Individual at Wandsworth

Investigation into the circumstances surrounding the
death of a prisoner at HMP Wandsworth
in January 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
February 2007
This is the report of an investigation into the death of man, who was found hanging in
his cell at HMP Wandsworth. Staff attempted to resuscitate him but, sadly, without
success. He was 49 years old.
I offer my sincere sympathy and condolences to the man's family and friends for their
loss.
The investigation was carried out by two of my investigators. I am grateful to the
Governor of Wandsworth and to the governor who acted as liaison officer, for their
assistance.
One of my Family Liaison Officers contacted the man’s family to ascertain any
concerns they had about the man’s care. She will ensure that they receive a copy of
the findings. This was a complex and time-consuming investigation dealing with a
number of important issues. Consequently, the publication of the report has been
delayed, for which I extend my apologies to all concerned.
The man was a life sentenced prisoner. At the time of his death, he had served ten
years, three years more than his minimum tariff. He spent most of his time at HMP
Wakefield, where his life was very settled and he had had a tight-knit group of friends
who provided companionship and support. In spite of this, in October 2005, he tried
to harm himself and spent three months being cared for in the healthcare centre. In
November 2005, he was charged with a further serious offence. In early January
2006, he was moved to HMP Wandsworth to be close to the London court where his
trial was to be held. The circumstances of the transfer were such that staff did not
have access to his computerised records and, for a time, the man was given a new
prison number.
The wing at Wandsworth on which he was located was being refurbished and the
physical conditions were far from ideal. The man was away from his friends and
their support. He was also facing a new charge that, if proven, would have meant
many more years in prison. On the evening before his death, he was bullied by a
group of prisoners who congregated outside his cell calling him names and
threatening him.
The following afternoon, eight days after appearing at court and arriving at
Wandsworth, the man was found hanging from a bed sheet attached to the window
bars. Rigor mortis had set in and he had obviously been in that position for several
hours when staff found him. If all the required checks had been carried out correctly,
the man would have been found much sooner.
I make eight recommendations in this report.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2007
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CONTENTS
Summary 4
The Investigation Process 6
HMP Wakefield and HMP Wandsworth 8
Key Events 9
Issues 18
Recommendations 24
Annexes
1. Documents considered during the investigation 26
2. Clinical review 27
3. Transcripts and notes of interviews 29
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SUMMARY
The man was born in 1956 and was 49 years old when he died in HMP Wandsworth
in January 2006. He was a life sentenced prisoner (lifer) who had been in prison for
ten years, three years more than his recommended minimum tariff. He had been in
Wandsworth for only eight days, after being transferred to London to be tried for a
further serious offence.
In June 1995, the man had been arrested and charged with a number of serious,
sexual offences. In October, he was convicted and remanded in custody while
psychiatric reports were prepared. During this time, he spent a period of time being
assessed at Ashworth Hospital. However, in June 1996, he was sentenced to life
imprisonment with a judge’s recommendation that he serve a minimum of 12 years
before being considered for parole. In 2001, this tariff was reduced on appeal to
seven years.
The man spent the first two years in London prisons before being transferred to HMP
Wakefield in April 1998. It took him a considerable time to settle into prison life and
begin courses to address his offending behaviour. However, he attended full-time
education where he studied ‘A’ levels, before moving onto a degree course with the
Open University. He eventually began a Sex Offender Treatment Programme
(SOTP) in April 2002, but was removed after only two months. He had failed to face
up to the circumstances of his offences and threatened another participant.
Staff reassessed him several times over the following years but they did not allow
him to restart the course. They felt that his behaviour and attitude did not reach the
standard necessary to undertake the course. The man was very aware that his
failure to complete the course had a negative impact on his parole hearing in 2004.
The board members noted that the man said he was willing to do the course.
However, because he had not yet completed it, he could not show that his risk to the
public had decreased during his imprisonment. The man’s solicitors engaged in
lengthy correspondence with prison staff in an effort to get him onto a course as
soon as possible. However, as late as October 2005, he was told that he would be
assessed again in January 2006.
Early in the morning of 26 October 2005, the man was found with a ligature and
marks round his neck. He told Wakefield staff he had tried to strangle himself. He
was immediately moved to the prison healthcare centre and put on an F2052SH
plan. (The F2052SH form describes the problems facing a prisoner at risk of
harming himself and implements a plan to help him through a period of crisis.) The
man told staff that he had taken the action because he could not face more time in
prison, and as a result of the uncertainty over starting the SOTP. Over the next four
weeks, his depression gradually lifted and he began to interact with the people
around him.
However, in November, the man was arrested and charged with an offence that pre-
dated the offences for which he was already in prison. In the days afterwards, he
told staff that he wished his suicide attempt had been successful. During the next
few weeks, his mental health gradually improved and the F2052SH was closed on
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22 December. In December, lawyers from the Crown Prosecution Service made a
successful application to have the trial held in London.
The man appeared at Blackfriars Crown Court in January 2006 and was then taken
to Wandsworth. On arrival, there were problems with the computer system and staff
could not access his records from Wakefield. This caused a number of difficulties.
Among others, it meant that staff did not know that the man had made a suicide
attempt and, until only three weeks earlier, had been on an F2052SH. He was put in
a shared cell on the Onslow Centre which houses vulnerable prisoners. At the time,
the living conditions were uncomfortable due to building work which was in progress.
Over the next few days, staff resolved the problems relating to his transfer and, as a
lifer, he was given a single cell. However, on the night before he died, he was
subjected to concerted bullying that went unnoticed by staff.
Early the following day, the man appeared to be fine when checked by officers on
night duty. But several checks that should have been carried out during the rest of
the morning were not completed. As a result, staff did not realise that he had not
been seen at all that morning. Only at lunchtime was his absence noted and an
officer investigated. She discovered the man hanging from the window bars in his
cell. It was clear he had been there for some considerable time. In spite of a
concerted and efficient effort to resuscitate the man, he was beyond help. Sadly, at
12:26pm, the prison doctor and paramedics confirmed his death.
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THE INVESTIGATION PROCESS
1. The man died in January 2006. My investigators opened the investigation the
following Monday when they visited the prison. They met the Governor and
representatives of the Independent Monitoring Board and Prison Officers’
Association. They saw the man’s cell and walked round the Onslow Centre.
2. The investigators interviewed staff and prisoners at Wandsworth, staff at
Wakefield and prisoners who had been in Wandsworth but had since moved
to other locations.
3. One of my Family Liaison Officers spoke to the man’s brother to ask if the
family had any concerns that they wanted included in the investigation. They
raised a number of issues including the man’s earlier attempt to take his life,
the care he received and the failure to return his possessions to the family. I
hope this report goes some way to answering these questions.
4. A clinical review was commissioned from Wandsworth Primary Care Trust.
One of their joint Medical Directors carried out the review and I thank him for
undertaking this task. The conclusions and recommendations have been
considered and are discussed in the section of the report on issues
considered. The full report can be found at Annex 2.
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HMP WAKEFIELD and HMP WANDSWORTH
5. HMP Wakefield is a high-security prison for men. The current building is of
Victorian radial block design. The cells are single and have integral
sanitation. It is now a main centre for lifer prisoners with the focus on serious
sex offenders. The average prison roll is approximately 700, including a
maximum of 100 Category A and 10 High Risk Category A prisoners.
6. The prison accepts prisoners serving over five years imprisonment, primarily
for sexual offences or those who have previously committed sexual offences.
Preference is given to those who are willing to participate in offence-focused
treatment programmes.
7. HMP Wandsworth is a large prison in South West London, with a separate
vulnerable prisoner unit. It is currently able to hold 1,416 prisoners and is the
largest prison in London. Alongside Liverpool, which is of similar size, it is
one of the largest prisons in Western Europe. It is a local prison and so
accepts all suitable prisoners from courts in its catchment area.
8. The prison was built in 1851, and the residential areas remain in the original
buildings. There has been extensive refurbishment and modernisation of the
wings, including in-cell sanitation, privacy screens for cells occupied by more
than one prisoner, and in-cell electricity.
9. There are two main parts to the prison. The Heathfield Centre is the main
prison and has five wings, each with four landings. The Onslow Centre
houses the vulnerable prisoners unit and has three wings holding
approximately 330 prisoners. All wings have in-cell sanitation and in-cell
electricity is currently being installed. At the time the man was there, building
work was being carried out and scaffolding and tarpaulins prevented much
natural light from entering the building.
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KEY EVENTS
10. The man was remanded into custody at Wandsworth by West London
magistrates in June 1995. He was convicted in October and further
remanded for a psychiatric report to be prepared under Section 12 of the
Mental Health Act (1983). In November, two further psychiatric reports were
ordered. In February 1996, the court was satisfied that the man was suffering
from a mental illness and an Interim Hospital Order was made, admitting the
man to Ashworth Hospital. While waiting for a place at Ashworth, the man
continued to be held at Wandsworth.
11. The psychiatrists who prepared the reports on the man did not agree in their
recommendations to the court. InJune 1996, the judge decided against
making a hospital order and sentenced the man to four terms of life
imprisonment, with a recommendation that he serve a minimum of 12 years.
This was later reduced on appeal to a minimum of seven years.
12. On sentence, all life sentenced prisoners (lifers) are advised by the trial judge
of the minimum period of imprisonment that they must serve. No life sentence
prisoner can expect to be released before they have served the minimum
sentence period (tariff). Regular risk assessments are carried out in order to
assess a lifer’s progress and whether they are ready to progress to a lower
category prison, including open conditions, or release. Once released, the
licensee is supervised by the probation service. Although, the supervisory
element of that licence may be cancelled when appropriate, the licensee
remains liable to recall to prison for the rest of their natural life.
13. The man served the early part of his sentence in a number of London prisons
but, in April 1998, he was transferred to HMP Wakefield. He remained there
until a week before his death, when he was moved back to HMP Wandsworth
pending court appearances for a further charge.
14. The man took many months to settle into prison life and routine and begin the
work and courses identified in his sentence plan. However, in June 1999, he
completed an Alcohol Education Course and two months later he began full-
time education. Over the next two years, he studied a number of subjects at
GCSE and AS level and in 2001 he began an Open University course. He
also completed a stress management course. After a psychiatric assessment,
the man was put on the waiting list for an Enhanced Thinking Skills (ETS)
course and Sex Offender Treatment Programme (SOTP) to help him address
his offending behaviour. He eventually completed an ETS course in March
2002.
15. The following month, he started the SOTP. However, the man was removed
from the course after two months, due to failure to address issues surrounding
his offence and his disruptive behaviour. This included threatening another
prisoner who gave him negative feedback during a session. Staff informed
the man that he would not be reassessed for the course until he had achieved
“a period of stable and appropriate behaviour”.
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16. The man’s suitability was re-assessed several times over the next three
years, but each time he was judged not to be ready to resume the course. At
his parole hearing in February 2004, the board members noted that his failure
to complete the SOTP meant that his risk level had not reduced during his
period of imprisonment. The board did note, however, his stated willingness
to do the course. Parole was refused and the next review date was set for
2005. This was later postponed at the man’s request. His solicitors kept in
regular correspondence with prison staff about his need, as a matter of
urgency, to complete an SOTP. In October 2005, he was told that he would
be reassessed for the SOTP in January 2006.
17. Shortly after 8:00am on 26 October, the man was discovered in his Wakefield
cell with a ligature fashioned from a bed sheet and marks on his neck. He
told officers that he had tried to take his life by strangling himself. He was
immediately moved to an in-patient ward in the healthcare centre and an
F2052SH Self Harm at Risk form was opened. The man told staff that he felt
unable to carry on due to the stress of his impending SOTP. However, he
was not attending the SOTP, nor did he have a firm date when he would
begin one. Two days later, he told a member of staff that the problem was the
length of time that it was taking for him to start an SOTP, as he felt he should
have completed one by then. He was also very aware of the fact that he was
still in prison three years beyond his minimum tariff.
18. Over the next two weeks, the man remained in the healthcare centre as staff
continued to be concerned about his low mood and failure to initiate contact
with others. A chaplaincy visitor described him as, “closed down … the
complete opposite to his usual outgoing self”. The only comment the man
would make about his self harm was that he could not face any more time in
prison. He spent most of his day sleeping or watching television. By 13
November, he appeared to be a bit brighter and he began to play snooker and
hold brief conversations with staff. He also attended education classes in the
healthcare centre. A week later, staff noted that the man was beginning to
laugh and joke with other prisoners.
19. However, on 22 November 2005, a teacher reported that during education the
man had said that he “did not want to be here any more”. She felt that he
could be at increased risk of self harm, so staff began to monitor him closely
once again. His mood gradually lifted over the next few days but he
continued to spend most of his time watching television and sleeping.
20. In November, the man was arrested and questioned by detectives from the
Metropolitan Police about events that had taken place in 1995. (This would
have been a complete surprise to him.) The interviews were conducted at a
police station in Wakefield. The police were made aware that the man was on
an open F2052SH, and agreed to supervise him closely whilst he was in their
custody. After being questioned, the man was charged with a further serious
sexual offence and returned to Wakefield. When he returned to prison he told
staff about the new charge and said that he felt a bit down. The following day,
he appeared in court where he was remanded in custody. Over the next few
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days, he appeared fairly relaxed and spent some time playing pool. However,
he told a member of staff that the new charge had “knocked him for six”.
21. In early December, the man appeared in court again, via a video link. During
the proceedings, the Crown Prosecution Service (CPS) asked for the case to
be transferred to a London court, because the alleged offence was being
investigated by detectives from the Metropolitan Police. On his return to
healthcare, the man said that his head was full of problems and that he
wished his suicide attempt had worked. The following day he agreed to ask
for his parole hearing to be postponed until after the new charge had been
dealt with. His solicitor wrote three days later, informing him that the CPS
application was likely to be granted.
22. Over the next two weeks, the man appeared gradually to become less
depressed and on 22 December the F2052SH was closed. However, he
remained in healthcare. He then received another letter from his solicitors
informing him that his case had been transferred to Blackfriars Crown Court
and that the next hearing would be early in the new year. They added that,
before the hearing, the court should issue a production order to enable him to
be transferred from Wakefield to a London prison. In a letter sent the
following day, they informed the man that the court date had been set for early
January 2006 and the hearing would agree a timetable for the case. On 30
December, the man met a member of staff for a review meeting following the
closure of the F2052SH. He appeared to be coping and gave the officer no
cause for concern.
23. The first notice that staff at Wakefield had about the man’s court appearance
in London was the day before he was due in court. Just after 2:00pm, one of
the custody clerks received an email requiring them to send the man to
Blackfriars Crown Court the following day. She spoke to a clerk at the court
and asked if it was possible to have the man appear via a video link. When
told this was not possible, she arranged that he would arrive at the court in
time to appear at 2:00pm. The custody clerk contacted the local prisoner
escort service to book the trip for the following day. She was told that the
man would have to spend the night in a London prison, as the round trip could
not be done in a day. However, they could not tell her at which prison he
would be staying.
The man’s time at Wandsworth
24. The following day, the man was taken from Wakefield to Blackfriars Crown
Court in London. At the hearing he pleaded not guilty and the trial was set for
late February. His lawyer told my investigator that the man understood the
impact of the new charge and was resigned to the probable outcome. She
said that he looked depressed, but he behaved rationally in light of the
situation that he was facing.
25. After his court appearance, the man was taken to Wandsworth. On his
arrival, he told officers that he was a lifer and gave them his prison number.
When an officer entered the number on the computer, the front page of the
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man’s record appeared but it could not be accessed any further, nor could it
be updated. The problem was that, because he was still on the computer
system at Wakefield, staff at Wandsworth could neither see the whole record
nor update it to reflect that the man was now at Wandsworth. As it was late,
staff resolved the immediate problem of how to take the man onto
Wandsworth’s roll by giving him a new prison number.
26. The Wandsworth staff intended to revert to the man’s original number once
the problem had been rectified. They did not telephone Wakefield to try to
resolve the problem immediately. (However, it should be noted that it was
early evening and the discipline office at Wakefield would have been closed.)
27. The man asked to be put on Rule 45. (Rule 45 provides vulnerable prisoners
with accommodation separate from the main prison.) At Wandsworth,
vulnerable prisoners are housed in the Onslow Centre, which is where the
man went after completing reception procedures.
28. The first part of the reception health check was completed by a nurse in
reception. She observed the problems the uniformed staff had in entering the
man’s prison number into the computer. She noted that the screen indicated
that, although he had been on an F2052SH plan, it had now ended. As the
computer screen was locked, she did not know when the F2052SH booklet
had been closed.
29. When the man left Wakefield, a Prisoner Escort Record form accompanied
him, first to the court and then to Wandsworth. Section 3 of the form lists a
number of risk categories that may apply to individuals, one of which is
suicide or self-harm. This was not checked, nor was any reference made in
the space for further information to the man’s recent, lengthy stay in the
healthcare centre. Had either part of the form been completed, it would have
alerted staff at Wandsworth.
30. As he was transferring from another prison, the nurse looked through the
man’s accompanying medical records. They showed that he was receiving
medication. She therefore appropriately referred the man to the doctor to get
his medicine prescribed. The man saw the doctor who wrote out a
prescription. The doctor added a note to the medical record that simply said,
“medication done”. My investigators were unable to speak to the doctor who
saw the man on reception as, before an interview could be arranged, his
contract was terminated. However, the nurse explained that the man’s
records showed that he was taking sleeping tablets, anti-depressants and
antibiotics.
31. The man was allocated a shared cell on the Onslow Centre. The next day, he
attended an induction session during which he asked a lot of questions. His
main concerns appeared to be why he had been given a new prison number
and whether his money had been transferred. He also said that, as he was a
lifer, he wanted a single cell rather than the two-man cell he was currently in.
11
32. The induction officer spoke to the custody officer to try to resolve the issue of
the two numbers. She then asked staff at Wakefield about his money, as it
was not showing on the computer, and was told that it had been transferred to
Wandsworth. Staff in Wandsworth’s finance department explained that until
the system was altered back to the original prison number it could not be
accessed. The induction officer passed this information to the man and said
that it would not be resolved until after the approaching weekend. The
problem of two numbers also meant that the money on the man’s telephone
PIN card could not be transferred. As a result, he could not make telephone
calls. However, staff allowed the man to use an office telephone to make a
call. The induction officer also told him to put in an application for a single
cell.
33. Over the weekend, the man did not attend the treatment room to take his
medication as he should have done. The prescription charts record Did Not
Attend (DNA) for Saturday, Sunday and Monday.
34. The man put in an application for a single cell first thing on Monday morning.
It was approved and he moved into one the next day. It was on H wing on the
‘threes’ landing, which actually means on the first floor, and was very close to
the centre. (The centre is the area where the three wings come together and
where the wing office and senior officer’s offices are located.) The man told
another prisoner that the cell was cold. My investigators were told that there
were problems with the heating system that meant the wing was unusually
cold.
35. On Tuesday, the man again failed to go to the treatment room for his
medication. The male nurse who was on duty that day, left a note in his cell,
asking him to collect his medication but he did not do so. Again, staff
recorded DNA against his name. The following day, the male nurse informed
his colleague, a more experienced, female nurse about the man’s failure to
collect his medication. The female nurse went up to the man’s cell and he
said that he did not want his medication and that he was fine. When asked,
he said he did not want to see a doctor either. The nurse entered “Refused”
against his name in the prescription chart. The following day (Thursday) she
asked the male nurse to try to persuade the man to take his medications, as
she thought a man to man appeal might have more success. However,
although the male nurse took the medication to the cell, the man said he was
fine and refused to take it. Again, his refusal was recorded on the prescription
sheet.
36. After this refusal, the two nurses decided to refer the man to the doctor, as the
first step in ensuring that he was seen by a member of the psychiatric team.
The female nurse explained to my investigators that it is possible for nurses to
submit a psychiatric referral form. However, it is sometimes quicker to refer
the prisoner to the doctor and for the doctor to make the referral to the
psychiatric team. The list to see the doctor on Friday was already full, so they
put his name on the Monday list.
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37. Also on Thursday, the man thanked the induction officer for her help with the
problems related to his prison number which had now been resolved. He had
reverted to using his lifer number and his money and PIN phone card were
again usable. The man was on his way to work at the time and the induction
officer thought he seemed fine.
38. The man had been assigned to work in the laundry and had his induction that
morning. When he was there, he told another prisoner that he was cold and
his cell was cold. The man did not return to the laundry after lunch but spent
the afternoon on the wing. After the workers returned to the wing at the end
of the afternoon, the man went to the cell of another prisoner who worked in
the laundry and asked if he could borrow a couple of items. The man stood in
the doorway and the two men chatted for a few minutes.
39. After the evening meal, due to a shortage of staff, only the prisoners who
worked as cleaners were given association and time out of their cells. During
this period of association, a group of the cleaners gathered outside the man’s
cell and shouted abuse at him through the locked door. They also threatened
that, unless he gave them canteen items such as tobacco and sweets, they
would spread the story that he and another prisoner had been seen engaging
in a sexual act.
40. My investigators spoke to the other prisoner alleged to have been involved in
the sexual act and he totally denied the allegation. They also spoke to the
prisoners who were supposed to have seen the activity happening. The
prisoners denied that they had seen any such thing and named other
prisoners as the source of the rumour. The other named prisoners also
denied seeing anything and starting the rumour. I can only conclude that the
rumour was manufactured in a malicious attempt to extort tobacco and other
canteen items from the man. The very limited contact between the man and
the laundry worker appears to have provided the idea for the rumour and
subsequent bullying.
41. In spite of the fact that about 25 cleaners were on association, no prison
officers appear to have been supervising the men on the landings. Had any
officers been present, they could not have failed to hear the noise and seen
the group of prisoners crowded around the man’s door. According to
prisoners, there was quite a lot of noise and it went on for some time during
which the size of the group fluctuated as individuals came and went. For the
man, it must have been a very unpleasant experience.
42. Staff did not become aware of these events until after the man’s death when a
prisoner informed an officer. The then governor of the Onslow Centre
investigated the matter locally and her report and all information were passed
to my investigators.
43. The night staff checked all prisoners in the Onslow Centre at about 5:45am on
Friday morning, as they are required to do. At that check, the man was still in
bed. After that, he was not seen again until the discovery of his body at
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12:10pm. A number of checks on his location and his cell ought to have
meant that he was discovered much earlier than he was.
44. The last person to see the man alive appears to have been one of the night
shift officers. The two night officers did a roll check from approximately
5:30am to 5:45am, towards the end of their shift. One remembered counting
the men on H3 landing, including the man who died. He told my investigator
that, although he did not know the man, he was absolutely convinced that he
was alive in his bed at the time of the morning roll check. He explained that it
was his practice to stay at a cell until he was sure that the man or men inside
were alive. He also recalled, after learning of the man’s death, that on the
side of H3 that included his cell, all the prisoners were still in their beds when
he checked them.
45. At some point after the roll check, it seems the man secured one of his bed
sheets to the window bars and hanged himself from it. At that time, each cell
in the Onslow Centre had a privacy curtain that stretched almost fully across
the width of the cell. It ensured that a prisoner using the toilet and washbasin,
which are located under the window, could do so without being observed.
The curtain was not floor length, which meant that feet were visible in the 18-
inch gap from the floor to the hem of the curtain. The man pulled the curtain
across his cell. It is not possible to say when exactly when he did this.
46. The first time an officer should have checked on the man was for the morning
roll check. It is the policy at Wandsworth that the officers who relieve the
night shift must carry out a roll check at the start of their shift, at approximately
7:30am. They then sign to confirm that the check was done. On Friday
morning, the labour officer signed to say that he had conducted the morning
check. However, when he spoke to my investigators, he admitted that he had
not carried out the check although he had signed to say that he had. He
explained that when he came on duty, he helped the two night shift officers do
their check. When it was time for him to do the morning check, another call
was made on his time and he did not do the count. Although he knew that a
new count should have been done, he used the number from the night shift
check as the morning roll. The officer has since reached retirement age and
has now left the Prison Service.
47. At 7:45am, the cell doors are unlocked to allow the prisoners to get ready for
the morning activities. The officers who unlock do not count the prisoners or
stop to chat with them, although some greet the men as they open the doors.
The then governor of the Onslow Centre said that she would expect that staff
who unlock in the morning to check that the prisoner is in the cell and that he
is alive. If a prisoner appeared to be behind the privacy curtain, the officer
should verbally confirm that he was okay.
48. Once the prisoners are unlocked, they are able to use the showers and
telephones, or collect hot water to make a cup of tea. They do not collect
food for breakfast as ‘breakfast packs’ are issued. (This means that when
they collect their evening meal, they are given a pack for breakfast the
following morning containing cereal, milk and sachets of tea and coffee.
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Many prisoners also take extra bread with their evening meal, in order to keep
some for breakfast.) Accordingly, there is no reason for officers to notice
whether or not a prisoner comes out of his cell after being unlocked in the
morning.
49. At approximately 8:30am, the prisoners are called to work and those who
work or attend education leave the landings. Some prisoners do not work -
for example those on remand who chose not to, men of retirement age and
those who are too ill. These men are left unlocked and are free to move
about the wing until the workers return before lunch, when all prisoners are
then locked up. During the morning, the wings are usually quite busy and
noisy.
50. The next occasion when the man could have been discovered was during the
cell fabric checks. Officers check each cell every day and then sign and
record the time they complete the checks on each landing. They look for
damage to the walls, floors, doors and window bars, to ensure that no attempt
at escape is being made. They check the fittings and also have a cursory
look around for any items in the cell which should not be there. All the officers
who spoke to my investigators said that, if a curtain was pulled across the cell,
they would pull it back as they have to go behind the curtain to check the
toilet, sink and window. The staff who spoke to my investigators were all quite
clear that, when doing any kind of check, unless a prisoner was behind the
curtain, they would tell the prisoner to keep it pulled back.
51. On Friday morning, two officers carried out the cell fabric checks on the third
landing and one of them signed to say they were completed at 8:45am. The
fact that the man was not discovered during the checks has one of two
explanations. It may be that the man was out of his cell during the fabric
check and returned later. However, my investigators could find no-one who
remembered seeing the man that morning. It would also mean that he left his
cell for a time, then returned and moved behind the curtain almost
immediately. We know that by approximately 9:00am the curtain was pulled
across the cell.
52. Alternatively, the man could have been behind the curtain which would mean
a proper check was not done on his cell. Officers explained to my
investigators that it might be possible to miss out a cell during a check. If they
were called away in the middle of a check, they might not recall accurately
what cell they had reached. As a result, they might continue not where they
left off but at a nearby cell. However, all the staff were all clear that each cell
must be checked each day and what a check requires.
53. The next time a working prisoner’s absence should be noted is at about
9:00am, after the labour officer has checked the workshops to note which
men have not reported for work. They then cross reference this with the list of
prisoners who have a valid reason for being absent, for example those having
a visit or who are sick. Prisoners who are not at work without a valid reason
are not paid for the time they miss. The labour officer then looks for absent
15
prisoners, beginning with their cell and then moving to a general search of the
wing.
54. The labour officer that Friday recorded that the man was not at work in the
laundry. He went to his cell and looked through the observation hatch but did
not see him. He noted that the privacy curtain was pulled across the cell but
did not go in and pull the curtain back. Had he taken a minute or two to do so,
the man would have been found much earlier. However, the labour officer
explained that he had a lot of tasks that morning and he decided to look for
the man later. He did not inform a wing manager that he could not locate the
man or ask another officer to look for him. For the remainder of the morning,
no one took any action to find the man.
The discovery of the man
55. At 11:45 am, prisoners return from morning activities and are locked in their
cells. At midday, they are unlocked a few at a time to collect their lunch from
the hot plate on the ground floor. An orderly (a prisoner) has a list of
prisoners and the meals they have ordered and checks off the names as the
men collect their food. When the man did not collect his meal, the prisoner
alerted an officer at the hot plate and an officer on the third landing went to his
cell. She immediately noted that it was extremely cold in the cell as both
windows were open. As it was too cold for somebody to be sitting there, she
assumed that the man was not in the cell and that he must be at a visit or a
religious service. As the privacy curtain was pulled across the cell, she pulled
it back and discovered the man hanging.
56. The officer immediately ran to the door and shouted to another officer at the
end of the landing to help. She then returned to the man and supported his
weight. The other officer came in and went to the other side and they were
able to raise him further. Further officers heard her shout and ran to assist. A
third officer arrived very shortly afterwards and released the bedsheet from
the window. They moved the man to the bed where they removed the
bedsheet. As they did this, a nurse arrived and told them to lay the man on
the floor so that she could begin treating him. Once the man was on the floor,
an officer used the radio he was carrying to contact the control room and ask
for the hospital response team to attend. (The responding nurse rightly asked
for the man to be moved to the floor. The Governor may wish to remind all
staff of the requirement in Annex C of PSO 2700 to place an unconscious
prisoner on his / her back on a flat, solid surface.)
57. Two nurses were in the treatment room on the ground floor dispensing
medication when an officer asked them to go to help the man. One went
ahead while the other collected the emergency bag and oxygen cylinder
before going upstairs. At the cell, officers told the second nurse that they had
called for the duty nurse, the doctor and an ambulance.
58. The second nurse noted that the man’s skin was cold, he had no pulse and
was not breathing. She noted the presence of rigor mortis (the stiffening of
the body after death). His jaw was shut tight and she could not open his
16
mouth to put in an airway. As a result, she put a face mask over his nose and
mouth and administered oxygen through it. The nurses also performed the
chest compressions necessary to carry out cardio-pulmonary resuscitation.
After a short time, the duty prison doctor arrived as did the paramedics. They
each examined the man and at 12:26pm agreed that there was nothing more
that could be done for him and that he had died.
59. The governor of the Onslow Centre and another governor visited the man’s
next of kin to inform them of his death. Unfortunately, there was a delay of
some hours while they checked the address and then travelled through rush
hour traffic to reach the family home. There was a further delay while prison
staff liaised with police officers from the local police station. To date, neither
the man’s property nor his money have been returned to his family.
17
ISSUES
The F2052SH plan and support for the man
60. When staff at Wakefield learned of the man’s attempt to take his life, they
acted quickly and put support in place. He was admitted to healthcare, where
he was put on regular but intermittent observations and an F2052SH plan was
opened at once. The first review meeting was held within the required
timescale and was attended by staff from a range of departments. The man’s
mental health was monitored throughout his time in healthcare and whilst the
F2052SH was open.
61. However, it appears that staff did not consider contacting the man’s family to
include them in his support plan. PSO 2700 Suicide and Self-harm
Prevention states in paragraph 3.4.3, “After consultation with the prisoner, the
nominated next of kin must be notified, unless:
• There is a clinical reason not to, or
• If aged 18 and over, the prisoner does not consent, or
• The prisoner’s support plan indicates otherwise.”
There is nothing on the record to show that staff considered encouraging the
man to include his family in his support plan. Wakefield has now moved onto
the new Assessment Care in Custody and Teamwork (ACCT) system for
supporting prisoners who are at risk of self-harm. It also includes a
requirement to involve the next of kin in support if the prisoner gives his
consent.
The Governor of Wakefield should remind staff of the requirement in
PSO 2700 to involve the family in the support of a prisoner on an ACCT
plan and introduce an audit of records to establish compliance.
Prison numbers and the computer system
62. It is not clear whether the man was expecting to return to Wakefield the day
after appearing in court. His solicitor had written in December 2005, saying
that he would be transferred to a London prison while his case was being
heard. But staff at Wakefield fully expected the man to be returned to them as
soon as possible. He was therefore sent to court and Wandsworth with only
some of his documentation. His possessions remained at Wakefield. My
investigators looked at the circumstances of the transfer, but were unable to
find any documents relating to an arranged transfer or an indication of how
long the man was to remain at Wandsworth.
63. When the man arrived at Wandsworth, he gave officers the prison number he
had used for many years. However, when staff entered it into the Local
Inmate Database System (LIDS), they could see only the front page and could
not add or change any information. This caused problems both for the staff
and, more importantly, for the man. The reception staff resolved the
immediate issue by giving him a new number, meaning that the man could be
put onto the roll at Wandsworth. However, it meant that for almost five days
the man did not have access to his money or to his phone card. It obviously
18
concerned him as he spoke to officers about it for several days until the
problems were resolved.
64. The difficulties arose because of the way LIDS is set up – each prison’s
database is stand-alone and is not fully accessible across the prison estate.
When the man was taken to Blackfriars Crown Court staff at Wakefield did not
know which prison he would be taken to for the night. Had they known, they
would have entered the details onto LIDS and the man would have been
removed from Wakefield’s system and roll and added to the other prison’s.
The man had to be removed from the roll at Wakefield in order to keep their
roll correct. Staff in the discipline office had to enter a destination for the man
and the only destination they were sure of was the court. The man was then
on the roll of the court and neither Wakefield nor Wandsworth could access
his records beyond the first page. The problem was only resolved when the
man was removed from the court roll and put onto Wandsworth’s. That then
allowed Wandsworth to take him on to their roll and revert to his original
prison number. Only then did the man get access to his money and PIN
phone card.
65. Another important ramification was that, although staff could see that the man
had been on an F2052SH form, they could not access the screen that gave
the date it had been closed. Had they been able to do so, they would have
seen that it had been closed just over two weeks previously. However, I am
surprised that staff in reception who saw the information about the F2052SH
did not ask the man when it had been closed. The information would have
been useful to add to the medical record, particularly as the man was on anti-
depressant medication. It should also have informed the decision on the Cell
Sharing Risk Assessment.
66. I have been pleased to learn that the problems experienced during the
transfer of the man from Wakefield to Wandsworth via the London court will
not occur when LIDS is replaced with the new C-NOMIS computer system.
When it is fully in place, the new system will allow staff in all areas of the
National Offender Management Service (NOMS) to access and update
information on any person on the system.
Health checks
67. The medical notes show that, before the man left Wakefield, he was assessed
as being ‘fit for court and any overnight stay’. The record does not record
whether the assessment looked at his recent mental health problems and the
recently closed F2052SH. In his report, the clinical reviewer highlighted the
importance of monitoring the man’s mental health, especially as he was facing
a new charge. It would have been helpful if the assessment had mentioned
the F2052SH and the man’s self-harm.
Wakefield West PCT in partnership with HMP Wakefield should ensure
that all prisoners being transferred have recent self-harm attempts and
F2052SH plans noted in the clinical record at the assessment prior to
movement.
19
68. When the man arrived at Wandsworth, a nurse completed the health
procedures in reception. She took his medical record which had travelled with
him from Wakefield. She saw from the record that he was prescribed a
number of medications and, as required, she referred the man to see the duty
doctor before going to the wings. She also noted from the LIDS screen that
he had been on an F2052SH but it was now closed. Because of the problems
accessing the man’s full record on the computer, the reception nurse could
not find out when the plan had been closed. Unfortunately, she did not ask
the man for this information. When asked why she had not done so, the
nurse replied that she hoped the doctor would speak to the man about this.
She said that the man looked fine and was happy that he was going to see a
doctor. He did not mention that he was facing a new charge.
69. Although the closure of the F2052SH is mentioned in the medical record,
there is no way of knowing whether the doctor read this or discussed the
man’s mental health with him. As already noted, the only record of the
consultation was that medications were prescribed. The brevity of the entry
leaves that part of the man’s medical assessment blank.
70. As a prisoner who was transferred from another prison, the man did not
undergo the full First Reception Health Check as a new prisoner would have
done. Nor did he have a follow up health check at a later date. As part of the
First Night procedures, the man would have been asked if he wanted to be
referred for a well-man check up, but that check is voluntary. There is no
formal health screen process for a transfer prisoner. As a result, it appears
that no-one asked the man about the F2052SH, thus missing an opportunity
to have learned about his recent mental health needs.
The Wandsworth PCT in partnership with the prison should ensure that
all prisoners, including those transferred from other prisons, receive a
structured and well documented health review that includes mental
health issues.
Living conditions on the Onslow Centre
71. During the week he spent in Wandsworth, the man passed the time playing
pool and table football (my investigators were told that he was a very good
player). He chatted with some other prisoners and his impending trial was
obviously in his thoughts. He told one prisoner that he had already done a
long time in prison and was looking at a potential life sentence. When talking
to another prisoner, he said that he had destroyed his life. However, staff and
prisoners generally commented that the man was very quiet and mainly kept
to himself.
72. This was very different to his life in Wakefield where he was known to the staff
and had a group of close friends. There, he was part of a tight-knit group of
men from the same ethnic background who cooked their own food and ate
together. They supported the man, and his personal officer said that they had
20
a calming influence on him. When he moved to the healthcare centre, they
sent him cards that showed concern and support.
73. The building housing the Onslow Centre was very dark, due the building work
that was going on at the time. The outside of the wing was covered in
scaffolding and the skylights were covered over to prevent materials falling
onto those below. A boiler was broken and there was no hot water available
in the showers. A prisoner told my investigators that he had given the man
his newspaper to read in his cell. He later discovered that the man had put
the pages on his bed for warmth.
74. The man was not issued with a battery-powered television as there were none
available at the time. According to his property cards, the man’s radio/CD
player had remained at Wakefield along with his other property as the staff
there had expected him to return after an overnight stay in London. When my
investigators saw the man’s cell, they noted that, apart from two library books,
it was quite bare. The living conditions in Wandsworth must have seemed
very stark compared to the life he had had in Wakefield.
The Governor of Wandsworth should consider providing sufficient
televisions to ensure that there is one per cell available.
The bullying on Thursday evening
75. Shortly after the start of the investigation, several prisoners informed my
investigators that the man had been bullied and blackmailed for his canteen.
In an effort to establish the truth of the allegations, my investigators spoke to
six men who had been prisoners on the Onslow Centre when the man was
there. Their accounts differed somewhat, but they all described a very similar
scene that occurred during association on Thursday evening. One prisoner
said that the prisoners had returned the following morning and that the man
had spoken to the induction officer when she unlocked his cell. However,
none of the other prisoners corroborated this information and I conclude that it
was rumour and unreliable.
76. It is disturbing to learn that a group of approximately six to eight prisoners was
confident enough openly and noisily to bully another prisoner. Even more
disturbing is the apparent absence of officers from the landings supervising
association. When asked where the officers were whilst the ‘mob’ was at the
man’s door, the prisoners replied that they were not on the landings. The
cleaners are generally in positions of trust, but they are still prisoners who
must be supervised. The lack of supervision on the last night of the man’s life
meant that others were able to subject him to serious verbal abuse and
threats.
77. The local enquiry that was carried out by the the governor of the Onslow
Centre of the unit did not find any evidence of the man being bullied. My
investigators spoke to the prisoner who made the initial allegation and a
number of the cleaners named as being involved in the spreading of the
rumour and the bullying. They all confirmed that the disturbance had taken
21
place. I can only conclude that whilst the prisoners were willing to give
information to my investigators, they were more reticent when being
questioned by prison staff.
78. The apparent lack of supervision appears to be in keeping with the autonomy
the cleaners seemed to have had up to the middle of January 2006. One
prisoner told my investigators that he had arranged a job as a cleaner on his
second day in the prison. He explained that all he did was have a word with
one of the prisoners who was already a cleaner. During the early part of the
investigation, my staff were told that cleaners held supplies of equipment such
as mugs and blankets. They also held the application forms so that any
prisoner who wanted to make an application, including a medical one, had to
ask a cleaner for the correct form. The investigators were told that several
cleaners abused this responsibility by not issuing equipment or forms when
they were asked to. They discussed these issues with the unit manager and
prompt action was taken and the responsibilities removed from the cleaners.
Application forms are now readily available from a rack outside the wing
office. At the same time, a number of cleaners, including those named as
being involved in the bullying, were transferred to other prisons.
Missed checks on Friday morning
79. The man was not seen alive at any time after 5:45am when the officers on
night duty did the roll check towards the end of their shift. During the morning,
several other checks ought to have been carried out that should have resulted
in staff finding the man significantly earlier than actually happened. Either the
checks were not done, or they were not done to the required standard. The
result was that the man was not found until lunchtime when there was no
possibility that a successful resuscitation could be carried out. The list of
failures makes unhappy reading. It is also worrying that, in effect, a prisoner
disappeared from view for a whole morning without any action being taken to
discover his whereabouts.
The Governor of Wandsworth should remind all wing staff that a
morning roll check must physically be completed before being signed
for in accordance with local policies and procedures.
The Governor of Wandsworth should remind officers who unlock
prisoners in the morning to check that the prisoners are in the cell and
are well.
80. The two most serious omissions lie at the door of the one officer who has now
retired from the Prison Service. Had he not done so, I would have
recommended that the Governor consider an investigation under the code of
discipline. Whilst there is no excuse for his signing for a check that he did not
carry out, there were mitigating factors in his failure to search for the man on
Friday morning. As the labour officer, he had a long list of tasks to carry out
during his shift. (The role of labour officer at the time does appear to have
been far more heavily weighted than that of a landing officer, especially as it
involved tracking down prisoners who had unexpectedly failed to attend work.)
22
The unit manager raised this issue during her interview with my investigators
and indicated her intention of carrying out an assessment and reallocation of
the duties of the officers on the Onslow Centre.
81. The other probable omission is the lack of a cell fabric check on the man’s
cell. An officer signed to say that the threes landings had been checked. If
the timings that were recorded are accurate, he and the officer who assisted
him did the cell checks for the threes landings between 8:15am and 8:45am.
With 15 cells on each side of the wing, that means that the two officers
checked 30 cells in 15 minutes. That would imply that each cell check took
approximately a minute. It is impossible to say what happened about the
man’s cell fabric check, apart from noting the speed with which the whole
landing was completed.
The Governor should remind staff of the importance of ensuring that no
cells are missed during the daily fabric checks.
Return of the man’s possessions
82. When my Family Liaison Officer contacted the man’s family in early
November 2006, she was told they still had not received his property and
money from the prison. The man’s brother had tried several times to contact
staff about this but without success. I have made the Governor aware of this
lack of care for the family and, at the time of writing this report, he is resolving
the matter. I am aware of occasions where the staff at Wandsworth have
been very caring and considerate in their treatment of bereaved relatives. It
is, therefore, all the more disappointing that this care was not given to the
man’s family.
The Governor should investigate the cause of the unreasonable delay in
returning the man’s possessions and take action to prevent a
recurrence.
23
RECOMMENDATIONS
The Governor of Wakefield should remind staff of the requirement in
PSO 2700 to involve the family in the support of a prisoner on an ACCT
plan and introduce an audit of records to establish compliance.
This recommendation has been accepted.
Wakefield West PCT in partnership with HMP Wakefield should ensure
that all prisoners being transferred have recent self-harm attempts and
2052SH plans noted in the clinical record at the assessment prior to
movement.
This recommendation has been accepted.
The Wandsworth PCT in partnership with the prison should ensure that
all prisoners, including those transferred from other prisons receive a
structured and well documented health review that includes mental
health issues.
This recommendation has been partially accepted and the resource
implications will be examined. In the meantime, the prison transferring the
prisoner should ensure that the clinical record is up to date and complete and
that it accompanies the prisoner. The Head of Health Services at
Wandsworth will ensure that the system is reviewed with the intent that the
clinical record of each prisoner being transferred is read and an entry made in
the record to this effect. An action plan will be entered in the clinical record
where necessary and brought to the attention of relevant staff.
The local PCT is currently re-assessing the requirements for healthcare
provision in Wandsworth and have now included a section on physical and
mental health reviews for all patients arriving at the prison. The computerised
medical record system that all local GPs use will also be installed in the prison
to improve the quality of information staff will have on their patients.
The Governor of Wandsworth should consider providing sufficient
televisions to ensure that there is one per cell available.
In-cell electricity was being installed on the Onslow Unit at the time of the
man’s death. This has now been completed and each cell now has a
television.
The Governor of Wandsworth should remind all wing staff that a
morning roll check must physically be completed before being signed
for in accordance with local policies and procedures.
The Governor of Wandsworth should remind officers who unlock
prisoners in the morning to check that the prisoners are in the cell and
are well.
24
The Governor of Wandsworth should remind staff of the importance of
ensuring that no cells are missed during the daily fabric checks.
For the three recommendations above, Governor’s Orders have been issued
on these three subjects. The Local Security Strategy document also sets out
in detail the correct procedures. This is published on the intranet and is
available at all times to staff.
The Governor of Wandsworth should investigate the cause of the
unreasonable delay in returning the man’s possessions and take action
to prevent a recurrence.
One of members of the Senior Management Team has been in contact with
the man’s family to ask what their wishes were regarding his property. The
family have not yet confirmed what property they want to have forwarded to
them.
25
ANNEXES
1. Documents considered during the investigation
Core Record
Custody File
Security File
Medical Records
Parole dossier
Lifer file
Correspondence from the man’s solicitors regarding his new court case
Emails and notes supplied by the Custody clerk at Wakefield relating to the man’s
movements on 5 January 2006
26