recommendations in my draft report have been
accepted. In response to observations made by the National Offender Management
Service I have made minor changes in paragraphs 28 and 46 to the draft report I
issued in December 2009.
The man’s family emailed 23 additional questions to me after they had read the draft
report and, drawing substantially on information supplied by HMP Wellingborough, I
have responded to these questions in a letter to the family.
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.
Jane Webb
Acting Prisons and Probation Ombudsman June 2010
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CONTENTS
Summary
The Investigation Process
HMP Wellingborough
Findings
Issues
Conclusions
Recommendations
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SUMMARY
The man was 34 years old at the time of his death in April 2009. He appeared at a
Magistrates Court and was remanded in custody to Wormwood Scrubs where he
arrived on 14 April. A suicide warning form was safely passed from the escort
contractor to staff in the reception area at Wormwood Scrubs to alert them to the fact
that he might be a suicide risk and that he had been in contact with community
mental health agencies in the past. An Assessment, Care in Custody and Teamwork
(ACCT) document was opened as a consequence on 14 April. It remained open
continuously until he was granted bail on 8 May with a condition that he resided at
his parents’ address.
On 3 November, the man was convicted at Crown Court and he was then held at
Wormwood Scrubs for a second time so that a pre-sentence report could be written.
On 1 December, he returned to Crown Court where he was sentenced to eight years’
imprisonment. On 19 December, he transferred from Wormwood Scrubs to HMP
Wellingborough in Northamptonshire.
A second ACCT form was opened on 23 December at Wellingborough after the man
wrote an application form saying he had mental health problems. He wrote that if he
spent one more night in a cell with anyone he would be pushed beyond his limit and
would snap. The man was duly moved to a single cell but by 29 December his
condition appeared to have stabilised. At the ACCT review held on that date, which
was chaired by a Senior Officer (SO), the ACCT was closed.
The man remained on E wing, the Induction Unit at Wellingborough, until 27 January
2009 when he transferred to C wing. He occupied cell C2-15 on the top landing of C
wing from that date until his death. Also on 27 January, he was reviewed by Nurse A
of the prison’s mental health team following his report that something had been
brushing against his body. Nurse A referred him to an experienced psychiatrist who
visits Wellingborough on a weekly basis. The psychiatrist saw him on three
occasions between 30 January and 20 February.
The man was a compliant prisoner who had no adjudications for offences against the
prison rules and his security file was almost empty. He wrote a significant number of
complaints and application forms during his time at Wellingborough and particularly
once he had been transferred to C wing. In all he wrote 12 formal complaint forms
and he submitted 19 applications during the two and a half months he spent on C
wing. An especially important document was the one he wrote on 22 January in
which he complained about the behaviour of SO A at the time she had closed his
ACCT form on 29 December 2008. Although the governing governor wrote on the
form that his complaint was to be investigated by a residential governor, she appears
not to have received that instruction at the time and no investigation proceeded until
19 March.
The man started work in the motorcycle maintenance shop at Wellingborough on 2
March. Then on 12 March, a day after a wide ranging sentence planning review, he
submitted an application for transfer to HMP Acklington in Northumberland. The
system in operation at Wellingborough required the transfer application form to be
signed by several members of staff before a decision on rejection or support was
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made in the Observation Classification and Allocation Unit (OCA). Nineteen days
passed between the date on which he wrote the form and the date when his
personal officer signed the necessary second stage of the document.
To the man it seemed that he never obtained answers to legitimate questions he was
asking. Nearly two months passed before his complaint about SO A was
investigated, although on two separate occasions he had sent application forms to
the residential governor quoting the reference number of his original complaint. After
completing his transfer application form he submitted further complaint forms
emphasising the number of transfer applications and unanswered applications he
had already put forward. Twice he received responses from staff in the OCA Unit
that they had not received the necessary transfer document and they would not
decide on the merits of his application until they did. He assumed that he was being
victimised in retaliation for the complaint he had submitted about SO A. In a
complaint form dated 29 March he warned that sooner or later a prisoner being
treated in that way would snap.
On 2 April, a member of the prison’s Independent Monitoring Board went to see the
man in the motorcycle workshop in response to a letter sent to the Board by the
man’s partner. The letter advised them that his applications never seemed to get
processed or that they were lost somehow in the system. The next day he was
visited in the workshop by Nurse A to whom he seemed very well, so much so that
she even discussed with him the possibility of removing him from the mental health
team’s caseload. The same day a member of the OCA Unit sent him a reply to
inform him that his application for transfer to Acklington had been supported and
despatched to that prison. There is no clear evidence that he received that reply.
Two days later, on 4 April, the man sent his final formal complaint by confidential
access to the governing governor. He wrote that since submitting his complaint
about SO A he had had nothing but problems and he was being victimised. He felt
that nothing he put his name to got dealt with and warned that the situation was
pushing him too far and that he could not cope. The Governor instructed the newly
appointed Deputy Head of Residence to deal with these matters and he went to see
the man in the motorcycle workshop on the afternoon of 7 April. In preparation for
the meeting the Deputy Head of Residence had seen a written response to the
Acklington transfer application in the man’s wing file but it immediately became
apparent that the man himself was unaware of that positive development.
Nevertheless the session between the two men ended on good terms and the
Deputy Head of Residence had no concerns whatsoever about the man’s state of
mind.
The man had appealed against his sentence but, on 2 April, the Criminal Appeal
Office at the Royal Courts of Justice sent a letter to the Governor of Wormwood
Scrubs, with a copy for him, advising him that a single judge had rejected his appeal.
The letter to the Governor of Wormwood Scrubs was received at Wellingborough on
8 April and it appears that the man received the letter addressed to him just before
2.00pm on the afternoon of 9 April. Just before and just after 2.00pm that afternoon
he made a total of four telephone calls to his partner and his mother. Transcripts of
these telephone calls, to which my investigators have listened, indicate that he was
in a most distressed state, particularly in the two calls to his partner. She was
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alarmed by what she heard and at 2.50pm a phone call was made to the prison to
warn that he was talking of killing himself.
It took some time before the switchboard operator was able to transmit that message
to PO A, who in turn instructed Officer A to check on the man’s welfare. Officer A
was not immediately able to gain access to the cell because the man had created a
barricade by moving his bed flush with the cell door. When Officer A forced his way
into the cell with the aid of a broom handle, he found the man hanging from a pipe
that runs the length of the cell just below the ceiling on the left-hand side. Staff cut
the ligature from around the man’s neck and placed him on the landing floor just
outside his cell. Skilled rescue efforts began at 3.50pm just after Officer B rang the
alarm bell and they continued ceaselessly until a visiting doctor pronounced him
dead at 4.40pm. Every possible effort was made to resuscitate him with ambulance
paramedics arriving at his cell by 4.01pm and they in turn called in the Helimed
helicopter ambulance which touched down on the prison’s exercise yard at 4.35pm.
As a result of my investigation I make 17 recommendations (the clinical reviewer has
made five further clinical recommendations, all of which I endorse) and I regard
those relating to notification of appeal results and the outcome of applications and
complaints as being particularly important. Despite careful safeguards at
Wellingborough it seems that the man was unsupported by staff when he received
the news that his appeal had been rejected. I consider that the risk of this
information coming to him in uncontrolled fashion was increased, and perhaps
substantially so, because the letter from the Criminal Appeal Office made its way to
Wellingborough via Wormwood Scrubs and not directly. I also believe that the
systems at Wellingborough for dealing with applications and complaints were
inefficient and unreliable. The applications system was very good at recording the
beginning of each application made by a prisoner but woefully inadequate when it
came to recording the response and ensuring that the prisoner was aware of that
response. The central defect in the complaints system was that there was no
differentiation between an interim and substantive response to a prisoner’s
complaint. Therefore all parties, apart from the man himself, appear for nearly two
months to have operated on the erroneous assumption that the interim response
given by the Governor to the man’s serious complaint about SO A was actually the
final word on the matter.
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THE INVESTIGATION PROCESS
1. The investigation of the circumstances surrounding the man’s death was
undertaken by two colleagues from my office. Due to the intervening Easter
holiday weekend, their first visit to Wellingborough was made a week after his
death. They collected a range of documents relating to his periods in custody
at Wormwood Scrubs and Wellingborough.
2. Notices to staff and prisoners announcing my investigation were displayed
around the prison. On his first visit, the Assistant Ombudsman met with the
Governor of Wellingborough, the Secretary of the Prison Officers’ Association
at the prison and the Chair of the Independent Monitoring Board. No written
responses were received to the Notices inviting staff and prisoners to
contribute to my investigation.
3. One of my Family Liaison Officers made contact with the man’s parents and
with his partner. They were invited to meet with my investigators and both his
parents and his partner chose to do so. I have endeavoured to answer all of
the family’s and partner’s questions during the course of this investigation. I
invited a response from the Governor of Wellingborough to 17 of the
questions posed by the man’s parents.
4. My investigators interviewed 31 people over 11 working days between May
and October 2009. They conducted interviews with prison officers and other
staff at Wellingborough, with prisoners, with clinical staff, with a member of
the Independent Monitoring Board at Wellingborough and with the psychiatrist
who saw the man on three separate occasions in January and February 2009.
5. I wrote to the local Primary Care Trust requesting a clinical review that would
examine any relevant healthcare issues and assess the care provided to the
man. I am grateful to the PCT for commissioning this review from the clinical
reviewer, who is a general practitioner in Northamptonshire and PCT adviser
to the PCT. I am grateful to him for working closely with my investigators
throughout the investigation and for undertaking joint interviews with clinical
staff alongside them.
6. My investigators met with a Detective Sergeant and a Detective Constable of
Northamptonshire Police, along with their Support Officer. The Detective
Sergeant and Detective Constable led the investigation of the man’s death for
Northamptonshire Police and I am most obliged to them for sharing with my
investigators documents they obtained inside his cell immediately following
his death.
7. My investigators visited C2-15, the cell where the man died, a number of
times. They also established contact with the office of HM Coroner for
Northamptonshire. A copy of my report will be submitted to the coroner to
assist with her enquiries and the forthcoming inquest.
8. My investigators have studied with care reports by Prison Service governors
on the last two self-inflicted deaths at Wellingborough, which occurred in 2001
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and 2003. They sought guidance on appropriate arrangements for attending
to the spiritual needs of Roman Catholic prisoners (especially at times of
emergency or death) from two Roman Catholic members of the chaplaincy
team at Wellingborough and from the Principal Roman Catholic Chaplain in
the National Offender Management Service.
9. The letter dated 2 April from the Criminal Appeal Office at the Royal Courts of
Justice appears to have had a profound effect on the man’s state of mind.
Accordingly, my investigators made telephone contact with the Court Manager
in the Criminal Appeal Office at the Royal Courts of Justice to discuss the
circumstances in which the man received news of his rejected appeal and any
refinements to procedure which might be suggested by the circumstances of
his death. My investigators consulted the Head of Prisoner Rights,
Responsibilities and Communications section in the Safer Custody and
Offender Policy Group, in relation to the National Offender Management
Service’s communications policy.
10. When my investigation was at an advanced stage I received a note from the
editor of the annually published Prisons Handbook. He had received a letter
dated 8 July from a prisoner at HMP Highpoint in Suffolk which contained an
allegation that staff had failed to intervene with sufficient urgency when the
man was found hanging. I set out in the Issues section of this report the
efforts made by my investigators to speak with the source of this information.
The Assistant Ombudsman conducted a second interview with a prison officer
at Wellingborough as a direct response to the information contained in the
prisoner’s letter.
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HMP WELLINGBOROUGH
11. Wellingborough is a Category C training prison for adult male sentenced
prisoners. It opened as a borstal in 1963 and held young offenders until 1990,
when it became a training prison for Category C adult men. There are nine
residential wings, with wings A to E having been built in 1963 and the
remaining four wings being of much more recent construction. The prison is
certified to hold 636 men normally, with its operational (maximum) capacity
being 646.
12. Wellingborough was inspected in August 2008 by HM Chief Inspector of
Prisons and her report on that inspection was published in December 2008.
13. In her introductory remarks she wrote that Wellingborough:
‘… is not a well known, or a particularly difficult, prison. But it is one of the
weakest that we have recently inspected, failing to provide the basics of
training and resettlement which should be at the core of its work.’
14. At page 23 of her report she wrote that much of the cellular accommodation
on A to E wings was in extremely poor condition in terms of maintenance, but
particularly in terms of cleanliness.
15. My investigators had a close working relationship with the Independent
Monitoring Board at Wellingborough throughout the investigative period
preceding the issuing of this report. The interview with a member of the IMB
appears as one of the annexes. In September 2009, the IMB issued their
report for the period from June 2008 to May 2009. The executive summary
observes that:
‘Despite some shortcomings shown in performance tables and
improvements needed particularly in resettlement and rehabilitation, the
IMB does not recognise HMP Wellingborough, overall, as a poor
performing prison. By some measures and by internal audit inspection,
some aspects of performance and culture are improved and improving.’
16. Prisoner suicide is a rare occurrence at Wellingborough. During the five and
a half years since I assumed responsibility for investigating the deaths of all
prisoners in England and Wales there have been no other apparently self-
inflicted deaths at Wellingborough. (One prisoner has died as a result of
natural causes.) My investigators have studied reports written by Prison
Service governors on self-inflicted deaths that occurred at Wellingborough in
October 2001 and July 2003. The 2001 report includes the information that
the previous death in custody at Wellingborough had been in July 1992.
There are few areas of similarity between the man’s death and those of the
two men in 2001 and 2003. The man who died in 2003 was much younger
than the man who is the subject of this report and had already served five
custodial sentences as a young offender prior to his death. The man who
died in 2001 was serving a much shorter sentence than the man who died in
2009. He had served a previous prison sentence and, although his family and
10
girlfriend knew he was feeling desperate, he gave no indications to prison
staff.
17. On 27 April 2009, the then Secretary of State for Justice made a statement in
Parliament on the Government’s prison and probation policy. As part of that
statement he said:
‘Two poorly performing public prisons will be market tested this year,
Birmingham and Wellingborough. Public, private and third sector
providers will all be invited to bid.’
18. My understanding is that bids in response to this market test must be
submitted by February 2010.
19. On the same date the Ministry of Justice published a document entitled
‘Capacity and Competition Policy for Prisons and Probation.’ Part of the
document deals with competition in prisons and the third paragraph of that
section contains the following statement of government policy:
‘High cost or low performing public sector prisons have been identified
through set performance and financial criteria. There are prisons within
the public estate that have consistently performed poorly and have had
opportunity to improve. We believe there are significant improvements in
quality of service and efficiency available through application of
competition. Two of these high cost or low performing prisons will be
market tested in 2009.’
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FINDINGS
First period of custody at HMP Wormwood Scrubs
20. The man was arrested in the early hours and was taken initially to a police
station. The custody record completed by the sergeant there said that the
man was under the influence of alcohol and had been drinking but was co-
operative. The sergeant completed a risk assessment soon after the man’s
arrival. In answer to the question ‘Have you seen a doctor or been taken to
hospital’, the box ‘yes’ was ticked and the sergeant entered ‘psychiatric
disorder bi-polar.’ When asked if he was taking any tablets or medication, the
man responded that he was taking 150 mgs of Venlafaxine, 60 mgs of
Chlordiazepoxide and Librium. When asked if he was suffering from any
mental health problems or depression, he responded that he was bi-polar. In
answer to the question ‘Have you ever tried to harm yourself?’ he replied that
he had slashed his head with a razor blade. In the section of the form headed
‘Custody Officer Assessment’, the sergeant wrote that the man was
apparently suffering from a mental condition (bi-polar). He also wrote that he
was drunk or appeared to be drunk and medical assessment was advisable.
21. The man appeared at Magistrates Court on 14 April. The magistrates decided
that he should be sent to Crown Court on 2 July and, in the meantime, was to
be held in custody at HMP Wormwood Scrubs. Escort staff belonging to the
private contracting firm SERCO had the responsibility of conveying him from
court to Wormwood Scrubs. He had no previous convictions and had never
been to prison before. A prisoner escort record (PER) is used to convey
information about risk as a prisoner is passed from one part of the criminal
justice system to the next. When he transferred from the police station to
Magistrates Court on 14 April, ticks were placed in the risk category boxes of
the PER form headed ‘Medical, Security and Other’. In the medical category
the boxes indicating medical and mental condition were ticked, and in the
category headed ‘Other’ there was a reference to a perceived risk of suicide
or self-harm by hanging. In the section of the form where further information
about risk could be written, there was an entry which said ‘Mental health
issues – medicated’.
22. A form entitled ‘Suicide/Self-Harm Warning Form’ should be used to convey
information about possible risk of suicide from escort contractors to their
colleagues in a local prison receiving a new prisoner from court. Such a form
was indeed raised by the SERCO supervisor at Feltham on 14 April. In the
section of the form devoted to nature of the concern, the boxes ticked were
those indicating statements of intent to ‘self-harm/commit suicide, bizarre
behaviour or other signs of mental disorder, seems very depressed and acts
of self-harm within the last month’. The same section included information
from the man’s mental health worker who stated that he had extreme mental
health issues. He had a history of self-harm within the previous six months,
with the method used being cutting. Section 4 of the self-harm warning form
enables the writer to include further information and this section states the
following: ‘She states he has harmed himself recently and has just come out
of hospital. Needs to be watched as a high risk of suicide/self-harm.’ The
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form is designed to ensure that information about risk and staff concern is
transferred smoothly from one agency to another. This certainly happened on
14 April in this case. The last two boxes on the form contain names and
signatures from Officer C at HMP Wormwood Scrubs, signed at 7.00pm on 14
April, and from healthcare screener, Nurse B, who signed the form at 8.51pm
the same evening.
23. A Cell Sharing Risk Assessment form (CSRA) must be completed when a
prisoner is first received at each new prison. The CSRA completed at
Wormwood Scrubs on the evening of 14 April was clearly informed by the
self-harm warning form referred to in the previous paragraph although the
CSRA is especially designed to establish whether someone poses a risk to
fellow prisoners. In response to question seven in Section 2 of the form,
Officer D wrote that the man did not have an open 2052SH (the document
previously used in the Prison Service to support prisoners at risk of self-harm
or suicide). He referred to the warning form which indicated that the man had
self-harmed recently and had also recently come out of hospital. Officer D
wrote that the man had no intention to self-harm at present. He also referred
to paperwork suggesting bi-polar disorder and to the man’s denial of this.
Officer D believed there was a high risk that the man might assault a cellmate.
Section 3 of the CSRA must be completed by a member of the healthcare
team and Nurse B concurred with Officer D’s opinion that there was a high
risk that the man might assault a cellmate. The form required Nurse B,
following a self-harm assessment, to note any concerns that had been raised.
The concerns to which the nurse referred were:
• The man was known to the CMHT (Community Mental Health Team)
• Has mental health problems
• History of self-harm
• Arrived with self-harm warning form
• ACCT document raised
29. ACCT stands for Assessment, Care in Custody and Teamwork and is a
process whereby staff can work together to provide individual care to
prisoners who are in distress, in order to help defuse a potentially suicidal
crisis or to help prisoners better manage and reduce their distress. Nurse B
duly opened an ACCT document at 8.51pm on 14 April. The Concern and
Keep Safe section at the front of the ACCT document requires the relevant
member of staff to explain why he is concerned. Nurse B wrote that the man
had self-harmed in the past and arrived at the prison with a self-harm warning
form from court. The nurse added that the man stated he was low in mood
and that he abused alcohol, for which he was prescribed medication at the
time. Nurse B also recorded that the man had mental health problems. The
Immediate Action Plan devised by a Principal Officer (PO), the orderly officer
at Wormwood Scrubs that evening, was that the man should be located in a
single cell, that he should have hourly overnight observations with five entries
being made in the ACCT document through the night. He should also have
access to the Samaritans if he required it.
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30. On the morning of 15 April, the man was assessed at 10.45am by a trained
ACCT assessor and then at 11.20am the first review of his ACCT status was
held. The three people attending that review were the man himself, Officer E
(who had just completed the ACCT assessment) and a Senior Officer (SO),
the Unit Manager. The summary of the case review observed that the man
was new in prison and very shocked about being on remand. His solicitor
was trying to get bail and the ACCT document should remain open until he
had completed the induction period at Wormwood Scrubs. A care map was
drawn up to advise him of people who could provide support to him and to
encourage alternatives to self injury. One of the actions included on the care
map was that he should have a gym card so that he could attend the
gymnasium ‘to help his depression’. Staff recognised the importance of his
being able to contact his solicitor. It was agreed that he could use the office
telephone to speak with his solicitor, which happened by the end of that day.
The second page of the ACCT document identifies any triggers or warning
signs to which special attention must be paid. In this case the trigger
identified was that he would not get bail. The Unit Manager decided that a
further ACCT review should take place three days later, on 18 April.
31. The man’s second ACCT review was duly held on 18 April. The review was
again chaired by the Unit Manager, and the man and Officer F also attended.
The summary of the review said that due to the man’s care map not being
completed, and the fact that he was prescribed Librium for alcohol withdrawal,
his ACCT should remain open. It was recorded that a visit had been booked
for the next day and that a video link for bail the following week had been
arranged by his solicitor. He was described as very optimistic.
32. A third ACCT review was scheduled for 25 April and again the review on that
date was chaired by the Unit Manager. The two other persons attending were
the man himself and SO B. The summary of the review noted that the man’s
medication had been changed but he was still having trouble sleeping. The
video link for bail had not taken place and he felt in limbo. A further attempt to
obtain bail would be made the following week and the Unit Manager decided
that the ACCT document should remain open due to the specified trigger
point. (When the ACCT document was first opened the possibility that he
would not get bail had been identified as a warning sign that should prompt an
immediate additional ACCT review.)
33. The Unit Manager set 5 May as the date for the next ACCT review and on that
date the people attending were identical to those at the 25 April review. The
entry made by him in the summary of case review section said:
‘The man is going for bail tomorrow; this could be a trigger point if not
successful. Keep ACCT open, review after tomorrow.’
34. The ACCT reviews in relation to the man at Wormwood Scrubs demonstrated
most impressive staff continuity. At the next ACCT review, scheduled for 7
May, the personnel attending were identical for the third time running. The
Unit Manager’s summary of the ACCT review observed that the man was still
waiting for a bail decision. Accordingly, he wrote that he would facilitate a
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telephone call to the man’s solicitor so that he could find out. Due to the
decision about bail being a trigger point, the Unit Manager decided to keep
the ACCT document open and indicated that the next case review was to take
place on 14 May.
35. The ongoing record section of the ACCT document was used by a range of
staff at Wormwood Scrubs to make observations about significant
conversations or observations they had with the man. Some of the most
informative entries in the record were made by members of the prison’s
chaplaincy team. On 22 April, for example, a member of the chaplaincy team
made an entry at 2.45pm which said: ‘Says he is feeling down because the
police are threatening to destroy his new car if not collected by Friday. Says
he is hoping for bail when he goes to court at the end of this week.’
36. On 6 May, at 3.00pm a Sister wrote an entry which said:
‘Spoke through the door. His cousins have visited his mother to break the
news he’s in prison and she took it well. She is putting up bail and he’s
waiting to hear whether it’s being granted. If it is, he will go up north to
stay with her. He uses the prayer card I gave him and finds it helpful.’
37. The Record of Events (F2052A) section of the man’s core prison record
contains very little information about the period of almost a month he spent in
Wormwood Scrubs in April/May 2008. A stamp dated 14 April in the Record
of Events booklet states that the issues identified during reception that day
were ‘High risk CSRA and self-harm/suicide’ but there is no further
information in that document about the nature of the self-harm that had been
identified. The one other entry in the Record of Events booklet was made by
Officer F on 3 May and states:
‘This man keeps himself to himself. Is currently on ACCT. Always seen
smoking. Keeps cell clean and tidy. No other concerns at this time.’
38. The bail decision to which reference had been made so many times in the
man’s ACCT document was eventually made on 8 May. On that date, the
Crown Court granted him application for bail after his father provided a
financial surety. The conditions included a requirement that he should live
and sleep each night at his parents’ address and should not come south of
the M62 motorway, subject to the exception of entering London for court
hearings or to visit his solicitors by prior appointment.
Second period of custody at HMP Wormwood Scrubs
39. On 3 November, the man was convicted at Crown Court. He was remanded
in custody at HMP Wormwood Scrubs again this time so that a pre-sentence
report could be written by a probation officer before his next appearance at
the Crown Court. On reception at Wormwood Scrubs he was seen by a
Healthcare Worker for a first reception health screen. His arrival at the prison
appears to have been much more low key than his first reception in April
2008. The nurse wrote on the F2169 (first reception health screen) that he
15
had last been in prison in March 2008. He said that he had seen a doctor in
the last few months to have a stomach problem checked up. He confirmed
that he was receiving prescribed medication: Lansoprazole, Fluoxetine and
Librium and he also had a Ventolin inhaler. He told the nurse that he drank
alcohol occasionally but had consumed none in the week before coming into
custody. He had not taken any drugs in the previous month.
40. In the section of the form devoted to mental health, the man replied that he
had received treatment from a psychiatrist outside prison for depression.
When asked if he had ever stayed in a psychiatric hospital, he revealed that
he had most recently been discharged from a hospital in west London. He
had already informed the nurse he was receiving Fluoxetine and he added
that his current dose was 40 mgs daily. He said that he had never tried to
harm himself, which was at variance with the information he had given the
Metropolitan Police when they arrested him in April 2008. He told the nurse
he would not consider harming himself in prison and, in response, the nurse
recorded his impression of the man’s behaviour and mental state as being
that he appeared stable in mood. Additional information recorded was that he
stated that he had no self-harm thoughts, he suffered from depression and he
was known to mental health services. The nurse referred him to the prison’s
doctor and mental health inreach team.
41. The pre-sentence report requested by the Crown Court was written by a
probation officer in west London. He wrote the report on 25 November in time
for the man’s next court appearance the following week. By this time he had
already been convicted of four offences but the probation officer wrote that he
continued to maintain his innocence.
42. The man admitted to the probation officer that he had indulged in binge
drinking in the past. He had sought advice from an Alcohol Counselling
Service and was successfully helped to control his drinking levels. He
informed the probation officer that he was being treated for depression when
the offences occurred. He attributed his depression to the stress he was
facing while being harassed by his former girlfriend’s family. At the end of his
pre-sentence report the probation officer indicated that he had been asked by
the court to make an assessment of dangerousness. His response was as
follows:
‘Due to the unusual background to this case and to the man’s continuing
denial. He has removed himself from the locality of the incident and
therefore is no longer in contact with the victim. There is nothing known
about him to indicate he presents a danger to the public at large.’
43. The concluding paragraph in the probation officer’s pre-sentence report said:
‘The man is aware that a custodial sentence will be imposed today. He
has indicated to me that he will discuss an appeal with his legal
representative, while requesting a transfer to a prison closest to his
parents’ home.’
16
44. The man returned to Crown Court in December when he was sentenced to
eight years imprisonment. An entry in his continuous clinical describes him as
feeling ‘gutted’ by the sentence he had received. He was described in the
same entry as not being suicidal. On 5 December, the Observation
Classification and Allocation (OCA) Unit at Wormwood Scrubs considered the
information then known to them about him. It was decided that he should be
allocated to HMP The Mount in Hertfordshire as a category C prisoner.
(Category C is the second lowest security category.) Two weeks later he was
transferred from Wormwood Scrubs to HMP Wellingborough rather than The
Mount.
45. The available evidence does not appear to indicate that the man was
perceived as being at risk of self-harm or suicide during the month and a half
he spent at Wormwood Scrubs between early November and mid December
2008. The cell sharing risk assessment (CSRA) completed by Officer G and
Nurse C on 3 November contained no reference to issues of self-harm. There
is no requirement in the CSRA to comment on self-harm issues beyond
stating whether the prisoner is or has been on an ACCT. The CSRA
accepted his statement that he had not previously been on a form 2052SH or
an ACCT. (The man had, of course, been on an ACCT document
continuously throughout the month he spent at Wormwood Scrubs in
April/May six months previously.) Both the officer and the nurse ticked the
box which indicated that they perceived his risk of harm to others as being low
whereas he had been classified as high risk six months previously. Four
separate entries were made by four separate officers in the Record of Events
(F2052A) booklet opened at Wormwood Scrubs on 3 November. The first
entry was made on 12 November and said: ‘No problems caused. Quiet and
respectful.’ A further entry on 30 November noted that he was polite to staff
and followed the wing regime. A three word entry on 6 December said
’unknown to me’ and the final entry in the Record of Events booklet a week
later observed that he complied with the wing regime and created no
concerns.
46. Perhaps the most revealing document from this period of time is a
questionnaire that staff in the Offender Management Unit at Wormwood
Scrubs asked the man to complete so that they could provide him with a
sentence plan most suited to his needs. The date on which he completed the
questionnaire is not given but he wrote his location as cell A4-18 and his
Record of Events booklet indicates that he occupied cell A4-18 after 1
December 2008. It is likely therefore that he completed the questionnaire
during the first fortnight in December.
47. A question on the first page of the questionnaire asked the man to say
whether at the time of the offence anything was a disinhibitor, with examples
given to him being drugs, alcohol, medication or psychiatric problems. He
replied that he was suffering with depression and had drunk that day. At
question nine of the questionnaire he was asked how he was coping at
Wormwood Scrubs and replied with a question mark, then wrote: ‘Frustration,
can’t sleep or get on doing things. No-one tells you nothing.’ At Section 11 of
the form, which dealt with attitudes, he was asked how he felt about other
17
prisoners and responded that he preferred to keep himself to himself and was
wary of others. Question 12 asked him about health considerations and he
wrote that he was taking medication for depression and a bad stomach. In
answer to a question about any serious health issues in the past, he wrote:
‘Alcoholism, battled with it for a long time. However now I consider myself
a recovered alcoholic and help others with drug/alcohol problems at
Lifeline and Outlook. Would like to become drug/alcohol counsellor.’
Arrival at HMP Wellingborough on 19 December 2008
48. When the man arrived at Wellingborough on 19 December, the two members
of staff who had most significant contact with him on the day were Officer A
and Nurse D. They completed a Cell Sharing Risk Assessment on him and
both of them were experienced staff who knew what they were doing. In
interview Officer A explained that he had worked in the reception area at
Wellingborough for two years before the man’s arrival. He said that it is
extremely common for Wellingborough to receive prisoners from the large
London prisons such as Pentonville, Wormwood Scrubs and Wandsworth.
Although he was being interviewed five months after the man’s arrival at
Wellingborough, he could remember him well because he described him as
quite a big sort of lad and recalled that he still had quite a strong accent.
49. Officer A reckoned he would have spent in excess of an hour with the man
personally and probably about four hours in total with him and the other
prisoners who had come with him from Wormwood Scrubs. Officer A spent
quite a bit of time with him because he seemed ‘quite nervy’ due to the fact
that this was his first custodial sentence. At question four in Section two of
the CSRA, he recorded the fact that the man had previously been on an
ACCT document. It had been closed on 14 May 2008 and, in the same box,
he noted that this was the man’s first custodial sentence. Officer A explained
that he had spoken to him about the closed ACCT document. The man said it
was something that was behind him and he was not feeling low in any way on
19 December. So for that reason and because:
‘… he seemed an all round good egg and someone that was able to cope
and mix with other prisoners without any problems, I actually put that the
rate of risk of harm to others, I put that down as low.’
50. Nurse D’s assessment on the CSRA was also that the man’s risk to other
prisoners was low. Therefore for the first four days of his period at
Wellingborough he shared a cell, E1-29, with another man.
51. In contrast to the handwritten clinical records used at Wormwood Scrubs,
patient records at Wellingborough were computerised by the time of the man’s
arrival. The entry made on his electronic patient record at 3.01pm on the
afternoon of 19 December suggests that his first reception health screen at
the prison was conducted by a healthcare assistant. In interview Nurse D
explained to my investigators that the woman who made the electronic
reception entries was at the time a new healthcare assistant. Nurse D was
18
with her throughout the time of contact with the man and her entries on the
patient record were made under Nurse D’s full supervision.
52. My investigators established in interview that Nurse D is a very experienced
Registered General Nurse who trained 26 years ago and who has worked at
HMP Wellingborough for the last ten years. Nurse D said she particularly
remembered the man because they talked about the rock group Madness.
She said that her interview with him lasted approximately 20 minutes and she
felt that he visibly relaxed because, in addition to answering straightforward
medical questions, they also chatted about non prison events. He was one of
11 new prisoners she had to see that afternoon and, in interview, she
explained that was quite a large number. Nevertheless she said that she
spent longer with him than she normally did with a new prisoner. He told her
that he had attempted suicide or harmed himself in 2006 out of prison but he
had not harmed himself within the prison system. She noted that he had been
treated by a psychiatrist in the community and that he had been admitted to a
psychiatric hospital prior to being in prison. She was confident that she would
have indicated verbally to one of her mental health team colleagues that she
would like him to be assessed. She added that she would normally have to
make the referral by e-mail but did not need to do so on a Friday afternoon
because prisoners are locked in their cells ‘which means there’s no access to
prisoners for assessment, therefore they [her nursing colleagues] are in their
office doing paperwork.’
53. The man spent the first few weeks of his time at Wellingborough on E wing,
the prison’s induction unit. The induction process at Wellingborough was
explained to my investigators by Officer H who has spent all of his five year
working life at Wellingborough as a prison officer on that unit. In interview he
described induction as follows:
‘The induction process at Wellingborough happens to every prisoner who
comes into the jail. No-one slips through; everyone who comes into the
jail has to sit the induction. It’s held on Echo wing; predominantly most of
the induction process is actually held on the wing, however for two or three
of the induction processes you [the new prisoners] do leave the wing to go
off to other departments, ie the gymnasium, the chaplaincy centre,
sometimes to education. A lot of it’s done on the wing but some of it is
done off.’
54. He explained that one of the induction officers gives a first night talk to new
prisoners in the reception area. The man’s Wellingborough Record of Events
document (wing file) contains an entry made by Officer I on 20 December
which says that he had arrived the previous day from Wormwood Scrubs, was
happy to be at Wellingborough and seemed to the officer to have a good
attitude. On 20 December, Officer I and the man also signed
Wellingborough’s communications compact which explains to prisoners the
prison’s policy on a number of issues including the PIN phone system and the
rules for monitoring all incoming and outgoing mail. The latter part of the
document indicates that the correspondence of prisoners at Wellingborough is
subject to a maximum five per cent routine reading on a random basis. The
19
document explains further that correspondence sent in or out that is legally
privileged (prison rule 39) or to a confidential access organisation will not
normally be opened.
55. My investigators were supplied with a document headed F2055C, Training
Record, which sets out 15 separate areas that should be covered during a
prisoner’s induction period of approximately seven days. Only three of the 15
topics had a signature and date against them. Officer H was confident that
the man would have covered all 15 topics on the induction programme and
assumed that officers on the day had failed to sign the induction record. I
draw this procedural lapse to the Governor’s attention. If it is considered that
induction is an essential part of the Wellingborough experience for each
prisoner, then it is clearly desirable to be able to demonstrate that they have
received every constituent part of the induction package.
ACCT document open between 23 and 29 December
56. A crisis occurred on 22 December, just three days after the man’s arrival at
Wellingborough. He used an application form which prisoners can send to a
whole range of departments in the prison, such as Probation, Residential,
Governor, Healthcare Centre or Visits, to convey the following message:
‘Move me to a single cell. I have mental health problems and if I spend
one more night in a cell with anyone it’s going to push me beyond my limit.
I will snap. I would rather spend Christmas in Seg [the Segregation Unit].
I will kill myself or someone else.’
57. It appears that this urgent message was first discovered by a member of staff
the following day. On 23 December, Officer J opened an ACCT document
and on the Concern and Keep Safe form at page three of the ACCT
document, wrote:
‘Upon interview the man stated he’s struggling to cope sharing with his
current cellmate. He felt his only way out of the cell was to threaten to kill
himself or someone else. He has a history of self-harm and is currently on
anti-depressants that he may have stopped taking. He had a very out of
character outburst then burst into tears. He left an application in the post-
box stating if we didn’t move him he would kill himself or someone else.’
58. There are six boxes which a member of staff can tick on the Concern and
Keep Safe form. They are used as a prompt to indicate to prison staff what
the main problems may be. Officer J ticked box number one relating to a
suicide attempt or statement of intent to kill self, box number three relating to
unusual behaviour or talk, box number four relating to very low mood and box
number five relating to problems with drug or alcohol withdrawal. He made
his entry on the Concern and Keep Safe form at 11.30am By 12 noon, half an
hour later, an immediate action plan had been drawn up by Senior Officer C,
the Unit Manager on E wing that day, with agreement to the action plan also
being given by Officer J himself and Officer K. SO C explained to my
investigators that, although he was not a trained nurse, he had worked as a
20
hospital and healthcare officer in the Prison Service for 18 years from 1985
until 2003. In 2003 he switched from healthcare to general prison duties.
59. The action plan drawn up by SO C and his colleagues had five constituent
parts. The first decision was that the man would be moved to a single cell.
The second decision was that he should be observed hourly by staff and that
an entry should be made in the ongoing record section of the ACCT document
once in the morning, once in the afternoon and once in the evening, with four
further entries made through the night period. The third decision was that he
should immediately be offered a Samaritans telephone and the fourth was
that he should immediately be offered access to a Listener. (A Samaritans
telephone gives a prisoner the opportunity to make confidential contact with a
member of the Samaritans organisation in the community nearest to the
prison. A Listener is a fellow prisoner who has been trained by the
Samaritans to offer confidential support and emotional assistance to prisoners
in crisis.) The fifth and last part of the plan was that the Healthcare Centre
should be contacted as soon as possible to resolve his medication issues.
SO C made entries in two different documents. In an un-timed entry dated 23
December in the man’s wing file he wrote:
‘The man was very upset and tearful this morning, his attitude to staff a
little terse.
‘After some discussion with him and Officer K it was decided to move him
to a single cell … We have ascertained that he has spent some time in a
hospital in Middlesex for obs (depression). He has attempted to harm
himself in the past (ligature). He is pleased with what we have done and
feels we are listening. He is not as tearful but still upset. ACCT document
opened.’
60. SO C made the first entry in the ongoing record section of the man’s ACCT
document at page 21. His entry at 12.30pm on 23 December read:
‘The man was tearful and terse with staff this morning and on interview it
became obvious his cellmate and lack of medication was upsetting him …
it was therefore considered prudent to move him to a single cell and open
an ACCT document.’
61. An unsigned entry in the ongoing record section of the ACCT document at
5.00pm noted that the man had now moved cell, he had discussed his
problems and his mood was much brighter. He stated he had no intentions of
killing himself at present but he appeared to the writer to be an impulsive
person and ‘we are awaiting the outcome of our request for a visit Saturday’.
The writer concluded this entry by saying that he had no immediate concerns
and he could see no ideas of harming himself.
62. On the afternoon of 23 December, Officer L, a trained ACCT assessor, carried
out a lengthy assessment interview with the man. (ACCT assessors undergo
five days of training and their task is to gather as much risk pertinent
information as they can from the prisoner for whom an ACCT document has
21
been opened so that subsequent ACCT reviews are informed by as much
good quality information as possible.) The interview between the assessor
and the man began at approximately 1.30pm. The man explained at the
outset that he had been sharing a cell with another prisoner who, over the
previous three days, had continuously played loud music which did not allow
him to watch television or have any peace. He then noticed that items
belonging to him were going missing but, when he spoke to his cellmate about
his behaviour, the latter ignored his concerns. He then submitted the
application form, to which Officer J responded.
63. Officer L asked the man about previous acts of self-harm or suicide attempts.
The man told him that an ACCT document had been opened in May at
Wormwood Scrubs but he could not recollect why. He told Officer L that he
had tried to hang himself in the community. He had intended to die in order to
take himself away from his problems.
64. In response to questions about his current mental state, the man told Officer L
that he was taking Prozac for his depression. He admitted to the officer that,
due to his distress over the weekend, he had been working out a way of
hanging himself but those suicidal thoughts had gone. He told Officer L that
he was glad to be alive and had no plans to kill himself. In response to
questions about reasons for living, he said he had a girlfriend who would visit
him and he also had contact with his daughter from a previous relationship.
65. Officer L asked the man if there were any other areas of concern and he
replied that he had a visit booked at Wormwood Scrubs for the coming
Saturday, 27 December. He wondered if that visit would be honoured at
Wellingborough. After conducting his interview with him, Officer L wrote up
the assessment interview section of the ACCT document between pages
seven and nine and timed it at 3.45pm on 23 December. That means he had
devoted over two hours that afternoon to a lengthy discussion with the man
and then a careful and detailed written summary of the various issues the two
men had discussed.
66. Nurse A is a registered mental health nurse at Wellingborough and she first
made contact with the man during the afternoon of 23 December. At that time
she joined Officer L as he was nearing the end of his ACCT assessment
interview with the man. On the morning of 24 December, Christmas Eve,
Nurse A carried out a mental health assessment of the man. She first made
some handwritten notes in a Northamptonshire Healthcare document headed
‘Prison Liaison Assessment’ and then entered her assessment electronically
on his Patient Record. In the section of the electronic record headed
‘Presentation’, she wrote:
‘The man put in an appeal against his conviction
‘Placed on an ACCT yesterday after threatening to kill himself/others due
to the stress of sharing a cell, he is presenting quite a different picture
today.
22
‘Although he does have a history of depression and a hanging attempt in
the past, the stated threats may well have been in order to achieve an
outcome he has now achieved, ie a single cell.
‘In the past, he has used alcohol as a coping mechanism but realises this
does not help him ultimately. Now on Fluoxetine, he advised that
previously prescribed Venlafaxine did not suit him.
‘Since yesterday afternoon, he reports improved mood, sleep and appetite.
He finds going to the gym helps and currently describes self as fine with
no thoughts of harming self/others and no voices or paranoia.
‘Something of a protective factor may be his relationship with his partner
who visits him and with whom he may well live again on release. He is
close to his eldest daughter.’
67. In the summary section of the same document Nurse A wrote that:
‘The man is known to a [Community Mental Health Team] and reports
fluctuating moods previously dealt with by the use of alcohol as a coping
mechanism. There was a previous hanging attempt but he appeared
settled at assessment although to remain on an ACCT until the New Year.
No stated threats to harm self/others.’
68. In the assessed mental health need section of the document Nurse A wrote
that the man appeared settled on Fluoxetine:
‘… but remains on an ACCT opened yesterday, possibly after threatening
to kill self/another to get his own cell, although does have a single
attempted hanging in the past. He reports an element of fluctuating mood
however.’
69. At the end of the form, in the section entitled ‘Required Links to Mental Health
Services,’ Nurse A wrote:
‘Attend ACCT reviews and follow up fortnightly to monitor mental state.’
70. The first case review following the opening of an ACCT document should take
place within 24 hours. In the man’s case the first review was held on time, at
11.00am on the morning of 24 December. The review was attended by SO C
and the man himself and, next to the names of Officer L and Nurse A, SO C
has written ‘phone’. In interview he explained to my investigator that these
two colleagues had not attended the review in person but the reference to
phone would mean that he had contacted them in advance of the review. In
his summary of the case review he wrote:
‘The man has been seen by all concerned with his problems, all of which
have been resolved. We have discussed his cell sharing risk assessment
which is now high (the word high is underlined twice). He is aware this will
be reviewed regularly. There are no obvious signs of ideation of suicide.
23
His mood is good and his attitude positive. He is aware that staff will help
him and assures me he will do so if required. Overall much improved.’
71. SO C had three boxes from which to select when predicting the likelihood of
further risk behaviours: the boxes indicated low, raised or high. He ticked the
box ‘low’ and decided that the next ACCT review should proceed on 29
December. He and the man had signed a care map on 23 December which
identified the two issues to be resolved as being the man’s constantly noisy
cellmate and medication. A computerised record of cell moves states that the
man moved from E1-29 to cell E2-18 at 1.28pm on 24 December, though an
entry at 5.00pm in the ongoing records section of his ACCT document
suggests that the cell move had already taken place by teatime on 23
December. As to the medication question, SO C wrote that his healthcare
colleagues had been informed and the matter was resolved.
72. Staff on E wing continued to make regular entries in the ongoing ACCT record
from the time of SO C’s first review until the document was closed on 29
December. Representative entries include one at 4.50pm on Christmas Eve
made by Officer M which said:
‘Had a quick chat. Appears OK. Wished me Happy Xmas. Locked up
happy.’
73. At 11.20am on Christmas Day, Officer N wrote that he had spoken to the man
who had said he was much more settled now that he had a single cell and
had no intention of self-harming. At 3.00pm on 26 December, Officer O wrote
in the ongoing record that the man had spoken to him about his mail being
diverted from his last prison. Officer O wrote that he seemed in a good mood
and had no concerns or problems. Another entry at midday on 27 December,
apparently again made by Officer O, noted that the man had collected his
lunch and had said he was happy to be in a single cell and that his medication
was now sorted.
74. The man’s second ACCT case review took place on the afternoon of 29
December. The record of case review document appears to show that the
three people attending that second review were SO A, the man himself and
Officer I. SO C, rather than SO A, signed in the box for the case manager’s
signature at the bottom of the form and supplied a date of 29 December. In
interview subsequently, SO C agreed that the handwriting in the section of the
form devoted to a summary of the review was his own. That section of the
form recorded a decision that the man’s ACCT document should be closed
because his problems were resolved and his concerns had diminished.
75. As a result of his interview with SO A on 25 June 2009, my investigator is
satisfied beyond doubt that she, rather than SO C, was the case manager
who chaired the review on 29 December which closed the man’s ACCT
document. There are three main reasons for coming to this conclusion.
76. The first reason centres on the information set down in the concluding entries
in the ongoing record section of the man’s ACCT document. At 10.30am on
24
the morning of 29 December, Officer P wrote that the man was sitting with
another prisoner reading the paper and appeared in good spirits. Officer P
then wrote that a review with healthcare had been arranged for 1.45pm that
day. The final entry in the ongoing record section of the ACCT document was
made at 2.00pm on 29 December by SO A. The entry reads:
‘ACCT review held with Officer P and Nurse E [one of the trained mental
health nurses at Wellingborough]. All issues reviewed; states that since
moving into a cell on his own and having all of his issues resolved he no
longer feels the need to be on an ACCT.’
77. Secondly, PO B wrote an investigation report on 19 March 2009 about the
circumstances in which the man’s ACCT had been closed on 29 December
and his report indicated that the three members of staff present at the review
had been SO A, Officer P and Nurse E.
78. Still more compelling evidence about the circumstances in which the man’s
ACCT document was closed was supplied by SO A herself when she was
interviewed by my investigator on 25 June 2009. When asked to explain
whether she or SO C had chaired the review on 29 December, she said:
‘The problem has happened here is because I did chair it, I signed it off
there [pointing to her entry in the ongoing record] but I didn’t sign it off on
here [pointing to the record of case review document] because I didn’t
know to do that and that’s the honest answer ... I didn’t understand all of
the bits of paper that I needed to fill in and I think that SO C sort of jumped
to my aid and put my name in at that time and wrote it as closed, that’s the
only way I can explain it.’
79. My investigator asked SO A when she thought SO C made his entries on the
record of case review, wondering if it was more probable he made his entry
on the very same day as she conducted the review or a week later, on 6
January 2009, when he carried out a post closure review. She replied that, in
her opinion, it was more probable that he had made his entry around 6
January because there is only one senior officer in charge of E wing at any
one time and on 29 December she was the SO in charge. On 6 January, she
calculated she was probably on a rest day and she surmised that he was
‘dotting the i’s and crossing the t’s that I’d omitted to do by filling in the form
for my error that I’d made’. Later in the interview she explained that she had
transferred to E wing just before Christmas after four years in the Security
Department and she believed that the ACCT review she conducted on 29
December was the first one she had done.
80. At the post closure review of the man’s ACCT on 6 January, SO C wrote that
the man was now very settled, though still concerned about the possibility that
he would have to share a cell on some occasion. He felt that the man had no
major issues and that his family life and medication problems had all been
resolved. There was no obvious evidence of suicidal ideas.
25
81. On 12 January, the man met with his Offender Supervisor for the first time. In
interview she explained to my investigator that she is employed by
Northamptonshire Probation and is based in the Offender Management Unit
at Wellingborough. She further explained that offender supervisors are the
link between the prisoner and the offender manager, the probation officer in
the outside community. She saw her role as being to drive the sentence plan
and to ensure that an OASys is completed on low and medium risk prisoners.
She defined OASys as a risk management tool that looks at all factors that
may contribute to why someone is offending. She added that OASys puts
together a risk management plan and a sentence plan in an effort to help
reduce the risk of further offending:
‘It looks at what can be put into place to address factors that contribute to
offending and also looks at practical resettlement issues in terms of
accommodation and employment, as well as offence related programmes.’
82. At the end of a one hour meeting between the man and his Offender
Supervisor, they agreed a number of action points, including that he would
apply for a drug-free wing where he would be subject to voluntary drug
testing; that he would attend Alcoholics Anonymous (AA) meetings; that he
would seek information on being an Insider (a scheme where prisoners
mentor new prisoners but it only ran on E wing which he was scheduled to
leave shortly); to consider re-training options whilst in custody. He also told
her that he was planning to appeal against his conviction and was waiting at
that stage to hear from his solicitor.
83. There is limited information about the man’s life on E wing after the ACCT
document had been closed. On 11 January 2009, Officer Q wrote that the
man seemed to be getting on well on the wing. He seemed happy, was
associating well, volunteered for cleaning and seemed to be quite jovial.
Officer Q could see no issues of concern at that time. On 12 January, the
same day as his first meeting with his Offender Supervisor, an officer made
an entry in the wing file to the effect that he had found burnt foil during a
routine cell search. (The presence of burnt foil would usually suggest a
prisoner had been taking illegal drugs.) When challenged after the search,
the man stated the foil was not his and that he was willing to go for a ‘piss
test’ if the officer wanted. The officer explained to him that he was the sole
occupant of his cell. The evidence which had been found could constitute
sufficient grounds for a mandatory drugs test based on grounds of reasonable
suspicion about his behaviour. The officer wrote that the man did not take this
information well and walked off with a negative mood.
84. On 22 January, the man wrote a formal complaint about the circumstances in
which his ACCT document had been closed on 29 December. In total he was
to write 12 formal complaints during his time at Wellingborough and this was
the second of the 12. (A formal complaint form enables a prisoner to
complain under the complaints procedure. The guidance at the top of the
form explains that wherever possible complaints should be sorted out
informally by a prisoner speaking to his wing officer or making an application.
Prisoners are advised that the complaint form should be used only if they
26
have been unable to resolve their complaints in that relatively informal way.)
He wrote his complaint in the following terms:
‘Upon having an ACCT closed by a woman SO on E wing I was told ‘it’s a
miracle, amazing’. When I asked what she meant she replied ‘Well, when
you want something else we’ll open an ACCT again. You got what you
want and you’re OK now!’ This was in front of Mrs P and a woman from
mental health. She also said she had never done an ACCT before. This
was said rudely, humiliated me and she was very patronising. I was only
on ACCT because my medication was not given correctly.’
85. The bottom of the complaint form invites a prisoner to say what he thinks
should be done about the complaint and the man wrote:
‘SO be properly trained in dealing with people who are mentally ill, as this
was not the type of behaviour I would expect from an SO and not setting
Mrs P a good example. SO to be cautioned as to taking an ACCT as a
joke! And not a way of prisoners getting things.’
86. The man’s complaint was sent to the governing Governor at Wellingborough.
On the back of the form the Governor thanked the man in writing for his
information and said he would pass the details on to his wing governor to look
into the matter. The man’s residential governor, in interview with my
investigator, was adamant that she had not received the complaint document
from the Governor at the end of January. When asked how she would have
expected the matter to be brought to her attention, she replied that she would
have expected to receive the complaint form directly from the Governor. She
was quite certain that the Governor had not given the document directly to her
at that time.
87. The member of staff the man had in mind when he wrote his complaint was
SO A and nearly two months would pass before an investigation was
commissioned into the allegations that he had made against her.
88. All 12 of the complaint forms written by the man during his time at
Wellingborough are listed in the following table:
27
The complaints made by the man at Wellingborough
Serial Date of Subject Date of reply Who replied? Comments
Number complaint
I2967/12/08 Not known Move to a single 29.12.08 A PO
cell or Seg.
E4115/1/09 22.1.09 Complaint about Interim reply on Governor Sent by
SO A 26.1.09 confidential
‘’I will pass the access. No
details to your substantive
wing governor’’ reply till
19.3.09
E4120/1/09 Not known Unacceptable 29.1.09 Governor Not a suitable
noise from cell subject for
2-21 confidential
access
C4323/2/09 21.2.09 Disburse cash 24.2.09 Finance Admin £150 given to
Officer cashier to
process
C4324/2/09 21.2.09 Broken window 23.2.09 SO Call logged with
in cell Planet FM
C4408/3/09 5.3.09 19 unanswered 9.3.09 PO Typed
apps. Transfer response. Have
only found four
apps
C4520/3/09 20.3.09 Missing items in 24.3.09 OCA No evidence of
cell, move out of transfer apps
here
C4573/3/09 29.3.09 Move to any 31.3.09 OCA Manager No record of
other prison any transfer
apps
C4574/3/09 29.3.09 Cell window 1.4.09 Site Manager One of my
won’t shut managers will
look at this
C0001/4/09 30.3.09 I am being 2.4.09 OCA Manager Transfer
victimised application. is
on its way to me
C0002/4/09 30.3.09 Gym session 1.4.09 PAMS Admin PAMS informed
cancelled Officer by gym you
were missing
C0044/4/09 4.4.09 Previous 6.4.09 Governor Sent by
complaints not confidential
answered, I am access.
being victimised I will ask Duty
Govr. to deal
with this matter
C0054/4/09 4.4.09 Same complaint 7.4.09 Duty Governor We met today in
as above the motorbike
workshop
89. Also on 22 January, Officer J made an entry about the man in the wing
observation book. (This is a book used by staff to bring information of
28
importance about prisoners on the wing to the attention of their colleagues.)
Officer J, who had opened the ACCT document on the man a month
previously, made the following entry:
‘Had an outburst this morning on the landing saying he wasn’t going to do
anything or leave the wing until we sorted our computers out. He has also
submitted an app [application] saying he has baseline subliminal
messages constantly in his head. This has all come about because he
has stated his date of birth and release dates are wrong on LIDS.’
90. LIDS is an abbreviation for Local Inmate Database System, a computerised
system used by the Prison Service to store information about every prisoner
in custody.
Transfer to C Wing on 27 January 2009
91. On 27 January, the man was transferred from E wing to C wing. He was
located in cell C2-15, a single cell on the top floor of C wing at the far end of a
spur (bank of cells). He was the sole occupant of cell C2-15 and that
continued to be his cell until his death in April 2009. Officer R made a note in
his wing file that a particular officer was to be his personal officer and that the
man was happy to be on the wing. There is no record of any contact between
the man and his personal officer until mid March. In interview Officer B told
my investigator that the personal officer had been unwell at the time and had
subsequently transferred from being a prison officer to other duties.
92. Also on 27 January, the man was reviewed on the wing by mental health
Nurse A. In his electronic patient record, she recounted that, whilst he
appeared settled, he had reported experiencing sensations of something
brushing against his body when he was in bed at night. This had the effect of
making him scream in fright. He did not believe this to be related to previous
drug use. She does not indicate whether this contact was on E wing or C
wing. I believe it was the former because the time of the entry is 10.36am and
he did not move to C wing until after lunch that day. Further internal evidence
is that he complained to her about the noise being made by stereos on the
wing and his belief that officers were ignoring the matter. At around the same
time he had submitted another formal complaint form on which he gave his
location as E wing and said that he had already spoken about the matter to
the principal officer on E wing. The burden of his complaint was about a
constant unacceptable level of noise coming from cell 2-21 even when the
occupant of that cell was not on the landing or in the cell.
93. On 28 January, Officer S made an entry in the man’s wing file, saying that the
man had approached him at lunchtime and told him that a razor blade had
been left in his food the previous day. Officer S submitted a Security
Information Report (SIR) and a Violence Reduction Incident Alert Report
(VR1) to the appropriate departments in the prison. On the VR1, which is
used to report any incident that might relate to anti social, unacceptable or
violent behaviour, he ticked the categories that seemed to apply as being
assault, bullying and threats other. In section two of the form he wrote:
29
‘At lunchtime on 28/1/09 the man spoke to me on the landing and told me
that the day before he’d put his sandwich in his cell and went to get his hot
water. When he returned there was a razor blade in his sandwich. This
prisoner is new on the wing.’
94. Officer S reported in section three of the VR1 form that he had informed his
line manager and made an entry in the wing observation book.
95. The department at Wellingborough responsible for both suicide prevention
and violence reduction was named Prisoner Care at the time although this
has subsequently been changed to Safer Custody. A SO was the full-time
Prisoner Care co-ordinator. He decided that Officer S’s report should be
investigated by a manager from the Residential One group of staff.
96. An account of his investigation was given by SO D on a VR2 form on 2
February. He wrote:
‘I have spoken to the man about him finding a razor blade in his baguette
on Tuesday teatime on C wing, he does not know who would do this and
can only assume it was some type of intimidation from a prisoner on the
wing.
‘He has no obvious problems with any prisoners and thinks it may be due
to his large stature and being new on the wing. Despite this he has not
received any direct threats and nothing else has happened since this time.
I have asked him if he feels safe on the wing, this he does and will report
any further instances to wing staff.’
97. SO D’s opinion was that no further action could be taken at that time as there
were no identified perpetrators and that was therefore the box he ticked in
section five at the bottom of the VR2 form. The following day the Prison Care
Co-ordinator closed the case on the Violence Reduction Case tracker form
(VR11) by ticking the necessary box in the closure section of the form to say
that the required further action had been completed. The SIR submitted by
Officer S also, reassuringly, led to the Prison Care Co-ordinator receiving an
e-mail from a member of the Security Department on 30 January. She asked
the Prison Care Co-ordinator to monitor the situation and inform the Security
Department of any further information.
98. The razor blade in the man’s baguette appears to have been an isolated
incident because there is no other evidence that he was under any kind of
threat or pressure from other prisoners during the three and a half months he
spent at Wellingborough. The incident occurred just a few hours after his
arrival on C wing and many staff and prisoners commented to my
investigators about the man’s imposing physical presence. On arrival at
Wellingborough on 19 December, Nurse D recorded his height as being 1.88
metres (6’ 2’) and his weight as 118 kilograms (18 stones 8 pounds). A
representative account of how he was seen by other prisoners on the wing
30
was given to my investigators by a fellow prisoner. In interview he said that
the man:
‘… was a very nice fellow and didn’t have any enemies or anything, he
was a really quiet lad.’
99. Later in the interview he added:
‘… he struck me as a happy go lucky, jolly fellow he was. Really quiet, he
never really mixed with a lot of different people in the wing, but never had
any enemies, if you know what I mean, either. Just kept himself to
himself, he used to chat to us travelling lads on the wing.’
100. On 30 January a consultant psychiatrist, who is contracted to visit
Wellingborough on a fortnightly basis, saw the man for the first time and
conducted a detailed psychiatric assessment. Nurse A, who had reviewed the
man on the wing three days previously, made a note in his electronic patient
record after the consultation with the psychiatrist which said:
‘Diagnosis: depressive illness, relevant in nature. Plan: try a five day
sleeping pill, review next week, consider increase in Fluoxetine.’
101. On 3 February, the man submitted an application (log number C174/09) to his
personal officer.
102. A table of all 19 applications made by the man on C Wing follows:
31
The applications made by the man on C Wing at Wellingborough
No. Date Sent to What Response Who Z Answer Notes made
+ log logged about? from? drive by my
no. investigator
1) 29.1.09 OMU Enrol for Yes Admin ETS app.
C137 any courses officer form
Enclosed
30.1.09
2) 29.1.09 Prisoner monies Do not
C141 have form
3) 31.1.09 Reception Do not
C152 have form
4) 3.2.09 Personal officer Emergency No Reply not
C174 pin credit known
5) 16.2.09 Security Phone nos. Y Security No issues White copy
C222 off mobile in 4.3.09 in cell
property
6) 17.2.09 Personal officer Do not No
C225 have form
7) 22.2.09 Pin phones To add 2 months
C247 partner, after arrival
mother, at W’boro
friend to list
of nos.
8) 22.2.09 Reception Post bank Y Reception No Card White copy
C248 card to handed in cell
partner out on
25.2.09
9) 25.2.09 Governor Have you Y Residential Have not White copy
C255 received my Gov received in cell
formal complaint
complaint?
6.3.09
10) 3.3.09 Reception I would like Y No We will White copy
C278 to sign arrange in cell
Halifax
bank cards 4.3.09
11) 5.3.09 Pin phone Add nos. to Allowed list
C288 my pin shows they
were added
12) 5.3.09 OMU Meet to Reply not Did meet on
C292 discuss my known 11.3.09
sentence
plan
13) 5.3.09 Reception Do not No
C293 have form
14) 9.3.09 Governor Outcome of Y Governor Will White copy
C320 complaint? respond in cell
within 14
days
15) 19.3.09 OMU IMB would Y Offender Reception White copy
C358 not have Supervisor has in cell
received my received.
app. Have Nos. 358,
copied to 359, 360
IMB also
allocated to
another
32
16) 19.3.09 Governor 19 Y PO No Please prisoner
C359 unanswered advise
apps., move what you White copy
me now are in cell
asking for
27.3.09
17) 19.3.09 Allocations/OCA Move me to Y OCA Co- No White copy
C360 Acklington ordinator transfer in cell
request
from you
24.3.09
18) 31.3.09 Personal officer Applied Don’t No
C423 and OCA again for have reply
Acklington
19) 2.4.09 Wing SO Do not No
C435 have form
103. The man wrote that he had applied to SO C on E wing the previous week for
emergency PIN credit as he had large problems outside prison. On 11
February, he wrote a letter which was in the file of documents from the
Offender Management Unit made available to my investigators after his death.
The letter does not indicate to whom it was addressed and says:
‘In light of recent events in my life outside of HMP Wellingborough I have
applied multiple times to take telephone numbers off my mobile which is
held in Property and one app is dated 13/1/09 and this seems to not be
happening. Also I have tried as to date unsuccessfully to forward some of
my private money from my account to my partner to allow her to visit me at
HMP Wellingborough … Can I have emergency PIN credit so I can speak
to her and get new address.’
104. The psychiatrist saw the man on both 13 and 20 February. His note on 13
February in the man’s continuous clinical record observed that he remained
low in mood with increased anxiety and increased muscular tension in his
body. The man had increased aggressive thoughts and feared he would lose
control. His sleep was interrupted and his energy and concentration were
diminished. The psychiatrist noted that the man had no suicidal thoughts or
thoughts of harming others. He wrote a four-fold plan in the clinical record:
1. Fluoxetine to be increased from 40 to 60 mgs per day.
2. Diazepam to be prescribed for the next seven days.
3. The man to be reviewed the following week in clinic; and
4. RMN (Registered Mental Health Nurse) to follow up.
105. The psychiatrist saw the man for a third and last time on 20 February. On that
occasion he wrote in the clinical record that the man’s mood was lifting and he
had no muscular tension or aggressive thoughts but his sleep was still
interrupted and his energy level was still low. On this occasion the
psychiatrist’s plan was that the man should have Zolpiden tablets for three
days and he should be followed up by the RMN.
33
106. The psychiatrist also decided that the man could have his tablets in
possession ‘after sleeping’. Nurse A’s electronic note about this in the man’s
patient record was that he should have Zolpiden for three nights (to help him
sleep) after which he ‘may have IP [in possession] medication’. A further
note by her at 1.54pm on the afternoon of 20 February said that he was to
have Zolpiden for three nights after which ‘to continue with prescribed anti
depressant [the Fluoxetine] on an IP basis’.
107. The man wrote two formal complaint forms on 21 February. In the first of
these (serial number C/4323/2/09) he complained that he had been trying to
disburse cash to his partner for four weeks but his requests had been
repeatedly cancelled for no apparent reason. On 24 February an admin
officer in the Finance Department wrote back to him:
‘As we have received several applications and phone calls from the wing,
this has created confusion over which ones you wanted processed and
hopefully now this has been sorted. Today I have deducted £150 and this
will be given to the cashier to process.’
108. The second complaint form written on 21 February was about a broken
window in the man’s cell. He wrote that it had been broken since he moved in
four weeks previously and that it allowed snow storms and cold weather to
enter the cell. He also complained that his window would not shut. He asked
for the glass to be replaced and the window fixed so that it could close. In
response SO E, of the Residential One group, wrote that a call had been
logged with Planet FM to request that the Works Department repair the
window. My investigators interviewed the Site Manager at Wellingborough on
28 May about the broken window. He explained that Planet FM is a
computerised system used in Wellingborough and most other prisons to
record service request jobs and small repairs. He gave examples including
broken glass, a broken light, a water leak or a broken tap. He said that the
window job in the man’s cell was received on his Planet FM system on 24
February at 12.30pm. The job was then issued to one of his painters who
does repairs to glass around the prison. He said:
‘The job was given to one of my members of staff and the job took three
hours to do. He did three hours of work and he closed the job off on the
25th.’
109. The Site Manager explained further that at the end of each day each member
of his staff has to put in a timesheet on which they log the number of jobs they
have undertaken. If the job has not been completed, that information would
be supplied on the timesheet. In this particular case, his information was that
the necessary job had duly been completed.
110. By 24 February a month had passed since the man had submitted his
complaint about SO A to the governing Governor. Since he had received no
reply, he wrote an application (log number C255/09) to the Residential
Governor. He asked her if she had received his formal complaint, for which
he supplied both a reference number and date. He said that the governing
34
Governor should have forwarded the complaint to her on 26 January. He
asked her to contact him if she needed any further information or could let him
know the outcome. In response she wrote to the man on 6 March, telling him
that she had not received a copy of his complaint but that she would enquire
about it and respond to him accordingly.
111. On 2 March, the man began full-time work in the motorcycle maintenance
workshop, a job he retained until the time of his death. He had filled in an
application to work in the motorcycle shop on 29 January. He had to satisfy
some basic health and safety rules and regulations in areas such as fire
awareness and evacuation from workshops in case of emergencies before he
could start full-time work. In interview one of the two instructors in that shop
explained that the man had done general maintenance work on motorbikes,
‘assessing brakes, assessing wheels, tyres, that sort of thing’. He described
him as a hard worker who came down to the shop and got on with his work.
112. The man told his instructor that he enjoyed the work and liked to be in the
workshop. He spent a lot of time there and, according to the Instructor,
seemed happy there, getting on with his work. He confirmed my investigator’s
assumption that the man was one of the better qualified prisoners in the shop
at that time. He recalled that, although it had been the man’s first time in
prison, he seemed to interact very well with the other men and, if another
student seemed to be struggling, the man who is the subject of this report was
always happy to lend him a hand:
‘He seemed to enjoy his work but saying that he would also stop work to
help other students if they needed a hand. He was always very helpful to
other students and very knowledgeable.’
113. On 5 March, one day before the Residential Governor’s response to his
application of 25 February, the man submitted another formal complaint with
serial number C/4408. In this complaint he said:
‘I believe that since putting a complaint in January against SO on E wing
not only has nothing been done about it but I have 19 unanswered
applications. [He wrote 19 both in words and numbers and underlined
both.] Many requests for cash disbursal denied until after five weeks and
filling out formal complaints. And no response to prison transfer. I totally
believe that I am being victimised because of my original complaint,
ignored apps regularly.’
114. The man ticked a box to say that he believed his complaint was about bullying
and, in the section asking what he wanted to see done, he responded that he
wished to be moved to another prison as per request and then added
‘Acklington asap’.
115. The man’s complaint was answered by PO A. In interview she told my
investigator that she had worked at Wellingborough as a principal officer for
four and a half years. At the time that she replied to him she was the principal
officer on Residential One, which comprised A, B, C and D wings. She wrote
35
to him that she was unable to comment on the E wing SO complaint as she
believed that was a confidential access complaint to which she did not have
access. She added that she had checked the applications database and had
found:
‘… only four applications, of which education and OMU [Offender
Management Unit] have replied and the governor (x 2) replied stating that
they could not find your application.’
116. She wrote that she could find no record of 19 applications.
117. At page 13 of her interview with my investigator in late May 2009, PO A was
asked if at the time she would have been concerned that 15 of the 19
applications that the man said he had completed could not be traced. She
was asked if that was ‘par for the course’ at Wellingborough and, in a very
striking response, she said: ‘I regret to say it’s par for the course.’ She
apologised to the man for the delay in organising his cash disbursement and
at the end of her response told him that she had checked the transfer
database, on which his name did not appear. She had contacted OCA (the
Observation Classification and Allocation Unit which is responsible for
arranging transfers in and out of the prison) to confirm whether they had
received an application from him and, if so, its status. She closed by advising
him that, if he had not already submitted a transfer application, he should
speak to wing staff who would give him the relevant paperwork.
118. The man sent a further application to the Residential Governor on 9 March.
On the form at the section headed ‘Details of my application’ he wrote:
‘Have you received complaint serial number F/4115/1/09, it should have
been sent to the Residential Governor on 26/1/09 from the Governor. Can
she update me as to outcome.’
119. The Residential Governor wrote back the same day to say that she had
already responded to this application, that she would obtain a copy of his
original complaint and she would respond to him within 14 days.
120. On 11 March, an important meeting was held in the OMU to review the man’s
sentence plan. The meeting began at 10.30am and was attended by the
man’s offender supervisor and the man himself. The man’s Offender
Manager in Northumberland did not attend in person but was in telephone
contact throughout. In her feedback, the Offender Supervisor wrote that:
‘The man is currently a standard regime prisoner and has no adjudications
to date. Since arriving at Wellingborough he has completed applications
for CARATs, IMB, VDT and drug free wing. Also attends AA meetings on
a Tuesday evening and has expressed an interest in becoming involved in
the PASRO mentoring scheme. [In interview she explained that PASRO is
a course that addresses drug use and is an abbreviation for Prisons
Against Substance Related Offending. Each prison has a CARATs team
of drug workers who support prisoners who have problems with drugs,
36
including alcohol.] ACCT was opened on 23.12.08 to 29.12.08 – the man
reported that this was due to feeling extremely depressed and down about
his current situation. No self-harming. He tells me that he suffers from
depression and is prescribed anti depressants. MHIT [Mental Health
Inreach Team] assessment has been completed’.
121. In the section of the sentence plan form dealing with an offender’s self-
perception, the Offender Supervisor wrote:
‘The man is currently in the process of appealing against sentence.
Although he has completed numerous applications, he has expressed
concerns that they have not been received. He acknowledged the benefits
of retraining whilst in custody as his previous employment will not be
available to him on release. Also expressed an interest in becoming
involved in PASRO mentoring scheme, drawing on his previous
experience of working with Lifeline on a voluntary basis. He has recently
completed an application requesting transfer to HMP Accrington [sic, this
should read Acklington] ’
122. Four objectives were listed in the objectives setting part of the form. The first
was that the man should attend a CARATs assessment so that he could
engage with CARATs to identify any ongoing issues regarding drugs and
alcohol. The Offender Supervisor wrote that he was currently attending AA
meetings. A second objective was that he should comply with voluntary drug
testing and it was noted that he had applied to the VDT (Voluntary Drug
Testing Unit). A third objective was that he should increase his work related
skills and she wrote that he was currently attending the motorcycle workshop.
It was agreed that he should engage with the Information and Guidance Unit
in the Education Department to discuss a structured learning plan. The final
objective agreed with him at this sentence plan review meeting was that he
should work towards category D, enabling him to move on to an open prison.
The attributes that were written down as being required were positive
behaviour and attitude, prison employment, remain adjudication free, achieve
enhanced, constructive use of time. (The Prison Service’s national Incentives
and Earned Privileges Scheme has three levels, with basic being the lowest,
standard in the middle and enhanced as the highest level a prisoner can
attain.)
123. The eighth paragraph of the sentence plan document included a space for the
offender manager’s comments. The Offender Manager acknowledged the
man’s willingness to use his time constructively and supported his interest in
becoming involved in a drug mentoring scheme. She advised him that she
would be willing to meet with his partner if she would find this helpful. It was
agreed that the OASys and sentence planning documents would be reviewed
once his appeal process had been completed.
124. Following his sentence planning board the man lost no time in submitting an
application for transfer to Acklington. The very next day he completed his
section of a document headed ‘HMP Wellingborough – Prisoner Transfer
Application’. On the form he wrote that he wanted to go to Acklington. As a
37
reason for transfer he wrote this would be easier to receive visits. He added
that he was being victimised in Wellingborough for complaining about a
Senior Officer and that his probation officer supported and recommended the
move. Although he completed his section on 12 March, the form still had
several stages to pass through before it reached the OCA Department for
their decision as to whether he met the criteria for the prison he had
requested. Three intervening people had to comment on his application
before it reached the OCA Department and the first of these comments from
his personal officer was not written until 31 March, 19 days after the man
wrote his request.
125. No entries were made by staff on the man’s wing file between 28 January and
13 March, but on the latter date an officer wrote that he had taken over as
personal officer. He completed a monthly IEP review and wrote that there
were no issues or problems.
126. The Offender Supervisor sent the man a note on 16 March to let him know
that she had contacted various departments with regard to applications he
had submitted. At his sentence planning board the previous week, he had
expressed concern that he had completed numerous applications but they
appeared not to have been received. She was therefore being commendably
supportive and proactive by endeavouring to find out what had become of
these applications. She reported that CARATs and the Independent
Monitoring Board had not received his application. She had completed a
referral to CARATs and hoped they would contact him soon. In fact the case
record maintained by her CARATs colleagues at Wellingborough states that a
referral was not received from her until 6 April and, when a CARATs worker
attempted to see him the following day, he was unavailable because he was
in the motorcycle shop. He had not been seen by the CARATs team by the
time of his death. The Offender Supervisor reported that the IMB would not
accept a referral from her, so he would need to complete another application
to them. She indicated that the OCA had not received his transfer form so
unfortunately that would need to be resubmitted. She asked him to let her
know if there was any progress with his appeal.
127. On 18 March, the man wrote three further applications. One of them was
addressed to his Offender Supervisor. In it he wrote:
‘IMB would not have received my app because as I have stated none of
my apps get answered and just seem to vanish!’
128. The man wrote that Offender Management did not apply to him because he
was not an offender and that, if the prison would not co-operate with him, he
was not going to co-operate with anyone else. The Offender Supervisor wrote
a response, dated either 23 or 25 March, which said that Reception/Property,
as well as herself, had received his applications and, as mentioned in her
recent note of 16 March, she had completed a referral to CARATs. She
assured him that she had copied his current application to the IMB and she
was hopeful that they would arrange to see him. She reiterated that the IMB
were not prepared to accept a referral from her on his behalf. Documents
38
supplied to my investigator by the Chair of the Independent Monitoring Board
at Wellingborough indicate that the man’s application of 18 March was indeed
received by the IMB and given log number 34/09. He had important contacts
with two members of the IMB in April, to which I will refer in due course.
129. The second application form completed by the man on 18 March is shown on
the C wing applications log as having been sent to the Residential Governor,
but at the top of the form itself she has been crossed out and a tick has been
put against wing manager instead. On the form the man wrote that since he
had put in his complaint about the SO he had 19 unanswered applications:
‘… which I have proof of five prison transfer apps, of which none have
been received by OCA. In the past two months I’ve repeatedly asked for
IMB request form and still not got one. This is victimisation. Move me
now.’
130. The response to this application was written by PO A on 27 March and asked
the man to advise what he was asking for.
131. The third application form completed by the man on 18 March was addressed
to the Allocation/OCA Department. On the form he wrote that he had applied
to move to Acklington over five times:
‘… and my Probation tell me I ain’t even on the list. If it’s too far for
Probation to come and see me, which the Offender Manager says it is,
then it’s too far for elderly parents to travel to see me. Move me.’
132. In a response to the man’s application dated 24 March the OCA Co-ordinator
wrote that they had not received a transfer request application from him. She
invited him to submit one and it would then get processed.
133. On 19 March, nearly two months after the man had submitted his complaint to
the Governor about the way in which SO A had conducted his ACCT review
on 29 December 2008, he was sent a memorandum of reply from the
Residential Governor. In interview, she told my investigator that she believed
she had received an application from the man on or around 19 March
querying her response to the complaint he had made about SO A in the 22
January document with serial number F/4115/1/09. She told my investigator
that on 19 March she was able to identify the complaint number on the
original complaint. She could therefore track it with the complaints clerk,
which is when she discovered that the man was waiting for her to respond to
him.
134. The Residential Governor said that when she received the complaint on or
around 19 March, she asked one of the principal officers, PO B in the
Operations Group, to investigate the matter for her by examining the ACCT
document and speaking with relevant people. In an undated document PO B
wrote that he had been tasked by the Residential Governor to look into events
during an ACCT review that took place on 29 December. PO B wrote that at
the time the man was due a routine ACCT review in the presence of SO A,
39
Officer P and mental health nurse, Nurse E. PO B reported that
approximately a month after the review the man complained about the way
SO A had conducted the review, alleging that she had been rude and
patronising and that she was not qualified to carry out this review. PO B
added that he had spoken to both Officer P and Nurse E to ascertain the
facts.
135. Officer P remembered that the review was held in the back office in E wing
and that SO A and Nurse E were in attendance. His recollection was that SO
A was direct with the man; she stated facts and listened to his replies. In his
opinion SO A had been forthright without being rude and did not attempt to
humiliate the man.
136. Nurse E recalled that the man had two issues at the review, one being his
medication and the other his desire not to be located in a double cell. At the
time of the review both of these issues had been resolved and that is why the
ACCT had been closed after discussion with all parties present. Her opinion
was that SO A had been business-like in her approach. She believed that SO
A had conducted herself and the review in a professional manner:
‘… only guilty of being to the point and in no way rude or patronising.’
137. Despite the fact that the man had complained about humiliating treatment by
SO A and that she had taken the ACCT as a joke, PO B did not include any
response from SO A in his report to the Residential Governor, nor did he
explain in his report why he had not done so. In interview the Residential
Governor told my investigator that she believed PO B had written the report
on 19 March, a day when SO A was not on duty. She said she was aware
that nearly two months had passed since the complaint had initially been
submitted and she decided that she must expedite a response rather than
leave it any longer.
138. The Residential Governor’s memorandum of 19 March to the man informed
him that she had obtained a copy of his complaint and the matter had been
investigated. She wrote that the staff involved in his ACCT review both stated
that SO A had been professional and in no way rude or patronising. The
issues that had been raised on his ACCT document had been resolved by the
review and, with the agreement of all, the document had been closed. She
informed him:
‘I am satisfied that SO A acted professionally at all times during this
difficult time for you and I will not be pursuing the matter further.’
139. On 20 March, two days after he had sent an application form to the OCA
Department stating his wish to be moved to Acklington, the man completed
another formal complaint form, serial number C/4520/3/09. In the complaint
section of the form he wrote that it was now the fifth time that he had applied
for transfer. He said he had proof of 19 unanswered applications and warned
that he should not be fobbed off. He alleged that since Security Department
staff had been in his room, his ID card, a book of ten stamps and envelopes
40
had gone missing. He added that he never left his door open. He wrote
‘Move out of here’ in the box which invited him to say what should be done
about his complaint. On the reverse of the form a response was written by
the OCA Co-ordinator on 24 March, the very same day on which she
responded to the application of 18 March about transfer. Her response said:
‘I have checked our records and can find no evidence that you have
submitted any transfer application. Please contact your personal officer
who will complete the official transfer application for you. Once I receive it
in the OCA Department, it will be processed immediately.’
140. On 23 March, the man sent a complaint to the IMB at Wellingborough. He
wrote that he had made a confidential complaint against a senior officer and
since then he had proof of 19 unanswered applications. He also wrote of five
prison transfer requests that the OCA claimed not to have received and cash
disbursement requests and property handout forms which were ignored or
cancelled. He wrote that the person who was meant to be dealing with his
complaint had not received it even two months later and in his opinion he was
clearly being victimised because of the serious complaint he had put in. He
said he had spent five weeks in a cell without a window despite requesting
that it be fixed and he asked the IMB to help him get moved out of
Wellingborough soon.
141. Also on 23 March, the Offender Supervisor sent a memorandum to the IMB
attaching a copy of a recent application ‘received by the above named
prisoner’. She wrote that the man had told her that he had previously
completed applications asking to see a representative from the IMB but he
believed they had not been received. She asked for him to be seen by a
member of the Board. My assumption is that the application to which she
referred was the one written by the man on 18 March as in the lower half of
that document she wrote to him that she had copied ‘this application to IMB
who will hopefully arrange to see you’. The IMB’s log of applications received
shows two from him in March 2009, one dated 18 March and the second
dated 23 March. A second member of the IMB at Wellingborough went to see
the man about his two applications on 8 April, the day before his death. By
that date he had already had very significant interaction with another member
of the IMB, on 2 April, exactly a week before his death.
142. On 29 March, the man submitted another formal complaint form in which he
again complained about the delay in transferring him and about being
victimised. In the complaint section of the document he wrote:
‘Weekly for over 2 months I have applied to have a prison transfer
supported by Probation and OMU. OCA still have not received my app.
Also weekly attempts to contact IMB and no contact. I have proof of over
19 unanswered apps and strongly suggest this is because of a complaint I
put in against SO on E wing which coincidentally the Residential Governor
never received! I am being victimised. Sooner or later an inmate being
treated this way will snap. Everything I put my name to goes in the bin!
41
From cash dispersals to general apps! I am being treated unfairly and
have reported all this previously. It’s gone on too long.’
143. The man wrote that he wanted three things to be done. He wished to be
moved to any other prison, he wanted contact with the IMB and he requested
an investigation as to why his complaint (about SO A) had been covered up
and not received by the Residential Governor until he brought it to her
attention. This complaint was received by the Complaints Clerk on 30 March.
The following day the OCA Manager wrote a response which informed him
that she had no record of any transfer applications from him on the transfer
database. She added that as soon as an application from him was received it
would be actioned. Also on 29 March, he wrote a second complaint form
about the window in his cell, having previously complained about it on 21
February. He wrote that the window would still not shut and he was suffering
from sub zero temperatures and snow storms in his cell. He acknowledged
that the glass had been replaced but concluded by observing that, as usual,
all his applications got ignored. In the box on the form asking him to write
down what should be done about his complaint, he responded as follows:
‘Supply body warmers, in cell kettle and thermals to keep warm or fix
window. As this seems to be unmanageable transfer to a prison that will
answer my apps and does not underperform as badly as this place.’
144. The response to the man’s complaint was supplied by the Site Manager on 1
April. He wrote that the man’s window had been reported to his department
on 24 February and fixed on 26 February. He said that no further reports of it
still being broken had been received until now. He indicated that he would
send one of his managers to look at the problem as soon as he could.
145. When my investigator interviewed the Site Manager about the window in the
man’s cell and related matters, he revealed that there had been additional
contact with his department on 24 and 25 March. He referred to a call on the
Planet FM system from Officer T on C wing. Service request W000607231
described the problem as being that the window pane had come out of the cell
window and the instruction was that cell C2-15’s window needs sticking back
into frame. The Site Manager told my investigator that the problem was
reported by Officer T at 9.13am on 24 March and fixed the same day. He said
that one of his painters had done the repair on 24 March and handed in his
timesheet to that effect that evening. The timesheet was processed by an
administrative colleague in his department and showed the job as being
closed on 25 March.
146. In relation to the man’s complaint of 29 March, the Site Manager’s written
response that there had been no further reports about the window since 26
February overlooked the repair on 24 March referred to in the previous
paragraph. He explained that the Planet FM system is very complicated and
it can be very difficult to find reports about specific cells due to:
‘.. the way that people put the service request actually onto the system.
They’re not very specific … and then when you come to try and find that
42
on our system, you’ve got to go through every single item that’s happened
on that wing.’
147. My investigator asked the Site Manager if the promise that the manager would
look at the window had been kept. He said that the manager had done so on
the same day that he wrote his reply to the man. There was no document
about the visit because he is a manager and the Site Manager said that
managers are not issued with job sheets, so the instruction from himself to the
manager was conveyed verbally.
148. The man wrote two further formal complaints on 30 March. The first of these
(serial number C/0001/4/09) highlighted, for the second day running, that he
was being victimised. In the complaint section of the document he wrote:
‘I am being victimised. None of any of my applications (now 20+) ever get
processed. Now 7 apps for transfer not received by OCA! This is very
frustrating and causing me many problems and unacceptable.’
149. In the bottom section of the form he requested, for the second day running, to
be moved to a prison which did not underperform as much as
Wellingborough.
150. This complaint of 30 March about the failure to transfer him was submitted
prior to the OCA manager’s response to his complaint written the previous
day. She also wrote the response on 2 April to the 30 March complaint and
said:
‘I have spoken to your personal officer who states that he is only aware of
one transfer application that was submitted by yourself yesterday (1/4/09)
and is currently on its way to me. When I receive it I will forward your
details to Acklington.’
151. The man’s second complaint on 30 March was about the cancellation of his
weight training session in the gymnasium on the morning of 18 March.
Apparently the session had been cancelled because he had not attended the
equivalent session on Wednesday 11 March. (Of course on that date he had
been required to attend the very significant sentence planning case
conference in the OMU with his Offender Supervisor and his Offender
Manager.) He threw down a challenge in his complaint. He said:
‘The gym say I was not there! Work say I was not at work and wing staff
know I was not on the wing. So where did I evaporate to from 10.30 to
11.45 on Wednesday 11/03/09.’
152. The responses that the man wanted to his complaint were that PAMS should
be issued with a notification of bad behaviour for not knowing where he was
and his second moves session in the gymnasium should be reinstated.
(PAMS is an abbreviation for Prisoners Allocation Management System and
was described to my investigator as a timetable which enables staff to predict
a prisoner’s movement for a whole week at a time.) He tantalised his readers
43
by writing that he had proof of where he had been but did not indicate on this
complaint form that he had been perfectly lawfully in the Offender
Management Unit at the disputed time.
153. The response to the man’s complaint was written by an administrative officer
in the PAMS office. She attached a copy of his personal activity programme
for the working week from 9-13 March 2009. The major movement of
prisoners to work at Wellingborough is at 8.45am and 1.45pm but there is a
second opportunity (second moves) for prisoners to move to work, education,
gymnasium or other approved areas in the middle of each morning and
afternoon.
154. The man’s personal activity programme for the week beginning Monday 9
March showed that he should be in the motorcycle shop throughout Monday,
Thursday and Friday of the week. On Tuesday and Wednesday he was
required to be in the motorcycle shop for three of the four working sessions
and was permitted to attend the gym for weight training from 10.00am till
11.45am on both days.
155. The administrative officer’s written reply was as follows:
‘On 11/3/09 (see attached print-off) you should have been at the gym,
second session, PAMS were informed by the gym that you were missing
and issued you with a notification of bad behaviour. There was no reason
given by the wing to tell us you couldn’t go to the gym.
‘If you have any other queries please speak to the wing or gym and/or
provide evidence of where you were.’
156. On 31 March, the personal officer made a second personal officer entry on
the man’s wing file. He wrote ‘transfer app processed, 6 months wing history
attached and passed for SO’s [attention]. No other issues at present.’
157. On the prisoner transfer application form, underneath the reasons for transfer
supplied by the man on 12 March, the personal officer made an entry in the
personal officer comments section of the form to the effect that the man was
reasonably quiet on the wing, associating well with staff and other prisoners
and there were no issues. The senior officer who wrote the next section on
the form on 1 April said that he/she supported the officer’s comments.
158. It is possible that the personal officer’s activity on 31 March was prompted by
an application the man wrote on 30 March. This application, the penultimate
one of the man’s 19 applications on C wing, was received on 31 March by
Officer T and was entered on the C wing applications log on the same day.
The boxes ticked at the top of the application were personal officer and
allocations/OCA and on the document the man wrote:
‘I have recently applied again to move to Acklington, as requested by OM
and OMU. Have you received the application because all previous
attempts have never been received.’
44
159. On 1 April, the man wrote a letter headed ‘Notification of Bad Behaviour’. I do
not know if he had already received the response written by the administration
officer on 1 April to his complaint of 30 March about the cancellation of his
gym session on 18 March. His letter appears to suggest that a ‘Notification of
Bad Behaviour’ form should be issued to the PAMS office for the reason that:
‘For issuing a Bad Behaviour notice to the man and cancelling his gym
session on 18/03/2009 for not attending gym on 11/03/09 10-11.45. If I
was not at work, gym or on the wing please tell me where you think I was
because it is your job to know where I was, not my responsibility to run
round informing everyone just in case they feel like cancelling my
sessions.
‘Alternatively cancel my notification of Bad Behaviour with a Good
Behaviour notification, reinstate my gym session and let me wear my little
gold star like a little school kid or ask me where I was and I may tell you
what you should have been telling me!’
160. The following day an administrative clerk in the Labour and Regimes Office at
Wellingborough wrote to the man, explaining in the first paragraph of his letter
that it was being sent in response to his behaviour that morning in the Labour
Office and the notification of bad behaviour issued on 11 March for non
attendance in the gym.
161. The clerk reported that he had made further enquiries as to the man’s
whereabouts on 11 March and it transpired that he had had a telephone
conference in the Offender Management Unit with his offender supervisor and
offender manager. His letter went on:
‘Your Offender Supervisor however did not make the appointment through
the PAMS office, because of this we were unaware of any such telephone
conference. That is the reason you were recorded missing from the gym
and issued the Notification of Behaviour.
‘In light of this I have no option other than to revoke the Notification of
Behaviour I issued that day. I will of course inform wing staff so an entry
can be made in your wing history to that effect. However because of your
disrespectful attitude and behaviour displayed to my colleague and myself
this morning in the Labour Office, I am issuing you with a Notification of
Behaviour.’
‘Your attitude and behaviour was unacceptable and will not be tolerated.
Any further instances will result in disciplinary action being taken.’
162. The clerk attached a new Notification of Behaviour (NOB) form to his letter.
The NOB was dated 9.00am on 2 April. It notified the man that he had been
given the document for unacceptable behaviour, namely disrespectful
behaviour and poor attitude towards staff in the Labour Office. The document
informed him that if he wished to appeal against the notification of
45
unacceptable behaviour he should do so within seven days via an application
to his wing senior officer.
163. My investigator interviewed the clerk about the circumstances that had led to
the writing of his letter and issuing of the NOB form on 2 April. He explained
that at the material time he was employed as an administrative clerk in the
PAMS and Labour Office which deals with prisoners’ movement, allocation
and work. The first and only time when he saw the man was at about 9.00am
on the morning of 2 April, which was a time of mass movement to work or
gymnasium or else of prisoners coming back from exercise and returning to
the wing. He said that the man came in:
‘… very abrupt in his manner and he had a piece of paper in his hand
which was folded at the time, which he threw. He came into the office,
stood next to one of the desks and threw it onto my colleague’s desk.’
164. The clerk told my investigator that he had never seen the man before that
day. He asked the man who he was and what his sudden visit was all about.
The man told him that if he read the letter he would find out but he left the
office shortly afterwards after a visit which the clerk estimated lasted no more
than half a minute to a minute in total. He added that although he and his
colleague, the administrative officer, who was also in the office at the time, did
not fear any danger from the man, he was very abrupt and rude in his
dealings with the two members of staff.
165. My investigator asked the clerk about the NOB system and he explained it
was not just for poor behaviour but also rewarded good behaviour. He said
that a NOB was issued for an offence less serious than one which would
result in a prisoner appearing in front of a governor to face a charge of
infringing the Prison Rules. He described NOB as ‘a lesser punishment
where their behaviour is challenged basically’. He explained that any member
of staff can issue a Notification of Behaviour but he was clear that neither he
nor his colleague in the PAMS office had the authority to cancel any prisoner’s
gym session. Such power resided with the gymnasium staff, though his
understanding was that they would tend to give prisoners one or two chances
before cancelling gym sessions. He linked the NOB system to the prison’s
Incentives and Earned Privileges (IEP) scheme. He said that if three separate
NOBs were issued to a prisoner, that would trigger a review of his IEP status
with a possibility that he could be downgraded. He told my investigator that
downgrading the man’s IEP status from standard to basic regime would have
had an impact on the number of gym sessions he could attend each week.
166. On the afternoon of 2 April an IMB member, who has been a member of the
Independent Monitoring Board at Wellingborough for nearly ten years,
attended the prison with the expectation that he would pick up some routine
applications. On the desk in the IMB office lay an unopened, recorded
delivery letter to the IMB. He opened the letter and discovered it had been
written on 29 March by the man’s partner.
46
167. In the letter the man’s partner wrote that she was concerned about him and
the way he was being treated at Wellingborough. In particular, she wrote, he
had put in several applications on a number of occasions but they never
seemed to get processed or they seemed to get lost somehow in the system.
The letter continued as follows:
‘The man has approached several members of staff regarding the issues
he has and gets sent from one department to another or to another officer
who tells him he needs to speak to another officer.
‘It is also the opinion of him that he is being victimised by officers of HMP
Wellingborough as he made complaints regarding a senior officer and the
way in which he was spoke to and treated by this SO and requests for a
transfer since have been lost!
‘He has been making constant attempts since January 2009 to contact
you, the Independent Monitoring Board, and is left believing that his
attempts have been blocked due to the complaints made.
‘It would be much appreciated by myself and the man if these matters
were looked into by the IMB and on receipt of this complaint that contact or
a written reply be sent both to myself and him.
‘I am utterly disappointed and disgusted that whilst he resides at HMP
Wellingborough he feels and will continue to feel discouraged, isolated and
silenced not only by the officing staff but also the system!’
168. The IMB member subsequently wrote a report for his IMB colleagues about
what he had done after reading the letter. He established, through the PAMS
office, that the man’s cell was on C wing and that he had a job in the
motorcycle workshop.
169. The IMB member interviewed the man in the motorcycle workshop. He told
him that his parents were in their 70s and could not travel to see him. He also
said that his partner could not afford the travel costs. He told the IMB
member that none of his applications had been responded to and his transfer
request had not been followed up.
170. In the note to his colleagues the IMB member said that, while he had offered
to pursue the man’s many complaints, it seemed to him that his greatest need
was for a transfer north and that should be the first priority. The man agreed
and the IMB member promised to do all he could to help.
171. After the motorcycle workshop the IMB member visited C wing where he was
able to speak to the man’s personal officer. The IMB member recorded the
personal officer as saying that he had been away for five weeks and was just
getting to know the man. His assessment of the personal officer was that he
was straightforward and honest.
47
172. The IMB member then called at the OCA office but found that the OCA
Manager was not there at that time. He wrote that her colleague (the OCA
Co-ordinator) said that she (presumably the OCA Manager) had only that
morning been dealing with the man’s transfer and the IMB member was
happy that things were beginning to move. He then returned to the
motorcycle workshop where he spoke again with the man. The IMB member
updated him on the information he had obtained since their previous
conversation, especially about his move somewhere north. The man thanked
the IMB member for the news and hoped that the prison to which he went
would be Acklington.
173. My investigators interviewed the IMB member about the contact he had had
with the man on the afternoon of 2 April. His account was of great interest, as
his independence and objectivity could be assumed to be of a very high order.
As noted above, he is not a paid member of staff at HMP Wellingborough but
a member of the Independent Monitoring Board of nearly a decade’s standing.
During the interview he revealed that he had been a minister of religion since
1964 and for many of these years he had also been a hospital chaplain. My
investigators asked him how common it is for relatives of prisoners at
Wellingborough to write to the IMB, complaining about the treatment they are
getting at the prison. He responded:
‘Well overall I wouldn’t really know but from my experience it’s absolutely
unique, a one and only.’
174. My investigators asked the IMB member to assess how long he spent with the
man during the afternoon of 2 April and how much time in total he devoted to
his efforts to sort out the matters raised by the man’s partner in her letter to
the IMB. He estimated that he spent probably seven to ten minutes with him
in the first instance. He added that the man was the only prisoner he dealt
with that afternoon, which was fairly unusual, but:
‘… because of the nature of it and her letter [the man’s partner’s letter]
coming recorded delivery, I thought we owed it to her to do the very best
we could do and this I did.’
175. The IMB member confirmed that he had not had time to deal with any of the
other routine applications he had expected to encounter that afternoon
because the man’s was a much more detailed case than on an average day.
His recollection was that he:
‘… spent the whole two hours just dealing with his case and no other.’
176. In view of the fact that the IMB member had significant interaction with the
man just a week before his death, my investigators asked if he had given any
indication that he was a man in distress or torment. His reply was:
‘No, I didn’t get that impression at all, he was fed up that he wasn’t getting
replies but he seemed to be pleased that we had given him some
48
information in the right direction and really when I heard the name of who
the person was (who died a week later) I was just shocked’.’
He was asked why he was so shocked and responded:
‘Well, nothing had happened on the occasion when I saw him to give me
the thought that he might be of an unstable mind … He wanted to move
on and I thought the news I’d given him was going to please him and it
seemed to do so.’
177. The C wing applications log indicates that the man made the last of his 19
wing applications on 2 April. The application was directed to the wing SO and
had log number C435/09 but my investigators have not been able to locate it.
On 3 April, the personal officer made a fairly lengthy entry in the wing file
which said:
‘The man has brought to my attention that he has 19 unanswered general
apps. I have sat down with him and gone through problems such as his
window being broken. I have also warned him of the sarcasm in the letters
he has written. Although he may find it humorous, I explained how some
people might be offended. He seems happier now he knows at least I am
listening to him and we can work together to resolve any future issues.’
178. In interview the personal officer explained that the man came to him and said
he wanted a quiet word in one of the back offices on the wing. He recalled
that he was always reasonably quiet and never asked a lot of him as some of
the other prisoners did. In answer to a question about what his problems
were at that time, replied:
‘… the main ones were (1) his window, his applications that apparently
went unanswered and also he was asking about the transfer applications
as well, the stages of that.’
179. When talking about the window, the personal officer recollected that the man
had said his window had been broken for some time. He had already
requested that it be reported and fixed but that still had not happened. He
was asked if he had seen the window and responded:
‘I went up with him afterwards and saw it and I brought him down with me
and logged it onto the computer, onto Planet FM, and I wrote down the log
number for him and gave it to him.’
180. There is clear evidence to confirm the personal officer’s account of having
reported the window problem on 3 April. The Site Manager referred to the
personal officer’s involvement in the interview he gave my investigators on 28
May, and also supplied the Planet FM documents that show him as having
logged the window problem on 3 April at 1.53pm. The description of the
problem was that the window was not closing fully and the further detail
supplied by the personal officer was that the prisoner in cell 2-15 was
complaining that the window was not closing fully and he was very cold at
49
night. The Site Manager said to my investigators that the job was completed
the same day and the Planet FM timesheet (W080612643) shows the job as
having been closed on the Planet computer system on 6 April, the following
Monday.
181. My investigators asked the personal officer about his reference to sarcasm in
the letters that the man had written. An example given by him was that the
man had asked about being promoted to enhanced on the IEP scheme and it
was along the lines of:
‘… can I be Enhanced so I can play loud music and annoy officers and
always bang up late’ which I obviously explained to him, you know that’s
not the way, the best way of going about asking questions about becoming
Enhanced.’
182. My investigators asked the personal officer to describe the man’s demeanour
and he replied that the man was consistent and never asked a lot of him:
‘Every time I spoke to him he was very humorous, quite jovial. Obviously
showed frustration at the applications that he felt he wasn’t getting an
answer from and I felt he’d coped with it by being humorous and as I said
the sarcastic comments in the other applications was his way of dealing
with it.’
183. The same day, 3 April, the man’s application for transfer to Acklington
reached the OCA Unit at long last. After the transfer application form had
been signed by the senior officer on C wing the next stage was for it to
proceed to the Offender Supervisor. She wrote that he planned to reside in
the north-east on release and that transfer to Acklington would assist his
resettlement. The date on which she signed the document was 4/3/09 but, in
interview on 29 May, she accepted that she had made a mistake. She said
that she had got her 3s and her 4s ‘back to front’ and should have signed the
document 3/4/09 instead of 4/3/09 as she did.
184. The last section of the transfer application document is for the OCA to
complete. The options for the OCA Unit were either to approve the
application and send it off to the requested prison or to reject it and follow up
with notification to the offender. The Executive Officer in charge of the unit
circled the ‘approved’ option and dated her signature as being given on 3
April. The same day her colleague wrote a letter to the transfer clerk in the
OCA Department at Acklington. The letter informed Acklington that the man
had requested a transfer there and his application and wing history were
attached to assist Acklington with reaching a decision. My investigator asked
her in interview if a response from Acklington had been received by the time
of the man’s death. She said it had not and that Acklington were allowed 20
days in which to reply. She also told my investigator that she was the person
who had sent a response from Wellingborough’s OCA unit to the man about
his transfer request. The undated, unsigned document read as follows:
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‘Your application for transfer has been processed and submitted to your
requested establishment. If no answer has been received by 1 May 2009
the establishment will be contacted for a response. Please note that due
to national population pressures, Cat C to Cat C transfers are experiencing
delays and are taking longer than expected to complete. Requests to
establishments in the south and south-east are currently severely affected
by the population issues and a transfer to this area could take a significant
amount of time to complete.’
185. My investigator asked her why she had sent a standard letter to the man with
references to prisons in the south-east when he had expressly asked for
transfer to a prison in the north-east. She replied:
‘That is the standard letter that we send out. I should think 80 per cent of
our applications are to the south and the south-east and obviously, with
him he knew that he wasn’t going to the south and south-east.’
186. My investigator asked her if the man should not have had a slightly different
letter because his application was not for a south-east prison. She replied:
‘Often with it being in the north of England we probably would have had a
similar problem getting the transport because we do not control it. It’s all
controlled by PMU [Population Management Unit].’
187. On 2 April, Nurse A made a note in the man’s electronic patient record that
she had called to review him on the wing but he was at work in the motorcycle
shop. In a further note on 3 April at 11.22 am she reported that she had
reviewed him at work. She wrote that he:
‘… appears to be doing very well at present and can look back and see
how he’s improved. No stated problem. Has possible appeal against his
sentence August/September. He would prefer to stay on MHT caseload
for the moment.’
188. In interview my investigator asked Nurse A how she had decided that the man
was due for a review at the beginning of April. She replied that she might
have looked at her list of patients and decided who she had not seen for a
little while and who needed review. He had not come to her attention in any
other way. When asked how he seemed when she reviewed him on the
morning of 3 April, she gave a lengthy reply as follows:
‘He was very well. We went off and sat in a little kitchen at the workshop.
He was happy and smiling, pleasant and chatty and he said he could look
back and see how he’d improved. There were no stated problems and I
also felt, the fact that he was holding down a job in the motorcycles, which
is quite responsible and which he was clearly enjoying and it’s a very
sought after job in the prison, I felt this added to my overall impression that
he was doing very well. He mentioned his possible appeal, well there was
an appeal expected but he wasn’t sure of the date, he thought it would be
August or September and because he was so well I actually asked him
51
would he prefer to stay on the mental health team caseload for the
moment? Because he looked so well it was difficult to see what more we
could do for him. Because he was settled on his medication, we were
getting good reports seeing him regularly around. He really did seem very
happy.’
189. Nurse A said that the man had indicated a preference not to be removed from
the mental health team’s caseload at that time. My investigator asked why
but she responded that he had not given a reason. My investigator asked her
whether on 3 April he seemed the best she had seen him, the worst she had
seen him or somewhere in the middle. She replied that he was the best she
had seen him and that there were no indications whatsoever to her that he
would take his life. When she heard the news of his death she was shocked
and upset:
‘… because he’s the last person I thought would do that. Even though I
knew he had attempted once before, I really didn’t expect it. I was very
shocked.’
190. On Saturday 4 April, the man wrote his final formal complaint form. In the
complaint section of the document he wrote:
‘Since entering what I considered to be a serious complaint against a
senior officer in January (serial number F/4115/1/09) dated 22/1/09 I have
had nothing but problems. I believe I am being victimised. I now have a
whole load of unanswered applications, approximately 30, from things like
my window still is not fixed to prison transfer apps. IMB forms never
processed. I had to get my family to write to get them to come and see me
… My family and myself view the situation as very serious and has gone
on too long.’
191. In the box at the bottom of the form asking him to say what should be done
about his complaint, the man wrote:
‘Complaint F41115 was never passed to the Residential Governor. Now
she has had it over a month and I suggest it has been covered up or not
dealt with seriously. I want it dealt with and moved out this prison! Asap
as nothing I put my name to gets dealt with! And situation is pushing me
too far. I can [presumably meaning cannot] cope. Please come and look
at apps, this situation is a disgrace.’
192. The man sent this complaint by confidential access to the governing Governor
at Wellingborough who signed and dated the form on 6 April and wrote on the
reverse that he would ask his newly appointed deputy Head of Residence to
deal with the matter.
193. The deputy Head of Residence went to see the man on 7 April in the
motorcycle workshop then wrote a response on the reverse of the complaint
form just underneath the governing Governor’s handwritten entry. His
response said:
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‘We met today in the motorbike workshop to talk about the issues
regarding victimisation due to making a previous complaint. I informed
you that I had checked your wing file prior to our meeting where I found a
return slip from OCA acknowledging your application for transfer. I also
read your letters of complaint regarding private cash disbursement and an
IEP warning regarding workplace issues. You reiterated that you had put
in numerous applications and that you had not had replies to them. I
informed you that I could not find any supporting evidence and without that
could not check into them. I advised you that in future you could make a
complaint to me directly if you felt that was an issue in the future. You
stated that you were happy with this. I will also check with the
Maintenance Department about your cell window.’
194. My investigator interviewed the deputy Head of Residence about this
significant meeting he had held with the man just two days before his death.
He transferred to HMP Wellingborough on 30 March, so he had been working
there for just a week before he met him. He is an experienced and long
serving member of staff who joined the Prison Service 30 years ago and has
worked his way up through the ranks from officer to governor grade. He spent
22 years working as a healthcare officer, senior officer and principal officer
before transferring to general duties.
195. The deputy Head of Residence’s written response on the reverse of the man’s
complaint form refers to the research he conducted before meeting him and to
the return from OCA (dated 3 April) acknowledging his application for transfer.
My investigator asked the deputy Head of Residence if the man was aware
when the two men spoke on 7 April of the OCA response. He said:
‘No, in fact, initially there was a distrust of the information I was giving him.
I suppose, and again I am supposing from his point of view, he had put or
alleged that he’d put this request in for a transfer in that hadn’t been
responded to and there was this brand new governor appearing in front of
him in the workshop telling him that all of a sudden there has been a
response from the OCA. So we had to talk through the issues I think,
initially that of trust and the fact that I will not tell him a lie had I not seen it
and that’s a fact that I had seen it and we got on to conversations about
where he wanted to transfer to.’
196. My investigator was disturbed to hear that the man did not appear to have
received a reply from the OCA. He asked the deputy Head of Residence if he
had seen the response in the man’s wing file and he replied that he had. But
when he spoke with the man who is the subject of this report in the
motorcycle shop on 7 April, the man had not received the response to his
transfer application. He told my investigator that the man’s account was that
he had not seen a document from the OCA or been informed by the staff.
The following exchange then took place between my investigator and the
deputy Head of Residence:
53
Investigator: I’m aware of the application system at Wellingborough
where a bit of paper goes into post boxes, one hopes it
gets to the relevant department and they send a bit of
paper back to the prisoner. Is it your experience or not
that bits of paper sent by departments don’t seem
sometimes or often to get to the prisoners for whom they
are intended?
Dep Head of Res: Yes, I think there’s twofold you know. Some bits of paper
that are intended for the prisoner don’t end up being
given to the prisoner. But equally when the staff do have
possession of a piece of paper and they file it in the wing
file that’s not always communicated to the prisoner even
if it relates to them.
197. On 8 April, a second IMB board member sent an e-mail at 2.41pm to the
Chair of the IMB at Wellingborough. Her e-mail informed him that she had
picked up two applications from the man and had gone to see him. He told
her that he had seen a member of the IMB the previous week but did not
know who it was. He thought, correctly, that the IMB contact the previous
week had been initiated by a letter from his girlfriend.
198. The Chair of the IMB wrote a Serious Incident Report about the
circumstances of the man’s death. In an entry at 12.45pm on 14 April, he
wrote that he had spoken with the second IMB member who had seen the
man the day before:
‘She thought he was a reasonable person who had grievances about
applications going missing but seemed fairly cheery and good humoured.
No indication that he contemplated harming himself at all.’
199. On the morning of Thursday 9 April, the man went to work in the motorcycle
shop as normal. According to his personal activity programme, the afternoon
was split into two parts with movement to the motorcycle shop due to take
place at 1.45pm and then the possibility of a further general movement of
prisoners to employment, education or gymnasium at approximately 3.00pm.
It appears that during the early part of the afternoon of 9 April he received a
letter from the Criminal Appeal Office at the Royal Courts of Justice in London
informing him that his appeal against sentence had been unsuccessful. The
letter was sent on 2 April on behalf of the Registrar at the Criminal Appeal
Office. Two copies of the Registrar’s letter of 2 April were sent to the
Governor at Wormwood Scrubs with further copies going to the solicitors
representing the man and to his barrister. The Registrar’s letter to the
Governor of Wormwood Scrubs indicated that one copy of the Order rejecting
the appeal was to be retained by the Governor on file and the other copy was
to be given to the man.
200. The documents despatched by the Criminal Appeal Office included an Order
made by a single judge which announced that he had refused the man’s
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application for permission to appeal against his eight year sentence on the
following grounds:
‘This was a serious case of the infliction of grievous bodily harm with
intent, of which you were found guilty after a full trial. You attacked your
victim with an axe, inflicting a deep cut in the top of his head. The learned
judge correctly identified a number of aggravating features … This case
was within the second category identified on page 13 of the Definitive
Guideline of the Sentencing Guidelines Counsel. In view of the
aggravating features and notwithstanding your previous good character
the sentence of eight years imprisonment was within that guideline and
entirely justified.’
201. In interview with my investigator, Officer B recalled that she distributed mail to
prisoners on C wing that day just as they were getting ready to go to work at
about 1.55pm or 2.00pm. She remembered that one of the letters was
addressed to the man. He was standing ready to go to work so she handed it
to him. She explained to my investigators that she did not know who the letter
was from or what it was about, as mail is not checked on the wing. She said
she could not be certain but she thought that he received a legal letter that
day and she saw him go straight to the telephone afterwards. She was asked
by my investigators why she thought it was a legal letter and her recollection
was that it had a solicitor’s stamp on it. She added that, whereas normal post
is cut open and checked before it is issued to prisoners, privileged letters
which are covered by Prison Rule 39 (for example between a solicitor and
his/her prisoner client) are normally delivered to the relevant wing separately
and unopened.
202. Wellingborough’s PIN phone records show that the man made four telephone
calls on the afternoon of 9 April between 1.59pm and 2.11pm. The prison had
no reason at the time of his death to be routinely monitoring his phone calls,
so were completely unaware until after his death of the content of these four
calls. After his death the Call Records Report itemising every call made by
him was checked and the four final telephone calls of his life were transcribed
by an administrative officer who works in the Security Department at
Wellingborough. My investigators have both listened to and read the
transcripts of these four calls.
203. At 1.59pm the man made a telephone call lasting one minute 22 seconds to
his mother. Very early in the call he told her that his appeal had been
refused. He then asked his mother to ring his solicitors. His mother said she
had photocopied all relevant documents and he replied that he needed ‘every
bit of paperwork … but it’s a bit of a waste of time now’.
204. The man’s second phone call at 2.02pm was to his partner. As he speaks to
her, he is clearly extremely upset and the transcriber has written on five
separate occasions during a call lasting just 56 seconds that he is crying. At
the beginning of the conversation he tells his partner ‘It’s all over’ and then
just a few seconds later, ‘They’ve refused [crying] my appeal.’ Towards the
55
end of the conversation the transcription records him as saying ‘That’s it now
alright’, and when his partner responds ‘Listen’ he says [crying] ‘That’s it.’
205. The man made a second phone call of four minutes and eight seconds
duration to his mother at 2.06pm. At the beginning of the conversation his
mother explained that she had telephoned his solicitor but she was still out at
lunch. In response to his mother’s advice to keep calm, he said ‘I know
exactly what I’ve got to do’ and then used exactly the same form of words a
second time. After a conversation with his sister, he again spoke with his
mother and complained about the quality of the legal advice he had received
from his solicitors, adding that he wanted the paperwork from his mother so
that he could instruct a different firm of solicitors. At the end of the
conversation his mother spoke of his wish for a prison transfer in response to
which he said ‘I’m not going to be around to get a transfer.’
206. The last of the four telephone calls was of 51 seconds duration and was again
a call from the man to his partner. At the beginning of the conversation she
exhorts him to be strong but he replies that ‘it’s just too late for that.’ He tells
his partner that she knows what he has got to do and she replies, ‘No, you
don’t have to.’
207. Although the man’s acute distress is immediately apparent in the transcripts,
the staff on the wing at the time were unaware of the torment he was
experiencing. Officer U is a regular C wing officer and explained in interview
that he saw the man come out of the telephone box on the ground floor of C
wing and go upstairs just after the last instruction had been given by staff for
prisoners to go to their afternoon employment. He did a roll check on C wing
with a colleague, Officer R, after prisoners had moved to work. He then saw
the man come back downstairs and use the other telephone near the staff
office. He said that, because the man was not a problem to staff, the two
officers did not bother questioning him at all. He could not recall any situation
before that afternoon when the man had been on the telephone at a time
when he ought to have been at work. The officers decided that they would
give him an opportunity to go to work at the time of second moves in mid
afternoon. Officer U remembered that when he and his colleague had
finished checking the roll he came back to the bottom of the stairs and saw
that the man had just finished a telephone call. He continued:
‘I said to him, I think I said to him ‘your door is still open for you, do you
want to come out second moves and go second moves to work?’ and he
didn’t turn around to me but he said to me ‘No, I’m alright gov, that’s fine,
I’m not going to bother today’ or words to that effect, I can’t remember the
exact words but that’s what he said to me.’
208. The man then went upstairs and the officers heard him shut his door on the
top landing (the 2s) on C wing. Officer U added that there was sufficient trust
between them and that the man could be relied upon to close his own cell
door shut behind him rather than requiring the officer to do so.
56
209. My investigator asked Officer U if the man had given any reason for not going
to work that afternoon. The officer replied that he had not given a reason. He
explained that when the man told him, ‘No, I’m alright gov’ he did not sound
distressed so he assumed that for whatever reason he simply did not want to
go to work that afternoon.
210. One of the questions asked by the man’s family was whether the officer
suspected that the man was out of character or upset that particular
afternoon. Officer U’s response was as follows:
‘During my short exchange, from my experience, I didn’t think he was
upset. From his voice, the way he spoke to me he didn’t sound upset.
Yes, it was out of character for him not to go to work because he always
attended work, but when I had that interaction with him he didn’t sound
upset and I didn’t see his face, but he didn’t sound upset and it didn’t give
me any undue concern for his welfare.’
211. The first indication Wellingborough received that something might be amiss
with the man came in a telephone call made to the prison at 2.50pm. The
prison’s IT and Communications Manager told my investigators that
Wellingborough has not installed call logging software that would enable my
investigators to establish the precise time of external phone calls to the prison
or internal calls made within the prison to another internal extension. I am
therefore extremely grateful to a member of staff to obtain the precise time of
her phone call from British Telecom at the express request of my
investigators. In response to this information, a phone call was made to the
prison and notified them on behalf of his partner.
212. The phone call was received by an administrative assistant who at the time
was the PIN phone clerk in the Security Department. She had previously
worked in the switchboard office for a couple of months when she first took up
employment at Wellingborough in August 2008. On the afternoon of 9 April
she had been asked to cover in the switchboard office for the usual
switchboard operator who was off duty. She wrote a Security Information
Report about the call she had received and timed her SIR at 3.05pm. In it she
wrote:
‘Whilst covering switchboard I received a call from the carer of the man’s
partner who stated she had just received a call from the man’s partner who
had just heard from him whose mood was very low and he told his partner
he was going to kill himself.’
213. In interview the administrative assistant explained that she received the call
from a lady speaking on behalf of the man’s partner at a time she believed to
be approximately 3.00pm. She said she had never received a call of such
significance before and she kept the caller on the line while she attempted to
transfer her to the Prisoner Care Department (subsequently renamed Safer
Custody Department). She received no response from the Prisoner Care
Department but she reassured the caller that she would ensure the
information was passed to an appropriate colleague. She said that, as soon
57
as she put the telephone down, she made telephone contact with the Security
Manager at Wellingborough [this was the manager of the department in which
the administrative assistant generally worked]. The Security Manager advised
her that she should contact PO A who had just taken over a few days before
as manager of the Safer Custody Department.
214. The administrative assistant endeavoured to call PO A but could not reach her
at first and spoke with an officer. She told the officer that PO A was to call her
on the switchboard as soon as she received her message. She estimated
that approximately five minutes then passed and when she had still not
received a return call from PO A she again rang the Security Manager for
guidance. The Security Manager advised her to contact the Communications
Room in the Security Office so that they could put out a radio message for PO
A. In interview the administrative assistant recalled that within a couple of
minutes PO A rang her in the switchboard office and she was able to explain
the situation to her. She recollected that PO A told her that she would send
some officers up to the man’s cell. My investigators asked her in interview to
estimate how much time passed before she was able to relay the message to
PO A. Her estimate was that about 20 minutes had elapsed.
215. It is abundantly and commendably clear that staff who have written
statements and given interviews about the circumstances of the afternoon of 9
April have done so independently and without collusion. It is, however,
impossible to be certain about many of the timings between 2.50pm and
3.50pm. In interview PO A told my investigator that she had her conversation
with the administrative officer at 3.40pm or 3.45pm. Officer A wrote in a
statement on 7 May that at approximately 3.20pm whilst he was working in
the reception area, he received a phone call asking him to attend C wing to
replace Officer R who was required for an emergency escort. Officer A’s
statement continued by saying that at approximately 3.30pm he attended C
wing and took a phone call from PO A as he arrived at the office. PO A, who
at that time was on D wing, asked Officer A if the man was on the wing. By
looking at the wing roll board Officer A was able to confirm that he was.
Officer A’s statement said that PO A had received a telephone message from
the man’s partner, though of course it was the administrative assistant who
had that conversation, and she was worried about his state of mind. PO A
asked Officer A to check on the man who is the subject of this report,
interview him and get back to her.
216. It seems to me that Officer A’s timing of 3.30pm is more likely to be accurate
than PO A’s timing of 3.45pm because of the level of detail Officer A can
supply about the afternoon. Also I have no doubt whatsoever about the
administrative officer’s anxiety to make sure that the message of concern
about the man’s welfare was relayed to an appropriate colleague at the
earliest possible opportunity. I am aware of Officer U’s recollection (in his
statement to the Governor) that Officer A received the telephone call from PO
A at approximately 3.45pm. I also note Officer U’s response in interview that
he spoke with Officer A for a number of minutes on C wing before the phone
call, whereas Officer A said in interview that the very first task he undertook
58
when he arrived on C wing was to answer the telephone ringing in the wing
office.
217. After receiving PO A’s instruction, Officer A proceeded without delay to cell
C2-15 which is at the very end of the long spur on the topmost landing of the
wing (the 2s). When he looked through the observation panel in the cell door,
his first impression was that the cell was unoccupied. Officer A thought about
walking away from the cell but he then reasoned that the man must be inside
because the bed had been pulled into the centre of the cell. This meant there
was no opportunity to either close or open the door because the gap between
door and bed was only a couple of centimetres. Officer A pressed his head
really hard against the observation panel and he could make out an arm as he
looked into the left-hand side of the cell. Officer A was not yet alarmed
because he was aware that on dozens and dozens of occasions, as he
expressed it, prisoners would either stand or sit in the furthest corner of the
cell so that observation by staff was impossible or very difficult.
218. In interview Officer A said that all he could see was the first two fingers of the
man’s arm. Despite pushing with all his might at the cell door, the barricade
the man had created (by positioning his bed hard against the door) meant that
Officer A was able to push it inwards only by about two inches. A door jack is
the officially approved mechanism to enable staff to break into a barricaded
cell. However Officer A said in interview that he was becoming quite anxious
about the situation and viewed the door jack as a ‘long, lethargic process’.
Officer A told one of the wing cleaners to obtain a broom handle and to find
another member of staff. The wing cleaner located Officer B, who was the
cleaning officer on the wing that afternoon, and she supplied the cleaner with
a broom handle from the stores cabinet on the first floor. Officer B followed
him up to the second floor of the wing to see if her colleague needed any
support.
219. Using the broom handle as a lever, Officer A managed to force his way into
the cell by pushing the man’s bed over to the right-hand side (as Officer A
looked into the cell from the doorway). Officer A could now see the man
hanging from the pipe that runs along the cell wall on the left-hand side at
ceiling level. His tongue was described by Officer A as completely out to the
left-hand side and his feet were obstructed behind the toilet. He said that the
ligature was made from bedsheets and was green in colour. His recollection
afterwards was that the man had used the edging of his sheets which he
described as the strongest part because it is sewn over. He said that the man
had plaited the sheets together and put them round the pipes several times
with his head inside. He added that the man had put a plastic knife inside the
noose and had ‘tourniqued it up so it was tight against (his neck) and then
dropped his body weight down after standing on the toilet lid.’
220. Officer A drew his anti ligature knife, took the man’s weight by grabbing hold
of his legs and cut through the ligature. At that moment Officer B arrived in
the cell and Officer A told her to press the alarm bell located nearby on the
landing. The time at which Officer B pressed the alarm bell was clearly
recorded as being 3.50pm in the daily log maintained in the Communications
59
Room. The first two colleagues to join Officers A and B were Officer U and
SO F, who had been talking to each other in the C wing office. In his
statement to the Governor, Officer U said that the cleaner came to the office
and said, ‘Gov, I think they need your muscle up there, there is a barricade.’
As he and SO F were walking out of the office, the general alarm bell sounded
so both men ran upstairs and headed for the man’s cell. When Officer U
reached the cell he saw Officer A holding the body. Officer A told him to
move the man’s legs which were stuck behind the toilet seat.
221. In his statement to the Governor of 8 May, SO F wrote that when he arrived at
the cell just behind Officer U, Officer A asked him to grab the man’s arm and
help him to pull the man out from the cell onto the landing immediately
outside. In interview SO F explained that the decision to move him out of the
cell was taken because the cells are very small and there was not enough
room to move about. He added that the man was rather a large man (as
already indicated he was 6’ 2’ tall and weighed 18 stones) and he pointed out
that both he and Officer A were quite big men also. When my investigator
saw the man’s cell a few days after his death it was still somewhat cluttered. I
judge that the decision to remove him from the cell was appropriate in the
circumstances, especially since he had moved his bed out of position.
222. In interview Officer A explained that, although he has received no recent first-
aid training from the Prison Service, he is a professional diver and had
completed a rescue diver course. He possessed in-date qualifications for
first-aid and heart-start. At 3.50pm Officer V was on corridor patrol when the
general alarm sounded. When he arrived on C2 landing he saw the man on
his back with Officer A by his head and SO F kneeling by his left side trying to
take a pulse. SO F stated that there was no pulse so Officer V told Officer A
to give a rescue breath. When SO F again stated there was no pulse, the
officer began chest compressions.
223. In interview Officer V recalled that when he arrived on the landing the man
was blue, his tongue was hanging out and he could see that he had had a
ligature around his neck because of the marks around the neck. He explained
that he has an up to date first-aid at work qualification and had received
refresher training just a short time before the man’s death. He had previously
been a first-aid instructor and added that, as he had served in the Armed
Forces, he has always had a first-aid background. He said that Officer A gave
the man a couple of rescue breaths which were literally mouth to mouth
because at that time Officer A was not wearing a face mask. Officer V
shouted for a colleague to give Officer A a face mask and that was done. He
recalled that as soon as he began chest compressions a quantity of vomit and
other matter came out of the man’s mouth. Once that had been cleaned away
Officer A resumed giving the man mouth to mouth, but with the face mask in
position.
224. The orderly officer arrived at the man’s cell as Officers A and V were
commencing cardio pulmonary resuscitation (CPR) and SO F was checking
for a pulse. In interview she explained that as orderly officer she was in
charge of the running of the establishment and the running of the regime.
60
She had to respond to and deal with any incidents that occurred and she was
immediately accountable to the duty governor of the day. She is a very
experienced middle manager, having worked in the Prison Service for 20
years, of which the last five have been spent as a PO at Wellingborough.
When she heard SO F say that the man had no pulse, she immediately went
onto her radio and called for Healthcare Level 1 assistance. (Level 1 denotes
a life threatening injury or a situation where a prisoner has no breath or no
pulse and is the most serious level of healthcare request at Wellingborough.)
225. The orderly officer also wasted no time in calling for an ambulance. In
interview she recollected that, after calling for healthcare assistance, she
looked down and saw her colleagues working on the man. He had been sick
and she knew at that stage that, whatever her healthcare colleagues might
say, he would have to go to outside hospital. She reasoned that an
ambulance should be requested straightaway because it could always be
stood down if not subsequently required. She instructed her colleague, SO G,
to go to a quieter part of the landing and call for an ambulance over his radio.
The prison’s Communications Room log notes a call for an ambulance at
3.55pm. Information supplied by the East Midlands Ambulance Service
shows that an ambulance was called at 3.56pm, reached the prison at 3.59pm
and that the paramedics in the ambulance were with the man by 4.01pm.
226. On the afternoon of 9 April Nurse D was Hotel 1, which meant that she was
the qualified nurse required to carry a radio and to respond to any emergency
calls. She is a very experienced nurse who began her training in 1983 and
who has practised continuously as a nurse since then. She told my
investigator that she had worked for many years at the General Hospital in the
Medical Admission Unit where patients come from GPs or from the Accident &
Emergency Unit with medical, rather than surgical, conditions. She also told
my investigator that she always does an annual basic life support and
immediate life support course which is slightly higher in complexity than the
basic course. In previous years she underwent the annual training at
Northampton General Hospital’s Resuscitation Unit, but in 2009 all members
of the healthcare department at Wellingborough were trained onsite by an
external training organisation. She revealed that she had had to use her
emergency resuscitation training twice at the prison in the last three years,
once for a prisoner and once for a member of staff.
227. When Nurse D heard the general alarm bell followed by the reference to a
Level 1 healthcare emergency she made her way instantly to C wing,
accompanied by a Healthcare Assistant. They took an emergency bag with
them from the healthcare centre but, at the time, the bag did not contain a
defibrillator and oxygen. When Nurse D arrived at the wing and saw the
nature of the emergency, she asked an officer to collect the necessary
additional equipment for her. She said that when she reached the man’s cell
Officers A and V were carrying out CPR. The man appeared lifeless,
according to the entry she subsequently made in his clinical record, and the
officers reported that he was not breathing and had no pulse. She asked her
two colleagues if they wanted her to take over CPR but they both said that
they wished to carry on.
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228. In interview Nurse D told my investigator that the CPR Officers A and V were
giving to the man appeared as effective as it could have been, so she
concentrated on putting defibrillator pads on his chest. She then asked the
two officers to stop doing CPR while the machine checked for a heart rate and
heart rhythm. The members of staff stood back but the defibrillator suggested
there was no shockable rhythm and, because the advice from the machine
was that no electrical shock should be administered, the two officers carried
on with CPR. In her note on the man’s patient record she wrote that a Laerdal
mask was used with 15 litres of oxygen. In interview she said that she put the
Laerdal mask on so that Officer A could give breaths through the mask but
she added that there was a lot of vomit and it was very difficult to clear an
airway.
229. There is clear evidence that prison officers carried on with chest
compressions in an effort to resuscitate the man for approximately 50 minutes
from 3.50pm until 4.40pm when he was pronounced dead. The first two men
administering CPR were Officers A and V. The orderly officer explained that
at one stage she gave instructions that Officers A and B should be taken
away from the landing so that they had some support while other colleagues
endeavoured to revive the man. In her statement to the Governor of 9 April,
the orderly officer wrote that SO F, Officer U and Officer V rotated to continue
CPR. Officer A came back to the landing and PO C then assisted with CPR.
In interview Nurse D explained that she also took part in one episode of chest
compressions. The orderly officer explained how she instructed the staff to
rotate the physically arduous task of administering chest compressions to the
man. She said:
‘I’d asked Officer V previously to let somebody take over and he was quite
committed in that he wanted to carry on. When the paramedics arrived
and said that they wanted us to continue with the chest compressions
while they did everything else, I instructed him that somebody else would
take over and I think SO F was first because he was the closest. And I
said to SO F ‘right, now take over’. And they had a system going, they all
did 200 chest compressions and then the next person would step in. But
they were counting down, so that the minute they finished their last one
the next person was straight in carrying on with the next chest
compressions.’
230. The two paramedics who attended the man were Number 7156 and another
female paramedic 7327 whose signature is not easily legible. In the Chief
Complaint section of their standard form they wrote ‘Hanging – cardiac arrest’
and in the History of Complaint section they wrote that, when they arrived on
the scene, excellent CPR was in progress. The man had vomited and his
airway was partially blocked. They wrote that CPR continued and his airway
was suctioned. The paramedics tried intubation five times but it failed. They
referred to him having a crushed windpipe and wrote of a ligature mark
around his neck. The paramedics recorded that they carried out advanced
CPR as per their guidelines, with oxygen, atropine and adrenaline being
administered between 4.02pm and 4.24pm.
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231. Although the paramedics were able to administer more advanced CPR
techniques than Nurse D and her prison officer colleagues, they in turn
decided at approximately 4.10pm that further assistance was required from an
air ambulance. (I am aware of only one other occasion when a doctor has
arrived by helicopter at a prison outside London to attend to a prisoner at risk
of death.) The Communications Room’s daily log indicates that an air
ambulance was en route at 4.10pm and that it landed on the prison’s exercise
yard at 4.35pm. The request from the ambulance paramedics that an air
ambulance should be called was quite unprecedented and required the
orderly officer and her governor colleagues to think ‘outside the box’. Prison
governors are very nervous about helicopters hovering above their
establishments but the governing Governor took the commendable and
correct decision that the preservation of the man’s life was a higher priority
than any threat to the prison’s security. The orderly officer told my
investigators that, although her first thought had been that the helicopter
should land outside the prison’s secure perimeter, that particular strategy was
not feasible because there were too many cars on the car park. The
helicopter therefore landed on the prison’s exercise yard and two members of
staff had already been positioned on the yard in high visibility jackets so that
the helicopter could clearly see where to land. As soon as the helicopter had
touched down, a doctor and another paramedic were brought straight to
where the man was lying immediately outside his cell.
232. The doctor pronounced the man dead at 4.40pm. The two paramedics from
the East Midlands Ambulance Service who had arrived outside his cell at
4.01pm signed a Patient Report Form at 4.40pm in formal recognition of the
fact.
233. When the man arrived at Wormwood Scrubs for the second time on 3
November 2008, he had named his parents as his next of kin. The note left
by him in his cell identified his partner as his next of kin but that information
appears not to have been disclosed to senior staff at the prison by Police until
17 April. According to the interview given to my investigators by the Imam
and Co-ordinating Chaplain at Wellingborough, there was some discussion on
the evening of 9 April about the way in which news of his death should be
broken to his parents. The decision eventually taken was that the news would
be conveyed by police officers from the area where the parents lived rather
than by prison staff. The log maintained by family liaison officers at
Wellingborough shows that the man’s father first telephoned the prison at
9.50pm on 9 April after the police had visited his home. On 10 April, the
family liaison officer at Wellingborough arranged for her counterparts at the
other prison to visit the man’s parents and that visit proceeded on 11 April.
In interview the Imam told my investigators that, once he knew the man had
died and that he was a Roman Catholic, he contacted the nun who is the main
point of contact for Roman Catholic prisoners at Wellingborough. There is no
full-time Roman Catholic chaplain at Wellingborough so a Sister visits the
prison each Thursday morning and returns on Saturdays with a Roman
Catholic priest for Mass. The day of the man’s death was a Thursday and the
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Sister had already been to and left the prison. The Imam asked her at about
5.30pm on 9 April if it would be possible for her or another Roman Catholic to
come to Wellingborough to perform the Last Rites. He said:
‘… she informed me that it would be difficult at this time and she asked
me who else was in the establishment and I informed her of another
Christian colleague.’
234. The colleague is a Baptist colleague and the Sister told the Imam that she
would be happy for her to pray for the man. The Baptist chaplain agreed to
this request and said a prayer by his body.
235. The man’s funeral was held on 23 April and was attended by the governing
Governor and one of the prison’s Family Liaison Officers.
236. Both the man’s parents and his partner were given an opportunity to visit
Wellingborough, with the visits proceeding on 28 April. His partner visited at
noon when she was taken to the motorcycle shop and his cell. Later that
afternoon his parents visited the prison. They met in the chapel with three
prisoners who had known their son, and in the motorcycle shop they received
a certificate that had been awarded to him. They visited his cell and the
gymnasium and received items of property from his cell and the sum of
money that he had held in his prison bank account. His next of kin were
invited to a memorial service, held in the prison chapel, which was attended
by prisoners and staff on 8 June.
237. Appropriate arrangements were made to support the staff who had been most
intimately involved with the man on the afternoon of 9 April. A hot debrief was
held at the prison on the evening of 9 April so that staff could discuss what
they had done that afternoon, any issues that had arisen and be reminded of
the support they could receive from the staff care team. In interview the
orderly officer described the care team as a group of staff of various ranks
who are trained in counselling skills and who are there to support staff who
are involved in any incident. Staff who had been involved in the efforts to
resuscitate the man were offered the opportunity of leaving the prison early
before the end of their shift but they all declined. One officer said he would
have been alone with his dog if he went home and he preferred the human
companionship he received by remaining with his colleagues at work.
238. Some weeks after the man’s death a critical incident debrief took place at the
prison which was an opportunity for staff to talk in a supported atmosphere
with external facilitators about their emotions, how they felt and how they had
been affected by his death. My investigators asked staff about the quality of
the support that had been offered to them. A representative reply was: ‘I was
very happy with the support. I was happy with the debrief afterwards as well,
everything was in place.’
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ISSUES
Clinical Care
239. I am very grateful to the clinical reviewer who, commissioned by the local
Primary Care Trust (PCT), has supplied a clinical review and worked in very
close collaboration with my investigators in the months between the man’s
death and issuing of this draft report. He is an experienced and highly
qualified general practitioner who is PCT advisor to the PCT, a member of the
Royal College of General Practitioners, and a Fellow of the Royal College of
Surgeons and Physicians in Glasgow. I am especially grateful to him for
making contact with the general practitioners.
240. In his clinical review the clinical reviewer reports that the man had three
known admissions to the Mental Health Unit. These admissions were on 18
July 2007, 14 January and 8 February 2008. In relation to these three
admissions, his review reports that the man:
‘Was given a diagnosis of recurrent depressive disorder with alcohol
misuse. He was known to have taken an overdose and continued to have
suicidal thoughts. He had mild liver impairment associated with his
drinking. He also had gastric problems including vomiting. His main
purpose of admissions had been for detoxification. His depression was
treated with Venlafaxine 225mg, he was also treated with 20mg
Omeprazole for gastric symptoms from his gastritis from drinking.’
241. After the man was bailed from Wormwood Scrubs on 8 May 2008 he moved
to stay with his parents and changed GP to the practice with which he had
been registered during his childhood. During this time the clinical reviewer
reports that his depression was treated with Venlafaxine 225mg initially and
then converted to Fluoxetine 40mg to improve his symptom control. The GP
changed the medication for his gastric symptoms from Omeprazole to
Lansoprazole. He was seen monthly by his GP and no markers to indicate
risk of self-harm were in place, according to the clinical reviewer, at that time.
242. The clinical reviewer’s review refers to the mental health review carried out by
Nurse A on 24 December and to the three occasions when the man was seen
by the consultant psychiatrist. He refers to the fact that the notes in the man’s
computerised medical record after the psychiatrist saw him on 30 January are
much shorter than the paper notes made contemporaneously by the
psychiatrist. The psychiatrist saw him again on 13 February when his
medication was reviewed and changed. The clinical reviewer notes that a
review planned with the psychiatrist took place as expected on 20 February
with appropriate medical records to support it. He mentions the review
conducted by Nurse A on 3 April and writes that:
‘… there is a less clear plan with regard to the ongoing follow-up of him
[the man] at this point in time, although things appear to be going well and
there is some suggestion he might be discharged from the mental health
team.’
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243. The clinical reviewer was proactive and lost little time in obtaining the man’s
community mental health notes from the Community Mental Health Team.
These notes contained a clear and detailed discharge summary but he
believes the prison had no access to them during the man’s time in custody.
244. The contract for delivery of healthcare at Wellingborough is held by Care UK.
I am grateful to the Healthcare Manager for Care UK at Wellingborough for
making available to my investigators a copy of the report written following the
company’s own case review. The review was completed soon after the man’s
death and contains a number of recommendations which are in close
alignment with my own analysis and the recommendations made in the
clinical reviewer’s review.
245. The clinical reviewer’s study of the man’s general prison records leads him to
conclude that his physical and mental health appeared to settle during his
time at Wellingborough and he ‘certainly seemed well a week before his
death’. He observes, however, that there were a number of circumstances
with regard to the man’s time in custody that appeared to deteriorate. The
man had a number of complaints and allegations with regard to his time at the
prison. The reviewer writes that:
‘… this clearly was upsetting him and his appeal against sentencing
seemed critical to his state of mind. I had access to his suicide note and
the contents of his four phone calls undertaken on the day of his death.
This shows an increasingly frustrated and distressed individual. As part of
my review, I had access to the questions from the man’s parents with
regard to the circumstances surrounding his death.’
246. In the key findings and recommendation section of his report, the clinical
reviewer finds that overall the medical care the man received was of a very
high standard. He was seen by a number of members of a multidisciplinary
team which he considers to be adequately resourced and well-trained. He
favourably compares the care the man actually received at Wellingborough
with the care he might have received in the community. In particular, he
reports that the resuscitation attempt was considered exemplary by the
specialist medical and paramedic teams who attended.
247. A number of recommendations flow from the clinical reviewer’s analysis of the
man’s clinical care. On reviewing the notes, he found that there seemed to be
no attempt to obtain previous medical records on detention in custody,
particularly with regard to the mental health records from the Community
Mental Health Team. As already recorded, it was the clinical reviewer himself
who obtained these records for my investigation. His first recommendation,
which I fully endorse, is as follows:
I recommend there is a policy for requesting previous medical
information from community mental health teams, other prisons and
secondary care and robust systems to act on this information.
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248. It is pleasing to note that the same issue was highlighted in the case review
conducted in May 2009 by Care UK. Their recommendation is that, where
there has been prior involvement of community services identified at the time
of reception, the patient’s clinical record should be reviewed to ascertain if
information is available from previous healthcare providers. When information
has not previously been obtained, it should be sought at the earliest
opportunity.
249. As the man was asthmatic, the clinical reviewer would have expected an
asthma care review to have taken place at some point fairly soon after his
arrival at Wellingborough. He could find no assessment of asthma
management in the notes. His second recommendation, which I endorse, is:
I recommend the prison reviews its capacity to provide chronic disease
management in a timely fashion.
250. The clinical reviewer refers to a suggestion in the man’s records that his blood
pressure should be rechecked after a medical at Wormwood Scrubs on 4
November but this appears not to have been done. He expresses the view
that the robustness of medical records and the extensiveness of the
information recorded at physical health checks need to be reviewed. His third
recommendation, which I endorse, is:
I recommend the clinical team reviews the quality of medical notes
entries on a regular basis and includes this in its clinical staff training
plans. This should include entries from meetings where patients are
discussed as well as clinical consultation. The inreach team should be
included in this review. Entries should be transcribed accurately from
paper records and have clear ongoing action plans including
management plans, review intervals and referrals between teams so that
any clinician not familiar with the patient can understand any planned
care from the computer notes.
251. The clinical reviewer is concerned about the system for allocating cases to the
mental health team. In the man’s case no details were recorded and he refers
disapprovingly to:
‘… an email system embedded in their clinical computer [which] cannot be
recalled or seen by any other than the addressee.’
252. The clinical reviewer then turns to examine the information discussed at the
weekly Friday meeting of the mental health team. Although he accepts that
discussion of the management of the caseload and ongoing review and
management of mental health cases is of a good standard, he bemoans the
absence of a record in the medical notes (and especially in the computerised
medical record) in a way that could be accessed in the future. He also refers
to a daily briefing attended by all healthcare staff, including a representative
from the mental health inreach team. He acknowledges that this meeting
produces a daily handover log but the log is not copied into the notes of
individual prisoners, nor is it ‘particularly available for all staff’.
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253. The clinical reviewer reports that mental health notes are still recorded on
paper (I assume he is thinking particularly about the three reviews of the
man’s mental health undertaken by the psychiatrist) and transcribed onto the
computer system. He observes that there is significant truncation when the
notes are transcribed and that some thoroughness of information appears to
be lost in this process. He finds that the medical records show clear plans for
treatment and for review interval until 20 February. After that date there does
not appear to be a clear plan with regard to contact and follow-up of the man’s
mental health care. I endorse the two recommendations made by the clinical
reviewer about these matters which are:
I recommend that a review of the email referral system takes place. Any
referral should be clearly documented in the notes with a copy of the
referral information attached. This should include communication
between the pharmacy team, primary care and the inreach team.
Decisions from referrals should be included in the notes even if no
action is taken.
I recommend that the health care team reviews communication methods
between the primary care team and the mental health teams. Decisions
about risk, review and follow up should be recorded where all clinicians
have access to them and should be available within the computer
record.
254. Care UK’s own case review also makes recommendations about the need for
decisions and referrals to be adequately documented in clinical records. The
first recommendation made by Care UK is that all healthcare referrals to both
primary care and mental health Inreach teams should be documented in the
patient’s clinical notes. Care UK adds that the referral process should be
monitored and audited to ensure all referrals are actioned. In a related
recommendation Care UK accepts that electronic recording of patient
consultations during the consultation itself may be impractical. The Care UK
review recommends, however, that full and detailed transcriptions of paper-
based notes should be entered in the electronic patient record at the earliest
opportunity.
255. Two other Care UK recommendations about the need for clearly
communicated decisions are as follows:
‘When consideration is given to changing a patient’s medication and/or the
dose of those medications, the decisions made should be clearly
documented and communicated to the patient. If consideration is merely
subject to the next review appointment, this should be clearly documented.
‘Patient reviews should be clearly communicated in the clinical record and
adhered to. If reviews are planned for 2 weeks then systems should
ensure the review occurs within that time. If review periods change
following improvements of the patient, care plan should be updated to
reflect this.’
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256. It is encouraging that colleagues working for Care UK have themselves
identified ways in which their practice could be improved, and I endorse these
four recommendations related to the proper recording of clinical decisions.
257. The clinical reviewer emphasises the importance of conveying relevant
information on the OASys system to clinical professionals to contribute to their
assessment of the risk associated with certain individuals’ mental health. As
to resuscitation equipment and its location, he reports that the prison
healthcare team have plans to improve this by locating resuscitation
equipment at key strategic locations within the prison. I am aware that Nurse
D had to send for additional equipment as soon as she arrived at the man’s
cell, but I do not make a formal recommendation about this as I understand
that Wellingborough has taken steps to obtain more equipment.
258. A relevant recommendation made in the December 2008 report from HM
Chief Inspector of Prisons following an announced inspection of
Wellingborough, was that a full audit of resuscitation equipment should be
undertaken by a professional with the relevant skills and competencies. The
prison’s action plan in response to that recommendation indicates that a full
audit has been undertaken, and three new grab bags have been purchased
and furnished with the equipment recommended in that audit. An additional
automatic external defibrillator was also due to arrive at the prison by the end
of July 2009.
259. The clinical reviewer’s final recommendation is that a policy for receiving
Helimed should be agreed. This is a reference to the emergency helicopter
service supplied by Warwickshire and Northamptonshire Air Ambulance, and I
have duly made a recommendation about this requirement at a later stage of
my report.
Applications and Complaints at Wellingborough
260. In her report in December 2008, HM Chief Inspector of Prisons devoted a
section to applications and complaints. At Chapter 3.112 of her report she
wrote:
‘A good system of triplicate application forms had been introduced, which
should have allowed staff to track the progress of individual applications
and confirm that the prisoner had received a reply. However, this system
was not thoroughly or consistently applied on all wings, undermining its
effectiveness. Also, a large number of application forms, each specific to
a particular area or function within the prison, continued to be used in
preference to the triplicate generic form. The introduction of a
computerised application log gave all staff access to details such as when
the application had been received and what action had been taken in
response. While this was a good initiative, it had been in place for only a
few weeks and none of the staff we spoke to below the rank of senior
officer were aware of its existence.’
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261. The Prison Service Order dealing with requests and complaints is PSO 2510
which is entitled ‘Prisoners’ Requests and Complaints Procedure’. At Chapter
3 the PSO states that the oral and written application system provides a
means whereby most routine matters can be dealt with quickly and in a
systematic way. At Chapter 3.1.5 the PSO says:
‘The application system is an intermediate process between simply
speaking to an officer on the one hand and invoking the formal complaints
procedures on the other. It can be highly effective in meeting needs or
settling grievances relatively informally and at an early stage. Dealing with
a request or complaint quickly and fairly at this stage should mean fewer
formal complaints later on.’
262. My investigators studied only the complaints made by the man and did not
examine the range of complaints made by other prisoners in the way that HM
Chief Inspector of Prisons and her colleagues did when they scrutinised the
applications process at Wellingborough in August 2008. As noted earlier,
during his time at Wellingborough he made a total of 29 applications, ten on E
wing and a further 19 on C wing. Close analysis of these 29 applications
appears to suggest a number of significant structural problems in the way that
the applications process operates at Wellingborough. There is evidence that
major flaws in the applications and complaints system at the prison had an
adverse impact on the man’s mental equilibrium and wellbeing, and also on
his belief that the prison authorities would deal fairly and in timely fashion with
his legitimate requests and with matters that were of considerable importance
to him.
Applications
263. My investigators studied the applications log books kept on both E and C
wings. These log books contain details of all the applications made by
prisoners on the wing and of the area or person to whom each individual
application was sent. It is on the basis of these applications logs that my
investigators are able to say with confidence that the man wrote ten
applications on E wing and then a further 19 applications after his transfer to
C wing in late January 2009. In a number of cases there would be no record
that he had ever made an application if the applications log books did not
exist because my investigators have been unable to trace either the original
application or the answer, if any, that was given to it. Examples of this
problem are the applications made by the man on 29 January to prisoner
monies (log number C141/09); to reception on 31 January (log number
C152/09); to his personal officer on 17 February (log number C225/09); to
reception on 5 March (log number C293/09) and to his wing Senior Officer on
2 April (log number C435/09).
264. A Notice to Staff about a new wing application system was issued on 11
December 2006 by the previous Governor at Wellingborough. His notice
informed his staff that the new application form would consist of three carbon
copy sheets. The bottom sheet is pink and should be given back to the
prisoner once he has completed his application and brought it to the attention
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of staff on his wing. The remaining two sheets on the application form should
be sent to the relevant department for an answer, with the prisoner being
given the middle (yellow) sheet when the answer comes back to his wing.
The top (white) sheet should be placed in his wing file. If that system were
operating smoothly it should always be possible to find the top white sheet
containing the relevant answer in a prisoner’s wing file, but the man’s wing file
was not replete with completed and answered application forms. For
example, a reply to the application he made to his personal officer on 3
February has not been located. Sometimes, although the answer to his
application could not be found, it was possible to establish from other prison
documents that the question he raised had been properly dealt with. An
example of this is the PIN phone application he made on 5 March. He asked
for the telephone numbers of his daughter and five friends to be added to the
list of approved numbers he was permitted to call on the PIN phone system.
The allowed list of PIN phone numbers seen by my investigators shows that
these names and numbers were indeed added to the list.
265. A very troubling systemic problem at the time of the man’s death was that
Wellingborough had an excellent record of the applications despatched by the
man and all other prisoners making applications on his wings. However, there
was no written indication whatsoever on the wing application logs that
answers to these applications had come back to the wing and had been
received by the prisoner initially making them. The Notice to Staff issued by
the previous Governor in December 2006 instructed staff that, when
completed by the prisoner, wing staff would log the application in the log book
and number it. Once the answer from the relevant department had been
received on the wing, the application would be logged back into the log book.
In the wing application log books for E and C wings the five columns on the
left-hand side of the log book have been filled in meticulously for every
application. These columns provide information about the log number, the
prisoner’s name, his number, the date of the application and the area or
person to whom the application has been sent. But the remaining four
columns of the two log books are completely empty, which means that no
written information has been entered about the crucial stages of the
application recording when it has been received back on the wing, when a
copy has been given to the prisoner, when a copy has been placed in his wing
file and when a weekly follow-up has been made on any occasion when an
answer has not been received. The seventh column of the two log books
contains the important safeguard of a staff signature when the copy of the
application form containing the answer has been handed over to the prisoner.
But the potential safeguards supplied by this column have been absolutely
undermined by the fact that there is no recorded information of any
description after the point when the prisoner has made his application and it
has left the wing.
266. On 16 June 2008 the current Governor at Wellingborough issued Notice to
Staff number 95/08. This Notice observed that over recent months the correct
application procedure had not always been followed. Staff were reminded of
the system introduced by the previous Governor which required them to log
each application in the wing applications log book and also to log the answer
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in the book once it was received. The Governor’s Notice also announced
that:
‘In order to support wing staff in their task of dealing with applications, the
main non residential areas will now be required to keep a log of
applications received and action taken, in order to provide accountability.
The applications log can be found on the Z drive in the folder labelled
‘Applications Log’ and is in the form of an Excel spreadsheet. Each area
is required to enter information about each application received.’
267. It will be seen from preceding paragraphs that wing staff were completely
ignoring the instructions from both the Governor and his predecessor to
record information about answers to applications in the wing log books. My
investigator studied the Z drive with the Custody Office manager at
Wellingborough to find out if it was a more reliable source of information about
the applications the man had made and the corresponding answers sent to
him. My investigator and the Custody Office manager discovered that there
was no reference to any of the ten applications he had made on E wing on the
Z drive. As to applications made on C wing, my investigator and the Custody
Office manager found that eight of the 19 applications made by him did not
appear on the Z drive, though four of these were to his personal officer or
wing SO. I note that the Governor’s Notice requires only the main non
residential areas to keep a log of applications received and action taken, but
my enquiries would appear to suggest that it is not just non residential staff
who may fail to deal with a prisoner’s application promptly and effectively.
268. If over 40 per cent of the 19 applications the man made on C wing do not
feature on the Z drive, there must be some doubt about its usefulness as an
auditing tool. My investigator discussed the effectiveness of the application
system at Wellingborough during his interview with PO A on 28 May. She
responded in writing on 9 March to a formal complaint made by the man on 5
March, in which he wrote of his belief that since putting in a complaint in
January against SO A nothing had been done about the complaint and 19 of
his applications had gone unanswered. He wrote of his total belief that he
was being victimised because of his original complaint against the SO, and
the fact that his applications were being regularly ignored.
269. In her response of 9 March PO A wrote that she had checked the applications
database but had found only four applications. She wrote that Education and
the Offender Management Unit had replied, and the Governor had replied on
two further occasions stating that he/she could not find the man’s applications.
She reported that she could find no record of 19 applications. She is an
experienced manager at Wellingborough who said in interview that she had
management responsibility for A, B, C and D wings between May 2008 and 6
April 2009. Three days prior to the man’s death she became the residential
PO for B and D wings and manager of the Safer Custody Department. As I
have reported at para 118 above, the following exchange took place between
my investigator and PO A:
72
Investigator: At the time [when she was responding to the
man’s complaint of 5 March] would you be
concerned that 15 of the 19 applications that he
says he’s completed cannot be traced or is that
par for the course at Wellingborough?
PO A: I regret to say it’s par for the course.
270. At the end of her interview PO A said that the Ombudsman should make a
recommendation about the need for the application system at Wellingborough
to ‘run better’. She accepted that wing staff were not normally logging
answers to applications on the wing log books when they were received and
expressed the view that it is important for the date to be put in the log book.
271. The impression I have gained as I read through the applications made by the
man and the responses he received is that these were mainly paper exercises
and that there was little face to face contact between him and the people
responding to his applications. I am acutely aware of the resource constraints
under which prison staff operate. But I applaud the fact that in the last week
of his life both the IMB member and the Head of Residence went to see him
face to face. My report is being written with the benefit of hindsight and I do
not make a formal recommendation about this matter. The Governor may,
however, wish to share with staff my view that on certain occasions a face to
face meeting in response to an application is both the right thing to do and a
sensible method of ensuring that an issue is adequately addressed before it
assumes much bigger and time consuming proportions. I observe that the
man sent application forms to the Residential Governor on both 25 February
and 9 March. In the first of these applications he asked her if she had
received his formal complaint about SO A which the Governor should have
forwarded to her on 26 January. On 6 March, she wrote back that she had
not received a copy of his complaint. When he sent a further application to
her on 9 March, asking if she could update him as to the outcome of his
complaint, she wrote back the very same day that she would obtain a copy of
his original complaint and respond within 14 days.
272. In his application to the Residential Governor dated 19 March, the man said
that since complaining about an SO he had put forward 19 unanswered
applications and that, of his five transfer applications, none had been received
by the OCA Department. He said that his treatment amounted to victimisation
and demanded to be moved straightaway. The response to that application
was written by PO A who, on 27 March, asked him to advise what it was he
was asking for.
273. On the same day, the man sent a similarly distressed and angry application
form to the OCA Department. In it he said that he had applied to move to
Acklington over five times, but the response of 24 March to that application
from the OCA Co-ordinator said that they had not received a transfer request
application from him. Prisoners should feel that their applications are being
clearly heard and understood, and I repeat my view that a judicious use of
face to face interviews may be a sensible and time effective method of
73
defusing prisoner frustration and getting to the heart of the matter that should
be addressed.
Complaints
274. The man wrote 12 complaint forms during his time at Wellingborough and,
since these complaint forms provide a revealing insight into his frame of mind
in the weeks immediately prior to his death, my investigators have paid close
attention to the way in which the complaints system works at the prison.
275. At Section 3.114 of her December 2008 report, HM Chief Inspector of Prisons
had some harsh words to say about complaints, as follows:
‘The established quality assurance system [in relation to complaints] was
not robustly monitored and, overall, we found the quality of responses to
complaints to be inadequate. In our sample of over 200 completed
complaints, several had replies that were difficult to read or did not identify
who had written them; many did not fully address the issue raised by the
prisoner and few gave helpful guidance on what alternative or additional
action the complainant might wish to take. Too many had been signed off
as completed even though they contained only an interim response,
usually promising further investigation. There was no system for recording
the eventual outcomes of these cases.’
276. Her recommendation was that incomplete or deferred responses to
complaints should be tracked and the timing and nature of the final outcome
should be recorded.
277. In their annual report for the period from June 2008 to May 2009 the
Independent Monitoring Board at Wellingborough include a paragraph, at
Section 6.30, which refers to some evidence in the reporting period that
improvements are required to the way in which complaints are managed. The
Board write:
‘While the monitoring of standards for audit can seem to demonstrate
compliance, from a prisoner’s point of view complaints filed before a
satisfactory outcome has been achieved or written answers which have
been delegated to a member of staff with little understanding of the issue,
can be very frustrating.’
278. There are some significant introductory remarks in the first chapter of Prison
Service Order 2510 which deals with the procedure for handling prisoners’
requests and complaints. They explain why an effective and credible
complaints system is so important:
‘An effective system for dealing with prisoners’ requests and complaints
underpins much of prison life. It helps to ensure that the Prison Service
meets its obligation of dealing fairly, openly and humanely with prisoners.
It also helps staff by inspiring in prisoners greater confidence that their
needs and welfare are being looked after, by reducing tension and by
74
promoting better relations between prisoners and staff. A prison’s
equilibrium is more likely to be maintained if prisoners feel they have an
accessible and effective means of making a request, an outlet for their
grievances and confidence that their requests or complaints will be
considered properly, with reasons given for decisions.’
As Ombudsman, I strongly endorse what is said in this extract from the PSO.
279. The PSO also contains information about the target dates within which
responses to complaints from prisoners should generally be given. The
response to any complaint against a member of staff should be supplied
within ten weekdays and the response when a prisoner submits a complaint
by confidential access to the governing Governor ought to come within seven
weekdays. The PSO establishes that prisoners have the right to make a
complaint under confidential access (in a sealed envelope) to the governing
Governor or Chair of the IMB at the prison where they are held. The PSO
adds that confidential access may be especially appropriate when a complaint
is about a particularly serious or sensitive matter. Chapter 9.2.6 of the PSO
indicates that, on receipt of a confidential access complaint, the complaints
clerk must register the complaint and allocate a serial number before passing
the envelope, unopened, to the person to whom it is addressed. The recipient
should send the reply in a sealed envelope to the prisoner via the complaints
clerk, with the clerk being required to register the date of the reply and to
forward the envelope unopened to the prisoner.
280. Most of the 12 complaint forms submitted by the man were handled with
reasonable speed and efficiency, but a fundamental flaw was
Wellingborough’s failure at the time to distinguish between an interim and a
substantive reply to a complaint. HM Chief Inspector of Prisons’ form of
words in the Healthy Prison section of her report at paragraph 27, was that
‘‘too many [complaints] were signed off as completed but only contained an
interim response, with no evidence that the complaint had been substantively
dealt with’’.
281. The complaint form that created enduring problems was the one written by the
man on 22 January 2009. That complaint was sent by confidential access to
the Governor and alleged that, when his ACCT form was closed by SO A on E
wing, she had spoken to him in a rude and patronising fashion and had
humiliated him. On 26 January, the Governor wrote back to the man thanking
him for his information and telling him that he would pass on the details to his
wing governor so that she could look into the matter. In interview the wing
governor was adamant that she did not receive any instruction from the
Governor at the time to conduct an investigation of SO A’s behaviour.
Despite the application forms that the man sent to her on 25 February and 9
March, it appears that the wing governor did not appreciate an investigation
was required until 19 March when she commissioned one from PO B. In the
meantime the man submitted a string of applications and complaint forms
about a range of issues, but especially about his desire for transfer to
Acklington. When he did not receive replies that engaged with the questions
he was asking, he assumed that he was being victimised in retaliation for the
75
complaint he had lodged against SO A. His distress, frustration, suspicion
and loss of equilibrium are apparent in a number of the complaint forms he
wrote subsequently. In his complaint dated 5 March, dealt with by PO A, he
wrote that since putting in a complaint in January against the SO on E wing
nothing had been done about it and there were a further 19 unanswered
applications. He asked for a move to Acklington as soon as possible.
282. On 20 March, the man wrote in a complaint form that it was the fifth time he
had applied for transfer and that he had proof of 19 unanswered applications.
On 29 March his complaint form stated that he had applied weekly for over
two months to be transferred to another prison but still the OCA Department
had not received his application. He had made weekly attempts to contact the
Independent Monitoring Board but had had no contact. He had proof of over
19 unanswered applications and strongly suggested that was because of the
complaint he had put in against the SO on E wing. As I have reported in para
143, the 29 March complaint continued thus:
‘I am being victimised. Sooner or later a inmate being treat this way will
snap. Everything I put my name to goes in the bin! I am being treated
unfairly and have reported all this previously. It’s gone on too long.’
283. In his complaint form dated 30 March the man alleged that he was being
victimised and that none of his applications (now 20+) was ever processed.
He had made seven applications for transfer but they had not been received
by the OCA Department. He wrote that ’this is very frustrating and causing
me many problems and unacceptable’.
284. The final formal complaint form submitted by the man was dated 4 April and
observed that, since he had entered his complaint against the Senior Officer
on 22 January, he had had nothing but problems and believed he was being
victimised. He wrote that there were now approximately 30 unanswered
applications. In the box indicating what he would like to see done about his
complaint, he appears to suggest that he had not received a response from
the Residential Governor despite her memorandum to him of 19 March which
told him that his complaint about SO A had been investigated and that the
matter would not be pursued further. He wrote:
‘Complaint F/4115/1/09 was never passed to the Residential Governor.
Now she has had it over a month and I suggest it has been covered up or
not dealt with seriously. I want it dealt with and moved out this prison asap
as nothing I put my name to gets dealt with! And situation is pushing me
too far I can cope. [I assume that he intended to write that he could not
cope.] Please come and look at apps. This situation is a disgrace.’
285. The newly appointed deputy Head of Residence at Wellingborough
responded quickly, efficiently and in person to the Governor’s instruction that
he deal with the matters raised in the man’s final complaint form. He
prepared for his meeting with the man in the motorcycle workshop by reading
his wing file, and he therefore knew that his request for a transfer to
Acklington had very recently been approved by the OCA Department.
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However, when he began to discuss the transfer with the prisoner, it became
apparent that the man was unaware of the OCA decision. In the words of the
deputy Head of Residence that I have quoted at para 196 above:
‘Initially there was a distrust of the information I was giving him. I suppose
from the man’s point of view he’d put this request in for a transfer that
hadn’t been responded to and there was this brand new governor
appearing in front of him in the workshop telling him that all of a sudden
there has been a response from the OCA.’
286. After the deputy Head of Residence’s disconcerting revelation that the man
did not seem to have received his reply from the OCA Department by the
afternoon of 7 April, my investigator asked him if responses to applications at
Wellingborough sometimes or often did not reach the prisoners for whom they
were intended. He responded thus (see above para 197):
‘Yes I think there’s twofold you know, some bits of paper that are intended
for the prisoner don’t end up being given to the prisoner. But equally when
the staff do have possession of a piece of paper and they file it in the wing
file that’s not always communicated to the prisoner, even if it relates to
them.’
287. The deputy Head of Residence’s experience in the workshop underscores the
fact that it is an individual prisoner who begins each application or complaint.
It is therefore of critical importance for the integrity of these systems that the
prisoner has confidence that his voice will be heard and that he will receive a
personal reply in timely fashion to the matters which have been exercising
him. I accordingly make the following recommendations:
As a matter of urgency the Governor should ensure that Wellingborough
has an application system in which prisoners (and staff) can have
confidence.
In particular he should ensure that there is a robust and reliable system
for supplying a personal answer to each application in timely fashion to
the prisoner who made it.
The Governor should ensure that prisoners receive personal replies to
their complaints within the timescales stipulated in PSO 2510. He
should also ensure that any prisoner who receives an interim reply to
his complaint is subsequently given a substantive reply in timely
fashion.
77
The ACCT document opened between 23 and 29 December 2008
288. Soon after the man arrived at Wellingborough he wrote an application form,
on 22 December 2008, in which he asked to be moved to a single cell. He
maintained that if he spent one more night in a cell with anyone it would push
him beyond his limit and he would snap. He predicted that he would either kill
himself or someone else. The response to this application when it was
received on the morning of 23 December was rapid, detailed and appropriate.
An ACCT document was opened by Officer J at 11.30am and an immediate
action plan had been agreed within half an hour. A particularly impressive
feature of the ACCT process was the assessment interview conducted by
Officer L on the afternoon of 23 December. Officer L is a trained ACCT
assessor and so it is his job to conduct assessment interviews when an ACCT
document has been opened. The levels of care and attention he devoted to
the task are clear and noteworthy. Officer L’s assessment supplied
comprehensive and reliable information for his colleagues who participated in
the first ACCT case review on the morning of 24 December. It is obviously of
the utmost importance that an assessor wins the prisoner’s confidence and
supplies as much reliable information as possible on which any future support
strategy will be based.
The Governor should thank Officer L for the professional and diligent
way in which he undertook his work on 23 December and he should be
formally commended for its quality.
289. The first ACCT review on 24 December was attended only by SO C and the
man himself, but this was not a major defect because staffing levels may have
been reduced on Christmas Eve and the process was informed by the quality
of Officer L’s work and the mental health assessment conducted by Nurse A.
The man had already been moved to a single cell so the major source of his
stress and distress on 22 December had already been addressed.
290. As to the case review held on 29 December, when the man’s ACCT document
was closed, I am in no doubt that the three members of staff who attended
with him were SO A, Officer P and Nurse E. SO A recorded at the end of the
ongoing record that all issues were reviewed with the man stating that, since
moving into a cell on his own and having all his issues resolved, he no longer
felt the need to be on an ACCT. A number of good entries had been made on
preceding pages of the ongoing record which clearly showed staff not merely
observing him but also interacting with him. I am therefore entirely satisfied
that the decision to close his ACCT on 29 December was appropriate in the
circumstances.
291. I do not imagine that two separate ACCT reviews took place on 29 December
and I therefore assume that the signature and details supplied by SO C on the
bottom half of the second case review were entered on a subsequent date.
That would also suggest that Officer I did not attend the case review on 29
December although the top half of the second case review states that he did.
SO A was very candid in her interview with my investigator on 25 June 2009.
She confirmed that she had chaired the review on 29 December and made an
78
entry on the ongoing record but she had not signed the record of case review
because she did not know she was required to do so. SO A had been
working in the Security Department, transferring to E wing just before
Christmas, and she said that the man’s was the first ACCT review that she
had done in over four years. SO A’s unfamiliarity with all the requirements of
the case manager role in the ACCT process points to a clear training
requirement. The number of open ACCT documents during the time that my
investigators conducted interviews at Wellingborough was never in excess of
five or six, so it seems possible that some members of staff may not have
many opportunities to practise and develop their expertise in the case
manager role.
The Governor should ensure that all case managers at Wellingborough
are adequately trained for their role.
The Governor should consider whether refresher training should be
offered or provided when less experienced ACCT case managers
transfer to wing based responsibilities.
Was the man victimised at Wellingborough?
292. Four of the man’s complaint forms written in March and April convey the
certainty in his own mind that he was being victimised as a direct
consequence of submitting a complaint against SO A. In complaint forms
dated 5 March, 29 March, 30 March and 4 April he made that explicit link. In
his final complaint form dated 4 April, for example, he wrote:
‘Since entering what I consider to be a serious complaint against a senior
officer in January dated 22/1/09 I have had nothing but problems. I
believe I am being victimised.’
293. Two and a half pages of the seven page list of questions supplied to my
investigators by the man’s parents are devoted to the topic of prison
complaints and victimisation.
294. The definition of ‘victimisation’ given in Collins English Dictionary is
‘punishment or discrimination against someone selectively or unfairly’. I have
considered the man’s position carefully and I do not believe there is any
evidence that he was punished or discriminated against as a consequence of
his complaint about SO A and the closure of his ACCT document on 29
December 2008. My judgement is that many of his applications and his
particular complaint in relation to SO A were dealt with so badly or so slowly
because of poor communication, human error or systems failures at
Wellingborough. I do not think there was a concerted or malevolent staff
determination to punish him or to deny him responses to which he was
entitled because he had complained about the conduct of a senior officer.
295. The formal complaint form written by the man on 30 March about the
cancellation of his gym sessions from 18 March is an example of innocent
human error leading to a situation that doubtless appeared arbitrary and unfair
79
to the man. In the complaint form he referred to gym staff saying he had not
attended his session on 11 March. Of course he could not have been there
because at the material time he was attending a very important sentence
planning meeting with the Offender Supervisor and, by telephone, with his
Offender Manager. In interview the Offender Supervisor readily admitted that
she had forgotten to notify the PAMS Office that he would be meeting with her
on 11 March, and thus the relevant authorities elsewhere in the prison
assumed that he had been absent without leave from his required location
(the gymnasium). This was a small slip by the Offender Supervisor which had
regrettable consequences for the man, but it should be seen in the context of
the determined way in which she championed his interests during the three
months that she worked with him. I note with particular approval the way in
which she pursued applications to which he had not received replies with
other departments and with the Independent Monitoring Board.
296. In interview the Residential Governor was adamant that she had not been told
by the governing Governor about the man’s complaint in relation to SO A,
which was received by the Governor on 26 January. The Governor doubtless
expected that the necessary action would flow from a handwritten note he
attached to the complaint form. The blue post-it style note was retrieved from
the man’s cell by Police on the afternoon of 9 April and subsequently seen by
my investigators at Wellingborough Police Station. The note said: ‘Residential
Governor, could you note and take what action you feel is appropriate before
passing back to relevant staff.’ I am happy to accept the Residential
Governor’s assurance that she did not receive the Governor’s instruction at
that time. It appears that she did not appreciate until 19 March that the man
had complained about SO A and that further investigation of that complaint
was therefore required. I think, however, that the application forms the man
sent to the Residential Governor on 25 February and 9 March created
opportunities that should have been taken to undertake or commission an
investigation more promptly than eventually happened.
297. Powerful evidence for my conclusion that the man was not deliberately
targeted for active, malevolent retribution is the way in which SO A was
herself treated when the man’s allegation was investigated nearly two months
after he had made the initial complaint. I was surprised to learn that PO B’s
investigation of the complaint against SO A was concluded on 19 March
without her being given an opportunity to respond formally to the man’s
allegation. I am aware of the Residential Governor’s view that it was
important the matter be concluded urgently and that SO A was not on duty on
19 March. But in interview on 25 June she told my investigator that she
returned to duty on 23 March after a number of rest days, and I would have
expected PO B to be aware of that information at the time. A central principle
of natural justice is that a person against whom a complaint or allegation has
been made should be aware of the nature of that complaint so that she/he has
an opportunity to explain what happened or to offer a defence or to refute the
allegation. SO A was given no such opportunity in March 2009, and I have no
reason to doubt her veracity when she told my investigator that she had not
been aware of the man’s complaint until he wrote to her on 22 June.
80
298. SO A mounted a stout defence of her reputation during interview with my
investigator on 25 June. Amongst other things she indicated that she is a
very experienced member of staff and that, prior to becoming a prison officer,
she had been a nurse for five years. During that time she had done six
months of psychiatric nursing which gave her good additional insight into the
way that people behave in prison. She declared that she had been
professional and compassionate and had encouraged the man during the
ACCT review to move forward and carry on. She recalled that he had come
across very positively during the ACCT review, his problems had been
resolved, he had settled on the wing and he was happy for the ACCT
document to be closed because he knew that he could access further support
if need be.
299. It is a great pity that SO A was not given a chance to make these same points
three months earlier and that PO B’s investigation was confined to the
recollections of the two other members of staff, Officer P and Nurse E, who
attended the closure interview with the man and SO A. Since such a long
time had elapsed before PO B undertook his investigation, I suggest it would
have been infinitely preferable to delay the reply to the man for just a few days
(with an interim reply being sent to him) so that SO A had an opportunity to
hear firsthand of the allegation against her and to participate in the
investigatory process.
300. The application that fuelled the man’s belief that he was being victimised was
for transfer to the other prison, and the very lengthy delay before that perfectly
legitimate request received appropriate attention understandably contributed
to his feelings of frustration, tension and suspicion. On 12 March, he
completed his section of a prisoner transfer application form, although I note
HM Chief Inspector of Prisons’ observation at Chapter 3.112 of her report on
Wellingborough that a large number of application forms, each specific to a
particular area or function within the prison, continued to be used in
preference to what she described as a good system of triplicate application
forms. The new wing application system introduced by the former Governor’s
Notice to Staff in December 2006 indicated that some applications would still
require the original forms to be attached but the only categories identified in
his list were stores, police days, clothing, reception, cash disbursements and
labour. The list contained no mention of transfer applications. The transfer
application form has to go through a number of hands before it is either
approved or rejected in the OCA Department. After the prisoner’s contribution
there are boxes to be completed by his personal officer then senior officer and
Offender Supervisor before the final OCA decision.
301. The man’s application form appears to have been becalmed between 12 and
31 March when his personal officer made the necessary entry. During
interview my investigators asked him about this lengthy delay, and he
speculated that the form might have been lost or that the man might not have
handed it in on the day he dated it. It is certainly possible that the man wrote
the form and then failed to pass it on swiftly to the personal officer, though this
seems rather unlikely to me in view of the fact that PO A had written to him on
9 March in a complaint response about transfer applications. More
81
significantly, the option of transfer to Acklington had been discussed in detail
at the sentence planning conference with the Offender Supervisor and the
Offender Manager only the day before. My investigators checked on the
personal officer’s working arrangements for the 20 days between 12 and 31
March. Five of these 20 days were rest days but he was rostered to be on
duty for the remaining 15 days during this period.
302. If, as is probable, the man did indeed pass on his transfer application form on
12 March, one can readily imagine the sense of frustration he must have
experienced over the next three weeks as he waited for a response. He had
kept his side of the bargain by submitting a transfer application on the correct
paperwork after he had been at Wellingborough for eight or more weeks. But
when he asked in subsequent complaint forms about the progress of his
transfer application he was consistently told that the necessary form had not
arrived in the OCA Department and that they could not take action until they
got it. His complaint form of 20 March said that it was the fifth time he had
applied for transfer but the answer on 24 March from the OCA Co-ordinator,
recorded in para 140 and repeated here, was as follows:
‘I have checked our records and can find no evidence that you have
submitted any transfer applications. Please contact your personal officer
who will complete the official transfer application for you. Once I receive it
in the OCA Department it will be processed immediately.’
303. This scenario was repeated a few days later. On 29 March, the man wrote
another formal complaint form which he began by stating that on a weekly
basis for over two months he had applied to have a prison transfer, which was
supported by Probation and OMU. The response from the OCA manager was
swift, as it came on 31 March, but must have been most disheartening for him
as she wrote:
‘I have no record of any transfer applications from you on the transfer
database. As soon as an application is received from you it will be
actioned.’
304. The OCA Co-ordinator told my investigator in interview that the delay the man
had to endure was ‘more or less a one-off as our system does work’. On the
other hand I note with interest that under the heading ‘Transfers to Other
Establishments’ the IMB at Wellingborough report thus at paragraph 6.29 in
relation to the period from June 2008 to May 2009:
‘In this reporting period there has been some evidence that this process
[OCA] has been managed poorly. Changes of personnel locally and high
numbers in the prison system nationally have been contributory factors.
This particular process seems only to attract appropriate urgency when
moves are needed for security purposes. [The man’s move was at his
own request and he was certainly not perceived as a security problem or
threat.] For prisoners it is very frustrating when inevitable delays are
compounded by an apparent lack of urgency and rigour locally.’
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305. It is also disappointing that the response the man was sent to such a
contentious application was unsigned, undated and appears to have been a
standard document sent to prisoners requesting a transfer to prisons in either
the south or south-east of the country. The relevant sentence is ‘Requests to
establishments in the south and south-east are currently severely affected by
the population issues and a transfer to this area could take a significant
amount of time to complete’. Population issues in the south-east were of no
relevance to the man whose request was to transfer to a prison in an isolated
part of the country near the Scottish border. A reply which addressed his
particular situation could and should have been sent.
306. My other observation about the existing transfer application form is that
potentially there can be some delay before the OCA Department becomes
aware that a prisoner has submitted an application. I wonder, in the light of
the man’s experience, whether it is wise for a requirement to be imposed that
the form passes through so many intervening stages between the prisoner
and the OCA Department. Might it not be preferable for the form to go directly
from the prisoner to the OCA so that the application can be lodged there and
the responsibility for chasing any additional comments from their colleagues
would then reside with the OCA?
I recommend that the Governor reviews the transfer application system
within three months of receipt of this report. The review should pay
particular attention to:
• The form to be used
• The route it takes
• The need for a suitably individualised response
• A guarantee that the prisoner has safely received that response
83
How did the man learn that his application for leave to appeal against sentence
had been refused?
307. There is little doubt that the trigger event which appears to have led the man
to take his own life on the afternoon of 9 April was the crushing impact of a
letter which I deduce he received that afternoon from the Criminal Appeal
Office at the Royal Courts of Justice. The letter, dated 2 April 2009, informed
him that the single judge had refused him permission to appeal against
sentence. The letter from the Criminal Appeal Office conveying that
information was sent first not to Wellingborough but to Wormwood Scrubs, the
prison where he had been held for 19 days in December 2008 immediately
after being sentenced to eight years imprisonment on 1 December. The
Criminal Appeal Office despatches four copies of the Order with one copy
going to the Governor of the prison where the appellant is held, one copy
going to the appellant himself, one copy going to his solicitors and one to his
barrister.
308. When the system works smoothly a copy of the letter from the Criminal
Appeal Office goes to the prison where the prisoner is currently being held,
with a second smaller envelope which conveys the judge’s decision to the
prisoner being contained inside the larger envelope addressed to the
Governor. My investigators asked the Criminal Appeal Office to post two
standard letters to them and the Appeal Office duly did so. The second letter,
for the prisoner, has a large and very clear stamp on the outer envelope which
contains the words ‘Criminal Appeal Office – Confidential under Rule 39A/YOI
Rule 14’. (Prison Rule 39 permits a prisoner to send and receive privileged
correspondence, to legal advisers and to specialist organisations like the
Prisons and Probation Ombudsman’s office, which cannot be opened or read
by prison staff.)
309. The first paragraph of the Criminal Appeal Office’s letter to the Governor of
Wormwood Scrubs dated 2 April informed him that two copies of the Order
made by the single judge were enclosed. The letter then indicated that the
judge had refused the man’s application for leave to appeal against sentence.
The second paragraph explained that one copy of the letter was for the
Governor to retain on his file, with the other copy being given to the man,
together with the covering letter addressed to him. The third paragraph of the
letter instructed that a prison officer should insert the date on the reverse of
form SJ at Part 2A and should then hand the form to the applicant without
delay.
310. The letter closed by telling the Governor that, if the applicant was no longer
held at Wormwood Scrubs, the papers should be forwarded to him at his new
prison. In capital letters the last paragraph of the letter asked the Governor in
all cases to acknowledge receipt of the forms using a proforma attached by
the court, and to provide the applicant’s current address if he was no longer
held at Wormwood Scrubs.
311. The letter was signed on behalf of the Registrar at the Criminal Appeal Office.
My investigator was informed by the Court Manager at the Royal Courts of
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Justice that Wormwood Scrubs did not send the proforma as requested to
notify the Criminal Appeal Office that the man had moved on to
Wellingborough.
312. My investigator discussed the arrangements for processing such
correspondence at Wormwood Scrubs with both the governor in charge of the
Business Management Unit at the prison and the Head of Custody. These
two managers were unable to say exactly what had happened to the letter
from the Criminal Appeal Office at Wormwood Scrubs because apparently no
written record is kept of such documents at the time when they are forwarded
to the prisoner’s new address. The Head of Custody estimated that three or
four similar letters are received at Wormwood Scrubs each month. She said
that normal practice would be for the letter to be opened by an operational
support grade member of staff at the prison and then sent, already opened, to
the Custody Office. My working assumption is that the letter from the Criminal
Appeal Office would indeed have been opened at Wormwood Scrubs rather
than being sent onto Wellingborough unopened because the address on the
outside of the envelope would be that of the Governor at Wormwood Scrubs
rather than the man who is the subject of this report. It would only become
apparent that the letter for the man was to be given to him once the outer,
Governor’s letter had been opened.
313. The letter to the Governor of Wormwood Scrubs was received in the Custody
Office at Wellingborough on 8 April. The Adjudications and Productions Clerk
at the time when the man died made an entry in her Register of Appellants
book (BR006) to that effect. She was insistent in interview that, although she
safely received the Court’s letter of 2 April to the Governor at Wormwood
Scrubs, she did not receive a second copy of the single judge’s decision in an
attached Rule 39 letter for the man. Due to pressure of work she did not
issue the correspondence from the Criminal Appeal Office within 24 hours as
she would normally expect to do. She was certain that the Governor’s version
of the Order was still in her pending tray when she went off duty on the
afternoon of 9 April, the day of the man’s death.
314. A copy of the letter from the Criminal Appeal Office was also sent on 2 April to
the man’s solicitors. My investigator made contact with the solicitor who acted
for the man. In a letter dated 3 July she wrote to my investigator that the
barrister acting for the man at Grays Inn Square chambers had lodged an
appeal against sentence and advised that there were no grounds to appeal
against conviction. She added that the man had instructed the solicitors in
respect of his appeal against conviction.
315. The firm of solicitors received their copy of the letter from the Criminal Appeal
Office on 3 April and the solicitor revealed that she dealt with the letter on 9
April, e-mailing the barrister for his advice on whether to renew the
application. Her intention was to write to the man once she had received
advice from the barrister. She added that she spoke with the man’s mother
on 9 April and confirmed that she was awaiting Counsel’s advice before
proceeding. She asked the man’s mother to invite him to telephone her so
that she could advise him of his options.
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316. In a second letter to my investigator, dated 14 July, the solicitor confirmed that
she had not sent a copy of the appeal decision to the man prior to or after his
death. She added that no-one from her office had sent the appeal decision to
him.
317. The copy of the letter from the Criminal Appeal Office removed from the
man’s cell after his death has been made available to my investigators by
Northamptonshire Police. The covering letter from the court found in his cell
after his death was addressed to the man himself. The expectation of the
Registrar at the Criminal Appeal Office, as set out in his covering letter of 2
April to the Governor of Wormwood Scrubs, was that a prison officer would
insert the date on the reverse of the form announcing the judge’s decision.
The letter to the man found by the police in his cell on 9 April contains the
following sentence:
‘The prison officer (usually the legal aid officer) should have written on the
back of Form SJ the date you were given the form.’
318. The reverse of Form SJ recovered by the police from the man’s cell on 9 April
is annexed to my report. The reverse side is blank and contains neither a
date nor a prison officer’s signature at Part 2A of the form.
319. Officer B remembers giving the man a letter at about 1.50pm or 2.00pm on
the afternoon of 9 April. She thought in interview that the letter had a
solicitor’s stamp on it and was unopened. It seems highly likely that this was
the point at which the man learned that his appeal against sentence had been
rejected. The timing of the calls he made that afternoon to his mother and his
partner is evidence of that, with the first call being made at 1.59pm to his
mother. At the very start of that conversation he told his mother that ‘they’ve
refused my appeal’ and at the end of the conversation, she promised her son
that she would get onto the solicitors now. In the second conversation of the
afternoon, with his partner, he said three times over in a short conversation
‘They’ve refused my appeal.’ The extent of his psychological distress can be
gauged from the fact that on five separate occasions during the conversation
the transcript records him as crying while he spoke.
320. It is not easy to establish how such a significant letter came to be in the man’s
hands without being passed to him in carefully controlled fashion. No criticism
at all should be directed at Officer B who struck my investigators as a caring
and compassionate officer with good insight into the life of the wing and the
man’s behaviour. She was simply issuing a large number of letters to a big
group of prisoners at an exceptionally busy time of the day as prisoners were
preparing to go to their respective afternoon activities.
321. A number of safeguards designed to ensure that such significant news was
broken to the man in a suitably controlled way demonstrably did not operate
successfully. Ironically, the Governor had introduced a new system for the
distribution of official prisoner documentation just three days before the man’s
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death. On 3 April, he published Notice to Staff 032/09 which advised his staff
as follows:
‘The Custody Office currently requires an officer to come to the Admin
Block to collect official documents (immigration, parole, court etc). As of 6
April the Custody Office will issue documents directly to the wings in a
similar style to the complaints system.
‘Staff in the Custody Office will indicate what action is required with the
documents received and give each document a log number and a target
date for completion. On receipt of this to the wing, the appropriate action
should be taken within the set timescale and a cover sheet must be
returned to the Custody Office signed by the member of staff handling the
document.’
322. For each piece of official documentation there was an accompanying form
containing such details as target date, log number and prisoner’s name, and
requiring the relevant member of staff to take the necessary action, sign the
form and then return it to the Custody Office by the target date. It is clear that
the letter from the Criminal Appeal Office was exactly the kind of document
the Governor had in mind when he issued the Notice to Staff. Regrettably,
the safeguard of issuing the official document to the prisoner and asking him
to sign the marked areas, or issuing the document to the prisoner, asking him
to sign the marked areas and also requiring a member of staff to complete
applicable marked areas, was not implemented with regard to the man’s
letter. It does not appear that he received it in the expected carefully
controlled fashion.
323. There was a second Wellingborough safeguard that might have protected the
man from the consequences of receiving the single judge’s decision
unsupported by a member of prison staff. This was the practice of listing
official letters issued to prisoners each day. My investigators obtained a copy
of the register kept in the Security Department which requires a manager to
sign for all Rule 39 letters received for prisoners on the wings for which they
are responsible. On 9 April, SO F signed for three Rule 39 letters for
prisoners on A wing, two for prisoners on B wing, four for prisoners on C wing
and one for a prisoner on D wing. On the same date SO C signed for five
Rule 39 letters addressed to prisoners on E wing. The man’s name did not
appear on the list of four C wing prisoners to whom Rule 39 letters were
addressed.
324. There were some other small opportunities which, if taken, would have
increased the likelihood that the letter from the Criminal Appeal Office went
directly to Wellingborough, rather than going to the wrong prison first. On 13
January, the Criminal Appeal Office sent a letter to both the Governor at
Wormwood Scrubs and the man acknowledging his notice and grounds of
appeal, and notifying him that his application would be sent to a casework
group who would prepare his case papers for a single judge if his grounds of
appeal were judged to be effective. By 13 January, the man had already
been at Wellingborough for nearly a month. But the 13 January letter does
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not appear to have resulted in the Criminal Appeal Office learning that he was
no longer at Wormwood Scrubs. In conversation with my investigator the
Court Manager in the Criminal Appeal Office told him that best practice is for
her staff to check on an electronic system called the Inmate Information
System (IIS) as to a prisoner’s whereabouts before despatching
correspondence to him/her. (The same practice applies in my own office.)
But she could not be sure that such a check had been run prior to the 2 April
letter being despatched.
325. I am of the view that it is the Prison Service’s responsibility to notify the
Criminal Appeal Office of a prisoner’s whereabouts and the man’s case
underlines the importance of this being done as a matter of course. My
judgement is that sending the 2 April letter initially to Wormwood Scrubs
increased the risk that the man’s copy of the decision would become
separated from the Governor’s copy. His death demonstrates the possible
consequences if routine and ostensibly insignificant elements of process or
bureaucracy (such as dealing with correspondence from the Criminal Appeal
Office or applications and complaints made by an individual prisoner) do not
operate smoothly.
326. It is manifestly inefficient and time wasting for correspondence from the Royal
Courts of Justice to be sent to the wrong address. My investigators’
conversations with senior managers at Wormwood Scrubs and with the Court
Manager at the RCJ indicate that this is a well known problem. This seems to
me to be an area where the criminal justice system could and should be much
better integrated. I believe that risk and wasteful delays could be reduced if a
senior manager from the National Offender Management Service were to
meet soon with a counterpart from the Royal Courts of Justice. I do not intend
to draw up the agenda for such a meeting but I am attracted to the option of
requiring the prison that holds an appellant to be responsible for notifying the
RCJ as to his whereabouts. That appears to be the intention underlying
Prison Service Order (PSO) 2605, as discussed in the following paragraph. A
very simple proforma or e-mail could be sent to the RCJ with the news that an
appellant formerly at Wandsworth or Wormwood Scrubs is now at
Wellingborough, and that any future correspondence about his appeal should
therefore be directed to Wellingborough.
I recommend that the Director General of the National Offender
Management Service invites one of his senior managers to meet soon
with a counterpart from the Royal Courts of Justice in order to refine
and improve existing communication systems for conveying appeal
decisions.
327. PSO 2605 sets out the role and responsibilities of the Legal Services Officer
(LSO). Chapter 2.2 of the order is sub-headed ‘The need for the LSO’ and
decrees that:
‘Every prison must have a designated officer, who has received
appropriate training, whose duty is to ensure that no prisoner who is likely
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to need a legal service fails to apply for it due to ignorance or general
inadequacy.’
328. Chapter 2.6 requires that the LSO should see all new prisoners on the
morning after their reception. Chapter 6 of the order deals with appeals.
Section 6.2 establishes the following mandatory action: ’The LSO must see all
prisoners who are or could become appellants on the morning after their
arrival at the prison.’
329. At the time of the man’s death my understanding is that Wellingborough did
not have a LSO. I am aware of the resource implications of appointing an
LSO but the Introduction to PSO 2605 contains a mandatory action paragraph
(at section 6) which appears to require all prisons holding appellants to
appoint one. One of the LSO’s major identified duties is ’to see all prisoners
who are or could become appellants on the morning after their arrival at the
prison’. I accordingly make the following recommendation:
The Governor should ensure that all prisoners at Wellingborough have
access to the legal services identified in PSO 2605. In particular,
prisoners who are appellants should be seen on the morning after their
arrival at the prison.
Did anyone notice a change in the man’s behaviour in the days before he
died? Were there any signs that he might be suicidal?
330. The information made available to my investigators from a wide range of
sources is that no-one noticed a change in the man’s behaviour in the days
before his death. No-one with whom he came into contact in the last few days
before 9 April had the slightest inkling that he would be found hanging in his
cell.
331. The evidence supplied by mental health Nurse A is important in this context.
She decided to review the man at the beginning of April and went to see him
in the motorcycle workshop on 3 April. As I have already quoted in para 189,
in her interview Nurse A said that she and the man sat in a little kitchen at the
workshop and he was very well:
‘He was happy and smiling, pleasant and chatty and he said he could look
back and see how he’d improved. There were no stated problems and I
also felt he was holding down a job in the motorcycles which is quite
responsible and which he was clearly enjoying as it’s a very sought after
job in the prison … I actually asked him would he prefer to stay on the
Mental Health Team caseload for the moment. Because he looked so well
it was difficult to see what more we could do for him. He was settled on
his medication, he really did seem very happy.’
332. On 6 April, the man was visited at Wellingborough by a solicitor employed by
a firm of criminal and family law specialists in Bedfordshire. He and the
solicitor discussed the basis for his appeal, and also some prison issues on
which she took his instructions in order to pass them to colleagues in her
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prison law department. She wrote to the man’s mother on 15 April and his
mother in turn made the letter available to my investigator so that it could be
considered as part of my investigation into the circumstances of her son’s
death.
333. According to the solicitor’s letter, the man told her that his existing solicitors
had launched an appeal for him but he had not seen a response and asked if
she could provide a second opinion. Her assessment of his demeanour on 6
April was as follows:
‘My opinion of the man at the time was that he was proactive in terms of
his case and just wanted a second opinion as to what had happened. We
left it that he would seek his papers from you and I would contact his
solicitors regarding the situation and to request their papers. He wrote to
me the same day as the visit to confirm this and had said that he also
wished to work on the appeal himself and appeared to be very active. I
did not form the opinion at any stage that there was anything within his
demeanour for me to be concerned about.’
334. The prisoners who observed the man at very close quarters did not notice
anything amiss in the days preceding his death. A prisoner’s cell was on the
opposite side of the landing from the man’s and the two men saw each other
frequently every day. The prisoner explained in interview (see above, para
99) that when they came up for food:
‘Both of us would be like standing at the door and be chatting every day.
He seemed fine to be honest with you, he was a very nice fellow and didn’t
have any enemies or anything, he was a really quiet lad.’
335. During interview one of my investigators asked the prisoner if there was
anything that gave him cause for concern at any point or in the run-up to the
man’s death. His reply was clear:
‘Not once. That’s why I couldn’t believe it myself. Because I used to
speak to him, see him, when we got opened up we were the first two
people that would see each other. I’d be the first one to see him and be
the last one to see him every night because we’re facing each other and
we’re waiting for the officers to come and unlock the doors. We’d be
standing at the door chatting … He didn’t give me any reason to be
suspicious at all. That’s being honest with you; not at all. He seemed like,
he seemed happier than other fellows I see in this prison to be honest with
you.’
336. As I have reported earlier, the IMB member has been a minister of religion for
45 years and a hospital chaplain for a long period of time. He has been a
member of the Independent Monitoring Board at Wellingborough for a decade
and is therefore a most experienced observer of the human condition and of
life at Wellingborough. He had significant contact with the man exactly a
week before the man’s death, prompted by the letter sent to the IMB at
Wellingborough by his partner. My investigator asked him if the man gave
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any indications during the interactions the two men had on 2 April that he was
a man in distress or in torment. He replied:
‘No, I didn’t get that impression at all, he was fed up that he wasn’t getting
replies but he seemed to be pleased that we had given him some
information in the right direction and really when I heard the name of who
the person was [who had died] I was just shocked.’
337. When my investigator asked the IMB member why he was so shocked his
response was:
‘Well nothing had happened on the occasion when I saw him to give me
the thought that he might be of an unstable mind … Yes he wanted to
move on and I thought the news I’d given him was going to please him and
it seemed to do so.’
338. The deputy Head of Residence at Wellingborough joined the Prison Service
30 years ago and spent the first 22 years of his career working as a
healthcare officer, senior officer and principal officer. He saw the man in the
motorcycle workshop during the afternoon of 7 April, just two days before his
death. His recollection of their encounter was as follows:
‘At the beginning I think he was surprised to see a governor in the
workshop but when I introduced myself he obviously shook my hand and
was quite willing and quite open, an engaging man. I didn’t detect, he
wasn’t angry, he wasn’t portraying any anger or any sadness, he was just
putting his case across about what had happened to him in the past and
what he thought the issues were.’
339. The deputy Head of Residence thought that the man accepted the
assurances he gave about how things would be in the future:
‘… at the end he was smiling and laughing about because we carried on
the conversation about the motorcycle workshop and the fact that he
enjoyed working there and the interaction with the prisoners around the
workshop. And we got talking about motorbikes because it’s an interest of
mine as well and obviously an interest of his because he was doing the
workshop and I know two other prisoners joined in that conversation so it
was shared conversation at the end of the conversation. Like I said people
were laughing and joking so I didn’t leave him thinking that he was about to
harm himself.’
He felt that the man was looking forward to a transfer by the end of their
conversation and ‘his mood didn’t suggest that he was depressed at that
particular time’.
340. The deputy Head of Residence confirmed that he had been trained in ACCT
assessing and management and had undertaken mental awareness training
during his time as a healthcare principal officer. He agreed with my
investigator that he had the training and expertise to make a judgement about
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when an ACCT document needs to be opened. He was asked if the need for
an ACCT crossed his mind during his interview with the man and replied no.
341. Officer B is a regular officer on C wing and has been employed as a prison
officer at Wellingborough for the last six years. In interview she recalled that
when the man first came on the wing at the end of January he was very quiet,
very much kept himself to himself and almost looked ‘a bit on the down side.’
She observed that slowly, within a matter of a few weeks, he started to come
out of himself a little, he started talking more, he made good friends with
another prisoner and he also helped several prisoners who had problems with
the language barrier or with legal paperwork. She said that in the run-up to
his death everything seemed fine and her description of life on his landing
was as follows:
‘When we [the staff] were standing on the landing for association we had
little talks with him and we had a laugh and we all got on alright and we all
liked him because he was easy to get on with. Always polite to staff and
he was never rude or giving us any worries in any kind of way. He
seemed a strong character, I mean a couple of nights before it was, he
even told me about his time in a band and he played in Germany because
I’m German and you know, we had a bit of a laugh and a giggle and
everything seemed fine.’
Staff actions on the afternoon of 9 April
342. All the evidence available to me indicates that the man’s death was self-
inflicted. It is possible that, if he had been compelled to attend work on the
afternoon of 9 April, he would not have died. His parents asked a number of
questions about this issue and requested that I consider why he was allowed
not to go to his job in the motorcycle workshop. My investigator discussed
this matter during an interview with Officer U who gave a detailed and
convincing explanation of his thought process when permitting the man to
return to his cell rather than attend work. At the beginning of the interview my
investigator asked Officer U about his relationship with the man:
‘There are lots of prisoners on the wings, 66 prisoners on the wing and he
was one of the ones that I had good interaction with and got closer to, we
had that rapport where we could take the mick out of each other and that
sort of thing. Working in the prison, for prisoners and officers, that sort of
thing needs to happen for everyone to get along.’
343. My investigator asked Officer U about the qualities that distinguish a better
prison officer from a less good one. He replied:
‘Someone that’s actually approachable I believe, because if you actually
meet and talk to prisoners on a one to one level, you need to be able to
understand how they are, what they’re feeling, what they’re going through
and actually by being able to converse with people, just like me and you
conversing now, you get to know that person a little bit better and you get
to know the way they are thinking and that sort of thing.’
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344. Officer U saw that the man was making a phone call at the time when other
prisoners on the wing went to work and offered him an opportunity to go to the
motorcycle workshop at the time of second moves in mid afternoon. His
recollection in interview was that the man who is the subject of this report did
not turn round to him but said ‘No, I’m alright gov, that’s fine, I’m not going to
bother today’ or words to that effect. Officer U recalled that at 2.15 or 2.30pm
he and his colleague, Officer R, heard the man go upstairs to his cell and shut
the door behind him. My investigator asked Officer U if it was acceptable for a
prisoner not to go where he should be. In response he said:
‘We normally issue a Notice of Behaviour to someone which is basically if
they choose for no particular reason to go to work, they just for example
can’t be bothered, there’s a Notification of Behaviour that we give to them
that it’s unacceptable and that’s part of the Incentive and Earned Privilege
Scheme that the prison runs. But obviously as an experienced officer
knowing the prisoners, at times you do use your discretion and sometimes
you think well, that person obviously they don’t want to go to work for a
particular reason and it’s not in their character to not go to work. So you
just think, well for want of a better word, we’ll ‘give them the squeeze’
today you know, let them deal with whatever they’ve got to deal with, let
them have that time.’
345. Officer U subsequently explained that ‘giving them the squeeze’ meant giving
the man a bit of leeway. He added:
‘Knowing him as I know him, he’s an honest guy you know, I knew that
he’s not one that tries to play the system if you like, so me and Officer R
gave him that leeway.’
346. My investigator asked Officer U if issuing a Notification of Behaviour to a
reliable prisoner such as the man might be counter-productive and he
responded thus:
‘Yes exactly yes, they are a model prisoner, they follow the rules and
regimes and everything and suddenly the first time they decide not to do it
they get this negative thing, it’s not good for them, so that’s why you give
that little bit. You use your experience basically and give that little bit of
leeway to people that do follow the rules, regimes and everything all the
time.’
347. Officer U knew that it was out of character for the man not to go to the
motorcycle shop because he always attended work. However, after the man
had made his phone calls and the two men spoke, Officer U said that ‘he
didn’t sound upset and it didn’t give me any undue concern for his welfare.’
348. At the start of his interview with my investigators on 26 June, Officer U
diffidently produced a sheet of paper on which he had written a tribute to the
man. His tribute was read out to the staff and prisoners who attended the
memorial service at Wellingborough on 8 June. The tribute conveys the
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affection in which the two men held each other and the insight Officer U had
into the man’s character:
‘I knew there would be a few characters on C wing, it’s lively, one of them
characters was the man who died on 9 April but in a good way. I had a
good rapport with him. He would often stand at the edge of his door which
was at the end of the spur on C wing and watch people going about their
business. He often would comment on how strange some people were
and laugh at the younger people on the wing. My main thoughts on him
were that he was a decent, genuine man, you knew where you stood with
him. He had a dry sense of humour and mixed well with his fellow peers
on the wing. I for one miss him and if all prisoners were like this man then
prison would be a better place to work and live in.’
349. I do not reproach Officer U for one moment for his decision to permit the man
to return to his cell on 9 April. I believe that he exercised his discretion in an
entirely appropriate and reasonable way. His relationship with the man was
proper and professional but clearly cordial. Prison officers have to exercise
their judgement many times each day and they are often alone when required
to do so. I do not fault his judgement on the afternoon of 9 April, which I find
to have been based on humane, respectful and well informed principles.
The hour between 2.50pm and 3.50pm on 9 April
350. The times at which various events happened between 2.50pm and 3.50pm
are unclear and some written statements and interviews from staff give
conflicting accounts. The call logging software installed at Wellingborough
enables the precise time of internal to external telephone calls to be
established but similar information cannot be obtained for internal/internal
calls or for external/internal calls. Thanks to information supplied by the
women’s refuge where the man’s partner was living at the time, I am entirely
confident that a member of staff at the refuge made a phone call to the prison
on behalf of the man’s partner at 2.50pm. That call lasted for 165 seconds. I
am also entirely confident that a general alarm bell was pressed on C wing by
Officer B at 3.50pm because that time and information are contained in the
prison’s communications daily log.
351. The Security Information Report subsequently completed by the
administrative assistant indicated that she was working on the switchboard
when the telephone call was recieved to say that the man’s mood was low
and he had just told his partner that he was going to kill himself. The
administrative assistant was an inexperienced member of staff who happened
to be covering the switchboard that afternoon in the absence of the regular
switchboard operator. Never before in her career had she been required to
deal with a message of such gravity and urgency. She was not overwhelmed
by the task but made great efforts to pass the information onto her colleagues.
While the worker at the refuge was still on the line, she endeavoured to
transfer the call to the Prisoner Care (now Safer Custody) Department but
there was no-one present to answer the phone.
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352. The administrative assistant sought advice from the prison’s Security Principal
Officer and therefore the person in charge of the department where the
administrative assistant usually worked. The Security Principal Officer
instructed her to make contact with PO A who had recently assumed
responsibility for the Prisoner Care Department in addition to two of the
residential wings. But she was not able to make immediate contact with PO A
and she estimates that she waited for about five minutes before again
telephoning the Security Principal Officer for further guidance. On this
occasion the Security Principal Officer told her to telephone the prison’s
Communications Room so that they could put out a radio message for PO A,
and shortly afterwards PO A did indeed ring her.
353. I commend the administrative assistant for making strenuous efforts to resolve
the situation as quickly as she could. When she encountered setbacks she
did not give up but persisted with her attempts to ensure that the message
she had received was passed on to an appropriate colleague. She was
confronted with a grave situation for which there was no clear written
guidance in the switchboard office where she was working.
I recommend that the Governor draws up a set of contingency plans to
ensure that any member of staff operating the switchboard has clear
written guidance about what to do in a range of possible emergencies.
354. In interview the administrative assistant thought that perhaps 20 minutes
passed before she was able to pass on the message from the worker at the
refuge to PO A, whereas in interview PO A thought that she had first made
contact with her colleague on the switchboard at 3.40pm or 3.45pm. The next
significant development was that PO A spoke to Officer A by telephone and
asked him to check on the man’s welfare. In a statement he wrote on 7 May,
Officer A recounted that, at approximately 3.20pm whilst he was working in
reception, he received a phone call asking him to proceed to C wing so that
he could take over from Officer R, who was required for an emergency escort.
Officer A’s recollection was that he reached C wing at approximately 3.30pm.
He was still taking his coat off on arrival when the telephone rang and he
received his instructions from PO A. I note that Officer U’s statement to the
Governor times the phone call between PO A and Officer A at approximately
3.45pm. Officer U’s memory (at page 20 of the interview he gave to my
investigators) was that he spent 5 to 15 minutes chatting in the C wing office
with Officer A before the latter received PO A’s telephone call. At page 35 of
his interview, Officer A said that he walked straight onto the wing, he
answered the phone call straightaway and he then went straight to the man’s
cell door. I accept Officer A’s account that, as soon as he had finished the
telephone call with PO A, he went directly to the man’s cell door and tried to
gain access.
355. Gaining access to the cell did not prove a straightforward business. At first
Officer A thought the cell was unoccupied. He then realised that a barricade
had been constructed in the form of the man’s bed which had been pushed up
against the door in the centre of the cell. Showing notable initiative, he made
a split second decision that using a broom handle as a wedge would enable
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him to gain access to the cell more quickly than waiting for a door jack which
would normally be used in such contingencies. There was no broom handle
immediately to hand and Officer A told a nearby prison cleaner to find one for
him and to bring another member of staff.
356. Officer A’s account, though only his account, suggests that fully 20 minutes
passed between his arrival at the man’s cell at approximately 3.30pm and the
time when he gained entry at 3.50pm. An interval of 20 minutes appears
lengthy but I should point out that all the timings between 2.50 and 3.50pm
are unverified and the only times about which I am certain are those at the
very beginning and end of the hour. Both PO A and Officer U said in interview
that Officer A went to check on the man’s welfare at a later time than his own
estimate and PO A thought (page 22 of her interview) that no more than ten
minutes passed between her conversation with the administrative assistant on
the switchboard and the ringing of the alarm bell at 3.50pm.
357. It may be that it took Officer A less than 20 minutes to enter the man’s cell but
there were no straightforward or rapid methods that he could adopt to achieve
his objective. He feared that waiting for a door jack would be ‘a long lethargic
process. And now I’m getting quite anxious that there’s a sense of urgency to
get in there.’ I do not believe that Officer A could have gained entry to the cell
any more quickly than he did, although precious minutes obviously elapsed at
the beginning of the hour before the administrative assistant was able to
locate and brief PO A.
358. The wide variation between some of the staff statements made available to
my investigators increases the credibility of the documents because it is
abundantly clear that no central co-ordination or doctoring of these statements
has taken place. I must, however, point out that some potentially important
witnesses did not write statements to the Governor at all and many of the
statements I now possess were written several weeks after the man’s death
and only at the request of my investigators. The prison’s own contingency
plan (document 20 – Death of a Prisoner in Custody) requires staff who are
first at the scene to write a statement to the Governor about the incident and
their actions. A note in bold at the end of Section 20.1 of the contingency plan
informs staff that the exact time of each action must be accurately recorded
as the information is vital to the police, the coroner and all investigations. I
am in complete agreement with the letter and the spirit of that instruction.
I recommend that written statements should be obtained in timely
fashion from all staff who can provide significant evidence after the
death of a prisoner.
359. Many of the prison officers interviewed by my investigators made the point
that it is easy for prisoners to construct barricades in cells in the old wings of
the prison because beds are not bolted to the floor. I draw this matter to the
Governor’s attention but make no recommendation as it is an operational
issue and I am not aware of all the resource constraints. The Governor is
already aware of the ease with which pipes at ceiling level can be used as
ligature points in end cells such as C2-15, the one occupied by the man. I
96
make no formal recommendation in relation to the pipe in his cell in view of
correspondence sent to me by the Governor on 17 July 2009. In his letter the
Governor said:
‘The pipe that was used for a ligature point in the man’s cell is a heating
pipe forming part of the wing heating system. These pipes are present in
the majority of cells at the end of each spur on A, B, C and D wings. They
are the original heating pipes installed when the prison was built in 1963;
no modification or replacement of these heating systems has been
conducted since installation.’
360. The establishment submitted an Estates Investment Proposal bid to the
Property Board in March 2005 for the full refurbishment of these wings. This
bid would have included a replacement heating system to the current
standards. Although Custodial Property has recently conducted an estate
strategic review, no project has yet been agreed for the refurbishment of this
accommodation.
361. I note the Wellingborough IMB’s trenchant concern about the physical
environment at the prison as expressed at paragraph 6.21 of their most recent
annual report. The Board write:
‘As in previous reports the Board notes the inadequacy and poor repair of
the original wings A-E. These older wings do not appear to be fit for
purpose either in respect of prisoners’ facilities or with regard to prisoner
safety. The NOMS Property Board have to decide what to do with the
findings of the NOMS custodial property strategic review.’
362. Exactly an hour passed between the time of the phone call to the prison and
the moment when Officer B rang the alarm bell on C wing. Even if this time
interval had been very much shorter it is by no means certain that the man
could have been saved. He left a note, described as a suicide note in the
pathologist’s post mortem report, prominently displayed (according to
information from my Northamptonshire police colleagues) on top of his bed.
He erected a barricade which made immediate access to his cell impossible.
According to Officer A, the man used the edging of his bedsheets, described
by Officer A as the strongest part, to fashion the ligature. He also put a plastic
knife inside the ligature and then ‘tourniqued it up’ (Officer A’s expression).
My Collins dictionary defines ‘tourniquet’ as any instrument or device for
temporarily constricting an artery of the arm or leg to control bleeding. It
would appear that the man was using the plastic knife to increase the
throttling potential of the ligature he had made.
363. At the request of HM Coroner for Northampstonshire, a Professor of Forensic
Pathology at Leicester University and a Home Office registered Forensic
Pathologist, conducted a post mortem at Leicester Royal Infirmary on 15 April.
His professional statement indicates that he is a most eminent and
experienced pathologist who is a Fellow of the Royal College of Pathologists,
a Fellow of the Forensic Science Society and a founding Fellow of the Faculty
of Forensic and Legal Medicine at the Royal College of Physicians. He was
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the founder editor in chief of the International Forensic Journal, ‘Forensic
Science Medicine and Pathology’, which he edited until December 2008.
364. In the comments section at the end of his post mortem report the Professor
gives the cause of the man’s death as ‘hanging’. He writes that there were no
marks present to suggest that the deceased had been restrained against his
will or had been the victim of a violent assault. In the sixth paragraph of the
comments section, he writes of his opinion that the man’s death occurred
within three – four minutes after the application of the ligature. The full
paragraph reads as follows:
‘I am of the opinion that the deceased had died as a result of hanging.
From the peer reviewed literature and videoed incidents of adult deaths
due to hanging then in the case of the deceased unconsciousness (sic)
may have been lost within a matter of seconds once the weight of the body
was applied via the neck to the ligature. The deceased may then have
gone through a sequence of events, whilst unconscious, which has
ultimately led to hypoxic brain injury and death. Although it is not possible
to be certain how long this entire process may have taken in any single
individual, from the published literature it is likely that death occurred
within 3-4 minutes after the application of the ligature.’
The efforts to revive the man once he was found hanging
365. The efforts to revive the man between 3.50pm and 4.40pm were enormously
impressive in terms of their duration, resource intensiveness and skill. It is
difficult to think of anything more that could have been done. I trust that the
man’s parents and partner will draw some small comfort from the knowledge
that such skill and commitment was shown in the efforts to resuscitate him.
366. The staff who arrived in response to the alarm bell included some highly
trained and knowledgeable individuals. Officer A, who first found the man
hanging in cell C2-15, is a professional diver and was trained in both first-aid
and heart-start as a result, although he said in interview that he had not
received first-aid training in the Prison Service. Officer V, who began cardio-
pulmonary resuscitation with Officer A, explained in interview that he had
previously been a first-aid instructor and at the time of the man’s death he
was in date with his first-aid training, having received refresher training very
shortly before 9 April. Nurse D paid tribute to the quality of the life support
work done by her prison officer colleagues and said:
‘The officers seemed to know very well what they were doing. After the
event I did say to Officer V ‘How often have you done that?’ because I
thought his and everybody else’s technique was so good and he explained
to me that he’d never had to carry out basic life support before.’
367. Nurse D herself is a very experienced nurse who trained in 1983 and worked
in a medical admission unit, which she described as a fairly acute emergency
area, for many years prior to taking up employment at Wellingborough a
decade ago. In interview she told my investigators that she always does an
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annual basic life support and an immediate life support course which is of a
slightly higher level. She indicated that until 2008 she received her annual life
support refresher training at Northampton General Hospital’s Resuscitation
Unit but in 2009 she and all her colleagues in the Healthcare Department at
HMP Wellingborough received the necessary refresher training onsite. This is
a most encouraging example of good practice and I trust it will be maintained
in future years.
368. Paramedics from the East Midlands Ambulance Service arrived in the man’s
cell quickly. The Patient Report Form they completed indicates that the time
when they received the emergency call was 3.56pm, the time when they
arrived at the scene was 3.59pm and the time when they arrived at the patient
was 4.01pm. In the History of Chief Complaint section of the form the
paramedics wrote that on arrival excellent CPR was in progress. At page 29
of her interview with my investigators Nurse D recalled that when the
paramedics arrived it was a fairly calm situation considering its severity. She
said the CPR was going well so that, when the paramedics arrived, one took
over the man’s airway. Instead of the other having to do chest compressions
she was able, thanks to the high quality of the work being done by the prison
officers, to concentrate on what Nurse D called ‘the advanced part of things’.
369. Soon after the ambulance paramedics arrived they decided to call in
helicopter assistance from Warwickshire and Northamptonshire Air
Ambulance, with the prison’s communications daily log showing that an air
ambulance was en route at 4.10pm. The ambulance paramedics
administered a range of drugs to the man between 4.02pm and 4.24pm and
the communications log indicates that the air ambulance landed on the
prison’s exercise yard at 4.35pm. It was completely unprecedented for a
helicopter to land within Wellingborough’s secure perimeter but this was the
only option available in view of the number of cars parked on the external
carpark, the first option considered. The prison had no contingency plan for
such an extraordinary event. Indeed I can recall only one other example of a
helicopter being called in to a prison outside the immediate London area
during the last five and a half years when I have investigated every death of a
prisoner in England and Wales. The fact that arrangements were made in a
very limited timespan to decide where the helicopter should land, and to
appoint staff in high visibility jackets to guide it in, reflects enormous credit on
the orderly officer of the day and the governing Governor who approved the
necessary actions. Regrettably the doctor on board the air ambulance was
unable to do anything more for the man than his colleagues had already
accomplished. He pronounced death at 4.40pm, shortly after his arrival at the
prison. Two recommendations flow from my analysis of the sterling, though
ultimately unavailing, efforts to revive the man that afternoon.
I recommend that Wellingborough’s contingency plans be expanded to
include a section on the actions to be taken in the event that an air
ambulance is required to respond to a medical emergency.
I recommend that staff, to be identified by the Governor of
Wellingborough, should be formally commended by the Director of
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Offender Management for the East Midlands in recognition of the valiant
efforts they made to revive the man. The orderly officer should receive
the same level of commendation for the calm and effective way in which
she undertook her duties as orderly officer at the time.
Events after the man’s death
370. The Prison Service has issued detailed guidance about liaising with bereaved
families following a death in custody in a supplement to Chapter 4 of PSO
2710 which is devoted to follow-up to deaths in custody. The supplementary
guidance says that ‘the first contact must be made directly by the
establishment so that the family recognise that the death is a matter of great
concern to the establishment’. The guidance explains that the family must be
informed as soon as possible after the death, and for that reason I fully accept
that it was not feasible for staff from Wellingborough to travel to the home of
the man’s parents. However, the supplementary guidance states at Section
4.10 that: ‘If distance from the prison presents a problem, a dedicated Family
Liaison Officer or chaplain based in the area nearest the family home could
inform the family face to face.’
371. At Section 4.12 the guidance observes that the option of relying on police
officers to break the news is generally poor practice because they may not
have been appropriately trained and they may not have any knowledge about
prisons.
372. I accept that the man’s father was able to make telephone contact with
Wellingborough on the evening of 9 April after the police had broken the news
of his son’s death. But I am disappointed that prison staff from the prisons in
the area were not deployed for this task.
373. Despite the Prison Service’s own guidance that using the police to break
news of a death is generally poor practice, I have reported on 15 deaths in the
last 12 months where police, rather than prison, staff have conveyed the
news.
I recommend that the Governor should use his own staff or staff from
another prison to break news of a prisoner’s death to next of kin in line
with the strongly expressed guidance set out in the supplement to
Chapter 4 of PSO 2710.
374. I note that in their most recent annual report the IMB observes that religious
needs at Wellingborough have traditionally been well catered for. The Board
complains however that the post of Anglican chaplain has been vacant since
February. The Board’s view is that not providing a full-time Anglican chaplain
for a prison the size of Wellingborough is unacceptable. The man was a
Roman Catholic, not an Anglican, but it was disheartening to learn that the
Imam could not find a Roman Catholic priest or nun who was able and willing
to come to the prison to pray for him.
10 0
375. My investigator made a number of enquiries to establish why it was not
possible for a Roman Catholic priest to come to the prison. A factor of some
importance is that the man died on Maundy Thursday at the beginning of the
Easter weekend, one of the highlights of the Christian year. My investigator
telephoned the Sister, a nun in her 80s who lives in a convent on the opposite
side of town from the prison. She had already been to the prison on the
morning of the man’s death and told my investigator that she was unable to
return because she had promised to help at services in the community that
evening. She told my investigator that the parish priest in Wellingborough
could not attend at the prison because he suffers from arthritis and ulcerated
legs and is unable to climb stairs and explained that a number of priests from
elsewhere in Northamptonshire come to the prison to say Mass on Saturdays.
One of these priests is a Monsignor in a nearby town but she said he could
not come to the prison because he was taking services in the community on
the day in question. In any event, during a telephone conversation with my
investigator, the Monsignor said that he did not receive a message about the
man’s death until the morning of Good Friday, the next day.
376. My investigator discussed with the Principal Roman Catholic Chaplain for the
National Offender Management Service the best way of obtaining a Roman
Catholic priest in the event of emergency or death. He was firmly of the view
that the prison should have in place a robust contingency arrangement for
contacting the appropriate faith chaplain in such a situation. He said that the
prison should contact directly the sessional chaplain responsible for
sacramental care. He strongly advised that there should be clarity of
expectation on the prison’s part about what sessional chaplains will do and
when they will attend the prison.
377. I thank the Principal Roman Catholic chaplain for his assistance and duly
make the recommendation that he suggested:
The Governor should ensure that there are robust contingency
arrangements for contacting the appropriate faith chaplain in the event
of emergency or death.
Personal officers and Training
378. The introduction to Wellingborough’s policy document on the Personal Officer
Scheme says that:
‘… the personal officer provides a focal point for offenders and a personal
relationship through which constructive work can be developed and
progress can be discussed.’
379. I note that the man does not appear to have had any meaningful personal
officer contact whatsoever for the first 3 months of his time at Wellingborough
until an officer took over as his personal officer on 13 March. The only
reference to the Personal Officer Scheme before 13 March came on 27
January when the man who later died was first located on C wing and an
entry in his wing file said which officer would be his personal officer. Officer B
10 1
told my investigators that the personal officer may have been absent sick for a
period of time, although mandatory action number 9 in Wellingborough’s
Personal Officer policy document is that, in the long-term absence of a
personal officer, the Senior Officer will consider reallocation of that officer’s
offenders.
380. I have studied the Personal Officer scheme at Wellingborough only as it
related to the man but I note that at Chapter 2.34 of her December 2008
report on Wellingborough HM Chief Inspector of Prisons writes:
‘While there were some good personal officer entries on wing history
sheets, the majority showed minimal engagement with prisoners. There
were also inconsistencies in the number of entries made, with some files
detailing regular contact, but others containing no entries for over a month;
most only made one comment every two weeks.’
381. In the man’s case my assumption is that he was denied the kind of personal
support and assistance that the Personal Officer Scheme could have given
him, as a relatively inexperienced prisoner with significant personal problems,
until the second half of March when a new personal officer assumed the role.
382. The personal officer was not an experienced officer and he had only
concluded his initial training at the end of October 2008. In interview he
revealed that he had been allocated to personal officer work very shortly
thereafter. He was given an opportunity to learn about wing operations,
including personal officer work, in the ninth and last week of his initial training
course in October 2008 but he did not attend the prison’s training course on
the Personal Officer Scheme run by experienced senior officers until 31
March 2009. Despite having attended that training, he was unclear about
whether Wellingborough had a guidance document on personal officers, and
about the target contact he should have with the prisoners for whom he was
responsible, when my investigators asked him about these matters on 21
May. The 11th of the mandatory actions in Wellingborough’s policy document
requires wing managers to sign a random selection of wing files weekly to
ensure that personal officers are completing their fortnightly entries in the
wing files, and that any action points have been followed up.
383. The October 2006 policy document appears to recognise the potential and
value of the Personal Officer Scheme at Wellingborough, but my analysis of
the man’s prison files raises questions about whether prisoners always have a
personal officer, about the speed with which appropriate training is given, and
about the level of knowledge possessed by inexperienced staff in relation to
this area of their work.
I invite the Governor, within three months of reception of this draft
report, to conduct a standstill check of at least five per cent of
prisoners’ wing files at Wellingborough to establish whether personal
officer entries are being made with the frequency he requires, with a
view to providing appropriate training for his staff informed by that
exercise.
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First Aid Training
384. In the opinion of both Nurse D and the ambulance paramedics from the East
Midlands Ambulance Service who arrived just after 4.00pm, the quality of
cardio pulmonary resuscitation given to the man was excellent. It is
abundantly clear that some of the prison officers who endeavoured so
strenuously to bring the man back to life were highly trained and highly skilled
people. Their efforts to revive him demonstrate the importance of having a
pool of prison staff who possess relevant first-aid and resuscitation skills. On
this occasion the first wave of staff who arrived at the man’s cell in response
to the alarm bell included Officer A, whose first-aid skills exist thanks to the
professional diving he does away from the Prison Service, and Officer V who
has had extensive first-aid training and has been a first-aid instructor. On
another day such expertise might not have been available, and the prison
officers interviewed by my investigators all recognised the value of first-aid
training. Officer V and, especially, Officer A both requested that I make a
recommendation about first-aid training. I was moved to do so after reading in
the orderly officer’s interview of the immense efforts made by these men and
their colleagues to bring the man back to life. The orderly officer said:
‘I’ve been involved, unfortunately, in death in custodies before. But that’s
the first one I’ve been in where staff have fought so long and so hard. And
the staff were really working really hard, they were really passionate ... I
think if they could have got him back through willpower alone, they would
have done that because I’ve never been in that situation and that’s what
hit me really, was the staff worked so hard for such a really long period of
time … For 50 minutes I stood there and I was the manager and I was kind
of directing other people and making sure things got in and things got
done. But I stood there and watched for 50 minutes staff give their all and
those staff, the 3 that were doing the chest compressions, they worked
really hard ... They didn’t want to be relieved, they didn’t want to give up,
they wanted to continue to work and to fight.’
385. The response might not always be of such a high order but the Governor will
wish to ensure that he can call on sufficient residential staff with first-aid
expertise to respond in an emergency.
The Governor should review the number of trained first-aid staff at his
disposal in residential areas of the prison and should provide first-aid
training or refresher training to match predictable needs.
The letter written by a prisoner at HMP Highpoint
386. When my investigation was at an advanced stage I received a note from the
editor of the ‘Prisons Handbook’. He had received a letter dated 8 July from a
prisoner at HMP Highpoint in Suffolk, which contained an allegation that staff
had failed to intervene with sufficient urgency when the man was found
hanging. I set out in the Issues section of this report the efforts made by my
investigators to speak with the source of this information. My investigator
10 3
conducted a second interview with a prison officer at Wellingborough as a
direct response to the information contained in the prisoner’s letter.
387. The prisoner’s letter to the editor said that he was writing in response to a
letter from a prisoner at Wellingborough ‘about a white inmate who hung
himself during late May/early June this year’. According to this information, a
Muslim prisoner had run down to the office on C wing at approximately
3.00pm and told the three officers there that a prisoner was hanging himself.
The officers allegedly laughed at the Muslim prisoner and ignored him.
According to the prisoner, the Muslim prisoner went back to the white man’s
cell then ran back to the office a second time, saying, ‘You keep laughing,
when he’s dead then you will know.’ His letter continued that the officers went
up one by one and tried to ‘bring him back but it was too late’.
388. My investigator made telephone contact with the prisoner at Highpoint and
asked him if he was willing to supply further information. He was initially
reluctant to supply the name of his source at Wellingborough because he
feared that reprisals would be taken against his source by staff. In mid
August he made contact with my investigator and told him that the man who
had allegedly witnessed staff malpractice at Wellingborough was a prisoner
who had just been released and was therefore willing to talk to my
investigators. My investigator made contact with this prisoner who told him
that he wished to speak face to face at his home in Bedford. My investigator
arranged to meet the former prisoner at Bedford railway station on the
evening of 10 September but he did not keep the appointment. My
investigator made contact with the prisoner’s family in Bedford but they were
unable to locate him and, after waiting in vain for two hours, my investigator
returned to London.
389. One of the allegations made in the prisoner’s letter is that at approximately
3.00pm there were three prison officers in the C wing office who laughed at a
Muslim prisoner when he told them that a white prisoner had hanged himself.
Some of the information in the letter is clearly inaccurate. The man was found
hanging in early April of this year and not in late May or early June. The letter
supplies no identifying information whatever about the three officers who
allegedly laughed at the Muslim prisoner and ignored him. The letter does not
make it possible to establish their gender, race or seniority. My investigators
nevertheless took the view that it would be better to explore these very
imprecise allegations than to do no further investigation.
390. My investigator returned to Wellingborough in October 2009 and interviewed
Officer U for a second time. I have absolutely no information to suggest that
he was guilty of any impropriety on that afternoon, but my investigator
reasoned that Officer U might be able to supply useful information as he was
one of the three officers rostered for duty on C wing on the afternoon of the
man’s death. His two colleagues on C wing at the beginning of the afternoon
were Officer R and Officer B. After 3.00pm Officer R left C wing to carry out
escort duties at the General Hospital and he was replaced by Officer A.
Officer B was the cleaning officer that afternoon and my investigator assumed
10 4
she would be walking around the wing a good deal in order to supervise and
support the prisoner cleaners.
391. In interview Officer U told my investigator that he thought approximately eight
prisoners would be out and about on C wing during the afternoon. Prisoners
who were unemployed would be locked in their cells and prisoners on
education or working in the workshops would be at the appropriate locations.
He said the eight prisoners would be a combination of cleaners and Race
Relations representatives. He said he was not aware that events like those
documented in the prisoner’s letter actually happened that afternoon. He
himself was working for a significant part of the early afternoon in the back
office where he was alone. He explained that the back office is not ‘glassed’
so prisoners cannot see into it and staff cannot see out of it. Officer U told my
investigator that there would not be many times during the afternoon when
three members of staff would be in the main office, although from time to time
the regular C wing staff might be visited by a superior from the Residence
group or someone like the Orderly Officer of the day (a principal officer).
392. Officer A’s account of his involvement with the man that afternoon is that he
went by himself at approximately 3.30pm to the cell on C2 landing. In
interview Officer U confirmed that Officer A went up to the second landing by
himself and he did not seem agitated to Officer U at the time. Officer U was in
the main C wing office (the glassed office) talking to SO F, although Officer U
was not sure about the time when SO F arrived.
393. Officer U recalled that the cleaner came down to the main office and said
‘they need your muscle up there’. He added that the cleaner had not come to
the office earlier in the afternoon and, when he conveyed the message that
muscle was required, only Officer U and SO F were in the office. As they
were proceeding to walk away from the office the alarm bell went and they
made their way hurriedly towards Officer A, fearing that he might be in
difficulty. The cleaner was released from prison on 8 May 2009 and, although
my investigator has written inviting him to assist with my investigation, he has
not thus far replied.
394. Officer U denied that any reprisals had taken place against prisoners after the
man’s death. He remembered taking a telephone call from reception soon
afterwards saying that an identified prisoner was due to go somewhere and,
although he could not remember the details clearly, he thought it was
something to do with immigration.
395. A possible interpretation of the prisoner’s letter is that staff were given
information by prisoners before the man’s death that he was vulnerable.
Officer U told my investigator that the staff had no concerns about the man
before his death. Had they done so, they would have made an entry in the
observation book on the wing and/or they would have informed an ACCT
assessor. Officer U is himself an ACCT assessor and therefore has a better
understanding than most of the support mechanisms available to and required
by potentially suicidal prisoners.
10 5
396. The current position is therefore that an imprecise allegation about staff
conduct during the afternoon of 9 April has been conveyed indirectly to my
office by a prisoner who at the time was not held at Wellingborough. With the
very limited information at their disposal my investigators have done their best
to establish what happened around 3.00pm on 9 April. I have discovered no
evidence at all to substantiate any allegation that staff behaved improperly on
C wing on 9 April. It is indeed the case that Officer A proceeded alone to
check on the man’s welfare in cell C2-15, but this was an entirely appropriate
response to the gravity of the situation as it was then understood. Officer U
and SO F were in process of responding to the information they had just
received from the cleaner when the alarm bell was rung. The level of care,
compassion and professionalism which was then demonstrated by all
members of staff until the time when the man was pronounced dead at
4.40pm was outstanding. The prisoner who sent the letter from Highpoint did
not directly witness the events on C wing on the afternoon of 9 April, whereas
the man who says he was there at the time has not made himself available for
the interview he himself had requested.
The IMB Member
397. The IMB Member has served on the Independent Monitoring Board at
Wellingborough for the last decade. The work of members of the IMB is
voluntary and unpaid, and it is unusual for the contribution of an individual
Board Member to figure so prominently in one of my reports as the IMB
Member does in this one. He will not be expecting public acclamation from
the Ombudsman for what he did on the afternoon of 2 April but it is right that I
should pay tribute to the quality of his intervention.
398. When he attended the prison on the afternoon of 2 April he anticipated that he
would pick up and process some routine applications. When he came across
the unprecedented recorded delivery letter from the man’s partner to the IMB
he demonstrated flexibility and tenacity by abandoning his existing plan and
devoting the rest of the afternoon to the man’s case and no other. He made it
his business to deal with the matters raised in the letter from the man’s
partner as effectively as he possibly could. He sought out the man himself,
his personal officer and staff in the OCA Unit, reflecting his belief that
progressing the transfer application was the highest priority.
399. The IMB Member described his motivation in interview thus: ‘I thought we
owed it to her [the man’s partner] to do the very best we could do and this I
did’. In view of his partner’s complaint in her letter of 29 March to the IMB that
the man who later died felt discouraged, isolated and silenced at
Wellingborough, it is particularly noteworthy that the IMB Member not only
explored the issues vigorously but went back to the man to report in person
what he had found. Grateful as I am to the IMB member for his determined
intervention, I remain acutely aware that he should not have needed to spend
an entire afternoon checking on the progress of the man’s transfer application.
I commend the IMB Member for the quality of the work he undertook on
2 April for the man and his partner, and I invite the Chair of the IMB at
10 6
Wellingborough to bring my remarks to the attention of a wider IMB
audience.
10 7
CONCLUSIONS
400. My examination of all the evidence available to me suggests that the man
killed himself and intended to do so. I am in little doubt that his discovery,
apparently on the last afternoon of his life, that his appeal against sentence
had been rejected had an enormous and damaging impact on his mental
equilibrium.
401. The man’s levels of stress and frustration in the days before his death appear
to have been materially increased by his perception that his applications and
complaints at Wellingborough were not being answered. In a complaint
written just 11 days before his death, he expressed the opinion that everything
he put his name to went in the bin. He warned that sooner or later a prisoner
who was being victimised, as he believed he was, would snap.
402. The man’s voice was actually being heard. Both the IMB Member and the
deputy Head of Residence went to see him at work in the motorcycle
maintenance workshop in the week prior to his death. However, the
assurances he was given would doubtless have proved still more convincing if
he had received written, as well as verbal, proof of the answers to his
applications and complaints.
403. The man seemed very well to Nurse A when she reviewed his mental health
in the motorcycle shop on 3 April. But after learning of his rejected appeal the
distress and anguish the man was experiencing are evident in the telephone
calls he made just before and just after 2.00pm to his mother and partner. He
should not have been unsupported when he received his letter from the
Criminal Appeal Office, but I fear that he read that decision alone. A number
of safeguards that should have protected him failed to operate. The
documents from the Criminal Appeal Office went to Wormwood Scrubs
though he had been transferred from there to Wellingborough over three and
a half months earlier. Systems carefully put in place by the Governor of
Wellingborough to ensure that such important documents were adequately
processed before distribution to an individual prisoner appear to have been
bypassed on this occasion.
404. The man had a number of underlying vulnerabilities as identified by the
experienced psychiatrist who saw him at the prison on three occasions in
January and February. When asked in interview about the possible impact of
his rejected appeal, the psychiatrist said:
‘One can never be certain, however I think it is a stressful factor in
someone who has a degree of vulnerability such as his. Somebody with
recurrent depressive disorder, needing high doses of medication, required
admissions to hospital before, attempted serious self-harm before, it may
have come as a serious last blow that he couldn’t handle.’
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RECOMMENDATIONS
For the Director General of the National Offender Management Service:
1. I recommend that the Director General of the National Offender Management
Service invites one of his senior managers to meet soon with a counterpart
from the Royal Courts of Justice in order to refine and improve existing
communication systems for conveying appeal decisions.
For the Governor of HMP Wellingborough:
2. As a matter of urgency the Governor should ensure that Wellingborough has
an application system in which prisoners (and staff) can have confidence.
3. In particular he should ensure that there is a robust and reliable system for
supplying a personal answer to each application in timely fashion to the
prisoner who made it.
4. The Governor should ensure that prisoners receive personal replies to their
complaints within the timescales stipulated in PSO 2510. He should also
ensure that any prisoner who receives an interim reply to his complaint is
subsequently given a substantive reply in timely fashion.
5. The Governor should thank Officer L for the professional and diligent way in
which he undertook his work on 23 December and he should be formally
commended for its quality.
6. The Governor should ensure that all case managers at Wellingborough are
adequately trained for their role.
7. The Governor should consider whether refresher training should be offered or
provided when less experienced ACCT case managers transfer to wing based
responsibilities.
8. I recommend that the Governor reviews the transfer application system within
three months of receipt of this report. The review should pay particular
attention to:
• The form to be used
• The route it takes
• The need for a suitably individualised response
• A guarantee that the prisoner has safely received that response
9. I recommend that the Governor draws up a set of contingency plans to ensure
that any member of staff operating the switchboard has clear written guidance
about what to do in a range of possible emergencies.
10. I recommend that written statements should be obtained in timely fashion
from all staff who can provide significant evidence after the death of a
prisoner.
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11. I recommend that Wellingborough’s contingency plans be expanded to
include a section on the actions to be taken in the event that an air ambulance
is required to respond to a medical emergency.
12. I recommend that staff, to be identified by the Governor of Wellingborough,
should be formally commended by the Director of Offender Management for
the East Midlands in recognition of the valiant efforts they made to revive the
man on 9 April 2009. The orderly officer should receive the same level of
commendation for the calm and effective way in which she undertook her
duties as orderly officer at the time.
13. I recommend that the Governor should use his own staff or staff from another
prison to break news of a prisoner’s death to next of kin in line with the
strongly expressed guidance set out in the supplement to Chapter 4 of PSO
2710.
14. The Governor should ensure that there are robust contingency arrangements
for contacting the appropriate faith chaplain in the event of emergency or
death.
15. I invite the Governor, within three months of reception of this draft report, to
conduct a standstill check of at least five per cent of prisoners’ wing files at
Wellingborough to establish whether personal officer entries are being made
with the frequency he requires, with a view to providing appropriate training
for his staff informed by that exercise.
16. The Governor should review the number of trained first-aid staff at his
disposal in residential areas of the prison and should provide first-aid training
or refresher training to match predictable needs.
For the Chair of the IMB at Wellingborough:
17. I commend the IMB Member for the quality of the work he undertook on 2
April for the man and his partner, and I invite the Chair of the IMB at
Wellingborough to bring my remarks to the attention of a wider IMB audience.
For the Healthcare Manager:
18. I recommend there is a policy for requesting previous medical information
from community, mental health teams, other prisons and secondary care and
robust systems to act on this information.
19. I recommend the prison reviews its capacity to provide chronic disease
management in a timely fashion.
20. I recommend the clinical team reviews the quality of medical notes entries on
a regular basis and includes this in its clinical staff training plans. This should
include entries from meetings where patients are discussed as well as clinical
consultation. The inreach team should be included in this review. Entries
should be transcribed accurately from paper records and have clear ongoing
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action plans including management plans, review intervals and referrals
between teams so that any clinician not familiar with the patient can
understand any planned care from the computer notes.
21. I recommend that a review of the email referral system takes place. Any
referral should be clearly documented in the notes with a copy of the referral
information attached. This should include communication between the
pharmacy team, primary care and the inreach team. Decisions from referrals
should be included in the notes even if no action is taken.
22. I recommend that the health care team reviews communication methods
between the primary care team and the mental health teams. Decisions
about risk, review and follow up should be recorded where all clinicians have
access to them and should be available within the computer record.
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