Individual at The Verne

Investigation into the circumstances surrounding the
death of a man in July 2010 at hospital
whilst in the custody of HMP The Verne
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2011
This is the report of an investigation into the circumstances surrounding the death of
a man, a prisoner at HMP The Verne. He died in July 2010 and was 50 years old. I
would like to offer my sincere sympathy and condolences to his family for their loss.
I am sorry that my report has been delayed and I regret any additional distress which
this has caused.
The investigation was carried out on behalf of the Ombudsman by my colleague. I
would like to thank the Governor of The Verne and her staff for their co-operation
during the course of our enquiries.
The local Primary Care Trust (PCT) was commissioned to conduct a clinical review
into the standard of healthcare he received whilst in custody at The Verne. They
appointed a clinical reviewer and I would like to thank him for his review.
One of my family liaison officers contacted the man’s family to inform them of our
investigation and give them the opportunity to raise any issues about the care which
he received whilst he was in custody.
He was found by a fellow prisoner at the bottom of a stairwell. Despite extensive first
aid and resuscitation attempts, he died later that day in hospital. Sadly, the
circumstances surrounding his death remain unclear. In common with the police
investigation and the National Offender Management Services’ health and safety
investigation, I have been unable to determine the exact circumstances surrounding
his death. I am sorry that this will inevitably cause additional distress to his family.
The Coroner has recorded his death as being caused by multiple injuries due to
blunt trauma.
I make five recommendations in my report regarding staffing levels at night, Close
Circuit television and first aid matters.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Thea Walton
Acting Deputy Prisons and Probation Ombudsman June 2011
2
CONTENTS
Summary
The investigation process
HMP The Verne
Key findings
Issues
Conclusion
Recommendations
3
SUMMARY
1. The man was remanded into HMP Dorchester on 8 June 2009, charged with
serious offences. He appeared in court three times before being granted bail on
17 August. His trial was scheduled for 9 December. He was found guilty of his
offences and sentenced to five years imprisonment. He was received back into
custody at Dorchester.
2. He was transferred to HMP The Verne on 5 January 2010. During his time at
The Verne, he participated in an Alcohol Relapse Prevention Programme and
applied to see the Counselling, Assessment, Referral, Advice Throughcare
(CARATs) team. He was employed by the gardens party where he helped look
after the prison grounds, and grew vegetables and herbs for the kitchen. He was
said to be an “outstanding member of the team” by the Head of Horticulture.
3. During the early hours of the morning of 4 July, he was found by another
prisoner, lying at the bottom of the stairs of A wing. It appeared that he had fallen
from a height. The prisoner notified the member of staff, an Operational Support
Grade (OSG), who was responsible for the wing during the night. The OSG went
to the bottom of the stairs and, after seeing his condition, called for urgent
assistance and for an ambulance to be called. Despite the extensive first aid
efforts of both staff and paramedics, he died later that morning at hospital.
4. The police conducted an investigation into the circumstances surrounding his
death. They concluded that there was no third party involvement and that the
cause of his fall was unexplained. Health and safety representatives from the
National Offender Management Service (NOMS) also conducted an investigation.
They found no evidence to suggest that his fall was an accident and have also
concluded that the incident cannot be explained. I have also been unable to
establish a definite cause for his fall.
5. I make five recommendations as a result of this investigation. These concern the
number of staff on duty at night, the provision of CCTV in the wings and several
recommendations concerning first aid equipment and training.
4
THE INVESTIGATION PROCESS
6. One of my investigators opened the investigation at The Verne on 15 July 2010.
She met senior prison managers, including the Deputy Governor, and took copies
of prison documentation relating to him. Notices of the investigation were issued
to staff and prisoners, inviting those who wished to provide information regarding
his death to make themselves known to the investigator. No-one came forward in
response to the notices. She visited the prison on 17 August, and 21 and 22
September, to interview staff and prisoners.
7. The investigator wrote to the Chief Executive of the local Primary Care Trust
(PCT) to commission a clinical review. The PCT asked the clinical reviewer to
carry out the review of the care received by him whilst he was at The Verne. He
received a copy of the relevant medical documents upon which he based his
findings.
8. My investigator contacted HM Coroner for Western Dorset District to inform him
of the nature and scope of the investigation. Upon completion, a copy of my
report will be sent to the Coroner to assist his enquiries into the man’s death. He
provided the investigator with a copy of the report of the post mortem following
the death.
9. One of the Ombudsman’s family liaison officers contacted the man’s family at the
beginning of the investigation. She informed them of the investigation and
offered them the opportunity to raise any questions or concerns they would like
addressed during the investigation. His sister raised the following issues:
(cid:127) Why was he out of his cell so early?
(cid:127) Is there any CCTV footage of the wing or stairwell?
(cid:127) What are the circumstances surrounding him going over the
banister and falling 30 feet?
(cid:127) Was the emergency response adequate?
10. However, his mother told the family liaison officer that she was sure that her
son’s death was an accident. She described him as being happy in prison, said
that he looked well and enjoyed his job working in the prison’s gardens. She
contrasted this with how he had looked before he went to prison when he had
been drinking too much.
5
HMP THE VERNE
11. The Verne is a category C training prison for adult men on the Isle of Portland,
Dorset. It holds up to 607 prisoners who are mainly life sentenced prisoners or
those who have received a determinate sentence (where the number of years
imprisonment to be served is decided by the sentencing judge). Foreign national
prisoners form a large part of the population.
12. Inside the secure perimeter walls of the prison, there is minimal physical security
and prisoners are able to move freely around the prison. For this reason, only
those prisoners who meet the strict reception criteria are accepted. Suitable
prisoners, among other factors, must:
(cid:127) be 25 years of age or older
(cid:127) have at least nine months of their sentence left to serve
(cid:127) have no history of escape or attempted escape
(cid:127) have no history of racism
(cid:127) have no significant history of prison drug trafficking or dealing
(cid:127) not require intensive psychiatric intervention
(cid:127) not be assessed as posing a high risk to other prisoners.
13. The man’s cell was situated in A wing, which is one of six purpose built house
blocks. Each wing can accommodate a maximum of 86 prisoners on three floors,
and most prisoners occupy single cells. All the prisoners have keys to their
rooms and A1 wing, where he lived, only accommodates enhanced level
prisoners. (Under the Incentives and Earned Privileges scheme, prisoners are
assessed according to a number of factors, and rated as basic, standard or
enhanced. Enhanced prisoners receive privileges compared to other prisoners,
depending on the scheme run in the prison.) Prisoners are required to be in their
rooms by 11.30pm until 6.30am, but otherwise they are able to move around the
wing freely at all other times.
14. At night one Operational Support Grade (OSG) has responsibility for the entire
wing. When not carrying out his roll checks, he is located in the ground floor wing
office.
15. There is no 24 hour healthcare at the prison, and in the case of an emergency
outside of normal working hours, a call is made to an on-call doctor. Dorset
Community Health Services (DCHS) provides healthcare between 9.00am and
5.00pm, seven days a week. Out of hours provision is sub-contracted to South
West Ambulance Service Trust who also provide the out of hours emergency
response.
16. The National Offender Management Service (NOMS) publishes quarterly
performance ratings for all prisons in England and Wales. The ratings are based
on a set framework and prisons can be rated from one to four (with four indicating
‘exceptional’ performance). The Verne has achieved a rating of three (‘good’
performance) for the last four published quarters.
6
Previous investigations by the Prisons and Probation Ombudsman
17. My office has investigated six previous deaths at The Verne. Although there are
no similarities between the circumstances of the man’s death and the others I
have investigated, I have previously made recommendations about the provision
of first aid training. The last recommendation on this issue, however, was made
after he had died. I have also made a recommendation that staff on nights
should be trained to use a defibrillator, and that more defibrillators should be
provided. Although this recommendation was partially accepted in January 2010,
I make a similar recommendation as a result of this investigation. A response to
the draft report from Dorset Community Health Services noted that an additional
defibrillator has been purchased, however the Governor has said that the Prison
Officers Association (POA) would not support prison officers in its use, as they
were not medically qualified. They also said that the first response should be to
call the emergency services.
HM Chief Inspector of Prisons (HMCIP)
18. The most recent available inspection report by HMCIP relates to a full announced
inspection of the prison conducted in August 2007. (HMCIP inspected The Verne
again in 2010 but the report is not yet available.) The then Chief Inspector noted
the good relationships between staff and prisoners and reported that earlier
concerns about safety had been “largely addressed”. However, she said that
violence reduction and safer custody policies were not sufficiently robust.
19. Inspectors found that the violence reduction strategy did not meet the needs of
the population and there were no interventions to encourage bullies to confront
their behaviour. However, the inspection found little evidence of violence at The
Verne, and prisoners said they felt safe there.
Independent Monitoring Board (IMB)
20. Each prison in England and Wales is monitored by an independent board of
volunteers drawn from the local community. Members of the Board have access
to every part of the prison and all prisoners held there. The Board must produce
an annual report, the latest available for The Verne covering the period May 2009
to May 2010.
21. The IMB reported on “great improvements” in safer custody in their 2009 report.
However, during the following year’s report they noted that:
“… the optimism voiced by the IMB in the 2009 report has unfortunately
failed to persist throughout the year. The appointment of a non-uniform
Safer Custody Co-ordinator, whose post was meant to be safeguarded (i.e.
the person doing the job was not meant to be moved to another area in the
event of staff shortages/changes) did not last long.”
22. The IMB also reported that “there have not been many anti-bullying files opened
in recent months, and there are some concerns that not all incidents are being
reported – and if not why not”.
7
Health and Safety (H&S)
23. A member of the IMB attends quarterly Health and Safety meetings. There were
no serious incidents in the prison during the year. The IMB noted that “the H&S
department at The Verne, which includes a full time Fire Officer and part time
clerk, are all very committed”.
24. Officers and civilian staff are able to attend regular internal courses on Health
and Safety. The majority of the IMB members have attended both a health and
safety and manual-handling course.
25. Due to the age of some buildings, which date back to about 1873, some areas
continue to be damp and require de-humidifying on a regular basis. These areas
(which are known as casements) house education and library facilities and the
Kainos residential wing (which is used as a therapeutic community) as well as
other offices. There are other areas which are not fully utilised because of Health
and Safety legislation.
8
KEY FINDINGS
26. The man was remanded into custody at HMP Dorchester on 8 June 2009,
charged with serious offences. He had previously come into contact with the
legal system on a number of occasions, for various offences, and had served a
custodial sentence 18 years previously.
27. During his first reception health screen on arrival at Dorchester, he stated that he
was a smoker, drunk a bottle of vodka a day, suffered from boils on his groin,
was allergic to amoxicillin (an anti-biotic) and had high cholesterol. Prison Doctor
A prescribed simvastatin (a drug used to control elevated cholesterol) and asprin
for his high cholesterol and also consented to him having his own flip flop sandals
sent in (although the reason for this is not clear).
28. On 14 July, he attended an appointment with Prison Doctor A about the boils on
his groin. He was prescribed Betadine spay (an antiseptic spray) and advised
that, if this did not help, he should return to be prescribed antibiotics. On 17 July,
he went back to healthcare and was examined by Prison Doctor B, who
prescribed antibiotics and an anti-fungal cream.
29. He attended three court appearances during June and July. He was granted bail
on 5 August, on the conditions that he surrendered his passport, adhered to a
curfew, wore an electronic tag and presented himself to a police station every
day. He was also not allowed to enter Dorset, except for the purposes of his
court appearances.
30. On 9 December, he was found guilty of his offences and was sentenced to five
years imprisonment. He was received back into custody at Dorchester, where he
had another first reception health screen. It was noted in his medical record that
he had no signs of depression and his blood pressure was elevated. Prison
Doctor A also re-prescribed simvastatin and aspirin. His blood pressure was then
monitored weekly and recorded in his medical record.
31. He transferred to The Verne on 5 January 2010. He received another first
reception health screen and it was recorded in his medical record that he was
suitable for cell sharing (a cell sharing risk assessment was conducted).
However, he was allocated a single cell as he snored heavily.
32. The next day, he had a review with Nurse A, a mental health nurse. She
recorded that he appeared calm and had no issues at present. During his review,
he said that he had smoked cannabis in the last month and so she referred him
to the drugs service.
33. He saw a Counselling, Assessment, Referral, Advice and Throughcare (CARATs)
worker on 26 January, and underwent an assessment. He scored medium to high
on the alcohol audit and was put forward for the Alcohol Relapse Prevention
Group Programme. He completed all ten sessions during March and April and
his report was sent to the Offender Management Unit (OMU).
9
34. During his time at The Verne, he continued to suffer from persistent boils on his
groin, on his neck and under his armpit. He was prescribed various antibiotics
and anti-inflammatory creams to treat the boils, and also had them lanced.
35. On 19 March, he saw Prison Doctor C regarding the boils on his groin. It is
recorded in his medical record that he said that he had been suffering with
“dribbling” after urination for the previous eighteen months. The doctor referred
him to a urology consultant. An appointment was made for 24 June, but he did
not attend. There is no information in the prison documentation to explain why he
did not attend this appointment.
36. He saw Prison Doctor D on 19 April to discuss his high cholesterol level. He said
that he would prefer to try and diet and exercise as opposed to taking tablets to
reduce his cholesterol. The doctor referred him to the gym for an appropriate
exercise regime. He attended the gym in the mornings and his weight was
monitored.
37. He referred himself to see the CARATs team on 18 May. He was seen by a
CARATs worker on 26 May for his assessment. During his assessment, he
stated that he had a history of drug and alcohol abuse, but that he had
undergone a Twelve Step drug treatment programme in the community and had
remained drug free for ten years. He had started drinking which had led to
snorting cocaine. She recorded that he was unsure whether he to do a CARATs
or the Twelve Step programme. He was also due in court soon and was unsure
what prison he would be coming back to. He stated that he would refer himself
back to CARATs once he was settled.
38. On 30 June, he was examined by Prison Doctor D as he was experiencing back
pain. The doctor prescribed an analgesic (pain relieving) cream and he passed a
sick note to the wing officers to be excused from work. During an interview with
the investigator, the Head of Horticulture, said:
“The week prior to his death it was a bit strange to be told he’s gone sick but
sort of two to three days prior to that he did mention to me … that he’d got
some worry about some Confiscation Order and hearing.”
He said that this was unusual as the man would normally talk to him or his
colleague about his affairs. However, Prisoner A, who had the same legal
representatives as him, said that he did not think he had been that concerned
about the Confiscation Order or returning to Dorchester.
39. He was due to go to court on 2 July for the confiscation hearing. Despite telling
the Head of Horticulture that he was worried about going to court (as he did not
know which prison he would go back to and he wanted to return to The Verne,
and also that he might get an extended sentence), his friend said he did not think
he was overly concerned about the hearing. The court appearance was
postponed and a new date had not been arranged before he died.
40. On 3 July, he had a visit from his girlfriend. The visit went well and he was said
to have been in good sprits afterwards. His girlfriend told the police after his
10
death that the visit had been entirely pleasant and friendly. There had been no
suggestion of ill feeling between them or within his family, and he had not
mentioned getting any bad news.
41. That evening, as it was his birthday, some of the prisoners on A wing arranged to
have a party. He made some sandwiches and a fruit salad. As a World Cup
football match was being played that night, some prisoners (including him) sat
around eating tea and watching the match. Prisoner A explained that four or five
prisoners had their doors open and they moved freely from one room to another
enjoying the evening. At about 10.00pm, after the match, he said that all the
prisoners returned to their own rooms and he did not see or hear from him again
that night.
4 July
42. The OSG was the member of staff on duty overnight on A wing from 9.00pm on 3
July to 8.00am on 4 July. He was responsible for approximately 80 prisoners.
He said during his interview with the investigator that his main job was to patrol
the wing at half hour intervals. He completed his last round of checks at 5.58am.
(Officers are required to check in electronically at various points across the wing
during the night, confirming they were there and the time. At the end of a shift an
electronic print out is generated. This is known as pegging.) The wing rule
states that prisoners should return to their own rooms by 11.30pm. However, he
confirmed that there are no observation panels on the prisoners’ doors and he
does not go into any rooms to check on the prisoners. In between patrols, he
remains in a locked office on the ground floor.
43. He told my investigator that the wings had been quiet as normal that evening. He
had walked the length of the wing on the second landing (which is where the
man’s cell was located) and did not see anybody, but he had heard the
movement of early risers and a shower running at approximately 6.00am. He
then returned to the wing office. He said that he heard a thud about 15 minutes
later, and possibly a noise which he thought was made by a plastic bin, but did
not go to investigate as he did not think it was anything unusual.
44. Around 6.25am, Prisoner B had got up to go to the toilet on the first floor.
Prisoners are permitted to leave their rooms after 6.30am, but many are up and
about earlier than that. The investigator was told that the man was an early riser,
but otherwise it is not clear whether there was a specific reason why he was out
of his cell at that time.
45. Whilst the prisoner was in the toilet, he heard loud breathing. He followed the
direction of the sound out on to the landing and looked over the railing, where he
saw a prisoner, later identified as the man, lying at the bottom of the stairs.
46. At this point, Prisoner C was coming down the stairs from the second landing.
He too had heard heavy breathing and he met the other prisoner on the first
landing. Prisoner B pointed out the man, who was lying on his back on the floor
at the bottom of the stairs. He asked the other prisoner to inform the OSG, and
then went to the bottom of the stairs to see if he could help.
11
47. Prisoner C knocked on the wing office door and informed the OSG that he had
come down for some hot water and that someone was lying on the floor at the
bottom of the stairs. He told the OSG that the man was panting and he assumed
that he was injured, but did not know for sure and could not see any blood at this
point. The OSG asked if he had seen what had happened to which the prisoner
shook his head.
48. The OSG went to the bottom of the stairwell and found the man lying flat on his
back with one leg raised at the knee. He observed that he was groaning, had a
head wound at back of his head which was bleeding, and was breathing heavily.
He called an urgent message over the radio, requesting assistance and an
ambulance. He made the call at approximately 6.25am.
49. Another OSG who was located in the control room dialled ‘999’ to request an
ambulance and informed them of the situation. At this time, two officers and a
Senior Officer (SO) had heard the emergency call over the radio and arrived at
the scene (these were officers managing the prison during the night). Officer A
recalled at interview that the man had blood at the left side of the back of his
head, which was pooled around his head. He ran to the wing office to get the first
aid kit and assisted the OSG administer first aid. (The officer had attained his
first aid certificate the week before and the OSG had last attended a course three
years earlier.) The officer applied a dressing to his head to try and stem the
bleeding. At this point, he appeared unconscious, had one eye open and one
eye closed and was breathing slowly and deeply. He did not move at all.
50. The contents of the first aid kit from the office were inadequate for the officer’s
needs, so he asked Officer B to get more dressings to help stop the bleeding.
The officer then ran around the wings to take dressings from the first aid boxes.
Officer C, who had also heard the emergency call and ran to the scene, then ran
to the segregation unit to get some blankets to cover him and keep him warm.
Officer A did not ask anyone to collect the single defibrillator in the prison as
nobody, apart from healthcare staff, knew how to use it. He was still breathing at
this time. DCHS said in response to this report that there are two defibrillators
based at the prison, one in healthcare and one in the segregation unit. Also that
first aid boxes are the responsibility of the prison to stock, although DCHS would
be happy to advise on the contents.
51. The officers were unable to identify him and the SO went on to the wing and
asked a prisoner to identify him. The SO returned to the foot of the stairs. She
became increasingly worried that he might die as he was foaming at the mouth
and his eyes had rolled back. The SO spoke to the ambulance control at 6.37am
and updated them about the situation. The ambulance control advised that the
officers should continue talking to him, keep a compression on his head and
ensure that his mouth was clear from obstruction until the paramedics arrived.
The officers followed this advice and three paramedics arrived at A wing at
6.44am.
52. Officer C sealed off the wing with incident tape. He looked around the wings to
see if he could find the prisoner who had alerted the OSG. While doing this, he
12
saw his identification card and keys just inside his cell, and closed the door.
Meanwhile, the SO requested a camera from security so that she could take
photographs of the scene. At interview she told the investigator that not having
access to a camera at night (apart from going through Security staff) was
inconvenient, because she wanted to take pictures of the immediate scene. It
was noted that he had been wearing flip flop sandals. Each sandal was found on
a different stair close to where he was discovered.
53. The paramedics took over from the OSG and Officer A in administering first aid to
him and they prepared him to be transferred to hospital. As the paramedics were
putting him on the board to be taken to the ambulance, they noticed a dent in his
spine and bruising on his shoulder and on his hip. During this time, the SO
arranged an escort to accompany him to hospital and informed the duty Governor
of the incident. He was taken to hospital at 7.20am, escorted by two officers. No
restraints were used at any time.
54. The ambulance arrived at the hospital at approximately 7.45am. Officer D stated
during his interview with the investigator that on arrival there was “a team ready
to go … people worked on him straight away”. At 7.50am, hospital staff asked for
details of his medical information. Officer E contacted the prison and a nurse
went to healthcare where she telephoned the hospital to give them the relevant
details.
55. The duty governor that day held a hot debrief meeting with the staff involved in
the incident before they went off duty. He discussed the incident to try and
establish the circumstances. He also asked if the staff were alright or whether
they needed the support of the care team. Officers talked about their
involvement in the morning’s incident and highlighted any concerns they had with
the emergency response and the resources that were available. Officer A
mentioned the lack of first aid equipment, in particular absorbent pads, on the
wing.
56. Despite the extensive first aid efforts of both prison and medical staff, the man
died at 8.25am. During his interview, Officer D stated that
“… the doctor came out … then informed us that he had died actually not
long after we’d actually arrived there but they’d obviously continued to work
on him for approximately three quarters of an hour.”
The officer then telephoned the prison from the hospital and confirmed that he
had died.
57. At 8.43am, the duty governor informed the chaplain that the man had died. He
attempted to telephone the man’s mother, but was unable to reach her on the
telephone and so left a message on her answer machine informing her that there
had been an incident. He passed the mother’s details to the chaplain and asked
him to contact her and inform her about her son’s death the incident. The
chaplain was also unable to contact her as she was out on a day trip. He spoke
with the Roman Catholic Minister of the area where she lived in London who
offered to assist if required.
13
58. The police arrived at the prison at 9.25am and went to the stairwell on A1 wing.
As the incident was unexplained and had not been witnessed by anyone, the
police treated his fall as suspicious. A Scene of Crime Officer arrived and began
to evaluate the scene, taking photographs as evidence and going to the third floor
to see if there was any obvious explanation as to how he had fallen over the rail.
The police officers also began to take statements from the staff who responded to
the incident.
59. The duty governor contacted HMP Pentonville at 11.14am, to ask for assistance
to contact the man’s mother. Another prisoner at The Verne telephoned the
man’s girlfriend in the meantime and told her that he had been involved in an
incident. The man’s girlfriend and sister then began to telephone the prison to
ask for more information. The duty governor confirmed that there had been an
incident, but was unable to tell them any further details as the next of kin had still
not been informed. The deputy governor contacted the duty governor at HMP
Pentonville again at 3.30pm to ask them to contact the man’s mother.
60. At 3.40pm, the deputy governor began trying to contact the man’s sister. He
managed to gain contact with her at 5.00pm and formally told her of her brother’s
death. It is unclear why this took so long, given that she had already contacted
the prison earlier that day. The Governor of HMP Pentonville telephoned the
deputy governor at 6.00pm to confirm that his staff had spoken to all of the man’s
relatives and next of kin. An officer was appointed as the prison’s family liaison
officer until another family liaison officer returned from leave. The officer liaised
with the family regarding any concerns they had and the procedure for returning
his property.
61. In the meantime, there appeared to be some confusion amongst prisoners on A
wing about what had happened to him. Eventually, an officer spoke to a group of
prisoners to explain what had happened and put up notices informing them that
he had died. All prisoners who were being monitored through the Assessment,
Care in Custody and Teamwork support procedures (ACCT, which ensures that
prisoners at risk of harming themselves are properly monitored and supported)
were reviewed. All the prisoners were reminded of the services of Listeners
(other prisoners who are trained to speak and listen to others in distress) and
Samaritans.
62. A critical incident debrief was held for staff about three weeks after he died.
63. The post-mortem was held on 5 July. It concluded that there was evidence that
he had sustained a fractured skull, multiple rib injuries and a fractured pelvis.
There was also haemorrhaging around both renal pelves (a part of the ureter in
the kidney) and within both thoracic (chest) cavities. It was determined that the
likely cause of death was multiple injuries due to blunt trauma.
64. Another officer took over the role of prison family liaison officer on 22 July when
he returned from annual leave. He telephoned the funeral director who told him
that the funeral had taken place on 20 July. On 2 August, my investigator was
told by the Ombudsman’s family liaison officer that the prison had paid for
14
transport to the funeral director but not for the funeral. After speaking with the
investigator, the prison family liaison officer spoke to the Governor and Deputy
Governor about this matter. They immediately agreed that the funeral expenses
would be paid for by the prison once the funeral director submitted an invoice
which was completed the next day.
65. A Detective Chief Inspector (DCI) led an investigation into the circumstances of
the man’s death. She was satisfied that there were no suspicious circumstances
surrounding the incident and there was no evidence or suggestion of any third
party involvement or foul play. She concluded that the cause of his fall in the
stairwell was unexplained.
66. The NOMS South West Regional Health, Safety and Fire Safety Advisor and the
Health and Safety Advisor at The Verne conducted a health and safety
investigation into the circumstances of the man’s fall. They looked at various
prison and wing documentation, including wing logs, cleaning procedures,
photographs and staff statements as part of their investigation as well as
conducting a thorough evaluation of the area that he fell. The health and safety
investigation concluded that
“We have not found any evidence that would lead us to conclude that his
death was as a result of an accident as we could not find a reasonable
cause or failure that could lead to the same.”
67. A clinical reviewer carried out the clinical review for the man. He was also unable
to form an opinion as to why he had died. However, he determined that he had
received good care whilst he was in prison.
15
ISSUES
Night time staffing levels
68. It is of some concern to me that only one Operation Support Grade is on duty on
A wing of a night, with responsibility for approximately 80 prisoners. My
investigator spoke to the Head of Residence about this, and he said that the
prisoners on the wing are all risk assessed. Amongst other things they have to
be aged over 25 years, have more than nine months to serve and be assessed
as a low escape risk.
69. Despite the risk assessment, I am concerned that the OSG on night duty locks
himself in the ground floor office, only leaving the office to conduct his checks.
Although the wing rule is that all prisoners should be in their own room by
11.30pm, the OSG has no way of checking this as they do not open the doors to
see in to the rooms, and the doors do not have observation panels. In essence,
as all prisoners have keys to their rooms, they can effectively move about as they
choose. I understand that these arrangements are the same for other wings, and
that no incidents of a similar nature have occurred. However, this casts doubt on
whether this is a safe environment for either prisoners or staff.
The Governor should ensure that a review into night staffing levels is
carried out immediately to ensure that both prisoners and staff are safe.
Closed circuit television (CCTV)
70. Following on from the previous issue, the absence of CCTV on A wing
compounds the risk of an incident occurring without detection. If the current
staffing level remains as it is (an OSG who is usually locked in an office), I
suggest that CCTV would give both prisoners and staff extra protection. This is
particularly true of areas that are difficult to monitor, such as stairwells. It is
perhaps an obvious point, but if CCTV had been installed, then the man’s death
could at least have been explained, if not prevented.
The Governor should consider installing CCTV on the wings.
First aid equipment and training
71. Staff who administered first aid to the man commented on the lack of equipment
(for example, absorbent pads and bandages) in the boxes located on the wing.
They had to run to other locations to find suitable items to assist the first-aiders.
It is clearly important that those attempting to give first aid have as much of the
correct equipment as possible. While it is unlikely, given the injuries which he
suffered in the fall, that he would have survived even with adequate supplies
being immediately to hand, in other circumstances this might be vital.
The Governor should ensure that first aid boxes are adequately stocked at
all times and also that other items (which cannot fit in the box) are available
on the wing.
16
72. The OSG, who was on duty on A Wing, said that he had received first aid training
in 2009. However, the senior officer said that all OSGs who work nights received
part day training over three years ago. I do not think that this is unacceptable
given that an OSG is the sole member of staff on duty at night, and given that no
healthcare staff are on duty during the night. Whilst I accept that the OSG will
radio through an emergency call to colleagues, they will inevitably be the first
member of staff at the scene and I believe that they should have an up to date
first aid qualification. It also seems that Officer A was the only officer who
responded to the emergency who had current first aid training.
The Governor should ensure that a cross section of all staff, and all the staff
who work at night, should have an up to date first aid qualification.
Although in this case a defibrillator was not needed as the man was still
breathing, I am concerned to learn that there is only one machine in the prison
(DCHS have since said there are two machines in the prison) and only the
healthcare staff know how to operate it. I have raised this matter in a
recommendation following a previous investigation and I am concerned that this
has still not been satisfactorily addressed. Given the absence of 24 hour
healthcare cover, it is important that a cross section of staff, particularly those
who work at night, are able to use the defibrillator.
The Governor should ensure that a cross section of staff, but in particular
those who work night duty, are trained to use the prison’s defibrillator.
Delay in informing the man’s family
73. It is clear to me that the prison made every effort to contact the man’s mother, but
was unable to do so as she was away for the day. I can see from the prison
documentation that he had only named his mother as his next of kin. However,
as his mother was unavailable and his sister had rung the prison (after being
telephoned by a prisoner and told what had happened), I think that it would have
been sensible for prison staff to confirm her identity and disclose what had
happened. I make no formal recommendation in this regard, but would prefer to
see a more pragmatic approach to difficult situations such as these.
Funeral costs
74. My investigator was informed by the prison’s liaison officer that the prison did not
initially offer to pay for the man’s funeral costs, although they had agreed to pay
for him to be taken from the hospital to the funeral director. This was eventually
rectified once my investigator made the Governor aware of the omission and the
Governor agreed to contribute towards the funeral expenses. Prison Service
Order (PSO) 2710 (Follow up to deaths in custody) states that the prison should
offer to pay reasonable funeral expenses. The PSO considers that £3,000 is a
reasonable amount. I make no formal recommendation but take the opportunity
to remind the Governor of his responsibility.
17
Health and Safety investigation
75. The Health and Safety investigation concluded that the prison had systems in
place for maintaining the floors, stairs and handrail in a safe condition and that
the handrail was at the requisite height prescribed in the regulations. Also the
floors and stairs were kept clean and staff checked that the cleaning was carried
out properly.
76. There was no evidence to suggest that there were any trip hazards, and no
witness evidence to the incident itself. There was also no evidence that the man
had any disability or medical condition which could have caused him to fall.
77. The report concluded that there was no evidence to conclude that his death was
due to an accident. Neither could the investigation find a reasonable cause or
failure which would suggest this to be the case.
Aftercare for staff and prisoners
78. Some of the staff who were interviewed by the investigator were concerned that
they had been overlooked and they were not invited to either the hot debrief or
the critical incident debrief. In particular, the Head of Horticulture said that he felt
let down that he did not get the opportunity to speak to anybody about the man’s
death. Similarly, prisoners on A wing who were concerned about him, or were
friends with him, felt they could have been told earlier about what had happened.
However, it was good practice that all those receiving ACCT suppport were
reviewed and prisoners were given access to a chaplain and to the Listeners and
Samaritans should they need it.
Access to cameras
79. The night duty senior officer said that it would be useful to have immediate
access to a camera in case of emergency situations. As I understand it, the
current arrangement is that a member of security staff is asked to supply the
camera from the Security Department. Although I make no formal
recommendation here, I would ask that the Governor considers what resources
should be available to the night staff.
18
CONCLUSION
80. It is with regret that the Ombudsman’s investigation, along with the police and
Health and Safety investigations, has been unable to establish the circumstances
which led to the man’s death. There is no evidence to suggest, in the weeks
leading up to his death, that he might have intended to take his own life. Equally,
it is not clear why he was awake at that time or why he was in the stairwell.
Although there is a possibility that he was concerned about a Confiscation Order
hearing, which he mentioned to the Head of Horticulture, another prisoner and
friend said that this was not the case. In any event the hearing was postponed
and another date had not been arranged.
81. The Health and Safety report concluded that the stair rail was in a safe condition
and at the prescribed height (1.10 metres high), that there was no evidence of
any trip hazards or a slippery floor and he did not appear to have had a disability
or medical condition which would have increased his risk of falling. Although it
appears that he was wearing his flip-flop sandals when he fell, there is no
evidence to suggest that this played a part in his fall.
82. The police investigation, conducted shortly after his fall was reported, concluded
that there was no evidence of anyone else being involved in what happened.
83. Although I hope that I have answered most of the questions raised by his family, I
am sorry that I, along with the police and NOMS, have been unable to shed any
more light on what happened to him on the morning of 4 July. They will have the
opportunity to ask more questions at the Coroner’s inquest.
19
RECOMMENDATIONS
1. The Governor should ensure that a review into night staffing levels is carried
out immediately to ensure that both staff and prisoners are safe.
This recommendation was accepted by the prison. Action by 31 August
2011.
2. The Governor should consider installing CCTV on the wings.
This recommendation was partially accepted by the prison. Estimated
cost to be prepared by the Estates Manager and bid compiled if
appropriate/feasible. Action by 31 August 2011
3. The Governor should ensure that first aid boxes are adequately stocked at all
times and also that other items (which can not fit in the box) are available on
the wing.
This recommendation was partially accepted. A supply of additional
dressings/absorbent pads to be provided to wings as recommended.
Action by 31 August 2011.
4. The Governor should ensure that a cross section of all staff, and all staff who
work at night, should have an up to date first aid qualification.
This recommendation was accepted by the prison. All night staff are
now trained.
5. The Governor should ensure that a cross section of staff, but in particular
those who work night duty, are trained to use the prison’s defibrillator.
This recommendation was not accepted by the prison. A National
Agreement and Union Acceptance would be required. At present no
non-medical personnel are trained and there are no plans to change
this.
20