Individual at Preston

INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING THE
DEATH OF
A MAN AT HMP PRESTON IN MARCH 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
November 2005
The man died whilst a prisoner at HMP Preston in March 2005. He was found
hanging in a cell in Preston’s Care and Separation Unit (Segregation Unit) just
after lunchtime. This is the report of an investigation into the man’s death.
I wish to offer my sincere sympathy and condolences to the man’s family and
friends for their loss. I know that the staff and prisoners at Preston who knew
him share those sentiments.
Two of my colleagues undertook the investigation. One of my family liaison
officers has maintained contact with the man’s family.
I wish to extend my thanks to the Governor and his staff at Preston for their
help and co-operation during this investigation. I am also grateful to the
clinical reviewer from Preston Primary Care Trust, for instigating a clinical
review of the man’s care.
The death of this man was one of an alarming number of apparently self
inflicted deaths to have occurred in a segregation unit in the past year. In this
case, the man had given absolutely no indication that he might have been at
risk. However I note that he was completing his detoxification. I also note
that there was only one member of staff on duty in the segregation unit at the
time he died, but the cell was subject to CCTV coverage. The man’s death, at
a particularly young age, is a demonstration that modern technology is no
guarantee of safer custody.
The report has been anonymised for publication on the PPO website.
Stephen Shaw CBE November 2005
Prisons and Probation Ombudsman
CONTENTS
Summary
Investigation methodology
HMP Preston
Events prior to the man’s death
Discovery of the man’s death
Next of kin
Observations and conclusions
Recommendations
Good Practice
Summary
1. The man was a 21-year-old man from Lancashire. The Magistrates’ Court
remanded him into custody in March 2005 for breaching his Drug
Treatment and Testing Order. Upon arrest he spat at the arresting Police
Officer and was further charged with assault.
2. Prison escort contractors took the man to Preston. As he looked
physically younger then his 21 years, reception staff ensured that he did
not pass through reception until they had confirmed his age. He was
identified as having a drug habit and placed on C1 wing, the Drug
Dependency Unit, on a nine-day drug dependency detoxification. The
man was described by staff and prisoners as a popular individual.
3. C1 wing is below ground level and is a wing that, at the time of
investigation, did not have in cell electricity. Prisoners had access to
battery-operated radios in their cells. Two days before his death, the man
was talking to other inmates about getting off of the wing by carrying out a
sit down protest or barricading himself in a cell.
4. On Wednesday 9 March, the man and other prisoners attended a
massage and relaxation class in the gymnasium. He appeared to enjoy
the class and recorded that it was, “alright okay” on a feedback sheet. He
then had exercise on the exercise yard. On leaving the exercise yard, he
communicated to a prisoner friend on another wing by shouting up through
the prisoner’s cell window. He shouted that he would see him later.
5. The man returned to the wing as lunch was being served. He and a fellow
prisoner went into cell C21 and shut the door. Staff unlocked the door
and persuaded them to leave. They were both placed on a Governor’s
Report, charged with an offence against Prison Rules. They walked
unaided and without the use of restraints to the Care and Separation and
Unit. The man was searched and placed in a cell with closed circuit
television at around midday.
6. A prison officer physically checked him at 12:35pm by looking into the cell.
At that time he was alive and standing at the back of the cell. The officer
did not check him again. At 1:35pm, he was found hanging from his bunk
bed. He had used his shoelace as a ligature. Despite a prolonged
resuscitation attempt by Health Care Staff and Paramedics, the prison
doctor pronounced him dead at 2:00pm.
Investigation Methodology
7. The investigation was conducted by two of my investigators. The
investigation was opened at Preston on Friday 11 March 2005. The
Governor and his staff made available the man’s core file and a number of
other documents for examination. Notices were issued to staff and
prisoners informing them of the investigation.
8. Representatives of the Prison Officers’ Association (POA) and the
Independent Monitoring Board (IMB) were met by my investigators,
informed of the investigation and offered their full co-operation. Contact
was made with Lancashire police who carried out the initial police
investigation.
9. Documents relating to the man’s time in custody were examined and a
number of prison staff and prisoners were interviewed. My investigators
contacted the Coroner’s Officer at Preston to brief him on the nature and
scope of my investigation, and to request a copy of the Post Mortem
report.
10. Preston Primary Care Trust undertook a clinical audit of the man’s care
whilst in prison custody. The PCT report is still awaited.
11. One of the investigators and a family liaison officer met the man’s father to
discuss the investigation and to provide an opportunity for the family to
raise questions and concerns.
HMP Preston
12. Preston is a local prison situated near the town centre. It was originally
built in 1790, and rebuilt and subsequently enlarged in mid-Victorian times.
It is being modernised and developed under a rolling programme of
refurbishment. It is currently a local prison serving Crown Court centres at
Preston, Burnley, Lancaster and Barrow.
13. HM Chief Inspector of Prisons in her most recent inspection report on
Preston in July 2004 made the following observation:
“Preston’s problems are common to many local prisons historic
decrepit buildings, under investment, a history of poor industrial
relations, and an ever increasing number of prisoners, many of them
challenging and needy. It is commendable that Preston has
nevertheless made some headway and has a clear vision of what
needs to be done to provide positive outcomes for its prisoners. It
deserves some breathing space to achieve this; but is unlikely to get it
given the current population crisis.”
Description of residential units
A Wing: Short-term convicted prisoners
B Wing: Mixed convicted and remand prisoners
C Wing: Drug detoxification unit and voluntary testing unit
D Wing: First night centre and prisoner induction
F Wing: Vulnerable prisoners unit
G Wing: Risk-assessed workers and category D prisoners
Drug Dependency Unit (DDU)
14. The Drug Dependency Unit is located in the basement of C wing and has
58 beds. It is freshly painted. The establishment is undergoing a rolling
programme of refurbishment but, at the time of this report, the cells in the
Drug Dependency Unit had no in cell electricity. Prisoners had access to
battery-operated radios in their cells.
Care and Separation Unit (CSU)
15. The Care and Separation Unit is located in the basement of A wing. The
CSU comprises 16 cells and two special cells. Eight of the cells have in-
cell closed circuit television that is recorded on a 24 hour loop with a
television monitor in the wing office. The CSU incorporates an office and
an adjudication room. The unit is staffed daily by a Senior Officer and
three Officers, Monday to Saturday, and a Senior Officer and two Officers
on Sundays. However, during the lunch period and in the mornings and
night when the prisoners are locked in their cells, one Officer covers the
unit.
16. At the time of the investigation the unit was clean and tidy and the cells in
a good state of repair. A number of cells contained bunk beds.
Events prior to the man’s death
17. The man was arrested on 28 February for breaching his Drug Treatment
and Testing Order. At the time of his arrest, he spat at the police officer
who detained him and was further charged with assault. The Magistrates
Court remanded him into custody on 1 March. He was conveyed by the
escort service to Preston. He arrived at Preston where the reception
officer saw him in reception.
18. The officer particularly remembered the man. He described him in
interview as looking much younger than his 21 years. The man
acknowledged that he looked young, that he had been imprisoned before
and that he had no concerns about entering the prison, as he would have
acquaintances in Preston. The reception officer completed a cell sharing
risk assessment form on him. He was then placed on C1 wing, the Drug
Dependency Unit.
19. The following day a registered general nurse and registered mental nurse
(RMN) with experience of working in community based Drug Teams, saw
the man on the Drug Dependency Unit. He was being seen as part of an
initial counselling, assessment, referral, advice and through care (CARAT)
interview. The nurse made a comprehensive record of her contact with
the man and placed him on a nine-day drug detoxification programme.
The only separate recollection she has of him is that he looked very
young.
20. A prisoner who shared a cell with the man between Saturday 5 March and
Wednesday 9, March was interviewed as part of the investigation. He
described the man as being immature and small for his age, describing
him as looking 13 or 14 years old. He said the man’s interaction with other
prisoners was good describing him entering other prisoners’ cells when
looking for tobacco or cigarette papers.
21. The man mentioned to his former cellmate the name of a particular officer
he did not like. The man said the officer was strict when dealing with
prisoners. He talked about getting off of the wing. He talked about going
down the block (Care and Separation Unit) but also knew that it would not
get him permanently off of the wing. The man mentioned refusing to go
back to his cell after association, but said he could not do that because he
could not get enough people to support him.
22. His cellmate stated that the man saw his probation officer on an afternoon
just before he died. When he came back to their cell he said, “It looks like
I am looking at four years in prison”. He remained quiet for the rest of the
day.
23. The man’s probation officer visited him on Monday 7 March. He informed
her that he was coping with prison and knew a few of his fellow inmates.
She saw no indication in his demeanour and speech that he was
considering taking his own life. They briefly discussed a custodial
sentence, however as the offence was a minor assault, she informed him
that it would be unlikely that he would receive a custodial sentence and if
he did it would only be for a period of a few months. At the conclusion of
their meeting the man told her that he would see her in court the following
week.
24. Another prisoner at Preston and a friend of the man outside prison spoke
with him on the Monday before he died. The man was talking about
getting off the wing with another prisoner. He told him that he was having
problems, that he was suffering from withdrawal and that he desperately
wanted to get off the wing. The man spoke at length about barricading
himself behind the door or doing something stupid because he really
wanted to get off the wing. His friend asked him if he was being bullied
and he replied by asking who was going to bully him. The man’s friend
was of the opinion that the man was very confident despite his size.
25. The man’s friend subsequently spoke to the man through his cell window
as the man was going to and returning from the exercise yard. He
describes them exchanging light hearted abuse with each other and the
man said, “I will be over shortly”
26. On Wednesday 9 March between 8:45am and 10:15am, the man attended
a massage and relaxation class in the gymnasium. The officer taking the
class remembers him taking part in the activity. He did not show any signs
of distress.
27. A second prisoner, who was on the Drug Dependency Unit when the man
arrived on the unit, was interviewed. He too had known the man outside
prison. He described the man’s interaction with other prisoners as good.
He commented that the man did not like a member of staff on the unit.
28. The second prisoner described going to the relaxation class at the
gymnasium with the man on the morning of his death. The second
prisoner and his partner at the class felt uncomfortable and left the class.
He described the man as having good interaction with the other prisoners
and physical education officers.
29. He saw the man later that morning on the exercise yard when they
exercised for between 45 minutes and an hour. He described him as,
“alright, bubbly not down in the slightest”. At lunchtime on the Drug
Dependency Unit, he was aware that something had gone on with the man
and saw him walk past his cell. The man said “See you later”. He was told
later that day that the man had died.
30. A third prisoner was at Preston on the Drug Dependency Unit when the
man arrived on the unit. In interview he stated “They put stickers on the
man’s cell door, little stickers with faces on them.” These were intended to
indicate that the man was a baby, a reference to his young appearance.
He stated that the man didn’t mind. Later on in the interview, the prisoner
claims, a wing officer had placed the stickers on the cell. The prisoner
explained that he partnered the man at a massage and relaxation class in
the gymnasium on the morning he died. He described the class as quite
good.
31. The physical education officers who ran the massage and relaxation class
on the morning of the man’s death were interviewed. The man’s
interaction with the staff and other prisoners was good. At the end of the
class, the man was asked how he found it and he replied, “I find it okay. It
reminds me of something I did on the out on a project”. The first PE officer
did not perceive him to be distressed in any way. The man wrote feed
back on the class stating “all right okay”. The officer did not see anyone
who completed the class who was distressed or showing any signs of
hopelessness. They were all joining in, they were all communicating with
each other and the class atmosphere was good, calm and relaxing.
32. The PE officer and his colleague are experienced officers who said they
were shocked when later that day they heard the sad news of the man’s
death.
33. A fourth prisoner at Preston stated in interview that he knew the man from
the Drug Dependency Unit, as he was a friend of his cellmate. He knew
him from the exercise yard and association. He describes him as happy
and well liked by the other prisoners. He went to the exercise class with
the man on the day that he died. The prisoner did not stay at the class, as
he felt uncomfortable. He was of the view that the man was alright.
34. The wing officer first met the man on 2 March when he started duty. He
stated that the man seemed to know a lot of the lads, and added that he
did not show any signs of suicidal tendencies or self harm. The officer
commented, “The staff were worried because he was so young looking
that he may have been bullied at some time but the banter was good”. He
explained that the man was laughing and joking and always seemed to be
going from one cell to another. In the officer’s view the man was like any
other inmate.
35. The wing officer remembers the day the man died. The man had been to
the gym and out on the exercise yard. He and another prisoner had gone
into another prisoner’s cell and jammed something at the back of the door.
The second wing officer talked them out of the cell, and both prisoners
demanded to go to the CSU. The officer saw both prisoners being
escorted unrestrained from the wing. He says he cannot recall seeing any
stickers on the man’s cell door and, if he had he says he would have
removed them.
36. A third wing officer who worked on the Drug Dependency Unit, recalls the
man as the youngest looking prisoner she had seen at Preston. She
recalls that on 9 March before lunch was served, the man had what she
describes as a slight tantrum. He said he wanted to move off of the wing.
She explained that there was no room to move anybody off at the moment.
He then had his lunch.
37. The officer became aware of an incident where the man and another
prisoner had gone to a cell not theirs (C21). A fourth wing officer put his
foot in the cell door, preventing it closing and talked them out of the cell. ,
She then saw the prisoners being taken unrestrained from the Drug
Dependency Unit.
38. A fifth wing officer commented that the man looked young for his age and
was popular with the other prisoners. She said at 12:00 midday on 9
March she had been working in the treatment hatch on the Drug
Dependency Unit where medication is dispensed to the prisoners. She
then began locking prisoners in their cells after they had collected their
meals. She saw the man enter cell 21 and knew that was not his cell.
She went to the door to ask him what he was doing and he slammed it in
her face. She attempted to open the door with her key and the occupants
slid a cabinet in front of the door. A prison officer and a duty officer went
to her assistance. They opened the door, and talked them out. The man
and a fellow prisoner left the cell.
39. The fifth wing officer then completed the forms placing the man and his
fellow prisoner on report. She had no more dealings with the two men.
40. The duty officer corroborates the fifth wing officer’s account. He said that
he saw both the prisoners walked unrestrained off the unit.
41. The unit officer was working in the Care and Separation Unit on
Wednesday 9 March when he saw the fourth wing officer and the second
wing officer walk onto the unit with the man and his fellow prisoner. He
describes the man as slightly agitated but compliant. The man was strip
searched to ensure that he did not have anything on him with which he
could have harmed himself or others. After the completion of the strip
search, he was placed in cell S1 22. He walked into the cell of his own
accord.
42. The second prison officer started work on 9 March at midday and went
straight to the CSU. The staff went off duty at 12:30pm. The officer was
aware that one of the prisoners was on a self-harm watch. He physically
checked all the prisoners and then checked the roll for the unit and
recorded in his incident statement “seven live bodies.” He states that the
man was standing in his cell.
43. Cell 22 has an overt closed circuit camera with a recording facility, and a
display monitor within the Care and Separation Unit staff office. The
camera recorded the man entering the cell at 11:48am. His last
movements are recorded at the rear of the bunk bed furthermost away
from the door at 12:28pm.
Discovery of the man’s death
44. At 1:35pm, the third prison officer opened the man’s cell in the Care and
Separation Unit to collect his dinner tray. On opening the cell door, she
saw him in a sitting position at the back of the cell. She asked him if he
had a tray and the man did not reply. She then stepped further into the
cell and realised there was a shoelace around his neck, tied to the frame
of the bunk bed. She stepped back out of the cell into the landing shouting
Code 1, indicating to the staff that there was a hanging incident.
45. The fourth and fifth prison officers entered the cell. The fifth prison officer
physically lifted the man whilst the fourth officer cut him down with his
issued ligature knife. They then carried the man onto the landing outside
his cell and placed him in the recovery position. Medical staff arrived and
began resuscitation procedures.
46. A prisoner cleaner in the Care and Separation Unit was working at the
time the third prison officer discovered the man. He heard her shout Code
1 and as instructed he went back to his cell and was locked in. He did not
know the man or have any knowledge of him.
47. A prisoner in the Care and Separation Unit, heard the third prison officer
shout Code1 and call for fish hook which is a reference to an anti ligature
knife.
48. The duty governor on call on the day of the man’s death was informed by
telephone that two prisoners had been removed from the Drug
Dependency Unit to the Care and Separation Unit. As she was in a
meeting, she decided to sign the relevant paperwork at the conclusion of
her meeting. At 1:30pm, as a result of a Code 1 message over her radio,
she attended the CSU. There were medical staff in attendance dealing
with the incident. She signed the paperwork for the man and his fellow
prisoner, and started making arrangements to have prison staff escort the
man out of the prison. Attempts were made to contact the man’s next of
kin.
49. The head of healthcare, said she was aware of a Code 1 incident being
broadcast over the prison internal communication radio system and the
location. She ran to the incident and requested en route that a member of
staff bring the defibrillator. Upon arrival, she saw that a number of staff
had already responded and mouth to mouth resuscitation and chest
compressions were being given to the man by her staff. The emergency
equipment bag was already there. Two other staff were putting together
the Ambu bag equipment. The head of healthcare requested, further
oxygen be brought to the incident as it was possible that the resuscitation
could be prolonged.
50. The head of healthcare then went to help her staff in resuscitating the
man. The nurse performing mouth to mouth was having difficulty obtaining
a seal around the man’s mouth with the resuscitation mask. The head of
healthcare then took over giving direct skin to skin mouth to mouth
resuscitation. They then used an oxygen Ambu bag on the man. The
ambulance team arrived whilst resuscitation was being given. The
defibrillator was attached but gave a flat reading. The prison doctor
arrived. After 20 minutes of trying to resuscitate the man, the prison
doctor, the paramedics and the head of healthcare decided to call an end
to the resuscitation attempt.
51. The prison doctor pronounced the man dead at 2.00pm.
Next of Kin
52. As soon as the man had died the chaplain tried to trace the man’s next of
kin. The man had only given part addresses or part details of his next of
kin, which made them difficult to contact. His father was eventually traced
with the help of the South Wales Police. One of my family liaison officers
continues to have contact with the man’s father and sister.
Observations and Conclusion
53. The man led a chaotic life. He had an expensive drug habit that he funded
through crime. Although aged 21 he looked much younger than his years.
He arrived at Preston on 1 March and was subsequently placed on a nine-
day drug detoxification programme within the Drug Dependency Unit.
Staff and prisoners describe him as a popular person who interacted well
with other prisoners, some of whom he knew from outside prison. Whilst
on the Drug Dependency Unit he shared a cell with another prisoner, and
participated in the gymnasium, library and exercise. There is some
suggestion made by prisoners that he did not interact well with one
particular officer. On the day of his death, he had attended a massage
and relaxation class and showed no outward signs of isolation or despair.
He exercised with other prisoners, and shouted to a fellow prisoner that he
would see him later. It is known he discussed getting off of the wing with
other prisoners, talking about a sit down protest and a barricade to effect
his move.
54. The man had nearly completed his drug detoxification programme and
would have been relocated to a wing when space became available.
55. On Wednesday 9 March, the man and his fellow prisoner, who was on a
self-harm watch, barricaded themselves in a cell. They were taken to the
CSU. Unfortunately, they were taken at a time of day when the unit was
going onto patrol state. One member of staff was relieving the senior
officer and three staff on duty in order that they could have their lunch.
56. At the time the man and his fellow prisoner were taken to the unit there
were five other prisoners located there. The man was placed in a single
cell and was alone for the first time since he had arrived at Preston. The
cell had an active closed circuit television camera, which recorded his last
movements alive. The officer on duty checked him at 12:35pm and he
says that the man was alive and standing at the back of his cell. The Care
and Separation Unit hourly prisoner check sheet, has been signed at
12:00 midday but there was not a signed entry for 1:00pm. The officer on
duty is aware that he did not sign the check sheet at 1:00pm.
57. The man was found hanging in his cell at 1:35pm when the senior officer
and his three Officers returned from lunch.
58. An attempt was made to revive the man by qualified nurses and staff
working on him for over 25 minutes, prior to a doctor pronouncing he had
died.
59. There was no indication from those staff and prisoners interviewed that the
man had any inclination to take his own life.
60. The allegation made against a particular prison officer by some of the
prisoners has been brought to the attention of the Governor.
61. The report has been completed without the benefit of the clinical review.
Should the clinical review raise separate issues relating to the man’s
healthcare needs, a supplementary report will be submitted.
Recommendations
1. I recommend that bunk beds are removed from the Care and
Separation Unit.
2. I recommend that the governor reviews the use and recording of CCTV
in light of the sad circumstances of the man’s death.
3. I recommend that the governor reminds senior colleagues that staffing
levels in the Care and Separation Unit during patrol state should be
routinely risk assessed in light of specific operational demands.
4. I recommend that the governor reviews staffing levels in the Care and
Separation Unit during patrol state.
5. I recommend the inclusion of smaller resuscitation face masks in first
aid kits.
Good Practice
The response by the staff on finding the man and those staff involved in the
resuscitation attempt was excellent.
I also commend the level of detailed note taking in the RMN’s initial
assessment of the man.