Individual at Rye Hill

Investigation into the circumstances surrounding the
death of a man at
HMP Rye Hill in June 2006
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2009
This is one of the most worrying reports I have issued in nearly five years of investigating
deaths in custody.
The man was 33 years old when he died at HMP Rye Hill on 10 June 2006. He came from
Ukraine and, after a sentence of imprisonment, was awaiting deportation. His time in
custody had taken him to eight different prisons. In the period leading up to his death, the
man had been repeatedly blood-letting.
After extensive efforts by my investigators, the Coroner’s office, the British Embassy in Kiev,
and the Ukrainian Embassy in London, the man’s father and family were traced. My report
will be extremely disturbing for them to read, and I offer my sincere condolences.
Two of my investigators carried out the investigation. I also asked a clinical review of the
healthcare and treatment received by the man whilst he was in custody, and I am grateful for
the assistance of the clinical reviewer and that of her colleagues.
All in all, this has been an extremely complex investigation to which we have needed to
devote much time and effort to understand what happened. The earlier drafts of this report
resulted in many comments from the parties, and we have considered very carefully
everything we have been told. A variety of amendments have been made and new material
added. I believe that what follows is an authoritative account of the circumstances that
culminated in the man’s death. However, the scale of the investigation has meant a delay in
issuing my report for which I must apologise.
An important part of any investigator’s work is the examination and questioning of available
documentation and evidence. Unfortunately, the prison records are incomplete which
means that the chronology prior to the man’s arrival at Rye Hill has been difficult for my
investigators to follow. However, they have been able to piece together the most significant
events. These show that there were times when the man was a difficult man to manage, but
other periods when his behaviour was settled. Although my report concentrates on the
months the man spent at Rye Hill, it would be wrong to exclude the salient points from this
earlier time in custody. To do so might suggest to the reader that his problems only
manifested themselves after his arrival at Rye Hill.
As part of my report, I have included the most important conclusions of the clinical review
and its recommendations, together with my own. In a report in which there is much to cause
alarm and anger, one of my recommendations concerns members of staff whom I believe
should be commended.
For the last few months of his life, the man was monitored under the Prison Service’s suicide
and self harm monitoring and support arrangements because of his serious self harming
behaviour. The last four months were spent at Rye Hill, and I have been distressed to learn
of the conditions the man lived and died in. This report reflects a tragic catalogue of self
harm and abuse. Sadly, Rye Hill did not provide sufficient care to protect him.
An additional issue in this case was the man’s immigration status. It seems that the man
was almost certainly not held with proper authority between 29 March 2006 and 12 May
2006.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2009
2
Note on report structure
My report is divided into several sections, a list of which can be found in the contents
on page 5. The initial sections explain how the investigation was carried out, identify
the different prisons where the man was held, and present background information
about him. Additionally, there is a section which explains relevant prison and clinical
terminology.
The Key Events section informs the reader of the factual information in a
chronological order from the date the man was first received into prison. Although
the report covers the full length of the man’s imprisonment, the main findings, issues
and recommendations concentrate on the period he spent in Rye Hill.
There are a number of significant dates where I identify issues relating to the man’s
care and treatment whilst at Rye Hill. These dates are sub-headed within the Key
Events section.
The report names a number of individuals who had contact with the man and
identifies several members of staff whose actions have raised concern. However, I
recognise that other people were also responsible for the man’s care and for this
reason have made a recommendation for Global Solutions Limited (GSL) – now part
of Group 4 Securicor (G4S) Care and Justice Services - to investigate key dates
separately. Only in this way will GSL be able to ascertain clearly who was
responsible for actions and inactions.
Issues, concerns and areas of good practice are discussed in greater detail in the
Issues section. Recommendations which result from issues or concerns are made at
this point and are also listed separately in the final section of the report.
As with all my reports, I refer to the deceased by the name indicated by the next of
kin, unless no preference is suggested.
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CONTENTS
Summary 7
The Investigation Process 9
The Prisons where the man was held
(cid:127) Brixton 16
(cid:127) Wandsworth 16
(cid:127) The Verne 16
(cid:127) Guys Marsh 16
(cid:127) Wayland 17
(cid:127) Highpoint 17
(cid:127) Norwich 17
(cid:127) Rye Hill 17
Prison and Clinical Terminology 19
Key Events 27
After the man’s death 75
Issues 78
Conclusion 93
Recommendations 94
Outline of the Primecare Internal Inquiry report 97
Summary of meeting on 5 January 2009 with the 101
Director and Head of Safer Custody at Rye Hill
4
SUMMARY
The man arrived in the United Kingdom from Ukraine on 30 April 1998 on an
employment visa. In December that year he applied for asylum, but this was
refused in 2001.
In April 2002, the man was remanded into custody charged with burglary. He
was released in June that year. After being charged with further burglary
offences, he was returned to custody in September and sentenced in June
2003 to seven years imprisonment. As a result of his conviction and sentence,
the Immigration and Nationality Department (IND) of the Home Office (now the
United Kingdom Border Agency (UKBA) but for ease and consistency with the
prison records at the time referred to as IND in this report) was informed and
proceedings to deport the man back to Ukraine were started.
During the early stages of his sentence, the man appeared relatively settled but
for a variety of reasons he would ask to transfer to other prisons. He was
described in various documents as “manipulating” situations to obtain a
transfer, and this would take the form of refusing food and minor self harm. He
told prison staff that he had been in hospital in London after apparently feeling
mentally unwell, but said he had not had a mental health assessment. He also
told prison staff that he would be killed by members of the Russian Mafia if he
returned to Ukraine because they believed he was a police informant.
Due to the food refusal, the man began to lose weight and it was deemed
necessary to transfer him to a prison where he could receive appropriate
medical care. After a while the man was given a place at a suitable prison and,
after assessing his needs, he was given food supplements to build him up. At
the same time, he became eligible for presumptive parole. However, although
the process began, the rules were not applied correctly and parole was not
granted.
In January 2006, the man agreed to transfer to Rye Hill. On 23 February 2006,
staff from Rye Hill arrived at HMP Norwich to collect him and the transfer took
place. Once again he appeared to settle down and engage positively with the
prison regime. However, this changed soon after the initial decision not to
grant parole was reviewed and found to be wrong. After the review, parole was
correctly granted and the man became more challenging in his behaviour,
increasing his level of self harm and food refusal.
Such was the increase in the man’s self harm that special meetings were held
to determine the appropriate level of care and support required. Unfortunately,
what was agreed for his medical care and assessment was not carried out and
the man’s mental health was never formally assessed. The man was dealt with
in the main as if he were refusing treatment. However, the only signed
treatment refusal form dated from his first period in prison custody (2002) and
by then was no longer applicable.
The man’s level of self harm increased such that on one occasion staff
described his cell as having been covered in blood from the early hours,
through to the night time. It appears that he was only moved to healthcare after
5
a senior manager received complaints from a chaplain and heard threats that
prisoners would not return to their cells to be locked in for the night.
On the day he died, the man was being observed constantly by officers. There
are notes showing that he had been in great distress, lying on the floor of his
cell and experiencing great difficulty in moving because he was so weak.
When he asked for water, neither prison staff nor the duty nurse went into his
cell to assist him, and he had to struggle to a hatch in the cell door to collect it.
Shortly before midnight on 9 June 2006, the man was seen kneeling at the end
of his bed, with his arms and head laid upon it. The officer watching him
became concerned that he could not hear the man breathing and asked for
medical assistance. He had died and there was nothing that staff were able to
do to save him.
6
THE INVESTIGATION PROCESS
1. When my office was notified of the man’s death, the Deputy Ombudsman at
the time and one of my investigators opened the investigation at Rye Hill on
12 June 2006. They met the prison’s Director at the time, and he briefed them
about what had happened. After the meeting the investigation was allocated
to two of my investigators.
2. On 19 June, HM Chief Inspector of Prisons gave the Deputy Ombudsman
copies of three letters which she had received from Rye Hill. Two were from a
member of Rye Hill staff, a Prison Custody Officer (PCO) – PCO A and the
other was from the man himself. One of the PCO’s letters referred to her own
experience of Rye Hill’s healthcare arrangements, whilst the other referred to
her concerns regarding the man’s care. In his letter, the man referred to his
wish not to be deported to Ukraine and also touched on his self harm. All
three letters were handed to my investigators for their consideration.
3. I am aware that GSL, the company responsible for Rye Hill, commissioned an
internal investigation into the matters raised by the PCO. I am grateful to GSL
for their agreement to annex their report to my own.
4. One of my Family Liaison Officers (FLOs) telephoned the prison’s Deputy
Director on 23 June 2006. My FLO asked for details of the man’s next of kin
and whether the prison had informed the Ukrainian Embassy of the death of
one of its citizens. The Deputy Director said there was no known family and it
was not within the prison’s remit to inform the Embassy.
5. On 3 July, the investigators and one of my Assistant Ombudsmen, now
Deputy Ombudsman, returned to Rye Hill to continue the investigation.
During a search of the prison records, a telephone number was found that
was believed to be for a member of the man’s family. The number was later
passed to the Coroner’s Officer, for him to follow up. The following day, the
investigators met members of the prison’s Independent Monitoring Board
(IMB) to discuss the investigation process.
6. My investigators were given access to the man’s prison records. They
examined the documents and used them to inform their decisions on whom to
interview. The interviews did not include everyone who had contact with the
man whilst at Rye Hill, but concentrated on those who had the more significant
dealings with him. Unfortunately, one of the managers they wished to speak
to had been suspended from work on an unrelated matter and so could not be
interviewed.
7. On 6 July, the investigators went to the home of PCO A to interview her about
her letter to the Chief Inspector of Prisons, and to see what information she
had relating to the man’s care and treatment at Rye Hill.
8. Five days later (11 July 2006), the clinical review was commissioned. At a
meeting with my investigators and the clinical reviewer to discuss the
investigation’s findings to date, my Deputy Ombudsman confirmed that she
7
would be requesting a panel review to assist the clinical reviewer with her
work and that she would oversee the clinical review report including the
conclusions and recommendations. Additionally, the clinical reviewer agreed
to lead the investigation interviews with medical staff. These began on 7
August.
9. On 8 August, my investigators met the then Detective Chief Inspector (DCI) in
charge of the police investigation into the man’s death. At that meeting the
investigators told the DCI about their concerns regarding the man’s care. The
DCI told them that he would refer the case to the Crown Prosecution Service
(CPS) for advice.
10. Six days later, on 14 August, the DCI told my investigators that the CPS
wanted to meet the investigation team in September at their office in York to
discuss the initial findings.
11. As per my office’s guidance on feedback to institutional heads, the
investigators met the prison Director on 18 August and gave further feedback
about the progress of the investigation. This was subsequently confirmed in
writing.
12. Following the referral to the CPS, my investigators, a registered mental health
nurse on the clinical review panel and the DCI met on 8 September with a
CPS lawyer. The outcome was that the police were taking no further action at
that stage. However, it was left open that, once my report was completed, the
Coroner might wish to consider directing the police to reconsider the
information.
13. After carrying out further interviews, the investigators met the then Deputy
Director of Rye Hill, on 26 September. They provided him with more details
about their findings and concerns. As previously, the investigators confirmed
this in writing to the then Director.
14. After consultation with my then Deputy Ombudsman, my investigators wrote to
the prison Director to request a meeting to discuss the initial findings of the
clinical review. The Director was asked to invite a senior member of staff from
Primecare’s headquarters. The meeting was arranged for 19 December. A
copy of the clinical findings was sent in draft to the Director for him to share
with all parties attending the meeting. The clinical findings were shared on the
understanding that the report covered the important points of concern, but was
still in the investigative stage and subject to amendments.
15. On 19 December, my investigators, then Deputy Ombudsman, the clinical
reviewer met the prison Director, the Deputy Director, the Managing Director,
Offender Management and Immigration Service, GSL, the Regional Offender
Manager, the Primecare Service Director, a doctor from Primecare and the
Home Office Controller. The outcome was that Primecare – the company
contracted by GSL to provide healthcare at Rye Hill at the time –
commissioned its own inquiry into members of Rye Hill healthcare staff.
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16. Primecare’s report states that their inquiry team was made up of three
independent clinical professionals experienced in general and mental
healthcare in a secure environment and a Primecare employee with a prison
background. A report on the findings of the internal inquiry was completed
and a copy sent to my Deputy Ombudsman in April 2007. After reading the
Primecare report, my Deputy Ombudsman remained satisfied with the findings
of the clinical review panel which my office had commissioned and advised my
investigation team that no amendments needed to be made to the clinical
review as a result. At the request of Primecare, I have annexed their internal
inquiry report to this report. Additionally, I have added a brief note regarding
their report findings and recommendations at the end of my own
Recommendations section.
17. On 21 December, due to the lack of progress in finding the man’s family, my
investigators telephoned the British Embassy in Ukraine and asked for their
assistance. A scenes of crime officer based at the Embassy agreed to
circulate details to other agencies. Additionally, the investigators were able to
provide details of a possible address for the man’s relatives that they had
obtained through the immigration service.
18. The following month, on 2 January 2007, my investigators were told by the
Coroner’s officer that the man’s father had been traced a few days earlier and
informed of his son’s death.
19. One of my investigators was contacted by a member of staff from an
International Funeral Directors. They had been appointed to repatriate the
man’s ashes back to Ukraine. The investigators contacted the Deputy
Director who agreed to contribute up to £3,000 towards the cost of the
cremation and repatriation.
20. As my family liaison officer had by then left my office, another FLO, wrote to
the man’s father in Ukraine explaining my role and inviting him to contribute
towards this report. The letter was translated and sent on 10 January. On 1
February, one of my investigators received a telephone call from the Ukrainian
Embassy in London. They had been contacted by the man’s father who
wanted my investigators to know that he would like to meet them at his home
in Ukraine. After agreeing to the request, my investigators arranged to travel
at a later date to meet him and his lawyer, which they did in May 2007.
(Additionally, at the request of the family’s legal representatives in the UK, my
investigators returned to Ukraine to discuss the draft report in August 2008.)
21. At the same time as this investigation was ongoing, a separate unconnected
criminal trial was taking place at Northampton Crown Court relating to the
death of a prisoner at Rye Hill. The trial judge was aware of this investigation
and directed me to send him the file relating to the man. After seeking legal
advice, I did so.
22. Following the criminal trial, BBC Panorama broadcast an investigation into
Rye Hill. As part of the documentary, they referred to my investigation into the
man’s death and interviewed the man’s father at his home. On the same day,
the Home Office Controller at Rye Hill rang one of my investigators to ask
9
when my report would be ready as he was responding to a request from the
Home Secretary.
23. On 28 March, my investigators contacted IND because they were concerned
that the man might not have been held lawfully during his final months in
custody. They requested that a senior official re-examine his immigration
files. The following month, on 24 April, one of my investigators met the senior
official at IND. The official agreed to examine the files further and report back
his findings.
24. By this point, the then Director of Rye Hill, had retired and his line manager,
(the managing director) had asked that all further communication regarding
the man should be directed to him personally. My investigators wrote to the
managing director on 18 May outlining additional concerns to those raised
previously. These related specifically to two prison managers, and to two
members of staff whom they felt ought to be commended for their actions.
25. On 25 May, my investigators travelled to Ukraine to meet the man’s father, his
lawyer, daughter and son in law, at their home. The man’s father and his
family welcomed my staff and they told him about the investigation and their
concerns, and the man’s father shared his. The investigators used the
services of a local translator.
26. After returning to the UK, my investigators were contacted by a member of
staff from IND. She told them that the man might not have been held in prison
lawfully.
27. In the event of my reports making criticism of an individual or organisation, I
issue the draft report in advance under my disclosure policy. This allows for
any individual or organisation named to correct any factual errors or identify
any omissions. In line with the disclosure policy, the draft report was advance
disclosed on 8 October 2007 to GSL.
28. Following advance disclosure, I received feedback from various individuals
who were criticised. I have noted their comments and have made
amendments where I consider it necessary. A second draft report was issued
with 14 days advance disclosure on 18 February 2008. As noted, at
Primecare’s request I have also annexed their internal inquiry report which
they commissioned following the meeting with my investigation team on 19
December 2006. Prior to the draft report being published to all interested
parties in April 2008, an application was made by the Medical Defence Union
(MDU) by way of Judicial Review to prevent this. The application was
withdrawn by MDU after the Judge refused to grant an injunction.
29. One of the members of staff my investigators wished to interview was being
investigated over another unrelated matter and suspended from duty and was
therefore unavailable for interview. Following the advance disclosure of my
draft report, my investigators made further attempts to interview the staff
member. They wrote to the staff member to invite her for interview and sent
the letter via the new Director of Rye Hill. The Director told my investigators
that the staff member was on sick leave and not available for interview but she
would hand the letter to the staff member on her return. My investigators have
10
had no further response from either the Director or the staff member and are
therefore unable to include her version of the events on 23 May 2006.
30. Since my draft report was disclosed to GSL, I have received feedback from
the prison via the Prison Service’s Safer Custody and Offender Policy Group.
I am pleased to note that all of my recommendations referred to GSL have
been accepted with the exception of two which have been partially accepted.
Their response to the recommendations is noted in the final section of this
report. Before issuing the final report my investigators invited the Director to
update them of any changes and progress since the man’s death. The offer
was accepted, and on 5 January 2009 my investigators met with the Director
and Rye Hill’s Head of Safer Custody. I have summarised the meeting at the
end of the Recommendations section of this report.
11
THE MAN
31. On 30 April 1998, the man arrived in the UK having travelled on an
employment visa. He claimed asylum in December of that year. He was
refused asylum in September 2001 and appealed against the decision the
following month. A few months later (February 2002), the man, who was now
regarded as an “overstayer”, signed an appeal waiver that would allow him to
be removed from the UK back to Ukraine. (Overstayer is a term used by the
immigration service to describe someone who has remained in the country
longer than authorised.) Arrangements were made for the man to travel to
Ukraine on 25 February. He was supposed to make his own way to the
airport but failed to appear.
32. The man was remanded into custody to HMP Brixton, charged with burglary,
on 26 April 2002. He had no other police records on file except for a driving
offence for which he had been banned from driving and given a fine. The man
returned to court in relation to the burglary charges on 21 June and was
discharged. The prison records relating to this period of custody have been
destroyed (I understand this is normal procedure), and therefore I do not have
an explanation for the man’s discharge from court.
33. According to later prison records, the man told prison staff that he had been in
hospital once before he was imprisoned. He said that in June 2002 he
attended the Accident and Emergency Department at Charing Cross Hospital,
saying that he was ‘feeling crazy’. He told prison staff that he was not
admitted and was assessed as not having a mental illness.
34. The man was arrested and charged with further burglary offences, and on 20
September 2002 was again remanded into custody at Brixton. The
immigration authorities were notified by the prison that he had been arrested.
As well as being remanded in custody, the man was served with a deportation
order which meant that he was also being detained as an “overstayer”.
35. On 6 December, the man returned to court and was then taken to HMP
Wandsworth rather than to Brixton. Whilst at Wandsworth, he was
interviewed by police officers (this is not unusual for any remand prisoner).
Although he did not say so at the time, later in his sentence he told prison staff
that he was worried that other prisoners thought he was a police informant.
As a result, the man believed his life would be in danger from members of the
Russian Mafia if he were to return to Ukraine. He also said that he owed
money to people in Ukraine. The man’s father told my investigators that, in
his opinion, this was not true.
36. On 12 June 2003, the man was sentenced to seven years imprisonment for
six counts of burglary, with a court recommendation that he should be
deported at the end of his sentence. (The long sentence reflected the
commercial nature of the burglaries and the value of the items stolen.) Two
months later, the man’s asylum appeal was dismissed by the immigration
authorities. It would appear from immigration records that, even though he
had signed the appeal waiver in 2002, his application had continued.
12
37. Whilst in prison, the man completed several educational courses - including
levels one and two in literacy and numeracy - and was undertaking an Open
University course in mathematics. During his time at HMP The Verne (one of
the prisons he spent time in), the man joined an educational course in building
and construction. Prison records show that the man’s tutor described him as
a good learner, keen to make changes and with a proved commitment in
completing the course.
38. After leaving The Verne in February 2005, the man never spent more than a
few months in any one prison. During his time in custody, the man went to
eight different prisons, and at each one made requests to transfer to
somewhere else. The reason for the requests varied from wanting to be
closer to London for ease of people visiting him, to better gymnasium facilities,
improved regimes and workshops. The man also frequently asked to be
transferred to a segregation unit or to a prison with an in-patient healthcare
centre.
39. On a number of occasions the man refused food in order to obtain a transfer.
In November 2005, he refused food for 28 days, telling staff that he wanted to
go to a prison with in-patient healthcare facilities. Prison records indicate that
the man would “manipulate” a situation in order to obtain a move, but none of
the records gives reasons why. On many occasions the evidence suggests
he would self harm so that he could get a transfer or a move to a healthcare
centre.
40. The prison records show that from 16 October 2005 the man was regularly
monitored under the Prison Service’s self harm procedures until his death in
June 2006. Prior to this, the only recorded incidents of self harm were when
he appeared at court in April 2002 and September 2002.
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THE PRISONS WHERE THE MAN WAS HELD
HMP Brixton
41. The original buildings date from 1819, and there are four main residential units
and a healthcare centre. ‘A’ wing houses 264 prisoners in 143 cells, the
majority of which are for two prisoners. ‘B’ wing has 86 cells, some of which
are shared, and is mainly used for foreign national prisoners. ‘C’ wing has 69
double cells and operates primarily as a centre for drug treatment
programmes. ‘G’ wing has 151 cells, 61 of which are double cells.
Additionally, it has a first night centre and induction unit. ‘D’ wing has a 26
bed in-patient facility, concentrating on acute mental health care.
42. The prison's primary role is to serve the local magistrates’ courts and Inner
London and Southwark Crown Courts, and it holds remand and trial prisoners.
It is intended that convicted prisoners should be allocated to another prison
with facilities appropriate to their sentence and needs.
HMP Wandsworth
43. Wandsworth is a large prison in south west London, with a separate
vulnerable prisoner unit. It currently holds 1,650 prisoners and is the largest
prison in the UK and one of the largest in Western Europe. The prison was
built in 1851, and the residential areas remain in the original buildings. There
has been extensive refurbishment and modernisation of the wings, including
in-cell sanitation, privacy screens for cells occupied by more than one
prisoner, and installation of in-cell electricity.
HMP The Verne
44. The Verne is a category C training prison for adult men on the Isle of Portland
in Dorset. The original buildings date from 1873 when it was built as a citadel
fortress to overlook Portland Harbour. It was taken over as a prison in 1949,
using the existing citadel defences for dormitory accommodation and
workshops. A number of purpose built houseblocks were constructed in the
early 1970s. The prison takes a wide range of prisoners, including 50 life
sentence prisoners.
HMP Guys Marsh
45. Guys Marsh opened in 1960 as a Borstal and became a Young Offender
Institution (YOI) in 1984. After completion of perimeter fencing in 1992, it
became a closed establishment and started to accommodate adults. It is now
a category C prison and closed YOI, holding up to 578 prisoners. There are
currently nine living units, one for young offenders, and the remainder for
adults.
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HMP Wayland
46. Wayland is a category C adult male training prison in Norfolk. Since opening
in 1985, the buildings have been expanded on three occasions, and the prison
is now made up of eight residential units with an operational capacity of 709.
The accommodation is mainly single cell, although there is some shared
accommodation. The prison has a healthcare centre, but there are no in-
patient facilities and any prisoner who requires in-patient care is transferred to
HMP Norwich.
HMP Highpoint
47. Highpoint is situated in Suffolk and built on a former Royal Air Force base.
The prison opened in 1975 as a category C prison. There are eight units with
cellular accommodation, and the operational capacity is 816.
HMP Norwich
48. Norwich prison is situated within the city of that name in Norfolk. It is a local
prison taking remand prisoners, but also holds category C convicted adults,
and young offenders. At the time the man was there, the operational capacity
was 824, with the vast majority of accommodation being in single cells. The
prison has a healthcare centre, providing a 28 bed in-patient facility for those
with physical or mental health needs, and in-patient facilities for Wayland and
HMP Blundeston.
HMP Rye Hill
49. Rye Hill is a contracted out prison, privately managed by Global Solutions
Limited (GSL) – now part of G4S. It opened in 2001 as a purpose built
training prison for sentenced adult men with a minimum of 18 months left to
serve. It has an operational capacity of 660 prisoners, and the
accommodation is in eight units.
50. All private prisons have a Controller who links the prison to the Home
Office/Ministry of Justice and oversees the contract to ensure the company is
delivering its contractual obligations. Much of the terminology in private
prisons differs from that in the public sector prisons. For example, the
Governor is known as the Director, and prison officers are called prison
custody officers (PCOs).
51. Healthcare at Rye Hill at the time of the man’s death was provided by another
private company, Primecare Forensic Medical Ltd (PFM). The healthcare
centre is staffed 24 hours a day by qualified nurses and healthcare assistants.
Visiting specialists, based on need, include a doctor, dentist, optician,
chiropodist and psychiatrist. There are eight beds for prisoners requiring in-
patient care.
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52. The staffing structure at Rye Hill is as follows:
(cid:127) Director
The Director is in overall charge of the prison.
(cid:127) Duty Director
Members of the senior management team take on the role of Duty
Director on a rota basis. The Duty Director is in charge of the operational
management of the prison on a day to day basis.
(cid:127) Oscar 1
This is the code for the Orderly Officer, a middle manager discipline
grade. The managers rotate responsibility for managing the prison on a
daily basis and report to the Duty Director.
(cid:127) Duty Security Manager (DSM)
A first line junior manager (discipline). They assist Oscar 1 and are
responsible for tasks such as moving prisoners and rostering staff duties.
In public prisons this post is known at Oscar 2.
(cid:127) Residential Managers
Residential managers are responsible for the day to day running of a unit.
(cid:127) Prison Custody Officers (PCOs)
PCOs are front line officers working on the units directly with prisoners.
In public prisons they are called prison officers.
53. In April 2005, Her Majesty’s Chief Inspector of Prisons, Dame Anne Owers,
carried out an unannounced inspection of Rye Hill. In the introduction to her
report, the Chief Inspector wrote that: “the prison had deteriorated to the
extent that we considered that it was at the time an unsafe and unstable
environment, both for prisoners and staff … So great were the concerns that I
immediately informed Ministers and urged the Chief Executive of the National
Offender Management Service to take immediate and decisive action.”
54. In her introduction, the Chief Inspector went on to say: “Staff were
inadequately supported by managers and were sometimes surviving by
ignoring misbehaviour or evidence of illicit possessions.” She added:
“Managers were not a visible presence on the wings, we were told by
prisoners and staff that they rarely made an appearance when prisoners were
unlocked.”
55. The Chief Inspector was impressed by the enthusiasm of the officers and their
positive approach to their task and to prisoners. However, her report said it
was evident that some critical systems, such as suicide prevention and
personal officer work, were suffering because staff were unable or did not
know how to engage with either prisoners or the appropriate systems.
16
PRISON AND CLINICAL TERMINOLOGY
Buddies/Listeners
56. Buddies are prisoners who have been selected to support other prisoners who
may be feeling vulnerable. They work alongside the safer custody manager
and receive training to help them support prisoners who could be suicidal.
Listeners provide a similar service but receive training through the
Samaritans.
Clinical Panel Reviews
57. Clinical panel reviews are made up of a group of medical specialists able to
give an informed professional opinion about the level of medical treatment and
to assess medical care.
Emergency Codes
58. To ensure a correct response from healthcare as to what type of emergency
medical equipment to bring to a patient, Rye Hill uses a code which is
transmitted over the local prison radio system. A code one alerts the medical
team of the danger of immediate death. A code two alerts the medical team of
the need for urgent medical assistance in a less life threatening situation than
a code one.
First Night Risk Assessment
59. First night risk assessment documents have been developed to ask a series of
questions designed to gather as much information as possible about the
prisoner. They cover areas such as accommodation, employment, courses
and family. They also deal with the prison rules, disability and public
protection.
Food Refusal
60. Under prison rules, the refusal of food is not officially recognised until three
days of not eating have elapsed. After this, healthcare staff will monitor the
prisoner and take observations including weight.
Incident Reports
61. When an event occurs in prison that affects security or the safety of a prisoner
or member of staff the details are recorded on an incident form. The
information is analysed and any action required then taken. If necessary, the
reported incident is passed to Prison Service Headquarters for their
information.
Independent Monitoring Board (IMB)
62. Each prison has its own IMB who are independent and have access to all
parts of the prison. They may report directly to Ministers.
17
Mental Capacity
63. Individuals who are mentally capable are entitled to refuse treatment. The
Mental Health Act (2005) states that:
‘a person lacks capacity in relation to a matter if at the material time he is
unable to make a decision for himself in relation to the matter because of an
impairment of, or a disturbance in the functioning of, the mind or brain.’
In this case, prison healthcare staff decided that the man was capable of
determing whether or not to accept treatment.
Mental Health In-reach Team (MHIRT)
64. The team provide support and continuous care to those prisoners whose lives
have been disrupted by symptoms of serious mental illness.
Night State
65. Night state is when all prisoners are locked into their cells and staffing levels
are at the minimum. Access around the prison is restricted to the few people
on duty who have keys. Additionally, movement in and out of the prison is
restricted to essential moves only.
66. Before unlocking a cell door at night, consideration has to be given to how the
prisoner is reacting or is likely to react. It is for this reason that, unless the
prisoner is in a life threatening situation, cell doors are not normally opened
without sufficient officers being present.
67. At Rye Hill, the night manager has the authority to open a cell during the night
in an emergency situation. At other times, the night manager should seek the
permission of the on call director.
Personal Officer Scheme
68. The work of personal officers is central to the care of prisoners and the
security of the establishment. A personal or group officer scheme and/or a
shared working arrangement is required in each prison so that particular staff
get to know particular prisoners, and prisoners can turn to them for advice and
assistance.
Prison Service Orders (PSOs)
69. Prison Service Orders are long term instructions from the Prison Service and
issued to all prisons. Each has a title and unique reference number. Any
mandatory instructions to Governors or Directors of contracted prisons
contained within a PSO are written in italics. Since the man’s death a number
of PSOs will have changed, and my report refers to the guidance given in the
PSOs in effect at the time.
PSO 0500 Reception Screening
70. PSO 0500 concerns reception procedures and sets out the standard actions
to be completed in the first two to three hours after a prisoner arrives in an
establishment. One requirement is a first reception health screen assessment
18
which should identify any immediate physical or mental health problems,
significant drug or alcohol abuse, and risk of suicide and/or self-harm.
71. Whenever a prisoner is transferred to another prison, all of the prison records
should accompany them. In this way, the receiving prison has a full record of
significant information available.
PSO 1025 Prisoner Escort Form (PER)
72. In England and Wales, the majority of prisoner movement to and from prisons
is carried out by private firms specialising in escorting prisoners using secure
vehicles. The Prisoner Escort Record (PER) is a standard form used by the
police, escort companies and the Prison Service. It contains information
which is shared about the risks posed by prisoners moving within the criminal
justice system. The form highlights and assesses the risks posed by
prisoners, and their vulnerability, and is also a record of events during a
prisoner’s movement.
PSO 1301 Handling a Death in Custody
73. All prisons have local contingency plans for dealing with a death in custody.
The purpose of the plans is to guide staff in the immediate actions to take
following the discovery of someone who has died. The plans give additional
information on how to support staff, prisoners and the bereaved family.
PSO 1600 Use of Force
74. The PSO states that force is only to be used when necessary and the
minimum force must be used. Wherever possible, nursing staff should be
present or asked to attend before force is used.
75. Rye Hill officers who use force on prisoners are referred to as the First
Response Team.
PSO 1700 Prison Rule 45 Segregation (Good Order or Discipline)
76. When it is desirable for the maintenance of the good order or discipline of the
prison, or in the interest of the prisoner, that they should not associate with
others the Governor or Director may arrange for the prisoner to be segregated
and removed from association. (Association means a time when prisoners
are allowed to meet each other and watch television together, play games or
simply relax.)
77. As part of the admission procedures to a segregation unit, a segregation
safety algorithm is completed. The document assesses the suitability of
placing a prisoner in the unit depending on health and risk to themselves and
others. It is completed by a segregation officer, and nursing staff, and signed
off by a senior manager.
PSO 2000 Adjudications
78. Discipline procedures are provided for by Prison and Young Offender
Institution Rules which set out all disciplinary offences and punishments. The
rules empower Independent Adjudicators, Governors and Controllers to
19
investigate the charges. Prisoners have the opportunity to hear what the
allegations are and to present their case. The aim is to provide fair and just
treatment for prisoners and victims by ensuring that all adjudications are
conducted in accordance with the principles of natural justice and without
unfair discrimination. Should the allegation be equivalent to a serious criminal
offence, the police may be asked to investigate and consider prosecution.
PSO 2700 Suicide and Self harm Monitoring
79. This sets out the procedures for monitoring prisoners considered to be at risk
of harming themselves. The original procedure, the F2052SH, has been
replaced by the Assessment, Care in Custody and Teamwork document
(ACCT). The document can be opened by any member of staff who is
concerned about a prisoner having thoughts of self harm, or who is suspected
to be vulnerable. The PSO lists the type of monitoring and support that is to
be provided.
80. It is not desirable to place anyone on a F2052SH/ACCT into the segregation
unit. The practice is not banned but is positively discouraged by the Prison
Service.
81. In Rye Hill’s case, suicide and self harm monitoring is referred to as SASH.
SASH reviews are usually held weekly, although more frequently if necessary.
The meeting is multi-disciplinary and designed to obtain a cross-section of
opinion, and should include the prisoner under discussion.
82. The PSO requires that a residential manager or a Duty Director/Governor
audits the quality of entries in a F2052SH/ACCT at least twice weekly. The
local policy at Rye Hill for monitoring open SASH records is that the Duty
Director is required to check the documents on a daily basis
83. In addition to the SASH record, Rye Hill has developed its own document –
the ‘unit special watch record’ – which is intended to record observations at
ten minute intervals.
84. PSO 2700 states: “Routine case reviews are not required when a prisoner is
located in healthcare on a regular scheduled basis in recognition of the fact
that the prisoner will in this circumstance have a nursing care plan. However,
it is good practice to do so when possible, and a nursing care plan must not
be used in place of the F2052SH.” It goes on to say that a case review must
be conducted in healthcare:
(cid:127) When a prisoner harms themselves (unless an alternative review level in
the event of further self harming is specified in the support plan).
(cid:127) Prior to the prisoner’s discharge to normal residential accommodation.
85. The PSO also contains the following mandatory instruction, at paragraph
4.2.6: “When an at risk prisoner is in the HCC [healthcare centre] or under
intermittent supervision or constant observation elsewhere in the
establishment, a doctor or nurse must be consulted before any news known to
be unfavourable to the prisoner is communicated to him or her.”
20
86. Prisoners placed under constant observation should be urgently referred for
mental health assessment. Their case must be reviewed as soon as is
practicable, and certainly within 24 hours. Case reviews must be held at least
three times during the establishment’s core working day.
87. Safer custody officers oversee the suicide and self harm monitoring
procedures on behalf of the Governor or Director.
88. In addition to PSO 2700, Rye Hill and Primecare have their own local policies
for suicide and self harm.
PSO 3050 Continuity of healthcare for prisoners
89. PSO 3050 was implemented in February 2006 and contains guidance to
improve the continuity of healthcare received by prisoners. It gives guidance
on reception, transfer and discharge of prisoners, with a particular focus on
those with ongoing health needs.
PSO 3845 Blood borne and related communicable diseases
90. Chapter two of this PSO outlines the management of risk situations and offers
procedures to minimise risk. Although I do not list every detail of the PSO, I
do identify the more salient sections of the instructions below. The sections I
refer to are sections one, three, five and routine precautions. I make no
suggestion that the man was suffering from any communicable disease; the
assumption is that the prison should comply with the instructions contained
within the PSO.
91. Section One: Risk Management:
(cid:127) Some aspects of Prison Service work may expose staff to communicable
diseases. This part of the order gives instructions on how to keep the risk
of infection to a minimum and details the recommended procedures for
dealing with risk situations.
(cid:127) Under the Management of Health and Safety at Work Regulations,
governors in prison establishments must ensure that assessments are
carried out to determine the level of risk associated with work activities,
and decide if any additional precautions are required. The Control of
Substances Hazardous to Health Regulations 1994, which cover micro-
biological agents, will also apply to these situations. The procedures form
an integral part of the control measures required under both these sets of
regulations.
(cid:127) A description of routine precautions is given in the section ‘Guidelines for
Cleaning up Blood and Body Fluid Spillages’. All incidents involving the
spillage of blood and body fluids (including saliva, vomit and urine) must
be treated with care because of the possible risk from blood-borne
infections including Hepatitis B and C and HIV. Routine precautions are
simple and sensible. They assume that all body fluids from all friends,
relatives, colleagues, clients and prisoners could be infectious.
21
(cid:127) The main operational risk to prison staff occurs if blood from an infected
person comes into contact with an open wound, rash or sore, or if the skin
is punctured by a contaminated needle or other sharp object. This is most
likely to occur during searching, whilst dealing with violent or self harming
prisoners, or in incidents involving major blood and body fluid spillages, for
example suicide attempts or bloody fights.
92. Section Three: Precautions to be employed during a violent incident:
(cid:127) In a violent incident, the main risk of infection is from being hit, spat at,
bitten, struck with a needle or sharp object, or from being drenched with
urine. It is important to remember that, although risk of infection with HIV
from a needle stick injury or a bloody fight may be low, it is not non-
existent. There is a risk of Hepatitis B and C from contact with
contaminated saliva or blood. It is known that Hepatitis B can be
transmitted by urine, but it is not known whether the same is true for
Hepatitis C. Examples of incidents requiring medical advice:
An incident involving a great deal of blood, such as a suicide or suicide
attempt.
93. Section Five: Guidelines for clearing up blood and body fluid spillages (bio-
cleaning):
(cid:127) It is likely that, whilst at work, prison staff will come into contact with blood
and body fluid spillages. It is always important to take sensible
precautions when there is a spillage of this nature, and to treat all such
fluids as if they were infected, whether they are from a colleague, relative,
friend or prisoner. Observing these precautions, known in this document
as ‘routine precautions’, will help safeguard against infections which are
carried in the blood or other body fluids.
94. Routine precautions, procedures to prevent infection from blood borne viruses
that might be present in any spill of blood or other body fluid:
(cid:127) Avoid direct contact with blood and body fluids. When dealing with these
fluids, wear disposable gloves and apron. Use disposable towels and
tissues, and other equipment where appropriate.
(cid:127) Dispose of all waste and contaminated material in yellow plastic bags, to
be collected in accordance with local arrangements.
(cid:127) When dealing with the large amount of blood associated with suicide or
serious self injury by ‘slashing’, more elaborate safety measures must be
taken. Staff dealing with this type of spillage must first seal off the area,
which must be closed to all but essential personnel.
(cid:127) Employing the principles of routine precautions, staff must attempt to avoid
contact with spilt fluids, and wear protective clothing.
(cid:127) A footbath containing bleach solution placed at the threshold of the
contaminated area will help to stop waste matter from being spread
elsewhere on footwear.
(cid:127) Contaminated clothing and other waste must be sealed into yellow plastic
bags and collected for safe disposal.
22
PSO 4400 Incentives and Earned Privileges Scheme (IEP Scheme)
95. All prisons operate an IEP scheme for prisoners to encourage responsible
behaviour, participation in constructive activity and to progress through the
prison system. There are three levels, basic, standard and enhanced. Basic
prisoners are given the minimum regime and facilities, and standard and
enhanced prisoners have higher wages, additional visits, in cell television and
other facilities, depending upon the resources available. Enhanced level
provides the most rewards.
PSO 4630 Immigration and Foreign Nationals
96. PSO 4630 describes the legal status of immigration cases as follows:
(cid:127) An immigration detainee is a person detained under the Immigration Acts.
Foreign National Prisoners may be subject to immigration control whilst on
remand, convicted but unsentenced or serving a custodial sentence. They
are held in what is commonly known as ‘dual detention’, but their status is
the same as that of any other prisoner. This means that a subject is
detained sequentially; first by remand or conviction by the courts and then
upon expiry of their custodial sentence under:
A court recommendation for deportation or
A warrant served by the Immigration Service.
97. Persons recommended for deportation by the court, but who would otherwise
be eligible for immediate release because of time spent on remand, may be
detained on the court’s recommendation only (Schedule 3 to the 1971
Immigration Act) unless the Immigration Service or court directs otherwise.
98. When a prisoner is held beyond their release date and is located in a prison
which does not normally hold unconvicted prisoners, they must be informed
that they will be held with convicted prisoners and their agreement must be
recorded. Annex C is the document used for this purpose.
99. The UK Border Agency (UKBA), formerly IND, is the responsible authority for
immigration matters.
PSO 6000 Early Removal Scheme (ERS)
100. All foreign national prisoners serving a determinate sentence of three months
and over must be considered for eligibility for removal from the UK under the
ERS. Those serving a determinate sentence of four years or more, and who
should be released under the provisions of the Criminal Justice Act 1991,
must also be considered for early release on presumptive parole. They are
eligible to be considered for early release on presumptive parole once they
have served half of the sentence and are automatically released at the two
thirds point. Unlike other prisoners, those subject to deportation and fit the
criteria for ERS cannot opt-out of the presumptive parole process.
23
PSO 9000 Categorisation
101. Categorisation and allocation of prisoners is a critical task. Effectively
assigning prisoners to the correct security category and allocating them to an
appropriate prison helps to ensure that they do not escape, abscond or
threaten the control of establishments. It also means that prisoners are not
held in security conditions which are higher than necessary.
102. Categorisation, recategorisation and allocation are also vital to the sentence
management of prisoners. Combined with balancing security issues and the
needs of the prisoner, this helps prisoners to use their sentences
constructively, to tackle their offending behaviour and to prepare for release.
103. There are four security categories:
(cid:127) Category A prisoners are held in the highest security. Their escape would
be highly dangerous to the public, the police or the security of the state.
(cid:127) Category B prisoners do not require the very highest conditions of security.
(cid:127) Category C prisoners cannot be trusted in open conditions, but are unlikely
to make a determined attempt to escape.
(cid:127) Category D prisoners can reasonably be trusted in open conditions.
Her Majesty’s Chief Inspector of Prisons
104. Her Majesty’s Chief Insector of Prisons for England and Wales runs an
independent inspectorate that reports on conditions for and the treatment of
those in prison, young offender institutions and immigration removal centres.
It promotes the concept of 'healthy prisons' in which staff work effectively to
support prisoners and detainees to reduce reoffending or achieve other
agreed outcomes.
105. The Chief Inspector is appointed from outside the Prison Service. The current
incumbent is Dame Anne Owers.
24
KEY EVENTS
25 April 2002
106. Under the terms of the Police and Criminal Evidence Act, anyone detained in
police custody and considered to be either physically or mentally unwell
should be interviewed and assessed by a doctor in the first instance. The
doctor is required to complete a Forensic Medical Examination (FME) form,
which is given a unique serial number. The form includes their medical
findings and instructions, such as monitoring individuals considered to be at
risk of harming themselves. The doctor assesses the individual’s suitability to
be interviewed and gives or withholds their consent to the interview, and any
charges or transfers. If the person arrested is not assessed as sufficiently
mentally well to be interviewed alone, the doctor can recommend that an
appropriate adult is present.
107. At 3.10am on 25 April 2002, whilst in police custody, the man was interviewed
by a police doctor. The police doctor completed the FME form, serial number
413568, and noted that the man was at risk of self harm and should be in a
cell with closed circuit television coverage (CCTV). Although the copy of the
form given to my investigators is difficult to read, I believe the doctor
recommended a MHT review prior to interview, and presume that this refers to
a mental health team.
108. A further FME form, serial number 413572, was completed by a different
doctor 40 minutes later. The second doctor recorded that the man had no
current medical problems, and was not taking medication. He described the
man as being in a difficult personal situation, and depressed because of it.
The doctor wrote that the man needed to be assessed by a psychiatrist as he
had tried to kill himself on more than one occasion, and had cut his wrists with
a razor blade at court. The doctor assessed the man as coherent and
rational, but wanting to kill himself and having said he had nothing to live for.
The doctor recorded that the man was fit to be detained by the police, and
should be in a cell with CCTV as he was a suicide risk. The doctor also said
that the man was fit to be interviewed with an appropriate adult, but the report
does not explain the details of his difficult personal situation or the
requirement for an appropriate adult to be present. My investigators have
been unable to determine whether an appropriate adult was present or not.
109. Later that day at 7.54pm, a third FME form, serial number 413574, was
completed by the police doctor. The doctor recorded that the man had a clean
wound to the mid to lower palm side of his left forearm, which had had eight
sutures inserted at hospital. (This appears to be referring to the cut made
earlier that day.) The man told the doctor that he did not want to talk about
the wound. There was also an old injury on his right wrist which had scabbed
over. The doctor wrote that the man knew why he had been arrested, and
had been interviewed and was waiting to be charged. The doctor also noted
that the man did not make eye contact, and was uncooperative but alert.
25
HMP Brixton: 26 April 2002 – 6 December 2002
110. On 26 April, the man was taken from the police station to Horseferry Road
Magistrates Court, from where he was remanded into custody at Brixton
prison. When he arrived at the prison, he went through the normal prison
reception procedures.
111. During the First Reception Health Screening interview, the man’s weight was
recorded as 66.8kg and his height as 1m70. The man told the person carrying
out the assessment that he had deliberately cut his wrists in an attempt to
commit suicide. Although there is no record of when or where the incident
took place, it would appear to refer to the injury when the man was in police
custody. The assessor asked the man how he currently felt, and circled the
“yes” option on the reception form in response to the following questions:
(cid:127) Have you ever deliberately harmed yourself?
(cid:127) Have you ever attempted suicide?
In response to the following questions, the assessor has circled the “no”
option:
(cid:127) Do you feel like hurting yourself at the moment?
(cid:127) Are you feeling suicidal?
The assessor noted on the form that the man was excessively withdrawn and
anxious, but there was no indication that he had a history of mental health
treatment. From looking at the prison record, it appears that a F2052SH
document was opened and the man monitored under its procedures.
112. That day the man was seen by the prison doctor. The doctor’s entry in the
medical record notes that the man was drunk and wanted to kill himself but
does not say when this conversation took place. Although the prescription
chart shows that the man was then prescribed Amitriptyline for ‘anxiety and
alcohol’, the doctor’s written record notes that the man only used alcohol
socially. The notes also show that there was evidence of self harm and a cut
wrist.
113. On 13 May, the man was referred to the mental health outreach team because
he was on an open F2052SH document, but he refused to co-operate with
healthcare staff. He was seen and assessed 11 days later by a member of
the outreach team who noted that the man appeared depressive and
uncooperative. The man refused to give any information to the assessor, but
was offered outreach support should he require it.
114. The following month (6 June 2002), the man signed a medical treatment
refusal form which, although it should have been, was not countersigned by a
witness. The man signed to say that he was refusing an appointment,
medication and treatment prescribed by a doctor. He also acknowledged that
the consequences of his actions had been explained to him.
26
115. The man returned to court on 14 June. Whilst there, a medical examination
showed that he had cut his left forearm in two places, but does not note where
he was when the injuries occurred. (I assume that this refers again to the cuts
made at court.) The man returned to Brixton later in the day, and was
admitted to the prison healthcare centre where his injuries were treated.
Antibiotics and anti-depressants were prescribed. Two days later, he signed a
second treatment refusal form. On this occasion it was countersigned, albeit
with an illegible signature.
116. After another court appearance on 21 June, the man was discharged from
court. My investigators have been unable to determine from any records why
the man was discharged.
117. The man’s personal circumstances after his discharge from court are not
known. However, he was rearrested by police in September.
118. On 20 September, the man appeared at West London Magistrates Court on
burglary charges, and was again remanded in custody. As it was a new
period of remand, the man was given a new prison number, and a further First
Reception Health Screen assessment was carried out. The form indicates
that concerns were expressed whilst he was at court, either by police,
probation or another agency, and noted that an F2052SH document had been
opened on 20 September.
119. The mental health section of the form shows that the assessor has circled “no”
to the questions which received an affirmative answer five months previously
when the man first arrived at Brixton.
120. In preparation for the man’s next court appearance, a specialist registrar and a
registered mental health nurse (RMN) from West London Mental Health NHS
Trust wrote a confidential psychiatric report on 26 September. The doctor
wrote that the man had cooperated with the assessment and, as his command
of the English language was good, an interpreter was not required. The man
told the doctor that his mood was “okay”, but that he no longer cared about
anything. He expressed some suicidal ideas and said that, on a daily basis,
he wanted to kill himself because of his personal circumstances. The man
told the doctor he cut his forearm whilst at Horseferry Road Magistrates Court
because he was angry. The doctor noted that during the interview the man
did not express any intention to harm himself or take his life.
121. It was the specialist registrar’s opinion that the man had no history of mental
illness or other psychiatric disorder, and he noted that the man had once
attended a psychiatric hospital when he was assessed as having no mental
illness. The doctor wrote that the man was distressed by his predicament, but
there was no evidence to suggest any mental disorder. He concluded that the
man was fit to stand trial, should not be diverted from the criminal justice
system, and required no further psychiatric assessment or treatment.
122. On 10 October, the open F2052SH document was reviewed and closed. The
man remained at Brixton until 6 December, and there are no records of further
significant events.
27
HMP Wandsworth: 6 December 2002 – 19 December 2003
123. After being taken from Brixton to appear at court, the man was transferred as
a remand prisoner to Wandsworth on 6 December. He appears to have
settled down to prison life, and there are no records of further injuries.
124. Whilst at Wandsworth, the man was visited by police officers. This is not
uncommon for prisoners with outstanding court matters or charges. The man
is not known to have said anything about this at the time, but referred back to
it later in his sentence when appealing against his deportation (he was to
claim that others believed he was a police informer).
125. On 12 June 2003, the man was taken to Middlesex Guildhall Crown Court and
sentenced to seven years imprisonment, after which he returned to
Wandsworth as a convicted prisoner. In September, he was re-categorised
from B to C, and arrangements were made to transfer him to a suitable prison
in line with his categorisation. On 19 December, the man transferred to HMP
The Verne.
HMP The Verne: 19 December 2003 – 4 February 2005
126. Staff at The Verne repeated the standard reception processes. The man told
the reception officer that he had not previously been on an F2052SH.
127. The man appears to have cooperated with the induction process, and signed
the wing compact. The incentive file also shows that the man settled well into
the prison. At the monthly incentive review on 8 January, records show the
man was working regularly in the construction workshop and had been
upgraded to the enhanced level. The next review, later in the month, also
noted that the man was settled. The wing history file shows that, with the
exception of removal of his radio for a week in February as he had been
playing it loudly, the man was settled in his new environment for the first four
months.
128. At approximately 10.50pm on 19 March 2004, the man and another prisoner
had a fight and were injured. The man was bitten on his face and forearm.
He asked to be tested for Hepatitis and other blood borne diseases and was
referred for antiviral therapy and blood tests. The Hepatitis vaccination was
offered on 21 March. The medical record notes that the man refused to
attend. He later changed his mind and started the vaccination course on 23
March. Both men were charged, and the man’s records show he was taken to
the segregation unit pending adjudication. The adjudication record shows that
a Governor opened the hearing the following day and the man pleaded not
guilty to the charge. The Governor adjourned the hearing and referred the
case to the police as a possible assault. The record does not show which
prisoner the Governor considered to be the assailant, although the man
subsequently stated that he had been attacked.
129. The segregation and wing history records do not show whether the man
remained in segregation or returned to his own wing pending the outcome of
the police enquiries. However, it appears that he returned to his wing.
28
130. The man’s medical record for the beginning of April 2004 notes a request by
healthcare for a psychiatric referral because of concerns that he was
depressed. He was described as pale, withdrawn and having lost weight.
The man was not taking food from the hotplate, although he had told officers
that he was eating items purchased from the prison shop.
131. On 20 April, the man was seen by a RMN but refused to allow the nurse to
carry out clinical observations and said he would not come out of his cell until
he was transferred. He was described as difficult to engage in conversation or
with any form of healthcare.
132. The police decided to take no further action regarding the fight in March and
referred it back to the prison to be dealt with under normal disciplinary rules.
On 28 April, the Governor reopened the adjudication and found the man guilty
of fighting. He received a punishment of three days cellular confinement,
suspended for three months. Despite the fight and adjudication, the next
month’s IEP review on 18 May shows that the man was still considered
suitable to remain on the enhanced level.
133. However, the following month’s IEP review on 5 June records that the man
was “going down hill”, and it was suggested that his IEP level be re-assessed.
The suggestion was based on the man’s failure to tell officers when he
returned to the wing by booking in at the office. The next two reviews show
that the man had not come to the attention of staff again, and he appears to
have attended work as normal and associated with other prisoners. The
assessor decided that no change was required to his IEP level. The prison
records describe the man as a recluse who did not leave his cell or have
anything to do with anyone else.
134. The man submitted an application to transfer to HMP The Mount. He had not
received a response to his request one month later and therefore submitted a
complaint form. The response was that his application was being considered.
After a further two months without an answer, he submitted another form. The
man was told that he had been accepted at The Mount and his transfer would
be arranged.
135. Over the next four months the man made several further complaints as he had
not been transferred. In the complaint dated 8 November, he said that
another prisoner he knew had gone to The Mount and so he [the man] no
longer wanted to move there as he did not want to meet the other prisoner.
The man asked instead to go to HMP Guys Marsh.
HMP Guys Marsh: 4 February 2005 – 9 August 2005
136. On arrival at Guys Marsh, the man was interviewed by a member of the
healthcare team. The reception health screen document was completed and
recorded the man’s weight as 85kg. When asked if he had ever harmed
himself or attempted suicide, the man said he had not.
29
137. The following week (11 February 2005), an officer recorded in the man’s wing
history record that he had introduced himself as his personal officer. He wrote
on 26 February that the man attended education classes in the mornings, and
worked in the gardens in the afternoon. The officer considered that the man
had made a good start at the prison.
138. From then until June, the man’s record is extremely positive and there were
no concerns about his behaviour. He remained on the enhanced IEP scheme,
attended work regularly and used the gymnasium at every opportunity. On 10
April, he asked to transfer to a prison nearer to London, as he said he wanted
to be closer to his family and friends.
139. Two months later, on 16 June, another officer recorded in the man’s history
sheet that he was not his usual self and had missed work as he was ill. The
officer referred to a problem in the workshop, but did not explain what it was.
The same day, a different officer recorded that the man had been seen by a
member of healthcare staff who advised that he should rest for the day and
not eat anything. However, the man did not take the advice and did eat a
meal.
140. From then on, and with little in the way of explanation, the man’s behaviour
deteriorated to the point where he was placed on the basic IEP regime
because he refused to go to work. He began to disengage from officers and
would not talk to them, simply responding to their questions with a grunt.
141. On 25 July, another entry in the history sheet noted the man’s request to be
taken to the segregation unit as he said that he did not feel safe on the wing.
The officer noted that the man very rarely left his cell and preferred to sleep,
read or write. The investigators have found no evidence of the nature of the
man’s anxieties, or whether they were ever investigated.
142. The prison segregation unit history record, although not comprehensively
completed, shows that the man was taken to the unit at 8.10pm on 2 August.
The records do not make it clear why he was moved although there is an entry
the following day showing a pending adjudication. The segregation algorithm
has not been completed correctly and does not make clear the initial reason
for segregation. Five days later an entry was made in the records showing
that the man continued to be held in the segregation unit for failing to comply
with the prison regime and not returning to normal accommodation. The
record shows that the man did not communicate with staff, was withdrawn and
did not take all of his meals.
143. As a result of his earlier request to transfer to a prison closer to London, the
man left Guys Marsh to go to HMP Wayland. (Wayland is in Norfolk and is in
fact little closer to London than Guys Marsh.) The length of the journey is
such that he stayed one night at HMP Wormwood Scrubs on the way.
30
HMP Wayland: 10 August 2005 – 15 September 2005
144. When the man arrived at Wayland, he went through the customary reception
procedures. Despite being downgraded at Guys Marsh to the basic IEP level,
the officer recorded that he was an enhanced prisoner.
145. An officer completed part of the reception documents and noted that there
was no evidence that the man had previously been monitored by an
F2052SH. The officer recorded that the information was obtained from prison
records, and assessed the man as low risk and suitable for multi cell location.
146. The man’s wing history sheet records on 16 August that a report was
submitted to the security department saying he had refused to return to his
cell. Later that day an officer reported that, together with a Senior Officer
(SO), he had spoken to the man to try to help him with his problems. The man
was offered a change of cell and access to a computer to assist with his
education studies. He refused the cell move as he wanted a single cell. From
then on, and again without a recorded explanation, the man’s behaviour
deteriorated.
147. By 22 August 2005, the man had completed the induction period and was
required to move to a normal cell on D wing. He refused to leave and was
placed on disciplinary report. The man told staff that he did not smoke, but
when offered a no smoking cell he changed his mind and said that he was a
smoker. Once again staff found him a suitable cell, which he also refused.
There was an adjudication hearing on 24 August. The man was found guilty
of refusing to relocate to D wing. He was punished with five days stoppage of
earnings, suspended for one month.
148. On 26 August, the man again refused to move to D wing and was once more
placed on disciplinary report. The adjudication was heard the following day
and, in addition to activating the previous punishment, the adjudicating
Governor imposed 14 days loss of canteen and association. An IEP review
was held on 29 August when the man was downgraded to a standard regime.
He was also warned that he would be downgraded to basic regime if his
behaviour deteriorated further.
149. At the beginning of September, the man refused a third time to move location
and was again placed on report. He pleaded guilty at the next day’s
adjudication and was punished with 21 days without privileges, including the
loss of the cell television. The man was placed on report again on 5
September after refusing to leave an office on A wing. This time he was
punished with 14 days cellular confinement in the segregation unit, a severe
punishment.
150. The man’s behaviour continued to deteriorate. The segregation unit history
record shows that he began to refuse food but does not explain his reasons.
Officers logged which meals were refused and also informed the healthcare
department. The food refusal log shows that, between 6 and 9 September,
The man refused some but not all of his meals. He was allowed to select his
meal beforehand, and then agreed to eat it.
31
151. An officer talked to the man about transferring to another prison. The entry
made in the wing history sheet notes that the man was willing to move to the
south of England. He asked to transfer to HMP Coldingley so that he could
earn higher wages and send money home to his family in Ukraine. There is
no evidence to show that he had ever previously sent money home. The
officer also noted that the man said that his mother had recently died, but that
he had not been told. The officer added that it appeared to be due to a
breakdown in communication at a previous establishment.
152. In the meantime, the transfer clerk at the prison wrote a note to the man
confirming that his application to transfer to HMP Coldingley had been sent.
The man must have also asked about a transfer to Wandsworth, because in
the note to the man the clerk told him that if he wanted to return to
Wandsworth he should submit a new application.
153. From then on, the man’s behaviour improved, and there were no other
occasions at Wayland when he refused meals or caused problems. He asked
for Open University books to be supplied, although it is not clear whether his
request was ever granted at Wayland. I can confirm, however, that later in his
sentence he was undertaking an Open University mathematics course.
154. During the period the man was at Wayland, he reached the date when he had
served half his sentence, and under PSO 6000 the prison should have started
the parole process under the Early Release Scheme (ERS). My investigators
could find no evidence in the prison records to show that this happened.
155. Although the records do not show a date, it appears that the man was granted
a transfer to Coldingley, but on the day of the transfer he refused to go.
Instead, on 15 September, the man transferred to HMP Highpoint.
HMP Highpoint: 15 September 2005 – 4 January 2006.
156. The man was interviewed in reception. On this occasion the officer said that
there was evidence in the prison records that the man had previously been on
an F2052SH. Additionally, and for the first time, the officer noted that the man
said he was concerned about sharing a cell because sharing with a prisoner
who smoked would affect his health. The officer assessed the man as low
risk, which was confirmed by the healthcare officer who completed the third
section of the form. Section four was completed by another officer, and the
man was allocated to a cell on the induction wing.
157. The man settled in well to the prison routine and positive comments were
made in his wing history record. He left the induction wing without incident,
and was allocated a single cell on B wing. At the IEP review on 9 October
2005, he was re-graded to standard regime. The same day the man was
described in the wing history record as a quiet prisoner, but one who at times
was arrogant.
32
158. The following week, on 16 October, the man rang his cell call bell and an
officer went to see him. He had a cut to his left forearm, but there is no record
of how the injury occurred. The medical record notes that the man was not
very communicative with healthcare staff, and asked to go to the segregation
unit. He accepted healthcare treatment and an F2052SH was opened. The
next day, an officer recorded that the man was being checked five times an
hour. The medical notes for the rest of the month indicate that the man
continued to be uncommunicative and said that he wanted to be transferred to
segregation or another prison. The possibility of a language barrier was
identified on 22 October, but the healthcare manager had a good rapport with
the man and was confident that he could understand English.
159. During the morning of 26 October, a F2052SH review meeting was held. The
man refused to attend. It was agreed that the psychiatric nurse would assess
the man that day and, if no concerns were raised, the F2052SH would be
closed. The medical record for the same day notes that the man was
assessed by a member of the Mental Health In-reach Team (MHIRT), but it
was not possible to assess his mental health as he refused to talk to the
member of staff. He continued to say that he wished to be segregated, and it
was noted in the F2052SH record that he was “controlling the situation” and
“manipulating” the officers. Despite this, the F2052SH document was closed.
160. Two days later (28 October), the man rang his cell bell again. An officer
answered the call and found the man with another cut to his left arm. The
officer reported that the man wanted to go to the segregation unit, and added
that the man said he had spoken to staff about his problems, although no
details of their nature were recorded. A registered mental health nurse (RMN)
attended, and saw a large cut on the man’s left forearm. The man refused to
go to healthcare for treatment, and a second F2052SH was opened. This
required him to be observed at least five times per hour. A nurse saw him
again later in the day, and he was offered more treatment and counselling but
refused both as he still wanted to move to the segregation unit. The clinical
review has found that a thorough assessment of the man’s condition was
documented in the medical notes.
161. A senior officer wrote in the wing history record that, on the instructions of a
senior manager, the man was to be relocated to the segregation unit. My
investigators could find no explanation for moving the man to the segregation
unit other than it is what he asked for.
162. The man was taken to an outside hospital the next day (29 October) so that
the injury to his left arm could be stitched. The Prisoner Escort Record (PER)
indicates that he cooperated with the escort officers and allowed the doctor to
treat his arm.
163. The following day an F2052SH case review was held at which the man
attended. It was recorded that the man was very defensive and accused staff
of working for the police. The man was apparently angry at being asked
questions, and told the meeting that he had been fine at Guys Marsh and now
wanted to go to Coldingley. The review decided that the level of monitoring
was to remain the same.
33
164. A further review was held the following day, 31 October. The man attended
but was described as uncooperative. The man told the meeting that he was
happy to be in the segregation unit and had no thoughts of self harm. The
meeting noted that he was eating well. The F2052SH was to continue, but the
level of observations reduced, and the prison psychology department were to
be told.
165. On 1 November, the man was seen by a member of the prison psychology
team. He engaged in conversation, but apparently with limited eye contact.
The man acknowledged that he had harmed himself to get to the segregation
unit, and wanted a transfer to Coldingley. He told the psychologist that he
was not suicidal, but was prepared to harm himself to get what he wanted.
166. Three days later (4 November), a further case review was held. The meeting
agreed that the man was not displaying any signs of self harm, and decided to
close the F2052SH.
167. Sixteen days later (20 November), for the first time at Highpoint, the man
stopped taking food. On 23 November, as part of the monitoring procedures,
he was seen by the prison doctor. The doctor requested that the man be
assessed by a member of the MHIRT. The following day, the man was seen
by a nurse from MHIRT, but he refused to communicate except to say that he
would not eat or drink unless he was moved from the prison.
168. On 29 November, due to the length of time the man had refused food, a new
F2052SH was opened. A full case review meeting was convened, and was
attended by a range of staff including the head of healthcare. The man was
invited to attend the meeting, but refused. A comprehensive plan was
prepared for the man’s welfare and included the following instructions:
(cid:127) F2052SH to be opened, with five observations per hour
(cid:127) the man to be interviewed by a member of the MHIRT
(cid:127) doctor to see the man daily
(cid:127) healthcare to attempt clinical observations twice daily
(cid:127) segregation unit staff to interact with him
(cid:127) National Operations Unit to be informed
(cid:127) healthcare staff to inform the man of the consequences of his actions
(cid:127) food to be placed in his cell and removed after one hour
(cid:127) care plan by healthcare and supplements to be offered.
169. The man was also seen by an RMN that day who recorded that he “appeared
to be maintaining a high level of control and manipulation in his interactions
34
with staff. This would indicate that there is unlikely to be any psychosis
present at this time. Belligerent, uncooperative with periods of non-
compliance with regimes, appears to be his strategy of achieving whatever is
his goal at the time.”
170. The records show that the man continued to be generally uncooperative with
staff, but on 30 November he agreed to speak to an officer the following day.
The conversation included a reference to IND and the officer agreed to refer
the man’s case to them. The officer also agreed to contact the prison
education department to seek their assistance with the man’s studies.
171. A healthcare plan was drawn up on 1 December 2005 and the man remained
in the segregation unit where he was observed five times per hour. The head
of healthcare issued a notice to staff which clearly outlined the care
requirements for the man and the responsibilities of staff.
172. On 3 December, the man’s weight was recorded as 74 kg. This was more
than when he was first admitted to prison. Between 1 and 9 December, the
food refusal log shows that he was taking some meals. As a result the log
was closed, and F2052SH monitoring stopped.
173. On 11 December, a senior officer recorded that at 4.20pm the man picked up
his Bible and shouted, “time for round two. I will not take any food starting
from next week.” There is no record of what prompted the man to make the
statement, but the following day he said that he would not eat as long as he
was at Highpoint. The following day, due to his refusing food once again, the
food refusal log was reopened. The man was weighed again on 13
December, and his weight had risen to 75kg.
174. Four days later (17 December), the man cut his left wrist in a number of
places and an urgent healthcare response was requested by segregation unit
staff. A member of the healthcare team assessed the man’s wound, but he
would not allow treatment to be administered. A dry dressing was given to
him, but he threw it out of the window. The healthcare staff member advised
the segregation staff that, if at any time the man changed his mind about
receiving treatment, healthcare would attend.
175. Because of concern about the man’s safety, the level of observations was
increased to a constant watch. He continued to be uncooperative and refuse
food. The prison doctor, visited at 11.00am and, following a long discussion,
the man allowed him to dress his wounds. At 2.00pm, the man allowed the
nurse to redress his wounds again, and said that he felt a little better. The
following day, his care plan was re-written to reflect his changing care
requirements.
176. On 21 December, the man received the results of his Open University studies.
He had passed his maths exams.
177. One week later (28 December), the man completed a complaint form saying
he had been held in the segregation unit for ten weeks. He wrote that staff
were not looking after him and threatened not to eat until he was transferred to
35
a prison with 24 hour healthcare. He alleged that, because he was not British,
he was not being treated fairly. My investigators have examined the records
and are satisfied that the complaint and allegation of improper discrimination
were dealt with appropriately in concluding that the man was held in
segregation at his own request for his own safety. It was also explained to
him that he would need to eat before a transfer could take place.
178. The following day, the segregation senior officer and the head of healthcare
became more concerned about the man’s deteriorating health. The head of
healthcare shared her concern with a governor who in turn contacted the duty
governor at HMP Chelmsford and requested a transfer for the man. The head
of healthcare then contacted the head of healthcare at Chelmsford and gave a
verbal handover. The Chelmsford head of healthcare was concerned about
the man’s “manipulative” behaviour. The head of healthcare, at Highpoint
explained that it was his physical health she was worried about, and that it
was no longer appropriate for the man to be in the segregation unit.
179. On 30 December, the man was escorted by the head of healthcare and prison
officers to Chelmsford. It had been arranged with the healthcare manager at
Chelmsford that the man was to be transferred to normal location and
observed by healthcare. However, the initial meeting between the man, the
head of healthcare from Highpoint and the Chelmsford doctor was not a happy
one. The prison doctor subsequently wrote comprehensive notes of the day in
the man’s medical record. He wrote that the man had refused to talk to the
doctor at Chelmsford during the assessment because he felt that the doctor
was being aggressive towards him. The doctor at Chelmsford subsequently
refused to admit the man and he was returned to the segregation unit at
Highpoint. The man submitted a complaint form. A senior officer wrote in
response to the complaint, telling the man that it was being dealt with at
management level. I am unaware of the final outcome.
180. Upon the man’s return to Highpoint, the F2052SH constant observations
resumed. He continued to be uncooperative, although did allow his weight to
be taken. It was recorded at 65kg, 10kg lighter than when the man was last
weighed on 13 December. When staff tried to speak to him, he said only that
he had no problems. He threw his food supplement drink out of the cell on
one occasion, and continued to refuse food and drink. On 31 December, the
medical records noted that he smelt of ketones1, which indicated that his
health was deteriorating significantly.
181. The head of healthcare considered that the man required an inpatient bed and
enquiries were to be made to several prisons with the necessary facilities to
see if they could take the man. In the meantime, the head of healthcare told
1Ketosis is a potentially serious condition in which excessive amounts of chemicals called ketones accumulate in
the body. Ketones are normal products of fat metabolism, but are produced in excess when glucose is not
available for the body to use as an energy source, for example in starvation or poorly controlled diabetes.
Symptoms include sweet, fruity smelling breath, loss of appetite, nausea and abdominal pain. If left untreated the
condition may result in confusion, unconsciousness and death. The treatment is the same as for diabetes unless
it is due to fasting or starvation, in which case a nutritious diet is usually effective.
36
staff that if the man’s condition deteriorated further he was to be admitted to
West Suffolk Hospital.
182. On 1 January 2006, after 21 days of food refusal, the man swallowed a
considerable amount of Eurax cream that had been given to him for a skin
complaint. He later began to bang his head repeatedly on the wall. The
clinical reviewers note that this behaviour differed from his previous deliberate
self injury and was a possible indication that his mental health state was
deteriorating. This was recognised by the prison doctor and the head of
healthcare who arranged a transfer for the man to a prison offering 24 hour
healthcare.
183. The man’s behaviour led to bruising and external bleeding, but he would not
allow healthcare staff to administer treatment. The prison doctor
recommended that he should be monitored in case of internal bleeding or
altered behaviour. The doctor recorded that he had told the man that his
health was deteriorating, and he was at risk of kidney and heart failure as well
as brain damage.
184. The following day, the man asked to see the prison doctor as he was suffering
from abdominal and lower back pain. He told the doctor that he was worried
that it was “very serious and that he might die”. The diagnosis was that the
man had a urine infection. It was treated appropriately.
185. By 3 January 2006, the man had refused food for 23 days and his weight had
fallen to 61kg. In response to the head of healthcare’ request for a suitable
prison for the man to be transferred to, HMP Norwich agreed to take him.
Arrangements were quickly dealt with and the man moved to Norwich the
following day.
HMP Norwich: 4 January 2006 – 23 February 2006
186. When he arrived at Norwich, the man went through the usual reception
procedures and was interviewed in reception by an officer. The interview was
followed by a review of the open F2052SH. As Norwich no longer operated
the F2052SH system, an ACCT form was opened instead. An entry was
made in the history record that the man was eating, and the level of
observation had been reduced from constant to hourly.
187. The officer was concerned about the man being allocated a shared cell as he
had told the officer he would not share with anyone. The officer therefore
considered that the man was not suitable to share a cell. A nurse from the
healthcare team agreed with the assessment.
188. The nurse evaluated the man’s nursing care plan, and his physical
observations and a nutritional assessment were documented. She also took
blood and urine samples for testing. The nurse noted that the man said he did
not want anything to do with Russian or Ukrainian prisoners, although no
reason was recorded. A care plan was prepared. It recognised the man’s
food refusal history, and aimed to improve his appetite and increase his
37
weight. He was to be reviewed and weighed each week, and offered a high
protein diet with food supplements.
189. At some point, the Custody Support Manager at HMP Rye Hill, telephoned
Norwich and asked if they had a prisoner who they could exchange for one
who was causing problems at Rye Hill. He told them that his priority was to
move the prisoner as he had been in the segregation unit at Rye Hill for some
time and needed to be given a fresh start at a new prison.
190. A senior officer at Norwich spoke to the man on 10 January about transferring
to Rye Hill, and recorded that he was happy about the proposal. The senior
officer added that the man appeared fit and well, and was doing fitness
training. He was weighed that day and his weight had risen slightly to 65kg.
191. A week later (17 January 2006), the ACCT document was reviewed and
closed. On 24 January, a safer custody officer carried out a Post Closure
Interview. The officer and the man discussed the ACCT monitoring and the
care plan. The officer noted that the man’s only worry was about completing
an application for a further Open University course before the closing date. In
the event, before the end of the conversation a member of the education
department arrived to help the man complete the forms.
192. Through the normal prison administration procedures it was recognised that
the man was subject to PSO 6000 (Early Removal Scheme) and that parole
procedures had not commenced. The necessary documents were then
completed and assessed by a senior manager at Norwich. The manager
decided that the man was not suitable for parole, as he had not addressed his
offending behaviour. However, the manager concerned had mistakenly
applied the wrong rule. Under the terms of the PSO, he should have granted
the man presumptive parole and arrangements made to deport him back to
Ukraine. The man did not want parole but, under the rules of the PSO, he had
no right to opt out.
193. An officer recorded on 18 February that the man was a quiet individual who
was not causing any problems. Five days later, on 23 February, the custody
support manager and Rye Hill prison custody officers arrived at Norwich to
collect the man and take him to their establishment.
HMP Rye Hill: 23 February 2006 – 10 June 2006
194. During an informal discussion, the custody support manager at Rye Hill,
confirmed to my investigators that Rye Hill had had a difficult prisoner whom
they wished to transfer to another prison, and that he and a manager at
Norwich had agreed to exchange one prisoner for another. The custody
support manager told the investigators that Norwich identified two prisoners to
him who were suitable for Rye Hill, and he agreed to take the man. He said
that he was not aware at the time that the man was subject to deportation. He
added that it did not make any difference, as the man was a serving prisoner
and he wanted to move the other prisoner on.
38
195. The custody support manager told my investigators that the man did not
cause any problems during the journey from Norwich to Rye Hill. After he
arrived, a prison custody officer (PCO) completed the cell sharing risk
assessment (CSRA) form, noting that the man had previously been on an
ACCT and raising concerns about him sharing a cell. The officer assessed
the level of risk as medium and added that, if the man was to be placed in a
double cell, a further risk assessment would be required. The third section of
the form was completed by nurse A who assessed the level of risk as low, and
added that if the man was to share a cell it should be with a non-smoker. The
officer also filled in some of the First Night Risk Assessment document.
Although parts were omitted, it did include the man’s history of harming
himself.
196. Nurse A carried out the reception healthcare screen and recorded that the
man had no physical, mental health, or substance misuse problems, and had
no thought of suicide or self harm. Although it was not long since the man had
begun to eat again, the nurse did not weigh him, refer him to the doctor or
order a special diet. This was despite clear care plans from Highpoint and
Norwich.
197. At interview, nurse A told the investigators that she had been busy on the day
the man arrived at Rye Hill. She said that healthcare was short staffed and
they did not always have time to read clinical notes from other establishments.
198. Contrary to the local reception policy which says that the medical officer will
assess a prisoner’s fitness to work and use the gymnasium, nurse A
completed the assessment. She recorded that the man was fit for heavy work
and the gymnasium and signed the form on the doctor’s behalf. The review
panel also note that there is no evidence in the man’s medical records that the
doctor assessed him.
199. Several of the prison’s ‘buddies’ assist officers with the reception of new
arrivals at Rye Hill. A buddy was in reception when the man arrived. He said
that when they first met, the man talked about joining an education class and
completing his degree in maths. The buddy thought that the man was fine
and looked physically well. The buddy also assists with the induction
procedure, and said that the man completed the two week process without
any problems. He described the man as talkative and said that he was fully
involved with the prison regime. Following reception, the man was located on
Carling Unit.
200. At interview, PCO A told the investigators that she worked on Carling Unit in
February 2006 when the man arrived. She described him as a quiet man who
never had to be reminded to follow an officer’s instruction and who conformed
to the prison routine. She said he was small with a solid build and not
emaciated. PCO A said the man was clean and neat in his ways, and ate and
drank normally. However, she said that at one point in February she was
worried that he was so quiet, and would look people in the face without saying
anything, and did not mix much with other prisoners. She said she spoke to
the unit manager about the man and was told that there were no problems.
39
201. As part of the normal checking of sentence calculation and the identification of
prisoners subject to release on early licence a member of Rye Hill’s custody
team realised that the man’s parole paperwork was incorrect. She believed
that the decision taken at Norwich not to grant the man presumptive parole
was wrong and not in line with the PSO. The custody team member brought
this to the attention of senior manager A at the prison. On 29 March, the
manager reviewed the earlier parole decision made at Norwich and agreed
with the custody team member’s assessment and granted the man
presumptive parole. This meant arrangements could be made to deport him.
My investigators are not sure if the man was told of this decision at the time.
202. The man’s wing history record shows very little information following the first
two months of his arrival at Rye Hill. However, it does confirm that, up until 3
April, the man went to the prison gymnasium regularly, and on occasions
twice daily.
203. On 4 April, the man wrote to Buckingham Palace, the Prime Minister, the
Independent Police Complaints Commission (IPCC) and to HM Chief
Inspector of Prisons. The letters were similar in content. They reflected the
man’s belief that other Russian prisoners suspected him of being a police
informant, and that he did not want to be deported for fear of repercussions
back in Ukraine. At the end of his letter, the man wrote that he did not care
about himself and had not eaten for six days. He added that he did not care if
he lived or died.
204. The man sent the letters using recorded delivery to ensure that their receipt
was signed for. My investigators found that Buckingham Palace and the
Prime Minister’s Office passed on the man’s letter to the Prison Service but
could not determine if the IPCC had done the same. The investigators have
not been able to establish what if anything the Prison Service did with the
letters. Unfortunately, the man’s letter to the Chief Inspector was also not
handled promptly. I understand that the Chief Inspector has subsequently
taken measures to reinforce her policy that all prisoners’ letters are responded
to speedily and appropriately, although she is of course unable to investigate
individual prisoners’ cases.
205. My investigators checked the prison records to see if they could identify
anything to verify that the man was not eating, as he had stated in his letters.
They found no evidence of him refusing food at that stage.
206. On 11 April, the man completed a complaint form about a dental appointment
that he said he had requested during the reception health screen, but which
had not been facilitated. He was told that an appointment had been made for
20 April. The appointment was subsequently cancelled as the dentist was
absent on sick leave.
21 April
207. On 21 April, the man refused to return to his cell after being unlocked to
collect his lunch. An officer who was on the unit at time, PCO B told my
investigators at interview that the man was sitting outside his cell, along with
40
his property, but would not tell staff why. The PCO B described the man as
slim, pale and looking anaemic and ill. Permission was given by the Duty
Director of the day and the Home Office Controller to use reasonable force to
return the man to his cell. A unit manager, unit manager A, ordered the man
into the cell, and explained that force might be used if he did not. The man did
not respond or explain his actions. The unit manager instructed the officers to
use force to return him to his cell.
208. According to PCO B’s incident report, he took the man’s right arm and used
an appropriate control and restraint technique to relocate him in the cell. The
PCO said, “The man did not resist, but his body became limp and he glided
into the cell.” He lay flat on the floor, still without saying anything, and was
checked before the officers locked him in. The PCO said that he did not
remember any evidence of self harm, and the cell looked bare, as the man’s
property was outside. There is no entry in the medical records to show that
nursing staff were asked to attend this planned use of force, as per the
guidance in the PSO.
209. Shortly afterwards, PCO C arrived at the unit to commence his duty. He told
the investigators, during an informal discussion, that the man told him he
wanted to be taken to the segregation unit. The officer told the investigators
that he believed the request had been refused earlier in the day. The man
said to the PCO, “watch what I do then”, but the officer did not know what he
meant.
210. Later that day at 2.29pm, the man pressed his cell call button and PCO C
responded. When he looked through the door observation panel, he saw that
the man had blood on his right sleeve. The man showed his right arm and the
PCO could see two cuts. The PCO called for medical assistance using the
local code 2 procedures, and nurse B came to the cell.
211. In the meantime, PCO C opened an F2052SH (SASH) document. He
recorded in the SASH that the man was annoyed because the education
department would not let him use a computer to complete his course work,
and was apparently depressed about his parole and the thought of being
deported. The investigators have been unable to establish what if anything
was done to help him. (One of the education tutors has since told my
investigators that the man, and other prisoners who needed a computer for
course work, would check if there was space available in one of the
classrooms. If there was space, they were able to go. Because it worked on
an ad hoc basis, the man’s name would not necessarily have been on the
education list and therefore, the officer on education duty might have refused
to let him attend. The education department would not have been aware of
any refusal unless the prisoner told them when they saw someone from
education again. The tutor did not recall the man ever telling her he had had a
problem gaining access when she saw him on the wing. She recalls the man
being an “exceptional” student with whom the tutor said she had a very good
working relationship.)
212. The man refused to allow nurse B to treat him, and she later recorded in the
SASH document healthcare assessment, section (1a): “called to see, has two
41
cuts to right arm, wants off the unit and go to segregation unit, won’t say why.
Refused healthcare treatment. 15.50hrs refusing to talk to any staff.”
213. At section (1b) of the assessment, nurse B instructed that the man should
remain in his cell and be observed six times per hour. She also gave interim
instructions that he should be offered the support of healthcare, the chaplain,
officers and counsellors as requested. The nurse signed the document at
3.45pm, and referred the injury to the doctor to assess him within 24 hours.
Despite the dental appointment, this is the first entry in the medical notes
since the man’s reception at Rye Hill on 23 February.
214. Just over an hour later, at 4.50pm, PCO C noticed a small pool of blood in the
cell when he was speaking to the man. The PCO asked whether he wanted
medical treatment and recorded in the SASH document that the man refused
to be seen in his cell. The medical record shows that healthcare was notified
at the time but it is not clear whether they went to see the man or not. Another
entry was made 40 minutes later by an unidentified member of staff who noted
that the man refused his evening meal.
215. The medical record shows that a nurse telephoned the residential unit at
7.30pm to enquire whether the man would accept treatment and was told that
he would not. It is not clear what, if anything, was done about this.
216. At 9.10pm, another PCO, PCO D who was carrying out the SASH
observations, called a second code 2 for medical assistance for the man. The
prison incident report states that the man’s cell floor was covered in blood.
nurse A came to the cell, and recorded in the medical record at 9.25pm that
the man would not acknowledge her. She interpreted this as meaning that he
refused to allow her to treat him.
22 – 30 April
217. On 22 April at 8.15am, unit manager B recorded in the SASH document that
the man was moved to cell 22 because cell 33 was a health hazard. The Duty
Security Manager (DSM) was asked to arrange for cell 33 to be biologically
cleaned as soon as possible. The prison would have been in night state, but it
is clear that the man had been left in a dirty cell for over 11 hours before being
moved.
218. At what appears to be 9.32am, prison doctor A completed section 2a of the
SASH document opened the previous day. He wrote that it was,
“inappropriate for this man to be seen in healthcare in view of extreme
aggression and non cooperation”, and recommended that the man should
remain on the unit. When interviewed for this investigation, the doctor could
not remember how he had reached the conclusion that the man was
aggressive, and thought that it might have originated in the records. My
investigators found no evidence in any record of the man being aggressive
before this date. The medical record for that day shows that the man refused
to see a counsellor.
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219. For the next two days, the majority of the entries in the SASH document
describe the man as aggressive, and that he refused meals and medical care.
However, one entry shows that the man apologised to an officer for the way
he had spoken the previous day, and on another occasion it was noted that
the man spoke calmly to staff.
220. A SASH review took place on 24 April at 11.00am. The man was asked if he
would like to attend, but did not answer or take part. Healthcare staff did not
attend the review either, but it is not known why. The review meeting decided
that, as the man was withdrawn and had not attended the review, the SASH
document was to remain open.
221. At 8.45pm that evening, another PCO, PCO E, (who was carrying out the
SASH observations) called a code 2 as the man had a cut to his right arm.
This was recorded as due to self harm. Healthcare staff attended, but again
recorded that the man refused to allow treatment to be administered. The
medical records show the time as 8.45am, and note that the injury was
caused either by a cut or by opening an old wound. The prison incident
reporting procedure shows the time as approximately 8.45pm, and I am
satisfied that is correct.
222. Between 24 and 29 April, the SASH document records that the man ate
bread, butter and jam, but did not take meals from the wing food servery. A
further case review was held on 26 April. This noted his food refusal and
recommended ongoing support, including seeing a doctor and a prison buddy.
The man’s food refusal was not entered into the medical records.
223. By 27 April, the man’s behaviour on the wing had improved sufficiently for a
member of staff to write that he was polite and talking to members of staff.
However, the same day he refused to attend the doctor’s appointment. A
second dental appointment, in lieu of the appointment arranged for 21 April,
was cancelled that afternoon as the dental nurse had gone off duty sick.
224. At 8.15pm on 29 April, a member of staff recorded in the SASH record that the
man complained of pain and a swollen arm, and had asked to see healthcare.
A note was made in the SASH record that healthcare staff did not want to go
to the wing, and the man did not feel comfortable about going to healthcare.
The medical record does not contain a record of this exchange, and no
treatment was given despite this being an occasion when the man was
requesting medical attention.
225. An hour later, at 9.20pm, the man showed his arm to the officer who noted
that it was very swollen. He asked the man if he would like painkillers, but he
refused. The officer also noted that the man was smiling and chatting during
the night. However, at 6.30am the next morning (30 April) the officer noticed a
cut to the man’s right arm and blood on the floor. The man told the officer that
he wanted to go to the segregation unit, but was unable to explain why he
wanted to move until he got there. A code 2 was called and responded to by
healthcare staff, but it appears that the man refused treatment. The sequence
of events that followed is unclear, but resulted in him being taken to
healthcare at 8.50am. The SASH documents note that the man was seen
43
picking at the cuts on his arm and had smeared blood across the observation
panel, obscuring the view into the cell. The medical records state that the
man’s hygiene was poor. His right arm had two cuts which were not healing
and contained pus, and his left arm had a deep cut which required stitching by
outside hospital. The nurse who responded to the code 2 gave instructions to
increase the level of observations to every five minutes for one hour, but if the
bleeding stopped to return the level to six per hour. No treatment was given.
226. Whilst in healthcare, another of the residential unit managers, unit manager C,
spoke to the man and noted in the SASH document that he had a number of
issues which concerned him. They were that he was not able to use
computers in education, his mother had died, and parole had been granted so
he believed he would be deported. The man told the unit manager C that he
wanted to make his own decisions, and was aware that no one else could help
him. At the end of the conversation, the man agreed to have a bath, change
his clothes and accept medical treatment. The medical records show that he
allowed a nurse to take medical observations that morning.
227. That afternoon, the man was taken to St Cross Hospital for further treatment.
However, within one hour of leaving the prison, he was taken back as he
would not cooperate with medical staff. The SASH document shows that he
was uncooperative, but does not explain why, or in what way. When he
arrived back at the prison, the man was taken to healthcare briefly.
228. At 6.10pm, the man was taken to a different residential unit, Hastings unit, and
his previous cell was bio-cleaned. His wounds had not been treated by
healthcare or the hospital, and so were presumably still open. The SASH
record notes that he was unhappy about moving units, but a buddy had
spoken to him about it and walked over with him. The man was said to be
afraid that other prisoners would call him names because he had cut himself,
and was on a watch.
3 May
229. The man pressed his cell call button at 12.46am on 3 May. A PCO noticed
blood on the floor, and called for medical assistance. The night manager and
nurse C went to the cell, but the man again refused to allow treatment unless
he was taken to either the segregation unit or healthcare. According to the
clinical notes, there was a large pool of blood on the floor that the nurse
thought had been mixed with water. The man refused to show his wounds to
the nurse. A bandage was seen on the cell floor and removed.
230. The man told staff that he had not felt safe on his previous unit, Carling unit,
but would not answer any questions and so his reason for pressing the cell
bell was unclear. The night manager and nurse found a razor blade and a
pack of razor blades in the cell, and removed them. It is not clear if the man
took the razor blades with him, or if they had been left by a previous occupant.
I am pleased to note that the manager took the appropriate decision to
remove the razor blades from the man.
231. Healthcare was called again at 1.10am as there was more blood on the floor.
Once again, nurse C who attended thought that it had been mixed with water.
44
A tourniquet was noticed on the top of the man’s arm, but there are no records
about any discussion or intervention. (Tourniquets are used to apply pressure
to the veins to prevent bleeding.) The nurse and night manager went into the
cell, but the man refused to allow treatment unless he was moved to
healthcare or segregation as he said that he felt unsafe on the unit. He did
not say why. The nurse remained in the wing office for the next hour whilst
observations of the man continued. The medical records for that morning
show that the nurse made repeated efforts to engage with the man.
232. The chaplain manager, Reverend A, at Rye Hill provides counselling, pastoral
and spiritual care to prisoners and staff. As well as working at Rye Hill, he
also works at an Immigration Centre. At interview, the Reverend A said that,
due to his immigration experience, an officer asked him to speak to the man
which he agreed to do. The SASH record shows he visited the man at
10.11am, remaining with him for approximately 20 minutes. Reverend A
described the man as an intelligent and smart man, but unstable. For
example, the man constantly changed his mind about what he wanted,
particularly in relation to the deportation process. Reverend A felt that the
man agreed to see him because he too is a foreign national. Reverend A said
he started to build up a rapport with the man, sufficient to enable him to
discuss accepting medical treatment. Additionally, he offered assistance in
completing the man’s deportation appeal documents.
233. At interview, Reverend A described how, when he arrived at the cell, he saw
the floor and the man’s duvet covered in blood. He explained to the man that
he would need to accept medical treatment in order that his wounds would not
become infected. The man agreed to this, providing that he could be seen in
healthcare, but did not want a uniformed member of staff to take him. It was
agreed that Reverend A would take the man to healthcare.
234. A case review took place at 11.30am, chaired by senior manager B at the
prison. It was well attended by a cross-section of prison staff and a prison
buddy, but not by the man who had refused. The summary of the review
shows an agreed support plan and monitoring arrangements were put in
place.
235. The SASH document records that the man was taken to healthcare at
12.45pm, and seen by nurse D at 12.50pm. He allowed her to look at the
wounds on his arm, and she noticed that he was pale. The nurse took a blood
test and sent it to a local hospital for urgent analysis.
236. The next entries in the SASH record are at 1.48pm, when the man was
waiting in healthcare, at 1.54pm when he was waiting to see a second prison
doctor, Dr B, and ten minutes later when he returned to the residential unit.
Entries in the medical record show that the man refused to speak to the doctor
and left the room to return to his unit. Apparently, he also refused to speak to
the counsellor.
237. When the man returned to his cell, it was being bio-cleaned and an officer
asked the DSM to locate him in healthcare, although the records do not show
why. However the request was refused. (It is unclear whether it was the DSM
45
or healthcare that refused this move.) At 2.18pm, PCO B, who was carrying
out the SASH observations, wrote in the SASH document that the man was
“ghostly white” in colour, and he had told him to put his feet above his head to
improve the circulation of his blood. The medical records state that the unit
telephoned healthcare at 2.30pm, saying that the man had removed the
dressings from his wounds and would not allow anyone to replace them.
None of the records shows what action was taken.
238. At 3.00pm, nurse D received a telephone call from the laboratory with the
results of the man’s blood tests. They showed that his haemoglobin levels
were 5.7 which is low. However, the written report showed that the level was
even lower at 5 (the normal range is between 13 and 17). The nurse said that
the information was passed to the prison doctor B, who instructed her to
arrange for the man to go to outside hospital for a blood transfusion. The
clinical review states that the man would have felt extremely weak and tired as
a consequence of low haemoglobin levels.
239. Arrangements were made for the man to go for the blood transfusion that
afternoon, but he refused. A Registered Mental Nurse (RMN), RMN A, went
to see the man, but was unsuccessful in engaging him in conversation. The
importance of having a blood transfusion was explained, but the man
continued to refuse to go. The clinical review panel thinks it is likely that the
man would have been so ill that he would have felt unable to undertake the
journey without adequate support. It is not clear from the medical notes what
arrangements were in place for transferring the man to hospital, and whether
these had been explained in order for him to feel comfortable and able to
attend hospital.
4 – 8 May
240. On 4 May, the man had a third dental appointment he refused to attend.
However, there was reported to be some improvement to the man’s attitude,
as he talked more to staff than he had done previously.
241. Prison doctor A visited the man in his cell at 12.00pm, but the man did not
respond. He also refused to allow his dressings to be changed by the nurse.
In interview, doctor A said that he was made aware of the blood results from
the previous day. He said he interpreted the results in the light of his
knowledge of the man. He knew that the man was cutting himself, and that he
was bleeding as a consequence. The doctor recommended that a psychiatric
assessment should be arranged. In interview he explained that he was
referring to a psychiatric nursing assessment which was dependent on the
availability of a suitably qualified nurse. He said in interview, “I would certainly
get a nursing assessment as a precursor to getting a psychiatric assessment,
because our psychiatrist comes once a week”.
242. Prison doctor A also said that the man’s medical records contained no
evidence that he was mentally ill, and he could not be treated without giving
consent. He added that the man could be treated under common law, in his
best interests, if he collapsed. He also said that the man, “wasn’t going to
accept treatment, wasn’t going to hospital for a transfusion”, and as a result
thought that “there was nothing to do”. The doctor said it was quite clear to
46
him that the man did have capacity to refuse treatment. He went on to say
that he agreed a psychiatric assessment should have been done as a matter
of course, but “was completely confident that the assessment would have said
there was no mental illness”.
243. Later, the man was given hot water but refused to accept his midday and
evening meals. He asked to see the chaplain and a message was left on the
chaplain’s telephone. Another member of the chaplaincy team, the prison
Imam, dealt with the message and went to see him at 6.00pm.
244. The next day (5 May), the man was called to healthcare to see the doctor or
nurse, but he refused to attend and healthcare staff did not go to see him on
the unit. The clinical records do not say why he was asked to attend
healthcare.
245. Between 4 and 7 May, it appears that the man refused some meals, but there
is conflicting information in the SASH record and communication room log.
During routine checks of the wings, the Duty Director recorded in the SASH
document that the man refused some meals, and added that it was unclear
whether this was a protest.
246. Healthcare staff went to the unit to see the man on 7 May, but he refused to
allow the nurse to treat him. The nurse gave him a dressing and a saline
solution, and advised him how to clean and dress the wounds himself.
9 May
247. As the man was subject to deportation at the end of his sentence, form Annex
C was issued to him by a member of the prison custody section. The prison
file shows that the form was not returned to the custody section, and the
records state that the man refused to acknowledge the form. (The SASH
document does not refer to the form being issued.)
248. The clinical review shows that the man had a doctor’s appointment scheduled
at some point during 9 May, but did not attend. There is no explanation of
why he did not attend in the medical records. However, an entry in the SASH
record at 3.45pm written by PCO F records that the man wanted to see
healthcare. The officer contacted healthcare and medical staff asked for the
man to be taken there. PCO F told them that the man said he was unable to
go to healthcare and asked medical staff to see him on the residential unit.
The officer noted in the SASH record that healthcare refused to do this. The
man’s clinical record notes that healthcare staff did not go to unit because of
his complex medical history, and he was not seen at all.
249. Because the SASH documents do not record the time that Annex C was
issued to the man, it is difficult to establish whether his request to see
healthcare was a direct result of the form being given to him. Equally, it is not
known whether healthcare staff were told that Annex C had been issued.
47
10 May
250. The prison’s Safer Custody Officer (SCO), went to see the man in the morning
as part of the preparations for the SASH review. In interview she said that, as
part of her role, she visited the man most days to see if he wanted anything.
She noted that, as on previous occasions, the man did not reply when she
spoke to him, refused to have his wounds dressed and would not attend the
review.
251. The SASH review took place at 10.00am and considered 11 prisoners on
open SASH documents, including the man. The meeting was attended by the
Deputy Director, the SCO, the chaplain, a member of healthcare and prison
staff. They were aware of the man’s worries about being deported, and the
Deputy Director asked the custody department, to put the man in touch with
immigration advisory organisations and check that he had legal
representation. The man was described by those at the meeting as being, “in
a very bad way, his reluctance to get his wounds cleared up could make him
very ill even though he is not self harming seriously”. It was recognised that
his reluctance to have his wounds treated could make the man very ill, even
though his injuries were individually not serious. The review agreed that he
should continue to be observed six times an hour, and should be required to
respond at least three times per hour.
11 – 17 May
252. Nurse D contacted the residential unit to ask for the man to be taken to
healthcare for treatment, but he refused to attend. The medical records note
that the man had refused meals, but was eating bread and butter. The nurse
asked the staff on the unit to try to observe the man’s intake of fluids.
253. The man remained in his cell all day on 12 May, either asleep or watching
television. At 11.30am, he acknowledged PCO G who was carrying out
security checks, and agreed to have some lunch. At 12.20am, another officer,
PCO H, recorded that the man accepted the meal and was very polite. At
6.40pm, another PCO, PCO I, also noted an improvement, and the man asked
for his dinner.
254. The prison custody department received the ‘Notice of Decision to Deport and
Appeal’, issued by IND, which should have been passed to the man. The
notice was not handed to him until several days later.
255. The entries in the SASH record for 13 and 14 May are poor or missing and,
with the exception of that made by PCO I at 5.00pm, give little information
about the man’s condition. PCO I wrote that the man was improving, eating
and speaking to some staff. The officer wrote that she thought the man
needed to develop the confidence to come out of his cell.
256. On 15 May, healthcare contacted the unit to offer the man treatment for his
wounds, but he again refused. The clinical notes do not show whether any
follow up action was made. The same day, the deportation papers received
on 12 May were sent to the unit. There is no record to show that the man was
issued with the documents until 17 May when unit manager D issued them
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and the man refused to sign them. This event was not recorded in either the
SASH or medical records.
257. A SASH review took place at 10.35am on 17 May, and again the man did not
attend. The meeting heard that the man was eating and speaking to staff, but
no reference was made to the deportation forms. My investigators found no
evidence that healthcare was informed that the man had been issued with the
deportation papers as per the instructions contained in PSO 2700. Although
the receipt of the deportation papers was a potential trigger for self harm, as
staff at the meeting were unaware of them they reduced the level of
observations to twice per hour.
258. The SASH document shows that the man spent the majority of the day
watching television in his cell. However, in the evening he went to the prison
shop to collect goods that he had ordered previously. Unfortunately, the order
was incorrect. It is not known how he reacted to the error, or what was done
to correct it.
18 May
259. At 3.00am on 18 May, the man cut himself in his cell, and a code 2 was called
and healthcare staff attended. It was recorded that the man responded to
them, but refused to allow the injury to be treated, saying that he wished to be
left alone. There was a large pool of blood on the floor and the level of
observations was increased to six times per hour.
260. Later that morning, at 8.50am, a second code 2 message was issued as the
man had harmed himself again. The SCO, prison doctor and the DSM went to
the cell and found the man collapsed on his bed and a large pool of blood on
the floor. The SCO said that the man refused to allow anyone into the cell,
was abusive and refused all medical intervention. She described him as weak
and looking unwell. He did not have a t-shirt on and she saw that he looked
thin and underweight, and had a cut above the top of the waist of his trousers.
There were more cuts on his arms, and she judged from the mark on the floor
that he had lost a lot of blood. The doctor estimated the blood loss at
approximately one pint.
261. The man later allowed observations of his pulse, blood pressure and breathing
to be taken, and doctor A noted that he responded to stimulation but refused
to allow any intervention. My investigators are aware that an ambulance was
called, but it is not known why it was deemed necessary. At interview, doctor
A could not recall whether he had requested the ambulance. In interview, he
said that he asked the man to accept help saying “… no man deserves to die
like this”. He added that he was sure that the man knew he was going to die.
262. The SCO remained with the man until the ambulance arrived at 9.15am. She
said he was virtually unconscious before he allowed anyone to touch him and
the paramedics could move him on to the stretcher. She said that the man
then seemed to gather some strength, and began to use abusive language
and fight, as the paramedics lifted him into the ambulance. The clinical review
panel’s view is that, on this occasion, the man might have been treated
without consent.
49
263. Prison staff took the man to hospital at 9.35am. He was sedated and
preparations were made for him to have a blood transfusion. Two litres of
blood were administered by 11.05am after which he was taken to an
observation ward. The escort officers informed the communications room that
the man would remain in hospital overnight. At 2.30pm, an escort officer
recorded that the man had stopped complying with the treatment and pulled a
drip out. A hospital consultant tried to speak to the man, but he refused to
communicate. The man asked to see a counsellor and a mental health nurse
came to his bedside. The escort officer wrote in the log, “refused to speak in
the presence of officers”, and there is no indication that a private conversation
was offered. Arrangements were made for the man to return to Rye Hill, and
he arrived back in healthcare at 3.40pm where he remained overnight.
19 May
264. On 19 May, prison doctor A made an entry in the medical record that he had
attempted to assess the man who had refused. It is not documented in the
clinical notes how the man communicated his refusal and whether he was
capable of making an informed decision. The entry goes on to say that he
[the man] was “clearly not mentally ill, no medical intervention indicated at
present, nor any accepted by the patient. No need to be in healthcare,
suggest he returns to Unit.”
265. The clinical review panel are concerned that, despite being unable to assess
the man, prison doctor A concluded that there was no need for him to be in
healthcare. This is of particular concern to the clinical review panel as the
man’s haemoglobin level was still low having been recorded as 5.3 the
previous day. Additionally, the blood transfusion had not been completed.
266. At approximately 9.20am, DSM A, and the unit manager D went to the
healthcare centre to discuss moving the man back to the unit as suggested by
the prison doctor. The man told them that he was being bullied on the unit,
and so they left to discuss the matter with someone from the senior
management team. Ten minutes later, the man harmed himself again. Nurse
D saw him in his cell, but he would not let her treat him.
267. The SASH document shows that, at approximately 10.40am, the man went to
the sink and collapsed onto the floor. Before healthcare staff were able to
return, he managed to climb back onto the bed. When nurse D arrived she
went into the cell and managed to take his observations. She noted that he
was pale, his pulse was slightly fast and his blood pressure was dangerously
low.
268. Nurse D told prison doctor A and noted in the medical record “Nil ordered”,
meaning that the doctor did not give any instructions for medical intervention
or treatment. In interview, prison doctor A was asked about the entry in the
medical record. He said that, “The man was determined to die … He was
going to go on refusing medication or any medical intervention or any help of
any sort … And when he had the opportunity he would cut again and he would
die.” Prison doctor A described the man as stable and not mentally ill. He
said that it would be possible to administer treatment against the will of a
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patient with such low blood pressure, depending on their state of collapse. He
went on to say that there was nothing that anybody could do as the man had
“made up his mind”. An ambulance was not called on this occasion. Nurse D
said at interview that this was because the man was refusing treatment, but
there is no treatment refusal form.
269. The SCO spoke to healthcare staff and was aware that, if the man carried on
losing blood, he could go into organ failure and die at any time. She spoke to
the Deputy Director who decided to call an extraordinary SASH review. That
day, the Deputy Director held two SASH reviews to look at the man’s situation,
neither of which were attended by the man.
270. The first meeting, at 1.00pm, primarily discussed the man’s medical condition
and noted that he had lost a large amount of blood through repeated self
harm. Prison doctor A said that it was possible that the man could die in
custody, especially if he developed organ failure. The minutes of the meeting
note that no further medical intervention was deemed necessary. The
meeting also noted the man’s feelings about deportation, and decided to
inform the relevant authorities of his situation. The level of SASH
observations was increased to constant, and staff were required to obtain a
response from him every ten minutes. If no response was obtained,
healthcare was to be informed.
271. The second SASH review, at 3.00pm, produced a detailed action plan. The
first action was to inform the Coroner’s office. This was a precaution so that
the Coroner was aware that there was a potential death at the prison. The
head of healthcare, told the meeting that there was no requirement to inform
the Coroner, and that the man should be treated as any other patient. Despite
not having met the man, the head of healthcare told the meeting that there
was no evidence that he had a current mental health diagnosis. Nevertheless,
the Deputy Director requested an urgent psychiatric assessment.
272. At interview, the head of healthcare confirmed that it was the prison that
insisted on the psychiatric assessment, rather than healthcare. However, the
clinical review notes that the medical records show an entry made by the head
of healthcare some 30 minutes before the first review meeting, in which she
wrote that she had attempted to contact the psychiatrist. It is not clear why, if
medical staff had decided there were no mental health issues and it was the
prison that insisted on a psychiatric assessment, the head of healthcare
appears to have tried to contact the psychiatrist.
273. The remaining action points from the second meeting were to contact IND,
produce a chronology of events and contacts regarding the deportation, and
produce a log of the man’s self harm history. I am satisfied that the Deputy
Director gave clear instructions as to what he wanted doing and what was
expected.
274. Although the prison buddy could not recall the actual date, he told the
investigators that he first became aware of the man harming himself about
three to four weeks after the man arrived at Rye Hill. He had seen him
occasionally beforehand as the man went about the prison. However, on 19
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May, the buddy was asked to see the man on the residential unit. He said he
was shocked when he saw the change in the man, describing his appearance
as looking like a “zombie”, and that he was depressed, unshaven and had lost
a lot of weight. The buddy said the man had cut himself “quite badly”. He
stayed with him for about 45 minutes, during which time the man refused to
accept any dressing for his wounds and would not explain why he had harmed
himself. The man told the reception buddy that he did not want to eat and
wanted to die quickly by cutting himself or by hanging. He said he was
disappointed to still be alive despite cutting himself. The reception buddy said
the man’s problems were that he was unable to find his wife and child, and he
was afraid that the Russian Mafia would kill him.
275. The reception buddy said he told the man that he would need to be fit and well
if he was to appeal against deportation, and managed to get his agreement to
go to outside hospital for a blood transfusion. At 5.08pm, healthcare staff
were informed and prison doctor A arranged for the man to be admitted to an
external hospital. The prison dealt with the arrangements quickly and staff
were ready to take him at 6.10pm, but the man then declined, saying that he
wanted to go the next day.
276. Contained within the documents obtained by the investigators was an undated
memorandum written to the Deputy Director by the custody support manager
(CSM), a senior manager at Rye Hill. The CSM told the Deputy Director that
he had spoken to the man, together with the buddy. The CSM said the man
told him he tried to take his own life, believing he would go to sleep and not
wake up. He added that the man was concerned that, if he were deported to
his home, he would be killed. The CSM also said that the man was concerned
that, if he moved to London, members of the Russian Mafia would have him
killed.
20 – 22 May
277. The SASH document for 20 May notes that the man ate and drank, was polite
and did not present any control problems. Prison doctor A saw the man, and
wrote in the medical record that he was asleep and had refused to have
medical observations. It is not clear when the man refused to have any
observations carried out. The doctor added that, in his view, there was no
need for the man to be in healthcare. The DSM was informed that the man
was fit to return to the residential unit, despite the man’s dangerously low
blood pressure which had been recorded the previous day.
278. The Duty Director of the day, senior manager B, saw the man and asked that
he should remain in healthcare over the weekend. The medical record states
that the Duty Director was concerned to avoid “antagonising him by returning
him to the unit [residential]”, where he might self harm and there would not be
“enough staff to take him out”. The investigators believe this to be a reference
to taking the man to an outside hospital.
279. At 2.20pm, the man allowed a nurse to take nursing observations. He also
asked to see a Roman Catholic priest, and a message was left on the
chaplaincy answerphone.
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280. Just over five hours later at 7.50pm, PCO J who was carrying out SASH
observations noted that the man appeared unsteady on his feet and looked
“ghostly pale and tired”. There is no record of the action taken. The Duty
Director, senior manager B, saw the man at 9.00pm, and made no mention of
the man’s appearance, the Duty Director noted that, when he spoke to the
man, he said he was okay.
281. At 9.30pm, PCO K, now carrying out the SASH observations, noted that the
man said that he felt very cold and shivery, and had a “funny tummy”. The
officer asked a nurse to see him, but the man refused to speak to healthcare.
The medical records do not show any mention of this.
282. The SASH entries for the remainder of the night show that the man was
restless. However, the following morning (21 May) prison doctor A again
recorded that the man was stable and there was no reason for him to remain
in healthcare.
283. On 22 May, the prison’s management team began a two day meeting away
from the prison, and at midday a senior manager, based at HMP Wolds
arrived at Rye Hill to cover for the Director. The senior manager from the
Wolds, had worked at Rye Hill previously and had some knowledge of its staff
and routines. He told the investigators that, prior to taking over, he was
briefed by Duty Director, senior manager C, and the Director who told him
about the man’s situation. The Director told the Wolds senior manager that
the man was on a constant watch and, in the event of him being taken to
outside hospital, documents were available which outlined his history over the
previous months.
284. During the day, the head of healthcare provided the Deputy Director with the
self-harm summary requested at the case review on 19 May. She wrote that
there was no evidence, either anecdotal or assessed, of the man having any
mental health history. Her summary said that since 2002 the man had a
history of saying that he wanted to kill himself, and often said he felt suicidal
every day. The head of healthcare observed that the man chose cutting
himself and food refusal as his methods of self harm, and often appeared to
use them to obtain what he wanted such as transfers or moves in the prison.
She noted that, once he obtained something, he would “change his goal
posts” and had been described as “manipulative and always wanting to be in
control”. The summary ends by saying that the man did not engage with
healthcare but was improving physically and was fit for normal location.
285. In interview, the head of healthcare said that, in the course of preparing the
summary, she noted that the man had refused treatment on 40 occasions,
both at Rye Hill and at previous prisons, which had caused difficulties for
nursing staff.
286. At 5.10pm, the man was transferred from healthcare to Hastings unit. The
records do not give any indication why he was returned to the unit.
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Another PCO, PCO L, who was one of the escorting officers, recorded in the
SASH document that “The man has stated that he will be taken out to hospital
today or will die”. The investigators could find no information in the records to
show what was done in response to the man’s words.
287. PCO M came on duty at 8.45pm, and took over the SASH observations. In
interview, he said that officers watched for an hour at a time, and he remained
until just before 10.00pm. He was briefed by the previous officer, and recalled
that the man was quiet when he came on duty and was lying on the bottom
bunk watching television.
288. At approximately 10.00pm, PCO M handed over the SASH observations duty
to PCO N. Soon after taking over the observations, PCO N asked for medical
assistance as the man was picking at his wounds. PCO O was on duty that
evening, and attended with the Registered General Nurse (RGN), nurse E.
Nurse E wrote in the medical record, “asked if the man was ok or wanted any
help, there was no response”. The nurse added, “was unable to see the
wounds”. It is unclear from the clinical notes whether or not nurse E entered
the cell to assess the injuries but he was aware of the man’s self harm history.
289. PCO O took over the SASH observations from 11.00pm until almost midnight,
and at other times during the night. He said that the man was agitated and
paced about the cell. He smoked a lot and asked for a light a couple of times.
There was no more conversation between them, and the man would not talk
about what was bothering him. PCO O said that the man spat quite regularly
at the door and floor.
23 May
290. At 1.00am, a code 2 was called by PCO M who had returned to the SASH
observation duty and seen the man picking his wounds. A number of prison
and healthcare staff responded to the call. PCO M and nurse E stood at the
door trying to get a response, but did not unlock the door. PCO M told my
investigator that he could see blood on the mattress and floor during the night,
but did not remember when he first noticed it. He moved away from the door
so that others could speak. He did not hear the man say very much, in
particular whether he was willing to be treated.
291. Nurse E recorded in the SASH log, “Called to see code 2. Blood on bed.
Unable to see arm. Refusing to speak to me. Asked if I could just look at his
arm, would not respond. Just sitting watching TV. Blood on bed, does not
look to be a large amount.” At interview, Nurse E clarified that his
observations were not based on a physical examination of the man as he did
not ask the night manager to unlock the cell. He said the man looked up from
the television and told him to “go away, I don’t want to see you”. Nurse E did
not think it was necessary to go into the cell, and instead looked through the
observation glass and spoke through the gap in the door (the quarter inch gap
between the door and the doorframe).
292. PCO O also responded to the code 2 call, and described a puddle of what he
thought was watered down blood on the floor. In interview he said that it
appeared to have been thinned, did not smell and was not clotting. He was
54
present whilst nurse E talked to the man, but did not remember what was said
and did not think that the night manager had been asked to open the cell.
293. The night manager, night manager A, that night also went to the man’s cell.
She had been told that the man had opened an old wound and there was
blood all over the sheets. In interview, she said that they could not see what
the man had done to himself as he was sitting with his back to the door,
watching television and playing with his arm. She said that nurse E offered
treatment, and that the man either refused to reply, grunted or swore, and this
was taken to mean that he refused the offer. Because the man was being
constantly observed by staff, the night manager said that she was not unduly
concerned and knew that someone would be watching him all the time. She
described him as awake, fine and watching television, and so not in danger.
294. A second code 2 was called an hour later at 2.00am by PCO Q, as the man
had again harmed himself. Several staff responded to the call, including PCO
M, PCO O, PCO Q, nurse E and night manager A. The communication log
records that permission to enter the cell was requested 20 minutes later at
2.20am, and the senior manager from HMP Wolds (who was still acting as
Duty Director) was informed by telephone. It is of concern that there was a 20
minute delay before staff entered the cell, especially as this was the second
code 2 in an hour.
295. It is worth noting that the cell the man was in at that time measures
approximately 3.76 metres x 2.14 metres, although it tapers in length at one
point to 3.14 metres to accommodate sanitary pipes. On the right hand side
as you enter the cell are two single beds in a bunk bed arrangement. Each
bed measures approximately 2 metres x 0.87 metres. The lower bed is raised
off the ground, and both beds are attached to the cell wall. As well as the
beds, there is a toilet, sink, wardrobe and desk. Four staff (PCO O, PCO M,
PCO Q and nurse E) went into the cell. At interview, all the staff gave slightly
different accounts of what they had seen.
296. Nurse E said he saw the man standing at the sink and then moving back to
the bed, a distance of about three steps. He noticed that more blood was
present than before, and described it as a pool approximately three foot by
one foot across, which he estimated as between 300 and 400 millilitres. He
spoke to the man and knocked on the door for about eight to ten minutes,
discussing with night manager A the possibility that he might have a weapon.
The man made no reply and so nurse E decided that he needed to go into the
cell. The night manager unlocked the door, and nurse E went in. The PCO O
said he had a cursory look round the cell as they went in, and there was no
time or need to search the cell, as they were focused on the man.
297. Nurse E stood nearest to the man, with the three officers behind him and
another officer and the night manager outside the cell. Night manager A said
at interview that she saw blood on the bedding and fresh blood on the floor,
which she described as the size of a tea plate. She said the man had tied
some socks around his arm like a tourniquet. Because the night manager was
the key holder, she said that she tried not to become involved with managing
the situation.
55
298. PCO M told the investigators that he remembered the man lying on his back
on the floor and saw a substantial amount of blood. He said the staff lifted the
man on to the bed, which he did not resist. PCO M said that the man was
quiet, very pale and did not appear to be conscious. He also said that he
could see a substantial amount of blood coming from his forearm, but could
not recall which one. (His account differs from those of the other three staff
present who said that they found the man on the bed rather than the floor.)
299. PCO Q said that the man was lying on his bed, and did not respond when they
arrived. He said the man’s eyes were closed but he could see that he was
breathing. The officer said it was the first time he had met the man, whom he
described as thin and gaunt. He said he did not notice any sign of blood in the
cell.
300. At interview, nurse E said the man was lying on his stomach, with his right arm
hanging over the side of the bed. They turned him on to his back so that
medical checks could be carried out. He was unable to say whether the man
was semi-conscious, but he did not speak when the nurse told him what he
was going to do. He described the man as stiff, but that he did not resist
being turned over. Nurse E pulled up the sleeve of the man’s t-shirt which
was blood stained. He started to carry out medical observations, including
taking his blood pressure and lifting his eye lids to check his pupils. (night
manager A said that nurse E also removed the socks tied round the man’s
arm.) The checks were satisfactory and nurse E decided that there was no
need to admit the man to healthcare or outside hospital.
301. Whilst nurse E was considering what action was needed, the man punched
him on the left arm, shouting to him to go away and leave him alone. PCO M
described the man lying still, without responding and then suddenly lashing
out, swinging one of his arms in the direction of nurse E who said he was
shocked and left the cell straightaway. Night manager A described nurse E as
angry about being hit. She said that the RGN had not had a chance to dress
the wound.
302. The three officers restrained the man and he did not resist. As the man was
not causing any further problems, the officers left the cell and PCO O locked
the door. PCO O said that he did not notice any blood as he was pre-
occupied with dealing with the situation.
303. Night manager A said in interview that she did not consider moving the man
out of the blood stained cell because his mood was volatile and she was
concerned for the safety of the staff. She confirmed the cell was not
searched.
304. Nurse E looked back into the cell through the observation panel and saw that
the man was sitting up in bed and grinning at him. At interview, he confirmed
that no treatment was administered and there was no discussion about
moving the man.
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305. The senior manager from HMP Wolds told my investigator that he was
telephoned at approximately 2.15am on 23 May. He was told that the man
had superficially harmed himself and, although his arms had been bleeding,
this had since stopped. The information he received was that the man was
threatening and staff felt that it would be unsafe to go in. Staff told him that
they expected the man to resist, so he clarified that there was no medical
intervention needed insofar as the man had stopped bleeding. The senior
manager added that, as the man was on constant observations, unless his
circumstances changed during the night there was no need to enter the cell
and “force the issue”, and any matters would be dealt with in the morning.
The senior manager said he was not contacted a second time and he
assumed that nothing had changed, nor was he asked for permission to enter
the cell and was unaware that a member of staff had been assaulted. (Upon
receiving his interview transcript, the senior manager told my investigators that
he had been mistaken and had received more than one telephone call that
night, although not all related to the man.)
306. The prison buddy became aware of the man’s self harm attempts and went to
see him at about 8.30am. He told my investigators that he looked through the
observation panel and saw blood in the cell. He described the blood as mixed
with water. It was all round the floor, on the bedding and down the side of the
bed.
307. The officer on SASH observations opened the door to check the man and the
buddy took the opportunity to ask the man what he had done. The buddy said
that he got no reply and the man kept turning over to face the wall. He said
that the staff tried to enter to clean the cell, but the man refused to let them in.
308. At 9.00am, as is customary at Rye Hill on weekday mornings, all the prison’s
managers met to discuss the events of the previous 24 hours and make any
necessary operational decisions. The meeting on 23 May was chaired by the
Wolds senior manager in the absence of the usual management team. About
12 staff were present, however the senior manager could not remember their
names. This is because he was temporarily covering duties at Rye Hill and
did not know the names of all the staff. The senior manager briefed them on
his knowledge of the events concerning the man and said that medical
intervention had not been required. Although he had not seen for himself the
condition of the cell or the man, he told the meeting that there was a small
amount of blood on the floor which required cleaning that morning. He was
assured that it would be dealt with although, because he did not know the staff
names, he did not know who gave the assurance.
309. From examining documents, my investigators were able to determine the
names of Oscar 1 and the DSM on duty that morning. At interview the DSM,
DSM B, told my investigators that she would not have attended the morning
meeting, but Oscar 1 would have. DSM B could not remember any
information regarding the man being handed over to her that morning. As
mentioned earlier in my report, Oscar 1 was the staff member who had been
suspended and has been unavailable for interview.
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310. The senior manager from the Wolds said the meeting lasted about ten
minutes, after which he continued with his other duties. He spent the
remainder of the morning in the segregation unit, leaving it at approximately
1.30pm. He then began to go round the other wings and, as part of the Duty
Director responsibilities, began to check the SASH documents. About half
way through the checks, and before arriving at Hastings unit, he received an
urgent telephone call on a matter unrelated to the man. This occupied the rest
of the day and meant that the remaining SASH documents, including the
man’s, were not checked.
311. The SASH document shows that the man did not accept any meals on 23 May
and remained in his cell. The officers were required to obtain a response from
him every ten minutes. PCO B took over from PCO R at 12.52pm, and
continued the observations until 3.10pm. PCO R told him what was required,
and also that blood had been on the floor since 3.00am that morning. (I am
satisfied from other records that blood had actually been there since at least
1.00am.)
312. At interview, PCO B described the man‘s complexion as very pale and almost
anaemic. His forearms were badly marked with recent scars. PCO B had
been told about the incidents during the night and saw the blood on the cell
floor. He said that the cell smelt, adding that the blood went from the door to
the window and across the width of the cell. As well as the floor, he said it
was “dripping off the mattress.” (The man had no quilt, only a sheet because
the quilt was being laundered and had not been replaced.) PCO B added that
some of the blood had dried, and it was difficult to find a place to step that did
not have blood. Because PCO B had had to walk on the blood stained floor to
check the man, he asked for a replacement pair of shoes. He was told by a
manager to have his shoes bio cleaned instead.
313. PCO B said that the man would occasionally grunt when he checked him, but
did not say very much at all. The PCO said he asked a unit officer about the
quilt and was told that it would be returned when it was dry. PCO B said other
prisoners in the unit were concerned about the man’s welfare. He voiced his
own concerns about the condition of the cell to PCO S, one of the unit’s staff.
He said PCO S was also concerned and had apparently made two or three
telephone calls to the DSM, who he believed to have been DSM A. PCO S
confirmed to the investigators during an informal discussion that the cell floor
was covered in congealed blood.
314. PCO B handed over to PCO T at approximately 3.20pm, and took over again
at 4.30pm. The man was still lying on his bed, and was watching the
television.
315. DSM A was on the late shift from 1.00pm to 9.00pm. At some stage during
the afternoon, she went to Hastings unit and saw the man’s cell. At interview,
DSM A said that she looked inside the man’s cell and saw a large amount of
what she thought was dried blood on the floor. She said she had not taken
any action to deal with it. She could not explain why no action had been taken
other than to say no code 2 alarms were called during her shift.
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316. Another unit manager, unit manger E, also came on duty at about 1.30pm and
carried the radio with call sign Oscar 1. He had received a handover from a
manager, whose name he could not recall, but which he said did not include
anything about the man.
317. The Wolds senior manager said he was not consulted about the man again,
and at about 5.30pm he prepared to leave the prison. He gave a handwritten
note identifying the units he had visited to the oncoming senior manager,
senior manager D. Senior manager D had returned from the manager’s
residential meeting, and took over as Duty Director. On the handover note,
there is a cross next to Hastings unit to indicate that it had not at that time
been visited by the Duty Director. The Wolds senior manager said he told
senior manager D about the man’s self harm during the night, and also about
the blood on the cell floor which he believed had been dealt with.
318. At 5.45pm, PCO A volunteered to give PCO B a break from the constant
watch. She told the investigators that she had first met the man when he
arrived at Rye Hill in February 2006. PCO A had been on sick leave from 28
March to 22 May and not seen the man again until she took over the watch on
23 May.
319. At interview, PCO A gave a graphic account of her recollection of the events
that evening. She said PCO B asked her if she was squeamish about blood,
and when she looked into the cell she was shocked by what she saw. PCO A
said she did not recognise the man at first and was shocked by the change in
his condition, describing him as looking worn out. PCO A said the cell door
was locked. When she looked in, the floor from the window to the door was
covered in blood, with a thick pool in the middle. PCO A said the bed had a
bare foam mattress which was also covered in blood. The man was lying on
the bed covered by a black and white striped plastic mattress cover.
320. PCO A told the investigators that she went into the cell and the man said that
he would not speak to her. She told him that she would continue to enter the
cell and would touch him on the shoulder to get a response, regardless of
whether he spoke to her or not.
321. She told the investigators that other prisoners began complaining to her about
the man’s condition. She described the atmosphere on the unit as tense. The
prisoners wanted the situation to be dealt with, and were looking in the cell
whenever she went in. They complained that officers were walking in the
blood in the cell and then back onto the landing, which was unhygienic. They
were also unhappy that the cell was alongside the meal servery area.
322. There is a Roman Catholic (RC) chaplain who works on a part time basis at
Rye Hill. He had had previous discussions with the man, who had asked to be
confirmed. However, when the man realised that the RC chaplain was not an
ordained priest, he decided not to speak to him. Despite this, the RC chaplain
said he told the man he would assist him with his deportation papers.
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323. On the evening of 23 May, the RC chaplain went to speak to the man about
the deportation issue. When he arrived at the cell, PCO A told him that it was
in an awful state and he should be prepared for a shock. He went inside the
cell and the floor from the wall to the door was covered in dried blood. He was
concerned that bacteria might be present. He described one small clean
patch, where he was able to stand to speak to the man. The RC chaplain
added that the man had no bed linen, and was covered by a plastic mattress
cover. This prevented him from seeing the condition of the man’s body.
324. The RC chaplain said the man did not speak to him and so he left and asked
PCO A how long the blood had been on the floor. She told him that,
according to the records, it had been there since 2.00am that morning. He
said that both he and PCO A were very distressed about the state the man
was in, as were some of the prisoners. The RC chaplain went to the unit
office and telephoned the control room to ask the Duty Director, senior
manager D, to contact him. The RC chaplain said that during the next hour he
spoke to senior manager D three times about the situation, and was told that
he would send a manager to assess it. The RC chaplain said he asked senior
manager D if he had been to see the cell for himself and senior manager D
told him that he had not.
325. At interview, senior manager D confirmed he was telephoned by the RC
chaplain. He described his manner as “agitated and concerned”. He said he
told him that he would find out the details and take the appropriate action.
After one of the calls from the RC chaplain, senior manager D contacted the
Oscar 1 that day, unit manager E, to ask him to go and check the man’s cell.
He said he expected Oscar 1 to go into the cell and try to speak to the man.
Senior manager D said that he did not go himself as he thought that he could
trust the managers to give him the information and, having come on duty from
an external meeting, he was not wearing his prison uniform.
326. Oscar 1 (unit manager E) said he first became aware of the man harming
himself when he and DSM A were called to senior manager D’s office at about
6.00pm and told about the telephone calls from the RC chaplain. Oscar 1 said
senior manager D asked them to look at the cell and report back to him.
327. In the meantime, the RC chaplain went to healthcare to inform the staff of the
man’s situation, but nobody was present when he arrived. He asked the
control room to locate a nurse, and when a nurse telephoned him he repeated
the information about the man. The RC chaplain was told that the man had
already been offered all the help they could give and had assaulted a nurse
the previous night. The medical records do not show any reference to the
conversation having taken place.
328. Due to the unrelated matter that the Wolds senior manager had been dealing
with earlier in the day, senior manager D said he called all the managers to his
office. At the end of the meeting, he asked Oscar 1 (unit manager E) about
the man’s cell and was told that he had not yet been to see it. The senior
manager D said Oscar 1 assured him that he would go to Hastings unit
straight after the meeting. It appears that this was about 7.30pm.
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329. At interview, Oscar 1 said both he and DSM A went to the cell. He said the
RC chaplain and PCO A were also present and he had to begin by calming
them down as they were angry at the situation. Other prisoners were about
and told them that the man should be removed and the cell cleaned. (In
response to the advance disclosure of my draft report, DSM A said that the
man would not leave his cell during association because he felt he was being
bullied. My investigators have found no evidence to show that the man was
being bullied, or that the prison investigated the allegation.)
330. Oscar 1 said he opened the cell door and saw the man lying on the bed,
wrapped in his quilt. He spoke to the man who did not reply or acknowledge
that he was in the cell. Oscar 1 said the cell was empty and there was not a
lot of property in it. He described a puddle of blood on the floor, about the size
of an A4 piece of paper, and also on the quilt. When the investigators asked if
he was certain about the amount of blood, he reconsidered his answer. It
appears to the investigators that he was unsure whether he was referring to
the man’s cell, or another cell. It is also unclear whether the man had been
given his quilt back at that stage. I make no criticism as Oscar 1 was not
interviewed until 16 February 2007, and clearly the memory fades. He had
asked prison management for a copy of his original statement, made soon
after 23 May, but it had not been supplied to him. He did remember seeing a
small amount of blood on the man’s quilt.
331. The investigators asked Oscar 1 if he considered searching the cell and the
man to find what he had used to cut himself. Oscar 1 said he had not
searched the cell, but with hindsight felt that he should have. He left the unit,
and went to the senior manager D’s office to brief him about the blood. He
said the cell required bio cleaning. Oscar 1 also reported to second senior
manager D the threat from prisoners on the unit about the way the man was
being treated.
332. Senior manager D said Oscar 1 telephoned him and reported a substantial
amount of blood in the cell, which he did not think looked fresh. Senior
manager D asked Oscar 1 if he had seen any wounds, and was told that the
man was completely covered by the quilt. There is no evidence to confirm
when the quilt was returned. Oscar 1 also told him that the man was awake
but refusing to speak. Oscar 1 said that the cell was not a suitable place for
the man to stay. He was told that another prisoner had complained about the
cell, and had threatened that prisoners would refuse to return to their cells that
night. Oscar 1 said that PCO A was “in cahoots” with prisoners and also
thought it was outrageous that the man was in those conditions.
333. Senior manager D said he did not take seriously the threat of prisoners
refusing to lock up that evening and therefore did not identify the threat as a
potential incident requiring intervention. He told the investigators he had
considered two options. One was to move the man to the segregation unit,
but he had decided that was inappropriate. The alternative and more
favourable option was to move him to healthcare. He said DSM A thought
that the man would refuse to move whilst other prisoners were around. Senior
manager D did not want to use force to move him and considered bio-cleaning
the cell whilst he was still in it. This was rejected as the prisoners trained in
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bio-cleaning, who would carry out the task, said it was unsafe to use the
chemicals in the man’s presence.
334. Senior manager D telephoned the prison Director to seek advice regarding the
man’s location. They agreed that the man should be left where he was until
the other prisoners were locked away 20 minutes later, and should then be
moved to healthcare. DSM A was asked to deal with the move and
arrangements were made for bio-cleaning to start the following day.
335. Nurse F was telephoned by senior manager D and understood that the man
was being transferred to healthcare to allow the cell to be bio-cleaned. Her
understanding was that the man would only be there that evening or
overnight, and was not being moved because of any healthcare needs.
336. Senior manager D spoke to the RC chaplain later, and told him what was
arranged for the man. The RC chaplain returned to the unit at about 8.35pm,
together with another member of the chaplaincy whom he had asked to
witness the situation.
337. The RC chaplain told the investigators that they arrived just as the man left his
cell. They were concerned that he had to walk from the unit to healthcare.
The RC chaplain described the man as weak and vulnerable, and he believed
that a wheelchair should have been provided. PCO A told him later that the
man had had to walk, which the RC chaplain felt was cruel.
338. PCO A and DSM A moved the man to healthcare. The PCO described him as
swaying and unsteady on his feet. She said he lacked the energy to walk and
she started to help him. Because his clothing was covered in blood, she put
protective gloves on and placed her arm under his. She pulled him towards
her to support him. She said that DSM A told her that she should not touch
the man. PCO A said that she felt his body pulling her, but it had no weight.
My investigators asked DSM A if she considered providing a wheelchair and
she said that she had not. She said that PCO A helped the man to walk and
she opened the gates between the unit and healthcare.
339. PCO A said that, when they arrived into healthcare, the bed was not ready.
She said the man was about to fall, and she supported him while the bed was
cleared after which he collapsed on to it. PCO A added that the nurse asked
to look at his wounds, but the man refused saying he wanted to be left alone.
The man allowed PCO A to remove his jumper, but again said he wanted to
be left alone. In her interview, DSM A said that a nurse was present and
asked to see the man’s wounds. He grumbled, and this was taken to mean
that he refused treatment.
340. Nurse F was the day nurse on duty when the man was taken to healthcare
and due to leave the prison after handing over to nurse E. She described the
man as pale, but able to stand unsupported, and she did not think the situation
was serious. She explained the consequences of treatment and thought he
understood the implications.
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341. Nurse E said the man was placed in the cell and then the staff went into the
nursing office. He said that healthcare would not accept responsibility for the
man as he was not admitted as a patient. He went on to say that nurse F told
PCO A to wait until an officer was available to monitor the man. He said that
the PCO became angry as she was anxious to go off duty as her shift had
already ended. Nurse E said he and DSM A tried to calm the situation
between PCO A and nurse F.
342. At interview, PCO A said she was angry with the nurses, and acknowledged
that she felt one of them had treated her badly when she herself had been
taken ill at the prison earlier in the year. She said she felt healthcare was
treating the man “worse than an animal”, adding that one of the nurses said he
would not look after the man as he had been assaulted by him that morning.
343. DSM A told the investigators that she reported the argument between nurse F
and PCO A in writing to senior manager D, at his request. However, she did
not submit a similar report about the man’s condition because she said it had
not been asked for. DSM A explained that incident reports were prepared
after a prisoner self harmed and not in other circumstances. I question why it
was seen relevant to submit a report to senior manager D about an argument
and not take similar action relating to the disturbing events that day. The
records show that the man remained in healthcare overnight with observations
carried out by prison custody officers rather than by nursing staff.
344. Nurse E was present when the man arrived into healthcare. He said the man
was still wearing the same clothes as when he had examined him at 2.00am
that morning. My investigators asked whether a care plan was put in place for
the man. Nurse E said that, as the man was admitted at the request of the
prison management, he was not considered to be a patient but a prisoner. He
said that this meant that a care plan was unnecessary and the man was the
prison’s responsibility.
345. My investigators asked the head of healthcare about a care plan and she
confirmed what nurse E had said. She explained that when prison
management placed a prisoner in healthcare he was not regarded as a
patient. Healthcare would take no responsibility and this in turn meant that the
prison would supply an officer to look after the prisoner. The head of
healthcare said healthcare would only treat a prisoner as a patient if medical
staff arranged the admission. In that event, healthcare staff would look after
him.
346. During my investigation a senior member of GSL, made my investigators
aware of two letters of complaint that had been written to the Chief Inspector
of Prisons, by PCO A. The Inspectorate is not an investigatory body, and the
Chief Inspector had referred the letters to the GSL head office for them to deal
with. The company commissioned an internal investigation into the issues
raised by PCO A.
347. The first letter raised her concerns about the man’s treatment on 23 May. The
second was a personal complaint about her own treatment by the healthcare
department when she had taken ill at the prison earlier in the year. Although
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my terms of reference do not extend to the PCO’s personal complaint, I
mention it to give a fuller picture of events at the time.
24 May
348. During the morning, the RC chaplain went to see the man but found him
asleep. At the same time, the Deputy Director convened an extra multi-
disciplinary case review at 11.30am. This was well attended by a cross-
section of staff and a counsellor. However, no medical staff were present
although it is not clear whether they chose not to attend or were not notified of
the meeting.
349. At the meeting, senior manager D told the Deputy Director that the man had
been left in the blood-stained cell all the previous day. The minute of the
previous meeting noted the seriousness of the man’s condition, in particular
prison doctor A’s comment that he could die in prison. It was the view of the
meeting that no treatment could be given unless the man became
unconscious, and the Deputy Director added that he was to remain in
healthcare for the foreseeable future. He said that, because the man was
weak, even if he refused to allow treatment it was preferable for him to be in
healthcare.
350. Reverend A reported his conversation with the man, and said he had
considered using an interpreter but one was not needed as the man’s
understanding of English was good. He added that if the man thought a
speaker was getting too close to him, he would start to say that he did not
understand. Reverend A said that the man’s main issues were that he did not
want to be on a residential unit and did not want to be deported. The man had
told him he wanted attention because he felt neglected, and had said he did
not want to kill himself.
351. The meeting considered the man’s deportation status, and recommended that
IND be advised of his situation so that the deportation process could be
speeded up. It was also decided that Reverend A should make sure that the
man knew about the deportation appeal process.
352. The record of the meeting shows that consideration was given to the activities
available to the man. It was suggested that access to the library and
education would be beneficial. A range of caseworkers rather than one
individual would keep contact with him, and it was thought that his interest in
football could be a topic of conversation. Reverend A said a member of the
chaplaincy team would visit each day. Given the seriousness of the situation,
and the man’s refusal of treatment, the prison notified the Prison Service’s
National Operations Unit and the GSL press office.
353. As agreed at the meeting, the Safer Custody Officer (SCO) returned to see
the man at 2.50pm, and offered reading material. He told her to go away.
She described him as unpredictable and wanting to control situations, saying
on some days he would tell her to go away and other days would allow her to
stay.
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354. Reverend A returned to see the man, and asked about his grounds for
appealing against his deportation order. The man said he wanted to apply for
asylum because of his mother’s death, but the Reverend advised that it was
not a sufficient reason. Reverend A wrote that the man should not be
deported because he had no family to return to in Ukraine. The man then said
that he did not want his mother brought into the case, and so Reverend A
deleted what he had written. He said the man then accused him of being an
undercover immigration official, and so he left.
355. At 3.10pm, the SCO noted in the SASH document that the man had signed his
appeal papers. An hour later, the Duty Director visited the man and recorded
in the SASH document that the man had not eaten or spoken during the day.
Despite the events of the previous day, this was the first occasion that a
senior manager had visited the man since 9.30am on 22 May, some 30 hours
previously.
356. At 5.00pm, the man ate a packed lunch and drank a cup of tea. He then
accepted a second lunch, but refused another drink. At 8.40pm, PCO M
recorded in the SASH document that the man was quiet and settled. Just
after 10.30pm, the man asked the PCO O, who had taken over the watch, for
a cup of hot water. He said at interview he told the man that he could not
have the hot water as drinks were only provided at lock up, and not on request
throughout the night. The PCO O noted in the SASH document that the man
drank several cups of cold water and ate the second packed lunch.
25 May – 31 May
357. On 25 May a probation officer based at Rye Hill, visited the man and tried
unsuccessfully to talk to him about football as suggested at the SASH review.
The man asked for books to read, which the probation officer provided the
following day. Also on 26 May, the probation officer told Reverend A that the
man had asked to see him again. However, I understand that when the
Reverend arrived, the man swore at him. It is noted in the SASH document
that the man refused his canteen on 26 May, but it is unclear whether this
meant he refused to make an order or refused to accept what had been
ordered previously.
358. The next day (27 May), the man refused all meals and drinks during the day.
The medical records state that he had demanded a toothbrush and
toothpaste, and his manner to staff was very rude.
359. PCO M was again responsible for the SASH observations, and at interview
said he remembered the man asking for hot water for a drink at 9.22pm. He
said the request was again refused as prisoners are expected to collect flasks
of hot water before they are locked up for the night, and hot water is not
provided after the prison has gone into night state. He recalled that prisoners
in healthcare cells were not provided with flasks, and understood that no
special privileges should be given to them.
360. Over the next two days, the man appeared to settle down. He began to eat
properly, and made no more attempts to harm himself. As a result, on 29 May
the SASH observations were reduced to six observations per hour.
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361. On 30 May, the probation officer returned to see the man, and noted that he
still appeared hostile and did not want to talk. The probation officer thought
that the man was suspicious of him and other staff, and was ‘fickle’ in what he
said. He said he did not think that the man appeared to be genuinely troubled,
and said he did not welcome offers of assistance.
362. The following day, a case review was held at 11.30am. It was chaired by the
Duty Director, senior manager B, and was well attended by a wide cross-
section of staff. The Duty Director, told the meeting the man was not invited
because he would not engage in conversation and refused to speak to
anyone. He said he had tried to talk to him about his own visit to Ukraine, but
had been unsuccessful.
363. The Duty Director, senior manager B, reminded those present of the man’s
history and the actions agreed at the review the previous week. Reverend A
and the probation officer reported their contact, and the meeting discussed
whether the man was trying to “manipulate” his situation regarding his
location.
364. The head of healthcare reported that the man had made no more attempts to
harm himself since he moved to healthcare, and did not appear to have
mental health problems. The psychiatric assessment had not yet taken place
nor had the head of healthcare assessed him. She told the meeting that he
was eating well and getting plenty of sleep, and was in no danger of collapse.
She said that the man kept making new demands and continued to refuse
treatment. She said that no treatment could be forced upon him.
365. The head of healthcare recommended that the best course of action was for
the man to rest, eat and exercise. She told the meeting there was no need for
the SASH document to remain open as the man was not at risk of self
harming whilst he was in healthcare. The head of healthcare added that he
could return to normal location. Contradictorily, she told the meeting that, if
the man were to remain in healthcare, he should continue to be monitored
under the SASH procedures.
366. The meeting considered whether a regime such as that in the segregation unit
would be appropriate for the man. The reason for doing this was so that he
and staff were aware of his entitlements and to “ensure that he was not
treating healthcare as a hotel”. There is no evidence to show that he was in
fact placed on a regime akin to one in the segregation unit.
367. The Duty Director confirmed that the man would remain in healthcare for the
foreseeable future, and that the level of monitoring should be reduced to three
times per hour.
1 – 8 June
368. During the first week of June 2006, the prison records show that the man
appeared to have settled down. He placed an order for goods from the prison
shop, including a newspaper. He had a hair cut and obtained clean clothing.
In addition to cleaning himself up, he also cleaned his cell. Although he
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accepted most meals, there were occasions when he refused them,
particularly on 2 June, when it was noted in the medical record that he felt sick
if he ate and sick if he did not.
369. At a SASH review on 7 June, the meeting commented that the man had had a
settled week, and noted that he had not self harmed since 23 May. The level
of observations was three times per hour and it was decided that they should
continue at this level and that the man should remain in healthcare.
9 – 10 June
370. The man slept well during the night of 8 June, and gave no cause for concern.
However, the following morning he again began picking at his wounds and
refused medical treatment. The SCO saw him during the day when she went
to check his SASH book. She described him as weak, thin and very
underweight, with dark rings round his eyes. He was able to move around the
cell, but she said he was staggering about. Later in the morning, the man
refused to complete the form for ordering goods from the canteen.
371. At 1.30pm, PCO U saw blood on the man’s quilt and went into the cell. She
noted in the special watch log that the man told her that he was okay, and did
not reply when asked if he wanted his wounds dressing.
372. The head of healthcare said in interview that she spoke to the man for the first
time on 9 June. She spent some time with him trying to draw him out and
engage him in conversation. She described the man as a small, pale,
bearded man who was neither verbally aggressive nor physically threatening.
Her memory was that he was wearing a short sleeved top, and the only wound
she could remember seeing was on the t-shirt of his arm. She said she was
unaware of the death of the man’s mother, despite having been at the SASH
review meeting on 31 May when Reverend A brought it to their attention. The
head of healthcare added that the man asked to see a priest and said he was
being bullied by other prisoners. She did not believe that the man was
clinically depressed. (The investigators have found no evidence that the man
was being bullied or that any action was taken regarding his allegations.)
373. One hour later, PCO U made a second request for healthcare to see the man
as he had increased his wound picking. The head of healthcare spoke to him
again but he said that he did not want to see healthcare but wanted a
smoker’s pack. Neither the head of healthcare nor PCO U were authorised to
issue a smoker’s pack, which is the responsibility of an operational manager.
The head of healthcare said the man had money in his account and would
have been able to buy his own cigarettes. The request was referred to the
DSM, DSM A.
374. Twenty minutes later, the head of healthcare was called to the man’s cell
again. She noted in the medical record that there was a pool of blood on the
floor, and that she asked him to allow her to treat his arm but he would not
speak to her. Because the man had lost more blood, the head of healthcare
increased the level of observations to constant watch, and informed the DSM
and prison doctor A of the change. (In interview, senior manager B said that
he was the Duty Director who authorised the return to constant observations.)
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375. Some time afterwards, because there was blood on the floor which had to be
cleaned, DSM A authorised a move from cell 1 (where the man was located)
to the adjacent cell, number 2. She described the pool of liquid, which was
thought by staff to be blood mixed with urine, as about two feet round and the
size of an A3 piece of paper. DSM A said she arranged a first response team
in case force was required to move the man to the clean cell. In the event,
force was not needed and the man, wrapped in a sheet and wearing boxer
shorts, walked independently into cell 2 where he lay on the bed. At interview,
DSM A described the man as very weak, not speaking and holding onto the
wall and door to avoid stumbling. Despite his weakness, he was not assisted
to move into the second cell.
376. The medical record shows that two more attempts were made to treat the
man’s injuries. On one occasion he told the staff to go away and he did not
reply at all on the other. He was given prison tracksuit trousers at 3.55pm. At
4.53pm and 5.14pm he asked for a t-shirt and jumper, but there is no record
whether they were provided.
377. The SASH document notes that, at about 5.20pm, the man was picking at his
arms and blood came out “like a tap”. Ten minutes later, he vomited and was
noticed to be breathing heavily. The man lifted his head and spat on the floor,
and did not reply when the nurse asked how he was. Five minutes later, the
head of healthcare and nurse F again attempted to check the man’s injuries.
He said no to them and, because he raised his voice and appeared to be
annoyed, they left the cell.
378. An entry in the SASH document shows that at 6.47pm the man was laying on
his side and trying to vomit again. At 7.55pm, he asked for water which was
given to him.
379. At about 8.00pm, DSM A was telephoned and told that the man had re-
opened his wounds. On this occasion she did not request a first response
team. Instead, both she and the Oscar 1, unit manager F, that night, went to
the cell together. The head of healthcare was also present. DSM A said that
the man was coherent and able to understand what she said to him.
380. As cell 2 now had blood in it and cell 1 had been cleaned, the man was moved
back to cell 1. As before, the man was not helped to move and used the wall
and door frame to support himself.
381. My investigators asked Oscar 1 whether the man was searched before
returning to cell 1, or if the cell had been searched before the man went into it.
He was unable to confirm what actions were taken, and said that the cell
would have been empty.
382. Between 7.55pm and 8.50pm, the head of healthcare made three entries in
the medical record. DSM A said the man ignored what the head of healthcare
told him. DSM A left the cell and continued her duties until the end of her shift
when she handed over to the night manager, night manager A.
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383. The head of healthcare told the man that he needed a blood transfusion as he
was damaging his organs which she said would eventually fail. She did not
tell him that organ failure would lead to his death. She told my investigators
he said he understood what she was saying. She asked whether he would
allow his wounds to be dressed and have a blood transfusion. His voice rose
and he became irritable if she asked more than two or three times so she did
not pursue the matter further.
384. At about 8.50pm, the rosters manager, collected a radio and took over the
observations from PCO V. She said at interview that she had carried out
lower level SASH observations when she was an officer, but had not done any
constant observations previously. She was told that staff would be rotated
throughout the night, and she should carry out observations for the first couple
of hours.
385. Before the rosters manager got to the cell, she was told that she would be
required to observe the man six times per hour. When she arrived at the cell,
she received a handover from the PCO V who told her that the level of
observations had been increased to constant and that the man had been
refusing treatment. The PCO V explained that constant observations meant
standing outside the cell door, with the observation panel open, so that she
could see in. At interview, the rosters manager said she remained standing,
except when she sat on the chair by the door in order to write the records.
She said the cell was clean and there was no evidence of any blood.
386. While the rosters manager stood at the cell door, the head of healthcare
arrived and spoke to her and the man. The head of healthcare said that the
man did not have enough blood inside him and so his organs would fail. At
interview, the head of healthcare said she tried to discover from the man why
he had been harming himself, and explained the damage that he was doing to
his body. She told the man that he was an intelligent man and asked why he
would not let her help him. The rosters manager said the man acknowledged
what was said, and indicated that he was in pain but refused to allow any
treatment.
387. The rosters manager told my investigators that the man asked the head of
healthcare for a doctor because he felt sick. My investigators asked the head
of healthcare about this and she said she told him that his sickness was due
to blood loss. She told him that she could call the doctor, but said that what
he needed was a blood transfusion. She asked if he would go to hospital for a
transfusion, and he again said no, pulled the sheet over his head and ignored
her. She told the investigators she did not think that he was going to die, but
that the man would have refused any interventions from a doctor or
paramedics.
388. The last entry the head of healthcare made in the medical record noted that
the man had said he felt sick and she had told him he needed to go out for a
blood transfusion. She did not record the man’s request for a doctor and did
not facilitate it. Shortly afterwards, nurse E arrived for duty. After handing
over to him, the head of healthcare left the prison for the night.
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389. The rosters manager told the investigators that approximately 40 minutes later
she tried to talk to the man. He asked her for water and complained of pain.
The rosters manager went on to say that she asked nurse E to get the water,
as she was not allowed to stop the observations. Nurse E returned with the
water and saw the man lying on the floor. Rather than calling the night
manager to enter the cell, the water was placed on the cell door hatch. In
order to get it, the man had to get up from the floor and walk to collect it. The
rosters manager said took it took him a while to get it as he was so weak.
390. At interview, nurse E said he asked the man if he could go into the cell to carry
out observations, but the man refused and said to give him half an hour.
Nurse E said that, after taking the water, the man went first to the bed, and
then to the floor again.
391. The rosters manager noted in the SASH document that the Duty Director,
senior manager B, arrived at 9.45pm to carry out his daily Duty Director
checks, and sign the man’s SASH document, before leaving the prison for the
night. The Duty Director looked through the door and saw the man lying on
the bed on his side. Nurse E told him that the man had asked him to return in
half an hour, although he did not expect to be allowed to carry out the checks.
At interview, the Duty Director said that he was not aware of the head of
healthcare’s earlier remark to the rosters manager about the man’s lack of
blood and the potential for organ failure.
392. Night manager A was night manager again and went to healthcare at
approximately 10.25pm as part of the normal routine for locking up the prison
for the night. In interview she did not remember looking into the man’s cell
and did not know what his condition was. Nurse E said he asked her if it was
alright for him to go into the cell and take the man’s blood pressure. She
agreed. At interview, she said she knew of the occasion when force was used
to restrain the man on 23 May and therefore arranged for additional staff to be
present when the cell was unlocked. When nurse E asked the man if he could
do the medical observations, she did not hear his reply, but nurse E told her
that the man had refused permission.
393. The SASH document notes that at 10.35pm the man asked for more water,
which was again given at the hatch. At interview, the rosters manager said
she watched him return to bed and described every step as being a huge
effort. She saw him lie on the bed, change position, and pull the sheet on and
off, adding that he did not talk but only moaned. The rosters manager said the
man got back on the floor and removed the sheet. He then moved under the
sink, where he lay for a while, before kneeling over the bottom of the bed. He
had removed his t-shirt and she could see that his stomach was going in and
out. When asked by my investigators if she considered this to be normal
behaviour, the rosters manager said she thought that the man was just
uncomfortable and restless due to pain. She said she could hear him making
a noise as though it was an effort to move.
394. At 11.40pm, the rosters manager handed over the constant watch to PCO O.
She told him that the man was very weak, and had refused treatment, but had
asked for and been given water. She then went to other duties in the prison.
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395. PCO O recorded his first observation in the SASH document at 11.51pm. He
noted that the man was kneeling over the end of the bed and that he could
hear him breathing. At interview he described the man as being unable to get
into bed, but he knew he was alive as he could see his stomach moving in and
out and could hear him breathing quietly. PCO O spoke to the man through
the hatch in the door, and asked whether it was time to see the nurse. He
said that the man shook his head, which he thought indicated that he did not
want the nurse.
396. Night manager A returned to healthcare to tell PCO O how long he would
remain on the SASH observations. She looked through the flap in the door
and saw the man kneeling on the floor, with his hands and head on the bed.
She could not see his face, and he did not say anything. The night manager
asked PCO O what was wrong with the man. The PCO replied that the man
appeared to lack the energy to get back on to the bed. The night manager
also asked nurse E what was wrong with the man. Nurse E said that the man
apparently did not have the energy to get back onto the bed and had, ten
minutes earlier, been lying on the floor under the sink. At interview, the night
manager said she replied “fair enough” to nurse E and then left to return to her
office. The night manager said that she thought the man would either crawl
into bed, or would sleep in the kneeling position.
397. A few minutes later, at about 11.55pm, PCO O looked into the cell. He could
not see any sign of the man breathing and decided that the situation was more
serious, so asked nurse E to look at him.
398. Nurse E banged on the door and called the man’s name, but could not obtain
a response. PCO O asked whether he should call for code 1 emergency
assistance. Nurse E agreed and ran to the treatment room to collect
emergency equipment.
399. Shortly afterwards, night manager A, the rosters manager and PCO Q arrived
in response to the code 1 and the night manager opened the cell. They went
into the cell and nurse E took hold of the man’s shoulder to shake him. As he
did so, the man fell backwards towards one of the officers who caught his
shoulders and laid him on the floor. Nurse E said he felt for the man’s pulse,
but it was not present so he asked PCO O to help administer cardio
pulmonary resuscitation (CPR). PCO O administered chest compressions
and nurse E attached the defibrillator. It instructed them to continue CPR,
which they did using a face mask and oxygen. In the meantime, the night
manager went to the office to call for an ambulance. After a few
compressions, PCO O said some fluid came out of the man’s mouth and he
thought that they had managed to revive him. PCO Q alternated with PCO O
so that compressions could be delivered continuously.
400. Whilst the staff were carrying out CPR on the man, there was another radio
message asking for assistance with a fire on a residential unit. The night
manager left healthcare to deal with the fire. PCO O, PCO Q and nurse E
continued with CPR until the arrival of paramedics.
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401. The ambulance arrived at 12.20am, and the rosters manager left the
healthcare centre to escort the paramedics to the man’s cell. The paramedics
took over administering CPR. At 12.25am, an emergency nurse practitioner
arrived by car, followed five minutes later by a second ambulance which the
investigators believe was responding to the fire.
402. The paramedics carried out their own tests, and confirmed the man’s death a
few minutes afterwards. In line with the prison contingency plans for deaths in
custody, the police were called. Night manager A, who had returned, sealed
the cell to ensure that nothing was touched pending police enquiries.
403. The police officers arrived and unit manager D broke the seal to re-enter the
cell and formally identify the man. The cell was locked again and the rosters
manager remained outside it until the undertakers removed the man’s body at
4.15am.
404. The man was taken to the mortuary and a post mortem was carried out. The
pathologist found a razor blade under the man’s body when he was removed
from the operating table.
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AFTER THE MAN’S DEATH
405. Following any serious incident in prison it is normal practice to carry out an
immediate “hot debrief”. Hot debriefs are arranged to ensure that information
is gathered as soon as possible and decisions can be made for any action
which should be taken. A hot debrief did not take place after the man’s death.
406. Additionally, the Prison Service suggests providing a “critical incident debrief”.
They allow those involved a particular incident to speak about what went well
and not so well, and how they as individuals are feeling. However, the PSO
dealing with the care of staff does not make a critical incident debrief a
mandatory instruction, and it is therefore left to the discretion of individual
Governors or Directors to offer the service. As with the hot debrief, a critical
incident debrief was not carried out after the man’s death.
407. The Director ensured that the prison’s local care team was in place and
support services made available to prisoners and staff. However, for at least
one member of staff, the interview with my investigators was the first
opportunity to talk about the man’s death.
408. Following any death in custody, the prison is required to review all prisoners
who are being monitored under suicide prevention procedures. This is a
precautionary measure to ensure that those who are feeling suicidal are
supported appropriately. When the Safer Custody Officer, arrived for duty on
Monday 12 June, she discovered that reviews had not been carried out. She
immediately ensured that all the prisoners on open SASH documents were
reviewed.
409. Other than a cursory check of the prison records, little appears to have been
done by the prison to trace the man’s family or inform the Ukrainian Embassy.
410. The Deputy Director forwarded copies of two letters, received in the prison
after the man’s death, to my investigators. My investigators believed the
letters, which were not written in English, contained an address and arranged
to have them translated. The outcome was positive and, after involving the
Coroner’s office, the Ukrainian Embassy in London, and the British Embassy
in Kiev, the man’s father was eventually traced in December 2006 and told
that his son had died. Sadly, it was six months after the man died before his
family knew what had happened to him.
411. Once the Ukrainian Embassy confirmed that the man’s father had been
traced, my investigators telephoned him using an international translation
agency. My family liaison officer then wrote to the man’s father to tell him
about my investigation and offer the opportunity to raise any questions
concerning the care and treatment the man received whilst he was in prison.
412. The man’s father asked to meet the investigators, and they travelled to
Ukraine on 25 May 2007 to meet him, his daughter and son in law, plus the
family lawyer. My investigators were assisted by an interpreter based in
Ukraine and the man’s family were given the opportunity to ask any questions.
My investigators were also able to return the man’s property to his father. I
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hope that the meeting helped the man’s family to understand the extent of my
investigation and answer some of their initial questions.
413. The man’s father told my investigators that the man had graduated from high
school and then went into the construction industry. He studied English for
four years, and could speak the language well. The man had responded to an
advertisement in Ukraine offering employment in England and the opportunity
to improve his language skills. When the man arrived in England the work
was not what he expected, and after a short time he left for London where he
found further employment with a bus company.
414. During the meeting, the man’s father said his son remained in contact with his
family until 2002, but did not contact them again until June 2005 when he rang
to tell his father he was in prison. The man’s father asked my investigators
why the man had committed a crime and been in prison. My investigators
were able to give him the details of his conviction and sentence, but were
unable to explain why he had committed the crime. They also told him about
the different prisons that the man went to and why he had moved.
415. My investigators told the man’s father that his son had told immigration
officials he did not want to return to Ukraine for fear of being killed. The man’s
father said he could not understand why his son would say this, and went on
to say he had purchased a flat for his son to live in, which was unusual for
someone of the man’s age in Ukraine.
416. The man’s father asked why it had taken so long to tell him about the man’s
death. My investigators explained what had happened and also gave him a
letter from the managing director which he had given to my investigators to
pass on. The man wanted me to know that he and his family were angry
about receiving the letter at this stage, some 12 months after the man’s death,
and felt it was too late to offer condolences. Additionally, he said he and his
family were very upset to be told of the man’s death when they were
celebrating Christmas.
417. The man’s father asked my investigators if they could return the two letters,
mentioned earlier, that he had sent to the man. The investigators had copies
of the letters and have asked Rye Hill to return the originals. I am pleased to
note that the originals have now been returned to the man’s father.
418. Finally, the man’s father asked the investigators if they were satisfied with the
level of care the man received from Rye Hill. The man will receive a copy of
this report which makes my views very apparent.
419. As part of the investigation, my investigators requested information about the
man’s immigration status from IND. One of my investigators also met with a
member of staff from IND. The primary concern was whether or not the man
was lawfully detained between the period he was granted parole (29 March
2006) and the date the authority to detain (IS91) was received at Rye Hill (12
May 2006).
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420. On 29 May 2007, my investigators received an email from a criminal
caseworker at IND with a note of explanation of the deportation process and
how it applied for the man. It appears that IND failed to follow the correct
process and did not consider detaining the man under immigration powers on
the expiry of his sentence, pending deportation. Their reason was that, prior
to May 2006, the processes were poorly defined and there were insufficient
trained staff to deal with a large number of cases being considered. The note
added that, regrettably, IND did not at any point consider whether to detain the
man under immigration powers, despite notification from Wayland and
Norwich before 21 January 2006 when he became eligible for parole. IND
concluded that it appears there may not have been any immigration powers
under which the man could have been detained beyond his release date. He
was therefore unlawfully held at Rye Hill.
421. I am grateful to UKBA (formerly IND) for their co-operation in this case as my
office does not have powers to investigate their actions. I will share my report
with the Director General of UKBA and the Director of Criminal Casework
Directorate who may wish to examine this matter further.
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ISSUES
Prison Transfers
422. The man was transferred to seven different prisons before arriving at Rye Hill.
Although his self harm history made him a difficult man to manage, there is no
evidence that he transferred because any of the prisons were unable to cope.
Instead, the transfers were at his request or represented normal progression
through the prison system.
423. I am satisfied that the man’s transfers were not because any establishment
refused to accommodate him. Additionally, I am satisfied that the final transfer
to Rye Hill was an arrangement agreed between Rye Hill and Norwich,
instigated by a manager at Rye Hill.
Training and Development
424. Despite the man’s medical history and care plan at Norwich, from his
reception into Rye Hill there are no more entries in his medical record until 21
April which suggests that no medical observations were being carried out.
425. The medical records show that healthcare staff were called to see the man on
21 April after he had self harmed. The clinical review panel believes that the
man’s behaviour began to deteriorate from around this date and this was not
recognised. His dental appointment for that day had been cancelled and the
panel believes that this, combined with his fear of being deported and not
getting access to computers, may have led to a change in behaviour.
Training in basic mental health awareness should be provided for all
grades of staff, to enable them to recognise trigger points in relation to
changes in behaviour which may lead to adverse consequences.
Searching prisoners on ACCT or F2052SH
426. It is clear that the man had access to razor blades and was allowed to keep
them in his possession. It would seem from the evidence that little was done
to find what the man used to cut himself, as he does not appear to have been
searched after harming himself or following cell moves. For example, I have
already described how, during the post mortem examination, a razor blade
was found on the mortuary table.
427. Whilst razor blades are not an unauthorised item, I question the sense of
allowing a prisoner who may have been using them to harm himself to have
them unmonitored.
The Director should ensure that appropriate systems are in place to
monitor the use of razor blades by any prisoner being monitored under
the suicide prevention procedures.
The Director should ensure that appropriate searching systems are in
place.
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Information sharing
428. PSO 2700 contains the following mandatory instruction at paragraph 4.2.6:
“When an at risk prisoner is in the HCC [healthcare centre] or under
intermittent supervision or constant observation elsewhere in the
establishment, a doctor or nurse must be consulted before any news known to
be unfavourable to the prisoner is communicated to him or her.”
429. Throughout my report there are numerous examples of breakdowns in
communication. This has been found by my investigators in the prison files
and by the clinical review panel in the clinical records. For example, on 9 May
2006 the man was issued with Annex C relating to his immigration status.
That day he asked to see healthcare, but because there is no record of the
time he was issued with Annex C it is not possible to establish if receiving it
led to his request. Equally, it is not known whether healthcare was ever
informed that Annex C had been issued.
430. Another example was on 17 May 2006 when the man was issued with
deportation papers. A SASH review took place the same day and the panel
heard that the man was eating and speaking to staff. But there is no
indication that they were aware of the deportation form being or about to be
issued. It was already apparent that the man was worried about deportation,
and the clinical review panel believes receipt of the form was a potential
trigger for self harm.
431. Issuing of the deportation papers does not appear to have been taken into
account at the SASH review, possibly because the meeting was unaware of
them. As a result, the levels of the man’s SASH observations were reduced to
twice hourly.
432. My investigators found no evidence to suggest that instructions in PSO 2700
had been followed.
The Director should ensure that the mandatory instructions contained in
PSO 2700 are in place and followed.
433. There were at least two occasions when medical or nursing staff did not
attend SASH reviews. In the man’s case, there were complex health issues
and his health was deteriorating. In cases like this it is essential that
healthcare contribute to the SASH process. It provides an opportunity for
them to share as well as to gather relevant information.
Primecare should remind all healthcare staff of their professional
responsibility to engage in multi-disciplinary case conferences.
The Director should ensure that all relevant information is shared and
recorded appropriately.
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23 May 2006
434. Some of the man’s behaviour was challenging and required careful and
compassionate management. As can be seen from my report, despite his
challenging behaviour, he would and did engage with staff at times. It is
evident that he responded positively to those who were persistent, even when
he told them to go away. There is very little evidence that he was treated
compassionately on 23 May and the events of the day make particularly
disturbing reading.
Medical assistance and observations
435. During the early hours of 23 May, PCO M saw the man picking at his wounds,
and blood on his mattress and the floor. He used his prison radio to call a
code 2.
436. I described earlier how nurse E was one of the staff who responded to the call,
along with other PCOs and night manager A. Surprisingly, nurse E carried out
his assessment by trying to talk to the man through the gap between the cell
door and door frame which is approximately a quarter inch wide, and looking
through the cell door observation glass.
437. My investigators are aware of a similar finding in relation to a death
investigated at Rye Hill in 2005. I described the healthcare for that man as
poor. As with the man, most of the medical consultations took place through a
locked door. This practice was unacceptable then and remains unacceptable
now.
438. A second code 2 was called at 2.00am and staff responded quickly. The
accounts of what happened next are conflicting, but all show a 20 minute
delay before staff entered the cell and tried to tend to the man.
439. After the man struck out at nurse E and was restrained, the staff left the cell.
Although nurse E was doubtless shocked, and entirely entitled to protection
from assault, it does concern me that the man was left without medical
treatment in a blood stained cell.
Blood stained cell
440. At the manager’s morning meeting that day, the Wolds senior manager told
the managers present that there was blood on the man’s cell floor which
would require cleaning. At interview, he said he had not seen the cell for
himself but was assured it would be dealt with.
441. The cell has been described to my investigators as being covered in blood, so
much so that staff had to stand in the blood when checking on the man.
General hygiene became a concern as the cell had begun to smell of the
blood.
442. The man’s cell remained uncleaned all day. He was also left with a plastic
mattress cover as his only means of keeping covered. It is neither decent nor
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humane that he had to live in this condition. It is also unacceptable that staff
had to walk through the blood when they entered the cell, and that one
member of staff was told to bio-clean his shoes. They should have been
disposed of correctly and replaced.
443. The instructions in PSO3845 - Blood borne and related communicable
diseases were not followed, and therefore the risk of infection to staff and
prisoners was unnecessarily increased.
The Director should ensure that the instructions contained within PSO
3845 are implemented and followed.
444. The clinical review panel comments that the man was kept in a medically
unsafe environment with regard to the risk of infection. They add that, given
his apparent continuing blood loss, he would have been at risk of potential
peripheral shutdown.
GSL should be satisfied that robust systems are in place to ensure that
no prisoner is ever left in similar circumstances to those of the man on
23 May 2006.
Duty Security Manager A
445. DSM A, the duty DSM that afternoon, told the investigators that she had been
to Hastings unit in the afternoon and had seen the man’s cell.
446. I have already described how the DSM took no action to have the man moved
out of an unfit cell, primarily because he had not self-harmed on her shift. As
a manager, and in particular the duty manager for that shift, I would have
expected at the very minimum for the DSM to have reported this situation to a
senior colleague who could have authorised a move. Instead, she did
nothing.
447. I acknowledge that, when the DSM came on duty at 1.00pm that afternoon,
the man had been in a blood stained cell for at least 12 hours. This situation
could have and should have been dealt with much earlier in the day, as the
DSM rightly pointed out in her feedback following advance disclosure.
However, the fact remains that it had not been dealt with and when she saw
the cell for herself she took no action.
Senior Manager D
448. Senior manager D made a number of crucial decisions which are
questionable, none more so than not seeing at first hand the situation on
Hastings unit on 23 May 2006.
449. It will be a matter of concern to GSL that senior manager D was fully aware of
his staff being visibly upset and angry at the man’s condition and the state of
his cell. He did not attend to the distressed staff, choosing instead to remain
in his office (due in part to not wearing his company uniform).
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450. In his advance disclosure feedback, senior manager D said that he felt that by
moving the man to healthcare he had supported his staff by taking receipt of
their concerns and moving the man. I am pleased that senior manager D
ensured that the man was moved to healthcare. However, I am satisfied that
the evidence shows that senior manager D and his managers placed
emphasis on his staff being in “cahoots” with prisoners rather than being
distressed. Indeed, the only matter that senior manager D asked for a report
on was in relation to an altercation PCO A had had with another member of
staff that evening when helping the man over to healthcare.
451. I understand senior manager D had also been told of a threat of indiscipline,
which he did not regard as serious. Following advance disclosure of my draft
report, senior manager D pointed out that his Prison Service Incident
Command training would not have permitted him to go to the scene of an
incident. This is so that the most senior person on duty at the time can take
charge and oversee the incident from an area where communication can take
place unhindered with advisers. I do not dispute the policy for handling an
incident. However, we have already established that senior manager D did
not take the threat seriously and, therefore, did not consider it to be an
incident. For that reason he should not have found it necessary to implement
the relevant Incident Command procedures.
452. There are a number of questions regarding decisions taken by DSM A and
senior manager D that day. This report has clearly established their actions
were not of a standard expected. However, it is my view that the responsibility
for the man’s care was not theirs alone and other managers at all levels had a
responsibility towards the man. I have been unable to establish the extent of
this for reasons explained earlier. I believe that GSL should re-examine the
events of that day.
GSL should investigate the circumstances of 23 May 2006 and the
decisions taken by managers at all levels that day.
Admission to healthcare
453. The man walked to healthcare despite being in a very weak condition. My
investigators saw a wheelchair in the administration block when they visited
the prison, but are aware from interviews with staff that it was not used to
assist the man. PCO A was the only member of staff to assist the man as he
walked to healthcare. Whilst I do not make a formal recommendation about
the use of wheelchairs, the Director may wish to remind staff about the
availability of aids for prisoners experiencing mobility difficulties.
454. It is clear from staff interviews that the intention was to temporarily move the
man to healthcare overnight while his cell was bio-cleaned. It was not
because managers or healthcare staff thought it was the appropriate place for
him to be.
455. Medical staff have confirmed that the man had been admitted into healthcare
by prison staff and not by healthcare. They regarded him as a ‘prisoner’ not
as a ‘patient’. As a result, no care plan was put in place.
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456. The investigators questioned this rationale and found that, if a prisoner is
admitted into healthcare by a member of healthcare staff, they were regarded
as a patient and a care plan was drawn up. However, if a member of Rye Hill
staff decides to place a prisoner into healthcare, even on strong medical
grounds such as in the man’s case, healthcare accepted no responsibility for
him and regarded him as a prisoner, rather than patient.
457. My investigators brought the matter to the attention of the Director who had
not known about it. He assured the investigators that the practice would end
with immediate effect. Whilst I welcome his decision, it is worrying that he had
not previously known about it. To date, the Director has not informed me of
the action he has taken.
PCO A and the RC chaplain
458. It is clear from the evidence that PCO A and the RC chaplain both recognised
the seriousness of the man’s situation that day. Despite not receiving the
level of support from their managers that the situation warranted, they did their
best to protect the man.
PCO A and the RC chaplain should be commended for their efforts in
demanding that prison management cared for the man appropriately.
9 June
459. Because he once again harmed himself, and as blood was present in the cell,
the man had to move cells within healthcare. As before, despite being
obviously weak, he was not assisted. He had to hold onto the wall and door to
stop himself from falling over whilst prison and healthcare staff watched him.
460. The head of healthcare told my investigators that she spoke to the man for the
first time on 9 June 2006. Given her role as head of healthcare, and given the
fact the man had been in healthcare for some time and had a history of
complex health issues, I find this very surprising.
461. The evidence shows that the man regularly refused medical treatment during
his sentence. However, on 9 June he felt so ill that he asked to see a doctor
but this was not facilitated. Later, before leaving the prison for the evening,
The head of healthcare told the rosters manager that the man did not have
much blood inside him and that his organs might fail. I refer to the head of
healthcare’s conduct later in this report.
462. A short while later, the man was seen lying on his cell floor. Both the rosters
manager and nurse E described him as weak and struggling to move. Despite
this, when the man asked for water he had to struggle to the door to get it. My
investigators were told this was because the prison was in night state.
However, in order to carry out medical observations, the cell was later
unlocked. It is difficult to understand why the cell of such a weak man could
not have been unlocked to give him liquids.
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463. The rosters manager, although acting at the time as constant observation
officer, was a manager and had all the managerial tools available to her. She
saw at first hand the distress the man was in and had been told of his serious
condition. She did not challenge the situation. I question her inaction.
GSL should examine the inaction of the Rosters Manager on 10 June
2006.
The final moments of the man’s life
464. I accept that nurse E had asked the man if he could take his observations and
the man refused. However, the level of medical care in prison should be
equivalent to that available in the community. It would be hard to imagine a
situation in any hospital where it was acceptable for a nurse to allow a patient
to remain on the floor, knowing they did not have the energy to return to bed
without assistance. The final moments of the man’s life – frail, presumably
exhausted, kneeling at the end of his bed with his arms extended – are painful
to consider.
465. Nurse E failed to provide a reasonable standard of care for the man. I have
already mentioned that Primecare have commissioned their own investigation
into his actions that night. I refer again to nurse E’s conduct later in this
report.
466. Night manager A was in charge of the prison that night. She too was aware
that the man was weak and did not have energy to get back onto his bed.
She had the option to insist a doctor or an ambulance was called. She was
the one person on duty that night who had direct access to the Duty Director
or Director. Instead, the night manager did nothing.
GSL should examine the decisions taken by the night manager on 23
May and 10 June 2006.
467. I accept that the man might well have refused to be treated, and may possibly
have become angry or lashed out. But for several staff to be aware of his
condition and leave him on the floor was utterly unacceptable.
Medical treatment refusal
468. Throughout the man’s period in custody there are records of him refusing
medical treatment and not receiving medical care. These become more
frequent whilst at Rye Hill, when for example he would not speak to staff or
allow his wounds to be treated.
469. The rationale from Rye Hill was that he refused treatment and could not be
treated without consent. However, the only witnessed confirmation of the man
refusing treatment was on 17 June 2002 when he signed a disclaimer. The
records show that the disclaimer was not updated and was in fact written
during his previous time in custody, four years before he went to Rye Hill.
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470. The head of healthcare and prison doctor A both said in their interviews that
the man had the mental capacity to refuse treatment and they could not force
it upon him. However, this was not based on any formal assessment. Indeed,
it would appear on this basis that on 18 May, when the man was taken to
outside hospital for treatment, it was without his consent. Whilst I appreciate
healthcare staff may have had his best interests in mind, I find this
inconsistent approach confusing and concerning.
471. All refusals of treatment or clinical intervention should, as a minimum, be
documented in the clinical notes. If any significant event such as self harm
requires treatment which is refused, a treatment refusal form should be signed
by the prisoner. Refusal to sign the form should be documented in the clinical
notes and witnessed by a second member of staff. This did not happen on
any occasion in the man’s case.
472. Rye Hill’s local healthcare policy on management and prevention of self harm
mentions the procedure for prisoners refusing treatment. However, there
should be a specific policy for the refusal of treatment. Staff should be aware
that failure to respond to medical staff is not the same as refusing treatment.
The Director in conjunction with the healthcare provider should ensure
that there is a local auditable policy for the management of prisoners
refusing treatment. This should be developed in accordance with the
Department of Health guidelines and relevant PSO.
Clinical documentation
473. The clinical review panel has identified a number of inaccuracies and
omissions in the man’s clinical notes. These include unsigned, wrongly timed
entries as well as missing information. This is not in keeping with National
Medical Council (NMC) guidance.
Primecare should remind all staff to follow their professional body’s
guidelines on documentation, records and record keeping and a clinical
audit tool should be developed to monitor compliance with professional
standards.
Standards of care
474. On 22 April 2006, prison doctor A completed the relevant section of the man’s
SASH document. He noted that the man should be cared for on the
residential unit as it was inappropriate for him to be in healthcare due to
extreme aggression and non-cooperation. At interview, doctor A could not
recall making this entry and said he did not remember the man being an
aggressive person and was therefore unable to expand on the comment.
475. The clinical review panel was concerned that a healthcare professional
considered a prisoner with complex healthcare needs would be
inappropriately placed in healthcare due to non-cooperation and aggression.
Irrespective of whether or not the doctor could remember why he made the
entry, admission to healthcare should not be denied on the basis of a
prisoner’s behaviour.
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476. An act of self harm does not necessarily warrant automatic transfer to a
healthcare unit. In fact, the majority of cases can be effectively managed on
residential units. However, given the man’s previous self harm and medical
history, the clinical reviewers and my investigators consider that a transfer to
healthcare would have been appropriate so that the man could have been
monitored and assessed by medical staff. It would have provided an
opportunity to gather a comprehensive overview of his needs, and formulate
an appropriate care plan.
477. The panel has commented that it would be appropriate for a care plan to be
managed on a residential wing as well as in healthcare. Therefore, even if
location in healthcare was considered unnecessary, a care plan should have
been in place and regularly evaluated by medical staff.
478. The lack of care planning and poor communication resulted in the man’s
needs not being thoroughly assessed or met. There is no evidence of a
comprehensive overview of the man’s health needs throughout his time in Rye
Hill.
479. In a case review meeting held on 24 May 2006 to discuss the man, the Deputy
Director reminded those attending of the prison doctor A’s view that the man
could die in prison. The Deputy Director took the decision that the man should
remain in healthcare, even if he were to refuse treatment, as he was weak. I
welcome the Deputy Director’s positive intervention.
Primecare should remind all healthcare professionals that they have a
duty of care to prisoners who are entitled to receive safe and competent
care. This includes referring to other relevant healthcare professionals
as necessary.
Primecare should introduce a policy ensuring a documented care
pathway approach is adopted to address physical and mental health
needs regardless of the location of a prisoner.
Healthcare management
Prison Doctor A
480. Prison doctor A, recently retired from National Health Service (NHS) practice,
had worked at Rye Hill for approximately two years. He said at interview that
he is section 12 approved, which means he is approved to detain a patient
under the Mental Health Act. He said he felt self harming was a sign of
manipulative behaviour and psychological distress, rather than mental illness.
He went on to say that he was absolutely sure the man understood he would
die if he refused to have a blood transfusion. However, the clinical review
panel comments that this significant fact is not documented in the clinical
notes. The prison doctor also said he believed the man wanted to die, and
was not depressed.
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481. During his interview, prison doctor A said he was sceptical of the diagnosis of
depression within the Prison Service. He suggested there are a lot of people
inappropriately on anti-depressants and added, “You have to take it on the
chin, that’s life”.
482. The laboratory request for further investigation into the man’s abnormal blood
test results was not acted upon as the prison doctor thought it was an
automatic follow up as the laboratory were not aware of the man’s history.
483. On 19 May 2006, prison doctor A saw the man during the morning (before
9.20am) when he attempted to assess him. The man refused to be assessed.
The prison doctor noted in the medical record ‘…no need [the man] to be on
healthcare, suggest return to unit’. The clinical review panel have noted that
when the man’s blood pressure was recorded at 40/34 at 10.45am, following a
self harm episode at 9.20am, prison doctor A was made aware but did not visit
him and no treatment was ordered despite commenting in a case review later
that day that the man ‘could die in custody especially if he goes into organ
failure’.
484. According to prison doctor A’s entries in the medical records, he was unable
to engage with the man. It is therefore unclear how he concluded that the
man was not mentally ill, and felt able to comment on the man’s capacity or
otherwise to refuse care. Several entries were made to request a psychiatric
referral. This did not happen and the clinical review panel believes this
information was vital in determining whether the man was competent or not to
refuse treatment.
485. The prison doctor was responsible for the man’s physical and mental health
care. He should have ensured that the psychiatric assessment requested was
carried out in line with PSO 2700 and Primecare’s policy on self harm. His
failure to do this and to recognise the man’s deteriorating mental and physical
health resulted in significant shortcomings in the standard of care reasonably
expected.
Primecare should consider an investigation into the clinical
management of the man by the prison doctor and if necessary consider
a referral to the General Medical Council Fitness to Practice Board.
The Head of Healthcare
486. The head of healthcare, a qualified registered mental health nurse for 20
years, had been the healthcare manager at Rye Hill for over three years. As
well as her nursing qualifications, the head of healthcare has a Master’s
degree in Person Centred Counselling.
487. The head of healthcare said in interview that she did not consider that self
harming was always a sign of mental illness. She explained that people self
harm for many different reasons, often “as a way of coping rather than actually
dying”. She went on to say that, although some people do self harm to
attempt suicide, in her experience much of it is a method of coping with
emotional distress.
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488. It is of concern to the clinical review panel that the head of healthcare, a
qualified psychiatric nurse, felt that prolific self harming, treatment refusal,
food refusal, a history of suicidal ideation and depression, did not suggest to
her a ‘mental health history’.
489. The head of healthcare also said she “did not buy in to the philosophy that self
harming is attention seeking or manipulative behaviour”. On the other hand,
she said that it is sometimes done to gain attention and felt that you need to
look at “why the person needs attention and not why they actually self harm”.
There is no evidence in the clinical notes that the head of healthcare or her
healthcare team made any determined attempt to encourage the man to
engage with them in order to ascertain the reason for his persistent self harm.
490. At interview, the head of healthcare said she was unaware of the problems the
man was actually experiencing. She said he had never really engaged very
much in conversation with healthcare staff. The head of healthcare said that,
“Care plans should be written in partnership with the patient ideally and there
was no real partnership going on with the man.” She went on to say there
was not a care plan for the man because he was not identified as having any
health needs at the time, other than his cuts. She said the fact that he would
not engage with staff was a not a problem which required a care plan. This is
despite comprehensive notes in the man’s medical record from Highpoint and
Norwich.
491. The clinical panel’s observation is that the man had a variety of problems that
warranted care planning, but that there was no clear care plan designed to
meet his complex needs.
492. With the head of healthcare’s qualifications, she should have been well placed
to ensure that continuing attempts were made to engage the man in a
therapeutic relationship. There are concerns regarding her lack of
involvement and leadership in assessing the needs of an apparently
desperately disturbed patient, resulting in her and her team’s failure to attend
to the man’s deteriorating condition.
493. The head of healthcare said that the urgent psychiatric referral requested in
the review meetings on 19 May and 24 May came from prison not healthcare
staff. She had an ‘informal’ discussion with the psychiatrist during which she
told him that, in her opinion, the man had ‘full capacity to refuse treatment’. In
interview, the head of healthcare said she only met the man the day before he
died. Whilst this itself is a concern, the clinical review panel believes that,
without meeting the man, the head of healthcare was not in an informed
position to enable her to accurately discuss his mental well being, character
and capacity.
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494. Despite the head of healthcare’s qualifications and position in the prison, she
did not undertake a mental health nursing assessment. This would have
given the healthcare team a good indication of the man’s mental state even in
the absence of an assessment by a psychiatrist. Furthermore, PSO 2700
states that prisoners placed under constant observation should be urgently
referred for a mental health assessment.
495. It is also a matter of concern that, during the case review on 19 May, the
prison doctor said the man could ‘die at any time’. The head of healthcare
said at interview that she did not remember anyone at the meeting questioning
what they were going to do. The panel believes that, as the manager of
healthcare, it was the head of healthcare’s responsibility to act upon this
information and implement an appropriate plan of care.
496. The head of healthcare said during the case review on 31 May that she
considered the man to be at no risk of self harm whilst in healthcare. He was
eating well and was in no danger of collapsing, and she added that he did not
want to return to the unit. She also said she felt the man did not require an
open SASH document, but if he were to remain on healthcare the watch would
need to remain open. I cannot understand the rationale for this. The clinical
review panel also finds it surprising that, considering the man’s blood loss and
need for rest and food, the head of healthcare did not feel healthcare was a
suitable location.
497. On 9 June 2006, a few hours before the man died, the head of healthcare
spent some time trying to engage him. During her interview, she mentioned
that he asked to see a doctor but she did not call one. She said she explained
to the man that he needed to go out for a blood transfusion and that this is
what the doctor would also say. I think that not calling a doctor was simply
unacceptable and demonstrated a poor standard of care. The clinical review
panel has also commented that the man’s request to see a doctor was not
documented in the medical notes.
498. It is the healthcare manager’s responsibility to direct her team and to ensure
that adequate policies and procedures are in place to provide a safe and
caring environment for the patients in their care. The head of healthcare failed
to provide the standard of care reasonably expected for the man both as a
registered mental health nurse and as healthcare manager.
Primecare should consider an investigation into the head of healthcare’s
management of this case. If necessary, consideration should be given
to a referral to the National Medical Council Fitness to Practice Board.
Nurse E
499. Nurse E, a registered general nurse, had worked at Rye Hill prison as a staff
nurse for 18 months. The first 12 months of his employment were as an
agency nurse. Subsequently, he was an employee of Primecare. He has
received no specific training in caring for people who self harm or those
refusing treatment.
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500. At interview, nurse E said he did not have much contact with the man as he
worked on night duty. He also said that every time he saw the man he would
refuse treatment. The RGN confirmed that he believed the man understood
his request to look at his wounds, although he felt that he might not have
understood anything more detailed than that.
501. On 23 May at 1:00am, nurse E was called to Hastings unit by the prison
custody officer carrying out the SASH observations. I have already explained
that nurse E did not enter the man’s cell. During his interview, he said that he
was unable to say what the man’s medical condition was at that stage
because he did not enter the cell.
502. Nurse E confirmed that there were three or four members of staff present and
so he did not feel unsafe to enter the cell. He said that, in retrospect, it would
have been better to have entered the cell to try and persuade the man to
accept treatment. However, he had been led to believe that opening doors at
night should be avoided for security reasons. The clinical review panel
considers that not entering the man’s cell resulted in poor care delivery by the
nurse.
503. Nurse E was in the healthcare unit on the evening when the man was taken
there by PCO A. He confirmed that he knew the man had been in the blood
stained cell all day and he agreed that this posed a risk of infection. He told
the investigators about the disagreement between the healthcare staff and the
PCO when she tried to hand over to healthcare staff. The panel is concerned
about the PCO’s allegation that nurse E said he would not treat the man
because he had assaulted him earlier that day.
504. I have explained that nurse E was on duty the night that the man died and that
he witnessed him lying on the floor, weak and with no energy to get back onto
the bed. Nurse E said during his interview that he had no idea how ill the man
really was on the night he died, although he was aware that the man had a
low HB (haemoglobin) and had lost a lot of blood. This highlights the need for
proper handovers and records as the head of healthcare had already told the
rosters manager that the man’s organs might fail.
505. The clinical review panel believes that nurse E did not, when compared to the
standard of care reasonably expected, deliver even the most basic nursing
care to the man. I accept that people can die suddenly. However, it is of the
greatest concern that someone can die kneeling at his bedside because he
did not have the energy to get back onto his bed, and particularly in a
healthcare unit with a qualified nurse on duty and an officer on constant
watch.
Primecare should consider undertaking an investigation into the actions
of nurse E on 23 May and 9 June and if necessary consider disciplinary
action and referral to the NMC Fitness to Practice Board.
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Nurse A
506. Nurse A had worked at Rye Hill for three years. She has received no specific
training or instruction in caring for people who self harm.
507. The nurse said that she did not remember admitting the man to Rye Hill and in
fact did not remember him at all. Having looked at the transfer check-in list
during her interview, the nurse confirmed that it was she who had admitted the
man to Rye Hill on 23 February 2006.
508. The prisoners being transferred in that evening were seen by nurse A as part
of her duties. It was her responsibility to complete the relevant medical
screening documentation. Clinical records from previous prisons should be
considered as part of the reception health assessment. This helps ensure a
full medical history is taken into consideration when assessing, planning and
delivering care.
509. The clinical review panel have found that these documents were only partially
completed in the man’s case. The documents said that the man had no
physical, mental health or substance misuse problems, and had no self-harm
or suicidal ideation. The nurse also documented that he was fit for heavy
work and use of the gym, despite the man’s recent 23 day food refusal. She
signed to authorise all this on behalf of the doctor, which is contrary to local
policy.
510. At interview, the nurse said the reception nurses are busy and short-staffed
and therefore cannot look through every single page of the medical record. It
was evident to the clinical review panel that, from the assessment the nurse
made on the man that day, she had not read the key points on his clinical
records. The panel found that the nurse failed to follow-up and act upon the
nutritional assessment which had been carried out the previous month and
which was documented just a few lines above her entry in the clinical notes.
They felt these omissions resulted in a failure to grasp even his most basic
healthcare requirements.
511. The nurse only partially completed the ‘assessment for suitability for in-
possession medication’ form and she left the ‘decision’ section blank. She
explained during her interview that this would have been because she
required the doctor to assess the man. Her entry in the clinical notes reads
‘states no physical or mental health problems’. The man was not seen again
by healthcare staff until 21 April, some two months later.
512. The clinical review panel believe that essential information regarding the
man’s care was missed. This was despite clear care plans from Highpoint
and Norwich prisons outlining the man’s self harming behaviour and food
refusal, plus the Norwich care plan outlining action regarding his food refusal.
The actions needed were clearly outlined, but were not followed up by
healthcare staff at Rye Hill.
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513. The clinical review panel believe that the nurse A’s omissions may have had a
detrimental effect on the care offered to the man during his time in Rye Hill.
There was no continuity of care for the man on his admission to Rye Hill which
was in part due to the poor reception procedure.
Primecare should consider an internal investigation into the actions and
omissions of nurse A, specifically relating to the reception health screen
procedure on 23 February 2006.
Primecare should ensure that the local reception health screen policy is
reviewed to ensure that it reflects relevant prison and health service
standards and policies.
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CONCLUSION
514. As the clinical review panel has acknowledged, it is clear that the man
presented with complex needs which posed a challenge to Rye Hill healthcare
staff. However, the lack of care planning and multi-disciplinary team approach
resulted in a failure by the prison to provide the reasonable standard of care to
which the man was entitled.
515. Healthcare staff used the fact that the man would not engage to explain their
lack of care. Engagement with any patient cannot be formed by casual, brief
discussions. Healthcare staff should have made more persistent and
consistent efforts to encourage the man to explain his concerns.
516. Prison custody officers and managers are not medically qualified to respond to
the complex needs of prisoners who harm themselves. As a result of the
healthcare team failing to accept responsibility for the man’s health and
wellbeing, there were significant shortcomings in the delivery of care.
517. The law recognises that a competent adult has the right to refuse treatment,
even where the exercise of that right is likely to cause death. However, due to
the failure of healthcare staff to follow PSO 2700 and Primecare’s local self
harm policy to obtain an up to date psychiatric assessment, we are unable to
determine the man’s competency to refuse treatment.
518. The clinical review panel has concluded that there was a failure to monitor and
assess the man on a regular basis by various members of healthcare staff at
Rye Hill. They also found that there were serious omissions in the delivery of
care and care planning for the man.
519. I have been very disturbed to read about the last few months of the man’s life
and the unprofessional way in which he was treated at Rye Hill. In particular,
the disgraceful events of 23 May and 9 June make dismal reading and will
undoubtedly be distressing for the man’s family. I am not satisfied that the
man was given the level of care, decency and medical treatment that he was
entitled to receive from some staff at Rye Hill.
520. This said, there were a few staff who attempted to provide the right care for
the man. The Deputy Director recognised the seriousness of the situation in
May. He requested an urgent psychiatric assessment and gave instructions
for the man to be kept in healthcare. The actions of PCO A and the RC
chaplain show that there were members of the Rye Hill team who were
prepared to fight for the man’s proper care and treatment. However, overall
this is as sad and shameful account as any I have penned in the near five
years I have been investigating deaths in custody. That the man was almost
certainly held unlawfully for seven weeks until a month before he died casts a
further shadow over the whole tragedy.
A copy of this report should be sent to the Director General of the
National Offender Management Service and the Secretary of State for
Justice for their consideration.
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RECOMMENDATIONS
I have received GSL’s response to the report recommendations and have
included these individually below. Where appropriate, GSL have responded
to some of the clinical recommendations, however, where not appropriate,
they have forwarded these to Primecare for action.
GSL have also notified me that they have terminated the contract with
Primecare at Rye Hill, with effect from April 2008.
1. The Director should ensure that appropriate systems are in place to monitor
the use of razor blades by any prisoner being monitored under the suicide
prevention procedures.
GSL have partially accepted the recommendation and completed the changes.
2. The Director should ensure that appropriate searching systems are in place.
GSL have accepted the recommendation and completed the changes.
3. The Director should ensure that the mandatory instructions contained in PSO
2700 are in place and followed.
GSL have accepted the recommendation and completed the changes.
4. The Director should ensure that all relevant information is shared and recorded
appropriately.
GSL have accepted the recommendation and completed the changes.
5. GSL should be satisfied that robust systems are in place to ensure that no
prisoner is ever left in similar circumstances to those of the man on 23 May
2006.
GSL have accepted the recommendation and completed the changes.
6. GSL should investigate the circumstances of 23 May 2006 and the decisions
taken by managers at all levels that day.
GSL have accepted the recommendation.
7. The Director should ensure that the instructions contained within PSO 3845
are implemented and followed.
GSL have accepted the recommendation and completed the changes.
8. PCO A and the RC chaplain should be commended for their efforts in
demanding that prison management cared for the man appropriately.
GSL have partially accepted the recommendation and written to the RC
chaplain only, as PCO A is no longer employed by them.
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9. GSL should examine the inaction of the rosters manager on 10 June 2006
GSL have accepted the recommendation.
10. GSL should examine the decisions taken by the night manager on 23 May
and10 June 2006.
GSL have accepted the recommendation.
11. The Director in conjunction with the healthcare provider should ensure that
there is a local auditable policy for the management of prisoners refusing
treatment. This should be developed in accordance with the Department of
Health guidelines and relevant PSO.
GSL have accepted the recommendation and completed the changes.
12. A copy of this report should be sent to the Director General of the National
Offender Management Service and the Secretary of State for Justice for their
consideration.
GSL have accepted the recommendation.
Clinical Review Panel Recommendations
13. Training in basic mental health awareness should be provided for all grades of
staff, to enable them to recognise trigger points in relation to changes in
behaviour which may lead to adverse consequences.
GSL have accepted the recommendation and completed the changes .
14. Primecare should remind all healthcare staff of their professional responsibility
to engage in multi-disciplinary case conferences.
GSL have accepted the recommendation and completed the changes.
15. Primecare should remind all staff to follow their professional body’s guidelines
on documentation, records and record keeping and a clinical audit tool should
be developed to monitor compliance with professional standards.
GSL have accepted the recommendation and completed the changes.
16. Primecare should remind all healthcare professionals that they have a duty of
care to prisoners who are entitled to receive safe and competent care. This
includes referring to other relevant healthcare professionals as necessary.
GSL have accepted the recommendation and completed the changes.
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17. Primecare should introduce a policy ensuring a documented care pathway
approach is adopted to address physical and mental health needs regardless
of the location of a prisoner.
GSL have accepted the recommendation and completed the changes.
18. Primecare should consider an investigation into the clinical management of the
man by prison doctor A and, if necessary consider a referral to the General
Medical Council Fitness to Practice Board.
GSL have referred the recommendation to Primecare. My office has not
received a response from Primecare regarding this recommendation.
19. Primecare should consider an investigation into the head of healthcare’s
management of this case. If necessary, consideration should be given to a
referral to the National Medical Council (NMC) Fitness to Practice Board.
GSL have referred the recommendation to Primecare. My office has not
received a response from Primecare regarding this recommendation.
20. Primecare should consider undertaking an investigation into the actions of
nurse E on 23 May and 9 June and if necessary consider disciplinary action
and referral to the NMC Fitness to Practice Board.
GSL have referred the recommendation to Primecare. My office has not
received a response from Primecare regarding this recommendation.
21. Primecare should consider an internal investigation into the actions and
omissions of nurse A, specifically relating to the reception health screen
procedure on 23 February 2006.
GSL have referred the recommendation to Primecare. My office has not
received a response from Primecare regarding this recommendation.
22. Primecare should ensure that the local reception health screen policy is
reviewed to ensure that it reflects relevant prison and health service standards
and policies.
GSL have accepted the recommendation and completed the changes.
Although Primecare did not formally respond to my recommendations, following the
inquest, the Medical Defence Union asked me to acknowledge within my report that
Primecare had decided the doctor did not fulfil the criteria for referral to the GMC. I
also understand Primecare decided to take no action in relation to its other staff
mentioned in my report
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OUTLINE OF THE PRIMECARE INTERNAL INQUIRY REPORT
a) On 20 December 2006, following a meeting between interested parties regarding
the initial findings of my clinical review team, terms of reference were issued by
Primecare to their own inquiry team. The inquiry team were asked to investigate
“the healthcare provided for [the man] from 23 February until 10 June 2006 at
HMP Rye Hill”. The inquiry report shows that, on 9 January 2007, the terms of
reference were amended “to provide for a wider inquiry than just the
circumstances surrounding the death of the man, and seek to ensure that our
inquiry does not in any way transgress into territory properly covered by the
ongoing Prison and Probation Ombudsman and Coroners investigations”.
b) The amended terms of reference are set out as follows:
1. Any failure in the healthcare systems and operational protocols at Rye Hill.
2. The standards of delivery of clinical care by the health professionals at Rye
Hill.
3. The accountability of any health staff for any failure to properly care for the
man at Rye Hill.
4. Any element of best practice, in either the healthcare staff or systems at Rye
Hill.
c) Primecare’s inquiry team was led by a previous prison governor and employed by
Primecare at the time of the inquiry. The inquiry lead was assisted by three non-
Primecare clinical professionals:- a prison doctor, a consultant psychiatrist and a
registered mental health nurse.
d) The methodology of the inquiry shows that the team were given access to
relevant documents and conducted formal interviews with the head of healthcare,
three other members of staff. Interview notes and a full list of documents can be
found in their report.
e) In their Executive Summary, the team explained that their enquiries focused
upon:
(cid:127) “Perceptions of the Healthcare Service within Rye Hill
(cid:127) Clinical and Management Documentation
(cid:127) Healthcare Policies and Procedures
(cid:127) HMCIP and Prisons and Probation Ombudsman reports
(cid:127) Healthcare Service Requirement and links with the NHS”.
f) Their findings were that “whilst there are aspects of healthcare delivery and
governance that would benefit from improvement the general level of healthcare
provided at Rye Hill is satisfactory”.
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g) Also within their Summary, the inquiry team raised concerns about my draft
clinical review. One of their concerns was the knowledge and experience of my
clinical review panel in terms of delivering healthcare in a secure environment
and issues relating to self harm. I acknowledge that, at the time of writing their
inquiry report, their team were unaware of the experience of my clinical panel.
For clarification my panel members were (roles and experience given as they
were at the time of the review):
(1) The RGN ONC – Lead clinical reviewer, Prisons and Probation
Ombudsman (PPO). The clinical reviewer worked in the National
Health Service for five and half years. From 1988 to 2005 she worked
in healthcare recruitment which included recruitment of healthcare
professionals into the Prison Service. Since 2004, the clinical reviewer
has been employed on a contract basis for the PPO to carry out clinical
reviews and up to the time of the man’s death had completed
approximately 18 reviews.
(2) An RMN – Forensic Psychiatric Addiction Nurse Therapist. The RMN
has four years experience working in a secure unit which provides care
for patients sectioned under the Mental Health Act (1983) and with
enduring mental health illnesses. Prior to this the RMN worked for 12
months in the community drug and alcohol team.
(3) An RGN – Staff Nurse. The RGN has ten years experience in Accident
and Emergency (A&E) nursing.
(4) An RGN – Prison Healthcare Manager. The RGN has 17 years
experience in A&E departments, five of these as the Senior Nurse
Manager. The RGN was the healthcare manager in a high security
prison for four and a half years.
(5) A Chartered Forensic Psychologist, BA (Hons) Psychology, MSc
Forensic Psychology. At the time of the clinical review, the Chartered
Forensic Psychologist was Head of Forensic Psychology in a secure
unit providing care for patients sectioned under the Mental Health Act
(1983) and with enduring mental health illnesses. Prior to this the
Chartered Forensic Psychologist had worked in a prison environment
as part of her specialist training and with young offenders for five years.
She is currently employed by a PCT in a Secure Training Unit for 12-17
year olds.
h) The panel was overseen by my former Deputy Ombudsman, MSt. (Cantab) BSc.
(Open) RN, ex-prison governor grade and Area Health Advisor for the Prison
Service. Additionally, the panel received support from my investigators.
i) A further point raised by the inquiry team is in relation to four members of
healthcare staff who have been criticised in my report. The inquiry report states
that following a presentation of my draft clinical review on 18 December 2006
(this should read 19 December), three of the four staff were suspended from
duty. I consider that it is necessary to make it clear to the reader that the
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decision to suspend the staff was not that of my office. The draft clinical review
recommended that Primecare conduct their own investigation and if necessary,
make referrals to the appropriate professional body. Although, I have received a
copy of the inquiry team’s report, I have to date not received a response from
Primecare regarding their actions in response to those recommendations. One of
my investigators wrote to Primecare on 12 September 2008 for an update but
one has not been received.
j) The Primecare inquiry team, in their report, have said they wanted to achieve a
“wider view” rather than “focus on a snapshot of one particular point in time”. As
a result they looked at the perceptions of the healthcare service within Rye Hill.
My report has focused on the man and the care and treatment he received, and
therefore my investigators have not conducted a similar exercise.
k) The inquiry team then considered the healthcare services within Rye Hill and
produced conclusions, six main findings, three areas of good practice and 20
recommendations. Several of the recommendations are similar to my own.
However, there are findings and recommendations in the Primecare report which
differ from those in my report. I do not propose to compare every finding in this
report. Primecare’s report has been annexed and full details can be read there.
My office has not received any communication from Primecare regarding their
response or actions to recommendations made in their internal inquiry report.
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SUMMARY OF MEETING ON 5 JANUARY 2009 WITH THE DIRECTOR AND
HEAD OF SAFER CUSTODY OF RYE HILL
l) Because of the length of time which has passed since issuing my first draft report
in October 2007, my investigators offered GSL the opportunity to provide an
update on actions taken following my recommendations. I also thought it
important to reflect and acknowledge the changes implemented by the current
Director, and her senior management team.
Healthcare
m) The Director told my investigators that GSL had terminated the contract with
Primecare in April 2008. She said that this was as result of the man’s death, two
previous deaths at the prison, as well as a poor Chief Inspector’s report. The
Director added that the healthcare provision is now provided ‘in-house’ by
medical staff directly employed by GSL.
n) My investigators were told that the prison is now forging strong links with the local
Primary Care Trust (PCT). Unlike public sector prisons, the PCT is not
responsible for commissioning services in contracted out prisons. It is pleasing,
therefore, to note that Rye Hill have worked towards developing such links and
have secured some funding support from the PCT for healthcare services.
o) The Head of Safer Custody, told my investigators that there is better healthcare
involvement in the ACCT process. He said that an RMN always attends ACCT
reviews. Additionally, the new Deputy Healthcare Manager leads on mental
health awareness training for new prison custody officers as part of their initial
training. The Deputy Healthcare Manager also leads and supports ACCT
assessors at their quarterly meetings.
p) The prison have produced a Health Improvement Plan which identifies areas of
development such as physical resources, mental health, patient safety,
medicines management, staff development and recruitment, continuity of case
management and discharge planning. The Plan uses a traffic light system to
monitor and action the identified areas. The Director said that, although there
were still teething problems with the new healthcare department, she was happy
with the progression plans.
q) In my draft report I recommended that several of the healthcare policies be
reviewed. This was also a recommendation made by Primecare in their internal
investigation. Because the healthcare services are now being provided ‘in-
house’, the Director said that previous policies would all be reviewed. This is also
part of the Health Improvement Plan.
Safer custody
r) At the time of the man’s death, there was one officer who dealt with co-ordinating
ACCT reviews and issues relating to prisoners on ACCT. The Director has since
appointed a Head of Safer Custody. His role encompasses suicide and self harm
prevention as well as violence reduction and anti-bullying. He is supported by a
co-ordinator and an administrator. There are also prisoners who act as safer
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custody representatives on each unit. Although at the time of the man’s death,
prisoners had access to ‘Buddies’, the prison now operates a Samaritan trained
‘Listener’ scheme similar to that which is run in other prisons.
s) The Head of Safer Custody said that the profile of safer custody is now high in
Rye Hill. He added that the prison has good links with the East Midlands area
safer custody advisor who he said provides excellent support and advice.
t) Since his arrival, the Head of Safer Custody said that he had introduced a
number of new monitoring systems. As an example, he showed my investigators
a monitoring information board which highlights every recorded incident of self
harm. This is reproduced onto a weekly document so that any patterns or issues
can be easily identified and action taken. The Head of Safer Custody has also
introduced a fortnightly review meeting which discusses all prisoners on open
ACCTs – this is additional to the individual ACCT reviews. Unit managers are the
ACCT case managers and they are required to attend the fortnightly meetings, as
well as other relevant staff including healthcare, and a member of the IMB.
u) The prison now also holds ‘enhanced review’ meetings in which they encourage
prisoners’ families to be involved in the ACCT care plan (with the prisoner’s
consent). The meetings are held to discuss prisoners who are carrying out
prolific acts of self harm, whose current ACCT care plan needs to be revised or
who have been identified as having “major issues”. The Head of Safer Custody
said that staff are now better at identifying issues and triggers. He gave an
example of a prisoner who staff had identified as not coping particularly well and
they believed might benefit from having a budgie in his cell. An officer contacted
the Head of Safer Custody with this suggestion which was agreed and as a result
the prisoner now works in the prison aviary and appears to be more settled.
v) The Head of Safer Custody and the Director said that the Prison Service
Standards Audit Unit had assessed the ACCT process and were satisfied the
quality.
Additional progress
w) Since taking over as Director, the Director has increased the level of PCOs on
each unit from two to three. This should allow for better interaction between staff
and prisoners.
x) Training for managers at all levels is provided by G4S, and the prison is
supporting Management Development Programme (MDP) training for all staff as
a development opportunity. The Director told my investigators that Rye Hill is
looking at developing a university degree course for their new entrant prison
custody officers.
y) Senior managers at Rye Hill now wear civilian clothing. This is in response to
concerns that managers were not visible on the units at Rye Hill. The Head of
Safer Custody said that prisoners are now aware when there are senior
managers on the unit and do approach them.
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