Individual at Leeds

Investigation into the circumstances surrounding the
death of a man at HMP Leeds
in January 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2010
This is the report of an investigation into the death from hanging of a man at HMP
Leeds in January 2009. The man, a remand prisoner, was found at around 9.38am
in his cell on C wing in an apparently seated position on the bottom bed of a bunk,
having attached a ligature from the top bunk. (Although the cell was equipped for
double occupancy, his cell mate had moved out two days earlier.) It was clear that
he had been dead for some time and resuscitation was not attempted. He was aged
34.
I offer my sincere condolences to the man’s family and to all those touched by his
passing. I am conscious that this investigation report has been much delayed and
that this will only have added to the family’s anguish.
The investigation was carried out by one of my Investigators. He conducted the
interviews jointly with another Investigator. Because of ill-health, he was unable to
complete the investigation, and this report has been written up by other colleagues.
A Family Liaison Officer and my Senior Family Liaison Officer have been in contact
with the man’s family.
A clinical review of the treatment the man received in custody was undertaken by a
clinical reviewer on behalf of the Primary Care Trust. I am most grateful to him for
his contribution. (A copy of his review is annexed to this report.)
I must also thank the Governor of Leeds and his staff for their assistance during the
course of the investigation.
The man was fearful of the long sentence he expected to face if convicted. It is also
probable that at the time of his death he was coming off illicitly obtained opiates.
Although in retrospect his behaviour and attitude might also suggest he was clinically
depressed, he gave few signs away to other prisoners or staff.
My report raises a number of issues about his treatment while in custody. However,
I do not believe his actions in January 2009 could reasonably have been anticipated.
There are seven recommendations to the Governor, and eight in the clinical review
for the attention of the Head of Healthcare.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Acting Prisons and Probation Ombudsman November 2010
2
CONTENTS
Summary
The investigation process
HMP Leeds
Key findings
Issues
Conclusions
Recommendations
3
SUMMARY
The man died in his cell on C wing in HMP Leeds in January 2009. He was aged 34
and had been in prison custody for over five months. He had a long history of drug
use and mostly minor offending. However, he was fearful that the charge he was
facing at the time of his death might have led to an indeterminate sentence for public
protection.
On arrival in custody, there were inadequacies in the way his risk of self harm was
assessed. The clinical review carried out as part of this investigation is critical of
some decisions taken in respect of him by a prison doctor.
He shared with his co-accused for most of his time at Leeds, but he was the single
occupant of a double cell at the time of his death. During December 2008, his
behaviour became more unpredictable and he stopped attending a workshop. The
investigation has uncovered evidence of illicit drug use, and possible depression and
withdrawal symptoms.
It is unclear whether staff were considering reducing him to the basic regime shortly
before his death. They were under a misapprehension that he was a sentenced
prisoner and therefore required to work. Four days before he died, he pleaded guilty
at an adjudication for failing to undergo a mandatory drug test. He was serving the
punishment for this offence against the Prison Rules when he died.
When he was discovered in his cell it was judged that he was already dead and
resuscitation was (correctly) not attempted. Comprehensive logs and records of
action were kept.
I conclude that staff could not reasonably have predicted the actions that led to his
death. However, the report contains seven recommendations for the Governor plus
other matters for him to consider. In addition, the clinical review makes eight
recommendations for the Head of Healthcare.
4
THE INVESTIGATION PROCESS
1. The Ombudsman was notified of the man’s death at 12.15pm in January
2009.
2. An investigator was appointed as the Ombudsman’s Investigator. He
conducted the interviews jointly with another Investigator. Because of ill-
health, he was unable to complete the investigation, and this report has been
written up by other colleagues.
3. He arranged for notices about the investigation to be issued for staff and
prisoners on 22 January. He also wrote on the same date to the local PCT to
request a clinical review. (The clinical review by the clinical reviewer was
received on 6 October 2009.) Contact was also made with HM Coroner.
4. One of the Ombudsman’s Family Liaison Officers spoke to the man’s sister on
26 January, and followed this up with a letter. On 10 February, the
investigator and Family Liaison Officer met with the man’s mother and her
sister.
5. The family raised many questions that the investigation has endeavoured to
answer. They asked whether and how his mental health was assessed in
prison. They highlighted how his most recent custodial sentence seemed
different to the other periods he had spent in prison. They wanted to know
whether his mental health was reviewed on an ongoing basis.
6. The family were keen that my investigator speak to other prisoners who could
provide helpful information about him. They asked why a member of staff
checking on him did not see that he had hanged himself much earlier on the
morning he died. They also wanted to know why the member of staff who
found him had gone to his cell.
7. The family suggested that the prison’s Family Liaison Officer (FLO) should be
more readily contactable. They also thought that the FLO should assist a
prisoner’s family during the initial period of contact with the Coroner’s office,
for instance during a visit to the mortuary. Whilst they sympathised with the
FLO’s difficult role, they thought that there were some lessons to be learned in
this instance.
8. The Ombudsman regrets that, because of the investigator’s ill-health, the
family have had to wait over a year since the man’s death before reading this
account of what occurred.
9. Following the Family Liaison Officer’s retirement, the Ombudsman’s Senior
Family Liaison Officer has been in contact with the family.
10. The investigator shared his initial findings and conclusions with the Acting
Deputy Governor of Leeds on 8 April 2009.
5
HMP LEEDS
11. HMP Leeds is a local prison serving the courts of West Yorkshire. It has four
Victorian wings and two modern wings. The operational capacity (maximum
crowded capacity) is 1,154.
12. The relevant report from the prison’s Independent Monitoring Board (IMB) is
dated 2009 but in fact covers the period for 1 January 2008 to 1 January
2009. (IMB members, who are unpaid volunteers, provide lay and
independent oversight of prisons with each Board being responsible for
submitting an annual report to the Secretary of State for Justice.) The Board’s
overall judgement in 2009 was that:
“… within the constraints of budgets and staff selection and
recruitment, HMP Leeds is providing a generally safe environment for
prisoners and slowly improving the respect shown to them by staff.”
13. The IMB judged Healthcare to be “a well managed and forward thinking
department.” In respect of safer custody, the Board reported that details in
Assessment, Care in Custody and Teamwork (ACCT) forms were “regularly
checked for quality … resulting in clearer, improved information.” ACCT is the
National Offender Management Service’s process for supporting and
monitoring prisoners at risk of self-harm. The IMB praised the work of
Listeners, prisoners trained by the Samaritans to support their peers, as
“excellent”. However, the reception area was “totally unsuitable for its
functions … due to the large volume of prisoners received each day …” The
average time for prisoners to go through reception was said to be “30 to 50
mins”.
14. The Board referred to “often fraught relationships between prisoners and
officers” and suggested the personal officer scheme was not operating well in
the eyes of prisoners.
15. The most recent inspection of HMP Leeds by HM Chief Inspector of Prisons
was an unannounced inspection carried out between 5-14 December 2007.
In the introduction to her report, she referred to Leeds’ “chequered history.”
She added:
“This unannounced inspection found that there were still considerable
problems in the prison, but that vigorous management attempts were
being made to grapple with them. Leeds was still failing to perform
sufficiently well in any of our key areas, except for resettlement …”
16. She said that prisoner safety had rightly attracted management attention and
first night support arrangements were much improved. There was also an
“innovative safer custody unit, largely for those withdrawing from drugs”.
However:
“this approach had not percolated down to staff on the wings … Many
of the prisoners’ safety problems stemmed from the distant and
6
negative relationship between most staff and prisoners. Only around
half the prisoners surveyed said that most staff treated them with
respect.”
17. In the body of her report, she criticised reception processes as unsuitable
(she recommended that the reception area should be replaced or “fully
remodelled”). She added:
“Recent strategic attention had been paid to suicide and self harm
policy but basic support for prisoners at risk was not good enough.”
18. She reported that vulnerable prisoners were held separately on A wing:
“Arrangements for holding an overspill of vulnerable prisoners on other
wings were extremely poor. Some had spent some months in
conditions where they felt unsafe and had few, or even no,
opportunities for association or exercise.”
19. She further reported:
“Around 250 men were on drug maintenance programmes and about
50 were detoxifying. Clinical management was a joint responsibility of
the substance misuse and health services … Most prisoners could
begin detoxification or maintenance programmes immediately. All new
arrivals were considered for the safer custody detoxification
programme, which provided good support. However, prisoners not on
the programme had little or no psychosocial support.”
20. On 12 January 2009, the Governor of Leeds issued a Governor’s Order (2/09)
on the subject of roll checks. Referring to the 6.30am unlock roll check, the
Order said, “… an unlock roll check should be conducted and signed for (in
the wing book) by BOTH the night start and early start staff from each area.”
(Emphasis in original.) As I discuss in the ‘Issues’ section of the report, the
officer who completed a roll check on the morning the man died had not yet
familiarised himself with this instruction.
21. From 2004 until the date of this report, I and my colleagues have conducted
17 investigations at Leeds following apparently self inflicted deaths. In 2008
there was one such death and in 2009 there were three, including that of the
man. The prisoner who died just over six months after him was also a
vulnerable prisoner held on the overspill accommodation on C4 landing and
he too was the sole occupant of his cell at the time of his death as his
cellmate had gone to A Wing for a period of association.
7
KEY FINDINGS
22. On 21 July 2008, the man was arrested and charged with four offences
involving driving. After appearing at court, he was granted bail.
23. On Sunday 10 August, he was arrested again and taken to a police station.
He was charged with assault with intent to rob, burglary of a dwelling
(committed while on bail) and – later that evening – with refusing to provide a
sample to be tested for the presence of class A drugs (also, by definition,
whilst on bail). The police doctor recorded that he was “very sleepy” but that
he denied recent alcohol or drug abuse. He was prescribed methadone at
7.00pm on 11 August. A West Yorkshire Police Risk Assessment Report
dated 12 August recorded he as saying ‘yes’ when asked if he took
methadone but ‘no’ in respect of depression or self harm. He was not to
regain his liberty before his death.
24. After appearing at Magistrates Court on Tuesday 12 August 2008, he (along
with his co-accused) was remanded into custody at HMP Leeds. Details of
his current prescription for methadone were faxed to the prison by the Drug
Interventions Programme based in the police station. Contact was
subsequently made by Leeds Healthcare with his community GP.
25. On reception into Leeds, he gave his mother as his next of kin. His religion
was recorded as Roman Catholic and it was noted that he was a smoker.
26. On arrival at Leeds, he went through the standard first reception health
screen. Nurse A recorded that he was on methadone and using street heroin.
She noted that he had been prescribed Prozac (fluoxetine) for depression
although he had taken none in the previous five days. She referred him on to
the Substance Misuse Clinic, the Sexual Health Clinic, the Blood Clinic and to
see the duty doctor. (He refused an opportunity to attend the genitor-urinary
medicine clinic the following month.) The form also notes, “Need TB
(tuberculosis) referral. Contact with known TB carrier.” (Following referral, no
further action was deemed necessary.)
27. He acknowledged depression when asked if he had ever suffered from any
form of mental illness. The first question on the health screen that relates to
suicide risk factors is: “For some people coming into prison can be difficult,
and a few find it so hard that they might consider harming themselves. Do
you feel like that now, or even suicidal?” There is nothing handwritten
underneath the question on the screening form to indicate whether or not he
was either asked or indeed answered the question.
28. If the patient answers yes, an Assessment, Care in Custody and Teamwork
(ACCT) form should be opened. (ACCT is the Prison Service’s system for
supporting and monitoring prisoners at risk of harming themselves.)
However, his replies to the other questions scored only a total of four, well
below the threshold of ten which again should trigger the opening of an
ACCT.
8
29. The nurse told the investigator that she and her colleagues regularly ask
newly arrived prisoners if they are having any current thoughts of suicide.
During interview, she also said that she would have made a specific note in
his records if he had been tearful or seemed to be in a low mood.
30. His reception urine drug screen tested positive for methadone, Subutex,
cocaine, opiates and amphetamines. On being questioned, he acknowledged
heroin and methadone use, and infrequent use of amphetamines. He said he
was not a user of crack or cocaine. (In interview, the nurse pointed out that
prisoners may test positive for amphetamines without being users as heroin is
often cut with amphetamines.)
31. The cell sharing risk assessment (CSRA) completed by Officer A judged that
he was low risk to share a cell. However, the form also contains the following
observations:
“On methadone for drugs misuse. States was very upset and
considered suicide on this arrest due to the offence. On anti-
depression tablets.”
Despite the reference to suicide, the officer did not open an ACCT document.
It is not clear whether this form was seen by the nurse. In her interview, the
officer said she had received no training in ACCT but would feel comfortable
opening an ACCT form. She could not say if she had seen the co-accused
before the man or if either had seen the nurse before they saw her. In her
interview, the nurse thought it most likely that she would have seen the man
after he had seen the officer.
32. According to the print-out of the man’s medical record, he was also seen by
Prison Doctor A on 12 August. The record reads as follows:
“H/O depression
Has been using crack – therefore Prozac not written up. To have six
weeks and then review mental health status.
Drug addiction – opioids
In view of sentence likely – pleading guilty to the charge written up for
one week at 40mls and then reduce at 5mls per week and then on to
the detox schedule.
Remanded on new charge of assault with intent to rob … States he is
facing 5-10 years and an IPP status as he has previous robbery on his
record.” [Courts have the power in certain circumstances to impose an
Indeterminate Public Protection (IPP) sentence to detain in prison
people who pose a significant risk to members of the public until they
no longer pose such a risk.]
33. The proforma received by Leeds Healthcare from the man’s community GP
refers to “Depression – tremor … so changed to sertraline 50mg daily.”
Another hand has added, “Prison Doctor A said to withhold antidepressants.”
9
34. In interview, the doctor said the man told him he had been using crack
cocaine. As noted above, he had not said this to the nurse.
35. The doctor’s involvement with him is discussed at length in the clinical
reviewer’s clinical review and in that section of this report which summarises
his findings.
36. The man’s co-accused was also judged as low risk for cell sharing, and the
two men were placed together in a safer cell in the prison’s First Night Centre.
The co-accused was on an open ACCT form, so sharing would have provided
some additional protection for the man too. (The co-accused’s ACCT was
closed the next day. I note that it was closed by the co-accused and the Unit
Manager alone, and that the timing of entries on the ongoing record was very
predictable. The care offered to the co-accused is not a matter for this report,
save in respect of its impact upon the man, but the Governor will wish to
ensure that ACCT processes at Leeds are more robust than was evident on
this occasion.)
37. On 13 August, the man applied for vulnerable prisoner status. He gave his
reasons as follows:
“Other inmates have found out that I have just arrived back in prison
and what my crime is. I now fear for my safety.”
The application was granted “due to the nature of the offence, which involved
an elderly man.” The co-accused made the same application and it too was
granted. The two men continued to share their accommodation.
38. The co-accused’s history sheets contain only two items relevant to this
investigation. The first (dated 12 September 2008) says he was well settled
on the wing and with his long-term cell mate (the man). I report on the second
entry below.
39. A Safer Custody Access Programme Referral Form was completed on 13
August, noting as risk factors the man’s methadone use, the charge of
assault, and the fact that he had “fallen out with family”. The triage outcome
completed by a registered mental nurse, Nurse B, said no further actions were
required, albeit he was described as “Very guarded. Monosyllabic in
responses.” In interview, she said the only written information she had was
the referral form itself.
40. The man was also referred to the prison’s CARATs drugs team. (CARATs
stands for Counselling, Assessment, Referral Advice and Throughcare
Services. The non clinical treatment needs of the majority of prisoners with
substance misuse problems are met through CARATs.) His file contains a
note saying that he had “No history of overdose/self harm/attempt suicide”. It
suggests that he said he first started abusing drugs at the age of 27, and that
half his friends were heroin or crack users and half were non-users. It was
said he had limited support from his family as “he stole from them.” He said
he was using £20 worth of heroin daily “IV [intravenous] arms x2” and £50
10
worth of crack twice a week. He had been in touch with the Lifeline Drugs
Intervention Project for ten months prior to coming into custody and been
prescribed methadone but “used on top of script”.
41. According to his CARATS case record, in November and December 2008,
three unsuccessful attempts were made to complete a new Drug Interventions
Record (DIR). He was either on exercise, association (when prisoners are
unlocked from their cells to socialise, make telephone calls and shower) or at
court. On one of these occasions, he did not respond when an officer
shouted for him.
42. Because of the variety of charges that he faced, his status as a prisoner is
somewhat complicated to follow. (In addition to the charges above, he had
also been convicted of criminal damage on 19 June 2008 and fined £170 with
a default term of seven days.) Save for the most serious charge – that of
assault with intent to rob – the Ombudsman does not believe that the disposal
of the various charges is relevant to the circumstances of his death.
However, for the sake of completeness, it should be explained that on 28
October he pleaded guilty to the charge of assault with intent to rob. His legal
advisers asked the court to defer sentencing and the court agreed to this. He
was therefore held in custody as a convicted, Judgement Respited (JR)
prisoner (judgement respited, or delayed).
43. On 5 November, he was sentenced to 17 weeks imprisonment for dangerous
driving and seven days concurrent for the fine default. A charge of taking and
driving away was discontinued, and no separate penalty was imposed in
respect of two Road Traffic Act offences (driving without insurance and driving
without a licence). However, as the court ordered that the 85 days that he
had by then spent on remand should be allowed against his sentence, in
practice he was a convicted prisoner for just four days (5-8 November
inclusive).
44. This meant that after 8 November, he reverted to being held in custody as a
JR prisoner in respect of the charge of assault with intent to rob until 23
December. On that date, it was recorded that his guilty plea had been
cancelled and he reverted to being a prisoner on remand awaiting trial. This
was because he had changed solicitors and his new legal advisers disagreed
with the advice he had previously been given to plead guilty. They
successfully persuaded the court to accept a reversal of his earlier plea. His
unconvicted status may be relevant to the circumstances of his death as will
be shown below.
45. He was located in cell C4-08 from 19 August to 17 November, and in cell C4-
05 thereafter. (C wing houses the overflow of vulnerable prisoners from A
wing.) He shared with his co-accused first in C4-08 and then in cell C4-05
until 16 January 2009 when the co-accused moved next door but one into C4-
07. Between 16 and 18 January, he shared with another cellmate (who had
moved from I1-23). The cellmate moved to cell A2-15 on 18 January, leaving
the man as the sole occupant of a double cell. It is apparent from records that
11
he had been offered the opportunity of moving to A wing but both he and the
co-accused had declined.
46. It is not clear why they stopped sharing. The co-accused says in interview
that it was simply that they were doing everything together “and it was getting
too much for both of us”. In his interview, Prisoner A alleged that the two men
had been arguing as the man said he played no part in the robbery while the
co-accused blamed him for carrying a knife. The man’s former personal
officer, Officer B, simply notes, “I was surprised that they’d actually split up
because they were very close.”
47. During the autumn of 2008, the man made a variety of court appearances via
videolink in respect of the charges he was facing. Again, it is not believed that
the details are crucial for an understanding of the circumstances of his death.
It may be noted in passing that, on 5 September 2008, the police requested
His production at the police station for an identity parade but that on 11
September he refused to attend. Healthcare staff deemed him fit for court on
19 August, 5 September, 5 November, 17 November, 17 December and 23
December.
48. He received a visit from his mother on 30 October 2008.
49. The Police National Computer print-out for him at the time of his arrest in
August had warning signals for violence and escape risk. The Prisoner Escort
Record (PER form) that accompanied him from the police station to
Magistrates Court on 12 August is likewise marked for violence and escape
risk, and for drugs/alcohol. A note on the form reads:
“PNC markers for violence and being an escaper. Graze to chin. Uses
methadone. No other information disclosed. Methadone given in
custody under doctor’s supervision.”
50. Other PER forms are retained on his core file. The details of warning
markings are as follows:
19 August Medical: Mental
Warnings: Violence
Others: Drugs, VP [vulnerable prisoner]
5 September Medical: Condition
Warnings: NK [Not known]
Others: NK
5 November Medical: Condition
Warnings: NK
Others: VP
16 November Medical: Mental
Vulnerable
12
R45-VP [R45 refers to the Prison Service rule for
identifying vulnerable prisoners.]
17 December Mental issue
VP
23 December Violence
VP
There are evident discrepancies between the forms, but none flags up a
concern for self-harm.
51. The following entries appear on the man’s history sheets from September
onwards:
5.9.08 Located C4-08
3.11.08 This prisoner says he is a TX [meaning unconvicted] but the
computer says he is now a JR. I have explained to him that as a
JR he has to go to work. I will be unlocking him from [sic] work
this afternoon.
3.11.08 Warning not given, awaiting education interview. Has been told
that he is required to attend if accepted.
16.11.08 Spoke with the man who is settled as he is sharing with the co-
accused. No concerns raised at the moment.
30.11.08 The man is allocated workshop 3 and has been attending which
is a positive step.
9.11 (a misprint for 9.12).08 The man has been offered a move to A
wing to assist with his going to Shop 3. He however declined as
he wanted to stay with the co-accused. No other problems at
the moment.
10.11 (a misprint for 10.12).08 Regular entries good comments a fair
representation. [A management check]
11.12.08 Given a warning by myself after being caught in a cell after
being brought from C wing to A wing for work. When told of my
actions became argumentative and also aggressive. I had
informed him that this was not the first time I had caught him.
[Entry by an officer] The Incentives and Earned Privileges [IEP]
warning report adds the detail, “became argumentative and
aggressive calling me an ‘idiot’ and telling me to do what I want.”
(IEP is the Prison Service system for awarding privileges, such
as extra visits, for good behaviour.)
13
12.12.08 Warning endorsed for above entry.
30.12.08 Change of status from JR to trial (successful application to
vacate plea).
6.1.09 Warning raised for failing to attend Shop 3. [Officer] (The IEP
warning report adds the detail, “Just slammed the door shut.”)
7.1.09 Warning endorsed. When speaking to the man, he stated ‘the
job was doing his head in’. I offered to contact the workshop
and enquire about an alternative job in the shop, but this was
not good enough. Still said he wouldn’t go!! [Officer]
12.1.09 Unlocked for Shop 3. Refused to go. I told him if he didn’t go
he would get a warning issued. He refused to speak to me and
just turned over in bed. A very poor attitude. [Officer] (The IEP
warning report adds the detail of what the officer said: “You are
convicted and have to go to work. If you refuse you will be given
a warning.”)
12.1.09 This is his 3rd warning in a few weeks. I think a stint on basic.
Paperwork pulled together for basic review. [Unsigned]
15.1.09 The man refused to attend a random MDT [Mandatory Drug
Test]. It was explained to him the consequences of his refusal,
but he still refused. Subsequently P.O.R. [Put on report.]
52. The behaviour report for the IEPS review notes that he was “Not enthusiastic,
no motivation, does as little as possible.” Under wing behaviour, it was noted
that his attitude was poor, and behaviour, conformity and cleanliness were all
below average. It is not known if he was in fact reduced to basic regime at
the time of his death.
53. Also on his file is a change of status form from JR to TRL (Trial) with effect
from 23 December 2008. In other words, the grounds for giving him the IEP
warnings and eventually reducing him to basic were ill-founded. As Officer C,
an instructional officer in workshop 3, pointed out in interview, “… he decided
to go no work, no pay which as a remand prisoner that was his right to do.”
(The officer’s evidence is also to the effect that he was adamant of his
innocence and blamed his co-accused.)
54. On 16 January 2009, he faced an adjudication (a prison disciplinary hearing)
presided over by the Governor. He pleaded guilty to a charge under
paragraph 51-22 of the Prison Rules for refusing to obey a lawful order (that
is, his refusal to undertake the MDT). He was punished with seven days
stoppage of earnings at 50 per cent, ten days loss of canteen/use of private
cash, and five days loss of association.
14
55. It seems certain that he was using illicit drugs while in custody. Prisoner A
has alleged that he was taking morphine in the form of injecting crushed
tablets (the prisoner further alleges they were supplied by the co-accused).
The co-accused said in interview that the man was “trying to buy tramadol and
stuff.” (Tramadol is a synthetic pain relieving medication which can be
abused.) In his interview, the man’s cousin says that four days before his
death his demeanour had changed – perhaps because he was withdrawing,
perhaps because he feared an IPP sentence. In interview, Prisoner A says
that on the night before his death the man was without tobacco and “rattling”
(symptoms of enforced withdrawal from drugs).
56. There are no references to the man (or to either of his cellmates) in the C
wing Observation Book for January 2009.
57. Officer C made the early morning roll check at roughly 5.00am to 5.30am. He
said in interview that he could not guarantee that he saw each prisoner as it
was still dark.
Events in January 2009
58. According to his incident report, the man was discovered hanging at
approximately 9.38am by Officer D. Around 40 minutes earlier, he had been
unlocking those vulnerable prisoners on the 4’s landing who required
treatments/medication. On unlocking cell C4-07 [he says C4-06 but I think he
may have been mistaken], the co-accused asked if he could be let out to get
some tobacco from his former cellmate in C4-05. He was told this was not
possible at that time, as the staff were trying to clear the landings for a staff
meeting. After the meeting, the officer returned to the landing and attended to
a cell bell from the co-accused who again asked if he could get some tobacco,
and if the officer could get it from his former cellmate. The officer opened the
observation panel to cell C4-05, “it appeared that the man was sat on the
edge of the bottom bunk with his head down”. The officer opened the cell
door and saw that he was suspended from the top bunk in an apparently
seated position with a ligature around his neck. The officer who, like the other
landing staff, was not carrying a radio, “immediately raised the alarm whilst
running towards the general alarm on the 4’s landing informing Officer E we
needed a nurse or medic at cell C4-05 and pressed the general alarm.” He
then returned to the cell and cut him down with his ligature knife. Another two
officers then entered the cell and Officer F checked for a pulse but without
success. Officer D’s statement continues:
“I noticed that the man’s hands were tightly clenched and red in colour.
His face was drip white and his lips were blue. His eyes were open.”
Officer D then left the cell and was taken to a quiet area where he was
supported by members of the staff care team and other members of staff.
(The officer was new in service and had only been at Leeds since December
13 2008.)
15
59. Officer E’s statement says that he followed Officer D into cell C4-05, closely
followed by two more officers. He says that Officer G was assisting Officer D
before Officer D left the cell and Officer F entered. Officers F and G then
pulled the man’s body 1 ft into the cell to enable them to close the door and
seal the area. Officer F placed a towel over the man’s face. In interview,
Officer E added little to this account.
60. Officer G’s report reads as follows:
“I was on duty on C3 landing …. When I reached the cell, Officer D was
inside the cell. I saw that he was using his ‘fish knife’ to cut a ligature
which was tied to the top bunk bed. I asked Officer D to move further
into the cell so that I could assist him. He managed to cut through the
ligature and the man fell to the floor … I took hold of him and I
immediately noticed that his body was cold and clammy, his eyes were
partially open and appeared lifeless, his hands were in a clenched fist
position and all his joints were stiff and rigid. It was impossible to place
him in any type of recovery position. The ligature, a torn bedsheet,
was tight around his neck.
“Officer F came into the cell and checked for a pulse. I told Officer D to
leave the cell. Officer F confirmed there was no pulse. We then
moved the man approx 1 foot further into the cell to clear the door area
and allow closure, after Prison Doctor B attended the scene. I secured
the cell door.”
In his interview, Officer G confirmed this account, adding that the man’s
television was on.
61. Officer F’s report confirms this account. He says he checked for a pulse but
found none. He adds:
“In my opinion, just the sight of him and the colour of his face and
hands being blue, also the stiffness of his body, that he was already
dead.”
62. Senior Officer A’s report simply says that she attended on responding to a
general alarm bell, and confirms the details of the man’s body. A Principal
Officer (the Orderly Officer, known by the code sign Oscar 1) then attended
and she handed over the incident to him. She repeated those details in
interview, adding that she had left the cell with Officer D who was “obviously
quite visibly shaken”.
63. When found, the man was fully clothed.
64. In interview, several of the officers mentioned that the primary care manager
was at the cell very quickly and that it was she who called for a doctor.
65. A comprehensive Scene Log was kept separately by three different officers. It
shows that the man was found by Officer D at 9.40am. Three officers
16
attended, along with Officer H and Senior Officer A. The doctor attended at
9.45am. The prison’s Police Liaison Officer viewed the cell at 10.20am. At
10.58am, Senior Officer B was told that paramedics would not be attending.
The police were present at 11.00am, and a Detective Inspector and a Scenes
of Crime Officer arrived with other police officers at 11.35am. Photographs
were taken. The Coroner’s Officer arrived at 1.25pm, and the man’s body
was removed from the cell at 2.25pm.
66. The Control Room Incident Checklist shows that a General Alarm was
sounded on C wing at 9.38am and that Oscar 1, Oscar 2 (the Assistant
Orderly Officer), and Victor 1 (the Duty Governor) were informed. Oscar 1
(the Principal Officer) was asked to attend C wing at 9.42am. The command
suite was opened at 9.45am when the man’s death was confirmed. The
ambulance was called at 9.47am but stood down in light of the confirmation
that he had died.
67. The Control Room Death in Custody Action Sheet also shows that correct
actions were followed. An ambulance was called at 9.57am, the IMB was
informed shortly after 10.00am, and the police were contacted at 10.10am.
National Offender Management Service (NOMS) Headquarters had been
informed by 10.27am.
68. The Control Room log is equally comprehensive. It shows, amongst other
things, that the command suite was opened at 9.50am. Arrangements for a
hot debrief to be held in the centre boardroom were already under way by
10.04am. A member of the prison’s care team had been with those first on
scene. There was a subsequent discussion “to ensure support later for staff
as so many of them are new to the Service.”
69. At 10.50am, an entry in the log reads as follows:
“Interview with the officer indicates that he signed for the role [sic] but
did not complete role check [sic].”
A handwritten note of interview with the officer timed at 10.36am and signed
by the duty governor says, amongst other things:
“Roll check – signed for number
No roll check
Night staff did roll check – Officer C.”
70. Reviews of the 27 prisoners on open ACCTs were to be completed by the
afternoon.
71. By 11.27, taxis were being ordered to take the prison’s Family Liaison Officers
to inform the man’s next of kin. They were to be accompanied by a governor.
They left the prison at 11.54am, arriving at his mother’s home at 12.40pm
(where they also met his sister). They stayed until 1.55pm. A Family Liaison
log was opened.
17
72. An entry in the Control Room log at 12.15pm reads:
“SO C spoke to Officer I who said, ‘Prisoner A and Prisoner B, cell C4-46
stated that they had seen the man on the floor and wanted to know why staff
didn’t administer CPR.’ Referred to chaplaincy. After seeing chaplaincy,
one prisoner stated that the man’s cell bell light was on when the door
opened.”
73. In interview for this investigation, the prisoner repeated the allegation that the
cell bell light was on, saying that he was 100 per cent certain. He alleged that
Officer F turned it off. However, in his interview the officer raised no issues
about CPR (Cardio pulmonary resuscitation) and expressly said that the
man’s cell bell light was not on – although two lights further along the landing
were illuminated. Officer D said in interview that the man’s television was on
but his cell bell light was not illuminated. Officer F denied in interview that he
had turned off any cell bell light.
74. Original documents were collated for the police liaison officer, and incident
reports were gathered from Officer G, SO A, Officer E, Officer D, and Officer
F.
75. The Control Room log was closed at 2.04pm.
76. The Action Sheet completed by the duty governor is also comprehensive. It
confirms that the Governor was informed at 9.55am, and that he then rang the
area manager at 09.57. NOMS National Operations Unit was informed at
10.15am. Notices for prisoners and staff were drafted. (The duty governor
does not normally work at Leeds but was assisting because other senior staff
were on an away-day.)
77. Minor and insubstantial inconsistencies with respect to timing aside, I am very
impressed both by the quality of the documentation and the actions taken.
This was good practice.
78. Prison Doctor B pronounced death at 9.45am. Her entry in the man’s medical
record says:
“Call to C wing at 09.40, staff report he was found hanging from upper
bunk, when seen by me had been cut down, ligature still around neck.
Was lying on his back, cold and blue, rigor mortis advanced, arms
flexed.”
In interview for this investigation, the doctor repeated that “there was already
quite advanced rigor mortis” when she examined him. For this reason, she
did not think it was critical that the ligature was still around his neck, “At that
point blood certainly wouldn’t have flowed.”
79. The post mortem report by the Home Office Consultant Forensic Pathologist
records the medical cause of death as hanging. The pathologist concludes
that there was “no evidence of any other natural disease or other injuries that
18
could have caused or contributed towards death”. Toxicological analyses
revealed the presence of a low level of morphine. The toxicology report says
the opiate concentration was “unlikely to have contributed to the mechanism
of death. It is unclear if this [the finding of opiates] originates from therapeutic
or illicit use of morphine containing compounds.” (As reported earlier, the
man had not been prescribed methadone for some months and it must be
concluded therefore that the opiate use was in fact illicit.)
80. The man left no letter or note to explain his actions or intentions. In his
interview for this investigation, the co-accused said that on the night before
his death the man had asked for a stamp so that he could write to his mother.
No such letter has been traced.
81. An entry in the co-accused’s history sheets for 20 January 2009 reads as
follows:
“At 11.00hrs spoke to co-accused about the death in custody of the
man. He stated that he had known him since the age of 9. He says he
was shocked by his actions but was coming to terms with what had
happened …”
In interview, the co-accused said he had known the man since they were in
children’s homes, but that before meeting in July 2008 they had not seen
each other for 15 years or so.
82. The man’s funeral was held on 16 February 2009.
19
ISSUES
Clinical review
83. The clinical review (attached as annex 1) was compiled by a clinical reviewer,
a General Practitioner based in Leeds. It is relevant that his practice has a
reputation for assisting otherwise hard-to-reach patients and socially excluded
groups such as those with substance misuse problems. He is accredited as a
GP with a special interest in addiction services. My office received his review
on 6 October 2009.
84. He begins his review by noting that prisoners in general, and white prisoners
on remand in local prisons and who have a history of substance misuse or
mental health problems, are disproportionately at risk of suicide. He adds,
“Change of location or routine as well as disciplinary problems are also
factors.” However, he rightly says that it remains very difficult to identify those
prisoners most likely to attempt to harm themselves. In respect of asphyxia,
he says that unconsciousness can occur within several seconds with brain
death through oxygen starvation occurring within a few minutes.
85. He sets out what happened to the man on reception in respect of the First
Reception Health Screen and the Cell Sharing Risk Assessment. He notes
that no answer was given to Question 15 on the Health Screen which asks if
the prisoner feels like harming himself or is suicidal. As reported earlier, the
score for the other questions was four (below the trigger level of ten), an
ACCT was not opened.
86. He records that Prison Doctor A prescribed what were to become weaning
doses of methadone and that, by the middle of September 2008 the man had
stopped receiving methadone medication.
87. The clinical reviewer notes a second entry by the prison doctor (also reported
earlier): “history of depression. Has been using crack – therefore Prozac not
written up. To have six weeks and then review mental health status.” During
interview, the doctor said he would have expected the prisoners themselves
to be responsible for making arrangements for this mental health review.
However, as the clinical reviewer points out, this first consultation with the
doctor was in fact the only time the man was seen by a doctor during his time
in Leeds.
88. After his first night in custody, the man was seen by a mental health nurse,
Nurse B. This was an automatic referral because of the risk factors (drug
misuse, nature of offence, isolation from family) that had been identified. As
shown above, he was very guarded in his responses and the nurse did not
have access to other sources of information (medical notes, First Reception
Health Screen, CSRA).
89. A standard proforma was sent to the man’s GP in the community on 13
August. The reply from the GP confirmed that he had been treated for
depression with fluoxetine initially but that, because of a side effect, this had
20
been changed to sertraline 50mg daily. A hand-written note on the GP’s reply
reads, “Prison Doctor A said to withhold antidepressants.” In a subsequent
report (dated 8 June 2009), the GP said the man was an infrequent attendee
at her practice (twice in 2005, then nothing until 13 June 2008 when he had
complained of suffering low mood for at least a year). She gave details of his
heroin usage, his occasional use of crack and cocaine, and his “history of
using significant amounts of stimulants which was giving rise to emotional
lability [instability].”
90. The man’s prison medical records contain no other entries of significance,
save that he failed to attend a routine healthcare triage clinic on 19
September 2008. The clinical reviewer speculates that this may have been to
follow up the mental health review suggested on his first night in custody. He
notes that there was no follow up of this missed appointment.
91. The clinical reviewer also sets out the other events (remaining on A wing,
ceasing attending the workshop, probable illicit drug use and withdrawal, fears
about likely sentence, single roll check) that have been outlined earlier.
92. His findings and conclusions are as follows:
• Potentially important information given at the CSRA was not available
to or shared with the nurse or doctor conducting the initial screenings.
• An ACCT might have been opened if the concerns regarding self-harm
raised at the CSRA had been further discussed with the clinicians.
• The reception health screen does not have a prompt to ask how long a
prisoner has suffered from a condition like depression.
• Although Prison Doctor A recorded a history of depression, there is no
record of any discussion about the severity, history, or the effects of
treatment:
“In fact Prison Doctor A appears more concerned that the man
was potentially taking crack so he made a decision to stop the
antidepressant medication. There was no attempted
assessment as to the amount of crack cocaine that the man was
taking and it is possible that he was an infrequent user. It does
seem therefore a little odd that, if an interaction between the two
was the major concern (and the doctor would have known that
crack cocaine is not an illicit drug often used in prison), the
antidepressant was stopped. The apparent concerns over the
use of crack cocaine and SSRI [selective serotonin reuptake
inhibitor] antidepressants expressed by the doctor during
interview are not supported by any literature that I have come
across. Personally I would have had no issue with prescribing
an SSRI antidepressant to someone with a drug misuse problem
and depression though recognising the likely difficulties in
achieving progress in the depression if the underlying cause of
21
this is habitual use of cocaine. The doctor would have known
that the crack cocaine usage would now be at an end once the
man was in custody so why was the medication not continued
whilst information was obtained from the GP who had prescribed
it? There does appear to be a request that a mental health
review is undertaken though I am not sure that relying on the
prisoner to make his own appointment for this was appropriate.
Even if this is the usual practice then there needs to be a robust
mechanism in place to either follow up a ‘Did Not Attend’
appointment or better still to formally request a review from a
prisoner by attendance or outreach visit. I would have preferred
a mental health review to take place within the first two weeks
and certainly it would have been appropriate to have assessed
his mental health during and at the end of his enforced
detoxification from methadone which would have been
approximately six weeks later.”
• The clinical reviewer criticises the fact that the mental health nurse,
Nurse B, had no access to information on the CSRA or the
healthscreen or medical notes: “… this is just another instance where
sharing information preferably prior to consultation is the minimum
standard that should be achieved.”
• It is likely that the man was suffering withdrawal symptoms from illicit
drugs:
“He refused a mandatory drugs test a few days prior to his death
and certainly his supply of illicit drugs appeared to dry up when
his cell-mate moved out 4 days prior to his suicide. The lack of
morphine leading to opiate withdrawal symptoms and his
reluctance to seek help in prison for his addiction would have
certainly compounded any depressive feelings. It does appear
that he had significant withdrawal symptoms the day or so prior
to his death and he described the sense of despair he felt at this
and other issues to a fellow prisoner who says he did ask staff to
keep an eye on him. However he did not flag up his problems to
any of the staff and this would have been in keeping with his
personality. Obviously if he had not been going through an
acute withdrawal then he may not have made the decision to
take his own life. If this drug misuse problem and acute
withdrawal had been flagged up then appropriate help could
have been offered and he might have been observed more
closely.”
• It is likely that he died in the early hours of 20 January:
“On the day of his death it is probable that a roll check was not
done in the early morning at about 6.30am-7.00am. His body
was discovered just three hours later but since the stage of rigor
mortis (the stiffening of a body due to muscle contracture after
22
death) appeared to be pretty advanced then it is more than likely
that death had occurred before this time and probably more
likely in the early hours of the morning.”
93. The clinical reviewer judges that the man’s clinical care at the time of his
reception into Leeds could have been improved:
“Whether antidepressant medication should have been continued is
certainly an issue as is the lack of a formal assessment of his
depression. That said I feel that the deficiencies as highlighted above
did not have a significant impact on the eventual unfortunate outcome.”
He summarises his report as follows:
“The man was facing the prospect of a long sentence in prison. This
was certainly a major concern to him especially the thought of having a
very long sentence. This was not the first occasion that he had been in
prison and he was in HMP Leeds for five months before he took his
own life by the method of hanging himself with a ligature made out of a
bed sheet. He also had a long history of drug misuse problems and
though he was receiving treatment for this at the time of his arrest he
had remained an intravenous poly drug misuser up to being taken into
custody. He had also begun treatment for a depressive episode two
months prior to his arrest and arrival at HMP Leeds. This treatment
was stopped when he came into prison and he was not reassessed at
any stage to see if such treatment needed restarting. It is possible that
his depression had recurred though it was not apparent to those who
knew him and come in to contact with him. It is also very likely that he
had been taking illicit morphine for some time prior to his death though
it is probable that the supply of this had stopped a few days before
January 20th 2009. This would have led him having to endure opiate
withdrawal symptoms in the few days before his death. He did not
seek any help for this or indeed with regard to any depressive feelings
he had. On the day of his death it is likely that a roll check of prisoners
was not done and so discovery of him was probably delayed. However
I do not feel this had any bearing on the tragic outcome.”
94. He makes the following recommendations to the Head of Healthcare, all of
which I endorse:
Procedures/protocols for information sharing between reception staff
need to be reviewed to ensure that information received by one party is
available to all.
Documentation (First Reception Health Screen) used at reception needs
to be reviewed and updated to gather more useful data with regard to
mental health issues.
23
Important medical information gathered at reception screening (by
whoever) should find its way into the medical notes – coded where
possible and preferably added to the record via a suitable template.
The pro-forma sent to GPs requesting information needs to be reviewed
and updated to be able to prompt for more information especially for
certain conditions such as mental health problems.
Information/letters received from outside agencies such as those from
drug clinics also needs to be reviewed by healthcare staff and coded
where possible and again recorded via a suitable template.
Antidepressant medication should be continued unless there are
compelling reasons to stop it. It should be continued until at least both
the following have been completed: A suitable assessment of the
depression and confirmation of medication and rationale for its use.
Information on any mental health issues raised at reception, with
consent, should be readily available to all healthcare and possibly wider
staff groups who come into contact with a prisoner in the first few days
and possibly longer.
A protocol for review appointments and follow up of defaulters should
be developed that is clear and does not rely on the prisoner to make his
own appointment.
95. The clinical reviewer says it is pleasing that a number of these
recommendations have already been highlighted by the Healthcare
department following their own review.
It should be noted that Prison Doctor A presented a robust defence of his decisions
in respect of the man – notably the decision not to prescribe anti-depressants and
placing the responsibility to arrange a mental health review on the patient – in his
interview which is reproduced as an annex to this report.
Safer custody
96. The man died some five months after entering custody. Because of the time
that had elapsed, I do not consider that any failures in respect of his initial
health screening directly contributed to his death. However, it is clear that
such failures did occur in that those making decisions about his welfare seem
not to have been in possession of all the relevant information. It is not entirely
clear in what order the first reception health screen and the cell sharing risk
assessment were carried out, nor what information was before the nurse who
carried out the health screen. However, in retrospect it is surprising that there
was no mental health referral for him and it is arguable that, in possession of
all relevant information, either the nurse or the officer conducting the CSRA
could reasonably have opened an ACCT form. It is also noteworthy that
Nurse B, who conducted the safer custody triage, did not know about his
depression, previous prescription for Prozac, or suicidal thoughts. However,
24
the fact that he was placed in a cell with his co-accused who was on ACCT
monitoring must, in effect, have provided initial extra protection for the man
himself.
97. The Ombudsman understands that, since the man’s death, Leeds has
introduced new procedures to try to ensure that information about a prisoner’s
risk is effectively shared between staff. The following recommendation is
intended to reinforce those procedures:
The Governor should review information sharing in respect of
prisoners’ risk factors for suicide and self-harm.
Prisoner Escort Record (PER) forms
98. As noted in the text, the information included on the man’s various Prisoner
Escort Records during his time in custody was not consistent from form to
form. Again, this cannot be related to the circumstances of his death, but is a
matter the Governor will wish to review:
The Governor should review the quality of entries on PER forms and
advise staff accordingly.
Incentives and Earned Privileges Scheme (IEPS)
99. It is not clear from the paperwork seen by the investigator whether the man
was in fact reduced to the basic level of the IEPS shortly before his death.
The fact that he retained his television suggests he had not actually been
reduced to basic. However, it is also clear that some staff were under the
misapprehension that he was a convicted prisoner and therefore required to
work. As it was, his plea had been vacated and he should have been treated
as a remand prisoner who could choose to work but was not required to. The
fact that he had signed a No Work – No Pay form seems to have been
overlooked during the IEPS process.
100. It is also disappointing that little or no effort seems to have been made to
ascertain the reasons that he wanted to stop working in the workshop. In
retrospect, it seems very possible that he was experiencing a depressive
episode or suffering the effects of illicit drug use or withdrawal therefrom.
The Governor should satisfy himself that the IEPS is being operated
appropriately, and that those prisoners who are not required to work are
not being improperly reduced to basic level.
Adjudication and Drug Taking
101. Four days before his death, he faced an adjudication and pleaded guilty to
refusing to obey a lawful order to undertake a mandatory drugs test. He was
serving the punishment of seven days stoppage of earnings at 50 per cent,
ten days loss of canteen/use of private cash, and five days loss of association
when he died.
25
102. There can be no criticism of the decision to bring a charge against him. A
prisoner’s refusal to undertake an MDT undermines the Prison Service’s anti-
drugs policy. If anything, the punishment he received – presumably reflecting
his demeanour and guilty plea – was at the lenient end of the spectrum.
There was no reason to suppose that he was at significantly greater risk of
self-harm as a result of the adjudication and punishment.
103. It seems certain, according to information supplied by other prisoners after his
death, that he was using illicitly obtained drugs while in custody – probably in
the form of injecting crushed tablets of prescribed drugs. It also seems likely
that he was suffering from withdrawal symptoms in the days running up to his
death. Although no formal recommendation is justified, the Governor will wish
to consider if, following an adjudication for refusing to undertake an MDT, staff
could be more proactive in investigating a prisoner’s possible drug use. It is
notable that none of the staff interviewed had identified that he was taking
drugs or considered that drug misuse might have explained his mood and
behaviour in the period before his death.
Roll check
104. In interview, the night officer on C wing, Officer C, explained that he had
carried out the early morning check at roughly 5.00am to 5.30am. It would
appear from his interview that he could not guarantee seeing every prisoner
during the check as it was dark. According to Principal Officer A, “Officer J
had signed for the prisoners and allowed Officer C to leave from his night
duties without actually checking the prisoners and doing a physical count on
the wing …” It seems that Officers J and K did not carry out a separate
check.
105. The Governor’s Order mandating a different approach to the first roll check of
the day is dated 12 January 2009. However, it is unclear if the procedure that
both night and incoming day staff carry out a physical check was actually
implemented on C wing before the day of the man’s death
106. Officer J told the investigation that he understood that new instructions
regarding morning counts had been placed on the prison’s intranet but he had
not had a chance to read them. It was the first time he had done a 6.30am
start and he was not familiar with the procedures, “… as was customary at the
time, I accepted the roll from [Officer C].” He said he understood from Officer
C that the man “was sat on the end of the bed, watching the television.”
Officer F said in interview that the television was still on in the cell when he
entered it on responding to the alarm.
107. It seems almost certain that the man had died some hours before the early
morning roll check, and that therefore this uncertainty as to the correct
procedure was not relevant to his death. However, the Governor will wish to
use the opportunity afforded by this investigation to review how effective are
the current roll check procedures:
26
The Governor should satisfy himself that roll check procedures are
being operated appropriately.
Was the man’s cell bell light on?
108. One prisoner has alleged that the man’s cell bell light was illuminated when
he was found. The implication would be that the man had rung the bell but
that no member of staff had come to check on him. Although one cannot be
certain, the weight of evidence suggests that the prisoner is mistaken. His
fellow prisoner has not endorsed his recollection, the co-accused has
explained why Officer F went to the cell when he did, and the evidence of staff
members (Officers D, F, and G) is that the cell bell light was not illuminated.
Raising the alarm
109. Officer D had no radio and did the right thing in raising the alarm in the way he
did. However, the Governor should review the provision of radios. Readers
of my report may find it surprising that wing staff are not routinely in
possession of a radio:
The Governor should review the provision of radios to wing staff.
110. It is also questionable whether Officer D should have entered the man’s cell
before raising the alarm. In interview, the officer said: “…we’re trained not to
go into a cell in that situation on our own because it could well be something
that’s been set up.” This is not in line with Prison Service guidance which is
that there are circumstances when life may be threatened when it is
acceptable to enter a cell alone. Although it is not believed that it made any
difference to the man, it could do so on some future occasion when seconds
may be critical to life or death:
The Governor should remind staff of the circumstances in which it is
proper to enter a cell alone.
Was it right not to attempt resuscitation?
111. The accounts given by the officers and by SO A, all include evidence that
rigor mortis had set in by the time the man was discovered. Prison Doctor B
confirmed that in her entry in the medical record. In these circumstances, it
was entirely reasonable not to commence resuscitation efforts. Attempting
resuscitation on someone who is already clearly dead is not respectful to their
memory nor fair to those engaged in the effort.
112. However, although no personal criticism of Officer D is intended (he was an
inexperienced member of staff placed in an unenviable position), it is
surprising that the ligature was not cut in such a way that it was no longer
around the man’s neck. Although it is not believed that it had any impact on
the outcome for him, it too could be the difference between life and death on
another occasion.
27
The Governor should remind staff that anti-ligature knives should be
used to cut through a ligature where it attaches around the neck.
Quality of record keeping
113. As noted in the body of this report, the logs kept and actions taken after the
man was discovered were first rate.
This was an example of good practice.
Family liaison
114. The news that the man had died was passed on in person by two Leeds
family liaison officers accompanied by a governor. This was in line with
Prison Service guidance and was good practice. The man’s mother explained
to the investigator that she was told by staff at the mortuary that she could not
see her son’s body until after the post mortem was completed. I recognise
the distress caused to the family.
115. The family say that landline telephone numbers were left by the Leeds staff
but that they had great difficulty in getting through. The family have
suggested that it would be better had they been left a dedicated mobile
number. Although the Ombudsman makes no formal recommendation, he is
sympathetic to the family’s concerns and the FLOs at Leeds may wish to
reflect upon this suggestion for the future.
116. The family also say that they would have found it helpful if a FLO had
accompanied them to the mortuary. They would also have found it helpful if
the FLO could have liaised with the Coroner’s Officer on their behalf.
117. The family have suggested that the FLO would arrange to ring at a specific
time and then be up to an hour late in calling. They also say that they did not
receive answers to all their questions, and on one occasion the family feel she
spoke too freely in front of the Coroner’s Officer. They appreciate that it was
her first experience as a FLO and that this must have been hard. However,
they would like to give clear feedback from their experience.
118. The prison made a contribution of £3,500 to the funeral expenses.
119. Again, the Ombudsman draws all these comments to the attention of the
prison.
120. The family’s comments aside, it should be noted that the FLO kept a very
comprehensive Family Liaison log.
Staff and prisoner care
121. So far as the Ombudsman can judge, Leeds reacted well to the tragedy of the
man’s death in terms of the support that it offered other prisoners at risk and
to the staff involved. In the immediate emergency situation, SO A did
28
especially well to remove Officer D from the cell given that he was clearly
distressed by the experience.
29
CONCLUSIONS
122. The man did not come to frequent attention, and those staff who spoke about
him referred to his generally quiet demeanour, general politeness, and small
circle of friends. However, it could also be argued that there was limited
evidence of proactive efforts to get to know him. His probable abuse of illicit
opiates while in custody, though known about by some of his prisoner friends
and acquaintances, was not noted by staff.
123. It would appear that he was entirely content to be located on C wing, and for
most of the time he was co-located with his co-accused. The co-accused
himself has given an account of why the two men stopped sharing, but it is
possible that the tensions between them were rather deeper.
124. During December 2008, the man’s behaviour became more unpredictable. In
retrospect, his decision to stop attending the workshop and his general
lethargy may have been an indication of a recurrence of his depression or of
withdrawing from drugs. However, there was little attempt by staff to inquire
into this, save for a misplaced attempt to reduce his IEPS level to basic –
apparently in the false belief that he was a convicted prisoner and therefore
required to work.
125. At the time of his death, he was serving a relatively modest punishment for
refusing to undergo a mandatory drug test. He was also in single occupation
of a double cell, having shared for the previous five months in custody.
Nevertheless, there was no reason for staff to suppose that these two factors
placed him at much greater risk of suicide or self-harm. He was also far from
alone in facing the prospect of an indeterminate sentence if convicted.
126. In sum, he did not present in such a way that staff could reasonably have
anticipated that he would take his own life. Nevertheless, the investigation
has revealed a significant number of issues that the Governor and Head of
Healthcare will need to take forward.
30
RECOMMENDATIONS
To the Head of Healthcare:
1. Procedures/protocols for information sharing between reception staff need to
be reviewed to ensure that information received by one party is available to
all.
The recommendation was accepted. The Ombudsman received the following
response:
‘There is currently in place an information sharing agreement between the
prison and the PCT.’
2. Documentation (First Reception Health Screen) used at reception needs to be
reviewed and updated to gather more useful data with regard to mental health
issues.
The recommendation was accepted. The Ombudsman received the following
response:
‘Health screening is now electronic. As part of the reception team a Mental
Health Nurse is allocated to reception to work with patients with potential
mental health issues.’
3. Important medical information gathered at reception screening (by whoever)
should find its way into the medical notes – coded where possible and
preferably added to the record via a suitable template.
The recommendation was accepted. The Ombudsman received the following
response:
‘Medical information is entered into the patients notes following an electronic
template. Medical issues are Read Coded and Flagged if there are any health
issues.’
4. The pro-forma sent to GPs requesting information needs to be reviewed and
updated to be able to prompt for more information especially for certain
conditions such as mental health problems.
The recommendation was accepted. The Ombudsman received the following
response:
‘A review of the current pro-forma and procedure will be carried out.’
5. Information/letters received from outside agencies such as those from drug
clinics also needs to be reviewed by healthcare staff and coded where
possible and again recorded via a suitable template.
31
The recommendation was accepted. The Ombudsman received the following
response:
‘All medication received and given via drugs agencies is entered into the
clinical notes. In the case of medication being given from outside services’
e.g. methadone, confirmation of the dose is obtained. If no confirmation, then
a dispensing process is in place to maintain the patients’ care.’
6. Antidepressant medication should be continued unless there are compelling
reasons to stop it. It should be continued until at least both the following have
been completed: A suitable assessment of the depression and confirmation of
medication and rationale for its use.
The recommendation was accepted. The Ombudsman received the following
response:
‘In this particular case there was a compelling reason for the Doctor not to
prescribe the anti-depressants. The GP will make his decision and if needed
the primary care mental health team will offer an assessment.’
7. Information on any mental health issues raised at reception, with consent,
should be readily available to all healthcare and possibly wider staff groups
who come into contact with a prisoner in the first few days and possibly
longer.
The recommendation was accepted. The Ombudsman received the following
response:
‘A review of the existing practice will be carried out to discover the best way of
passing this information on without breaching the patient’s confidentiality.’
8. A protocol for review appointments and follow up of defaulters should be
developed that is clear and does not rely on the prisoner to make his own
appointment.
The recommendation was accepted. The Ombudsman received the following
response:
‘A review of the current procedure will take place, with a view to improving all
follow up appointments.’
To the Governor:
9. The Governor should review information sharing in respect of prisoners’ risk
factors for suicide and self-harm.
The recommendation was accepted. The Ombudsman received the following
response:
32
‘New systems were audited during a Prison Service Standards Audit Unit visit
in January. There were found to be effective.’
10. The Governor should review the quality of entries on PER forms and advise
staff accordingly.
The recommendation was accepted. The Ombudsman received the following
response:
‘A selection of PER forms are now checked as part of the management
process to ensure they have been completed in accordance with national
instructions.’
11. The Governor should satisfy himself that the IEPS is being operated
appropriately, and that those prisoners who are not required to work are not
being improperly reduced to basic level.
The recommendation was accepted. The Ombudsman received the following
response:
‘IEP procedures are subjected to regular internal audit. A recent audit has
been completed with an action plan to ensure 100% compliance due to be
completed by the end of July 2010.’
12. The Governor should satisfy himself that roll check procedures are being
operated appropriately.
The recommendation was accepted. The Ombudsman received the following
response:
‘Each day an area or areas are tested as to their ability to maintain an
accurate roll.’
13. The Governor should review the provision of radios to wing staff.
The recommendation was accepted. The Ombudsman received the following
response:
‘A review of the provision of radios to wing staff will be undertaken.’
14. The Governor should remind staff of the circumstances in which it is proper to
enter a cell alone.
The recommendation was accepted. The Ombudsman received the following
response:
‘Night staff will be reminded of the procedure as part of their ‘start of duty’
briefing.’
33
15. The Governor should remind staff that anti-ligature knives should be used to
cut through a ligature where it attaches around the neck.
The recommendation was accepted. The Ombudsman received the following
response:
‘Staff Information Notice to be issued and re-issued annually.’
Good practice
16. The logs kept and actions taken after the man was discovered were first rate.
34