Individual at Swaleside

Investigation into the circumstances surrounding the
death of a man
at HMP Swaleside in April 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2011
This is the report on an investigation into the circumstances of the death of a 46 year
old man who apparently took his own life in HMP Swaleside in April 2010. I offer my
condolences to the man’s family.
One of my family liaison officers spoke with the man’s family to explain our role and
offer the opportunity for them to be involved. I would like to thank the man’s family
for their contribution to this investigation under such distressing circumstances. I
hope that my report answers their questions. I apologise for the delay in issuing this
report, and the additional distress which this has undoubtedly caused.
The investigation was undertaken by a senior investigator. We would like to thank
the Governor of Swaleside and his staff for their co-operation. I commissioned a
review of the man’s clinical care whilst in custody, which was carried out by a clinical
reviewer on behalf of Eastern and Coastal Kent Primary Care Trust (PCT). I am
grateful to him for his review and his contribution to my investigation.
The man had been in prison for a number of years and moved, unsuccessfully, to
open conditions on more than one occasion. He was diagnosed with a personality
disorder and depression and had recently returned from a period in a specialist
hospital. He had been referred back to the Parole Board and received the reports on
his conduct four days before he took his life. The man had made a number of
attempts on his own life over the years and, when he took his life, was again being
supported by the prison’s monitoring measures for those thought to be at risk of
harming themselves.
In the draft of this report my office made nine recommendations. The first was a
national recommendation concerning sentence planning. The draft commented on
prisoners’ medical appointments, the personal officer scheme, monitoring prisoners
subject to self harm monitoring and the actions to be taken when a prisoner is found
hanging. The draft also considered the family’s view of the information and support
which they received from prison staff and made another recommendation regarding
relationships with bereaved families.
I am pleased to see that the National Offender Management Service has accepted
eight of the recommendations and partially accepted the other. I am also particularly
grateful to the man’s family for their detailed and considered response to the draft. I
hope the amendments in this final report go some way to addressing their concerns.
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.
Nigel Newcomen
Prisons and Probation Ombudsman October 2011
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CONTENTS
Summary
The investigation process
HMP Swaleside
Key events
Issues
Conclusion
Recommendations
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SUMMARY
1. The man was convicted of murder and sentenced to life imprisonment in
1991. He had therefore spent many years in prison. He had progressed
through the system and had on three occasions been transferred to open
conditions (a lower security prison where prisoners have a greater degree of
trust). He found it difficult to adjust to these moves and each time had moved
back into closed conditions, once at his own request.
2. The Parole Board considered the man’s case in December 2007. The Board
did not recommend a return to open conditions but asked for him to be
referred back in December 2009 to enable the man to work with a
psychologist to understand the motivation for his offence. The Board also
recommended that he should undertake a cognitive skills booster course (an
offender programme to help prisoners recognise and understand their thought
processes in relation to their offending) and work on forming alternative
coping strategies.
3. The man transferred to HMP Swaleside in January 2009, and in June of that
year was found hanging in his cell. Staff managed to cut the ligature and he
was treated in the healthcare centre. This was the latest of a number of
apparent suicide attempts that he had made through his sentence. He was
put on special measures to support those felt to be at risk of harming
themselves (known as Assessment, Care in Custody and Teamwork –
ACCT).
4. As the Parole Board were due to consider his case in December, the prison
began to collate reports to put before the Board. In early August, the
psychology department submitted a note, saying that they would not prepare
a report as the targets set in the last psychological assessment had not been
completed, and the department was unable to carry out this work.
5. Arrangements were started to assess the man for a transfer to a hospital for
the treatment of prisoners with mental health needs, and he moved there in
December. December was also the month when the man’s case should have
been referred back to the Parole Board. As he had been transferred to
hospital, the process was put on hold until he returned to prison. Although his
family felt that he seemed to settle well at the hospital, the man had some
difficulty with the regime there. In February 2010 he asked to be returned to
prison. Staff encouraged him to stay but, over the forthcoming weeks, his
frame of mind deteriorated. By early March, staff at the hospital decided that
his motivation had decreased to the extent that he should return to prison.
6. On arriving back at Swaleside, the man threatened to harm himself if he was
not placed in healthcare. Although he was persuaded that it was in his best
interests to remain on ordinary location, he was placed under the ACCT
support measures as a precaution. It appears that he may have been buying
drugs from other prisoners and had got into debt. Arrangements were made
for him to collect his medication at a different time from other prisoners, so
that he would not encounter those to whom he may have been indebted.
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7. The man’s papers had been collated to be referred to the Parole Board once
again. They were disclosed to his legal representative on 23 March, and then
to the man himself on 29 March.
8. Although a friend said that the man had seemed a bit down, there were no
serious, immediate concerns about him. He remained subject to ACCT
support and was checked by staff once per hour. He continued to express
concerns about his future.
9. On a day in early April, the man slept all morning and declined to collect his
lunch, telling staff that he was okay. The prisoners were then locked in their
cells for the lunch period. Staff checked on the man at 12.58pm, when no
concerns were reported. The staff unlocked the cells on the man’s landing at
approximately 1.45pm. As the officer unlocked his cell, she looked through
the observation hatch and saw him apparently standing facing her. She
unlocked the door and moved on.
10. However, a few seconds later, some prisoners went into the man’s cell and
found that he was hanging. They raised the alarm, and staff arrived quickly.
They cut him down and worked to resuscitate him. Prison healthcare staff
attended, and attempts at resuscitation continued until an ambulance crew
arrived and took over. The resuscitation efforts proved unsuccessful and his
death was declared by the ambulance crew.
11. The prison contacted the man’s next of kin. He died on Easter weekend,
when the prison’s only trained family liaison officer was on annual leave. He
came in to the prison to contact the family but, after giving details of what had
happened, he told them that he was on leave for the following week and no
one was covering the position. Relations between the prison and the family
became strained, and eventually another member of staff acted as the liaison.
12. I make nine recommendations. The first is to the National Offender
Management Service and concerns sentence planning. The other
recommendations address outstanding medical appointments, the personal
officer scheme, monitoring prisoners subject to ACCT procedures and the
actions to be taken on finding prisoners hanging. I also recommend that
steps are taken to address any difficulties between a bereaved family and the
family liaison officer.
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THE INVESTIGATION PROCESS
13. My investigator was given full access to all relevant records relating to the
man, including his prison and medical files. During the investigation he visited
Swaleside and spoke to that staff responsible for the man’s care, and the
prisoners who knew him. He interviewed six members of staff and one
prisoner, and all but one of these interviews were recorded. The other
interview was conducted over the telephone. Copies of the transcripts were
sent to the interviewees to confirm their accuracy. My investigator also spoke
to the Acting Governor and the vice-chair of the Independent Monitoring
Board. My investigator made himself available to speak to the Prison Officers
Association and the chaplaincy.
14. Notices were posted to staff and prisoners about my investigation, inviting
contributions if necessary but none were received. My investigator had
access to statements made by relevant staff after the man died.
15. Eastern and Coastal Kent Primary Care Trust (PCT) asked a clinical reviewer
to carry out a review of the man’s clinical care. I am grateful to him for
undertaking this review. Unfortunately, there was a delay before the clinical
reviewer was appointed and his review was not received until late February
2011 which is why my own report is late. My investigator discussed aspects
of the man’s treatment both with healthcare staff at Swaleside and with the
reviewer.
16. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of my investigation and request a copy of the post mortem report.
My report will be sent to the Coroner to assist in his enquiries into the man’s
death.
17. One of my Family Liaison Officers (FLOs) spoke with the man’s niece, who
was the point of contact on behalf of her mother (the man’s listed next of kin).
She told her of my investigation and invited her and the man’s family to ask
any questions or raise any issues for consideration. My Family Liaison Officer
and investigator met with the man’s sister, niece and brother-in-law to discuss
the investigation and listen to their concerns about the care which the man
received. His family asked if my investigation could consider the following
issues:
• the level of psychiatric support he had received, both before and after the
period spent at the hospital for the treatment of prisoners with mental
health needs
• the limited engagement of the Probation Service throughout the man’s
sentence
• the arrangements regarding the man’s Parole Board review whilst he was
at the hospital for the treatment of prisoners with mental health needs
• the appropriateness and quality of any self-harm monitoring
• the appropriateness of the actions of the officer who unlocked the man
shortly before he was found hanging
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• the quality and appropriateness of the family liaison arrangements
following the man’s death.
18. At the suggestion of the man’s family, my investigator also spoke to the man’s
prison law consultant about some of the issues raised. I have done my best
to address the concerns raised by the man’s family, including their helpful and
detailed comments on the draft report. I hope my report helps them better
understand the events leading to the man’s death.
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HMP SWALESIDE
19. Swaleside is a category B prison (for prisoners not requiring top security
conditions, but for whom escape must be made difficult) which is part of the
three prison cluster on the Isle of Sheppey in Kent. It holds long-term
prisoners, including a large number on indeterminate sentences (serving
sentences of no fixed length but until the risk to the public is judged to have
been reduced), who have more than 18 months left to serve on sentences of
at least four years. It had an operational capacity of 1,132 as of February
2010.
Healthcare
20. There is a daytime general practitioner service from Monday to Friday and an
out of hours service provided by South East Health. The healthcare staff
include the healthcare manager, nurses, healthcare officers and a pharmacy
technician. Primary care services include a Well Person Clinic for long-term
illnesses such as asthma or diabetes, primary and secondary mental health
care, Integrated Drug Treatment Service (IDTS), sexual health, optical care,
dentistry, physiotherapy, radiography, weight management, blood clinics, and
palliative care. The prison has an 18-bed in-patient unit for prisoners with
physical or mental health problems, which is staffed 24 hours a day.
Suicide and self harm monitoring
21. Assessment, Care in Custody and Teamwork (ACCT) is the system used by
prisons in England and Wales to monitor and support prisoners assessed as
at risk of suicide or self harm. Once placed on ACCT, the prisoner is
supervised at regular intervals according to the perceived level of risk.
22. Each prisoner is assessed within 24 hours and then reviewed at intervals
decided on an individual basis. The ACCT guidance says that, to be effective,
the review should involve the key people, forming a case review team, who
know the person at risk or are involved in their care. The key questions for
each review are listed as:
• Have the problems that caused the ACCT plan to be opened now been
resolved?
• If not, what needs to be done to resolve them?
• Have any further problems arisen that are now causing distress and more
risk?
• If so, what action can be taken to address these?
• Is the person at risk now in contact with friends, family or other support?
• Does the person at risk now have something in their lives that they feel
good about?
• If not, how can this be improved?
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23. Over time, the reviews should also consider other factors such as:
• Distress – has anything changed to make the person at risk more or less
desperate?
• Resources – has anything changed that makes the person at risk now feel
more or less alone?
• Previous suicidal behaviour – has anything changed that makes suicide
more familiar or more acceptable to the person at risk?
• Suicide intention or plan – has anything changed to show that the person
at risk is either more or less prepared to kill themselves?
• Pattern of self harm – is self harm becoming more or less frequent?
24. An ACCT plan can be opened by anyone working in the prison. An ACCT
should be opened when anyone has any concerns whatsoever that a prisoner
may be at risk of harming him or herself. Among other things, the ACCT
guidance states that prisoners should be cared for in a safe environment and
the case review team decide the most appropriate place to locate an
individual prisoner.
25. Once it has been agreed that ACCT support is no longer required, a post-
closure interview must be held to ensure that problems have been resolved or
reduced and that the level of risk has sufficiently dropped. The date for the
interview is a matter for the case review team to decided, but it must be within
seven days of the ACCT support coming to an end.
Parole for mental health patients
26. All prisoners who are compulsorily admitted to hospital under the Mental
Health Act have their parole process suspended whilst they are in hospital. If
they are prisoners who have served their sentence, they can be released into
the community to go to hospital. If they are serving indeterminate sentences,
the parole process is suspended for the duration of their hospital stay.
Previous deaths at HMP Swaleside
27. Since my office took over responsibility for investigating deaths in custody in
April 2004, there have been 17 deaths in Swaleside prior to this man’s, five of
which were self-inflicted. There have since been two further deaths, one of
which was self-inflicted. My office’s previous reports have also made
recommendations about family liaison matters.
Her Majesty’s Inspectorate of Prisons
28. The last inspection of Swaleside by the Her Majesty’s Chief Inspector of
Prisons was an announced inspection in April 2008. The inspectors found
Swaleside to be a safe and respectful prison, which was impressive given the
many serious offenders held. The report was positive about the overall
operation of the personal officer scheme, but made a recommendation which
included ensuring that the expectations of personal officers were clear. In
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considering ACCT procedures, the report noted that the standards were
variable.
Independent Monitoring Board
29. Each prison in England and Wales has an Independent Monitoring Board
made up of unpaid volunteers from the local community appointed by the
Secretary of State for Justice. The Board is responsible for monitoring day-to-
day life in the prison and to ensure that proper standards of care and decency
are maintained.
30. The report published for the year 2009-10 by the IMB for Swaleside noted that
the psychology department was understaffed, that the prison has no policy
that makes an explicit link between educational need and offender
progression, and that there were delays with parole reports. The report says
that there is a significant drug problem in the prison.
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KEY EVENTS
31. The man was convicted of murder in 1991. He had been staying with a man
he met whilst hitchhiking, and claimed that the man came into his bedroom
with a knife and sexually attacked him. In the ensuing struggle he stabbed
and killed the man.
32. Sentenced to life imprisonment, the man moved through the prison system.
He undertook a number of offender courses (courses which help prisoners
address areas which may have contributed to their offending), including
Enhanced Thinking Skills, and anger and stress management courses. He
also took further education courses, gaining academic qualifications in art,
mathematics, and English.
33. In 1997, the man disclosed that when he was a child, he had been sexually
abused. This happened when he was a pupil at a school for blind children,
and the alleged perpetrator had been a teacher there.
34. The man served his sentence in a number of prisons. In August 2000, while
at HMP Wymott, he made an attempt to take his own life. He was found with
a ligature around his neck, which was safely removed.
35. After some time in HMP Lindholme and HMP Latchmere House, the man was
transferred to HMP Doncaster on 16 July 2001. Whilst there, in April 2002, he
was assessed for Post Traumatic Stress Disorder (PTSD: a psychological and
physical condition caused by very frightening or distressing events. The
person often relives the event through nightmares and flashbacks. They may
have problems concentrating and sleeping, and feel isolated and detached).
The prison psychologist concluded that the man suffered from a PTSD which
was rated as severe. This appeared to stem from a number of traumatic
events in his life. The man specifically identified the sexual abuse and the
death of his victim as the causes, although the report does not make clear if
he meant the abuse which he said he suffered as a child, or whether he
meant abuse by the victim of his offence.
36. By early 2003, the man was judged ready to be transferred to open or
Category D conditions. (These are prisons with low security, designed for
prisoners who can be given a higher degree of trust, are less likely to escape,
and who are thought to pose a low level of risk to the public.) He moved to
HMP Wealstun on 13 February 2003. However, he had trouble coping with
the new regime and he went on a town visit a week later but did not return.
After remaining unlawfully at large for just over a week, the man gave himself
up on 28 February. He was returned to closed conditions, initially going to
HMP Bullingdon on 1 March, before transferring to HMP Bedford, and then on
to HMP Haverigg on 16 April. After two months in HMP Risley, the man was
transferred to HMP Ranby on 8 October.
37. The Parole Board considered the man’s case on 23 July 2004, and
recommended that he was ready once more to move to open conditions. On
21 September he transferred to HMP Kirkham. However, on 20 October, the
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man told staff that he felt as though he was at risk of absconding. He was
finding it difficult to cope, and felt that he was receiving little support for his
PTSD. He asked to go back to a closed prison and, on 21 October, he
returned to HMP Ranby, a category C prison.
38. After contact with staff at Ranby and at Kirkham, the Secretary of State
agreed that the man could once again return to open conditions without
referral to the Parole Board. On 15 March 2005, he was transferred to HMP
Hewell Grange, another category D prison. He was released on temporary
licence for an unescorted town visit a month later on 16 April. He smelt of
alcohol when he returned that evening, and was unsteady on his feet.
39. Nevertheless, approval was given for a period of five days home leave in July.
Arrangements were made for the man to stay in an approved probation
hostel. He was given a drug test beforehand and the results, which were
positive for opiates and cannabis, were given to him whilst he was at the
hostel. He remained at the hostel, but then decided not to return to custody
and absconded. He was found by the police on 16 July, and returned to
closed conditions. He arrived in HMP Manchester on 18 July, before moving
on to HMP Featherstone on 3 August.
40. In December 2005, the man’s solicitors arranged for a psychiatric report to be
prepared for the Parole Board. This report gave the opinion that he displayed
symptoms of PTSD, but not the full syndrome and neither did he suffer from a
personality disorder. He had significant personality traits such as anxiety and
emotional instability, and it seemed clear that he would require significant
support to move from prison back into the community.
41. The Parole Board considered the man’s case in January 2006 and identified
specific areas of work which he should undertake in order to progress. He
should take the cognitive skills programme, undergo in-depth work to explore
the motivation for his offence, and be assessed by a forensic psychologist to
establish the impact of past psychological experiences and personality
problems.
42. During the morning of 3 August, the man pressed his cell bell. He was
subject to ACCT support at the time, and staff found him with a ligature, made
from a shoelace, around his neck. Staff removed the ligature and no
treatment was required. He remained in Featherstone for a short while longer
and then transferred to HMP Lancaster on 20 October.
43. The man felt that he was having difficulty obtaining proper cooperation from
the Probation Service. Having been unsuccessful whilst he was in open
prison, he wanted to find out about going to a Langley House hostel instead.
Langley House is a charitable institution which helps offenders to adapt from
the prison environment to the community. In order to consider the man’s
referral, Langley House needed some documentation from the Probation
Service. The service did not consider that Langley House was appropriate
and did not forward the necessary papers. Through his legal representative
the man threatened to take the issue to a judicial review in February 2007.
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The service agreed to forward the documents which were accompanied by a
letter which did not support the move.
44. The files show nothing of particular significance until the morning of 10 July
2007. The man rang his cell bell and told staff that he had tried to hang
himself from his window. He had managed to free himself, but was upset. He
had got into debt with other prisoners, and was being pressured. He was
transferred to HMP Wolds on 16 November.
45. Intelligence indicates that the man got into debt again fairly quickly. On 24
December, he set fire to his cell in the segregation unit, where he had been
taken after failing to comply with the prison regime. He was placed on ACCT
support, and remained so until 6 January 2008.
46. The Parole Board considered the man’s case on 20 December. The reports
for the Board generally agreed that he was not yet ready to be re-tested in
open conditions. The psychologist’s report considered the explanation which
the man had given for his index offence. He said that, whilst staying at his
victim’s house, his victim had come into the man’s bedroom with a knife. The
man now maintained that he had been raped at knifepoint, something which
he had not revealed previously. The trial judge had described the man’s
version of events as “highly improbable” and medical evidence suggested that
the victim had a knife held to his throat for some time. The psychologist also
suggested that there was no corroboration for the man’s claims to have been
abused whilst a schoolboy. She was concerned that the man denied any
homosexual preferences, although there was evidence to support them. The
man was unhappy with the report and was also concerned that a single report
cast serious doubt on his account of events. He was also unhappy with the
Probation Service representation at his parole hearing. His usual probation
officer was not available and so another probation officer, whom he had not
met before, attended instead.
47. The man received notification of the Board’s decision on 9 January. The
Board had not recommended that he should be released or transferred to
open conditions. His case would be referred back to the Board in December
2009 to enable him to undertake work previously identified, including in-depth
work with a psychologist to explain his motivation for the index offence. The
Board also recommended that he should undertake a cognitive skills booster
course and work on forming alternative coping strategies.
48. The man transferred to HMP Altcourse on 20 February 2008, and on to HMP
Rye Hill on 19 May.
49. On the evening of 3 September, whilst at Rye Hill, the man pressed his cell
bell and staff found that he had cut his wrist. He was treated, taken to the
healthcare centre, and placed on ACCT support which remained in place until
16 September. A note in the man’s medical file indicates that, on 30 October,
he took 38 paracetamol tablets, together with an amount of a prescribed drug
he was taking. He was very tearful and depressed, saying that he wanted to
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die. He was referred to outside hospital and, on his return to prison, was
again placed on ACCT support.
50. As part of his sentence progression, the man transferred to HMP Swaleside
on 27 January 2009. On 11 February, he cut his wrist and needed treatment
from healthcare staff. He told staff that he was having problems with drugs,
and was under pressure to pay for them. He was once again placed on
ACCT support.
51. A report on 2 June indicates that the man had been bullied by at least one
other prisoner. Before any action was taken, he was moved to the
segregation unit after refusing to go into his cell when it was due to be locked.
(Separately, the alleged main perpetrator had also moved from the wing.)
The man’s mental state was assessed on 8 June whilst he was still in the
segregation unit. (Segregation units are separate from the ordinary prison
wings, and prisoners are held either for their own protection or to ensure the
good running of the prison.) His mood was depressed, and he felt hopeless
without a transfer to another prison on the horizon. He had written to his
solicitor, describing his low mood, hopelessness and thoughts of suicide.
52. On 11 June, the man was found hanging from a window in the shower room.
He had made a ligature from his bedclothes. Staff cut him down, and he was
treated in the healthcare centre. He remained on ACCT support until 20
June.
53. The prison psychiatrist reviewed the man the next day, 12 June. He told the
doctor that his mood had deteriorated over the previous month, in light of an
assessment by an independent psychologist. He was concerned that he
might be transferred to a Dangerous People with Severe Personality Disorder
(DPSD) Unit. (DPSD units treat prisoners who are considered to pose a high
risk of harm to others.) The prospect of going to a DPSD unit had brought up
memories of childhood sexual abuse and his index offence.
54. The man was due to be considered again by the Parole Board in December
and so the relevant prison departments were asked in July for the necessary
reports. On 3 August, the forensic psychology department returned a note
saying that a psychology report would not be submitted for his parole dossier
because the targets set in the last psychological assessment (in April 2007),
following the previous Parole Board request, had not been completed. The
Sheppey Cluster forensic psychology department was not funded for one-to-
one work with prisoners and so they were unable to complete the work
recommended by the Parole Board in 2007.
55. In view of the previous recommendations that the man needed psychological
input, consideration was given to whether he would benefit from treatment at
a centre for forensic mental health. Based at the hospital for prisoners with
mental health needs, the unit provides in-patient treatment for offenders who
are suffering from a mental disorder which cannot be managed by general
psychiatric services.
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56. The assessment process began and the man had a psychiatric assessment
on 1 October. The assessment concluded that he suffered from Antisocial
Personality Disorder, Avoidant Personality Disorder, and probable Obsessive
Compulsive Personality Disorder. (Personality disorders are patterns of
perceiving, reacting and relating to other people and events that are relatively
inflexible and impair their ability to function socially.) Additionally, the man
showed evidence of Recurrent Depressive Disorder (a tendency to suffer
repeated periods depression), substance misuse (the assessment described
him experiencing symptoms of physical dependence on heroin), and
symptoms suggestive of Post Traumatic Stress Disorder. There were
discrepancies in his account of his childhood and the motivation for his
offence, which would benefit from further exploration. It was thought that he
could benefit from the treatment programmes offered at the hospital for the
treatment of prisoners with mental health needs and so he was referred for
further assessment.
57. A nursing assessment was carried out on 15 October. The man appeared
motivated to engage with the treatment at the hospital, and again it was
thought that he would benefit from admission.
58. The man moved to the hospital for the treatment of prisoners with mental
health needs on 8 December. Initially he was anxious and only participated in
meetings in a small way. But he said that he found the environment positive
and supportive, and his family believed that he was settling well. However, he
told staff that he would find it difficult to explore childhood experiences or his
offence in a group setting. Towards the end of December, he made it known
that he was considering returning to prison as he was uncomfortable with the
attitudes of some other patients. In early January 2010, he continued to
express concerns, feeling uncomfortable and finding it difficult to participate,
to comply with the ward rules, and live so far from his family. He was
encouraged to stay and cooperate with his treatment, which he agreed to do.
59. Throughout January, the man said that his mood was deteriorating and the
unit reminded him of the boarding school which he attended as a child. He
was having difficulty engaging with the treatment and said regularly that he
wanted to return to prison. He began to withdraw from his treatment but was
again encouraged to stay and try to engage.
60. When a prisoner is transferred to hospital for long term mental health
treatment, their Parole Board reviews are put on hold until they return to
prison. This was the case with this man, who the Board had been due to
consider in December 2009. His family gained the impression from him that
he liked being in the hospital and felt that he was benefiting from being there,
but that he was concerned about the delay to the Parole Board hearing. His
family thought that this was the reason why he wanted to return to prison.
61. The man continued to experience problems with his eyesight, which were
exacerbated when he was hit by a snowball in early January. He was referred
to an optician, and checked at outside hospital for possible glaucoma,
although the results were inconclusive.
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62. On 17 February, the man complained of a headache, and said that he had
passed out three times over the weekend. The following day he said that he
passed out again, though he recovered quickly. He saw a doctor and his
antidepressant medication (the man had been taking anti-depressants for
some years) was adjusted. He complained of passing out on the next two
days, but an electrocardiogram (ECG, an electrical recording of the heart) and
his other clinical observations (such as blood pressure and pulse rate) were
normal.
63. In a session with his psychologist on 22 February, the man produced a letter
which appeared to express suicidal thoughts. He was encouraged to think of
ways of keeping himself safe. The following day he saw a doctor in
connection with losing consciousness. It was thought that this could be stress
related but, as a precaution, he was urgently referred to the neurology
department.
64. It was noted on 24 February that the man said that he wished to return to
prison. He said that he was depressed, although staff said there was no
consistent evidence of this condition. But he was becoming more distressed
about remaining in hospital, and losing the motivation to engage. He was
found with unauthorised items in his room and said that he wanted to go on to
the roof in order to jump off. He was transferred to another room, initially
against his wishes.
65. At a multi-disciplinary meeting on 8 March, it was agreed that the man was
not showing enough motivation to benefit from treatment in the unit and
should be transferred back to prison. He would be reassessed with a view to
returning to the hospital if he showed more insight into his difficulties and
increased motivation for treatment.
66. Staff at the hospital noted that, on his return to prison, the man should initially
be located in the healthcare centre, remain on his current medication and
engage with the psychiatric team to review the difficulties which he had
experienced at the unit. He should be encouraged to find appropriate
solutions to difficulties. It was also noted that he had outstanding referrals to
an ophthalmologist (eye specialist) and a neurologist (dealing with the
nervous system).
67. A doctor at the hospital provided a detailed discharge summary, which was
dated 8 March. He said that the man said that he had used heroin, cocaine
and ecstasy since coming into prison. He described developing symptoms of
physical dependence on heroin earlier the previous year whilst he was at
HMP Swaleside, saying that he engineered a move to the segregation unit in
order to stop using drugs. He claimed to have last used heroin six months
previously. He described regularly getting into debt as a result of his drug
misuse, and believed it likely that he would be tempted to misuse drugs again
if he was on normal location.
16
68. The man returned from the hospital for the treatment of prisoners with mental
health needs to Swaleside on 11 March. He was initially allocated to the
healthcare centre, to assist his transition back to the prison environment but,
on 14 March, he was told that a single cell on D wing was ready for him. On
hearing this, the man threatened to harm himself with a razor blade if he could
not remain an in-patient in the healthcare centre. He needed support, and in
view of his threats to harm himself, an ACCT plan was opened at 10.00am.
69. Staff were aware that the man had harmed himself in the past. The level of
supervision (the number of times staff must have some meaningful interaction
with him) was set at once per session when the man was out on association,
every 15 minutes during patrol time, and once per hour during the night.
70. The first ACCT review was held at 3.00pm that afternoon. The man said that
he felt most vulnerable when he was locked in his cell. He said that he felt
low and paranoid about mixing with other people. He tried to use his time
constructively, either cleaning or doing art work. The level of supervision
remained unaltered, and the next review was set for 18 March, when the
mental health in-reach team (MHIT) would also be invited.
71. Following discussion with a member of the mental health in-reach team on 16
March, it was agreed that it would be in his best interests to remain on normal
location. He would remain on the team’s case load and see the prison
psychiatrist, after which a care plan was to be set in place.
72. When he had returned to Swaleside from hospital, the man had met up with a
fellow prisoner whom he had known earlier in his sentence. The fellow
prisoner had recently arrived in Swaleside and the man seemed pleased to
have a friend on the wing. They were seen interacting frequently and well.
73. On 19 March, the man told a member of staff that he had not collected his
medication for two days. He said he was being bullied by another prisoner
when he went to healthcare. He refused to give names, but said that he had
had trouble with this person previously. The fellow prisoner whom the man
had known earlier in his sentence told my investigator that, rather than being
bullied, the man had got into debt for buying medication from other prisoners.
Arrangements were made for him to collect his medication earlier than usual
so that he did not encounter people to whom he was indebted whilst collecting
it.
74. A review of the man’s ACCT plan was held on 20 March. The papers do not
make clear why this did not happen on 18 March as planned. The record
does not show that the MHIT attended as had been planned. It was apparent
that the man remained very upset and wondered if he had made a mistake by
returning to Swaleside.
75. The ACCT caremap notes that the man was to be encouraged to interact
more with staff and prisoners on the wing, in order to feel safer there. Staff
were to try to ensure a safe environment for him, in order to stop him from
wanting to move to healthcare. The Regimes Department (responsible for
17
planning for prisoners) would assess targets for him as he felt that he had no
goals. The man was reminded that he could speak to staff and/or the
Listeners (prisoners trained by the Samaritans, who provide a confidential
support service to other prisoners) if he wished. Supervision by staff was
increased to one observation per hour at all times. When staff checked on
him later that afternoon, he seemed to be content with the advice to speak to
staff if he felt low. He handed over a home-made noose.
76. It was noted on 21 March that the man had not collected his medication the
previous day and so the drugs were taken to him that afternoon.
77. An extra ACCT review was held on 22 March, after one of the man’s friends
died. He was upset when he heard the news and asked to see the chaplain.
He told the chaplain that he felt isolated on the wing after all the support he
received in the hospital. He was encouraged to come out of his cell as much
as possible and mix with the others. That afternoon, the man asked to speak
to a Listener.
78. Many prisons operate a personal officer scheme which allocates an officer to
each prisoner. The officer’s role is to offer support, be the first port of call for
any queries, and generally keep a watch on the prisoner and their well-being.
On 27 March, the man was allocated a personal officer. However, the officer
told my investigator that he had no training to be a personal officer and was
not told that he was expected to carry out the role for the man. He was not
aware that the man had been allocated to him until he noticed that he
appeared on his list of prisoners on his computer profile. The officer said that
he had no significant contact with the man, who seemed distant. The officer
said that the man only had any interaction with his friend or with other staff in
connection with the man’s ACCT plan.
79. On his return to prison, the process to refer the man’s case back to the Parole
Board resumed. The dossier was completed and disclosed to the man’s
solicitor and to the Parole Board on 23 March. A copy of the dossier was
given to the man on 29 March. The papers were due to be taken through the
Intensive Case Management (ICM) process. (ICM ensures that the relevant
information required by the Parole Board is accurate and up to date.)
Because of the short time since he returned from hospital, the date for the
Board to consider his case had not yet been made.
80. A management check was made of the ACCT plan on the morning of 27
March. The manager noted two omissions: no trigger warnings were noted on
the form and the care map had not been signed by the man.
81. The next ACCT review was held later that day. The man reported still feeling
low, and was upset about his parole report. He mentioned wanting to move to
a prison in the north. It was agreed that his personal officer would help him to
make a transfer application as well as helping him to apply for accumulated
visits. (Accumulated visits mean that the prisoner moves temporarily to a
prison near to their family to receive the visits which have not been taken
because the family live too far away.) In the meantime, the man was content
18
for the level of supervision to remain the same as previously. The next review
was set for 3 April.
82. According to his fellow prisoner and friend, the man was “a bit down” at the
end of March. He told his friend that the Parole Board had not yet seen his
dossier and he was concerned about his sister, who he said was suffering
from cancer.
83. During the course of the investigation, my investigator was told that on 1 April
the man bought and took some heroin. There is no further intelligence to
confirm or deny this.
84. The vice-chair of the Independent Monitoring Board for Swaleside saw the
man during the course of her work on 2 April. She told the investigator that
the man expressed concern for his sister, who he said was suffering from
cancer. But other than being worried about her, she thought that he appeared
to be in a good mood.
85. The man also spoke to his sister on the telephone that day. She told the
investigator that her brother seemed to be in good spirits, and was looking
forward to receiving some headphones that she would be sending to him.
Likewise, the man’s fellow prisoner and friend saw no indication that the man
was intending to harm himself, saying that he was making plans for his
canteen order the following Tuesday.
86. Nothing untoward came to light during the night before the man’s death. Staff
checked on him once an hour as set down in the ACCT caremap and, if he
was asleep, they ensured that they saw some movement. All the cells were
unlocked at 8.45am the following morning, at which time the man remained
asleep. According to the ACCT plan ongoing record, he was not checked by
staff again until 10.47am when he was still asleep, and movement was noted.
87. When he was next checked at 11.55am, the man remained asleep. On this
occasion the member of staff woke him up as he had not collected his lunch.
The man told the officer that he was not hungry but was otherwise alright.
The officer said that she would return to check on him again soon. Fifteen
minutes later, at 12.10pm, a further officer checked on the man again at
approximately the same time when the cells were due to be locked for lunch.
He was once again asleep and again the officer noticed some movement.
88. At 12.15pm, a further officer checked on the man and five minutes later, at
12.20pm, the cells were locked for the lunch period. The officer again
checked on the man at 12.58pm, when he was lying on his left side. The
officer made sure that he was moving and breathing.
89. All the cells on E wing were unlocked after lunch at approximately 1.45pm.
An officer unlocked the cells on the man’s landing. She looked through the
observation hatch of the man’s cell and saw him apparently standing, facing
her. She then unlocked the cell and continued along the wing (officers do not
ordinarily go into cells when they are unlocking the doors).
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90. Very shortly afterwards, within a minute, some prisoners went into the man’s
cell. They found him hanging from the window bars, using a ligature made
from bedding. One of the prisoners supported the man’s body while the
others called for help.
91. Two officers were both on the stairs a few feet from the man’s cell and they
heard the prisoners’ calls. They went straight to the cell and, on seeing what
had happened one of the officers told her colleague to raise the alarm. Using
her cut-down tool the officer cut the ligature and together they lowered the
man to the floor. The officer put the man into the recovery position and told
everyone else to leave the cell.
92. A Senior Officer (SO) was on duty on E wing and responded to the alarm. He
ran to the cell, arriving at approximately 1.50pm. The senior officer took
charge and immediately began to perform cardio pulmonary resuscitation
(CPR), undertaking chest compressions and asking his colleague to manage
the man’s airways (what used to be termed mouth-to-mouth resuscitation). In
his statement and again in interview, the senior officer said that he formed the
impression that the man was already dead. But he continued to attempt
resuscitation whilst waiting for medical help. He continued to perform chest
compressions, but his colleague was becoming increasingly distressed and so
he told her to stop mouth-to-mouth.
93. A nurse was the member of healthcare staff on duty that day with
responsibility for emergency response. When she heard the general alarm on
the radio, she picked up the emergency response “grab bag” and made her
way to the man’s cell. (The “grab bag” contains medical equipment to allow
staff to treat most emergency situations. This includes a defibrillator in case
of heart problems, an ambu-bag to assist patients having difficulty breathing
and oxygen.) The senior officer was still performing chest compressions on
the man, and he briefed the nurse about what had happened.
94. The nurse assessed the man, but was unable to detect any obvious signs of
life. She applied the ambu-bag (an inflatable bag with a mouthpiece, used to
force oxygen into the lungs). She applied the defibrillator (a machine applied
to a patient’s chest via pads, which advises the user whether the patient has
any heart activity that might respond to stimulus. If so, the machine can apply
electrical impulses to the heart in order to reintroduce a normal rhythm). The
defibrillator did not detect any rhythm from the man’s heart.
95. When the emergency had been called, an ambulance had been summoned.
By this time a healthcare officer had arrived in the cell, and she, the nurse and
the senior officer continued to perform CPR until paramedics arrived.
96. The paramedics reached the cell at 2.08pm. The nurse briefed them on what
had happened and the medical treatment given. The paramedics took over
from the prison staff. They were unable to detect any signs of life and, at
2.18pm, the paramedics pronounced that the man had died.
20
97. An apparent suicide note was later found in the man’s cell, which was handed
to the police. The man expressed feelings of hopelessness, and that he was
not receiving help that he needed. He said that he was unable to put across
how he was feeling.
98. A debrief was held that afternoon. (Hot debriefs are held as soon as possible
on the same day after a death in custody. They are held to ensure that staff
involved have an opportunity to discuss any issues arising). It was made
clear that support was available to staff, both at the time and subsequently.
99. Prisoners were informed of what had happened that afternoon. Listeners
were brought onto the wing to provide support if required. All the prisoners
who were subject to ACCT support had their cases reviewed within 24 hours
100. A memorial service was held in the prison chapel on Thursday 8 April.
Informing the family
101. Due to the distance between Swaleside and the home of the man’s sister, his
listed next of kin, news of his death was relayed to them by Greater
Manchester Police in the early evening of the day of the man’s death. They
passed on contact details for the family liaison officer at Swaleside. Little
more detail was available. The man’s brother-in-law telephoned the number,
but there was no answer and he tried again via the prison’s main switchboard.
The operator appeared to be unaware that there had been a death in the
prison, but eventually the man’s brother-in-law managed to speak to the
family liaison officer at Swaleside.
102. The family liaison officer expressed his sympathy on behalf of the prison,
passed on the information which was available and explained the family
liaison officer role. The following day, the man’s niece telephoned the family
liaison officer. She explained that she worked for the Prison Service and, at
her mother’s request, would act as the single point of contact for the family.
She asked some questions, some of which the family liaison officer was able
to explain and others which he could not answer. He said that he was on
leave for the following week, but that as it was a Bank Holiday weekend (it
was Easter Sunday), he thought that the Coroner’s proceedings would be
unlikely to progress much whilst he was away. The man’s niece asked for an
alternative contact, but told the investigator that the family liaison officer was
unable to name another person who would know about her uncle’s death.
103. The man’s niece contacted the prison again on 6 April to ask for further
information. She spoke to the family liaison officer, but he was shortly due to
leave the prison and so he gave her contact details to the duty governor. The
duty governor was dealing with adjudications at the time, but he put them on
hold in order to speak to her. He answered her questions as best he could,
explaining that although it was the Coroner’s decision to release the suicide
note which the man had left, he was able to tell her some of the details. The
man’s niece asked if the chaplain would contact her mother, which he did the
following day.
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104. The family liaison officer returned from leave on 11 April and, on either that
day or the following day, (the prison and family liaison logs differ) he took
another call from the man’s niece. She had a number of additional questions
but, as the family liaison officer had just returned from annual leave, he was
unable to answer them all at that time. The relationship between the two was
becoming strained, and the man’s niece felt that it might be helpful to have a
different point of liaison. The family liaison officer spoke to a senior officer
and asked if he might be able to help reduce the tension.
105. Over the following days, there were further telephone calls between the man’s
niece and the family liaison officer. Again there was some tension, the man’s
niece feeling that she was not given all the information which she asked for,
and the family liaison officer having difficulty communicating why he was
unable to provide all the information which she wanted.
106. In view of the problems which seemed to exist between the man’s family and
the prison, the governor telephoned the man’s niece on 15 April. He
explained that he wanted to make sure that communication improved, and
asked her what the family wanted. There had been a breakdown in
communication over the prison writing to the man’s sister. When the man’s
niece had said that she wanted to be the single point of contact, the prison
understood that to mean that she did not want anyone to write to her mother.
However, this had not been her intention. The governor asked her to set out
what the family wanted in an email, which she subsequently did.
107. The following day, 16 April, was the day of the man’s funeral. The governor
telephoned the man’s niece in order to address the issues contained in her
email. She pointed out that it was the day of the funeral and asked if this
could be addressed at another time.
108. Over the following days there was further contact between the prison and the
family. The relationship was close to breaking down, and the contact
remained difficult for both parties. This extended to communications over the
return of the man’s property. The family thought that they had made it clear
that they would prefer a courier service to be used, but the prison thought it
more personal for a member of staff to take the property to the man’s sister’s
home. This meant that she had to check and sign for the property, which she
felt unable to do at the time.
Post mortem
109. A post mortem examination was carried out on 7 April at outside hospital.
The post mortem report gave the cause of the man’s death as “suspension”.
22
ISSUES
Preparation for the man’s case to be referred to the Parole Board
110. When they considered the man’s case in 2007, the Parole Board asked to
consider him again after another two years, to allow him to undertake
identified work. However in August 2009 the psychology department refused
to contribute to his parole dossier on the grounds that the targets had not
been completed. They pointed out that the psychology department at
Swaleside did not have the capacity to complete the work which the Parole
Board had recommended. The Board had also recommended that he should
undertake a cognitive skills booster course, and the papers do not make it
clear whether the man actually did so.
111. I find this very troubling. While the clinical reviewer points out that the man
seems to have been offered support within a care plan, an intervention had
been specifically identified as necessary by the Parole Board but had not
taken place. It appears to be bad planning to have sent the man to a prison
where that specified intervention is not available. His family said that his
powerlessness to engage with the mental health services was a source of
frustration for the man. Bearing in mind the obstacle this would place to him
progressing with his sentence, I think that this is understandable.
112. Once the psychology department declined to provide a report for the Parole
Board, the man’s consideration for a place at the hospital for the treatment of
prisoners with mental health needs seems to have been taken forward
properly. The clinical reviewer says that arrangements for his referral to the
hospital seem entirely appropriate, and that the prison psychiatrist provided a
clear and detailed referral letter to the unit.
113. However, once prisoners have been compulsorily admitted under the Mental
Health Act (which was necessary to allow the man to go to hospital), their
parole applications are suspended. The man had arrived in Swaleside in
January 2009, with his case due to be referred back to the Parole Board the
following December. There was an outstanding recommendation from the
Parole Board for psychological intervention, but this did not begin until he
transferred to the hospital for the treatment of prisoners with mental health
needs in December, the month the Board were due to consider his case. So
his referral to the Board was suspended at the point that it should have
happened, despite him being in Swaleside for almost a year by that point. I
regard this delay as unacceptable.
114. The man’s family said that it seemed to them that the move to the hospital
had suited him well. He appeared happier and more confident. As well as
psychiatric support and intervention, the hospital offered a wide variety of
activities, which included allowing him to exercise his talent for art. But he
expressed concern that the parole process was on hold, and his family
thought this might have been the reason he decided to leave the hospital and
return to prison.
23
115. The man was undoubtedly concerned about his future. He complained of
difficulty engaging with the Probation Service to plan towards his eventual
release. His family confirmed that this caused the man some concern. I think
that such engagement should be part of sentence planning.
116. After his transfer back to Swaleside, the man does not appear to have had
any contact with the psychology department. His return from hospital back to
prison was an opportunity for his sentence plan to be re-evaluated. However,
this does not seem to have happened. Accepting the fact that the man had
trouble in engaging at the hospital, the Prison Service should nevertheless
have ensured that outstanding Parole Board recommendations could be
addressed. Instead he was returned to Swaleside, where the necessary
psychiatric input was not available.
117. The lack of clear goals was one of the issues identified as a problem for the
man in his ACCT plans. At the review on 20 March it was agreed that the
Regimes Department were to assess targets for him as he felt that he had
nothing to aim for. The papers do not, however, show that this was taken
forward.
118. It seems that the man did not have the benefit of any plans to take him
forward through his sentence. His family told my investigator that for some
years he had been unhappy about what he perceived as lack of engagement
with the Probation Service. He was sent to Swaleside with an outstanding
recommendation from the Parole Board, but the prison did not have the facility
to address it. He did not transfer to the hospital for the treatment of prisoners
with mental health needs to begin his treatment until the Board were already
due to consider his case again. I do not think it is acceptable that such
difficulties should only come to light when the problem had already occurred.
I recommend that the Governor ensures that prisoners’ sentence progression
needs are assessed on arrival in the prison, to ensure that any anomalies are
addressed without delay.
The National Offender Management Service should consider how to
ensure that, when interventions are identified for prisoners, they are
allocated to establishments able to deliver them.
The Governor should ensure that effective sentence plans are
considered for all prisoners on arrival, ensuring that any outstanding
work or intervention is planned and provided for.
Outstanding medical appointments
119. On his return from the hospital, the man had two outstanding medical
appointments, with the ophthalmologist and neurologist. It does not appear
that they were followed up. Medical appointments are an important aspect of
providing continuity of care and it is vital to the health and wellbeing of
prisoners that such appointments are followed up by the receiving prison.
24
The Head of Healthcare should ensure that effective systems are in
place to identify and act upon any outstanding medical appointments
for incoming prisoners.
Personal officer scheme
120. The man was allocated a personal officer. However, his personal officer was
not formally notified that the man had been allocated to him, and only noticed
when the man’s name appeared on his electronic list. He had not received
any training in what a personal officer’s duties included. Although he was
aware that the man was subject to ACCT support, he did not have a great
deal of interaction with him.
121. At the ACCT review on 27 March it was agreed that the man’s personal officer
would assist in a transfer application as well as helping him to apply for
accumulated visits. But it does not appear that this was taken forward, and it
is not clear whether the request was passed on to the man’s personal officer.
122. If the man had a stronger relationship with his personal officer, it might have
provided an opportunity for him to raise any of the issues that were troubling
him, such as concern over his lack of contact with mental health services or
delays with his case being put to the Parole Board. It is not possible to say
whether this would have had any affect on the tragic outcome, but the
Governor should assess the operation of the personal officer scheme and
satisfy himself that it is operating to an acceptable standard.
The Governor should consider the operation of the personal officer
scheme in Swaleside, and whether prisoners are receiving adequate
support from their personal officers.
Managing the man’s ACCT support
123. When a management check was conducted on the man’s ACCT plan on 27
March, it was noted that the trigger warnings were not noted at the front of the
form. It was also noted that the man himself had not signed the caremap. In
general, the observations on him were within the correct time limits.
Sometimes his observations were made slightly beyond the hour. Although
this was usually by less than 15 minutes, there were occasions when an
observation appears to have been missed out or when there was more than
an hour between checks. Broadly speaking the observations were regular
and frequent, and in the hours before the man died were carried out correctly
so that any deficiencies are unlikely to have made any difference to the
outcome. But the Governor may wish to remind staff of the importance of
carrying out ACCT supervision as directed.
124. On 19 March, the man told a member of staff that he had not collected his
medication for two days. Even though arrangements were made to overcome
the reasons for this, he again did not collect his medication on 21 March. This
was not noted until the following day. I suggest that a prisoner on an ACCT
plan who misses their anti-depression medication should be considered at
25
heightened risk and this should have been noted immediately. The Head of
Healthcare may wish to consider whether there are adequate measures in
place to monitor the distribution of medication to prisoners receiving ACCT
support.
The Head of Healthcare should consider whether there are adequate
measures in place to monitor the distribution of medication to prisoners
receiving ACCT support.
Unlocking the man’s cell door
125. There are inherent difficulties in trying to establish a true timeline for
emergency situations. Witnesses do not automatically note the time they saw
things or what others were doing when they themselves reacted. The times
given for events from witness statements do contradict each other, and in
drawing conclusions as to timings it is necessary to consider all the evidence
and judge the most probable sequence. It seems likely to me that, when the
man’s cell door was unlocked at 1.45pm on the day of his death, he was
already dead. The last time he had been seen alive was the ACCT check at
12.58pm. We have no certain evidence of exactly how long it was between
the man being unlocked and being found. Staff who attempted to revive him
minutes after he was found could not detect any signs of life, although they
rightly continued with attempts to revive him until paramedics took over. I
note that the man’s family are of the opinion that as the time lapse between
him being unlocked and him being found is uncertain, no conclusion as to
whether he was alive when unlocked can be drawn.
126. An officer was responsible for unlocking the cells on the wing which included
the man’s cell. Bearing in mind that the man was subject to ACCT support at
the time, my investigator questioned the officer about unlocking the man and
the check she made through the observation hatch on doing so. She
explained her understanding of the check as threefold. Firstly, to confirm the
prisoner’s position to ensure the officer’s own safety when the door is
unlocked. Secondly, to ensure that the prisoner is physically present in the
cell and has not escaped. Thirdly, as far as possible, to ensure the prisoner’s
wellbeing.
127. The officer told the investigator that she remembered checking on the man
and knew that he was subject to ACCT monitoring. When she looked through
the observation hatch, she saw him apparently standing facing her, looking at
the observation panel. This is something many prisoners do when they hear
other cells being unlocked, anticipating their own unlock. The man’s cell was
towards the end of his wing, and was one of the last to be unlocked. The
officer realised with hindsight that, when she looked in on the man, he must
have been hanging. But at the time, with the position of his body and the way
he had secured the ligature around his neck and behind his head, it simply
appeared that he was standing facing the door.
128. I have given this issue close consideration. The officer was aware that the
man was subject to ACCT support. I would usually expect a member of staff
26
unlocking a prisoner on an ACCT plan to gain a response from them to
ensure that there were no problems. The officer believed that the man was
standing in his cell facing her and waiting for her to unlock his door. As it was
common for prisoners to stand facing the door when they heard others being
unlocked, it therefore appeared to her that he was alright. In the event, the
officer was sadly mistaken.
129. The man was subject to ACCT support. He had made attempts to take his
own life on previous occasions through his sentence. At least some of his
attempts appeared to be less than a serious attempt to kill himself and more
of an expression of needing help and support. On this last occasion, the man
may have hanged himself facing his cell door so that he could easily be seen
and rescued. He was due to have his ACCT review that afternoon and may
have wanted those at the meeting to be aware of how he was feeling,
although of course we have no way of knowing his thoughts or intentions. I
am aware that his family do not believe that the note found in his cell read as
a suicide note, and believe it likely that the man wanted to be found and did
not intend to take his own life.
130. While I accept that the officer did check on the man and genuinely believed
that he was alright, he was a man with a history of suicide attempts who was
subject to ACCT monitoring. I recommend that the Governor remind all staff
of the importance of being extra vigilant when dealing with prisoners on ACCT
support.
The Governor should remind staff of the importance of extra vigilance
when unlocking prisoners who are subject to ACCT support.
Response to the man being found
131. Once staff were alerted to the fact that the man was hanging, the response
seems to have been swift. Two officers cut the ligature, lowered him down
and called for help. One of the officers put the man into the recovery position.
If he was not breathing, putting him in the recovery position would not have
provided any benefit. The officer received some first aid training as part of her
initial training on joining the service, but none since. Prison Service Order
(PSO) 2700 contains guidance to staff on actions to be taken when
discovering a prisoner hanging. In Annex 13A the PSO says that after cutting
the ligature and lowering the prisoner, staff should:
“ … 3. Place the prisoner on his/her back on a flat, solid surface.
4. Check for signs of life, i.e. breathing, pulse, any movement of the body
5. If not breathing and/or no pulse is present, clear airway and attempt
resuscitation, using a face mask with non-return valve, unless rigor mortis
of the limbs has clearly set in.”
132. As mentioned above, it is likely that the man had died by this point.
Nonetheless, the Governor should remind staff of the guidance.
27
The Governor should remind staff of the guidance contained in PSO
2700 of the actions to be taken when a prisoner is found hanging.
133. A senior officer arrived at the cell very soon afterwards, and began to perform
CPR whilst instructing the officer to assist by performing mouth-to-mouth
resuscitation. The senior officer thought that the man was already dead, but
rightly continued to attempt resuscitation whilst waiting for medical help. But
the officer was becoming increasingly distressed, so he instructed her to stop.
I have to consider whether, in the circumstances, the senior officer was right
to do so. PSO 2700 gives the policy on resuscitation and says:
“Resuscitation: Policy remains that staff should continue to attempt
resuscitation – as appropriate to the injury – until told to stop by a
healthcare professional, e.g. a member of the Ambulance Service or a
doctor, or rigor mortis has clearly set in …”
134. Even though he thought that the man was dead, the senior officer continued
to attempt resuscitation until (and beyond) the arrival of a nurse. He also had
a duty to his staff, and his colleague was clearly becoming upset. It is unlikely
that it made any difference to the outcome for the man.
135. In the circumstances I do not think it is fair to criticize the senior officer, who
reacted efficiently and professionally in a very difficult situation. The clinical
reviewer agrees, and notes that the officer had already given some rescue
breaths before she stopped. That, followed by chest compressions, still
constitutes good resuscitation technique. But the officer’s reaction may have
been exacerbated by performing mouth-to-mouth resuscitation without a
mouth shield. I understand that all staff in Swaleside now carry mouth shields
in case they need to perform resuscitation. I welcome this news, and ask the
Governor to remind staff of the importance of carrying them.
136. A nurse arrived at the cell soon after the senior officer, followed by a
healthcare officer. The man received full medical assistance until the
paramedics confirmed that he had died. The clinical reviewer recommends
that staff rotas should include staff who have had recent first aid training, but
says that the resuscitation attempts on the man were “exemplary”.
137. I think it is important to mention the view of the man’s friend in relation to the
response when he was found. His friend was across the landing from the
man’s cell at the time. He told my investigator that in trying to revive him, staff
“couldn’t have done more” for his friend. I hope that this provides some
degree of comfort for the man’s family.
Family liaison
138. It is clear there were problems in family liaison in this case. The family liaison
officer in this case was Swaleside’s only trained family liaison officer at the
time. When the man died, the family liaison officer was actually on leave but
came back to work to perform these duties, which in itself is commendable.
But his leave was due to continue through the following week. This meant
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that the family did not have a contact in the prison in the days following the
man’s death, a time when most families benefit from having someone who is
knowledgeable and able to help and support them through what is an
unfamiliar process at such a distressing time.
139. On the family liaison officer’s return from leave, there were further problems in
relations between the prison and the family. Both the family and the prison
provided contact logs to my investigator. Eventually, in response to a request
by the family, it was agreed that a different point of contact should be
provided. But it seems that by then the relationship was already on the verge
of breaking down. The family said that they felt significantly distressed by the
liaison with the prison which, in turn, undermined their confidence both with
regard to the care which the man received and the information they were
given regarding the circumstances of his death.
140. Liaising with the family of a prisoner who has taken their own life is a very
difficult task, for which prison staff receive special training. Families react in
different ways and have different needs regarding their interaction with the
prison. This must be recognised and given due weight. In this instance, the
liaison may have initially appeared to be more complicated because the man’s
niece was a Prison Service colleague. This should not, though, be perceived
as the family needing any more or less sensitivity than any other bereaved
family.
141. It is important to remember that, first and foremost, the man’s niece was a
bereaved relative. The prison as a whole, not just the family liaison officer,
must be sensitive to the family’s needs. If there are problems in the
relationship with the person acting as liaison officer, then they should be
addressed as a matter of priority. This is not apportioning blame to the officer
concerned, but ensuring that families are supported through a difficult time in
a way that is sensitive to their individual needs and circumstances. In this
case, the prison’s reluctance to review their existing arrangements, which they
felt had worked well in the past, caused the man’s family considerable
distress.
142. I understand that two Swaleside staff members are currently being trained in
family liaison duties and I welcome this news. The Governor will wish to
ensure that future family liaison arrangements have in-built processes to
monitor the contact and ensure that any problems are identified and
addressed at an early stage.
The Governor should ensure that, if the nominated family liaison officer
is unavailable, an alternative should be provided.
The Governor should satisfy himself that the family liaison
arrangements ensure that any problems in relation to bereaved families
are identified and addressed at an early stage.
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CONCLUSION
143. The man had been in prison for a number of years. He had progressed as far
as open prison on three separate occasions, but had been unable to cope
with the regime and had ended up back in a closed prison. He had some
anxiety about how he could progress towards release.
144. When the Parole Board last considered his case, they recommended that
some intensive psychological work was undertaken before they next saw his
papers. There were important issues for the man that needed to be
addressed. But the man was not given the chance to undertake the work
identified until the time that his case was due to be referred to the Parole
Board. He was transferred to a specialist unit, and his referral to the Board
was adjourned while he was there. He failed to settle, possibly because of
the delay to his Parole Board application, and returned to prison.
145. Once back in prison, the man’s Parole Board application was restarted. He
was, though, rather despondent about his prospects. He seems to have
taken some drugs that were not prescribed to him, and got into debt with other
prisoners. He was subject to special monitoring for those thought to be at risk
of harming themselves, something he had done a number of times previously.
146. Nevertheless, those around him thought that he seemed to be developing a
more positive attitude. He remained on special monitoring, but there were no
significant concerns that he would imminently harm himself.
147. During the lunch period on the day of his death, the man made a ligature from
bedclothes and hanged himself in his cell. When the cell door was unlocked,
the officer responsible did not notice what the man had done. But almost
immediately some prisoners went into his cell, and raised the alarm. Staff
responded and provided first aid until an ambulance arrived, but attempts at
resuscitation were unsuccessful.
148. The man’s family were informed, but relations between them and the prison
quickly deteriorated. Eventually the prison changed the main liaison officer,
but by this time the relationship was close to breaking down.
149. I make nine recommendations. The first is a national recommendation
concerning prisoners being sent to prisons where they can achieve their
sentence planning goals. My other recommendations relate to prisoner
allocation, outstanding medical appointments, the personal officer scheme,
monitoring prisoners who are at risk of harming themselves and the actions to
be taken when someone is found hanging. I also comment on the apparent
breakdown in the relationship between the bereaved family and the liaison
officer, suggesting that it should have been addressed earlier.
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RECOMMENDATIONS
1. The National Offender Management Service should consider how to ensure
that, when interventions are identified for prisoners, they are allocated to
establishments able to deliver them.
This recommendation was partially accepted. Responses were received from
Swaleside, Rehabilitation Services in the National Offender Management
Service, and the Population Management Unit of the National Offender
Management Service.
Swaleside said:
“[The man] was sectioned under the mental health act, from HMP Swaleside, as that
was the best course of action to manage his circumstances at that time. If an
individual is later returned to custody, they are usually returned to the sending
establishment. The offender’s OASys will then be reviewed and consideration would
be given to the SPRM and the most appropriate establishment to deliver the
interventions.
Unfortunately there are often large demands for courses at all establishments, and as
the demand for courses change, what each establishment delivers changes too and
this has to be reflected in offenders’ sentence plans. This is not an issue resolvable
at establishment level, the Governing Governor will write to the DDC asking him to
raise with the NOMS board the need for transfers to be influenced by Sentence
Planning needs.”
NOMS Rehabilitation Services said:
“I have looked at the relevant recommendation from the PPO report as
requested from the RSG perspective and our view is that this is a local rather than a
central matter.
Centrally, we have issued guidance on sentence planning and on the suitability of
accredited interventions for offenders. However the management of individual
offender’s access to and attendance on programmes is a local matter.
It is for offender management and population management teams locally to make the
necessary arrangements to enable access to interventions required, including the
arrangements to facilitate transfers where necessary.
I understand that guidance re: the transfer of prisons has also been issued centrally
by population management.”
NOMS Population Management Unit said:
“Population Management Unit receive several hundred individual transfer requests
(singleton transfers) on a weekly basis; these can be moves for a plethora of reasons
which would include (but is not exclusive to), further court appearances, discipline
moves due to segregation, progressive move due to recategorisation,
progressive/onward allocation for courses/interventions.
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At the time of [the man’s] death, PMU held a database for the allocation of life
sentence prisoners, this database was apparent as most/all establishments in the
training estate operated a limit (or operational cap) for the number of lifers they could
hold. It is realistic to say that all establishments were operating at their prescribed
limit, and would accept transfers on a 'one out, one in basis'. The consequence of
this is that the process was slow, and progress for lifers was delayed.
In July last year, PSI (Prison Service Instruction) 36/10 Chapter 4 life sentence
prisoners was introduced, it instructed the removal of caps for ISP (Indeterminate
Sentence Prisoners) prisoners at prisons, and stated that the onward allocation for
ISP prisoners should not differentiate from that of determinate sentence prisoners.
PMU rely on sending/receiving establishments to agree the transfer of prisoners,
including for those moving for interventions, PMU do not broker any transfers, we
facilitate the logistics, and avail the space(s) at the prison allocated to. It is for the
prisons to highlight how much of a priority every move is, thus making PMU aware
(depending on the availability of space) whether the move needs to be expedited. We
receive approximately 400 single transfer requests a week, of which around 150 are
actioned; this figure takes into account the contractor's resource availability, and also
space availability at receiving prisons.”
2. The Governor should ensure that effective sentence plans are considered for
all prisoners on arrival, ensuring that any outstanding work or intervention is
planned and provided for.
This recommendation was accepted. NOMS said:
“We are currently exploring how we link up Sentence Planning, Activities and
Induction, to ensure that Offenders are given a seamless experience in HMP
Swaleside. It needs to be noted that this has only recently returned to full control of
the governor of HMP Swaleside, and he has already appointed a Head of Sentence
Management to address this issue.
It is entirely feasible that had this been in place, we may have identified that [the
man] needed to be moved to another site to continue his progressive work, however
it is unlikely in the short time frame between returning from secure unit, that [the man]
would have gained a transfer given the acute population pressure we were facing at
that time.”
3. The Head of Healthcare should ensure that effective systems are in place to
identify and act upon any outstanding medical appointments for incoming
prisoners.
This recommendation has been accepted. NOMS said:
“This is part of the existing healthcare reception process. Outstanding appointments
are flagged and actioned.”
4. The Governor should consider the operation of the personal officer scheme in
Swaleside, and whether prisoners are receiving adequate support from their
personal officers.
This recommendation was accepted. NOMS said:
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“The Governor and SMT (Senior Management Team) are currently reviewing the
Personal Officer Scheme. Early thinking is that the title Personal Officer will be re-
badged Line Manager. The prisoner’s Line Manager will become more involved in
sentence management with an emphasis of assisting prisoners who require
additional support to make them better citizens and reduce their risks to the public.
Prisoner Consultative Meetings have agreed this way forward.”
5. The Head of Healthcare should consider whether there are adequate
measures in place to monitor the distribution of medication to prisoners
subject to ACCT procedures.
This recommendation was accepted. NOMS said:
“Primary Mental Health Manager will ensure that those prisoners who are assessed
as being at risk of self harm are routinely reviewed for concordance with their
medication. A Healthcare Notice to Staff (will be issued).”
6. The Governor should remind staff of the importance of extra vigilance when
unlocking prisoners subject to ACCT procedures.
NOMS accepted this recommendation. They commented:
“The Safer Custody Manager will prepare a written Notice to Staff, additionally
briefing will be given by Wing Managers to their staff reminding them of the
importance of extra vigilance when unlocking prisoners who are subject to ACCT
procedures.”
7. The Governor should remind staff of the guidance contained in PSO 2700 of
the actions to be taken on finding a prisoner is found hanging.
NOMS accepted this recommendation. They said:
“The Safer Custody Manager will show a DVD demonstrating the correct course of
action at the next full staff meeting. A Notice to Staff giving precise instructions will
also be issued.”
8. The Governor should ensure that, if the nominated family liaison officer is
unavailable, an alternative should be provided.
This recommendation was accepted. NOMS commented:
“At the moment Swaleside have one fully trained FLO. Two additional managers
have been identified for training and their learning paths have been updated. If the
trained FLO is unavailable the Governor has an agreement with the Sheppey
Prisons’ Group that a FLO from Elmley, Standford Hill or Central Services will be
made available.”
9. The Governor should satisfy himself that family liaison arrangements ensure
that any problems in relation to bereaved families are identified and
addressed at an early stage.
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This recommendation was accepted. NOMS said:
“FLO will be briefed by the Head of Residence to ensure that the families are
contacted in the first instance and that problems are addressed as soon as possible
at the earliest possible opportunity.”
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