Individual at Wandsworth

Investigation into the circumstances surrounding
the death of a man
at HMP Wandsworth on 12 June 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2011
Final Report: January 2011
This is the report of an investigation into the circumstances surrounding the death of
a man. The man, a black South Londoner, was 25 years old when he died in HMP
Wandsworth on 12 June 2009.
The man had been released from prison on licence in March 2009, but reoffended in
April. He was remanded into custody for the new offences. (Unaware that the man
was no longer in the community, the Probation Service began the process of
recalling him to custody after he failed to comply with his licence conditions.) The
man was taken to HMP Pentonville where he made a serious attempt to take his own
life.
When the man returned from hospital after his suicide attempt, staff arranged to
transfer him to Wandsworth in mid-May because he said he felt safer there. He was
mistakenly taken to Brixton for a night but transferred to Wandsworth the next day.
Towards the end of May, the man made a court appearance and afterwards returned
to Pentonville rather than to Wandsworth. My report considers the circumstances of
this move in some detail
A few days later, the man tried again to take his own life. He returned to
Wandsworth on 9 June.
Overnight on 11 June, the man asked to be removed from his shared cell and was
placed in a cell on his own. At lunchtime on 12 June, staff found him hanging in his
cell. Sadly, their efforts to resuscitate him were unsuccessful.
I extend my sincere condolences to the man’s family. They have acted with
considerable dignity during what has been a very difficult period for them.
The investigation was completed by my investigators. Given the scope of the
investigation, they were assisted at various junctures by other colleagues. The
investigation team visited Wandsworth, Pentonville and Brixton and spoke with about
50 different members of staff. In addition, my Senior Family Liaison Officer
contacted the man’s mother and told her about my investigation. She and the
investigator visited the man’s mother to update the family on the progress of the
investigation.
A clinical review of the treatment that the man received in custody was undertaken
by a clinical reviewer, appointed on an independent basis by Wandsworth Primary
Care Trust. The clinical reviewer assessed whether the care that the man received
in custody was comparable to that he would have been offered in the community. I
am grateful for his assistance. A copy of the clinical review is annexed to my report.
I would like to thank both staff and prisoners at Wandsworth, Pentonville and Brixton
for their cooperation whilst the investigation was completed.
This has been a much more complex investigation than usual because three prisons
were involved and many questions needed to be answered. I hope that my report
provides the family and the other parties involved with as full an assessment as
possible of what transpired.
Final Report: January 2011 2
I have also been conscious of the wider public concern about the transfer of
prisoners between Pentonville and Wandsworth at the time of inspections by HM
Chief Inspector of Prisons. The man was not moved directly as a consequence of
the inspection of Wandsworth that took place at the beginning of June 2009.
However, I conclude that his second spell at Pentonville may well have been
influenced by the fact of the inspection, and my report also draws attention to the
indirect effects on him of the series of transfers as a whole.
These matters had already been the subject of disciplinary inquiries. However, I
recommended in the draft version of this report that the National Offender
Management Service (NOMS) review the new evidence that it contained to
determine whether a renewed disciplinary investigation was justified. Following
publication of the draft report, NOMS accepted the recommendation and responded,
indicating that the new evidence would not prompt them to conduct a further
disciplinary investigation.
The man was a vulnerable prisoner who had experienced mental health problems for
some years. Whilst I have made many recommendations to the National Offender
Management Service, and am critical of some decisions that were made, I have also
highlighted some elements of good practice in what is otherwise a very bleak story.
Acting Prisons and Probation Ombudsman January 2011
Final Report: January 2011 3
CONTENTS
Glossary
Summary
The Investigation Process
HMP Wandsworth
HMP Pentonville
The man
Key Findings:
Release on licence
HMP Pentonville 21 April – 12 May
Admission to hospital
Return from hospital to Pentonville
HMP Brixton 12 – 13 May
HMP Wandsworth 13 – 26 May
Camberwell Green Magistrates’ Court 26 May
HMP Pentonville 26 May – 9 June
HMP Wandsworth 9 – 12 June
Issues:
Drug and alcohol withdrawal
Medication
Recall to prison
Prison transfers
Mental health treatment and hospitalisation
The man’s location in each prison
Preparing for the man’s return to Wandsworth on 9 June
Assessment, Care in Custody and Teamwork (ACCT) monitoring
Indications that the man was at risk of harming himself 11-12 June
ACCT Training
Cell Sharing Risk Assessments
Clinical records
Pharmacy
Nurse 4
Preserving the man’s dignity after his death
Informing the man’s family of his death
Good practice
Conclusion
Recommendations and responses
Annexes
Final Report: January 2011 4
GLOSSARY
Approved Premises
A hostel where the Probation Service can accommodate offenders released from
prison on licence.
Assessment, Care in Custody and Teamwork (ACCT)
An ACCT document is opened if a prisoner is thought to be at risk of harming
themselves. The prisoner is interviewed and a plan for their care is drawn up in
response to their needs and concerns. The process is ongoing and the document
remains open whilst the risk remains. An ACCT review should be held at least once
a week. Any staff who have contact with a prisoner can make entries in the
document. The frequency of observations by staff is set out on the front cover, for
example, ‘hourly’. Staff must check the prisoner at least this often, they should
conduct their observations at random intervals and write down all the checks in the
ongoing record. Some of the scheduled checks must be ‘quality observations’,
meaning that the member of staff speaks to the prisoner at some length and has
meaningful interaction with him in order to gauge his presentation and the risk he
may present to himself.
ACO Assistant Chief Officer (in the Probation Service)
Adrenaline
A drug used to treat cardiac arrest
Appropriate adult
If an individual is vulnerable or has mental health problems, it may be necessary for
an appropriate adult to accompany them to formal appointments such as a probation
interview. This adult can offer assurance, assist with communication and make sure
that the individual understands what is happening. They can be a friend or a
professional person working with the individual such as a psychiatric nurse or a
social worker.
Atropine
A drug which can be injected to increase a person’s heart rate
Bedwatch
If a prisoner is admitted to hospital he is escorted by prison officers at all times as
part of a bedwatch. He may be handcuffed to an officer depending on the risk he is
assessed as presenting to the public and whether or not he is sedated. A bedwatch
log is kept throughout the hospital stay and managers from the prison regularly visit
the hospital to check on the prisoner.
Final Report: January 2011 5
Canteen
A prisoner has a weekly amount of money to spend on items such as cigarettes.
The amount of money they can spend on items available from the canteen depends
on factors such as whether they have a job in the prison.
Counselling, Assessment, Referral, Advice and Throughcare Services
(CARATS)
There is a CARATS team in each prison which works with substance misusers.
CMHT Community Mental Health Team
CPN Community psychiatric nurse
CPR Cardio pulmonary resuscitation
CSRA Cell Sharing Risk Assessment
Defibrillator
A machine used to reset an irregular heart rhythm with a dose of electrical energy.
Escort chain
A chain approximately eight feet long with a handcuff on each end. It allows hospital
staff to carry on treating the prisoner without the officer chained to him getting in the
way.
FLO Family Liaison Officer
HEMS Helicopter Emergency Medical Service
HMIP Her Majesty’s Inspectorate of Prisons
ICU Intensive Care Unit
IIS Inmate Information System
In-Reach Team
Healthcare staff with mental health training who treat prisoners with severe and
enduring mental health problems.
Listener
Prisoners who are trained by the Samaritans to spend time with others who are in
crisis. Any information that a prisoner may disclose to a Listener is treated
confidentially, just as a telephone call to the Samaritans would be.
Final Report: January 2011 6
Medical hold
When a prisoner is prevented from transferring between prisons because he has to
remain at his current prison on health grounds such as attending a hospital
appointment.
Mirtazapine
An antidepressant
NOMS National Offender Management Service
NOMS comprises the Prison and Probation Services. However, I will continue to
refer to the Prison Service and the Probation Service for reasons of clarity within the
report.
OCA Department Observation, Classification and Allocation Department
The OCA team in a prison is responsible for organising prisoner transfers, both one-
off moves and group moves, which are organised at a national level by the PMU.
Offender manager
Probation officers are now known as offender managers.
Olanzapine
An antipsychotic drug used to treat schizophrenia
OMU Offender Management Unit
Operation Trident
The division of the Metropolitan Police which addresses gun crime among young,
black Londoners.
OSG Operational Support Grade (member of prison staff)
PCT Primary Care Trust
PER
Person Escort Record, completed every time a prisoner is transferred to or from a
prison or taken to court.
PLO Police Liaison Officer
Final Report: January 2011 7
PMU Population Management Unit
Based in central London, the PMU department organises the movement of offenders
between prisons in England and Wales. They inform a prison of the numbers to be
moved, and the OCA department identifies suitable candidates for transfer.
PO Principal Officer
PSO Prison Service Order
Procyclidine
Medication used to treat the man’s wry neck (torticollis, a condition whereby the
individual tilts their head to one side whilst their chin points upwards and in the other
direction.) The man would often hold his neck at an awkward angle which seemed
to worsen when he was anxious. Staff and prisoners remembered that he frequently
looked away from the person he was talking to.
Risperidone
An antipsychotic drug used to treat schizophrenia
Serco
A private company responsible for the running of the custody suites in London
courts. Their staff transfer prisoners between prison and court.
SIR Security Incident Report
SO Senior Officer
St Mungo’s
A charity which helps prisoners find accommodation upon release.
Telephone PIN number
Every prisoner is provided with a PIN number in order to use the public telephone on
their wing to speak to friends and family. Each PIN number is unique and the
prisoner’s telephone calls are logged.
VPU Vulnerable Prisoners Unit
Some prisoners who cannot cope or who feel unsafe amongst the general prison
population ask for vulnerable prisoner status. They are held in a VPU separate from
the rest of the prison and can no longer associate with the other prisoners.
Final Report: January 2011 8
Anonymised report
A large number of staff at three different prisons are referred to in the report. As a
result, when the report was anonymised, staff appearing in chronological order were
given the following designation:
(cid:127) Staff at Pentonville are referred to by their job title and a letter from the
beginning of the alphabet eg: Governor A, Nurse A…
(cid:127) Staff at Brixton are referred to by their job title and a letter from the end of the
alphabet eg: Governor Z, Nurse Z…
(cid:127) Staff at Wandsworth are referred to by their job title and a number eg:
Governor 1, Nurse 1…
Final Report: January 2011 9
SUMMARY
The man was released on licence from HMP Wandsworth on 20 March 2009. He
had been in custody before and been monitored by the Assessment, Care in
Custody and Teamwork (ACCT) procedures on more than one occasion in the past.
He had a history of mental health difficulties and was diagnosed with paranoid
schizophrenia and a possible anti-social personality disorder. He attended his
appointments with his offender manager and the local Community Mental Health
Team (CMHT) during the next few weeks and resided at an approved premises run
by the Probation Service. On 14 April, he reoffended. He was not recalled by the
offender manager but was warned about his behaviour.
A week later, on 21 April, the man made a court appearance in relation to the new
offences and was remanded into custody. He consequently missed an appointment
with his offender manager the same day and, when he did not return to the approved
premises, was recalled to custody.
Prisoners remanded at Camberwell Green Magistrates’ Court are normally taken to
HMP Brixton. However, because one of the man’s relatives works at Brixton, he was
taken to HMP Pentonville instead. A doctor opened an Assessment, Care in
Custody and Teamwork document because the man said that he was hearing voices
telling him to harm himself. The man said that he had recently misused drugs and
alcohol in the community, but the doctor did not think that he had withdrawal
symptoms.
The next day a prison officer interviewed the man as part of the ACCT process and
organised a move to the detoxification unit. Later in the morning the man requested
vulnerable prisoner status because he feared for his safety. He was worried that,
coming from South London, he might be harmed by North London gang members.
Staff planned to move the man to the Vulnerable Prisoners Unit (VPU) after lunch,
but before this could happen he tried to hang himself using a ligature. Staff
managed to revive him and he was taken to the Royal London Hospital. His
condition was serious and he was visited in hospital by his family.
The man returned to Pentonville on 28 April. He was located in the healthcare
centre and initially kept under constant supervision as a precaution. The ACCT
document remained open, though the frequency of observations was reduced as the
days passed. The man settled in but continued to ask to move to Wandsworth,
where he said he would feel safer. Because of his serious attempt to take his own
life, staff thought that the move was in the man’s best interests. Healthcare staff
liaised with their colleagues in Wandsworth and the Governors of both prisons
agreed the transfer.
Following a court appearance at Camberwell Green on 12 May, the man was
supposed to move to Wandsworth, but the instruction was not clearly marked on his
Person Escort Record (PER) and he was instead taken to Brixton. Staff at Brixton
were reluctant to receive him because their healthcare staff had not been advised of
his arrival. The duty governor contacted both Wandsworth and Pentonville and, in
the man’s best interests, agreed to hold him in Brixton for one night to allow the
Final Report: January 2011 10
breakdown in communication to be resolved. The man was kept under constant
supervision in the healthcare centre as a precaution.
The following day, 13 May, the confusion was resolved and the man transferred to
Wandsworth. He spent two nights in the first night centre before being moved to the
VPU (known as the Onslow Centre). On 19 May, the ACCT document which had
been open for nearly a month was closed.
A week later, on 26 May, the man made another appearance at Camberwell Green.
He was fined in relation to the recent offences but remained in custody because he
had been recalled by the Probation Service. Brixton was asked to receive the man
from court, so the duty governor at Brixton, Governor Z, spoke to his counterpart at
Wandsworth, Governor 3. Governor 3 refused to accept the man and telephoned
the duty governor at Pentonville, Governor A. Governor A initially refused to receive
the man because she thought it inappropriate after his recent attempt to take his own
life. Governor C, the then Governor of Pentonville, subsequently agreed to accept
the man after he spoke to Governor 1, the then Governor of Wandsworth.
Governor C was concerned about the man and personally checked on him. The
man was kept under constant supervision in the healthcare centre until the following
morning. On 27 May, Governor C and Governor 1 agreed that the man would return
to Wandsworth after 6 June, following a scheduled inspection by Her Majesty’s
Inspectorate of Prisons (HMIP) between 1 and 5 June. Later that morning, the man
was discharged from the healthcare centre onto the VPU following a case review
that was not part of the ACCT process. He was told by Governor A, who led the
review, that he would return to Wandsworth after 6 June.
The same day, 27 May, Governor A asked an officer in the Observation,
Classification and Allocation (OCA) department to organise the man’s transfer back
to Wandsworth. The booking was made and collection was scheduled for 1 June.
However, none of the staff working with the man were told about the forthcoming
move and no preparations were made. Over the next few days, the man remained
on the VPU and was not assessed by any healthcare staff. On 31 May, he
expressed suicidal thoughts to a senior officer (SO) and a second ACCT document
was opened.
The man was interviewed and ACCT observations were set at half hourly intervals
overnight. He showed a ligature to an officer and the holes in the light fitting that he
planned to attach it to. The following morning, 1 June, the man was checked and
found in the midst of a second attempt to hang himself. The officer prevented him
from harming himself and he was moved to the healthcare centre where he was
placed under constant supervision, preventing the scheduled transfer from taking
place. A mental health assessment by the CMHT had been scheduled for 1 June at
Wandsworth. It did not take place because the man was still located in Pentonville.
Observations were gradually reduced whilst the man remained in the healthcare
centre. His mood seemed to stabilise and, from 4 June, he was observed every
hour. He returned to Wandsworth, where he continued to say he felt safer, on 9
June. He travelled back with prisoners who had been temporarily transferred out of
Wandsworth to Pentonville for the duration of the HMIP inspection. Following an
Final Report: January 2011 11
internal Prison Service investigation of their temporary transfers, charges were
recommended against five managers at the two prisons. At subsequent disciplinary
hearings, charges against two managers were dismissed. Charges against the other
three managers were proved. In light of the new evidence in this report, I have
recommended that the Director General of NOMS considers whether a renewed
disciplinary investigation is warranted.
The man’s ACCT document remained open and he went back to the Onslow Centre
again. The following day, 10 June, the ACCT document was reviewed. The man
spoke about his involvement with gangs. The staff running the review encouraged
him to report any information to the police. The Police Liaison Officer (PLO) was
consulted and arranged for the man to speak to an officer from Operation Trident.
Following the review, the man went to speak to a Listener.
The most recent entry on the front cover of the ACCT document had been made at
Pentonville and instructed staff to make hourly observations. However, between 9
and 12 June, staff on the Onslow Centre only maintained hourly checks at night,
recording intermittent observations during the day.
The next day, 11 June, the man moved into a cell with prisoner 7 after both men
approached staff. Their cell share lasted from late afternoon until about midnight,
when the man asked to be removed from the cell, saying that prisoner 7 had made
sexual advances towards him. He was relocated on his own to a different cell.
At the morning briefing on 12 June, staff were told that the man had been removed
from the cell overnight. During the morning the man was observed by three different
officers who all noted that he did not respond to them and was staring at the wall.
The second officer asked a member of the In-Reach team to assess the man. An
ACCT review was not scheduled that morning and the frequency of observations
was not increased, remaining intermittent during the day.
Officer 10, the final officer to note the man’s appearance during the morning, made
an entry in the ACCT document at 12.30pm after locking him in his cell alone over
lunch. The same officer returned to the cell shortly after 1.00pm to check if the man
wanted to attend the Muslim prayer service, but got no verbal response. He did not
make a further entry in the ACCT document but told his colleagues that he was
worried about the man.
At 1.40pm, Officer 11 checked the man, prompted by her colleague’s concern. She
found him hanging in his cell and immediately called for assistance. Staff entered
the cell, cut the man down, removed the ligature and began to try to resuscitate him.
The emergency healthcare response nurse brought two doctors with her. Both
paramedics and an air ambulance crew joined the effort to revive the man. He did
not respond and was declared dead shortly before 2.20pm.
The prison’s family liaison officer (FLO) reached the man’s mother’s home address
just after 4.30pm. By this stage, a prisoner had already used a mobile telephone to
inform her of her son’s death.
Final Report: January 2011 12
My report explores a variety of issues, including the transfer of prisoners, the use of
ACCT documents and the appropriateness of cell sharing arrangements. I have
examined the man’s recall to custody and the possibility that he might have gone to
hospital instead. The investigation has revealed that the man was moved four times
in a seven week period. I conclude that these transfers were not always in his best
interests and that they interrupted the continuity of his care.
Final Report: January 2011 13
THE INVESTIGATION PROCESS
1. The investigators were notified of the man’s death on 12 June. Notices were
issued to staff and prisoners telling them about the investigation process and
inviting them to contact my investigators.
2. The investigator contacted the liaison officer, the Safer Custody Manager at
Wandsworth. When he visited Wandsworth on 16 June, he met the then
Governor, Governor 1. On the same day, the investigator spoke to three
prisoners. He was also provided with copies of the man’s prison records.
The originals were given to the coroner’s office.
3. Two weeks later, on 1 July, the investigator returned to Wandsworth to
examine the man’s cell and collect further documentation. On 16 July, both
investigators interviewed seven members of staff at Pentonville. On 4 and 5
August, they interviewed a further 12 members of staff at Wandsworth.
4. Some weeks later an internal Prison Service investigation was begun after
HMIP identified attempts ‘at a managerial level to subvert the inspection
process’. Although the man was not moved with the prisoners who
transferred to Pentonville on the weekend before the inspection at
Wandsworth, my investigators obtained documents which suggested that
consideration of the inspection may have influenced the decision to relocate
the man to Pentonville on 26 May and the subsequent timescale for his return
to Wandsworth. In order to determine the circumstances under which the
man moved between prisons, my investigators decided to interview a number
of governors.
5. The investigator liaised with the internal Prison Service investigator during this
period. The internal Prison Service investigator was commissioned by the
Director of Offender Management for London to conduct an internal Prison
Service investigation of the circumstances surrounding the transfer of
prisoners. Some cooperation was required on a practical level, as the two
investigation teams were interviewing the same members of staff at
Wandsworth and Pentonville at about the same time.
6. The investigator advised the internal Prison Service investigator of those staff
he had already spoken to who had voiced suspicions about the influence of
the inspection. The internal Prison Service investigator subsequently
provided the investigator with copies of emails he had not previously seen.
The internal Prison Service investigator requested copies of a booking form
and a case review, which the investigator provided.
7. On 12 August, the investigator visited Wandsworth with two colleagues to
interview Governor 3. That morning the investigators had also interviewed a
number of prisoners. A week later, on 18 August, the investigators returned
to Pentonville to interview four members of healthcare staff. Later that day
they were joined by a colleague when they interviewed the then Governor of
Pentonille, Governor C, and Governor A.
Final Report: January 2011 14
8. Two days later, on 20 August, the investigator visited Streatham CMHT to
interview two members of staff. On 15 September, the investigatorsI
interviewed Governor 1. A week later, on 23 September, the investigators
interviewed three members of staff at HMP Brixton.
9. The investigators returned to Wandsworth on 1 October to interview a further
five members of staff. Despite several requests, staff at Wandsworth had
been unable to locate the first ACCT document opened between 21 April and
19 May. However, the document was located on 1 October after the new
Governor asked staff to conduct a further search at my investigators’ request.
10. The next day, 2 October, the investigators interviewed another governor who
worked at Brixton when the man was in custody. The interview was
conducted at my office.
11. My investigation team were provided with copies of the internal Prison Service
investigator’s report and relevant annexes when it was published in early
October. As a result of the internal investigation, five governors faced
disciplinary hearings. Following the hearings the charges against the
Governors of Wandsworth and Pentonville were dismissed. Charges were
proved against the other three managers, who were reprimanded. The
investigator requested, and was provided with, transcripts of the hearings.
12. On 28 October, the investigator visited Wandsworth. He interviewed a nurse,
reinterviewed a member of staff and spoke to two prisoners, recording one of
the interviews. On 5 November, the investigator went back to Wandsworth to
interview a nurse, and then visited the coroner’s office to obtain copies of
documents which had not been provided when he opened the investigation.
13. The investigator returned to Pentonville, interviewing three members of staff
on 10 November and another two on 12 November, one of whom he had
spoken to before. On 17 November, he visited Croydon to speak to staff at
the NOMS Public Protection Casework Section. On 8 December, he made
another visit to Pentonville to speak with two more members of staff. Finally,
on 26 January 2010 the investigator interviewed two nurses at Wandsworth.
14. My investigators wrote to the local Coroner’s office at the start of my
investigation to inform them of its nature and scope. The Coroner later
obtained a copy of the post mortem report. HM Coroner will be provided with
a copy of my report.
15. The investigator contacted Wandsworth Primary Care Trust (PCT) to ask that
a clinical review be carried out with regard to the medical treatment which the
man received in custody. The purpose of this review is to establish whether
the care which the man was offered in prison was comparable with that he
would have received in the community. The man’s family asked that the
clinical reviewer should be independent of the PCT and should have some
knowledge of mental health issues. A clinical reviewer was appointed to
complete the review, which is annexed to my report.
Final Report: January 2011 15
16. My Senior Family Liaison Officer (FLO) contacted the man’s mother on 7 July
2009. She told the man’s mother about the purpose of my investigation and
asked about the concerns she had regarding the treatment her son received
in custody. The senior FLO and the investigator visited the man’s mother on
28 July to offer further information and to hear her concerns first hand.
Following the publication on 20 October 2009 of the HMIP reports relating to
Wandsworth and Pentonville, the senior FLO and the investigator visited the
man’s mother on 29 October to update her on the progress of the
investigation.
17. The man’s mother had a number of concerns about her son’s time in custody:
(cid:127) She was distressed to learn from my investigator about his second
attempt to take his own life on 1 June 2009 and wanted to know why
prison staff had not told her about it at the time.
(cid:127) The man’s mother asked whether her son’s neck condition (the man
held his neck at an awkward angle which became more pronounced
when he was stressed) was aggravated by prescription of the wrong
medication whilst he was held during an earlier part of his prison
sentence. My investigator advised the man’s mother that the report
would necessarily focus on her son’s most recent period of
imprisonment.
(cid:127) She was concerned that Wandsworth healthcare staff told her on the
telephone on 11 June 2009 that he would not be escorted to a hospital
appointment on 17 June to treat his neck problem. There is no record
of this conversation in the man’s clinical record and neither is there a
record of a planned hospital visit.
(cid:127) The man’s mother wanted to know what had happened to items of her
son’s property that she gave him whilst he was in hospital.
(cid:127) She wanted to know how often her son had been checked before he
died and, given his mental health difficulties, why he was allowed to be
on his own in a cell when he took his own life. She wanted to know
more about her son’s cell sharing arrangements in the days before he
took his own life.
(cid:127) The man’s mother and her solicitor also wanted to know more about
her son’s recall to custody and the Parole Board’s decision not to
recommend his re-release.
(cid:127) Following media attention surrounding transfers between Wandsworth
and Pentonville, my investigators advised the man’s mother that the
report would address her son’s movements around the London prison
system.
18. I hope that the draft version of my report provided the man’s mother with the
answers to at least some of her questions. Some of the details no doubt
Final Report: January 2011 16
proved to be upsetting for the man’s family to read. Some of the report is
regrettably but necessarily complicated. After the draft report of the
investigation was published, the senior FLO and the investigator visited the
man’s mother and her solicitor on 11 May 2010 to explain the principal
findings and recommendations. A response on behalf of the family was not
received before the Ombudsman published the final version of the report in
January 2011.
Final Report: January 2011 17
HMP WANDSWORTH
19. Wandsworth is the largest prison in England and Wales, holding a maximum
of about 1,660 men. Prisoners are either held on remand, awaiting sentence
or serving sentences. As a local prison, a large number of prisoners travel
back and forth from Wandsworth each week day to make appearances at the
London courts.
20. As a vulnerable prisoner, the man was held on the VPU (known as the
Onslow Centre). This is a separate building from the rest of the prison and
holds about 360 prisoners on three wings. The population is made up of
prisoners who have asked for vulnerable prisoner status and might be at risk
amongst the general prison population.
Healthcare
21. In July 2007 Wandsworth Teaching PCT commissioned a private company,
Secure Healthcare, to provide healthcare at Wandsworth and employ the
medical staff. However, the company went into liquidation in September
2009. The healthcare team are currently employed by the part of NHS
Wandsworth which provides services, rather than commissions them.
22. Healthcare provision is divided between primary care (treating physical health
problems), substance misuse (treating drug and alcohol users) and the In-
Reach team (treating mental health problems), which is funded by South West
London and St George’s Hospital Mental Health NHS Trust. The In-Reach
Team has the equivalent of one full time consultant psychiatrist and one staff
grade psychiatrist post. The team also includes two CPNs, three dual
diagnosis nurses and another CPN who doubles as the team manager.
23. The Addison Unit is a 12 bed inpatient unit accommodating prisoners with
severe and enduring mental health needs who are experiencing acute
difficulties. The unit won an award recognising the service it provides earlier
in 2009. There are no inpatient facilities for prisoners with physical health
problems. There are two treatment rooms on the Onslow Centre. The prison
pharmacy uses a number of technicians to carry out its functions. When my
investigators visited Wandsworth, all were temporary agency staff.
HM Chief Inspector of Prisons
24. HM Chief Inspector of Prisons completed an announced inspection of
Wandsworth between 1 and 5 June 2009.
25. Prisoners who had transferred to Pentonville the weekend before her
inspection, who did not include the man, returned to Wandsworth on 9 June.
Shortly afterwards, some complained to HMIP. Members of the inspection
team returned to Wandsworth and discovered, in the Chief Inspector’s words,
that efforts had been made ‘at a managerial level to subvert the inspection
process’. Five prisoners from Wandsworth’s segregation unit and VPU were
transferred to Pentonville to temporarily remove them from Wandsworth whilst
Final Report: January 2011 18
the inspection team visited. When the transfers took place, some of the
prisoners objected and self-harmed.
26. The Chief Inspector found that there had been a reciprocal arrangement in
place between Wandsworth and Pentonville to remove what were perceived
to be ‘difficult’ prisoners from each prison whilst HMIP visited. Wandsworth
had temporarily accepted some of Pentonville’s prisoners when their
inspection was held between 11 and 15 May.
27. The report of the inspection of Wandsworth, published on 20 October 2009,
was critical. The Chief Inspector remarked that, had it not been for the
attempt to ‘subvert the inspection process’, Wandsworth would have emerged
as a prison making good progress. She wrote:
‘…the prison’s reputation has been seriously tarnished by the
irresponsible, pointless, and potentially dangerous actions instigated at
managerial level …
‘In terms of the effect on the inspection, the prisoner transfers were
completely pointless.
‘…the transfers [have cast] doubt on the governance of the prison and the
commitment, at senior level, to the safe and respectful treatment of those
in its care.
‘[This] is deplorable, not only because of the effects on individuals, but
because of the underlying mind-set: that prisoners are merely pieces to be
moved around the board to meet performance targets or burnish the
reputation of the prison.’
28. The man was not one of the five prisoners identified in a subsequent internal
Prison Service investigation as having been deliberately moved out of
Wandsworth to Pentonville. However, as I go on to describe in the ‘Key
Findings’ section of this report, the man did move unexpectedly to Pentonville
following a court appearance a few days before HMIP arrived at Wandsworth.
He did not return to Wandsworth until the inspection concluded. My
investigators have explored whether his movements around the London
prison system were influenced by the inspection. I discuss the evidence they
gathered in the ‘Issues’ section of the report.
29. The Chief Inspector recommended that senior managers in particular needed
to be reminded that care for prisoners is their prime responsibility. She also
recommended that prisoners who are at risk of self-harm are only moved to a
different prison when it is in their best interests.
30. Aside from the attempt to affect the outcome of the inspection, the Chief
Inspector found that staff awareness of the use of the ACCT process had
improved, but that the quality of the documents was variable or even poor.
The inspection team discovered a failure to put in place and monitor ACCT
action plans following my investigations of previous deaths at Wandsworth.
Final Report: January 2011 19
Four prisoners had taken their own lives since the previous inspection, but
only two action plans could be produced.
31. HMIP examined the response to my investigations of deaths in Wandsworth
and prison staff reported that all the recommendations made by my office had
been put into practice. However, the Chief Inspector found that that this claim
was ‘clearly false’ in some instances. For example, prisoners were not being
given prior notification of transfer out of the prison, nor were they being given
the chance to have the proposed transfer reviewed if they protested. The
inspection team were ‘deeply concerned’ that the prison management team
appeared to have ‘completely lost sight of the issues that had previously
contributed to deaths in custody’.
32. The monthly safer prisons meeting was well attended and HMIP considered
the suicide prevention strategy to be comprehensive, albeit with some
qualifications. However, no investigations were carried out in relation to eight
near-deaths (incidents where a prisoner could have died but was revived)
which had taken place in the previous six months. The Chief Inspector
recommended that all the recommendations resulting from my investigations
of deaths in custody should be implemented consistently.
33. With regard to the delivery of healthcare, the Chief Inspector found that there
was too much reliance on agency staff to fill vacancies. She recommended
that the vacancies be filled permanently. She indicated that the different
teams responsible for providing healthcare were not well integrated and
recommended that sufficient mental health nurses were recruited to meet the
demands of a prison the size of Wandsworth.
Previous investigations of deaths at Wandsworth
34. Since 2004, I have conducted 11 investigations of self inflicted deaths in
Wandsworth. (Most involved the prisoner hanging himself, but one involved a
man refusing food and another involved an overdose of medication.)
Additionally, I have investigated the death of a man who took his own life very
shortly after being released from Wandsworth.
35. When I investigated the death of a prisoner in August 2005, I recommended
that the completion of new CSRAs should take into account information
contained in previous assessments. I also recommended that the frequency
of observations should be stated on the front cover of a prisoner’s ACCT
document. I revisit both issues in this report.
36. Following my investigation of the death of a prisoner in October 2007, I
recommended that, if the In-Reach team is working with a particular prisoner,
they should be included in the ACCT process and work in liaison with the
Safer Prisons team. My investigators have found that the inclusion of the In-
Reach team in the ACCT process remained a concern. When Wandsworth
responded to the draft report about the man’s death, they said that the
situation had ‘generally improved’ and that a member of the In-Reach team
was assigned to each wing to attend ACCT reviews.
Final Report: January 2011 20
37. The investigation with most direct relevance to the man’s death was that into
the circumstances of the death of a prisoner on the Onslow Centre in August
2007. I found that the man transferred to Wandsworth without records being
made of who authorised the transfer. It was unclear what preparations were
made for the man’s arrival. He was held in the healthcare centre at the
sending prison but placed on the Onslow Centre at Wandsworth. The man
was located in a shared cell with another vulnerable prisoner with mental
health problems. The arrangement was unsuitable and the man asked to be
moved.
38. The man was the subject of an ACCT document. Despite staff being provided
with new and concerning information, the risk he presented to himself was not
reviewed and the frequency of observations was not increased. At the time
that the man was found hanging in his cell, he should have been checked at
least ten minutes earlier.
39. Following the investigation I highlighted the importance of keeping a proper
transfer register. I discussed the suitability of cell sharing arrangements and
recommended that staff take account of concerns about an existing occupant
when placing a new prisoner in a cell. I recommended that the Governor
satisfy himself that staff were properly trained in the use of ACCT documents.
I highlighted the need to take account of new information during the ACCT
review process to inform risk assessments. I drew attention to the need for
senior staff to regularly check ACCT documents to ensure they are being
properly completed. The man’s experiences on the Onslow Centre are similar
to those of the man who died in August 2007.
Independent Monitoring Board (IMB)
40. The most recent annual report published by the IMB at Wandsworth covers
the year from June 2008 to May 2009. (The IMB at each prison is made up of
members of the public who are both independent and unpaid. They monitor
the day-to-day life in their local prison and ensure that proper standards of
care and decency are maintained.)
41. The Board made their comments before HMIP’s report was published. The
IMB praised the efforts of the management team and noted that
improvements continued to be made. It was felt that the ‘old’ Wandsworth,
and the bad reputation it carried, was beginning to be replaced by a ‘new’
Wandsworth where staff treated prisoners ‘fairly and with respect’. The Board
commented that ‘relationships between prisoners and officers [are] so much
better than just a few years ago’.
42. The IMB expressed concern regarding the provision of primary healthcare,
before it became clear that the company responsible had gone into
liquidation. The Board was also critical of a reliance on agency staff. They
commented on the high number of prisoners experiencing mental health
difficulties at Wandsworth and expressed the concern that the In-Reach team
was too small to ‘have a real impact’ on the scale of the problem.
Final Report: January 2011 21
43. The IMB thought that the process for referring a prisoner to the In-Reach team
was unsatisfactory and asked that the provision of mental healthcare be
reviewed to ensure that different agencies were working together effectively.
They also noted that internal communication between those staff delivering
primary healthcare and those treating mental health problems was poor, and
that joint meetings to discuss prisoners were rare.
44. With regard to vulnerable prisoners, the IMB thought it inappropriate that they
were having to be accommodated in the first night centre for ‘days or weeks’
when they first arrived, before moving across to the Onslow Centre when
there was room to accommodate them. (The man spent two nights on the
first night centre in mid-May before a place was found for him on the Onslow
Centre.) The Board said that the Onslow Centre suffered from overcrowding.
They asked that a decision be taken regarding its future:
‘The future of [the Onslow Centre] … gives ground for considerable
concern. The Ministry of Justice has delayed taking a decision on
whether to rebuild or refurbish this unit and we have acute fears about
the consequences of a major system failure …’
45. As far as the use of ACCT documents was concerned, the Board commented
that:
‘Staff awareness of prisoners’ vulnerability appears heightened with a
commensurate improvement in the quality of [entries].’
46. Despite the acknowledged improvement, the IMB found the recording of
information in ACCT documents to be variable. They also noted that ACCT
reviews were not always attended by representatives from other agencies.
The Board highlighted the failure by wing managers to always monitor their
staff’s entries in ACCT documents. The IMB also said that:
‘The high percentage of prisoners suffering from mental illness means
that vulnerable men are held in conditions conducive to self harm and
volatility.’
Performance rating
47. Prison quarterly ratings published on 26 June 2009 by the Ministry of Justice
show that Wandsworth scored 3 overall, indicating a good performance. The
prison achieved the same score in the previous and subsequent quarter. The
minimum score is 1 (serious concerns) and the maximum is 4 (exceptional
performance). The rating takes into account 34 different aspects of the way
the prison is currently operating.
Final Report: January 2011 22
HMP PENTONVILLE
48. Pentonville is a category B prison holding a maximum of 1,152 men. As a
local prison, it receives new prisoners from the London courts on a daily
basis. In general, men remain in Pentonville whilst held on remand or serving
short sentences. Those serving longer sentences are transferred to another
prison.
Healthcare
49. As of 1 April 2009, NHS Islington assumed responsibility for delivering primary
healthcare. Camden and Islington NHS Foundation Trust run the substance
misuse and In-Reach teams. Barnet, Enfield and Haringey Mental Health
Trust have responsibility for delivering forensic psychiatric services.
50. The prison provides 24 hour nursing cover. There is a dedicated team of
psychiatrists attending to prisoners with severe and enduring mental health
problems. Doctors visit the prison regularly to run general surgeries.
Emergency out of hours doctors are provided by Camidoc, a local provider in
the Camden area. There is a 22 bed inpatient facility in the healthcare centre,
16 of which are reserved for psychiatric treatment.
HM Chief Inspector of Prisons
51. HMIP completed an announced inspection of Pentonville between 11 and 15
May 2009. The Chief Inspector found that the then Governor, Governor C,
had made undoubted improvements to the prison during his tenure. She
credited his team with striving to ensure that prisoners receive a reasonable
standard of care, something that has not always been the case previously.
After recent poor inspections, the latest visit initially gave cause for optimism.
52. However, the Chief Inspector wrote that any improvements were
overshadowed by the temporary transfer of six prisoners to Wandsworth for
the duration of the inspection, putting the men at risk. (These events are
described in the previous section entitled ‘HMP Wandsworth’.) The Chief
Inspector commented that the Pentonville inspection would be remembered
for:
‘…exposing the irresponsible, pointless and potentially dangerous
actions of some managers, who lost sight of their primary duty to the
prisoners in their care.’
53. Despite her criticism of the deliberate movement of potentially vulnerable
prisoners during the inspection period, the Chief Inspector found that there
was in general terms a ‘strong focus’ on safer custody procedures at
Pentonville. The Chief Inspector found that most vulnerable prisoners felt
safe both in the VPU and in the prison as a whole. The men spoke highly of
the staff who worked on the VPU (where the man was held between 27 May
and 1 June).
Final Report: January 2011 23
54. HMIP examined the response to my investigations of deaths in Pentonville.
They found that, although a consolidated safer custody action plan was in
place, this did not address all of the recommendations I had made as a result
of my investigations, nor all of the Coroner’s findings at the subsequent
inquests. The Chief Inspector wrote that ACCT assessments were generally
good, but that few ACCT reviews involved other agencies.
55. With regard to healthcare provision, The Chief Inspector found that the
medical staff enjoyed ‘robust support’ from the various Trusts involved.
Despite an ‘excellent’ healthcare centre, she wrote that ‘primary mental
healthcare, and the speed of transfer to NHS facilities for those with acute
mental illness, were inadequate’. The inspection team found a significant
number of prisoners waiting for transfer to a secure mental health bed. The
management of these transfers was judged to be ‘poor’. The Chief Inspector
wrote that a mental health nurse visited the wings on a weekly basis to
support prison staff.
56. Prisoners’ wing history sheets were not completed to the satisfaction of the
inspection team. Staff made few entries and there was no reference to any
special care needs that prisoners might have.
Independent Monitoring Board (IMB)
57. The most recent annual report published by the IMB at Pentonville covers the
year from April 2008 to March 2009. The Board thought that ‘too many’
prisoners with mental health difficulties who required a higher level of support
than resources would allow were being held at the prison. The Board found
that a shortage of beds in the healthcare centre meant that prisoners who
might receive specialist mental health treatment in the community were being
cared for whilst living on the wings. (However, the man was able to be
accommodated in the healthcare centre twice when this was considered
appropriate.)
58. With regard to the VPU, the Board commented that staff shortages had
affected prisoners’ ability to access healthcare services. (When the man was
held in the VPU in late May, he was not checked by any healthcare staff.)
The IMB commented that a ‘great deal’ remains to be done if Pentonville is to
be brought up to a satisfactory standard. However, they praised the efforts of
Governor C.
Performance rating
59. Prison quarterly ratings published on 26 June 2009 by the Ministry of Justice
show that Pentonville scored 2 overall, indicating that the prison’s
performance required further development. The prison achieved the same
score in both the previous and subsequent quarters. (As noted in paragraph
47 above, the maximum possible score is 4.)
Final Report: January 2011 24
THE MAN
60. The man was a 25 year old, black South Londoner who, when he died, was
making plans for a life abroad. He was interested in studying maths and
English and was making efforts to address his substance misuse. He had
three siblings and had been brought up by his mother.
61. The man first came into contact with psychiatric services in April 2003. He
was admitted to hospital between November 2003 and February 2004 and
between August and November 2004. In between these admissions he made
three attempts to take his own life (on one occasion using a ligature) and was
described as ‘acutely psychotic’ at the time of the second admission. He was
diagnosed with paranoid schizophrenia and a possible anti-social personality
disorder. His behaviour proved difficult to manage and staff struggled to
engage with him. Whilst admitted to hospital, he went absent for periods of
time.
62. In May 2005, the man was formally admitted to Lambeth Hospital under the
Mental Health Act. He absconded shortly afterwards, but was returned to the
hospital by the police in early July. His behaviour seems to have been
particularly chaotic and his mental disorder particularly severe during this
period. He heard voices and was prescribed anti-psychotic medication. He
was misusing class A drugs and alcohol in the community.
63. It is unclear from the documents available to my investigators exactly when
the man left hospital again. By the following month, he had returned to the
community and committed offences of robbery and possession of an imitation
firearm. He was remanded into custody and taken to Wandsworth. In
February 2006, the man received a custodial sentence of four years (for
robbery and possession of an imitation firearm). The probation officer who
wrote the pre-sentence report at the time noted that the man required an
appropriate adult to be present during interview.
64. Because of his time served on remand, the man’s sentence expiry date was
set as 31 August 2009. In 2006, he moved regularly between HMP
Maidstone and HMP Swaleside. The following year, he was held at
Maidstone, Swaleside, HMP Elmley, HMP Leicester and HMP Preston, HMP
Nottingham, HMP Brixton and Wandsworth.
65. Early on in the man’s sentence, concerns were raised about his suitability for
cell sharing. In May 2006, a CSRA was completed at HMP Maidstone. Staff
assessed that the man required a single cell because of his ongoing mental
health problems. Later that year he tried to stab an officer in the neck and
also attacked a prisoner. A couple of weeks later, he assaulted night staff
using a shard of glass.
66. In January 2007, the man stabbed another prisoner in the buttocks with a
knife. Later that year he again attacked a member of staff with a piece of
glass. A further CSRA was carried out at HMP Swaleside in January 2007.
Final Report: January 2011 25
The man was still considered unsuitable to share a cell because of the high
risk he presented to others.
67. During 2006 and 2007 concerns were raised about the possibility of the man
harming himself in prison and a number of separate ACCT documents were
opened. The man was initially released from Wandsworth on licence on 19
September 2007. However, in the middle of October 2007, he was recalled to
custody after failing to comply with the terms of his licence. He returned to
Wandsworth and remained there until March 2009.
Final Report: January 2011 26
KEY FINDINGS
Release on licence
68. In early 2009, preparations began for the man’s second release on licence.
The seconded probation officer in HMP Wandsworth completed a report for
the Parole Board in early February indicating that the man was making
progress. At the same time, the manager of the mental health in-reach team
at Wandsworth liaised with Streatham Community Mental Health Team
(CMHT) to ensure that support was in place for the man upon his release.
The man’s offender manager liaised with the CMHT and found
accommodation for the man in a Probation Service approved premises in
Tulse Hill, South London.
69. The man’s Community Psychiatric Nurse (CPN) from the CMHT, assessed
the man together with his colleague on 6 March in Wandsworth. Two weeks
later, on 20 March, the man was released on licence on the condition that he
lived and slept each night at the approved premises. He also had to report to
both his CPN and his offender manager every week. The same day, the
man’s offender manager telephoned the CMHT because the man had been
released from Wandsworth without his medication. A member of staff from
the CMHT took his prescription to the approved premises.
70. The man kept all of his appointments with the probation service and the
CMHT during the next few weeks, but committed four motoring offences on 14
April (driving a vehicle without a licence, driving whilst disqualified, failing to
provide the police with a name and address and having no insurance).
71. The next day, 15 April, the man kept his prearranged appointment with his
offender manager. She issued him with a verbal warning in relation to his
reoffending but decided not recall him to custody for the new offences. She
told the man that any further failure to comply with his licence conditions
would result in a final warning and consideration of recall to custody. The
man’s offender manager contacted the CMHT to arrange additional support
for the man.
72. The man visited the CMHT the same day where he was assessed by another
nurse from the CMHT and a specialist registrar at the CMHT. They noted that
his mood seemed lower, reviewed his medication and additionally prescribed
an anti-depressant.
73. On 21 April, the man appeared at Camberwell Green Magistrates’ Court in
relation to the driving offences. He was remanded into custody at about
midday. The man’s offender manager told my investigator that her colleagues
working in the court failed to notify either her or the approved premises of the
man’s court appearance and his remand into custody.
74. On the same day, the man was scheduled to keep his regular weekly
appointment at the probation office. When he did not attend, the man’s
offender manager discussed how to proceed with her manager. She
Final Report: January 2011 27
attempted to telephone the man, she contacted the approved premises and
she issued a warning letter. In her email to approved premises staff, she
instructed them to initiate an immediate out of hours emergency recall if the
man did not return before the nightly curfew.
75. Because the man was now in prison, he did not return to the approved
premises and the emergency out of hours recall request was submitted at
11.50pm on 21 April. The decision to recall the man was prompted by his
failures to attend the probation office and comply with his curfew at the
approved premises. The circumstances of the breach of licence were detailed
as follows:
‘The man failed to return to [the] approved premises and comply with
his curfew conditions on the night of 21 April 2009 and was recalled
by the hostel staff on an emergency basis. He also failed to attend
his supervision appointment on 21 April with the man’s offender
manager, his offender manager. He did not make contact with either
his offender manager or the hostel staff to confirm reasons for failing
to comply. Attempts were made to contact him but his mobile phone
appeared to be switched off.’
76. Prisoners remanded into custody at Camberwell Green normally transfer to
HMP Brixton. However, when he returned to his cell in the court, the man told
a member of Serco staff that one of his cousins worked at the prison. Serco
staff liaised with the duty governor at Brixton, Governor V. Governor V
confirmed that, because the man’s relative worked in the prison, it would be
inappropriate for him to go there.
77. Governor W took over from Governor V as duty governor at about 12.30pm.
Because she did not want to keep the man waiting unnecessarily at
Camberwell Green, Governor W asked Principal Officer Z to use her contacts
with colleagues at HMP Pentonville to arrange for the man to be taken there
instead. Principal Officer Z told my investigators that she telephoned
Pentonville and spoke to Principal Officer A. The duty governor at Pentonville
that day, Governor A, remembers being advised by Principal Officer A that
Brixton were asking them to accept the man. Governor A agreed because of
the presence of the man’s relative on the staff at Brixton. Brixton arranged
with Serco staff at the court for the man to be taken directly from Camberwell
Green to Pentonville.
HMP Pentonville
21 April – 12 May
78. The man left Camberwell Green at about 2.50pm and arrived at Pentonville
just before 4.00pm on 21 April. He was allocated a new prisoner number,
although he had been in custody before and already had a pre-existing
number. In effect, an alternative second record for the man was created on
the Prison Service’s database.
Final Report: January 2011 28
79. In the reception area a Cell Sharing Risk Assessment (CSRA) was completed
by Officer A. The man’s history of self harm and suicidal thoughts and misuse
of drugs and alcohol were recorded. His vulnerability and mental health
problems were highlighted. When completing a CSRA, to a large extent staff
depend on information supplied by the prisoner himself about his previous
behaviour in custody. The man did not tell the officer that he had assaulted
both staff and prisoners in the past. Officer A assessed the man as
presenting a low risk of harm to others.
80. Nurse A assessed the man. She recorded the man’s alcohol and heroin
misuse during the initial health screening. She noted that he was diagnosed
with schizophrenia, for which he said he was being prescribed 6mg per day of
risperidone, 2mg per day of procyclidine and 5mg per day of olanzapine.
81. The nurse noted that the man suffered from epilepsy, seemed depressed and
was under the care of Streatham CMHT. Because the man told her that he
was hearing voices telling him to harm himself and she noticed self harm
scars on his arms, Nurse A referred him to Doctor A, a prison doctor.
82. The man told Doctor A that he had been drinking up to four small bottles of
whisky per day. He said that he had last consumed alcohol the day before,
20 April, and last misused heroin on 16 April. The doctor told my investigators
that the man was not presenting with drug or alcohol withdrawal symptoms.
Doctor A decided not to refer the man to the prison’s detoxification unit for the
time being and did not prescribe any medication to ease any withdrawal
symptoms as none was evident. The doctor told my investigators that a
subsequent check for withdrawal symptoms would take place during a
secondary health assessment the next morning.
83. Based on the man’s history of mental health problems and his vulnerable
presentation, the doctor opened an Assessment, Care in Custody and
Teamwork (ACCT) document. Doctor A also completed a mental health
referral to the In-Reach team. Although the man told Nurse A that he was
prescribed anti-psychotic medication in the community, Doctor A was
reluctant to issue any drugs until the information was confirmed with the
CMHT the next day. He prescribed the man 15mg per day of mirtazapine in
the meantime. Completing the healthcare section of the CSRA, Doctor A did
not identify any concerns about cell sharing, and assessed the man as
presenting a low risk to others.
84. The first entry in the ACCT document recorded that the man did not want to
be in Pentonville and wished to move to a South London prison. At 8.25pm,
Senior Officer A completed the ACCT immediate action plan. The man was
located with Prisoner A in a shared cell on the third landing of A wing (the first
night centre, where prisoners generally spend the first week or so in
Pentonville). Prisoner A had initially been placed in a different cell, but was
moved to share with the man after 45 minutes because he did not get on with
his original cellmate. As part of the ACCT process, staff checked on the man
at least once an hour.
Final Report: January 2011 29
22 April
85. The following morning, 22 April, Officer B (a trained ACCT assessor) went to
the man’s cell where he was still asleep. Officer B told my investigators that
his cellmate had gone to court. She woke the man and took him to an office
on the wing to carry out his initial ACCT assessment interview (which must be
completed within 24 hours of the ACCT document being opened). She told
my investigator that the assessment interview began at 9.30am and lasted
about 45 minutes.
86. Officer B remembered that the man was holding his neck at an awkward
angle when they spoke. (Staff and prisoners agreed that this problem
seemed more pronounced when the man became anxious.) The man said
that he was hearing voices telling him to harm himself. The officer noted that
the voices were strong and persistent and that the man had a history of
mental health problems.
87. During the interview, the man said that he would be ‘better off dead than
alive’. He said that ‘so much’ was going on in his head. He told the officer
that the recent death of a cousin had worsened his feelings of depression.
The officer remembered the man saying that he wanted to ‘be with his cousin’.
She referred him to the prison chaplain with a view to bereavement
counselling.
88. The man told Officer B that he wanted to transfer to Wandsworth to be nearer
to his family, and she advised him that any move would need to be approved
by a governor. He asked for help to address his substance misuse. The
officer recalled that the man looked like somebody who might be withdrawing
because his mouth was drooping and his eyes were watering. He did not look
well but she could not be sure whether this was a result of his mental health
problems or his substance misuse.
89. On the morning after a prisoner’s first night in custody, a nurse carries out a
secondary health assessment following the initial screening in the reception
area the day before. Having finished the assessment interview, Officer B took
the man down to wait outside the nurse’s treatment room.
90. Because the man had asked for help with drug and alcohol withdrawal, Officer
B walked over to the detoxification unit on B wing to speak to a substance
misuse nurse, who agreed to organise a place for the man on the unit as soon
as possible. Officer B referred the man to the CARATS (Counselling,
Assessment, Referral, Advice and Throughcare Services) team and the In-
Reach team.
91. When she returned from the detoxification unit, Officer B sat down with Senior
Officer B and the man to complete the ‘action following assessment’ section of
the ACCT document. It was noted that the man was quite clearly depressed
but that, once his detoxification medication took effect, he might start to feel
better. A space had been found on the detoxification unit and the man was
supposed to move there later in the day. The risk the man presented to
Final Report: January 2011 30
himself was assessed as ‘low’. Officer B told my investigators that she
thought there was an ‘imminent’ likelihood of ‘suicidal intent’, but she believed
the planned move to the detoxification unit would reduce the risk.
92. The ACCT document appears to indicate that the intended level of
observations remained once an hour during the morning of 22 April, although
this is somewhat unclear. Officer B remembered that she did not amend the
frequency of the checks.
93. Following Officer B’s referral, later that morning the man spoke to Chaplain A.
The chaplain agreed to ask the Imam to visit the man as he was a Muslim.
The man was escorted to the induction room by Officer C, where he met a
variety of staff who could assist him in prison, such as a member of the
CARATS team and a worker from St Mungo’s.
94. As Officer C took the man back to his cell, he told her that he was scared of
being in Pentonville. He said that, as a member of a South London gang, he
was anxious about being placed amongst rival gang members in a North
London prison. Because of the sensitive nature of their conversation, Officer
C took the man back to the induction room, where they would have more
privacy.
95. Officer C told the man that he could apply to move to Wandsworth. She also
suggested moving him to another part of Pentonville. However, because the
man was so anxious, Officer C offered him vulnerable prisoner status. In
prison, this is known as ‘taking rule 45’. It means that the person is removed
from the general prison population for their own protection and placed on a
dedicated wing with other vulnerable prisoners.
96. The man had previously been located on the Vulnerable Prisoners Unit (VPU)
at Wandsworth (known as the Onslow Centre) before his release on licence.
He feared for his safety if he stayed amongst the general prison population
and decided to accept Officer C’s offer of a move to the VPU in Pentonville.
Officer C asked the duty governor to assist her.
97. Governor B (the duty governor) and Officer C interviewed the man at about
11.00am that day. They completed a ‘Management of Vulnerable Prisoners’
document. The interview lasted about an hour. Although the man was
scared, Officer C recalled in interview that he remained calm and was grateful
to be offered protection. She thought that he was afraid of being attacked by
other prisoners. She knew he was currently the subject of an ACCT
document, but she did not recall him mentioning any suicidal thoughts whilst
they arranged the move to the VPU.
98. The man spoke clearly during the interview and Officer C thought that he
understood what was going to happen. She did not observe any significant
mental health problems. The officer remembered that the man held his neck
at an awkward angle. He was granted vulnerable prisoner status. Governor
B tried to ease his anxiety by proposing a transfer to Wandsworth (where he
Final Report: January 2011 31
said he had felt safe on the Onslow Centre) following his next court
appearance in May.
99. Officer C told the man to pack up his belongings as he would move to a cell
on Pentonville’s VPU on G1 landing straight after lunch. (Officer C explained
to my investigators that, because the meeting finished at about 12.10pm, the
last time for movements around the prison before lunch had passed.) In the
meanwhile Prisoner A was moved into a different cell because the man’s ‘rule
45’ status meant that he could no longer share with a prisoner from the
general population. Having collected his meal, the man was locked alone in
his cell for lunch at about 12.30pm.
100. An entry was made in the man’s ACCT document by a CARATS worker at
1.10pm, indicating that he agreed to an assessment following Officer B’s
referral earlier that morning. Officer C completed a Security Incident Report
(SIR) outlining the man’s concerns regarding gangs in Pentonville.
101. Following the lunchtime lock up from 12.30pm to 1.30pm approximately, the
other prisoners were unlocked for afternoon exercise. Officer C had told the
man that, as vulnerable prisoners had to be kept separate from the general
population, he would have to wait until the other prisoners left before he was
moved to the VPU. She told her colleagues who were unlocking cells with her
that the man had signed up to rule 45.
102. A short while later, Officer C was walking past the man’s cell when she acted
on a feeling of concern. Looking through the observation flap at about
2.20pm, she saw the man in a seated position on the bottom bunk bed. She
realised that he was suspended slightly above the mattress and had tied a
towel around his neck, attaching it to the frame of the bed above him. Officer
C immediately shouted for assistance and Officer D and Officer E, who were
unlocking prisoners on the other side of the landing, joined her.
103. Officer C opened the cell door. She and Officer D used their anti-ligature
knives to cut through the towel that the man had used to hang himself. The
material was very thick and it took both officers’ efforts with their knives to
remove the ligature. In the meanwhile, Officer E told the control room that a
‘level one’ emergency was underway. Healthcare staff were instructed to
attend immediately and an emergency ambulance was requested.
104. Supporting the man, the officers moved him to the floor. His pupils were fixed
and dilated. Officer C tilted and supported his head and cleared his airway to
give breaths whilst Officer E began giving chest compressions. The man
began to respond to their efforts. Officer D stood by the entrance of the cell to
ensure that the healthcare staff could see where to go and reach the man as
quickly as possible.
105. Healthcare staff arrived at the cell at 2.22pm. Nurse B and Nurse C found a
pulse and took over the resuscitation of the man. They were joined by
colleagues including Doctor B, Doctor C and the Head of Primary Care
Nursing at Pentonville. Paramedics reached the wing at 2.30pm and the crew
Final Report: January 2011 32
of an air ambulance arrived at 2.42pm. The air ambulance team attributed the
man’s survival to the initial efforts of the staff. He nearly died and his
successful resuscitation was far from certain. The Head of Primary Care
Nursing at Pentonville recalled in interview that he and Doctor B had not
expected the man to survive.
Admission to hospital
106. At about 3.10pm the man was taken by ambulance to the Royal London
Hospital. Given the seriousness of his attempt to take his own life, Governor
C held a debrief meeting shortly before 4.00pm. The debrief was intended to
give staff a chance to collect their thoughts, learn any immediate lessons from
the emergency and access support if they had been affected by events.
107. The man initially stayed in the Intensive Care Unit (ICU) at the Royal London.
He was in a critical condition to begin with and was not handcuffed whilst he
was sedated. Escorting staff sitting with the man at the hospital were to
contact the duty governor for advice regarding restraints when the man’s
condition improved.
23 April
108. The next day, 23 April, the mental health referral from Doctor A reached the
prison’s In-Reach team. The man remained sedated at the Royal London and
a machine was helping him to breathe. His mother and sister arrived in the
early afternoon. At about 5.00pm he regained consciousness and he became
agitated overnight as the sedative wore off.
109. On the same day staff at the Tulse Hill approved premises had discovered
that the man had returned to prison and was now under escort in hospital.
They told the man’s offender manager’s line manager because she was away
from the office.
24 April
110. The man was moved to a private room the following day. Given that he had
made escape attempts in the past, the risk he presented as a prisoner and his
difficult behaviour since waking, the man was cuffed to one of the officers
from this point onwards by an escort chain.
111. On the same day, 24 April, the Request for Recall report completed by the
man’s offender manager was approved. The man’s offender manager had
noted that the man had complied with his reporting instructions until 21 April.
She wrote that concerns had been raised about his mental health problems
and behaviour at the hostel, but that these had been managed. The man’s
offender manager’s line manager and the Assistant Chief Officer (ACO) for
Lambeth had both approved the man’s recall to custody and agreed that he
had breached his licence conditions.
Final Report: January 2011 33
112. Staff at the Public Protection Casework Section, the department of the
National Offender Management Service (NOMS) which administers recalls,
were unaware of the man’s whereabouts and had instructed the police to
arrest him. The reasons given for the revocation of licence were:
‘You have failed to be well behaved, not commit any offence and not
do anything which could undermine the purposes of your supervision,
which are to protect the public, prevent you from reoffending and help
you to resettle successfully into the community.
‘You failed to keep in touch with your supervising officer in accordance
with instructions.
‘You failed to live permanently at the address approved by your
supervising officer and failed to notify him or her in advance of your
change of address or proposed stay (even for one night) away from
that approved address.’
113. Officer F spent time at the hospital as the bedwatch officer during this period.
In interview, he recalled that the man was confused and did not understand
why he was in hospital. Entries made in the ACCT document show that the
man was disoriented and agitated in the days after he woke up in hospital and
had no idea why he was a prisoner again. He asked questions about his
family, his next court appearance and his prison sentence. Whilst the man
was in hospital, the prison arranged and paid for taxis to take his mother to
visit her son in hospital.
26 April
114. Two days later, on 26 April, the man was interviewed by a psychiatrist in
hospital. He recalled the police arresting him for driving offences but could
not remember trying to hang himself. He said that he had enemies in
Pentonville and was hearing the devil’s voice telling him to kill himself.
115. Still unaware that the man had re-entered custody, the Public Protection
Casework Section checked the Prison Service’s Inmate Information System
(IIS) on 27 April. Their staff did not identify from the computer records that the
man was back in prison, albeit presently discharged to hospital. On the same
day, the man’s offender manager returned to the probation office and
telephoned the man’s mother to discuss her son’s remand into custody.
27 April
116. Principal Officer B submitted a Security Incident Report (SIR) on 27 April
concerning the man’s possible ties to gang culture. Whilst the PO was visiting
the hospital, the man spoke about an ‘ongoing feud’ between North and South
London gangs, his fears for his safety as a result and his wish to return to
Final Report: January 2011 34
Wandsworth. Principal Officer B told my investigator that the man was not
completely coherent when they spoke and he was unsure of the accuracy of
the information he provided. Nonetheless, he felt obliged to record it in an
SIR.
Return from hospital to Pentonville
28 April
117. The man returned to Pentonville from the Royal London shortly before 2.00pm
on 28 April. He was placed in a single cell on the healthcare centre and a
CPN, Mental Health Nurse A, was allocated to him. The ACCT document
remained open and he was kept under constant observation. Constant
supervision at Pentonville means that a nurse stayed with the man at all
times. He was in a dedicated cell with both a door and a barred gate so that
he could easily be observed by staff. During the day, the door is pinned back
and the prisoner can be seen through the bars of the locked gate. At night,
the door is locked and staff use the observation flap to check the prisoner.
118. Later, on 28 April, the man’s condition was reviewed by Doctor D (consultant
forensic psychiatrist) and his colleague Doctor E (speciality doctor in forensic
psychiatry). He told the doctors that he had been hearing voices and felt
unsafe amongst the general Pentonville prison population, believing that other
prisoners wanted to kill him. Doctor E remembered the man saying that this
feeling had contributed to the attempt to take his own life on 22 April.
119. The man indicated that his suicidal thoughts were unpredictable, but that he
was not feeling ‘too suicidal’ at present. He told the doctors that he had been
‘doing well in Wandsworth’ before his release on licence. Doctor D noted that
the man seemed ‘preoccupied’ with returning there.
120. Doctor D told my investigators that the man spoke clearly and coherently.
Both he and Doctor E told my investigators that the man had been ‘pleasant
and cooperative’ during the consultation. Doctor E recalled that he seemed
stable and calm. She remembered that each time she encountered the man
in the healthcare centre during this period, he would talk about his desire to
transfer to Wandsworth.
121. To assist understanding of the man’s previous mental health problems, the
manager of the mental health in-reach team at Pentonville contacted
Streatham CMHT, who faxed across a discharge summary dating from 2004.
Doctor D instructed that the man continue to be prescribed 7mg per day of
risperidone and 15mg per day of mirtazapine. The man was visited by the
duty governor at about 5.00pm. During the evening, he was seen talking to
himself for a prolonged period of time.
29 April
122. At 3.00pm the next day, 29 April, on the advice of Doctor D, the ACCT
observations were reduced from constant supervision to every 15 minutes
Final Report: January 2011 35
until 8.00am the next morning. (The checks were to be further reduced to
every 30 minutes from 8.00am until 4.00pm on 30 April, and from then on the
man was to be checked at hourly intervals.)
123. The first review of the ACCT document took place the same afternoon.
Senior Officer C led the meeting with Doctor D in attendance. The man
seemed relaxed and said that he was no longer thinking about harming
himself. The risk he presented to himself was assessed as ‘low’ (as opposed
to either ‘raised’ or ‘high’). He voiced his desire to be transferred to
Wandsworth and his anxiety at being held in Pentonville. He expressed a
wish for increased contact with his family so visiting orders were to be issued.
He was given a television in the hope that he would benefit from some
distraction. The next ACCT review was scheduled for 6 May.
124. In interview, Senior Officer C remembered that the man appeared ‘slightly
paranoid and overly nervous’ when he returned from hospital. He told my
investigators that the man settled in quickly on the healthcare centre. He
complied with his medication and mixed well with the other prisoners,
attending reading and writing classes. His condition stabilised and slowly
improved. The man was assured that his return to Wandsworth was in hand.
125. Doctor D wrote in the man’s medical record that he felt safer in the healthcare
centre but would feel safer still in Wandsworth. The doctor decided that the
man should stay in the healthcare centre because the risk that he would harm
himself would increase if he moved anywhere else in Pentonville. Doctor D
supported the proposed transfer to Wandsworth and understood that
Governor C was considering the man’s request.
126. The doctor told my investigators that he spoke to the Head of Healthcare at
Pentonville about the proposed transfer. The man continued to hear voices,
seemed depressed and told the doctor that ‘at times it would be easier to die
than live’. However, there was no evidence of further self harm or that the
man had a specific plan to take his own life. Doctor D recalled that the man
complied with his medication and took it regularly whilst he was in Pentonville.
30 April
127. The chaplain visited the man on the afternoon of 30 April and they talked
about his fear of Pentonville and his desire to return to a South London prison.
The next day, 1 May, the man spoke to the Imam, who made an entry in his
ACCT document noting similar sentiments. The same morning, Senior Officer
C planned to pursue the proposed transfer to Wandsworth with the prison’s
Offender Management Unit (OMU).
128. Governor C told my investigators that he visited the man a couple of times in
the healthcare centre to receive updates on his condition. He remembered
the Head of Healthcare at Pentonville and his colleagues telling him about
the man’s anxiety at remaining in Pentonville and his wish to return to
Wandsworth. Governor C took into account the man’s serious attempt to take
his own life, the reasonable nature of the request and the need to provide
Final Report: January 2011 36
greater stability. He planned to seek Wandsworth’s assurance that they
would accept the man as soon as it was appropriate to transfer him.
129. Governor C approached Governor 1 (the then Governor of Wandsworth) in
early May to obtain his agreement to the man’s transfer. Neither man could
remember in interview precisely when or how they spoke, but both confirmed
that they had had the conversation.
130. Governor 1 recalled Governor C explaining that the man had made a very
serious attempt on his own life, that staff at Pentonville had been affected by
the incident and it was thought inappropriate for him to remain at Pentonville
for any longer than necessary. Governor 1 remembered Governor C telling
him that the man was ‘very keen’ to return to Wandsworth, where he felt safer.
Governor C asked Governor 1 to accept the man at Wandsworth and he
agreed. Governor 1 could not recall any subsequent involvement in helping to
oversee the planned transfer, but he thought that he would have had
discussions with colleagues in advance of the man’s arrival.
5 May
131. Doctor D reviewed the man’s mental health again on 5 May. The man was in
a better mood and said that the voices were ‘not too harsh’ at present. He
continued to talk about his association with a South London gang and express
his fear of being harmed if he was placed with the general prison population,
which included prisoners who he said were demanding money from him. The
doctor noted that the man was not currently expressing suicidal thoughts.
Later that day, Doctor D wrote a referral letter to a specialist registrar at
Streatham CMHT, asking him to visit the man in prison and assess him. He
wrote:
‘In view of the serious nature of the suicide attempt, I am of the opinion
that he might benefit from further assessment in hospital …’
132. The man was provided with a telephone PIN number on 5 May. The same
day, Officer G told the man that he was subject to ‘medical hold’ and could not
be transferred out of Pentonville for the time being. However, Senior Officer
C told healthcare staff later that the man would return to Wandsworth a week
later, on 12 May, following a court appearance. Plans were made to liaise
with the In-Reach team at Wandsworth prior to his arrival.
133. Staff at the Public Protection Casework Section made a second check of the
Prison Service computer records on the same day. They discovered from the
records that the man had been held in Pentonville since 28 rather than 21
April. Staff emailed a licence recall pack to Pentonville for immediate
distribution to the man.
6 May
134. Senior Officer C and a mental health nurse completed the second review of
the man’s ACCT document at 7.00pm on 6 May. It was noted that he had
Final Report: January 2011 37
settled down and made excellent progress since arriving in the healthcare
centre. He was taking his medication and his mood was stable, although he
continued to hear the voices in his head. He had some thoughts about
harming himself but said he did not plan to act on them. The man was
content to remain in the healthcare centre until his transfer to Wandsworth on
12 May. He was to be checked at two hourly intervals and staff were to make
an entry in his ACCT document each time. The risk he presented to himself
was still assessed as ‘low’.
135. Acting Ward Manager Nurse D liaised with the manager of the mental health
in-reach team at Wandsworth to organise the forthcoming transfer. The
manager of the mental health in-reach team at Wandsworth had worked with
the man before his release on licence. Nurse D told her about the man’s
return to custody and his recent attempt to take his own life. The manager of
the mental health in-reach team at Wandsworth planned to assess the man
and manage his care when he arrived. She told the In-Reach team that the
man would be coming to Wandsworth and his arrival was discussed at their
referral meeting on 12 May.
136. Nurse D recalled that he telephoned the man’s mother several times to
update her on her son’s progress. He arranged for her to send in money for
the man to buy items such as tobacco. He also arranged for the Head of
Healthcare at Pentonville , to confirm the man’s transfer from Pentonville’s
healthcare department to Wandsworth’s with the Head of Healthcare at
Wandsworth.
137. During this period the man could not work and had very little money to spend
on tobacco. Nurse D remembered that the duty governors who came to the
healthcare centre to check on the man’s wellbeing generously allowed him to
have an emergency smoker’s pack virtually every other day because he was
such a regular smoker and it helped to keep him calm.
7 May
138. On 7 May, the man seemed lower in mood and asked to speak to a Listener.
The same day, the Head of Primary Care Nursing at Pentonville noted in the
man’s medical record that a handover should take place between healthcare
and discipline staff at both prisons before his transfer to Wandsworth on 12
May. The Head of Primary Care Nursing at Pentonville told my investigators
that Senior Officer C and Nurse D took responsibility for this. He emphasised
that the reception centre at Wandsworth should be told about the man’s
transfer. The Head of Primary Care Nursing at Pentonville stressed in the
clinical record that it was ‘extremely important’ that the planned move be
marked on the Person Escort Record (PER) that accompanied the man to
court.
139. Later that day, Mental Health Nurse A telephoned Nurse 1 (a member of the
In-Reach team at Wandsworth). She told her that the man would be arriving
on 12 May and faxed his records across. Mental Health Nurse A wrote on the
Final Report: January 2011 38
fax that the man was ‘relatively settled’ and was taking his medication, but
was still thinking about harming himself.
8 May
140. The next day, 8 May, Senior Officer C emailed Nurse 2 (a nurse at
Wandsworth) about the transfer. He wrote that the man had ‘attempted
suicide because he was here’ and ‘there is a danger he will try again if he
stays here longer than his court date’.
141. The man made no further attempts to harm himself before he left Pentonville.
His mood remained relatively stable and he complied with the prison regime.
His mother visited him on the afternoon of 9 May. She brought some things
for him and he seemed to be in a positive mood . afterwards
10 May
142. Having spoken to Nurse 2, Nurse D emailed her a summary on 10 May of the
man’s recent medical history. He described the progress the man had made
and the ongoing concerns. He indicated that the man did not appear to have
sustained any brain damage as a result of his attempted hanging on 22 April.
He wrote that the man had threatened to make another attempt on his life if
he were to come back to Pentonville.
143. The same day, Senior Officer C emailed the Head of Primary Care Nursing at
Pentonville asking him to telephone Serco to instruct them that the man must
be taken from court to Wandsworth, naming Nurse 2 as a contact at
Wandsworth. Senior Officer C made an entry in the man’s wing history sheet
stating that the ACCT document remained open primarily because he was still
in Pentonville. The next day, 11 May, it was noted in the man’s ACCT
document that he was in an upbeat mood, was getting on well with staff and
prisoners alike and did not expect to return to Pentonville after his court
appearance.
12 May
144. On 12 May shortly after 7.30am, Senior Officer D, the Safer Custody Manager
at Pentonville, emailed Senior Officer Y in the Safer Custody department at
Brixton. He wrote to advise Senior Officer Y that the man would be arriving at
Brixton following a court appearance later that day. (Senior Officer D had not
been told about the plan to return the man to Wandsworth.) He indicated that
staff at Brixton should contact Pentonville’s healthcare centre for a handover
after the man arrived. He noted that an ACCT document was currently open.
Senior Officer E emailed Senior Officer D at 7.53am telling him that the man
was actually supposed to go to Wandsworth. Senior Officer Y replied to
Senior Officer D later that morning, confirming that reception staff at Brixton
had been told to expect the man.
145. The man left Pentonville at 8.15am that morning and arrived at Camberwell
Green Magistrates’ Court just after 9.00am. The PER was not marked to
Final Report: January 2011 39
indicate the planned transfer to Wandsworth. The Head of Healthcare at
Pentonville and Senior Officer C both confirmed that they worked on the
mistaken assumption that prisoners leaving Camberwell Green are
automatically taken to Wandsworth. This was the case in the past, but the
situation had changed quite some time ago. Prisoners returning to custody
from Camberwell Green are taken to Brixton as a matter of routine, unless
Serco staff are aware of a particular reason why this should not happen.
146. At 10.40am, the man was assessed by the court psychologist in the cells. He
appeared in court at about midday and was once again remanded into
custody. His medical record was read out in court (in which it clearly stated
that he should be taken to Wandsworth) but this information does not seem to
have been acted upon.
HMP Brixton
12 May – 13 May
147. During the morning, Senior Officer Y forwarded the email from Senior Officer
D to the duty governor at Brixton, Governor X. Governor X told Serco staff at
Camberwell Green Magistrates’ Court that Brixton could not accept the man
because there had been no prior agreement between the healthcare
departments at Brixton and Pentonville. (The London Area Male Locals
Transfer Protocol states that the healthcare managers at both the sending
and receiving prison must reach an agreement before a prisoner transfers
from a healthcare setting.)
148. Finishing his shift at about 12.30pm, Governor X handed over to the incoming
duty governor, Governor Y, who also spoke to Serco staff at the court.
Governor Y then telephoned the Serco control centre, who seemed unaware
of Brixton’s objections to the man’s transfer. At 4.28pm, the man was placed
on an escort vehicle and taken to Brixton, arriving there at 5.35pm. He was
held in the Serco van at the prison gate. Healthcare staff in the reception
area checked the man’s medical record, learnt about the planned transfer to
Wandsworth and the need for a comprehensive handover to be conducted.
149. Governor Y telephoned Governor 2, the duty governor at Wandsworth. He
told Governor Y that he was not aware of any pre-existing arrangement and
refused to accept the man. Governor Y thought that Governor 2 had been
dealing with another incident at Wandsworth when they spoke together.
Governor Y telephoned the duty governor at Pentonville, Governor D.
Governor D apologised and acknowledged that there had been a breakdown
in communication.
150. Concerned about the man’s continuity of care, Governor Y initially thought
that the London Transfer Protocol should be followed and the man should
return to Pentonville’s healthcare centre. However, Governor D told Governor
Y that the man had felt unsafe at Pentonville. He asked if the man could be
held at Brixton for the night and taken to Wandsworth the next day, once the
relevant staff at Pentonville and Wandsworth were at work and could resolve
Final Report: January 2011 40
the confusion. (It was early evening at this point and most healthcare staff
would have left for the day.)
151. Governor Y decided to accept the man as a prisoner overnight on the proviso
that he would go to Wandsworth the next day. He considered that it would
take too long to return the man to Pentonville, and he was mindful of the
distress that returning there might cause him. Governor Y was also aware of
the considerable time the man had already spent sitting in the Serco van
whilst a decision was made. He thought that accepting the man was the ‘least
risky, and most decent thing to do’.
152. The third review of the man’s ACCT document was carried out by Brixton
staff, Governor Y and Senior Officer Z, at 7.15pm. They noted that the man
was surprised to have arrived at Brixton but seemed settled. The man was
placed in a double cell on the healthcare wing with a prisoner who was not
subject to ACCT monitoring. Although the man presented as stable, staff
were conscious that the planned transfer to Wandsworth had been disrupted
and he was now in unfamiliar surroundings.
153. Observations were increased from once every two hours to three checks per
hour (although they actually took place every 15 minutes during the night).
Governor Y recalled placing the man under what he referred to as constant
supervision as a precaution. The risk of the man harming himself was
assessed and increased to ‘raised’.
154. Governor Y telephoned Pentonville and spoke to ‘the charge nurse on duty’,
who told him that the man had been stable and had not made any further
attempts to harm himself since 22 April. Governor Y read the man’s file to
familiarise himself with his recent history and telephoned Governor 2 (at
Wandsworth) to request the transfer the next day. He was told that
Wandsworth would first need to clarify who had arranged the transfer.
Governor Y went to visit the man in his cell before he left the prison for the
evening.
155. The man was assessed by a doctor at 8.15pm. He told the doctor that he felt
settled. They discussed his recent attempt to take his own life at Pentonville.
He showed insight into his mental health problems and said that he was able
to manage the voices he could hear. He said that he was not currently having
any suicidal thoughts. The doctor prescribed 5mg of procyclidine, 15mg of
mirtazapine and 7mg of risperidone. The man slept through the night.
13 May
156. The next day, 13 May, healthcare staff at Pentonville arrived at work and
realised that the plan to transfer the man to Wandsworth had gone awry. The
Head of Healthcare at Pentonville telephoned the Head of Healthcare at
Wandsworth, who agreed to accept the man from Brixton.
Final Report: January 2011 41
157. Nurse D spoke to the manager of the mental health in-reach team at
Wandsworth. They agreed that the man would be transferred to Wandsworth
later that day and the manager of the mental health in-reach team at
Wandsworth would assess him the following morning. Nurse D contacted
Brixton to tell them that Wandsworth had accepted the man.
158. An escort was organised by Pentonville, as the failure to clearly mark the PER
was theirs. Governor Y asked Principal Officer Z to arrange for the man to be
escorted to Wandsworth by three prison officers. They left Brixton at 5.50pm
and arrived at 6.35pm. It was noted in the man’s ACCT document that he
was ‘in rather good spirits’ and was ‘happy’ to be at Wandsworth.
HMP Wandsworth
13 May – 26 May
159. Officer 1 completed a CSRA and assessed the man as a low risk of harm to
others. The man was examined by Nurse 2 in the reception area at 9.15pm.
Nurse 2 completed the healthcare section of the CSRA and referred the man
to Doctor 1.
160. Although the man was reluctant to speak about his recent attempt to take his
own life, Doctor 1 read about it in his medical record. The man told her that
he was hearing voices but ‘was managing to block them out’ and was not
currently having suicidal thoughts. He said that he was glad his recent suicide
attempt had been unsuccessful.
161. Doctor 1 noted in the man’s medical record that the Onslow Centre, where he
was anxious to be located, was currently short of beds. As a vulnerable
prisoner, he had to be kept away from the general prison population. She
reassured the man that he would be moved to the Onslow Centre as soon as
there was space available. Doctor 1 continued his prescription of 15mg of
mirtazapine and 5mg of procyclidine daily.
162. Overnight, the man was checked every 20 minutes instead of 15 minutes as
he had been at Brixton. This actually adhered to the original decision the
previous night for ACCT monitoring to take place three times an hour.
14 May
163. The man spent the next two nights in a cell on the first night centre, waiting to
move to the Onslow Centre. His ACCT document was reviewed for a fourth
time at 8.45am the next morning, 14 May. Senior Officer 1 and Senior Officer
2 on the first night centre carried out the review but did not comment on the
risk of the man harming himself. They recorded that the man was still hearing
voices, but his medication was helping him to control his thoughts.
164. The frequency of observations was amended from three times an hour to
hourly both during the day and at night. (This frequency was marked clearly
on the front cover of the ACCT document, in the record of the review and in
the ongoing record. However, as I discuss later in the Issues section of my
Final Report: January 2011 42
report, this frequency was not adhered to by staff.) It was planned that a
member of the In-Reach Team should attend the next ACCT review on 19
May. It was also noted that the man had a lot of queries because ‘he has
been in a few prisons lately’.
165. Shortly before midday, the man was assessed by the manager of the mental
health in-reach team at Wandsworth in the Listeners’ Suite on the first night
centre. They had a lengthy discussion about his recent attempt to take his
own life and the events leading up to his recall to prison. The man confirmed
that he had wanted to end his life and was afraid of other prisoners in
Pentonville. He denied having any current suicidal thoughts. In interview, the
manager of the mental health in-reach team at Wandsworth remembered that
the man engaged with her and was glad to be back in Wandsworth. He was
very keen to get his old job back on the Onslow Centre. The manager of the
mental health in-reach team at Wandsworth was ‘really reassured’ by his
presentation. They agreed to focus on preparations for his likely release at
the end of his sentence in August. The man asked the manager of the mental
health in-reach team at Wandsworth to refer him to an organisation that might
be able to help him with accommodation upon release. The manager of the
mental health in-reach team at Wandsworth agreed to contact the man’s
sister to update her on his progress.
166. The manager of the mental health in-reach team at Wandsworth telephoned
the man’s CPN at the CMHT. She told him that the man had arrived at
Wandsworth. (The man’s CPN had most recently received a letter from
Doctor D at Pentonville asking the CMHT to assess the man, with a view to
admitting him to hospital.) The manager of the mental health in-reach team at
Wandsworth arranged for the man’s CPN and a specialist registrar at the
CMHT to assess the man in Wandsworth on 1 June. The manager of the
mental health in-reach team at Wandsworth wanted the man’s CPN to make
plans to support the man after his release in August.
15 May
167. At 3.30pm the man spoke to a Listener. At 10.15am the next day, 15 May, he
moved from the first night centre to K wing on the Onslow Centre. The man
was assigned a personal officer, who wrote in his wing history sheet that he
was settling in well. He told staff that he wanted to share a cell with
‘somebody suitable’. The man’s mood appears to have been good throughout
the rest of the day.
16 May
168. The following day, 16 May, the man’s cellmate took an overdose of diazepam.
Afterwards, the man was thought to be ‘a bit upset, but OK’. Having returned
to the Onslow Centre, he wanted to obtain employment as a wing cleaner.
However, he was unable to work due to a long standing injury (deep vein
thrombosis in his right leg).
Final Report: January 2011 43
169. The man was allocated a new cellmate, Prisoner 1. An officer noticed that the
two men seemed to ‘click’. Prisoner 1 remembered that the man kept active
and took his medication regularly. He recalled that they had got on well.
19 May
170. The ACCT document was reviewed for a fifth time and closed at 8.15am on
19 May. The man, Senior Officer 3, Senior Officer 4 and a member of the
IMB attended the review. The manager of the mental health in-reach team at
Wandsworth had planned to be there but was out of the prison at Springfield
University Hospital at the time. The risk that the man presented to himself
was reduced to ‘low’. It was recorded that he was ‘happy’ for the ACCT
document to be closed, and would access either the Listeners or the
Samaritans telephone service if he had any further thoughts of harming
himself. A post-closure ACCT review was scheduled for 11.00am on 26 May.
24 May
171. At 6.10pm on 24 May, the man activated his cell bell and asked to speak to
the Samaritans. He was placed in the care suite to make a telephone call,
returning to his cell at 7.00pm. The post-closure ACCT review was conducted
by Senior Officer 5 at 10.00am the next day, 25 May, a day earlier than
scheduled. The SO noted that the man had settled back onto the Onslow
Centre well. No further concerns regarding self harm were recorded.
Camberwell Green Magistrates’ Court
26 May
172. The man left Wandsworth to make a scheduled court appearance at 7.50am
on 26 May. His PER was not marked to indicate that he should return to
Wandsworth. He appeared at Camberwell Green and was sentenced for the
four driving offences committed in April. He was fined £50 or a day’s
imprisonment in relation to the offence of having no insurance, and £100 or a
day’s imprisonment in relation to the offence of driving whilst disqualified. No
separate penalties were imposed for the offences of failing to give a name or
address to the police and having no licence. Because the man had been held
on remand for over a month, the sentence was deemed to have been served.
However, the man remained in custody because of the recall initiated on 22
April and he returned to the court cells.
173. Serco staff at the court telephoned reception staff at Brixton and asked them
to accept the man. (As previously indicated, Brixton is the prison where men
remanded at Camberwell Green are supposed to be taken as a matter of
course.) Reception staff telephoned the duty governor, Governor Z. They
advised him that the man could not be held at Brixton because of the
previously identified conflict of interest.
174. Governor Z told my investigators that he telephoned the Serco supervisor in
the cells at Camberwell Green. He explained to the supervisor that Brixton
would not be able to receive the man because a family member worked at the
Final Report: January 2011 44
prison. Governor Z thought that the man ‘must have been’ in the court cells at
the time of his telephone call and had not yet left in the Serco van. The
member of Serco staff he spoke to told Governor Z that the man had come
from Wandsworth that morning. For this reason, Governor Z decided to
telephone the duty governor at Wandsworth, Governor 3.
175. During interview, Governor Z recalled telling Governor 3 that Serco were
asking him to accept the man, but that he could not because of the conflict of
interest. He told the investigators that he was certain that he told Governor 3
that the man had come from Wandsworth that morning. Governor Z
remembered knowing about the attempt which the man made to take his own
life in Pentonville in April, although he could not recall if he mentioned it to
Governor 3.
176. Governor Z said in interview that Governor 3 refused to accept the man into
Wandsworth, instead telling Governor Z that he would have to resolve the
problem because Camberwell Green was a court served by Brixton. He
remembered during interview that Governor 3 said, ‘He’s not ours, he’s yours’.
However, Governor Z recalled that, after he re-emphasised the conflict of
interest, Governor 3 replied, ‘Leave it with me’.
177. After speaking to Governor 3, Governor Z was left with the impression that the
man would return to Wandsworth. He did not remember thinking that
Governor 3 would try to place the man in a different London prison. He told
my investigators that he spoke to Governor 3 ‘once or twice’ about the man.
178. Governor 3 told my investigators that he had two or three telephone
conversations with Governor Z. Afterwards, Governor 3 telephoned
Pentonville and spoke to the duty governor, Governor A. He asked her to
accept the man. He thought that the man should either go to Brixton, the
prison serving Camberwell Green, or Pentonville, where he had begun his
recall to custody.
179. By his own admission, Governor 3 did not investigate the man’s background
or the reason he had transferred to Wandsworth two weeks earlier. He told
my investigators that the forthcoming inspection at Wandsworth influenced his
reluctance to accept the man, something I discuss in the ‘Issues’ section of
the report. Governor 3 perceived Wandsworth as having accepted too many
transfers in the past, whilst, in his opinion, other London prisons had not made
similar efforts in return.
180. During interview, Governor A recalled having a disagreement with Governor 3
on the telephone. She remembered mentioning the recent attempt the man
had made on his own life. For this reason she thought it was inappropriate to
accept the man back at Pentonville. Governor A remembered that Mr
Governor 3 told her that Governor C had already agreed the transfer with
Governor 1. She told my investigators that Governor 3 made a direct
reference to the forthcoming inspection at Wandsworth, suggesting that she
would be assisting him if she accepted the man. (Governor A only told
Final Report: January 2011 45
Governor C about this part of her conversation with Governor 3 some weeks
later.)
181. Unhappy with the conversation, Governor A wanted to clarify with Governor C
whether he had agreed to the transfer. Governor C told her that he had not
agreed to it and he was displeased that Governor 3 was claiming otherwise.
Governor C told my investigators that he immediately telephoned Governor 1
in his office at Wandsworth. The telephone call took place at 1.17pm.
182. Governor C established with Governor 1 that he had not yet agreed to accept
the man at Pentonville. Governor C expressed his reluctance for the man to
return to Pentonville (given his recent attempt to take his own life in April and
his anxiety about the prison) and Governor 1 agreed that the man belonged at
Wandsworth. During interview, Governor C recollected his thoughts at the
time:
‘And I can assure you, you know when I’ve thought about those issues
and I think if I’m being honest with myself I wish things hadn’t occurred
full stop because I think actually just some better organisation, he
shouldn’t have come back [to Pentonville].’
183. The conversation ended with Governor C agreeing to accept the man back
into Pentonville in the short term. Governor C obtained Governor 1’s
agreement in principle that the man would return to Wandsworth. Governor C
thought that he offered a timescale of two weeks before the man returned.
Governor 1 could not recall discussing a timescale.
184. Governor C told my investigators that he agreed to accept the man because
he was under the impression that he had already left the court and was en
route to Pentonville in an escort vehicle. Governor A thought that it was she
who made this assumption and then gave Governor C the same impression.
Neither of them had spoken to Serco staff or knew for certain that the man
was already on his way. The PER relating to the man’s transfer indicates that
he actually left Camberwell Green for Pentonville at 2.37pm, an hour and
twenty minutes after the telephone call.
185. Governor 3 made an entry regarding the man in the Wandsworth duty
governors’ log. He wrote:
‘The man out to court – meant to be Brixton court, but is family member
to officer. Had come here from Pentonville, re-directed back there on
agreement between Governor 1 and Governor C.’
186. Neither Governor C nor Governor 1 recorded their decision making. Governor
3 told my investigators that he had not been asked to accept any other
prisoner transfers that day. On 26 May, the population of Wandsworth was
below the maximum number and there was space for the man to have
returned that evening.
Final Report: January 2011 46
HMP Pentonville
26 May – 9 June
187. Governor A advised Nurse D that the man was returning to Pentonville.
Nurse D telephoned the manager of the mental health in-reach team at
Wandsworth to obtain an update on his condition. She told him that the man
had been located on the Onslow Centre and that his ACCT document had
been closed a week before. They discussed the man’s forthcoming
appointment with the CMHT on 1 June.
188. A CSRA was completed by Officer A. The officer spoke to the man, who told
him that he felt ‘much happier within himself and … mentally stronger’. The
man told the officer that he was a vulnerable prisoner and would need to be
placed on the VPU. The recent serious suicide attempt and subsequent
hospital admission were noted. Officer A assessed the man as presenting a
low risk of harm to others.
189. In view of the man’s reluctance to return to Pentonville and his previous
attempt to take his life there, Nurse D thought it prudent to place him under
constant supervision overnight in the healthcare centre until he could be
assessed the following day. Governor C agreed to constant supervision as a
precaution. An ACCT document was not opened. Nurse D said that the
decision to begin constant supervision resulted from the man’s history of self
harm, rather than his presentation on 26 May. He recalled that the man made
no threats to harm himself on this occasion.
190. Shortly after his arrival, Governor C went to visit the man in the healthcare
centre to check on his welfare. (Governor A told my investigators that she
was busy elsewhere in the prison and Governor C agreed to go on her
behalf.) Governor C spent about ten minutes with the man. He recalled in
interview that the man did not present as a prisoner ‘in crisis’. Governor C
told the man that he should not have come back to Pentonville and that he
(Governor C) had sought assurance that the man would return to
Wandsworth. The man asked him to locate his missing property.
191. Nurse D telephoned the man’s mother whilst Governor C was present to tell
her that her son was ‘safe and well’. They talked about a postal order she
wanted to send her son. Nurse D reassured the man that he had spoken to
his mother. Governor C commended Nurse D for the sensitive way he had
spoken to the man’s mother.
192. The man told Mental Health Nurse B that he was apprehensive about
returning to the wings at Pentonville. However, he seemed to settle down and
said that he was not thinking about harming himself. Mental Health Nurse B
wrote in his medical record that the man would be assessed by ‘the ward
doctor’ the following day. Later in the evening, the man asked for his
medication but his chart could not be located either in the healthcare centre or
the reception area. (He was given risperidone, mirtazapine and procyclidine
by a doctor the next day.) The man settled down and slept through the night.
Final Report: January 2011 47
27 May
193. At 8.40am the next morning, 27 May, Governor C emailed Governor 1 the
following message with the subject heading ‘The man’:
‘Governor 1’
‘As promised we took him - he came from court though without his
possessions. The prisoner nearly died at the Ville [Pentonville] so I
would be grateful if you could get someone to send these over as we
will look very silly if this isn't resolved. We took him back with others
who you kindly held during our inspection. The only request I have is
that post your inspection if you could take the man back - probably at
his next court date after the inspection. The reasons for this are:
‘He is actually a Brixton court but has a relative in the prison that
means they can't hold him.
‘His near miss at Pentonville did cause some obvious concern - the
reason he gave for self harm being the location of the Ville and those
he knows at the prison.
‘He has requested Wandsworth as a favoured location and in the short
term you had him he seemed to have got to normal VP location and
working.
‘My suggestion will be to do a case review to see if we can progress to
our VP unit (because of the last incident hear [sic] we managed
overnight through the HCC [healthcare centre] - his family already
showing some concern he is hear [sic]). I spoke to him personally and
he seems much more settled than when we first had him.
‘Hope the above makes sense.
‘Governor C’
194. Governor 1 replied at 8.42am, copying in Governor 4 (a manager at
Wandsworth) and Wandsworth’s Deputy Governor, Governor 5:
‘Governor C
‘Happy to take him back any time from 6 June. I will get his
possessions to you today
‘Governor 4 - please organise
‘Governor 1’
Final Report: January 2011 48
195. Governor C forwarded both emails to Governor E, the Head of Healthcare at
Pentonville , the Head of Primary Care Nursing at Pentonville and Governor A
at 8.43am, adding:
‘Governor E
‘Can you get him reviewed to see if we can reasonably progress [the
man] to the VP unit – I will pursue the return to Wandsworth with
Governor 1. He does seem much better if we can get him to the VP
unit that I understand he asked for on his return.’
196. The Head of Healthcare at Pentonville replied to Governor C at 10.11am:
‘Governor C:
‘Nurse D aware of the case now. Governor A to meet up there [the
healthcare centre] at 10.30am and hopefully we can manage his care
here and transfer until 6th June. (D-Day!)’
197. Governor A conducted the man’s case review in the healthcare centre at
about 11.00am. (This review was not a formal part of ACCT monitoring. The
most recent ACCT document had been closed a week previously.) As well as
Governor A and the man, the meeting was attended by Nurse D (a registered
general nurse) and Senior Officer A. Senior Officer A remembered being
asked by Governor A to come to the review because the man was likely to be
discharged to the VPU, where she worked. Nurse D remembered that the
man said that he would move to the VPU as long as he was provided with
tobacco.
198. No mental health staff, doctor or psychiatrist were at the ACCT review,
although this seems to have been the intention the previous evening. It was
nonetheless noted that medical advice had been sought and the healthcare
team at Wandsworth would need to be contacted to confirm what medication
the man was currently taking.
199. During the review the man’s recent attempt to take his own life at Pentonville
was discussed. It was recognised by those present that Pentonville had a
negative impact on the man and he felt vulnerable amongst the general prison
population. He told Governor A and her colleagues that he felt threatened by
prisoners in Pentonville and expressed his desire to return to Wandsworth. It
was noted that the issue of self harm had been addressed in detail when the
man arrived the previous day.
200. The man said that, if he was going to stay at Pentonville for the time being, he
wanted to be placed on the VPU. Nurse D and Senior Officer A both thought
that the man was ‘happy’ to be moving to the VPU. Senior Officer A
remembered that he had appeared ‘cheery’ during the review. She
remembered that his main worry was getting some tobacco. She thought that
the man understood what he was told and managed to articulate himself well
Final Report: January 2011 49
during the review. Governor A recalled that the man participated fully in the
decision to relocate him and was in an ‘upbeat’ mood following the meeting.
201. Governor A told the man that he would return to Wandsworth after 6 June.
(She offered this date after the emails between Governor C and Governor 1
that were forwarded to her earlier that day.) It was noted that the man’s mood
improved upon being given this news.
202. During the case review the man complained that his property had not followed
him from Wandsworth. He was told that arrangements were being made for it
to be forwarded to Pentonville. The man had still not received a pair of
trainers that his mother gave him when he was in hospital in April. Governor
A asked Senior Officer A to ensure that the man’s property was returned to
him.
203. The man expressed concern that his mother had just been sent a
Wandsworth Visiting Order and he might not be able to see her having since
transferred to a different prison. He was told that she would be able to use
the same order to visit him at Pentonville. The man was a heavy smoker and
was anxious that, having submitted his canteen form at Wandsworth, he might
miss out on his weekly supplies. Staff agreed to confirm how much the man
had to spend and resolve his worries about getting cigarettes.
204. The man was prescribed 7mg of risperidone per day, 15mg of mirtazapine
and 5mg of procyclidine. He was discharged from the healthcare centre at
about 3.00pm once a cell had been found for him on the VPU (located on G1
landing). He does not seem to have been allocated an In-Reach worker to
monitor his mental health.
205. After the review, Governor A telephoned Officer H in the Observation,
Classification and Allocation (OCA) department to ask her to arrange for the
man to be moved to Wandsworth. Officer H explained that this would have to
be organised at a national level by the Population Management Unit (PMU) in
central London. She did not remember Governor A giving her a timescale for
the planned return, although Governor A told my investigators that she
thought she had asked for the move to take place from 6 June.
206. Officer H booked the move for the following week commencing 1 June. She
completed a PMU Inter-Prison Escort Booking Form which named Governor 1
at Wandsworth and Governor A at Pentonville as the governors agreeing the
transfer. The request was sent electronically to the PMU shortly before
Wednesday lunchtime, after which no more requests are accepted.
207. Between 27 May and 1 June, there is no evidence that the man was assessed
by a member of the In-Reach team, or indeed anybody from the healthcare
department. No entries were made in his medical record.
208. The man was located in a shared cell on the VPU. Senior Officer A
encountered the man several times during the next few days. On each
Final Report: January 2011 50
occasion, he told her that he did not like Pentonville and asked when he
would return to Wandsworth.
30 May
209. At about 4.00pm on 30 May, Prisoner B was placed in the man’s cell. He had
just arrived from Wandsworth. (The Prison Service investigation conducted
by the internal Prison Service investigator later established that he was one of
the prisoners who had been moved out of Wandsworth temporarily whilst Her
Majesty’s Inspectorate of Prisons visited between 1 and 5 June.)
31 May
210. Senior Officer A was asked to speak to the man by a colleague at 2.35pm on
Sunday 31 May. She became concerned about him and opened an ACCT
document. She was aware of his attempt to take his own life in April. She
told my investigators that he seemed more ‘reflective’ in comparison with his
presentation during the case review four days earlier on 27 May. The man
told her that he was hearing voices telling him to harm himself. His mood was
low and he said that he was reliving the events of 22 April (when he had tried
to hang himself from the bunk bed).
211. Completing the ‘Immediate Action Plan’ section of the ACCT document,
Senior Officer A noted the concern about the man’s cell sharing
arrangements. She wrote that he was to move to a single cell. Senior Officer
A initially decided that the man would be checked once an hour. However,
until the man’s initial assessment was completed, after consulting Principal
Officer B, the level of observations was quickly amended to every 15 minutes
at 3.05pm.
212. Senior Officer A asked Officer F (a trained ACCT assessor who worked
elsewhere on G wing) to carry out an assessment interview with the man at
about 3.15pm. The man told Officer F that he was not getting on with his cell
mate (Prisoner B) and was told that he would be moved to a different cell.
When he spoke to my investigator, Officer F recalled that the man’s difficulties
with his cell mate were contributing towards his thoughts of harming himself.
The officer could not recall the specific nature of the problem with Prisoner B.
213. The man told the officer that he was ‘very stressed and anxious’ since leaving
Wandsworth. He expressed a wish to return to the Onslow Centre. The man
talked about recent problems with his post, canteen and money. He told the
officer that having no tobacco and sweets was not helping him to settle and
he asked for a smokers’ pack. Officer F told my investigator that the man
smoked quite a lot and had mentioned to him that the small amount of
tobacco he received was insufficient to meet his needs.
214. The man said that he had not spoken to his family since he arrived at
Pentonville on 26 May. He was concerned about the lack of contact and
worried that he might be perceived as a burden by his family. He was not
Final Report: January 2011 51
sleeping properly. He said that he could not relax and felt that everybody was
‘against him’ and that people were ‘looking at him’.
215. During the interview, the man seemed nervous, panicky, restless and
confused. He told Officer F that he was hearing voices telling him to do
things. The officer wrote that the man had ‘obvious mental health concerns’
and struggled to distinguish between what was real and what was delusion.
He recalled that the man was quite hard to engage with.
216. The man told Officer F that he felt ‘awful [and] depressed’. The officer noted
the man’s fear that ‘it might happen again’ (meaning an attempt to take his
life) and wrote that he was having ‘mild thoughts’ of suicide. The man told
Officer F that he was not sure if ‘it is better to live or die’. When asked how he
might attempt to take his own life, he replied that he had thought about
swallowing a razor or cutting his throat.
217. No members of the In-Reach team work in the prison at the weekend (the
ACCT document was opened on a Sunday). Officer F said that he did not
consider seeking advice from an out-of-hours doctor, and did not discuss the
possibility of doing so with Senior Officer A.
218. Officer F accompanied the man to his cell after the interview. The officer
wanted to find out whether the man had made any firm plans to take his own
life. He obtained the man’s consent to look around his cell. The man showed
Officer F holes in the light fitting that he had thought about using to hang
himself. (The officer was unsure whether the man had made the holes
himself or whether they had already been there, but he thought it unlikely that
the man had made them.)
219. The man also produced a length of torn bed sheet from under his pillow. He
told the officer that he planned to use it as a ligature. Officer F told my
investigator that he confiscated the ligature, although he could not specifically
recall doing so.
220. At about 4.10pm, Senior Officer A rejoined the man and Officer F and they
completed the ‘Action Following Assessment’ and ‘Care Map’ sections of the
ACCT document together. Senior Officer A remembered that the man was
not upset, but was ‘adamant’ that he did not want to remain in Pentonville.
221. It was agreed between the man and the officers that he would try to spend
time out of his cell on exercise and association and would tell them if he
started to make specific plans to take his own life. The man planned to write
to his family and Officer Taylor agreed to telephone his mother. Concerned
about the man’s presentation, Officer F completed a referral to the In-Reach
team requesting a mental health assessment.
222. The officers recorded the risk the man presented to himself as ‘raised’.
Senior Officer A set the level of observations at every half hour throughout the
day and night. When he spoke to my investigators, Officer Taylor confirmed
Final Report: January 2011 52
that he was satisfied after finding the ligature that the frequency of
observations was appropriately set at half-hourly intervals.
223. At about 5.00pm, Officer F left a message on the man’s mother’s answering
machine. He also asked a governor about the possibility of the man returning
to Wandsworth. (When he spoke to my investigator, Officer F could not recall
either the name of the governor or the outcome of the conversation.) The
officer told the man about the actions he had taken and recalled that he
seemed calmer. By 5.20pm the man was placed on his own in a different cell
on the VPU.
224. On 31 May, Governor F completed the last section of the CSRA which was
begun on 26 May. (I presume that he wrote his comments after the ACCT
document was opened.) He noted that the man was to stay in a single cell
because of his ‘erratic behaviour’ and because he had been ‘threatening to
harm his cell mate’. He indicated that the decision should be reviewed in four
weeks time.
1 June
225. On the next day, Monday 1 June, the man’s CPN and the specialist registrar
at the CMHT were due to assess the man at Wandsworth (coincidentally the
date when the inspection was due to begin). However, the manager of the
mental health in-reach team at Wandsworth telephoned the man’s CPN to
cancel the visit as the man was by now in Pentonville. The manager of the
mental health in-reach team at Wandsworth told the man’s CPN that she
expected the man to return to Wandsworth within a short period of time, and
that they could rearrange the assessment when this happened.
226. Although the man was checked at half hourly intervals throughout the night,
the pattern seems to have been interrupted during the handover from the
night shift to the day shift. After a check was recorded in the ACCT document
at 7.10am on 1 June, no further entries were made until 55 minutes later
when Officer I went to see the man at 8.05am in his cell on the VPU. Officer I
told my investigators that the morning roll check (which includes seeing each
prisoner in their cell) and the daily briefing took place during this period.
Although no entry was made in the ACCT document, it is possible that the
man was checked by the day staff coming on duty during the 55 minute gap.
227. Officer I told my investigators that he began his shift on the VPU at 7.30am
and led the morning briefing. After the meeting, he said that his first task as
‘officer in charge’ was to personally check those prisoners with an open ACCT
document and make a note in their ongoing record. Arriving at the man’s cell,
Officer I looked through the observation flap and saw him standing on a chair
in the middle of the cell. The man had a torn bed sheet tied around his neck,
which was attached to the light fitting on the ceiling. As the officer opened the
cell door, the man jumped off the chair.
228. Going immediately into the cell, Officer I grabbed the man’s waist with one
arm in order to lift and support him. He used his other hand to reach for his
Final Report: January 2011 53
anti-ligature knife and used it to cut through the bed sheet. Once it was cut,
he lowered the man to the floor. The man was still conscious. Officer I blew
his whistle and used his radio to call for the emergency healthcare staff to
respond. He remembered the nurse arriving very promptly.
229. The ligature was removed from the man’s neck and he was treated by Nurse
B in the nurses’ station on the VPU. Officer I remained with the man whilst
the nurse assessed him. He did not appear to have sustained any significant
injury as a result of what was his second attempt to take his life. The man
had made superficial cuts to his arms which were cleaned and dressed.
230. Officer I and Principal Officer B agreed that the man should be placed under
constant supervision in a gated cell in the healthcare centre. The officer told
my investigators that the man was admitted to a single cell in the healthcare
centre within approximately 45 minutes. Officer I walked the man over to the
centre. He was assessed by the duty doctor and remained under constant
supervision in a single cell. Officer I remained and had a conversation with
the man before he returned to the VPU.
231. Staff from G4S (another private company which escorts prisoners for the
Prison Service) were booked to collect the man and transfer him to
Wandsworth the same morning, 1 June. The move was a result of the
request Officer H had made on 27 May. However, an apparent breakdown in
communication meant that neither G4S nor the Pentonville OCA department
told the staff working with the man about the scheduled move.
232. Prisoners due to be transferred have to be assessed as fit to travel by a
member of healthcare staff 24 hours beforehand. The healthcare team also
have to prepare the prisoner’s medical records for transfer. Neither of these
things happened. Neither the man nor the healthcare staff were aware of the
planned move until later in the morning on 1 June.
233. Senior Officer C told my investigators that he was telephoned in the
healthcare centre by a member of staff working in the reception area. The
member of staff told him that the man was due to transfer to Wandsworth
immediately as part of a ‘planned national move’. The SO estimated that the
call took place between 10.00am and 11.00am. He could not recall in
interview if the man had yet arrived in the healthcare centre following his
attempt to take his own life.
234. Wanting to find out more, Senior Officer C contacted reception staff at
Wandsworth who confirmed that they were expecting the man that day.
Wandsworth had received details of the move from the PMU by email at the
end of the previous week. Senior Officer C confirmed that no details of the
transfer had been diarised on the prisoner information system at Pentonville.
235. The move did not go ahead because the man had been located in the
healthcare department under constant supervision. Senior Officer C
discussed the transfer with the Head of Healthcare at Pentonville and they
agreed that it would be inappropriate to move the man in the circumstances.
Final Report: January 2011 54
236. The man’s new ACCT document, opened the previous afternoon, was
reviewed for the first time at 10.15am. The review was chaired by Senior
Officer C with the man and the manager of the mental health in-reach team at
Pentonville present. The level of risk that the man would harm himself was
increased from ‘raised’ to ‘high’ following the attempted hanging earlier that
morning. The change to constant supervision from half-hourly observations
was noted.
237. Because of the man’s unpredictable behaviour, the manager of the mental
health in-reach team at Pentonville thought that constant supervision should
remain in place for at least 24 hours until he had been assessed by a
psychiatrist. The manager of the mental health in-reach team at Pentonville
did not think that the man was showing any signs of active psychosis but was
worried that his behaviour remained unpredictable. The manager of the
mental health in-reach team at Pentonville told my investigators that the man
was calm and engaged with the staff at the review. Senior Officer C recalled
in interview that the man had not been able to speak very clearly.
238. The man told the staff that he had not planned the attempt to take his own life
that morning, and it was an impulsive act. The manager of the mental health
in-reach team at Pentonville wrote in the man’s medical record that he was
hearing voices. He had felt both unsafe and unable to seek out assistance
from staff before he made the second attempt on his life. The man said he
felt safer in the healthcare centre, indicating that he was no longer thinking
about harming himself. He said that he still wanted to return to Wandsworth
and did not feel safe in the VPU at Pentonville. He asked for a television, a
smokers’ pack and to telephone his family.
239. At 12.30pm, the Imam spent time with the man and described him as agitated
and restless. At 1.00pm, Senior Officer C told the man that his actions that
morning had delayed his return to Wandsworth which, initially, he took badly.
They agreed that the man should ‘sit out his time’ at Pentonville until a new
transfer could be organised. In addition to constant supervision, hourly quality
observations were recorded in the ACCT document. Senior Officer C told my
investigators that the man settled into life on the healthcare centre.
240. By 5.00pm that day, the man had been given some tobacco and had a
television in his cell. During the evening he seemed restless and was
observed talking to himself and hearing voices. At about 10.00pm, he had a
lengthy discussion with agency Healthcare Assistant A about his frustration at
remaining in Pentonville. Healthcare Assistant A stayed with him to continue
the constant supervision overnight. She sat outside the cell and checked the
man through the observation flap every 15 minutes.
241. Healthcare Assistant A recalled in interview that the man was reluctant to
discuss the attempt to take his own life earlier that day. She remembered his
mood being ‘very flat’. She thought that he had resigned himself to the
likelihood that he would again attempt suicide at some point, sensing that he
was ‘biding his time’ in this regard. The man was worried about his
Final Report: January 2011 55
possessions and said that he missed his mother. Healthcare Assistant A
suggested that he should talk to the day staff about organising a telephone
call home. He took his medication and slept through the night.
2 June
242. On the following day, 2 June, the man was assessed by Doctor D, who had
been unaware of his return to Pentonville until he moved to the healthcare
centre on 1 June. Also present were Doctor E and Doctor F (another doctor
specialising in forensic psychiatry).
243. The man told the doctors that he initially felt well after moving to the VPU on
27 May. He started to experience paranoid thoughts the next day because of
his fear of a gang member who, he believed, wanted to harm him. He said
that he started to have panic attacks and hear voices telling him to harm
himself. He confirmed that he had not planned to take his own life on 1 June
and that it had been a spontaneous act. The man was not currently thinking
about suicide but still thought other prisoners were talking about him.
244. Doctor E recalled that the man seemed stable and engaged with the
conversation. Doctor D remembered that the man had not seemed especially
low in mood. Doctor D thought that he was gradually recovering from the
events of the previous day. He drew a parallel with the man’s presentation
when he returned from hospital at the end of April.
245. Doctor D was inclined to believe that the man’s fear of rival gang members
might have some basis in fact. When he had previously assessed the man in
April and May, he was unsure whether his mental health difficulties had
exaggerated his perception of any danger he might be in. Doctor D thought
that there was a ‘significant possibility’ that the man’s anxiety was based on a
genuine risk to his safety from other prisoners.
246. Although the man reported symptoms of psychosis, the doctors could not find
any evidence of it. They decided that the ACCT observations should continue
to be made every 15 minutes and he should remain in the healthcare centre
until he was transferred back to Wandsworth. (Mental Health Nurse B wrote
in the man’s medical record later in the day that he would be returning to
Wandsworth on 8 June.)
247. The second review of the man’s ACCT document took place in the healthcare
centre at 11.00am the same day. Senior Officer E, the man, a nurse and two
officers attended the meeting. As per the doctors’ assessment, the level of
checks was set at every 15 minutes. (Hourly entries were made in the ACCT
document.) The risk the man presented to himself was still assessed as
‘high’.
248. The man thought other prisoners in Pentonville were talking about him. He
felt scared and paranoid. He said that he felt more secure in the healthcare
centre but would feel safer still in Wandsworth. It was noted that the risk of
self harm resulted predominantly from being in Pentonville. The man had not
Final Report: January 2011 56
spoken to his family following the second attempt to take his own life. Staff
made the arrangements and he spoke to his mother on the telephone at about
3.00pm.
3 June
249. At about 4.30pm the next day, 3 June, the ACCT document was reviewed for
a third time. Senior Officer E chaired the meeting with the man, an officer and
Nurse D in attendance. The man was told that he would be transferring back
to Wandsworth on either Saturday 6 or Monday 8 June and he was pleased to
hear this news. He said he was not thinking about harming himself. Asked if
he would talk to either prison staff or the Listeners if he was considering
harming himself again, he replied that he ‘did not know’.
250. The risk that the man presented to himself was reduced to ‘raised’. On the
advice of Doctor D, the level of observations was kept at every 15 minutes.
The next ACCT review was scheduled for 7 June. It was noted in the man’s
wing history file that he was mixing with the other prisoners in the healthcare
centre. Senior Officer E told my investigators that he was not ‘excessively
concerned’ about the man ‘at the time’, having met him and reviewed his
ACCT document on two consecutive days.
251. The same day, 3 June, the Parole Board reviewed the man’s recall to
custody. The panel made no recommendation as to release and the recall
remained in place.
4 June
252. The man was assessed by Doctor D just after midday the following day, 4
June. The doctor thought that the man’s mood was improving. He was
sleeping and eating well and taking exercise. He was not thinking about
harming himself and felt safe in the healthcare centre. The man said that he
was hearing voices telling him that his family would be harmed. He believed
that other prisoners were talking about him. However, Doctor D considered
that the man’s feelings of paranoia were less intense. Because the man was
still experiencing some psychotic symptoms, the doctor increased his dosage
of risperidone from 7mg to 8mg per day.
253. Doctor D thought that the man should remain in the healthcare centre until he
transferred back to Wandsworth. He advised that the ACCT observations
could be reduced from every 15 minutes to hourly. Later that afternoon,
Senior Officer C confirmed in the ACCT ongoing record that hourly
observations had started, although a review was not held to formally
acknowledge this decision. Constant supervision ended at 3.15pm.
(Although the man was to be checked every hour as part of the ACCT
process, Senior Officer E told my investigators that prisoners in the healthcare
centre are checked on a half hourly basis as a matter of routine.)
Final Report: January 2011 57
5 June
254. The man was seen talking to himself on 5 June. However he remained calm,
associated with other prisoners and took his medication. Senior Officer C
noted in the ACCT document on 6 June that the transfer to Wandsworth had
been organised for 9 June. The only other outstanding issue was the man’s
canteen. During the early evening of 7 June, the man was heard shouting
loudly in response to the voices he was hearing. He was checked every hour
by staff and settled down later that night, although he continued to talk loudly
in his sleep.
8 June
255. At about 9.30am on 8 June, Officer J in Pentonville’s OCA department
emailed healthcare staff, identifying six prisoners who needed to be assessed
as fit for transfer to Wandsworth the next day. Amongst the names were the
man, Prisoner 3 and Prisoner 2. (The subsequent internal NOMS
investigation established that the latter two prisoners transferred to
Pentonville at the end of May so that they would not be present during the
inspection at Wandsworth. As I discuss in the ‘Issues’ section of the report,
although he returned to Wandsworth at the same time as these prisoners, the
man had moved to Pentonville before them following a court appearance.)
Beneath the names he commented:
‘Please note that the Wandsworth inmates are all going back after
doing them a fav[our] by holding them here for a week.’
256. Later that morning the man was assessed by a member of healthcare staff as
fit to transfer back to Wandsworth the next day. Officer J then emailed
Wandsworth to confirm that the man would be transferring there ‘tomorrow
with the rest of your … inmates’. He noted that the man would be leaving
Pentonville’s healthcare centre and that the transfer had been agreed by
Governor 1.
257. The same day, the Head of Healthcare at Pentonville telephoned the Head of
Healthcare at Wandsworth. The Head of Healthcare at Wandsworth was not
available so the Head of Healthcare at Pentonville spoke to a female
colleague. The Head of Healthcare at Pentonville told her that the man would
be returning to Wandsworth the next day from Pentonville’s healthcare centre.
He told her about the attempted hanging on 1 June and said that the man’s
condition was stable and improving. The Head of Healthcare at Pentonville
did not make an entry in the man’s medical record about their telephone
conversation.
9 June
258. The man’s ACCT document was reviewed for a fourth time at 8.10am on 9
June, the same morning that he returned to Wandsworth. He seemed to be in
a good mood. Senior Officer C led the meeting, with the man and a
healthcare officer present. The level of risk which the man presented to
Final Report: January 2011 58
himself was reduced to ‘low’. (The SO based his decision on the man’s
presentation, his stabilised mood in the last eight days and his positive
attitude towards his transfer back to Wandsworth.) The frequency of
observations remained at hourly. Senior Officer C noted that the ACCT
document should remain open whilst the man moved to Wandsworth and be
reviewed the next day.
259. On 9 June, the Parole Board’s review of the man’s recall to custody was
published. The decision not to release the man was communicated
electronically to Pentonville, but it is unclear whether it reached the man, as
he moved to Wandsworth on the same day. The email may have been
forwarded to Wandsworth, but there is no clear indication whether or not the
information was given to the man.
HMP Wandsworth
9 – 12 June
260. Just after midday on 9 June, the man was placed on an escort vehicle and
arrived at Wandsworth at 1.40pm. He returned with other prisoners including
Prisoner B, Prisoner 3 and Prisoner 2.
261. Prisoner 3 and Prisoner 2 both told my investigator that they remembered
the man being quiet and subdued during the journey. Prisoner 3
remembered that the man had said during the journey that he wanted to kill
himself. Prisoner 2 confirmed that the prisoners had discussed their
suspicions about the reason for their removal from Wandsworth during the
journey. (The internal Prison Service investigation established that these men
were deliberately transferred from Wandsworth to Pentonville over the
weekend of 29 May to 1 June prior to the inspection.) Prisoner 2 told the
investigator that the man was convinced that he had also been moved
because of the inspection.
262. The man was interviewed at about 3.00pm. A CSRA was completed by
Officer 2. She did not comment on the cell sharing risk concerns identified by
Governor F on 31 May. She told my investigators her interview with the man
was ‘unremarkable’. She did not remember the man crying (which is what the
other prisoners said about him). She said that, if he had seemed especially
upset, she would have offered to place him with a Listener and made an entry
in his ACCT document.
263. As a vulnerable prisoner, Officer 2 said that the man was separated from the
other prisoners during the reception process and she expected him to
progress to the Onslow Centre. Although the man had come from
Pentonville’s healthcare centre, Officer 2 did not remember any discussion of
a move to Wandsworth’s healthcare centre. During the reception process,
only healthcare staff are allowed to open the prisoner’s confidential medical
record.
264. The man underwent an initial health screening conducted by Nurse 3, who
referred him to the doctor. Nurse 3 completed the medical section of the
Final Report: January 2011 59
CSRA. Both Officer 2 and Nurse 3 assessed the man as representing a low
risk to other prisoners.
265. Prisoner 2 recalled that the man became more disturbed whilst they waited in
a cell for the doctor on the first night centre. He said that the man started
talking to himself, his mood deteriorated and he started crying. Prisoner 2
tried to comfort the man, who he described as looking like a ‘small child in
distress’. Prisoner 2 told my investigators that he tried to alert Nurse 4, to the
man’s distress. He remembered that the nurse told him not to interfere.
Prisoner 2 claimed that Nurse 4 told the man to ‘pull himself together’.
266. My investigator interviewed Nurse 5, a nurse who Prisoner 2 said worked on
the first night centre on 9 June. Nurse 5 recalled that he had unlocked both
Prisoner 2 and the man to be assessed by Doctor 1. He did not remember
Nurse 4 working with him that day. He remembered that Prisoner 2 told him
that the man ‘was not looking good’. From his presentation, Nurse 5 thought
that the man was ‘not quite himself’ and ‘a bit more disturbed’. My
investigator also spoke to another of Nurse 4’s colleagues, Nurse 6. She said
that she worked with Nurse 4 on 9 June but did not recall that either of them
visited the first night centre.
267. Doctor 1 assessed the man at about 6.30pm. She told my investigator that
the man was ‘very, very tearful’ and ‘very upset’ about his recent return to
Pentonville. However, the man told her that he was glad to be back at
Wandsworth and was not thinking about harming himself. Doctor 1 continued
his prescription of 8mg of risperidone, 15mg of mirtazapine and 5mg of
procyclidine. Nurse 5 explained to my investigator that he collected the
medication from another wing and gave it to the man in the consultation room.
268. At about 7.00pm, the man arrived on the Onslow Centre and was placed with
Prisoner 4 in a cell on the fourth landing of G wing. He spoke with his mother
on the telephone that evening. Senior Officer 5 remembered speaking to the
man and thought that he seemed ‘genuinely happy’ to be back on the Onslow
Centre. He asked the man if he had any immediate concerns. He replied that
he did not. Senior Officer 5 told him that, because of the late hour and the
number of prisoners on open ACCTs on the Onslow Centre, his own ACCT
document might not be reviewed until the morning.
269. The actual frequency of ACCT observations decreased following the man’s
arrival at Wandsworth, although the final entry on the front cover of the
document (made by Doctor D on 4 June) remained ‘hourly’. Until he left
Pentonville, the man had been checked every hour both during the day and
night and entries made accordingly in the ACCT document. Although hourly
night time observations remained in place, hourly day time checks stopped at
Wandsworth. This level of intermittent observations during the daytime
remained in place after the ACCT review on 10 June until the man’s death.
Final Report: January 2011 60
10 June
270. Shortly before 11.00am the next day, 10 June, the man’s ACCT document
was reviewed for a fifth time by Senior Officer 5 (the ACCT case manager)
and Officer 3 (a member of the Safer Prisons team). Officer 3 had talked to
Senior Officer 5 whilst making a routine check of open ACCT documents on
the Onslow Centre. Senior Officer 5 told his colleague that he thought the
review might lead to the ACCT document being closed because the man had
returned to familiar surroundings on the Onslow Centre. Officer 3 agreed to
attend the review because Senior Officer 5 was considering closing the
document. Officer 3 remembered that Senior Officer 5 was surprised that the
man had returned with a new ACCT document, as the last one had been
closed just before he left Wandsworth.
271. Officer 3 was unaware of the man’s two recent suicide attempts at Pentonville
when he helped to carry out the review. He confirmed that he had not read
the open ACCT document and relied on what Senior Officer 5 told him
beforehand.
272. Senior Officer 5 told my investigators that the meeting lasted from about
11.00am to 1.00pm, including a short break. Officer 3 agreed that the three
men talked for about two hours. He thought the formal review lasted until
about midday, whilst the remaining hour was spent trying to address the
concerns the man raised.
273. The two men noticed that the man seemed withdrawn, frightened and
nervous. He spoke in a low voice, almost whispering. Officer 3 told my
investigators that the man was ‘quiet, apprehensive, reticent and subdued’.
The man was worried that other prisoners were outside the door
eavesdropping on their conversation. Officer 3 offered to leave the room
because Senior Officer 5 thought that the man would be more comfortable
talking one-to-one with a familiar face. However, the man was content for
Officer 3 to remain.
274. The man said that he had been threatened by rival gang members in
Pentonville. He thought that his family were in danger if he did not hand over
compensation money that the men knew he was due to receive. He said that
the gang members knew where his family lived. He explained that he had
considered taking his own life to remove the threat to his family’s wellbeing.
Officer 3 told my investigators,
‘I asked [the man] directly … whether taking his own life … would solve
his problem for his family and he said it would.’
275. Once the man said this, Officer 3 recalled that all parties present agreed that
the ACCT document should remain open. The man started to provide specific
information about gangs, at which point Senior Officer 5 started to make
written notes. He alluded to a recent fatal shooting outside the prison.
Final Report: January 2011 61
276. Senior Officer 5 encouraged the man to report the information to the police.
With the man’s agreement, and whilst he was still in the room, Senior Officer
5 telephoned the prison’s police liaison officer (PLO) to discuss the best way
to address the man’s concerns about gangs.
277. Officer 3 recalled that the man’s mood began to lift as the conversation went
on and he seemed reassured by the measures being taken to act on his
concerns. The officer was encouraged by the man’s presentation at the end
of the interview and did not consider that he was actively considering taking
his own life. Senior Officer 5 thought that the man seemed ‘a lot more
buoyant’ as he left. However, he remembered turning to Officer 3 and saying,
‘That’s not the [man] I know.’
278. The risk that the man would harm himself was increased from ‘low’ to ‘raised’.
Although the risk level was raised and Senior Officer 5 ticked to indicate that
the frequency of observations had been reviewed, the records were not
amended either on the front cover of the ACCT document or elsewhere
inside. The two men recollected that the man was supposed to be checked
once an hour during the night and that three ‘quality observations’ were to be
recorded during the day. (However, as I have said above, the last entry on
the cover remained ‘Doctor D’ at Pentonville on 4 June.) The next ACCT
review was planned for 17 June.
279. Shortly after the ACCT review finished, the man spoke to a Listener at 1.30pm
and returned to his cell at 3.15pm. (He did the same at 9.25pm that evening,
returning to his cell at 10.15pm.) Later that afternoon, Senior Officer 5 told
the man that the PLO had contacted Operation Trident (the Metropolitan
Police division which addresses gun crime among young, black Londoners)
and was arranging for an officer to visit him to discuss his concerns about
gangs. Senior Officer 5 told my investigators that he reassured the man that
the meeting would be arranged discreetly away from the wing so that other
prisoners would not find out about it.
280. A police officer from Operation Trident originally planned to interview the man
on 11 June. However, he thought that the information staff had so far passed
on was unreliable and so he delayed his visit until 15 June. (The man was not
told about the specific timing of the police officer’s visit and would not
therefore have known that he had postponed it.)
281. During the day, Nurse 7 brought the man’s risperidone prescription to his cell,
as he had not come to collect it from the hatch. the man told her he was also
prescribed 30mg of mirtazapine. Nurse 7 gave the man this medication but
subsequently discovered that the dosage should have been 15mg. She went
back to speak to the man and apologised for the error. Nurse 7 advised him
that he might feel a little sleepier than usual, but recalled that he did not seem
worried. She reported the error to her line manager.
282. Following their arrival back in Wandsworth on 9 June, Prisoner 3 told my
investigators that he continued to be concerned about the man. He
remembered the man visiting him in his cell on 10 and 11 June. He seemed
Final Report: January 2011 62
depressed and anxious, and he held his neck at an awkward angle in an even
more pronounced manner. Prisoner 5 noticed that the man seemed troubled,
stressed and withdrawn after returning from Pentonville. He thought that the
man was not his usual self and that his mental health might be ‘deteriorating’.
Prisoner 1 told my investigators that he saw the man speaking to healthcare
staff ‘on a number of occasions’ between 9 and 12 June, ‘pleading to see a
psychiatrist’. Prisoner 6 remembered seeing the man approach wing
managers (SOs) asking for help with his mental health problems. There are
no references to these incidents in the clinical record completed by staff.
11 June
283. The next morning, 11 June, the man was seen ‘laughing and joking’ with other
prisoners. He was still in a good mood at lunchtime. Later that day, Senior
Officer 4 told my investigators that the man and Prisoner 7 approached him
and asked to share a cell. Senior Officer 4 said he checked with the man (in
case pressure was being put on him) but he confirmed that he wanted to
share with Prisoner 7. The SO did not think at the time that the arrangement
would have a detrimental effect on either man. At about 4.50pm, at Senior
Officer 4’s request, Officer 4 (the movements officer responsible for
organising cell sharing) placed the man and Prisoner 7 in the same cell.
284. Senior Officer 4 issued the man with an emergency smokers’ pack because
his canteen had not followed him from Pentonville. At 5.25pm it was noted
that the man was ‘a little bit subdued’. When spoken to at 7.15pm, the man
said very little in reply and nodded.
285. At 9.40pm that night, Prisoner 7 activated the cell bell and Officer 5 answered.
Prisoner 7 asked to speak to a Listener. The officer consulted the Listeners,
who advised him that Prisoner 7’s care plan did not allow him to speak to
them because he had abused the facility in the past. Prisoner 7 was
permitted to telephone the Samaritans instead.
286. The officers patrolling the Onslow Centre overnight do not have keys, but they
carry a sealed pouch (containing keys) which they can break open in an
emergency. To open prisoners’ cells, they ask one of the officers in charge of
the prison (the night orderly officer or Oscar 2) to come over with keys.
Officer 5 recalled that Officer 6 (Oscar 2) opened the cell door to let Prisoner
7 out. The man was standing near the door.
287. At 9.55pm, whilst Prisoner 7 was being escorted to the Listeners’ suite, he
threatened to harm himself. He also told Officer 5 that he was worried about
the man. Whilst Prisoner 7 was out of the cell, Officer 5 checked on the man,
who was quiet but said that he was ‘fine’. Prisoner 7 went into the Listeners’
suite to make his telephone call and returned to the shared cell at 10.20pm.
Officer 5 again took the opportunity to check on the man, who again replied
that he was ‘fine’. The officer knew the man quite well, and thought that he
seemed ‘alright’.
Final Report: January 2011 63
288. Prisoner 7 told my investigators that the man talked to himself during the
evening, saying, ‘Leave me alone, you are not going to kill me.’ He
remembered the man putting a blanket over his head and tying a towel
around his neck. Prisoner 7 said that he told Officer 5 about the ligature that
the man had placed around his neck and warned him that the man might try to
kill himself. Officer 5 told my investigator that he did not see the man with
anything tied around his neck.
289. At 11.45pm, the man rang the cell bell. Officer 7 went to the cell and spoke to
the man through the observation flap. He asked to be taken to the Listeners’
suite. Ten minutes later Officer 6 arrived and unlocked the man with Officer 5.
They escorted the man to the Listeners’ suite. Officer 7 had already gone to
the suite and was waiting for them.
290. Standing outside the suite, the man spoke to Officer 5, explaining that he did
not want to go back to the cell. Officer 5 thought the cell share with Prisoner 7
was working and so the man’s comments were unexpected. He recorded in
the wing observation book and the ACCT document that the man did not feel
comfortable. Officer 5 wrote that the man felt threatened and was worried for
his safety. He noted the man’s anxiety that Prisoner 7 would do something to
him whilst he slept.
291. When my investigators interviewed Officer 5, it became clear that the man
had told him that Prisoner 7 made sexual advances towards him. The sexual
element of Prisoner 7’s intimidating behaviour was not recorded by the
officers at the time in either document. (Prisoner 2 remembered that the man
told him the next day that Prisoner 7 had threatened to kill him.)
292. Officer 5 told Officer 6 that the man did not want to return to his cell. He
thought that he had conveyed the sexual nature of the threat to Officer 6.
Officer 7 recalled that he went to the main office on the Onslow Centre and
determined with a colleague that the only unoccupied cell was on the third
landing of K wing. Officer 5 remembered that Officer 6 made the decision to
move the man into a different cell. Within a few minutes, Officer 7 returned to
the man who was still speaking to Officer 5 and gave him the option of moving
to the empty single cell. The man agreed.
12 June
293. Just after midnight on 12 June, the man agreed to move and was located on
his own in cell K3-22 by Officer 5. He did not go back into the cell shared with
Prisoner 7 and the officers moved his belongings for him. Officer 7 recorded
in the wing observation book that the new arrangement was to be reviewed
when the day staff came on duty. The frequency of the ACCT observations
did not change. The man appeared to settle and did not make any further
requests that night. Officer 7 and Officer 5 both remembered that the man
seemed relieved to be moving out of the cell.
294. Although the man told staff that he wanted to move because he felt
threatened by Prisoner 7, Prisoner 7 told my investigator that he and the man
Final Report: January 2011 64
did not argue. He thought that the man intended to take his own life and
wanted to move to a single cell in order to do so. At 3.35am, Prisoner 7
activated his cell bell and asked to telephone the Samaritans. He was told
that he had used up his allocated quota of call time. He threatened to harm
himself, an ACCT document was opened and he was taken to the Listeners’
suite.
295. At the morning briefing shortly after 7.30am on 12 June, staff coming on duty
were told that the man had asked to move out of the cell he shared with
Prisoner 7 and had been placed on his own overnight. An ACCT review was
not scheduled for later that day, even though the man had changed location.
296. At 7.50am, Officer 8 opened the man’s cell. He seemed quieter than usual
and was sitting on the bed. In interview, Officer 8 remembered asking the
man a couple of times if he was alright, without getting a reply. Instead of
engaging with the officer, he stared at the wall, appearing blank and
unresponsive. Officer 8 made an entry to this effect in the man’s ACCT
document.
297. Between 8.00am and 8.30am, Senior Officer 5 spoke to the man and asked
him how he was. The man said that he had had trouble sleeping because
Prisoner 7 would not stop talking in the night and had been ‘driving him mad’.
Senior Officer 5 told my investigator that he was not concerned about the
man’s likelihood of harming himself following their conversation.
298. Later on, Prisoner 1 invited the man for coffee in his cell because he was
concerned by his low mood. He remembered that the man struggled to
express himself and was nearly crying. Prisoner 1 ‘thought [the man] was
having a breakdown’. Several other prisoners had gathered in the cell
because they were concerned about the man.
299. Another prisoner recalled that the man’s mood brightened when Prisoner 1
offered to share a cell with him. Prisoner 8 recalled that he spent about 20
minutes in Prisoner 1’s cell with the man at about 10.00am trying to cheer him
up. He said that the man’s mood was low and he was ‘very emotional’.
Prisoner 8 also offered to share a cell with the man. He told my investigators
that the man said he ‘could not cope’ on his own.
300. When he spoke to my investigators, Prisoner 8 remembered the man telling
him on 12 June that he had tied a towel around his neck the previous evening,
frightening Prisoner 7 and causing him to press the cell bell. Prisoner 8 said
that the man told him that Officer 5 had entered the cell, removed the towel
and transferred him to another cell. Prisoner 8 said that he asked Officer 5 on
the evening of 12 June if it was true, to which the officer replied it was.
However, when my investigators interviewed Officer 5, he did not remember
the man tying anything around his neck. Equally, the officer could not have
entered the cell without a senior colleague with keys being present. Officer
5’s keys were in a sealed pouch which was not opened during that night.
Final Report: January 2011 65
301. At about 10.00am, Officer 9 (who was working on the fourth landing of the
Onslow Centre that day) was asked by Prisoner 1 and another prisoner to
come and speak to the man. They were worried about their friend and asked
for him to be assessed by a member of healthcare staff. The prisoners
accompanied Officer 9 to Prisoner 1’s cell on the fourth landing of K wing.
They found the man sitting on the bed, looking vacantly upwards at the wall.
302. Officer 9 asked the man if he had taken his medication or if he would like to
speak to a Listener. He got no response to either question and the man
avoided eye contact. Officer 9 became concerned about his ‘bizarre’
behaviour and told the other prisoners that he would arrange for the man to
be assessed. Officer 9 was unaware at the time of the two recent attempts by
the man to take his own life at Pentonville.
303. Officer 9 telephoned the In-Reach team from an office on the second landing
and spoke to the manager of the team. The officer described his concerns,
mentioned that the man was the subject of an open ACCT document and
asked for somebody to come to the Onslow Centre and assess the man. The
manager of the mental health in-reach team agreed to carry out the
assessment herself.
304. Whilst Officer 9 was on the telephone to the In-Reach team, coincidentally
Officer 8 went to check on the man following his observation earlier that
morning. Officer 8 could not find the man in his cell and returned to the office
where he found Officer 9 still on the telephone talking to the manager of the
mental health in-reach team about the man.
305. The manager of the mental health in-reach team had an appointment at
Springfield Hospital at 12.00pm, and returned to the prison shortly after
2.00pm. She planned to assess the man upon her return. Officer 9 did not
remember a specific timescale being mentioned on the telephone. The
manager of the mental health in-reach team said that a call from the Onslow
Centre requesting an assessment was ‘not at all unusual’. She only
remembered the telephone conversation because she was surprised to learn
that the man had returned to Wandsworth. This was the first time anybody
had let her know. The manager of the mental health in-reach team had most
recently assessed the man on 14 May. Between 9 and 12 June, the man was
not referred to the In-Reach team and nobody from the team assessed him.
306. Finishing his telephone conversation, Officer 9 told Officer 8 that he had seen
the man in Prisoner 1’s cell and was concerned about his behaviour. He told
Officer 8 that he had asked a member of the In-Reach team to assess the
man. Officer 9 did not recall Officer 8 mentioning his similar observation of
the man earlier that morning. Officer 8 did not go and check on the man after
talking to Officer 9 because he realised that his colleague had just checked
and taken steps to help him.
307. Officer 8 was working on the third landing where the man’s ACCT document
was kept in the office. The officer made an entry in the document reflecting
Officer 9’s encounter with the man and the action taken. Officer 9 did not
Final Report: January 2011 66
make his own entry about his concerns and his conversation with the
manager of the mental health in-reach team (although he knew that the man
was the subject of an ACCT document) because he was working on the fourth
landing and did not have ready access to it. The officer was unaware until
after the man died that Officer 8 had made an entry for him. Neither officer
asked a manager to review the ACCT document or the frequency of
observations.
308. To allay the other prisoners’ concerns, Officer 9 told Prisoner 1 and another
prisoner that he had asked for the man to be assessed. He did not tell the
man, who was still in Prisoner 1’s cell a few feet away. Officer 9 thought that
the information might be better conveyed by the man’s friends, as he still did
not respond to the officer.
309. The man did not withdraw completely from daily prison life during the morning.
A number of staff told my investigators about seeing him mix with other
prisoners and walking along the landings. Prisoner 2 remembered the man
visiting him in his cell. He told my investigator that the man had not spoken to
him about any suicidal thoughts.
310. Officer 4 was the movements officer that morning. She heard at the morning
briefing that the man had been moved to a single cell overnight as a
temporary measure. However, she told my investigators that she did not want
to allocate a new cell mate and return the man to a shared cell until he had
been assessed by the In-Reach team. She had not spoken to the man about
relocation by the time that he took his own life later in the day.
311. Because he was worried about the man, risoner 1 asked Officer 4 if they
could share a cell. (They had previously shared a cell in May.) Because she
knew that both prisoners had mental health problems, Officer 4 told Prisoner 1
that she would first need to consult her SO and the In-Reach team regarding
the suitability of the proposal. Officer 4 was concerned that locating two
vulnerable prisoners with mental health difficulties together might not be the
most appropriate decision.
312. Prisoner 7 told my investigator that he remembered the man walking along
the landing with a laundry bag on his head at about midday. However,
nobody else my investigators spoke to recalled the incident taking place.
313. The man was a practising Muslim. At about 11.30am, Prisoner 8 helped to
prepare the faith room on the second landing of the Onslow Centre for the
Muslim prayer service. Muslim prisoners moved the chairs out of the way to
allow the prayer mats to be laid out for the 1.00pm service. Prisoner 8 told my
investigators that the man helped to set up the service before collecting his
lunch and being locked in his cell. Officer 8 remembered seeing the man
collect his lunch. Officer 10 recalled seeing the man return to his cell carrying
a full plate of food between midday and 12.30pm.
314. At about 12.30pm, Officer 10 began locking prisoners in their cells for lunch.
When he got to the man’s cell, he saw him sitting on a chair. He was facing
Final Report: January 2011 67
away from the door towards the window, bent over in a seated position with
his elbows on his knees and his head in his hands. Officer 10 asked
repeatedly if the man was alright, but he did not respond. The man glanced
over his shoulder back at the officer, but did not say anything. Officer 10
could not recall if the man had eaten his meal.
315. By now it was about 12.40pm. Officer 10 told my investigators that he locked
the cell, went to the landing office and recorded his observation in the ACCT
document. He could not remember reading the entries made earlier that
morning by Officer 8 and Officer 9. He remembered one of his colleagues
mentioning that the In-Reach team were planning to assess the man.
316. Officer 8 remembered having a short discussion with Officer 10 when he
made the entry, saying words to the effect that the man was ‘still not right’.
No further entries were made in the ACCT document after Officer 10 wrote in
it.
317. Officer 10 was responsible for unlocking the Muslim prisoners on his landing
so that they could go to the Friday prayer service. He told my investigators
that he would normally refer to a list of Muslim prisoners provided by the
Imam. However, he recalled that he had not received a list that day so relied
instead on the information written on each prisoner’s cell door plate.
318. The officer began unlocking the cells at about 12.50pm, but he initially
overlooked the man although he was a registered Muslim. He thought he
might have missed him because the man had only just arrived back on the
Onslow Centre and he was not used to him being present for Friday prayers.
319. Those prisoners who had been unlocked made their way to the second
landing. The service was due to begin at about 1.00pm. When the man did
not arrive, Prisoner 8 shouted up to Officer 10 asking him to check if the man
wanted to come.
320. Shortly after 1.00pm, Officer 10 returned to the man’s cell. He could not be
certain in interview if he looked through the observation flap or unlocked the
door to ask the man if he wanted to attend the prayer service. However,
Officer 10 said that he remembered that the man was still sitting at the table
facing away from the door, but this time his head was up and he was looking
at the window at the back of the cell.
321. Officer 10 told my investigators that he asked the man if he wanted to go to
the service, but did not get either a physical or verbal response. He said that
he shouted down to Prisoner 8, ‘I’ve got no answer.’ Prisoner 8 confirmed
that Officer 10 asked the man if he wanted to attend the prayer service.
Officer 10 did not make a further entry in the man’s ACCT document to reflect
his visit to the man’s cell.
322. Before he left the Onslow Centre at about 1.15pm to take his lunch break,
Officer 10 told his colleagues that the man did not look very well. He recalled
telling Officer 11 that the man had neither replied nor wanted to go to Muslim
Final Report: January 2011 68
prayers. Officer 11 was working during the lunch patrol state (when prisoners
are locked in their cells) with Senior Officer 3, Officer 12 and Officer 13.
(Senior Officer 3 and Senior Officer 5 were in charge of the Onslow Centre
that day.)
323. Prompted by Officer 10, Officer 11 went to check on the man in cell 22 on the
third landing of K wing at about 1.40pm. Her concern was also triggered by
reading the most recent entry made by Officer 10 in the man’s ACCT
document.
324. As I have noted, the last entry on the front cover of the ACCT document
regarding the frequency of observations had been made by Doctor D at
Pentonville on 4 June. Staff on the Onslow Centre should have checked the
man every hour. However, observations in the daytime were intermittent
between 9 and 12 June. Officer 11 checked the man 70 minutes after Officer
10 made the last written entry in the ACCT document. (Although the man had
been seen by Officer 10 in between these times when he asked about the
prayer service.)
325. Advising Senior Officer 3 where she was going, Officer 11 walked to the
man’s cell and looked through the small observation hole in the door. She
could not see anything so she opened the observation flap fully. The man’s
privacy curtain was pulled across and he was partly obscured. However,
Officer 11 realised that he was too high up to be standing on the ground and
so she knew that something was wrong.
326. Officer 11 ran back towards the centre of the Onslow Centre and shouted
from the third landing for Senior Officer 3 and her other colleagues to assist
her urgently. She was joined by Senior Officer 3, as well as Officer 13 and
Officer 12, both of whom had been overseeing the Muslim prayer service
which continued in a locked room on the second landing.
327. After Officer 11 opened the cell door, Senior Officer 3 and Officer 13 went into
the cell. Officer 11 remained outside in order to direct staff to the emergency.
The man was hanging by a ligature (made from a torn bed sheet) from the
bars on his cell window. He was facing towards the door. Senior Officer 3
and Officer 13 supported the man’s weight, whilst Officer 13 used his anti-
ligature knife to cut through the bed sheet. Once the ligature had been cut,
the man was lowered to the ground and placed on his back on the floor of the
cell, with his head towards the door. The remaining piece of the ligature was
removed from his neck. Officer 13 knelt by the man but could not find a pulse.
He was still warm but his pupils were fixed and dilated and he was not
breathing.
328. Officer 14 was working in his office on the third landing of K wing when he
heard a commotion and went to help. He arrived at the cell and Officer 13
sought his advice about beginning resuscitation. Senior Officer 3 and Officer
11 stood outside the cell. Senior Officer 5 (a qualified first aider) reached the
cell. The man did not respond to Senior Officer 5’s voice or gentle shaking.
Final Report: January 2011 69
The SO cleared the man’s airway and began giving compressions and rescue
breaths.
329. Officer 12, who followed shortly behind Officer 13, was asked to use his radio
to inform the control room that a ‘code 1’ emergency was underway. (A ‘code
1’ call lets staff know that the prisoner is in an immediately life-threatening
situation.) The officer did so and asked for urgent healthcare assistance to
come immediately to the third landing of K wing where a prisoner had hanged
himself.
330. Control room staff initially relayed an incorrect location to the healthcare team,
and Officer 12 immediately requested via the radio that the error should be
corrected. Although control room staff relayed the correct wing and landing to
healthcare staff across the radio net, Officer 12 had given the number of the
adjoining cell.
331. Officer 12 went to check if any nurses were by chance present on the wing,
but found none. Once sufficient discipline and emergency healthcare
response staff attended, Officer 12 returned to the Muslim prayer service,
where he had left the prisoners locked in with the Imam.
332. Doctor 1 and Doctor 2 were at lunch with Nurse 8 in the staff cafeteria when,
as the designated healthcare emergency response that day, she received the
‘code 1’ call over the radio. The doctors and Nurse 8 arrived at the man’s cell
at approximately 1.45pm, within about two minutes of receiving the call. (The
cafeteria is located next to the Onslow Centre, and Doctor 1 explained that
they could not have been any closer to hand.)
333. The prison’s incident log confirms that an ambulance was called at 1.47pm.
Officer 15 collected an oxygen cylinder from the second landing at the
doctors’ request and brought it to the cell.
334. Doctor 1 and Nurse 8 completed an assessment of the man and could not find
a pulse. They took over cardio-pulmonary resuscitation (CPR) from Senior
Officer 5. The doctors and Nurse 8 continued to give rescue breaths and
chest compressions in rotation but the man remained unresponsive. Doctor 1
inserted a plastic airway into the man’s throat and placed a face mask
attached to an inflatable bag over his mouth so that oxygen could be
administered. A defibrillator (a machine which can be used to reset an
irregular heart rhythm with a dose of electrical energy) was attached to the
man. However, no heart rhythm was detected and consequently the machine
advised that an electric shock should not be administered.
335. Principal Officer 1 (the prison’s orderly officer) arrived on the landing and told
Senior Officer 3 that a member of staff should keep an ongoing record of the
emergency. Senior Officer 3 assigned this task to Officer 15. The doctors
asked Officer 15 to request adrenaline (used to treat cardiac arrest) and
atropine (used to speed up a person’s heart rate) from the prison pharmacy.
Because she was busy recording the emergency log, Officer 15 asked Officer
14 to telephone the pharmacy.
Final Report: January 2011 70
336. Officer 14 made the telephone call and told a male pharmacy technician that a
prisoner had hanged himself. The officer said that staff working on the man
had asked for adrenaline and atropine. Officer 14 remembered the technician
asking him to collect the medication. He recalled emphasising that it was an
emergency and that the prisoner was in a critical condition.
337. During interview, Officer 14 said that the technician continued to suggest that
he collect the drugs. (The pharmacy is a considerable distance from the
Onslow Centre wing on the other side of the prison.) The officer did not think
that the technician grasped the severity of the situation. He raised his voice
and repeated his request before ending the telephone conversation.
338. Very shortly afterwards, Officer 14 received a telephone call from the
pharmacy. A female member of staff suggested to him that supplies of
adrenaline and atropine were kept on the wing. The officer firmly suggested
that the healthcare team working on the man would not be asking for
pharmacy staff to provide the drugs if they could be easily accessed on the
Onslow Centre.
339. Officer 14 continued to emphasise the critical nature of the emergency and
became frustrated at his inability to make the female member of staff
understand how important it was to bring the drugs without delay. The
second telephone conversation ended with the female member of staff
agreeing that the drugs would be brought to K wing.
340. My investigator spoke to the principal pharmacist. She confirmed that the
technicians working that day were temporary agency staff who no longer work
at Wandsworth. She was unable to identify the male technician, but identified
the female technician.
341. The principal pharmacist said that the female technician approached her
during the emergency. She remembered that the female technician then left
the pharmacy to take the adrenaline to the man’s cell. The principal
pharmacist told my investigator that she telephoned Officer 14 to let him know
that the female technician was on her way. The principal pharmacist
explained that the pharmacy does not carry atropine in stock, and therefore
this could not be provided during the emergency.
342. The ambulance arrived at the prison gates at about 1.50pm. At approximately
1.53pm, the ambulance technicians reached the wing and joined the
resuscitation attempt. The technicians were not carrying adrenaline or
atropine because they are not qualified to administer these drugs. The duty
governor, Governor 4, arrived on the landing at 1.55pm. Governor 1 attended
a few minutes later, at 1.58pm.
343. Shortly before 2.00pm, the Helicopter Emergency Medical Service air
ambulance crew touched down near the prison. The air ambulance doctor
and a paramedic arrived at the gate at 1.59pm and were taken to the Onslow
Final Report: January 2011 71
Centre. The air ambulance doctor brought adrenaline, which Doctor 1
administered. (The adrenaline from the prison pharmacy had not yet arrived.)
344. Doctor 2 and Doctor 1 moved out of the cell to allow Nurse 8, the air
ambulance doctor and the paramedics space to continue their efforts. A tube
was inserted down the man’s throat to try to help him breathe and he was
given medication to try to restart his heart via a drip in his arm. However, staff
were unable to revive him and all involved agreed that the resuscitation
attempt should end. The air ambulance doctor declared the man’s death at
2.18pm.
345. Doctor 1 approached Governor 1 on the landing. Upset, she voiced her
suspicion that the man had been deliberately removed from Wandsworth
during the inspection. Governor 1 told my investigators that he was
concerned about Doctor 1’s claim and went to check prisoner movement
records. He remembered speaking to the deputy governor at Pentonville,
Governor G, to allay his concerns.
346. A hot debrief was led by Principal Officer 1. At 2.45pm, Governor 1, Governor
4, Governor 5 (the deputy governor), Governor 6, Governor 7 and the
chaplain met to plan how te man’s family should be informed of his death.
Governor 7 was asked to act as the prison’s family liaison officer (FLO) and it
was agreed that he would take the chaplain with him to visit the family. The
man’s mother lives in South London, not very far from Wandsworth.
347. At 3.00pm, Prisoner 7 asked to speak to a Listener and was placed in the
care suite. All the prisoners in the Onslow Centre who were subject to ACCT
monitoring were reviewed at approximately 4.20pm.
348. Searching through the core record, Governor 7 could not firmly establish the
name and address of the man’s next of kin. He checked the social visits
records. He had to assume that the man’s mother was her son’s nominated
next of kin (the information is not recorded on the visits paperwork). Governor
7 estimated that locating these details took about half an hour.
349. Governor 7 decided not to use his own car to visit the family, but instead to
find a driver and make use of a 12 seater minibus. He was concerned about
getting lost and told my investigators that the Prison Service vehicle was
equipped with a satellite navigation device, something his own car did not
have. The minibus has an orange stripe down the side and Prison Service
markings. Governor 7 assumed that the vehicle was parked inside
Wandsworth, but it was actually located outside the prison.
350. During interview, Governor 7 told my investigators that he asked an
Operational Support Grade (OSG) member of staff to drive, as he did not
want to waste time parking when they arrived. He also did not wish to leave a
Prison Service vehicle parked close to the home, where the man’s relatives
might see it.
Final Report: January 2011 72
351. Having left the prison, Governor 7 and his colleagues had to travel
approximately three to four miles to reach the address. Governor 7
remembered that it was a Friday afternoon and the traffic was very heavy.
352. Shortly after 4.30pm, the man’s mother telephoned the prison. She had been
informed of her son’s death by a prisoner on the Onslow Centre who used a
mobile telephone. Governor 7 and the chaplain knocked on her door as she
was on the telephone to Governor 4 at the prison.
353. The man’s post mortem was held a week later on 19 June with a family
representative present. Some of the man’s family attended a memorial
service held at Wandsworth on 24 June. His funeral took place on 14 July at
Brixton Seventh Day Adventist Church. Governor 7 and the Safer Custody
Manager at Wandsworth attended on behalf of their colleagues. The prison
contributed £3,470 towards the costs of the funeral.
354. Doctor 1 told my investigator that she was not advised of a follow-up critical
incident debrief after 12 June. She was similarly unaware of Secure
Healthcare organising a review of the man’s treatment with the healthcare
staff involved.
Final Report: January 2011 73
ISSUES
355. The man’s experiences in custody prompt a significant number of questions.
Although it became clear that his transfers between prisons require
explanation, this was far from the only area of concern identified by my
investigators. Amongst the issues I explore are the man’s recall to custody,
the possibility of his hospitalisation, his location within each prison, the use of
the ACCT document and the appropriateness of cell sharing arrangements.
Where possible, I try to order my discussion of the issues to reflect the way in
which events unfolded.
Drug and alcohol withdrawal
356. The man’s original pre-sentence report recorded a history of crack cocaine,
heroin and alcohol misuse. When the man arrived at Pentonville on 21 April,
he was referred by a nurse to Doctor A for assessment during the reception
process. The man told the nurse that he had last used class A drugs on 16
April, and last drank alcohol on 20 April. Doctor A did not refer the man to the
detoxification unit. He did not issue any medication to treat either drug or
alcohol withdrawal.
357. The next day, Officer B completed an ACCT assessment interview and noted
that the man was asking for help with his drug and alcohol problem. A nurse
agreed to accept him on the detoxification unit. However, before the man
could begin detoxification, he attempted to take his own life.
358. My investigator interviewed Doctor A. He explained that the man did not
present with any withdrawal symptoms when he assessed him. He recalled
that the man’s description of his alcohol and drug use was ‘moderate and
vague’. He told my investigators:
‘[The man] didn’t come across as a full alcoholic or someone with a
dependency and he didn’t come across as an opiate addict who
needed support medication and transfer to the special unit.’
359. With regard to the possible impact of alcohol withdrawal on the man’s state of
mind, Doctor A acknowledged that alcohol has a calming effect and that
withdrawal can cause the prisoner to become either ‘physically or mentally
upset’. However, he did not consider the man to be withdrawing.
360. On the evidence available, Doctor A did not consider that the man’s
substance misuse needs warranted referral to the detoxification unit. He did
however make a referral to the In-Reach team and opened an ACCT
document. The man reported using four small bottles of whisky a day before
he came into prison, but Doctor A said that he was not shaking and his
physical presentation did not indicate an immediate withdrawal from alcohol.
361. Whilst in his experience most prisoners request an opiate substitute at the first
opportunity, Doctor A remembered that the man did not ask for help with his
substance misuse. He explained that Pentonville does not allow the
Final Report: January 2011 74
prescription of an opiate substitute on the first night in custody. Therefore,
although a request for detoxification was identified the following day, the man
could not have been prescribed methadone or subutex on his first night and
so he did not lose any ‘treatment time’.
362. Doctor A knew that a nurse should complete a secondary assessment of the
man the next morning. The doctor explained that the follow-up check
presents another opportunity to check for signs of withdrawal and acts as a
‘safety net’. I concur with the clinical reviewer, who found that Doctor A’s
decision not to admit the man for detoxification was ‘entirely appropriate’.
Medication
363. The man told the nurse in reception on 21 April that he was prescribed
olanzapine and risperidone. However, Doctor A acted cautiously and only
prescribed mirtazapine. Doctor A confirmed that he is only willing to prescribe
mirtazapine to prisoners with mental health problems on their first night in
custody, because this drug ‘carries no danger’. Although prisoners may tell
him that they take other anti-psychotic drugs in the community, the doctor
expressed reluctance to provide prisoners with them until a nurse has
contacted their community doctor to verify the information.
364. Doctor A said that he balanced the risk associated with the prisoner being
temporarily deprived of anti-psychotic medication against the risk associated
with providing it if they were lying. He chose not to prescribe until their
information could be corroborated. If the prisoner could produce evidence of
the prescription, Doctor A told my investigator he would accept this.
365. The doctor said that confirming medication with community surgeries is a daily
task for healthcare staff when new prisoners arrive in reception. Doctor A
expected staff to confirm the prescription and issue the prisoner’s medication
the day after he arrived in custody.
366. Although the prisoner might miss a day’s anti-psychotic medication, Doctor A
explained that he did not think that the drug would leave the bloodstream
entirely if the individual has been taking a continuous prescription. He did not
believe that the prisoner would completely lose the therapeutic effect of the
medication if the prescription was resumed after one day’s absence. Doctor A
accepted that failing to continue the prescription during the reception process
carries some risks but said that missing a dose is manageable. The doctor
explained that this way of working is his personal choice and he has not
discussed the policy with colleagues.
367. Doctor A has particular concerns about anti-psychotic medication. He
explained that experience had taught him that some prisoners would lie to
obtain it because they enjoy the sleepy sensation which it gives. He
expressed concern that, once he wrote a prescription, there was no process
to review it until days or weeks later.
368. The clinical reviewer does not agree with Doctor A. He comments:
Final Report: January 2011 75
‘Anti-psychotic medication should always be prescribed to a prisoner at
reception for first night if he informs a member of staff he is prescribed it.
Prison staff have understandable concerns that prisoners can falsely
inform staff they are prescribed anti-psychotics because they are
misused for their sedative effects. However if there are delays in
prisoners receiving prescribed anti-psychotics the risks of relapse of a
psychotic illness are high. Further information to confirm the prescription
can be obtained in the following days.’
369. I endorse the clinical reviewer’s recommendation and make another regarding
the need to review prescriptions.
If a new prisoner tells a doctor during the reception process that he is
being prescribed anti-psychotic medication, the Head of Healthcare at
Pentonville should ensure that the prescription is continued on the first
night in custody. The prescription should be confirmed with the
community provider by the end of the next working day.
The Head of Healthcare at Pentonville should ensure that all
prescriptions are reviewed at pre-determined intervals and that staff
understand the review process.
Medication error
370. The man returned to Pentonville unexpectedly on 26 May. His regular
medication could not be given to him that night because the healthcare staff
could not locate his medication chart in either the reception area or the
healthcare centre. He was given his prescription the next day.
371. On the evening of 10 June, by mistake Nurse 7 gave the man 30mg of
mirtazapine rather than the 15mg that he was prescribed. She provided my
investigators with the following statement:
‘15mg [of mirtazapine] once daily at night is the introductory dose - the
doctor reviews the patient after a couple of weeks, and decides whether
he remains depressed enough to need to receive 30mg once daily at
night, which is the commonest dose, or whether 15mg is sufficient. A few
patients then progress to 45mg once daily at night in due course.
‘We cannot know whether the man's dose would have been increased,
had he lived, and I obviously would not have intentionally increased it in
the absence of a prescription. The 30mg that the man received would
not have been toxic, and would not have caused agitation (mirtazapine is
a sedative antidepressant, hence prescribed at night) or lowered his
mood.
‘The brief interaction that I had with the man gave me no cause for
concern, other than in regard to my own culpability for the drug error - he
had a right to know that this had happened, and that I would be reporting
Final Report: January 2011 76
it to the Sister in charge, and he had a right to an apology, which I made
to him. His presentation did not differ in any way from that which was
normal for him - courteous, pleasant, and with no apparent evidence of
mental distress, allowing for the fact that I was not conducting a formal
assessment of his mental state.’
372. Nurse 7 showed admirable honesty in providing my investigators with a full
account of her actions. She also fulfilled her responsibility as a registered
nurse by reporting her error to her own line manager. The clinical reviewer
confirmed that 30mg is the usual therapeutic dose of mirtazapine and would
not have caused the man any ill effects. I commend Nurse 7 for her personal
apology to the man at the time and her subsequent candour. I consider that
her error was unintentional and that she acted swiftly to correct the mistake.
Recall to prison
373. Having examined the paperwork relating to the man’s recall to custody, my
investigators had a number of questions about the way it was implemented.
They had identified breakdowns in communication between the different
agencies involved and sought further clarification about what can be a
complicated process.
374. The investigator approached the Public Protection Casework Section, part of
the NOMS Public Protection Unit. This department oversees the recall
process. The investigator interviewed the Head of the Post-Release
Casework Section and the Deputy Head of the Section. They assisted the
investigator to understand what the Head of the Post-Release Casework
Section observed to have been ‘an unfortunate collision of events’. The recall
process was not as straightforward as it might have been because of initial
communication problems between the different criminal justice agencies
involved.
375. The man was released on licence on 20 March. He was required to attend
weekly appointments with both his offender manager and his CPN. It was a
condition of his licence that he return to an approved premises run by the
probation service each night to sleep. Until he came into custody on 21 April,
I understand that the man complied with his licence conditions. However, it
was noted that his mental health problems appeared to be worsening and he
was causing some concern in the approved premises. Nonetheless, the
man’s offender manager thought that his behaviour was being managed
satisfactorily.
376. However, on 14 April, the man was arrested by the police after committing
new driving offences. He was charged but initially remained on bail. Because
the offences were not related to the offence of robbery for which he had
received the original four year prison sentence, because the offences were
less serious and because the man was otherwise complying with the terms of
his licence, the man’s offender manager chose not to recall him to custody.
Instead, she met him at the probation office on 15 April and issued a warning
relating to the new offences. She told the man that any further problems with
Final Report: January 2011 77
his behaviour or failures to comply with his licence would result in a final
warning and consideration of recall to custody.
377. The man appeared at court in relation to the driving offences on 21 April. It
does not seem that he told staff at the approved premises where he was
going before he left that morning. The court remanded him into custody prior
to sentencing. Neither the man’s offender manager nor the approved
premises were told by their probation colleagues at the court that the man had
made an appearance and been taken to prison. The man was due to attend
an appointment with his offender manager later that day.
378. Believing he was still in the community, the man’s offender manager thought
that the man had chosen not to attend their scheduled appointment and had
therefore failed to comply with his licence conditions. She took the
appropriate action based on the information available to her at the time and
instructed staff at the approved premises to initiate an out of hours recall if the
man did not return before his curfew that night. The hostel staff carried out
the recall as directed just before midnight on 21 April, citing the man’s failure
to return to the approved premises.
379. The man was assessed as presenting a high risk of serious harm to the
public, and was therefore the subject of an emergency ‘standard recall’. Such
a recall had to be processed within two hours, and it was completed shortly
after 1.00am on 22 April. The man’s final risk assessment was completed on
24 April 2009. The risk he presented to others was assessed as high.
380. Because he had been recalled to custody, the man was not in a position to
attend either his probation appointment or go back to the approved premises.
The Probation Service’s ‘Request for Recall’ cited the man’s failure to report
at the probation office on 21 April, his failure to return to the approved
premises and comply with his curfew conditions and his failure to contact
either the hostel or his offender manager. The recall was not triggered by the
recently committed driving offences as the man’s offender manager had
issued a separate verbal warning in relation to these on 15 April.
381. The man’s offender manager has confirmed to my investigator that she was
not told of the man’s remand into custody on 21 April. When an individual
being supervised by the probation service appears in court, probation staff
should advise the judge of the offender’s response to supervision and also
inform the supervising officer so that they can take appropriate action. The
offender management IT system used by London Probation should clearly
provide court staff with the offender manager’s name and the case history.
London Probation Trust should ensure that staff working in court
promptly inform the relevant offender manager and other colleagues
working with the offender (such as approved premises staff) of the
outcome of a court appearance.
382. The Public Protection Casework Section processed the recall and notified the
police that they should arrest the man. The revocation of the man’s licence is
Final Report: January 2011 78
dated 21 April. (The Casework Section were also unaware at this stage that
the man had returned to prison.) The Head of the Post-Release Casework
Section said that his team next become involved in the recall process when
the individual has been arrested by the police and returned to prison. He
confirmed that it is the prison’s responsibility to inform the Casework Section
immediately because he and his colleagues are legally obliged to prepare and
send a recall dossier to the Parole Board within 28 days of the offender’s
return to custody.
383. In the man’s case, Pentonville did not notify the Casework Section of the
man’s arrival on 21 April (the day that he came back into prison). This is
understandable because, when the man arrived from court that day, the recall
had not yet been processed (it was only initiated shortly before midnight) and
consequently no information had been entered on the Inmate Information
System (IIS) by the Head of the Post-Release Casework Section’s team for
prison staff to check.
384. The Head of the Post-Release Casework Section and his deputy indicated
that prisons do not always inform the Casework Section immediately of the
return of a licence recall prisoner to custody. Therefore, as a precautionary
measure, they carry out ‘unlawfully at large’ checks using IIS to confirm
whether the offender has re-entered the prison system.
385. The deputy head of the section told my investigator that her team’s first check
was carried out on 27 April. Her staff consulted the computer records but did
not identify that the man was back in prison and therefore took no action.
This may have been because he had been discharged to the Royal London
Hospital under escort. My investigators have looked at IIS themselves and
the man’s removal to hospital as a serving prisoner was correctly recorded by
Pentonville staff.
386. IIS is a very out-of-date and basic piece of computer software that is due to be
replaced. There is no facility to record significant detail about the prisoner’s
circumstances. If Casework Section staff only checked the front page of the
man’s records, his return to custody may not have been readily apparent.
However, further examination of the pages relating to the man’s movements
would have revealed his imprisonment and subsequent escort to hospital.
The Head of the Public Protection Casework Section should ensure that
staff carrying out ‘unlawfully at large’ checks are trained to access and
correctly interpret a prisoner’s complete IIS record.
387. I note that approved premises staff and the man’s offender manager’s line
manager were eventually told about the man’s return to custody on 23 April.
The man’s offender manager confirmed this information when she returned to
the office on 27 April. It would have helped the Casework Section if probation
staff had communicated this information to them at the first opportunity.
Final Report: January 2011 79
London Probation Trust should remind staff to check with the Public
Protection Casework Section if they discover from another source that a
recalled offender has been returned to prison.
388. The man returned to prison from hospital on 28 April. By this stage, details of
the recall had been entered onto IIS by the Casework Section and were
available to prison staff. However, the deputy head of the section said that
Pentonville staff did not inform the Casework Section that they were holding
the man. Because the man was not a newly arrived prisoner and was
returning from hospital, it is possible that a full check of IIS was not
completed. The deputy head of the section also thought that the second
failure by prison staff to notify her section on 28 April may have resulted from
confusion over his prison number.
389. The man was mistakenly assigned a second prison number when he returned
to custody which may have led to staff not checking details of his recall.
Nonetheless, the deputy head of the section told my investigator that prison
staff should search for all the records relating to a prisoner using their
surname and date of birth. Had Pentonville staff done so, they would have
located the man’s original prison number, together with the details of his
recall.
The Governor of Pentonville should ensure that staff perform a thorough
search of prison information systems when a new prisoner arrives in
custody. As well as the individual’s prison number, staff should also
check their surname and date of birth.
The Governor of Pentonville should remind staff of the importance of
notifying the Public Protection Casework Section immediately when a
prisoner whose licence has been revoked arrives at the prison.
390. The Casework Section performed a second IIS check on 5 May and identified
for the first time that the man was back in custody. Consulting the computer
records, the Head of the Post-Release Casework Section’s team mistakenly
thought that the man returned to Pentonville on 28 April, rather than 21 April.
My investigators have looked subsequently at IIS, and the records show the
man’s return to custody on the earlier, correct date.
391. The deputy head of the section explained that information about the man’s
recall was issued to Pentonville on 5 May. (Although the copy of the letter in
the man’s prison file is dated 8 May.) It was emailed to the custody mailbox at
Pentonville for staff to print off and distribute. The Licence Recall Officer at
Pentonville told my investigator that this paperwork would normally have been
passed to the man by the Legal Aid Officer, who is also required to explain the
recall process.
392. We do not know if the man received the recall pack. Amongst the documents
was Annex A, which the man was supposed to sign and date to confirm that
the recall process had been fully explained to him. Pentonville had to return
the signed copy of the annex to the Casework Section within five days. The
Final Report: January 2011 80
man did not sign Annex A and it was not returned. A blank copy remains in
his prison file. It is not clear whether the man saw the document, still less
whether he read and understood it.
393. Annex A asks the offender to indicate if they wish to instruct a solicitor to
make representations to the Parole Board via the Casework Section. The
deputy head of the section confirmed that the man made no such
representations. There is nothing in the recall file to indicate that the man
ever instructed a legal representative to contest his recall to custody.
394. Annex 4L of Prison Service Order (PSO) 2700 suggests a strategy for
reducing risk amongst recalled prisoners:
‘Staff [could be] trained to guide prisoners as to their entitlements, give
them early advice about their right of appeal and opportunities for re-
release and help them make contact with a solicitor if required …’
395. My investigator asked the Head of the Post-Release Casework Section and
his deputy about the difficulty a prisoner with mental health problems, such as
the man, might have in understanding the recall process. It is relatively
complex and some of the prison staff interviewed by my investigators
suggested that the man did not always seem to fully grasp his circumstances.
The original pre-sentence report recorded that, in some circumstances, the
man required an appropriate adult to accompany him to interviews and
appointments.
396. We do not know whether the man understood either his right to contest the
recall, the reasons for the revocation of his licence or how to find a solicitor.
The deputy head of the section confirmed that the Casework Section has not
issued any set guidance to prison staff regarding delivering recall information
to offenders with mental health needs.
The National Offender Management Service should consider whether to
issue guidance to prison staff in England and Wales outlining how best
to explain the recall process to prisoners with mental health difficulties.
They may wish to recommend that, if a prisoner is registered with an In-
Reach team, a member of that team is present.
397. The Head of the Post-Release Casework Section and his deputy explained to
my investigator that the Casework Section is legally required to submit a recall
dossier to the Parole Board for their consideration within 28 days of the
offender’s return to prison. They accepted that their staff were late to submit
the man’s dossier and breached the target.
398. My investigator explored the logic behind the man’s recall to custody with the
Head of the Post-Release Casework Section and his deputy. They agreed
that the reasons the offender manager gave for the recall were the man’s
failures to attend the probation office and the approved premises on 21 April,
rather than his reoffending on 14 April. Given that the man was taken to
prison on 21 April, he could not reasonably have been expected to meet his
Final Report: January 2011 81
licence conditions. The stated trigger for the recall does therefore, in
retrospect, seem unfair, and might indeed have appeared so at the time from
the man’s perspective.
399. The Head of the Post-Release Casework Section described an ‘unfortunate
sequence of events’. However, I am satisfied that the man’s offender
manager acted in good faith on the basis of the evidence available. Neither
the Probation Service nor the Casework Section realised straightaway that the
man had returned to prison.
400. Although the Request for Recall report referred to the man’s failure to attend
the office and the approved premises, it also stated that the man had
breached another (more general) condition of his licence, which the Head of
the Post-Release Casework Section said is ‘commonly, but not invariably’
cited as a reason for revocation:
‘You have failed to be well behaved, not commit any offence and not do
anything which could undermine the purposes of your supervision, which
are to protect the public, prevent you from reoffending and help you to
resettle successfully into the community.’
401. The Head of the Post-Release Casework Section confirmed that offender
managers can ask the Casework Section to consider rescinding a recall if the
offender is still in the community. The Casework section did not receive a
request to rescind from the Probation Service. However, because the man
had already entered custody, the Head of the Post-Release Casework
Section and his deputy said that the Casework Section could not have taken
any action anyway. As well, the Head of the Post-Release Casework Section
explained that, because the man was assessed as representing a high risk of
serious harm to the public, his re-release could only be considered by the
Parole Board. The Casework Section does not have the authority to re-
assess the reasons for recall before the Board meets.
402. The man was held in custody between 21 April and 26 May in relation to the
recent driving offences. This period of imprisonment was concurrent to, but
separate from the recall. The Casework Section could not have intervened to
release the man from prison during this period. The recall dossier arrived at
the Parole Board on 27 May. It should have been sent by either 19 or 26
May, depending on which date one considers correct. In either case, the
dossier was supposed to reach the Board before the man was sentenced for
the driving offences.
403. From the point the dossier reached the Board, the man’s case was out of the
Casework Section’s hands. No action could be taken regarding his recall until
the Parole Board made their decision. As it turned out, the Board decided not
to release the man and acknowledged the problematic nature of the original
reasons for recall. I am satisfied that the man’s continuous imprisonment
during this period can be accounted for.
Final Report: January 2011 82
Consideration by the Parole Board
404. The deputy head of the section indicated that the Casework Section would not
review a specific prisoner’s recall until after the Parole Board had considered
the case. Due to the volume of recall dossiers being compiled, no single case
can be explored in detail during the first 28 days unless a solicitor or offender
manager approaches the section. The man did not instruct a solicitor and the
Probation Service did not contact the section again after completing the recall
paperwork.
405. The Head of the Post-Release Casework Section stressed the importance of
the Parole Board’s final decision. Both he and his deputy pointed out that an
offender’s behaviour is looked at ‘in the round’ by the panel. The risk
assessment process involves consideration of a variety of information, and
the panel is not confined solely to the specific reasons for recall. Even when
recent reoffending does not trigger a recall, it can be a factor in the decision
not to release an offender. Reoffending is an indication that supervision on
licence may not be working. Although the offender is attending appointments,
they may not be engaging to reduce their likelihood of reoffending.
406. The Parole Board was asked to review the man’s recall to custody on 27 May.
They carried out the review in a timely fashion on 3 June and made no
recommendation as to the man’s release. The Board acknowledged the
confusion over the original reason for recall:
‘The panel now understands that [the man] failed to comply with
licence conditions on 21 April 2009 because he had been remanded in
custody in relation to the driving offences pending the preparation of a
[pre sentence report]. He subsequently attempted to commit suicide
and received CPR and spent a period of time in intensive care.’
407. The Board agreed that the man had complied with his licence conditions prior
to 21 April. In refusing to release him again on licence, they explained their
reasoning. The man’s offender manager did not support the man’s re-release
on licence. Her assessment dated 5 May indicated that the man’s behaviour
was presently unmanageable in the community. The Board took into account
the seriousness of the original offence of robbery, the man’s history of
offending behaviour, his previous failures to comply with the instructions of
courts and the fact that he had previously had to be recalled to custody when
first released on licence in 2007. They also bore in mind the commission of
further offences on 14 April.
408. Although a comprehensive risk management plan had been put in place, the
Board noted that a similarly thorough plan was implemented in March, but it
did not prevent the man from reoffending. The panel was therefore not
satisfied that the risk the man presented to the public could be satisfactorily
managed in the community. They acknowledged that, in making their
decision, they did not possess either detailed information about the recently
committed driving offences or an up-to-date assessment of the man’s mental
health.
Final Report: January 2011 83
409. The Head of the Post-Release Casework Section pointed out that the original
pre-sentence report and the offender manager’s newly produced assessment
of the suitability for re-release both mention the man’s mental health
problems. However, the writer of the original pre-sentence report did not have
access to a psychiatric report.
410. The man’s offender manager’s report considering the possibility of re-release
was submitted to the Casework Section on 7 May. The Parole Board were
unaware of the outcome of the man’s court appearance on 26 May. They
would not have known about his second attempt to take his own life on 1
June. No accommodation was in place for the man if he were to be released.
The man would have lost his place in the Tulse Hill hostel after coming back
into prison and places are relatively scarce and can take some while to
organise.
411. The Board’s findings were emailed to the Licence Recall Officer at Pentonville
at 11.33am on 9 June. She told my investigator that, because the man left
Pentonville that morning, she would normally have forwarded the information
by email to Wandsworth’s custody inbox. (She no longer had a copy of the
email and could not remember the man’s case specifically.)
412. It is unclear whether the man was ultimately told of the Board’s decision by a
member of Wandsworth staff before he died. The Head of the Post-Release
Casework Section expressed concern that news of the Parole Board’s refusal
might have contributed towards the man’s decision to end his own life.
However, there is nothing in his records to indicate that the information was
passed on or that the man reacted to the news.
413. The 28 day timescale for submission of the recall dossier to the Board is a
legislative requirement designed to prioritise public protection and return the
offender to prison as quickly as possible. The Head of the Post-Release
Casework Section said that it is not feasible to commission a full psychiatric
report within 28 days. He explained that his section has agreed with the
Parole Board that a full mental health assessment will take three months to
prepare.
414. The work done by the Casework Section during the initial 28 day period from
the time the offender re-enters prison is, in the words of the deputy head of
the section, ‘process-driven’. The time scale only allows the Casework
Section to gather existing documents (such as the original pre-sentence
report) and ask the offender manager to prepare a report commenting on the
prisoner’s suitability for release. The offender manager can make reference
to new developments in their report.
415. If the Board considers the recall and makes no recommendation for release,
then the Casework Section is obliged to conduct an ongoing review of the
case. (Unfortunately The man died before this could take place.) The Head
of the Post-Release Casework Section and his deputy both thought that,
given that the man’s sentence was due to expire in August, there would
Final Report: January 2011 84
probably not have been time for further reviews. It is likely that he would have
stayed in prison until his release date.
416. Offenders are entitled to appeal against the Parole Board’s decision and can
request an oral hearing within 14 days. In the meantime, the Casework
Section can begin to gather new evidence such as a psychiatric assessment.
The deputy head of the section told my investigator that it is during this latter
stage that a senior caseworker can consider individual cases in greater detail.
During the initial 28 days, it is not practical to do so because of the hundreds
of recalls to custody that are dealt with.
Prison transfers
417. Between 21 April and 12 June, the man transferred between London prisons
four times. I do not know whether the number of transfers had any bearing on
his decision to take his life. I am satisfied that some transfers were expressly
for his own benefit. I have explored all of the evidence available to determine
as far as is possible why each move took place. At each stage, I have
assessed whether, as a prisoner with mental health problems who had
previously attempted to take his own life, the man’s continuity of care was
affected.
418. The clinical reviewer has considered the impact that the number of transfers
had on the man. He explains why the man’s movement around the prison
system was unhelpful:
‘The man’s frequent and unpredictable transfers from prison to prison are
likely to have exacerbated his fragile mental state. Even in the best
functioning system there is difficulty in transferring information from prison
to prison, and his frequent moves compounded this. There were frequent
breakdowns in communication and a lack of information on transfer.
Communication between agencies became stretched and finally broke
down.
‘Good quality mental health care is best provided by a single team, who
are able to develop a personal relationship and acquire knowledge of an
individual’s illness and personal needs. In these circumstances patients
can begin to feel safe, and the risks, particularly of self-harm or suicide,
diminish. This failed to happen during the man’s period of imprisonment,
despite the efforts of a number of prison officers and the healthcare staff.
‘In my opinion the number of transfers were likely to have had a significant
effect on the man’s mental state, significantly increasing his risk of harm to
himself.’
21 April
419. As the man had appeared at Camberwell Green Court, he would normally
have been remanded in custody at Brixton. However, staff at Brixton correctly
identified a conflict of interest because the man’s cousin worked at the prison.
Final Report: January 2011 85
They needed to make alternative arrangements and time was pressing as the
man was waiting in the court cells. There was no obligation to locate the man
in another prison in South London, and I am satisfied that consideration could
not be given at such short notice to placing him in the London prison closest
to his family’s home. Equally, it would not be reasonable to have expected
staff to have tried to place the man in the prison where he was held prior to
his release on licence (which happened to be Wandsworth).
420. Governor W (the duty governor at Brixton) asked Principal Officer Z to use her
contacts to locate the man in another London prison. Principal Officer Z had
ties with Pentonville and telephoned Principal Officer A. When Principal
Officer A spoke to her, Governor A agreed to accept the man. At this stage,
staff at Brixton and Pentonville could not reasonably have known about the
man’s mental health problems, his dislike of Pentonville or his desire to return
to Wandsworth. They were issues that would subsequently become
apparent.
421. I consider that staff acted promptly and reasonably to locate the man. His
best interests were prioritised to ensure that he was not located in Brixton
even temporarily, only to then have to be moved again because of the conflict
of interest. My investigators have established that Governor 3 (the duty
governor at Wandsworth) was not asked to accept the man on 21 April,
although the prison had space to accommodate him. From the moment
Principal Officer Z was asked to facilitate a transfer, it would seem that
Pentonville was always the intended destination.
12 May
422. Having attempted to take his own life, the man was taken to the Royal London
Hospital. He returned to Pentonville and was kept under close observation in
the healthcare centre. He repeatedly expressed his anxieties about remaining
in Pentonville and his wish to transfer to Wandsworth, where he said he felt
safer and had been held before he was released on licence. Such was the
concern about the man that plans were made to return him to Wandsworth.
423. The Pentonville Governor, Governor C, spoke to the Wandsworth Governor,
Governor 1, about the man’s circumstances in early May and Governor 1
agreed to accept him. Preparations for the transfer took place over more than
a week and the man was given several days notice of the move. Nurse D
liaised with the manager of the mental health in-reach team at Wandsworth to
allow her team to prepare for the man’s arrival. The Heads of Healthcare at
both prisons spoke to each other. Nurse D provided Wandsworth with a
discharge summary.
424. Regrettably these excellent preparations did not include Senior Officer D
(Pentonville’s Safer Custody Manager) who was apparently unaware of the
plan. On the morning of 12 May, he still thought the man would automatically
transfer to Brixton after his appearance at Camberwell Green. He emailed
Brixton to complete a handover. Whilst this oversight was unfortunate, I do
not make a recommendation. However, the Governor of Pentonville may wish
Final Report: January 2011 86
to review the channels of communication between the Safer Custody
department and healthcare staff.
425. I am satisfied that the move to Wandsworth was organised in the man’s best
interests and was well intended. Staff listened to what the man told them
about his feelings of anxiety at Pentonville and acted appropriately to reduce
the risk he presented to himself. His continuity of care was considered, and
measures were put in place to ensure that staff at Wandsworth were prepared
for his arrival.
426. HMIP carried out an announced inspection of Pentonville between 11 and 15
May. I consider that the scheduling of the man’s transfer to Wandsworth near
the beginning of this period was coincidental. The move had been planned
since early May and was intended to make the man feel safer, rather than
remove him from Pentonville during the inspection. The transfer to
Wandsworth was supposed to be permanent.
427. The man was supposed to move to Wandsworth after his court appearance.
Despite the intentions of healthcare staff, the PER was not marked
accordingly. During interview, Governor C accepted that the failure to transfer
the man to Wandsworth on 12 May was a consequence of Pentonville staff
not properly communicating their intention on the PER. Even though portions
of the man’s medical record were read out in court, the intention to move him
to Wandsworth was not acted upon. (Judges can offer guidance to Serco
staff if relevant information is presented in court.) Instead, the man was
placed on a van to go to Brixton.
428. Governor Y (the duty governor at Brixton) realised that the man was arriving,
via court, from the healthcare centre at Pentonville. However, he thought it
inappropriate to accept the man into Brixton’s healthcare centre without prior
agreement by their healthcare manager. Prior agreement is a requirement of
the Prison Service London Area Males Local Transfer Protocol. (There is no
evidence in the man’s records of a London Protocol pro forma being
completed by Pentonville staff as should have happened.) Liaising with the
other prisons involved, Governor Y found that the duty governor at
Wandsworth also did not know about the transfer organised by healthcare
staff.
429. The duty governor at Pentonville recognised the error when Governor Y
contacted him. Governor Y prioritised the man’s safety and accepted him into
Brixton for the night. He acted cautiously, keeping the man under constant
supervision in the healthcare centre. Governor Y knew about the man’s
recent attempt to take his own life and seems to have been very much
attuned to the risk he presented.
13 May
430. I consider that Governor Y acted appropriately on the evening of 12 May. He
obtained relevant information, took account of the risk issues and acted in the
man’s best interests. Although the man’s continuity of care was disrupted, I
Final Report: January 2011 87
am satisfied that the disruption was kept to a minimum and the action taken
was reasonable. The man’s temporary location in Brixton could not have
been reasonably avoided by that prison’s staff. The man moved promptly to
Wandsworth the following day.
26 May
431. The transfer which took place on 26 May was the one which least appeared to
have been arranged in the man’s own interests. Establishing the chronology
of events involved speaking to several governors as well as considering other
evidence. The investigation was further complicated by additional evidence
coming to light in the course of the Prison Service’s own investigation.
432. The man stayed at Wandsworth until he was taken to Pentonville after
appearing in court on 26 May. He was no longer the subject of an open
ACCT document and was not subject to medical hold. Doctor 1 told my
investigators that she only tended to use the option of placing a prisoner on
medical hold if they had an upcoming hospital appointment or an operation
scheduled. She could not recall placing a prisoner on medical hold solely
because she thought that they would benefit from a stable environment,
although she thought it might be possible.
433. The man’s transfer to Pentonville from Wandsworth following a court
appearance was authorised by the Governors of the two prisons as their
respective duty governors were unable to agree. The move was not
scheduled and an explanation was not readily apparent. My investigators
interviewed those who made decisions regarding the man’s transfer to
Pentonville on 26 May and those who influenced the timescale of his return to
Wandsworth. They spoke to Governor 3, Governor C, Governor A, Governor
1 and Governor Z to clarify their understanding of events.
434. Concerns about the transfer were initially raised by two prisoners on the
Onslow Centre. Prisoner 3 and Prisoner 2 first complained to my investigator
when he visited Wandsworth in June, soon after the man died. The two
prisoners also wrote to HMIP. They alleged that they had been deliberately
moved out of Wandsworth prior to HMIP’s visit between 1 and 5 June. They
had transferred to Pentonville the weekend before the inspection and returned
on 9 June in the same van as the man. The prisoners thought that the man’s
transfer to Pentonville on 26 May was also intended to remove him from
Wandsworth for the duration of the inspection.
435. HMIP returned to Wandsworth and concluded that short term transfers had
been organised to remove prisoners temporarily during the inspection period.
An internal investigation was then carried out by the Prison Service which
confirmed that managers at both prisons had made a reciprocal arrangement.
When HMIP visited Pentonville from 11 to 15 May, six prisoners had been
temporarily transferred to Wandsworth. Similarly, it was established that five
men moved from Wandsworth to Pentonville on a short term basis before
HMIP visited.
Final Report: January 2011 88
436. As I have said earlier, the Chief Inspector of Prisons has criticised the
‘attempts, at a managerial level, to subvert the inspection process’. I have
reflected her opinions in the earlier sections of this report entitled ‘HMP
Wandsworth’ and ‘HMP Pentonville’. In her annual report, issued several
months after the original inspection reports, the Chief Inspector said that
some managers had made ‘the welfare of prisoners subordinate to the desire
to impress inspectors’.
437. Following the internal Prison Service investigation, charges were
recommended against five managers at the two prisons. At subsequent
disciplinary hearings, charges against two managers were dismissed.
Charges against the other three managers were proved. One received a final
written warning and was removed from the field of promotion. Another
received a written warning. The other received formal guidance.
438. As far as the man is concerned, the internal Prison Service investigation
found that he was not one of the five prisoners who were deliberately escorted
to Pentonville on the weekend prior to the inspection. His move took place a
few days earlier after a scheduled court appearance.
439. Nonetheless, both the Prison Service’s investigation and the enquiries of my
own investigators found evidence to suggest at the very least a connection
between the forthcoming inspection and the failure to return the man to
Wandsworth after court on 26 May. The evidence also suggests some
association between the duration of the inspection and the failure to return the
man to Wandsworth until 9 June. (Although a transfer back to Wandsworth
was booked for 1 June, staff at Pentonville working with the man were not
aware of it and it did not take place after he tried to take his own life for a
second time.)
440. During interview, Doctor D and Nurse D at Pentonville and the manager of the
mental health in-reach team and Doctor 1 at Wandsworth voiced their
suspicions that the man transferred to Pentonville because of HMIP’s
imminent visit. Given the effort staff put in to organise the original transfer in
mid-May and the amount of liaison involved, it is perhaps not surprising that
some were baffled by the man’s return to Pentonville only two weeks later.
441. The man left Wandsworth for Camberwell Green on the morning of 26 May.
There was nothing marked on his PER to indicate that he should return to
Wandsworth afterwards, rather than being taken to Brixton (as prisoners
normally are from Camberwell Green). PSO 1025 guides staff in completing
PERs. The PSO does not require them to mark a PER to this effect.
442. However, had the PER been marked accordingly, the subsequent
involvement of a number of governors would have been unnecessary, and I
am confident that the man would have returned to Wandsworth. The same
mistake had been made on 12 May, when Pentonville healthcare staff failed
to mark the PER to indicate the man’s intended transfer to Wandsworth. On
both occasions Serco staff at Camberwell Green tried to transfer the man to
Final Report: January 2011 89
Brixton because they were not provided with pertinent information on the
PER.
To ensure continuity of care, Offender Health should instruct In-Reach
teams to write under ‘Health Risks’ on the Risk Indicator page of the
PER the intended return destination of a prisoner under their care if that
prisoner is appearing at a court that will not automatically return them to
the dispatching prison.
Governor 3
443. The first governor my investigators spoke to was Governor 3, the duty
governor at Wandsworth on 26 May. Governor 3 remembered receiving two
or three telephone calls from Governor Z (the duty governor at Brixton). He
said Governor Z explained that the man was currently at Camberwell Green
Magistrates’ Court and that a conflict of interest meant it was inappropriate for
Brixton to receive him.
444. Governor 3 refused to accept the man. He remembered telling Mr Governor
Z, ‘He’s not our court.’ Governor 3 did not consider the man to be a
‘Wandsworth prisoner’. He formed this opinion because prisoners leaving
Camberwell Green are normally taken to Brixton. Governor 3 also knew that
the man had started his recall to custody in Pentonville. He thought that
either Brixton or Pentonville should accept the man and that it was nothing to
do with Wandsworth.
445. During interview, Governor 3 said that he was unaware of the efforts made
earlier in the month to transfer the man to Wandsworth. When he spoke to
Governor Z, he could not be sure whether he realised that the man had been
held in Wandsworth for the previous two weeks. He thought on reflection that
he must have known.
446. When he spoke to my investigators, Governor 3 commented that he would not
normally refuse to assist another duty governor. He was not especially
anxious about population pressures and the prison was not full that day.
Governor 3 commented that the prison population was ‘relatively low’ in late
May 2009.
447. Governor 3 told my investigators that he did not think it was a ‘sensible
decision’ to accept a prisoner who ‘was coming with certain issues’ and who
was not (he believed) a ‘Wandsworth prisoner’. He considered that to accept
such a prisoner would create additional pressure during the stressful
inspection period.
448. If another prison was asking Wandsworth to accept a prisoner, Governor 3
thought it likely that the prisoner had ‘issues’. He was not minded to ‘do
favours’ for other prisons at the time. He felt that Wandsworth sometimes
accepted prisoners too readily without this being reciprocated. However, he
confirmed that he was not asked to accept any other prisoners on 26 May,
Final Report: January 2011 90
and was not asked to facilitate any other ‘governor to governor’ transfers
around that time.
449. During interview, Governor 3 accepted in retrospect that the man had been in
Wandsworth until the morning of 26 May and therefore his return would not
have created any new pressures for staff. However, at the time he thought
that the man was a prospective new arrival.
450. Having refused Governor Z’s request, Governor 3 decided to ask the duty
governor at Pentonville, Governor A, to accept the man. He approached
Pentonville because he knew the man had recently been held there.
Governor 3 recalled that Governor A refused to accept the man and advised
him of the man’s recent attempt to take his own life in Pentonville.
451. Governor 3 did not recall discussing the man’s recent transfer to Wandsworth.
He remembered Governor A expressing her belief that the man was a
‘Wandsworth prisoner’. Governor 3 persisted but Governor A still refused and
they failed to reach an agreement.
452. After finishing the telephone call with Governor A, Governor 3 remembered
speaking to Governor 1 in a corridor in the administration block. He
remembered telling Governor 1 about his dealings with Governor Z and
Governor A, and saying that he did not want to accept somebody with ‘issues’
who was either a Brixton or Pentonville prisoner.
453. Governor 3 could not recall whether he and Governor 1 discussed the
information Governor A provided (about the man’s recent attempt to take his
own life) or the man’s presence in Wandsworth until that morning. He said
that they did not discuss the forthcoming inspection. Governor 3 told my
investigators that Governor 1 then went away to make a telephone call to
Governor C. Later, he recalled Governor 1 telling him that Pentonville had
agreed to accept the man.
454. With the benefit of hindsight, Governor 3 said that he unequivocally regretted
his decision to refuse to accept the man back into Wandsworth. He
recognised that the man had no particular association with Pentonville, that
efforts had been made to remove him from that prison, and that Brixton acted
legitimately in avoiding the conflict of interest created by the presence of a
family member.
455. I consider that Governor 3 was disinclined to assist Brixton when Governor Z
approached him on the telephone. His unwillingness resulted, to some
extent, from the pressure he felt because of the imminent inspection.
Governor 3 said that the inspection influenced ‘every decision’ he made
during this period, including his refusal to accept the man. He thought that the
man’s transfer was ‘somebody else’s issue’ and their responsibility. Governor
3 told my investigators about the prison’s preparation for the inspection, which
he described as the most important event to take place at Wandsworth that
year:
Final Report: January 2011 91
‘It was a bit like you know the Olympics, you prepare for it, you want to
be as good as you can.’
456. I am satisfied that Governor 3 did not refuse to accept the man in particular
because of his unique background or circumstances. He did not attempt to
familiarise himself with the man’s background or find out whether he was truly
a ‘prisoner with issues’. He did not contact the Onslow Centre. He told my
investigators that his telephone conversations with Governor Z were brief. In
my assessment, Governor 3 refused to accept the man because he was
conscious of the pressure on Wandsworth during a very busy period. He was
reluctant to accept any prisoners above and beyond those who he knew
should automatically return to Wandsworth.
457. Governor Z is certain that he advised Governor 3 during their earliest
telephone calls on 26 May that the man had been held at Wandsworth until
that morning. Yet Governor 3 continued to ask other prisons to accept the
man and did not check with colleagues on the Onslow Centre.
458. Governor A told the investigators that Governor 3 suggested to her that she
accept a prisoner in part because an inspection was taking place at
Wandsworth. Governor 3 also apparently misled Governor A when he
claimed that Governor C and Governor 1 had already agreed to the transfer to
Pentonville. Neither Governor was aware of any such agreement.
Furthermore, Governor 3 ignored Governor A when she expressed her
serious doubts about the suitability of the man’s transfer to Pentonville
because of recent events.
Governor Z
459. My investigators also interviewed Governor Z. His reception staff told him that
Serco were asking Brixton to accept the man from Camberwell Green.
Governor Z was aware that the conflict of interest meant the man should not
be held at Brixton. He telephoned the Serco cell supervisor at Camberwell
Green, who, he recalled, told him that the man had come from Wandsworth
that morning.
460. This information prompted Governor Z to telephone Governor 3. He told Mr
Governor 3 about the conflict of interest. He remembered Governor 3 saying
that Camberwell Green was a court that Brixton served and that therefore
Governor Z should agree to receive the man. He recalled Governor 3 saying,
‘He’s not ours, he’s yours.’ Governor Z was certain that he informed
Governor 3 that the man had been held at Wandsworth until early that
morning. He did not recall Governor 3 making reference to the forthcoming
inspection at Wandsworth.
461. When he spoke to Governor 3, Governor Z thought that the man ‘must have’
still been waiting in the cells at Camberwell Green to be transferred.
Governor Z recalled speaking to Governor 3 once or twice about the man. He
did not recall Governor 3 saying that he would ask Pentonville to accept the
Final Report: January 2011 92
man. After they finished speaking, Governor Z thought that Governor 3 was
going to accept the man at Wandsworth.
462. Governor Z said that, in his experience, it was rare for Serco to place a
prisoner on an escort vehicle without the destination prison first being properly
agreed. During his time working at Brixton, he said that this situation had not
arisen.
Governor A
463. My investigators spoke to Governor A to obtain her account of her
conversation with Governor 3. She said that she recalled the man’s
circumstances as soon as Governor 3 mentioned his name. His attempt to
take his own life had had a significant impact on staff in Pentonville. Although
Governor A had not met the man, he was the only recent example of a
prisoner coming close to taking his own life and consequently she
remembered it well.
464. When she spoke to Governor 3, Governor A told my investigators that she
refused to accept the man and explained her concerns. She told him about
the man’s recent attempt to take his own life. She stressed that a return to
Pentonville would be unwise and inappropriate because it would increase the
risk that the man might harm himself.
465. During interview, Governor A recalled that Governor 3 insisted that the man
transfer to Pentonville because he was not a ‘Wandsworth prisoner’.
Governor A replied that the man was also not a Pentonville prisoner. (She
knew from her dealings in relation to the conflict of interest on 21 April that the
man was originally a Brixton prisoner.) She was also aware of the efforts
made in early May to return the man to Wandsworth. She reiterated recent
events to Governor 3, her unhappiness with his request and her objections to
the proposed transfer.
466. When she spoke to my investigators, Governor A remembered that Governor
3 made an explicit reference to the inspection. She recalled that he referred
to the forthcoming visit to Wandsworth by HMIP, alluded to his belief that the
man was a difficult prisoner to manage and asked for her assistance in
accepting the man.
467. Thinking back, Governor A said that she did not tell her Governor, Governor
C, about Governor 3’s reference to the inspection on 26 May, instead
mentioning it several weeks later when the influence of the inspection on
prisoner movements became an issue. She said that she had apologised to
Governor C for not mentioning it earlier, but told my investigators that her
main concern on 26 May had been the impact that returning to Pentonville
would have on the man.
468. Following her refusal to accept the man, Governor A said that Governor 3 told
her that their respective Governors had already agreed the transfer. She was
confused by this and did not understand why Governor C had not advised her
Final Report: January 2011 93
if this was the case. Governor A ended the telephone call in order to clarify
the position with Governor C. She discovered that Governor C had not
agreed to the transfer.
469. Governor A remembered that Governor C immediately telephoned Governor 1
while she was in the room. During their telephone conversation, Governor A
recalled that Governor C told Governor 1 that the man had tried to take his
own life at Pentonville. She remembered that the conversation ended with
Governor C agreeing to accept the man into Pentonville because he was
‘already en route’, with the proviso that he should return to Wandsworth after
a ‘settling in’ period at Pentonville.
470. Governor A said Governor C firmly believed that staff had a duty of care to
accept a prisoner who was already en route to Pentonville rather than redirect
him once he reached the prison. Governor A confirmed that she had been
told to accept a prisoner in the short term as a general rule and assess the
situation afterwards. In this instance, Governor A told my investigators that
the instruction to accept the man because he was en route took priority over
her original concerns about risk. However, the final decision rested with
Governor C.
471. When she spoke to my investigators, Governor A thought she might have
given Governor C the impression that the man was already being transported
to their prison. She had made an assumption and neither she nor Governor C
confirmed with Serco staff whether the man had actually left the court. She
thought the Serco staff at the court had to obtain permission before placing a
prisoner on a van to Pentonville.
472. A case review was conducted in the healthcare centre at Pentonville on 27
May to assess the man before he was discharged. Governor C had
suggested that the man be located on the VPU. Governor A chaired the
review and told the man that he would return to Wandsworth from 6 June. My
investigators asked Governor A why she chose this specific date and she said
that she could not give an explanation.
473. The internal Prison Service investigation addressing the transfers of prisoners
subsequently provided my investigators with the emails exchanged between
Governor C and Governor 1 which are reproduced in the ‘Key Findings’
section of my report. The emails (in which the Governors agreed that the man
would return to Wandsworth from 6 June after the inspection team had left)
were forwarded to Governor A before she carried out the case review.
Governor C
474. Governor C thought that the man’s transfer to Wandsworth on 13 May would
last for the remainder of his time in custody. He had not foreseen a reason
why the man would transfer to a different London prison after that date. In
interview, Governor C remembered that the man felt that he had moved to an
environment where he felt safer and wanted to be.
Final Report: January 2011 94
475. My investigators spoke to Governor C about the events of 26 May. He
recalled that Governor A entered his office and asked him if he had agreed
with Governor 1 to accept the man. Governor C told Governor A that he had
made no such agreement. He remembered her saying that Governor 3 had
claimed that such an agreement had been reached. Governor C decided to
telephone Governor 1 immediately whilst Governor A remained in the room
because he was upset that he was supposed to have agreed to a transfer
when he had not. He did not like being ‘misquoted’, particularly because he
was familiar with the man’s history.
476. During interview, Governor C said that he did not make a record of his
conversation with Governor 1 because he did not think he would need to. He
remembered telling Governor 1 that he had not agreed to accept the man. He
recalled referring to the man’s attempt to take his own life at Pentonville.
477. Governor C did not think that a return to Pentonville should happen because it
was neither the ‘right move’ nor a ‘very clever move’. He told my investigators
that this remained his opinion at the time of their interview. He pointed out
that both prisons had worked hard to transfer the man to Wandsworth. He
thought that the man should ‘return’ to Wandsworth after his court
appearance. He wondered whether Governor 3 was using Governor 1’s
authorisation without the latter’s knowledge. Governor C thought that
Governor 3 was misquoting both of them and that Governor 1 had not been
fully briefed by Governor 3 before the two Governors spoke.
478. Governor C said that the telephone conversation lasted at most five minutes.
He established with Governor 1 that Wandsworth had accepted the man
earlier that month. He told Governor 1 that the man should not be in
Pentonville and should return to Wandsworth.
479. Governor C recalled that he and Governor 1 discussed the fact that the man
was a person at serious risk of self harm and established that the risk was
exacerbated at Pentonville. Governor C said that there was ‘an awareness in
[his] mind’ of the man’s recent history at Pentonville. He remembered
Governor 1 agreeing that Wandsworth was where the man should be located.
480. During interview, Governor C remembered that he had been under the
impression that the man was already en route to Pentonville. Despite
believing that a transfer to Pentonville was not sensible, he accepted the man
because he thought he was on his way and he did not want him travelling
back and forth across London.
481. Governor C stressed his belief that prisoners should not be turned away from
Pentonville if they are either en route or ‘on the forecourt’. He said that it was
his policy to accept a prisoner in the first instance and then assess their
circumstances. At the time, he thought to refuse the man would have been a
‘silly decision’. He said that he wished that he had ‘done a bit more digging’ to
find out exactly where the man was.
Final Report: January 2011 95
482. Governor C confirmed that Governor 1 was willing to accept the man back
into Wandsworth and did not raise any objections. Governor C thought that it
was he, rather than Governor 1, who set the timescale for return of two
weeks. He agreed to hold the man for a short while, although he did not want
the arrangement to ‘drag on and on’. He could not remember why he thought
the man was already en route, or whether somebody else told him this.
483. After the man arrived at Pentonville, Governor C visited him in his cell in the
healthcare centre. He wanted to satisfy himself that the man felt safe.
Governor C said that it was very rare for a Governor to do this but he was
aware of the man’s vulnerability and the risks surrounding him. He made sure
that the man had been assessed by a nurse. He told the man that he would
only be held at Pentonville on a temporary basis and that Wandsworth had
agreed to his return.
484. Governor C’s acceptance of the man on 26 May might seem to contradict the
concerns he and Governor A shared. Additionally, Nurse D was sufficiently
worried to recommend constant supervision and Governor C sufficiently
concerned to check on the man personally. My investigators asked why, if the
man was accepted because he was en route to Pentonville, he could not have
returned to Wandsworth under escort the next day (a situation mirrored by the
man’s unintended stay for one night at Brixton between 12 and 13 May and
the prompt transfer to Wandsworth on that occasion).
485. Thinking back, Governor C did not consider that the man presented as a
‘prisoner in crisis’ when he saw him in the healthcare centre. Nurse D also
told my investigators that he placed the man under constant supervision not
because of his presentation on 26 May, but because of his history of self
harm. Governor C said that, if he had had acute concerns about the man, he
would have held him overnight and then organised an escort back to
Wandsworth the next morning. However, the man did not give Governor C
any additional cause for anxiety.
486. Governor C said that he knew enough about the risk the man presented to
himself to recognise that he should not remain in Pentonville ‘in the long term’.
He thought he had made a decision which was ‘reasonable and safe’ for the
man. However, he commented that he would not have accepted the man at
Pentonville if he had ‘dug that little bit deeper’ on 26 May.
487. Emails exchanged between Governor C and Governor 1 early on 27 May
show that they agreed the man would return to Wandsworth from 6 June after
the inspection ended. At the time my investigators interviewed Governor C,
the emails had not yet been retrieved. My investigators did not therefore raise
the issue. (Governor C produced a further statement after the email was
located during the course of the Prison Service’s internal investigation.)
488. During interview, Governor C was ‘as certain as he could be’ that neither he
nor Governor 1 discussed the forthcoming inspection at Wandsworth when
they spoke on the telephone. He thought that he would remember if such a
discussion had taken place because it would have been inappropriate. He
Final Report: January 2011 96
said that the timescale he set for the man’s transfer back to Wandsworth of
two weeks was ‘completely arbitrary’ and he could not remember why he
settled on it.
489. When he spoke to my investigators, Governor C maintained that the
forthcoming inspection at Wandsworth did not affect his decision making. He
said that the first time he realised that there might be a link between the
inspection and the man’s transfers was some weeks later, when Governor A
told him that Governor 3 had made reference to it.
490. My investigators asked Governor C why Governor A told the man that he
would return to Wandsworth after 6 June. He could not explain the choice of
date and agreed that it did not look ‘very sensible or clear’. He acknowledged
that the date was ‘random’, particularly since it was a Saturday, which is not a
day on which transfers normally occur. The investigator suggested that, given
the effort both prisons had put into relocating the man to Wandsworth in early
May, the action taken in late May did not appear to be consistent. Governor C
agreed and acknowledged that he and his colleagues might have placed more
emphasis on the man’s history at Pentonville when organising the transfer
back to Wandsworth. He said that he wished that he had considered
returning the man more quickly, perhaps using a specially arranged escort
vehicle.
491. Some weeks after their interview with Governor C, my investigators were
provided with a copy of the emails exchanged between the Governors on 27
May. The content of Governor C’s correspondence seemed to conflict with
what he had said during interview. He told my investigators that Governor A
had come to him some weeks after the man died and explained for the first
time the reference Governor 3 had made to the inspection when he tried to
persuade her to accept the man at Pentonville on 26 May.
492. During interview, Governor C was also unable to satisfactorily account for the
choice of 6 June as a return date for the man. (This date was determined by
the Governors in their emails.)
493. As I have indicated, Governor C provided my investigators with a further
statement when he returned a signed copy of his transcript. He had been
provided with a copy of his own email dated 27 May. He said that he had not
remembered writing the email when my investigators spoke to him. He
acknowledged that his email showed an intention not to return the man to
Wandsworth until the completion of the inspection. He wrote in his statement:
‘I am as confident as I can be this was my view rather than that of
Governor 1 (nor that asked by Governor 1).’
494. Governor C acknowledged that his email demonstrated an awareness of the
dates of the inspection at Wandsworth. He expressed the hope that the
eventual booking of a transfer for 1 June (albeit one not carried out because
the man had attempted to take his own life for a second time) showed that a
quicker return was subsequently planned.
Final Report: January 2011 97
495. The reappearance of the email caused Governor C to consider whether he
and Governor 1 had discussed the inspection during their telephone
conversation on 26 May. He said that he did not think that the inspection was
discussed.
496. In his statement, Governor C maintained that he accepted the man into
Pentonville for the reasons explained in his original interview (namely his
belief that the man was already en route). However, he agreed that the email
demonstrated that he had considered the Inspectorate’s visit to Wandsworth
at some stage between the telephone conversation on 26 May and the
sending of the email on 27 May.
497. Governor C thought that he agreed that the man should stay at Pentonville
until after the end of the Wandsworth inspection because he knew that this
was ‘about two weeks away’. He emphasised that he did not make the
arrangement ‘as a way of deliberately affecting the care plan for [the man]’.
498. With regard to the email, Governor C said that he could not be sure exactly
why he had written it, other than to resolve the issue of the man’s property.
Governor C emphasised that he was not aware in advance that the man might
be transferred from court on 26 May. He reiterated that he checked on the
man’s welfare personally, took up the issue he raised regarding property and
asked for a case review to take place. Governor C did not think that the
decision he made had an impact on the man’s death.
499. The outcome of the telephone conversation between Governor C and
Governor 1 on 26 May would seem to contradict their previous decision
making relating to the man, whom they had previously agreed to transfer to
Wandsworth where he felt safer. Both men acknowledged that this was
supposed to be a permanent transfer. None of the other staff my
investigators interviewed interpreted the move as anything other than a long
term one to help the man. Many were surprised by his sudden return to
Pentonville.
500. Both men also accepted that their involvement in the movements of particular
prisoners was a rare event for them, so it seems reasonable to surmise that
they would remember the man’s situation. Governor C in particular was
aware of the man’s recent attempt to take his own life and knew that he
presented a risk to himself in Pentonville. He chaired the hot debrief on 22
April and personally checked on the man’s welfare when he returned to
Pentonville on 26 May. (Whilst his action in this regard was commendable, it
also highlights how worried his staff were.)
501. Governor C’s agreement to the man’s return is difficult to understand.
Governor A protested when Governor 3 suggested the transfer. A serious
attempt by the man to take his own life was still fresh in the minds of
Pentonville staff. Furthermore, Governor 1 said he was willing to accept the
man back at Wandsworth.
Final Report: January 2011 98
502. Governor C told my investigators that he agreed to accept the man during the
telephone conversation with Governor 1 because he thought that he was
already en route from court. Neither he nor Governor A spoke to Serco staff
to confirm this. During interview, none of the governors my investigators
spoke to were able to recollect with certainty when their discussions about the
man took place on 26 May. (As the duty governor, Governor A pointed out
that she would have dealt with numerous telephone enquiries and worked in
all areas of the prison. As such, she emphasised that she would struggle to
recollect the timing of one particular call.)
503. My investigators have since obtained records confirming that Governor C
made his telephone call to Governor 1 at 1.17pm. The PER shows that the
man actually left Camberwell Green for Pentonville an hour and twenty
minutes later, at 2.37pm. Governor A has agreed that it was she who
probably gave Governor C the impression that the man was en route.
504. If Governor C thought that the man was en route to the prison, and was
sufficiently concerned about him to approve constant supervision after he was
assessed by healthcare staff, then it is surprising that Pentonville did not
endeavour to return the man to Wandsworth at the earliest available
opportunity. Governor C acknowledged that this could have been done. I
note that space was available to accommodate the man at Wandsworth
throughout this period, particularly after the weekend of 30 and 31 May, when
Prisoner 3, Prisoner 2 and the other prisoners were temporarily removed.
Governor 1
505. Having interviewed Governor C, my investigators spoke to Governor 1 to
discuss his recollection of events. Before the interview began, Governor 1
made my investigators aware that the internal Prison Service investigation
had just retrieved the emails exchanged between the two Governors dated 27
May.
506. Governor 1 confirmed that Governor C explained the reasons why the man
needed to leave Pentonville when they spoke in early May. He remembered
authorising the transfer to Wandsworth. He could not remember whether he
was aware of the man then arriving in Wandsworth. He commented that ‘[the
transfer] certainly wasn’t agreed as a temporary move’ but was rather
intended to be permanent.
507. When Governor 1 received the telephone call from Governor C on 26 May, he
did not think that Governor 3 had briefed him about the man beforehand. He
recalled not really knowing what Governor C was ‘exasperated’ about and
having to ask him to explain the man’s circumstances. He therefore thought it
was unlikely that Governor 3 had already spoken to him. With regard to
Governor C’s exasperated tone, Governor 1 presumed that he was annoyed
because he was being asked to involve himself in an individual prisoner’s
move, something that does not normally fall to a governing Governor.
Final Report: January 2011 99
508. Governor 1 said that he only subsequently realised that Governor C was
agitated because he had been told by Governor A that he was already
supposed to have agreed to accept the man, when he had not done so. He
did not recall Governor C mentioning Governor A’s assertion during the
telephone conversation. He said that, if he had been told at the time that
Governor 3 was making claims on his behalf, he would have taken the matter
up with him immediately after the telephone call (and he did not do so).
509. During interview, Governor 1 recalled the gist of their conversation. He
remembered that Governor C asked him why Governor 3 would not accept
the man back into Wandsworth, given that Governor 1 had previously agreed
to accept him. As the conversation progressed, Governor 1 remembered
realising who the man was and what he had been told about his recent
circumstances.
510. Governor 1 told my investigators that Governor C agreed to take the man for
the time being because he did not want him to travel back and forth across
London. Governor 1 explained that he made a commitment to subsequently
accept the man back into Wandsworth and acknowledged the two men’s
original agreement. He did not believe that he discussed a timescale for the
man’s return with Governor C on the telephone. He told my investigators that
he did not discuss the forthcoming inspection at Wandsworth with Governor C
during the telephone call.
511. Governor 1 remembered that Governor C perceived the man to be at risk in
Pentonville and was initially very reluctant to receive him. My investigators
asked Governor 1 why more effort had not been made to move the man back
to Wandsworth immediately once the situation was clarified. Governor 1 said
that responsibility for returning the man lay with Governor C, as the sending
prison has to organise an escort. He acknowledged that Governor C was
very worried about the man in early May, but thought he might have
considered the risk to be reduced when he checked him on 26 May.
512. My investigators spoke to Governor 1 about the emails dated 27 May. He
said that it did not make sense for him to ‘scheme’ for the man to be removed
from Wandsworth during the inspection period. Governor 1 explained that he
had agreed to receive the man after 6 June because he was replying directly
to Governor C’s offer to keep the man until the inspection concluded (on 5
June). My investigators asked him why he had agreed to the suggestion.
Governor 1 explained that he knew from what Governor C had said that the
man was being well cared for. He said that he relied on Governor C’s
judgement and would have been prepared to accept the man back in
Wandsworth immediately if this was what Governor C had suggested.
513. Governor 1 was clear that the man did not transfer to Pentonville because of
who he was or the problems he might represent during the inspection. He
thought that Governor C’s probable intent in writing that he would return the
man to Wandsworth after the inspection was to offer to do another Governor a
favour and relieve pressure at Wandsworth during an especially hectic period.
Final Report: January 2011 100
Governor 1 said that it was what he would have done if a colleague had been
going through a similarly busy time in their prison.
514. During interview, Governor 1 said that he had not directed his staff to refuse
to accept ‘difficult prisoners’. He denied that Governor 3 would have felt it
right to do so because of anything he had said as the Governor. He said that
the man, as a vulnerable individual, was exactly the type of person he wanted
the inspection team to meet, to demonstrate the level of care now being
afforded to prisoners.
515. Contemporaneous evidence is generally to be preferred to any other.
However, emails may be drafted speedily and usually without a great deal of
thought. I have quoted Governor C and Governor 1 at length because, as
senior governors with distinguished records, their accounts of their decision-
making deserve to be heard with respect. The question, therefore, is how
much weight to place on the wording of the emails Governor C and Governor
1 exchanged on the morning of 27 May. The content of Governor C’s
exchange in particular leaves the reader with the impression that the
forthcoming inspection certainly influenced the man’s movements.
Furthermore, Governor 1 accepted Governor C’s suggestion that the man
would not be returned to Wandsworth until after the inspection ended and
replied that the man would return to Wandsworth from 6 June (the day after
the inspection finished). Governor A subsequently provided the man with this
date at the case review.
1 June
516. Although the man was told he would transfer after 6 June, my investigator has
confirmed that a move to Wandsworth was organised by Pentonville staff for 1
June. On 27 May, Governor A asked Officer H in Pentonville’s OCA
department to arrange for the man to move to Wandsworth. Although Officer
H did not remember Governor A providing a timescale for the planned return,
Governor A told my investigator that she had said it was to be 6 June.
Governor A said she asked Officer H to try to organise an automatic transfer
that would not mean paying for additional staff to transport the man.
517. Officer H told my investigator that she emailed a completed booking form to
the PMU before lunchtime on Wednesday 27 May. She requested that the
move should take place in the following week, commencing 1 June. G4S
Care and Justice Services have provided inter-prison transfer documents
which confirm that the requested move was booked for 1 June. Their staff
planned to collect the man in a van that morning and take him to Wandsworth.
Officer H told my investigators that the response to her request was ‘very,
very quick’.
518. However, an apparent breakdown in communication meant that either G4S or
the OCA department in Pentonville did not inform healthcare or discipline staff
working with the man of the scheduled move. Prisoners due to be transferred
have to be assessed as fit to travel by a member of healthcare staff 24 hours
in advance of the move. Because 1 June was a Monday, Officer H said that
Final Report: January 2011 101
the healthcare assessment of fitness for transfer should have taken place on
Friday 29 May. Senior Officer C told my investigators that the healthcare
team would normally be asked to prepare a prisoner’s medical file for transfer
in advance of a nationally organised move. Neither of these things happened.
519. None of the staff my investigators spoke to at Pentonville were given advance
warning of the transfer taking place on Monday 1 June. Senior Officer C was
told on the telephone in the middle of the morning. The planned move had
not been recorded on Pentonville’s prisoner information system. The SO was
certain that the man had not been told about the transfer before he made a
second attempt to take his own life. By the time the news reached staff, the
man was on his way to the healthcare centre under constant supervision.
Senior Officer C and the Head of Healthcare at Pentonville agreed that a
transfer in the circumstances would be inappropriate, so the van left without
the man.
520. Because a prisoner cannot leave the prison without being assessed as fit for
transfer, it is unlikely that the move could have taken place on the morning of
1 June even if the man had not tried to harm himself. With no advance
warning, staff would have struggled to assess the man for transfer, print off
his medical records and collect his core prison record before the van left.
8 June
521. On 8 June, Officer J emailed Pentonville healthcare staff identifying six
prisoners who needed to be assessed for transfer to Wandsworth the next
day. Amongst them was the man. Officer J commented that the prisoners
were returning to Wandsworth after Pentonville had “done them a favour by
holding them” for a week.
522. Officer J agreed that, in retrospect, the email he sent might be misleading. He
said he had been referring to the other five prisoners when he mentioned
‘doing Wandsworth a favour’. He had not meant to refer to the man. He
explained that, to the best of his recollection, there had been a space left on
the escort vehicle after transport was organised for the other prisoners. He
said that the man had been added to the group when the OCA department
were told that he was ready to return to Wandsworth.
523. From the evidence of the governors and staff, I am satisfied that, on both 26
and 27 May, anticipation of the forthcoming inspection at Wandsworth
influenced the thinking of those responsible for the man’s movement around
the London prison system. The failure to return the man to Wandsworth as
quickly as Brixton managed on 13 May is marked.
524. I have borne in mind throughout my consideration of the man’s transfers
between prisons that he was a vulnerable prisoner with mental health
difficulties. I consider that the transfer on 26 May was not in his best
interests. It was an avoidable disruption to his continuity of care triggered
initially by the failure to mark his PER for return to Wandsworth. The man
was removed from a prison where he said he felt safe and was returned to a
Final Report: January 2011 102
prison that had caused him considerable anxiety. Officer 3 remembered the
man saying on 10 June that he had recognised prisoners he was afraid of
when he returned to Pentonville, reawakening old anxieties.
525. After the man arrived on 26 May, a great deal of concern was shown for him
during the first 24 hours. However, as I detail elsewhere, this degree of
concern fell away. Between 27 May and 1 June the man was not assessed
by any healthcare staff. He had been discharged from the healthcare centre
onto the VPU without authorisation from a staff member with mental health
training. He was told he would not return to Wandsworth until after 6 June.
(Although a move was organised by the PMU for 1 June, neither the man nor
the staff working with him were told about it.)
526. The man was under the impression that he would have to remain in
Pentonville for at least another ten days. He had previously lived in the
healthcare centre for his own safety. This time, he was placed on the VPU
and was not assessed by healthcare staff in the days that followed.
527. I consider that the man’s return to Pentonville did not assist any recovery he
might have been making in the Onslow Centre at Wandsworth. His mood
deteriorated and he made a second attempt to take his own life early on 1
June before the requested national move could occur. He was deprived of a
planned visit from his CMHT at Wandsworth, also scheduled for 1 June.
528. Following the second attempt by the man to take his own life, Doctor D told
my investigators that he would not have wanted to keep the man in
Pentonville for any longer than at all necessary, as the environment had such
a negative effect on him. He thought a transfer to Wandsworth as soon as
practicable was the right way forward.
529. Although some transfers took place to improve the man’s welfare or occurred
accidentally, I consider that the number of times he moved around the London
prison system was undesirable. His continuity of care was disrupted. I
believe that the man’s second period of detention in Pentonville had further
negative repercussions for him which did not serve to make him feel safer.
Contact with other transferred prisoners
530. I am also concerned that the movement of prisoners to, in the words of the
Chief Inspector of Prisons, ‘subvert the inspection process’, may have had an
additional, unanticipated consequence. Regardless of the degree of influence
the inspection had on the man’s own movements, he seems to have been
exposed to the suspicions which other prisoners had over their own sudden
transfers when he shared a cell with one of them and later travelled on the
van back to Wandsworth. The other prisoners were upset about their own
treatment. The internal Prison Service investigation established that Prisoner
3 and Prisoner 2 were so affected by the unexpected move on the weekend of
30 and 31 May that they tried to harm themselves.
Final Report: January 2011 103
531. As I have said, on 30 May the man was joined in his cell on the VPU at
Pentonville by Prisoner B. Prisoner B was subsequently identified by the
internal Prison Service investigation as one of the prisoners who was moved
deliberately and temporarily. We do not know what the two men talked about.
Within 24 hours of Prisoner B’s arrival, the man became upset and was
moved to a cell on his own. It was noted in the CSRA that the man was
threatening to harm his cellmate. The next day he tried to take his own life for
the second time.
532. The man travelled back to Wandsworth on 9 June with prisoners who were
temporarily transferred during the inspection period. Prisoner 2 told my
investigator that the prisoners had a conversation on the van back to
Wandsworth during which they shared their suspicions about what had
happened to them. Prisoner 2 said that he was determined not to let the
temporary transfers go unchallenged. He told my investigator that the man
was aware of the other prisoners’ anger and their belief that he had been
moved for the same reasons as them.
533. During interview, Prisoner 2 remembered talking to the man on the journey
back to Wandsworth. The prisoners were sitting in separate cells on the van
but could hear each other’s voices. Prisoner 2 said that he was in the cell
next to the man. He described the man’s mood as ‘subdued’. He told my
investigator that the man was ‘quite adamant’ that he had also been moved to
Pentonville because of the forthcoming inspection at Wandsworth.
534. Prisoner 2 thought the man had held this conviction before they boarded the
van and he had not had the idea after listening to the suspicions of the others.
During interview, he said that the man could not find another explanation to
account for his transfer to Pentonville. Regardless of the ambiguous
reasoning that lay behind the man’s own move, his own perception of why he
was moved (at least according to his fellow prisoner) may carry some
significance. I acknowledge that Prisoner 2’s evidence has proved both
reliable (he correctly alerted the Inspectorate to the deliberate transferring of
prisoners) and less reliable (his criticisms of Nurse 4, as I go on to discuss,
were contradicted by the testimony of other nurses).
535. As I already indicated, the broader actions taken by managers at Wandsworth
and Pentonville to remove prisoners prior to their announced inspections have
been considered by an internal Prison Service investigation. The
investigation resulted in disciplinary hearings against five managers and
charges being proved against three. There are strong arguments of fairness
against re-opening a disciplinary investigation – especially one conducted at
the most senior level. However, I should say for the record that, in other
circumstances, the evidence I have discussed in relation to the man’s transfer
on 26 May would certainly have prompted me to recommend that the Prison
Service should investigate the conduct of the managers involved. More to the
point, my investigation has revealed some new facts not known at the time of
the internal investigation – and it also draws attention to the indirect
consequences for the man of the series of transfers as a whole. I have
chosen, therefore, to make the following recommendation:
Final Report: January 2011 104
The Director General of NOMS should review the new evidence in this
report to determine whether a renewed disciplinary investigation is
warranted.
Transfer register
536. My investigators have evaluated Wandsworth’s action plan in response to my
investigation of the death of another prisoner on the Onslow Centre in August
2007. I recommended that the Governor should remind staff of the
importance of keeping a transfer register. In the action plan Wandsworth
confirmed that a transfer register was in place and that a Governor’s Order
had been issued to staff. However, although my investigator asked to see a
copy of the Order, staff were unable to provide one. Several staff interviewed
by my investigator were unaware of the existence of a register.
537. The Governor, Governor 1, told my investigators that he remembered
accepting the original recommendation. He thought that he had actioned it,
but was unsure how he had intended the register to work. My investigators
found no evidence of a single, comprehensive transfer register which detailed
prisoners’ movements and the reasons for them. Instead, they were shown a
number of ring binders and diaries which, whilst they detailed some names
and dates of movements, did not explain why the person was transferring.
There was no mention of the man in any of the documentation.
538. Governor 3 made a note of his involvement in the man’s case on 26 May in
Wandsworth’s duty governor’s log. Neither Governor C nor Governor 1
recorded their decision making on the same day (nor were they obliged to).
My investigators subsequently had difficulty establishing the reasoning behind
the decision to transfer the man. Had the Governors’ thinking been clearly
recorded at the time in a transfer register, this would have been of assistance
to both them and the subsequent investigation.
The Governors of Wandsworth and Pentonville should each introduce a
central transfer register. The register should be used by all
departments. Staff should record their decision making in relation to all
ad hoc transfers which are not organised at a national level.
539. Following the confusion about the man’s intended destination on 12 May,
Governor Y rang the duty governor at Wandsworth. Despite plans having
been put in place over a period of more than a week by healthcare staff,
Governor 2 was unaware of the planned transfer from Pentonville and refused
to accept the man. Neither the Head of In-Reach nor the Head of Healthcare
seem to have notified the duty governor. This incident supports the need for a
proper transfer log in which healthcare staff could have made an entry and to
which Governor 2 could have referred.
The Head of Healthcare at Wandsworth should ensure that the relevant
duty governor is always informed on the day if a healthcare to
healthcare transfer is anticipated.
Final Report: January 2011 105
Care of the man’s property and canteen
540. It would seem that the man’s movements back and forth between
Wandsworth and Pentonville disrupted his access to his belongings and a
regular supply of tobacco.
541. Governor C wrote in his email dated 27 May that the man had arrived at
Pentonville from court without his belongings. He asked Governor 1 to
arrange for the man’s property to be sent on from Wandsworth. Governor 4
(a Wandsworth governor) checked and initially understood that the man had
no stored property (which is returned to a prisoner upon release) other than a
mobile telephone.
542. Replying, Governor C wrote that the man was missing items he had kept in
his cell such as his prayer mat, Qur’an and canteen. He indicated that the
man had been provided with new canteen in the interim. Governor 4 asked
Senior Officer 5 to check the man’s former cell on the Onslow Centre. By the
end of the day Senior Officer 5 had confirmed with Prisoner 1 that the man
had taken the majority of his belongings and his canteen with him. However,
he had left behind his Qur’an, prayer mat and trainers. On 29 May, Governor
4 arranged for these items to follow the man to Pentonville.
543. It does not appear that the man was able to work in prison because of a long
standing injury to his leg and therefore he had little money. He became
stressed without tobacco. Staff told my investigators that they would issue
emergency smokers’ packs to the man so that his mood did not deteriorate.
544. Officer Taylor sat with the man in the hospital in April and interviewed him on
31 May. He recalled that the man was a ‘medium to heavy smoker’ for whom
£2.50 per week income was insufficient to purchase the amount of tobacco he
needed. He thought that, when the man said that he did not have his
canteen, what he meant was that he did not have funds to buy what he
wanted.
545. Prisoner 8 remembered that the man complained when he returned to
Wandsworth on 9 June that he had not had any canteen at Pentonville. The
same day staff at Wandsworth issued the man with an emergency smokers’
pack. It is conceivable that it had been a little while since the man had last
been issued with tobacco at Pentonville. Senior Officer 4 issued another
emergency smokers’ pack on 11 June because the man’s canteen had not
followed him from Pentonville. It is disappointing that the man’s belongings
did not accompany him on his moves between prisons. Their loss may well
have added to his distress. However, I am satisfied that staff at both prisons
tried as best they could to provide the man with tobacco because they
understood how agitated he became without it.
Final Report: January 2011 106
Mental health treatment and hospitalisation
546. The man had a history of psychiatric treatment and was diagnosed with
paranoid schizophrenia. In 2005, he was detained in hospital under the
Mental Health Act. Although he complied with his licence conditions between
20 March and 21 April, it had been noticed by both the offender manager and
the CMHT that his mental health problems seemed to be worsening again.
The deterioration in his condition caused the man’s offender manager to ask
the CMHT to reassess the man.
547. Once he returned to custody, the man immediately became distressed and
made a serious attempt to take his own life. Returning from the Royal London
Hospital, he gradually seemed to stabilise. On 5 May, Doctor D, a psychiatrist
working at Pentonville, wrote to Streatham CMHT seeking their help. The
clinical reviewer describes this referral as ‘timely’. Doctor D was sufficiently
concerned about the man’s mental health to write the following:
‘In view of the serious nature of the suicide attempt, I am of the opinion
that [the man] might benefit from further assessment in hospital …’
548. Having received Doctor D’s letter, the man’s CPN spoke with he manager of
the mental health in-reach team at Wandsworth on 14 May. The man had just
returned to Wandsworth. The man’s CPN and a specialist registrar at the
CMHT arranged to visit him on 1 June. The man’s CPN said that this was the
earliest date both he and the specialist registrar at the CMHT could attend
together to complete an assessment.
549. Doctor D judged that the man was no longer suicidal. The man’s CPN did not
recall thinking that the assessment needed to be completed urgently. He told
my investigator that he and the specialist registrar at the CMHT planned to
visit the man ‘with an open mind’ as far as treatment options were concerned.
He planned to check if the man’s presentation had changed and whether he
might benefit from hospital admission.
550. In other words, although Doctor D had suggested the possibility of
hospitalisation, neither the man’s CPN nor his colleague definitely thought that
this would be necessary. The removal of a prisoner to hospital under section
is not undertaken lightly, and the man’s mental health problems had not been
sufficiently severe as to warrant sectioning whilst he was being treated by the
CMHT in March and April. The man’s CPN told my investigator that, following
the proposed assessment on 1 June, he might equally have been making
plans for the man’s treatment in the community after his release from prison.
551. Nonetheless, since the man’s CPN had last assessed him, the man’s mental
health had worsened and he had attempted to take his own life. Doctor D had
more recent experience of the man’s mental health needs and thought that
transfer to hospital under section 47 of the Mental Health Act was one avenue
worth exploring. The doctor thought it important that mental health workers
with experience of the man’s presentation in the community should assess
whether his condition in prison was markedly different.
Final Report: January 2011 107
552. Unfortunately, because the man transferred to Pentonville on 26 May and did
not return to Wandsworth until 9 June, the man’s CPN had to cancel his visit.
He planned to assess the man once he returned to Wandsworth. The
manager of the mental health in-reach team at Wandsworth advised the
man’s CPN that the man was supposed to be returning in the very near future
when she would arrange a new appointment. The man’s CPN thought that
this made sense because the In-Reach team at Wandsworth knew the man
well. The lack of urgency in rearranging the appointment suggests that the
man’s CPN and his colleagues did not see immediate hospitalisation as a
likely possibility.
553. Additionally, staff at Pentonville who treated the man in the healthcare centre
after his first and second attempts to take his own life (in early May and early
June) observed that his mood soon stabilised. Nurse D told my investigator
that the man did not present as having a ‘severe and enduring’ mental
disorder (although I note that Nurse D has no formal mental health training).
He considered that the man was somebody whose paranoid schizophrenia
was ‘well controlled’ by medication.
554. Prisoner 2, who travelled back to Wandsworth with the man on 9 June, said
that there were ‘any number of inmates with far more serious psychological[ly]
disruptive issues than [the man]’ on the Onslow Centre. Doctor D and Doctor
E both noted on 2 June that the man showed no signs of psychotic symptoms.
555. Doctor D himself indicated that he was not surprised that the man returned to
the VPU at Wandsworth rather than the healthcare centre. He said that the
man was only held in the healthcare centre at Pentonville because he felt so
unsafe in any other location in the prison. In other words, he did not feel that
the man was experiencing mental health problems that required treatment in
a healthcare setting.
556. The manager of the mental health in-reach team at Wandsworth did not think
that the man’s CPN and his colleague were likely to transfer the man to
hospital because he was glad to be back on the Onslow Centre. She told my
investigators that there had been some discussion of the man’s diagnosis
when he was held at Wandsworth prior to release in March 2009. There was
some debate over whether he had a mental illness or a personality disorder.
The In-Reach team at Wandsworth referred the man to a personality disorder
specialist in 2008, who referred the man back to the CMHT. The specialist
considered that the original diagnosis of a mental illness was correct and the
problem was not a personality disorder.
557. I cannot entirely discount the possibility that the man could have been
removed to hospital under the Mental Health Act. Because of the transfer to
Pentonville, the mental health assessment did not take place. On the day the
man’s CPN’s visit was supposed to have seen him at Wandsworth (1 June),
the man made a second attempt to take his own life at Pentonville.
Final Report: January 2011 108
The man’s location in each prison
558. Between April and June, the man was variously located amongst the general
prison population, on VPUs and in healthcare centres, seemingly without any
consistency. My investigators explored the thinking that lay behind these
choices.
21 April – 13 May
559. On 21 April, the man arrived at Pentonville and was placed in a shared cell
amongst the general prison population. The next day he asked for vulnerable
prisoner status and was moved to a cell on his own pending transfer to the
VPU. He made an attempt to take his own life before he could be moved and
was taken to hospital. He returned to the healthcare centre, where he
remained in a single cell for approximately two weeks. Doctor D kept the man
in the healthcare centre because he felt unsafe in any other location in
Pentonville.
560. The man transferred to Brixton for one night and was placed in a cell on the
healthcare wing as a precaution with another prisoner who was not the
subject of an ACCT document.
13 May – 26 May
561. On 13 May, the man transferred to Wandsworth. Although the move was
organised by the healthcare teams at Pentonville and Wandsworth, the man
was not initially admitted to a healthcare setting as one might have expected.
Instead, he spent two nights in the first night centre before moving to the
Onslow Centre. This seems confusing, as the intention was a ‘healthcare to
healthcare’ move. Nurse D liaised with the manager of the mental health in-
reach team at Wandsworth and the Head of Healthcare at Pentonville with
the Head of Healthcare at Wandsworth. When the man inadvertently arrived
at Brixton, the main reason Governor Y was reluctant to accept him was
because he had come from Pentonville’s healthcare centre, and nothing had
been agreed with the healthcare centre at Brixton.
562. The decision to place the man on the VPU at Wandsworth was based partly
on his familiarity with the unit, which offered stability and continuity. Staff
were keen to locate the man on the Onslow Centre because he said he felt
safe there. However, the move took place in the context of a lack of available
healthcare facilities in Wandsworth.
563. In comparison, Pentonville is a smaller prison but with ten more inpatient beds
than Wandsworth and a better staffed psychiatric team. Wandsworth holds
more than 1,600 men but only has 12 inpatient beds, all located in the
Addison Unit. This facility is occupied by prisoners with severe and enduring
mental health difficulties awaiting relocation to a secure unit in the community.
The manager of the mental health in-reach team at Wandsworth said that the
Final Report: January 2011 109
Onslow Centre was a more appropriate location for the man than the Addison
Unit.
564. An example of the limited provision of inpatient facilities at Wandsworth is the
way in which constant supervision is carried out. Prisoners are normally
moved to a suitable cell in a prison’s healthcare centre. And each time the
man was placed under constant supervision at Pentonville, he was
immediately located in the healthcare centre. However, constant supervision
of Wandsworth prisoners usually has to be carried out in the prisoner’s
original location.
565. Wandsworth responded to the draft version of this report. They stressed that
it can be beneficial for a prisoner to remain amongst friendly prisoners and
familiar staff on their own wing. They also said that, if the psychiatric team
identified that a prisoner was feeling actively suicidal due to severe and
enduring mental health issues, he ‘would likely’ be moved to the Addison Unit
under constant supervision.
566. The London Area Male Locals Transfer Protocol states that a prisoner leaving
a prison’s healthcare centre should initially be located in a similar healthcare
setting when they transfer to a new prison. This is not what happened to the
man. In theory, either the man should have been discharged onto the VPU at
Pentonville a few days before the transfer to acclimatise him to a non-
healthcare setting. Or the man should (again in theory) have been located in
the healthcare centre at Wandsworth for a few days to monitor him before
discharging him to the VPU.
567. However, neither of these courses of action was open to staff. The man did
not feel safe outside the healthcare centre at Pentonville and so a discharge
to the VPU could not be trialled there. Wandsworth only has healthcare beds
available to prisoners with the most severe mental health problems (which the
man was not considered to be). The move from Pentonville’s healthcare
centre to the Wandsworth VPU is therefore understandable, if not ideal. The
logic of the move might have been better documented in the man’s medical
record.
568. The inpatient healthcare facilities at Wandsworth seem inadequate in
comparison with Pentonville. Pentonville is smaller but has more inpatient
beds. There were few available options for healthcare staff to consider when
the man transferred to Wandsworth. The clinical reviewer highlights his
experience of a smaller prison that has twice as many inpatient beds.
Wandsworth Primary Care Trust should review the inpatient healthcare
facilities at Wandsworth. Consideration should be given to increasing
the capacity for prisoners with mental health problems and suicidal
thoughts who do not fit the criteria of the Addison Unit.
Final Report: January 2011 110
26 May – 1 June
569. Returning to Pentonville on 26 May, the man was kept in a single cell in the
healthcare centre overnight as a precaution after his previous attempt to take
his own life. The next day the man was discharged to a shared cell in the
VPU following a case review, even though the CSRA completed the day
before indicated the need for a single cell.
570. Paragraph 18 of annex 8G of PSO 2700 states:
‘Where referrals have been made to specialist staff or those staff are
already involved in the care of the prisoner, they must be invited to
attend the next case review. Where attendance is not possible, they
must provide input in writing or by telephone to that case review (and
subsequent reviews if requested).’
571. Neither a psychiatrist nor another member of healthcare staff with mental
health training was present during the case review. The only nurse present,
Nurse D, had no mental health training. Mental Health Nurse B spoke to the
man the night before but did not attend the review.
572. Nurse D thought that a psychiatrist did not attend the case review because
there was not a ‘medical reason’ for the man to be in the healthcare centre.
Rather, staff used it as a ‘place of safety’. Nurse D thought that the man’s
presentation seemed the same as when he was last at Pentonville. He had
no additional concerns about the man’s mental health.
573. The logic dictating the man’s location during this period is somewhat
confused. Nurse D said that the man was initially admitted to the healthcare
centre under constant supervision because staff were concerned about the
risk he might present to himself after returning to Pentonville, rather than as a
result of his mental health problems. However, the two issues seem
indivisible. The man’s state of mind was deemed sufficiently fragile to warrant
continual observation at first, but his discharge the next day was achieved
without advice from a mental health specialist.
574. Governor A led the case review, which lasted about an hour, although it was
not part of her regular duties. (She was asked by Governor C to carry out the
review because she had been the duty governor when the man arrived. This
decision made sense in the circumstances and demonstrated good practice.)
She thought that Nurse D was able to offer sufficient advice about the man’s
ongoing care. In interview, she remembered that the man wanted to return to
Wandsworth and was in a ’relaxed’ and ‘upbeat’ mood. Senior Officer A, who
also attended, agreed that the man seemed ‘cheery’.
575. During interview, Governor A recalled that the man did not want to stay in the
healthcare centre and asked to move to the VPU to find employment. Nurse
D recalled that the man was happy to move as long as he was given tobacco.
Governor A was keen to replicate the recent ‘period of stability’ the man
experienced on the VPU at Wandsworth. She did not realise that the man
Final Report: January 2011 111
had been kept on the healthcare centre at Pentonville in late April and early
May for his own safety. Governor A considered discharge to the VPU
appropriate and said that the decision was arrived at with the man’s consent.
She told the man to approach staff on the VPU if he became anxious.
576. Senior Officer A remembered that the decision to discharge the man to the
VPU was effectively taken before the review began. The SO was asked to
attend because she was a manager on the unit. Governor C suggested
discharging the man to the VPU in the email he forwarded to Governor A
before the case review. Nurse D remembered that the case review was
intended to resolve how the man was to be discharged, not whether.
577. I am satisfied that Governor A thought she was acting in the man’s best
interests. However, whilst the man consented to move to the VPU, he had
not previously spent any length of time outside the healthcare centre at
Pentonville. Senior Officer D, the clinical reviewer, thinks it possible that a
psychiatrist might have decided not to discharge the man at the case review.
They might have balanced the man’s stable presentation on 27 May against
his history of paranoid schizophrenia and his recent attempt to take his own
life.
578. Doctor D oversaw the man’s psychiatric treatment in early May. He only
became aware of the man’s return to Pentonville after the second attempt to
take his life on 1 June. Nobody who dealt with the man on 26 and 27 May in
the healthcare centre appears to have asked a psychiatrist to assess him or
referred him to the In-Reach team. Doctor D told my investigators that he
might have been inclined to keep the man in the healthcare centre until he
returned to Wandsworth as a precaution. Doctor D commented that the
centre is physically separate from the main prison buildings, which allowed
the man to feel removed from the danger he perceived himself to be in.
579. During interview, Doctor D told my investigators that a review of forensic
psychiatric services at Pentonville was conducted in spring 2009. As a result,
it is now expected that a doctor should attend a case review when there is a
possibility of a patient with mental health problems being discharged from the
healthcare centre. There will also be a follow-up assessment of the prisoner
by a psychiatrist within seven days of discharge.
580. Paragraph 27 of annex 8G of PSO 2700 states:
‘A pre-discharge Case Review must take place before a prisoner is
returned to ordinary location from being resident in the Healthcare
Centre… What healthcare will be doing to continue support of the
prisoner must be clearly documented in the ACCT Plan.’
581. A commendable amount of attention was paid to the man’s care during his
first 24 hours back in Pentonville. Senior Officer A remembered that the man
initially seemed content on the VPU. However, he repeatedly asked when he
would be returning to Wandsworth. The man was not assessed by any
healthcare staff between the case review on 27 May and 1 June when he
Final Report: January 2011 112
again tried to take his life. He had not been examined by a psychiatrist since
coming back to Pentonville and does not seem to have been allocated an In-
Reach worker. An ACCT document was opened on 31 May. The man had
only previously spent one night in Pentonville outside the healthcare centre,
on 21 April.
582. When my investigators spoke to Governor C, the email he sent on 27 May in
which he suggested moving the man to the VPU had not been retrieved.
Governor C told my investigators in interview that he would have preferred the
man to have remained in the healthcare centre and did not expect him to be
discharged to the VPU.
583. The man had significant mental health problems and was prone to feelings of
paranoia. Doctor D thought that any location outside the healthcare centre at
Pentonville caused the man anxiety. On both 22 April and 1 June he
attempted to take his own life in non-healthcare settings. Had his discharge
to the VPU been combined with regular monitoring by the In-Reach team, it
would have been more understandable.
The Head of Healthcare at Pentonville should ensure that the primary
healthcare team makes an immediate referral to the In-Reach team when
a prisoner is placed under constant supervision.
1 June – 12 June
584. Having attempted to take his own life, the man returned to the healthcare
centre at Pentonville and stayed there until he went to Wandsworth. Once
again, and for the same reasons as before, on 9 June the man moved from
the healthcare centre at Pentonville to the VPU at Wandsworth. The In-
Reach team did not learn that he had come back until three days later when
Officer 9 telephoned the manager of the mental health in-reach team at
Wandsworth. She intended to assess the man that afternoon but he took his
own life shortly before she planned to visit.
585. The decision not to locate the man in the Wandsworth healthcare centre was
supported in retrospect by the Pentonville doctor, who did not necessarily
expect him to transfer to another healthcare centre. Doctor D said that he
kept the man in healthcare because of the particular anxiety being at
Pentonville provoked. He said that there was no other reason to keep the
man there once he stabilised and made steady progress after the attempts on
his life in April and early June. Doctor D and the Head of Healthcare at
Pentonville both confirmed that improved presentation could be expected to
lead to discharge to the VPU.
Preparing for the man’s return to Wandsworth on 9 June
586. Although the man transferred from the Pentonville healthcare centre on 9
June, the Wandsworth In-Reach team did not know about his return until the
morning of 12 June. Officer 9’s telephone call to the manager of the mental
Final Report: January 2011 113
health in-reach team was when she realised that he was back in Wandsworth.
The clinical reviewer comments:
‘It was particularly unfortunate that the In-Reach team in HMP
Wandsworth was not aware of [the man’s] final move until the last
moment, and he was therefore not assessed by a mental health
professional, despite an obvious deterioration in his mental state.
‘The significant deterioration in the man’s mental state from 9 to 12
June was not fully recognised and appropriate intervention was not
requested until the morning he died. Had the mental health team
known of his return and assessed him, they could have considered
further treatment.’
587. Staff at both prisons successfully organised a healthcare-to-healthcare
transfer in early May when the man moved to Wandsworth for the first time.
However, it appears that their effective planning was not repeated when he
moved in June. Pentonville’s In-Reach team do not appear to have informed
their counterparts at Wandsworth. The Head of Healthcare at Pentonville
telephoned the Head of Healthcare at Wandsworth’s office on 8 June to
advise the primary healthcare department at Wandsworth of the man’s
imminent return, but this message does not seem to have been conveyed to
the In-Reach team.
588. Doctor 1 and Nurse 3 did not refer the man to the In-Reach team when he
arrived on 9 June. I understand from the Head of Healthcare at Wandsworth
that referrals are not made automatically and reception healthcare staff may
have been at a disadvantage because, as I will go on to outline, the man’s up-
to-date medical records do not seem to have accompanied him. Although the
manager of the mental health in-reach team prepared for the man’s return to
Wandsworth, she did not have a specific return date. She thought that either
Wandsworth reception staff or Pentonville healthcare staff would tell her when
he was due to return.
589. Prisoner 1 said that he saw the man speaking to healthcare staff on the
Onslow Centre ‘on a number of occasions’ between 9 and 12 June, ‘pleading
to see a psychiatrist’. Prisoner 8 told my investigators that the man was ‘very
distressed’ in the days before he died. Prisoner 6 remembered that the man
was a ‘completely different person’ when he returned from Pentonville. He
recalled the man getting worse over those three or four days.
590. Prisoner 6 said that staff ignored the man’s repeated requests for help. He
remembered that he had ‘dragged’ the man to the medical hatch to ask
healthcare staff to assess him, but was told that the man was receiving his
medication. Given that the manager of the mental health in-reach team at
Wandsworth was surprised to learn of the man’s return from Officer 9 on 12
June, it would appear that the In-Reach team were not told about the requests
the other prisoners said the man made.
Final Report: January 2011 114
591. As well as the In-Reach team, the Safer Prisons team responsible for
monitoring self harm were not given advance warning of the man’s return
either. Officer 3 did not recall any communication with staff at Pentonville
before the man arrived. The ACCT document that travels with the prisoner is
the main source of information about the risk of self harm. However, Officer 3
thought that some communication between Safer Custody Managers at the
two prisons regarding the transfer of particularly vulnerable prisoners would
be advisable.
The Heads of Healthcare and In-Reach at Wandsworth should review the
way in which information is communicated between them. The Head of
Healthcare should ensure that prisoners with a history of mental health
problems are referred to the In-Reach team for an assessment during
the reception process.
Assessment, Care in Custody and Teamwork (ACCT) monitoring
Pentonville - 22 April
592. Staff at Pentonville opened ACCT documents on 21 April and 31 May, in both
instances followed by an attempt by the man to take his life a day later. On
both occasions, staff recognised the risks and their monitoring meant that the
man was found and kept alive. However, there were gaps in the procedures.
593. On the morning of 22 April, although observations were supposed to be
recorded every hour, the entries were made less frequently. However, during
the course of the morning the man had several contacts with staff. He
attended an assessment interview with Officer B, an induction appointment
with Officer C, and then spent over an hour with the duty governor and Officer
C dealing with his request for vulnerable prisoner status. Therefore, although
the entries made do not indicate regular checks, the man did spend most of
the morning with staff. The exception was between 1.10pm, when a CARATS
worker made an entry in the ACCT document, and 2.20pm, when the man
was found hanging.
594. The ACCT document for 21 and 22 April does not make the intended level of
observations clear. Although Senior Officer A indicated the need for hourly
observations in the ‘immediate action plan’ on 21 April, neither Officer B nor
Senior Officer B referred to the frequency of checks in the assessment
interview notes, ‘Action following assessment’ section or ‘Care map’. A
review of the ACCT document did not take place until after the man returned
from hospital.
595. The front cover of the ACCT document, where the frequency of observations
is supposed to be recorded, is unclear. It contains three entries stating ‘1 x
hourly’, ‘2 x hourly’ and ‘30 minutes’, before a further entry which is dated 23
April. The first entry was presumably made by Senior Officer A. It is not clear
whether the next two entries were made before the man attempted to take his
life. The ongoing record in the ACCT document shows initial hourly entries
Final Report: January 2011 115
throughout the night of 21 April before, as already detailed, entries become
intermittent the next morning. Paragraph 45 of annex 8G of PSO 2700 states:
‘Whenever changes are made to the frequency of conversations and
observations, the member of staff noting that change on the front of the
ACCT Plan must write their initials and the time and date by that note.’
596. I therefore make the following recommendation:
The Governor of Pentonville should ensure that, when staff write the
intended frequency of observations on the front cover of an ACCT
document, they note their initials, the date and time next to their entry.
597. Officer B told my investigator that she felt unable to increase the frequency of
observations on the morning of 22 April above an hourly check whilst the man
remained in the first night centre. She thought that increased monitoring
required a move to a healthcare setting where nursing staff were equipped to
make more frequent checks. Officer Taylor expressed a similar view
regarding the possibility of going beyond half-hourly observations on the VPU
on 31 May. He thought an increase would amount to constant supervision
and necessitate a move to the healthcare centre. It would appear that staff
require clarification on this point.
The Governor of Pentonville should ensure that staff understand the
maximum frequency of ACCT checks possible on normal location before
a prisoner has to be moved to a healthcare setting for observation.
598. Having carried out her assessment interview with the man, Officer B
completed the ‘Action following assessment’ section of the document with
Senior Officer B. They decided that the risk the man presented to himself was
‘low’. This seems to contradict Officer B’s recollection when she spoke to my
investigator. She thought that the man was depressed and that there was an
imminent risk of possible self harm. However, the entry in the ACCT
document signed by Senior Officer B and Officer B indicates that they thought
a referral to the detoxification unit would improve the man’s mood. The risk
assessment seems to contradict the man’s comments in the assessment
interview that he would be ‘better off dead than alive’, not to mention Officer
B’s observation that his mood was ‘very low’.
Pentonville - 29 April
599. The man returned from hospital on 28 April. At the first ACCT review held the
following day, the risk that he would harm himself was assessed as low. Yet
he was placed under constant supervision. These decisions seem
contradictory. Paragraph 3 of annex 8Y of PSO 2700 states:
‘[Constant supervision] is required when it is believed that the prisoner
could, at any time, make an attempt to kill themselves.’
Final Report: January 2011 116
600. Given that the man was recovering from a serious attempt to take his own life
and had only just returned to a custodial environment the previous day, I am
surprised by the decision to assess the risk as low. The use of constant
supervision implies that the risk assessment should have been
commensurately higher.
Wandsworth - 13 - 19 May
601. Staff at Brixton were sufficiently concerned on 12 May to increase the man’s
observations to three times an hour and locate him in their healthcare centre.
In the event, a written entry was actually made every 15 minutes. After the
man moved to Wandsworth on 13 May, staff made entries in the ACCT every
20 minutes until the following morning. Wandsworth staff seem to have
followed the original, intended supervision level.
602. On the morning of 14 May, the man’s ACCT document was reviewed and the
frequency of observations was altered to hourly during the night and day. The
frequency was clearly marked on the front of the document, in the ongoing
record and on the review itself. However, the number of recorded
observations did not match the intended level. Staff initially recorded entries
on an hourly basis. However, after 10.15am on 15 May, staff wrote in the
document at 2.00pm, 5.30pm, and 7.40pm before recommencing hourly
observations at 9.00pm.
603. Similarly, on 16 May, after 7.15am staff made entries at 8.30am, 11.45am,
12.15pm, 2.30pm, 4.30pm, 5.50pm, 6.55pm and 7.25pm before
recommencing hourly recording at 9.00pm. On 17 May, after 7.30am officers
wrote in the document at 8.45am, 12.30pm, 3.10pm, 5.00pm, 5.50pm and
6.55pm before hourly entries started again at 8.00pm. The next day (18
May), after 6.00am staff recorded observations at 7.20am, 7.45am, 8.15am,
12.15pm, 5.25pm and 8.15pm before returning to an hourly schedule
overnight. The next morning (19 May), shortly before the ACCT document
was closed, officers did not make an entry between 6.00am and 7.20am.
604. Staff did not carry out the planned hourly checks. Although the man did not
try to harm himself during this period, the way in which the ACCT document
was completed might indicate either the need for further training or a
fundamental misunderstanding by staff.
605. I note that for two days running there was a gap in recorded observations
between 6.00am and 7.20am. This time of day, when night staff hand over to
day staff, was identified as a problem when I investigated the death of another
prisoner in August 2007. It was difficult for my investigators to discern from
the wing observation book when the handover took place and who was
responsible for the prisoners.
606. This was especially important because ACCT observations tended to be
overlooked or to decrease during the handover period. The prison introduced
the use of a stamp to encourage staff to record in the wing observation book
when they came on shift and took responsibility for the prisoners. My
Final Report: January 2011 117
investigators saw examples of the use of this stamp when they investigated
the man’s death. The stamp requires the member of staff to write the date but
not the time, which was not always recorded by staff manually.
The Governor of Wandsworth should ensure that the stamp used during
the handover period between the night and day staff is amended so that
it requires staff to record the date and time of the handover.
Pentonville - 26 – 27 May
607. The man returned to Pentonville on 26 May. Staff were understandably
cautious following the recent events. Governor A, Governor C and Nurse D
were sufficiently concerned about the risk the man might present to himself to
place him in the healthcare centre under constant supervision. My
investigators asked why an ACCT document was not opened, given that the
risk they were concerned about was presumably one of self harm.
608. As I have already indicated, PSO 2700 makes it clear that constant
supervision should be employed when a prisoner is at imminent risk of taking
their own life. The simultaneous opening of an ACCT document would
therefore seem to be both logical and strongly advisable.
609. Governor A said that constant supervision was deemed necessary as a
precautionary measure because of the man’s attempt to take his own life in
April, which she described as having come ‘out of the blue’. She did not
identify any signs of increased risk when she spoke to the man on 27 May.
Governor A was unsure whether an ACCT document should be opened if
there is sufficient concern to place a prisoner under constant supervision.
610. Governor C could not recall whether the man had been the subject of ACCT
monitoring on 26 May. He thought the case review held on 27 May was an
ACCT review. In retrospect, he agreed that opening an ACCT document
when the man arrived at Pentonville was a ‘sound suggestion’ that he did not
think of at the time. Governor C agreed that an open ACCT document might
have prompted staff to keep a keener eye on the man’s welfare across the
days that followed.
611. Nurse D told my investigator that the decision to place the man under
constant supervision had been his as he was the acting ward manager. He
wanted to make sure the man was safe. His decision was based on the
man’s history at Pentonville, rather than a response to his presentation on 26
May. Nurse D remembered there being ‘no indication that [the man] was
going to self harm’. Nonetheless, if Nurse D was sufficiently worried about the
man on the basis of what he had done and might do, I consider that opening
an ACCT document would have been a sensible safeguard.
The Governor of Pentonville should ensure that an ACCT document is
always opened if a prisoner is placed under constant supervision.
Final Report: January 2011 118
Pentonville - 31 May
612. Over the next few days, it seems that the man presented no serious concerns
to the staff on G1 landing. Officer I remembered him being a ‘polite and
compliant’ prisoner who gave no cause for particular concern.
613. Because the second ACCT document was opened on a Sunday, none of the
In-Reach team was on hand and staff did not consult the out-of-hours doctor.
Officer F told my investigator that he did not consider consulting a healthcare
professional or discuss the possibility with Senior Officer A, who opened the
ACCT document.
614. Officer F said that he found assessment interviews more productive if they
were conducted on a one-to-one basis. He suggested that he would adopt a
multi-disciplinary approach during subsequent ACCT reviews. Officer F
highlighted the need to begin the assessment interview as quickly as possible
once the decision to start ACCT monitoring had been taken.
615. The man had not been assessed by a psychiatrist since he returned to
Pentonville, and had not had any contact with the In-Reach team since 27
May. Officer F referred the man to the In-Reach team because he was
concerned about his mental health following their interview. The man said
that he had experienced difficulties with his cellmate and was moved to a
single cell.
616. After the assessment interview, the man showed Officer F a ligature he had
fashioned from a torn bed sheet and holes in the light fitting in his cell which
he had thought about hanging himself from. Officer F could not remember
confiscating the ligature but was sure that he had done so. He did not make a
written record to confirm this. He remembered telling Senior Officer A about
the ligature. The next morning, the man used the same method to make a
second attempt on his own life.
The Governor of Pentonville should ensure that staff make a record in a
prisoner’s ACCT document when they find and confiscate a means of
self harm such as a ligature.
617. Senior Officer A opened the ACCT document on 31 May and set the
frequency of observations at hourly. On the advice of a Principal Officer, the
frequency was increased to every 15 minutes before the assessment
interview. Following the completion of the assessment interview, it was
reduced to half hourly. Senior Officer A set the frequency of observations
based on Officer F’s assessment of the man.
618. Both members of staff were familiar with the man’s recent circumstances.
Senior Officer A was involved in the opening of the first ACCT document on
21 April and attended the man’s case review on 27 May. Officer F sat with
the man at the hospital in April.
Final Report: January 2011 119
619. Thinking back in interview, Officer F considered the decision to set the level of
risk at ‘raised’ was appropriate. He said that the setting of half-hourly
observations was consistent with the information available. Officer F
indicated that the level of observations was consistent with the monitoring
afforded other prisoners presenting with similar concerns.
620. Officer F thought that the next step from half hourly checks would be constant
supervision in a healthcare setting (although the frequency had been set at
every 15 minutes earlier in the day). He remembered being surprised when
he heard about the man’s attempt to take his own life the next day.
Pentonville - 1 June
621. The man was discovered in the process of trying to take his own life at
8.05am on 1 June. Until Officer I entered the cell, there is no record in the
ACCT document of the man having been checked for 55 minutes, despite the
frequency of observations being set at every half hour. Officer I told my
investigators that this period was when the oncoming day staff carried out
their roll check to ensure prisoners were accounted for. He thought that,
although an entry had not been made in the ACCT document, a member of
staff had almost certainly checked the man at around 7.30am. Senior Officer
A and Senior Officer D agreed that the handover from night staff to day staff
might explain the failure to record half-hourly observations.
Pentonville - 4 June
622. On 4 June, Doctor D assessed the man during his rounds and decided that
the frequency of observations should be reduced to hourly. The reduction in
observations was implemented without the ACCT document being reviewed.
A review was last held on 3 June and another would be conducted on 9 June.
Pentonville - 9 June
623. At the final ACCT review held at Pentonville, the risk the man represented to
himself was reduced to low. However, the reduction in risk does not correlate
with the maintenance of hourly observations.
Wandsworth - 9 - 12 June
624. Paragraph 12 of annex 8G of PSO 2700 indicates that an open ACCT
document must be reviewed within 24 hours of transfer to a new prison. In
the meantime the prisoner must be kept safe. A review had been held at
Pentonville early in the morning of 9 June. The man transferred to
Wandsworth at lunchtime and arrived on the Onslow Centre in the early
evening. Because he wanted a colleague to join him for the review, Senior
Officer 5 spoke to the man and decided to hold the next ACCT review the
following morning.
625. Senior Officer 5 and Officer 3 carried out the final review of the man’s ACCT
document on 10 June. The man was anxious and expressed suicidal
Final Report: January 2011 120
thoughts. The two men did not think the man was ‘actively contemplating
suicide’, although Officer 3 acknowledged that they did not ask him if he
planned to take his own life. The two men increased the risk of self harm from
‘low’ to ‘raised’. Senior Officer 5 said he would have considered setting the
risk as ‘high’ had the man’s mood not improved during the meeting. Officer 3
commented that, had he known about the man’s two previous attempts to
take his own life, he would have assessed the risk as ‘high’.
626. I am concerned that the frequency of observations was not amended to reflect
the increased level of risk. Paragraph 42 of annex 8G of PSO 2700 states:
‘The frequency of conversations and observations (day and night) must
be appropriate to the individual’s assessed level of risk …’
627. When they spoke to my investigators, staff on the Onslow Centre were under
the impression that the man was supposed to have been checked hourly
during the night. However, they thought that only three ‘quality interactions’
with staff were to be recorded during the day around the breakfast, lunch and
dinner periods. Staff seemed to think that prisoners were being regularly
observed on association during the day, even if specific checks were not
recorded in the ACCT document.
628. The perception of the staff tallies with the frequency of observations entered
in the ACCT document between 9 and 12 June, both before and after the
review. Officer 3’s recollection of the level of observations was ‘hazy’. He
said that he did not think he and Senior Officer 5 discussed changing the
frequency during the review.
629. After the review, Senior Officer 5 wrote up the ACCT document. He did not
indicate any amendment to the frequency of observations. (He ticked a box
indicating that the frequency had been reviewed, but did not make any written
remarks as to the outcome.) Paragraph 43 of annex 8G of PSO 2700 states:
‘Conversations with and observations of the at-risk prisoner must take
place at least as frequently as stated in the ‘required frequency of
conversations and observations’ box on the front cover. Staff
responsible for observing particular prisoners – including night staff –
will need to ensure they are familiar with the requirements in that
individual’s ACCT Plan. The Manager – for each shift – of the unit
where the prisoner resides is responsible for ensuring that
conversations and observations are completed as per the requirements
set out on the front cover the ACCT Plan.’
630. Senior Officer 5 did not alter the front cover of the ACCT document, where the
frequency of observations is supposed to be written for ease of reference.
(Following a previous investigation of a death at Wandsworth, I stressed the
need for staff to use the front cover.) The last entry on the cover was made
by Doctor D at Pentonville on 4 June. It indicated the need for hourly
observations day and night. No further changes are evident.
Final Report: January 2011 121
631. Staff on the Onslow Centre did not follow the instructions on the cover and,
instead, made intermittent entries during the day. After the ACCT review
finished at about 1.00pm, only two entries were made in the document before
9.00pm that evening. The man was then checked every hour overnight, but
between 7.00am and 9.00pm the next day, 11 June, he was only checked six
times. He was once again monitored on an hourly basis overnight, but after
6.30am on 12 June he was checked at 7.50am, 10.00am and 12.30pm.
632. The last entry was made in the ACCT document at 12.30pm by Officer 10.
He told my investigators that he also asked the man if he wanted to attend the
Muslim prayer service at about 1.10pm, but he did not record this observation
in the ACCT document. He told his colleagues that he was concerned about
The man. Prompted by Officer 10, Officer 11 checked the man at 1.40pm.
More than an hour had passed between the last written observation and
Officer 11 finding the man hanging in his cell.
633. The cover of the ACCT document is unambiguous. There should have been
an entry once an hour, day or night. The Safer Custody Manager at
Wandsworth recognised that staff on the Onslow Centre did not correctly
carry out the ACCT observations. I consider that staff and managers require
further training in the use and running of an ACCT document. I also consider
that managers chairing ACCT reviews would benefit from retraining with
regard to the relationship between risk levels and the frequency of
observations, as well as the accurate completion of an ACCT document. I
repeat a recommendation I made in relation to the death of another prisoner
in August 2007.
The Governor of Wandsworth should ensure that all staff working on the
Onslow Centre receive further training in the use, completion and day-
to-day operation of the ACCT document as soon as is practicable.
Particular emphasis should be placed on identifying new risk indicators,
holding ACCT reviews promptly and amending the frequency of
observations to reflect the level of risk.
ACCT review - Wandsworth - 10 June
634. Officer 3 told my investigator that he had not read the man’s ACCT document
before he and Senior Officer 5 began the review. Instead he relied on Senior
Officer 5, as the case manager, to tell him about the man. Officer 3 was not
aware that the man had come from Pentonville’s healthcare centre the day
before. He did not know about the man’s two previous attempts to take his
own life in Pentonville. Although I have made a previous recommendation in
this regard, nobody from the In-Reach team was either consulted or asked to
attend the review. In fact, the team were not told of the man’s return to
Wandsworth until 12 June.
635. The man expressed his fears that North London gang members were
threatening to harm his family if he did not give them money. It remains
unclear whether his fears were well founded. Staff were unsure of the extent
the man’s mental health problems amplified his anxiety. Prisoner 8 said that
Final Report: January 2011 122
the man would hear ‘powerful voices’ telling him that other people were going
to harm his family. Nonetheless, whether or not the man’s fears for his family
were real, the important thing is that they caused him genuine concern.
636. Officer 3 remembered that Senior Officer 5 wanted to show the man that they
were taking the apparent threat to his family seriously. Senior Officer 5 asked
the man to provide specific details so they could help him. The man
suggested that he had information about the recent shooting which had taken
place outside Wandsworth. Senior Officer 5 wrote down the information and
telephoned the police liaison officer (PLO) whilst the man was in the room.
The PLO then contacted Operation Trident. During the afternoon, Senior
Officer 5 told the man to expect a visit from a police officer.
637. The ACCT review lasted about two hours which, in my experience, is
unusually long, although there was a break. Officer 3 thought that the actual
review took about half that time, whilst the remainder was spent addressing
the issues raised. At the start, the man was noticeably anxious. By the end,
the two SOs said his mood had improved. However, within half an hour, the
man asked to speak to a Listener.
638. I have no doubt that the approach of the two senior officers to the ACCT
review was well intentioned. Officer 3 told my investigator that the review was
‘supportive and collaborative’. He said that the man agreed to the police’s
involvement after he was given different options for proceeding with his
concerns. Officer 3 thought that the man seemed reassured by the steps
taken and trusted them to treat the information confidentially.
639. Officer 3 thought that the man appeared ‘visibly relaxed’ when the review
ended. He recalled feeling reassured because the man was smiling. Officer
3 remembered that the man became more responsive as the conversation
progressed. He thought that the man seemed relieved to talk about his
concerns and to be listened to.
640. When the interview started, the man was worried that other prisoners were
listening outside the door. He expressed anxiety that other prisoners would
discover that he was going to provide Operation Trident with information.
Operation Trident is a high profile police unit and, although Senior Officer 5
promised that his interview with the police would be conducted discreetly, the
man told him that he was frightened of being thought an informer.
641. Officer 3 and Senior Officer 5 made strenuous efforts to take the man’s fears
seriously and act decisively in order to reassure him. However, given his
vulnerability, recent history of self harm and mental health difficulties, the
presence of a mental health professional at the review would have been
highly desirable. A multi-disciplinary approach may have greatly assisted the
officers to gauge the way in which the man would respond to the involvement
of the police and the escalation of his concerns. The clinical reviewer
comments:
Final Report: January 2011 123
‘Following an ACCT review at HMP Wandsworth a decision was taken to
report [the man’s] concerns [about gangs] to the police, and the man was
told he would be interviewed. The man’s mental state was fragile at the
time, and it is possible that he may have been worried about the
consequences for him or his family of police involvement. In retrospect the
decision to report these concerns to the police should have been taken in
a more considered way, and with the support of the mental health team at
HMP Wandsworth.’
642. Paragraph 17 of annex 8G of PSO 2700 recommends a multi disciplinary
approach to successive ACCT reviews involving ‘a wider range of staff and
specialists’.
The Governor of Wandsworth should remind staff conducting ACCT
reviews to invite contributions from the In-Reach team when a prisoner
has a diagnosed mental disorder.
Indications that the man was at risk of harming himself
Wandsworth - 11 - 12 June
643. During the night of 11 June, Officer 7 and Officer 5 removed the man from his
cell after he said that he had been threatened by Prisoner 7. The officers did
not record that the threats were of a sexual nature. Neither the officers nor
the overnight management team (Oscar 1 and Oscar 2, who were present)
amended the frequency of observations following the trauma the man had
reported and his move to a cell on his own.
644. Officer 7 told my investigators that he had not received any ACCT training.
He did not know about the man’s two recent attempts to take his own life at
Pentonville. He did not realise that the man had recently arrived at
Wandsworth from Pentonville’s healthcare centre. Nevertheless he said that
he felt able to increase the frequency of ACCT checks during the night after
he had liaised with the night orderly officer.
645. During interview, Officer 5 explained that he is a trained ACCT assessor.
(This means that he can interview prisoners considered to be at risk of
harming themselves, assess them and make recommendations to managers.)
Officer 5 was also unaware of the man’s recent attempts to take his own life.
The officer thought that the man settled after he was moved to his own cell
and he believed that the problem had been dealt with appropriately.
646. The man told Officer 5 that Prisoner 7 had made sexual advances towards
him. He recalled telling Officer 6 at the time, but did not record the particular
nature of the threats for the day staff who arrived the following morning.
647. Prisoner 7 and Prisoner 8 both told my investigators that the man tied a towel
around his neck on the night of 11 June. This action supposedly prompted
Prisoner 7 to press the cell bell. They said Officer 5 entered the cell and
removed the towel. The man apparently told Prisoner 8 about the incident the
Final Report: January 2011 124
following morning. Prisoner 8 said he asked Officer 5 the following evening if
it was true, and the officer said it was. However, when my investigators spoke
to Officer 5 he denied having seen the man with anything tied around his
neck. There is no written record of such an incident. Equally, the officer
could not have entered the cell without the night orderly officer (who had keys)
being present. Officer 5’s keys were in a sealed pouch which was not opened
during that night.
648. Had the day staff known of the specific nature of the threats, it is possible that
they would have given more consideration to reviewing the ACCT document.
Officer 5 explained that, although he did not record the sexual nature of the
threat, he felt that he had conveyed it by writing that the man felt
uncomfortable and unsafe. He thought that his colleagues would understand,
by implication, that there had been a sexual aspect to the threat.
649. Officer 7 thought that moving the man to a cell on his own effectively resolved
his anxiety. Both he and Officer 5 remembered that the man seemed relieved
when he moved. The officer recalled that it was as if ‘a weight had been lifted
from his shoulders’. He considered that the man had been made ‘comfortable
and safe’.
650. Given the man’s altered circumstances overnight, his upset and removal to a
single cell, as well as the allegation of sexual threats, I consider that a review
of the ACCT document and the frequency of observations should have been
held early on the morning of 12 June. Officer 3 (a member of the Safer
Prisons team) confirmed that he would normally expect an ACCT document to
be reviewed the next morning if a prisoner moved into a single cell overnight
or fell out with his cellmate.
651. The Cell Sharing Risk Assessments (CSRAs) demonstrate a lack of
agreement as to whether the man should share a cell. A review of the ACCT
document would have prompted staff to consider whether it was safe for the
man to remain in a single cell. Prisoner 8 told my investigators that he was
unhappy for the man to be locked in a single cell over lunchtime. He thought
the man seemed distressed earlier that morning and was hearing voices.
652. The day staff were told at the morning briefing of the man’s removal from the
cell. Officer 8, who checked the man immediately afterwards, said that this
would not have been a particularly unusual event and the news did not prompt
him to be additionally concerned about him.
653. Officer 8 found that the man did not reply when he checked him. He noted his
concerns in the ACCT document but did not suggest to a manager that a
review be held. He told my investigators that the man ‘could be very up and
down sometimes’ and, although quieter than usual, there was nothing to
indicate that something was ‘drastically wrong’. Officer 8 said that he did not
know the full extent of the man’s recent attempts to take his own life at
Pentonville. He made a mental note to check the man later.
Final Report: January 2011 125
654. Prisoners alerted Officer 9 to the man’s behaviour at about 10.00am. He
asked the In-Reach team to assess the man because his behaviour ‘was
something out of the norm’. He did not ask his manager to schedule an
ACCT review. He thought that he had addressed the situation by involving
the In-Reach team. Officer 9 was not aware of the man’s recent attempts to
take his own life in Pentonville. The officer thought the man’s behaviour was
sufficiently worrying to ask for a mental health assessment, but he did not
think the man was going to harm himself.
655. Officer 8, who had made the earlier entry, went to check the man because he
was still concerned about him. Officer 9 told Officer 8 about the referral to the
In-Reach team. Officer 8 made an entry for Officer 9 in the man’s ACCT
document although staff should make their own contemporaneous records.
Officer 8 explained that he had been keen to make it clear that the man had
been checked.
656. Officer 9 did not recall Officer 8 mentioning his worries about the man when
they spoke together. Officer 9 did not read the ACCT document that morning
because he was working on a different landing. Officer 8 recorded a pattern
of concerning behaviour in the ACCT document. He thought that the man
could sometimes behave in this manner and might be ‘back to normal’ by
lunchtime after speaking to friends.
657. Officer 10 made the final entry in the man’s ACCT document at about
12.30pm. It was similar to the previous two entries. Officer 10 told my
investigators that he had not been especially concerned about the man when
he made the entry, and ascribed his unresponsiveness to the ‘ups and downs’
in his behaviour that he had exhibited in the past.
658. During interview, Officer 8 said that he and Officer 10 shared their concerns
about the man not being ‘right’. He commented that, by lunchtime, it was
beginning to become clear that ‘it’s probably a bit more than just a mood
swing’. Officer 8 recalled that staff were starting to become more concerned.
He could not remember anybody telephoning the In-Reach team to hasten
their assessment.
659. Officer 8 was aware of all three observations made that morning. When my
investigators asked him for his views of how the ACCT document was used,
he said that he regretted that staff left the man alone in his cell over the lunch
period. Officer 8 agreed that, with the benefit of hindsight, the ACCT
document should have been reviewed.
660. Checking if he wanted to go to the Muslim prayer service shortly after 1.00pm,
Officer 10 did not get a reply from the man. The officer was not ‘overly
worried’ by his silence, and ascribed it once again to his ‘ups and downs’ in
prison. Officer 10 found it a ‘little strange’ that the man, with whom he
considered he had a good relationship, would not talk to him.
661. However, Officer 10 recalled how the man could sometimes be obstructive
with staff and sometimes was very quiet and withdrawn. The officer said that
Final Report: January 2011 126
he had ‘no thought’ that the man might try to harm himself before he left for
lunch. He believed that the man’s unresponsive behaviour was just ‘the man
being the man’. In isolation, it appeared to Officer 10 that his experience was
within the normal parameters of the man’s behaviour. He did not make an
entry regarding his second observation of the man. However, he did advise a
colleague to check the man over lunch, which was commendable.
662. Officer 8 and Officer 10 were both aware that Officer 9 had asked the In-
Reach team to assess the man (although none of the three knew when the
manager of the mental health in-reach team planned to visit). Officer 10 did
not read the most recent entries in the ACCT document which might have
helped him to identify a pattern of behaviour. Officer 10 said that, as the
officer responsible for checking that prisoners go to work, he tended to move
on and off the wing and probably did not spend much time on the Onslow
Centre that morning. He would not have been in a position to observe the
man’s ongoing lack of engagement with staff.
663. Senior Officer 3, one of the managers on the wing, knew about the
observations made by the different officers. He did not recall knowing that the
In-Reach team had been asked to assess the man. During the morning, three
officers made separate observations about the man’s withdrawn attitude. He
was in a cell on his own, following the disagreement with Prisoner 7, and
remained locked up alone when he took his own life. The In-Reach team
were asked to assess him. Any of these events might have triggered a review
of the ACCT document and the frequency of observations, but did not.
Paragraph 8.6.12 of PSO 2700 states:
‘If an at-risk prisoner is allocated to a single cell… additional measures
must be put in place to compensate for any added risk involved in the
individual being alone… Options include:
‘Locating the prisoner in a cell that is easier to supervise by staff
‘Increasing the frequency of staff conversations and observations
‘Combining attendance at work, education or day-centre activities
during the day with increased levels of staff conversations and
observation when the individual is in his/her cell.’
664. Staff at Wandsworth were largely unfamiliar with the man’s recent history of
serious self harm. The second, open ACCT document detailed the events of
1 June at Pentonville. Although the man’s first attempt to take his own life on
22 April was mentioned in the second document, it might have been difficult
for staff to grasp the significance of it.
665. Wandsworth officers do not seem to me to have been as keenly attuned as
their colleagues at Pentonville to the risk the man presented to himself. This
is understandable, as both previous serious self harm attempts took place in
Pentonville. Concern at Pentonville was inevitably heightened because the
experiences were vivid and traumatic for officers. Nonetheless, some of the
Final Report: January 2011 127
information was available to staff at Wandsworth if the ACCT document was
read carefully.
666. The day staff were told at the morning briefing about the failure of the cell
share the previous night and the man’s move to a single cell. This information
seems to have represented the clearest opportunity to review the risk the man
presented to himself.
667. Although the man repeatedly failed to engage with staff during the morning,
he was also seen out on the landings at different times, whether to set out the
prayer service or collect his lunch. Staff made their observations and
completed the ACCT document appropriately. Some information was shared,
for instance about the In-Reach referral. If the ACCT document is to be a
meaningful document, it is fair to suggest that staff should learn about the
ongoing situation by reading recent entries. Officer 3 said that he would
expect staff to tell their managers if a prisoner continued to be
uncommunicative and unresponsive. Some of the officers thought the man’s
behaviour that morning was not unusual. In this context, his lack of
engagement with staff following the incident in the middle of the night of 11
June only really assumes significance with the benefit of hindsight.
ACCT training
668. During the course of the investigation, both Doctor 1 at Wandsworth and
Doctor A at Pentonville told my investigators that they had not received any
formal training regarding use of the ACCT document. Nonetheless, both
doctors have familiarised themselves with the process over time and felt
confident about making entries. Doctor A opened the ACCT document on 21
April. I make the following recommendation.
The Heads of Healthcare at both Wandsworth and Pentonville should
ensure that all staff, including doctors, who have contact with prisoners
receive formal training in the use of the ACCT document.
Cell Sharing Risk Assessments (CSRAs)
669. Earlier on in the man’s sentence, concerns were raised about his suitability for
cell sharing. Staff assessed that the man required a single cell because of his
ongoing mental health problems and the risk he presented to others. He had
assaulted prisoners and staff in 2006 and 2007.
670. The completion of CSRAs between April and June 2009 was somewhat
inconsistent. My investigators were provided with four assessments
completed on 21 April, 13 May, 26 May and 9 June. (There is no evidence of
a CSRA being completed on 12 May at Brixton.) The quality of the CSRAs
varies and they sometimes contradict each other. None accurately records
that the man had previously assaulted other prisoners.
671. Because CSRAs are completed in reception when time is often limited,
officers rely to a significant degree on the prisoner to disclose information
Final Report: January 2011 128
about himself. Information about the man’s assaults on other prisoners was
contained in previous CSRAs and security incident reports, but staff do not
seem to have consulted these documents.
672. The assessment completed at Pentonville on 21 April indicated that the man
presented a low risk of harm to other prisoners and was suitable to share a
cell. When asked if the man had previously been the subject of an ACCT
document (or its predecessor, the 2052SH), Officer A ticked ‘no’ (although the
man was the subject of extensive suicide and self harm monitoring in 2006
and 2007). Based on what the man told him, the officer did not identify any
previous assaults on staff or prisoners. However, Officer A recognised the
man’s vulnerability and mental health difficulties. The man shared a cell for
one night amongst the general prison population before requesting vulnerable
prisoner status and making an attempt on his own life.
673. Officer 1 completed a CSRA at Wandsworth on 13 May. Once again, the
officer relied on the man to disclose relevant information. No previous
assaults on staff and prisoners were recorded. The man was assessed as
presenting a low risk of harm to others. The likelihood of self harm was
identified. Much of the information was copied from the last CSRA.
The Governor of Wandsworth should ensure that staff completing
CSRAs do not copy information verbatim from another CSRA, but rather
combine previous assessments with the prisoner’s presentation to
support and inform their own judgement.
674. When the man arrived at Pentonville on 26 May, Officer A completed the front
page of the CSRA. The man again did not disclose previous assaults on staff
or prisoners and so the officer did not identify concerns about cell sharing.
However, helpful and detailed information about the man’s state of mind, the
recent attempt to take his life and his status as a vulnerable prisoner was
included. Nurse D completed the healthcare section of the form and
assessed the man as presenting a medium risk to other prisoners.
675. The final section of the form, which is supposed to be completed by an officer
locating the prisoner after their arrival, was filled in five days later by Governor
F on 31 May. He presumably wrote his comments after the man spoke to
Senior Officer A, was relocated to a single cell and an ACCT document had
been opened. Governor F identified the need for the man to be held in a
single cell because of his erratic behaviour and because he was threatening
to harm his cellmate. He indicated that this decision should be reviewed in
four weeks time.
The Governor of Pentonville should ensure that staff complete all four
sections of a prisoner’s CSRA the day the prisoner arrives.
676. The last CSRA, completed at Wandsworth on 9 June by Officer 2 and Nurse
3, contains very little detail and makes no reference to any of the concerns
relating to cell sharing raised on 31 May. They had been noted both in the
previous CSRA and in the ACCT document opened on 31 May (where Senior
Final Report: January 2011 129
Officer A wrote that the man should be located in a single cell because he
was ‘high risk’). Still relying on the man for information, Officer 2 did not
identify his previous violent behaviour in custody. The man was assessed as
presenting a low risk of harm to others.
677. CSRAs rely on staff making a professional assessment at the time in
question. However, reference to previous CSRAs would have helped staff to
accurately and consistently have assessed the man’s suitability to share a
cell. There is no easy solution when a prisoner like the man may sometimes
be at risk on his own, but may equally occasionally present a risk to cellmates.
Sharing with another prisoner on the night of 11 June probably had a negative
impact on the man. Yet locating him alone in a cell over lunchtime the next
day was something about which other prisoners expressed concern, as they
felt the man should not be left on his own.
678. There is no indication that the man was actually violent towards either staff or
prisoners during his final period of imprisonment. Nonetheless, it seems to
have been recognised at various junctures that sharing a cell might not be
appropriate. At other times this information does not seem to have been
considered. I amend a recommendation I made following a previous
investigation at Wandsworth:
The Governors of Pentonville and Wandsworth should ensure that staff
completing Cell Sharing Risk Assessments (CSRAs) consult previous
CSRAs for relevant information. Previous CSRAs should be stored
together in date order.
Cell sharing on 11 June
679. When I investigated the death of another prisoner at Wandsworth in 2007, I
recommended that staff should think very carefully before placing together
two vulnerable prisoners who both had significant mental health problems.
Whilst sometimes prisoners can support each other, bringing two fragile
prisoners with histories of self harm together may also be counter-productive.
680. During the afternoon of 11 June, the man was located in the same cell as
Prisoner 7. Seven hours later, the man asked to move out of the cell. The
man told Officer 5 that Prisoner 7 had made sexual advances towards him.
The officer recorded that the man felt threatened but did not write that the
threats were of a sexual nature. In the early hours of the morning, staff
opened an ACCT document in relation to Prisoner 7. The next morning the
man did not speak to staff and the In-Reach team were asked to assess him.
681. Officer 5 suggested that threats of a sexual nature were unremarkable on the
Onslow Centre, which was why he did not specifically refer to the sexual
element at the time. He thought that his phrasing adequately communicated
to his colleagues what had transpired. However, the man’s mood changed
the next morning, and it might have been useful for staff to have had a fuller
understanding of the situation.
Final Report: January 2011 130
The Governor of Wandsworth should ensure that detailed information
about the nature of any threats towards a prisoner are clearly recorded
by staff, particularly in an ACCT document if one is open.
682. Without exception, staff on the Onslow Centre described Prisoner 7 as a
demanding prisoner who used up a lot of staff time and resources. He had a
history of being unable to share with other prisoners, and staff tried on several
occasions to place him with an appropriate cellmate.
683. Officer 10 thought that the proposed cell share was unsuitable. He said that it
was well known on the Onslow Centre that nobody wanted to share with
Prisoner 7. He recalled that Prisoner 7 would be ‘up all night, banging and
crashing’. He explained that Prisoner 7 had a lot of problems and staff had
tried a variety of strategies to facilitate a successful cell share over ‘days and
days’. Officer 10 was not surprised to be told at the morning briefing the next
day that the man had moved out overnight.
684. Officer 7 explained that prisoners who shared with Prisoner 7 often asked to
be moved, saying that they did not ‘want to go back in there’. Officer 5 said
that both staff and prisoners found it difficult to cope with Prisoner 7. Senior
Officer 5 remembered the man complaining on 12 June that Prisoner 7 was
constantly talking to him in the night, ‘driving him up the wall’ when he wanted
to sleep.
685. Officer 8 said that Prisoner 7 had difficulty sleeping and that ‘one night [of cell
sharing] was enough for most people’. He said he was unsurprised that the
cell share did not work out and commented that it was never going to be a
long-term proposition because Prisoner 7 was so demanding.
686. During the ACCT review on 10 June, Officer 3 remembered discussing the
prospect of the man sharing a cell with Prisoner 7. He recalled that it was an
arrangement that both men requested. Officer 3 thought that the man
seemed content with the arrangement, and he did not see any reason to
object to it. He commented that it was not unusual for two vulnerable
prisoners with histories of self harm to share a cell on the Onslow Centre if
they both asked for the move.
687. Senior Officer 4 asked Officer 4 to organise the cell share on 11 June. Senior
Officer 4 told my investigators that Prisoner 7 is a ‘poor coper’ who has long
had trouble sharing a cell. The SO was trying to find a cell mate who might
stabilise his behaviour and be a positive influence. During interview, Senior
Officer 4 said that Prisoner 7 came to his office with the man and suggested
the cell share. The SO checked with the man if he felt pressurised to share
with Prisoner 7. The man said he was not and told the SO that he would ‘give
it a go’.
688. Senior Officer 4 did not know the man very well. He thought the man was a
‘poor coper’ and seemed troubled. He knew that the man was the subject of
an ACCT document, but was not fully aware of his two recent attempts to take
his own life at Pentonville. (The ACCT document recorded the second
Final Report: January 2011 131
attempt.) Senior Officer 4 had a better understanding of Prisoner 7’s history
and problems. The SO thought that the proposed share might be a good idea
as a ‘trial run’ and asked Officer 4 to organise it. Officer 4 only knew that the
man had made one suicide attempt at Pentonville. She was not aware of the
seriousness of the attempt in April. Officer 4 was aware that Prisoner 7
regularly asked for a new cell mate and knew that he experienced mental
health problems.
689. When he spoke to my investigators, Senior Officer 4 said that he would not
have authorised the proposed cell share if he had thought it would prove
unsafe. If either man had been assessed as a high risk of harm on their most
recent CSRA, Senior Officer 4 said he would not have allowed the
arrangement to proceed. Had he thought that either man was a medium risk,
Senior Officer 4 said he would have discussed the proposed share with a
colleague.
690. Recent evidence of the difficulty the man had in sharing a cell was available to
Wandsworth staff. Senior Officer A opened the second ACCT document on
31 May at Pentonville and wrote ‘high risk – to remain in single cell’. The man
told her that he was not getting on with his cellmate. For much of his time in
custody since 21 April, the man had been held in single cell accommodation
in the Pentonville healthcare centre.
691. Senior Officer A accepted that Prisoner 7’s risk assessment varied. My
investigators looked at entries made in the wing observation book before,
during and after the man’s location on the Onslow Centre in May and June. A
disproportionate number of entries relate to Prisoner 7, whose behaviour was
frequently disturbed and disruptive, affecting other prisoners. On more than
one document from March and April 2009, ‘high risk’ was clearly marked.
Prisoner 7 tried to set fire to his cell in March. In August 2009, Officer 4 told
my investigators that Prisoner 7 was located in a ‘high risk single cell’ at that
time.
692. Prisoner 7 frequently asked to visit the Listeners’ suite. On 10 June, he did so
in the afternoon and evening, coincidentally following the man on both
occasions. Prisoner 7 had moved cells on 10 June. Although not the subject
of an ACCT document the day he was allocated to share with the man, he
was both before and very shortly after the man died. Paragraph 8.6.9 of PSO
2700 states:
‘Two prisoners on open ACCT Plans or in the post-closure phase of
ACCT, or a combination of each, must not be located together in a
double cell, unless a case review team – having considered the care of
both prisoners – decides they will both benefit from sharing with each
other. Similar consideration needs to be given where staff are aware that
prisoners have recently had an ACCT Plan closed.’
693. Senior Officer 4, Officer 4 and Senior Officer 3 all said that they considered
two prisoners’ willingness to share to be a primary consideration and a strong
indication of compatibility. Whilst the wishes of prisoners are important, I am
Final Report: January 2011 132
concerned that they should not override professional risk assessment.
Prisoners may not always be the best judges of the suitability of cell sharing.
Following publication of the draft report, NOMS provided the following
response to this paragraph:
‘Yes, it should not override professional risk assessment, but in many
instances we need to base a risk assessment on the opinion of the prisoner
and what they feel will help them. By not doing so, we are discouraging them
from taking responsibility for their own care and ignoring their opinion of what
they think is best for them. It is a difficult balance to achieve, but it seems
unfair to criticise staff for a judgement call that was considered amongst staff
and with the man on definitely two occasions. It was then agreed that it would
be put into place on a trial basis.’
694. A slightly fuller risk assessment might have identified reasons why the man
should not share a cell with Prisoner 7. Senior Officer 4 could have benefited
from the In-Reach team’s advice since both men had mental health problems.
695. Senior Officer 4 was not helped by the most recent CSRA, which he consulted
before agreeing to the proposed share and which contained little detail.
Officer 4 was familiar with the man’s history of mental health problems and
agreed with my investigators that the CSRA did not adequately reflect these.
696. Officer 4 also looked at the most recent CSRA when she carried out Senior
Officer 4’s request. She said that she would normally only consult other
documents if time allowed. She would not necessarily read a prisoner’s
ACCT document which did not automatically pertain to the risk they
represented to others. She agreed that the ACCT document could provide
useful information about a prisoner’s state of mind.
697. Neither Senior Officer 4 nor Officer 4 recorded their decision making
regarding the proposed cell share. Paragraph 8.6.8 of PSO 2700 states:
‘When locating an at-risk prisoner in shared accommodation account
must be taken of the suitability of the cellmate, and consideration given of
the impact on and ability of the cellmate to cope with the individual
situation. The F2052A (history sheet) is a suitable place to document
such consideration.’
698. The desire to address the disproportionate demands Prisoner 7 was making
on staff by finding a suitable cellmate was understandable. I am concerned
that this wish may have overridden consideration of the impact his behaviour
would have on somebody like the man. From what staff told my investigators,
Prisoner 7 would not have offered stability and support. I acknowledge that
the man jointly requested the cell share, but note that he spoke to Senior
Officer 4 in Prisoner 7’s presence.
699. Wandsworth’s own CSRA Management Booklet indicates that a prisoner’s
assessment should be reviewed if there is ‘a significant event that triggers
concern’. The booklet gives the examples of triggers such as acute mental
Final Report: January 2011 133
illness or staff receiving new information. A new CSRA was not completed on
the morning of 12 June.
700. Officer 4 was the movements officer on the morning of 12 June. It was her
job to review the man’s location and find a suitable new sharing arrangement.
Another prisoner with mental health problems asked if the man could move
into his cell. Officer 4 decided to seek the manager of the mental health in-
reach team’s advice when she assessed the man later that day because she
was concerned about placing two prisoners with mental health difficulties
together. I consider that Officer 4 showed sound judgement. She doubted
whether the newly proposed share would be in the man’s best interests.
Thus, the man had not been allocated a new cell mate by lunchtime. Senior
Officer 3 confirmed that the intention had been for the man to be relocated
with a new cellmate before the end of the day.
Clinical records
701. When my investigator collected the man’s file from Wandsworth, he was only
given a clinical record printout from Pentonville between 21 April to 12 May.
There was no copy of the part of the man’s clinical record relating to the
second period at Pentonville between 26 May and 9 June. My investigator
later obtained a full printout from Pentonville.
702. The missing record would have contained pertinent information for any
healthcare staff who assessed the man between 9 and 12 June at
Wandsworth. Clinical records at the two prisons cannot be shared
electronically and a physical printout has to be sent with the prisoner when
they transfer. It would appear that an up-to-date printout was not sent with
the man on 9 June.
The Head of Healthcare at Pentonville should ensure that an up to date
copy of a prisoner’s clinical record is always sent with them when they
transfer out.
703. The Head of Healthcare at Pentonville told my investigators that he failed to
record two telephone conversations in the man’s clinical record. On 13 May,
he spoke to the Head of Healthcare at Wandsworth to resolve confusion
about the transfer which had gone awry. On 8 June, he spoke to one of the
Head of Healthcare at Wandsworth’s colleagues to let his healthcare team
know that the man was transferring back to them the next day.
The Head of Healthcare at Pentonville should remind staff of the
importance of recording all correspondence about a patient in their
clinical record.
Pharmacy
704. During the emergency on 12 June, Officer 14 was asked to request
adrenaline and atropine from the prison’s pharmacy. He said that he spoke to
two members of staff in succession who were unhelpful. He thought that they
Final Report: January 2011 134
seemed reluctant to respond to the emergency and did not seem to grasp the
urgency of the situation. They suggested to the officer that he visit the
pharmacy to collect the adrenaline. They thought that the doctors working on
the man should use the adrenaline in the emergency drug box or the
emergency bag, both of which are in the treatment room on the Onslow
Centre. The pharmacy is located on the opposite side of the prison to the
Onslow Centre, quite some distance away.
705. My investigator discussed the officer’s concerns with the principal pharmacist.
She explained that the pharmacy technicians Officer 14 spoke to were agency
staff (although the female technician was regarded as semi-permanent,
having worked at Wandsworth for over a year). Both members of staff have
left the prison, and my investigator was unable to interview them.
706. The principal pharmacist confirmed that the female technician carried a set of
keys and knew her way around the prison. The principal pharmacist was
unsure how long the male technician had worked in the pharmacy. She could
not say whether he carried keys, or would have felt confident to find his way to
the Onslow Centre. It is conceivable that the first person the officer
telephoned lacked confidence within the prison environment. This may have
resulted in his unhelpful attitude and failure to respond immediately to the
emergency. However, this does not adequately explain why the male
technician did not immediately ask a colleague to take the adrenaline.
707. When my investigator talked to the principal pharmacist, she suggested that
staff trying to resuscitate the man could have made use of adrenaline stored
on the wing. However, Nurse 8 explained why the doctors requested
adrenaline from the pharmacy. She said that, in her experience, the
emergency drug box containing adrenaline is often locked away in a cupboard
in the treatment room. The principal pharmacist said that this box is not
supposed to be locked away and should always be located on top of the
cupboard.
708. Every nurse has a key to the treatment room. However, they do not
automatically have keys to the cupboards. Because the emergency
happened over lunchtime, the nurse in charge of the treatment room and in
possession of the key to the cupboard was not present on the wing.
709. With regard to the adrenaline found in the emergency bag, Nurse 8 indicated
that this is a small amount contained in an Epipen (a pre-filled syringe
designed to be given when a patient suffers an allergic reaction or
anaphylactic shock). She did not think that this type of equipment would have
proven adequate because there was only a small amount of adrenaline and
the way the Epipen is designed would make it difficult to deliver the drug
directly into a vein.
710. As far as the request for atropine is concerned, the principal pharmacist told
my investigator that the pharmacy does not stock this drug. She explained
that she has encountered problems obtaining supplies.
Final Report: January 2011 135
711. The reaction of the pharmacy technicians to Officer 14 was disappointing. It
is hard to understand why the officer apparently had to argue with pharmacy
staff and justify his request. The technicians should have responded
unquestioningly, even if the telephone call had been a false alarm. In the
event, adrenaline brought by the air ambulance crew was administered to the
man before the female technician reached his cell.
712. One of the reasons why pharmacy staff responded in the manner they did
may be that all the technicians are temporary workers sourced from agencies.
The principal pharmacist confirmed that she has no permanent staff at this
grade. I am concerned that technicians may lack confidence moving around
the prison quickly in an emergency, and may not understand the shorthand
used by staff communicating over the radio and telephone.
Wandsworth Primary Care Trust should renew attempts to recruit
permanent pharmacy technicians.
The Head of Healthcare at Wandsworth should devise a protocol with
the Principal Pharmacist to ensure that pharmacy staff respond
immediately and unquestioningly when asked to provide drugs for
prisoners, especially during an emergency.
The Head of Healthcare at Wandsworth and the Principal Pharmacist
should explore the possibility of stocking atropine in the pharmacy.
The Head of Healthcare at Wandsworth and the Principal Pharmacist
should ensure that the emergency drugs boxes in each treatment room
are not locked away at any time. Consideration should be given to
mounting them on the wall.
Nurse 4
713. When my investigator visited the Onslow Centre shortly after the man died, he
spoke to Prisoner 2. He said that he had been concerned about the man
when they returned together to Wandsworth on 9 June. Prisoner 2
remembered that the man became increasingly distressed whilst they were
waiting to be assessed by Doctor 1 on the first night centre. Prisoner 2 said
that he explained to Nurse 4 that the man was disturbed and was talking
about taking his own life. He claimed that Nurse 4 said that this was ‘none of
his business’ and told the man to ‘pull himself together’. Prisoner 2 said that,
a few days after the man died, the nurse warned him not to say anything
about what had happened.
714. My investigators spoke to Nurse 4 on 5 August whilst they were conducting
interviews on the Onslow Centre. He denied working on the first night centre
on 9 June and suggested that the investigator should speak to the Head of
Healthcare at Wandsworth to confirm the shift pattern for that day. The
investigator met the Head of Healthcare on 28 October and was provided with
a copy of the rota, which showed that Nurse 4 worked in Wandsworth on 9
June but was not scheduled to be on the first night centre. On 28 October,
Final Report: January 2011 136
my investigator also conducted a further, taped interview with Prisoner 2,
during which he reiterated his claim. Another prisoner, Prisoner 3, supported
his statement.
715. On 5 November, the investigator conducted a recorded interview with Nurse
4. He said that he did not work on the first night centre on 9 June and was
working elsewhere in the prison with his colleague, Nurse 6. He told my
investigator that he had not worked on the first night centre for a long time.
He said that the incident described by Prisoner 2 did not take place.
716. My investigator interviewed Nurse 6. She confirmed that she worked with
Nurse 4 on 9 June but could not recollect visiting the first night centre with
him. Prisoner 2 said Nurse 5, another nurse, was present on the first night
centre at the time of the alleged incident. My investigator also spoke to Nurse
5. He confirmed that he worked on the first night centre with Doctor 1 on 9
June. Nurse 5 could not recall Nurse 4 being present and confirmed that he
unlocked both Prisoner 2 and the man from their cell to take them to see the
doctor. Given that the statements provided by Nurse 4’s colleagues support
his version of events, I am satisfied that nothing untoward occurred.
Preserving the man’s dIgnity after his death
717. After the man died, Prisoner 6 said that he walked past the cell and saw the
man’s body. He was upset by this and thought that the doorway should have
been covered. However, statements given by two other prisoners to the
police at the time indicate that a sheet had been placed across the entrance
by the time they were released from their cells. On balance, I am satisfied
that staff took appropriate steps to preserve the man’s dignity.
Informing the man’s family of his death
718. The man was declared dead shortly before 2.20pm on 12 June. His family
live in a nearby part of South London, just under four miles away. The family
liaison team reached the address two hours later, just after 4.30pm. By this
stage, the man’s mother had already been telephoned by a prisoner on the
Onslow Centre who had a mobile telephone and informed her of her son’s
death. She was actually on the telephone to the prison when Governor 7 and
the chaplain arrived. My investigators asked Governor 7 if anything had
prevented him from informing the man’s mother more promptly.
719. Governor 7 was assigned as the FLO at 2.45pm. He was unable to firmly
establish the name and address of the man’s next of kin in his core record.
Instead, he found the man’s mother’s name and address in social visits
paperwork. Governor 7 made an assumption that the man’s mother was the
nominated next of kin.
720. Having found the man’s mother’s address, Governor 7 considered how best to
travel there. He decided against using his own car as he was concerned
about finding the address and did not want to struggle to park the car when
they arrived. He also decided against using a taxi as the company with whom
Final Report: January 2011 137
Wandsworth have an account is not located in the vicinity and waiting times
for collection are often unreasonable.
721. In the event, Governor 7 and the chaplain opted to use an eight seater
prisoner escort vehicle. Governor 7 asked an OSG to drive them, drop them
off and park the vehicle a discreet distance away. Governor 7 was conscious
of getting lost and told my investigators that the Prison Service van was
equipped with a satellite navigation device, something his own car did not
have.
722. Governor 7 assumed that the vehicle was parked inside the prison but it was
parked outside the grounds. Some additional time was taken up meeting the
driver, exiting the prison and reaching the vehicle. Governor 7 explained that
the traffic was heavy, first because that part of London is regularly congested,
and secondly because it was Friday afternoon.
723. I have no doubt that the decisions made by Governor 7 were well intentioned.
He believes that he and his colleagues could not realistically have made the
journey any quicker than they did. He told my investigators that, even with the
benefit of hindsight, he would not do anything differently.
724. However, when a relative lives so close to the prison, it is regrettable that
notification takes over two hours and a prisoner is able to make contact first.
Because mobile telephones are an acknowledged (albeit illegal) part of prison
life, rapid notification can be crucial.
725. Although Governor 7 could not initially determine the details of the nominated
next of kin from the man’s records, my investigators subsequently found three
different forms providing this information. One was completed as part of the
core record on 21 April and gave the man’s sister’s name and the family’s
address. The other two forms, completed on 21 April and 26 May at
Pentonville as part of the induction process, named the man’s mother as the
next of kin and recorded the same address. Because he could not identify the
required information from these documents, Governor 7 spent (by his
estimate) half an hour looking through the social visits paperwork.
726. In my experience, it is common for a FLO to use their own transport in order
to hasten the notification process. Although Governor 7 was worried about
parking and getting lost and wanted a vehicle with a satellite navigation
device, the choice of a prisoner escort vehicle may not have been
appropriate. The van and the driver seem to have taken a little while to
locate. The vehicle was also conspicuous, being a 12 seater minibus with an
orange stripe down the side and Prison Service markings.
727. As regards the taxi account, from what my investigators have gathered this is
a far from adequate arrangement. Prison staff often need taxis at short
notice, for example when following a prisoner escort to hospital. The firm is
located in another part of London and the arrangement is impractical such
that staff actively seek alternatives.
Final Report: January 2011 138
728. Governor 7’s avoidance of the prison’s usual taxi firm is understandable.
However, another member of staff mentioned that he uses an alternative
company based very close to Wandsworth. In future, the designated FLO
may wish to keep several alternative taxi telephone numbers to hand for just
such an emergency. The Governor of Wandsworth may wish to think about
reassigning the prison’s taxi account to a company in the immediate locality.
The Governor of Wandsworth should remind the designated FLO to use
the quickest form of transport available to reach the next of kin.
729. My investigator and FLO visited the man’s mother some weeks later. It
became apparent that she did not realise that her son had made another
attempt to take his own life on 1 June. She was aware of the first attempt and
the family had visited the man in hospital. However, staff at Pentonville do not
seem to have advised the family of the second attempt.
730. Paragraph 13.3.3 of PSO 2700 indicates that, after an incident of self harm,
staff should ask the prisoner if they want their family to be contacted. The
nominated next of kin must be notified unless the prisoner refuses to consent.
There is no record in the ACCT document of a conversation with the man on 1
June about informing his family. This is surprising given the considerable
care that was previously taken to accommodate the man’s family when he
stayed at hospital. The lack of contact is also unusual given how aware staff
at Pentonville were of the man’s circumstances.
The Governor of Pentonville should remind staff of the requirements of
PSO 2700. After an incident of self harm, staff should ask the prisoner if
they want their nominated next of kin to be informed. The next of kin
should be told unless the prisoner refuses to provide their consent.
Good practice
731. I am conscious that my investigation has been necessarily critical of both
Pentonville and Wandsworth. I would like to conclude by highlighting
examples of good practice. First, I note the efforts to which the manager of
the mental health in-reach team at Wandsworth and her colleagues went to
prepare for the man’s release on 20 March. The pre-release liaison that took
place between the CMHT, the prison, the offender manager and the approved
premises provided the man with appropriate support in the community. I also
note the man’s offender manager’s attempts to put in place support for the
man in the community.
732. The clinical reviewer praises the efforts of the In-Reach teams at both prisons
between April and June:
‘Many professionals appeared sympathetic to [the man’s] circumstances.
In my opinion his overall treatment for his mental illness was equitable
with services available outside prison. There are a number of examples
of good practice by professionals in the In-Reach teams.’
Final Report: January 2011 139
733. I also draw attention to the commendable actions of Officer C and her
colleagues on 22 April. Just when the man tried to take his own life, Officer C
decided to check him because she was concerned. When she found the man
hanging in his cell, she and her colleagues took swift action to cut him down
and begin resuscitation. I understand that, without the rapid intervention of
the officers and healthcare staff, the paramedics who subsequently attended
said that they would not have been able to successfully revive the man.
734. The hot debrief meeting run by Governor C later the same day was a
thorough exploration of the lessons to be learnt from the emergency. During
the man’s stay in hospital over the next few days, the management team at
Pentonville showed sensitivity in not cuffing him whilst he was sedated. They
paid for the man’s mother to travel to the hospital by taxi. When the man
returned to the healthcare centre, effective liaison took place between the two
prisons to keep the man safe and return him to Wandsworth.
735. Governor Y’s acceptance of the man at Brixton on 12 May showed very sound
judgement. He gathered information, considered what was in the man’s best
interests and acted cautiously in monitoring his safety. He contacted the
other prisons and attempted to resolve a confusing situation which was not of
his making.
736. Returning to Pentonville, the man made a second attempt to take his own life
at the beginning of June. Officer I checked him and acted quickly to cut him
down.
737. That the man subsequently took his own life should not detract from any of
these achievements.
Final Report: January 2011 140
CONCLUSION
738. The man was a prisoner with mental health difficulties held in an imperfect
prison system. He moved four times in a seven week period, something
which I believe interrupted his continuity of care. My investigation highlights
examples of good practice by individual members of staff. For example, plans
for the man’s first move from Pentonville to Wandsworth were made in
considerable detail (albeit they were not implemented successfully).
However, my investigators found strong evidence to suggest that one of the
transfers between prisons was not in the man’s best interests. Of the four
moves, two were at his own request, one happened accidentally and his
return to Pentonville on 26 May may well have been influenced by the
forthcoming inspection of Wandsworth.
739. The Prison Service has already mounted a disciplinary investigation into the
series of transfers between Pentonville and Wandsworth at the time of
inspections by HM Chief Inspector of Prisons. The man was not one of the
prisoners transferred directly as a consequence of the inspection of
Wandsworth at the beginning of June 2009. However, the circumstances of
his transfer on 26 May would certainly have led me to have recommended a
disciplinary investigation had one not already taken place. As it is, my report
reveals new facts not known at the time of the Prison Service’s internal inquiry
and draws attention to the indirect impact on the man of the transfers as a
whole. For those reasons, I have recommended that the Director Genral of
NOMS reviews the new evidence to determine whether a renewed disciplinary
investigation is required.
740. Individuals with mental health needs, drug and alcohol misuse problems and
a history of associated offending too often fail to get the help they need. The
man was most probably not so unwell as to warrant sectioning in a hospital.
However, his mental health problems were still pronounced and resulted in
poor decision making in the community.
741. Before too long the man reoffended, despite the efforts of his offender
manager and his local mental health team. The prison system is poorly
equipped to give people such as the man the care and support they need. He
was held in large local prisons, where a significant proportion of the
population may have similar mental health concerns.
742. The man was unwell and I believe that he should have had a stable
environment where he felt safe. This did not happen for the reasons I have
explored. Paradoxically, it was at Wandsworth, where he said he would feel
safe, that he took his life.
743. A number of staff had tried to make sure that the man moved to Wandsworth
after a very serious suicide attempt at Pentonville. Yet within a fortnight their
good work was undone and he was back in a prison to which he had been
assured he would not return. The man transferred back to Wandsworth after
another suicide attempt at Pentonville. It is impossible to gauge with certainty
the impact the various moves had on his mental health, but frequent transfers
Final Report: January 2011 141
are a known risk factor for self-harm and suicide, especially amongst the
already vulnerable.
744. In the last few days of his life, the man was placed in a cell with a prisoner
who was well known for being extremely difficult to share with. He told staff
that his cellmate had made a threat of a sexual nature towards him. He was
encouraged to speak to Operation Trident, although we cannot know what
impact their involvement had on his state of mind. His changing
circumstances and concerning presentation on the morning of 12 June
unfortunately did not prompt staff to review the ACCT monitoring.
745. There are many lessons to be learned from the circumstances surrounding
the man’s death. Above all, prisoners with significant mental health needs
should be provided with continuity of care and a stable custodial environment.
For a variety of reasons – some by chance, some by design – these benefits
were not afforded to the man.
Final Report: January 2011 142
RECOMMENDATIONS
Recommendations for Wandsworth
1. The Head of Healthcare at Wandsworth should ensure that the relevant duty
governor is always informed on the day if a healthcare to healthcare transfer
is anticipated.
NOMS accepted the recommendation and provided the following response:
‘The Head of Healthcare will (and remind healthcare managers also) to notify
the duty governor (duty manager 1) once a healthcare to healthcare
transferred has been requested by another establishment (i.e. requesting that
a prisoner transfer to HMP Wandsworth) or that the HMP Wandsworth
healthcare department is considering a transfer to another prison. In both of
these cases, healthcare is to advise the duty governor in terms of clinical
suitability, potential risk factors, availability of beds etc. However, the decision
lies with the duty governor (duty manager 1) in terms of agreeing the transfer
formally with their counterpart in the sending/ receiving establishment. Duty
managers will be advised accordingly.’
2. Wandsworth Primary Care Trust should review the inpatient healthcare
facilities at Wandsworth. Consideration should be given to increasing the
capacity for prisoners with mental health problems and suicidal thoughts who
do not fit the criteria of the Addison Unit.
NOMS accepted the recommendation and provided the following response:
‘This will be discussed as a part of the current service level agreement review
with South West London and St George’s Mental Health NHS Trust. The
primary care trust and prison are currently looking at capacity issues.’
3. The Heads of Healthcare and In-Reach at Wandsworth should review the way
in which information is communicated between them. The Head of
Healthcare should ensure that prisoners with a history of mental health
problems are referred to the In-Reach team for an assessment during the
reception process.
NOMS accepted the recommendation and provided the following response:
‘The Head of Healthcare is currently developing Primary Mental Health
services including a management role to assist in establishing clear
information and referral pathways. Referral to in-reach services will include
direct referral from reception.’
4. The Governor of Wandsworth should ensure that the stamp used during the
handover period between the night and day staff is amended so that it
requires staff to record the date and time of the handover.
NOMS accepted the recommendation and provided the following response:
Final Report: January 2011 143
‘Stamps will be adjusted accordingly’
5. The Governor of Wandsworth should ensure that all staff working on the
Onslow Centre receive further training in the use, completion and day-to-day
operation of the ACCT document as soon as is practicable. Particular
emphasis should be placed on identifying new risk indicators, holding ACCT
reviews promptly and amending the frequency of observations to reflect the
level of risk.
NOMS accepted the recommendation and provided the following response:
‘A training plan will be developed specifically for the Onslow unit, so that
training will take place every six months. The training will incorporate
concerns that have been raised as a result of death in custody investigations
as well as focusing on specific risk indicators for this population.’
6. The Governor of Wandsworth should remind staff conducting ACCT reviews
to invite contributions from the In-Reach team when a prisoner has a
diagnosed mental disorder.
NOMS accepted the recommendation and provided the following response:
‘It is accepted that the In-reach team should be involved in ACCT reviews of
prisoners who come under their remit. There is currently a member of the In-
reach team assigned to attend reviews in each area.
‘However, due to medical in confidence, it would cannot be assumed that
prison staff will always know whether a prisoner is presenting with severe and
enduring mental health issues and therefore, under the care of In-reach.
(1) The safer custody team will provide, on a weekly basis, a list of prisoners
currently on ACCT forms.
(2) If a prisoner is assigned to a CPN, In-reach will make a clear note on the
ACCT form of who the prisoner’s CPN is.
(3) Staff will be advised to contact this CPN to update them and get advice and
input if an ad hoc review takes place due to changes in the prisoner’s situation
e.g. act of self-harm. ‘
7. The Governor of Wandsworth should ensure that staff completing CSRAs do
not copy information verbatim from another CSRA, but rather combine
previous assessments with the prisoner’s presentation to support and inform
their own judgement.
NOMS accepted the recommendation and provided the following response:
Final Report: January 2011 144
‘This will be focused on in the induction training for new officers and the
current Violence Reduction Training for operational staff.’
8. The Governor of Wandsworth should ensure that detailed information about
the nature of any threats towards a prisoner are clearly recorded by staff,
particularly in an ACCT document if one is open.
NOMS accepted the recommendation and provided the following response:
‘A Governor’s Order will be published accordingly.’
9. Wandsworth Primary Care Trust should renew attempts to recruit permanent
pharmacy technicians.
NOMS accepted the recommendation and provided the following response:
‘Recruitment and short-listing has taken place. Interviews and appointments
should be completed by end of July 2010.’
10. The Head of Healthcare at Wandsworth should devise a protocol with the
Principal Pharmacist to ensure that pharmacy staff respond immediately and
unquestioningly when asked to provide drugs for prisoners, especially during
an emergency.
11. The Head of Healthcare at Wandsworth and the Principal Pharmacist should
explore the possibility of stocking atropine in the pharmacy.
12. The Head of Healthcare at Wandsworth and the Principal Pharmacist should
ensure that the emergency drugs boxes in each treatment room are not
locked away at any time. Consideration should be given to mounting them on
the wall.
NOMS accepted recommendations 10, 11 and 12 in principle and provided
the following response:
‘The Head of Healthcare will review the local resuscitation policy including the
range of drugs for emergencies. These will be available within the drug pouch
in the emergency resuscitation bags.’
13. The Governor of Wandsworth should remind the designated FLO to use the
quickest form of transport available to reach the next of kin.
NOMS accepted the recommendation and provided the following response:
‘The Governor will remind all FLOs. It will also be considered whether a phone
call to the family initially, particularly if they live far from the prison, would be
at times appropriate to ensure that the family are informed by the FLO rather
than another prisoner.’
Final Report: January 2011 145
Recommendations for Pentonville
14. If a new prisoner tells a doctor during the reception process that he is being
prescribed anti-psychotic medication, the Head of Healthcare at Pentonville
should ensure that the prescription is continued on the first night in custody.
The prescription should be confirmed with the community provider by the end
of the next working day.
NOMS accepted the recommendation and provided the following response:
‘To be discussed at the next patient safety committee and recommendation
implemented.’
15. The Head of Healthcare at Pentonville should ensure that all prescriptions are
reviewed at pre-determined intervals and that staff understand the review
process.
NOMS accepted the recommendation and provided the following response:
‘To be discussed at the next patient safety committee and recommendation
implemented.’
16. The Governor of Pentonville should ensure that staff perform a thorough
search of prison information systems when a new prisoner arrives in custody.
As well as the individual’s prison number, staff should also check their
surname and date of birth.
NOMS accepted the recommendation and provided the following response:
‘With the introduction of P-NOMIS, an offender is now given one prison
number which remains with them every time they enter prison, retaining all
their previous details and alerts, including case notes and self harm
behaviour.’
17. The Governor of Pentonville should remind staff of the importance of notifying
the Public Protection Casework Section immediately when a prisoner whose
licence has been revoked arrives at the prison.
NOMS accepted the recommendation and provided the following response:
‘Instructions to be issued to Offender Management unit by the Head of
Reducing Re-offending’
18. The Head of Healthcare at Pentonville should ensure that the primary
healthcare team makes an immediate referral to the In-Reach team when a
prisoner is placed under constant supervision.
NOMS accepted the recommendation and provided the following response:
Final Report: January 2011 146
‘To be discussed at the next patient safety committee and recommendation
implemented.’
19. The Governor of Pentonville should ensure that, when staff write the intended
frequency of observations on the front cover of an ACCT document, they note
their initials, the date and time next to their entry.
NOMS accepted the recommendation and provided the following response:
‘To be incorporated in a Notice to Staff and this action point will be included in
all future ACCT training. This will also be included as part of the managers
weekly ACCT checks.’
20. The Governor of Pentonville should ensure that staff understand the
maximum frequency of ACCT checks possible on normal location before a
prisoner has to be moved to a healthcare setting for observation.
NOMS accepted the recommendation and provided the following response:
‘Draft protocol currently with the head of Healthcare for comment, final draft to
be discussed and agreed at the patient safety committee and then published.’
21. The Governor of Pentonville should ensure that an ACCT document is always
opened if a prisoner is placed under constant supervision.
NOMS accepted the recommendation and provided the following response:
‘Draft protocol currently with the Head of Healthcare for comment, final draft to
be discussed and agreed at the patient safety committee, then published.’
22. The Governor of Pentonville should ensure that staff make a record in a
prisoner’s ACCT document when they find and confiscate a means of self
harm such as a ligature.
NOMS accepted the recommendation and provided the following response:
‘To be incorporated in a Notice to Staff and this action point will be
incorporated into all future ACCT training.’
23. The Governor of Pentonville should ensure that staff complete all four
sections of a prisoner’s CSRA the day the prisoner arrives.
The recommendation was incorrectly addressed to the Governor of
Wandsworth in the draft report. With the publication of the final report, I would
ask the Governor of Pentonville to consider it.
24. The Head of Healthcare at Pentonville should ensure that an up to date copy
of a prisoner’s clinical record is always sent with them when they transfer out.
NOMS accepted the recommendation and provided the following response:
Final Report: January 2011 147
‘To be discussed at the next patient safety committee and recommendation to
be implemented.’
25. The Head of Healthcare at Pentonville should remind staff of the importance
of recording all correspondence about a patient in their clinical record.
NOMS accepted the recommendation and provided the following response:
‘To be discussed at the next patient safety committee and recommendation to
be implemented.’
26. The Governor of Pentonville should remind staff of the requirements of PSO
2700. After an incident of self harm, staff should ask the prisoner if they want
their nominated next of kin to be informed. The next of kin should be told
unless the prisoner refuses to provide their consent.
NOMS accepted the recommendation and provided the following response:
‘This will be incorporated into the work of Pentonville’s Family Liaison Officer.’
Recommendations for Wandsworth and Pentonville
27. The Governors of Wandsworth and Pentonville should each introduce a
central transfer register. The register should be used by all departments.
Staff should record their decision making in relation to all ad hoc transfers
which are not organised at a national level.
NOMS accepted the recommendation and provided the following response:
‘A protocol has been introduced for all transfers within prisons in the London
area.’
28. The Heads of Healthcare at both Wandsworth and Pentonville should ensure
that all staff, including doctors, who have contact with prisoners receive formal
training in the use of the ACCT document.
NOMS accepted the recommendation and provided the following response:
‘Wandsworth. ACCT foundation training is currently a part of the induction
training for all staff. In liaison with healthcare, a training plan will be developed
specifically for healthcare staff, both permanent and locum.
‘Pentonville. To be discussed at the next patient safety committee and
recommendation to be implemented.’
29. The Governors of Pentonville and Wandsworth should ensure that staff
completing Cell Sharing Risk Assessments (CSRAs) consult previous CSRAs
for relevant information. Previous CSRAs should be stored together in date
order.
Final Report: January 2011 148
NOMS accepted the recommendation and provided the following response:
‘Wandsworth. This process has changed significantly due to the introduction
of P NOMIS. Although an electronic version of the CSRA is not yet available,
if there are particular concerns about a prisoner’s risks to others and a single
cell is advised, an update will be inputted by the duty governor in the
prisoner’s case notes which can be accessed by prison staff nationally.
Additionally, when a prisoner arrives from another prison, their current CSRA
level is clearly visible on the system.
‘Pentonville. P NOMIS will hold all previous CSRA information. Reception staff
will ensure they check through all documentation which arrives with the
prisoner and collate previous CSRAs together.’
Recommendations for London Probation Trust
30. London Probation Trust should ensure that staff working in court promptly
inform the relevant offender manager and other colleagues working with the
offender (such as approved premises staff) of the outcome of a court
appearance.
London Probation Trust accepted the recommendation and provided the
following response:
‘This is standard practice. Court staff routinely check to see whether or not
anyone appearing in Court is currently known. They then communicate the
result to the relevant Offender Manager.’
31. London Probation Trust should remind staff to check with the Public
Protection Casework Section (PPCS) if they discover from another source
that a recalled offender has been returned to prison.
London Probation Trust accepted the recommendation and provided the
following response:
‘There is a section in the recall report submitted to PPCS that asks specifically
whether or not the offender being recalled is already in custody. PPCS would
therefore know if a recalled offender has been returned to prison.’
Recommendation for the Public Protection Casework Section
32. The Head of the Public Protection Casework Section should ensure that staff
carrying out ‘unlawfully at large’ checks are trained to access and correctly
interpret a prisoner’s complete IIS record.
NOMS accepted the recommendation and provided the following response:
Final Report: January 2011 149
‘PPCS staff are trained to access and use IIS. PPCS will arrange for refresher
training to be given to all casework staff. This will be completed by the end of
August 2010.’
Recommendation for the National Offender Management Service
33. The National Offender Management Service should consider whether to issue
guidance to prison staff in England and Wales outlining how best to explain
the recall process to prisoners with mental health difficulties. They may wish
to recommend that, if a prisoner is registered with an In-Reach team, a
member of that team is present.
NOMS accepted the recommendation and provided the following response:
‘Guidance has been issued to prison staff which explains the recall process in
simple terms. PPCS will develop guidance for staff to use specifically for
prisoners with mental health issues.’
34. The Director General of NOMS should review the new evidence in this report
to determine whether a renewed disciplinary investigation is warranted.
NOMS accepted the recommendation and provided the following response:
‘A careful review of the evidence presented in the PPO Report has been
completed and as a result the Chief Executive Officer has decided that further
disciplinary investigation is not warranted.’
Recommendation for Offender Health
35. To ensure continuity of care, Offender Health should instruct In-Reach teams
to write under ‘Health Risks’ on the Risk Indicator page of the PER the
intended return destination of a prisoner under their care if that prisoner is
appearing at a court that will not automatically return them to the dispatching
prison.
Offender Health accepted the recommendation and provided the following
response:
‘Improving Health Supporting Justice, the national delivery plan of health and
the criminal justice programme board are working with the PCTs and
Commissioners to develop a pathway model and disseminate it.’
Response from the man’s family
The draft version of the report was published in May 2010. At the time of publication of the
final report, my senior family liaison officer had not received any comments from the man’s
family.
Final Report: January 2011 150