Individual at Portland

Investigation into the circumstances surrounding the death
of a man in November 2009
at HMYOI Portland
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2011
This is the report of an investigation into the death in November 2009 of a man, a
prisoner at HMYOI Portland. At about 6.30am that morning, he was found hanging
in his cell. Paramedics arrived quickly but he was pronounced dead. It was just six
weeks after his 18th birthday. He had been in custody since 15 October 2009, but
had only been at Portland for four days.
I extend to his family and friends my sincere sympathy and condolences for their
tragic and untimely loss.
The investigation was conducted by my colleague. It has been a complex and
protracted investigation as many issues have been examined. For this reason, he
was assisted at various times throughout the investigation by other colleagues. As
important as it has been to ensure that the report is accurate and thorough, I
recognise that the delay issuing may have added to the anxieties felt by the family. I
offer them my apologies for this.
As part of the investigation, I commissioned a clinical review of the management of
his health needs while he was in custody. This was conducted by a clinical reviewer
on behalf of the local Primary Care Trust. I am most grateful to him for his
contribution to the investigation.
I would also like to thank the Governors at Portland and HMYOI Feltham, and their
staff, for their co-operation and assistance. I owe special thanks to the liaison
officers. I also extend my thanks to the staff at the Youth Offending Service, some of
whom had known him for a number of years and had built up a good relationship
with him.
He was a troubled 18 year old who, just over a week before he was found hanging,
had been sentenced to five years imprisonment. When sentenced, there was no
indication that he might harm himself and he had not harmed himself when he had
been in custody before. His transfer to Portland, a prison some distance from his
family was, I judge, a significant factor.
My report includes two recommendations which primarily relate to Feltham. The first
relates to ensuring that follow-up action is taken when risks are identified on cell
sharing risk assessments. The second refers to the importance of completing
allocation and transfer documentation for young prisoners, ensuring that any
concerns relating to their transfer are documented. I also make further reference to
HM Chief Inspector of Prisons report which made a number of recommendations
relating to the general state of the accommodation in Portland. I hope that my
recommendations will prevent a similar tragedy occurring.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Thea Walton
Acting Prisons and Probation Ombudsman August 2011
2
CONTENTS
Summary
The investigation process
Background
HMYOI Portland
HMYOI Feltham
Key findings
Issues
Conclusions
3
SUMMARY
The man was just 18 years old when he was found hanging in his single cell at
HMYOI Portland in November 2009. At the time of his death, no concerns had been
raised about his risk of self-harm or suicide.
He was serving a five year sentence and had been in custody since 15 October
2009. He was initially remanded to HMYOI Feltham, and from there went to HMYOI
Reading. He was transferred back to Feltham and finally to Portland on 18
November, four days before his death.
Prior to 15 October, he had spent other periods in custody at Feltham. While his
behaviour was good at times, he was also involved in fights and altercations with
other prisoners. He also struggled with education, although his family and staff at
the Young Offender Service made good efforts to support him.
His life changed significantly in a short period of time. Having been convicted of the
offence, he went to court on 13 November. He was given a five year prison
sentence, which was less than he and his solicitor expected. This was followed by a
transfer to a prison some distance from his home and family. My investigation has
found no reason to believe that prison staff, or anyone else, suspected that he would
harm himself.
At around 8.30pm on Saturday 21 November, he was checked and all seemed well.
At the next check, the following morning at just after 6.30am, he was found hanging.
Staff went into the cell and cut the ligature. No attempt was made to resuscitate him
as rigor mortis was present. Ambulance paramedics arrived soon after and he was
pronounced dead.
A note was found in his cell after he died. He sent his love to his girlfriend and
indicated that he could not serve his prison sentence.
The clinical reviewer has found that his clinical care and treatment was comparable
to that which he could have expected in the community. My report includes two
recommendations which primarily relate to Feltham. The first is aimed at ensuring
follow-up action is taken when risks are identified when a cell sharing risk
assessment is completed. The second refers to the importance of fully completing
allocation and transfer documentation for young prisoners, ensuring that any
concerns relating to their transfer are documented.
4
THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened by one of the Ombudsman’s
investigators on 25 November 2009, when he met the Governor of Portland and
some of his staff. Notices of the investigation and terms of reference had
already been sent to invite anyone with any information to contact the
investigator. Notices were also sent to HMYOIs Feltham and Reading as he
had spent previous periods in custody there.
2. The investigator also met the Head of Healthcare, representatives of the Prison
Officers’ Association and a representative of the Independent Monitoring Board.
He visited all parts of the prison including the wing where the man lived, and
met the prison’s liaison officers.
3. The man’s prison records, including his medical record, were made available to
the investigator during his initial visit to the prison. Additional documents were
made available when he returned to conduct interviews. Telephone transcript
data was also provided.
4. As he had only been at Portland for four days, the investigator also reviewed his
prison records from HMYOI Feltham, where he transferred from. This was
followed by a number of interviews with staff there. Because of the
complexities of investigating the death of a young person in custody, the
investigator was assisted at various times in the investigation by other
colleagues from this office.
5. The investigation team also met with Youth Offender Service (YOS) and would
like to thank the Head of Service and his staff for their assistance. The YOS
shared their records and knowledge of him throughout the investigation and I
do not underestimate the valued work they did with him in the two years they
had contact with him.
6. A clinical review was commissioned from the local Primary Care Trust to
examine his medical care. I am grateful to the clinical reviewer for his review.
He reviewed his records from his community doctor and the prison healthcare,
and also transcripts of interviews undertaken by the investigator.
7. One of the Ombudsman’s Family Liaison Officers contacted the man’s mother
to inform her of the investigation and give her the opportunity to raise any
questions or concerns about the care her son received. The investigator and
Family Liaison Officer met her and her solicitor during the course of the
investigation. The family raised a number of concerns which I have listed
below. I hope that my report provides them with a better understanding of the
events leading to his death.
At HMYOI Reading
• Was he subject to 30 minute checks while he was at Reading?
5
• Did he share a cell at Reading with someone who was known to be from a
rival gang?
• Was he subject to aggressive cell searches at Reading and Feltham?
• Is there any evidence that he was targeted or bullied by rival gang
members during his time in custody?
• Is there any evidence that he may have been bullied during his transfer to
Portland?
At HMYOI Portland
• Why was Portland chosen above other YOIs closer to his home and
family?
• Did he receive a mental health assessment following sentencing, given
this was a change in his circumstances?
• Why did his Cell Sharing Risk Assessment appear to fluctuate between
low and medium risk?
• The family was concerned by the state of repair of his cell. The toilet was
black with limescale, the furniture broken and the bedding dirty. They
questioned the effect this could have on someone’s state of mind, given
their likely anxiety having arrived at a new prison.
• The family were told that he was checked when the power was switched
off at 2.30am on the morning that he died and he was fine. This is,
however, contrary to the records which state that no checks were made
during the night.
8. The man’s mother and her legal representative received a copy of my draft
report as part of the consultation process. Written representations were
provided on behalf of his mother in response to the findings of the investigation.
A number of issues were raised including the prison’s failure to identify him as a
high risk prisoner, the alleged bullying of him, the handling of his transfer to
Portland, the timing of the induction programme at Portland and the subsequent
time he spent confined to his cell and the adequacy of the response when he
was found. I am grateful to the family for the time they have taken to consider
the report and for the feedback they have felt able to share. The investigator
has considered the issues raised and has, where appropriate, amended the
report to reflect their comments. It was felt, however, that some of the issues
raised would be more appropriately addressed outside of this report. The
investigator has sought to address these in separate correspondence to the
man’s mother and legal representative.
6
BACKGROUND
HMYOI Portland
9. Portland opened in 1848 and held convicted adults until 1921, when it was
converted into a borstal (a type of youth prison intended to reform seriously
delinquent young people). It has been a Young Offender Institution since 1988,
and today holds young men aged between 18 and 21. Portland has an
operational capacity of 624.
10. The prison’s accommodation is in nine house blocks. Benbow, Raleigh, Drake,
Nelson, Grenville, Rodney, Hardy, Collingwood, and Beaufort. Rodney and
Hardy have electronic night sanitation (the cell door unlocks for a limited time to
allow the prisoner to go to the toilet), while the others have in-cell sanitation.
Hardy was closed in 2009 and Rodney was closed in early 2010 for
refurbishment. Grenville House is an Induction Unit, Beaufort is a Skills
Development Unit, and Raleigh is the Resettlement Wing and Collingwood a
'Super enhanced' wing. There is also a Care and Control Unit.
11. Healthcare services are provided from 7.45am to 8.00pm on weekdays and
from 8.00am to 5.30pm at weekends and so no healthcare staff were present.
HM Chief Inspector of Prison’s report
12. The most recent report on Portland by HM Chief Inspector of Prisons followed a
full announced inspection in July 2009, issued approximately two months
before the man died. The Chief Inspector noted:
“…It is in a remote location far away from most of its young offenders’
homes, mostly with old and forbidding buildings, some not fit for use. Until
fairly recently, staff attitudes and approach were equally negative and
outdated. This inspection, however, found a prison which had changed
both its outlook and its outcomes: with a focus on trying to provide a
positive and rehabilitative experience for the young men placed there, in
spite of the physical difficulties of the site.
“We have inspected other prisons recently, in unpromising locations in
rural areas far from prisoners’ homes, where we have found managers
and staff sunk into a condition of learned helplessness: expecting and
providing little. This was far from the case at Portland. Managers
recognised the problems of location and environment, but were
nevertheless determined to create a space in which young men could
have new and different opportunities. This had required a great deal of
effort, both with external partners and, equally importantly, from the whole
staff group.”
“Cells on the [induction unit] were appropriately equipped with basic
toiletries, writing materials and information leaflets, but not all had been
cleaned satisfactorily and some had graffiti.
7
“Many cells had noticeable amounts of graffiti, some obscene, on doors,
walls and furniture. Many walls were covered in toothpaste residue used
to display posters and pictures. We also saw some broken furniture in
cells. Some toilets and toilet screens were badly stained.”
13. Under the heading of “Safety”, the HMCIP report included the following in its
observations:
“Reception, first night and induction procedures were generally good
though prisoners were unoccupied for lengthy periods during induction.
Arrangements to prevent violence and self-harm were reasonable, but the
number of violent incidents and the use of force were significant.
“However, there was little evidence that most prisoners felt unsafe or
intimidated, and the prison's response to the threat of gang activity was
proportionate.
“An assessment of risk was incorporated into the induction passport
document completed for all new arrivals, and staff were alert and
responsive to potential risk factors. There were no designated first night
cells on the first night and induction unit, but staff were familiar with the
arrangements to identify new arrivals. Cells were prepared appropriately,
although not all were clean.
“Prisoners were reasonably positive about the content of the two-week
induction programme, although they complained about the time they spent
in cell between sessions. This was compounded by the wait to start the
programme, which was not run on a rolling basis.”
Independent Monitoring Board (IMB) report
14. IMB members are lay people appointed to each prison by the Secretary of State
for Justice to monitor the treatment of prisoners. They are not members of the
Prison Service, nor are they part of the prison’s management team. They are
required to report annually to the Secretary of State, highlighting good practice
and any areas of concern. The IMB annual report for HMP Portland for the
period 2009/2010, stated:
“Our role is to monitor the just and humane treatment of prisoners and the
range and adequacy of the programmes preparing them for release. The
Board reports on how well the prison meets the standards and
requirements placed on it and what impact these have on those in its
custody. Portland has performed extremely well against these criteria and
the rate of beneficial change appears to be increasing.”
Induction
15. At Portland, after their reception checks are completed, all new prisoners are
located to Grenville, the induction wing. All cells are single occupancy.
Prisoners are asked whether they have any immediate concerns, such as
disability, and about their general well being. The induction includes a further
8
assessment, medical screening, and input from the education and offender
management units. Prisoners are given a new reception pack, and telephone
pin numbers and visiting arrangements are explained. Prisoners remain on the
induction wing for around two weeks before being moved onto a residential
wing.
16. The induction programme starts on a Monday and lasts for four days. Prisoners
are interviewed and attend workshops delivered by various representatives
from the different agencies that work within the prison, such as Samaritans,
Safer Custody and the education department.
Critical Debrief
17. A critical debrief takes place after a serious incident. It gives the staff the
opportunity to understand the incident in greater detail, review their feelings and
normalise the reactions that some people experience after a traumatic incident.
Benefits include being able to discuss their experiences in a safe and
confidential environment and using the briefing as a learning event to try and
prevent repeat incidents.
Cut down tools
18. Cut down tools, also known as ligature or fish knives (because of their shape),
are designed for safely cutting ligatures and are carried by all officers and
healthcare staff in contact with prisoners.
Incentive and Earned Privilege Scheme (IEP)
19. There are three levels of prison regime under the Incentives and Earned
Privileges (IEP) scheme, that is basic, standard and enhanced. The higher the
regime, the more privileges a prisoner is allowed. Basic regime can be
imposed for a number of reasons including bad behaviour and failure to comply
with sentence planning.
Listeners and Greeters
20. Listeners are prisoners trained by the Samaritans to provide a confidential
service for other prisoners. They do not offer counselling but offer support,
particularly for prisoners at risk of self harm.
21. Greeters in Portland are prisoners who volunteer to work in the Induction wing,
welcoming new prisoners and explaining the processes they will encounter in
the early days of custody.
Reception
22. A Cell Sharing Risk Assessment (CSRA) is opened by reception officer who
complete the basic details. The form is handed to the First Night Centre staff
where a confidential interview is conducted. The document is then passed to
healthcare staff. The CSRA is intended to provide consistent and continuing
9
risk assessment regarding sharing cells. While primarily concerning cell
sharing, it also includes other occasions when space may be shared, for
example to accommodate a Listener.
23. Reception staff do not routinely have access to a prisoner’s past records and so
the prisoner is the main source of information. If a prisoner has transferred in,
his past record would arrive with him. All prisoners will also have a Person
Escort Record (PER, a document used when escorting a prisoner between
prisons, court and police stations) which includes risk pertinent information such
as risk to others and self.
24. The initial healthcare screen concentrates on the prisoner’s immediate well-
being, their mental health, risk of self harm or suicide and any drug or alcohol
withdrawal or detoxification issues.
Roll check
25. The roll check is the physical count of the number of prisoners on each wing
with a prison. Roll checks occur on a number of specified occasions during the
day and night, and staff must sign that the roll is correct.
26. At the weekends prisoners are unlocked for breakfast at approximately 8.40am,
lunch at about 11.30am and dinner at 4.30pm. Their cells are also normally
unlocked for two periods of association. The first commencing at 10.30am for
about an hour, and the afternoon/evening association commencing around
2.00pm for two hours. Between unlock at 8.40am and around 4.45pm,
prisoners can attend church, the gym, visits and healthcare. The evening roll
check is carried out at about 5.20pm when prisoners are locked in their cells for
the night.
Sealed key pouch
27. Operational Support Grades are generally on duty at night. OSGs do not have
keys to cells but carry a sealed pouch which contains a cell key which should
only be used in emergencies. During the night state, the whole house block is
also locked and the OSGs are locked within it. The house block doors can only
be opened by the night orderly officer, who is in charge of the prison, and who
will visit (and contact via radio) each house block throughout the night to check
that everything is satisfactory. OSGs can communicate with others outside of
their house block by radio or using the telephone in the office.
Suicide and self harm monitoring
28. The Assessment, Care in Custody and Teamwork (ACCT) procedures aim to
help and monitor prisoners at risk of harming themselves. The key aims of
ACCT are to create a safe and caring environment, identify prisoners’ individual
needs, and provide individualised care and support before, during and after a
period of crisis.
10
HMYOI Feltham
29. The original Feltham was built in 1854 as an Industrial School and was taken
over in 1910 by the Prison Commissioners as their second borstal institution.
The existing building opened as a Remand Centre in March 1988. The current
HM Prison and Young Offender Institution Feltham was formed by the
amalgamation of Ashford Remand Centre and Feltham Borstal in 1990/91. As
at 2nd February 2009, Feltham’s operational capacity was 762 prisoners.
30. Feltham holds young people from the age of 15 to 18. It also holds young
adults from the age of 18 to 21 placed in custody by the courts.
31. The grounds cover a large area, which is divided into two distinct and separate
residential sites. Young people under the age of 18 are accommodated in
Feltham A and young adult prisoners between 18 and 21 years old in Feltham
B. There are currently eight units for young people; one of which is Bittern, the
first night and induction unit. Each unit holds 30 young people.
32. Almost all the rooms are for single occupation. All rooms have integral
sanitation and TV. All areas operate the IEP scheme (Incentives and Earned
Privileges Scheme). There is an anti-bullying policy in place.
33. Feltham A and B run individual regimes. There are some services that are
shared by Feltham A and B, principally the Healthcare Centre, the Chapel and
the gym, and accessed from a shared corridor.
34. There are personal identification number (PIN) phones on each unit and every
young adult and young person is given his own PIN with an automatic £2 credit
when they arrive at Feltham. A similar PIN telephone system operates across
the prison estate.
Youth Offending Service (YOS)
35. The Youth Offending Service (YOS) aims to prevent young people from
offending, and to reduce re-offending by young people already known to the
police and the courts. The team is made up of staff employed by the council to
provide youth justice services, and specialists from partner agencies such as
the police, education, youth and Connexions services, health and probation
services and voluntary organisations.
Asset
36. Asset is a structured assessment tool to be used by youth offending teams in
England and Wales with all young offenders who come into contact with the
criminal justice system. It aims to look at the young person’s offences and
identify factors or circumstances, ranging from lack of educational attainment to
mental health problems, which may have contributed to such behaviour. The
information gathered from Asset is used to inform court reports so that
appropriate intervention programmes can be drawn up. It also highlights any
particular needs or difficulties the young person has, so that these can be
11
addressed. Asset will also help to measure changes in needs and risk of re-
offending over time.
Supervision Orders
37. A Supervision Order is a court order made to help a young person to avoid any
further offending. It can last up to three years. This order is supervised by a
member of the Youth Offending Service who is there to advise, assist and
encourage the young person, and will help to prevent them re-offending.
12
KEY EVENTS
38. On 6 July 2007, then aged 15, the man returned to London having lived in a
specialist care home in Birmingham for two and a half years. He and his
brother originally came to the attention of Social Services because they were
unable to be cared for by their parents. His placement in the care home was
largely due to his learning needs and social conduct disorder. (Conduct
disorder is a group of behavioural and emotional problems in children and
adolescents who have difficulty following rules and behaving in a socially
acceptable way.) He was considered by the courts to be a persistent young
offender because of the number of offences he had committed since 2002,
when he was ten.
39. He was released into the care of his mother, although technically he was under
a full care order from Social Services until he was 18. During the first three
months after he returned to London, he appeared to settle well with no reported
incidents. However, he began to spend more time with some of his old criminal
peers. By October 2007 his offending had resumed and he was arrested for
the offence of assault.
40. In January 2009, he was given a 12 month supervision order by the courts for a
previous offence. He was placed under the supervision of the Youth Offending
Service (YOS) for a year. He was required to attend their office regularly for
support and to address his offending behaviour. He had been subject to a
number of other supervision court orders over the years. On the whole, he
complied with their requirements although his attendance was sometimes
erratic.
41. A YOS Officer was assigned to him in January 2008 and she had regular
contact with him. She was interviewed by the investigation team. She said that
he was a very likeable young man but he was confused. He did not know how
to articulate his emotions or feelings and it took him quite a long time to build up
any form of trust with her. He was isolated, had no friends and no social
network where he lived.
42. Due to his haphazard early life, he had little education and severe learning
needs. Being under a full care order, he was expected to engage with the Sure
Start Foundation project. This involved regular meetings with their social
worker who had been assigned to act as a mentor to him. The mentor was
asked to help him adjust to being back in London, at home and with his family.
43. At interview with the investigator, the mentor said that he initially met him about
three times a week. They did creative work such as gardening and he also
helped to ensure that he went to his YOS appointments by taking him in his car.
This seems to have helped him, who the mentor described as someone who
did not engage well with adults. He said that working with he was “challenging
but enjoyable because he was a lovely lad”. The mentor’s work was assisted
by the man’s mother who wanted to ensure that her son complied with his
supervision order.
13
44. During the early contact between the YOS Officer, the mentor and the man,
when he was still of school age, he refused to go to school. He could not read
or write and wanted to take up full time employment. The YOS Officer tried to
encourage him to become involved in a number of YOS projects and managed
to agree a reduced educational timetable for him. This focused on core
subjects such as Maths, English and Information Technology. She said that,
although difficult, both she and his mentor formed a good relationship with him.
45. She told the investigation team that he often displayed a level of immaturity
which resulted in impulsive behaviour which the YOS tried to address with him.
A lot of his behaviour was alcohol induced which made him more violent and
aggressive. Despite this, she said that he never gave her any indication of ever
wanting to harm himself.
46. The mentor said that after he returned to live with his mother and settled in his
new surroundings, he began to try to re-establish himself amongst some of his
old peers. He liked to be “top dog” which attracted the pressures of managing
his peer group. He told my investigator that he soon learnt that, although he
was a 16 or 17 year old teenager, he often behaved like a 14 year old.
47. The YOS Officer’s contacts with him were documented in the YOS contact
electronic log. She and other members of the YOS met and communicated
with him. His parents were included as far as possible to help support him,
especially to ensure that he did not commit any more offences. She arranged a
number of activities and workshops to deal with conflict resolution skills,
behaviour and educational and social needs. As he had declared that he spent
about £20 per day on cannabis, sessions with local drug misuse adviser service
were also arranged.
48. In October, having committed a number of offences ranging from disorderly
behaviour to harassment, he received a 12 month Community Punishment
Order (CPO) with a curfew. He was also instructed to wear a tag. His YOS
Officer encouraged him to adhere to his curfew and accept the support but she
encountered difficulties as he would often not engage with the YOS or its
services.
49. In November, he accepted that he needed help with reading and writing and
started to attend one hour per week education support at the YOS. However
this was short lived, as in a meeting on 18 November, he was withdrawn,
negative and said that he did not care about continuing.
50. The mentor’s contact with him was initially quite structured and they agreed
specific days when they would meet. They often went to the gym together
which he enjoyed. As time went on, their meetings became more flexible to
accommodate his attendance at the education classes. Returning to the
classroom was difficult for him and he was involved in a few fights. The mentor
and the YOS Officer liaised to discuss ways of supporting and motivating him to
continue with his education and avoid offending. The mentor said the
difficulties were that he “never looked beyond where he was at, it’s where he
was at, not where he could get to”.
14
51. On 1 December, he was arrested and remanded overnight to go to the Youth
Court the following morning. He was charged with nine offences including
breach of bail conditions, common assault and theft. He was bailed by the
court to appear at a later date.
52. The YOS Officer continued to meet regularly with him. In their meeting on 11
December, he was very quiet and failed to engage in any conversation. She
said she wanted to draw up a strict intervention plan to ensure that he remained
out of trouble, but he remained uncooperative.
HMYOI Feltham – 27 December 2008
53. He was arrested again on 25 December for driving offences. He remained in
police custody until going to court on 27 December. The court remanded him
into custody at HMYOI Feltham A, for young people under 18. He spent his first
period in prison custody, on remand at HMYOI Feltham A side (for young
people under 18). Over the next couple of days he received a full induction on
Bittern unit, which is the induction wing. He was interviewed by staff and, in
response to routine questions, said that he had no thoughts of harming himself.
His only concern was that he might have a “problem with boys from Feltham,
but he will only defend himself if he is punched”.
54. Governor A manages the first days in custody services for young people and
young adults at Feltham. He oversees the reception, first night and induction
process for both sides of the prison. He explained that when a young adult
arrives at Feltham, a cell sharing risk assessment (CSRA) is carried out. The
assessment is reviewed before the young adult can move from the induction
unit to a residential wing. The man’s CSRA stated that he should be allocated
in a single cell and he repeated that he had no thoughts of wanting to harm
himself.
55. He was assigned Officer A as his remand review plan officer/offender
supervisor. At interview with the investigation team, she said that her role was
similar to a caseworker for young people. She manages the young people
whilst they are in custody, meeting them regularly to address any issues or
concerns and liaising with the YOS regarding remand or sentence planning
meetings.
56. In the officer’s Initial Review Plan meeting (form dated 30 December), she
noted that he was getting on “fine” in prison and had no concerns. She also
wrote “At present there are no concerns with him being a risk to himself, to
others or from others”.
57. He was involved in a fight with a prisoner on 12 January 2009. Mediation was
attempted but failed as the prisoner and two others said they disliked him. A
security report was filed on 14 January and staff were told to keep the three
prisoners apart from him to prevent any further fights. No further information
was recorded relating to his safety at this time.
15
58. On 15 January, he reported that he had been bullied by two other prisoners
whilst attending the gym. The anti-bullying procedures were invoked against
the two individuals.
Back in the community – 20 January 2009
59. A bail application was made for him and he was later released on 20 January.
The court imposed an Anti-Social Behaviour Order upon him, prohibiting him
from associating with other known peer criminals and entering particular areas
of Kent.
60. The YOS Officer continued to support him to address his offending behaviour.
She referred him to the Child and Adolescent Mental Health Service (CAMHS).
He agreed to cooperate but, after about four sessions, his appointments were
discontinued because the mental health worker retired and was not replaced.
The investigation team tried to obtain copies of any CAMHS reports written on
him via his mentor. However, despite requesting reports from the Social
Services, they were unable to provide any documentation.
61. Around two months after being released from Feltham, he was arrested on 21
March and charged with the offence of robbery committed in February. He
subsequently appeared before the Youth Court and was remanded back into
prison custody at Feltham. He was fully inducted into the prison and staff again
noted that he had no thoughts of wanting to harm himself.
Return to HMYOI Feltham – 14 April
62. He appeared at court on 14 April and was found guilty. He was returned to
prison custody at Feltham.
63. On 28 April, he went back to court and was released from custody but
immediately re-arrested on two further charges of violent robberies in February
and March. The YOS Officer said that he was very unhappy about this. He
was held in police custody overnight and returned to Feltham the following day,
29 April. He went through the reception screening process again. It was noted
that he had just left Feltham and had no problems about returning. He had no
history of self harm and stated “he would not harm himself”.
64. He remained on remand at Feltham and attended court and police stations on a
number of occasions. Whilst he was in custody he was given another YOS
Officer. She visited him each month to check his well-being and progress and
attend remand planning meetings with Officer A. On each occasion a Remand
Progress Review plan was completed. The officer also spoke to the man’s
mother who was able to contribute to his support and care. He received
numerous visits from friends and family. After he had been in custody for the
Christmas period, his mother said that she saw an improvement in his
behaviour and he began to engage better with the YOS staff.
65. YOS Officer A interviewed him and completed the Asset, dated 24 April and 30
June. It gave details of his offending history to date, his involvement with social
16
services and his difficult upbringing. It was noted that he had not engaged with
education although, whilst in Feltham, he was receiving one to one tuition and
responding well. He said that his use of alcohol and cannabis had declined,
both of which influenced his behaviour and distorted his ability to make sound
decisions. He described himself as feeling frustrated and worried. He was
angry with the criminal justice system and adamant that he did not commit the
robbery. He was also angry that he had been placed into care when he was
younger. He showed no thoughts of wanting to harm himself to her which was
noted in the Asset.
66. He was seen by a member of the Feltham chaplaincy team on 23 June. The
chaplain noted in his wing history sheet that he was “concerned about his
anticipated sentence. Not in a relaxed mood. Would be happy for another visit
in the future”.
67. Officer A and YOS Officer B assessed and held remand meetings with him over
the months. Initially his behaviour was poor and he was involved in several
fights and altercations. He was the subject of security reports, adjudications
(which are breaches of the Prison Rules) and subsequent loss of privileges.
Consideration was given to whether he could be a victim of bullying but this was
not thought to be applicable.
68. He settled into the regime and began going to daily workshops to improve his
literacy and numeric skills. He also went to an art workshop. His behaviour
was reported to have improved after some months, compared to when he first
arrived. Officer A described him as confident, especially as he was now very
familiar with Feltham A.
69. During August, his behaviour returned to being disruptive and abusive to other
prisoners and staff. Staff believed that he was “too comfortable” on the unit. He
was described as taking advantage of staff and unable to keep out of trouble for
long periods of time. This affected his attendance at education classes.
70. On the morning of 3 September, he refused to go to court and was placed on
report for his general conduct. He had a number of Incentive and Earned
Privilege (IEP) reviews and was put on the basic level, losing privileges such as
association time with other prisoners and canteen (snacks and tobacco). The
senior officer on the wing noted that he was a young man who needed a lot of
support and direction and so he was set a number of targets to improve his
behaviour.
71. Prisoner A was interviewed by the investigation team. He first met the man
when they were in the care home in Birmingham. They were friends but he
said that they “had their ups and downs”. After the man left the home they did
not see each other for many years, until they happened to meet again in
London during 2008. Although they resumed their friendship, they had a
disagreement and did not speak for a number of months until meeting again in
February 2009. (The man’s contact with the prisoner and other prisoners was
mentioned by his family and so my report mentions incidents in which he was
involved.)
17
72. When he committed the robbery in February 2009, the prisoner said that he
was with him. He was charged by the police and he believed that the prisoner
had “grassed him up to the police”. Approximately one month later (March
2009), the prisoner was committed into custody at Feltham, young adult side (B
side) for a different offence. He thought that the man was already in Feltham
but on the side of the prison for young people under the age of 18 (A side).
73. Although prisoners on the A and B side of the prison are generally kept apart,
there are occasions en-route to education, visits or the gym, when they transfer
through a communal corridor. The prisoner said that on one such occasion, he
came across him and they had a fight. The prisoner then began hearing
rumours from other prisoners that he was a “snitch and a grass”. He was
annoyed and approached him in the chapel (another area where A and B
prisoners can come into contact with each other) numerous times about this.
He said that they eventually settled their differences and, from around
March/April, were friendly again.
74. In spite of this, a number of SIRs were submitted by staff in August and
September surrounding the conflict between the prisoner and the man. The
prisoner alleged that the man had raped his sister and various threats were
made between the two, at the intermittent times they came into contact with
each other. Staff already aware of their dislike for each other, took appropriate
action to reduce any conflict that occurred.
75. On 8 September, YOS Officer A went to the Youth Court and was told that the
man’s trial had been suspended indefinitely as two other cases of robbery had
been identified. The details were being investigated by the police.
76. Officer A told the investigation team that she saw him on 20 September, the day
before he went to court, and he said that his solicitor would be applying for bail
but neither believed that it would be granted.
Release on bail – 21 September
77. He appeared at Crown Court on 21 September and was granted conditional
bail. YOS Officer A described him as overjoyed at being released as it meant
he would not be in custody on his 18th birthday and would be able to enjoy it.
78. The mentor had visited him a number of times whilst he was in custody and
after his release on bail. He saw him again on 14 October, the day before he
was sentenced. They talked about his court appearance and the fact that his
barrister had told him that there was a possibility he would be found guilty and
receive a significant sentence. He did not believe that he would be convicted.
HMPYOI Feltham – 15 October
79. He went to Crown Court on 15 October. He was found guilty of grievous bodily
harm, robbery and attempted robbery. He was remanded back into custody at
Feltham to return to court on 13 November for sentencing. The court adjourned
18
so that a pre-sentence report could be prepared by the YOS. The purpose of
the report is to inform the court about the circumstances of the young person
including background information about their life, family and relationships,
education and lifestyle. The reports highlight risk factors to their offending and
make recommendations about the most appropriate sentence.
80. As he was now 18 years old and an adult, he was taken to Feltham B (young
adult side) instead of Feltham A. He completed the reception and first night
screening and interview and no concerns were noted. He was seen by the
reception nurse who wrote “back into centre no new issues”. He was
considered suitable to share a cell, given a smokers’ pack and a free telephone
call. An “Initial Custody Interview” was conducted which looked at any “Risks of
Self Harm”. Again, no concerns were recorded for him and he was taken to the
Mallard unit (for second stage induction, remand and convicted wing).
HMYOI Reading – 16 October
81. For reasons which are unclear, he returned to court the following morning (16
October). He was assessed by the nurse in reception and deemed “fit for court,
no complaints”. After his court appearance, he was transferred to HMYOI
Reading. The investigation team found no reason why he was transferred to
Reading rather than returning to Feltham.
82. When he arrived at Reading, he completed the usual reception screening
process which included a Well Man clinic and he was examined by the nurse on
duty. His health was described as “normal” although he said he had a sore
throat and a broken finger. He also admitted smoking cannabis within the last
week. He was referred to the prison doctor, who noted that he had been
involved in a fight but had no injuries. No concerns were raised during the cell
sharing risk assessment (CSRA) and he was inducted into the prison.
83. As part of his induction, on the morning of 19 October, he underwent a mental
health screening. The clinical reviewer described the screening as a structured
questionnaire. It was conducted by Nurse A and divided into five sections
covering general information, risk, alcohol use, drug use and mood. He scored
the following:
Risk 0/10
Alcohol 2/20
Drugs 2/16
Mood 1/22 (the denominator of 22 should be 24, however there
appears to be an error within the form)
84. The total score of 5/70 is below the cut off point, which is 36, which triggers
consideration at the “high dependency” meeting. The outcome at the
conclusion of the screening included the advice to contact the Listener service
and the Samaritans if required, and referral to a substance misuse nurse. No
further follow up was thought necessary.
19
85. YOS Officer C was interviewed by the investigation team in relation to the pre-
sentence report she completed for him, dated 10 November 2009, at the
request of the court. She had also completed an Asset document. She
completed the reports in the absence of YOS Officer A, who was temporarily
away from the YOS office. He remained in Reading between 16 October and
13 November. She interviewed him on 28 October prior to writing her report.
She also contacted his mentor and spoke to his mother to gain more
information.
86. This meeting was the first time that she had met him. She described him as
open and co-operative throughout their discussion and she thought that he
seemed quite happy. She said that he was positive and very friendly. He
denied any thought of harming himself and the only vulnerability which she was
aware of was his learning difficulties. She assessed that he was at risk from
the “behaviour of other people”. He was also likely to be vulnerable because of
the disrupted care arrangements and his excessive use of alcohol. These were
issues that he had encountered from a young age.
87. She noted that he had been trying to make positive changes in his life but he
had experienced difficulties. He was angry and his behaviour was aggressive
which was demonstrated through his offending. However, she judged that
these tendencies appeared to lessen as he was getting older and maturing.
She said that he knew what he needed to do to improve his life but needed
support and guidance to help him achieve it.
88. She thought that inevitably he would receive a custodial sentence. He had
committed serious offences and he was aware that he might receive a long
sentence. As such, he was concerned that he would be away from his family
and his girlfriend, although he spoke positively about things he could do on
release from prison. Throughout the interview, he raised no concerns with her
about being at Reading.
89. On 12 November, a risk of serious harm assessment (ROSH) and risk
management assessment were completed by the YOS. Both tools are used in
the management and risk assessment of young persons. Neither highlighted
any risk concerns about him. The following was noted:
“Areas to focus on managing his anger, working around his alcohol
use, helping him learn pro-social skills, support and referring him to
probation as soon as he comes out.”
90. He appeared at Crown Court on 13 November for sentencing. No concerns
about his physical or mental health were noted on the Person Escort Record
(PER) form which accompanied him from Reading to court.
Return to HMYOI Feltham – 13 November
91. He was sentenced to five years imprisonment and transferred to Feltham B.
YOS Officer A went to court and explained to him that, as he was now 18 years
of age, responsibility for his sentence management would be transferred from
20
the YOS to the Probation Service and a probation officer would be allocated.
She thought that he took the news of his sentence well as he had previously
been told by his solicitor that it could be between seven and nine years. The
mentor told the investigation team that the man had a good relationship with
YOS Officer A and he thought that he would struggle to build up the trust with
his probation officer.
92. He arrived at Feltham at around 6.00pm. He went through the reception and
induction screening process. It was noted that he had received a five year
sentence but “expected much more”. No concerns were noted and he gave no
indication that he was thinking about harming himself. Due to the nature of his
offence, his CSRA was assessed as “medium” risk.
93. He was examined by Nurse B who also noted that he had no thoughts of self
harm, no immediate health concerns, and was fit to share a cell. He repeated
that he had expected a lengthier sentence. As is usual for new prisoners at
Feltham, he was checked hourly during his first night in custody. No concerns
were recorded by staff.
94. Officer A was unaware of the circumstances surrounding his bail conditions in
September, when he had been released. She said that usually when a young
person is about to make the transition from the young person to the young adult
side of the prison, a planning meeting takes place with his YOS. The prisoner
then has a handover where the young adult side of the prison is explained. She
was also unaware of his return to Feltham and therefore she did not know how
he reacted to his five year sentence. However, she knew that he had a number
of previous convictions and thought that he seemed prepared for a lengthy
sentence.
95. On 14 November, a security information report was raised. It noted that the
prisoner who he had fallen out with previously knew that he had returned to
Feltham. Staff believed that, if they came into contact with each other, there
was a high risk of violence and “Prisoner A might incite others to join in”.
96. Two days later, on 16 November, his CSRA was reviewed and a cell sharing
risk minimisation plan (CSRMP) form was completed. The CSRMP has to be
completed within a week of a prisoner’s arrival if they are identified as being
medium or high risk for cell sharing. The aim is to reduce the prisoner’s CSRA
level and make recommendations for the prisoner to attend programmes, for
example to address aggressive behaviour. The form noted that he did not get
on with his cellmate and was assessed as “increased risk” to others. He said
that he “will only [use violence to] defend himself”. He asked if Prisoner A was
in custody at Feltham and said that he wanted to “kill him”. His CSRA was
recorded as high/medium with staff commenting that “[he] poses no more risk
now than he did previously”. The investigation team interviewed two of the
three members of staff (SO A and Governor A) who signed the CSRMP but
neither could recall the detail of their involvement.
97. SO A was the unit manager and responsible for dealing with any problems that
arose around the Feltham B reception area. Because of his role, he explained
21
to the investigation team that his name appeared on documentation such as the
man’s CSRA minimisation form. He did not contribute to the assessments and
did not recall speaking to him. Staff did not report any concerns about either
the man or Prisoner A, whose name was mentioned on the CSRA minimisation
form. He passed the form to Governor A for approval. The Governor said that
the form raised no major concerns and, although he too had no recollection, he
said that he would have spoken to the man about moving to another cell. His
prison records contained no further information to suggest that any incidents
occurred with his cellmate.
98. The SO said that there was little physical difference between the layout of
Feltham A and B and the main difference was the atmosphere. He described
Feltham B as calm and mature whilst Feltham A, due to the younger prisoners,
was more prone to disruptions with alarm bells and prisoners fighting. He said
that Feltham had a very effective anti-bullying policy in place and staff went to
great lengths to locate prisoners in a place of their choice where they felt safe.
Sometimes this meant keeping a prisoner on the Kingfisher unit (first days in
custody unit) for a longer period of time.
99. On the morning of 17 November, Officer B printed a list of young adults who
were eligible to transfer from Feltham. During interview for this investigation,
the officer explained that there was pressure to free up spaces on the young
adult side of the YOI because of national prison population pressures. As such,
only young adults with a court appearance scheduled in the following three
months could remain at Feltham. Once a young adult was sentenced, it was
customary for them to transfer to another establishment. There were six young
adults on the transfer list on 17 November, one of whom was the man.
100. The Population Management Unit in the National Offender Management
Service (NOMS) manages prisoner movements around the country. Every day,
they inform each prison of the spaces which are available. The officer told the
investigation team that Feltham prisoners are routinely allocated spaces in
Portland, HMYOI Rochester and HMYOI Glen Parva. Of these three YOIs, only
Portland accepts young adults with sentences of five years or more. He
showed my investigator the list of young adults for transfer on 17 November.
Five of the six young adults on the transfer list on 17 November had sentences
of five years of more and they were all (including the man) allocated to
Portland.
101. To assist the allocation of a young adult, the allocation officer completes the
Initial Classification and Allocation of Young Offenders form, (also known as
ICA2). The officer completed section one of the form for him, noted that he was
allocated to Portland, and signed the form. The officer explained that the
remaining five sections are normally completed by the Offender Management
team. However, those parts of his form were left blank. The form should have
included sentence details, risk classification, any history of concerns about the
young adult and information about their family circumstances that might inform
the allocation decision. There is also space to record the young adult’s reaction
to his sentence and any factors to be taken into account when deciding on the
allocation.
22
102. The man’s had an offender manager. He interviewed him on 17 November, and
completed the document Initial Custody Plan for Young Adults. The plan is
used to address a prisoner’s offending behaviour. He recorded the following:
“Meeting with him to complete his LISARRT (London Initial Screening
and Referral Form) and to compile an initial custody plan. He had
problems reading and writing that needs addressing by education.”
The investigation team spoke to the offender manager but he had no
recollection of meeting him.
103. Once the allocation decision is made, the allocation officer tells the young
person where they will be transferred. Officer B said he could not remember
whether he or another member of his staff informed him of the decision.
However, he said that he normally speaks to young adults in the afternoon
either in their cells or a quiet room. If the prisoner is worried about transferring,
he explains how to ask for assisted visits and make an application to transfer
closer to home. He had no record that he had any such concerns. He signed
the allocations pro-forma to confirm he understood why he was going to
Portland and agreed to the transfer.
104. The next morning, 18 November, Nurse C completed a healthcare transfer
form. She explained to the investigator that healthcare receive a list every
evening of the young adults who are to be transferred the next day. Overnight,
their medical records are retrieved and prepared for transfer. She said that she
looks through the record to identify any medical issues which should be
resolved before the transfer. She also assesses whether any medication
should accompany the young adult and if there are concerns to be drawn to the
attention of the receiving establishment.
105. She completed his transfer form on 18 November. She had not met him before
and she based her assessment on the information in his medical record. He
had no outstanding medical or mental health issues and needed no medication.
She noted that he had “no suicide or self harm risk issues”. She explained that
she took Nurse B’s assessment on 13 November, in which no concerns were
highlighted, into consideration. As there were no other significant events
recorded in his record, she was satisfied that the nurse’s assessment was still
accurate and that he was fit to transfer.
106. She explained that a healthcare professional is present at reception as young
adults are taken to the escort van. The nurse could not confirm whether she
observed the transfer on 18 November. However, whichever colleague was
present would speak to anyone who was upset and any serious concerns would
be discussed with the senior officer. There are no records that he was upset to
be leaving Feltham, or that any concerns were raised with the reception senior
officer.
107. Operation Support Grade (OSG) Officer A was interviewed by my investigation
team. She works in the reception area and sees prisoners as they arrive or
23
depart. If she had any concerns, they would be addressed by herself and, if
necessary, the senior officer. She had come into contact with him several times
in reception and she thought that he generally appeared okay. On the day
when he was to be transferred to Portland, she was told by an officer (who she
could not recall) that he had been held alone in one of the reception holding
cells because he refused to transfer to Portland. Other prisoners waiting to
board the escort vehicle were held in another room.
108. Usually a Governor comes to reception to speak to any prisoner who refuses to
transfer to another establishment. The OSG told my investigator this was not
necessary because she asked him about his concerns. He confirmed that he
was okay and said that he had no issues with any of the prisoners at Portland.
He was concerned about his family being able to visit him because of the long
distance from their home. She said that she tried to reassure him that if he did
not receive many visits at Portland, they could be accumulated which meant
that he would return to Feltham for “accumulated visits”. He seemed to accept
her reassurance.
109. She said she was unsure as to whether he shared his concerns with any other
staff. She said that it was common for Feltham prisoners to worry about the
distance to Portland. She had compiled an information booklet, including
details about Portland, which was kept in the holding rooms. The reception
checks normally take about 45 minutes which gives them the opportunity to
read the booklet whilst they wait to leave. Unfortunately, she could not find the
booklet to show the investigation team and she was not sure when she first
introduced it.
HMYOI Portland – 18 November
110. Prisoners are escorted to courts, police stations and other prisons by a private
security company, G4S, which is contracted by the National Offender
Management Service. He travelled in the escort vehicle to Portland with five
other prisoners from Feltham. Two of the prisoners made themselves available
to be interviewed by the investigation team.
111. Prisoner B confirmed that, as well as travelling in the same vehicle, he also
knew him at Feltham. He had not seen him for a while until they met whilst
being transferred. He thought that his mood appeared to be okay although he
mentioned that he felt Portland was too great a distance away, especially for his
grandmother, to be able to visit him. Prisoner B did not know the other
prisoners, but he said that no one had any problems on the journey. He added
that, when he saw him later at Portland, he seemed happy and did not appear
“depressed”.
112. Prisoner C told the investigator that he first met him in the reception area whilst
they were undergoing their checks before departing for Portland. They had a
general chat which continued in the escort vehicle, with many of them talking
about how far Portland appeared to be. (Over the next couple of days, he
talked with him during association time. They spoke about prison life and
played pool and he described his mood as good.)
24
113. The escort vehicle arrived at Portland at around 1.10pm. Prisoner C said that
the reception staff were supportive. He noticed nothing in his demeanour that
caused him to be concerned about his welfare. No concerns about him were
noted on the PER which was handed over to Portland reception staff. He then
proceeded through the usual reception screening process.
114. At interview with the investigator, Officer C explained that normally Portland
received prisoners from Feltham on a Thursday and Reading on a Friday and
some of the other prisons throughout the week. He was on duty in reception
when the man arrived, although he could not recall him personally.
115. As is usual, the officer used the Portland reception questionnaire when he
interviewed him. The questionnaire is designed to elicit any information about
an individual’s wellbeing so that further support can be given if required. He
was asked a range of questions about his physical and mental health. He
would have had his PER and core record to assist his questioning. Throughout
the interview he raised no concerns with the officer and told the officer that he
did not consider himself to be vulnerable. The officer said that, being ACCT
trained, he observed the behaviour of new prisoners and assessed whether
they needed any additional support.
116. Whilst he was carrying out his duties, another officer arranges their prison
clothing and property. The prisoner is photographed and an identification card
made up. The whole process takes about ten minutes. Having gone through
the reception process, he was placed in the second holding cell in the reception
area.
117. At interview with the investigation team, Prisoner D at Portland said that he
worked in reception and on Grenville house block as a Greeter. (Grenville is
the induction wing.) His role was to greet all the new prisoners to help them
settle into the prison by answering any questions and allaying any fears they
may have. He explained that one of the rumours he had heard many new
prisoners express was that Portland was known as “Shank City” (a term used to
describe knife attacks). He told my investigator that he would quickly dispel this
as a rumour. In his view, Portland has a lot to offer prisoners.
118. He introduced himself to the man when he arrived. He was ”talkative and quite
bubbly” and seemed fine. The prisoner also worked in the induction wing
kitchen and explained that he came into contact with him quite often. During
their conversations, he asked the prisoner to write letters for him. Although he
could not recall the exact days, the prisoner was allowed by staff to visit him
twice in his cell to help him. He said that they often ended up laughing and
joking. He had shown pictures of his family to the prisoner who had no
concerns about him during any of their interactions.
119. Nurse D worked at Portland as an agency employee approximately twice a
week. At interview with the investigation team, he said that the prison reception
area was always staffed by a qualified nurse. On average, the nurse would
spend about 15 to 20 minutes with each prisoner. If a prisoner was subject to
25
self harm monitoring when they arrived, or had a severe psychiatric history, the
nurse would spend longer with him.
120. The nurse was one of two nurses on duty in the reception area and they
examined the prisoners in adjacent, private, rooms. When he conducted the
reception screening (entered on the computer at around 6.56pm), he had his
medical record from Feltham to refer to. He asked him a number of questions,
observing not just his verbal responses, but also his non-verbal and body
language. He had no long term medical conditions, was not taking any
medication and denied having any psychiatric or self harm history. Following
the assessment, he had no concerns about his demeanour. His CSRA was
noted as “low”. Although he had no immediate medical needs, he was given
the option to see the prison doctor the following morning, which he declined.
121. Nurse E entered his assessment on the computer system. This was because at
the time there was only one terminal in reception which was linked to the
healthcare system. As she was already entering details of new prisoners when
Nurse D had completed his examinations, she offered to assist by entering the
data which he had collected from the new prisoners.
After the reception screen
122. Although Officer D worked within the Grenville house block, he was in the
reception area when the man arrived. He reviewed his prison records and used
them to complete the CSRA. The officer noted that he had previously abused
alcohol and had been involved in fights and assaults on other prisoners whilst
at Feltham. For this reason, he noted his CSRA as “Medium”, meaning “No
immediate risk, but situation will need to be reviewed regularly”. The officer
knew that he was not being supervised by the ACCT monitoring procedures.
He confirmed that, once a prisoner completed their reception screening, they
are taken to the induction unit.
123. After taking him to Grenville house block, the officer completed the document
“Grenville 1st Night Officer Questionnaire” with him. He confirmed that he was
not taking any medication and denied having an alcohol problem. He said his
family did not know that he was at Portland, something the officer said could be
rectified by a telephone call after he completed his reception screening. In
response to the question “can you read and write”, he said that he struggled.
124. When interviewed, the officer only had a vague recollection of him. He asked
him whether he had a history of harming himself and any mental or physical
health problems. He said that he had no current thoughts of self harm and had
no other problems. He had been trained to use the ACCT procedures to
support prisoners at risk of harming themselves. He said that the man gave no
cause to consider opening the procedures. He did say he was concerned
about the distance from the prison to his home. There was a problem with his
telephone personal identification number (the PIN, which is used to access the
telephone network), although the officer could not remember what it was.
Nonetheless, he telephoned the man’s mother and allowed him to speak to her
26
to tell her where he was. At his request, the officer also spoke to his mother to
explain where the prison was and the arrangements for visiting.
125. He spoke to the officer for between 15 and 30 minutes. He was offered a
shower, smokers’ pack (tobacco), telephone call and television aerial. The
officer’s last question to him was whether he had any concerns that had not
been covered during the interview, to which he replied that he did not.
126. He was allocated to cell number eight on the third landing of Grenville. The cell
contained a Portland information pack which gave details about all the
departments such as healthcare, Samaritans and chaplaincy. No issues were
reported during his first night at Portland.
Thursday 19 November
127. The regime for new prisoners on their second day at Portland is to visit the
clothing stores to collect their prison clothing and then be assessed by
healthcare. This process is done as a group, and prisoners do not return to the
induction wing until they have all had their health checks.
128. Having collected his clothing, he went to the healthcare wing for a secondary
health screening assessment at around 11.13am. It was carried out by a
Healthcare Assistant (HCA). When interviewed by the investigation team, her
memory of him was vague, but she did remember that he presented no
immediate concerns to her. She had his medical record in her possession
when she interviewed him. She engaged in general conversation with him
about his physical and mental well-being. Nothing of concern was highlighted,
although she made a routine referral to the doctor for the following week
because of an old finger injury. His weight, height and blood pressure were all
measured.
129. Each prisoner is asked whether they misuse any substance or alcohol and, if
necessary, they are referred to the Counselling, Assessment, Referral, Advice
and Throughcare services. (The CARATs team provides non-clinical treatment
for prisoners with substance misuse problems.) He admitted using cannabis in
the past but did not want to be referred for any treatment.
130. The HCA said that if he had any issues which she was concerned about, she
would have referred him immediately either to the doctor on duty or a registered
mental health nurse. She said that most prisoners were mainly concerned
about the distance from home, which could result in them receiving fewer visits.
131. The chaplain told the investigation team that he saw all new prisoners as part
his pastoral duties. He visited him in his cell late that morning and spoke with
him for about five minutes about any concerns and his family and support
network. He provided him with leaflets about the chaplain and support services
in the prison. He did not think that he was struggling because he was in a new
prison or that he would harm himself. He said that he would immediately have
passed any concerns to the wing staff, as well as noting them in the pastoral
journal.
27
132. Officer E was appointed as his main personal officer. He meets his prisoners
regularly to help them with any concerns they might have. He introduced
himself to him over the lunch time period whilst he was eating his lunch in his
cell. They had a quick chat about Grenville and its function as an induction
wing. He was “co-operative”, understood what was being said to him and
raised no concerns. (This is in contrast to the family’s comment that another
prisoner told them that he alerted the officer to his anxieties about him.) The
officer told the investigation team that because of duties which took him away
from the wing and annual leave, he did not come into contact with him again.
Friday 20 November
133. On Friday, prisoners on Grenville house block do not have association. They
are unlocked at various times throughout the day to collect their meals, but
otherwise remain in their cells all day. If a prisoner wishes to use the
telephone, permission can be sought from staff and is usually granted. No
concerns or requests to use the telephone were recorded about him.
134. At interview with the investigation team, SO B explained that he was in charge
of the day to day running of the induction wing. The SO had no direct contact
with him but he was aware of him for two reasons. Firstly, he completed his cell
sharing risk minimisation plan (CSRMP) which is required for all prisoners
identified as medium risk on their CSRA. He was assessed as medium risk
because he abused alcohol and had been involved in fights at his previous
prison. The SO recommended that he should be referred to the Controlling
Anger and Learning to Manage (CALM) programme and Counselling,
Assessment, Referral, Advice and Throughcare services (CARATs).
135. Secondly the SO was involved as his name was flagged by the security
department. He was informed that, during routine monitoring of prisoner post
on the Grenville unit, a letter from Prisoner E had been examined. He referred
to the man, saying that he was upset to see him at Portland, and referred to
having fallen out when they were at Reading. The SO said that staff were
concerned about how they would interact when they met on the wing.
136. The prisoner was released from prison shortly after the man’s death and was
not interviewed for this investigation. He was however interviewed by Officer F
immediately following the death. He confirmed that he shared a cell with him at
Reading for about a month. He said that they had a good relationship and he
would write all his letters for him. However, just before the man left Reading,
they had an argument and parted on unfriendly terms. When he saw him at
Portland, he was unsure about how he would react, especially as in his words
“going to Feltham, sometimes going there can drive you nuts and make you
different”. However, he approached him to say that he wanted to be friends and
so they sorted out their differences. He told the prisoner that they “needed to
stick together on association”. They talked about his five year sentence, and
the prisoner said that he did not appear overly concerned about it.
137. The SO said that no concerns were reported about him that day.
28
Saturday 21 November
138. Having told the chaplain that he was Catholic, he went to the Roman Catholic
mass on Saturday morning at around 9.15am. He met Roman Catholic
Chaplain who informed him that she would visit him later for a general chat.
She went to see him in his cell later that morning. She described him as well
mannered and she was not concerned about his well being. She asked how he
was and whether he would like to come back to the chapel to discuss “a way
forward” for him following his fairly lengthy prison sentence. He seemed happy
with this suggestion and they agreed that the meeting would take place during
the following week.
139. Prisoners have their lunch between 11.30am to 12.30pm, and eat in their cells.
At the weekends, they are unlocked for association from 1.45pm and returned
to their cells by 5.30pm. (On weekdays, except Friday, prisoners have evening
association from around 5.30pm to 7.30pm.)
140. Prisoner telephone calls are recorded at Portland, but they are not monitored
simultaneously. It was only after his death when staff realised that he
telephoned his mother’s house at 2.29pm. He spoke with his grandmother
(known as his Nan), mother, brother and girlfriend although the majority of the
call was with his girlfriend. He made no mention of harming himself throughout
any of the conversation. He knew that he would only serve half of his five year
sentence and his girlfriend referred to it being 26 months which he described as
a “long time”. He said that he could telephone her anytime and intimated that
he intended to do some of the prison courses on offer. He described his
contact with staff and prisoners as good and said that he was not getting
involved in any trouble. He would however have preferred to remain at
Feltham. The telephone call lasted 23 minutes and 31 seconds.
141. Prisoner C spoke with him during association on Saturday. (In his interview he
said this was between 5.30pm and 7.30pm, but it was likely to have been
earlier as weekend association ends at 5.30pm.) He played pool and used the
telephone to call his family. The prisoner was aware he had spoken to his
grandmother. He said that his mood did not change after the telephone call or
throughout association. He had been “jolly” and was “laughing” in their
conversations. This was confirmed by Prisoner B, who said he seemed okay
during association and saw him “laughing”.
142. Prisoner F was interviewed by the investigation team. He worked on Grenville
as a Listener and was also a Greeter in reception when new prisoners arrived.
He believed that these schemes worked well to support prisoners. He
described the induction wing as “good” and “clean” and he felt that the staff
treated prisoners fairly. In his opinion, bullying was not an issue on the wing.
He had little contact with him, but when he saw him during association periods
he thought that he “seemed perfectly happy”.
143. Prisoner E was one of the prisoners who the man talked with during
association. They played pool and he “cheered” him up. He asked the prisoner
29
if he would write another letter for him on Sunday, to which he agreed. The
prisoner said that he gave him no indication that he was worried or thinking
about harming himself.
144. Prisoner D had brief contact with him during association, about five minutes
before they were locked in their cells. He talked about what he wanted to do
after he completed his sentence and appeared to be in a good mood. The
prisoner said that he appeared to have settled into Portland well and he was
mixing with the other prisoners.
145. Shortly after 5.30pm when prisoners were locked in their cells, Prisoner D (who
was still unlocked because he worked as a cleaner) went to visit him to make
sure that he was okay. He said he was fine and the prisoner returned to his
cell.
146. Officer G was his second personal officer. She told the investigators that she
normally introduced herself as a personal officer within five days of a prisoner’s
arrival. Due to his short period at Portland and her annual leave, she did not
introduce herself formally and they did not have a one to one meeting. She
came into contact with him during meal and association time when he did not
come to her attention in any adverse way.
147. OSG A was on duty that night on Grenville house block. She came on duty at
around 8.20pm and received a handover from the day staff when no problems
were reported. One of her first tasks is to conduct a roll check which, she told
the investigator, was at about 8.30pm. There were no problems or concerns
when she checked the occupants in each cell on the wing.
148. The OSG’s role is to patrol the landings during the night and make sure that
everything is satisfactory. Any prisoners who are being monitored by ACCT are
checked individually at agreed intervals. The OSG also carries out pegging
duties, meaning that every half hour they patrol the landings, recording their
progress on an electronic device at the end of the house block. During pegging
checks, staff only open a cell observation panel if there is a problem such as
loud music or the light being on in the early hours of the morning. She reported
no problems during her night shift.
149. Nelson house block is next to Grenville and OSG B was on duty there. The two
blocks are separated by gates which are left open during the night so that they
become one continuous “block” and staff can see from one to the other. The
Nelson office is on the “twos” landing (first floor) and the Grenville office is on
the “ones” landing (ground floor). The OSG described the distance between
the two house blocks as very short.
150. Portland does not use a specific code system in an emergency. OSG A said
that, if an emergency occurred and she needed assistance quickly, she would
alert others by shouting and/or pressing the emergency button on her radio.
151. Prisoner G was in the cell next door to the man and he was interviewed by the
prison security officer, a PO after his death. The prisoner said that he arrived at
30
Portland the day after him. They had not talked to each other but he described
him as “a nice bloke who just wanted to “do his bird” (meaning to complete his
prison sentence). He was “Not a hard nut but not someone that was being
bullied either. Just normal.”
152. On Saturday night, the prisoner said that it was quiet on the wing as everyone
was watching television. However, just before midnight, he heard a “thump”
sound, which he said was similar to a cup dropping off a table, and believed
that it came from the man’s cell.
Sunday 22 November
153. No concerns were reported during the night by the OSGs on either Grenville or
Nelson house blocks. OSG A confirmed that the man did not press his cell bell
for assistance. Just before 6.30am, both OSGs went to conduct their roll
checks and OSG A began to check the prisoners on Grenville.
154. When she reached his cell, she opened the observation flap and looked inside.
She saw something hanging down from the window and thought that he was
playing around. She shut the flap, but quickly re-opened it and realised that he
was hanging from the window bar at the back of the cell. She immediately
shouted “emergency” to attract OSG B’s attention.
155. OSG B responded immediately to her shout for assistance. She had started
her check near to Nelson house block and was close to where OSG B was
standing although on the next landing up. He ran up to the “threes” landing
(second floor) to join her who told him that a prisoner was hanging in the cell.
He looked through the observation panel of the cell and saw him hanging.
156. Whilst he was doing this, she used her radio to contact staff in the Control
Room to request further assistance. She broke the seal on her pouch to obtain
the cell door key. (Sealed pouches containing a cell key are carried by night
staff and are used to gain entry in an emergency to attend to a prisoner who is
in danger.)
157. The OSGs said that they went into the cell within seconds. OSG B jumped on
to the bed to try to cut the ligature with his ligature knife. OSG A attempted to
support the body and take the weight off the ligature. His weight made it
difficult for her to hold him up and so she swapped positions with OSG B. The
ligature, which appeared to be made from bed sheets, was very thick.
158. Two officers were the assistant orderly officers (second in charge of the prison)
on duty overnight. Officer H told the investigation team that it was a quiet night
until they heard OSG A’s call for assistance over the radio at about 6.30am.
They immediately made their way to Grenville, arriving in about 30 seconds.
159. Both officers went into the cell and found OSG A on the bed trying to cut the
ligature from the window bar and OSG B supporting the body. Officer H used
his radio to ask for an ambulance, recorded at 6.35am on the prison incident
31
log, and then helped OSG A try to cut the ligature. Officer I helped to support
the body.
160. He was wearing his prison clothes. Once the ligature was cut, OSG B and
Officer I lowered him on to his bed. His arms did not move and neither did his
body bend. Officer H had an up to date first aid qualification and he described
the body as stiff and his skin as mottled. He thought that rigor mortis was
present. He had severe bruising around his neck where the ligature had been.
Officer I examined him for signs of life but did not find any. Officer H noticed
that there was a note on top of his toilet.
161. The orderly officer in charge of the prison was SO C. With his assistant they
also responded to the OSG’s call for assistance. The SO told the investigation
team that when he arrived at Grenville house block, the four officers were in the
cell. The man was still in a hanging position by the window but the officers had
just cut the ligature and were lowering him to the bed. He assisted the staff to
do this.
162. He said that the man showed no signs of life. He said that the staff discussed
whether to attempt cardiopulmonary resuscitation but, given his condition, they
agreed that it was unlikely to be effective. The paramedics arrived at 6.45am
and they confirmed his death soon afterwards.
Events after the man’s death
163. All the officers left the cell and waited outside. The SO returned to the orderly
office to instigate the prison’s death in custody procedures and contact the
Governing Governor and the duty Governor. The police were notified and
started to arrive at the prison at 7.40am.
164. The letters which Prisoner D had written for him were found in his cell. They
were addressed to his “Nan” and “Mum”. Neither indicated that he had any
intention of taking his life. However another note and several drawings were
found which he appeared to have written himself. The note was addressed to
his girlfriend and said that he was sorry and “I just cant do it, miss you 2 much,
sorry baby I love you so much got to go”. It contained various drawings and
statements including “RIP, I am free”.
165. The Governor said that he was contacted at home at 6.45am by the SO, who
told him that there had been a death in custody. Having ensured that the SO
had begun to implement the contingency plan by contacting all the necessary
persons, he immediately made his way to the prison. When he arrived he
briefed the staff on duty and ensured that the cell was sealed to await the
arrival of the police. His prison records were gathered to ascertain his next of
kin details.
166. The duty Governor arrived at the prison soon after being contacted. He held a
debrief meeting with staff at around 10.30am. The prisoners who were subject
to ACCT monitoring were reviewed and offered support. At a later date, a
Critical Debrief meeting was held and attended by a number of staff.
32
167. A SO went to see Prisoner E to return the letter which he had written previously
that referred to the man and asked if he still wanted to send it out. The prisoner
was very upset by his death and said that he had written the letter before they
resolved their disagreement.
Contact with the man’s family
168. It was established that the man’s next of kin lived near Feltham. Wanting to
ensure that the news was broken to them as quickly as possible, the Governor
contacted HMYOI Feltham to ask their family liaison officer to visit and inform
them of his death. At about 1.00pm, staff at Feltham visited the family to break
the news. They asked to speak with staff at Portland and the Governor spoke
to the man’s mother and grandmother. He told them about the circumstances
surrounding his death and provided further information about the prison and
what would happen next.
169. The family liaison officer (FLO) from Portland also spoke with the family around
2.00pm. She began to arrange to meet the family and provided further
information, including the Coroner’s contact details. She went to Grenville
house block to find out any further information about him.
170. The following morning, 23 November, she spoke to his mother again to answer
further questions about his death. Arrangements were made for his family to
see him at the mortuary that afternoon. Both she and the chaplain arranged to
meet the family there. Afterwards arrangements were made for his funeral,
including offering financial assistance, as well as the return of his personal
property. The family were offered a visit to the prison to view his cell and talk to
any staff and prisoners who knew him.
171. His mother spoke positively about her continuing contact with the family liaison
officer. She told the investigation team that the officer maintained regular
contact and she found her to be kind and supportive.
172. The family visited the prison at a later date when they met the Governor and
some of his staff. Afterwards, his mother told the investigation team that
although she was not “surprised by the size of his cell”, she was “disgusted by
its state of repair”. In particular the toilet was black with limescale and she
described the cell as being in “squalor”. She thought that these surroundings
would have a detrimental effect on an individual’s state of mind.
173. His grandmother told the investigation team that she took a telephone call from
an unidentified prison officer on the morning after his death. The officer told her
that the power to his cell was turned off at 2.30am and he was fine at the time.
The family liaison officer confirmed to the investigation team that his
grandmother had raised this issue and she explained that the electricity is
switched off centrally at 2.00am. The prisons security manager said that
prisoners on the standard level of the IEP scheme, like the man, have no power
in their cells from 12.00am. The governor said that it is turned off from the
outside and does not include checking the prisoner.
33
174. The post mortem concluded that the cause of death was hanging.
175. The funeral later took place on 8 December.
34
ISSUES RAISED IN THE INVESTIGATION
Clinical care
176. The clinical reviewer reviewed the man’s community medical records and
summarised his findings as follows:
“These notes have made clear that this man’s developmental years were
complicated by a number of adverse events. The information to hand
provides a partial and patchy picture of a complex story. There is nothing in
these notes to indicate the presence of any mental illness however there are
indications that he showed evidence of a childhood conduct disorder of early
onset. This is a risk factor for persistent social problems in later life and is
associated with substance-misuse.”
177. The clinical reviewer also noted several psychosocial factors which placed him
at a higher risk of harming himself including his youth, gender and his
separation from family. At no time during his period in custody did he show any
evidence of any mental disorder to prison and healthcare staff. The reviewer
said that he received a well structured mental health assessment on 19 October
2009, and his responses support the view that he did not have a mental
disorder. He did not declare any risk factors to the staff when he was admitted
to Portland.
178. He had contact with healthcare staff when he came in and out of custody and
no risk that he might harm himself was highlighted.
The man’s contact with the Youth Offender Service
179. The YOS, and in particular YOS Officer A and the mentor, had a lot of contact
with him. It was clear from their records that they built up a good relationship
with him. He was seen regularly by the YOS and I believe that considerable
effort and interventions were tried in an attempt to address his offending
behaviour. This included engaging with his mother who also tried to support
him and liaised with the YOS and the mentor.
The man’s time at HMYOI Feltham
180. The investigation team were told by staff at Feltham that it was common for
prisoners in Feltham A to have issues with one another and some problems
appeared to originate in their communities. Fights evidently occur more often in
Feltham A than in Feltham B, where the prisoners are older and their behaviour
is more mature. The majority of the man’s time in custody was in Feltham A,
where he was involved in a number of fights. This was evidenced in the large
number of altercations recorded on security incident reports. As a
consequence he often came to the attention of staff, had a number of
adjudications and lost his IEP privileges on a number of occasions.
35
181. With regards to his safety, he became very familiar with life in Feltham and the
staff believed that he was confident there. There was only one incident when
he was bullied and I am satisfied that the staff took appropriate action. At no
time did he show any sign that he might harm himself or felt vulnerable at
Feltham.
182. He did threaten to kill another prisoner, which was recorded on a cell sharing
risk minimisation form (CSRMF) at Feltham less than a week before he died.
There is no evidence of any action taken on the matter or anything to suggest
that they came into contact again. Incidents of this nature require a response
from staff which should include implementing the violence reduction measures
and completing a security incident report.
The Governor at Feltham should remind staff that risks identified when
completing cell sharing risk assessments should be followed up by the
violence reduction measures and security incident reports.
The man’s time at HMYOI Reading
183. The family asked the investigators to consider some aspects of his time at
Reading including whether he was subject to 30 minute checks, who he shared
a cell with, whether he was bullied by members of a rival gang, and if his cell
was targeted for cell searches.
184. The prison and healthcare records for his stay at Reading are limited and they
contain no concerns about him. The Governor and Security Officer said that he
was not subject to ACCT monitoring and no incidents, including security
matters, were reported. They also said that his cell was not targeted for any
specific cell searches. The family also said that he wrote to his girlfriend from
Reading, saying that he had not eaten for two days. His medical or prison
records do not contain any information to suggest that he refused his meals.
185. His mother also said that a fellow prisoner had told her that he had been
subjected to “aggressive cell raids” by officers using plastic shields at Reading
and Feltham. If this type of force is used, it is the policy of the National
Offender Management Service that it should be documented. The investigation
team found no evidence that searches occurred or that force was used.
Being sentenced as an adult
186. Staff at Feltham told the investigation team about the differences between the
two sides of the prison. Officer A confirmed that, normally before a young
prisoner moves to the young adult side, a meeting takes place with the young
person, offender supervisor and the YOS. The young person is given a
handover and told about the young adult side of the prison. Because he came
back into custody after his 18th birthday, he did not receive the handover.
187. When he was sentenced for the first time as an adult, his YOS worker told him
that his case would be handed over to the probation service. She explained
36
that the level of support which the YOS gave might well be reduced and thought
this might have an impact on him.
188. There is no doubt that he was aware that he might receive a lengthy custodial
sentence. This view was supported by his YOS worker, who said that his legal
team also believed it. He did not voice any concerns to those closest to him.
On the other hand, in his conversation with his mentor before his court
appearance, he said that he did not think he would be convicted, which may
have been his way of dealing with what looked like an inevitable situation.
189. His mentor was not at court when he was sentenced. He had built up a good
relationship with him as his mentor and believed that he would have been
shocked by his conviction and struggled to serve a long sentence.
Furthermore, he said that the man may well have thought that he would serve
his sentence at Feltham. He believed that the length of sentence and the
transfer would have been a “great shock” to him who had got used to Feltham
and coped there. Being told that he was to be transferred within 24 hours was
a change that he thought he would not be able to cope with.
190. He told the investigation team that, although 18 years old, the man was
emotionally immature. He was a young man “still working out his emotions, and
growing up in the world and [finding] his place in the world”. He felt he would
have needed “a lot of time and support” to adjust and be able to understand
how things were going to be, “in a world he had no idea about”.
Transfer to HMYOI Portland
191. The family asked the investigation team to consider his transfer to Portland
which is further from his home.
192. Feltham transfers prisoners to HMYOI Glen Parva, Portland and HMYOI
Rochester. Of the three, only Portland accepts young adults with a five year
sentence. As this was his sentence, I consider that the allocation was
reasonable and inevitable. The National Offender Management Service aims to
locate prisoners near to their homes but a prisoner’s specialist requirements
have to take precedence over proximity. He was an adult, convicted at Crown
Court and serving a sentence which Portland accommodated. Like any other
prisoner in those circumstances, he was allocated to Portland.
193. However, I am concerned that he may not have had the opportunity to discuss
any anxieties that his allocation might have caused him. The investigation team
was told by his offender manager and allocation officer that they explain to
young adults who are anxious about applying to move nearer to home and how
to use the assisted visit scheme in the meantime. There is no evidence of
either discussion with him. The interview to complete the Initial Classification
and Allocation form (ICA2) form should have raised these issues. The form
was partially completed by the allocation officer, who provided a copy of his
signed acknowledgement of his allocation. However, the form is incomplete
and there is no record of how he felt about his transfer or any information about
his family situation that might have affected his allocation.
37
194. That this form, and I assume the interview, were incomplete was a missed
opportunity for him to raise any concerns about being transferred to a prison
which was some distance from his family. The form is designed to identify a
prisoner’s concerns about moving and it is important that it is completed
satisfactorily.
The Governor at Feltham should remind staff of the importance of
completing ICA2 documentation to ensure that each young prisoner has
the opportunity to voice any concerns about the transfer.
Discovering the man hanging
195. When he was discovered hanging, I am satisfied that the staff and ambulance
responded quickly. However, rigor mortis was present and so any attempt to
resuscitate him would have been futile. I believe that it would have been
undignified for him and distressing for the staff to have attempted resuscitation
when there were clearly no signs of life. The response by staff was in line with
the guidance given by the National Offender Management Service.
196. The investigation team however were made aware through interviews that one
member of staff that had attended his cell did not have current first aid training.
I consider it best practice that uniformed prison officer staff who are usually the
first responders to medical emergencies do have up to date first aid training
which enables them to commence CPR. Portland also do not use radio codes
which can distinguish between different types of emergencies. This has the
benefit of providing staff with more information about what to possibly expect
when they arrive at a cell in an emergency. Neither of these two issues raised
caused any delay in staff attending to him when he was discovered. However,
although I make no recommendations on the issues, I bring them to the
Governors attention as matters which he might wish to review.
197. A note was found in his cell after he was discovered. Some care seems to have
been taken when drafting the words and the sentiment expressed seems to be
a farewell to a girlfriend and his family. The note suggests that he felt unable to
face the prospect of a prolonged sentence and chose suicide as an escape.
Other family concerns
The man’s cell at Portland
198. His mother raised concerns about the condition of her son’s cell and whether
this may have contributed to his state of mind given the time he was required to
spend in his cell. The investigation team viewed the cell whilst opening the
investigation and did not consider the cell untypical of a standard cell on an
induction wing. They did not see any broken furniture; however his mother said
she noticed that a set of drawers and the television were broken when she
visited the cell. Prisoners stay on the induction wing for a short period before
being located more permanently on a residential wing.
38
199. The HMCIP report highlighted that, during their inspection, not all the cells and
toilets were clean. It made the following recommendations:
• Cells on Grenville unit should be adequately cleaned for each new occupant.
• There should be a painting programme to ensure all cells are clean and free
from graffiti. All toilets should be de-scaled. Staff should encourage all
prisoners to keep their cells clean and provide them with sufficient cleaning
materials.
200. The recommendations were made a short period prior to his arrival at Portland
and are part of many areas identified by the HMIC report to assist with
improving conditions at Portland. Although the investigation team were told that
prisoners are selected as “cleaners” on each wing and they have access to
various cleaning materials which are safe to use in a prison setting, I remind the
Governor of these recommendations and their implementation as soon as
possible.
HMP Portland Induction Programme
201. The family raised concerns that the induction programme at Portland only
begins on a Monday. This meant he had to wait four days for the programme to
start and there appears to have been very little for him to do in the interim.
They feel this is of particular concern in light of the fact that prisoners are of
higher risk of suicide in the first few days of custody and also at increased risk if
they have nothing to occupy themselves
202. Portland’s induction programme starts on Mondays. Friday is a full prison staff
training day and normally a non association day. New prisoners will not be
initially employed. He arrived on a Wednesday afternoon and so was not due
to commence full induction programme until the following Monday. He was
however reasonably occupied on his first two days in prison undergoing his
reception screening, secondary health screening and collecting of prison
clothing. In addition he had association, meetings with the prison chaplain and
his personal officer.
203. From the evidence available, he was confined to his cell (like all other
prisoners) without association for large parts of the day on Friday, his third day.
Prisoners have reduced activities on Saturday and Sunday due to a reduced
staffing level. The induction programme does not operate over this period.
There was no evidence to suggest he was denied access to speak to staff
during his stay at Portland.
204. In her last inspectorate report (September 2009), HM Inspector of Prisons also
raised concerns about the induction programme, recommending that “The first
week of the induction programme should be delivered as a rolling programme,
making use of a full range of multi-media” and that “Prisoners should be
unlocked when they are not actively participating in induction sessions”.
39
205. It is not possible to say with any certainty whether the outcome would have
been different had he been more occupied during this initial period in custody.
Based on the evidence available, I do not consider it likely that the earlier
commencement of the induction programme would have had a significant
impact on the time he spent in his cell (taking into account the time already
absorbed by the initial screening requirements and limited association at
weekends). I do not therefore consider, in this instance, that it would be realistic
or reasonable to make a recommendation above that already suggested by
HMCIP to improve practice in this area.
The man’s fears about his safety and that of his family
206. The family asked the investigators to consider whether he was afraid about his
and his family’s safety. The investigation team reviewed the Security
Intelligence Reports (SIRs) and found no direct evidence to suggest that his
family’s safety had ever been compromised. However amongst the reports,
there is one reference to his mother on 30 June which may be the incident she
refers to when she believes that her safety might have been compromised on a
visit to Feltham. I trust that the family did not feel vulnerable when they visited
Feltham and that the report provides some reassurance that their safety was
considered by staff.
207. In respect of his own safety, he was involved in a number of altercations at
Feltham. Naming a prisoner on an SIR suggests that the incident was
considered to be important and was relevant to his safety, as well as prison
security.
208. There is no doubt that he came to the attention of staff on many occasions. He
did not report any of the altercations with other prisoners as a reason to think
about harming himself. Nor did he tell staff that he had any suicidal thoughts.
Certainly staff commented that he appeared confident living at Feltham. I have
already recommended that consideration should have been given to using the
violent reduction policies and so make no further comment about the incidents
recorded on the SIRs.
40
CONCLUSION
209. There has been much research about whether prison custody is the appropriate
place for young people who offend. Her Majesty’s Inspector of Prisons reports
that “most children and young people who end up in prison come from sadly
predictable backgrounds”. The prison estate is therefore dealing with some of
the most challenging and vulnerable young people in society. Most of the
man’s stay at Feltham appeared to be a challenging period for him, as
evidenced by the number of altercations he was involved in.
210. That he was sentenced to five years in prison just over a week before his death
is worthy of note. Sadly, a common factor in prison suicides is that they occur
soon after coming into custody. He may well have been in custody several
times before but he had not been there as an adult or for a lengthy foreseeable
period and so his experiences will have been different.
211. The support he was given in the community changed as well. He had good and
well resourced relationships with his youth offending team workers although
both relationships took sometime to develop. This level of intervention is
difficult to continue within an adult prison setting.
212. Despite these risk factors, during his short stay at Portland, he showed no
obvious risks to the staff and prisoners who he came into contact with. He
spoke openly to reception staff about his concerns regarding the distance
between Portland and his family. This appeared to have been relieved by the
reception officer’s conversation with his mother. He socialised with other
prisoners, including one who had helped him write letters before, and did not
display any signs to them that he might harm himself. As well, from reviewing
the telephone call to his family the day before he took his life, there is no
suggestion that he intended to take his own life. Nevertheless, the note found
in his cell clearly indicates that he did not wish to serve his sentence and
continue living.
213. This investigation has been complex and included enquiries of a range of
criminal justice agencies. Although I make no recommendations in this regard,
it is worthy of note that so many staff who were interviewed had little
recollection of their contact with him. I am sure that it will be a matter of regret
to the Governors of the establishments and I am equally sure that it will provide
little comfort to his family. Furthermore I am struck that, although well
intentioned, much of the information which was intended to inform and reassure
him was given to him in written form. He was a young man whose education
was disrupted and limited and I find it hard to believe that information leaflets
would have relieved his anxieties.
41
RECOMMENDATIONS
1. The Governor at Feltham should remind staff that risks identified when
completing cell sharing risk assessments should be followed up by the violence
reduction measures and security incident reports.
The Prison Service has accepted this recommendation.
2. The Governor at Feltham should remind staff of the importance of completing
ICA2 documentation to ensure that each young prisoner has the opportunity to
voice any concerns about the transfer.
The Prison Service has accepted this recommendation.
42