Individual at Peterborough Magistrates Court

Investigation into the death of a man
at a Magistrates Court in February 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2009
This is the report of an investigation into the circumstances surrounding the death of
a man in February 2008 in a holding cell at a Magistrates Court. The man had
attended a hearing for non-payment of a fine that morning and was sentenced to
seven days in custody. A few hours later he was found collapsed and not breathing.
The final post mortem report was produced in December 2008. The man is thought
to have died as a result of the combined effects of alcohol and cocaine. He was only
24 years old.
I would like to offer my sincere condolences to the man’s family and to others who
have been affected by his death. I apologise for the delay in issuing my report and
for the additional distress this may have caused.
The investigation was initially led by one of my investigators. It was taken over by
one of my Assistant Ombudsmen in September 2008 when my investigator left my
office. We would like to thank the representative of the Prisoner Escort and Custody
Services (PECS), for providing information and arranging interviews to assist the
investigation. I am also grateful to the Detective Sergeant of Cambridgeshire
Constabulary for sight of the witness statements taken as part of the police
investigation.
This report tells a sad story of unusual circumstances. The man was in custody for
just around two and a half hours before he collapsed and subsequently died. My
investigation has concentrated on the few hours leading up to his death, and the
response from court staff when he was discovered on the floor of his cell. It is clear
that the man’s death was sudden and could not have been foreseen by those
responsible for his care. Having said that, my investigation has found that the
prescribed level of checks was not carried out by staff and that, in particular, the last
recorded check of the man at 1.30pm may not have taken place.
This is the fourth death I have investigated in a court setting since taking over all
such investigations in 2004. I make three recommendations, all of which were
accepted by G4S at draft consultation stage.
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 involved in my investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2009
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CONTENTS
Summary
The Investigation Process
G4S - Global Solutions Limited
Peterborough Magistrates Court
Key Findings
Issues
List of Recommendations
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SUMMARY
The man appeared at a Magistrates Court in February 2008 to answer for the non-
payment of a fine. He was sentenced to seven days in custody. Little was known
about him when Global Solutions Limited (GSL) staff collected him from the court
witness box. The man was asked a number of routine questions as part of the
‘booking in’ process. He told one of the Prisoner Custody Officers (PCOs) that he
had been in prison once before about six years earlier. According to the PCOs who
first took him upstairs to the custody area just after 11.00am, the man seemed
shocked to be in handcuffs but had accepted his short sentence.
In interview, the first PCO said that when the man was given a routine rub down
search he could smell alcohol or something sweet on his breath. He did not think
that the man seemed to be under the influence of alcohol and he was not slurring his
speech or unsteady on his feet. No visible signs of injury were evident during this
booking in process. At 11.14am, the man was placed in a cell on his own and was
given a drink. It was very quiet that day and only two other prisoners were being
held in other cells in the custody area. The man was not checked twice per hour as
laid down in GSL instructions, and was next seen at 12.23pm as part of the ‘lunch
run’. The man declined the meal pack, but did take a glass of water and cup of tea.
Some of the PCOs giving out the lunch packs subsequently recalled that the man
appeared to lose his balance, spilling some of his tea, before regaining his
composure. However, they were not concerned about him, and just thought that he
had ‘tripped over his feet’.
The court staff then had their lunch and no checks were made on the prisoners
during the lunch period. I have made a recommendation about ensuring the
minimum prescribed checks of two per hour are always carried out.
A second PCO said that he checked the man at 1.30pm, spoke to him, and that he
was okay. Shortly afterwards, around 1.36pm, another prisoner was unlocked so he
could use the toilet. When he was being locked back into his cell a few minutes
later, the second PCO checked on the man. He found the man collapsed face down
on the floor. The cell was opened quickly and staff saw blood coming from his nose
and mouth, and that the man was not breathing. The custody staff tried to
resuscitate the man whilst awaiting the arrival of an ambulance.
Rapid response paramedics arrived at 1.47pm, followed by another team of
paramedics a few minutes later. Despite further attempts to resuscitate the man, a
paramedic pronounced him dead at 2.07pm. The police doctor subsequently
confirmed the man’s death at 4.19pm. The paramedic report form indicated medical
staff thought that, as some signs of rigor mortis were already present, the man had
been dead for longer than the timing of the last check by the second PCO indicated.
The post mortem was completed in December 2008. The pathologist concludes
that, on the balance of probability, the man died of the combined effects of cocaine
and alcohol intoxication, most likely through the development of a cardiac
dysrhythmia (when the heart beats either very fast or very slow, or irregularly). He
considers that another explanation could be a fatal seizure associated with alcohol
withdrawal (if the man had a chronic alcohol problem) exacerbated by cocaine. It is
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probable that the man had drunk some alcohol before attending his court hearing,
but that the cocaine was taken after he was in the custody of court staff. At draft
consultation stage the man’s family asked for clarification as to whether any plastic
bag or wrapping (that might have contained the cocaine) was taken from the cell
after his death. My investigator contacted Cambridgeshire Constabulary. The police
said,
“We did not during the course of our investigation find / recover any type of
wrap or wrapping. When, how and what type of cocaine the man took we do not
know, the toxicology report suggests the cocaine was taken whilst at court, this
is our best evidence, but beyond that we do not know.”
The pathologist reports that the man had several marks of injury on his body, to his
face, back, knees and elbows. None of the custody staff noticed any bruises or cuts
to the man’s face during their interactions with him that morning. I do not think it
likely that custody staff inflicted these injuries either deliberately or whilst carrying out
unrecorded restraint procedures. My only explanation is that the man received the
injuries during his collapse onto the hard cell floor.
During interviews with my investigators, the second PCO maintained that he carried
out the check of the man at 1.30pm. A third PCO recorded that check. After
reviewing all of the evidence available to me, I was not persuaded that the second
PCO did in fact carry out that check. During the advance disclosure arrangements
that the Ombudsman has in place1, G4S (the new name for the company that
incorporates GSL) looked again at the evidence surrounding this last check and
concluded that there was no disciplinary case to answer by any of the staff on duty
that day.
In total, I make three recommendations.
1 Advance disclosure of the draft report takes place where individual staff are named and directly
criticised in the PPO report. The service in remit is given the opportunity to respond to the criticisms
before the report is sent out on general consultation.
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THE INVESTIGATION PROCESS
1. I was notified of the man’s death in February 2008 and, after some
consideration of the circumstances, I decided that the case did fall within my
remit to investigate. I appointed one of my investigators. An incident report,
custody documents, and police statements from staff and prisoners, were
made available to my investigator. Further information, including a copy of an
internal investigation carried out by Global Solutions Limited (GSL), was also
made available by the Eastern Area PECS contract manager.
2. During the course of the investigation, my investigator spoke at regular
intervals with the Detective Sergeant (DS) and his investigation team at
Cambridgeshire Constabulary. The DS agreed that my investigator could
begin the investigation after initial police enquiries were complete, and offered
to share information from his investigation. The DS forwarded a copy of all
police statements to my office via Cambridgeshire Constabulary
Headquarters. I am very grateful to the DS for sight of the documentation.
3. My investigator left my office in September 2008 and the case was taken over
by one of my Assistant Ombudsmen. After reviewing all of the evidence, my
Assistant Ombudsman decided to carry out some interviews herself. With the
aid of another of my Assistant Ombudsmen, she interviewed five members of
GSL staff at the end of October, toured the court cells area at Peterborough,
and spoke with the PECS contract manager and the Regional Manager for
G4S (the new name for GSL). The Regional Manager for G4S subsequently
arranged for sections of the company’s Operating Manual to be sent to my
Assistant Ombudsman.
4. HM Coroner was informed of the Ombudsman’s investigation. A preliminary
post mortem report found no evidence of natural disease or traumatic cause
of death. The final pathology and toxicology reports were completed in
December 2008. They are discussed in detail in a later section of my report
but the cause of death was given as “Combined effects of cocaine and alcohol
intoxication”.
5. One of my Family Liaison Officers (FLO) contacted the man’s next of kin
shortly after the investigation was opened. The FLO explained her role and
that of my office and provided information about the investigation process.
The man’s family will receive a copy of my report.
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G4S - GLOBAL SOLUTIONS LIMITED
6. G4S, formerly Global Solutions Limited, is a company is involved in many
business areas, one of which is to undertake prisoner movements into court
custody and the inter-prison transfer of prisoners. GSL took over
responsibility for prisoner transport from the police and Prison Service in
1993. Currently, G4S is contracted by the National Offender Management
Service to operate two of the four contract areas in England and Wales. G4S
employs and trains Prisoner Custody Officers (PCOs) to collect prisoners from
police and prison custody and deliver them to Magistrates, Crown and County
Courts. PCOs then have a duty to receive, process and hold prisoners at
courts until hearings are complete.
7. The company also provides court custody areas with additional staff,
responsible for keeping an electronic log of staff and prisoner actions whilst
prisoners are in G4S’s care. Since being awarded new prisoner movement
contracts in 2004, G4S has operated a computer system called the Prisoner
at Court System (PACS). It is standard practice for one member of staff to be
delegated as the recorder, with responsibility for inputting data on the
computer records, while other staff members carry out the necessary prisoner
contact duties. The recorder enters the actions that another person has
carried out, and at what time. The PACS system automatically records the
time that the data is entered. The system is password operated and it is usual
for other members of staff also to have password access to the system.
8. All G4S staff are trained in first aid to a certificate level. It is standard
procedure to refresh staff training when certificates are close to or have
expired.
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PETERBOROUGH MAGISTRATES COURT
9. Peterborough Magistrates Court was purpose built in the 1970s to hear civil,
adult criminal, youth, and family proceedings. There are two interview rooms
and the custody area has the capacity to hold male and female prisoners
separately. G4S operates the custody services within the court.
10. The last inspection report of the Cambridgeshire Magistrates Courts
Committee (which has since been abolished and its functions assumed by
Her Majesty’s Courts Service (HMCS)) was published in July 2002. In the
report, Her Majesty’s Chief Inspector of the Magistrates Courts Service said
that Peterborough’s courthouse facilities provided reasonable levels of
comfort for users and that the custody area was, in general, adequate for its
purpose. With regard to the facilities to conduct court business with the
appropriate level of privacy, HM Chief Inspector was more critical, and
commented that Peterborough’s interview facilities were unsatisfactory and
lacking in appropriate seclusion.
11. There is a CCTV system at the court which provides coverage of the
communal corridors and external entrances. HMCS does not routinely
provide CCTV cameras in custody areas, although there is a greater
likelihood of coverage in newly built courthouses and where courts have
undergone major refurbishment. There are no CCTV cameras in the custody
suite at Peterborough Magistrates Court. This has meant that the timings of
staff checks on the man could not be verified.
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KEY FINDINGS
The morning of 20 February 2008
12. The man travelled from Wisbech to Peterborough by bus for his court
appearance. His father told the police that he telephoned his family at around
9.30am to say he had arrived. It is not known what the man did next. At
some point that morning, either whilst en route to Peterborough or soon after
arriving, he drank some alcohol. Cambridgeshire Constabulary reviewed
CCTV footage of the courthouse entrance and this captured the man going
into the building at around 9.58am. He was called into courtroom 1 for his
hearing and was dealt with at 10.58am. As noted, the man was sentenced to
seven days imprisonment.
13. Two Prison Custody Officers were then called to courtroom 1 to receive the
man off bail and into custody. The 4th PCO attached himself to the man using
restraints in line with standard procedures. According to the 4th PCO’s
statement to the police (and confirmed during interview with my office), the
man seemed at first to be surprised to be restrained, but was compliant and
chatty.
14. Both PCOs escorted the man from the witness box (unusually, the man was in
the witness box, not the dock), out into the corridor and up the flight of stairs
to the custody area. In her statement to the police, the 5th PCO said that she
spoke with the man and “he seemed fine”. During my investigator’s interview,
the 5th PCO said that, as she walked up the stairs with the man, she asked
him if he had been in prison before and that he had replied, “Yes, a long time
ago.” She said that he had no problems walking up the stairs and that his
speech was normal.
15. At 11.02am, the man was taken into interview room 2, and, in line with normal
procedure, was given a ‘Level A’ search by the 1st PCO, the officer in charge
of the custody area that day. (Several staff were on a training course,
including the senior officer who is normally in charge.) The other staff in the
room were the 2nd PCO and the 4th PCO. (A ‘Level A’ search is a detailed rub
down search of a person. The person being searched is asked to remove
their shoes for examination, but is not required to undress. The search
includes a ‘wand’ passed over the body to check for any metal items such as
needles, foil or blades.)
16. The man was asked if he had anything in his pockets before being asked to
empty the contents onto the table. The 1st PCO recalled in his police
statement that, because the man’s hair was short, he could see there was
nothing concealed. During interview with my investigators, the 1st PCO said,
“I always do wand first in case of needles, razor blades and that. So I wanded
him, had a chat with him at the same time because I’m checking to see if
there’s anything in his mouth, so I’m getting him to speak to me”. (The wand
would first have been checked to ensure that it was working by passing it over
the PCO’s keys.) The wand would have been passed over the man in a
sweeping motion, starting at the collar.
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17. The man was then given a ‘pat down’ search. The 1st PCO said that, because
the man was wearing an olive green hoody, he first checked the hood to
ensure there was nothing concealed within it. He then checked the man’s
shoulder, moving his thumb into the armpit and then passing his hands down
his arm, using a downward motion to ensure that anything hidden would move
downwards. Next, the 1st PCO moved his hands down the sides and front of
the man’s body. As the 1st PCO went to run his thumbs around the waistband
of what the man was wearing, he realised that he was wearing a pair of shorts
underneath the jeans he had on. After checking the waistband and legs of the
jeans, the 1st PCO asked the man to undo his jeans to just above his knees so
that he could check the pair of shorts. Once done, the man was asked to pull
his jeans back up and then to sit down.
18. The 1st PCO described the man as “very, very chilled … he was quite happy”.
During their conversation, the man had said that he had been inside before
when he was a youngster. He said he wanted a cigarette and was
disappointed to learn that the court was a non-smoking building. The 1st PCO
thought that the search would have taken three or four minutes. He recalled
that the man’s breath smelled sweet, as though he had had a drink of alcohol
or chewed “pear drop” type sweets. He said that the man did not appear to
be drunk as he did not slur his words and was steady on his feet. The 1st
PCO did not notice any injuries on the man at the time of carrying out the
search.
19. Although no clothing was removed, any injuries that the man had to his face
and head area would have been clearly visible at this time. The 1st PCO told
the police in a follow up statement on 29 February 2008 that he could not
specifically remember asking the man to remove his trainers in order to
search the tongue, insoles and the man’s feet (the socks are not removed).
However, he said he must have done so because he always did this as part of
the search process. Nothing was found during the search.
20. At the same time, the 5th PCO collected the hard copy Prisoner Escort Record
(PER) from the 3rd PCO who was on reception desk duty that day. The 5th
PCO took the PER into the interview room. The 4th PCO completed the initial
pages of the 2050 record (the record that accompanies a person into prison).
He recorded details such as the man’s full name, home address, date of birth,
description, and next of kin information.
21. This was also the time when the 4th PCO assessed the man generally. In
interview, he said that the man appeared to understand the process, was able
to give all of the relevant information, and did not appear to be under the
influence of drugs or alcohol. The 4th PCO said he observed the man’s
general mannerisms, looked at his arms for signs of any previous self harm,
and asked whether he had any worries.
22. The man told the 4th PCO that he had done a sentence in a young offender’s
institution (his family say this was in Norwich), and that he was fine about
going to prison and not bothered about it. The PCO said that they chatted
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23. In his interview, the 2nd PCO described the man as a “cheeky chappie” and
said he had no concerns about him at all. He did not appear to be worried or
concerned about being in custody. The 2nd PCO told my investigators that he
did not recall smelling any alcohol on the man’s breath, and that he did not
remember seeing any injuries or bruising on his face.
24. When interviewed by the police, the 3rd PCO said that all the information she
had about the man was then recorded on the electronic version of the PER.
She booked the man into custody by telephone (under Operation Safeguard)
with the Operational Control Centre at Wakefield. The control centre
arranged for the man to be transferred to the custody of a local police station,
Bridge Street Police Station. The 3rd PCO recalled that the man did not ask
where he was going next. This was “a little unusual”.
25. Around 11.10am, the man was taken to the male side of the custody area by
the 4th PCO and allocated cell 4. The remaining paperwork was completed
and his transport to the police station was arranged. The 5th PCO told the
police that it was the policy to locate prisoners in single cells when possible.
There were only three prisoners in the custody area that day and so they were
accommodated separately.
The afternoon of 20 February
26. The 5th PCO went into the ‘crew room’, which is a communal staff area next to
interview room 1 around lunchtime. She saw the 3rd PCO who told her that,
apart from the man and the two occupants of cells 6 and 7, there were no
other prisoners due in that day. When interviewed by the police, the 5th PCO
described the day as quiet. On the day that my Assistant Ombudsmen
visited, there were 12 people in custody and they were told that this is a more
typical number.
27. According to the electronic PER, the man was next seen as part of the lunch
rounds at 12.23pm by the 1st, 2nd and 4th PCOs. The man was offered a
packed lunch and a drink. He declined the food but did accept a cup of tea
and water. The 4th PCO told the police and GSL’s internal investigator, who is
a Custody Team Leader, that the man appeared to ‘rock’ on his feet. He said
that this reminded him of how someone under the influence of alcohol would
move in an attempt to steady themselves. The 4th PCO went on to say that
the man only did this once, and that he could not say he had been drinking as
there was no alcohol smell on his breath, nor was his speech slurred.
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28. During interview with my investigators, the 4th PCO clarified that it was as the
man came to the cell door and took his cup of tea that he rocked back, as
though he had lost his balance. He recalled asking the man if he was alright
and that he had replied, “Yes.” The 4th PCO said it is not unusual for
prisoners to decline the lunch (a packed lunch of sandwiches, crisps and a
chocolate bar) and that this is simply relayed to the person entering the
information onto PACS so the food refusal is recorded. In this instance, the
entry was made as “Food and drink given”, so the food refusal was not
recorded. The 1st PCO brought a cup of water and told the investigators that
the man had a big grin on his face as he gave it to him. He thought that it was
when the man had his cup of tea in one hand and went to get the cup of water
with his other that he became unsteady on his feet for a second. The 1st PCO
said it might have been that he “tripped over himself”. All three PCOs then left
the cell and the 2nd PCO closed the door behind him.
29. Around 12.30pm, the 5th PCO left the courthouse with the 3rd PCO to buy
some food. Both told the police that they bought their lunch at 12.45pm and
returned to the custody area at the court around five or ten minutes later. The
4th PCO told my investigators that he sat in the crew room with the 1st and 2nd
PCOs eating their meals. The 5th and 3rd PCOs arrived back at the crew room
around 12.55pm. None of the staff said that they recalled hearing any cell
bells during the lunch period, and they were confident they would have heard
the audible buzzer had one gone off. No routine checks were carried out by
staff during the lunch period. Around 1.15pm, the 1st PCO was called over to
Peterborough Crown Court to deliver some vegetarian sandwiches to one of
the prisoners being detained there.
30. The 4th PCO went downstairs with the 1st PCO at about 1.20pm in order to
unlock the doors. (No member of staff is permitted to leave the court with
their keys for security reasons.) He remained outside for a short while in the
fresh air, returning between 1.30pm and 1.35pm just as “the buzzer went off”
for a prisoner who wanted to use the toilet. The 5th PCO stayed in the crew
room on her own while her colleagues went back to the custody and cell
areas. She thought that the 2nd and 4th PCOs had gone to interview room 1
(next to the male cells area). In fact, only the 2nd PCO was there as the 4th
PCO had gone downstairs to let the 1st PCO out to go to the Crown Court.
The 3rd PCO had gone to the PACS terminal at the front desk.
31. According to the electronic PER, the 2nd PCO checked the man’s cell at
1.30pm and spoke with him. (The electronic PER for one of the other
prisoners in cell male 7 also recorded a cell check time of 1.30pm.) The 4th
PCO was downstairs at 1.30pm. The 1st PCO was at the Crown Court. The
5th PCO was in the crew room. Only the 2nd and 3rd PCOs were in the
custody area.
32. According to the electronic PER, another prisoner in cell 6, was “spoken to” by
the 2nd PCO at 1.30pm. In his police statement, the prisoner thought that he
was in cell 6 and that this cell was immediately next to the man’s cell. The
prisoner was unsure of the exact time, but thought he was taken into court at
about 11.00am. (The PER states he was taken to court room 1 at 11.41am.)
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33. When my investigators spoke with the 2nd PCO, he said that he did carry out
the cell checks at 1.30pm. He could not recall why he had decided to do a
check at that time, just that he had. G4S indicated that it is standard practice
for an officer to undertake cell checks because they are due or for the
reception officer to remind officers cell checks are required. The 2nd PCO said
he opened the hatch, asked the man if he was okay, and that he had said
“Yes.” My investigator asked the 2nd PCO why, as the last person to see the
man alive at 1.30pm, he had not mentioned this in his statement to the police.
The 2nd PCO replied, “I only answered the questions that the police officer
asked me.” My investigator asked the 2nd PCO to try to recall exactly what the
man had been doing when he made the check at 1.30pm – for example, if he
was standing up, sitting down, or lying on the bench. She also asked if the
man was chatty, whether he smiled, and how he looked. The 2nd PCO said
he could not remember. He said that he presumed there were other PCOs
about. In fact, there were no other staff in the cells area.
34. The 4th PCO said that, when he came back upstairs and in through the main
door, he thought the 3rd PCO was at the desk (where the PACS terminal is)
and the 2nd PCO was sitting in interview room 1 (immediately adjacent to the
male cell area). A buzzer went off and 2nd and 4th PCOs responded.
35. Another prisoner, (cell 7), had pressed his buzzer because he needed to use
the toilet. In his police statement, the 2nd prisoner said this was at about
1.30pm, or shortly afterwards. The toilet is in the entrance to the cell area. It
is customary for two officers to unlock the prisoner and then wait just outside
the cell area (with the door closed to ensure privacy) whilst the prisoner uses
the toilet. Both PCOs stood just outside the cells area for two or three
minutes. At interview with my investigator, the 4th PCO said he did not
remember hearing any unusual noises or banging during these minutes and
no one else pressed their buzzer. The 2nd prisoner did not hear anything
either (the toilet area is immediately adjacent to the man’s cell). The other
prisoner was asleep in his cell and did not hear any noises. The 2nd PCO said
during interview that he thought he “heard a bang” but he could not say where
it had come from. When asked to clarify, the 2nd PCO replied, “I think I did but
I can’t say I’m 100 per cent sure on that.” The 2nd prisoner was then locked
back in his cell and the 2nd PCO commenced a visual check of the other cells.
36. The 2nd PCO said that when he reached the man’s cell he looked through the
observation panel and saw him lying face down. The 2nd PCO shouted to the
4th PCO “In here now,” then unlocked the door and both PCOs entered the
cell. The 4th PCO saw the man lying face down, with his head towards the
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37. The 2nd PCO knelt down beside the man and noticed that he had blood
around his nose. The 4th PCO said they began to roll the man onto his side
into the recovery position. Both PCOs said the man’s body did not feel rigid
as they did this. The 4th PCO said the man had some blood on his face.
38. According to the PER, the ambulance was called at 1.39pm by the 3rd PCO.
She shouted to the 5th PCO in the crew room for help. As the 5th PCO
entered the man’s cell, the 2nd PCO asked her to fetch some wipes. After the
2nd PCO used the wipes, the 4th PCO said he could see that the man’s lips
were blue. The man was then put onto his back and the 2nd PCO began chest
compressions whilst the 4th and 5th PCOs went to get a resusci-aid (a device
to protect someone giving mouth-to-mouth). The resusci-aid is kept in the first
aid box in the manager’s office (a few metres from the entrance to the cells
area). The 4th PCO told my investigators that he initially struggled to get the
plastic seal off the box, but then got it open and the 5th PCO took the
mouthpiece out.
39. During interview with my investigator, the 5th PCO said, “What I remember
about the first time I saw the man … were his hands, his hands were
clenched… both his hands.” She estimated that they took less than a minute
to collect the medical equipment.
40. When the 5th PCO returned to the man’s cell, she began to administer two
breaths to every set of chest compressions the 2nd PCO carried out. Both
PCOs said they heard a gurgling sound coming from the man and tilted him
onto his side. As they did, a small amount of fluid drained from his mouth.
The staff then rolled him onto his back and administered another set of chest
compressions and breaths. The 5th PCO said she could not see the man’s
chest rising as she gave him the breaths. The 5th PCO thought they had
rolled the man onto his side three times.
41. Meanwhile, the 4th PCO had asked the 3rd PCO to ask the 1st PCO to return to
the Magistrates Court. The 4th PCO said he would go downstairs to the van
area and open the doors, ready for the ambulance staff. It took the 1st PCO
approximately two minutes to get back and he saw the 4th PCO on the way in
through the vehicle area. The 1st PCO entered the custody suite, took some
gloves out of the drawer, and went into the man’s cell. He took it in turns to
administer chest compressions with the 2nd PCO whilst the 5th PCO was doing
mouth to mouth. He tried to rouse the man by shouting his name and rubbing
his arms and hands. The 1st PCO told my investigators that he was not able
to open up the man’s hands. He said two of his fingers had come up and he
could not get them down and they appeared to be “locked”. In his police
statement he said the man’s “fingers on both hands were scrunched up, finger
tips coming towards the palm of his hand and his fingers looked blue.” The 1st
PCO patted the man on the back to try to remove any obstructions from his
airway and rubbed his arms in order to try and rouse him.
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42. The first paramedic arrived in the downstairs van area at 1.45pm and got to
the cell two minutes later at 1.47pm. He told the 2nd and 5th PCOs to continue
CPR while he got his equipment in place. The paramedic also asked the 1st
PCO to cut the man’s clothes from his torso and then took over CPR from the
officers. The ambulance team arrived at 1.50pm. The 4th PCO said that
another ambulance team also arrived in the downstairs van area. The
ambulance crews took over efforts to resuscitate the man.
43. The Patient Report Form completed by the East of England Ambulance
Service records that they were called by 999 at 1.41pm and arrived at
1.45pm. They noted that the staff said they last checked the man at 1.30pm
and found him in cardiac arrest at 1.38pm. The form indicates that the
paramedics found that the man had no pulse, his skin was cyanosed and
cold, and that his pupils were unreactive and dilated. There was a small
amount of blood coming from his nose. They tried unsuccessfully to gain
access to a vein so that drugs could be administered. The man remained in
asystole (when there is no cardiac electrical activity) throughout their efforts,
and was recognised as dead at 2.07pm. The form records that one of the
man’s shoes was off when the paramedics arrived and that they removed the
other shoe and his clothing during their efforts to resuscitate him. The
paramedic completing the form wrote, “All ambulance staff agreed patient
appeared to have been in cardiac arrest longer than told given his colour,
marks to knees and rigidity of arms and legs.”
44. During interview, the 5th PCO said that she recalled the paramedics removing
a shoe from the man and “doing something to his toes”. The 5th PCO said
she had felt confident about using resuscitation techniques.
45. The 5th PCO asked the paramedics if she could go back into the cell where
the man lay after he had died. One of the paramedics accompanied her. She
wanted to say a prayer for the man. Her reason for wanting to do this was
because she did not want his mother to feel that he was all alone and that
nobody had cared. She said a prayer over the man and then left the cell.
Events following the man’s death
46. The 3rd PCO first telephoned GSL’s contract manager to notify him of the
man’s death. As the contract manager was in a meeting, the 3rd PCO spoke
to a person at GSL’s vehicle base to ask for assistance. The person made
her way to Peterborough Magistrates Court and helped The 3rd PCO deal with
telephone calls and the necessary paperwork following a death in custody.
47. The police arrived at approximately 2.30pm and began to take statements
from the staff on duty and the prisoners in the other cells. The police doctor
arrived in the custody area at 3.50pm and pronounced the man dead at
4.19pm. The man’s family were told of his death by a police family liaison
officer.
15
48. The following week, a debrief session was held for staff who had been on
duty. The 1st PCO said that he had found this session very good. He also
said that he felt very supported by management, and that he had been rung at
home and offered support. The 4th PCO said that on the following Monday he
spoke with some counsellors. He said that he felt GSL were there if needed,
but he did not know what else they could do.
49. On 29 February, both the 1st and 2nd PCOs gave further statements to the
police. In his follow up statement, the 2nd PCO confirmed that, when he
entered the man’s cell, he noticed that one of his white training shoes had
either been taken off or had come off, but that the man was wearing his other
shoe. The 2nd PCO explained that he did not know why the man was only
wearing one shoe, and confirmed that he had not removed his other shoe
during the course of administering CPR. In the 1st PCO’s follow up statement,
he gave a full description of what constituted a Level A search.
50. Shortly after the man’s death, GSL’s contract manager carried out an internal
investigation on behalf of GSL. GSL’s contract manager spoke to all the staff
on duty on 20 February and formed a picture of what happened to the man in
the few hours he was in the care and custody of staff. GSL’s contract
manager concluded that the man should have been checked more often than
he was. He made a recommendation reminding staff of the Standard
Operating Procedure that requires staff to carry out and record a minimum of
two checks per hour on all prisoners in court custody cells.
16
ISSUES
The post mortem and toxicology reports
51. A doctor carried out the toxicology tests on the man’s blood and urine. The
levels of ethanol in the blood and urine were 102mg/100ml and 165mg/100ml
respectively. The level of cocaine in the man’s blood was 217µg/l and in his
stomach, 12.4mg/l. The level of benzoylecgonine in his blood was 487µg/l.
Some cocaine metabolites were also present in the man’s urine (including
cocaethylene). No other drugs were detected. The toxicologist commented
that, “These results suggest likely social level use of alcohol and use of
cocaine in the hours prior to death.”
52. The post mortem was carried out by a Consultant Forensic Pathologist. The
man’s heart, lungs, liver, kidney and brain showed no signs of underlying
disease, and the pathologist concluded that there was no evidence of natural
disease that caused or contributed to his death.
53. The pathologist noted several marks of recent injury on the man’s body. He
recorded swelling of the left scalp, some bruising above the left eyebrow,
bruising and an abrasion above the right eyebrow, bruising down the bridge of
the nose, bruising and small abrasions around the mouth and lips, and
bruising and an abrasion on the chin. The man also had bruising around his
elbows, forearms, the front of his knees and on the front of his shins. His
back also had some bruises. The pathologist’s conclusion was,
“There are signs of trauma with evidence of multiple impacts to the
head / facial area including the nose. I cannot exclude the possibility
that some of these may represent marks of assault. However, given
the amount of bruising around the elbows and knees, it may well be the
case that these are due to repeated falls. Bruising identified over the
back may well also be due to a fall or falls. However, on the basis of
anatomical findings alone, I cannot exclude the possibility that they
occurred as a result of restraint at some stage.”
The pathologist noted the findings of a neuropathologist, who “described
features suggestive of mild to moderate non-fatal head injury”.
54. Continuing his conclusions, the pathologist wrote:
“In my opinion there is no evidence of any direct traumatic cause of
death … there is evidence of mild alcohol intoxication and recent use of
illicit cocaine whilst alcohol intoxicated … on the face of it they suggest
that there has been use of cocaine whilst at Court. In relation to
alcohol there is likely to have been a greater degree of intoxication
prior to attending Court with the final level detected at the time of death
reflecting a falling blood level …”
(This is supported by the higher urine alcohol level versus the blood alcohol
level.)
17
55. The pathologist suggested that the toxicological findings about alcohol and
cocaine use needed to be reconciled and that further information should be
sought in relation to the likely timing of the man’s facial and other injuries. He
said that they may relate to an earlier period of substantial alcohol intoxication
many hours before death.
56. In the concluding paragraph of his report the pathologist stated, “In my
opinion, it is likely at least on the balance of probability that the deceased died
of combined effects of cocaine and alcohol intoxication most likely through the
development of a cardiac dysrhythmia [when the heart beats either very fast
or very slow, or irregularly]. If the deceased was known to have chronic
alcohol abuse problems then a fatal seizure associated with alcohol
withdrawal and exacerbated by cocaine would be another possible mode of
death.” At draft consultation stage the man’s sister said that he did not have
alcohol abuse problems and that he would not be suffering from alcohol
withdrawal.
57. Blood alcohol concentration (BAC) is the concentration of alcohol in a
person’s blood. The number of drinks consumed is a poor measure of BAC,
largely because of variations in weight, sex and body fat. However, it is
generally accepted that the consumption from sober of one standard drink of
alcohol (that is 14 grams / 17.74ml ethanol content) will increase the average
person’s BAC roughly 0.02% to 0.05% and would return to 0% about one and
a half to three hours later.2 The United Kingdom legal limit for drivers is 80mg
of alcohol per 100ml of blood (0.08% expressed as BAC) or 107mg alcohol
per 100ml urine.
58. The man’s blood alcohol level at the time of his death was 102mg/100ml and
his urine level 165mg/100ml. He was therefore over the legal driving limit for
alcohol. An average person with a BAC of 0.102% would be more extrovert
and uninhibited in their behaviour. They would have impaired reflexes,
reasoning, depth perception and distance acuity, but the average person
would not be slurring their speech, staggering or having emotional swings of
behaviour.3 The 1st PCO said that he smelled something ‘sweet’ on the man’s
breath when he was speaking to him in the interview room shortly after
11.00am. He said, however, that the man did not appear to be drunk as he
was not slurring his words and was steady on his feet.
59. A pre-sentence report was written in October 2002 after the man had been
convicted of actual bodily harm. That offence had occurred as the man left a
public house after consuming about seven or eight pints of strong lager during
the course of the afternoon and evening. The man recognised that alcohol
was a contributory factor in the offence he committed, but said he was not
alcohol dependent. This information is clearly several years old and my
investigator does not know the extent to which the man’s drinking behaviour
may have changed subsequently. However, it is not suggested that the man
2 Taken from Wikipedia.com
3 Taken from Wikipedia.com
18
had drunk more than a moderate amount of alcohol before arriving at court on
the morning of his death.
60. The man took cocaine at some point during his time in court. My investigator
looked into how a person can collapse from the use of social levels of alcohol
and cocaine. Clinical data indicates that the concurrent use of alcohol and
cocaine is associated with increased risk of death from cardiovascular
complications, hepatotoxicity (chemical driven liver damage), and behaviour
leading to personal injury. The increased risk from the combined use of
alcohol and cocaine is enhanced by the formulation of a third compound,
ethylbenzoylecgonine (also known as cocaethylene). The toxicity of this
compound is greater than cocaine and its effects last longer on the body.4
Cocaethylene was identified as being present at the post mortem for the man.
Because the man did not die from personal injury or hepatotoxicity, the
pathologist concludes that the man is likely to have died from cardiac
dysrhythmia.
61. There is nothing to indicate that the man intentionally took his own life or that
he was even aware of the increased risk he was putting himself under by
taking cocaine when he was already under the influence of alcohol. The man
had no history of self harm or suicide attempts, and had appeared at ease
with coming into custody that day.
Bruising and injuries noted at post mortem
62. The post mortem report indicates that the man had bruising around his head
and facial area, back, elbows and knees. The pathologist indicated that they
may have been due to a fall or repeated falls, but he was unable to exclude
the possibility that they occurred as a result of restraint at some stage.
63. The police specifically asked the 1st and 4th PCOs, who were in the interview
room at the time that the man was searched, whether they remembered
seeing any marks or bruising. None of the PCOs my investigators spoke with
recalled any injuries visible on the man. The 1st PCO would have been best
placed to give an accurate account of any injuries to the man’s face and head
area as he was the officer carrying out the Level A rub down search. There is
no indication that the man had any injuries on his face at 11.00am, when this
search was carried out. The rub down search is a search with all clothes on
and so staff would not have been aware of whether the man had injuries to his
back, elbows or knees, but there was nothing in his demeanour to indicate
that he did.
64. The 1st, 2nd and 4th PCOs saw the man again at around 12.20pm, when they
were giving out the lunch packs. They did not report seeing any injuries to the
man’s head or face at this time.
65. There was no indication during my investigators’ interviews with the members
of court staff on duty that day that the man may have been involved in some
4 Taken from Emedicine.com
19
sort of unrecorded restraint procedure. The man, by all accounts, was easy
going and compliant with staff; a “model prisoner”. There does not appear to
have been any reason why any member of staff would have needed to
physically restrain the man, much less to have done so and then decided not
to record it via the appropriate mechanisms. When PCOs enter the cells area
they normally do so with another officer. There is usually a third PCO at the
desk immediately outside the cells area making entries in the PACS system. I
find it hard to believe that all these staff would have colluded to ‘cover up’ a
restraint or assault. The only time that this area was not staffed during 20
February was over the lunchtime period between 12.20pm and 1.30pm.
66. During this time the actions of individual staff have been described in their
statements – two had gone to buy their lunch from a local store, and the
others sat eating their lunch in the crew room before being joined by the other
two members of the team. There is no indication that anyone left for any
period of time and there were no unusual noises or buzzer presses from the
cells area. There is nothing in the police statements given by the other two
prisoners in the custody suite to suggest that the man was assaulted during
this lunchtime period. I therefore conclude that the man did not receive the
bruising to his body or facial area as a result of staff assault or restraint once
he was in the custody of the court.
67. I therefore have to speculate as to how the man may have come about his
body and facial injuries. Perhaps he fell to the ground very heavily as he
collapsed, landing face down with his knees, elbows and face taking the brunt
of the impact onto the cell floor. Perhaps he was able to get up but then
collapsed for a second time. (The timing of the man’s collapse is something
that I will discuss later in this report. Suffice to record here that such a fall(s)
would have made a certain amount of noise.)
Searching the man in interview room 2
68. The 1st PCO searched the man using routine Level A search techniques. This
is in accordance with Standard Operating Procedures for searching prisoners
in court custody. In his statements to the police, the 1st PCO detailed the
extent of his search and confirmed that, although he did not remember
specifically checking the man’s footwear, he would have done this as a matter
of course. Because one of the man’s trainers was off when the PCOs
attended his cell, it is possible that the cocaine that the man took at some
point had been hidden in his trainer or sock (although no wrapping or
container was found by the police). The paramedics recorded that they
removed the other trainer during their efforts to resuscitate the man.
69. I judge that the rub down search described by the 1st PCO followed the
guidelines given by GSL for carrying out this type of search. Whilst my
investigators were visiting Peterborough Magistrates Court they spoke with
the PECS contract manager and the Regional Manager for GSL. Both said
that it was rare to carry out a full search (that is, removing a person’s
clothing). According to the Operating Manual, a full search is only carried out
“in exceptional circumstances”. The Manual indicates that, when a full search
20
70. The Prison Service routinely carry out full searches of all adult men before
they leave prison to go to court. Those coming from home, off bail and into
court custody, receive a rub down search by court custody staff. Whilst there
is no guarantee that someone who is full searched has no hidden items, it is
plainly easier to conceal things about your person when your clothing and
underwear are not removed during searching. In a recent report into the
death of a man in another court, I asked G4S to consider whether to adopt
new procedures for those people who come off bail into custody. I asked
them to consider whether a full search would be appropriate in these
situations or whether an ‘enhanced’ rub down could be adopted, whereby the
person was asked to remove their shoes and socks for checking.
71. G4S responded to the recommendation in that report by saying that they did
not think a Level A (rub down) search could be extended in the way the report
suggested. Legal advice is that the removal of socks as part of a Level A rub
down search would constitute a more intrusive search than the standard
procedure. For this reason prisoners should not be asked to remove their
socks routinely but rather where there is intelligence or reasonable suspicion
that an item of contraband has been concealed and where it is considered to
be necessary and proportionate response. It would be difficult to justify the
routine removal of items of clothing as part of a rub down search as it would
begin to blur, unacceptably, the distinction between rub down search and a
full search. Finally it would be very difficult to sustain different definitions of a
rub down search at different places in the custodial system. A Level A search
is designed to be conducted in the same manner whether it is conducted by
prison staff in a prison or PCOs at court. Consistency is important in this
context, a different standard of rub down search would be practically and
legally difficult to justify.
72. I do not therefore repeat that recommendation here. The man did not display
behaviour during his booking in procedures that should have triggered the
threshold for a full search.
Single cell occupancy
73. The 5th PCO confirmed that it was GSL operating policy to locate prisoners in
single cells when possible. The exception is if the custody area is busy when,
through lack of space, prisoners are ‘doubled up’ (have to share a cell). Little
was known about the man when he was taken off bail and into the custody of
GSL staff. He was, therefore, not considered to be a risk to himself or others.
On the morning that the man was taken to cell 4, there were only two other
prisoners in the custody area and the 5th PCO told police that staff were
21
Regular checking of cells
74. During interview with my investigators, the 5th PCO explained that it is
normally herself or the 3rd PCO who works the PACS computer system. The
system allows the operator to record information against individual prisoners
and groups of prisoners. For example, the operator could record “prisoner
seen and spoken to” as a group instruction against every prisoner, rather than
having to make several individual entries. The 5th PCO said that, when the
officer comes out of the cells area and tells her about a check or toilet visit,
she records the officer’s name next to the entry about that prisoner.
75. In her statement to the police, the 3rd PCO gave a full explanation of the
PACS system, and her role as recorder. When asked by my investigators
how many checks on each prisoner was routinely required each hour she
replied, “it’s two or three times an hour”. She went on to explain that when a
PCO goes into the cell area to answer a buzzer, they generally check all the
other prisoners at the same time. The 3rd PCO added:
“If we haven’t had need to go in there for 15, 20 minutes, the desk
officer will usually say, ‘Oh I’ll need some cell checks,’ and then
somebody will go in and do them.”
The 3rd PCO told my investigators that she would only record a cell check
when someone told her that they had done one.
76. The 1st PCO told my investigators that after doing a check on prisoners you
go to the PACS person and shout out, “Cell check, such and such person,
sitting, standing, reading, appears to be asleep (as appropriate).”
77. The GSL Standard Operating Procedures (Edition 1, August 2004) sets out
the minimum requirements for carrying out cell checks. Paragraph 4.1.11
says the following:
“Staff are responsible for the continuing care of all prisoners and will check
all prisoners in their custody, both during escort and at court, to ensure
that their general welfare and well-being is being maintained. Prisoners
not subject to any special arrangements or risks will be checked at
irregular intervals with a minimum of two checks per hour …”
78. During interview with my investigators, the 2nd PCO said that he had read the
Standard Operating Procedures when he first started working for the
company, but that he was not very familiar with its contents. He did know of
the requirement to carry out two checks per hour on those prisoners who are
not deemed to need special monitoring. The instruction about cell checks is
22
79. According to the electronic PER on the PACS system, the man spent two
hours and 23 minutes in cell 4 before he was found collapsed. He was initially
located in the cell at 11.14am. He was seen again at 12.23pm when the
lunch packs were being given out, one hour and nine minutes after being put
into the cell. According to the electronic PER, the man was then seen twice in
quick succession, once at 1.30pm, and again at 1.38pm. The latter check on
the man was carried out when the 2nd PCO returned another prisoner to his
own cell, having escorted him to the toilet. My investigator compared the
man’s irregular checking times with those of another prisoner located in cell 7,
and found that the checking times, specifically over the lunchtime period, were
the same for both men.
80. The 3rd PCO explained that when she went out to lunch with the 5th PCO, her
colleagues (the 1st, 2nd and 4th PCOs) remained to carry out cell checks and
ensure that the prisoners were given lunch. The 3rd PCO returned from her
lunch at around 12.55pm. Her statement did not say when she resumed her
duties at the reception desk, but it did confirm that, when checks are carried
out, her colleagues inform her and she records the action and the name of the
PCO. In recalling the man’s cell checks, the 3rd PCO said, “All the updates I
put on the man’s log were completed within five minutes of me being told the
update by the PCO, I do not believe there were any delays in why this
information would not have been put on straightaway.”
81. The man was a normal risk prisoner and should have been checked at least
twice an hour, every hour. It is not clear why the man was not checked
between 11.14am and 12.23pm, when two checks should have been made.
No cell checks were made over the lunchtime period, between 12.23pm and
1.30pm. A further two checks should have been made during this period.
82. It was not clear during my investigators’ interviews who was accountable for
ensuring the minimum number of checks were carried out – the PACS
recorder or PCOs covering the cells area. The former is best placed to know
when the last check was made because the electronic record is directly in
front of them. I accept the account from staff that Wednesday 20 February
2008 was an exceptionally quiet day, with only three prisoners in the custody
area. This would inevitably mean that the number of visits to cells, for
example to answer cell bells, unlock for using the toilet, asking for a drink, or
solicitor meetings, would be reduced. If the routine checking of all the other
prisoners is usually done at the same time as these activities then I can see
why checks were missed on this day. However, I do not find this acceptable.
Fewer prisoners in the cells meant that staff were less busy than usual, and
so had less justification for overlooking the mandatory twice hourly checks.
Staff spent too much time in the crew room over the lunch period, and no one
23
G4S managers should ensure that the minimum of two cell checks per
hour are carried out by court custody staff in accordance with
paragraph 4.1.11 of the Standard Operating Procedures.
G4S should revise the local instructions given to staff working within
Peterborough Magistrates Court and replicate key requirements from
the Standard Operating Procedures so as to make them more accessible
and user friendly for staff.
The 1.30pm check
83. There are discrepancies between the statements that staff gave to the police
and the GSL internal investigator. The discrepancies are centred on whether
the man’s cell was checked at 1.30pm. None of the PCOs on duty that day
referred to the man’s cell check at 1.30pm when they were interviewed by the
police, just a few hours after his death. As I have mentioned, the PER stated
that the 2nd PCO carried out a check at 1.30pm, but he failed to mention this
check in his police statement. This check was recorded by the 3rd PCO.
84. During interview with my investigators, the 3rd PCO said that two PCOs
normally go into the cell complex together in case a cell needs to be opened.
She said, “You don’t want to put yourself in a position where you’re one on
one with a prisoner”. G4S responded that it was standard procedure for a
single officer to perform cell checks which require the officer to open cell
hatches and check individuals and that it is only when the cell door needs to
be opened that two officers are required.
85. The 2nd PCO said that, when carrying out a cell observation he would open
the hatch and say something like, “Are you alright?” If he got a response he
would shut the hatch and walk on. If the person was lying on the bench and
looked asleep, he normally opened the door and asked if the person was
okay. The 2nd PCO said that he always obtained a response of some sort
before moving on.
86. The PACS entry was made by the 3rd PCO at 1.30.39pm. During interview
with my investigators, the 3rd PCO confirmed that the entry would only have
been made in response to the 2nd PCO coming out of the cells area and telling
her that he had seen and spoken with the man. When asked whether she
could actually recall the 2nd PCO going into the cells area at that time she
said, “No, I don’t think I can. But he must have done because I put it on
PACS. Its months ago.” Regrettably, my interviews were not carried out until
October 2008 and so it is understandable that some detailed recollection of
the exact sequence of events had been forgotten. However, the 3rd PCO’s
police statement, made only a few hours after the man’s death, did not
mention the 1.30pm check. The 3rd PCO detailed only the time that the man
was found collapsed by both the 2nd and 4th PCOs at 1.38pm.
24
87. The PACS system also recorded that a check was made on the 1st prisoner in
cell 6 at 1.30pm, and indicated that the 2nd PCO saw and spoke with him. In
his police statement, the 1st prisoner said that after his court appearance at
12.00pm he returned to the cells area, fell asleep, and heard nothing else until
he was woken by staff to move to another cell. The PACS system recorded
the time he was moved to the female side of the custody area as 2.12pm.
This account casts doubt on the PACS entry that the 1st prisoner was “spoken
to” by the 2nd PCO at 1.30pm. The 1st prisoner indicated in his police
statement that he was asleep at this time. The 2nd PCO told my investigators
that, in such situations, he normally opens the cell and gets a response from
the prisoner who appears asleep. If this did happen, it would have meant the
2nd PCO opening a cell alone, as no other PCOs were in the custody area. If
the cell had not been unlocked, the check should have indicated that the 1st
prisoner “appeared asleep” on the PER record and not that he was “spoken
to”. If the 1st prisoner had been awake at 1.30pm, he would most surely have
heard the ensuing shouts and commotion after the man was found collapsed
a few minutes later and his police statement would have reflected this.
88. During the course of GSL’s own internal investigation, GSL’s contract
manager interviewed the same members of staff, including the 1st, 2nd and 4th
PCOs. In the 2nd PCO’s statement , made eight days after the man died, he
said,“... on the next cell check, I remember speaking to him, but can’t
remember what was said at approximately 13.30hrs.”
89. The 2nd PCO also said in his statement to GSL that the man was of no
concern to him at 1.30pm, and that his next contact was at around 1.36pm
when the man was found on the floor. The 2nd PCO said, “… at approx [sic]
13.36hrs I carried out a cell check on the man by opening the hatch and saw
him lying face down on the cell floor.”
90. His statement to the police suggested that the only check he made after the
lunch run at 12.23pm was the one recorded at 1.38pm on the PER. His
statement flows straight from the lunch run to the check when the man was
found collapsed. I find it difficult to understand why a crucial check, just seven
or eight minutes before a man was found collapsed and not breathing, was
not mentioned to the police. If it was the case at 1.30pm that the man was
fine and well, the 2nd PCO would surely have told police when recounting
events just a few hours later. However, during interview with my
investigators, the 2nd PCO said that he only answered the questions the police
put to him directly. During advance disclosure, G4S said that the police
drafted the staff statements and then asked the PCOs to check them. When
the custody staff were checking the statements, “they did so checking for
accuracy rather than omission”.
91. The 2nd PCO was asked by my investigators whether he could remember
where the man was in the cell at the 1.30pm check or how he had appeared.
The 2nd PCO said he could not remember any details, just that the man had
said he was okay. During discussions later on, the 2nd PCO made reference
to that fact that he had ‘re-lived’ the events of that day many times in his head.
It does therefore surprise me that the 2nd PCO was unable to recall any details
25
92. The ‘check’ at 1.30pm was of course recorded electronically, and the 3rd PCO
said during interview that she would only have made that entry in response to
being asked to do so by the 2nd PCO. But no other PCOs observed the
checks, or were even present in the cells area. The other two prisoners do
not mention being checked at 1.30pm in their statements to the police.
93. Rigor mortis5 is the stiffening of the body after death because of a loss of
Adenosine Triphosphate (ATP) from the body's muscles. ATP is the
substance that allows energy to flow to the muscles and help them work, and
without this the muscles become stiff and inflexible. Rigor mortis begins
throughout the body at the same time but the body's smaller muscles - such
as those in the face, neck, arms and shoulders - are affected first. Rigor
mortis normally appears within the body around two hours after death, with
the facial and upper neck and shoulder muscles first to show its effects.
94. My investigator found other references to rigor mortis that indicated it can start
as quickly as ten minutes after the person has died, but that one to two hours
is more usual.
95. When the man was found collapsed and not breathing at 1.38pm, the 1st and
5th PCOs both described some degree of stiffness in the man’s hands and
fingers when they were attempting to resuscitate him. The 1st PCO described
the man’s hands as being “scrunched up” and “locked”. The 5th PCO said his
hands “were clenched”. Although I am not medically qualified, I interpret
these descriptions as indicating that rigor mortis had started to set in. This
would lead to an estimate of the man’s time of death as being at least before
1.30pm, and in all likelihood some considerable period beforehand.
96. The East of England Ambulance Service Patient Report Form was completed
by a paramedic. It indicates that the paramedics were called at 1.41pm and
arrived at 1.45pm. In the section of the form headed, “History / Mechanism of
Injury”, he has written, “Cardiac arrest. Last checked 1330. Found in cardiac
arrest 1338. Patient had been found face down with blood from nose.” The
form goes on to show that the man was cold and cyanosed (a bluish colour of
the skin due to insufficient oxygen in the blood) and that both his pupils were
unreactive and dilated. The paramedic was unable to gain access to a vein in
order to administer medication. In the comments section of the form, the
paramedic wrote:
“… ECG asystole [no electrical activity in the heart]. CPR continued …
patient in asystole throughout … all ambulance staff agreed patient
appeared to have been in cardiac arrest longer than told given his
colour, marks to knees and rigidity of arms and legs.”
5 Explore Forensics (UK) website
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97. The report makes it clear that several medically trained professionals were all
of the view that the man had been dead for longer than the court staff told
them.
98. If the 1.30pm check was carried out by the 2nd PCO, then the man must have
collapsed and stopped breathing at some point within the following eight
minutes. A fall or falls heavy enough to cause considerable bruising to the
face, elbows, knees and back must have made some noise on the hard cell
floor, a noise that staff or prisoners just a few metres away would seem likely
to have heard. There were only three prisoners in the cells area that day, one
of whom was asleep, so there would have been only low levels of background
noise. During interview with my investigators, the 2nd PCO thought he might
have heard a “bang” whilst the 2nd prisoner was using the toilet, but the 4th
PCO did not remember hearing anything. If this “bang” that the 2nd PCO
might have heard was the man’s collapse, that would put the timing of the
collapse between 1.36pm and 1.38pm. There would have been no time for
rigor mortis to set in at all if this were the case. I am unconvinced that this
was the sequence of events that afternoon.
99. During interview with my investigators, the 2nd PCO was asked several times
whether he did carry out the 1.30pm check. Each time he replied that he did,
but could not provide any detailed recollection.
100. During advance disclosure, G4S reviewed all of the evidence that my
investigators had considered. I had made a recommendation that G4S carry
out a disciplinary investigation into the circumstances surrounding the 1.30pm
check. They responded by saying, “… The computerised custody records
show the check was completed and data entered on the system. The 4th PCO
has consistently confirmed the check was undertaken. The 3rd PCO has
confirmed she would not have entered data on the PACS system to indicate a
check had been undertaken if the 2nd PCO had not given her this
information… It is likely that the 2nd PCO was coming back through the cell
area door when he told the 3rd PCO that he had done the cell checks. The 3rd
PCO simply cannot now recall”.
101. G4S did not accept that a disciplinary investigation into this matter was
required. Primarily because of the evidence of the onset of rigor mortis, I
remain of the view that, on the balance of probabilities, the 1.30pm check did
not actually take place.
First Aid training
102. Paragraph 4.10.2 of the Operating Manual states that immediate first aid
should be administered by staff who will be trained as certificated first aiders
and who have their certification revised and training updated or refreshed on a
three year cycle. The life support offered by the PCOs in response to the
man’s collapse was commended by one of the paramedics. Administering life
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103. From various statements made to the police and during interviews with my
investigators, it was clear that not everything was at hand to respond
immediately to the man’s collapse. The 5th PCO had to leave the cell with the
4th PCO to obtain some items - a mouth piece, wipes and gloves. Staff could
have been issued with little packs containing gloves, wipes and a resusci-aid.
This could be attached to their belts and would ensure there was no delay,
however short, in commencing resuscitation. I would therefore ask G4S to
review the way that first aid equipment is stored at court and whether to issue
small medi-packs to its staff.
G4S should review the storage of first aid equipment at courts and
consider issuing small belt attached medi-packs to its staff.
Liaison with the man’s family
104. The family was told of the man’s death by the police. They were not offered
assistance towards funeral expenses, nor the chance to visit the custody area
in Peterborough Magistrates Court. They were not given details of a named
contact for any questions they might have wanted to ask about the man’s
death. These are all issues that the Prison Service has developed detailed
instructions and guidance about, transforming the way in which it liaises with
bereaved relatives. They apply whenever a person dies in prison custody,
whether by natural causes, accident or otherwise.
105. Even though deaths in court custody are rare, this being only the fourth such
death I have investigated since April 2004, I judge that procedures should be
put in place so that bereaved families are provided with appropriate
information, assistance and support. In the previous death in court custody
report that I referred to in paragraph 73, I asked PECS, who are responsible
for custody suites, and HMCS, who are responsible for courts, to draw up an
appropriate family liaison policy that reflects the good practice that the Prison
Service has developed.
106. The response to that recommendation was accepted. The reply said, “Prisons
have established procedures in line with PSO 2710 (Follow up to Death in
Custody) and the mechanisms to support them, such as care teams. While it
may not be possible to replicate these arrangements in the escort context,
PECS will be seeking to develop a national family liaison policy to provide the
necessary support. PECS intend to consider including this in the requirement
when the contracts for the escort of prisoners and their management at court
are re-tendered (in 2010)”. I do not therefore repeat that recommendation
here.
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RECOMMENDATIONS
1. G4S managers should ensure that the minimum of two cell checks per hour
are carried out by court custody staff in accordance with paragraph 4.1.11 of
the Standard Operating Procedures.
G4S accepted this recommendation at draft consultation stage and said, “This is
standard operating procedure as indicated in G4S Standard Operational Procedures
Manual. G4S managers will monitor more closely in addition PEM will periodically
test PERS to check compliance”.
2. G4S should revise the local instructions given to staff working within
Peterborough Magistrates Court and replicate key requirements from the
Standard Operating Procedures so as to make them more accessible and
user friendly for staff.
G4S accepted this recommendation at draft consultation stage and said, “Standard
Operating Procedures (SOPs) are available to all G4S staff. G4S managers will raise
with all staff the importance of adhering to SOP’s and will be included in refresher
training modules”.
3. G4S should review the storage of first aid equipment at courts and consider
issuing small belt attached medi-packs to its staff.
G4S accepted this recommendation at draft consultation stage and said, “G4S will
review the current arrangements and consider issuing belt attached medi packs to its
staff”.
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