Individual at Risley

Investigation into the circumstances surrounding the
death of a man in November 2005 whilst in the
custody
of HMP Risley
Report by the Prisons and Probation Ombudsman for
England and Wales
July 2007
This is the report of an investigation into the death of a man who was
discovered lying on the floor of a landing in a residential unit at HMP Risley in
November 2005. He had sustained serious head injuries. He died in hospital
without regaining consciousness. He was 41 years old.
I offer my sincere condolences to his family and to all those touched by the
loss of his life.
One of my Family Liaison Officers and an investigator met the man’s aunt to
learn of the particular concerns the family had about his death. That it should
have occurred in such violent circumstances must be particularly painful for
his family. I hope that this report answers many of their questions although it
will not lessen their grief.
The investigation was undertaken on my behalf by two of my Senior
Investigators. The Assistant Director of Health Standards at Warrington
Primary Care Trust undertook a clinical review of the care the man received
and I am grateful for her comprehensive report.
I also wish to acknowledge the assistance I have received from Cheshire
Police. I express my thanks too to the Governor of Risley and his staff for
their help and co-operation.
The responsibility for discovering how the man came to receive his injuries
and who perpetrated them has rested with the police rather than with my
office. My investigation and this report, which have inevitably been delayed
because of the primacy of the police inquiries and a recently concluded
criminal trial, focus on how Risley handled the discovery of the man and the
aftermath to these sad events.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2007
CONTENTS
Summary
The Investigation Process
HMP Risley
Key Events
The events of 13 November 2005
Issues
Recommendations
SUMMARY
On 8 December 2003, the man was convicted of several offences of burglary.
In January 2004, he was sentenced to four years imprisonment. It was not his
first time in custody. He spent short periods in Altcourse, Shrewsbury and
Blakenhurst before being transferred to HMP Risley on 25 August 2004.
There was little concern about his conduct and no current security information
on him.
On the morning of Sunday 13 November 2005, a prisoner approached two
officers in a spur office on Risley’s C wing to say there was a prisoner on the
ground floor landing of the south spur who was “in a bad way”. The prisoner
had seen the man lying unconscious and placed him in the recovery position
before seeking staff assistance.
The officers immediately made their way to the landing. It was evident that
the man was suffering from serious head and facial injuries. One officer
called over his radio for urgent medical assistance from healthcare staff, the
other went to fetch the wing senior officer.
Healthcare staff arrived and monitored the man’s condition. An ambulance
was called at 10.20am. As the man was already in the recovery position, had
a strong and steady pulse and the ambulance had been requested, the
healthcare staff did not initiate any medical interventions. However, the
ambulance did not arrive until half an hour after it had been called.
After the discovery of the man’s injuries, the prisoners on C wing remained
unlocked. They were able to go on to the outside exercise yard, attend a gym
class or go to church. Many of those who stayed on the wing remained on the
ground floor and watched staff tending to the man. Others went to the upper
landings and looked over the railings to observe what was happening. Some
shouted out their impatience at the non-appearance of the ambulance. In
order to create access for the paramedics, prisoners were given the choice of
being locked in their cells or going to the north spur of the wing. Some were
locked in their cells, but most chose to go to the other side.
At 10:56am, an alarm bell was activated on C wing north spur. There
appeared to be fighting and disorder taking place involving up to 100
prisoners. Chairs, snooker cues and mop wringers were being thrown. When
the disorder broke out, there were no officers supervising the north spur. At
least one prisoner was assaulted by others and was rescued by three staff
who threatened to use their staves if the prisoners did not withdraw. The
prisoners immediately backed down and the officers did not use their staves.
The violence was between prisoners rather than aimed at staff. Order was
restored within minutes and prisoners were eventually locked in their own
cells. A second prisoner was found to have been injured and both were taken
to the healthcare centre for treatment. Their injuries were not life-threatening.
The man was taken to the local hospital at 11:35am. He was then transferred
after surgery to a specialist unit at another hospital.
At lunchtime on 13 November, prisoners were allowed to collect their lunch a
few at a time. Extra staff were on duty given what had occurred during the
morning. Nevertheless, a prisoner entered the south servery and attacked
one of the servery workers. The assailant was in turn pursued by another
prisoner.
The Command Suite was opened by the duty governor to enable him to
manage the unfolding events. However, it was only in the afternoon that it
was realised that the police had not been called. They eventually attended at
3:20pm.
The man died 4 days later without regaining consciousness.
The day after his death, the Director General of the Prison Service wrote to
the man’s aunt to express his sympathy. His letter said that the police had
been called immediately to the prison after the assault. The family felt that
they had been given misinformation as the police had not in fact been
contacted until four hours after the man was found.
Risley did not appoint a Family Liaison Officer until after the man’s death.
Coupled with the perceived misinformation in the Director-General’s letter, this
led the man’s aunt to conclude that she did not wish to have any further
contact with the Prison Service although a prison Chaplain did remain in touch
with the family.
A clinical review of the care the man received before and after he was
attacked was carried out by a Medical Practitioner from Warrington Primary
Care Trust. She concluded that the care of the man after he had been
discovered was not as good as it might have been. She has made a number
of recommendations concerning the organisation of healthcare at Risley and
the initial response of healthcare staff when the man was discovered.
My report includes several recommendations concerning the arrangements
for prison-police liaison, family liaison and the management of serious
incidents at Risley. However, it recognises the efforts Risley made to
acknowledge the seriousness of the man’s death and to mark his passing.
THE INVESTIGATION PROCESS
1. My investigators visited Risley twice. They were given access to the
man’s prison records including his medical record, statements from
staff and other documentation concerning the events on the day that he
was assaulted.
2. My investigators met with the Detective Chief Inspector and the
Detective Inspector from Cheshire Police to agree a protocol for the
investigation of the man’s death and sharing information. I agreed to
delay the start of my investigation until the police had completed their
criminal investigation.
3. Notices to staff and prisoners announcing the investigation were
displayed around the prison. I was contacted by one prisoner who
wished to raise his concerns about the potential for violence at Risley.
My investigators met representatives from the Independent Monitoring
Board and the Prison Officers’ Association to offer them the opportunity
to raise relevant issues.
4. The man’s family were offered, and accepted, the opportunity to
contribute towards the investigation process. One of my Family Liaison
Officers visited the man’s aunt with one of the investigators to discuss
the issues she wished to raise. Regrettably, a few of the issues raised
by the man’s aunt have not been addressed as they fell outside of my
remit and were matters for the criminal investigation.
5. A clinical review was requested from Warrington Primary Care Trust. I
am grateful to the Assistant Director of Health Standards, for
undertaking this comprehensive review in a timely manner.
6. HM Coroner for Cheshire was contacted to inform him of the nature
and scope of my investigation and to request a copy of the post-
mortem report. A copy of my report has been given to the Coroner.
7. Following the conclusion of the recent criminal trial, a copy of the draft
report was provided to the Prison Service under our policy of advanced
disclosure where the actions of identifiable members of staff have been
criticised. The Prison Service’s response to the adverse comment
made in the clinical review is contained in the body of this report.
HMP RISLEY
8. HMP Risley was opened in 1964. It has had various roles since then,
but has been a medium security category C prison for male adults
since 2000. It holds up to 1,073 sentenced prisoners in mostly single
cell accommodation. Much of the prison has been rebuilt and
modernised in recent years. The redevelopment programme is still in
progress.
9. C wing holds 197 prisoners in mostly single cells. It consists of a north
and a south spur – each three storeys high, linked at each level by a
gated corridor with staff offices. Each landing has recreation areas for
prisoners to socialise, bathing facilities and telephones. At the time of
the man’s death, C wing prisoners were able to move freely between
both spurs, using the ground floor access, during association times.
10. My investigators met with the Governor. He said that historically C
wing had been one of the most difficult to manage as it had no
particular admission criteria, and accepted prisoners who did not need
or want the specific support provided in other wings (e.g. for drug
misuse, or for sexual offending). He said that, nevertheless, staff-
prisoner relationships had improved in the months leading up to the
man’s death and there had been no particular concerns about its
management.
11. Her Majesty’s Inspectorate of Prisons carried out an unannounced
follow-up inspection of Risley in May 2003. In the introduction to the
inspection report, there were comments about the treatment of
vulnerable prisoners (predominately, but not exclusively sex offenders).
The report stated:
“There was considerable anecdotal evidence, from both staff and
prisoners, of verbal and physical abuse, yet the establishment was not
monitoring or analysing to what extent, where and why this took place.
As a consequence there were effectively separate workshops as
vulnerable prisoners self-segregated, because of their fears about their
safety.”
It went on:
“Anti-bullying processes were under developed and there was no
investigation of the cause or nature of injuries, assaults and self harm.
This reflects a more general finding in the prison as a whole.”
12. Risley was re-inspected in February 2006. The report of the inspection
acknowledged that safety remained a significant concern, especially in
the light of the man’s death. Thirty per cent of prisoners reported to the
inspectors that they had felt unsafe at some point. The inspectorate
team was particularly worried by the lack of visible staffing. It
concluded:
“This is the second consecutive report that has raised concerns about
safety at Risley. Risley is still not a sufficiently safe prison and more
focus is required on violence reduction, supported by a more proactive
approach to prisoner supervision and a continued emphasis on
combating illegal drugs”.
KEY EVENTS
The events of 13 November 2005
13. On 13 November, there were six officers and one senior officer (SO) on
duty on C wing, the minimum staffing level for that wing for a Sunday
morning. Five of the officers normally worked on C wing. The sixth
officer was cross-deployed from another area so that the wing could be
unlocked. The wing SO described the start of the day as “a … very
quiet morning, nothing out of the ordinary … just a very, very ordinary
day …”
14. The normal routine for a Sunday morning is for prisoners to be
unlocked for breakfast at 8:00am. An optional cooked breakfast is
served, then prisoners have free time until midday to socialise on the
wing, remain in their cells or use their time as they wish. Activities on a
Sunday include the option of access to an outdoor exercise yard from
about 9:30am, Roman Catholic church at 10:15am, and gym (also at
10:15am) for those who have pre-booked. Lunch is served at about
11:45am and then prisoners are normally locked up at 12:15pm for a
roll check.
15. Three staff were detailed to work on the north spur and three officers
performed similar roles on the south spur. At about 8:05am, the man
was unlocked from cell C2-07 south by the first wing officer. In his
police statement, he said that the man was up and dressed, waiting to
come out of his cell when the officer opened his door. He noted that,
whilst the man had seemed a bit down, a bit quieter and unshaven the
day before, on 13 November he appeared “back to normal, he’d
shaved and was of a smarter appearance.” He was the only member
of staff who recalled having direct contact with the man that morning.
16. After breakfast, the second wing officer and the sixth officer went to the
outside exercise yard to make preparations for the start of the exercise
period. Although this left four staff on C wing, no officers were present
on the south spur of the wing for significant periods of time. The first
and the third wing officers carried out cell inspections of the wing,
starting with the north spur. The fourth wing officer left the south spur
to take a television to be x-rayed and resealed. He was accompanied
by a prisoner who needed to collect some clothing from reception. The
fifth officer was supervising cleaning duties on the north spur and the
wing SO was mobile between the spurs.
17. The exercise yard was open shortly after 9:00am. Prisoners were free
to wander in or out as they pleased, which was the usual practice. The
second wing officer recalled that, due to the cold weather, there were
probably no more than four prisoners on the yard that morning.
18. The fifth wing officer said he did not remember anything untoward. He
said the atmosphere on the wing seemed normal. Between 9:00am
and 10:00am, he was supervising general cleaning duties on the north
side. The wing SO said that he was organising a snooker competition
within the wing, so was moving between the spurs. He remembered
going to the north spur at about 9:45am. He pinned a notice about the
competition on the notice board, and had a brief chat with some of the
prisoners. He then went to the south spur, put up a notice and had a
chat with about eight prisoners who were at the snooker table. Just
before 10:00am, in his office on the ground floor, he began to
supervise an inter-prison phone call between a prisoner and his brother
in another prison. The first and the third wing officers carried out cell
checks until about 10:00am. They returned to the wing office to
complete the paperwork associated with the cell checks.
19. A prisoner on C wing, told my investigators that, at about 10:15 -
10:25am, he opened his cell door and saw “a crowd of people outside
the door all just sort of looking in one direction towards the stairs.” He
said he noticed the man lying under the stairs and thought he had been
knocked out. The prisoner went back into his cell briefly and when he
came out again, he noticed that the man appeared to be choking:
“… everyone was staring at him. No-one was going to go over to him,
so I went over and approached him, put him into the recovery position
because he was choking, tried speaking to him, waking him up, he was
having none of it … when I put him in the recovery position I realised
the injuries to his head you could see all the bruising through his hair
and he had like pretty thick hair, so then I knew that no prisoner could
give him medical attention that he needed, so I went to the office [and]
told the officers there was a lad that he was in a bad way.”
20. The prisoner said that another prisoner placed a [cardboard] box under
the man’s head. Asked how long he thought the man had been lying
by the stairs before he came out of his cell, the prisoner thought that it
was roughly five minutes but no longer than ten. He said that his
involvement ended after he told the officers about the man. He said he
went to the gym, came back an hour later, went to the north spur of the
wing, witnessed a disturbance and was sent back to the south spur.
21. The first wing officer told police that, between 10:05am and 10:10am, a
prisoner approached him and the third wing officer whilst they were in
the wing office and said there was a prisoner “in a bad way” on the
ones landing. Both members of staff left the office and went onto the
landing. The third wing officer saw the man lying unconscious under
the stairs on the south landing ground floor. The man’s head was
resting on a cardboard box, he was bleeding from his nose and mouth,
and had bumps and bruises all over his head. He described the man’s
breathing as noisy and rattling. He said he spoke to him, but there was
no response. He did not touch him but called for immediate medical
assistance over his radio whilst the first wing officer went to get the SO.
The Risley Control Room Daily Log shows that the request for
healthcare staff to go to C wing was made at 10:15am.
22. The first wing officer told my investigators that the man was “breathing
very, very heavily, rasping breathing, and his hand was twitching so I
knew he was alive, but it was obvious he wasn’t very well, he was in a
bad way.” He went immediately to fetch the wing SO who arrived
within a minute.
23. The wing SO said that, as he arrived, he radioed the communications
room and asked how long it would be before healthcare staff arrived.
He was told that the staff were on their way. The wing SO said that it
was a couple of minutes before he realised that the prisoner on the
floor was the man. There was a lot of blood coming from his nose but
it appeared to be a different colour to that of a normal nose bleed. He
recognised that the man had suffered a severe trauma to the head.
The wing SO noticed that, despite his injuries, there was little blood
around the man. He concluded that the man must have been
assaulted elsewhere and dumped on the landing. He said that
normally when there has been an incident, lots of prisoners gather
around. On this occasion, although there were a few people milling
around, a lot of prisoners were up on the upper levels looking down on
to the ground floor. But it seemed quiet and subdued.
24. A Registered Mental Health Nurse (RMN) was on duty in the treatment
room when he received the radio message to go to C wing
immediately. He was not sure of the nature of the incident and, when
he tried to telephone C wing, he was unable to get through.
Accordingly, he took an emergency bag with him. His colleague a
Registered General Nurse (RGN), followed him with oxygen. The RMN
recalled that it was quite noisy, with prisoners milling around. On
seeing the man, he told the wing SO that an emergency ambulance
needed to be called immediately. An officer told him that the man had
been assaulted. The RMN took the man’s pulse which was strong and
steady and noted that the man was breathing albeit with a snoring
sound. He attributed this to a possible broken nose. He thought that
the man might have suffered a spinal injury and, as he was already in
the recovery position and the ambulance on its way, did not want to
“interfere” with him. He noted that blood was oozing out of the man’s
sweatshirt and thought that the man had perhaps been stabbed, but he
could not locate a puncture wound. On seeing the man, the RGN
formed the opinion that he had suffered a head injury and that it might
be life threatening.
25. The RGN said that the man did not react to being spoken to. Besides
monitoring his pulse and blood pressure, there was little they could do
until the paramedics arrived. Both nurses said that the ambulance took
a considerable time to arrive. The RGN told my investigators:
“It was very frustrating. There were prisoners coming up and looking
over and you know, they were told to move away and they would come
back again, then they were up on the twos shouting ‘Where is the
ambulance?’ …we did ask on a couple of occasions where the
ambulance was and I have learnt since that they had already said that
they had put two out because they had got diverted because it was
only put through as an amber call …“
26. The RMN’s and the RGN’s perception of delay, commenting that the
ambulance “seemed to take for ever”. The Risley Control Room Daily
Log shows that an ambulance was requested at 10:20am. The call
was logged by the ambulance control room at 10:23am. An ambulance
was allocated at 10:34am. According to the clinical review, an
ambulance “was then mobile at 10:39am”. At 10:40am, the prison
telephoned the ambulance service to ask for the estimated time of
arrival. They were told that two ambulances had been sent but had
been diverted to other incidents. The call to attend to the man had now
been made a priority and would not be diverted. An ambulance arrived
at the prison at 10:50am. The RGN remained with the man until the
paramedics reached him at 10:56am. The man was treated and
stabilised by the paramedics and the ambulance eventually left Risley
at 11:35am.
27. After the man had been discovered, the principal officer (PO) was
asked to go to C wing in his role as the orderly officer in charge of
incident response that day. He told my investigators that it took him
three minutes to get to the wing. He described to my investigators
what he saw when he arrived:
“He was lying there … his body was shaking … he had obviously …
been hit or something very, very badly on his temple … the front of his
face had been severely beaten, his nose and his mouth, he was
struggling to breath. He was making a horrible noise trying to breath; I
take it trying to breath through the blood inside his mouth, he was
making this gurgling noise … he was clearly in a lot of trouble.”
28. The PO established through one of the nurses already present that the
man had a strong pulse and an ambulance had already been called.
He asked the duty governor to make his way to C wing to see what had
happened. He acknowledged to my investigators that this was an
unusual request as incidents are normally managed at the scene,
without the immediate intervention of the duty governor. The PO felt,
however, that the assault on the man had been so serious that the duty
governor needed to see what had happened.
29. In the meantime, the duty governor arrived and was concerned that
many prisoners still had full sight of the man on the floor. He asked for
a screen to be erected around the man to give him some privacy and to
control access to the area. This was done. Having reiterated to the
control room that the man was suffering from a serious head injury and
an ambulance was needed immediately, the duty governor said he told
the PO to “sort the ambulance out, sort the prisoners out and get your
staffing and get back to as near a normal regime as possible.” He then
went back to his office. At interview, he told my investigators that he
had gone to C wing thinking that the incident had already been dealt
with, and was unhappy on his arrival to see so many prisoners walking
about whilst the man was still there.
30. The wing SO instructed staff to obtain some blankets, which were
removed from the man’s cell, and a pillow. He asked his staff to check
the wing for sites where the man might have been attacked. A cell was
identified as seeming to have been freshly mopped. It was locked by
an officer and its occupant was taken for a strip search.
31. Before and during the period when the man had been found, one
prisoner had left C wing to attend the Roman Catholic Church service.
From about 9:00am, outside exercise was taking place where prisoners
were free to go on the yard if they wanted to. The second wing officer
was supervising the exercise yard with the sixth. She thought that no
more than four prisoners had been outside, although the sixth officer
thought there might have been six or seven. Exercise continued until
10:40am when it was terminated to allow the ambulance access to the
wing.
32. The Physical Education Instructor (PEI) arrived on C wing exercise
yard at about 10:20am to escort a pre-selected class list to the gym.
He recalled that about 25 prisoners were waiting for him, but he
collected only the 16 prisoners whose names were on the class list.
Six other prisoners from the class list, including the man, did not turn
up and were marked as absent. The PEI began his class at about
10:25am and did not return them until about 11:40am.
33. At about 10:35am, the PO decided that there were too many prisoners
in the vicinity where the man lay, and instructed staff to give prisoners
a choice either to be locked in their cells or continue with association
on the north spur if they wished. The fifth wing officer relayed this
message to prisoners over the tannoy.
34. Some prisoners who remained on C wing were standing nearby
watching staff attending to the man. More had congregated on the
landings above where the man was lying and observed or shouted
comments. The fourth wing officer said that he and other officers
moved the prisoners away from the man towards the centre of the
wing. He then stood at the top of the stairs from the ground floor to
prevent prisoners going up and down. When the ground floor was
clear, he and others checked the cells on the other landings to make
sure that the doors were locked. Then he checked the showers. He
found a prisoner taking a shower in the communal showers on the first
floor and told him he would have to go back to his cell.
35. The action of moving prisoners was welcomed by the nurses who were
monitoring the man’s condition. The RGN said that she found it off-
putting being stared and shouted at by the prisoners. The RMN said
that initially he was not bothered by the presence of other prisoners, as
it was a usual occurrence when dealing with an incident. However,
after a while he thought that the man needed more privacy and he
didn’t want “all this chaos around me …”
36. The PO said that the prisoners were compliant with moving over to the
north spur, so he did not think he needed additional staff to assist in
clearing the south spur. The assistant orderly officer, was the only
additional member of staff apart from the C wing officers assisting
officers to clear the landings. Asked by my investigators whether she
thought prisoners should have been locked up rather than given the
opportunity to go to the north spur, she replied that it would have been
very difficult trying to lock the prisoners located on the ground floor in
their cells. With the man still there, this might have exacerbated the
situation. She said it took about ten minutes to move all the prisoners
from the south to the north. They were quiet and moved in an orderly
fashion. She could not confirm that she had actually seen any staff on
the north side, but thought that there would have been at least an
officer on the ground floor and one on the top. At interview, the duty
governor was asked whether it was conceivable that prisoners had
been allowed to go to the north spur without supervision. He replied
that this definitely would not have happened and guessed there would
have been three or four officers present on the north spur.
37. Once all the prisoners had been ushered through to the north spur, the
wing SO waited at the entrance to the wing to assist the paramedics in
moving the man from the wing into the ambulance and out of the
prison. The first wing officer remained with the man and the
paramedics on the south spur. The third and fifth wing officers took the
prisoner whose cell appeared to have been freshly mopped to be
searched in an office on the first floor (“the twos”) in the sterile area
between the two spurs. The fourth wing officer remained on the first
floor on the south side. The second wing officer and the sixth officer
finished exercise early, so that the ambulance could get to the entrance
of C wing. The sixth officer went to the first floor of the south spur to
stop anyone using the stairwell and remained there. The second wing
officer went to the north spur initially. She said that it seemed a normal
atmosphere, with prisoners playing snooker, dominoes and asking her
questions. After 10-15 minutes, she went into the staff room, which
was through the gates, and into an office on the ground floor between
the spurs to remove her coat. At that moment, there were no officers
on the north spur.
38. The third and the fifth wing officers placed the clothing of the prisoner
who was to be strip searched into sealed bags and gave him fresh
prison clothing. They did not take his trainers, however, because they
did not have any clean footwear to give him in return. The prisoner
asserted that he had been on the north spur, prior to being searched
and not done anything. (I understand he was later exonerated from
any involvement in the man’s death.) As they were finishing the
search, the third wing officer heard loud banging coming from the
landing on the north side of the first floor. This was followed by an
alarm bell sounding at 10:56am.
39. The fifth wing officer requested assistance over his radio. The fourth
wing officer went through the sterile area and joined the third and the
fifth wing officers. According to the third wing officer in his police
statement, there was a major disturbance involving around 100
prisoners who were shouting loudly and throwing items. He told my
investigators that chairs, pool cues and wringers from metal mop
buckets were being thrown. The officers decided to draw their wooden
staves and opened the connecting doors to the landing. They raised
their staves and gave the prisoners an order to back away. The
prisoners responded instantly. The officers said that no prisoners were
struck by them. It was immediately obvious that at least one prisoner
involved in the melee had been injured and was bleeding profusely
from a cut on his head. He was rescued by the officers. The wing SO
arrived on the landing using the back staircase. He took the injured
prisoner away and handed him over to another member of staff for
treatment.
40. The second wing officer went back into the north spur when she heard
the alarm bell. She said she saw the three officers enter the spur from
the landing above. The prisoners who had congregated were moving
away from them. The PO said that, when he heard the alarm, he
entered the north spur from the ground floor and tried to get up the
stairs. Prisoners were blocking his path so he had to push his way
through. He described the scene he saw to my investigators:
“… at the far end of the landing there was as I said it was absolute
mayhem. There was people fighting and shouting, chairs and things
being thrown. There were two prisoners who had been hurt. I didn’t
see the first one, he had already been dragged out by two other
members of staff because I believe he was lying on the floor and he
had been literally been dragged out through the door, to safety … the
second fellow … had obviously been hit as well, he had, his shirt was
torn to bits”.
41. The PO immediate thought was to withdraw from the spur because the
prisoners far outnumbered the staff, but as he realised that “it was a
prisoner on prisoner affair rather than prisoners against staff” he
changed his mind. The PO asked for the rest of the prisoners to be
locked into the nearest cells, not necessarily their own, with the
assistance of staff from the rest of the prison who had responded to the
alarm bell. He said that the prisoners were not resisting staff and the
situation was under control within a few minutes. Once the wing was
quiet, prisoners were moved in small groups to their correct cells
throughout the wing. Those who were on the south spur were returned
there until staff were satisfied that all the prisoners could be accounted
for. This took an estimated 15-20 minutes.
42. The PO then debriefed his staff, checked that they were alright and
telephoned the duty governor to say that the wing had been locked up.
According to the PO, the duty governor asked for the prisoners to be
unlocked for association to continue. After some discussion, it was
decided that the prisoners on C wing would remain locked up and
lunch would be served in a controlled manner, only unlocking a few at
a time. The duty governor told my investigators that his intention had
been to get at least half of C wing up and running. At Risley, the
practice was to try to run a normal regime very quickly after a serious
event. At interview, the PO described the C wing officers as being
visibly shaken. Most of them had only been prison officers for a
comparatively short time. He said that staff felt the mood of the wing
(amongst prisoners) was that there was “unfinished business and that it
was very, very volatile, it was bubbling.”
43. The PEI handed over the C wing prisoners to an officer at the gate to
the wing at about 11:40am, after seeking permission from the control
room to do so. He was asked to return to C wing afterwards to assist
the serving of lunch. The PO estimated that there were ten more staff
than usual to help patrol the landings, given the assault on the man
and the subsequent disorder.
44. After the prisoners from the gym returned, the fourth wing officer and
four prisoners went to the kitchen to collect lunch. Rather than
everyone being unlocked as is usual, prisoners were allowed down to
the servery a few at a time to collect their lunch and then returned to
their cells. (There are two serveries on the wing, one for each spur.)
At 12:06pm, a prisoner entered the servery on the south spur and
struck one of the servery workers with an object in a sock. The
assailant turned and ran, pursued by the wing officer. He was caught,
restrained and taken to the segregation unit. Another prisoner ran after
the assailant, but was headed off by an officer before he could reach
him. That prisoner too was restrained by staff. Eventually, lunch was
resumed and the prison roll was declared correct at 1:02pm.
45. The duty governor told my investigators that he decided to open the
command suite after learning of the disorder on the north spur, which
initial intelligence indicated had been sparked after the two prisoners
suspected of attacking the man had been challenged. The command
suite is an incident room located in the administration building, away
from the prison residential units. The duty governor thought it had
been opened at about 11:30am, but written incident notes record the
command suite as being opened at 12:50pm. The duty governor was
joined by the other governor on duty that day, the PO, the assistant
orderly officer, with an Operational Support Grade as the collator. The
Prison Service’s National Operations Unit was informed of the situation
at 12:50, as were the Area Manager and the governing Governor
shortly afterwards.
46. The duty governor said that he had a check list of who needed to be
contacted and worked his way down the list. He thought he had asked
a member of staff earlier to contact the police, but could not remember
whom he gave the instruction to. It was only when the governing
Governor arrived at the prison, and asked whether the police had been
contacted, that Risley realised they had not been.
47. According to Cheshire Police, the initial telephone call from the prison
was timed at 2.05pm that day. An operator took the call and, after
some initial confusion over the correct address of the prison, the
incident was graded as a grade two response. This meant that the call
was to be treated as prompt and an officer should attend within one
hour. This was based on the force’s policy and the following facts -
The man was already in hospital, it was a serious assault but not in
progress, no uniformed response required due to the circumstances
and location and there was a specific request from the caller that no-
one attend at the prison.
48. The recording of Risley’s initial 999 call to the police at 2:05pm said in
part
“… although the Governor doesn’t want anyone to come in at the
moment, he’d like to speak to somebody if that’s possible.” My
investigators discussed with the police’s Senior Investigating Officer,
the Detective Inspector, the implications of the delay between the time
the man was discovered and the time the police eventually arrived (at
3:25pm). It was his opinion that this delayed the securing of the crime
scene by appropriately trained officers.
49. When the police arrived where the man had been discovered, they
found it secured and taped off wall to wall across the bottom of the
stairs including the cells on either side of the landing. Various police
teams then arrived during the afternoon and a number of prisoners
were arrested and taken to different police stations. Subsequent
contacts between Risley and the police were facilitated by the Police
Liaison Officer. I understand that the arrangement worked very well.
The Governor held a hot debrief for staff at 8:15pm that evening. He
updated staff on the man’s prognosis and thanked staff for their efforts.
50. After leaving Risley by ambulance, the man arrived at the local hospital
at 11:48am. After a CT scan, he was found to have severe brain
damage. The assistant orderly officer attempted to contact members
of the man’s family by telephone but was unable to reach anyone in
person. A member of Risley’s chaplaincy team was asked to continue
the task and contacted the man’s brother at 1:40pm to alert him to the
seriousness of the man’s condition. The man was given the last rites
and transferred that afternoon to the specialist hospital where he
underwent surgery. He remained unconscious and critically ill and his
prognosis was described by the hospital as very poor.
51. On 14 November, the man was released from custody on temporary
licence due to his condition. This meant he was no longer
accompanied by prison officers at his bedside, although he was visited
by a duty governor and the chaplain. Risley also maintained contact
with the hospital by telephone approximately every four hours to
ascertain the man’s condition. On 17 November, when Risley rang the
hospital at 10:10pm, they were told that the man had passed away at
7:45pm that evening. His family were present when he died.
52. A governor was appointed as Risley’s family liaison officer (FLO) for
the man’s family on 18 November. He contacted the man’s aunt by
telephone to offer members of the man’s family the opportunity to visit
Risley if they wished. The Director General of the Prison Service wrote
to the man’s aunt on 18 November to express his sympathy.
53. One of the investigators and my family liaison officer visited the man’s
aunt to learn of issues that she wished to raise. The aunt said she
wanted to know the reason for the man being attacked and why he had
been found under a stairwell when she had heard that previously he
had apparently been seen walking into another prisoner’s cell. She
said that she should have first been contacted by the prison FLO after
the man had been attacked, not after he had died. The family had lost
confidence in the Prison Service after receiving the Director General’s
letter which made reference to the police saying “the police were
immediately called into the prison following the assault …” However,
the police had made it clear to her that they had not been contacted by
Risley until some four hours after the assault on the man had been
discovered. As a consequence, she felt that she had been
misinformed and did not wish to have further contact with the Prison
Service as she could not rely on the information she had been given as
correct, although she did welcome contact with a priest from the
chaplaincy team.
54. Risley let staff and prisoners know about the man’s death through
informative notices which gave as much detail as they were able. A
book of condolence was opened on C wing for prisoners to write their
own tributes. In addition, a collection initiated by prisoners raised
£340.00. They were sent to the man’s family who were touched by the
generosity as well as the many sympathy cards they received. A floral
wreath was placed outside the man’s cell. A minute’s silence was held
at the prison in memory of the man and an inter-wing five-a-side
football match was organised but, due to the overwhelming number of
entries, was eventually cancelled as it was felt to be impractical.
55. During interviews with my investigators, several staff indicated that the
constant presence of drugs, gangs and mobile telephones had proved
a challenging combination to manage at Risley. This is borne out by
the recent report by Her Majesty’s Inspectorate of Prisons to which I
referred earlier and which explores the inter-relationship between
security issues and violence in the establishment in more detail.
56. The wing SO was asked by my investigators about issues on C wing
and relationships between different groups of prisoners. He said that C
wing had been tackling various issues like the use of drugs, assaults
and instability caused by prisoners arriving from other areas. But up
until the assault on the man it had been going through a fairly good
period.
57. The governor in charge of C wing was asked about the staff-prisoner
relationship before the man’s death. He said there had been a period
of instability a couple of years prior, marked by changes in wing
managers, but that things had turned around. He said the staff on C
wing had worked really hard and established a great deal of stability.
They had built up a team ethic and were engaging with prisoners to
establish good relationships. He felt that the staff had raised the wing
to a good standard and he was devastated by what happened to the
man. The governor acknowledged that prison can be a violent place
but said he had never come across this level of violence. He
expressed sympathy for the man’s family.
58. He acknowledged that Risley had a constant issue with countering
prisoner gangs connected to drugs. He said that, although there was
some intelligence that the man had used drugs, he was not involved in
anything more complex. My investigators checked the wing
observation book and security information but were unable to find
evidence to indicate that Risley could have foreseen the serious
assault on the man.
59. A post mortem was conducted on 18 November, the day after the
man’s death. It gave his cause of death as “blunt force trauma to the
head.” A clinical review into the care the man received at Risley was
conducted by the Assistant Director of Health Standards at Warrington
Primary Care Trust. In her report, she says that in an emergency
situation it would be expected that the nurses would have attended to
the man’s airway, breathing and circulation:
“Airway – The nurses should have made sure that the man’s airway
was clear, this did not appear to happen – the nurses did not examine
his airway, they assumed that he was breathing noisily because his
nose was broken.
“Breathing – The nurses should have ensured the man’s breathing
was optimised – the nurses did this by monitoring the man’s respiration
rate, but failed to attempt to address an abnormal rate by increasing
the patient’s uptake of oxygen. The nurses could have completed a
physical examination of the man to identify if there was a neck injury. It
may have been possible to lift the patients head slightly to facilitate
putting on the oxygen mask or, if not, a nurse could have held the
mask in place to increase uptake of oxygen.
“Circulation – the nurses appeared to have addressed the man’s
immediate needs in this respect as they monitored his pulse. However,
the nurses already identified that he had lost blood, appeared to have
bruising and appeared to be in pain. It would be reasonable to assume
that he would be shocked. When qualified health professionals attend
to a patient in an emergency situation it would have been reasonable to
expect that they use equipment and drugs available in the emergency
bag to establish IV access and start an infusion if they were trained to
do so. The two nurses in attendance did not identify this need and
were not trained to perform those skills. Members of the public may
have difficulty understanding why nurses had access to equipment that
could potentially save life that they were not trained to use. Although
the nurses were not trained to establish IV access, they could have
given oxygen and monitored the man’s level of consciousness more
closely. An accurate assessment of consciousness levels would have
assisted secondary care in his treatment.”
60. The RMN told the reviewer he had not dealt before with the type of
assault the man had suffered and felt out of his depth. He did ask for
an ambulance to be called and gave basic first aid. He took the man’s
pulse, but did not examine him for fear of disrupting an injury.
61. The clinical review concludes that, on balance, the care given to the
man was not as good as it could have been. However, “the review was
unable to establish whether or not the omissions of staff influenced the
outcome for the man. If he had received IV fluids and oxygen it may
have improved his prognosis.”
62. The clinical review queries why the officers who were first on the scene
did not call an ambulance straightaway rather than waiting for the
arrival of the nurses. My investigators asked Risley for their policy in
this regard. They were sent a memorandum from an Operational
Support Grade which read in part:
“ … I have looked everywhere and can’t find any instructions or
contingencies. I can confirm, however, that it is only control staff that
ring 999 for ambulances and that is only usually done at Healthcare’s
request i.e. in the event of a medical emergency, H1 would be
summoned to the scene and would then request emergency services
via control.”
63. The clinical review also expresses concern about the delay in the
arrival of the ambulance. The delay of over 30 minutes is outside the
expected national standard of eight minutes.
64. The review concludes that, “the issues raised in this review give cause
for concern both in terms of individual staff actions, team supervision
and the strategic and operational management of the service.
Therefore there are some recommendations to be made to the PCT
Board and the Prison Health Partnership Board in responding to this
report.”
65. It makes a number of recommendations that are listed at the end of this
report.
66. In line with the Prisons and Probation Ombudsman’s Office’s practice
of providing advance disclosure of draft reports to the Prison Service
where identifiable members of staff are criticised, the RMN and the
RGN were given sight of the report. Risley’s healthcare manager
asked for the following points to be considered:
67. “Immediately upon arrival at the scene, the nurses requested that an
Emergency Response Vehicle be called. The man had already been
placed in the recovery position and due to the perceived nature of the
injuries, the nurses felt that it was not appropriate to move him. He
was observed to be breathing adequately, therefore an airway was not
inserted, there were also concerns over causing further trauma to his
apparent facial injuries. The man’s circulation/cardiac output was
monitored via his pulse rate and peripheral circulation. Both nurses
were aware that an ambulance had been called and anticipated that
the paramedics would arrive imminently. The injuries that the man
sustained presented the nurses with an extremely critical situation.
This fell beyond the scope of their normal practice and duties, however
they are satisfied that the basic principles of life support were
observed.”
ISSUES
68. The man suffered serious injuries that led to his death four days later.
That these injuries should have occurred in prison makes them all the
more disturbing – perhaps all the more so given that they appear to
have taken place out of the blue in a relatively low security prison.
However, I have not found any evidence to suggest that Risley knew
an attack on the man was likely or imminent.
69. I have been careful to leave the question of what exactly occurred to
the police. I asked my investigators to focus on whether Risley’s
response to what happened was timely and appropriate.
70. The man was left lying on a landing. I have not been able to establish
with any certainty how long he was there before he was found, but
there are indications that he could have been there for some time. It is
clear that the actions of another prisoner who put the man in the
recovery position (having learnt first aid whilst in prison) were
invaluable.
71. Of the seven staff on duty on C wing that morning, three were allocated
to each spur with the senior officer mobile between the two spurs.
Most of the staff were carrying out tasks that took them away from
observing the landings and the prisoners for some time. This is partly
a matter of wing design, with offices located away from cell areas, and
meant that whatever took place could do so without staff seeing or
hearing anything untoward. This cannot have been lost on any
prisoners involved.
72. Even within a relatively low security establishment, there should not
have been periods when either spur was left unobserved by staff. All
the more so, given that 30 per cent of prisoners told HM Inspectorate of
Prisons that they felt unsafe at some point whilst in Risley, and
assaults and bullying are a concern in the prison in general. Although
Risley has been rebuilt to include modern facilities, CCTV has not been
installed.
The Governor should review the deployment of staff with the aim
of enhancing the level of surveillance, enabling prisoners to be
confident that their safety is a priority.
The Governor should consider the feasibility of providing means
of electronic surveillance.
73. When the third wing officer approached the man whilst he was lying
injured, he immediately called on his radio for healthcare staff to
attend. After they arrived five minutes later, an ambulance was
requested. The officer’s actions were prompt and there can be no
criticism attached to him. He acted in accordance with the existing
practice at Risley. There is no policy or instruction for staff being able
to telephone for an ambulance. A memorandum provided to my
investigators on the subject said, “it is only control staff that ring 999 for
ambulances …”
74. Prison Service policy, issued via a letter to governing Governors in
March 2004, on the access of ambulance and paramedic services
states:
“It is essential in clinical crises that prisoners should have rapid access
to emergency paramedical services … The critical factor in survival
rates is the time it takes a trained paramedic to reach the patient
(access for a vehicle is of secondary importance).
“It is the responsibility of the Governing Governor to ensure that a
protocol exists at each prison to facilitate the immediate access to both
the prison and the individual prisoner when emergency paramedic
services are summoned. It is also essential that internal procedures
should not waste undue time in summoning emergency assistance. It
should not; for example, be a requirement in every case for a member
of the Healthcare Team to attend the scene before Emergency
Services are called. However, a subsequent 999 call to the Ambulance
Service should be made to cancel the response if, after the original 999
call has been made, a member of the Healthcare Team arrive with the
patient and deem that an emergency ambulance response is not
required.”
75. It was obvious to staff from the time they saw the man that he had
been seriously injured. If the officer knew he could have requested an
ambulance immediately, it might have avoided the significant delay in
the arrival of an ambulance which then followed.
The Prison Service and Department of Health should re-issue the
guidance to all Governors on the calling of an emergency
ambulance and ensure that staff at all levels are aware of its
contents.
76. I can only imagine the anxiety of both staff and prisoners as they
waited for an ambulance to arrive. Thirty minutes is a very long time to
have to wait, given that the NHS standard deems eight minutes as
reasonable. It is important to say, however, that the ambulance service
has its own system for allocating ambulances and the Prison Service
cannot tell it what level of priority should be given.
The PCT should request that the Ambulance Service conduct a
serious event analysis of the allocation of the emergency service
vehicle for the man who died.
77. Creating a regime which allows prisoners as much free time out of their
cells as possible at the weekends is laudable. At Risley, prisoners
were unlocked from breakfast until lunchtime to do as they wished
within the wing. The duty governor spoke at interview about wanting to
get back to a normal routine as soon as possible. Ordinarily, I would
agree. However, from the descriptions staff have given of the man’s
condition there could have been no doubt that his condition was life-
threatening. It was likely that a serious criminal offence had been
committed by persons who were on the wing. The man’s medical
needs were addressed in terms of getting nurses to the scene, calling
an ambulance and making him as comfortable as possible. However,
the need to isolate the scene and preserve evidence by limiting
movement was pursued with less vigour or co-ordination.
78. After the man was found, prisoners were allowed to attend church, go
on to the exercise yard, leave the wing for the gym, even have a
shower – movements which provided opportunities for evidence to be
lost. Prisoners were able to approach the area for some twenty
minutes while the man was being attended to on the ground floor
landing. When they were guided away by officers, prisoners were still
able to overlook the scene by standing on the upper landings. I am not
convinced that this translated into sufficient regard for the management
of the unfolding events or recognition of its importance.
79. Prisoners were given a choice to be locked in their cells, which only a
minority exercised, or continue association on the north spur. It was
known that there were only six staff on the wing, two of whom were still
outside supervising exercise. When exercise was brought to an end,
this still left insufficient staff to monitor twice the number of prisoners
normally present on a spur, especially when there was likely to be a
heightened state of agitation after what had happened to the man.
There was no realisation by the manager that a significant number of
prisoners were being allowed to go to the north spur with only one
member of staff present, on the ground floor. Even if a disturbance
had not occurred, this situation would have been undesirable. And
when the member of staff left, albeit briefly, the prisoners were left to
themselves.
80. This is not just an issue about the numbers of staff vis-à-vis the number
of prisoners. Given that many prisoners may have known what exactly
had happened to the man, it was an incendiary situation waiting to
ignite. The three officers who successfully intervened when unrest
broke out showed bravery in confronting a dangerous situation to
rescue a prisoner and bringing the incident under control. Their actions
are to be commended. It is thanks to their courage that more prisoners
were not seriously injured or worse.
81. The assault in the servery afterwards, even during a controlled unlock,
showed that increased numbers of staff were not a sufficient deterrent
to any prisoner determined to attack another. However, the speed with
which the unrest was contained is an example of how potentially
dangerous situations may be minimised and controlled.
82. The duty governor opened the Command Suite after deciding that the
man’s injuries and the subsequent disorder constituted a serious
situation. Prison Service Order 1400 – the Incident Management
Manual deals with the strategy for the control of serious incidents. In
the section on post incident procedures it says:
“During and after a serious incident it is likely that crimes will have
been committed. If a prosecution is to be successful, the rules
governed by the PACE Act 1984 must be followed. Police advice …
will be critical in this respect … From the start of an incident, the Police
will wish to gather as much evidence as possible to assist in criminal
prosecutions.”
The Governor should review the existing arrangements for
dealing with serious incidents and consider whether the
establishment could benefit from consultation with the local
police concerning scene preservation and exhibit handling.
83. It is very regrettable that Risley did not inform the police until almost
four hours after the man was discovered. There was some confusion
as to who was supposed to contact them and what time the request
had been made. The duty governor was certain that he asked for the
police to be contacted, but could not recall who the request was
directed towards. In any event, it was not followed up and it was only
on the Governor’s arrival in the afternoon that it was realised that the
police had not been called. Earlier involvement by the police would
have been beneficial in directing the efforts made to manage the crime
scene, and collect and preserve evidence. However, I am heartened to
learn that, despite the initial delay, subsequent communication
between Risley and the police was excellent.
84. Unfortunately, Risley’s contact with the man’s family was less
successful. While the family were told of the man’s injuries, it was only
after the man’s death they were assigned a family liaison officer who
then contacted the man’s aunt. This was interpreted as a lack of
concern for the family, given that Risley had been responsible for the
man’s well-being.
85. It is also unfortunate that the letter sent by the Director General to the
man’s aunt the day after the man died said that the police were called
immediately. I do not know who prepared the letter, or what the
Director General meant by “immediately”, but the family’s unhappiness
demonstrates the importance of providing information that is as
unambiguous as possible. Because of what was perceived as
misinformation, the man’s family decided not to have further contact
with the Prison Service, although Risley’s Roman Catholic chaplain has
been of comfort to them.
86. The Governor may wish to satisfy himself that accurate information
was passed to the Director General’s office. The Director General may
wish to satisfy himself that he was fully appraised when he signed off
the letter to the man’s aunt.
87. Although family liaison officers are normally appointed following the
death of a prisoner, it would be good practice to consider whether one
is needed in cases where serious or life-threatening injuries have
occurred.
The Governor should devise a local contingency plan to cover
liaison with families in the event of serious and/or life-threatening
injury to prisoners.
88. The clinical review makes three recommendations that I endorse:
The Primary Care Trust, in agreement with the prison, should
determine the role of the healthcare team in responding to
healthcare emergencies on prison wings.
The Primary Care Trust should review the skill mix of staff in the
healthcare team so that the team can effectively deal with
healthcare emergencies.
The Primary Care Trust should ensure that incident reporting
processes at Risley are effective.
89. It was good practice to release the man on temporary licence, and
remove the bedside prison officer escort, the day after the man was
taken to hospital when it was considered he was unlikely to survive.
90. A number of actions were taken by Risley and C wing prisoners to
mark the man’s death which his family found touching and showed a
proper respect for him as a person.
RECOMMENDATIONS
National
The Prison Service and Department of Health should re-issue the
guidance to all Governors on the calling of an emergency ambulance
and ensure that staff at all levels are aware of its contents.
Local
The Governor should review the deployment of staff with the aim of
enhancing the level of surveillance, enabling prisoners to be confident
that their safety is a priority.
The Governor should consider the feasibility of installing means of
electronic surveillance.
The Governor should review the existing arrangements for dealing with
serious incidents and consider whether the establishment could benefit
from consultation with local police concerning scene preservation and
exhibit handling.
The Governor should devise a local contingency plan to cover liaison
with families in the event of a serious and/or life-threatening injury to
prisoners.
Primary Care Trust
The Primary Care Trust should request that the ambulance service
conduct a serious event analysis of the allocation of the emergency
service vehicle for the man who died.
The Primary Care Trust, in agreement with the prison, should determine
the role of the healthcare team in responding to healthcare emergencies
on prison wings.
The Primary Care Trust should review the skill mix of staff in the
healthcare team so that the team can effectively deal with healthcare
emergencies.
The Primary Care Trust should ensure that incident reporting processes
at Risley are effective.