Individual at Wakefield

Investigation into the circumstances surrounding the death of
a man at HMP Wakefield on 11 August 2004
Prisons and Probation Ombudsman
for England and Wales
March 2006
This is the report of an investigation into the death of the man who died on 11
August 2004 at Wakefield prison. The man was found hanging from the
window bars of his cell in the segregation unit, shortly after midnight.
The man was but a young man when he died. I offer my deepest sympathies
to his family, particularly to the man’s mother, who I know from my enquiries
was very close to her son as he was to her. I have great respect for the
dignity the family has shown.
One of my investigators led the investigation from my office. The senior
investigating officer was a Prison Service Governor. He was assisted by a
Principal Officer. I am grateful to them all.
I am grateful to the staff at Wakefield and Manchester for their assistance. I
am also grateful to the local police who, in carrying out their own enquiry,
assisted my investigation team and shared all available information.
Finally, I would like to thank the Prison Health Commissioning Manager for the
Wakefield West Primary Care Trust, who conducted a Clinical Review.
Stephen Shaw CBE March 2006
Prisons and Probation Ombudsman
2
Contents
SUMMARY.......................................................................................................5
INVESTIGATION OUTLINE.............................................................................7
BACKGROUND...............................................................................................8
The man................................................................................................8
Wakefield Prison...................................................................................8
VIEW OF HER MAJESTY’S CHIEF INSPECTOR OF PRISONS....................9
Segregation Unit ...................................................................................9
Prisoner Disciplinary Procedures..........................................................9
Anti-Bullying........................................................................................10
Preventing Self-Harm and Suicide......................................................11
SECURITY AND STANDARDS AUDIT .........................................................12
SECURITY AND STANDARDS AUDIT .........................................................12
Adjudications.......................................................................................12
Complaints Procedure.........................................................................12
Safer Establishments..........................................................................12
Segregation of Prisoners.....................................................................13
Suicide and Self-Harm Prevention......................................................13
MEASUREMENT OF THE QUALITY OF PRISON LIFE ...............................14
CHRONOLOGY OF EVENTS........................................................................15
30 January 2004 – 10 August 2004 ....................................................15
Discovery of the man...........................................................................19
PRISONERS’ AND STAFF VIEWS................................................................21
3
NON-MEDICAL ASSESSMENTS..................................................................24
Anti-Bullying Questionnaire.................................................................24
Cell Sharing Risk Assessment............................................................24
Risk Assessment for Court..................................................................24
Suicide Prevention and Anti-Bullying Proforma...................................25
F Wing / CSC Behavioural / Activity Risk Assessment Record...........25
CARATS..............................................................................................26
Life Sentence Planning.......................................................................26
Segregation Safety Algorithm..............................................................26
MEDICAL CARE............................................................................................28
Quality of Assessments.......................................................................28
Treatment for Mental and Physical Health..........................................28
Appropriateness of Location / Accommodation...................................28
ISSUES RAISED BY THE MAN’S FAMILY ...................................................31
RECOMMENDATIONS..................................................................................39
GOOD PRACTICE.........................................................................................40
4
Summary
This is the report of an investigation into the death of a man at Wakefield
prison. The man was 28 when he died on 11 August 2004. He was found
hanging from the window bars of his cell in the prison’s segregation unit.
The man was no stranger to the criminal justice system and had spent several
periods of time in custody for a range of offences. He lived in Manchester and
had a close relationship with his family: his mother and daughter in particular.
The man had been charged with four counts of attempted murder and three of
possessing a firearm with intent to endanger life, offences alleged to have
occurred in his home town. Due to the seriousness of the offences, the man
had been given the highest security status, category A.
The man’s victims were thought to have associates in HMP Manchester.
Because of his category A status, the possibility that he would help the police
identify his accomplices, and the fear of retribution from the victim’s relatives,
the Prison Service moved the man from Manchester to HMP Wakefield.
On the 5 February 2004, the man arrived at Wakefield. During initial health
screening procedures, the man said that he had self-harmed in 1998 by
making a cut to his wrist. He told the drug workers that he had a drug and
alcohol history.
The man was held on the remand wing at Wakefield, as he awaited trial. On
13 March, the man was placed on an open F2052SH (suicide and self-harm
monitoring procedures), after feeling suicidal, threatening to cut himself and
for making ligatures. The suicide and self-harm form was closed on 8 April.
On 12 July, the man alleged that one of the staff at Wakefield was harassing
him. He said that the officer had issued threats against him and had allegedly
assaulted him in a cell at Crown Court during an incident - at a court
appearance that day - for which the man had been charged under the Prison
Rules.
On 1 August, the man was moved back to Manchester for his trial. He was
sentenced to 20 years imprisonment on 4 August and stayed at Manchester
until his return to Wakefield on 6 August.
At the prison disciplinary adjudication relating to the events of 12 July, the
man pleaded guilty to abusing the officer and accepted the officer had not
assaulted him. As a result of this disciplinary hearing, along with one for
failing to take a Mandatory Drug Test on 9 August, the man was moved to the
segregation unit on 10 August.
Despite the presence of good policy documents, there are a number of issues
raised by this investigation. Wakefield needs to address a variety of matters,
particularly in its relatively new role as an establishment that holds
unconvicted prisoners.
5
The independent Clinical Review suggests that the man received a high level
of clinical care whilst at Wakefield, although, there remain areas for
improvement. The Clinical Review specifically highlights the training and
development of staff.
This report makes seven recommendations.
6
Investigation Outline
A Prison Service Governor was the Senior Investigating Officer. He was
assisted by a Principal Officer (PO). The investigation was co-ordinated by
one of my investigators.
The investigators visited the prison and were shown the areas where the man
would have been, including reception and induction, the healthcare unit, the
segregation unit and the wing on which the man was located.
They issued a notice to staff and prisoners inviting anyone with information
relating to the man’s death to make themselves known to the investigation
team. A number of prisoners came forward, as did a member of staff.
At both HMP Wakefield and HMP Manchester, the investigators spoke to the
Chairs of the Prison Officers’ Association and Independent Monitoring Board,
the prison chaplains, and various members of prison staff. They formally
interviewed ten members of staff and relied upon statements made to the
police for two others. Additionally, 15 prisoners were interviewed. Two
prisoners declined to assist the investigation.
Wakefield gave the investigators full access to all the documentation
surrounding the man’s time in prison. The police also provided copies of the
documents and statements in their possession. The investigators obtained
some further information from the probation and court services.
The investigators and the lead-investigating officer from West Yorkshire Police
met the man mother and brother, with the family’s solicitor.
Finally, the investigators commissioned the Prison Health Commissioning
Manager for the Wakefield West Primary Care Trust, to conduct a clinical
audit of the man’s care while in prison.
7
Background
The man
The man was born on 26 June 1976 in Manchester. He had 13 previous
convictions dating back to 1990. These convictions represented 34 offences.
Apart from periods on bail and remand, the man’s last recorded sentence of
custody was served at HMYOI Deerbolt, from which he was released on
licence on 3 November 1995.
Wakefield Prison
Wakefield holds mainly life sentence prisoners, with the focus on serious sex
offenders sentenced to four years or more. It recently took on a remand
function for potential category A prisoners. This unit is located on Bravo wing,
where the man was placed for the majority of time.
The prison provides workshops and an education department, offering both
full and part time education. The programmes department offers a range of
offending behaviour courses including FOCUS (Anti-drug taking programme),
the Sex Offender Treatment Programme and the Enhanced Thinking Skills
programme.
On the date of the man’s death, the prison roll was 553. The population broke
down as:
Life Sentence Prisoners 404
Determinate Sentence Prisoners 139
Category A prisoners 91
Potential category A prisoners 10
The roll on F wing (which includes the segregation unit and close supervision
centre) was 19 and there were 11 prisoners at Wakefield on open F2052SH
documents.
Wakefield was last subject to a Security and Standards audit in June 2004, at
which time it received a good rating. A more detailed review of the findings of
this audit, in respect to the man’s death, is contained later in this report.
8
View of Her Majesty’s Chief Inspector of Prisons
The Chief Inspector conducted a full inspection of Wakefield in October 2003.
Relevant findings are set out below.
Segregation Unit
HMCIP made three specific recommendations regarding the segregation unit:
1) Prisoners located in the segregation unit should receive daily access to
showers.
This is now the case in the segregation unit and was so when the man was
located there.
2) The medical officer should visit all prisoners in the segregation unit on a
daily basis.
This has been implemented for some time. A healthcare professional
(nurse or doctor) sees every prisoner in the segregation unit daily.
3) A monitoring system should be implemented to ensure that all sections of
Rule 45 (segregation under Good Order and Discipline) documentation are
completed appropriately.
Wakefield has implemented a series of management checks to ensure
these documents are completed correctly.
HMCIP made some other general comments about the segregation unit,
which was described as a place where prisoners were closely supervised and
movements were tightly controlled. Documentation was generally completed
to a good standard, and appropriate monitoring of prisoners’ physical,
emotional and mental well being took place.
The Chief Inspector’s report raised concerns at the number of prisoners
making allegations of intimidation or bullying. She acknowledged that alleged
assaults had been subject to appropriate levels of investigation, but registered
disquiet about the number of complaints made by prisoners.
Prisoner Disciplinary Procedures
HMCIP reported that they saw no evidence of intimidatory behaviour towards
prisoners who had been escorted to the segregation unit for adjudications.
The number of adjudications for a prison the size of Wakefield was low. They
observed that adjudications were conducted in a respectful manner and at a
pace to suit the individual needs of the prisoner. Prisoners were given every
opportunity to present their account of alleged incidents, call witnesses and
contact their legal advisors. There were some minor housekeeping points, but
generally HMCIP gave a very positive account of the operation of the
adjudication procedures.
9
Only two recommendations were made:
1) On receiving an adjudication punishment, prisoners should be issued with
written details explaining the appeal process.
This has been incorporated into the local adjudication procedures at
Wakefield.
2) Where pleas of mitigation are made, they should be taken into account by
the adjudicator when considering a punishment.
Tariffs including possible mitigating circumstances are raised at the regular
adjudication meetings.
Anti-Bullying
HMCIP concluded that the systems and procedures put in place to deal with
bullying were thorough and appeared to work effectively. Prisoners were
actively involved and most staff had a good knowledge of the anti-bullying
strategy. The Suicide Prevention and Anti-Bullying team dealt with
investigations efficiently and ensured that the victims received adequate
support. However, the sound casework being carried out by members of the
team would be enhanced if they were given the opportunity to participate in
specialist training. The absence of programme work was seen as a
weakness.
Three recommendations were made:
1) An annual prisoner survey on bullying should be carried out. The results
should inform all service developments in this area.
This has been accepted by the prison and will take place. A number of
other prisoner surveys, including the Measurement of the Quality of
Prisoner Life (MQPL) are also undertaken.
2) Members of the Suicide Prevention and Anti-Bullying team should
participate in specialist training relevant to their role.
A review of the training needs for SPAB team members has taken place.
Additional training courses have been identified as suitable to enhance this
role.
3) Prisoners identified as bullies should have the opportunity to participate in
programme work.
The prison also accepted this, and prisoners who have been identified as
bullies or possible bullies will not automatically be refused access to
treatment programmes, but will be individually risk assessed.
10
Preventing Self-Harm and Suicide
The HMCIP team said that, “Prisoners at risk of self-harm and suicide were
well managed by a multi-disciplinary team at Wakefield. A strong leadership
style and much good practice was evident.”
Three recommendations were made:
1) Care should be taken to record accurately and in detail the content of each
case conference in the F2052SH (the document used to monitor those at
risk of suicide or self-harm).
This has been accepted by the establishment which will task managers to
check this on their routine reviews.
2) Support plans for prisoners subject to F2052SH procedures should be
specifically tailored to meet the needs of the individual.
Again this has been accepted by the establishment which will task
managers to check this on their routine reviews.
3) Information obtained from the final management check undertaken on the
closure of an F2052SH document should be fed back to the Suicide
Prevention Committee to inform future policy and decision making.
The prison also accepts this recommendation and this information is now
fed through the Committee.
HMCIP also noted two areas of good practice:
1) Suicide Prevention and Anti-Bullying officers interviewed all new
receptions upon arrival at Wakefield to assess their risk of self-harm to
themselves and to others.
2) The Head of Residence conducted a final management check on all
closed F2052SHs to check quality. Areas of concerns were followed
through, with the Head of Residence personally advising staff of the
standards expected.
11
Security and Standards Audit
The investigators reviewed the Final Report of a Combined Security and
Standards Audit held at Wakefield in June 2004. This is a report published
after a comprehensive audit from the Prison Service Standards Audit Unit.
(Standards Audit Unit is part of the internal audit arrangement providing
assurance to line managers and the Director General on the performance of
public sector establishments.) Wakefield will be audited against Security
Standards each year and against all other Standards every other year.
Wakefield scored as follows:
(cid:1) 87% Standards
(cid:1) 88% Close Supervision Centre
(cid:1) 92% General Standards (Critical Baselines)
(cid:1) 92% Security
In respect of the standards that have specific relevance to this enquiry, the
audit produced the following results:
Adjudications
All prisoners receive the Notice of Report (F1127) with enough time to prepare
for the adjudication. The adjudicating governor records all relevant
information. There was one case in which an issue relating to legal
representation had been omitted. However, as this had been dealt with on
appeal to the Deputy Director General’s office a year ago and there has been
no recurrence, it was not treated as non-compliant.
Complaints Procedure
All prisoners have easy access to the Request / Complaints (R & C) forms in
open and confidential access formats. These are kept in all accommodation
areas alongside the posting boxes. These boxes are opened on a daily basis
and this is recorded by the R&C clerk on the register, along with reply dates.
There were a small number of R&C’s that did not meet the timescale, but a
99% return rate is commendable by any standard.
Safer Establishments
An Operational Manager has been appointed as the Anti-Bullying Co-
ordinator. No evidence was found that any unexplained or non-accidental
injuries have not been investigated and action taken as a result. The
Healthcare Centre (HCC) is the only area of the establishment that has multi-
occupancy rooms. It is imperative that cell sharing risk assessments are
properly completed and considered prior to prisoners being allocated into
these rooms.
12
Segregation of Prisoners
A staff selection policy is in force for the Segregation Unit, F Wing. All
authorisations for the use of segregation have been properly completed by the
appropriate grade of Operational Manager. There are some gaps in the
recording of “Governors Rounds”, although each prisoner held in the
segregation unit is seen by a member of the Healthcare Department daily.
Three Segregation Safety Algorithms for prisoners currently held in F wing
were not fully compliant.
Suicide and Self-Harm Prevention
Most baselines audited were found to be fully compliant, with only minor
action identified for those that were not. Evidence was found of one prisoner
not being seen by a doctor until three days after arrival. All cases of identified
risk, or actual self-harm, resulted in the activating of F2052SH procedures.
13
Measurement of the Quality of Prison Life
The Measurement of the Quality of Prison Life (MQPL) is a confidential survey
of prisoners developed by the Prisons Research Centre at the University of
Cambridge. It is now an essential component of the performance
measurement tools used by the Prison Service, and represents a quantitative
measure of the qualitative aspects of prison life. The survey is carried out by
a research team of psychologists from the Standards Audit Unit to assess
prisoners’ perception of their quality of life within establishments.
The survey results at Wakefield tend to support some of the findings of the
inspection by HM Chief Inspector of Prisons. They show that there is good
work going on with prisoners to address offending behaviour and that the
prison is clean with reasonable facilities for prisoners. There are, however,
tensions between some prisoners and certain staff, who are seen by prisoners
to be disrespectful and failing to meet the needs of the individual.
14
Chronology of Events
30 January 2004 – 10 August 2004
The man was initially arrested on 30 January 2004. He was charged with two
counts of attempted murder and appeared at Magistrates’ Court on 2
February. He was remanded into police custody, later being charged with a
further two counts of attempted murder and with three counts of possessing a
firearm with intent to endanger life. He was further remanded in custody and
was sent for trial at Crown Court, making five further appearances before his
trial commenced on 2 August 2004.
Two of the four charges were for crimes against members of a particular
family, whose associates were thought to be in prison in HMP Manchester.
Due to the nature of the charges, which involved the use of firearms, the
man’s security category was assessed and he was, made a potential
Category A prisoner. On the strength of this, and the possibility that he would
help the police identify his accomplices, he was taken to HMP Wakefield.
Wakefield had only recently taken on the role of holding remand and untried
prisoners who were subject to Category A.
On 5 February, the man arrived at Wakefield where he was located in the
Health Care Centre (HCC) as required by the local Suicide Prevention Policy.
The following day, he was reviewed under the Suicide Prevention and Anti
Bullying procedures and moved to B wing where the remand prisoners are
located. Here he again underwent Suicide Prevention and Anti Bullying
assessments and an induction interview. The man had no immediate
problems or concerns, other than getting in touch with his family. However,
during an interview with the establishment’s Suicide Prevention and Anti
Bullying team, the man said that in the past he had been subject to bullying
albeit not in prison.
During initial health screening procedures, the man said that he had self-
harmed in 1998, making a cut to his wrist. However, he said that this was not
a concerted effort more a ‘cry for help’.
A member of the prison CARATS team assessed the man shortly after his
reception to Wakefield. (CARATS provide a drug counselling, referral and
advice service.) Reports indicate that he was quite open and willing to
discuss his previous drug and alcohol history and was willing to address these
issues whilst in custody.
CARATS reports say that the man’s drug misuse dated back 15 years, using
cannabis daily. His use of cocaine and ecstasy was less regular, although
quite substantial, mainly on weekends or at social gatherings. The main
problem highlighted was alcohol abuse. The man said that he had tried
several times to cut down but had failed to do so.
The man was located on B wing, the remand unit, from 6 February to 13
March, during which time he displayed a reasonably positive approach and
15
attitude. He was placed on adjudication during this period for a positive
Mandatory Drug Test, but the charge was subsequently dismissed.
On 13 March, the man rang his cell bell and said that he was suicidal and
would “slash up”. He was located in a “safer cell” in the HCC, which was
constantly monitored by CCTV, and an F2052SH was opened.
On 14 March, whilst located in the HCC, the man commenced a “dirty
protest”. During this episode, the man used his inhaler to “give himself a
buzz” but later that day destroyed the inhaler. The inhaler was then taken off
him and from then on only issued to the man on request.
On 15 March, he rang his cell bell and told staff that he had removed the
elastic strip from his underpants and made a noose. He quickly handed this
over to the staff. On 16 March, the man ripped a blanket and fashioned a
ligature which he fastened around his neck. When staff challenged him, he
again handed over the ligature. These actions were accompanied by shouting
and ringing of the cell bell, ensuring staff were aware. However, he then went
on to make another ligature. At 3:20pm the man ceased his dirty protest, then
showered and was relocated to a clean cell in the Segregation Unit. The
Safety Algorithm was completed by a doctor, but not countersigned by a
governor grade. However a Governor signed the Rule 45 paperwork,
authorising segregation at 4:00pm that day.
On 17 March, the man was adjudicated upon for offences against Health and
Safety. On 18 March, he was subject to adjudication for failing to comply with
unit rules and was punished with seven days at half pay.
Also on 18 March, the man said that he had swallowed a razor blade after
making a small laceration to his left wrist. He first refused treatment, but later
agreed to allow the medical staff to treat him. He was seen by a doctor who
recommended he be taken to an outside hospital for x-ray, but as a non-
emergency case. The man made a further small cut to his thigh that
afternoon. On 19 March he was escorted to hospital and received treatment
for the alleged swallowed razor blade, but no blade was recovered.
On 24 March, the man was moved to another cell and given a television. The
man’s attitude changed for the better and he told staff that he was feeling
much brighter and in better spirits.
Between 19 and 31 March, the man remained located on F wing and his
behaviour improved to an acceptable level with no further incidents of note.
The officer on night duty on 29 March in the segregation unit when the man
asked for his inhaler, refused to provide it until the day staff came on a short
time later. The officer on night duty recalls this clearly and admits that he did
not give the inhaler to the man as the day staff were due on very shortly. He
said that they would be able to deal with this issue, as they were fully aware of
the circumstances surrounding the man’s medication. The Segregation Unit
Observation book records this incident as occurring at 7:00am. This would be
16
only a matter of minutes before the day staff would relieve the night duty. He
had previously give the man his inhaler (on 27 March), as this request had
occurred during the night.
On 31 March, the man moved back to B wing. Following a settled period,
coupled with an improved attitude and increased interaction with wing staff
and peers, the man’s F2052SH was closed in his absence on 8 April.
He was further reviewed seven days later and then fourteen days later. The
Head of Residence formally reviewed the quality of monitoring, and the
recording of events in the F2052SH booklet, on a management check sheet.
The man spent the following months located in B wing’s remand unit. He
received reasonably positive reports from unit staff throughout this period. It
appears that he was a regular user of the gymnasium and exercise periods.
He also received several visits from his solicitor.
On 12 July, the man alleged that the officer who had been on nights (29
March) assaulted him in the cell area of the Crown Court. In evidence, the
officer recalled the incident. He said that the man asked him for a light, to
which the officer replied that neither he nor the other member of staff (a PO
from Manchester) smoked or had any matches. The officer said that the man
then became abusive and threatening, even asking the officer to come into
the cell to settle the matter. The officer also recalls a member of the man’s
legal team asking him for his identity details, as a complaint would be made of
assault on the man. In fact, no formal complaint was received from the man’s
legal team; nor did the man raise the matter by any of the other formal
complaint channels.
The officer placed the man on a disciplinary charge for being abusive.
He works in the Operations Department at Wakefield, where he is a Category
A vehicle driver / navigator. His main duties would take him out of the prison
driving prisoners to court or to other prisons. Apart from being on duty in the
court cells, he would have few dealings with the prisoners on the escort. The
officer would have little regular contact with prisoners on the living units, apart
from occasional duties on the wings, and he would be on the roster for night
duty. There is no evidence of continued contact between the officer and the
man after this incident, and none to suggest that the officer assaulted the man
or treated him unprofessionally at any time.
On 1 August, the man was transferred to HMP Manchester for the
commencement of his trial at the following day. On reception at Manchester,
the man was located in the segregation unit for his own protection. A
Segregation Safety Algorithm was completed by a nurse and the decision
confirmed by a Governor. No medical concerns were raised and the man was
deemed fit for segregation.
The man was taken to court on a daily basis. On 4 August, he was sentenced
to 20 years imprisonment. On 6 August, the man returned to Wakefield and
17
was located in B wing. Between 6 and 9 August, prison staff documented that
the man was shocked at the length of his sentence, and that “it would take
sometime to sink in”. However, the staff did not consider the man to be a self-
harm risk.
On 9 August, the man was selected to take a targeted drug test. He refused
to take the test which requires the prisoner to give a urine sample. There had
been intelligence on the man, suggesting that he was involved in the provision
of drugs at Wakefield. the man was placed on a disciplinary report.
On 10 August, the man was taken to F wing (the Segregation Unit) for two
adjudications:
1. Rule 51, Paragraph 22 – Uses threatening, abusive or insulting words or
Behaviour. This related to the incident at Crown Court. The hearing of
this charge had been delayed on three previous occasions, the first two on
14 and 22 July, to allow the man to seek legal advice, and again on 30
July due to one of the witnesses being unavailable. The officer attended
the hearing to give evidence. The man pleaded guilty to this charge and
admitted that the officer had not assaulted him. The charge was proven
and a punishment of 28 days stoppage of earnings at 50% was imposed.
2. Rule 51, Paragraph 20 – Disobeys or fails to comply with any rule or
regulation applying to him. The man had refused to attend the Mandatory
Drugs Testing Suite for a drug test. The man pleaded guilty to this charge,
and when asked why he had refused the order he said, “I didn’t sleep until
5:00am and I haven’t had any drugs, I’m on voluntary testing”. The charge
was proved, with a punishment of seven days cellular confinement (CC),
exclusion from work, loss of association, loss of occupations in cell, and
loss of possessions in cell.
The man was located in cell F3 –11, and was subject to hourly checks, which
commenced at 12:00 noon.
A Segregation Safety Algorithm was completed by the locum prison doctor.
He confirmed that the man was not at risk and could be made subject to CC.
After the man’s death, the locum prison doctor wrote a memorandum to the
Governor, dated 11 August, confirming that he did not consider the man to be
at risk of self-harm, but saying that he thought that the man would be located
in one of the cells which has continuous camera monitoring as he thought was
standard practice. This is not recorded on the safety algorithm.
In a statement to the Police, the locum prison doctor said that whilst the man
did not display any signs of anxiety he advised staff that he did not believe the
man and that he told staff to put the man in a cell with camera cover. The
doctor says that he recorded this in the man’s Medical Record. However,
there is no record of any such entry.
If the doctor had any concerns over the man, he would have been expected to
complete the safety algorithm and to advise the adjudicating governor that the
18
man was not fit for CC. Also, he would have been expected to advise that the
man should be placed under the care of the F2052SH protocols or that the
man should be located in the Health Care Centre. The man had previously
been located in HCC, following an earlier self-harm attempt.
There is no evidence to suggest that the doctor had articulated his concerns
about the man to staff. Unfortunately, the locum prison doctor was not
available to be interviewed by the investigation team.
Discovery of the man
There is evidence of hourly checks made by F wing staff, commencing at
12:00 noon on 10 August, the last recorded entry being at 11:01pm. There
are no entries in the Staff Observation Book to indicate any notable actions or
changes in the man’s mood or behaviour. Indeed, there is only one entry in
the Staff Observation Book on F Wing for the whole of 10 August.
In evidence, an officer on night duty remembered carrying out these hourly
checks, saying that at 10:00pm, the man, “was sitting on his sink with his feet
on the chair, looking out of the window. There was nothing wrong with that
because a lot of them do. At 23:00pm, in the same position, he turned round,
acknowledged me, gave me a wave.”
The night duty officer said that he returned to the cell at approximately three
minutes past midnight, and saw the man hanging with a ligature around his
neck.
The night duty officer explained that he attempted to rouse the man by
shouting and kicking the door, but to no avail. He then went to the wing office
and contacted the orderly officer, by telephone. The night duty officer then
contacted the control room, which in turn alerted the paramedics and later the
police.
On receiving the telephone call, the Orderly Officer summoned two officers
from other posts and attended F wing. This is consistent with the local policy.
It took seven or eight minutes to arrive at the man’s cell.
Once the other officers had arrived, the night duty officer broke F wing’s
sealed key pouch and opened the cell door. As a security measure, staff on
nights do not routinely carry cell keys. Instead they are held in a pouch, which
is sealed. The seal must be broken to access the keys and this must be
formally recorded. The two officers that responded lifted the man, easing the
pressure from the ligature, which was fashioned from a bed sheet. The night
duty officer cut the ligature using ligature scissors. The man was then placed
on the cell floor on his back.
At this stage, a Healthcare Officer arrived. His initial assessment was that the
man “was pale in colour, with evidence of cyanosis in the facial area. No
breathing, no pulse and pupils were dilated”.
19
The officers who responded commenced CPR. At 12:16am, paramedics
arrived at the establishment and were escorted to F wing where, they
continued the resuscitation attempt. The paramedics ceased CPR at
approximately 12:40am.
In the meantime, the control room contacted the duty governor, and the duty
doctor. The duty governor arrived at 12:46am and the doctor at 12:55am.
Both attended the cell. At 1:10am, the doctor pronounced the man dead.
When staff left the cell at about 1:10am, orderly officer locked it and told staff
that the cell was to remain sealed, as it constituted a possible crime scene.
He confirmed that nothing had been removed from the cell.
At 1:51am, the police were informed and immediately informed the Coroner.
At 2:15am, a Police Constable from West Yorkshire Police arrived, followed at
2:25am by Detective Constable Cadman. At 3:00am, a Detective Sergeant
and Scenes of Crime Officer arrived at the prison.
The undertakers took the man’s body from the establishment at 4:54am, and
the establishment was secured at 4:59am.
Prison staff, the National Operations Unit and Press Office were contacted
according to the establishment’s contingency plans.
20
Prisoners’ and Staff Views
There is a remarkable consistency in the views of both staff and prisoners
about how the man presented himself in public. He was, to those who came
across him, a fairly self confident young man, slightly cocky, who gave the
impression of being anti-authority and generally “prison wise”. He did not give
the impression of being an individual who would allow himself to be bullied or
harassed, either by prisoners or by authority figures. This picture is one
which, in the main, would be supported by his family.
It is clear that staff and prisoners thought that the man did not constitute a risk
of serious self-harm and certainly not suicide, despite his self-harm attempts
in March 2004, and being on a F2052SH form 13 March to 8 April.
The prisoner who probably knew the man best was with the man at Wakefield
and Manchester. Indeed he shared a cell with the man at Manchester. He
claims that the man was generally in good spirits and mixed well with most
staff and prisoners, but was susceptible to mood swings when things did not
go his way. He did not particularly like being at Wakefield due to the high
number of sex offenders located there, a point the man made publicly. He
also did not like being at Wakefield because it made it difficult for his family to
visit.
The prisoner recalls at least two occasions when the man reacted angrily to
being denied access to a radio and to a light for his cigarette. The man’s
response was hostile and volatile, but the prisoner says these outbursts were
short-lived and the man would quickly regain his composure and return to a
more reasonable relationship with staff and prisoners. Staff who knew the
man generally endorse his conduct.
A B wing officer knew the man reasonably well. Apart from the man being
slightly immature and having the odd “blow up” if he did not get his way, he
said the man was a reasonable prisoner who did not present as being
particularly difficult to staff. At that time, there were no personal officers
assigned to specific prisoners. The Incentives and Earned Privileges
assessment of the man, and the F256C Conduct Report prepared for the
adjudicator, support this.
The B wing officer said that, if anything, the man would be more likely to sulk
and certainly did not react with physical violence. However, he would add the
odd threatening comment about his contacts on the outside, and told staff that
they should not forget that he was in for firearms offences. These comments
were seen as bravado not serious threats.
Whilst both men were at Manchester, the prisoner who was closest to him
claims the man appeared to be fine although concerned about certain aspects
of his case. He expected a long sentence but, given that he did not regard
himself as the main culprit, and no one had died, he thought that he would
receive about eight to ten years. There is little doubt that he was shocked by
the sentence of 20 years imprisonment.
21
The man was, to a great extent, consumed by the effect that his incarceration
would have on his family, and on his daughter and mother in particular. The
prisoner who was closest to him says that the man kept returning to this, time
after time, despite his efforts to keep up his spirits. The man showed
particular concern for his mother and dwelt on the point that he would not be
in a position to help her should she became ill, coupled closely with the fact
that his imprisonment itself might well have a negative impact on his mother’s
health.
Whilst the prisoner who was closest to him said the man never exhibited any
signs of self-harm or suicide, he believed that underneath his rather brash
exterior the man had real doubts about his ability to cope with the effects that
his sentence would have on his close family. The man also showed this frailty
to the wing SO, who can recall the man crying his cell in the segregation unit.
She is unable to remember the date, but it was before the man was sentenced
and during a conversation about the man’s mother. She did not consider it
necessary to open a F2052SH.
Another prisoner who knew the man well was an elderly prisoner who has
spent a considerable period in custody, the last eight years of which at
Wakefield. He acted to some degree as a father figure to the man, who would
seek him out for advice. They met in the HCC and later on exercise. He
describes the man as being troubled and fidgety, with considerable nervous
energy.
The man explained that he had come to an agreement with the police
whereby, if he were to assist the investigation, this would mitigate the
sentence he would be given at court. According to this prisoner, the man
considered this would mean nothing more than 12 years. The 20 year
sentence was described by as “a year for every bullet fired”. The man still
gave the impression that he could handle this and would have the sentence
reduced on appeal. This prisoner thought that this was a smokescreen and,
in reality, the man was not as resilient as he would wish people to believe.
There are recurring themes about the man, as detailed by prisoners. These
include the heavy sentence, being so far from his family and the ‘difficulty’ with
the officer on the escort.
A number of prisoners were particularly critical of the “culture” amongst some
staff at Wakefield. All prisoners said that the prison had a considerable
number of staff who treated prisoners well and did their best to help them.
However, some prisoners said that a minority of staff did not want to work
constructively with prisoners and appeared to go out of their way to make life
more difficult.
A prisoner thought that staff should have responded differently to the man’s
situation. Given that he had just been given a very long sentence, and that
the man had been seen talking to the Samaritans, they should have given the
man some latitude and not gone ahead with the adjudication on 10 August.
22
Another prisoner held the view that the man should have been offered more
assistance, as he thought that the man was suffering from clinical depression.
Even if staff could not identify a mental health issue, they should have been
able to detect that the man was having difficulties in coping with his situation.
Another prisoner was particularly critical of the environment at Wakefield and
in particular a range of uniformed staff who he said “ran the prison” for their
own benefit, regardless of management’s instructions. He cited an example
of how staff had allegedly flouted the express orders of the Governor. He
made great play on the incident with the officer at court and told the man “that
he should take it all the way”. He admitted that there was many good staff at
Wakefield, but the bullies and rogue elements amongst their colleagues
overshadowed them. (The investigation team are unable to confirm any of
these allegations. They are reported here because they formed part of the
evidence to this inquiry.)
Three prisoners made specific reference to the Segregation Unit at Wakefield.
They described it as an intimidating place, where prisoners are over controlled
and can be subject to over zealous behaviour by staff. However, two other
prisoners declared that they have not encountered any difficulty with either
prisoners or staff in the Segregation Unit.
Although there are differing views about the culture at Wakefield and whether
sufficient attention was given to the man’s perceived problems, not one of the
prisoners suggests that the man had been subject to any inappropriate actions by
staff whilst he was in the Segregation Unit.
23
Non-Medical Assessments
The following assessments were made about the man during his time at
Wakefield.
Anti-Bullying Questionnaire
This form is self-completed by the prisoner and is returned to the Programmes
Department (Psychology) for evaluation.
The man completed and returned this form which was undated. The man said
that he had been subject to bullying at Wakefield. He specifically mentioned
two occasions where he had been badly treated by the officer who placed him
on report, once because he was refused his inhaler, even though he required
it, and once when he was at court. The man claimed nothing was done about
the bullying and said that it did not always pay to report this activity, as there
was a risk of suffering further retribution.
Cell Sharing Risk Assessment
This form is completed at all prisons before prisoners are placed in shared
cells. It was completed at Manchester when the man returned for the start of
his trial. The assessment was dated 1 August. Based on answers from the
man and his available records, the man was assessed as a medium risk to
others (no immediate risk but situation to be reviewed regularly).
The HCC assessed the man as low risk (no current indication / evidence of
risk, suitable for multi-cell occupation). It was noted that he had previously
self-harmed, but stated that although depressed he was not suicidal, and the
medical officer should review him. There is no evidence that this took place.
However, he was assessed by the doctor, on 6 August, on his return to
Wakefield. The assessment expressed no concerns.
Risk Assessment for Court
Completed on 1 August, this is information for staff escorting a prisoner to
court or transferring to another prison. The assessment records that the man
should continue to be treated as a “Standard Risk Cat A prisoner” without any
requirement for special measures. It contains details of:
(cid:1) a general security assessment,
(cid:1) behaviour in prison,
(cid:1) physical security of court,
(cid:1) any criminal and offence issues,
(cid:1) visiting arrangements,
(cid:1) specific factors of concern, including escape history,
(cid:1) and analysis of the assessment.
24
Suicide Prevention and Anti-Bullying Proforma
Completed on 6 August on the man’s return to Wakefield from Manchester
after sentencing, this form records that:
(cid:1) an at risk of self-harm procedure F2052SH was not open,
(cid:1) the man had a history of self-harm,
(cid:1) the man had never made a serious attempt on his own life,
(cid:1) he had no history of being a bully, but had been a victim of bullying outside
of prison,
(cid:1) there was a history of drug abuse,
(cid:1) there were no current health care screening problems identified.
The assessment adds that the man had been on remand at Wakefield and
had been sentenced to 20 years on 4 August. The assessment said that he
was feeling a little depressed, as he realised that he was going to miss out on
his children growing up. The man was not on a F2052SH, but said that he
would not do anything stupid because of his children. The assessor reported
good eye contact with the man, who was also very talkative.
F Wing / CSC Behavioural / Activity Risk Assessment Record
This is a local form, completed on 10 August, devised to set the staffing levels
required to supervise specific prisoners during specific activities. It is used
more in respect of prisoners who are held in the Close Supervision Centre
and segregation unit.
It sets out the control measures in place and identifies any potential hazards
and actions to minimise risk. In respect of the man, it notes he was newly
sentenced, and would need to be monitored on a regular basis and given
ongoing support by staff. The assessment puts the risk factor as low, the
probability of any hazard as low and the severity of any hazard again as low.
It also records that the man should be given a “pool” radio, his canteen goods
and access to books and writing material. He should also be monitored
hourly.
The investigation team were told by the present Governor of Wakefield that
this form was not in fact completed on 10 August 2004, but that staff had been
ordered to complete the form, by the unit manager, the day after the man’s
death. On 9 August 2005, the Governor began a full internal disciplinary
investigation.
There is, however, ample evidence that the man received the identified
actions to minimise risk, i.e. he was monitored hourly and had access to the
items mentioned. Should the man have survived, the HCC staff would also
have seen him daily. The assessment was to some extent superfluous, as the
man had never constituted a serious control problem and did not require
additional staffing or special conditions to be unlocked, take exercise or at
mealtimes.
25
CARATS
This is an assessment process to determine the level of substance misuse by
a prisoner, and to offer support and guidance on how prisoners can manage
and curtail their addiction.
The man co-operated with the CARATS workers and told them of his misuse
of various drugs during an interview on 25 February. He had used cannabis,
cocaine, and ecstasy. He said that he did not take heroin, neither did he inject
any drugs. The man said that drug misuse had caused depression, panic
attacks and anxiety.
The most significant misuse was of alcohol, which caused the man to suffer
from alcohol poisoning, gastric enteritis, weight loss and ulcers. The misuse
of alcohol was considered to be the man’s main problem.
He said that he benefited from continued family support, and that he would be
willing to do drug related courses whilst in prison if convicted but, at that time,
did not wish any intervention by the CARATS team.
Life Sentence Planning
This is a short assessment, designed to identify prisoners who by nature of
the offence, may be given a life sentence. The man completed this on 11
February, when he said that he felt relaxed and safe in comparison to life “on
the out”. He gave details of his offence and that he intended to co-operate
with the police investigation. He confirmed that he was not subject to the self-
harm procedures, but admitted that he had attempted self-harm some seven
years previously following a split with his girl friend. He also recalled an
incident when he was felt depressed whilst in Wymott prison. The man
expressed no concerns about his current location on the remand wing and did
not require any specific support.
The man gave information that he currently had no co-accused, but that he
would be giving the police information to assist them to arrest his
accomplices.
It is clear from the range of assessments completed on the man that he had
problems of substance misuse and had bouts of anxiety. On occasions, this
manifested in sporadic, but somewhat token, episodes of self-harm. He did
not present to anyone as being liable to sustained and serious self-harm and
definitely not suicide. This is certainly the view of those who knew the man in
custody and that of his family.
Segregation Safety Algorithm
These documents are completed on every occasion a prisoner is placed in the
segregation unit. Either a registered nurse or doctor must complete parts A
and B. The final decision as to whether an individual is deemed suitable for
location in the segregation unit or to be subject to a punishment of cellular
26
confinement is made by a governor grade. These forms were completed as
follows:
18 9:50 Completed by a nurse, pre-adjudication. Governor
February am adjourned the adjudication and authorised the man to be
held under 24hr watch (CCTV) to monitor his behaviour.
16 3:45 Completed by a doctor, but not countersigned by a
March pm governor grade. However, a governor signed the Rule 45
paperwork authorising segregation at 4:00pm, that day.
14 9:40 Completed by a nurse and confirmed by a governor. The
July am man was deemed fit for segregation and no concerns
were raised.
1 9:30 Completed by a nurse and again the decision confirmed
August am by a governor. No medical concerns were raised and the
man was deemed fit for segregation.
10 9:25 Completed by a nurse and countersigned by governor.
August am This was prior to the adjudication and it confirmed that the
man had no issues or concerns and did not require HCC
intervention.
10 10:25 This was the second algorithm completed on that morning.
August am This time the form was completed by a doctor, to confirm
that the man was not only fit to be held in the segregation
unit but was also fit to undergo cellular confinement, if
imposed at the adjudication. The doctor noted that the
previous algorithm discounted any HCC intervention, that
there was “no compelling reason not to segregate”, and
that the man should be afforded access to HCC, chaplain
and a governor each day. A governor again confirmed
this position.
As referred to in page 21 of this report, the doctor wrote a memorandum to the
Governor following the man’s death.
27
Medical Care
The Prison Health Commissioning Manager at Wakefield West Primary Care
Trust, conducted the clinical review as follows:
(cid:1) Review the quality of assessments regarding the man’s mental and
physical health.
(cid:1) Review the appropriateness of any treatment that was given to the man,
for his mental and physical health.
(cid:1) Review the appropriateness of his location / accommodation particularly
the levels of observation.
Quality of Assessments
The clinical reviewer considers that the mental health assessments carried out
by the prison’s healthcare team were of a high quality and carried out by
appropriately qualified healthcare practitioners i.e. Registered Mental Nurses.
Similarly, all other clinical assessments undertaken by both nursing and
medical staff were also of good quality and the assessors were appropriately
qualified to complete these assignments. He notes that there is effective
multi-disciplinary team working which is evidenced from interview and a
review of the records.
The implementation of the procedures for the prevention of self-harm, as
described in the F2052SH instructions was appropriate at the relevant times.
Treatment for Mental and Physical Health
The clinical reviewer concludes that the prescribed and given treatments were
appropriate and well considered. No additional clinical treatments or
psychiatric referral (to specialist mental health trust psychiatrists) would have
been appropriate or indicated at the material time.
Appropriateness of Location / Accommodation
The man’s various prison locations were appropriate at that time, i.e.
appropriate utilisation of the HCC, followed by location in the Segregation Unit
following the man’s “dirty protest”.
The man was comprehensively clinically assessed whilst in the HCC. HCC
staff intervention and relocation to the segregation unit was appropriate on all
occasions.
The decisions taken to determine observation levels in the HCC and the
Segregation Unit were well considered and appropriate. From interview and
examination of the records, the staff consistently carried out the agreed
observation levels.
The clinical reviewer’s audit of the man’s clinical care strongly suggests that
the man received a high quality of both physical and mental health
28
interventions from the staff at Wakefield. He was not an individual with
serious or chronic mental health issues. He was also in reasonable physical
health.
Despite the very positive overview of the man’s clinical treatment, the reviewer
makes six recommendations.
1. All members of the HCC team should be up-dated on their Emergency Aid
training.
2. Members of the Segregation Unit should be competent in Emergency Aid.
3. Sufficient members of both the HCC and Segregation Unit teams should be
trained in the proficient use of defibrillators.
4. The F2052SH at Risk of Self-Harm Policy and Procedures need to be
reviewed and updated at a National level. The investigation team noted
that the F2052SH is being replaced with a new protocol, the Assessment
Care in Custody and Teamwork (ACCT). It improves on the F2052SH
procedures by concentrating on a more individualised “case work”
approach to the management of prisoners who may be a risk.
5. The Segregation Unit should consider the introduction of an effective key
worker system. The investigation team noted that all High Security prisons
have been required to implement new Segregation Unit strategies which
must, amongst other things, focus more closely on the individual needs of
the prisoner, and include key workers and case management conferences.
The new procedures must be in place by the end of 2005.
6. HMP Wakefield needs to develop its mental health services to ensure the
current good practices can improve and modernise, to ensure equivalence
to that which is available to the general public.
In addition, the reviewer notes four areas which he considered of good
practice:
1. Good mental health assessments and Segregation Safety Algorithms. It
has not been possible to further investigate and review the precise process
of clinical decision making as to how the doctor arrived at his decision to
authorise segregation because it has not been possible to either interview
him or substantiate and corroborate his comments in his letter to the
Governor. All gleaned evidence both within prison documents and through
interviews with prison staff indicates to the contrary the doctor’s comments
in his letter to the Governor.
2. High quality CARATS assessment, in particular the man’s alcohol
problems.
3. Good decision making, in terms of the man’s location whilst at Wakefield.
29
4. Both HCC and Segregation Unit staff treated the man in a very
professional and caring manner.
30
Issues Raised by the man’s Family
The man’s mother has raised concerns about the man’s arrest, his time in
custody and the trial. The man’s brother, returned to these points and raised
some new matters in a letter dated 16 April 2005.
My investigators did not look into the issues relating to the man’s arrest and
other matters which are to do with the conduct and outcome of the trial, as
these were not considered to be within my remit. Nor have they looked into
questions about the formal identification of the man, which is a matter for the
police and the Coroner.
I hope that most of the issues raised by the family are covered elsewhere in
this report. However, those matters not dealt with elsewhere are set out
below:
The man’s brother raises the question of a visit booked for the man’s
solicitor, on 15 July at 1:45pm. This was refused by officers, claiming
that the man did not want to see her, despite her office receiving a
phone call from the man at 9:00am that morning explicitly stating he
wanted a visit. The man said that he was convinced that prison officers
in his wing (B wing) were going to deny him access to his legal team.
The man insisted he had not cancelled the visit. The man wants to know
what further steps were taken after his solicitor complained.
The Governor of Wakefield wrote to the man’s solicitors, on 22 July, advising
them that it was the man who had refused to attend the visit, even after being
informed on two occasions that he had a legal visit booked. Staff on B Wing
recorded in the Staff Observation Book that the man had refused the visit. A
Security Information Report (S.I.R.) had been submitted by an officer on 15
July which states:
“On 15.7.04 this inmate) refused to attend a special visit. I asked him why he
had refused and he told me it was to drop staff “in the shit”. He said he had
been mistreated at court and was going to tell his solicitor we never offered
him a visit. I asked him why he was doing this and he said he was about to
ring his solicitor to ask why she had not turned up. He then said that would
teach us a lesson when we were up in front of the judge for refusing him a
visit.”
The man’s brother said that, on 19 July, another appointment was made
for his solicitor, a week in advance and for the whole day of 26 July, as
she was becoming increasingly worried that his trial was approaching.
Despite giving a week’s notice, she was informed on 23 July that the
prison was unable to accommodate all day visits, due to staff shortage.
When she suggested a morning visit, she was told the prison was fully
booked. Yet strangely she booked an all day visit. Coincidentally, it
appears that the man had misbehaved on the previous two days 22 and
23 July. The man wanted to know if any further action was taken.
31
The Governor replied to the man’s solicitors on 2 August acknowledging that
the all day visit had indeed been cancelled. This had been due to the
necessity to divert staff to cover heavy court escort commitments for the day
in question. The Governor went on to explain that the all day legal conference
facilities were over and above the normal legal visits arrangements, and were
a local initiative to assist prisoners and their legal teams. However, this would
be dependent upon sufficient staff being available to operate this facility,
which is in a different location to the main visiting area. Routine legal visits
would be booked through the usual procedures and would generally be based
on a first come, first served basis. Once full, all other requests would need to
be declined. It would appear that the all day facility was cancelled at short
notice and the normal legal visits were fully booked.
It is worth noting that the pressure on legal visits at Wakefield would have
increased dramatically after the prison took on the role of holding prisoners on
remand or awaiting trial. Previously the prison only accommodated sentenced
prisoners.
The period between the end of March and the man going back to Manchester
at the beginning of August was a comparatively settled time for him and he
had received other legal visits during the period.
The man’s brother wishes to know if it is the usual practice for sheets to
be in the cells in the segregation unit and, if so, where is the bedding
now.
It is normal for sheets to be part of the bedding in the segregation unit cells.
All items in the cell were retained in the cell and handed over to the police for
forensic examination and retention or disposal.
The family have requested to see the footage of the CCTV coverage of
the segregation unit.
The Detective Inspector in charge of the case is in possession of the CCTV
footage and arranged for the various views from different cameras to be
compiled to provide as accurate an overview as possible. The Inspector has
shared this with the family and solicitor.
Finally, the man’s brother cites various Home Office reports and news
items, suggesting that Wakefield has a history of self-harm and suicide,
especially in the segregation unit. He and his family are determined to
uncover any foul play which they believe the man was subject to at
Wakefield. The family believe that the man did not willingly take his own
life.
A key issue raised by the man’s brother is that they do not believe that the
man would willingly take his own life, and consider there has been malpractice
at Wakefield. The police have ruled out any suspicious circumstances or
criminal activity. This report has considered the way Wakefield looked after
the man during his time in custody, and whether this was fair and reasonable.
32
Findings and Conclusions
The man was 28 years of age when he died at Wakefield. He was a young
man, who had considerable experience of the criminal justice system and of
periods in custody. At the beginning of 2004, he found himself arrested for
serious offences which included the use of firearms.
The charges the man faced were serious, and resulted in him being assigned
to the highest security level when brought into Prison Service custody. I judge
that the decision to make the man a Category A prisoner was appropriate and
commensurate with the charges he faced.
There is evidence that at least one of the victims of the man’s offences had
connections with a family who had associates in Manchester prison. There
appears little doubt that the man would have been at risk of physical attack at
Manchester. The decision to move the man to the nearest alternative
establishment, Wakefield, was correct.
On arrival at Wakefield, the man was located in the HCC for the first night so
that an initial assessment could be completed prior to him being moved to a
general wing. The assessment suggested that he presented no problems of
risk to himself or other prisoners, so he was moved to the remand wing.
This is good practice for all new remand admissions.
The man adapted fairly well to his location on B wing and was seen as a
reasonable, if sometimes volatile, prisoner. An officer knew the man pretty
well, but states that at that time there were no personal officers assigned to
specific prisoners. Wakefield had done some considerable work on this
subject, having formally reviewed its Personal Officer Scheme in April 2004.
However, this does not appear to have ensured that all prisoners have
Personal Officers.
Recommendation: All prisoners, including those on remand, should be
assigned designated Personal Officers, and the role of the Personal
Officer should be explained to prisoners.
The man first exhibited signs of distress on 13 March when he told staff on B
Wing that he was feeling suicidal. The response of staff was to open a
F2052SH form and to make him the subject of additional monitoring and
support. This was a timely and proportionate response to the man’s feeling of
anxiety. The man was also moved to the HCC and located in a “safer cell”,
which was constantly monitored by CCTV.
The following day, the man commenced a dirty protest. On 15 and 16 March,
he made ligatures which he handed over to staff. His actions were
accompanied by shouting and ringing of the cell bell, ensuring that staff were
aware. Later that afternoon, the man ended his dirty protest. Once showered
and wearing clean clothing, he was relocated to the Segregation Unit still
under close monitoring. The Rule 45 paperwork for this period of segregation
33
was signed by a governor grade, but the Segregation Safety Algorithm was
not. As these documents were completed at about the same time, this
appears to be an oversight rather than the man being segregated without any
authority.
During this period in the HCC and Segregation Unit, the level and quality of
care for the man was very high, despite the dirty protest, the shouting and
dysfunctional behaviour. This is confirmed by the Clinical Review.
On 18 March, the man claimed to have swallowed a razor and made some
small cuts to his body. He was seen by the doctor who recommended that he
be taken to outside hospital for x-ray, but as a non-emergency case. The man
made a further small cut to his thigh that afternoon. He was taken to hospital
on 19 March for an examination. No trace of a razor blade was found.
The man was moved back onto his normal wing, B.2, on 31 March and
appeared to settle down well, although he was still being monitored under
F2052SH procedures. After a series of reviews, the man was taken off the
F2052SH on 8 April. There were then seven and 14 day reviews, and a check
by the Head of Residence.
During this very difficult period for the man, there is considerable evidence to
confirm that the man was treated professionally and compassionately by the
various staff who managed him.
The process of seven day and 14 day checks after the closure of the
F2052SH booklet is good practice, as is the documented quality review
by the Head of Residence.
On 12 July, the man said that he was assaulted by am officer, with whom he
had previously had a run in whilst in the segregation unit, over access to his
inhaler. The man alleged that the officer assaulted him in Crown Court. The
officer flatly denied this allegation. The man’s solicitors said that they would
be lodging a formal complaint on behalf of the man. This complaint was never
received and neither did the man invoke any of the other complaint
procedures.
At the adjudication on 10 August, the man pleaded guilty to abusing the officer
and admitted that the officer had not assaulted him. There is no other
evidence which suggests that the officer had assaulted the man or that he had
acted unprofessionally towards the man at any time.
On 4 August, the man was given 20 years imprisonment by the trial Judge.
There is no doubt that a sentence of that length was a significant blow to the
man. The man was initially taken from court to Manchester, where he was
located in the segregation unit. Although unhappy with the sentence, the man
did not display any suicidal or self-harm tendencies to staff at Manchester.
The man was returned to Wakefield on 6 August. Again, the man did not
present to staff as an individual who was contemplating any injury to himself.
34
The Suicide Prevention Strategy and Policy Document says that category A
remand prisoners who return from trial with a life sentence should be made
subject to the F2052SH procedures, monitored closely and consideration
given to whether they should be located in the HCC, as a precaution.
I consider that this is good practice.
Recommendation: The Governor should consider reviewing the
instruction, “Any remand category A prisoner receiving a life sentence
will have a F2052SH opened and be placed under consideration as to
whether or not to locate in the Healthcare Centre as a precaution”, to
include those prisoners who receive long determinate sentences.
On 9 August, the man was selected to take a targeted drug test. He refused
to take the test which requires the prisoner to give a urine sample. There had
been previous intelligence suggesting that the man was involved in provision
of drugs at Wakefield. The man was therefore placed on disciplinary report.
The following day, the man was taken to the segregation unit to face this
charge and the one for abusing the officer which had been held over from a
previous occasion. The man pleaded guilty to both charges and claimed in
mitigation that he did not wish to take the drugs test because “he had not slept
until 5:00am and that he had not taken drugs, as he was on a voluntary
testing compact”. The man was given seven days cellular confinement. This
would be completed in the segregation unit.
The conduct of the adjudication raises no procedural issues and the
punishments given for the two charges are in line with the normal tariffs.
The man had been subject to two Segregation Safety Algorithms that
morning. One was completed by a qualified nurse, the second shortly
afterwards by the doctor. Both assessments concluded that the man had no
presenting problems or difficulties which would preclude him being located in
the segregation unit, and that he was fit for the punishment of cellular
confinement. Staff interviewed said that the man give no indication that he
was at risk that morning.
The next day, the doctor told the Governor that he believed that the man
would be located in a cell with camera cover. In a statement to the police, the
doctor claimed that he told staff that the man should be put in a cell with
camera cover, and that he recorded this in the medical record. There is no
other evidence of this.
Healthcare guidelines say that record keeping is an integral part of clinical
care, providing a tool of professional practice and one that should help the
care process. Good record keeping ensures:
(cid:1) High standards of clinical care
(cid:1) Continuity of care
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(cid:1) Better communication and dissemination of information between
members of the inter-professional team
(cid:1) An accurate account of treatment, care planning and delivery
(cid:1) The ability to detect problems and changes in the patient’s condition at
an early stage.
From the available documentation, the doctor did not make any written entries
regarding specific instructions to staff about the location and level of
observation the man should be subject to. The failure of clinicians to make
adequate entries in the medical record means that the quality of care can be
compromised. In the case of the man, it meant he was not placed in a cell
with CCTV cover, as the multi-disciplinary team were not aware of this need.
All medical staff completing a safety algorithm must be clear as to which type
of cell and under what circumstances a prisoner will be held in segregation
unit, before completing the document. It is important that, when medical staff
have any concerns about the safety of a prisoner or have identified any risk
factors, this is clearly articulated to the staff in the segregation unit. This must
be written on both the safety algorithm and in the prisoner’s medical record.
Recommendation: Medical staff who complete the segregation Safety
Algorithm should be reminded that they must satisfy themselves that
they fully understand which type of cell and the conditions under which
the prisoner will be held, prior to signing the algorithm.
Recommendation: Medical staff should be reminded that if they have
any concerns about a prisoner, or have identified any possible risk
factors, they must articulate these clearly to the segregation unit staff
and record this in the Segregation Safety Algorithm and in the relevant
Inmate Clinical Record.
The man was located in cell F3-11 in the segregation unit. He was monitored
on an hourly basis. There are no comments or observations made in the staff
observation book for that day, apart from an entry that all was quiet. This
officer was the last to see the man alive, as he did his hourly check at
11:00pm. He recorded that the man acknowledged him and waved. It was on
his next check that he discovered the man hanging by a ligature from the cell
windows. The night officer alerted the night orderly officer who, with
assistance, went to F wing and initiated the contingency plans via the control
room.
F wing at Wakefield is situated against the front wall of the prison, next to the
administration building. It is separated from the main prisoner living units by a
series of gates and security fencing. The night orderly officer would be
located in the main prison for the majority of his duty period.
It takes between about six to eight minutes to move from the main prison.
The time taken depends upon having a dog patrol in place and movement
through the centrally controlled electrically locked gates. With the assistance
of two officers, entry was made to the cell, the man was cut down and
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resuscitation was started. The paramedics arrived at about 12:16am and
attempts to revive the man continued but to no avail. The doctor pronounced
the man dead at 1:10am.
The response to the discovery of the man and the follow up action was well
managed by the night orderly officer and the staff on duty, including the Duty
Governor. The contingency plans appear to have been well executed,
although the police were not informed until 1.51am, 40 minutes after death
had been certified. The cell had been properly secured and remained so until
handed over to the police at 2:15am.
On confirmation of the death, the police should be informed immediately. This
should be expressly written into the contingency plans and the responsibility
should be that of the officer in charge of the control room. It should not
require the presence of the duty governor or other senior manager to activate
this instruction.
Recommendation: The contingency plans should be altered to specify
that “Upon confirmation of the death of a prisoner, the control room
should immediately report this to the police”.
The segregation unit is isolated from the main prison. This means that
emergency access, particularly medical assistance, will be delayed due to its
location and the number of security barriers which must be overcome. The
unit is austere, having cells positioned on only one side of the house block,
unlike all other living units in the prison. F wing also holds prisoners held
under Prison Rule 46, who are part of the Close Supervision Centre system.
In this case, staff followed local policy and are not criticised for the delay in
entering the cell.
It may be that the segregation unit part of F wing would be better located
within the main prison. This would provide for easier access by staff to
provide the necessary support to and monitoring of those held in segregation.
It would certainly ease emergency intervention. In addition, it may assist in
removing a degree of the mystique surrounding the current segregation unit
simply by improving its accessibility.
I realise that this may not be achievable, but should be given due
consideration by the Governor and the Deputy Director General. If moving the
segregation unit is not feasible, then due consideration should be given to
having suitably qualified medical staff (nurses) on duty in the unit during nights
or able to access the unit quickly.
Recommendation: The Governor and the Deputy Director General
should consider the appropriateness of the current location of the
segregation unit within Wakefield, and the Governor of Wakefield should
consider the feasibility of a qualified nurse being part of the night
complement on F wing or healthcare staff having prompt access to the
unit in the event of an emergency.
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Whilst prisoners raised general matters of concern about life at Wakefield, the
investigators found no evidence that the man was mistreated, either at
Wakefield or in the short time he was at Manchester.
I am very concerned, however, to learn that there is evidence that a local risk
assessment form which purports to have been completed on 10 August was
not in fact completed until after the man’s death. The Governor has launched
an investigation into these allegations which are very serious indeed.
Wakefield West PCT has provided a clinical review into the care the man
received whilst at Wakefield. However, the report did not address the way in
which the doctor assessed that the man was fit for cellular confinement. The
Chief Executive may wish to look into the clinical review process, with a view
to improving the quality of reviews to ensure that all the issues are
appropriately reviewed.
Recommendation: I recommend that a copy of this report is sent to the
Chief Executive of the PCT so that he may consider the conduct of
clinical reviews to ensure that all the issues are covered.
The Programmes Department received a self-completed questionnaire from
the man. He said he had been subject to bullying and mentioned two specific
occasions. It is of concern that there is no evidence that this was formally
investigated. Such information should be promptly shared with the Suicide
Prevention and Anti Bullying team.
Whilst I do not believe the life sentence planning had any bearing on the
outcome of the man’s case, I question its use in his case. The man was not
expecting a life sentence, in fact he was expecting between eight and twelve
years. Furthermore, the offence for which he was charged would not have
attracted an automatic life sentence. Completing a life sentence planning
document for a prisoner not expecting such a sentence, if found guilty, would
do little to help their mental state during an already emotional time.
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Recommendations
1. The Governor and the Deputy Director General should consider the
appropriateness of the current location of the segregation unit within HMP
Wakefield, and the Governor of HMP Wakefield should consider the
feasibility of a qualified nurse being part of the night complement on F wing
or healthcare staff having prompt access to the unit in the event of an
emergency.
2. All prisoners, including those on remand, should be assigned designated
Personal Officers, and the role of the Personal Officer should be explained
to the prisoner.
3. The contingency plans should be altered to specify that, “Upon
confirmation of the death of a prisoner, the control room should
immediately report this to the police”.
4. Medical staff who complete the segregation Safety Algorithm should be
reminded that they must satisfy themselves that they fully understand
which type of cell and the conditions under which the prisoner will be held,
prior to signing the algorithm.
5. Medical staff should be reminded that if they have any concerns about a
prisoner, or have identified any possible risk factors, they must articulate
these clearly to the segregation unit staff and record this in the
Segregation Safety Algorithm and in the relevant Inmate Clinical Record.
6. The Governor should consider reviewing the instruction, whereby “Any
remand category A prisoner, receiving a life sentence will have a F2052SH
opened and be placed under consideration, as to whether or not to locate
in the HCC, as a precaution”, to include those remand prisoners who
receive long determinate sentences.
7. I recommend that a copy of this report is sent to the Chief Executive of the
PCT so that he may consider the conduct of clinical reviews to ensure that
all the issues are covered.
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Good Practice
1. Suicide Prevention and Anti Bullying team officers interview all new
receptions upon arrival at HMP Wakefield to assess their risk of self-harm
to themselves and to others.
2. The Head of Residence conducts a final management check on all closed
F2052SHs to check quality. I also welcome the process of 7 day and 14
day checks after the closure of the F2052SH booklet. Areas of concern
are followed through, with the Head of Residence personally advising staff
of the standards expected.
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