Individual at Wandsworth

Investigation into the circumstances surrounding
the death of a man at HMP Wandsworth in April 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2011
This is the report of the investigation into the circumstances surrounding the death of
a man. He was found hanging in his single cell at HMP Wandsworth in April 2010.
He was 31 years old and, having been convicted of several serious offences, was
waiting to be sentenced. I offer my sincere condolences to his family and all those
touched by his death.
The investigation was conducted by an investigator on my behalf. I would like to
thank the Governor of Wandsworth and his staff for their co-operation with the
investigation. I am particularly grateful to one senior officer for his work as the
investigation liaison officer.
The local primary care trust commissioned a clinical reviewer to review the clinical
care the man received. I am grateful to him for his timely review.
The man had been in prison before and, when arrested and remanded into custody
in July 2009, had several other outstanding charges progressing through the court
system. Because he had several court cases pending, he was transferred between
three London prisons from his remand in July until his death. Sadly this is not the
first time that I have commented on the impact of such transfers.
During his period in custody, he gave staff no indication that he was vulnerable or a
risk to himself. In fact, this investigation has identified no particular reasons for him
to have acted as he did. It is possible that he was worried that he might be facing a
long prison sentence, although he did not raise any such concerns with staff or
friends.
It is also possible that the man suffered with mental health problems, although
medical opinion was divided. Certainly, on some occasions he told staff that he had
a history of mental ill health and on others denied this. Regardless of whether he did
or did not have mental health problems, I am concerned to find procedural failings in
the transfer of clinical information between the prisons involved. It is not the first
time that I have identified such an issue in relation to a death at Wandsworth. I
make one recommendation to the Head of Healthcare. I also make one
recommendation to the Head of the Mental Health Inreach Team to clarify the
referral procedures between prisons.
Although generally his time in prison was uneventful, the man claimed to have a
violent temper and on one occasion, allegedly punched a fellow prisoner several
times. My third recommendation relates to the prison’s failure to deal with or explore
this violent outburst.
However, I do not think that his actions were foreseeable or, for that reason,
preventable. While I have identified procedural omissions, I do not think that the
recommendations I make would have altered the outcome.
The final version of my report includes the National Offender Management Service’s
(NOMS) response to the recommendations made.
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This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Acting Prisons and Probation Ombudsman January 2011
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CONTENTS
Summary
The investigation process
HMP Wandsworth
Key events
Issues
Conclusion
Recommendations
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SUMMARY
The man was remanded into the custody of HMP Wandsworth on 20 July 2009,
having been charged with wounding with intent, attempted robbery and possession
of a knife in a public place. It was not his first time in prison and, when remanded,
he also had a number of other cases proceeding through court.
On his arrival at Wandsworth, he told staff that he had no physical or mental health
problems and had never tried to harm himself. However, he said that he had a quick
temper, was aggressive and should not share a cell. Except for his first night at the
prison, he occupied a single cell.
In August, the man appeared in court in relation to another matter and, following his
appearance, transferred to HMP Pentonville. He had been in Pentonville before and
staff there believed that he suffered with mental health problems. During his three
weeks there, he received intervention from the prison’s specialist mental health
team. On 24 August, he was sentenced to 12 months in prison for a previous
offence of robbery.
The man transferred back to Wandsworth on 3 September. This investigation has
not been able to establish whether his Pentonville clinical records transferred with
him. Certainly, healthcare staff at Wandsworth do not appear to have known about
his contact with the Pentonville mental health team. Reception healthcare staff did
not refer him to the Wandsworth mental health team. Pentonville staff recorded that
they had left a message alerting the Wandsworth mental health team to his transfer.
However, he was not assessed and did not receive any mental health intervention
while at Wandsworth.
In November, a member of staff saw the man punching a fellow prisoner in the face
several times. As a result, he was moved to the Care and Separation Unit (CSU)
and adjudication proceedings began. (The CSU is a small, separate unit within the
prison where prisoners who cannot be managed on the main wings are held. They
are held in single cells and have a restricted regime. When a prisoner is accused of
breaking a prison rule, they must appear in front of a governor who listens to the
evidence and decides whether the prisoner is guilty of the charge. If the prisoner is
found guilty, the governor may impose a punishment, such as loss of earnings or
cellular confinement for a period of time. This process is known as adjudication.)
Eventually, the adjudication was dismissed because too much time had passed
since the incident. However, it seems that no other action was taken to explore the
man’s violent outburst. It was not recorded in any relevant documents and no work
was carried out to address his behaviour.
On several occasions, he refused to attend court, claiming that he was unwell.
However, following a court appearance on 15 February, he was transferred to HMP
Wormwood Scrubs, where he spent about three weeks. His time there appeared to
be relatively uneventful.
He moved back to Wandsworth on 8 March. Again, it has not been possible to
confirm whether his clinical records transferred with him; certainly there was no
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evidence of them in his medical file. However, following publication of the draft
version of this report, Wormwood Scrubs provided a copy of the electronic record
relating to his time there.
The man was convicted of the July offences in March 2010 and remanded back into
custody to await sentencing, which was due on 30 April. It seems that he might have
been told that the court was considering an indeterminate sentence for public
protection (IPP). (IPP sentences apply to those who commit certain serious violent
or sexual offences and who are deemed to pose a “significant risk of serious harm in
the future”. The sentencing court sets a minimum period of imprisonment required,
but the individual will only be released after that point if the risk to the public has
been reduced.) He gave no outward signs of being concerned about this possibility.
In the days prior to his death, he gave no indications that he was vulnerable or
struggling to cope. He asked a member of wing staff about a Playstation he had
brought from another prison, talked normally with his friend and appeared to be his
normal self.
In April a member of staff carrying out a routine check at about 8.00pm, looked into
the man’s cell and saw that he had a ligature around his neck. Staff responded
quickly and the ligature was cut and emergency first aid began. Despite the best
efforts of officers, two prison nurses and paramedics, he could not be resuscitated.
I make three recommendations as a result of this investigation. One is to the Head
of Healthcare and relates to transferring clinical information between prisons when a
prisoner transfers. The second is for the Head of the Wandsworth mental health
team and concerns the referral of prisoners to the team. The final recommendation
is for the Governor and concerns how allegations or incidents of violence should be
dealt with. Despite these failings, I take the view that the man’s death could not
have been foreseen, or therefore, prevented.
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THE INVESTIGATION PROCESS
1. The Ombudsman’s office was notified of the death of the man in April 2010. The
investigation was initially allocated to an investigator. In May, a colleague took
over the investigation.
2. Notices were issued inviting staff and prisoners to contact the investigator with
any information they felt might be relevant to the investigation. There was no
response to the notices. The investigator carried out interviews with staff and
prisoners at Wandsworth in July 2010. Additionally, she made telephone contact
with the man’s community offender supervisor and healthcare staff at HMP
Pentonville.
3. She was provided with relevant documentation covering the man’s time at
Wandsworth, including a copy of his prison records and the staff incident reports
written after his death. Copies of the electronic medical records relating to his
time at Pentonville and Wandsworth were provided but the medical file relating to
his time at HMP Wormwood Scrubs is missing and despite searches has not
been located.
4. The local PCT appointed a clinical reviewer to review the clinical care the man
received at Wandsworth. He had access to the medical record and transcripts of
the interviews the investigator carried out at Wandsworth. I am grateful to him
for his timely review.
5. HM Coroner for Inner West London was informed of the nature and scope of the
investigation. A copy of this report will be sent to him to assist with his inquiries.
6. One of the Ombudsman’s family liaison officers contacted the man’s family to
explain the investigation process and invite them to raise any concerns or
questions. They said that staff and another prisoner at Wandsworth told them
that he had seemed fine in the days before his death. There were no signs that
he was struggling to cope or was vulnerable.
7. When the family visited the prison to see his cell, they were told that a day or two
before his death the man asked for access to a Playstation. Later they were told
this was not the case, which left them confused. His family told the family liaison
officer that he thought he would be released soon and was looking to the future.
They felt that something was not right as there was no indication he was thinking
of taking his life. His family also wanted to know if he had broken any prison
rules or been in any trouble in the months leading to his death. I hope this report
helps to answer their questions and build a picture of his time in prison.
8. Since the Ombudsman began investigating all deaths in prisons in 2004, 15
prisoners (including the man) have apparently taken their lives while at
Wandsworth. In three other cases, aspects of the relevant paperwork have been
missing. In two of those cases, the paperwork appears to be missing as a result
of the prisoner transferring between London prisons. Investigations into deaths
at other London prisons have highlighted similar issues and so the Ombudsman
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will raise the matter by letter with the National Offender Management Service
(NOMS) and the National Health Service regional offender lead.
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HMP WANDSWORTH
9. HMP Wandsworth is the largest prison in the United Kingdom, holding up to
1,665 adult male prisoners. It is a local category B prison, accepting prisoners
on remand, convicted and sentenced from courts within the catchment area. The
prison is formed of five residential wings and two specialist units. The original
prison buildings date from 1851, but since 1989, the prison has been undergoing
extensive refurbishment and modernisation.
10. The National Offender Management Service (NOMS) publishes quarterly
performance ratings for all prisons in England and Wales. The ratings are based
on a set framework, and prisons can be rated from one to four (with four
indicating ‘exceptional’ performance). Wandsworth has achieved a rating of
three (‘good’ performance) for the last four published quarters.
HM Chief Inspector of Prisons (HMCIP)
11. The former Chief Inspector of Prisons conducted a full announced inspection of
Wandsworth in June 2009. She noted the “troubled” modern history of the
prison, remarking that during the 1990s and the beginning of the present century
the prison received several “highly critical” inspection reports.
12. The inspection highlighted that under the then Governor, considerable steps had
been taken to “change a previously resistant staff culture, increase the quality
and quantity of activities, and improve prisoners’ resettlement chances”. The
suicide prevention strategy was “comprehensive” if “not user-friendly”. On the
wings, relationships between staff and prisoners were “generally relaxed and
supportive” with staff responsive to prisoner requests. However, black and
minority ethnic prisoners were less positive about staff.
Independent Monitoring Board (IMB)
13. Prisons in England and Wales are also subject to monitoring by an IMB, made
up of volunteers from the local community. Members of the IMB have access to
every part of the prison and each prisoner there. They produce an annual
report, the latest available for Wandsworth covers the period June 2009 to May
2010.
14. The IMB report noted that while recent years had seen improvements across the
establishment, “for a number of reasons, this change has been reversed”. The
Board considered that some of the difficulties were caused by an area-wide
shortage of officers. Such shortages were identified as leading to deteriorating
staff-prisoner relationships, with prisoners’ frustration “palpable”. The Board
noted that self harm figures had doubled during the past year.
15. The Board noted that the healthcare providers went into receivership at the start
of the Board’s reporting period. Healthcare services were taken over by
Community Services Wandsworth, part of the Primary Care Trust. Mental
healthcare is provided by a separate local organisation. Recruitment of
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permanent staff was recognised as a difficulty, and the impact on administration
was particularly noted.
HMP Pentonville
16. HMP Pentonville is a large local prison in North London, with capacity for 1,152
adult male prisoners coming from courts within the catchment area. The prison
was last inspected by HMCIP in an unannounced visit in May 2009. The report
noted the “undoubted improvements” at the prison and the “strong focus” on
safer custody procedures.
HMP Wormwood Scrubs
17. HMP Wormwood Scrubs is a local prison serving the courts of North West
London. The prison can hold up to 1,239 adult male prisoners on remand or
sentenced. The prison was last inspected by HMCIP in June 2008. The report
noted that, over recent years, the prison had been making “slow but steady”
progress which appeared to have “halted”. However, there was no evidence of a
negative staff culture and violence reduction and suicide prevention work was
good.
Cell Sharing Risk Assessment (CSRA)
18. The CSRA assesses the risk a prisoner poses to other prisoners and whether
they are suitable for sharing a cell. The assessment considers a range of factors
including the prisoner’s past offences, whether they have displayed bullying or
violent tendencies in the past, and any substance misuse or mental health
problems. The prisoner is asked whether they have any concerns about sharing
a cell and this is also taken into account. One part is completed by a discipline
officer and the other by a member of healthcare staff. The staff conducting the
assessment must decide whether the prisoner poses a low, medium or high risk
to other prisoners. Prisoners assessed as high risk will generally be placed in a
single cell, but the risk assessment will be reviewed frequently. The prisoner
may be required to work on those factors that make them high risk.
Assessment, Care in Custody and Teamwork (ACCT)
19. ACCT is the Prison Service process for supporting and monitoring those
prisoners thought to be at risk of harming themselves. An ACCT plan can be
opened by anyone working in the prison if they have any concerns that a
prisoner might have tried, or, in the future, might try to harm himself. The
purpose of ACCT is to try to determine the level of risk posed, the steps that
might be taken to reduce this and the extent to which staff need to monitor and
supervise the prisoner. Levels of observations (where staff must check the
prisoner) and interactions (where staff must have a conversation with the
prisoner) are flexible and can be set according to the perceived risk of harm. If
staff perceive the risk of harm to be very high, the prisoner may be constantly
observed, with a member of staff positioned outside their cell at all times. Where
the perceived risk is lower, the level of observations may be several times an
hour or day. Observations also take place during the night. As part of the
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process a CAREMAP (plan of care, support and intervention) is put in place and
there should be regular multi-disciplinary review meetings. Wherever possible,
the prisoner at risk is also included in review meetings.
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KEY EVENTS
20. The man grew up in London. Having completed his GCSEs and gained a
qualification in leisure and tourism, he worked in sales, security and retail. His
life had become less stable, with some alcohol and drug use and he had been
unemployed since 2006. He had been convicted of a number of offences, some
of which were serious and led to earlier periods of imprisonment.
21. On 20 July 2009, the man was remanded into the custody of Wandsworth having
been arrested by the British Transport Police and charged with wounding with
intent, attempted robbery and carrying a knife in a public place. He also had
ongoing charges of robbery and abduction against him.
22. On his arrival at Wandsworth, the man underwent a Cell Sharing Risk
Assessment (CSRA). The officer completing the assessment noted that he said
he had no substance misuse problems and that there was no evidence that he
had a history of harming himself. The officer recorded, however, that he had
convictions for violence. The man said that he was concerned about sharing a
cell and was quick tempered and very aggressive. He told the officer that “small
things set him off and he will fight with cell mate”. The officer judged that he
posed a medium risk to other prisoners. A nurse completed the second part of
the assessment, noting no concerns and judging him to pose a low risk to other
prisoners.
23. The man was also assessed by a nurse who completed the First Reception
Healthscreen. (The purpose of the healthscreen is to identify any immediate
physical or mental health concerns requiring referral to the doctor or other
specialist service. It is largely reliant on the prisoner disclosing information
himself.) She recorded that he had no medical problems, was of normal mental
state and had no history of attempting to harm himself. The nurse noted that he
had no alcohol or drug problems. She concluded that he did not need any
further medical treatment at that time and that he could be given a cell on one of
the main prison wings. On his first night in the prison he was allocated a double
cell, sharing with another prisoner. He moved to a single cell on 21 July.
24. During his first days in prison, the man received his induction, providing him with
information about life at Wandsworth. Staff noted that no issues had been raised
about him, or by him, during the process. On 23 July, an officer completed the
Local Initial Screening and Reducing Reoffending Tool (LISSART) with him. He
told the officer that, prior to coming to prison, he had no fixed address and that
he needed help with accommodation. The officer recorded that she would refer
him to St Giles (a voluntary organisation providing housing assistance and
advice).
25. The man told the officer that he had not been in contact with his family and that
he was not expecting to receive any contact with friends or family while in prison.
When asked if he had children, he said he did and that they lived with their
mother. He said he did not want any help with his personal relationships. He
told the officer that he had been working part time as a self-employed freelance
writer and the job would be available on his release from prison. He said he was
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not interested in undertaking any education courses while in custody. He said he
had no debts but needed help arranging his benefits. The officer arranged to
refer him to the Job Centre.
26. The man told the officer that he used neither drugs nor alcohol. He said he had
no mental health problems, and had not had any in the past. He did not want to
be referred to the doctor or a mental health specialist. He said he had no
thoughts of suicide or self-harm. Finally, he said that he was not interested in
completing any offending behaviour courses because he was innocent of the
charges against him.
27. On 11 August, he appeared at court, where he was remanded into the custody of
HMP Pentonville. (Court cases are generally heard at the court in closest
geographical proximity to the location of the offence. Similarly, courts will usually
remand prisoners into the custody of the prison nearest to the court. Because he
had three ongoing cases being heard at separate courts across London, he was
remanded into three different London prisons between July 2009 and April 2010.)
At about 8.30pm, he was assessed by a nurse in reception who completed the
First Reception Healthscreen. She noted that he had transferred to Pentonville
from Wandsworth. She recorded that he had no substance misuse problems,
was not considered to be a risk to himself and had no mental health problems.
However, a separate entry by her made the same day noted that he had told her
that he “had mental health problems before but he is better now … states he is
not on medication anymore, he has stopped taking them”.
28. In fact, the man had been in custody at Pentonville before, most recently from 8
November 2008 to 11 June 2009. The medical notes from that period detail that
he said he had been diagnosed with schizophrenia and was being prescribed
medication. He told doctors that he sometimes heard voices which told him to
hurt himself or others and that he suffered with anxiety. While in custody, he
received intervention from the Mental Health In-Reach Team (MHIT, specialists
in mental health) and was prescribed diazepam (a sedative) and risperidone (an
antipsychotic medication).
29. However, a psychiatric report ordered by the court, completed in June 2009
concluded that the man did not suffer from a mental illness and had never been
admitted to a psychiatric hospital. The psychiatrist noted that he had a “tendency
to mislead … [In his view], he did it so that he could get out of prison quicker”.
He concluded that the tendency to mislead was not related to a mental illness but
was related to an “underlying antisocial personality”. (This report had been
attached to his clinical records and so was available to healthcare staff at
Pentonville.)
30. On 12 August, an entry in the medical record noted that the man had been
referred to the MHIT for a psychiatric assessment. A psychiatrist and a social
worker conducted the assessment on 27 August. Few notes were made in the
medical record, but the entry recorded that healthcare staff would continue the
“medication-free assessment” and review him in four weeks, or earlier if there
were any concerns, and that he would be referred to the day centre.
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31. The man was convicted of robbery on 24 August and received a 12 month prison
sentence. He appeared in court again on 3 September, in relation to the
wounding with intent, attempted robbery and possession of a knife offences and
was remanded into custody. On leaving court, he was taken back to
Wandsworth. A healthcare assistant (HCA) assessed him on his arrival, noting
that he was “fit and well”. Each prisoner arriving from another prison should be
accompanied by his medical record. However, there is nothing to indicate
whether his record accompanied him from Pentonville. If it did, there is no
evidence that any member of healthcare staff read the entries relating to his
mental health or referred him for further assessment.
32. The CSRA assessment was completed in reception. The officer conducting the
assessment recorded that the man had no substance misuse problems and was
not being monitored under the ACCT procedures. However, he told the officer
that he had concerns about sharing a cell, saying he had been assessed as high
risk at Pentonville (there was no CSRA relating to his time at Pentonville in his
prison file) and, in the past, at Wandsworth. He said he would fight any cell
mate. As a result, the officer judged him to pose a high risk to other prisoners.
The nurse completing the healthcare section of the form assessed him as posing
a low risk from a healthcare perspective and had no concerns about him. He
was given a single cell on one of the main prison wings.
33. Five days later, on 8 September, a wing governor conducted a CSRA review.
She recorded that the man had not displayed any violent or aggressive
behaviour and there was no security information relevant to the assessment. He
remained high risk because he would not share with anyone and threatened to
fight any cell mate. She noted that his personal officer should work with him to
reduce his risk and encourage him to share.
34. An entry on the Pentonville medical record notes that a member of staff
telephoned Wandsworth MHIT on 8 September and left a message telling them
that the man had been transferred. During the investigation, the investigator
spoke to the Head of the MHIT at Wandsworth. She said that he had not been
referred to the MHIT or discussed at any referral meetings. She explained that
Pentonville MHIT staff should know that in order to transfer a case, they must
complete referral paperwork and fax it to Wandsworth. She said this is an
established system and if any member of Wandsworth’s MHIT had received a
message about him, Pentonville would have been instructed to complete the
referral paperwork. The Head of the Pentonville MHIT told the investigator that
he was unaware of any such process. She confirmed that, on the basis of the
information in his Pentonville medical record, her team would have wanted to
assess and work with him.
35. The man appeared in court twice over the following few weeks and was
remanded in custody on both occasions. There appeared to be few concerns
about him at Wandsworth, other than those relating to his CSRA level. However,
on 1 November, he was seen punching another prisoner in the face several
times. He was taken to the Care and Separation Unit (CSU) and placed on
report, awaiting adjudication.
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36. When a prisoner is moved to the CSU they must be assessed by a member of
healthcare staff. The assessment, known as an algorithm, checks whether there
are any physical or mental health reasons not to segregate the prisoner. The
algorithm relating to 1 November is missing and has not been located, despite
searches at the prison. On 3 November, the man was examined by a nurse who
recorded that the swelling to his hand had reduced. (No further information
about the cause of the injury is recorded, but it is possible it was a result of his
having punched the other prisoner.) His time in segregation was uneventful.
37. The man’s adjudication was held on 3 November and he pleaded not guilty. As
the officer who had placed him on report did not attend to give evidence, and so
that he could seek legal advice, the hearing was adjourned. Prison Service
Order (PSO) 2000 - Adjudications, sets out the guidelines for conducting
adjudications. It stipulates that where an adjudication has been adjourned for
more than six weeks, the adjudicator must decide whether “natural justice has
been compromised by the delay in hearing the charge” (all mandatory
instructions in a PSO are written in italics). The man’s adjudication was not
heard until 26 January 2010, by which point it was “out of time” and was
dismissed.
38. He returned to a normal cell on D wing on 3 November. His CSRA was reviewed
and he remained high risk. There is no evidence in his prison file that any action
was taken to address his violent behaviour. Although the adjudication had been
adjourned, the investigator was told that staff should have initiated anti-bullying
procedures or at least tried to investigate the cause of the incident. As well, it
should have been noted in his wing file.
39. On 5 November, the man refused to attend court, saying he was unwell. He was
examined by a nurse and said that he had suffered with diarrhoea during the
night. This was the first of six occasions over a two month period when he
refused to attend court, often saying he felt unwell. The Deputy Head of
Healthcare said that it was quite common for prisoners to claim to be ill in order
to avoid attending court. She explained that any prisoner who makes such a
claim is examined by a nurse but it is difficult to ascertain whether they are
genuinely ill or making an excuse to avoid court. The nurse advised him to come
to the wing treatment room (where nurses are often located during the day) if he
felt unwell.
40. While at Wandsworth, the man applied for two work positions, Radio Wanno (the
prison radio station) and the canteen (where prisoners can buy a number of
items for personal use from their personal money). Both applications were
rejected because he was thought to have a quick temper and sometimes be
unco-operative, but he attended education classes between November 2009 and
January 2010. His tutor described him as knowledgeable, friendly, co-operative
and keen to participate in classes. It appears that he got on well with other
students and the tutor.
41. On 25 January 2010, the man was placed on report for a second time for
refusing to move from D wing to B wing. The adjudication was held two days
later and he was charged with disobeying a lawful order. He pleaded not guilty,
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saying that he had refused to move because he had not thought the officer was
giving him an order. He also said that he had “lots of trouble on B wing”. He
said that he had told the senior officer in charge of D wing that, if she checked
his file, she would find evidence of this. During the adjudication, the senior
officer said that she had checked his file and found no mention of problems with
other prisoners, or any specific problems on B wing. (There is nothing in his file
to suggest that he had problems with other prisoners, except for the occasion
when he was alleged to have punched another prisoner.) He said he did not
know the names of the prisoners he was having problems with. The governor
who was in charge of the adjudication found him guilty. The punishment was
seven days cellular confinement, loss of 80 percent of his earnings for a period of
28 days (prisoners earn money for attending education) and loss of canteen for
28 days. However, the punishment was suspended for three months.
42. During the course of the investigation, the investigator spoke to an officer who
was the man’s personal officer while he lived on D wing. (Wing officers are
allocated to work with particular prisoners and be their first port of call should
they have any questions or concerns.) The officer said that the man was a quiet
prisoner who was polite and respectful to staff. He was not aware that he had
any problems with other prisoners. The officer said he had never had any
concerns about him, either in terms of his risk to himself or his mental health. He
said that his cell was often quite dirty (which can be a sign of mental ill health)
but otherwise there were no indications that he might be struggling to cope.
43. On 15 February, the man appeared in court and the trial for the charge of
abduction began. At the end of the day, he was remanded into the custody of
Wormwood Scrubs. Once again, a CSRA was completed on arrival. He told the
officer undertaking the assessment that he had previously been convicted of
manslaughter and so he was assessed as high risk. However, the duty manager
overseeing the process that day made a later entry noting that he had lied about
his previous convictions and assessed him as low risk.
44. Two days later, on 17 February, he was found not guilty of abduction. He
remained at Wormwood Scrubs until 8 March. During his time at the prison, staff
apparently found him to be quiet, rarely mixing with other prisoners. They did not
record any concerns about him. A copy of the medical record relating to his time
at Wormwood Scrubs was provided to the investigator after the draft report was
published. The notes show that he sought no medical attention during his time at
the prison and that there were no indications of any mental health problems.
Healthcare staff recorded no concerns that he might pose a risk to himself.
45. The man appeared in court on 8 March and was remanded into Wandsworth’s
custody. He was seen in reception by another healthcare assistant, who noted
that he had transferred from Wandsworth and that he was “fit and well”. Again,
the Wandsworth medical notes do not record whether the Wormwood Scrubs
medical record arrived with him, and if so, whether any member of staff read it.
46. On this occasion, staff agreed that the man’s CSRA risk level should remain high
for one month. He agreed that he needed to address his anger management
problems and work towards sharing a cell. He was told he should apply to do the
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Enhanced Thinking Skills course (a prison programme targeting offending
behaviour) and an anger management course. He was given a single cell on A
wing.
47. Two days afterwards, on 10 March, he was found guilty of wounding with intent,
attempted robbery and carrying a knife in a public place. The judge asked his
offender manager (formerly known as a probation officer) to review his
dangerousness to help decide what sentence he should receive. It appears that
the judge was considering sentencing him to an indeterminate sentence for
public protection (IPP) and may have said so to him in court. In the meantime,
he was remanded back into custody.
48. On his return to Wandsworth, he was seen by a third healthcare assistant. She
recorded that he was “fit and well”. The deputy head of healthcare explained
that, ideally, a “change of status” examination is carried out when a prisoner
returned from court, in practice, this does not always happen. (When a prisoner
is convicted or sentenced at court, this is known as a “change of status”.
Because receiving bad news in court may increase a prisoner’s risk to himself, it
is considered good practice to carry out a healthcare screen to assess their
mental state.) It appears that he did not undergo a change of status
assessment.
49. A nurse examined the man on 26 March and made two entries in his medical
record. The first noted that he had “superficial lacerations” on his left hand. He
said he did not need any pain killers but the nurse cleaned and dressed the
wound. The second entry recorded that he was refusing to transfer to another
prison, saying he felt unwell. The nurse took his pulse and blood pressure
(which were both normal) and read his temperature (which was also normal).
The investigator spoke to the nurse about her examination of the man. She
could not remember ever having met him and could not recall any further details
about her entries, including how he had injured his hand. The prison has no
information regarding the transfer she mentioned in her entry. There is no other
mention of him having cut his hand and neither is there any indication that the
nurse considered opening the ACCT procedures.
50. The man appeared in court again on 8 April. Due to staff sickness, the review of
dangerousness had not yet been completed and so sentencing was adjourned
until 30 April.
51. During the course of the investigation, the investigator spoke to the man’s
community offender manager. She thought it likely that he knew the court was
considering an IPP sentence. She completed the Assessment of Risk of Serious
Harm for court (the review of dangerousness). She highlighted that he had
previous convictions for other violent offences, which, together with his current
offences demonstrated a “pattern of behaviour which places the public at risk”.
She concluded that he posed a “high risk” to the public. In the report, she
concluded that custody was “inevitable”.
52. As part of the investigation, the investigator interviewed a senior officer (SO), one
of the A wing managers. He said that A wing has a high turnover of prisoners
17
and holds a very mixed population, with some prisoners on remand and some
sentenced. He explained that, because of these factors, it can be hard for staff
to get to know the prisoners living on the wing. However, the SO said that he is
generally more familiar with those prisoners who cause trouble or who are being
monitored (for example under the ACCT process). He said that A wing is
considered to be a relatively stable and quiet wing.
53. The SO said that he did not know the man well. A few days before his death, he
spoke to the SO about getting access to a Playstation he had brought with him
from another establishment. The SO told him he would look into the matter. He
said that he had never had any reason to worry about him and that staff on A
wing did not raise any concerns about him, either during daily staff briefing
meetings or at other times. The SO was aware that he was assessed as high
risk on his CSRA (and was one of 26 such prisoners on A wing at the time) but
had never been told of any problems between him and other prisoners. The SO
said that he was polite and a “model prisoner” who attended Muslim prayers and
often prayed in his cell.
54. The investigator asked the SO whether staff would normally be told if a prisoner
had received news about the sort of sentence he could expect. The SO said that
this does not happen often as the courts do not routinely pass such information
to the prison. In his view, although it might be helpful for staff to know, the
number and turnover of prisoners on the wing meant that it would be difficult to
remember the specific circumstances of each individual. He said, however, that
prisoners are often confused about IPP sentences and may be told incorrect
information by other prisoners. He thought it would be helpful if staff were able to
explain how the sentence works and allay their concerns.
55. The SO said that he saw the man every day that he was on duty in the days
before his death. The man acknowledged him on each occasion that they saw
each other and gave no signs that anything was troubling him.
56. The investigator also spoke to a distant cousin of the man and also living on A
wing. He described the man as chatty and open and said he was often laughing
and joking with other prisoners. As far as he was aware, the man had no
problems with other prisoners and was not being bullied or in any trouble.
57. As the man’s cousin had been living outside the United Kingdom for some time,
he did not know very much about the man’s life outside prison, but he said that
there were no signs that anything was wrong. The man’s cousin attended full
time education at Wandsworth so did not spend a great deal of time with him.
However, he said that the two men talked daily and attended prayers at the
mosque together every Friday.
58. The man’s cousin told the investigator that in the period before the man’s death,
prisoners were locked in their cells much more than usual due, he thought, to
staff shortages. He said that some prisoners found this easier to cope with than
others. He thought that the man was someone who could cope, but said that it
could be hard when prisoners were not allowed out of their cells for showers or to
18
make telephone calls. He said he last saw him on Saturday 17 April, the day
before he took his life, when they had said hello to each other.
59. One Sunday in April, the A wing SO was working on the wing from 7.30am until
5.00pm. He remembered that, due to staff shortages, prisoners were not
unlocked very much over the weekend. However, he thought that A wing
prisoners had been unlocked for a period of exercise during the day. The SO
saw the man when he came to collect his lunch and again at tea time, at around
4.00pm. He appeared to be fine and did not talk to the SO, or raise any
concerns with staff. The SO was clear that if he, or any other member of staff,
had any concerns about a prisoner, they would begin the ACCT process.
60. A second SO began his shift at 5.00pm that evening. Due to staff shortages, he
was working as an officer on A wing. He was interviewed during the
investigation and said that he received a handover from the day staff at the
beginning of his shift. No mention was made of the man, or any concerns about
him. He was the only officer on A wing until 8.45pm. He explained that all of the
prisoners on the wing were locked in their cells at 5.00pm and that only those
being monitored under the ACCT process, or for some other reason, had to be
checked regularly. There was no reason for him to check the man, who was not
being monitored under any special procedures. He said that he walked around
the A wing landings and responded to cell bells. (Each cell at Wandsworth is
fitted with an emergency cell bell which prisoners can use to alert staff. They are
intended to be used in emergency situations and can only be turned off by a
member of staff pressing a button outside the cell.) The man did not use his cell
bell that evening.
61. At about 8.00pm, the SO began to carry out his roll check before the night staff
arrived. During a roll check, each prisoner is checked and counted and the cell
doors are checked to make sure they are locked. When he reached the man’s
cell, he looked through the observation panel in the cell door and saw him sitting
at the end of his bed. Although the cell was only occupied by him, it contained
bunk beds. The SO spoke to him and, on receiving no reply, looked more
closely. He realised that he had tied a ligature made from a bedsheet around his
neck and to the frame of the top bunk bed.
62. The SO unlocked the cell and went in. As he did so, he blew his whistle to alert
staff on other wings to an emergency. In his statement, written shortly after the
man’s death, he explained that he also used his radio to tell staff in the control
room that there was a “Code 1” situation and giving the cell location. He
explained that Code 1 signifies that someone is hanging. On hearing the call, a
member of staff from the control room called for an emergency ambulance.
63. The SO lifted the man’s body weight to relieve the pressure on his neck and
used his anti-ligature knife to try to cut the ligature. Because the ligature was
thick, he could not cut through it. By this point he had been joined in the cell by
an officer, who had heard the Code 1 call over his radio and made his way to the
cell with the duty manager, and the Developing Prison Service Manager (DPSM)
on duty. The officer and SO untied the ligature and laid the man on the cell floor.
19
64. Two nurses were the only two members of healthcare staff on duty that evening.
They were in the A2 treatment room (which is on the landing below the man’s
cell) sorting out the evening medication when they heard the emergency radio
call. One of the nurses was carrying the emergency healthcare radio, meaning
that he had to respond to any medical emergency in the prison. He picked up
the emergency response bag and the other nurse brought the bag containing the
oxygen cylinder. As they were already nearby, they arrived at the cell very
quickly.
65. The nurses arrived as the officer and SO were laying the man on the floor. They
checked him for signs of breathing or a pulse. On finding neither, they began
cardio pulmonary resuscitation (CPR), with assistance from the officer. The
emergency response nurse attached the automated external defibrillator (AED).
(An AED is a portable device which detects whether the heart is beating and, in
some circumstances, automatically delivers electric shocks to attempt to re-
establish a normal heartbeat.) The AED instructed the staff to continue CPR as
the man’s heart was not beating.
66. The ambulance arrived at the prison at 8.10pm and the paramedics took over the
care of the man. An air ambulance team, including an emergency doctor, arrived
at 8.25pm. Attempts to resuscitate him continued until 8.36pm, when the
emergency doctor pronounced that he had died.
Contact with the man’s family
67. On his arrival in prison, the man had not provided any next of kin details. On
Monday 19 April a governor who was appointed as the prison family liaison
officer and the prison Imam visited what was thought to be the man’s parents’
address but there was no reply. Prison staff found the mobile telephone number
for the man’s sister in her brother’s file and she agreed to meet the governor and
the Imam at her parents’ home.
68. Members of the man’s family visited Wandsworth to see his cell. During their
visit they met members of A wing staff and spoke to his cousin. The prison
family liaison officer and another member of prison staff attended the funeral
and, in line with Prison Service Order (PSO) 2710 - Follow up to a Death in
Custody, the prison offered to make a financial contribution towards the cost.
Support for prisoners
69. The man’s cousin found out that the man had died the morning after his death.
He was given support by staff and he had one session of counselling. He told
the investigator that a memorial service was held at the prison mosque.
70. The A wing SO confirmed that all prisoners being monitored under ACCT
procedures were reviewed and offered additional support. (This allows staff to
check whether other vulnerable prisoners have been affected by the news of the
death.)
20
Support for staff
71. Shortly after the man’s death, a hot debrief was held for all of the staff involved.
(The hot debrief should be held immediately after the incident and provides a
chance for staff to talk about events and share their feelings. It is a requirement
of PSO 2710.) Staff interviewed during the investigation said they had been
offered support by the prison, although one nurse said he would have liked more
support.
21
ISSUES
The man’s mental health
72. The local PCT commissioned a clinical reviewer to undertake a review of the
clinical care the man received. His review is attached as annex 1. The man
presented with only minor physical health problems while in custody but the
issue of his mental health was rather more complicated.
73. It is worth noting from the outset that mental health professionals were unable to
agree on whether he did indeed suffer from any mental illness. The medical
records relating to his periods at Pentonville provide the most comprehensive
discussion of this matter. They indicate that, while held at the prison, he had
regular contact with the MHIT and was prescribed medication as a result. He
told staff that he had spent time as an inpatient at a local psychiatric hospital
(although this was never confirmed and he later denied it).
74. Staff recorded that he might suffer with schizophrenia. However, in June 2009,
in relation to a previous court case, the man was assessed by a psychiatrist.
The author of the report concluded that he did not suffer with a mental illness.
The psychiatrist suggested that, in fact, he frequently gave untrue or misleading
information to healthcare staff, perhaps to facilitate an earlier release from
prison. On his arrival at Wandsworth in July 2009, he denied any history of
mental illness. Staff and prisoners at Wandsworth interviewed during the course
of this investigation said that they had never had reason to worry about his
mental health.
75. However, I am concerned that the transfer of medical information between the
prisons involved is not sufficiently robust. Prison Service Order (PSO) 3050 -
Continuity of healthcare for prisoners, paragraph 5.3 instructs that “[c]urrent
healthcare needs are assessed and continuity of care ensured when prisoners
are transferred between establishments …” (all mandatory instructions are
printed in italics). According to the PSO, this includes “[t]he identification of
physical and mental health problems …”.
76. The Deputy Head of Healthcare explained that any prisoner transferring to
Wandsworth from another establishment should be accompanied by their
medical record. (This takes the form of either a full paper record, or a print out of
the electronic record. At present, prisons across England and Wales use a
variety of clinical recording systems. Although the majority of prisons now keep
electronic records, those created in one prison are not accessible to staff working
in another prison. As a result, a paper print out of the record must be provided.)
She said that, in theory, reception staff should refuse to accept any prisoner
whose record has not been provided. However, she also said that in practice it is
more common for the transferring prison to be asked to courier the medical
record to Wandsworth immediately.
77. The man transferred from Pentonville to Wandsworth on 3 September. The
Deputy Head of Healthcare explained that reception is normally staffed by both a
nurse and a healthcare assistant. The nurse should review all the medical
22
records as they are received and decide whether there are any health concerns
requiring a referral to the doctor or other specialist service. Where there are no
concerns about the prisoner’s health, he will be briefly assessed by the
healthcare assistant before leaving reception.
78. An entry in the man’s medical record indicates that he was seen by a healthcare
assistant. She noted that he was fit and well. The entry does not record whether
the Pentonville medical records arrived with him or not. If they did, there is
nothing to indicate that any staff read them or noted his extensive mental health
history. The Deputy Head of Healthcare explained that the healthcare assistant
has since been dismissed from her position (on unrelated matters). The two
nurses on duty that day are unable to recall whether they saw his medical
records.
79. On 8 March 2010, the man transferred from Wormwood Scrubs to Wandsworth.
Again, there is no mention of any medical record accompanying him or any staff
noting his complex mental health history.
80. The man is not alone in being transferred between different London prisons. My
office has investigated the deaths of several prisoners whose circumstances
were not helped by frequent moves and relatively short stays. The reasons for
his moves are related to the location of his offences and the various courts which
he was remanded to. This is a complex issue which no doubt taxes many
officials in the National Offender Management Service. As such, I accept that
transfers are likely to continue and so make no recommendation in this regard.
However, because they are undoubtedly inevitable, it is all the more important
that prisoners’ records are moved at the same time.
81. While I accept that Wandsworth staff saw no signs that the man suffered mental
health problems, I am very concerned that they were unaware of his recent
history and treatment. The Deputy Head of Healthcare confirmed that, on the
basis of the information contained in the Pentonville records, reception staff
should have referred him to the MHIT.
82. The clinical reviewer notes that “throughout the NHS, patient care is hampered
by the lack of availability of paper records”. This is a situation which, he says,
has been “markedly improved” in general practice by the use of effective
electronic clinical systems. The Deputy Head of Healthcare confirmed that
Wandsworth is moving to the SystmOne electronic clinical system in mid-
October. She said that this should bring about improvements as every prison
using SystmOne will be able to access all of the records held on the system
(including prisoners held at different prisons).
83. Clearly, I welcome any improvements to the current system. However, until
SystmOne is in place in all prisons in England and Wales, there is still the
opportunity for omissions like this to occur. Moreover, this is not the first
investigation concerning a death at Wandsworth in which crucial paperwork
relating to the prisoner’s time at another prison has been missing. Nor is it the
first time that the medical record relating to a prisoner’s time at Pentonville has
either not arrived or not been acted upon at Wandsworth. The clinical reviewer
23
suggests that the medical record transfer process be reviewed and so I make the
following recommendation:
The Head of Healthcare should:
(cid:127) review the medical record transfer process
(cid:127) ensure that a robust policy exists, providing clear guidelines on
receiving and responding to information contained in medical
records.
84. It is also disheartening to learn that the system for referring patients between the
MHITs at Pentonville and Wandsworth failed on this occasion. An entry in the
Pentonville record indicates that a member of staff left a message for the
Wandsworth MHIT, telling them that the man had transferred to the prison. I
have not been able to establish whether anyone at Wandsworth was aware of
the message, certainly the MHIT had no contact with him while he was at the
prison. The Head of the MHIT at Wandsworth said that the team does not
accept telephone referrals in any case, and a paper referral form must be
completed and sent or faxed to the prison. She thought that most other London
prisons were aware of this procedure. The Head of the Pentonville MHIT had no
knowledge of such a system.
The Head of the Mental Health Inreach Team should ensure that the referral
process is widely publicised and explained to relevant staff at those
prisons most likely to refer patients.
The man’s alleged violent behaviour
85. On 1 November 2009, the man was allegedly seen punching a fellow prisoner in
the face several times. As a result he was placed on report and spent two days
in the CSU. Although adjudication proceedings began, the charge was
eventually dismissed because too much time had elapsed.
86. According to PSO 2750 - Violence Reduction, “[p]risoners involved in
unacceptable behaviour towards others must be appropriately and consistently
challenged and given support to improve their behaviour”. The PSO includes a
number of mandatory directions for how the prison should respond to such
behaviour. It directs that “[a]ny incidence or pattern of unacceptable behaviour
must be clearly recorded on the prisoner’s history sheet”. Furthermore, “[t]he
officer in charge of the wing must ensure that important information affecting
prisoner safety arriving on the wing … is prominently recorded in the wing
observation book and drawn to the attention of wing staff.” No mention of the
man’s alleged assault on the other prisoner is made in either his wing history
sheet or the wing observation book.
87. The investigator was provided with a copy of Wandsworth’s local Violence
Reduction Strategy 2009-10. The strategy directs that incidents of physical
violence be reported and recorded accurately. Perpetrators of violence should
be monitored via anti-social behaviour booklets. The strategy goes on to list a
number of places where information about the incident should be logged. There
24
is no evidence that any action was taken in response to the incident, save for
moving the man to the CSU to await adjudication.
The Governor should remind staff of their responsibilities under both PSO
2750 and the local Violence Reduction Strategy.
Staff shortages
88. During the course of the investigation, the man’s friend and fellow prisoner
mentioned that staff shortages in the weeks before the man’s death had meant
that prisoners on A wing were locked in their cells more than usual. It is possible
that additional time spent alone, without access to telephones and the support of
friends, might negatively impact on the frame of mind of an already vulnerable
prisoner. As such, it is an issue I have given some consideration to.
89. Wandsworth’s Minimum Staffing Levels Document details that from Monday to
Thursday, A wing should be staffed by a minimum of eight officers (including a
senior officer) during the day and six in the evening. On Friday, when no
evening association is held, the minimum staffing levels are eight officers during
the day and two during the evening. At the weekend, there is no evening
association and so the wing must be staffed by at least seven officers during the
day and one in the evening. The minimum staffing levels allow for a “decent,
basic regime” to be provided, including serving meals, exercise, visits,
association, changing bedding and clothes and access to healthcare.
90. The prison also provided a breakdown of staffing levels across the establishment
for the period between 5 April and 20 April and the diary sheets noting
restrictions to the normal regime for the same period. A wing was staffed by
fewer than the minimum level set out above on six occasions (once after the
man’s death). However, according to the diary, the wing regime was affected
only three times (again, once after the man’s death). On 9 April, the diary sheet
notes that the wing regime was “curtailed”. On Sunday 18 April, all of the main
prison wings were shut down early (after the meal had been served at about
4.00pm).
91. On the evidence provided, it appears that A wing suffered relatively minor regime
changes during the two weeks prior to the man’s death. Staff shortages will
inevitably impact on the lives of prisoners, but it seems that this impact was
limited, as far as possible, by the prison management team. I have seen no
evidence to suggest that he made any official or unofficial complaints about the
impact staffing shortages were having on him. It is also worth noting that his cell
was equipped with a television and that staff said that they often saw him reading
holy books in his cell.
The sentence the man was likely to receive
92. At the time of his death, the man had been found guilty of three serious offences
and was awaiting sentencing. He had quite recently been found guilty of robbery
and sentenced to 12 months in prison. Documents considered during the
25
investigation and interviews and conversations with staff indicate that he might
well have known that the sentencing court was considering an IPP sentence.
93. Reviews by HMCIP and the Prison Reform Trust suggest that prisoners who
receive IPP sentences are confused by them. They are not always clear how
long they will have to serve before release, or what courses they will need to
complete before release is considered by the Parole Board (the independent
body charged with assessing a prisoner’s risk and deciding when they are
suitable for release).
94. Of course, there is no way of knowing what was going through the man’s mind in
the days leading to his death. However, it is possible that the knowledge that he
might be facing a considerable sentence increased his vulnerability. That said,
he gave no indications, either to staff or his friend at the prison, that he was
particularly worried about his upcoming sentencing. Certainly, he gave staff no
opportunity to calm his fears or put in place any additional support.
The emergency response
95. The man was found during a routine check at about 8.00pm on 18 April. The SO
who found him, used his radio and the correct code to alert the prison to the
incident. He quickly went into the cell to try and cut the ligature and help the
man. Other staff joined him within minutes, and due to their proximity, healthcare
staff arrived very quickly with emergency first aid equipment. Despite their best
efforts, the use of a defibrillator and the arrival of the paramedics, he could not
be resuscitated.
96. I am pleased to find the response on this occasion was very efficient. Neither the
clinical reviewer nor I have identified any shortcomings and I am pleased to note
staff’s professional handling of the situation.
26
CONCLUSION
97. The man was remanded into the custody of Wandsworth on 20 July 2009,
charged with several serious offences. He had been convicted of other serious
offences in the past and had served several prison sentences. At the time of his
death, he was awaiting sentencing and, it seems, knew he might be facing an
indeterminate sentence.
98. Whether or not he suffered mental health problems is a matter of some question.
He had received treatment in the past and at other prisons, but there was
evidence to suggest he fabricated details of his illness, perhaps in the hope of a
shorter sentence.
99. During his time in prison, he moved between Wandsworth, Pentonville and
Wormwood Scrubs. He is not alone in moving so often and, on this occasion, it
seems that the transfers were inevitable. Sadly, this investigation has
highlighted procedural failures which meant that important information about his
mental health did not transfer with him. However, despite these failures, I have
found no evidence to suggest that staff at Wandsworth had reason to worry
about his vulnerability or risk to himself. At no point during his time on remand
was he monitored under suicide or self harm prevention procedures and I have
seen nothing to suggest that he should have been. I do not think that staff at
Wandsworth could have anticipated his actions or, therefore, prevented them. I
make three recommendations, but do not think that any would have prevented
his death.
27
RECOMMENDATIONS
At the draft report stage, the National Offender Management Service (NOMS)
responded to the recommendations made. That response is included in italics below
each recommendation.
1. The Head of Healthcare should:
(cid:127) review the medical record transfer process
(cid:127) ensure that a robust policy exists, providing clear guidelines on
receiving and responding to information contained in medical records.
This recommendation was accepted. NOMS responded:
“The prison service national IT system, System 1, has now been introduced at
Wandsworth. This will greatly enhance the transfer of data from prison to
prison. We are reviewing our reception processes and will produce within that
review a robust policy for nursing staff. This policy will address issues on
receiving and responding to information contained in medical records.”
2. The Head of the Mental Health Inreach Team should ensure that the referral
process is widely publicised and explained to relevant staff at those prisons
most likely to refer patients.
NOMS accepted this recommendation, noting that
“A referral protocol will be sent to all London, local prison In-Reach teams
explaining how that team should refer to our service if a prisoner has been
transferred to Wandsworth. The protocol will include a copy of our referral
form which can be faxed directly through to in-reach’s team base.”
3. The Governor should remind staff of their responsibilities under both PSO
2750 and the local Violence Reduction Strategy.
NOMS accepted this recommendation:
“The local Violence Reduction Policy and Strategy has recently been updated
– copies are available in all areas.
There is currently a full review being conducted on the reporting and recording
of violent incidences to ascertain how the current systems can be improved.
There was recently a full review of the IEP scheme at Wandsworth. Significant
changes have been made and the new system is due to roll out in the coming
weeks.”
28