Individual at Parc

INVESTIGATION INTO THE CIRCUMSTANCES
SURROUNDING THE DEATH OF A MAN AT HMP AND YOI
PARC IN JUNE 2006
REPORT BY THE PRISONS AND PROBATION
OMBUDSMAN FOR ENGLAND AND WALES
JUNE 2007
This is the final report of an investigation into the death of a man at HMP and YOI
Parc in June 2006. He was discovered hanging in his cell in the segregation unit,
suspended by a bed sheet. His death is being investigated by South Wales Police
who are satisfied that no one else was involved. The Police are continuing their
investigation on behalf of the coroner.
I offer my sincere condolences to the man’s family and friends for their loss. I hope
that this report answers their questions, but recognise that it may not alleviate their
distress or lessen their grief. They describe him as an intelligent young man, and
believe that, prior to his incarceration, he was showing signs of mental illness.
The man was born in 1986 in Burundi, and was 20 when he died. It is not known
when he first arrived in the United Kingdom, but prior to his arrest he was living in
Cardiff and working in a call centre to fund his studies. In December 2005, the man
appeared at Magistrates’ Court charged with a serious criminal offence, and was
remanded in custody pending his trial. This was the first time he had been in prison.
The man spent the last three months of his life in Parc’s segregation unit, and
physical restraint by staff was used on several occasions. After I issued a draft of
this report, Parc supplied CCTV footage of the one occasion when planned use of
Control and Restraint was exercised on him. I and other of my colleagues, including
two seconded from the Prison Service, have watched the film. It makes disturbing
viewing, and confirms my concerns about the use of Control and Restraint. Officers
struggled to restrain the man, whose immense strength was apparent, and their
efforts lasted a very long time.
Other than contact from staff and the Independent Monitoring Board, the man was
held in isolation and certainly without any involvement with his peers. All the
segregation unit’s procedures were properly carried out, and he was closely
monitored and assessed three times by a psychiatrist. But sadly, none of this led to
any change in his conditions. I judge that his treatment was at best unimaginative.
Given what is clear now about the distress he must have been feeling, at worst his
treatment was cruel.
The investigation was undertaken on my behalf by two of my investigators. The
scale of the investigation was determined at an early stage because of the
circumstances of the man’s death, and the concerns raised by his family. I am also
aware of the media interest.
I would like to express my thanks to the Director of Parc, her staff and the
Independent Monitoring Board for their help and active cooperation throughout my
investigation. I am grateful too to a doctor, of the Healthcare Inspectorate of Wales,
for her assistance.
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I also thank South Wales Police who have willingly shared their information, and
have been assisted by Her Majesty’s Chief Inspector of Prisons’ report of her
unannounced Inspection of Parc in January 2006. Finally, recognising the
significance of diversity matters, I obtained advice from the Prison Service’s race
equality advisor, and am very grateful for her help.
I make one national and 17 local recommendations. I am pleased to record here
that, in the time since the first draft of this report was issued, all my
recommendations have been accepted.
This report has been anonymised for publication on my web site.
Stephen Shaw CBE
Prisons and Probation Ombudsman June 2007
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CONTENTS
Summary
The investigation process
HMP and YOI Parc
Control and Restraint
Independent Monitoring Board
HMCIP Inspection
HMCIP thematic review of race relations in prisons
Key events
Post mortem and toxicology
Issues considered in the investigation
Conclusions
Recommendations
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SUMMARY
The man was born in Burundi in 1986. It is unclear when he moved with his
brothers to the United Kingdom. He was a student studying in England, although
living and working in Cardiff, when he was arrested and taken to HMP & YOI
Parc in December 2005. He had been remanded in custody for a serious
offence, and it was the first time he had been in prison. After his initial reception
he was located on B wing, the young adults wing. All subsequent bail
applications were refused, and he remained in custody.
Whilst on B wing, the man declared his innocence and, as a protest against being
in prison, refused his food. He was placed on a Form F2052SH, which is the
system for monitoring prisoners thought to be at risk of suicide or self harm. He
was visited regularly by staff from healthcare and the chaplaincy, and members
of the Independent Monitoring Board (IMB). He was also supported by the
prison’s counsellor. The man soon started to eat again, and was removed from
the self harm watch.
However, he was involved in fights with other prisoners, which his family believe
may have underlying issues of racism and bullying, and which resulted in
adjudications and loss of privileges. After three months on B wing, he was
moved to the segregation unit for his own protection after he was allegedly bullied
by other prisoners. Shortly afterwards, he assaulted a fellow young adult in the
unit, was placed on disciplinary report, and punished with a period of cellular
confinement. He was then involved in a number of clashes with staff, which
resulted in repeated use of control and restraint, further adjudications, and loss of
privileges. Because the man’s behaviour was unpredictable, from April 2006 until
his death it was a requirement that three officers were present when he was
unlocked from his cell.
The man was regularly reviewed, and he received all the mandatory visits by the
IMB, governors, healthcare and chaplaincy. However, none of this led to any
improvement in his behaviour, which continued to be disturbed and disruptive.
After appearing in court on one occasion, he refused to return to the transport.
From then until he died, he was considered to be at risk of escaping. He was put
on the E list of potential escapees, wore a distinctive uniform, and was monitored
at least every hour.
Control and Restraint was used on several occasions, and was filmed on the sole
occasion that its use was planned. Four officers wearing helmets and masks,
and carrying shields, went into the cell to remove the man’s E list clothes.
Another officer was present, giving directions to his colleagues. The incident
lasted approximately 12 minutes, in which time his head was pushed to his chest
and he was not lifted safely. It was evident that he was extremely strong and
staff had difficulty restraining him, but did not withdraw until they had succeeded.
The man remained in segregation for more than three months until his death,
without any peer group company.
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His behaviour became increasingly disturbed and unpredictable. He was
assessed on three separate occasions by two different psychiatrists who both
concluded that he was not mentally ill.
In the early morning of 29 June 2006, the man was found hanging by a ligature
attached to the window at the rear of his cell. Despite immediate attempts to
save his life, he died aged 20 years.
Since the conclusion of my investigation, the solicitor representing the man’s
family have made allegations of criminal behaviour by staff at the prison. The
South Wales Police are carrying out a thorough investigation into all the
circumstances leading to the death of the man on behalf of the Coroner. Should
any criminal matters be identified they will be part of their investigation.
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THE INVESTIGATION PROCESS
1. The investigation was conducted by two of my investigators who visited
Parc to open the investigation on 3 July 2006. Notices were issued to staff
and prisoners telling them of my investigation and its terms of reference,
and offering them the opportunity to participate. My investigators examined
the cell in the segregation unit where the man died, and were given
unrestricted access to the prison.
2. My investigators obtained the records relating to the man’s imprisonment,
and further records were subsequently provided. They received full
cooperation from South Wales Police, who supplied photographs of his cell.
I understand that the police conclude that no one else was involved in his
death.
3. More than 40 staff, prisoners and IMB members have been interviewed.
Those interviewed included the prison’s senior managers and the
Controller.
4. My investigators have referred to the investigation reports following deaths
of prisoners at Parc since 2004. They have also consulted the following
reports:
• Commission for Racial Equality (CRE) formal investigation into HM
Prison Service of England and Wales (December 2003)
• Her Majesty’s Chief Inspector of Prisons (HMCIP) unannounced
inspection in January 2006
• Independent Monitoring Board 2006.
5. An independent clinical review of the medical care the man received in Parc
has been provided by a doctor, of the Healthcare Inspectorate for Wales.
6. My investigators wrote to the man’s solicitor to obtain background
information. They established that the solicitor took over his case at his
request on 30 March. The solicitor representing the man’s family after his
death spoke to my investigators regarding criminal allegations, and was
advised to report the matter at senior level to the South Wales Police.
7. The investigators wrote to members of the public and former prisoners to
seek assistance in the investigation. They interviewed a prisoner in another
establishment who had information about Parc, and the transcript has been
shared with the prison’s Director as part of her internal investigation.
8. It became apparent at an early stage that the prison, and the man’s death,
may be the subject of a television programme. My investigator wrote to the
television company, informing them of the Ombudsman’s investigation and
asking for any relevant information. No information has been provided.
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9. One of my Family Liaison Officers, arranged a meeting on Tuesday 15
August 2006 with two of the man’s brothers. They raised the following
concerns, which my investigation attempts to answer:
• The man had told his family that he had been beaten by officers three
or four months prior to his death.
• They believe that drugs found in his cell had been planted by staff,
and want to know if he had been tested for drugs.
• They allege that there was evidence of overt racism against anyone
who was not Welsh, and felt that their brother was subject to racism.
• Although the man was checked every hour, the family believe that
two hours passed before he was found to have died.
• His physical and mental health had deteriorated whilst he was in
prison.
• They ask on which occasions were three officers present whenever
he was unlocked.
• Psychiatrists diagnosed that he was not psychotic, and his family are
concerned about the diagnosis, and want to know why he was not
assessed and treated for other conditions. On one visit his brothers
were told by an officer that their brother was “putting on” his
behaviour, and they believe that his real mental health problems
were overlooked.
• The man’s brothers spoke to whom they thought was the healthcare
manager, and she told them that their brother was assessed when he
entered the prison and was getting help. They describe her as rude.
• They have the names of five prisoners, some now released, who
would be willing to make statements about events at Parc. One
prisoner was in the segregation unit before the man’s death and
allegedly saw him being beaten up.
• The cell where the man died was repainted before their visit and they
would like to know why.
10. In April 2007, Parc prison provided the investigation team with a copy of the
CCTV coverage of the single occasion when the use of Control and
Restraint techniques was planned. Unplanned use of control and restraint
is not filmed, and no other film has been provided.
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HMP AND YOI PARC
11. Parc is a category B local prison which holds approximately 900 males,
including convicted adults and both convicted and remand young adults. (A
young adult is a person aged between 18 and 21 years.) It is the only
Welsh prison for young adult males.
12. The prison is in Bridgend, opened in 1997 and is the only private prison in
Wales. It is run by Group 4 Securicor Justice Services, and the person in
charge is the Director. Prisons run by private companies are governed by
the terms of contracts known as Service Level Agreements (SLAs) with the
state. As part of the SLA, the Home Office employs a Controller, of
Governor grade, to work at the prison and ensure that the contract is
complied with. The Director is not permitted to adjudicate on disciplinary
matters, and the responsibility is taken by the Controller.
13. Adjudication hearings consider allegations against prisoners that they may
have infringed Prison Rules. If prisoners are found guilty they can be
subject of a variety of punishments. Serious cases are referred to a district
judge who acts as an independent adjudicator.
14. All the cells at Parc, other than some in the segregation unit, have in-cell
sanitation, natural and forced ventilation, electricity and television for
standard and enhanced regime prisoners. Each wing has hot water boilers,
telephones, table tennis and pool tables, showers, laundry facilities and
association areas. Young offenders are permitted to wear their own
clothing except when on basic regime.
15. In common with other prisons, Parc operates the Incentives and Earned
Privileges Scheme which is designed to improve behaviour. The scheme is
well publicised, and young adults are told about it upon entry to the prison.
Depending on their behaviour, prisoners are on the basic, standard or
enhanced regime.
16. Young adults are all held on B wing, which has four units. Remand
prisoners on the standard regime, and those who are working, are in B1
unit. B2 accommodates convicted prisoners on standard regimes, and
working young adults. The drug voluntary testing unit is in B3, and the
induction unit is in B4.
Segregation Unit
17. The segregation unit has space for 24 prisoners, and is bright and clean.
Both adult and young offenders are held in the unit, on separate regimes,
but with the same staff. They are either held in the unit because of
breaches of prison discipline or for reasons of good order, or for their own
protection from other prisoners. There is no CCTV coverage of either the
cells or the communal areas in the segregation unit.
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18. Two cells are sparsely furnished, and used for prisoners who present a
discipline problem. Cell E2:09 is the special cell, and has no furniture, bed
or toilet. Cell E2:08 is known as an unfurnished cell, and has a toilet but no
bed or other furniture. Use of both cells can only be authorised by the
Controller. Prisoners held in cells E2:09 or E2:08 are subject to 15 minute
observations by staff.
19. Prisoners can make applications each day to use the telephone, see a
member of healthcare, or take a shower. They select meals from a
standard menu, and collect them from a servery. Since the start of my
investigation, young offenders have had access to PlayStations. Prisoners
held in the segregation unit for long periods for their own protection are
offered association and, where practicable, work in the unit.
20. Prisoners in the segregation unit are seen on arrival by a member of the
healthcare team and a manager who sign a safety algorithm confirming their
continued segregation. The prisoners are reviewed regularly by a board
consisting of the Controller, a manager, and healthcare and IMB
representatives.
Health Care Facilities
21. Health care at Parc is provided by Primecare Forensic Medical Services,
who employ a team comprising three doctors and 25 nurses to provide a 24
hour primary care service. The prison’s healthcare centre has 17 inpatient
beds. Nine of the nurses have a mental health qualification.
Control and Restraint
22. Control and Restraint (C&R) techniques are used at Parc in common with all
prisons in England and Wales. C&R is used by a team of three officers
(with the option of having another person involved to control the legs) in
order to manage a violent or unruly prisoner.
23. The deployment of a Three Officer Team is the approved method of dealing
with a violent or unruly prisoner. It must only be used as a last resort after
all other means of de-escalating the incident, not involving the use of force
(e.g. persuasion or negotiation), have been repeatedly tried and failed.
24. The use of force is only lawful if its use is:
• Reasonable
• Proportionate
• Necessary
• No more force than is necessary in the circumstances
25. C&R techniques only use the force that is necessary to enable staff to cope
competently and effectively with violent prisoners and potentially disruptive
situations, with the minimum risk of injury to staff or prisoners.
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26. Staff must continue to attempt to de-escalate the situation throughout the
incident with the aim of releasing holds and locks. Staff must not employ
C&R techniques when it is unnecessary to do so or in a manner which
entails the use of more force than is necessary. The application of C&R
holds may cause pain to a prisoner. If the prisoner is compliant, the holds
must be relaxed.
27. Planned use of C&R may occur when there is no urgency or immediate
danger. In these situations, a supervisor will prepare staff for the incident
and will notify a member of healthcare in advance who will attend and
observe the planned intervention. At Parc, pre-planned uses of force are
routinely videoed.
28. Unplanned use of C&R may occur when there is an immediate threat to
someone’s life/limb or to the security of an establishment and staff need to
intervene straightaway. In these situations a member of healthcare and a
supervising officer will attend as soon as possible.
29. Staff arriving as the ‘first on the scene’ at an incident involving violence (e.g.
a fight between two prisoners) must act in a common sense manner.
Individual officers must not put themselves in grave danger and it may be
prudent for them to await the arrival of other staff in such a situation.
30. Where fewer than three officers are present (or in the case of multiple
violent prisoners, a ratio of less than three officers to one violent prisoner),
and it is necessary to use force immediately, staff will need to use whatever
force is necessary to protect themselves and others - as long as such force
is reasonable and proportionate in the circumstances as they see them.
This advice also applies to incidents that may arise during the night where
fewer than three C&R trained staff are on duty in the establishment e.g. a
fire in a cell and staff must intervene in order to get the prisoner out of the
cell.
31. Training of staff in the actual techniques of C&R can only be carried out by
qualified C&R instructors. The techniques taught are detailed in the Prison
Service Training Manual
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INDEPENDENT MONITORING BOARD (IMB)
32. Every prison has an Independent Monitoring Board (IMB) made up of
members of the public appointed by the Home Secretary. Their purpose is
to monitor the day-to-day life in the prison, and ensure that proper
standards of care and decency are maintained.
33. Each IMB produces an annual report to the Home Secretary. The most
recent Parc IMB annual report covers the period 1 March 2005 – 28
February 2006. In relation to the segregation unit, they reported:
“the Board is still concerned that own interest young prisoners are being
kept in the unit for long periods because at the present time there is
nowhere else for them to be located. A number of young offenders
subject to indeterminate sentences have also been housed on the unit
with little knowledge as to how these inmates should be dealt with. The
Board requested that provision be made for own interest young offenders
in Wales.”
34. In the first ten months of 2006, the IMB attended 70 segregation review
boards, of which 49 were reviews after 72 hours in the unit, and 21 were
after 14 days. The Chair of the IMB reported no serious concerns about
decisions governing either the initial or continued segregation of prisoners.
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HMCIP INSPECTION
35. HMCIP undertook an unannounced inspection of Parc between 9 and 13
January 2006. The inspectors considered the recommendations made at
the previous announced inspection, and the extent to which they had been
achieved. I here highlight those recommendations which are relevant to the
man’s treatment.
Diversity
36. The report commented that black and ethnic minority prisoners made up a
small percentage of the population, and there was only one member of staff
from an ethnic minority group. Few black or other ethnic minority people
lived locally, and there was no evidence of a specific recruitment drive to
attract staff from further afield. The inspectors found that, despite criticism
in the CRE report three years earlier, a diversity action plan had not been
produced.
37. There were no positive images reflecting racial or cultural diversity on
display in the establishment or other visible promotions of diversity. The
Race Relations Liaison Officer had recently produced a good practical guide
and had begun to disseminate it through staff briefings.
38. The inspectors surveyed black and other ethnic minority prisoners who
reported negative perceptions, which indicated that positive action was
needed to ensure that the prison’s regimes did not discriminate indirectly,
and they had equal access to all services. The inspectors noted some
recent progress in improving the reporting systems, collecting and analysing
data and networking with external agencies. They recommended:
• ensuring a wider audience for the Race Relations Management Team
• all staff to be trained in race relations and diversity including their own
diversity policy
• deficiencies identified in the CRE report should be addressed
• there should be a specific recruitment drive to attract black and other
ethnic minority staff to work at Parc
• discriminatory patterns should be highlighted through ethnic
monitoring and appropriate action taken
• completed investigations of racist incidents should be monitored
independently and routinely
• staff and prisoners who display racist behaviour should be challenged
• victims and reporters of racist incidents should be protected
• there should be displays throughout the prison, and other activities
promoting diversity.
39. Since the HMCIP inspection in January 2006, Parc has produced an action
plan which promotes racial equality, and endeavour to remedy any
discrimination identified through monitoring and intervention. The prison is
part of an initiative with the local Valleys Race Equality Council (VALREC),
who act as consultants on all hate crimes, whether linked with race, religion
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or homophobia. VALREC is contracted to deliver training to all staff and
prisoner representatives, which is accredited as good practice by the CRE.
VALREC is to provide advice, assistance and support through monthly
surgeries that are accessible to all prisoners. They are also developing a
pilot scheme that addresses the attitudes of people convicted of racially
aggravated offences. VALREC will work with black or minority ethnic young
people who feel isolated and disconnected in a custodial setting.
40. Parc has upgraded the role of the diversity officer and suicide prevention
coordinator to a member of the management team and is developing a use
of an electronic database to capture all allegations of racism and bullying.
Segregation unit
41. HMCIP found that, on a typical day, seven of those held in the unit were
adults and eight were young adults. Six of the young adults were held for
their own protection, referred to as ‘own interest’. Of the 15 in the unit
during the inspection, seven had been segregated for two weeks or less,
but the longest period of continuous segregation of a young adult was more
then eight months. During the PPO investigation, one young adult had
been in the unit for his own protection for 12 months.
42. HMCIP concluded that the segregation unit was well managed, and there
were good relationships between staff and prisoners. The unit was clean,
properly equipped and there was no excessive graffiti. There was a fenced
exercise yard with a covered area so that prisoners could get out into the
fresh air even in inclement weather.
43. HMCIP made recommendations in relation to prisoners in segregation:
• the reason for the high use of force against young adults and juveniles
should be identified and the underlying causes addressed
• arrangements for education and other regime opportunities for longer
stay segregation unit prisoners should be improved and provided
consistently
• there should be additional activities for young adults segregated for
their own interest
• reasons for the use of the special cell accommodation should always
be recorded
• the special cell should not be used for prisoners who self harm.
Bullying
44. HMCIP found that Parc had an up to date bullying strategy which was
included in a prisoner’s induction, and staff had received training in it. A
course for bullies had been developed, but was little used. The inspectors
considered that there was no protocol to support the victim, and the
implementation of the strategy was ineffective.
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45. HMCIP said that the violence reduction co-ordinator had recorded 67
incidents of bullying in the 12 months prior to January 2006. Of those, 52
had occurred on B wing. There was no evidence that managers had noted
the disproportionate figures, or attempted to identify and address any
underlying causes. It was unclear how many more incidents there had been
as the violence reduction coordinator was not always informed. At the time
of the inspection in January 2006, no prisoners were being monitored for
bullying behaviour.
46. The inspectors identified the following additional concerns:
• identified bullies not being observed
• implementation of anti bullying courses
• no investigation into the bullying activity on B wing nor an action plan
developed
• there should be documentation and a support protocol for victims of
bullying. Staff should be alert to any bullying of vulnerable prisoners or
their visitors on the way to visits and should intervene if necessary
• a prisoner representative should attend violence reduction committee
meetings.
Use of force
47. The inspectors reported that staff recorded that they used force to restrain
prisoners on 216 occasions the previous year. The prisoners’ survey said
that black and minority ethnic prisoners and young adults were more likely
to be subject to force than white adult prisoners. However, HMCIP found no
evidence to substantiate the claim about black and minority ethnic
prisoners, but did confirm that regarding young adults. HMCIP considered
35 cases. The majority (31) of prisoners in the sample were white, and only
four were not. The majority (29) of prisoners in the sample were young
adults, and force had only been used with six adults.
Self Harm and Suicide
48. The inspection team found that there was an active and keen suicide
prevention coordinator, but she was not fully supported by other officers and
all managers. The quality of the suicide or self harm monitoring forms
(F2052SH) was poor, and prisoners on an open F2052SH were held in the
segregation unit contrary to correct procedures.
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HMCIP THEMATIC REVIEW OF RACE RELATIONS IN PRISONS
49. In December 2005, HMCIP published Parallel Worlds, a thematic review of
race relations in prisons. The research included survey material from 5,500
prisoners of all racial groups.
50. It is a comprehensive document which found that much progress has been
made and processes for addressing racism and discrimination were in
place. However, it said that there is no shared understanding of race issues
within prison. Prisoners from visible minorities reported poorer experiences
than white prisoners, and overwhelmingly said that they felt less safe, less
respected and had poorer access to the regime and facilities.
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KEY EVENTS
December 2005, B wing
51. The man appeared at Magistrates’ Court in December 2005 charged with a
serious criminal offence and was remanded in custody. Prison escort
contractors took him to Parc, and he passed through reception where he
was seen by an Officer and a Healthcare worker who completed the First
Reception Health Screen. It was indicated on the form that a medical
psychiatric report was not required, and that the man had not been in prison
before. He said that he had not seen a doctor recently, was in good health,
not taking medication, and had no recent injuries. The man said that he did
not suffer with asthma, diabetes, epilepsy fits, chest pains or tuberculosis,
sickle cell disease or allergies, and had no concerns about his physical
health. It was further noted that he did not abuse alcohol or drugs.
52. A Cell Sharing Risk Assessment (CSRA) form was completed by the officer
who recorded that the man was of medium risk of harm to others, meaning
that there was no immediate risk but his situation needed to be reviewed
regularly. After going through the reception process, he was taken to Unit B
where he was given a brief introduction to prison procedures by a unit
officer. The man’s reception process was completed on four days later. It
is recorded that he was also seen by the prison chaplain.
53. At 7:30am five days later on the man was taken by the prison escort service
to Magistrates’ Court where he was further remanded in custody. He
returned to the prison at 11:45am, and was placed in the same cell.
54. A unit officer spoke to the man the next day,as he had become aware that
he had not been eating. The man told the officer that he was innocent of
any offences, and was not eating in order to make a statement of his
innocence. The officer shared the information with the Duty Director and
healthcare.
55. A food monitoring sheet was opened on the following day which recorded
the man’s food intake, and he was assessed by the prison doctor, who
noted that he had been refusing food for three days. The doctor recorded
that there were no significant problems in relation to the man’s physical or
mental health, and no self harm concerns. He recorded that, as there were
no mental health concerns, his right to refuse food must be respected. A
urine test was carried out, and the results were normal.
56. The man was seen by the Safer Custody Officer, later the same day. She
recorded in his daily supervision record that the man said he was not eating
because he should not have been imprisoned on the basis of one allegation
from a housemate, and because his solicitor had not been to see him. The
officer contacted the man’s solicitor on his behalf and arranged for his
solicitor to visit. The man’s solicitor visited him on 2 January.
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57. On 3 January, the man was seen again by the Safer Custody Officer. She
noted that the man was adamant that he was not going to eat prison meals,
and nothing would change his mind. In addition to being visited by the
officer, the man was allocated a personal officer to discuss any concerns.
He was in a cell on his own and had in cell television. Although he refused
prison meals, he did eat food such as Pot Noodles which he purchased with
his own money.
58. The Safer Custody Officer referred the man to a qualified counsellor
employed by the prison to work on B wing. The counsellor said in interview
for this investigation that he found the man a very pleasant person. He
thought that the man had stopped eating to draw attention to himself as he
was angry at being in prison and his solicitor had not visited.
59. The counsellor was able to provide the man with comfort and support, and
to explain different ways that he could cope in prison. The man wanted to
see his solicitor which the Safer Custody Officer had arranged. The
counsellor, together with the Safer Custody Officer, tried to encourage the
man to eat so that he had more strength. They looked at coping
mechanisms, and encouraged him to explore what he was actually feeling.
The counsellor described the man as having a lot of anger, a lot of sadness,
and a lot of confusion as to what was happening to him, and what was
going to happen to him.
60. The counsellor continued to counsel the man regularly and saw him on a
number of occasions whilst he was on B wing. However, the counselling
stopped as a result of his transfer to the segregation unit.
61. The man was also visited by a member of the IMB, and they talked together
for about 20 minutes. She described him as obviously disturbed and
worried. He gave her the impression that he was angry, and was adamant
that he had not committed the offence he was charged with. They talked
about his background and life outside prison, and she said he was
disheartened about the practicalities of returning to his studies. She tried to
reassure him the world of education was always open to him.
4 January 2006, F2052SH opened
62. The IMB member was so concerned for the man that she visited him again
on 4 January on B wing, and was surprised to learn that he had begun a
hunger strike. She tried to encourage him to eat. A Form F2052SH was
opened the same day because of concerns raised by staff that the man had
not been eating. One officer wrote that a move to the Healthcare Centre
would be a benefit, as he could be monitored more closely. The man was
reviewed again by the doctor, but was not admitted to the Healthcare
Centre. Instead, the doctor requested that the man be placed under
observation by healthcare staff, and moved to a shared cell, although this
did not happen.
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63. The next day, the man was taken to and from court by escort contractors,
returning at 2:55pm. The doctor saw him again, and noted that he had lost
5 kg in weight in the fortnight since his admission.
64. On 6 January, a review of the man’s F2052SH review was conducted which
he attended. He gave no reason for refusing prison meals, but it was noted
that he had eaten his meal that day for the first time in ten days. It was
noted that he interacted well throughout the review, and appeared healthy
and coherent, saying he would continue to eat and did not want to be forced
to eat. The review decided to keep the F2052SH open, to monitor the man
closely, and review again in 14 days. He was observed by wing staff, and
was visited by the chaplain, IMB and members of his family. A Returned
Food Register was kept, and it recorded that he started eating again on 8
January after which he ate normally.
65. The man attended a gym induction session on 10 January. The next day
his medical records state that he was not eating again, and complaining of
constipation for which he was prescribed a laxative. However, other
records show that he continued to eat normally. The following day another
member of the IMB, visited the man. She thought he had ended his hunger
strike and that officers on the wing were pleased with his progress. It was
noted in his daily supervision record that he was eating, drinking and
associating with other prisoners. On 14 January, the man was given a
nurse triage appointment for 16 January, but he did not attend.
66. On 15 January at 2:35pm, two officers saw the man fighting with another
prisoner. The officers stood between the prisoners, and requested both to
return to their respective cells. The officers calmed the situation without
using force, and the man returned unassisted to his cell. He was examined
afterwards, and was free from injury. An ‘injury to prisoner form’ was
completed, the first of 17 completed whilst he was at Parc. The form has to
be completed whenever staff use force to restrain prisoners. The man was
placed on disciplinary report for fighting.
67. The Daily Supervision and Support records from 4 to 20 January were
examined for the investigation, and they show that the man was observed
by wing staff on average eight times over 24 hours. He told staff that he
was coming to terms with being in prison, but asked for a form so he could
complain about how he was treated beforehand. My investigator has been
unable to establish if the man was given any writing materials to make a
complaint.
16 January, adjudication hearing
68. The day after the fight, at 8:50am on 16 January, the man was taken to the
segregation unit for the adjudication hearing. He was found guilty of
fighting, and punished with loss of privileges for seven days. He returned to
B wing later in the day, and at 4:45pm was placed in a cell. The rules and
21
regulations of the wing were explained to him again. The following day, an
officer noted in the man’s daily supervision record that he was a very quiet
prisoner who did not cause any problems to staff.
69. In interview, the officer said the man was initially no problem at all. He
generally complied with the rules, was very quiet and kept himself to
himself. However, his behaviour began to deteriorate, sometimes he was
confrontational with staff, and had a bad attitude towards them. At other
times, he was polite, civil and had a very good approach when they spoke
to him. On 19 January, the man was a visited again by his brothers.
20 January, F2052SH closed
70. The F2052SH self harm review took place on 20 January. It noted that the
man had been eating regularly since 10 January, and was no longer a
concern to unit staff. The F2052SH was closed. He was described by an
officer as playing pool on the wing and being more sociable. The officer
described him as coming out of his shell and speaking to staff and
prisoners. The man was also having showers and taking care of his
personal hygiene. On 23 January, the man was located to B4 wing in a cell.
The same day he was visited by his brothers, and his solicitor.
9 and 10 February, use of force
71. On 9 February at 7:30pm, the man was seen by an officer on B4 landing
exchanging blows with another prisoner. Two officers shouted to them to
stop fighting, stood between them and escorted them to their respective
cells. The officers calmed the fight, without using force. The adjudication
hearing took place the next day, and both the man and the prisoner
received seven days loss of privileges. The man was moved to another cell
72. Later on 10 February at 7:30pm, three officers saw the man run over to the
pool tables and start punching the same prisoner in the head. One of the
officers shouted to the man to stop, but he continued to throw punches.
The officers restrained the man using approved Home Office control and
restraint techniques, and took him to his cell. They noted that he did not
sustain any injuries. In both days’ incidents the appropriate Record of Injury
to Prisoner Forms were completed.
73. The man was placed on a further report for fighting and in a written
statement said:
“To whom it may concern/prison adjudicator,
I am writing this letter as one of apology and to explain my action which I
understand is not acceptable and definitely disruptive. On 10 February,
I assaulted another inmate by the name of X. I was wrong for doing so
have apologised before and wish to do so again. My reason for writing
this letter is to give you an understanding as to what went on and to
22
show that I wasn’t the aggravator. As I tried to explain to the governor
there has been a history (bad) between me and X.
There was an occasion in the prison gym where I had asked X to use a
certain piece of equipment. I was told you can’t use it he’s next he’s a
coon although referring to his friend. The racist abuse was clearly
aimed at me as his friend was not a person of colour.
Another incident occurred were I got into a fight with X as I was hanging
around speaking to a mate, although X made the initial attack and I was
barely defending myself we were both reported and put on losses.
On the evening of 10 February I was verbally assaulted by X again as
he looked over where I was sitting and screamed ‘what’ an officer
witnessed this incident and could be called upon if needed. Although I
walked away from this certain incident. I became agitated and when I
went back to sit with friends who had agreed that I hadn’t made any
invitation, friendly taunting aggravated me more and I wrongly lost my
temper and attacked X. I apologise again for my actions and can say
they will not happen again.
Signed,
’The man’
74. There is no evidence that the man’s allegation of racism or underlying
bullying was reported or investigated.
75. The man attended the adjudication hearing on 13 February. The case was
adjourned in order that it could be heard by the independent adjudicator.
The next day, 14 February, the man received a visit from his brother. On 24
February, he received a written warning for failing to attend work.
28 February, adjudication hearing
76. On 28 February, a District Judge attended Parc and presided over the
adjudication for the fight on 10 February. The man was not legally
represented, pleaded guilty and was sentenced to an extra 21 days
imprisonment. The additional days would have been added to his sentence
had he been found guilty of the charges he faced and had received a
custodial sentence. On 2 March, his brothers visited him again.
4 March, drugs found in cell
77. At 3:05pm on 4 March, as a result of information that the man was in
possession of illicit drugs, four officers searched his cell. They found a
brown substance wrapped in a cigarette paper. The officers reported that
the man became agitated, threatening and abusive towards an officer and
alleged that the drug had been planted. He was physically restrained by the
officers. The man eventually became passive and was examined by a
23
nurse. She noted he had sustained a small cut inside his mouth, but it did
not require treatment.
78. The man was placed on a further disciplinary report for being threatening
and abusive towards staff, and for allegedly having a wrap of heroin in his
cell. An officer completed a prison security information report (SIR) in
relation to the brown substance. My investigator has found no evidence
that the brown substance was analysed. However, the man pleaded guilty
to possessing the drug at the adjudication hearing on 20 June.
79. On 5 March, a Registered Mental Nurse (RMN) saw the man. (the RMN
has now left Parc, and my investigator has written to ask her to participate
in this investigation but without any reply.) The medical record notes that
the man’s brother thought that he was mentally ill, which they had shared
with a member of the staff. This was the first indication in the records that
he might have had a mental illness. There is no evidence that the RMN
asked the man about his brother’s concerns, and no evidence of any other
follow up, either with him or his family, despite the fact that his brothers
were regular visitors.
80. At 6:50pm on 9 March, the man was on association on B wing when he was
seen grappling with another prisoner. They stopped when ordered to do so
by an officer, and both prisoners were reported for fighting. In a written
response to the charge, the man explained that he had an altercation over
using the telephone, and that he thought his actions were appropriate.
10 March, adjudication hearing, moved to segregation unit
81. The next day, 10 March, the man attended the adjudication hearing and
was punished with ten days cellular confinement. He was moved to a cell in
the segregation unit. He was moved again to another cell on 14 March, and
remained there until 19 March.
24
16 March, returned to B wing
82. The doctor saw the man in the segregation unit on 16 March, and assessed
him as fit and well. He was then returned to B wing where he remained for
the next week.
23 March, returned to the segregation unit
83. On 23 March, the man was taken by the security manager to the
segregation unit for his own interest after allegedly being bullied whilst on a
visit. My investigator has found that, although the man was said to have
been taken to the unit for his own protection, there are no records of him
having a visit that day, or of being bullied. He was located in cell, and a
segregation safety algorithm was completed which recorded that he had
been bullied on a visit.
84. A third member of the IMB, was informed of the man’s relocation and went
to the unit to see him. He found him sitting on the floor of his cell. The
member of the IMB described him as very angry and aggressive. The man
alleged that he was being bullied by some officers. The IMB member
enquired with the duty manager, if the man could have some writing
materials to put his complaint in writing. The IMB member was informed
that, because of his behaviour, he would not be allowed to have writing
materials until he calmed down. The man lost his temper, and IMB member
withdrew from the cell. The allegation of bullying by officers was not
reported or investigated.
24 March, segregation review board
85. As required, a segregation review board was held on 24 March within 24
hours of the man being located there. The board consisted of the controller,
an officer, a manager, an IMB member and a nurse. They decided that the
man should remain in the segregation unit until his next review on 31
March.
86. An officer, who works in the segregation unit, described the man as five foot
seven and of slight build. He had dreadlocks which were five or six inches
long, and at first he wore his own clothing. The officer described the man
as initially a polite prisoner, who interacted well. They had a mutual interest
in Cardiff, and the man told him that he was studying at university and about
the alleged offence. The officer said that the man used to watch television
and read books, and he would give him newspapers to read. The man used
to press his intercom to request to speak to the officer, and they frequently
talked together. He described him as mixed up, and having mood swings.
He also said that he spat repeatedly, and kept plastic bags and bowls full of
saliva in his cell. He described the man attacking officers, and urinating in
his clothing.
87. On 27 March at 7:45am, the man was moved to another cell in the
segregation unit after he assaulted a fellow prisoner as he walked past his
25
cell, and tried to drag him inside. Three officers used control and restraint
techniques to restrain him from committing a further assault. The man was
seen by a nurse who reported that he had not sustained any injury.
88. The incident was witnessed by another prisoner in the segregation unit who
worked as a wing cleaner. He explained that he and the prisoner walked
past the man’s cell, and the man grabbed the prisoner from behind. The
wing cleaner said nothing really happened, they had a little scuffle which
was broken up by staff. The wing cleaner said after this incident he saw the
man being restrained by staff on a few occasions, and he thought that the
methods used were appropriate.
27 March, adjudication hearing
89. On 27 March, the adjudication hearing took place in front of the Controller,
who imposed five days cellular confinement as the man was already on the
maximum losses for a young offender. He was seen between 6:30pm and
7:30pm that evening by his solicitor.
31 March, segregation review board
90. On 31 March, the segregation review board, which consisted of the
Controller, two managers and an IMB member, decided that the man
should remain in the segregation unit for his own interest.
91. Although the prison’s counsellor had stopped having regular sessions with
the man, he saw him three or four times when he was in the segregation
unit on other business and formed the opinion that he was very scared. On
the last occasion, an officer commented to him that the man was constantly
urinating in his clothing. The officer told him that they had to drag his
mattress out every morning because it was full of urine. The counsellor said
that he was aware of a rumour that the man had been beaten in the unit, but
he had no evidence of it taking place.
92. On 1 April at 6:50pm, the man was moved to another cell at his own
request. During the move the man was given permission to go back and
forth from his previous cell to pick up his belongings. After being locked in
his cell, he rang the buzzer and asked to return to his old cell to collect
some legal documents. An officer told the man that she would collect them
for him, but when the door was being shut the man put his foot in the door
to prevent closure. She instructed him to move his foot, which he did and
once inside, he complained that his foot had been injured. A nurse came to
assess his foot, but the man refused to let her examine it. However, she
was satisfied that there was no injury, as she saw him walking. The man
was placed on report for intentionally obstructing an officer in the execution
of her duty, and the adjudication hearing was scheduled for 25 April.
93. On 2 April at 10:52am, an officer responded to the man pressing his cell
intercom and kicking his door. When the door was opened, it was evident
that water had been thrown through the window from the exercise yard.
26
The officer reported that he became threatening and abusive towards her,
shouting in her face and waving his arms. She told him to sit on his bed
and calm down, but he did not comply with the request. The officer said
that he made a sudden movement in her direction, together with three other
officers the man was restrained using control and restraint methods. The
man complained of a pain in his ribs, but there were no visible signs of
injury and he was not deemed to require medical attention. The
adjudication hearing was listed for 23 May. There was no investigation of
the water thrown through the cell window.
94. Later that day at 4:10pm, the man refused to go back into his cell until he
was able to have a telephone call. The segregation supervisor, told the
man that he could not have a telephone call and ordered him back into his
cell. He refused to return, and was forcibly returned by two officers using
control and restraint methods. The incident was observed by an IMB
member, and a member of the healthcare staff was asked to examine the
man.
95. Ten minutes later, at 4:20pm, the duty nurse, a nurse, was escorted to the
man’s cell with four officers in attendance. They reported that the man ran
at one of the officers, and was again physically restrained by staff. The duty
manager, arrived to oversee the de-escalation of the incident. The nurse
then examined the man. She described his eyes as rolling, but was
satisfied that he required no medical intervention. This incident was also
reported for adjudication on 23 May.
96. On 3 April, the man was taken to Crown Court, and at 2:00pm he refused
an order to return to the escorting van to go back to the prison. He was
placed on report for failing to comply with an order.
97. At 4:10pm, the man was returning to his cell after having a shower. He
demanded a telephone call, although it was explained that he had no credit
left on his phone card. He was ordered to return to his cell by an officer, but
refused, and was placed back there by four officers using control and
restraint techniques. Ten minutes later, a nurse came to examine him,
accompanied by four officers. They reported that the man had charged
towards an officer, and that spontaneous control and restraint was used by
the officers. The duty manager arrived on the scene. The nurse recorded
that the man’s eyes were rolling, and he was placed on his back but again
became verbally aggressive towards staff. She was satisfied that no further
medical treatment was required.
4 April, segregation review board
98. The following day, four officers went to the man’s cell at 4:25pm. They
wanted to move him to another cell, because of fears that he would try to
escape from the prison. The man was treated as at risk of escaping
because of his refusal to get in the transport at court the previous day. The
officers reported that the man ran towards an officer in a very threatening
manner, and they restrained him using control and restraint techniques and
27
lowered him to the floor. He was moved to the other cell, where a nurse
assessed that there was a minimal period of violence and no other injuries.
99. The segregation review board was held the same day, with the Controller,
two managers, a member of the IMB, a nurse and the man. His case was
discussed, and it was decided that he should remain in the segregation unit.
The man was offered the support of a mental health nurse (RMN) but
refused. There is no record of the man’s behaviour whilst attending his
review. The doctor saw him two days later on 6 April and noted he was fit
and well.
100. The next day, an officer completed an SIR in which he reported that a night
officer had reported at the morning’s handover that the man had asked to
be let out of his cell and out of prison. The officer reported that the man had
said that he could not stay in prison any longer, and that officers should be
careful when unlocking him. It was the view of both officers that the man
was thinking about attempting to escape.
101. As a result of the information in the SIR, the then head of security, decided
to place the man on the E list, which is a list of prisoners thought likely to
mount an escape attempt. E list prisoners wear a distinctive overall when
they are being moved, and their movements are monitored every hour. He
remained an E list prisoner until his death. The man was seen again by a
member of the IMB who recalled that he was unhappy about being
photographed as part of his E list status.
7 April, moved to special cell
102. On 7 April at 7:15am, three officers were unlocking the man for his
breakfast. They asked him to stand at the rear of the cell before they
opened the door. As the door was opened, the man moved towards one of
the officers holding a plastic cutlery knife. The officer’s key chain was
attached to his belt, with the keys in the door in the approved manner. The
door was forced open wider which snapped the officer’s key chain. The
man was physically restrained by the officers using control and restraint
methods.
103. On the instruction of the duty manager the man was moved to the special
cell. A senior nurse attended at 7:40am, but was unable to examine the
man because of his violent behaviour. She could not see any injuries, and
recorded that RMN follow up should be arranged when he was calmer. The
doctor also attended but could not examine the man who was sitting behind
his door refusing to be seen. He eventually agreed to talk to a nurse. He
told her that he was not mentally ill, but said that he felt that segregation
and prison were detrimental to his mental health. He said that he wanted to
be released from prison or moved back to B block.
104. The man was also seen by, another member of the IMB, who recalled that
the Governor was talking to him to try to calm him down. When the IMB
member returned to the man’s cell later on, he was banging the door with
28
his feet. She described him as very aggressive, and said that he did not
want to see anybody or do anything. She said that the other prisoners were
out of their cells, and they wanted to get revenge on the man because of the
noise he was making.
8 April, moved out of special cell
105. On 8 April, the man was moved out of the special cell into another cell. He
was visited again by the IMB member who noted that he seemed fine but
was still proclaiming his innocence. He was seen by the doctor on 8 and 9
April and assessed as fit and well. The man had a visit from one of his
brothers on 9 April.
12 April, psychiatric assessment
106. A community consultant forensic psychiatrist, saw the man for the first time
on 12 April, together with her colleague. She described the man as an
articulate young man who presented as quite pleasant during the interview.
Staff had told her that they had concerns regarding the man’s violent
behaviour. He told her that he found it very hard being in prison, as it was
his first time. When she asked about the violence, the man explained that
he had to defend himself.
107. The psychiatrist said that, during the interview, she had no sense that the
man was mentally ill. She asked about psychotic and depressive
symptoms, but found no evidence of either. The man asked for a
psychiatric report, which he said would be a means of getting out of prison.
The psychiatrist said that she did not consider that the man needed to
transfer out of prison, and she not see any evidence of mental illness.
108. The man’s solicitor visited him at Parc on 12 and 13 April. The visits took
place in the main area for legal visits, and the solicitor said that they passed
without incident. He said that at no time during the visits did he notice
anything particularly wrong with the man who was lucid, able to understand
advice and provide detailed instructions.
109. On 14 April, a RMN reviewed the man who complained of losing blood and
his left side being frozen. The nurse found no physical problems on
examination. This is the first entry in the records which may indicate that
delusional beliefs were present. A doctor saw the man on 14, 15,16,17,18
and 19 April as part of the daily segregation routine and noted that he was
fit and well. On 17 April, the man’s brother visited again.
19 April, segregation review board
110. A review board was held on 19 April, with the controller, two members of the
IMB, an officer, a manager, a nurse and the man. His case was discussed,
and it was decided that he should remain in the segregation unit. There is
no record of how the man behaved during the review.
29
111. On 20 April, he was moved to another cell and the next day had a visit from
one of his brothers and a friend.
112. At 11:05am two days later, an officer was escorting the man from the
exercise yard back to his cell. He said that, as he was about to close the
cell door, he tried to push past him, demanding a shower. The man
punched the officer in his left eye and control and restraint techniques were
used to force him back into the cell. Control and restraint was used by the
officer with assistance from four other officers. The incident was supervised
by the duty manager, who talked to the man to try to get him to comply with
instructions. The officers reported that the man continued to struggle, was
abusive and accused staff of being racist. The allegation that staff were
racist was not reported or investigated. The man was moved to the special
cell, and a nurse attempted to assess whether he had any injuries.
However, because he was behaving aggressively, shouting and moving
around the cell, she was unable to assess him.
23 April, adjudication hearing
113. On 23 April, the man appeared before a Judge who carries out independent
adjudications, for the adjudications following the incidents on 1, 2 and 3 April,
and was given an extra 39 added days to be appended to any subsequent
court sentence of imprisonment.
114. At 9:15am the next day, 24 April, an officer accompanied the doctor to all
the prisoners in the segregation unit. He asked the man to go to the back of
the cell, and opened the door. The man rushed towards the officer, and
was restrained by four officers. A senior manager, was in the unit and saw
the man being restrained. A member of the IMB visited the man, but he did
not want to talk to her. He was later moved to the unfurnished cell.
115. The man’s solicitor was due to visit that morning at 9:30am, but received a
telephone call from an officer. The solicitor was told that there had been a
violent incident overnight, and the prison considered that the visit should not
take place as the solicitor’s personal safety was at risk. It is not known
whether the man was consulted about the impending solicitor’s visit. The
solicitor did come to the prison and was refused admission, as it was
reported that the man was acting so aggressively that a visit would be
impractical.
116. On 25 April, the man was taken by prison escort services to Crown Court,
and his solicitor saw him in the cell complex below the court. The solicitor
said that the man’s behaviour was extremely odd. He initially appeared
well, but then became extremely agitated. The man questioned the
solicitor’s origins, the existence of a barrister whom he thought was
conspiring against him, and repeatedly demanded release on bail. The
solicitor said that the man did not appreciate that his bail applications had
been exhausted, and he had no prospect of it being granted.
30
117. The man walked out of the court hearing, returning down the stairs back to
his cell. His solicitor and counsel went to see him, watched by three officers
standing outside the door. The solicitor said that he paced up and down the
room, holding a polystyrene cup and continually spitting into it. He
appeared extremely tense, and the solicitor thought that at any time he was
likely to become violent.
118. A young adult offender, was also at the court that day. He knew the man
from B wing, and was surprised to see him as he thought he had been
released. He heard the man banging on the cell door and shouting, and
was allowed inside to help calm him down. He said that, whilst they were
on B wing together, the man was ‘normal’ but now considered he was
suffering with a mental illness. He said that the man calmed down whilst he
was with him.
119. The man assaulted a member of the escorting staff whilst returning to the
prison. After his return, he was medically examined at 2:55pm by a nurse
who noted that he was fine and had no injuries. An SIR was completed
regarding the assault.
120. Later that day, at 6:00pm, four officers were issuing the man with some
water and instructed him to go to the back of the cell. One of the officers
held a shield when he opened the cell door, and the man rushed towards
the door and hit the shield. The door was closed and the duty manager
informed. The man was seen by a nurse at 6:05pm. The nurse recorded
that no injuries were seen or complained of.
121. A member of the IMB saw the man in his cell on 27 April. He was sitting on
the floor, calm but had nothing to say. He had seen the man on several
occasions, and described his behaviour as ranging from very aggressive to
very calm and polite.
27 April, psychiatric assessment
122. The same day, the psychiatrist interviewed the man for the second time.
The psychiatrist recalled that the prison doctor told her that at times the
man’s eyes became wide, and that he became sexually aroused before or
at the time of an assault. She was also told by staff that he soiled his
clothes deliberately. The psychiatrist said that it was a difficult interview
because officers with shields were present. The man sat at one end of the
table and the psychiatrist at the other.
123. The man told the psychiatrist that he had been seeing spaceships, but did
not appear distressed or frightened, and it was said as a joke. He then said
that he did not see the spaceships, but heard them. He also spoke about
ghosts and demons, but did not say he was feeling depressed. Again the
psychiatrist did not consider that the man was mentally ill, but rather that he
was angry about being in prison. When she asked about his assaults on
staff, the man said he knew what he was doing at all times. She thought
that an electroencephalogram (EEG), which is a test for organic brain
31
disease such as epilepsy or brain tumour, might be beneficial. The test was
not carried out. The psychiatrist recommended that the man remain in the
segregation unit.
27 April, case conference
124. A case conference also took place on 27 April, attended by segregation unit
officers and a senior nurse. They agreed that the man would be moved to a
normal cell and have his bedding returned. He would be monitored daily by
the doctor, and observed by segregation staff every 30 minutes. The
residential senior manager, and the deputy controller, issued a
management care plan for the man. The plan included the following
information and instructions:
“The man has over recent weeks displayed a very aggressive and
unpredictable attitude towards prison staff. This has resulted in a number
of actual and attempted assaults on the staff he has come in contact with.
The following is the management plan designed to ensure staff that are
charged with caring for the man, do so in as safe conditions as possible:
 Whilst in a normal location segregation unit cell the man will be
subject to thirty-minute observations, this will be recorded on a
Special cell observations form.
• PCO5 I/C Segregation unit and a minimum of three members of
staff are required at all times to unlock the man for any purpose, a
short shield will always be utilised.
• PCO5 I/C Segregation unit will carry a set of ratchet handcuffs at all
times. This is to ensure that the prisoner can be restrained by use
of ratchet handcuffs, as C&R techniques have very limited
effectiveness on the man.
• The man will be allowed a mattress in his cell during the day. After
serving his evening meal he will be issued with a sheet, a pillow and
a strip blanket, which will be removed the following morning after
Breakfast.
• The prisoner must be stood at the back wall when staff enter the
cell. If he refuses this instruction staff will not enter unless in an
emergency i.e. Self-harm.
• Staff will take all meals to the man’s cell. All meals will be served on
a polystyrene plate, a polystyrene cup will be provided for cold
drinks only.
• The man will have access to a period of exercise and a shower
each day, the PCO5 I/C Segregation unit and a minimum of three
32
members of staff with a short shield will supervise the man at all
times.
• Whilst the man is on the unit, or in the shower the segregation unit
will be in a patrol state, no other prisoners will be out of their cells
and all unit doors, offices and stores will be locked.
• The man will be strip searched prior to his exercise period and prior
to being relocated in his cell.
• Unit cleaners will clean the man’s cell whilst he is on exercise, unit
staff prior to him being re-located in his cell will then search it.
All staff need to be aware that they are dealing with a violent unpredictable
young man and must be on their guard at all times when unlocking his cell
or supervising him on the unit.
The duty director in consultation with the controller can only countermand
these instructions. The PCO5 I/C Segregation unit will inform the duty
director of any significant changes in behaviour/attitude of the prisoner.”
125. These arrangements, including the use of a shield and requirement for
‘back wall unlock’, remained in place until the man died. However, the plan
was only ever put in place during crisis for a short period
126. The doctor saw the man each day, merely noting that he was fit and well.
On 28 April, his solicitor wrote to the prison health department, suggesting
that he should be referred to the psychiatric team which visits the prison. A
reply was sent to the solicitor to the effect that the man had already been
subject to a psychiatric assessment.
127. The man’s solicitor and his counsel met him at Parc on 2 May. The meeting
took place in the segregation unit, with two prison officers standing at the
door with shields. The solicitor described the man as perfectly amicable,
and even jovial. He apologised for his behaviour the previous week. There
was no repetition of the disturbed behaviour the solicitor and counsel saw at
court, nor any sign of aggression or violent behaviour.
2 May, segregation review board
128. The following day, 2 May, the man was seen between 10:45am and
11:45am by two immigration officers.
129. A segregation review board was held later in the day, with the controller, a
manager, an officer, a member of the IMB and a nurse present. The man
was not present on this occasion. The board was told that he had no
medical or mental health issues. Because his behaviour was unpredictable,
they decided that he should remain in the unit and be reviewed again on 17
May.
33
130. The medical records note that a RMN discussed the man with the
psychiatrist because of the concern that the man became inappropriately
sexually aroused when he was restrained. The psychiatrist advised that the
man should be reviewed again by a psychiatrist at the next opportunity.
131. The man’s segregation history sheet on 5 May records that he said that he
had a problem. He asked to go out, saying that there was someone waiting
for him outside the prison. He was described as very strange, and it was
said the officers still needed to use a shield as they could not predict his
next move. He was seen again by the doctor who recorded in his medical
record that he was fit and well.
132. A member of the IMB saw the man on 10 May and recalled that he seemed
agitated.
11 May, psychiatric assessment
133. On 11 May, the man was assessed by a specialist registrar in forensic
psychiatry, in the segregation unit. The interview lasted approximately 15 to
20 minutes, and throughout three officers remained at the door. The
specialist psychiatrist had spoken to segregation staff about the man’s
behaviour. She described him as polite throughout the conversation, and
she did not detect any evidence of hostility or irritability towards her.
134. The man said that he had no previous psychiatric history and had not seen
any professionals about his mental health, but did mention that his brother
had talked to him about paranoia. The specialist psychiatrist referred to his
remarks about feeling that blood had been let out from his body, and he
said that he did not have that sensation. She established that it was not a
delusion or a hallucination. She also referred to his previous references to
spaceships, at which he smiled and said that he did not want to talk about
them. He confirmed that he had been eating and doing as much as he
could do within the segregation unit.
135. The specialist psychiatrist found no evidence of paranoia or psychotic
illness. She also considered that the man did not present as depressed,
and found no evidence of thoughts of suicide or self harm. The specialist
psychiatrist said she told the segregation staff that she found no evidence
that the man was mentally ill.
136. On 12, 13 and 14 May, the doctor saw the man as usual and noted that he
continued to be fit and well. On 15 May at 8:25am, he was in the exercise
yard when an officer reported that he ran towards her in a threatening and
abusive manner. He was restrained by four officers, using control and
restraint methods. He was placed on a disciplinary report for his behaviour.
17 May, segregation review board
137. A segregation review board was held 17 May, with the deputy controller, in
attendance together with a manager, an officer, a member of the IMB, a
34
nurse and the man. It was noted that the man’s behaviour continued to be
unpredictable, and he was advised to speak to staff when he faced difficult
situations. No healthcare issues were reported. The daily doctor’s visits
took place, and the man was reported to be fit and well. He was visited by
two of his brothers on 26 May.
31 May, segregation review board
138. The man was also present at the board on 31 May, together with the
controller, a manager, an officer, and two members of the IMB. The review
panel heard that the man had been behaving properly, but had the ability to
change his mood very quickly. It was decided that he should remain in the
segregation unit. No healthcare issues were reported.
139. An officer recorded in the man’s segregation history sheet that, when the
man’s flask was issued, he asked the officer to let him out as he said that
God had told him that he should not be locked up. A few days later, on 5
June, he refused his breakfast, lunch and evening meal. He was moved to
another cell, but would not talk or respond to staff. The doctor checked that
he was well.
140. At 5:00pm the next day, 6 June, an officer opened the man’s cell door in
order to give him his evening meal. The officer reported that the man
rushed towards his shield, and was restrained by five officers, with two more
officers supervising. The man was stripped of his E list clothing, and given
pyjamas to wear. He was also given his meal. A nurse assessed him ten
minutes later, and no injuries were reported. The man was subsequently
placed on a disciplinary report. The next day he was seen by a doctor who
observed him walking around his cell.
141. Two days later, at 7:35am on 8 June, two officers opened the man’s cell to
issue his E list clothes. They reported that, when the door was opened, the
man lunged towards on of the officers. With the assistance of four officers,
he was physically restrained and his clothing forcibly removed by order of
the duty manager. He was examined by a nurse, who noted that he had not
sustained any injuries. The man was again placed on a disciplinary report.
142. Later that morning, at 11:10am, the duty manager asked the man to move
to the back of his cell. He refused to do so, and the duty manager believed
that he had a concealed weapon. Four officers and the duty manager
physically restrained him using control and restraint techniques, and moved
him to the special cell. They reported that he continued to fight, and had to
be stripped of his clothes under restraint. The duty manager cut the man’s
top from him, and placed him in strip conditions. The use of force on this
occasion was pre-planned, and so was video recorded by officers.
143. The four officers wore protective clothing and were accompanied by the
duty manager who can be heard issuing directions and occasionally
speaking to the man. He resisted the officers’ efforts throughout, and his
strength was evident such that the officers struggled to accomplish their
35
goal. There was no evidence that they considered withdrawing to allow the
man to calm down. Although an officer usually used two hands to support
and protect the man’s head, on one occasion a single hand was used to
push his head on to his chest. He was lifted from one cell to another in an
unsafe manner. As his clothes were cut off, a towel was placed over his
buttocks, but removed more than once. The incident lasted approximately
12 minutes, seven minutes to remove him from the first cell and five minutes
to leave him in the second.
144. A nurse assessed the man in the cell, and recorded that there were no
visible injuries. The doctor interviewed the man later in the day, and found
no overt signs of psychosis. The doctor recorded that the man could be
quite articulate, which made his behaviour even more bizarre and
inexplicable. The doctor decided that he should be kept in an unfurnished
cell, under nursing supervision, and did not make an RMN referral.
145. The same day, an officer reported on a SIR that, whilst walking the man
from the visits area, he was very inquisitive about the use of the officer’s
keys. At 6:00pm that evening, the man was given his meal and drinking
water by a control and restraint team consisting of four officers. As soon as
the officers left the cell, the man pushed his food under the door. He was
seen by a nurse, who witnessed the incident. She noted that no injuries
were observed, but the man remained volatile. He was seen by the doctor
on 10 and 11 June. On 12 June, the doctor recorded that he had become
withdrawn and sullen, and continued to be capable of violence.
146. On 13 June, a Registered General Nurse (RGN) was called to the
segregation unit. The man had taken off his clothes, and was lying on the
floor. He was chanting that he was white, and refusing to acknowledge
officers. The nurse noted that the RMN had been informed, but there is no
record that an RMN responded.
14 June, segregation review board
147. The man was not present at the segregation review board on 14 June,
because of his unpredictable behaviour. The board consisted of two
managers, the controller, a nurse, a member of the IMB) and an officer.
They decided that the man should remain in the segregation unit until 28
June.
148. The man’s solicitor visited again on 15 June. The visit took place in the
segregation unit. During their conversation, the solicitor said that there
were no signs of any difficulties or outbursts, and he described their
discussion as meaningful. The man was visited by his brothers on 19 June.
20 June, adjudication hearing
149. It was noted in the segregation history sheet for 20 June that, for the second
time that day, the man urinated in his clothes. This was repeated during the
adjudication hearing. The hearing was in front of a District Judge, who
36
imposed an additional 42 days imprisonment for the incidents on 4 March,
22 and 24 April, 15 May and 6 and 8 June. The man did not dispute that
heroin had been found in his cell, but wrote the following statement:
“The powder must have been planted in my cell. I never saw any powder
or any heroin. Some officers came in. They searched my cell. They told
me to leave and move from my cell. I found that suspicious. I stayed by
the washing machine when I came back I was told what had been found.
I was beaten up. I have now decided to plead guilty. Too much bother to
argue my case.”
150. The man had a further visit from his brothers on 22 June. Four days later,
on 26 June, he appeared by video link to Crown Court. His solicitor
recorded that he was reasonably cheerful, and there were no signs of any
difficulties. He was described in his history sheet as appearing okay, and
took a shower and exercised.
151. On 27 June, the man again appeared fine, and complied with all staff
instructions. However, he was not eating properly and refused offers of
exercise. The doctor recorded that he was fit and well.
28 June, segregation review board
152. Before the segregation review board took place, a member of the IMB went
into the man’s cell to talk to him. Their conversation lasted for five or six
minutes. She described him as quite agitated, very thin and complaining of
back pain. She was told by an officer that he had seen a doctor that
morning, and would do so again the next day. As the man was so thin, the
IMB member was concerned about his weight and tried to persuade him to
eat. She asked him if he had had any lunch, to which he replied that he had
a sandwich and some chips. She told him that he should eat as he was a
young man with a lot to live for and needed to keep his strength up. She
said that she would return to see him on 30 June. That day, the man ate his
dinner, together with a cheese sandwich, crisps, chocolate biscuit, apple,
doughnut and a dish of chips.
153. The man did not attend the board because his behaviour was erratic. The
board consisted of a different controller, a manager, an officer, a nurse and
a member of the IMB. The board decided that the man should remain in the
segregation unit and be reviewed on 12 July.
154. After the board, the IMB member was informed that the man had
continuously pressed his cell buzzer, asking to see her again. She went
back to see him, escorted by an officer. She described the man as calmer
than he had been an hour earlier. He said that he had come to terms with
what he had done, and knew why he was in prison. An officer replied that
this was a good thing. The IMB member said that it was like speaking to
two different people within an hour. As she left, she told the man that she
would visit again on Friday. She then contacted another member of the IMB
37
to ask her to visit the man the following day. The second conversation also
lasted for five or six minutes.
155. An officer started work in the segregation unit at 8:30pm. He was the only
officer working in the segregation unit that night. He checked that the man
was in his cell at 8:31pm, then continued to check his cell approximately
hourly throughout the night. The officer said that at each check the man
appeared to be asleep in bed. The checks were electronically monitored on
the cell call system at 9:36:41pm, 10:32:11pm, 11:34:15pm, 00:35:19am,
01:24:10am and 02:33:03am.
29 June
156. The officer next checked the man’s cell at 3:30am, and switched on the cell
light from outside the cell to look through the observation panel. He saw the
man standing at the rear of the cell in a slumped manner and apparently
supporting himself against the back wall. The officer believed that the man
had hung himself, and immediately used his radio to call code red to the
control room. (Code red is the prison’s code for a full medical emergency,
and that assistance is required.)
157. A prisoner in the segregation unit that night said that he heard the night
officer crying and shouting ‘what you have done?’.
158. The officer used his night keys and entered the cell. He supported the
man’s body with his left arm, and saw a ligature made from a piece of bed
sheet around his neck. The other end of the ligature had been placed
through a hole in the perspex of the window. It appeared that he had burnt
a hole in his cell window using a cigarette and lighter. He had then
threaded his bed sheet through the hole to make a ligature.
159. The officer ripped the ligature away from the window. At this point, the night
manager and known as Oscar One, arrived and took the man from the
officer. They placed him on the cell floor, and immediately started cardio
pulmonary resuscitation (CPR) together with two members of healthcare
staff.
160. Two qualified paramedics with the Welsh Ambulance Service, were
allocated a call to the prison at 3:35am. They arrived at 3:40am and were
taken straight to the segregation unit. One of the paramedics saw the man
lying on the floor on his back with a blue coloured ligature around his neck,
the same colour as the bed sheet. There was a deep ligature mark around
the man’s neck. They examined him, and found no pulse, blood pressure,
or breathing respirations. They connected an Electro Cardio Machine
(ECG) to the man to confirm if there was any output from his heart, but
there was none. He was in a state of asystole, which means there is no
heart rhythm and the heart was dead. His body was cold, and the first signs
of rigor mortis were setting in. At 3:53am, the paramedic, pronounced that
the man had died.
38
161. The police and the on call prison doctor were called, and the doctor
confirmed the man;s death at 5:20am. The police preserved the cell for
photographs and forensic examination. They initially treated the cell as a
crime scene, taking photographs and removing the perspex window for
further examination. They also removed a handwritten note, which has
been kept by the police.
162. As soon as practicable, the Director of Parc, a manager and a Roman
Catholic chaplain, left the prison, to inform the man’s brothers of his death.
That visit and subsequent contact with his family is documented by the
manager, who acted as the Prison Family Liaison Officer. The prison
offered to pay the funeral costs for the man’s funeral, and subsequently
enabled the brothers to visit the cell where he had died. The man’s brothers
were disappointed to find that the cell had been freshly painted.
163. The Director of Parc, held a staff debrief after the man’s death. Those staff
and prisoners interviewed for my investigation said that they felt supported
by the prison.
39
POST MORTEM AND TOXICOLOGY
164. A pathologist carried out a post mortem examination on the man on 30 June
2006 at hospital. He commented:
“I have access to the man’s Prison Medical Record in which there are
sixteen sheets headed “report of an injury to a prisoner” and five sheets
indicating the use of special accommodation/mechanical restraints. The
record makes clear behavioural difficulties had been identified and there
were entries describing consultation with two Forensic Psychiatrists.
These doctors do not appear to have felt that the man fulfilled criteria for
mental disorder. I can see no record of intent to self harm being
identified. There appears to be regular review of his accommodation - in
a segregated cell.
“At 5:20am on 29 June 2006 there is a note detailing the finding of the
man with a ligature tied around his neck suspended through a hole burnt
through a perspex panel. He is recorded as having rigor mortis and the
body was said to be cold. He was declared dead.
“The post mortem findings do not suggest any recent struggle, assault
or violent restraint. There is no sign of recent self harm. The ligature
mark indicates suspension, in keeping with hanging and whilst the
absence of bleeding into the neck or petechiae in the eyes and face
means that it cannot be confirmed that the ligature must have tightened
around his neck during life, it must be recalled that such ‘pale faced’
hanging without any injuries are the most common findings in self
inflicted hanging. The ligature mark indicates that he must have been
suspended. There is no evidence indicating the necessary involvement
of any other person although it is advisable to carry out toxicological
analyses to ensure that he would have been capable of carrying out this
action and also - were he to be on any medication - to address issues
relating to state of mind.
“With a severed ligature and no photographs of the scene I am not in a
position to state whether or not the deceased would have been able to
effect self suspension. Were, however, evidence to be available that
self-suspension were feasible and no evidence to suggest the
involvement of any other person, then it would be my opinion that his
death was adequately explained by:
“1a Hanging.”
165. The pathologist carried out the post mortem toxicology examination. His
findings were reported to have given no cause for concern. No traces of
alcohol, paracetamol or opiates were found.
40
ISSUES CONSIDERED IN THE INVESTIGATION
The man’s health and wellbeing
166. It would appear from the evidence available that when first admitted to Parc,
the man exhibited no psychiatric symptoms that would have caused
concern. His first refusal of prison meals seems to have been a protest
against his incarceration as he believed himself to be innocent. Although he
was appropriately monitored under the suicide and self harm monitoring
arrangements, he was not moved to a shared cell despite the request from
nursing staff. The company of another prisoner might have assisted the
man to adjust to his environment.
167. The first documented evidence that the man might have psychiatric
problems followed the worries reported by his brothers. These were
eventually followed up by a mental health nurse. It is most unfortunate that
this was not deemed a priority, and that more information was not obtained
from the family.
168. The system for acquiring a specialist medical opinion in Parc is that officers
concerned about a prisoner’s health request a nursing assessment. The
nurse then discusses the case with a doctor or another nurse and obtains a
specialist referral, usually within two days. The treatment recommended by
the specialist would then be discussed with healthcare staff and followed
through. As the man’s behaviour continued to be disturbed, prison staff
followed the procedures correctly, and referred him for a specialist
psychiatric opinion. He was assessed three times, and on each occasion
found to have no mental illness.
169. The first psychiatric medical opinion indicated there was no evidence of
mental health problems. However, two days later,the man started talking
about having lost blood. More delusional beliefs, such as ghosts, demons
and spaceships, were expressed, and a second psychiatric opinion was
arranged. The psychiatrist confirmed her earlier diagnosis that he was not
mentally ill, but was having difficulty dealing with imprisonment. An EEG
test for organic brain disease, such as epilepsy or brain tumour was
recommended. It is unclear why it was not carried out. An EEG technician
could have attended the prison to carry out the test if this was more
appropriate in the circumstances.
170. Subsequently, a mental health nurse informed the psychiatrist of concerns
about the man’s increased levels of aggression and sexual arousal. There
is no evidence that these issues were ever dealt with. This is the last
documented input from a mental health nurse. The only other documented
evidence of RMN involvement was when the code red was called on the
morning that the man died.
171. A second psychiatrist assessed the man a month after the first. The
psychiatrist was aware that he had been talking about ghosts, dark
shadows, losing blood and feeling weak. However, the psychiatrist noted
41
that he did not want to talk about his earlier remarks and did not consider
him to be mentally ill.
172. I must not substitute my lay opinion for that of mental health professionals.
But none of the man’s references to blood loss, spaceships and the like are
consistent with normal behaviour. There is further evidence of behaviour
not entirely consistent with normality, such as that the man was guarded in
conversation, mistrusted people and chose to write rather then converse. A
further cause for concern, as reported by officers, was that he lay on the
floor, chanting that he was white. Although attended to by a general nurse,
who in turn informed a mental health nurse, it appears that no RMN
responded to the request for an assessment.
173. Aspects of his day to day personal care, such as food refusal, incessant
urinary incontinence and retention of cups of saliva, also suggest a young
man in need of care and professional support. Throughout his time in
custody, the man repeatedly broke Prison Rules. These were dealt with as
discipline matters and incurred increasingly severe punishments.
174. While his behaviour and mood continued to be bizarre, no further efforts
seem to have been made to understanding or treating it. He was held in
segregation, in conditions which were spartan. It could be argued that
being kept on a segregation unit for a protracted period of time in prison
with no peer group company did nothing to enhance the man’s mental
health. For example, placement in the healthcare centre would have
permitted constant assessment. Alternatively, a referral to a psychologist
could have been considered. At the very least, resumption of the
counselling sessions would have been a humane response. It is regrettable
that a young man, whose behaviour was so disturbed, should not have
been monitored more closely and frequently by specialist mental health
professionals. Notwithstanding the psychiatric assessment that he was not
mentally ill, the man’s behaviour continued to be erratic. A longer
assessment, for example as an inpatient in healthcare, might have led to a
greater understanding of his needs.
The Director should allow prisoners in all parts of the prison,
including the segregation unit, to have the same access to the
counselling service.
The man’s location at Parc
175. HMP Parc is the only prison in Wales which holds remand and sentenced
young adult males, including those who are vulnerable or who require
segregation. One reason the man remained at the prison was because, as
a remand prisoner, he was required to attend frequent court hearings in
Cardiff. However, Parc’s resources for dealing with his changeable and
disruptive behaviour were soon exhausted. Had he been sentenced, it
would have been easier for him to be transferred to an alternative prison in
England. The probable drawback would have been a longer journey for his
brothers when they came to visit him.
42
The Prison Service should review the provision of places for young
adult males in Wales, and ensure that there are sufficient resources
for vulnerable or disruptive prisoners.
Drugs found in the man’s cell
176. When drugs were found in the man’s cell, he protested his innocence and
claimed that the substances had been planted. Despite his protests, he
pleaded guilty at the adjudication on 20 June and, as a consequence, his
claim was not investigated separately. Moreover, my investigator was
unable to establish an evidential chain from the finding of the substance to
its analysis. He is therefore of the opinion that the finding of guilt was
flawed given the way in which staff learned that there were drugs in the
man’s cell and the unlikely hiding place (under the pillow). The man had no
history of drug use.
The Director should review the procedures for investigating and
collecting evidence when substances believed to be drugs are found.
Bullying
177. The initial explanation for the man’s removal to the segregation unit was
that it was for his own protection, as he was said to have been bullied on a
visit. It was the man, the alleged victim, who was taken off the wing and not
the alleged perpetrator. Whether or not the move was appropriate, the
allegation was not followed up and any bullying went unheeded.
The Director should review the prison’s anti-bullying policy,
particularly in relation to young offenders, and check that all acts of
violence between prisoners are fully investigated to establish any
underlying issues.
I endorse the recommendation made by the HMCIP that staff should
be alert to any bullying of prisoners or visitors on their way to visits
and should intervene and ensure the incident is properly recorded
and investigated.
E list status
178. The man was initially made an escape list prisoner on the basis of his
refusal to return to prison transport. He remained on the list as he talked of
not belonging in prison, and was said to have shown a keen interest in an
officer’s keys. Neither individually nor collectively, do these represent
strong grounds for keeping a disturbed and vulnerable young man on the E
list. Indeed, I doubt that the man’s continued E list status was appropriate.
However, I have found no evidence that his escape status was subject to
review or challenge.
43
The Director should review the procedure for placing a prisoner on the
E list and ensure that regular review’s are conducted.
Location in the segregation unit
179. The man was moved to the segregation unit in March 2006, and remained
there until he died. It is apparent that he presented significant discipline
problems to prison staff throughout most of his time in the unit. There were
many occasions when control and restraint techniques were used, though
they reduced from eight in April to one in May and one in June.
180. In light of the risk he posed to staff, I can understand why he remained in
segregation. However, I also note that a period of more than three months
in austere conditions and isolation must have taken its toll upon the man’s
physical and mental health. He was a vulnerable young man of 20, an
African in a Welsh prison with no previous experience of custody. To keep
a young offender in segregation for this length of time was at best
unimaginative. At worst, it was cruel.
The Director and senior management team at Parc should review the
use of segregation, in particular for prisoners who are young,
vulnerable or both.
Diversity
181. The man’s family has alleged that he was the victim of racism. Indeed,
throughout this report I have been conscious that I am writing about a young
man, originally from war-torn Burundi, held in a prison that (both from a staff
and prisoner perspective) is overwhelmingly white. However, in the course
of extensive interviews with staff and prisoners at Parc, my investigators
have detected no evidence of overt racist attitudes (though they are unlikely
to be displayed to an investigator.) The prisoners we spoke to appeared to
be sensitive and mainly tolerant to the man’s individuality, even when his
actions, such repeatedly kicking his cell door, singled him out from others.
Numbers of staff demonstrated positive attitudes, and referred to the
benefits of their diversity training, although this is not a complete indication
of whether or not discrimination exists.
182. I am also aware that the number of complaints of racism at Parc is low.
However, my investigators have noted that, since the investigation began, a
Diversity Manager has been appointed and the numbers of complaints have
increased. The prison considers this is due to increased awareness of the
importance of recording.
183. Nevertheless, there are aspects of the man’s treatment which did not
conform to best diversity practice. His family raised concerns about overt
racism against anyone who is not Welsh, and felt that he was a victim. My
investigators found evidence that the implications of his minority ethnic
background were not considered, and investigations of allegations of racism
were not carried out.
44
.
184. In February, the man wrote in a statement for an adjudication that another
prisoner had used racist language. In April, he accused staff of behaving in
a racist manner when he was restrained. There is no evidence that either
allegation was reported as a racist incident, investigated or followed up.
185. HMCIP found that the majority of the prison’s reports of bullying were on B
wing. The man was involved in three incidents of violence with white
prisoners on the same wing. Although the incidents were properly recorded
and dealt with as breaches of Prison Rules, there is no evidence that the
prison considered any possible underlying issues such as bullying or
racism.
The Director should remind staff that, when an allegation of racism is
made, it should be recorded and investigated.
The Director should review the Diversity Action Plan in the light of
this report, and extend its scope to reflect my findings. In particular,
the objectives of diversity and suicide awareness training should be
harmonised, rather then seen in isolation.
Use of force
186. The man’s family alleged that he was beaten up by prison staff three or four
months prior to his death. My investigation found no evidence that he had
been beaten by staff, although it has been documented that he was subject
to repeated use of force using control and restraint techniques. On all those
occasions, the required documentation was completed. Video footage was
taken on one pre-planned occasion when officers used force and a prison
manager supervised events. The film makes disturbing viewing. Officers
struggled to remove his clothes, and he continued to resist their efforts
throughout. The episode lasted approximately 12 minutes, and there were
a number of failures evident.
187. All the staff interviewed for the investigation confirmed that their training in
control and restraint was up to date. Staff who were not involved in use of
force confirmed that they were aware of approved methods being used in
the prison.
188. When the man was on B wing, he was involved in at least two fights with
other prisoners which were diffused peacefully by staff without the need for
control and restraint techniques. However, it is not self-evident that the
same efforts were made by segregation unit staff. Control and restraint was
used on 17 occasions, and on one occasion his clothes were cut off him.
There is no evidence that any attempt was made to calm and defuse the
situation by giving him time to consider his position, or by talking to him,
other than to issue instructions.
The Director should remind segregation staff of the absolute
requirement to use the minimum force necessary, and to seek
45
alternative ways of resolving difficult situations, including encouraging
a dialogue with prisoners.
Segregation unit
189. The segregation unit at Parc holds both adult and young offenders.
Moreover, Parc has no facilities for vulnerable young adults needing
protection, other than in the segregation unit. I have referred already to the
recommendations of HMCIP and to the views of the IMB. I am concerned
that the segregation unit is used for both adult and young adult offenders,
with the same staff, but on separate regimes. At the time of my
investigation, a young adult had been in the segregation unit for no less
than 12 months, with little prospect of suitable accommodation being found
in the immediate future.
190. There was little evidence that the personal officer scheme was working, and
officers took collective responsibility for all prisoners in the segregation unit.
An effective personal officer scheme should enhance relationships with
prisoners, and lead to a greater understanding of their individual needs.
191. Throughout his stay in the segregation unit, the man was subject to close
monitoring by staff either because his behaviour was disruptive, or because
he was an E list prisoner. There is an electronic record of the checks and,
although his family believe that more than two hours passed between the
last check and the discovery of his body, the records seem to confirm that
this was not the case. Nevertheless, it is surprising that there were signs of
rigor mortis when the man was examined by the paramedics.
192. A manager, the chaplain, and a member of the Independent Monitoring
Board must visit each prisoner in the segregation unit every day as a
safeguard. Each of them has very different roles, and prisoners may have
individual needs which they would not wish to share with others. The daily
record of the man’s conduct in the unit is inadequate, and much of the
information in the report has been obtained from the use of force forms, his
medical records, and from interviewing staff. The daily record does not
detail any efforts staff made to engage with him.
193. Each prisoner held in segregation has to be reviewed at defined periods by
a segregation review board, and the man’s took place as required. The
chair of the IMB reported that his members attended 70 boards from 1
January to 1 October 2006, and had no concerns about the care and
treatment of prisoners. The number of staff attending boards, their
continuity of attendance and their efforts to include the man are
commendable. However, it is disappointing that the boards appear to be a
passive process, rather then one which encouraged prisoners to move on,
and return to the wing or a different establishment.
The Director should review all aspects of the operation of the
segregation unit, including the effectiveness of the segregation
review boards.
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194. Unlike segregation units in many other local prisons, there is no CCTV
coverage of the communal areas. Although CCTV coverage might not have
prevented the man’s death, it would have provided corroboration of the
accounts given by staff. Furthermore, CCTV coverage would protect staff
against malicious allegations made against them.
The Director should consider the installation of CCTV within the
communal areas of the segregation unit.
195. The man was not deemed to be at risk of harming himself, and had not
been placed in a safer cell. His cell had a number of potential ligature
points, including perspex windows. He burnt through his window, using his
lighter and a plastic utensil, and was able to thread his bed sheet through
the hole to make an anchor point for the ligature.
The Director should review the use of perspex for windows at Parc.
196. During the time that the man melted through the window, the fire alarm in
the segregation unit was not activated.
The Director should review the effectiveness of the fire alarms in the
segregation unit.
Suicide and self harm awareness
197. The National Offender Management Service’s Safer Custody Group has
advised me that national training in suicide and self harm awareness does
not include specific guidance for staff in segregation units. However, since
my office became responsible for the investigation of deaths in custody, I
have been very troubled by the number of deaths occurring in segregation.
The Director should take advice from the National Offender
Management Service Safer Custody Group and ensure that suicide and
self harm training includes awareness of issues arising from:
• the individual circumstances of a prisoner, including their
ethnicity
• their location, especially the segregation unit.
The role of clinical staff within the segregation unit
198. Prison Service Order 1700 applies throughout all prisons in England and
Wales, including those in the private sector. It places specific
responsibilities on medical and nursing staff for all prisoners in a
segregation unit, and additional responsibilities for those located in the
special cell. The man’s records show that these duties were carried out.
However, it appears they were performed as administrative tasks and in my
view, they did not fulfil the intended function of promoting a prisoner’s
health, safety and well being. On too many occasions the man was merely
recorded as fit and well. I would have expected, healthcare professionals to
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have looked critically at the treatment he received, both in respect of his
location and the use of force.
199. When prisoners are subject of use of force they must quickly be assessed
by a nurse. Although I have no doubt that this occurs, it appears that the
nurse usually stands outside the cell, speaking to the prisoner through the
observation flap. Whilst staff must be safe, every effort should be made to
enable the nurse and prisoner to have face to face contact.
Primecare should review their monitoring of prisoners in the
segregation unit, especially at review boards, and when force has
been used.
Policy for dealing with an apparent death
200. Parc’s policy for responding to a prisoner who appears to have died is
derived from national Prison Service guidance. Staff are required to
summon help and request emergency medical assistance as soon as
possible. If a ligature has been used, staff should support the prisoner, cut
the ligature and place the prisoner on a flat solid surface. They should
check for signs of life, and if the prisoner not breathing, resuscitation should
be attempted unless the prisoner is clearly dead. The officer finding the
man correctly followed all the required procedures.
The man’s contact with his family and solicitor
201. Whilst in custody, the man received regular and frequent visits from his
family, a friend and his solicitor. His family mentioned concerns over their
brother’s mental health to prison staff, although the full extent of their
worries does not appear to have been documented. Family members were
not consulted for full details of his mental health, or asked to assist with any
aspect of his care whilst he was in custody. This would have been an
opportunity for the prison to work with the people the man cared for, in an
attempt to better meet his needs.
202. On one occasion, the man’s solicitor was told that, due to an incident
overnight, the prison considered that the risk to the solicitor was so great
that the visit should not take place. The solicitor attended the prison and
was refused admission, as it was reported that the man was acting so
aggressively that a visit would be impracticable. My investigator believes
this was a further missed opportunity for the prison to work openly and
transparently with the man’s solicitor, and to engage with him in his care
plan.
The Director should consider liaising with a prisoner’s family,
solicitors and others in formulating a care plan.
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Painting the cell
203. The man’s brothers visited the segregation unit and the cell where their
brother died. Believing they were acting in the best interest of his brothers
the prison had had the cell painted. My investigator does not believe there
was a sinister motive, the cell having been forensically examined and
photographed by the police prior to them handing it back to the prison.
The Director should remind Family Liaison Officers to consider the
family’s needs before painting a cell where a prisoner has died.
Other family concerns
204. The man’s family complained that they had spoken to a healthcare
manager, whom they said was named X, and described her attitude as
rude. My investigator has interviewed the healthcare manager, who is not
called X, and she denies any contact with the man’s brothers. There are no
members of healthcare staff with this name, and it is possible that the man’s
family misheard the name of the person they spoke to. I have asked the
prison to look into this further.
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CONCLUSIONS
205. The man was a young man, born in Burundi, whose brothers believed he
had a promising future ahead of him. He was remanded to prison awaiting
trial for a serious criminal allegation. It was his first time in prison, and he
had no previous convictions. All bail applications were refused. The prison
had a duty to keep him safe, but were sadly unable to do.
206. At first, he was held on the young adults wing where he went on hunger
strike to protest his innocence. As a result, he was placed on a self harm
watch, and removed from it only after he began eating. This brought him to
the attention of wing staff, the chaplaincy, the safer custody officer, and the
IMB, who all had contact with him. He was involved in fights with other
prisoners, which resulted in him losing privileges and being subject of
adjudications and cellular confinement.
207. On 23 March 2006, the man was taken to the segregation unit for his own
protection, after allegedly being bullied whilst on a visit. Whilst in the unit,
he was involved in a number of incidents which resulted in repeated use of
force by staff, many adjudications, and further periods that amounted to
solitary confinement. My viewing of the CCTV coverage of the one episode
of pre-planned use of C&R reinforces my concern about the manner of the
man’s treatment. He was without doubt a strong young man who presented
numerous difficulties for staff. Nevertheless, he was entitled to be treated
proportionately, safely and with dignity.
208. There is little evidence that the man associated with anyone of his own age,
although on one occasion when he was behaving bizarrely in court another
young prisoner sat with him and had a beneficial, calming effect. My
concerns about the use of the segregation units, especially for those who
are themselves vulnerable, have been made in a number of reports. I am
particularly concerned that a young man, isolated in any event on account
of his background and ethnicity, should have spent so long in segregation. I
note that Parc does not have a dedicated vulnerable young adults wing, and
Wales does not have an alternative prison for young adults.
209. The man was psychiatrically assessed on three occasions, and found not to
be suffering from mental illness. No further thought was given to an
explanation for his disruptive and disturbed behaviour. His detention was
regularly reviewed at review boards which decided that his continued
detention in the segregation unit was the only option.
210. Opportunities to engage his family and solicitor in his care plan were
missed. They have raised important concerns about racism and about his
care at Parc. I am pleased to note that, in the course of many hours in the
prison and free access throughout, my investigators have not witnessed any
racist attitudes or behaviour from either staff or prisoners. However, others
such as HMCIP and the CRE, with greater expertise and resources then my
own, have made criticisms which have been accepted and action plans put
in place.
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211. Sadly, as far as the man was concerned, those plans were inadequate and
did not ensure that he was treated in a sensitive way. A diversity
perspective should have been brought to bear on all aspects of his
imprisonment, especially when it was apparent to some that his mental
health was deteriorating when he was in the segregation unit. Coming from
a war-torn country, and being a black African in a overwhelmingly white
Welsh prison, are not excuses for violent behaviour. Prison staff have a
right to go about their jobs without the prospect of violence. However, it is
disappointing that the man’s treatment was so one-dimensional and
unimaginative. In retrospect, it is also now clear how much distress he must
have been feeling.
212. The man died a lonely death, having been in segregation for over three
months. He had no peer group company and was effectively in solitary
confinement. No issue has caused me more concern since I became
responsible for the investigation of all deaths in prisons than those deaths
occurring in segregation units. Like all too many prisoners who end up in
segregation, the man presented as a discipline problem but was
increasingly vulnerable himself.
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RECOMMENDATIONS
National
1. The National Offender Management Service should review the provision of
places for young adult males in Wales, and ensure that there are sufficient
resources for vulnerable or disruptive prisoners.
Local
2. The Director should allow prisoners in all parts of the prison, including the
segregation unit, to have the same access to the counselling service.
3. The Director should review the procedures for investigating and collecting
evidence when substances believed to be drugs are found.
4. The Director should review the prison’s anti-bullying policy, particularly in
relation to young offenders, and check that all acts of violence between
prisoners are fully investigated to establish any underlying issues.
5. I endorse the recommendation made by the HMCIP that staff should be
alert to any bullying of prisoners or visitors on their way to visits and should
intervene and ensure the incident is properly recorded and investigated.
6. The Director should review the procedure for placing a prisoner on the E list
and ensure that regular reviews are conducted.
7. The Director and senior management team at Parc should review the use of
segregation, in particular for prisoners who are young, vulnerable or both.
8. The Director should remind staff that, when an allegation of racism is made,
it should be recorded and investigated.
9. The Director should review the Diversity Action Plan in light of this report,
and extend its scope to reflect my findings. In particular, the objectives of
diversity and suicide awareness training should be harmonised, rather then
seen in isolation.
10. The Director should remind segregation staff of the absolute requirement to
use the minimum force necessary and to look at alternative solutions in
resolving difficult situations. Including encouraging a dialogue with
prisoners.
11. The Director should review all aspects of the operation of the segregation
unit, including the effectiveness of the segregation review boards.
12. The Director should consider the use of CCTV within the communal areas
of the segregation unit.
13. The Director should review the use of perspex for windows at Parc.
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14. The Director should review the effectiveness of the fire alarms in the
segregation unit.
15. The Director should take advice from the National Offender Management
Service Safer Custody Group and ensure that suicide and self harm training
includes awareness of issues arising from:
• the individual circumstances of a prisoner, including their ethnicity
• their location, especially the segregation unit.
16. Primecare should review their monitoring of prisoners in the segregation
unit, especially at review boards, and when force has been used.
17. The Director should consider liaising with a prisoner’s family, solicitors and
others when formulating a care plan.
18. The Director should remind Family Liaison Officers to consider the family’s
needs before painting a cell where a prisoner has died.
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