Individual at Leeds

Investigation into the circumstances surrounding the death
of a man at HMP Leeds in December 2006
A report by the Prisons and Probation Ombudsman
for England and Wales
September 2010
This is the report of an investigation into the death of a man at HMP Leeds in a day in
December 2006. Shortly before 6.00am that day, the man was found dead in his cell.
A post mortem examination conducted by a consultant forensic pathologist at a medico-
legal centre showed that the cause of death was hanging. The man died just before his
32nd birthday.
I offer my sincere condolences to the man’s family and friends for their tragic loss.
The investigation was conducted by one of my colleagues. I also commissioned a
clinical review of the management of the man’s health needs while he was in custody.
This was conducted by a doctor on behalf of the Leeds Primary Care Trust. I am
grateful to the doctor for his contribution to this investigation. I should also like to
express my appreciation to the then Governor and his staff at Leeds, and to the Director
and staff at Altcourse, for their assistance during the investigation. I am especially
grateful to the Principal Officers at Leeds and Altcourse for their invaluable contribution
as investigation liaison officers.
The initial investigation uncovered no evidence that the full details of the man’s
attempted suicide during the course of his arrest following the murder of his girlfriend
were passed on to Global Solutions (now G4S) escort staff or to reception staff at HMP
Altcourse by Cheshire Police. In the draft investigation report I issued in December
2007, I expressed my view that the failure by the police to alert the Prison Service to the
risk of suicide the man presented by the time he was remanded in custody on 2 October
2006 led to a flawed assessment of the man’s risk of suicide at Altcourse. However,
the police disputed this claim and, following a formal complaint lodged by the man’s
family, conducted an investigation supervised by the Independent Police Complaints
Commission (IPCC). As a result, I directed that my investigator should take no further
action with regard to the completion of my investigation until such time as the
investigation by the police had been brought to a conclusion. The investigation was
therefore formally suspended on 26 June 2008 and resumed on 18 December 2009.
My report takes account of the responses to earlier drafts from the Prison Service,
Cheshire, North Wales and West Yorkshire Police and the man’s family. It also takes
account of further interviews conducted by my investigator at Altcourse in January 2010.
I recognise that the considerable length of time taken to produce this report will have
added to the pain and frustration felt by the man’s family and I offer them my sincere
apologies for this.
I draw attention to two examples of good practice at HMP Altcourse.
I make a number of recommendations to the Director of HMP Altcourse and to the
Governor of HMP Leeds.
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This version of my report, published on my website, has been amended to remove the
names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Acting Prisons and Probation Ombudsman September 2010
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CONTENTS
Summary
Investigation process
Leeds and Altcourse prisons
Background
Key events at Altcourse prison: 2 October - 10 November 2006
Key events at Leeds prison: 10 November - 6 December 2006
Issues relating to the man’s period of custody at Altcourse
Issues relating to the man’s period of custody at Leeds
Family concerns
List of recommendations
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SUMMARY
The man who is the subject of this report was a 31 year old from Cheshire. In the early
hours of 26 September 2006, he allegedly killed his partner in a frenzied attack after
drinking and taking cocaine. He was arrested at approximately 8.35pm that day. At the
time, the man was on licence from an 18 month extended prison sentence handed
down in 2005 for assaulting the same woman. The man had been released from this
sentence at Acklington prison on 15 August 2006, just over a month prior to the
commission of the alleged murder.
During the process of his arrest, the man was seen by the police to inject himself with a
substance later confirmed as heroin. He produced a large bladed knife with which he
threatened the officers who consequently sprayed him with CS gas, disarmed and
arrested him. The police also noticed he had serious injuries to his hand, and cuts and
grazes on his head. The man was also drifting in and out of consciousness. The police
therefore called an ambulance and escorted him, under arrest, to hospital where his
injuries were assessed. On 28 September, he was transferred to another hospital
where he underwent an operation to repair the injuries to his hand. Whilst there, he
admitted to a doctor, in the presence of a police officer, that he had killed his girlfriend
and indicated that, having injected himself with heroin, he did not expect to wake up in
hospital. The man remained under police escort throughout his stay in hospital. On 29
September, he was discharged from hospital and taken to the Northern Custody Facility
at Runcorn for questioning. The following day, he was formally charged with murder
and other associated offences.
The man remained in police custody until 2 October, when he was taken to a
magistrates’ court. Here, he was remanded in custody at HMP Altcourse, a privately
managed local prison in Liverpool. A Detention Officer at the Northern Custody Facility
at Runcorn noted on a Prisoner Escort Record (PER) that the man presented a risk of
suicide or self-harm. Neither the details of the man’s alleged crime, nor those of his
suicide attempt during his arrest were known to the court staff who took possession of
the PER. There was some doubt as to what risk information was contained on a
medical form, completed by a doctor at Runcorn and passed on by the Detention Officer
to the Prisoner Custody Officer (PCO) from Global Solutions Limited (GSL – now G4S),
who escorted the man from the Northern Custody Facility in Runcorn to a magistrates’
court. That PCO raised a self-harm warning form because she thought the man was
depressed. The records show that, although the PER was signed at Altcourse, the self-
harm warning form was not. There was some doubt as to which members of the
reception team saw the information recorded on the PER or who, if anybody, saw the
suicide/self harm warning form. None of the reception team was aware of the fact that
the man had made a determined attempt to kill himself only one week earlier. The full
details of his suicide attempt and his state of mind thereafter were recorded only in the
police case summary – or Form MG5 – which the Police Liaison Officer at Altcourse
requested from the Cheshire Police on 17 October 2006, 15 days after the man’s arrival
at Altcourse. Thus, it was not available to reception staff when the initial health screen
took place and when the man’s risk of self-harm or suicide was first assessed by Prison
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Service staff. The Police Liaison Officer concerned told an IPCC supervised inquiry that
the Form MG5 served merely to inform considerations by the Prison Service Category A
Committee as to the man’s dangerousness and likelihood of escape, rather than to
assist in the assessment of his risk of self-harm or suicide. No clarity was established
either by my investigator or by the police as to what happened to the Form MG5. The
Prison Service told the police investigators that they had no record of the man having
been reported to the Category A Committee as a potential Category A prisoner in
October 2006, despite the assertion by staff at Altcourse that they received confirmation
on 18 October that the man did not meet the criteria for Category A. I believe that the
immediate assessment of the man’s risk of self-harm or suicide during the reception
procedures at Altcourse was undermined by the absence at that point of key information
from the police about his attempt at suicide during his arrest only a week earlier. Key
reception staff told my investigator that had they been aware of that fact, they might
have assessed his risk differently. That said, none of them considered that the man
was at risk of suicide when they assessed him. He displayed no obvious signs that he
was at risk of self-harm or suicide thereafter at Altcourse.
The man was held at HMP Altcourse until 10 November 2006 when he was transferred
to HMP Leeds for security reasons. Five days after his arrival, a request for information
regarding sentence planning was sent to the man’s Probation Officer. In his reply, the
Probation Officer drew attention to his concern that, in view of the seriousness of the
charges his client was facing, he presented a risk of self-harm. The investigation found
no evidence that this information was acted upon by anyone at Leeds. Whilst it does
not necessarily follow that had action been taken on this information a different result
would have ensued, this was, in my view, a significant and unacceptable systemic
failure.
The man did not settle at Leeds, and his behaviour deteriorated. He was warned on
several occasions that, if his poor behaviour continued, he faced the possibility of being
reduced to the basic regime. This would involve the loss of in - cell television and a
reduction in his entitlement to letters and visits. However, on 28 November, a manager
decided to try the man in another wing (C wing) in order to give him a fresh start.
On 30 November, an attempt was made to transfer the man to HMP Dovegate, a
category B training prison near Uttoxeter. (I cannot understand why a prisoner awaiting
trial for murder would have been considered for a move away from a Local prison.)
After waiting in reception for about four hours, the man was told the transfer would not
take place. I suggest this was an example of poor prisoner management. Certainly, the
man reacted badly to it. He was apparently keen to move to HMP Dovegate because
he had friends there, whereas at HMP Leeds he knew nobody. Matters were made
worse when, on the way back to the main prison from reception, he was told he would
be returning to D wing rather than C wing. The man initially refused to cooperate and
demanded to be placed in the segregation unit. After being restrained, he then fully
complied and went to D wing.
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The next day, managers reviewed the man’s position on the Incentives and Earned
Privileges (IEP) scheme in light of his poor behaviour. They decided he should be
reduced to the basic regime for a period of seven days. (This would have been
reviewed the day after his death.) I judge that this outcome might have been avoided if
his prospective transfer to HMP Dovegate had been better managed.
In early December, the man’s solicitor passed him a copy of the prosecution papers
setting out the evidence against him. According to a prisoner who saw him shortly
afterwards, the man was very upset by what he read. The prisoner thought this was the
trigger for the man’s suicide. During an exercise period later that day, the man told an
officer he was going to be charged with conspiracy to murder as well as murder.
However, the officer did not think the man appeared to be suicidal.
That evening, the man called a family member and told her he had nothing to look
forward to because he was never going to be released. He ended the call by saying, “I
don’t want to upset anyone but I can’t do this forever.” His call was not monitored. The
family member did not read anything significant into the man’s words as he apparently
often made similar remarks. She therefore did not report the conversation to anyone at
the prison. Shortly before 6.00am the next day, an officer found the man hanging in his
cell.
I applaud the decision taken at HMP Leeds on 28 November to try the man in a different
wing in order to give him a fresh start, but criticise the manner in which his prospective
move to HMP Dovegate was managed. I also criticise the manner in which the man
was told he was to go to D wing rather than C wing once the move to HMP Dovegate
had been cancelled.
I am concerned that West Yorkshire Police gave the man’s family erroneous information
as to the existence of a series of farewell letters found by them in the man’s cell after his
death. This was a source of much distress. (West Yorkshire Police have since
accepted this criticism, advised relevant staff regarding their conduct and apologised to
the man’s family.)
I draw attention to two examples of good practice at HMP Altcourse.
I make a number of recommendations to the Director of HMP Altcourse and to the
Governor of HMP Leeds.
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INVESTIGATION PROCESS
1. The investigation was opened on 12 December 2006 by one of my Assistant
Ombudsmen. On that day, notices were issued to staff and to prisoners
announcing the investigation and inviting anyone who wished to express any
information relating to the man’s death to make themselves known to my
investigator.
2. The investigation was carried out by one of my colleagues. I also commissioned
a clinical review of the management of the man’s health needs while he was in
custody. This was conducted by a doctor on behalf of the Leeds Primary Care
Trust.
3. On 1 February 2007, my investigator and one of my family liaison officers met
with members of the man’s family at their home in the presence of their solicitor.
During the meeting, a number of concerns were expressed about the manner in
which the man was treated by the police and by the Prison Service. Those
concerns have been addressed in this report.
4. Sixteen members of staff were interviewed at Altcourse. Thirteen members of
staff and two prisoners were interviewed at Leeds. Four members of staff
interviewed in March 2007 at Altcourse were re-interviewed in January 2010 at
the request of the man’s family solicitors.
5. The initial investigation uncovered no evidence that either the full details of the
man’s attempted suicide during the course of his arrest following the murder of
his girlfriend, or of his stated wish to die were passed on to GSL escort staff or to
reception staff at HMP Altcourse by the Cheshire Police. In the draft
investigation report I issued in December 2007, I expressed my view that the
significant failure by the police to alert the Prison Service to the risk of suicide the
man presented when he was remanded in custody on 2 October 2006 led to a
flawed assessment of the man’s risk of suicide at Altcourse. However, the police
disputed this claim and, following a formal complaint lodged by the man’s family,
conducted an investigation supervised by the Independent Police Complaints
Commission (IPPC). As a result, I directed that my investigator should take no
further action with regard to the completion of my investigation and report until
such time as the investigation by the police had been brought to a conclusion.
The investigation was formally suspended on 26 June 2008 and resumed on 18
December 2009 with the agreement of the police.
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LEEDS AND ALTCOURSE PRISONS
Leeds Prison
14. HMP Leeds is a Victorian local prison situated approximately two miles from the
city centre. It serves Magistrates’ and Crown Courts in the West Yorkshire area.
The establishment is one of the most overcrowded prisons in England and
Wales. At the time of the investigation it could hold up to 1,254 prisoners in 680
cells.
15. The accommodation comprises six residential wings, including the segregation
unit. There are also rooms and wards for 55 prisoners in the healthcare centre.
D Wing, where the man died, is the induction unit for the prison. The ground
floor is used as the First Night Centre where newly received prisoners spend a
short period adjusting to the experience of imprisonment before being moved
onto the induction wing.
Her Majesty’s Inspectorate of Prisons
16. The prison was inspected by Her Majesty’s Chief Inspector of Prisons in August
2005 when an unannounced inspection took place. The report of that inspection,
published in October that year, remarked on how difficult it was to sustain
progress in a crowded, inner city local prison in which cultures were hard to
change and which was operating under considerable daily pressure. Her
Majesty’s Chief Inspector of Prisons wrote:
“It was to the prison’s credit that it had largely managed to
sustain the good first night procedures that we commended at
the last inspection [in June and July 2003]; most prisoners felt
safe at this time. However, other aspects of the early days in
custody were under considerable pressure. Not all prisoners
were able to be placed on the induction wing and some spent
too long there. Less than a quarter of prisoners told us they
had had induction.”
17. The report commented that staff-prisoner relationships appeared to have
deteriorated since the last inspection. It also expressed concern about the
management of the segregation unit which was described as being run “in a
militaristic fashion”. The report also drew attention to a “high and mechanistic
level of the use of force”.
18. Although there had been some increases in activities for prisoners, there were
still only spaces for 60 per cent of the population. The figures showing the
periods when prisoners were able to spend time out of their cells were
misleading and association periods were often curtailed. However, Her Majesty’s
Chief Inspector of Prisons singled out resettlement for praise. She commented
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that a new resettlement policy had been agreed shortly before the inspection.
She said resettlement was well managed, especially for short term prisoners.
19. A further inspection took place in December 2007. As this was a year after the
man’s death, I have chosen not to comment on its contents.
Independent Monitoring Board
20. In their annual reports on Leeds for the 2005-2006 and 2006-2007, the
Independent Monitoring Board drew attention to no issues or concerns relevant
to this investigation.
Altcourse Prison
21. Altcourse is a Category B local prison that opened in 1997. It is privately
managed by Global Solutions Ltd (GSL). Situated near Aintree, some six miles
from Liverpool city centre, Altcourse serves Magistrates’ and Crown Courts in
Cheshire, North Wales and Merseyside. At the time of the investigation,
Altcourse held up to 1,108 male prisoners including 160 young offenders.
22. The accommodation at Altcourse comprises six main house blocks each divided
into two units. Each of the units is named after one of the fences on the Grand
National course at Aintree. Each unit is allocated a colour code for easy
identification by prisoners with reading difficulties. Young offenders and adult
prisoners are held together in all residential units. The two categories do not
share cells.
23. The prison is divided along its centre by buildings containing the healthcare
centre, rehabilitation unit, college, sports centre and segregation unit. An
organisation called Medacs has a contract with GSL to provide healthcare at
Altcourse. The healthcare centre has 24 hour nursing facilities and has beds for
up to 11 inpatients.
HM Inspectorate of Prisons (HMIP)
24. The HMIP inspection of Altcourse most approximate to the period during which
the man was at the prison took place in February 2005. Although the report of
that inspection drew attention to a number of weaknesses, the Chief Inspector
concluded that Altcourse was a very good prison that had benefited from
sustained and strong management. Towards the end of her introduction to the
report, the Chief Inspector of Prisons wrote:
“Staff actively encouraged prisoners to engage in work and
education: this heightened dynamic security and reduced
opportunities for bullying or the likelihood of self-harm due to
depression.”
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25. The investigation found nothing at Altcourse to alter the favourable remarks
made by the Chief Inspector of Prisons two years earlier.
26. In their annual report on Altcourse for the period July 2005 - June 2006, the
Independent Monitoring Board commented positively on many aspects of the
prison’s operation, including the care and treatment of prisoners. However, they
drew attention to their concern about the number of mobile telephones smuggled
into the prison for illegal use by prisoners, an issue that has featured in this
investigation.
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BACKGROUND
27. In 1998, the man met and married a girlfriend with whom he had a daughter.
However, they had violent arguments and in 2003 they separated. Shortly
afterwards, the man formed a relationship with the woman who was to become
the victim of his alleged crime of murder. As with his previous relationship, the
man began to have violent arguments with his new partner. In February 2005,
the man was given an extended sentence of 18 months in custody and three
years supervision in the community for causing her actual bodily harm. His
partner claimed he had used drugs prior to assaulting her.
28. The man spent the latter part of his custodial sentence at Acklington prison in
Northumberland. He was released on parole licence on 15 August 2006. The
man’s licence conditions required him to report immediately to his Probation
Officer and to keep in touch with him in accordance with his instructions. The
man was also required not to seek or communicate with his partner, or with his
former wife, without the prior approval of his Probation Officer. His licence
carried the following warning:
“Your sentence expires on 1.5.2010. If you are not recalled,
your licence will expire on 30.12.2009. From the remainder of
the period until the point at which your sentence expires you
are liable to be returned to custody if you are convicted of a
further imprisonable offence committed before your sentence
has fully expired.”
29. During the evening of 19 September 2006, the man is reported to have met his
partner and, with others, to have gone for a drink in a public house. Afterwards,
they went to a friend’s flat where some of them apparently took drugs. It is
alleged that, during the evening, the man lost his temper with his partner and
stabbed her many times with a kitchen knife. At 2.40am on 20 September, she
was found dead in the flat by paramedics.
Arrest
30. The man was apprehended at 8:35pm on Tuesday 26 September. As the police
officers approached him, he appeared to inject himself with a substance in his left
arm. When told to stop, he swore at the police and threatened them with a large
knife. He was then sprayed with CS gas, disarmed and arrested. The police
custody records show that the reasons for the man’s arrest included an alleged
assault on a woman, the alleged robbery of a motor vehicle, and the alleged false
imprisonment of a number of people who were in the flat when the alleged
murder took place.
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Admission to Hospital
31. As the man had injuries to his hand and appeared to be drifting in and out of
consciousness, the police called for an ambulance. The man was taken to the
Accident and Emergency Department at a local hospital, arriving at about
9.00pm. My investigator was given sight of the man’s Accident and Emergency
assessment sheet and other notes made after his admission to the hospital.
These had been obtained by the man’s family solicitors. The initial assessment
sheet confirms that the man had injuries to his head and hand. On a separate
form entitled, “Personal details on admission”, the reasons for admission were
logged as:
“unresponsive
GCS 3 on admission to A+E
Haematosis
Suicide attempt/iv heroin”
The form also noted that the man remained in police custody whilst in the
hospital.
32. The following are extracts from the notes by medical staff who saw him:
“26 September-
9.00pm: 31 year old man in police custody. Suspected of
involvement in murder. Seen to inject hand with heroin.
Unconscious with poor respiratory effect.
(illegible entry).
“27 September-
“Under arrest. Heroin O/D or suicide attempt last night …
wounds to right thumb and right … finger. “Right thumb –
wound dorsal aspect. EHL distal tendon clearly seen and
divided. Right .finger- tendon end clearly seen. Decreased
sensation. For transfer to Whiston plastics…”
33. At 1.00am on 27 September, the man was transferred to Cubicle E in the
Accident and Emergency Department of the local hospital. During the night, he
frequently vomited and was very abusive to the nursing staff. He remained
awake but drowsy for most of the night. At 9.00am, he suffered a panic attack
and had difficulty in breathing. His temperature rose to 37.8 degrees. His notes
show that, on occasions, he was tachycardic (i.e. experiencing an unusually
rapid heartbeat).
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34. At 1.30pm that day, the man was transferred to ward A5, still in police custody.
The notes made at the time show that nurses were unable to complete all
admission assessments as the man was still under the effects of heroin.
35. At 9.00pm, consideration was given to the man’s fitness for transfer to another
hospital. It was decided there was no medical reason to delay his transfer.
Routine observations were to continue. However, he was kept in the original
hospital overnight. It was noted the man needed a psychiatric review the
following day. The investigation found no evidence in the hospital notes to clarify
whether any psychiatric review took place at either of those hospitals.
Admission to Second Hospital
36. Early on 28 September, enquiries were made to ascertain whether a bed was
available for the man at the second hospital so that he could undergo an
operation to repair the injuries to his hand. These enquiries revealed that the
second hospital was not aware of any plan to transfer the man there. However,
at 10.50am, confirmation was received that the man could be transferred. Later
that day, the transfer took place. Whilst at the second hospital, the man said to a
doctor, “I murdered my girlfriend, then took an overdose. These people must
have got to me first. I didn’t expect to wake up in hospital. That wasn’t the plan.”
This statement was overheard by a policewoman who was guarding the man.
She asked the doctor if he would be willing to testify as to what the man had said.
The man subsequently gave his consent for the doctor formally to disclose his
confession to the police by way of providing a witness statement. The doctor did
so after taking advice as to patient confidentiality.
Northern Custody Facility at Runcorn
37. According to police records, the man was discharged from the second hospital
during the late afternoon of Friday 29 September. He was taken to the Northern
Custody Facility at Runcorn, arriving at 4.47pm. The records show that, shortly
after his arrival at Runcorn, the police asked the man if he had any illness or
injuries. The man said he had severed tendons in his right hand and had
sustained minor grazes, bruises and swellings. He said he had undergone an
operation the previous night and was currently taking antibiotics and painkillers
(fluocloxacillin and co-codamol). The man told the police his injuries had been
self-inflicted. An entry made in the police custody record on 29 September
shows the man was placed in a self-harm smock. At 9.05pm, the following entry
was made in the custody record:
“Update from [doctor]. Dp [detained person] has longstanding
depression, not taking meds, seen psychiatrist 10 years ago,
admitted to mental health institution 10 years ago, voluntarily.
Drinks 5 pints of alcohol a day and was released from prison 5
weeks ago. Smokes cannabis and snorts cocaine. Dp states
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he took a heroin overdose 12 days ago, suicidal intent. Doctor
suggests cctv constant watch…….”
38. The man was kept on constant watch throughout the remainder of his time in
police custody. He was occasionally visited by a doctor and his solicitor.
39. At 3.12pm on 30 September, the following entry was made in the custody record:
“DO spoke to Dp through hatch due to Dp crying. Gave cup of
water and tissue. Dp then stated, ‘I can’t live with myself. I
feel ashamed. She’s only 23 and I’ve killed her. I was coked
up and drunk.’ Dp then began to talk about his family and that
his 8 year old daughter would know he was a murderer.”
40. As the man was on parole licence at the time of his arrest, the National Probation
Service asked on 28 September for him to be recalled to prison. The reasons
cited were as follows:
“[The man] has been arrested for murder and an indication of
the strength of police evidence is likely to mean he will remain
in custody. Recall is sought bearing in mind the serious
nature of the offence before the court and the consequent
breach of licence conditions.”
41. The request for the man’s recall to prison was agreed on 29 September while he
was still in police custody.
42. At 8.17pm on Saturday 30 September, the man was formally charged with
murder and associated offences. He was refused bail because of the
seriousness of the charges.
43. Police records seen by my investigator show that, during interviews with police
officers in the presence of his solicitor, the man said he hit himself with the same
machete he used to kill his partner and “chopped his own finger with it”. He also
said he had intended to kill himself with heroin, and when he was arrested he
was “on his way to kill himself”.
44. At 10.10pm on 30 September, the following entry was made in the custody
record:
“Dp in pain from injuries to right hand. Previously seen by
[doctor] who verified medication in possession and left written
instructions. Dp appears to have missed 5.00pm doses of
both medications. 10.00pm doses given at 9.10pm due to
same and dp in discomfort as a result. Dp clearly distressed,
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anxious regarding being in a cell. Pain relief and antibiotics
given at 9.10pm.”
45. The police continued to keep the man on constant observation. At 10.33pm, the
doctor saw him and gave him 10mg Diazepam. The man slept until about
7.00am the next day when he was given a meal and a drink. At 4.16pm on 1
October, he was seen crying in his cell. At 5.29pm, he was allowed to make a
call to his sister-in-law. Later, he called his brother. The man became very upset
during both calls. However, he slept for most of the following night.
Appearance at Magistrates’ Court
46. Shortly after 8.00am on 2 October, the man was released into the custody of staff
from Global Solutions Ltd (GSL), a private security company - now known as
G4S - who escorted him to a Magistrates’ Court.
47. A Detention Officer completed a Prisoner Escort Record (PER) before handing
the man over to the GSL staff. The Detention Officer noted violence, weapons
and drugs as risk factors. He also ticked a box to show there was a risk of
suicide/self-harm. He recorded the following information in the section headed,
‘Further information about risk’:
“Injury to right arm. Further serious charges likely. Very
violent offender.”
48. The Detention Officer later provided a written statement to the police in which he
offered the following information:
“I cannot recall completing the PER form for [the man] but we
had set procedures in place and I therefore make this statement
from my usual practice. When preparing this PER I took into
account [the man’s] history and reviewed the entries on the PNC
(Police National Computer) system regarding the man. This
confirmed that the man had a history of violence and that he was
known to carry weapons. I therefore marked the boxes
confirming these concerns.
“I was also aware that on arrival in custody he had injuries to his
hand which had required surgery. When asked whether he had
ever tried to harm himself, he replied “yes”. He then confirmed
that the injuries he had sustained were self-inflicted during the
incident. I confirm that I was aware of this information when I
completed the PER form. I therefore confirmed that he had a
history of drug taking and that he was a known suicide/self harm
risk.
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“I cannot specifically recall whether or not the medical records
would have been attached to the PER form but I confirm that this
was my usual practice at the time. I believe that it is essential
that the escort officer is given as much information as possible.
Therefore the medical records would have completed the history
of our dealings with [the man]. For the avoidance of doubt, the
full Primecare notes would not have been attached as these are
notes that are retained by Primecare staff. We do not have
access to these records in the custody suite. The medical
records that we would have attached would have been the short
form notes that confirmed what Primecare had advised following
the examination. These short form notes would have set out the
brief detail of the examination and any medication prescribed.
This information was also summarised on the custody record.
“I have reviewed the transcript of the evidence given by the
escort officer. It is clear that she was fully aware of [the man’s]
medical condition and that he was fit to be transferred. She also
made her own assessment of [the man’s] condition. As I have
said, I cannot recall attaching the medical report but I note that
the escort officer has confirmed that it was attached. I can only
assume that because this was my normal practice at the time,
and from what the escort officer said, that I must have attached
the form.”
49. The Prisoner Custody Officer (PCO), who shall be referred to in this report as
PCO 1, confirmed at her first interview with my investigator (in March 2007) that
she was indeed the one who received the man into GSL custody at the Northern
Custody Facility at Runcorn in order to escort him to a magistrates’ court. PCO 1
told my investigator she arrived at the facility at about 7.40am on 2 October. She
said the man was one of six prisoners she had to take to court that day. She
said she could clearly remember the man because his right arm was in plaster
and because of his mental state. PCO 1 confirmed that she saw the PER and
signed it only to show that she had received the man from the custody suite staff,
the other details on the form having been completed by the custody suite staff.
PCO 1 went on to say that she later thought that the man seemed “very down”
and initially reluctant to engage in conversation. PCO 1 also pointed out that she
had read “his medical records that the doctor had opened up overnight”. She
said she could remember that these records had shown that the man was “quite
depressed”. (See also paragraph 55 below.)
Suicide/self-harm warning form
50. Such was the PCO 1’s concern about the man’s state of mind that she decided to
place him on a constant watch in the vehicle and therefore placed him in the
cubicle nearest to where she sat. PCO 1 also raised a suicide/self harm warning
17
form. [The purpose of this form is to record any perceived risk of self-harm or
suicide, and to communicate that information to the various agencies involved in
the supervision of the prisoner, so that appropriate decisions can be made as to
the management of the risk.]
51. PCO 1 recalled that there was another prisoner on board who had also been
charged with murder. The man asked if the two of them could travel in the same
cubicle. PCO 1 did not allow this, but remembered the man talking to the other
prisoner and trying to compare their circumstances.
52. During the journey, PCO 1 succeeded in getting the man to talk to
her. He told her he had injured his fingers during the “act of domestic
violence” for which he had been arrested and that he was in pain. He
was particularly concerned about the possibility of being
photographed by the press at court. PCO 1 recorded in the warning
form her concern that the man seemed depressed and that he had
been talking to other prisoners about being photographed.
53. The escort vehicle arrived at the magistrates’ court at 8.40am. PCO 1 told my
investigator that the man asked her if she would be able to escort him to prison
after his court appearance, but she told him she had to go elsewhere. PCO 1
then left to complete her other duties. She did not see the man again.
54. At her second interview with my investigator (conducted in January 2010 at the
request of the man’s family solicitor), PCO 1 confirmed that she saw nothing on
the PER made out by the Detention Officer or from any other source with regard
to the circumstances of the man’s arrest or what happened while he was in the
two hospitals referred to earlier in this report. Although she was concerned about
the man’s current state of mind, she was not aware that he had actually
attempted to kill himself during the process of being arrested only a week earlier.
PCO 1 told my investigator she had not, for example, seen the police custody
record relating to the man’s detention at Runcorn or the police case summary
(police form MG5) which included detailed information about the man’s alleged
offence, his confession to the murder of his girlfriend and his disclosure to a
doctor that he had injected himself with what he had hoped to be a lethal dose of
heroin during the course of his arrest. PCO 1 also confirmed that she did not
hear mention of any such details during the brief period she spent in the custody
suite before leaving with the man and five other prisoners for the magistrates’
court.
55. During the same interview, my investigator asked PCO 1 to try to describe the
“medical records” she had mentioned at her first interview. PCO 1 was able to
recall that what she saw took the form of a one page document which she
stapled to the PER. She agreed with my investigator’s suggestion that the form
she could recall was probably the same document described by the Detention
Officer. PCO 1 believed that the form to which she referred was made out at
18
10.00pm on 1 October - the night before she collected the man from the custody
suite - and contained information about his fitness to be detained and to travel.
She also thought it included comments about his lack of eye contact and his
state of depression at the time.
56. At about 11.00am on 2 October, PCO 1 having already left, the man was due to
move up from the court cells to appear before the Bench. However, he refused
to attend the courtroom. In his absence, he was remanded in custody at
Altcourse and ordered to appear at a crown court on 13 October.
57. A further Prisoner Custody Officer (who shall be referred to in this report as
PCO 2) escorted the man from the magistrates’ court to Altcourse. At her first
interview with my investigator (in March 2007), she told my investigator she could
remember the transfer. PCO 2 said she read the paperwork that had been
completed in respect of the man. This included the Prisoner Escort Record
(PER) and the suicide warning form made out by PCO 1. She, too, was unaware
of the suicide attempt made by the man at the point of arrest. However, PCO 2
saw that the self-harm risk box in the PER had been marked. She said that
when the man first boarded the van he was quiet. However, as soon as other
prisoners boarded, he struck up conversations with them. PCO 2 said the man
showed no sign of being suicidal during the journey to Altcourse.
19
KEY EVENTS AT ALTCOURSE PRISON: 2 OCTOBER - 10 NOVEMBER 2006
Handover of the man from GSL to Altcourse staff
58. The PER shows that the escort vehicle arrived at Altcourse at 3.30pm after a
journey of about 55 minutes. PCO 2 said she clearly remembered handing the
paperwork on the man to the admissions staff at the prison. At her first interview
with my investigator, PCO 2 pointed to the fact that parts A and B of the PER
were signed on her arrival with the man at Altcourse, showing that someone in
reception must have seen them. She was also confident that the suicide and
self-harm warning form was handed over to the admissions staff.
59. Prison Service Instruction (PSI) 51/2003 is the instrument which promulgated the
introduction of the suicide/self harm warning form. The PSI sets out clear
instructions for the handling of the form. Section 6 of the form should be signed
by the reporting Prisoner Custody Officer - in this case PCO 1 - so that there is a
record of who raised the form. Section 7 is for the admissions or reception staff
to sign when the prisoner arrives. Paragraph 18 of the PSI sets out the
requirement that, whenever a prisoner arrives at a prison accompanied by a
warning form, the PER, once seen by the reception officer, must be passed with
the warning form to the reception healthcare screener. Upon receipt of the
warning form and the PER, the healthcare screener must decide, having spoken
to the prisoner and considered all other information available, whether to open a
F2052SH (or ACCT). [Both these forms are tools designed by the Prison Service
to monitor and manage prisoners considered to be at risk of self harm or suicide.
The ACCT system - Assessment, Care in Custody and Teamwork - replaced that
of the F2052SH and was in place at the time of the man’s period in custody at
Altcourse and Leeds prior to his death.] Section 8 of the warning form should be
signed by the reception healthcare screener. In respect of the man’s form,
neither box was completed. This omission might suggest one of two things.
Either that the contents of the form were not communicated to the admissions
staff (although PCO 2 said they were), or that they had been but the staff who
received them simply did not sign the appropriate sections. My investigator
ascertained that the person who signed the PER when PCO 2 took the man to
the admissions area was an Admissions Manager. At interview, the Admissions
Manager had difficulty recalling the events of 2 October, and could not
specifically remember the man. However, he said he was sure he would have
seen the PER and the warning form, even though the latter was not signed.
60. At her second interview with my investigator (also conducted at the request of the
man’s family solicitor) in January 2010, PCO 2 said that, although she could not
be certain, she thought she was given the PER and the suicide/self harm warning
form for the man before leaving the magistrates’ court for Altcourse. She
assumed that the warning form had been slipped inside the PER. PCO 2 told my
investigator that she “wrote on part of the PER that he and his property were
handed over to Altcourse – the PER and the warning form would have been
20
handed over”. My investigator asked PCO 2 whether the short form (i.e. the
medical record) mentioned by PCO 1 was also left with the prison. PCO 2 said,
“I can’t remember to be honest. If that was there it would have been handed in”.
When asked why the warning form had not been signed by anyone at Altcourse,
PCO 2 said,
“I didn’t know that. I just assumed they’d sign it and hand it
back to you. They may have signed for the PER and the
warning form was inside it. So they may just have missed
signing the warning form.”
61. Like PCO 1, PCO 2 said she did not see the police custody record or the police
case summary (Form MG5) for the man.
Reception procedures and communication of risk information at Altcourse
62. The initial reception of any prisoner entails the completion of a range of
procedures. These include an initial fact finding interview with a
reception/admissions officer (who adds personal and criminal data to the
prisoner’s core prison record), a first reception health screen and a cell sharing
risk assessment.
Opening of core prison record
63. At interview, the Admissions Manager told my investigator that a protocol had
been agreed between Altcourse and the Courts Service whereby the first page of
prisoners’ core prison records is normally completed at court rather than at the
prison. This is to save time during the reception procedures. The Admissions
Manager confirmed that the man’s details were taken at court. These showed he
was born in Crewe in December 1974. The man said he was a builder and was
separated. He said he had been living in Warrington and his mother was his next
of kin.
Prison number
64. The man was allocated a new prison number, as if he was a “new” prisoner. In
fact, he should have been given the same prison number allocated to him on
reception at the outset of his extended sentence. However, the investigation
found that his previous sentence was not known by the admissions staff that day.
This error was rectified the next day, when the man’s status as a “licence
revokee” was recognised. At this point, his prison number was changed.
Although a new core prison record was opened for him, the medical file opened
at the beginning of his extended sentence was quickly retrieved and continued.
Thereafter, the man was treated as a sentenced prisoner subject to a further
charge. (Since this time, the Prison Service has introduced an information
technology programme known as PNOMIS by which it has become possible for
21
prisoners to be allocated the same prison number each time they are sent to
prison.)
Referral as a potential category A prisoner
65. During the reception procedures, a further PCO (who shall be referred to in this
report as PCO 3) notified the security department at Altcourse that the man had
been charged with murder so that action could be taken to refer him to Prison
Service Headquarters as a potential category A prisoner. Confirmation was
received on 18 October that the man did not meet the criteria for category A.
(See also paragraph 96 below. The Cheshire police have asserted that details of
the man’s alleged offence, his arrest on 26 September and his subsequent
disclosures in hospital were faxed to the Police Liaison Officer at Altcourse on 17
October in Form MG5 for the purpose of informing decisions made at the man’s
review by the Prison Service Category A committee. No clarity has been
established as to what happened to the document.)
Cell sharing risk assessment
66. The man’s core prison record shows a cell sharing risk assessment was carried
out during the reception procedures. The purpose of the risk assessment is to
enable the staff to assess any risk of harm that a prisoner may pose to another if
allocated to shared accommodation. The risk assessment form contains four
sections, each of which has to be completed and signed by different staff.
67. The first section requires the author to record, amongst other things, whether he
or she has received any documentation such as an open or closed F2052SH or
ACCT form. In this man’s case, the “no” box was ticked. This section was
completed by PCO 3.
68. The second section asks ten questions, one of which is, “Does the prisoner have
any previous convictions for the following: murder, sex offence, kidnapping,
manslaughter, false imprisonment, GBH, ABH (and other offences)?” In this
man’s case, the “no” box was ticked. In fact, the man was already serving a
sentence for Actual Bodily Harm. The other questions in the second section ask
the user to confirm whether the prisoner has a current F2052SH or ACCT form
and whether either of these documents has been opened in the past. This
section was also completed by PCO 3 who ticked the “no” box for each question.
At her first interview with my investigator (in March 2007), PCO 3 stressed the
boxes she ticked and the comments she made on the form were based on the
man’s own responses to the questions she put to him.
69. The third section asks questions about the prisoner’s mental condition and has to
be completed by a member of the healthcare staff. The user must judge from a
medical standpoint what level of risk a prisoner presents of harming others. In
this man’s case, the section was completed by a registered mental health nurse
22
(RMN) who judged that the risk was low. The form also requires the author to
comment whether any self-harm issues have arisen. The registered mental
health nurse ticked neither of the two boxes available. At her first interview with
my investigator (in March 2007) she could not explain why she did not do so.
She concluded that the man could share a cell.
70. The fourth and last section of the form requires the duty manager to countersign
the assessment. In this man’s case, the duty manager at the time confirmed he
had no concerns and agreed that the man could share a cell.
71. After the cell sharing risk assessment had been completed, PCO 3 made the
following entry in the man’s core prison record:
“Prisoner states ok. No issues raised. No problems being
here. No concerns raised. States no SASH [suicide and self-
harm] issues.”
72. At her second interview with my investigator (conducted at the request of the
man’s family solicitor) in January 2010, PCO 3 confirmed that she did not see the
police custody record or the police case summary (form MG5) and had no
knowledge of the circumstances of the man’s arrest or of what happened when
he was in the two hospitals mentioned earlier in this report. Thus, she did not
know he had attempted to kill himself a week earlier.
73. When asked whether she had seen on 2 October any type of medical notes
relating to the man, PCO 3 said to my investigator, “Not that I can recall. If I had
seen anything, it’s picked up on. But I can’t recall seeing anything.” PCO 3 went
on to say,
“I would have had his PER and his warrant and as far as I can
remember, that’s all I did have. Usually, you would get a
suicide warning form if there were any concerns about that. I
can’t remember seeing that.
“Normally he’s taken off the van and asked for his name and
date of birth by a manager so if a form was there that would
have been picked up by the manager. The manager on duty on
2 October would have taken the paperwork off the court
services staff and he would have been at the counter. I would
have seen [the man] next. Normal procedure is that anything
like the suicide warning form would be passed on by the
manager.”
23
74. My investigator also put the following statement to PCO 3:
“The regulations at the time required the escort staff to sign
section 6 of the warning form and the reception officer to sign
section 7. On [the man’s] warning form neither of these
sections was signed. There’s no doubt that a suicide warning
form was raised. What is in doubt is what happened to it when
[the man] arrived at Altcourse. The fact that the form was not
signed by anyone in reception could mean that it was seen but
not signed for or that it was not seen.”
75. PCO 3 suggested that the suicide warning form may have been inserted in the
PER along with the man’s warrant. However, she told my investigator,
“If I had seen a warning form and it wasn’t signed, I still would
have asked the prisoner. So the presence or absence of the
form wouldn’t make any difference to what I asked him. The
form would have acted as a sort of back up to the questions I
would have asked him. If he had said to me anything about
suicide or self harm, that would have prompted me to go
deeper.”
76. My investigator asked PCO 3 if she thought she might have done anything
differently if she had seen the case summary or the custody record and the
suicide warning form. PCO 3 said she would have raised a SASH (i.e an ACCT
form) regardless of what the man told her himself. She said that if he had told
her he felt alright, she would have told him she had information indicating
otherwise. However, PCO 3 reaffirmed the view she had expressed in her first
interview about the risk she felt the man had presented when she saw him. She
said,
“I feel I had no reason to open a F2052SH (ACCT) form. Today
is the first time I knew anything about what had happened to
[the man] when he was in hospital etc.”
77. PCO 3 confirmed that when she assessed the man’s risk of self harm or suicide
she did not take into account the fact that he had been charged with murder (a
factor that can lead to a heightened risk of suicide in some prisoners who face a
long prison sentence, especially in cases where the crime is of a domestic
nature.) She said she was satisfied that she had asked him the right questions
and that the man displayed no behaviour indicating he was lying when he said he
had no thoughts of self harm.
24
Healthcare screen
78. The registered mental health nurse (RMN), who completed the healthcare
element of the cell sharing risk assessment, also carried out a reception health
screen on the man. Using the ‘System One’ electronic medical information
system, the registered mental health nurse (RMN) recorded the man’s height,
weight, blood pressure and body mass index. The man disclosed to her that he
had previously taken cannabis and had taken cocaine in the previous month. He
told her he had severed tendons in his right hand for which he had undergone an
operation at outside hospital. The man said he had been prescribed flucloxacillin
(an antibiotic) and co-codamol (a painkiller).
79. As far as his mental health was concerned, the man said he had been prescribed
Zispin - an anti-depressant - during the previous six weeks but had stopped
taking it after being released from Acklington in August 2006.
80. At her first interview, the registered mental health nurse (RMN) said the man told
her he had no history of self-harm or attempted suicide and did not currently
have any such thoughts. She also said she could not remember whether she
saw the self-harm warning form completed by PCO 1. However, the registered
mental health nurse (RMN) confirmed that the man did not present to her as
being suicidal on reception.
81. The registered mental health nurse (RMN) also told my investigator she referred
the man for a mental health assessment as she thought he was depressed. The
System One print-out does not make any mention of this referral. A further check
of the programme on the computer itself, rather than the print-out, revealed that
the registered mental health nurse (RMN) did indeed refer the man. The
computer showed that the registered mental health nurse (RMN) had asked the
man if he was suicidal, and that he said he was not. The print-out does not
mention this. My investigator was advised that it was not always possible to gain
a print-out of all the data logged on the System One programme.
82. At her second interview (conducted at the request of the man’s family solicitor) in
January 2010, the registered mental health nurse (RMN) reiterated that she
could not recall seeing a suicide/ self-harm warning form. She said that if she
had seen one, she would probably have opened a F2052SH/ACCT. The
registered mental health nurse (RMN) told my investigator,
“You’d be silly not to because the decision’s made for you. I
looked at his medical record on System One before I came over
to see you and I saw that he told me he had no thoughts of self-
harm. But if I’d seen the warning form as I say the decision’s
made for you.”
25
83. When shown the PER that accompanied the man to Altcourse, the registered
mental health nurse (RMN) told my investigator she had not seen it. The
registered mental health nurse (RMN) also said she had not seen the one-page
medical form that may have been stapled to the PER. Neither had she seen the
form MG5 or the police custody record and therefore had no knowledge of the
man’s attempt to kill himself on 26 September. The registered mental health
nurse (RMN) said that if she had known that, she would have opened a
F2052SH/ACCT. However, she reiterated that at the time she conducted the
health screen, the man gave her no cause for concern.
Allocation to First Night Centre
84. Following the completion of the reception procedures, the man was allocated to
the First Night Centre. Here, a number of forms were completed by a further
PCO (who shall be referred to in this report as PCO 4). In the box headed, “Any
immediate concerns to include suicide and self-harm and bullying history”,
PCO 4 wrote, “None”.
85. The First Night Centre and the Induction Unit at Altcourse are jointly managed.
One of the joint managers interviewed the man. During the interview, the man
said he was aware that details of his offence had been reported in the press and
claimed everyone at Altcourse knew the charges against him. The man said he
was content to remain on normal location. The joint manager of the First Night
Centre and Induction Unit at Altcourse recorded these details in the man’s core
prison record and noted that, because he had been at Altcourse before in a unit
known as Melling Blue, he had asked to return there. The joint manager of the
First Night Centre and the Induction Unit at Altcourse advised the man to make a
formal application to do so.
86. My investigator was told that, as matter of routine, all prisoners undergoing their
first night at Altcourse are placed in the First Night Centre and are observed at
regular intervals - normally half hourly - throughout the night. Observations do
not cease until approximately 10.00am the next day when the oncoming shift
have had an opportunity to observe each prisoner themselves. My investigator
was also told that if, after that period, any prisoner demonstrated that he was
having difficulty in coping, observations would continue or, if necessary, self-
harm monitoring procedures would be implemented.
87. Records show that the man was observed between 9.00pm on 2 October and
10.00am the next day without event. The man told the manager of the First Night
Centre and the Induction Unit at Altcourse he had no thoughts of self-harm. As a
result, a decision was made to remove him from his first night watch.
88. Later that day, the joint manager of the First Night Centre and the Induction Unit
at Altcourse also recorded a conversation he had with the man about his arm
injury. The man told the manager he had injured his arm “during the incident”
26
with his girlfriend and that “it had not been done on purpose”. It was about this
time that the man moved from the First Night Centre to the Induction Wing.
Reception assessment by doctor
89. On 3 October, a doctor saw the man. The doctor used System One to record his
consultation. He took the man’s physical and mental health history. The man
told him he had overdosed at the time of his offence but that this was an
impulsive act only. (At consultation stage, the man’s mother expressed particular
concern about this remark. She said that suicide attempts were often impulsive
acts and that her son had overdosed on a substance he had not normally taken,
pointing to the likelihood that he had tried on this occasion to take his own life
and would continue to present a risk of further attempts. The man’s mother
pointed to the likelihood that a killing in a domestic context would lead to a
heightened risk. ) There were no notes available to the doctor to enable him to
make a more informed judgement of the man’s state of mind. The doctor wrote:
“Obviously quite anxious and has been prescribed Zoplicone [a hypnotic
drug] and Diazepam in custody. Change to Buspirone [an anti-anxiety
drug] twice daily. RMN and counselling F.U. [follow up].”
Interview with Probation Officer
90. On 4 October, the man was seen in the Induction Wing by his Probation Officer
about his licence recall and his offence. At this time, the man was in touch with
his eight year old daughter from his previous marriage. The Probation Officer
completed an initial child protection risk assessment. The Probation Officer also
noted in his record that he had been referred to counsellors and to the mental
health team.
91. On the same day, the Probation Officer completed form LSP 0 (Life Sentence
Plan). The form, completed in respect of any prisoner whose alleged criminal
offence renders them liable to be given a life sentence if found guilty at court,
requires the report writer to answer a number of questions. These, together with
the responses given by the Probation Officer in the man’s case, are as follows:
Question: “Any information relating to possible self-harm?”
Answer: “Placed on first night watch. But did not wish to
remain on the watch.”
Question: “Has the prisoner been located in Healthcare or
normal location?”
Answer: “Located as per normal procedure in the First
Night Centre.”
27
Question: “Does the prisoner require any additional support
at this time?”
Answer: “Has seen Chaplaincy and carers. Wishes to
see the counsellor.”
92. The man’s Probation Officer told my investigator that the man gave very little eye
contact during her interview with him. She formed a clear impression that he did
not wish to speak about his offence, not least because doing so might
compromise his trial. But the Probation Officer also said the man was ashamed
and devastated by what he had done. The Probation Officer also explained that
the “carers” to whom she referred during her interview with the man were
prisoners trained to listen to, and support, other prisoners in times of crisis. The
Probation Officer thought the carers were equivalent to those used as Listeners
in other prisons. Finally, the Probation Officer explained that the counsellors she
mentioned were staff employed in that role by the healthcare centre.
93. At 9.50am on 6 October, the man refused to move from the Induction Wing to
another wing. The record does not make clear to which wing he was due to
transfer. The man told two PCOs (who shall be referred to in this report as
PCO 5 and PCO 6) that his reason for not wanting to relocate was that he
wanted to be left alone as the funeral of his ex-girlfriend, whom he had been
accused of killing, was about to take place. As a result, PCO 5 decided to open
a Suicide and Self-Harm Communication Form A. At interview, PCO 5 explained
that this form is normally raised in respect of prisoners about whom staff are
concerned, but whose condition is not such as to warrant the initiation of formal
self-harm monitoring procedures. PCO 5 told my investigator that the Form A
would normally be closed within 48 hours. If staff considered it necessary to
keep the form open beyond that period, formal self-harm monitoring procedures
would be started. In the man’s case, the form was closed the next day after his
state of mind had been re-assessed.
Appointment at Hospital
94. On 11 October, the man was taken to outside hospital for a check-up following
his operation. The PER for the journey contained no indication of any risk of self-
harm.
Appearance at Crown Court
95. On 13 October, the man appeared at a Crown Court where he was committed for
trial.
28
Fax from Cheshire Police to Police Liaison Officer at Altcourse
96. The Cheshire police have asserted that on 17 October a fax was sent to their
Police Liaison Officer at Altcourse. The police said the fax included their own
summary of the case against the man (form MG5). This summary, a copy of
which was supplied to my investigator, clearly shows that the man had planned
to take his own life during the course of his arrest on 26 September. (This was
unbeknown to my investigator in March 2007, when no evidence of any such
action came to light from the interviews he conducted. No clarity was obtained
by my investigator during subsequent enquiries he made at Altcourse in January
2010 as to what happened to the document once the Police Liaison Officer at
Altcourse had received it but it was clear that none of the staff my investigator
interviewed had sight of it. This matter became the subject of a police
investigation supervised by the Independent Police Complaints Commission in
response to a complaint from the man’s family. This matter is discussed further
at paragraphs 155 - 173 below.)
Meeting with Mental Health In-Reach team
97. On 20 October, a member of the Mental Health In-Reach team saw the man. He
subsequently made the following entry in the man’s medical record:
“Seen on Canal Unit in treatment room. Presented as a little
anxious and tense but was not agitated and engaged freely in
conversation. Discussed past and contact with services both
inside prison and the outside. Only released from Acklington
on 10 August 06 and is shocked by the circumstances that
have led him back in prison. Has received letters and a visit
from the family but states he is too ashamed to contact them
and rather they just forgot about him. States that he comes
from a small town where everyone knows each other and that
his offence is a great source of shame to his family and
friends. Denies any intent to self-harm as he feels he will
adjust and recognises his need to be punished. States he has
friends on the wing and that they help him although they can’t
understand his current situation. States he can’t relax and he
is experiencing nightmares. Discussed the use of medication
but was unsure. Will see again.”
Refusal to keep appointment at Hospital
98. On 25 October, the man was due to return to outside hospital for a further
appointment. However, he refused to attend. A Prison Custody Officer (who
shall be referred to in this report as PCO 7) called the healthcare centre to inform
them of this. A member of the healthcare staff went to speak to the man and
advised him that, if he insisted on refusing, he would be required to sign a
29
disclaimer. The man cooperated with this, but gave no reasons for his refusal to
attend for his appointment.
Mental health team consultation
99. On the same day, a member of the Mental Health In-Reach Team saw the man
again as promised five days earlier. He wrote in the man’s medical record:
“Seen on the wing in order to follow up the discussion we had
about the possible use of medication. Says he is finding it
difficult to sleep and has lost his appetite. Clearly is having
some understandable difficulty in adjusting to his current
circumstances. Eye contact was poor but didn’t present as
being overly pre-occupied or distracted. Advised to contact me
should he feel his symptoms worsening. To make an
appointment with our GP regarding his medication. Has been
on Zispin [an anti-depressant] in the past.”
100. At interview, the member of the Mental Health In-Reach team explained that
when he said “our GP”, he meant whichever doctor was on duty the next day.
He told my investigator he did not see the man again. He also said he made an
appointment for the man to see the doctor the next day, but the man did not
attend. The member of the Mental Health In-Reach team explained that it was
for a doctor to consider and prescribe appropriate medication and that this was
the point of referring the man.
Discovery of mobile phone and accusations of threatening calls to a member of
the public
101. At about 9.00pm on 25 October, a further PCO (who shall be referred to as
PCO 8) carried out the last roll check of the day in Canal Blue unit, where the
man was located. As he checked the man’s cell, he saw him inside using a
mobile phone. PCO 8 summoned the assistance of other staff who carried out a
search of the cell occupied by the man and his cellmate as well as the adjacent
cell. The back cover of a mobile phone was found under the mattress on the bed
used by the man’s cellmate who was subsequently placed on a disciplinary
report for this matter. No action was taken against the man. No other mobile
phone parts were found.
102. On 27 October, the following entry was made in the man’s security file:
“Control Officer on nights received a call from a very
distressed female who would not give her name. She
informed the officer that she had just received a call from [the
man] from a mobile phone in his cell. He had made very bad
threats towards her. She was very distressed about [the man]
30
having phoned her from his cell and wants the mobile phone
removed at once from him. Officer informed the night duty
Operational Manager of this and asked that the female phone
security in the morning.”
Further refusal to attend a hospital appointment
103. On 1 November, the man was told he was to be taken to hospital but again he
refused to go. On the same day, it was noted that the man had been offered a
chance to take part in education classes but he declined. On 7 November, he
again refused to take part in education classes.
Transfer to Leeds
104. On 10 November, the man was transferred to HMP Leeds. My investigator
interviewed the Head of Operations at Altcourse in connection with this matter.
The Head of Operations at Altcourse explained that the man was regarded by
some staff at Altcourse as an influential prisoner “with a finger in every pie”. Staff
were used to seeing him, “surrounded by flocks of other prisoners who were
doing his bidding”. The Head of Operations at Altcourse also said the man had
earlier sent a friend to the cell of another prisoner whose sister would have been
called as a prosecution witness at his trial. On the man’s instructions, the friend
told the prisoner that he was a “grass” and that he would be assaulted.
105. The Head of Operations at Altcourse said the man and another, unnamed,
prisoner were moved from Altcourse to Leeds in exchange for two prisoners
Leeds wanted to move. The Head of Operations at Altcourse said the man’s
transfer to Leeds was arranged primarily because of his use of the mobile phone
on 25 October and the intelligence about threatening the brother of a prosecution
witness. The Head of Operations at Altcourse stressed the transfer was a
temporary measure only, “for a respite”.
106. The PER for the journey between Altcourse and Leeds noted that violence and
the concealment of weapons were considered to be risk factors for the man. The
PER carried no notation of any risk of self-harm.
107. The man’s core prison record was transferred to Leeds by the escorting staff,
along with his medical record. The medical file for the man presented to my
investigator had initially been opened at Altcourse in April 2005 at the outset of
the man’s previous period of custody. This file took the shape of a traditional
paper record, known as the Inmate Medical Record (IMR). The file contained
numerous notes and documents relating to the man’s time at Altcourse and
Acklington prisons. However, at the time of his next admission to Altcourse on 2
October 2006, the system for recording the details of prisoners’ medical history
was in the process of changing from the IMR to System One. When he
transferred from Altcourse to Leeds on 10 November, no print-out of the System
31
One record for the man for the period he was at Altcourse was inserted into the
paper file that travelled with him to Leeds.
32
KEY EVENTS AT LEEDS PRISON: 10 NOVEMBER - 6 DECEMBER 2006
108. The man arrived at Leeds at 2.00pm on 10 November 2006. The PER for the
journey carried no notation of any risk of self-harm.
Cell sharing risk assessment
109. Upon his arrival at Leeds, the man underwent a cell sharing risk assessment.
The man told the officer who completed the assessment he was not a person
who easily became frustrated or angry. He said he had no concerns about
sharing a cell. The form shows there were no concerns about the man’s risk of
harming himself. He was assessed as presenting a low risk of harming others.
He was therefore allocated a shared cell in D Wing.
Reception health screen
110. The man’s medical notes show that he was seen on reception by a doctor who
wrote in the file,
“Has been depressed for last few years. It started on marriage
splitting up. Not suicidal. Injury to right middle finger dorsally.
Unable to move IP joints. To be seen by RMN [Registered
Mental Nurse].”
The doctor prescribed Buspirone to reduce anxiety and Paroxitine, an anti-
depressant.
(My investigator was presented with no evidence to show that the man was
seen by a member of the mental health team before he died or that he was
definitely due to be seen on the day of his death. The medical record presented
to my investigator contained no prescription charts. Thus, it was not possible to
verify that the medication mentioned above was dispensed to the man. These
were matters of concern to the man’s family.)
Request for sentence planning information
111. Five days after his arrival at Leeds, a clerk in the Sentence Planning office sent a
form RFI (1) - Request For Information - to the Probation Service office in. The
man’s Probation Officer received the form and responded on 20 November. In
his response, he wrote:
“[The man] was recalled to prison having been charged with the murder of
his ex-partner, the victim of his offence of Section 47 Assault x2.
Concerns are raised in relation to self-harm due to the serious nature of
this charge with no plea entered at this time.”
33
112. The investigation found no evidence that this risk information was acted upon.
The clerk who sent the form to the man’s Probation Officer guessed that it was
probably filed in the man’s sentence planning folder by whoever received the
reply and kept there to await confirmation of the man’s conviction and sentence
at a later date, at which point the sentence planning process would have begun
in earnest. (See also my comments at paragraph 192 below.)
Discovery of mobile phone
113. On 21 November, officers found a mobile telephone wrapped in a towel in the
man’s cell. Although he was sharing a cell at the time, the man admitted
ownership of the phone. Both prisoners were placed on a disciplinary report.
The man was made subject to closed visits.
Recall hearing
114. On 22 November, the man’s recall to prison was reviewed by the Parole Board.
The Board decided he should not be released. Instead, they set a further review
date for 22 June 2007 when they would seek information about the outcome of
his outstanding court proceedings.
Issue of prisoner warning reports
115. The investigation found that at Leeds the staff are empowered to impose strikes
(minor sanctions) on prisoners for misdemeanours not sufficiently serious to
merit a disciplinary charge. A strike must be preceded by a formal warning to the
prisoner about his behaviour. If two strikes are awarded within 28 days, the
prisoner is normally warned that his status on the Incentives and Earned
Privileges (IEP) scheme might be reduced. If a third strike is imposed within the
same period, a reduction to the basic IEP level is normally activated. This results
in the removal of the privilege of watching in-cell television. It may also affect the
prisoner’s entitlement to letters and visits.
116. On 23 November, the wing manager issued the man a formal warning after he
had failed to get out bed in time for education classes. The wing manager
warned the man that, if he refused to do so, he would be issued a strike. In
response, the man said, “Strike me. I’ve done education all over the place.” In
the event, no strike was imposed on that occasion. However, later that day, an
officer issued a further warning to the man for ignoring previous warnings about
his habit of approaching other prisoners’ cell doors. When the officer issued the
warning, the man said to him, “You want to bring it on with me and you will lose.”
As a result, the man was given a strike.
117. The next day, 24 November, the man was issued another warning by the same
officer after refusing to move away from another prisoner’s cell. When the officer
34
issued his warning on this occasion, the man said to him, “I don’t give a ****.
Don’t f***ing hassle me.” The strike was therefore issued.
118. That same day, yet another warning was issued to the man, this time by another
officer. This was after the man tried to take receipt of something from under
another prisoner’s cell door and refused to move away when told to do so. The
man swore at the officer and became aggressive towards her. The officer
therefore issued a strike. In response, the man said, “I don’t give a fuck about
how many strikes I get.” The officer decided to count this and the previous strike
as one.
119. The next day, an entry was made in the wing Staff Observation Book warning
staff of the man’s aggressive behaviour. On 27 November, a further strike was
issued to the man after he displayed similar behaviour. He was also told he
would be considered for a reduction from the standard to the basic level of
privileges.
Transfer to C Wing for fresh start
120. In view of the man’s deteriorating behaviour, the wing manager decided to make
a positive intervention by considering whether a move to another wing might help
give the man a chance to make a fresh start. The next day (28 November), the
man was moved to C Wing.
Cancelled transfer to Dovegate
121. On 30 November, the man was taken to reception in order to prepare for a
transfer to Dovegate, a Category B training prison. Although there is no record of
the time the man was taken to reception from his cell, my investigator was told it
was likely to have been about 10.00am. At about 2.00pm, he was told Dovegate
had refused to accept him and his transfer would not take place. The
combination of having to wait in reception for four hours only to be told his
transfer was not going to take place annoyed the man. He reacted by refusing to
move from reception unless he was placed in the segregation unit. (This is a unit
in which prisoners are held if they are awaiting or serving a punishment for
infringements of prison rules, or if they need to be separated in their own
interests.) The Duty Governor of the day took charge of this incident. He told the
man he was to return to D wing as his cell in C wing was no longer available to
him. At about 2.30pm, the Duty Governor of the day managed to persuade the
man to leave reception. The Duty Governor of the day and two colleagues
accompanied the man back towards the wing. As they arrived at a point along
the route known as the “under-centre”, adjacent to the segregation unit, the man
again refused to move and repeated his earlier demand to be segregated. At this
juncture, the Duty Governor of the day decided the man should be restrained and
moved to D wing by force. Three members of staff therefore used Control and
Restraint techniques to restrain the man. These involved the use of arm and
35
head locks. The Duty Governor of the day told my investigator that these
methods were applied for a matter of seconds as the man quickly agreed to
move to D wing of his own accord. Thereafter, the man was escorted to cell D2-
41, a single cell, without further ado. The Use of Force forms completed by the
staff involved in restraining the man show he sustained no injuries.
122. At interview, the Duty Governor of the day said he had no knowledge of the
reasons behind the plan to transfer the man to Dovegate. Neither did he know
why Dovegate refused to accept him. My investigator could find no one at Leeds
who took the decision to arrange the transfer. A senior officer, (who shall be
referred to in this report as Senior Officer A) later speculated that the transfer
might have been cancelled because of the man’s outstanding court appearances.
Review of cell sharing risk
123. On 1 December, Senior Officer A chaired a meeting convened to review the
man’s cell sharing risk assessment and his status within the Incentives and
Earned Privileges Scheme. The following notes were made on the cell sharing
risk review proforma:
“Located from reception under escort by segregation staff,
duty governor, and duty orderly officer. Not happy about
transfer cancellation and relocation back to D Wing. Previous
threats, aggression. Placed on basic. Remain single cell
status. Access to Bereave.”
“Review date 8.12.06. Remain single cell status until after
22.12.06 - court appearance at Crown Court. Allowed access
to Chaplaincy, Samaritans and Listeners.”
124. The proforma was countersigned by a Governor who wrote:
“Review in one month or earlier if appropriate once he has had
time to come to terms with offence.”
125. At interview, Senior Officer A told my investigator that the decision to place the
man on the basic regime meant he lost his television set, two letters per week
and one visit per month. He also lost association - the ability to mix freely with
other prisoners in the wing at certain times of the day. Senior Officer A
confirmed that this loss of privileges was to last for seven days until 8 December.
At that point the man’s privilege level was to be reviewed. She also said the
man’s behaviour improved after his privilege level had been reduced. Instead of
being aggressive, the man did everything that was asked of him.
126. The record of the cell sharing risk review makes reference to the Samaritans and
Listeners (prisoners trained by the Samaritans to listen to prisoners in distress).
36
This implies that the review paneI might have thought the man was at risk of
suicide. My investigator put this point to Senior Officer A. He also put to her the
point made by the man’s family that his mental state was the cause of his bad
behaviour and that the reduction in privileges further contributed to his distress.
Senior Officer A said there was no information in the man’s history sheet, from
either the healthcare or security departments, or in the man’s actual behaviour to
cause staff to have concerns about distress. Senior Officer A said she and the
man had a discussion about his offence. During this discussion, Senior Officer A
talked in general terms about Listeners, the Samaritans and the chaplaincy as
people to whom he could talk if he wished. She said the man did not want to see
any Listeners or the Samaritans because he did not want to talk about his
personal business. The man told Senior Officer A he was not a religious man but
sometimes “used the chaplaincy”.
Visit by the man’s solicitor
127. On 5 December the man’s criminal solicitor visited him at 10.00am. The purpose
of the visit was to enable the man’s criminal solicitor to pass to her client a copy
of the prosecution papers. As she handed the papers to the man, the criminal
solicitor advised him that he might be upset by some of the contents. She
therefore offered to remove the statement she thought would be the most
distressing, but the man insisted on reading all the evidence.
128. The man told his criminal solicitor about the cancelled transfer to Dovegate. He
said he was particularly upset by this development as he did not know anyone at
Leeds but had friends at Dovegate with whom he could discuss his case.
129. The man’s criminal solicitor advised the man that the psychiatrist she had
instructed to assess him would see him the next day. The man told her he did
not want to tell the psychiatrist everything about his past as he was worried his
disclosures would upset his family. The solicitor told him the report would not be
read out in open court and advised him to tell the psychiatrist everything.
Conversation with an Officer on the exercise yard
130. Later that day an officer, a regular member of the D wing staff, spoke to the man
in the exercise yard shortly after he had seen his solicitor. In a statement
submitted by the officer five days after the man’s death, he reported as follows:
“At approximately 14.00hrs on Tuesday 5 December 2006, I
was on duty on D Wing. At this time, I was supervising D
Wing exercise with [a fellow officer]. I was stood counting
prisoners out onto the exercise yard when I recognised [the
man] from the week before when he was in cell D3-14. When
I saw the man, I said, ‘Ey up what you doing back on here?’
The last time I had seen him was when he moved over to C
37
Wing. [The man] replied, ‘Don’t ask. I went down to reception
last week to go to Forest Bank and sat in reception all
morning. They then twisted me up and took me to the seg. I
then came back on here as basic high risk. I have also been
told that I am getting charged with conspiracy to murder as
well as murder and stuck here until 22.12.06 so I am now
f***ed.’ At this point [the man] walked off down the steps onto
the yard and walked around talking with prisoners. He
seemed to me to be his usual self.
“When [the man] walked past me at the end of exercise he
said, ‘Ta Gov. See you later.’ That was the last time I spoke
to or saw [the man] that day.”
131. My investigator was presented with no evidence that the man was to be transferred
to Forest Bank prison. The officer later confirmed he meant to refer to Dovegate
rather than to Forest Bank.
132. At interview, the officer emphasised that at no stage did the man appear to him to
be suicidal.
133. In a statement later given to the police by the fellow officer who was in the
exercise yard at the time, he said that at about 7.00pm he noticed that the man’s
cell call light was on. When the officer approached the cell to ascertain what the
man wanted, he told the officer he wished to make a telephone call. The officer
told him he would arrange for him to make a call towards the end of the
association period at about 7.50pm. In his statement, the officer confirmed that
he saw the man using the telephone at about 8.05pm. He did not clarify who let
the man out of his cell to make the call or who it was that returned him to his cell
afterwards.
134. The investigation discovered that the call the man made was to a member of his
family. During the conversation, he referred to the fact that he had received the
prosecution papers setting out the case against him, a matter which had an effect
upon him. (See also my comments at paragraph 235 below.) The man also said
he was due to see a psychiatrist the next day. In earlier telephone calls to his
family, the man had expressed his concern to seek help for his inability to relate
to women. He was nevertheless of the view that nothing positive would come
from his meeting with the psychiatrist. The man told his family he was
anticipating having to stay in prison for a very long time indeed and could not
face up to that prospect. He also said he could not live with himself after killing
the woman he loved. The man ended his conversation with the words:
“I’ve got nothing to look forward to at all because they’re never
going to let me out. I don’t want to upset everyone, but I can’t
do this forever, do you know what I mean?”
38
135. My investigator spoke to the family member who answered the man’s call. She
said she did not read anything significant into the call as the man had often
spoken in the same manner. She said she had no reason to believe he was
about to commit suicide.
136. During his time at Leeds, the man’s mail was monitored. His telephone calls
were tape recorded but not simultaneously monitored. Thus, staff would not
have listened to this last telephone call.
Events on Day of Death
137. On duty in D Wing during the night/early morning of the man’s death were an
officer and an Operational Support Grade (OSG). The officer was principally
responsible for patrolling D2, D3 and D4 landings, while the OSG was deployed
mainly to the First Night Centre on D1 landing. The officer told my investigator
that at times when he was not patrolling he spent some time in the staff office on
D2 landing. This office is located opposite the cell occupied by the man at the
time.
138. At interview, the officer principally responsible for patrolling D2, D3 and D4
landings explained that before 5 December he knew nothing of the man as he
had been on leave in Australia until then. Before he started his shift, the officer
principally responsible for patrolling D2, D3 and D4 landings familiarised himself
with the cases of those prisoners for whom ACCT forms had been opened. The
man was not subject to an ACCT form. The officer said that at no stage during
the night could he recall hearing the man having any conversations with
prisoners in other cells. The officer explained that, in any event, it was never
easy to hear what prisoners in separate cells were saying to each other because
of the competing noises coming from televisions and stereo equipment. He also
pointed out that prisoners who wanted to communicate between cells usually
shouted through their windows where they knew they could make themselves
heard. Thus, their conversations were hardly audible to staff through the cell
door. The officer principally responsible for patrolling D2, D3 and D4 landings
also confirmed that the man did not press his cell bell that night.
The discovery of the man hanging
139. The officer principally responsible for patrolling D2, D3 and D4 landings
described his night shift as relatively quiet. He said nothing untoward occurred in
the wing until about 5.50am on the day of the man’s death when he began his
routine roll check of the wing prior to handing over to the day shift. At that time,
the officer approached the man’s cell. As he did so, he noticed the cell light was
on. The officer lifted the flap over the observation panel in the man’s cell door
and immediately saw him hanging from the conduit fixed to the ceiling. The man
had used a piece of bedsheet as a ligature. He was in a sitting position on the
39
top bunk, facing towards the cell wall and with his legs out in front of him. It
appeared to the officer that, after attaching the ligature to the conduit, the man
had deliberately fallen backwards so that the ligature would tighten when he was
in a position from which he could not rescue himself.
140. The officer used his radio to put out a “blue call” for urgent assistance. He
explained to my investigator that the term is a code used to draw attention to any
incident in which a prisoner is likely to have suffered some form of asphyxiation
and whose life is therefore in danger. The control room responded immediately
by broadcasting the same request to all staff. The officer said the control room
automatically calls for an ambulance whenever a “blue call” is sent over the
radio.
141. The officer principally responsible for patrolling D2, D3 and D4 landings told my
investigator he was reluctant to enter the man’s cell on his own. He explained
that in the past staff had been taken hostage after entering cells on their own in
response to what seemed to be a genuine emergency. The officer said there
were no policies or instructions in place at Leeds forbidding staff from entering
cells on their own. Rather, it was left to individual judgement as to when it was
appropriate to do so. The officer was convinced the man was dead. He
explained that this was not the first time he had found a prisoner hanging or had
seen a dead body. He said he could tell that the man was lifeless, even as he
was looking through the observation panel.
142. As the officer withdrew the cell key from his sealed pouch, the Night Orderly
Officer arrived at the cell followed by a number of other staff who had responded
to the emergency call. The Night Orderly Officer saw that the officer principally
responsible for patrolling D2, D3 and D4 landings had just withdrawn his key but
she said to him words to the effect, “Don’t bother, I’ll use mine.” The Night
Orderly Officer unlocked the cell door and let the officer into the cell. The officer
principally responsible for patrolling D2, D3 and D4 landings estimated that the
time lapse between his initial arrival at the cell and the Night Orderly Officer’s
arrival was about “two minutes or so”.
143. The officer principally responsible for patrolling D2, D3 and D4 landings entered
the cell with his colleagues (who shall be referred to in this report as officer 3 and
officer 4). The officer principally responsible for patrolling D2, D3 and D4
landings stood on a table so that he could reach and cut the ligature. Officer 4
passed him a pair of ligature scissors. (Although the officer principally
responsible for patrolling D2, D3 and D4 landings had a pair of his own on his
belt, he had difficulty withdrawing it from its pouch at the back of his belt.) The
officer cut through the ligature and removed it. He was very critical of the quality
of the scissors, likening them to the sort of scissors “they issue kids in a
kindergarten”.
40
144. As the officer principally responsible for patrolling D2, D3 and D4 landings cut the
ligature, Officer 3 and Officer 4 took the man’s weight and lifted him to the floor of
the cell. As they did so, they realised his limbs were stiff. His eyes were closed
and there was evidence of “pooling” (i.e. his blood had collected towards his
skin). A nurse arrived at the cell at this point. At interview, she confirmed that as
soon as she saw the man she knew he was dead and there was nothing she
could do for him. She nevertheless attached a defibrillator to the man’s chest “for
confirmation”. The machine advised not to shock.
145. At 5.59am, a paramedic crew arrived at the cell. They pronounced death at
6.02am. At this time, no-one noticed any final letters from the man to his family
or friends. However, at a later date, the police discovered a number of such
letters amongst other papers removed by Scenes of Crime Officers when they
first examined the man’s cell. (This matter is discussed further at paragraphs
214 - 216 below.)
146. Both the nurse who had attached the defibrillator to the man’s chest and the
officer principally responsible for patrolling D2, D3 and D4 landings told my
investigator of their disappointment at the lack of care offered to them in the
aftermath of their response to the emergency. The nurse said that none of her
managers asked her whether she was alright, either on the day or later. The
officer principally responsible for patrolling D2, D3 and D4 landings said that,
after he had left the man’s cell, someone asked him if he needed the care team.
The officer said he was a member of the care team. He said whomever it was he
spoke to then left, possibly under the illusion that, as he was a member of the
care team, he did not need any offer of care and that it was not necessary to call
on the services of anyone else in the team.
147. My investigator interviewed prisoners in the adjacent cells to see whether they
could cast any light on the man’s frame of mind during the previous day or during
the night. Both prisoners said they saw him the previous day and they had
several short conversations with him during the night in which they had talked
about football and other general topics. Both prisoners confirmed that at no
stage did the man say anything about wanting to kill himself during their
conversations with him that night.
148. However, one of the prisoner’s in the adjacent cells said to my investigator,
“[The man] did say on the exercise yard he was going to kill
himself before he handed himself in (sic). He didn’t say he
would do it in here. He didn’t say to me personally that he
was going to do it in here but he did intimate to me later he
was going to do it outside before he came in.
“I spoke to him the day before he died. I spoke to him when
he went to see his solicitor in the morning and he’s come
41
back with his statements. He said to me I could go to his cell
to read his statements. When I went to see him at dinner
time, I could see he was upset. His face was all red like he
had been crying and all the statements were all round him.
The last time I saw him was just before six.”
149. The same prisoner was also interviewed by the police. In a statement he
provided to them, he said,
“[The man] was in the next door cell from 13 November.
Since then he got more and more depressed. I knew he had
been in trouble with staff and had been placed on basic
regime with no tv, radio, or anything. He told me he couldn’t
face doing any of prison time. He once told me he should
have killed himself after he had killed his girlfriend.”
150. Both prisoners in the adjacent cells said that, at some stage during the night,
they heard a distinctive noise coming from the man’s cell as if a chair had fallen
over. However, neither prisoner attached any significance to this and so did not
report it to staff.
Informing the man’s next of kin
151. At 6.25am, the Duty Governor of the day telephoned one of the establishment’s
Family Liaison Officers to inform her of the man’s death. The Family Liaison
Officer immediately made her way to the prison. Upon her arrival at the prison,
the Deputy Governor asked the Family Liaison Officer, the Governor and another
senior manager at Leeds to inform the man’s next of kin of his death in person.
152. The man’s mother was listed in his prison record as his next of kin. The Family
Liaison Officer and her two colleagues left Leeds prison at 9.15am to go to the
address recorded. On their way, the Family Liaison Officer checked with the
police that the address was correct. She was told the house was for sale and
had been vacated. The Family Liaison Officer arrived at the house at 11.00am
and found it was indeed unoccupied. The police advised the Family Liaison
Officer to try another address where they thought the man’s mother might be
staying. The Family Liaison Officer and her colleagues left for that address and
arrived at 11.15. Nobody was in. The Family Liaison Officer therefore contacted
the man’s Probation Officer/Offender Manager and asked him if he knew of any
other addresses. He said no other addresses had been registered. At this point,
the Family Liaison Officer felt it was appropriate to contact the man’s mother on
her mobile telephone. However, there was no answer. The Family Liaison
Officer then telephoned the man’s brother on his mobile telephone. The man’s
sister-in-law answered. The Family Liaison Officer gave no details about the
man but asked if she and her colleagues could visit them. She was told they
could do so. The Family Liaison Officer and her colleagues arrived at 12.15.
42
They initially broke the news of the man’s death to his brother, and, when they
arrived later, to his mother and sister.
Funeral service
153. The man’s funeral took place on 21 December. At the family’s request, no one
from the prison attended. At interview, the Family Liaison Officer confirmed that
the Governor had offered to pay £1,000 towards the funeral expenses.
43
ISSUES ARISING FROM THE MAN’S PERIOD OF CUSTODY AT ALTCOURSE
154. Here I examine the following issues:
• The communication of risk-related information between the custody staff
at the Northern Custody Facility at Runcorn, GSL escort staff and
reception staff at Altcourse.
• The assessment of the man’s risk of suicide upon his arrival at Altcourse.
• Record keeping.
• The justification for transferring the man to Leeds.
• The passage of medical information between Altcourse and Leeds.
I make a number of recommendations and draw attention to two examples of
good practice.
The communication of risk-related information between staff at the Northern
Custody Facility at Runcorn, GSL escort staff and reception staff at Altcourse
(see paragraphs 47 - 61 above)
155. Information relating to the man’s risk of self-harm or suicide was recorded in the
following forms:
• a Prisoner Escort Record covering the man’s journey from Runcorn
Police station to a magistrates’ court and onward to Altcourse on 2
October 2006.
• a suicide warning form opened by Prisoner Custody Officer (PCO 1) at
the beginning of the above journey.
• a Form MG 5 used by the police as a summary of the criminal case
against the man
• a one-page medical form completed by Primecare. (At consultation stage,
Cheshire Police pointed out that PCO 1’s evidence suggests that she saw
more than one such form.)
Prisoner Escort Record
156. The Detention Officer completed the front page of a Prisoner Escort Record
(PER) before the man was escorted from the Northern Custody Facility at
Runcorn to a magistrates’ court on 2 October 2006. On it, he wrote, “Injury to
right arm. Further serious charges likely. Very violent offender.” The Detention
Officer also ticked a box to indicate that the man presented a risk of suicide/self-
harm. The Detention Officer later told an IPCC supervised investigation that he
ticked this box because the man had told him that the injuries he had sustained
to his hand were self-inflicted. It seems that the man may not have told the
Detention Officer about his attempt to kill himself by injecting himself with heroin.
No details of that event were entered on the PER. There is no evidence that the
44
Detention Officer saw the police case summary (Form MG5) in which these
details of these events were recorded.
157. The PER was handed to Prisoner Custody Officer (PCO 1) when the man left
Runcorn for the magistrates’ court on 2 October. PCO 1 signed the form purely
to record the fact that she had received the man into her custody for the purpose
of escorting him to court. She knew nothing of the man’s suicide attempt on 26
September. When PCO 1 arrived at the magistrates’ court, she handed the man
over to the court staff along with the accompanying paperwork, including the
PER. PCO 1 then departed for other duties.
158. Once the man’s court hearing was completed, he was taken to Altcourse under
escort by PCO 2 who noted that the PER contained an indication that the man
was at risk of suicide. However, like PCO 1, PCO 2 knew nothing of the man’s
suicide attempt on 26 September. PCO 2 said she handed the PER to the
admissions staff upon her arrival at Altcourse.
159. The person to whom the PER was handed at Altcourse was the admissions
manager. He told my investigator that, although he could not recollect the events
of 2 October 2006, he was sure he would have received the PER. (In fact he had
signed the PER to show that the man had been received from the escort.)
160. The PER was next seen by PCO 3 who administered the man’s reception into
Altcourse. PCO 3 did not know of the man’s suicide attempt on 26 September as
she had not seen the Form MG5.
Suicide/self - harm warning form
161. A suicide/self-harm warning form was opened by PCO 1 on 2 October because
she was concerned at the man’s state of mind. As required by the provisions of
Prison Service Instruction (PSI) 51/2003, PCO 1 signed section 6 of the form to
indicate the reasons for raising the form. When PCO 1 arrived at the
magistrates’ court, she handed the man over to the court staff along with the
accompanying paperwork, including the warning form.
162. PCO 2 took receipt of the paperwork at the court prior to her departure to
Altcourse with the man and five other prisoners. PCO 2 told my investigators she
handed the paperwork, including the warning form, to the admissions staff at
Altcourse.
163. PSI 51/2003 requires that section 7 of the warning form should be signed by
whichever reception officer receives the prisoner. However, the man’s warning
form was not signed at section 7, indicating perhaps that it was not seen. The
person to whom the warning form was handed was the admissions manager. He
told my investigator he would have seen the warning form despite the fact that it
was not signed to that effect.
45
164. The PSI also requires that the warning form should be passed to the reception
healthcare screener, together with the PER, so that he or she can make a
judgement as to whether it is necessary to open an ACCT form. The person who
conducted the man’s healthcare screen was a registered mental health nurse
(RMN). However, she told my investigator she could not recall seeing the
warning form. The registered mental health nurse (RMN) said that if she had
seen the form she would probably have opened an ACCT plan.
Form MG5
165. An investigation conducted by the North Wales police in 2008 established that,
on 17 October 2006, (15 days after the man arrived at Altcourse) a detective
constable of the (Cheshire Constabulary) Force Major Incident Team received a
telephone call from a detective constable of the North Wales Police Liaison
Officer at Altcourse, asking for a copy of the police case summary – the Form
MG5 – relating to the man’s alleged offence of murder. At 1.25pm that day, the
detective constable of the Cheshire Constabulary faxed the Form MG5 to the
North Wales Police Liaison Officer at Altcourse. Included in the form was the
following comment:
“At approximately 12.55pm on Thursday 28th September 2006,
PC4256 was guarding [the man] whilst he was a patient at [a]
hospital when he stated to a doctor in the presence of PC4256, ‘I
murdered my girlfriend then took an overdose. I didn’t expect to
wake up in hospital. That wasn’t the plan.’”
A number of admissions the man made whilst in hospital appeared later in the
report. These included confirmation that he intended to kill himself using heroin
and that when he as arrested, the man ‘was on his way to kill himself’.
166. When, during the course of the police investigation, the North Wales Police
Liaison Officer at Altcourse was interviewed, he said that although he knew he
was on duty on 17 October, he could not recall requesting the form. He made
the point that any request for a copy of the Form MG5 was for the purpose of
assessing a prisoner’s potential to escape rather than for the assessment of any
health risks. He told his interviewer that he was aware that the man had not met
the criteria for being made a category A prisoner and could not understand how
this decision had been reached unless the Prison Service had been in
possession of the Form MG5. (As I have pointed out in paragraph 65 above,
PCO 3, on 2 October, notified the security department at Altcourse that the man
had been charged with murder so that action could be taken to refer him to
Prison Service Headquarters as a potential category A prisoner. Confirmation
was received on 18 October that the man did not meet the criteria for category
A.)
46
167. The police investigator noted that the decision not to place the man in category A
was made the day after the fax was sent to Altcourse. My own investigator was
unable to ascertain what information was available to the Category A committee
at Prison Service Headquarters when they considered the man’s case. The
Directorate of High Security Prisons confirmed to the police on 19 November
2008 that they had no record of the man having been reported in as a potential
category A prisoner during the month of October 2006.
168. During the course of their investigation, the police attempted to ascertain whether
the Form MG5 had been filed in the man’s prison record. They were told by staff
at HMP Leeds that, after his death, his files had been sent to the Coroner to
whom further enquiries were made. The police examined the files received by
the Coroner and found that the Form MG5 was not amongst them.
One-page medical form
169. The Detention Officer, who supervised the man at Runcorn custody suite, told the
police he thought it was essential for the staff who are assigned the task of
escorting prisoners to court to be given as much information as possible about
each prisoner. He said that a “short form” medical record, setting out brief details
of any examination of the man and of any medication prescribed, raised by
Primecare - the organisation responsible at the time for the medical oversight of
prisoners in police custody - would have been included in the paperwork handed
to the escorting staff.
170. PCO 1 was the person who was tasked to supervise the man and five other
prisoners during the journey to the magistrates’ court. At her interview, PCO 1
was able to recall that she saw a medical record that took the form of a one page
document. She said this was stapled to the PER. She believed this document to
be the one described by the Detention Officer. PCO 1 thought the form had been
completed at 10.00pm on 1 October - the night before she escorted the man to
court. She believed it contained information about the man’s fitness to be
detained and to travel as well as comments about his lack of eye contact and his
state of depression at the time.
171. No such form, relevant to the man’s period in police custody prior to his
admission to Altcourse on 2 October 2006, was included with the medical
documentation presented to my investigator during the initial stages of the
investigation. However, the man’s family solicitors later provided my investigator
with a copy of the report of Operation Vogue, the IPCC supervised police
investigation into the family’s complaint about the passage of risk related
information between the custody suite and the magistrates’ court. My
investigator’s copy of the report contained four medical reports on the man
completed by Primecare. The reports were timed and dated as follows:
47
- Report 1: 29 September, 8.30pm
- Report 2: 30 September, 9.30pm
- Report 3: 30 September, 10.25pm
- Report 4: 1 October, 4.35pm
172. The reports completed on 29 September and 1October referred to the need for
the man to be kept on a constant watch via closed circuit television. Whilst these
reports seem to take the same form as those to which reference was made by
the Detention Officer and PCO 1, none of them is likely to be the one described
in paragraph 170 above.
Submissions from Cheshire Police
173. At consultation stage, Cheshire Police submitted the following comments:
“PCO 1 in her account provides a weight of evidence to confirm she did indeed
have sight of, and would have read in sufficient detail, the Primecare medical
reports that she states were attached to the PER at the point of her taking
responsibility for the escort of [the man].
“The Custody Record shows there were four separate occasions when Primecare
examined the man while he was in custody. Following each of these
examinations, Primecare produced 4 separate single page reports. The reports
bear two dates: the date the man was assessed and the date the report was
completed. The times referred to below are the times Primecare saw the man
and not the times the reports were written:
• 2005hrs on 29 September
• 2130hrs on 30 September
• 2225hrs on 30 September
• 1630hrs on 1 October
“In her account, PCO 1 recalls a report dated from the previous night. This could
possibly refer to either the third or the fourth medical report. PCO 1 specifically
refers to her belief that the report/s contained information on fitness for detention
and travel as well as lack of eye contact and depression. This detail is identical
to the narrative on the second medical report. PCO 1 further states that she was
aware of the specific suicide risk not only from her own observations of the man
but also to her briefing from the notes attached to the PER. The only specific
reference to suicidal intent is contained in the first medical report.
“Taking the Detention Officer’s and PCO 1’s recollections together, the weight of
the evidence would suggest that all four medical reports were indeed attached to
the PER by the Detention Officer and as a result they influenced PCO 1’s
concern for the welfare of the man from the point of his transfer from custody
until his arrival at the magistrates’ court.
48
“There is no reason therefore – from the Constabulary’s perspective – that those
reports should not have accompanied the PER and any other documentation
relating to risk from the court to the Prison Service.
“The PER identified that [the man] was at risk of suicide/self-harm. The medical
notes attached to the PER do make a specific reference to [the man] taking a
heroin overdose 12 days ago, if not the circumstances of that overdose. I would
submit there was sufficient information on the PER form for any reasonable
person to conclude [the man] was considered at significant risk of suicide/self-
harm throughout his period of detention and that in itself was sufficient evidence
to inform ongoing assessments of risk once received into the care, custody and
control of the Prison Service. Prison Custody Officer (PCO 2) confirms that she
saw the PER and the suicide warning form made out by PCO 1. If the four
medical reports were attached to the PER the additional information contained in
those reports reinforced the information contained on the face of the PER.
“It is accepted that the purpose of the MG5 Case Summary that the detective
constable of the Cheshire Constabulary faxed to the prison, at the request of the
North Wales Police Liaison Officer at Altcourse, was to assist the Prison Service
in allocating suitable category status to [the man]. The MG5 did include
information of [the man’s] alleged attempt to commit suicide shortly before his
arrest. It may be suggested that Recommendation 4 might equally apply to the
MG5.
“My final observation is that [the man] entered the prison system on 2 October
2006. He committed suicide shortly thereafter. The suggestion that the man’s
death may have been prevented if Cheshire Constabulary’s PER had contained
more information about the risk to the man of suicide/self-harm would carry more
weight if the man had committed suicide shortly after his arrival at Altcourse. The
risk of the man committing suicide or harming himself may have changed and the
risk increased or deceased during his period in prison as a result of a variety of
factors. The responsibility for reviewing and updating the assessment of the risk
of the man committing suicide in the period between him entering the system and
his death lies with the Prison Service.”
Conclusions
174. I do not call into question the veracity of the evidence submitted by the police
with regard to the information faxed to Altcourse on 17 October. I also take note
of the above submission from Cheshire Police. However, it remains my view that
the full details of the man’s alleged crime and of his attempt at suicide during the
course of his arrest should have been available to the GSL staff who escorted the
man to Altcourse and subsequently to the reception staff at the prison on the day
of the man’s arrival at Altcourse when the initial assessment of his risk of self-
harm or suicide was first undertaken. I do not hold Cheshire Police responsible
for the man’s death. In raising my concerns about the passage of risk
49
information between the police and the Prison Service, I seek to draw attention to
the importance I attach to the need for the highest standards of communication
between agencies to be preserved. In making recommendation 1 below, I hope
that the Director of Altcourse and Cheshire Police will work together to explore
ways of improving inter-agency communication systems and procedures where
risk information is concerned.
175. The fact that the man had allegedly killed his girlfriend was likely to result in his
imprisonment for life had he been found guilty of murder. The nature of the
killing, allegedly committed at a time when the man was on parole licence from a
sentence imposed for causing Actual Bodily Harm to the same person, was
apparently so brutal that it is highly probable he would have been given a very
long tariff by the judge. The man was likely to have known this. Prisoners who
find themselves facing the consequences of such crimes (brutal murders in a
family or other close relationship) are statistically amongst those who present the
highest risk of suicide in prison. The man’s attempt to kill himself by injecting
himself with heroin during the course of his arrest is clear evidence that he was in
that category.
The assessment of the man’s risk of suicide upon his arrival at Altcourse
176. Those staff at Altcourse who were interviewed told my investigator that the man
did not present as being at risk of suicide when he arrived. The admissions staff
based their assessment of that risk on the scant information contained in the
Prisoner Escort Record, the self-harm warning form - if, indeed, they saw these
forms - and on what the man told them. The man was likely to have been at a
higher risk of suicide than he was prepared to admit. Had staff known the full
details of what had led to his arrest, his failed suicide attempt and his admission
that he could not live with himself after having killed his girlfriend, they might
have judged his risk differently. The assessment of the man’s risk of suicide
should have been informed by the whole picture and not just part of it.
177. The doctor who was the author of the clinical review of the management of the
man’s health needs, writes on page 5 of his review:
“At HMP Altcourse, [the man’s] symptoms were initially
ascribed to a situational response to the crime he had
committed. The injection of heroin was categorised as an
impulsive action and much weight is placed on [the man’s]
denial of suicidal thoughts or intentions. Surprisingly, his use
of cocaine appears not to have been considered as a possible
cause. When cocaine is stopped or when binge drinking ends,
a crash follows almost immediately. Symptoms include:
50
• depressed mood
• fatigue
• generalised malaise
• vivid and unpleasant dreams
• agitation and restless behaviour.
“The depression can last for months following cessation of
long-term heavy use (particularly daily). Withdrawal
symptoms can also be associated with suicidal thoughts in
some people. There is a risk of suicide or overdose. Since at
least 50% of people addicted to cocaine have a co-existing
mental disorder (particularly depression and attention-deficit
disorder), these conditions should be treated aggressively.
“It is not clear how the severity of his symptoms or the level of
risk were assessed at Altcourse and no special measures
were introduced. However, had the suicide screen used at
first reception in HMP Leeds been applied to the man at this
stage,(i.e at Altcourse) it is likely that he would have hit the
trigger point for further intervention, including opening an
ACCT (Assessment, Care in Custody and Teamwork) form.”
178. The doctor who was the author of the clinical review makes the following
recommendation:
“HMP Altcourse Healthcare Service should review the
assessment and management of suicide risk and
depression.”
Recommendation 1
The Director of Altcourse should explore, with his police counterparts, methods
of ensuring that vital information about the risk of suicide presented by prisoners
in police custody is properly and comprehensively recorded on the PER and
effectively communicated to private security organisations and to the Prison
Service.
(I understand that since 2006, the format of the PER may have been changed.)
Record keeping
179. The suicide and self-harm warning form completed by PCO 1 who escorted the
man from Runcorn police station to a magistrates’ court on 2 October 2006 was
not signed by either admissions or healthcare staff at Altcourse. This significant
omission adds further doubt about what information was given to relevant staff
about the man’s risk factors during transit from police to prison custody.
51
Cell sharing risk assessment
180. The second section of the cell sharing risk assessment form asks ten questions,
one of which is, “Does the prisoner have any previous convictions for the
following: murder, sex offence, kidnapping, manslaughter, false imprisonment,
GBH, ABH (and other offences). In the man’s case, the “no” box was ticked. In
fact, the man was already serving a sentence for Actual Bodily Harm.
181. The third section asks questions about the prisoner’s mental condition and has to
be completed by a member of healthcare staff. The user must judge from a
medical standpoint what level of risk a prisoner presents of harming others. In
this man’s case, the section was completed by a nurse who judged that the risk
was low.
182. The form also requires the author to comment as to whether any self-harm
issues have arisen. The nurse ticked neither of the two boxes available. At
interview, she could not account for why she did not do so.
Recommendation 2
The Director of Altcourse should take urgent steps to remind his staff of the
importance of accurate and comprehensive completion of all documents relating
to prisoners, especially the suicide and self-harm warning and cell sharing risk
assessment forms. The Director should address any staff training needs in this
regard.
The justification for transferring the man to Leeds
183. When my investigator opened the investigation, he was told that the man might
have been transferred from Altcourse to Leeds as part of an overcrowding draft -
a means by which overcrowding at one prison is relieved by sending prisoners to
other prisons where there are vacancies. The investigation found that this was
not the case.
184. The Head of Operations at Altcourse explained that the man was moved on
security grounds. On 25 October 2006, the man was caught using a mobile
phone in his cell. Two days later, a distressed woman telephoned the prison to
report that she had received a threatening phone call from the man on his mobile
phone. It was thought the woman was likely to be a witness at his forthcoming
trial. At about this time, it also became apparent that the man had sent a friend
to the cell of another prisoner whose sister was likely to be a prosecution
witness. On the man’s instructions, the friend told the prisoner that he was a
“grass” and that he would be assaulted.
185. The Head of Operations at Altcourse described the man as a very influential
prisoner who “had a finger in every pie”. He said the move to Leeds was
52
arranged primarily because of his use of the mobile phone on 25 October and the
intelligence about threatening the brother of a potential prosecution witness. The
Head of Operations at Altcourse stressed that the transfer was a temporary
measure - “a respite” - and that the man would have been returned to Altcourse
for his trial.
186. While it is usually better for prisons to manage any threats to security and order
without recourse to transfer, I am conscious that the stability of a prison can be
threatened by the presence of those who bring pressure to bear on others. The
man was evidently regarded as such a prisoner. In my view, the apparent
attempt to threaten prosecution witnesses was a not improper reason for
arranging his temporary transfer. However, such a transfer was far from the only
course of action. Indeed, it was possible for the man to threaten those he
thought would give evidence against him from Leeds as well as from Altcourse.
(In fact, the man was caught using a mobile phone while he was in Leeds.) As
things turned out, the man made it clear to staff at Leeds that he resented being
there. I believe this contributed in part to his poor attitude and aggressive
behaviour.
The passage of medical information between Altcourse and Leeds
187. When the man was transferred to Leeds on 10 November 2006 his core prison
record was taken by the escorting staff, along with his medical record. The
medical file for the man presented to my investigator had initially been opened at
Altcourse in April 2005 at the outset of the man’s previous period of custody.
This file was a traditional paper record, known as the Inmate Medical Record
(IMR). It contained numerous notes and documents relating to the man’s time at
Altcourse and Acklington. However, at the time of his next admission to
Altcourse, on 2 October 2006, the system for recording the details of prisoners’
medical history was in the process of changing from the IMR to an electronic
system known as System One. On the day of his transfer, no print-out of the
electronic record for the man for the period he was at Altcourse was inserted into
the paper file that travelled with him to Leeds.
Recommendation 3
The Director of Altcourse, in liaison with Medacs, the contractor responsible for
the delivery of healthcare, should ensure that before any prisoner is transferred
to another prison the prisoner’s complete medical record is assembled. This
function should be regularly audited by an appropriate manager.
188. The doctor who was the author of the clinical review also touches on this issue in
his clinical review. He recommends as follows:
53
“The Prison Service should review the systems for
transferring important information between forensic medical
services and prison healthcare and transferring clinical
information held on computers.”
Good practice
First night watch
189. My investigator was told that, as matter of routine, all prisoners undergoing their
first night at Altcourse are placed in the First Night Centre and are observed at
regular intervals - normally half hourly - throughout the night. Observations do
not cease until approximately 10.00am the next day. My investigator was also
told that if, after that period, any prisoner were to demonstrate that he was having
difficulty in coping, observations would continue or, if necessary, self-harm
monitoring procedures would be implemented.
Self-harm communication form
190. My investigator was told that the self-harm communication form is normally
raised at Altcourse in respect of prisoners about whom staff are concerned, but
whose condition is not such as to warrant the initiation of formal self-harm
monitoring procedures. The expectation was that the form would normally be
open for no more than 48 hours. If staff considered it necessary to keep the form
open beyond that period, formal self-harm monitoring procedures would be
started if appropriate.
I regard both these systems as examples of good practice.
54
ISSUES RELATING TO THE MAN’S PERIOD OF CUSTODY AT LEEDS
191. Here I examine the following issues:
• Were the man’s mental health needs and risk of self-harm properly
identified and managed at Leeds?
• Was his prospective move to Dovegate properly handled?
• Were the regime restrictions placed upon him justified?
• Was it appropriate to keep him in a single cell?
• Was the response to the discovery of the man hanging prompt and
effective?
• The handling of the man’s letters found in his cell after his death.
I also examine whether the proper courtesies and support were offered to the
man’s family in the aftermath of his death and I provide answers to the concerns
his family expressed through their solicitor.
Were the man’s mental health needs and risk of self-harm or suicide properly
identified and managed at Leeds?
192. I have already expressed the view that had the full details of the man’s history
between 19 September and 2 October 2006 been available at the point of the
man’s reception at Altcourse, the assessment of his risk of suicide at that stage
might have been different. That said, there was little to indicate he was at risk of
suicide when he arrived at Leeds on 10 November. The PER for the journey
from Altcourse carried no notation of any such risk. The man was seen by a
doctor who noted a history of depression but recorded that the man did not
appear to be suicidal. He was referred for a mental health assessment. This
was due to take place on the day he died. The doctor prescribed Buspirone to
reduce anxiety and Paroxitine (an anti-depressant).
193. However I am alarmed by the fact that crucial risk-related information sent to the
Sentence Planning office at Leeds on 20 November 2006 seems not to have
been acted upon (see paragraph 113 above). The man’s Probation Officer had
the presence of mind to draw attention to his concerns that the serious nature of
the charge his client was facing was such as to render the man at risk of self-
harm. Whilst it does not follow that, had the information been acted upon, there
would have been a different outcome, the likelihood that the information was
simply ‘filed and forgotten’ represents, in my view, a significant and unacceptable
systemic failure which reflects badly on the approach by the then staff of the
Sentence Planning Unit to their duty of care for prisoners.
55
Recommendation 4
The Governor must take immediate steps to ensure that systems are put in place
to guarantee that risk-related information received from outside agencies about
prisoners is acted upon immediately.
194. Between his arrival at Leeds and the eve of his death, the man demonstrated no
obvious signs that he was contemplating suicide. However, it is clear that his
reading of the prosecution letters passed to him by his solicitor on 5 December
had a profound impact on him. During the exercise period that afternoon, one of
the officers supervising D wing exercise asked the man why he was back in D
Wing. The man replied:
“Don’t ask. I went down to reception last week to go to Forest
Bank [as noted earlier, it is assumed that he meant Dovegate]
and sat in reception all morning. They then twisted me up
[slang for being restrained] and took me to the seg. I then
came back on here as basic high risk [i.e on the basic regime
and considered to present a high risk of harming others]. I
have also been told I am getting charged with conspiracy to
murder as well as murder and stuck here until 22.12.06 so I
am now f***ed.”
195. The officer later told my investigator he thought the man seemed his usual self.
He emphasised that at no stage did the man appear to him to be suicidal.
196. However, the evidence later given to the police and to my investigator by one of
the prisoners in the adjacent cells gives a closer insight into the man’s state of
mind at that time. The prisoner told the police that the man had intimated to him
on the exercise yard one day that, before being arrested, he had intended to kill
himself. The prisoner also said the man told him that he could not face up to a
long prison sentence and that since 13 November when he was placed in the
next cell, the man, in his view, became more and more depressed. The prisoner
disclosed to the police that the man felt he should have killed himself after he had
killed his girlfriend.
197. During his interview with my investigator, the prisoner in one of the adjacent cells
disclosed that the man told him on the exercise yard one day that he was going
to kill himself before being arrested. The prisoner said,
“He didn’t say he would do it in here...he didn’t to me
personally that he was going to do it in here but he did
contemplate doing it outside before he came in.”
198. The prisoner in one of the adjacent cells said he thought the trigger for the man’s
suicide was his realisation of the full force of the prosecution case against him.
56
199. In a telephone call to his family later that day, the man said:
“I’ve got nothing to look forward to because they’re never
going to let me out. I don’t want to upset everyone but I can’t
do this forever, do you know what I mean?”
200. The family member who took the call did not read anything significant into the
man’s words because he often spoke in those terms. She did not pass on the
contents of the call to anyone at HMP Leeds. Despite the nature of that call, the
man still did not show any obvious signs to staff that he was contemplating suicide.
The two prisoners in the adjacent cells during the night of the man’s death told my
investigator that they talked with the man about topics such as football. They said
at no stage did the man say anything about wanting to kill himself or give them an
impression that he was in a frame of mind to do such a thing.
201. Whilst he was at Leeds, the man’s overt behaviour suggested to staff that he
was, in their view, an aggressive and truculent man. However, it would seem
that the man managed to hide his real feelings. Although it was clear to staff his
morale was low, he gave them no obvious signs that he was contemplating
suicide. Indeed, from the available evidence, it seems possible he did not
become actively suicidal until the day before his death. Even then, his manner
was not such as to give staff reason to believe he was about to kill himself. It is
difficult to identify specific ways in which staff at Leeds could have intervened to
prevent his death.
202. However, the doctor who was the author of the clinical review suggests that the
depression protocol at Leeds was not followed and recommends that the
healthcare department should reconsider the approach to screening risk in
prisoners who have committed serious crimes and who have been transferred
from other prisons. I agree.
Was the man’s prospective move to Dovegate properly handled?
Were the regime restrictions placed upon him justified?
203. On 21 November 2006, the man was placed on closed visits after being caught
with a mobile phone. Between 23 and 27 November, he was given a number of
warnings about his behaviour. He was advised he would be reduced to the basic
regime level, resulting in a loss of privileges, if his behaviour did not improve.
Despite this, genuine efforts were made to give the man a fresh start by
transferring him to C Wing on 28 November. I applaud this decision.
204. However, on 30 November, the man was taken to reception in order to prepare
for a transfer that day to Dovegate. After spending several hours waiting in
reception, he was told Dovegate would not accept him.
57
205. Even though the man was apparently content to transfer to Dovegate, I am not
sure there were good grounds for sending him there. More to the point, the fact
that he had to wait in reception for several hours, only to be told the transfer
would not proceed, is an example of poor prisoner management. It is perhaps
understandable that the man reacted badly. It would have been more
appropriate for his transfer to have been agreed or rejected before he was taken
from the wing. Although the man would still have been disappointed had this
happened, he would not have had his hopes dashed after a wait of about four
hours in reception.
206. The sudden cancellation of the man’s transfer was followed by a decision to re-
locate him to D Wing rather than return him to C Wing and to take him, at least
part of the way, under restraint. Whilst I accept that, given the man’s behaviour,
it was necessary to restrain him, the fact that it became necessary at all
stemmed from what had happened in reception.
207. None of the staff interviewed at Leeds knew why the man was due to be
transferred to Dovegate. (It is highly unusual for any prisoner to be transferred to
a training prison before he has been tried, convicted and sentenced, especially if
he is facing a life sentence as was this man.) Neither was my investigator able to
establish why the transfer was cancelled. However, it is most likely that it was
due to the fact that the man was still awaiting trial. Had the option of transferring
the man to Dovegate not arisen, this particular episode would have been
avoided.
Recommendation 5
The Governor should take immediate steps to ensure that decisions as to
allocations or transfers are communicated to prisoners in a manner that is both
timely and in keeping with the Prison Service’s policy of decency.
208. The next day, the man was placed on the basic regime because of the earlier
warnings he had been given about his conduct. No doubt his behaviour the
previous day was also taken into account. His reduction to the basic regime
meant he could not watch television in his cell, the number of letters he could
send out each week was reduced, and the number of visits per month were
decreased.
209. It is, of course, most unfortunate that, at a time when the man was already under
great pressure, these regime restrictions were imposed. They could not have
helped his morale. However, I believe that, aside from the comments I have
made about the man’s cancelled move to Dovegate, it was reasonable for staff to
impose sanctions given his behaviour.
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Was it appropriate to keep the man in a single cell?
210. A cell sharing risk review held on 1 December resulted in the decision to keep
the man in a single cell until after his court appearance due on 22 December. It
is easy, with the benefit of hindsight, to judge that the man should not have been
kept in a cell on his own. However, at the time this decision was made, the man
had not manifested any obvious signs he was contemplating suicide and was
therefore not subject to self-harm monitoring procedures. Furthermore, his
aggressive and uncooperative behaviour, whatever the cause, suggested he
presented a risk of harming others. I therefore raise no criticism of the decision
to keep the man in a single cell.
Was the response to the discovery of the man hanging prompt and effective?
211. The officer principally responsible for patrolling D2, D3 and D4 landings, and the
first person to discover the man hanging, said he was reluctant to enter the cell
on his own as he knew that in the past staff had been taken hostage when
entering a cell alone in response to what seemed to be a genuine emergency.
There is no evidence that this reluctance resulted in any undue delay in entering
the man’s cell once other staff had arrived. The officer principally responsible for
patrolling D2, D3 and D4 landings could not be certain that the man was dead
before he entered the cell. He could not have known at that stage whether the
man still had a pulse. That said, it became clear as soon as staff entered the cell
that the man was beyond recovery. However, any reluctance to enter a cell in
response to a life threatening situation carries with it the possibility that a delay
might occur with the result that a life could be lost.
Recommendation 6
The Governor should ensure that his staff are properly advised about the need to
enter a cell as swiftly as possible in the event of the discovery of a life
threatening situation and that considerations about personal security is weighed
against the need to preserve life.
212. The officer principally responsible for patrolling D2, D3 and D4 landings was
critical of the quality of the scissors provided to staff for cutting through materials
used as ligatures (as noted earlier, he described them as similar to those
provided in kindergartens). He said he had some difficulty in cutting through the
ligature used by the man. Whilst there is no evidence that the difficulty the officer
said he experienced affected the outcome in the man’s case, it is imperative that
all emergency equipment is fit for purpose.
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Recommendation 7
The Governor should procure and issue staff with serviceable cut down tools.
213. Both the nurse who had attached the defibrillator to the man’s chest and the
officer principally responsible for patrolling D2, D3 and D4 landings told my
investigator of their disappointment at the lack of care offered to them in the
aftermath of their response to the emergency.
Recommendation 8
The Governor should satisfy himself that appropriate arrangements are in place
to provide care and support for staff, including members of the care team, who
have been involved in the discovery of prisoners who have taken, or have
attempted to take, their own life.
The handling of letters found in the man’s cell after his death
214. My investigation found no evidence of any correspondence left by the man at the
time of his death indicating his intention to take his own life. However, a number
of documents found in the man’s cell after his death were seized by the West
Yorkshire police for use in their separate investigation. In a report submitted by
West Yorkshire police to the Coroner on 2 March 2008, the Detective Inspector in
charge of the police investigation wrote:
“There was a note found in the subsequent search of the cell
occupied by [the man]…I am of the opinion that this in no way can
be referred to as a ‘suicide note’ and my initial report reflected this
point.”
215. However, at a later date, the man’s family solicitor noticed that private letters
were visible in one of the photographs of the contents of the man’s cell that had
been taken by the police on the night of his death. The solicitor therefore asked
for copies of every document seized by the police. Amongst these documents
were found numerous letters written by the man to various members of his family
and to friends in which he expressed his sorrow for the pain he had caused them
and bade them his farewell.
216. This tardy discovery was a source of much distress to the man’s family and a
matter that will no doubt have been regretted by West Yorkshire Police. (West
Yorkshire Police have since accepted this criticism, advised relevant staff
regarding their conduct and apologised to the man’s family.)
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FAMILY CONCERNS
217. Here I provide responses to the concerns raised by the man’s family.
What action did the police take to prevent the man killing himself (e.g. constant
watch)?
218. These matters are dealt with in paragraphs 37 - 48.
What action was taken by those responsible for escorting the man from Runcorn
police station to a magistrates’ court and later to Altcourse prison to prevent him
from killing or harming himself? What handover did they have from the police
and what handover did they provide at Altcourse?
219. These matters are considered principally in paragraphs 49 – 77 and 156 – 173.
Was the man on a suicide watch on his admission to Altcourse? When did it
cease and why?
220. These matters are dealt with in paragraphs 62-89.
Was the man placed on a suicide watch at Leeds? If not, why not? Is it true that
Leeds would not have accepted him if he had been on such a watch?
221. The man was not placed on any self-harm monitoring procedures at Leeds where
he manifested to staff no indications that he was at risk of self-harm or suicide.
The investigation found no evidence to suggest that Leeds does not accept at
risk prisoners from other prisons.
Why was the man transferred from Altcourse to Leeds? Was it because he had to
be kept apart from another prisoner whose girlfriend was in the same flat as his
partner on the night she died?
222. The man was transferred to Leeds for security reasons. This matter is dealt with
in paragraphs 104 – 107 and 182 - 185.
What assessment was made of the man’s mental state from his arrest to his
death, and what treatment, if any, did he receive?
223. This is covered in the main body of the report and in the clinical review written by
the clinical reviewer on behalf of Leeds Primary Care Trust.
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Did the man suffer panic attacks prior to his release from Acklington prison in
August 2006? Were his medical records from that period of imprisonment
available when he returned to custody in September 2006?
224. As the clinical reviewer points out in his clinical review, no medical records for the
period the man spent at Acklington were available. It has therefore not been
possible to confirm whether the man experienced panic attacks at Acklington.
As the man was already on parole licence when he was arrested a month later,
should he have been given the same prison number at Altcourse as he had at
Acklington?
225. This is covered in paragraph 64.
Is it true that the man was placed on the basic regime at Leeds following an
incident when he had been made to wait in reception for approximately four
hours for transfer to Dovegate only to be told that the transfer had been
cancelled?
Why (in his state of mind) he was made to wait so long in reception?
Why he was going to be moved to Dovegate?
Why the transfer did not take place?
Why he was restrained and what happened next?
Whether he was placed on disciplinary charges.
Whether he was placed on the basic regime in relation to this incident.
226. These matters are covered at various points in the report.
Is it true that on another occasion the man was taken for a legal visit but made to
wait all afternoon when the visit had been cancelled by his solicitor by phone or
letter? The family believe that this contributed to his distress and have asked the
Ombudsman to investigate the incident.
227. The investigation could find no evidence in relation to this matter.
Is it true that the man was not allowed to have writing paper? (He sent a letter to
the family apologising for having to write on the back of a letter that they had sent
him because he had no paper.)
228. The investigation found that on 30 November the man’s privilege level was
reduced from standard to basic. One of the consequences of that reduction was
that his entitlement to letters was reduced from three per week to two. These
restrictions were still in force when he died. It has not been possible to prove
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whether there was any other reason why he chose to write on the back of a
previous letter.
Why was the man in a cell on his own?
229. This matter is covered in paragraphs 123 - 126 and 209.
Has any risk assessment been conducted of the provision of bunk beds in cells
of single occupation in the main prison? Was the man’s cell a single cell or a
double cell in single occupancy? If the latter, why?
230. The man occupied a cell in which two beds were provided as bunks. My
investigator was told by the wing manager that the operational requirement at
Leeds for the provision of accommodation is such that two beds are normally
required to be kept in every cell on normal location. The policy for the provision
of beds in the segregation unit was different. The wing manager told my
investigator that a management decision had been made some time earlier to
remove spare beds in the segregation unit partly because they were not needed
and partly because of the added risk two beds could pose.
The family understands that the man’s cell was opposite the staff room and that
his cell light was left on all night when he died. Who had control of the light
switch (inside or outside the cell)? Were any staff in the staff room overnight?
Could they have noticed that his cell light was on all night? Should this have
raised any concerns?
231. I have found no evidence to prove that the man’s cell light was switched on all
night. However, the member of staff who was on duty in D Wing that night, and
who was first to discover him hanging, noticed as he approached the man’s cell
at 5.50am on the morning of the man’s death that the cell light was indeed on. It
is not unusual for some prisoners to leave their light on all night: this tends to
happen, for example, when they fall asleep while watching television.
232. It is of course known that the man hanged himself by attaching a ligature to the
conduit carrying electricity to the light in his ceiling and then falling backwards
from the top bunk. It is likely that, in order to be able to see what he was doing
as he attached the ligature in this way, he needed to have the cell light on. Thus,
the light would have remained on from whenever he began the process.
Why was the man kept in D wing, the induction unit for so long? Is it true that the
facilities and regime in that wing are not as wide ranging as on other wings?
233. My investigator was told that prisoners are not kept on the induction wing for a
specified period. Some are moved onto other wings after a few days, while
others stay for a much longer period. The decision as to how long prisoners
remain on the wing is determined by individual needs and circumstances. In
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general terms, prisoners on D Wing do not go to work, whereas those in other
wings do. As a result, those on D Wing are likely to spend more time in their
cells. As this report shows, the man’s time on D wing was interrupted briefly on
28 November when he was moved to C wing to see if he could settle there. Two
days later he was returned to D wing. I take the view that the man was not kept
on D wing for an unusually long time.
What contact did the man have with other prisoners and staff during the night of
the man’s death?
234. The man was in cell D2-41 when he died. The adjacent cells were occupied by
two prisoners, both of whom were interviewed during the course of the
investigation. Both have said that during the eve of the man’s death they had
short, sporadic conversations with the man about football and other general
topics. They both confirmed that at no stage did he mention whether he was
depressed or that he may have been contemplating suicide.
235. However, one of the prisoners in the adjacent cells said that on the eve of the
man’s death, after the man had seen his solicitor, who passed him the
prosecution papers, he seemed to be very red faced as if he had been crying.
The prisoner also said that he saw the man walking slowly along the landing with
his head down. The prisoner was persuaded that the man was deeply affected
by what he read in the prosecution papers and that this may have triggered his
demise. (See also my comments at paragraph 134 above.)
236. Both prisoners in the adjacent cells said that at some stage during the night they
heard a noise coming from the man’s cell, rather like a chair falling over.
However, neither thought it significant or reported it to staff.
237. The officer on duty in D Wing that night confirmed that he had spent some time
during his shift in the office on the landing on which the man’s cell was located.
The officer also confirmed that the office is opposite that cell. The officer told my
investigator that at no stage during the night did he remember hearing any
conversations between the man and the prisoners in the neighbouring cells.
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LIST OF RECOMMENDATIONS
To the Director of Altcourse
Recommendation 1
The Director of Altcourse should explore, with his police counterparts, methods
of ensuring that vital information about the risk of suicide presented by prisoners
in police custody is properly and comprehensively recorded on the PER and
effectively communicated to private security organisations and to the Prison
Service. (A copy of this report has been provided to the Cheshire police.)
(I understand that since 2006, the format of the PER may have changed.)
Recommendation 2
The Director of Altcourse should take urgent steps to remind his staff of the
importance of accurate and comprehensive completion of all documents relating
to prisoners, especially the suicide and self-harm warning and cell sharing risk
assessment forms. The Director should address any staff training needs in this
regard.
Recommendation 3
The Director of Altcourse, in liaison with Medacs, the contractor responsible for
the delivery of healthcare, should ensure that before any prisoner is transferred
to another prison the prisoner’s complete medical record is assembled. This
function should be regularly audited by an appropriate manager.
Good practice
Automatic first night watch
My investigator was told that, as matter of routine, all prisoners undergoing their first
night at Altcourse are placed in the First Night Centre and are observed at regular
intervals - normally half hourly - throughout the night. Observations do not cease until
approximately 10.00am the next day when the oncoming shift have had an opportunity
to observe each prisoner themselves. My investigator was also told that if, after that
period, any prisoner were to demonstrate that he was having difficulty in coping,
observations would continue or, if necessary, self-harm monitoring procedures would be
implemented.
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Self-harm communication form
My investigator was told that the self-harm communication form is normally raised at
Altcourse in respect of prisoners about whom staff are concerned but whose condition is
not such as to warrant the initiation of formal self-harm monitoring procedures. The
expectation was that the form would normally be open for no more than 48 hours. If
staff considered it necessary to keep the form open beyond that period, formal self-
harm monitoring procedures would be started if appropriate.
I regard both these systems as examples of good practice.
To the Governor of Leeds
Recommendation 4
The Governor must take immediate steps to ensure that systems are put in place
to guarantee that risk-related information received from outside agencies about
prisoners is acted upon immediately
Recommendation 5
The Governor should take immediate steps to ensure that decisions as to
allocations or transfers are communicated to prisoners in a manner that is both
timely and in keeping with the Prison Service’s policy of decency.
Recommendation 6
The Governor should ensure that his staff are properly advised about the need to
enter a cell as swiftly as possible in the event of the discovery of a life
threatening situation and that considerations about personal security are
weighed against the need to preserve life.
Recommendation 7
The Governor should procure and issue staff with serviceable cut down tools.
Recommendation 8
The Governor should satisfy himself that appropriate arrangements are in place
to provide care and support for staff, including members of the care team, who
have been involved in the discovery of prisoners who have taken, or have
attempted to take, their own life.
(At consultation stage, the Prison Service accepted all the above recommendations.)
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Summary of recommendations made in the clinical review
The Prison Service should review the systems for transferring information
between forensic medical services and prison healthcare and transferring clinical
information held on computers between prisons.
HMP Altcourse Healthcare Service should review the assessment and
management of suicide risk and depression.
HMP Leeds should review the lack of adherence to the depression protocol and
reconsider the approach to screening risk in prisoners transferred from other
prisons but who have committed major crimes.
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