Individual at Featherstone

Investigation into the circumstances surrounding
the death of a man at HMP Featherstone
on 30 December 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
The man died at HMP Featherstone on 30 December 2008. He was just 21
years old. He was found hanging in his cell by the night staff at approximately
00.15am.
I offer my sincere sympathy and condolences to his family and friends, and
everyone affected by these tragic events.
The investigation into the circumstances of the man’s death was conducted
on my behalf by a colleague, Investigator C. My thanks go to the Governor of
Featherstone and his staff for their assistance. South Staffordshire Primary
Care Trust was asked to carry out a review of the man’s clinical care and I am
grateful for their contribution to my investigation.
During his time in custody, he had been involved in numerous altercations
and incidents with staff and fellow prisoners. He had spent time at a number
of prisons but was yet to engage in any offending behaviour courses at the
time of his death. At Featherstone, he became more agitated when a mobile
phone that he had illicitly procured was stolen from him. He had been using
the telephone to contact his partner and did not cope well with its theft.
Rumours on the wing appear to have added to his distress, and on the night
of his death he sought to contact his partner repeatedly but was unable to.
Although the man was often angry and behaved poorly, this can often mask
issues relating to self-harm. Towards the end of his life he became more
volatile, but there were no explicit indications that he would imminently harm
himself again. Nevertheless, as I note in my concluding words to this report,
he evidenced many of the known risk factors in prison suicides. He was a
disturbed young man with a history of self-harming by ligature. He had spent
much time in segregation, and been transferred from jail to jail. He was
worried about his relationship with his partner, and was in conflict with other
prisoners. He had stopped using mood-altering medication.
I make six recommendations regarding medical records, courses, follow-up
appointments, cell fittings, resuscitation and the training of family liaison
officers. I must apologise for the delay in issuing this sad and important
report.
Jane Webb
Acting Prisons and Probation Ombudsman
2
CONTENTS
Summary 4
The Investigation Process 6
HMP Featherstone 7
Key Findings 10
Issues 20
Conclusion 27
Recommendations 28
3
SUMMARY
On 11 June 2007, the man was arrested on suspicion of serious offences and
was subsequently sentenced to six and a half years imprisonment. During his
initial time in police custody and in the court cells, he made two attempts to
harm himself. When he arrived at HMYOI Glen Parva on 13 June, he was
judged to be at risk of harming himself and was provided additional support
using the process known as ACCT (Assessment, Care in Custody and
Teamwork). His behaviour throughout this time was disruptive and he was
involved with fights with other prisoners, a pattern that persisted throughout
his time in custody.
On 21 October 2007, he was transferred to HMYOI Swinfen Hall. He
remained disruptive and spent long periods of time in the Care and
Separation Unit. He was prescribed anti-depressant medication. On 25
March 2008, he made an attempt to hang himself. He was monitored using
ACCT procedures and was referred for a place on an Enhanced Thinking
Skills course (a general offending behaviour programme exploring problem-
solving skills).
He was transferred again on 5 July, this time to HMYOI Brinsford. Whilst at
Brinsford, he was again referred for a course to help him with his temper.
On 23 July, the man tied a ligature around his neck and the ACCT process
was begun again. He was referred to a doctor who prescribed Quetiapine, an
anti-psychotic drug normally used for the treatment of schizophrenia or bipolar
disorder. The doctor planned to review the man’s response to this medicine a
week later but he was transferred from Brinsford to HMP Hewell on 19
August. He continued with his medication but remained disruptive and
continued to challenge authority. He never managed to attend a programme
to help him with his behaviour because of a lack of available courses and his
moves between prisons.
The man only stayed at Hewell until 7 October when he was moved again,
this time to HMP Featherstone where he remained until his death. Staff in the
Safer Custody Team at Featherstone were alerted to his history of self-harm
and suicide attempts.
The man engaged in a heated argument with another prisoner on 21
December 2008 over the theft of a mobile phone that he had illegally procured
in the prison. Over the Christmas period the man became increasingly
agitated. He said that his mother and partner were receiving abusive phone
calls and text messages, which he believed were made by another prisoner.
On 29 December, the man had a lengthy telephone conversation with his
partner during which they argued about their relationship, although the call
ended with them saying that they loved each other. He later made a further
23 attempts to speak to his partner but was unable to do so. On the final call
at 7.42pm he left an angry message on the answerphone. He returned to his
cell and was locked in for the night.
4
At 00.15am that night, He was found suspended by a ligature from a light
fitting. Staff cut him down but there were no signs of life. He was confirmed
dead at 1.10am on 30 December.
My report contains six recommendations.
5
THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened on 31 December
2008 when my colleague, Investigator A, visited HMP Featherstone.
Investigator A met the Governor and the Deputy Head of Residence.
He also met someone from the Independent Monitoring Board, and
held a discussion with a member of staff from the Prison Officers’
Association. Investigator A then went to Cell 18 in House 5 where the
man had died. Notices were put up in the prison inviting any staff or
prisoners to speak with my investigator. No one came forward as a
result of these notices.
2. Following this visit Investigator A briefed another investigator,
Investigator B, who then took over the investigation. Investigator B
reviewed an initial bundle of papers sent to him from Featherstone in
preparation for his visit there on 20 January 2009. Investigator B met
the Governor before being taken to House 5 by the Deputy Head of
Residence. There they met the staff and had a general discussion
about the running of the House and memories of the man and the
events leading up to his death. One of the staff, Officer A, was present
when the man was found hanging and helped to cut him down. Officer
A took Investigator B to Cell 18 and described what he had found.
3. The Clinical Governance Manager for South Staffordshire NHS Primary
Care Trust conducted a clinical review of the man’s health needs and
care.
4. One of my Family Liaison Officers spoke to the man’s partner and also
to his mother. His partner raised several matters for the investigation to
consider. She was concerned to know why he had not been subject to
suicide prevention processes prior to his death, and wished to have
further information on some of his property. These concerns were
followed up in a letter from her solicitor and I hope that they are
addressed in this report.
5. The report was subsequently completed by another investigator,
Investigator C. Investigator C went to Featherstone on 5 October 2009
to conduct further interviews. He also asked the clinical reviewer and
Featherstone to provide additional information.
6. Following the publication of the draft report, the man’s partner
questioned why it had taken so long for my office to interview staff.
The initial investigator did conduct informal interviews but these were
not written up. I would like to apologise for the length of time this
investigation has taken.
6
HMP FEATHERSTONE
7. HMP Featherstone is a category C closed training prison for adult men
situated about six miles north of Wolverhampton. It holds a maximum
of 679 prisoners. The prison was built in 1976 and adjoins Brinsford
Young Offenders Institution.
8. Featherstone has seven houseblocks. House Four is classed as
normal location and House Five is the induction and reception unit.
The man was a resident in both of these Houses during his time at
Featherstone.
9. South Staffordshire Primary Care Trust commissions the health
services for prisoners at Featherstone. The healthcare department
offers a wide range of primary care services, including health
promotion and the management and treatment of long term and acute
medical conditions. Featherstone has no inpatient facility and the
health services are not available 24 hours. An independent provider of
primary care services provides out-of-hours services on behalf of the
NHS.
10. Shropshire and South Staffordshire Foundation NHS Trust provides
specialist mental health care to the prison. The Mental Health In-
Reach Team comprises Community Psychiatric Nurses (CPNs) and a
consultant psychiatrist. The CPNs work closely with the primary care
nurses and doctors to assess prisoners with potential mental health
problems. However, in its report for 2007-08, the Independent
Monitoring Board observed that mental health referrals had increased
and that missed appointments for mental health referrals were not
pursued.
11. The Psychology Department provides programmes to help prisoners to
address their problems. These include Enhanced Thinking Skills (ETS)
and Anger Management courses.
12. In common with all other prisons, Featherstone uses a documented
process to monitor and support prisoners assessed to be at risk of
suicide or self-harm. This is known as Assessment, Care in Custody
and Teamwork (ACCT). Once ACCT processes are begun, the
prisoner is observed at intervals determined by his perceived level of
risk.
Care and Separation Unit
13. The Care and Separation Unit is used to hold prisoners who are
segregated from others. This may be as a result of breaching prison
discipline or to protect them from other prisoners. When a prisoner is
brought into the Care and Separation Unit certain procedures must be
carried out. These include the completion of an Initial Segregation
Safety Screen and the beginning of a segregation history sheet.
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Control and restraint
14. Staff are authorised, where necessary, to use “control and restraint”
techniques which involve the use of reasonable force.
Incentives and earned privileges (IEP) scheme
15. The IEP system is intended to encourage and reward good behaviour
in prison. Prison Service PSO 4000 describes it as follows:
“The IEP scheme complements the discipline system by
rewarding good behaviour. In addition to any local aims, it is
intended to encourage prisoners and YOs [young offenders] to
behave responsibly, to participate in constructive activity, and to
progress through the system. This will foster a more disciplined
and controlled, and therefore safer environment for prisoners
and staff. It should also contribute to the reduction of re-
offending by encouraging prisoners to lead law-abiding,
productive and healthy lives.”
16. Prisoners are able to move up a level (basic, standard or enhanced)
and earn various privileges. Poor behaviour can result in moving down
a level or losing privileges. Privileges include association time and
extra visits.
Independent Monitoring Board
17. Each prison has an Independent Monitoring Board (IMB) made up of
members of the community. The Board’s role is to ensure that the
prison is properly run and that prisoners are treated decently. Each
Board produces an annual report for the Secretary of State. The most
recent report from the Featherstone IMB covers the period April 2008
to March 2009.
18. The IMB was concerned that the demand for places on the Enhanced
Thinking Skills (ETS) and Anger Management courses outstripped the
number of places available.
Her Majesty’s Chief Inspector of Prisons
19. Her Majesty’s Chief Inspector of Prisons undertook an inspection of
Featherstone from 20 – 24 October 2008. In her report, she described
Featherstone as a “… reasonably safe, respectful and purposeful
prison”. The report mentioned that staff-prisoner relationships were
generally good although there were some prisoners with very negative
views of staff.
20. Safer custody procedures were generally judged to be of an
encouraging standard, although further work was needed to tackle
8
Previous deaths at Featherstone
21. Featherstone experienced two other self-inflicted deaths in 2008. Both
of these deaths involved prisoners hanging themselves in their cells. In
an investigation report into one of the previous deaths, I highlighted the
issue of missed appointments for mental health referrals not being
pursued. I return to this issue in this report.
9
KEY FINDINGS
22. The man was arrested on suspicion of serious offences on 11 June
2007 and spent time in police cells and a court cell. During this period
he harmed himself on two occasions.
HMYOI Glen Parva
23. After his arrest, the man was received into HMYOI Glen Parva on 13
June 2007. The ACCT process was begun the same day as he had
harmed himself in police and court custody. The man was also low in
mood as he realised the seriousness of his offences, and anticipated a
significant custodial sentence. He later told staff that, although he had
harmed himself, he did not want to die as his partner was expecting his
child. Although staff acknowledged his statements that he would not
harm himself, they decided to maintain the ACCT processes until the
outcome of his court appearance on 21 June was known.
24. The man was found guilty of the charges he faced on 21 June and was
remanded to Glen Parva to await sentencing. He asked for the ACCT
process to be ended and it was closed.
25. However, on 12 July staff were concerned that the man’s mood had
altered. The security department informed staff that, during a
telephone call, he had told his partner he was going to hang himself.
Due to his history of self-harm, the ACCT process was recommenced.
The man told staff that his main issue was that he was unable to see
his partner, but he did not feel the ACCT processes were necessary.
26. A further mental health assessment was carried out on 23 July. The
man said that, although he sometimes experienced suicidal thoughts,
he would not act on them. He was offered regular support by the
mental health team. It was recommended that he be prescribed
Mirtazapine, an anti-depressant medicine.
27. He remained on the ACCT until 24 August. During the later ACCT
reviews, he consistently told staff that he was not contemplating
harming himself. However, he continued to behave disruptively and
was involved in fights with other prisoners. He was monitored and
supported in accordance with the anti-bullying strategy as well as the
ACCT process, as another prisoner had claimed that he had bullied
him.
28. The man was reported to have told court officials on 30 August that he
was feeling suicidal and wanted to harm himself, although he denied
this when he returned to Glen Parva. It was written in his medical file
that he had told staff that he only spoke about harming himself to
prevent being remanded in custody. The investigator was unable to
find out any further information about this incident.
10
29. The man was seen on a weekly basis by mental health nurses. On 5
September 2007, he was referred to a psychiatrist as he was feeling
paranoid and struggling to cope with his temper. An appointment was
due for 20 September but this was not kept as he was in court for
sentencing. He was sentenced to six and a half years in prison.
HMYOI Swinfen Hall
30. On 3 October, the man was transferred to HMYOI Swinfen Hall where
he stayed until July 2008. During his time at Swinfen Hall, he
continued to have problems managing his anger and regularly had
outbursts of violence that required him to be segregated from other
prisoners.
31. All prisoners are seen by a nurse or doctor when they arrive at a new
prison. The nurse who saw him when he arrived at Swinfen Hall
referred him to a mental health nurse for an assessment.
32. The mental health nurse saw him on 7 October. She noted his history
of drug abuse and previous attempts to harm himself. However, he did
not appear to be depressed at the time and there was no evidence that
he had any intention to deliberately harm himself.
33. Despite this, on 19 October officers asked a primary care nurse to see
him as they were concerned about his state of mind. The nurse
referred him to the mental health nurse for another review.
34. The following day, the man was disruptive in the visits hall at Swinfen
Hall and, on 21 October, he told the mental health nurse that he had
punched a window in frustration. He said he felt frustrated as he was
having problems with his partner and was only able to see her in a
room through windows because of problems in the past. (This type of
visit is known as a closed visit.)
35. The mental health nurse noted that he appeared frustrated and
agitated. She discussed anger management programmes but he said
that he did not wish to be referred. She wrote that she would revisit
this in the future.
36. The man’s prescription was reviewed on 13 November. The
Mirtazapine was discontinued and another anti-depressant, Citalopram,
was prescribed. He was not happy with this change and repeatedly
asked to be put back on Mirtazapine. He became more and more
disruptive.
37. ACCT processes were started on 27 November as he was feeling low
in mood due to his problems with his partner. The ACCT form was
closed the next day as staff were convinced that, whatever problems
he was experiencing, he did not intend to harm himself.
11
38. The man was housed in the Care and Separation Unit at Swinfen Hall
during most of January 2008 because of his continued disruptive
behaviour. However, he then seemed to settle into a more stable
approach to life. On 4 March, a mental health review took place and it
was noted that he was taking his anti-depressants and would like to
attend the gym. The man said that he still found it difficult to control his
temper, and the nurse noted that she would refer him to the gym and
psychology department.
39. Within a fortnight, the man’s disruptive behaviour had led to a further
period in segregation and, on 23 March, he suggested that he would go
on a hunger strike. He did not carry out this threat but attempted to
hang himself on 25 March. Staff found him on his bed with a noose
around his neck. He did not harm himself significantly and later said
that he had done so because he was irritated by staff, and because he
was only able to have closed visits with his partner. ACCT procedures
were begun and he was placed in a camera cell in the segregation unit
with a requirement for staff to observe him five times an hour. The
mental health in-reach team saw him the following day. Although he
was angry about the closed visits, he told staff that he did not intend to
harm himself. Following several reviews, the ACCT processes ended
on 15 April 2008.
40. Although the ACCT was closed, the man remained largely
uncooperative and, apart from a two day period, remained in the
segregation unit until 29 June 2008. He was downgraded to the basic
level on the Incentives and Earned Privileges scheme, and staff used
control and restraint methods on several occasions during this time.
He was checked regularly by nurses but usually refused to see them.
HMYOI Brinsford
41. The man demanded a transfer to another prison while at Swinfen Hall
because he claimed that no one liked him. He was transferred to
HMYOI Brinsford on 5 July 2008 where he remained for six weeks.
42. A nurse saw him on 6 July to carry out the routine health screening for
new prisoners and noted that no concerns were raised.
43. Prisons and young offenders institutions offer substance users
Counselling, Assessment, Referral, Advice and Throughcare Services
(CARATS). A CARATS worker saw the man on 11 July for an
assessment. He asked for a place on an Enhanced Thinking Skills
(ETS) course and to attend an Anger Control training course. It was
noted that he had been waiting for a place on an ETS course at
Swinfen Hall but had been transferred before one became available.
44. The man tied a ligature around his neck on 23 July and said that he
“wanted to end it all”. The nurse who attended to him noted that he
12
45. The man was re-classified as an adult prisoner on 12 August as he
was approaching his 21st birthday. This meant that plans were put in
place to transfer him from a young offenders institution to a prison.
When given this news he was argumentative, mostly about personal
belongings that he said had gone missing.
46. He continued to experience problems coping with his anger and
frustration. The next day, a mental health nurse saw him as he had
once again tied a ligature. He again said that he had not intended to
take his own life but was angry because he had been unable to have a
telephone call.
47. A prison doctor prescribed him 25mg of Quetiapine daily on 14 August
and said that he would see him in one week to review his progress.
Quetiapine is an anti-psychotic medicine licensed for the treatment of
schizophrenia and the manic phases of bipolar disease. The man did
not have either of these conditions but doctors may use their clinical
judgement to prescribe medicines for use beyond their licence if they
believe it to be in the interests of the patient. In the clinical review it is
noted that, “Quetiapine is used at low doses for the management of
agitation in the prison setting.” However, he was transferred to HMP
Hewell on 19 August, which meant that the review with the prison
doctor did not take place. It also meant that the man had still not got
onto an ETS course. I am unable to explain why this move took place.
HMP Hewell
48. The man was prescribed Quetiapine on arrival at Hewell on 19 August.
The cell sharing risk assessment document made no reference to any
self-harm issues and he was judged to be at medium risk to any cell-
mate. He appeared to settle in well to his new environment although
he continued to challenge authority.
49. A nurse saw him on 22 September because he was not taking his
medicine regularly as prescribed. The man felt that the medication was
not enough, and asked to be able to take it in the evening as the timing
of the morning dose interfered with his education.
13
HMP Featherstone
50. The man was transferred again on 7 October, this time to HMP
Featherstone. It is unclear why the decision was made to transfer him
after such a short period at Hewell. He was located on House Five, the
induction and reception unit at Featherstone. The cell sharing risk
assessment has a reference on it to the man’s previous self-harming
and aggressive behaviour. He was assessed as being at medium risk
to potential cellmates, but it was advised that he should not share a cell
with a black prisoner or a prisoner from another minority ethnic
background as he had expressed some racist opinions. An
acquaintance to the man, described him as quite volatile when he first
came to Featherstone and advised him to calm down.
51. An entry was made in the Public Protection Log at Featherstone on 13
October to alert the Safer Custody team to the man’s history of suicide
and attempts to harm himself. This information was passed on by
email on 16 October. The Safer Custody team contacted the Senior
Officer on his wing, who then interviewed him. No concerns were
raised regarding the man harming himself.
52. A CARATS worker discussed the idea of the man doing a P-ASRO
(Prisoners – Addressing Substance Related Offending) programme on
15 October. There is no record of a referral being made at this stage.
53. The man was found in possession of drugs on 19 October and was
charged with an offence under the Prison Rules. My investigator was
told that this charge was dismissed by the adjudicating governor. The
investigator could not find any further information about this, and
uncovered nothing to suggest that he was a regular drug user in prison.
54. The man had been referred to see the doctor during his reception
healthscreen. The doctor did not see him until 22 October. The man
asked for the dose of the Quetiapine to be increased. He said that it
was working but he remained very agitated. It was agreed to increase
the dose to 50mg daily and to review him again in two weeks. There
was no note recording his history of self-harm or suicide attempts or his
substance use.
55. It seems that the man was making attempts to address his behaviour
and to conform to the prison regime. He was given feedback by staff
on 24 October praising him for his efforts and that he had used the
induction to Featherstone to good effect.
56. On the same day, he made a written complaint about not being allowed
to have some photographs sent in by his partner. The photographs
were stored in his property box. (The property box is held in reception,
and is not in the possession of the prisoner.)
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57. A few days later, on 28 October 2008, he was placed in a single cell
due to his volatile behaviour and angry outbursts. He remained in
House Five until 29 October when he was moved to cell 92, House
Four, a normal residential unit. On 5 November, it was reported that he
appeared to have settled in well.
58. He saw the doctor again on 10 November. He said that he could not
sleep and was stressed. The doctor prescribed 50mg of Promethazine
to be taken at night. (Promethazine is an anti-histamine drug that can
be used as a sedative.) The doctor also decided to continue the
Quetiapine at the higher dose.
59. On 13 November, the man made another formal complaint about a
package he had yet to receive. On this occasion he had a reply on 14
November that advised him that a recorded letter had been received
that day which contained four photographs, a letter and five stamped
addressed envelopes.
60. It was reported by an officer on 16 November that he had been in
possession of a mobile telephone but another prisoner had stolen it
from his cell. The Security Information Report (SIR) that the officer
completed recommended that a cell search of the suspect should be
undertaken. The cell was searched but a mobile telephone was not
found.
61. The doctor was due to review him on 19 November but the man failed
to keep the appointment. A new appointment was made for 24
November but it appears that he did not attend this one either. This
was not followed up by the healthcare staff, as there was no system in
place to monitor patients who did not keep appointments.
62. An offender manager, reviewed the man’s sentence plan on 26
November and noted that he needed to carry on with his good
behaviour. He was referred to the Psychology Department for a place
on the anger management course. Unfortunately, the last anger
management course to be run at Featherstone in 2008 had just taken
place on 18-20 November. In response to the draft report, the National
Offender Management Service said: “This is a short duration non-
accredited course which consists of eight sessions over four days.
Programmes are not scheduled annually as they are delivered subject
to facilitator availability in between accredited programmes.”
63. The man was heard expressing racist views on 3 December, and the
following day he was referred to the Safer Custody Team as he felt in
danger from other prisoners after the loss of his mobile telephone. He
reportedly told staff that he was having problems, but would not tell
them anything substantive.
64. On 6 December staff became aware of intelligence that suggested the
man had a ‘shank’ - a hand made sharp weapon – in his cell. A senior
15
65. Following his expressed fear of other prisoners and the discovery of
the ‘shank’, the man was interviewed by a senior officer (the one that
had previously searched his cell) on 9 December as part of the Safer
Custody procedures. The man said that he was not feeling under as
much threat as he had been a few days earlier. The senior officer
noted that he was a quiet man who only told staff what he thought they
should know. He was told about the support mechanisms available
and encouraged to approach staff if he wanted help. When the
investigator spoke to the senior officer about this conversation, he was
unable to remember it. However, he did say that in his interactions
with the man he viewed him to be a prisoner who posed more of a
threat to others than to himself.
66. The man was awarded the ‘Level 2 Award in Food Safety in Catering’
on 15 December 2009.
67. On 21 December, he had a heated argument with another prisoner on
House Four. He accused the other prisoner of stealing his mobile
telephone. The SIR raised following this incident recommended that
the other prisoner involved should be added to the cell search list.
68. The next day, the man was moved from the Care and Separation Unit
to House 5, Cell 18, even though this House is primarily for the
induction and reception of new prisoners. He did not share a cell. The
man was noted to be agitated, saying that the prisoner with whom he
had been arguing was making threatening and abusive telephone calls
to his partner and his mother.
69. On 24 December, it was reported that the man was trying to find out
from other prisoners what would happen if a prisoner was to barricade
his cell. He also wanted to know if night staff carried keys. The SIR
submitted on this matter suggested that he should be monitored, and
spoken to by Senior Officer A. The investigator spoke to Senior Officer
A. Senior Officer A who was unable to remember this conversation
but said that this was the usual process followed at Featherstone.
Senior Officer A also said that, in his view, the man was much more
likely to be an aggressor than someone who might harm himself. He
said that the man came across as in control and he was not concerned
that he might harm himself.
16
70. On the same day a Governor replied to a complaint from the man
regarding the confiscated photographs. The man was told that he
should ask his partner to resend the photographs. Another SIR was
raised regarding the issue of prisoners using the man’s mobile
telephone to contact his partner.
71. On 28 December, it was reported that another prisoner was continuing
to make abusive telephone calls and send abusive text messages to
the man’s family and partner.
72. The following day, the man made a telephone call to his partner at
11.07am. It was a long conversation, which was monitored by
Featherstone security staff. He and his partner argued about their
relationship. However, they ended the call saying that they loved each
other and he said that he would call back at about 6.00pm.
73. The man subsequently made over 20 further telephone calls. He
telephoned friends and family trying to find his partner but did not
manage to speak to her. On the final call, at 7.42pm, the man left an
angry message on his partner’s answerphone. He said that he
believed she was having an affair, and that she had broken his heart.
74. At 8.15pm, Officer B began his night shift on House Five and checked
on all of the prisoners. Later, at 00.15am, Officer B was doing his
rounds when he heard music coming from the man’s cell. When he
looked through the flap he saw the man hanging from the light fitting.
He immediately radioed for assistance, entered the cell and held the
man up by his legs until Officer A arrived. Officer B said:
“I remember thinking when I was lifting him up … without fail
100% I knew he was dead I’m afraid.”
75. Officer B cut the ligature and they laid the man on the bunk. There was
no sign of life and he was cold to touch. He was also stiff as rigor
mortis was beginning to affect the body. (Rigor mortis is the stiffening
of the body after death because of a loss of Adenosine Triphosphate
(ATP) from the body's muscles. ATP is the substance that allows
energy to flow to the muscles and helps them work, and without this
the muscles become stiff and inflexible. Rigor mortis begins
throughout the body at the same time but the body's smaller muscles -
such as those in the face, neck, arms and shoulders - are affected first.
Rigor mortis normally appears within the body around two hours after
death. However, it should be noted that the speed of rigor mortis is
affected by a number of factors including the size of the person and the
ambient temperature.)
76. A letter was found on the floor of the cell addressed to the man’s
partner. This explained that he felt heartbroken because he believed
his partner to have been unfaithful.
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77. Badger Harmoni, the out-of-hours provider for the PCT, was called. At
1.10am on 30 December, a doctor arrived and certified that the man
was dead. In the early hours, a Family Liaison Officer was called and
appointed the prisons Family Liaison Officer.
78. Early in the morning of 30 December, a Governor, accompanied by the
Family Liaison Officer, visited the man’s partner to inform her of his
death. They initially visited an address but no-one was there. The
prison had a phone number for the man’s partner’s stepfather who
came and met the Governor, the Family Liaison Officer (FLO) and took
them to another address. They broke the news to the man’s partner
and left their contact details.
79. The FLO also spoke to the man’s mother. The FLO later returned the
man’s property to his partner. The man’s mother had also sent some
property in for him that arrived after his death. This was returned to
her.
80. Following the man’s death, staff overheard prisoners saying that two
prisoners had caused trouble for him by contacting his partner.
Another prisoner suggested to staff that the man was being ‘hassled’
by other prisoners.
81. Her Majesty’s Coroner asked for a post mortem examination.
Toxicology tests revealed no evidence of drugs or alcohol, and the
cause of his death was determined to be hanging.
Support for the man’s family
82. The FLO offered assistance to his partner and the Governor of
Featherstone offered a financial contribution to the funeral expenses.
83. The man’s partner has asked about the whereabouts of some photos
she had sent in to him. The FLO explained that they had been
destroyed as they were deemed to be inappropriate, and he was
unsure who had sent them.
Support for staff and prisoners
84. Officer B was very complimentary of the support offered to him by a
Senior Officer and Officer A immediately after the man was found. This
support continued through the following nights, and I am pleased to
acknowledge this in this report.
85. The care team was deployed to help any staff who felt affected by the
man’s death, and this support too was ongoing.
86. The Governor distributed a notice to inform prisoners of the man’s
passing. Staff personally told an acquaintance of the man about his
death which he told the investigator that he had appreciated. He also
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19
ISSUES
Clinical care
87. The clinical reviewer has looked into various areas of the man’s care
and I would encourage all of those responsible for prisoner healthcare
at Featherstone to note the recommendations made. The clinical
reviewer concludes that:
“… there is no evidence that the man’s management of clinical
care was inappropriate.”
88. However, the clinical reviewer criticises the standard of record keeping:
All medical records should be complete, accurate and signed and
dated by the person making the entry. The entry and signature
must be legible and made in line with good record keeping
standards.
Medication
89. The man was prescribed Quetiapine to help him control his emotions
and behaviour. The clinical reviewer notes that this medicine is
licensed for the treatment of people with schizophrenia or manic
phases of bipolar disorder. The clinical reviewer was told that
Quetiapine can be used at low dosages for the management of
agitation in a prison setting. In the clinical reviewer’s opinion:
“… the choice of drug and dose appear to have been
appropriate. The Head of Medicines Management’s view was
that whilst the use of this drug in this context is unlicensed, there
is no suggestion that based on the clinical opinion of the GPs
interviewed that this was anything other than appropriate, and
the standard of care satisfactory in this respect …“
90. The man failed to attend doctors’ appointments in the last six weeks of
his life. He did not collect his medicines after 6 December, and was
not seen by healthcare from this date on (except if he was seen in the
Care and Separation Unit on 22 December). The man was
complimented for his recent good behaviour on 26 November and it
may not have been a coincidence that, following 6 December, his
behaviour went downhill again. While I cannot prove a connection, it is
clearly disappointing that the man, with his known difficulties controlling
his emotions, failed to collect his medication. It is true that in the
community people have a choice whether to take their medication, and
this choice was open to the man as well. However, given the
vulnerability of so many prisoners, and the fact that the man himself
was on mood-altering medication, it is very regrettable that his decision
not to collect his medications was not followed up.
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91. The Healthcare Manager, told the investigator that, at the time, there
was no system to follow up patients who failed to attend appointments.
The clinical review makes reference to a new policy introduced in
January 2009 to flag any non-compliance with prescribed medication.
The clinical reviewer has made a recommendation on this matter which
I have adapted to read as follows:
The Head of Healthcare must ensure that a revised policy is fully
implemented to alert staff when appointments are missed or
drugs are not collected by prisoners on mood-altering medication.
Availability of courses
92. The clinical reviewer says that, although he underwent two mental
health assessments, no mental illness was ever identified. However, it
is clear from the account of the man’s time in custody that he had great
difficulty dealing with frustration and managing his anger. This led to
repeated episodes of violence and self-harm. Courses such as
Enhanced Thinking Skills and Anger Management are designed to help
prisoners deal with these issues in a more controlled way. He might
have benefited from participating in these courses. The man’s partner
has concerns that he was unable to access these courses.
93. The courses were discussed with him on a number of occasions and
there is a note that he was on a waiting list at Swinfen Hall but was
transferred before a place became available. It was not until 26
November 2008 at Featherstone that a referral is recorded, and by
then no courses were available.
94. I have not considered whether there are a sufficient number of such
courses, given the demand for places, but in the man’s case his
chances of finding a place were reduced as a result of the number of
prison moves he experienced. In response to the draft report, NOMS
said: “ETS courses run consistently throughout the year. Places on the
programme are subject to national selection criteria, which means that
access is based on a number of factors including risk and tariff expiry.”
(I may add that I am disappointed that a young prisoner was subject to
so many moves in such a relatively short time, whatever the impact on
his accessing offending behaviour programmes. The man’s partner
has also expressed her concerns with his frequent moves.)
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95. Each prison noted the need for him to attend a course, but he was
transferred before it ever came to fruition. Given that the prisons noted
his need to attend the courses, I believe it would have been beneficial
for this need to have been highlighted in his file before any transfer.
The receiving prison would then have been aware of the need for him
to attend the courses as soon as possible. This is a matter for NOMS
centrally to consider:
Governors should be reminded that any urgent need to attend
courses should be highlighted in the file of prisoners being
transferred between prisons.
Suicide and self-harm monitoring procedures
96. The man was not subject to ACCT monitoring procedures at the time of
his death. However, during his time in custody, staff had recognised
the times when he had harmed himself or appeared to be at risk of
doing so. ACCT monitoring procedures were begun five times before
he went to Featherstone and it appears that his safety was taken
seriously by prison staff. The man’s partner was of the view that an
ACCT should have been begun for him.
97. Annex 9P to PSO 2700 (Suicide and Self-Harm Management) states:
“It is easy to think that only people who appear openly
distressed or are quiet and withdrawn are at risk of hurting
themselves. As a result, the risk associated with difficult,
uncooperative individuals is commonly under-estimated and
misunderstood. There is an association between disruptive,
violent behaviour associated with ‘personality disorder’ and
personal distress, mental disorder, drug/alcohol problems, self-
harm and suicide. That is, people who behave ‘badly’ in ways
that infringe discipline are more likely to be simultaneously in
need to help and support than those who don’t. Some
individuals also provoke restraint situations and conflict with
their peers as a way of self-injuring.”
98. While at Featherstone, the man was at times uncooperative and
difficult. He had several volatile outbursts, was in conflict with other
prisoners, and spent time in the Care and Separation Unit. Despite
this, staff did not consider it necessary to instigate formal ACCT
procedures. When he arrived at Featherstone, the Safer Custody
Team was informed of his self-harming history and they ensured that
wing staff interviewed him. This is encouraging to note, and represents
an important way of attempting to safeguard prisoners. In the event,
he denied any self-harm or suicidal ideation which explains why an
ACCT was not begun.
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99. Following the discovery of the ‘shank’ in early December 2008, the
Safer Custody Team again ensured that the man was spoken to about
any thoughts of harming himself. Once again he denied that he had
any such intention. He was also spoken to on 24 December in
response to another Security Information Report. On each occasion
the staff member did not consider the man to be a risk to himself.
Despite his history of self-harm and suicide attempts, I judge that
Featherstone took their duty of care seriously. The Safer Custody
Team intervened twice in response to documentary and empirical
evidence that he might have been at risk. However, these
interventions raised no concerns sufficient for ACCT procedures to be
opened.
The harassment of the man by other prisoners
100. According to his acquaintance, the man was easily wound up,
particularly with regard to his partner. He had illicitly acquired a mobile
telephone while in prison. This was stolen by another prisoner which
greatly agitated the man. It appears that he had used the mobile
telephone to contact his partner and his subsequent inability to do so
caused him distress. This was added to by other prisoners apparently
using the mobile telephone to contact and abuse the man’s partner.
He was involved in a number of incidents with the prisoners he
believed to be the perpetrators. His acquaintance said that he would
get very wound up over any problem with his partner and “the whole
wing would hear about it”.
101. Prison staff filled out a number of SIRs regarding the man’s loss of his
mobile telephone and the effect this had on him. Cells of the
suspected perpetrators were searched by staff but the device was not
located. He was also moved in an attempt to separate him from the
prisoners he was in conflict with. The Safer Custody Manager, told the
investigator that such incidents were, at the time, deemed to be
predominantly security concerns and dealt with as such. However,
Safer Custody Manager explained that the situation had now changed
at Featherstone. Given the capacity for the use of mobile phones to
involve drugs, coercion and harassment, the Safer Custody Team is
now informed of all SIRs of this nature. This change in policy is to be
welcomed, and the experience at Featherstone could usefully be
shared with other prisons.
The light fitting in the man’s cell
102. Officer A told my investigator that two holes had been burned into the
sides of the cell light fitting and that the ligature he used had been
passed through these holes. The light fitting was made of a hard
plastic that was able to withstand the man’s body weight.
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103. The light fitting was replaced after his death and the replacement was
made of a lightweight plastic that would break if subjected to a heavy
weight.
104. The man was not in a safer cell and was not deemed to be at risk of
suicide at the time of his death. I understand that there were other
places in his cell where a ligature could have been tied. For this
reason, it would be disproportionate to recommend that all such light
fittings are changed at Featherstone. However, I have investigated all
too many deaths where the ligature was attached to a light fitting.
Thought should be given to this when prisons are built or refurbished,
and changes are made to any cell light fittings in the future.
I recommend that the National Offender Management Service
ensures that, where new prisons are built or old ones refurbished,
consideration be given to using a lightweight light fitting to
minimise the chance of it being used as a ligature point.
The discovery of the Man
105. He was found by Officer B who immediately raised the alarm. The
Night Orderly Officer, went to the cell with Officer A and found Officer B
supporting him. The man was cut down and put on the bunk. The
Night Orderly Officer told the investigator that the physical state of the
man’s body indicated that rigor mortis had set in and he was clearly
dead. The Night Orderly Officer described the situation as “obviously
hopeless”. The same officer also commented that he had received first
aid training and he performed the necessary checks before making this
judgement. He described the man as cold and stiffening. He had also
been incontinent. Annex 13A of PSO 2700 states:
“If not breathing and/ or no pulse is present, clear airway and
attempt resuscitation, using a face mask with non-return valve,
unless rigor mortis of the limbs has clearly set in.” (Emphasis in
original)
106. The clinical reviewer reports that:
“It is not standard practice, within prisons, for an ambulance to
be called or resuscitation attempted where there was clear
evidence that death had occurred some time earlier as appears
the case here ...”
107. Given the checks undertaken, and the existence of rigor mortis, I
accept that the man had passed away. In such circumstances, any
attempt at resuscitation would have been worthless. Worse still, it
would not have been respectful either to the staff asked to carry out
CPR or to the man’s memory. However, the tragedy of his death is an
opportunity for the Governor to ensure that his staff are aware of the
guidance if a prisoner is found in a life-threatening situation. I might
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The Governor should ensure staff are aware of the requirements
of PSO 2700 regarding actions following self-harm.
Issues concerning liaison with the man’s family
Availability of family liaison officers
108. My investigator was told by the FLO that he was asked to be the family
liaison officer despite not having had the formal family liaison officer
training. The FLO said that he had experience of the role in his
previous position at HMP Birmingham. Although such experience is
useful, it is disappointing that Featherstone had to use a member of
staff who had not had the recommended training. I understand that he
is due to undertake the training in March 2010. I would encourage the
Governor to ensure that he has a sufficient number of trained family
liaison officers:
The Governor should ensure that he has a sufficient number of
trained family liaison officers.
The man’s property
109. He had made formal complaints about not receiving property that had
been posted to him. In particular, he was upset because he was not
allowed to have some photographs sent to him by his partner. These
had been stored in his property box. These were later returned to his
partner.
110. Following the man’s death, a Family Liaison Officer was appointed by
the prison. Part of his duties in this capacity was to return the man’s
property to his partner as his listed next-of-kin. When the FLO saw
some photographs in the man’s cell he deemed them inappropriate and
arranged for them to be shredded.
111. When asked about this by my investigator, the FLO said he judged that
it was in her best interest to destroy the photographs. The man’s
partner raised this with my own Family Liaison Officer and
subsequently asked for them to be returned to her. The FLO’s actions
mean that the prison no longer has them and cannot fulfil this request.
112. I believe that the FLO acted in good faith but he would have been best
advised to deal with the photographs in a more sensitive manner,
recognising that they were not his to destroy. The Governor should
ensure that there is no repetition, and may wish to write to the man’s
partner about this matter. The man’s partner has also asked about the
remainder of his property. Although I am not aware of the details of her
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26
CONCLUSION
113. Although the man had engaged in many acts of self-harm during his
time in custody, I do not think that his decision to take his life when he
did could reasonably have been foreseen. At Featherstone, staff
engaged with him and attempted to ensure that he was not harbouring
thoughts of harming himself. He was clearly struggling with his
emotions and personal relationships but I do not think staff could have
anticipated the effect it would have on him.
114. Nevertheless, I think there are some important learning points from this
tragedy. It is particularly disappointing that no-one followed up the fact
he had stopped taking his medication. I have been pleased to learn
that a new policy is in place to prevent this happening again. The
inability of the man to access courses helpful to him is also a concern.
115. And I wonder about the extent to which anyone stood back and
considered the man’s situation as a whole. The man was a disturbed
young man with a history of self-harming by ligature. He had spent a
lot of time in segregation, and been transferred from jail to jail. He was
concerned by the state of his relationship with his partner, and in
conflict with other prisoners. He had stopped using mood-altering
medication. These are all risk factors in prison suicides.
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RECOMMENDATIONS
The National Offender Management Service had not responded fully to the
recommendations at the time of the publication of this report.
1. All medical records should be complete, accurate and signed and
dated by the person making the entry. The entry and signature must
be legible and made in line with good record keeping standards.
2. The Head of Healthcare must ensure that a revised policy is fully
implemented to alert staff when appointments are missed or drugs are
not collected by prisoners on mood-altering medication.
3. Governors should be reminded that any urgent need to attend courses
should be highlighted in the file of prisoners being transferred between
prisons.
4. I recommend that the National Offender Management Service ensures
that, where new prisons are built or old ones refurbished, consideration
be given to using a lightweight light fitting to minimise the chance of it
being used as a ligature point.
5. The Governor should ensure staff are aware of the requirements of
PSO 2700 regarding actions following self-harm.
6. The Governor should ensure that he has a sufficient number of trained
family liaison officers.
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