Individual at Belmarsh

Investigation into the circumstances surrounding the death
of a man at HMP Belmarsh,
in December 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
January 2007
This is the report of an investigation into the death a man who died at hospital,in
December 2005, having been taken there from HMP Belmarsh the previous day,
after being found hanging in his cell.
I wish to offer my sincere condolences to his family for their loss.
The man, who was 45 years of age, had been in custody for less than two
months. He was awaiting trial at the time of his death, but was also serving a
sentence as his licence for a previous offence had been revoked.
This investigation was conducted by two of my investigators. They and I are
grateful to the Governor of Belmarsh and her staff for their help and co-operation
during this investigation. I regret that one interview with a prisoner Listener was
not conducted as it should have been with a member of the Samaritans present.
The local Primary Care Trust was asked to carry out a clinical review into the
medical care that the man received in accordance with protocol agreed between
my office and the Department of Health. Unfortunately, the review was not
available at the time of preparing this report.
The man had been on an open F2052SH until three weeks before his death. I
judge that the closure of the F2052SH was justified by the circumstances at the
time. In common with many apparently self-inflicted deaths I investigate, in the
period immediately before his death the man had given neither staff nor fellow
prisoners any cause for concern over his wellbeing.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2007
Contents
Summary
Investigation methodology
HMP Belmarsh
Events prior to the man’s death
Events surrounding the man’s death
Findings and conclusions
Recommendations
Summary
1. The man was arrested in October 2005 for offences of theft and racially
aggravated assault. He was remanded into custody on 14 October to
HMP Belmarsh.
2. There were concerns at that stage about the man’s mood and possible
thoughts of self-harm, but these were not judged sufficient to warrant
the opening of a F2052SH booklet (the Prison Service documentation
for those at risk of suicide or self-harm).
3. On 17 October, the man was assessed by the detoxification medical
officer. She became aware of his low mood and that he was
expressing suicidal thoughts, and opened a F2052SH.
4. The man remained on the F2052SH until 10 November when it was
decided by staff and the man himself that the crisis period was over.
His mood had lifted, he said that he did not have thoughts of self-harm,
and he was happy with his two cellmates.
5. At a court appearance on 18 November, it was discovered that the
man’s licence granted in December 2004 following early release from a
five year custodial sentence had been revoked on 24 October 2005.
6. On 30 November, when his cellmates returned from a period of
exercise, they saw the man hanging by a strip of bed sheet from the
cell toilet door. Staff swiftly entered the cell and took him down.
Cardio Pulmonary Resuscitation was started and an ambulance called.
7. Eventually, after the arrival of the paramedics, some cardiac output
was detected and the man was transferred to hospital. Sadly, he died
the following day without regaining consciousness.
8. Given the order of events outlined in this report, I do not judge that the
man’s attempt on his life could have been predicted or directly
prevented. The decision to close his F2052SH three weeks earlier was
justified by the circumstances at the time, and he had given neither
staff nor fellow prisoners any further cause for concern.
9. I make four recommendations.
Investigation methodology
10. The investigation was opened at HMP Belmarsh on 4 December 2005.
The Governor and her staff produced the man’s core record and a
large number of other documents for examination. Notices were
distributed around the prison notifying staff and prisoners of the
investigation. A number of prison staff and prisoners were formally
interviewed.
11. My investigators liaised with the investigating officer from the
Metropolitan Police to discuss the circumstances surrounding the
man’s death.
12. On 9 January 2006, in accordance with my Terms of Reference, jointly
agreed with the Department of Health, the Primary Care Trust were
contacted and agreed to carry out a clinical review of the care the man
received whilst he was in custody. Unfortunately, the review was not
available when I completed this investigation report.
13. Her Majesty’s Coroner was contacted to inform him of the nature and
scope of my investigation and to request a copy of the Post Mortem
report. Upon completion, this report will be sent to the Coroner to
assist in his enquiries into the man’s death.
14. One of my family liaison officers contacted the man’s family. The
man’s brother asked for a letter to be written explaining the role of the
Ombudsman and a similar letter was sent to the man’s wife. After
receiving the draft copy of this report, the man’s brother requested
extra time before responding. Our normal 28 day limit was extended
on two occasions but in the end this report has had to be issued
without any feedback from the man’s family.
HMP Belmarsh
15. HMP Belmarsh became operational on 2 April 1991. It is a local prison
within the Prison Service’s high security estate. Belmarsh serves the
Central Criminal Court and its feeder Magistrates’ Courts in South East
London, as well as Crown and Magistrates’ Courts in South West
Essex.
16. Prisoners at Belmarsh are offered regular access to education or
workshops. The jail has two gymnasiums, one focusing on accredited
courses and one on recreational gym, with use of a sports hall and a
weights room.
17. A comprehensive detoxification and CARATs service is available to all
prisoners. (CARAT stands for Counselling, Advice, Referral,
Assessment and Throughcare.) Everyone coming into prison who is
identified as having a drug problem is assessed, given advice about
their misusing, and referred to the specific drug service they need.
18. Short term prisoners are offered help to resettle by a range of voluntary
and statutory agencies including seconded staff from the Department
of Work and Pensions, St Mungos (who offer a housing advice service)
and St Giles (who offer a peer support service for advice on housing
related issues).
19. A Listener scheme for prisoners at risk from suicide or self harm is in
operation. (Listeners are volunteer prisoners, trained by the
Samaritans.) A foreign national support group is also in operation.
20. From April 2005 Greenwich Teaching Primary Care Trust assumed
responsibility for commissioning healthcare services within HMP
Belmarsh and required that services met normal NHS standards,
however responsibility for provision of healthcare within Belmarsh
remained with the prison.
21. A three-storey building provides facilities for inpatients, outpatient
clinics, Primary Care Services and a purpose built Mental Health Day
Care Unit. Medical Primary Care and Psychiatric Services are
contracted in from local NHS providers on a full-time basis. The
inpatient unit has 33 beds, mainly used for psychiatric care with all cells
having integral sanitation. The Head of Healthcare leads the
multidisciplinary team comprising Nursing Grades, Healthcare Officers,
Discipline Officers and Nursing Assistants in conjunction with the
Mental Health Inreach Team and General Practitioners.
22. The Inreach Team provides a multi-disciplinary service across the
prison. Outpatient facilities include daily GP clinics and nurse-led
clinics (including for asthma, diabetes, coronary heart disease, HIV and
hepatitis). All new prisoners receive a comprehensive health screen on
reception. The Cass Unit (named after a former member of staff)
provides facilities for inpatients, discharged patients and outpatients on
a multi-disciplinary basis led by a Senior Occupational Therapist.
23. In the latest Prison Performance Ratings (first quarter 2005/06),
Belmarsh was rated as reaching performance level three (of four)
which is defined as ‘Meeting the majority of targets, experiencing no
significant problems in doing so, delivering a reasonable and decent
regime.’
24. The death of the man is the first apparently self-inflicted death to have
occurred at Belmarsh since the introduction of independent
investigation by the Prisons and Probation Ombudsman.
Events prior to the man’s death
25. The man was arrested in October 2005 for shoplifting and a racially
aggravated assault. It was documented that, when he was charged at
the Police Station, he said that he would try and self-harm.
26. When the man arrived at Belmarsh on Friday 14 October, a First
Reception Health Screen was completed. He said that, although he
had previously tried to harm himself two years ago by jumping in front
of a car, he did not have thoughts of self-harm at the present time.
Nevertheless, he was referred for a mental health assessment.
27. A urine test showed positive for cannabis and benzodiazepines. The
man was put onto a detoxification programme consisting of a
chlordiazepoxide reduction regime to manage his withdrawal from
alcohol.
28. A secondary health assessment was carried out the following day
when the man answered further questions about his health. When
asked about his current mood he admitted that it was low. A one to
one interview questionnaire was completed, and he again stated that
he did not feel suicidal at that time.
29. On Monday 17 October, the man was seen by the detoxification
medical officer. During that interview, he stated that he had suicidal
ideation, meaning that he was actively thinking of harming himself.
The doctor opened a F2052SH, the Prison Service’s self-harm at-risk
form designed to record the support plans put into place and the
observations of and interactions with the prisoner. The doctor decided
that the man should remain on normal houseblock location in a shared
cell and that he should be regularly monitored.
30. Later that day, at 9.50 pm, the man was seen in his cell trying to break
up a plastic razor to separate the blade. That was the only overt act of
potential self-harm noted by staff during his time on the F2052SH.
31. A review was held on 19 October when the man stated that he thought
that he might have killed himself the previous night if it had not been for
the presence of his cellmate. He told the review team of two previous
attempts he had made outside prison, by jumping from a bridge and
jumping in front of a car. He said that he had major problems with
alcohol and became very tearful towards the end of the review. It was
decided that he should remain on the F2052SH and that he should
have access to education in addition to the other measures already in
place.
32. On 21 October, the man returned to the Magistrates’ Court and was
further remanded on the theft and assault matters until November.
33. On 24 October, the licence on which the man had been released in
December 2004 was revoked. That revocation appears to have come
to light when he returned to court in November.
34. Another F2052SH review was held on 26 October at which the man
was present. It was noted that he spoke in a monotone and did not
make a single positive response.
35. On 28 October, he was seen by an occupational therapist. During the
extensive interview, he again spoke of his very low mood but said that
he had no motivation to act on his thoughts of self-harm. At the end of
the session it was decided that he should attend the Cass Unit
(occupational health) three times a week. This would enable his mood
and mental state to be monitored whilst he was participating in
constructive activities. It was also planned that the occupational
therapist would liaise with the psychiatrist about an out-patient’s
appointment.
36. During an F2052SH review held on 2 November, the man said that he
still had thoughts of self-harm due to his family not wanting any contact
with him. He also said that he would not self-harm whilst he was in a
shared cell. His detoxification medication had been extended and, with
the support of that medication, he was coping.
37. The man was seen by one of the prison’s psychiatrists on 7 November.
Again, it was an extensive interview during which he told the
psychiatrist about his drug and alcohol abuse and his relationship
problems. The outcome of that assessment was that the psychiatrist
decided to review the man in the outpatient’s clinic in four weeks time,
for him to attend the Cass unit and continue on the anti-depressant
medication. The psychiatrist was content for the F2052SH reviews to
continue unchanged as there had been no changes recently in his
mood and he appeared to be coping well in the house block.
38. On 10 November, another F2052SH review was held. The man was in
a noticeably better mental state and, now that his detoxification was
completed, he said that he felt much better. He also said that attending
education had helped him. The review team, with the man, agreed to
close the F2052SH booklet. He was reminded that he still had support
that he could access on the houseblock.
39. During his time on the F2052SH, the man had spoken to a Listener a
number of times. He had got on well with him as he spoke Punjabi as
well as English. During an interview with my investigators the Listener
agreed that the man was happy to come off the F2052SH and was in a
much better frame of mind.
40. On 18 November, the man attended the Magistrates’ Court and was
again remanded into custody, this time until December. As previously
noted, it appears that it was during this court attendance that the
revocation of his licence was discovered. My investigators have not
seen any documentation apart from the copy of the revocation
document itself. No action appears to have been taken regarding the
licence revocation and no reassessment of the man was undertaken.
41. On 24 November, the man was spoken to regarding a cell move to
spur one in order to be near the Listener. He declined the move saying
that he was happy in the cell he currently occupied.
42. His cellmates told my investigators that the man gave them no cause
for concern. He was friendly, talkative and would watch TV with them
as well as making tea for them or accepting tea made by them. As far
as they were concerned, what subsequently took place was totally
unexpected.
Events surrounding the man’s death
43. On 30 November 2005, at about 9 am, the cells on Houseblock 2 were
opened for the prisoners to go to exercise. The man’s two cellmates
left the cell, but he decided that he did not want to go. It was not the
first time that he had been left alone in his cell since coming off of the
F2052SH. The cell was re-secured.
44. At about 9.30 am, one of the houseblock cleaners heard a noise from
the man’s cell and, despite regulations prohibiting the cleaners
approaching the cell doors, he looked into the cell. Although he did not
know at the time who he was, he saw the man apparently standing with
his back to the toilet door. Another prisoner suggested that he was
probably meditating.
45. At 9.55 am, the man’s cellmate’s returned from exercise and looked
into their cell. It was dark but they could see the man apparently
standing with his back against the toilet door. They looked closer and
believed that he was hanging. They alerted the nearest officer. The
officer looked into the cell and opened the door. He shouted for other
staff and entered the cell. The man had tied a strip of torn bed sheet to
the kettle which he had placed over the top of the toilet door. He had
then fashioned a loop in the remaining strip and, after placing his head
in the loop, had leaned forward thereby constricting his neck.
46. Two officers ran to the cell and removed the ligature around the man’s
neck, whilst the officer first on scene, supported his weight. They laid
the man on the cell floor and one of the officers called a level one
emergency over her radio whilst checking the man’s airway. The
officer first on scene felt for a pulse, but could not find one.
47. A nurse arrived in the cell and began mouth to mouth resuscitation,
while the officer first on scene did the chest compressions. An
ambulance was called by the control room at 10 am. A second nurse
heard the radio call and responded with another officer. The second
nurse took over from the nurse on scene and called for the defibrillator,
which is kept on the houseblock. He attached the machine which
advised ‘No shock’ and they continued Cardio Pulmonary
Resuscitation (CPR).
48. A doctor arrived at the cell at 10.13 am, as the ambulance was
reversing up to the houseblock. The paramedics took over CPR and,
after intravenously administering some drugs, established cardiac
output.
49. Escort staff had been arranged and a risk assessment completed. Two
officers accompanied the man in the ambulance when it left Belmarsh
at 10.30 am. He was unconscious and was not restrained in any way.
50. The ambulance arrived at the hospital at 10.40 am. After a CT scan,
the man was moved to the Intensive Therapy Unit.
51. The man’s two cellmates were separately put into other cells with other
prisoners. Both men were upset by this and would have preferred to
remain together to talk about the man and what had happened.
52. A ‘hot debrief’ was held at the prison to give the staff involved the
opportunity to discuss what had taken place. The prison care team
also attended and spoke with the staff members. The man’s cellmates
and his former Listener were spoken to by senior staff and offered the
opportunity to speak with the chaplaincy and/or the Samaritans.
53. A Governor and the prison Sikh minister, visited the man’s brother and
notified him of what had occurred. His brother provided contact details
for the man’s estranged wife and she was also informed.
54. The man died at the hospital at midday on 1 December 2005.
55. The Post Mortem examination took place on 2 December 2005. The
cause of death was found to be hanging.
Findings and conclusions
56. The man arrived at Belmarsh during the afternoon of Friday 14 October
2005 with self-harm warning signals on his Prisoner Escort Risk (PER)
form. During the initial reception procedures and the first and
secondary health checks, he denied any thoughts of self-harm. When
he was seen by the detox medical officer after the weekend, she was
sufficiently concerned about the man’s mood and suicidal ideations to
open a F2052SH. Given that he was expressing thoughts of self-harm
and displaying signs of low mood, I am sure this was appropriate.
57. The period that he was on the open F2052SH was well documented
and he was properly supported. The reviews were conducted
correctly, although I would have liked to have seen more input from
healthcare staff on the review panels. The decision to close the
F2052SH appears also to have been justified, taking account of the
change in the man’s mood. His cellmates and his Listener/friend all
stated that they saw no sign of any intention on his part to self-harm at
that time or after.
58. All of the staff responded quickly to the discovery of the man hanging in
his cell. They are to be commended for their actions and the part they
played in re-establishing cardiac output.
59. The man’s licence was revoked on 24 October and that fact was
recognised when he returned from court on 18 November. I am
concerned that nothing appears to have been done in relation to the
revocation. It is not clear from the documents disclosed to my
investigators if he was aware of the revocation. The establishment is
unable to clarify this matter any further. I would have expected the
man to have at least been seen by a member of the mental health
team upon return from court to assess the impact of the revocation on
his mood, especially as he had recently been on an open F2052SH.
60. It was unfortunate that his cellmates were put into separate cells after
the the man was discovered hanging. Both men understood the need
to move from their shared cell but would have liked to have been re-
housed together. Should a similar circumstance occur in the future, I
hope that greater consideration be given to keeping cellmates together
if they so wish and if security issues permit.
61. In the circumstances described in this report, I do not believe that the
man’s attempt on his life could have been predicted, or directly
prevented.
Recommendations
The Governor should give consideration to the make-up of the
F2052SH review teams with a view to incorporating healthcare staff
on a regular basis.
The Governor should ensure that any significant changes in
prisoners’ circumstances are properly assessed, documented and
acted upon.
The Governor should ensure that a robust system is in place to
inform prisoners of any change in their status.
The Primary Care Trust was asked to undertake a clinical review into
the care the man received whilst at HMP Belmarsh in accordance
with the agreement between the Department of Health and the
Prisons and Probation Ombudsman. The report has yet to be
completed. Prison Health should arrange an urgent review into the
care received by the man.