Individual at Lewes

A Report by the
Prisons and
Probation
Ombudsman
Nigel Newcomen CBE
Investigation into the death of a man at HMP Lewes
in April 2007
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This is the report of an investigation into the death by murder of a man at HMP
Lewes in April 2007. The man, a sentenced prisoner, was found lying on the floor of
his cell in the Care and Support Unit with a ligature around his neck, just after
midnight. His cellmate was subsequently charged and convicted of his murder. He
was 25 years old.
The death of a loved one is always hard to bear. To lose someone in the
circumstances outlined in this case must have caused the family considerable
distress. I wish to offer my sincere condolences to the man’s family and friends for
their loss.
The investigation was led by my one of my investigators. I am grateful to the
Governor and staff of HMP Lewes whose assistance was of great help to my
investigators. I am also grateful to the DCI at Sussex Police whose liaison with my
investigator was of great assistance.
The man’s death was initially thought to have been self-inflicted. However, it was
later established that he had been murdered. My investigation has found that prison
procedures were appropriately carried out during his imprisonment. Although
information came to light that, with hindsight, might have raised doubt about the
relationship between the two prisoners, I am satisfied that staff could not reasonably
have foreseen the likelihood of his cellmate taking such extreme action.
I apologise for the delay in the publication of this report, this was due, in part, to the
police investigation and subsequent court case. I make one recommendation in this
case relating to cell sharing risk assessments and I also invite the Governor to
consider the handling and recording of critical incident debriefs.
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.
Stephen Shaw CBE
Prisons and Probation Ombudsman May 2010
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CONTENTS
Summary 5
The investigation process 7
HMP Lewes 8
Key events 10
Issues 16
Conclusion 18
Recommendations 19
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SUMMARY
At the time of his death, the man was 25 years old and serving a six year sentence
at HMP Lewes. He was found on the floor of his cell, just after midnight in April
2007, by staff who had responded to a cell bell. He had a ligature around his neck.
The prisoner, who shared his cell, was subsequently charged and found guilty of his
murder.
The man had first arrived at Lewes on 22 September 2006, having been committed
into custody for trial, together with co-defendants. He was initially charged with
murder. He had been assessed at court by a mentally disordered offender
assessment and diversion team due to the nature of the allegation against him. This
team found no evidence of mental health problems or self-harm and suicidal intent.
Later that day, on reception at Lewes, further healthcare checks, including a
subsequent assessment by a forensic psychiatrist, found neither any remarkable
physical health issues nor any mental health concerns. Initial cell sharing risk
assessments found the man to be low risk, and this assessment was maintained in
later reviews. He was consistently described by staff as polite, compliant and
generally mixed well with others.
As the man’s co-defendants were also on remand at Lewes, the prison took care to
ensure they were kept apart. There is no evidence they had any contact.
He fell down the wing stairs on 27 November, knocking himself unconscious. He
was quickly transferred to hospital, received appropriate treatment and recovered
satisfactorily. There is no evidence that anyone else was involved in this incident.
He was subjected to an apparently unprovoked assault by other prisoners on 21
December. He was again taken to hospital and found to have facial injuries,
including a broken bone in his left cheek. He was treated appropriately and returned
to prison the following day with a follow up appointment.
As the man’s cellmate had warned staff that he would be attacked again, the
Governor decided on 22 December, under Prison Rule 45, to locate him in the Care
and Support Unit (CAS) for his own safety and protection. Regular reviews in the
unit indicated that he was making good progress. No problems were identified
regarding his location in CAS.
The man’s cellmate arrived at Lewes on 19 January 2007. His Cell Sharing Risk
Assessment (CSRA) identified him as a medium risk. Some days later he was
located in the Care and Support Unit and shared a cell with the man. No concerns
were raised about this cell sharing arrangement. There is evidence that the man
thought his cellmate to be supportive and that they were friendly.
The man’s trial began on 5 March and concluded on 18 April. He was found not
guilty of murder, but guilty of manslaughter and was sentenced to six years
imprisonment the following day. He was re-assessed by healthcare staff following
his trial and found to be positive in attitude, with no self-harm or suicidal intent.
Healthcare staff continued to see him every day as required by the segregation
regime, but no problems or concerns were recorded as being raised with them. He
posted four letters to friends on 23 April, all of which were read by staff.
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Just after midnight, a cell bell alarm was pushed from both prisoners’ cell. The
cellmate told the staff who responded that the man had hung himself. Other prison
and healthcare staff responded within minutes to a radio alarm call, and swiftly
began cardio pulmonary resuscitation. Paramedics arrived about 20 minutes later
and, maintaining resuscitation efforts, transferred him to the County Hospital. A
doctor pronounced his death at 1.05am.
The man’s next of kin were told of his death later that day by the chaplain and
Governor. The staff care team were informed and prisoners were notified as well.
Owing to the lapse of time and the unavailability of key staff, it has been difficult to
establish whether a critical incident debrief was held.
Police conducted an investigation into the man’s murder and during this time the
Ombudsman’s investigation was halted. Statements provided to the police by other
prisoners and visitors to the cellmate indicate that he had said that he intended to kill
the man and make it look like suicide, that he had a fascination with killing someone
and he had been playing games of pain with the man. Tragically, it seems that his
threats to kill him were not taken seriously. If the prisoners or visitors had told prison
staff they could have taken action and I believe the man’s death might have been
prevented.
I make one recommendation relating to the need to review a CSRA if security
information suggests that a prisoner has an inappropriate interest in another
prisoner’s personal affairs.
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THE INVESTIGATION PROCESS
1. One of my investigators visited Lewes on 26 April 2007 to open this investigation
and liaised with senior prison staff and the police. All relevant prison records
relating to the man were made available. These included his main prison record,
medical records, and statements made by staff relating to his death.
2. Later that day, the Ombudsman’s investigation was halted, as the police
concluded his death was a possible homicide and they initiated a murder
investigation. This took precedence over the Ombudsman’s investigation which
could not resume until after any subsequent trial.
3. My investigation was re-opened after the trial and conviction of the cellmate for
murder in May 2008. Another one of my investigators led the investigation and
visited Lewes to interview staff. Sussex Police gave him case summary
documents, particularly those in relation to the cellmate, and an outline of the
case. The cellmate’s other prison records were not available due, firstly, to the
suspension of the investigation and, secondly, as he had been transferred to
another prison. My investigator later received copies of the cellmate’s CSRA
documents.
4. Unfortunately, by June 2008 virtually all the staff who had known the man and his
cellmate had either retired or had transferred to other establishments. My
investigator was therefore only able to interview one member of staff who had
been working on the Care and Support Unit at the time of the man’s death. This
interview was recorded and the transcript is attached to this report.
5. The investigator has studied all the relevant prison records available relating to
the man, as well as the documentation made available by the police. As the
death was due to murder, a review of his clinical care was not commissioned.
6. HM Coroner for East Sussex was informed of the nature and scope of my
investigation. Upon completion, my report will be sent to the Coroner to assist in
his enquiries into the man’s death.
7. One of my Family Liaison Officers wrote to the man’s parents to inform them of
my investigation and that it had been suspended, shortly after his death. The
Family Liaison Officer wrote to them again once my investigation had resumed
and there has been continuing contact with their solicitors. I hope this report
helps to address any questions the man’s family might have regarding the care
he received whilst in prison custody.
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HMP LEWES
8. HMP Lewes is a category B male local prison holding adult remand and short
term convicted prisoners as well as remand young adults. It serves the courts of
East and West Sussex. At the time of the man’s death, it had an operational
capacity of 558, which has now increased to 723 prisoners.
9. The majority of the accommodation, at the time, was shared cells, although there
were some single cells. The additional accommodation has been achieved
through the opening of a new single cell block housing 174 prisoners.
10. Incoming and outgoing mail is monitored by staff. Ten percent of prisoners’ mail
is normally read. If an individual is subject to mail monitoring all of his incoming
and outgoing mail may be read.
Care and Support Unit
11. The Care and Support Unit, which closed shortly after the man’s death, was
attached to the segregation unit, but in a separate annex. It accommodated up to
nine prisoners in four double and one single cell. The CAS unit held prisoners
who had been removed from general association under Prison Rule 45 for either
the good order or discipline of the prison or in their own interests. The unit
provided support and development to prisoners aimed at enabling them to
acquire new skills and strategies that would aid reintegration to normal location or
on transfer or release.
Night state
12. At night, all prisoners are locked in their cells and the number of staff in the
establishment is much lower than during the day. The night orderly officer is in
overall charge of the prison. The night orderly officer visits each wing or unit at
intervals through the night. Wings and units are in the care of night patrol
officers, responsible for monitoring security and safety. At Lewes, the patrol staff
include both trained prison officers and operational support grades (OSGs). The
night orderly officer carries a set of keys that allow him to access all areas of the
prison. Wing or unit patrol officers carry cell keys in a sealed pouch for
emergency use only. Written instructions prevent any officer from opening a
shared cell alone.
Her Majesty’s Chief Inspector of Prisons
13. The most recent inspection by Her Majesty’s Chief Inspector of Prisons was
unannounced and took place in August 2007. One of the recommendations in
that report is pertinent to the issues raised in this report. She recommended that
reintegration planning for prisoners on the Care and Support Unit should be
further developed, with targets that aim to improve prisoners’ behaviour and
increase their coping skills.
Independent Monitoring Board (IMB)
14. The IMB report to the Secretary of State for 2007-08 described the Segregation
and Care and Support Unit as well run. The report commended staff for the skill,
sensitivity and flexibility with which they managed needy prisoners within the unit.
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None of the issues raised within the IMB report are relevant to the circumstances
of the man’s death.
Previous deaths at HMP Lewes
15. The Ombudsman became responsible for investigating all deaths in custody in
April 2004. There are no similar recommendations in this case to any self-
inflicted or natural causes deaths investigated at Lewes.
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KEY EVENTS
16. The man was charged initially, together with two others, with the murder of a
homeless man in Brighton. He appeared at a Magistrates Court on 22
September 2006. A Prisoner Escort Record (PER) was prepared by Sussex
Police for his journey from police custody to court. It identifies one security risk
(that he may possess weapons, based on his previous offence of possessing a
knife), drugs and alcohol issues, and one other. No self-harm or suicide risks
were identified. (The PER is a record of all escorted journeys made by a
prisoner, it includes a section highlighting any known risks involved in moving that
prisoner.)
17. At court on 22 September, the man was assessed by the East Sussex mentally
disordered offender assessment and diversion scheme, a service provided by the
National Health Service (NHS). He was referred to the service due to the nature
of the murder allegation and to check any mental health issues. Their
assessment found no evidence of mental illness, or of any self-harm or suicidal
ideas or intent. It summarised his history, noting that he had been homeless in
the Brighton area for a year, and that the victim of the alleged offence had also
been a homeless man. The assessment recorded that he was under high levels
of stress, which he was managing, but was asking for night sedation to help him
sleep.
18. The court committed the man into prison custody awaiting trial at Crown Court on
6 October. He was taken from court to HMP Lewes. On reception at Lewes, he
was recorded as a homeless man, and gave the name of a girlfriend as his next
of kin.
19. The Cell Sharing Risk Assessment (CSRA) completed on the man’s first
reception at Lewes identified no immediate risk. (A CSRA is undertaken, normally
on reception and assesses any risks a prisoner may pose to sharing a cell with
another prisoner.)
20. The first health screen was completed on reception as required, and the second
health screen was completed later the same day. Neither revealed any
remarkable health issues. The possibility of depression was noted, but he was
assessed as generally well. He was reviewed by the doctor the following
morning who recorded there were no mental health concerns or any markers of
depression.
21. After completing the reception process, the man spent a short time in the First
Night Centre. The record of his time on this unit indicated that he was polite,
presented no concerns, but had to be kept apart from his co-defendants. His
prisoner personal record clearly recorded a warning flag identifying that, in
relation to his cell location, he must be separated from his co-defendants (who
were also being held in the prison).
22. Records show that on 25 September the man’s induction into the prison was
complete. His CSRA was reviewed and indicated that he continued to be low risk
and the need to refer him to the housing officer was noted. He was seen and
assessed by a community psychiatric nurse from the mental health in-reach
team, the same day. She found that he presented no evidence of severe or
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enduring mental health problems. However, given that he had been remanded
into custody on a charge of murder, she recorded a team decision to arrange for
him to be assessed by a forensic psychiatrist.
23. A forensic psychiatrist assessed the man on 29 September. He found no
evidence of existing mental illness, or enduring illness in the past. He diagnosed
insomnia for which he prescribed medication to help establish his sleep pattern,
and recorded that the man said he would never harm himself. The psychiatrist
concluded there was no need for any psychiatric follow up.
24. There is a record of an Authorised Contact Restriction, dated 6 November, which
was served on the man and which he signed to indicate he understood. At the
request of Sussex Police, his contact with the woman he had described as his
girlfriend and nominated next of kin was restricted, and he was not allowed to
write, telephone or contact her through third parties. Although there is no record
of his response to this restriction, there is nothing to suggest any continuing
adverse reaction.
25. The man was taken to Sussex Police on 23 November, to be charged in respect
of an assault occasioning actual bodily harm offence which had been committed
before his main offence.
26. He reported that he fell down the wing stairs on 27 November and was knocked
unconscious. He was treated in the healthcare unit and taken to hospital,
returning later in the day. He had a severe gash which was sutured and he was
appropriately monitored. He admitted having taken his cellmate’s medication the
previous evening, and was warned against repeating this behaviour. He was
reviewed satisfactorily on the wing the following day.
27. On 21 December, the man was subjected to an assault by other prisoners. He
reported that he had been assaulted whilst lying in his bed, named one of the
assailants and requested police involvement. He was taken immediately to the
hospital where it was confirmed he had facial injuries and a broken bone in his
left cheek. He received treatment and a follow up outpatient appointment was
arranged. The prison carried out an appropriate investigation into the alleged
assault but no formal charges were made against any prisoner.
28. Following the assault, the man’s former cellmate told staff that other prisoners
suspected him of being a sex offender, and warned staff that he would be
attacked again. The Governor authorised a decision, under the good order and
discipline Prison Rule 45, to move him to the Care and Support Unit (CAS),
attached to the segregation unit. The decision to authorise segregation was
properly recorded as necessary to ensure his safety and protection. The Initial
Segregation Safety Screen, with input from a medical officer, indicated there
were no healthcare needs which would make segregation inappropriate. There is
no record of any police involvement, which had initially been requested by him.
He was moved to the unit during the afternoon of 22 December.
29. In line with the prison policy for the CAS Unit, regular reviews of the man’s
progress were undertaken throughout his time there. The reviews took place at
least fortnightly and recorded his progress. Comments on him were
complimentary. He was described as a “quiet, polite and compliant man”, who
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mixed well with others on the unit. A prison officer, a member of staff on the CAS
unit, confirmed this written description of him when interviewed by my
investigator. Seen as always willing to help, it is noted he was one of the only
prisoners willing to clean up the unit, and that he was looking for a job when one
became available. He started attending education and achieved a key skills
certificate in problem solving in February 2007.
30. Each CAS review confirmed that the man should be kept on the unit for his own
protection. The medical record shows that healthcare staff continued to see him
every day. (These were primarily the routine healthcare checks required on a
segregated prisoner.) No major concerns were flagged following the checks.
31. On 3 January 2007, the man was taken to the Magistrates Court regarding the
assault offence. The court committed him for trial at the crown court, and he
returned to Lewes prison on remand.
32. The man’s cellmate arrived at Lewes prison on 19 January. He is recorded as
having been recalled to prison from parole. The cellmate had previously been
sentenced on 16 June 2005 to a four year six month custodial sentence for
robbery. His recall to prison coincided with being arrested and charged with a
further serious offence of robbery. The court remanded him into custody in
respect of this further offence.
33. A CSRA carried out on the cellmate identified him, in a tick box section of the
form, as a medium risk to himself or a cellmate. A hand written entry goes on to
say that staff believed he was at risk of harming himself. There was no indication
that he was likely to be a threat to a cellmate.
34. Although initially located in the healthcare centre, the cellmate moved to the CAS
unit and soon began sharing a cell with the man. The prison officer described the
cellmate as a ‘poor coper’. She recalled him as a likeable person and believed
that he was placed in the CAS unit as he could not manage in larger
environments. She said that the he was working with the mental health in-reach
team and believed that he liked being in the prison environment. She was not
able to recall precisely how they came to be sharing a cell. She thought it likely
that either or both had asked to be allowed to share a cell. She described how
on the unit the normal pattern is that when two prisoners found someone they
liked and got on with, and if they then asked to share a cell, it would be approved
as long as the CSRA did not identify any risk. She recalled that they both got on
together, would laugh and joke, and that she did not see any problem with them
sharing a cell.
35. A further CSRA review of the man was undertaken on 20 January. This review
maintained that he continued to be low risk. The review did contain a note, as an
aide memoire, questioning whether prison intelligence had any information
regarding risk, but without changing the conclusion. Two CAS reviews at the end
of January recorded him as making good progress, mixing well, and seemed to
be fine on the unit. Subsequent reviews reiterated these assessments.
36. The man was taken to hospital on 9 February for an outpatient appointment to
review progress on his injuries following the assault in December. The specialist
registrar in oral and facial surgery recorded that his injury had healed
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satisfactorily, though he still felt some jaw pain, for which he was prescribed
ibuprofen. His drugs chart shows that, together with some paracetamol, these
were the main medications prescribed to him.
37. An outgoing letter sent by the man, dated 12 February, was intercepted by prison
staff. In the letter, he described his cellmate as “my mate”. A report following a
further intercept, dated 27 February, suggests that he was attempting to find out
information on another inmate being held at Lewes who was alleged to have
assaulted an ex-girlfriend of his cellmate.
38. The man appeared at the crown court regularly during his trial from 5 March until
18 April. On 19 April, the jury found him not guilty of murder, but guilty of
manslaughter. He was sentenced to six years imprisonment. CAS reviews in
March and April, including the last undertaken on 11 April, continued to report
progress, and did not identify any problems or concerns.
39. Healthcare staff assessed the man in reception on his return from court on 18
April. The medical record notes that although shocked, following the
manslaughter conviction, his attitude was positive and he spoke about education
and family support. It was identified that he had no history of self-harm or any
suicidal thoughts, and said he wanted to return to his cell in the CAS unit where
he had a supportive cellmate. Healthcare staff continued to review him every day
following his sentence up to 23 April. The records show that no problems were
identified or disclosed. He was last seen by healthcare staff asleep on his bed on
23 April. The same day, he sent four letters to his friends, all of which were
monitored, but none were withheld. None of the letters suggested any fears
relating to his cellmate.
Events on the day of the man’s death
40. At approximately 12.02am an Operational Support Grade (OSG), who was
carrying out night patrol duties, answered a cell bell call from the cell occupied by
the man and his cellmate. When she opened the observational panel in the cell
door, the cellmate asked for help saying his cellmate had hanged himself. She
saw the man lying on the floor with a ligature around his neck, and asked the
cellmate to feel for a pulse, but he refused to touch him. The OSG immediately
called for assistance using her prison radio. Local operational instructions
prevented her from entering a cell alone holding more than one prisoner.
41. Within three minutes a Senior Officer (SO), the night orderly officer, arrived with
the assistant night orderly officer and an officer. The officer unlocked the cell
door and the night orderly officer saw the man on the floor with a torn bedsheet
ligature around his neck. The cellmate was immediately taken out of the cell.
The officer removed the ligature and the man was moved to the landing floor.
Neither the assistant night orderly officer nor the officer could find a pulse, so the
officer immediately started cardio pulmonary resuscitation (CPR) chest
compressions while the assistant night orderly officer undertook mouth to mouth
resuscitation. The night orderly officer checked for a carotid (neck) pulse but
could find none. The man was blue in colour.
42. Two nurses arrived within minutes, accompanied by the OSG. One nurse set up
the defibrillator (a machine that applies electrical impulses to the heart and
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advises whether there is any rhythm which might be stimulated) and applied
oxygen.
43. Staff continued CPR, taking turns, until the paramedics arrived at around
12.25am. The paramedics took over the life support management, maintaining
CPR, and requested police attendance. The man was taken to hospital at
12.50am, arriving at 1.00am. At 1.05am a hospital doctor pronounced that the
man had died.
44. The duty governor had been advised of events at 12.30am. The police were
called to the prison at 12.30am, arriving after the man had been taken to hospital.
The night orderly officer used the Lewes’ orderly officer incident pack checklist to
ensure a record was kept of the steps to be taken in the event of a death in
custody. The area office and national operations unit were informed by 1.40am.
45. The police maintained a guard on the cell, which was later sealed. Police
interviewed the cellmate in the early hours of the morning, and the prison co-
operated fully with the police investigation.
46. The duty governor arrived at the prison at about 1.00am. He ensured that all the
necessary documents were completed and carried out a “hot debrief” before staff
went off duty. A member of the care team attended and offered support to staff.
(Hot debriefs are primarily carried out to ensure staff have the opportunity to
discuss emotive issues and any lessons learned following serious incidents.
Minutes are not always taken at these meetings.) A critical incident debrief was
arranged for the following month.
47. Notices both for staff and prisoners were prepared and displayed later that day.
They advised of the man’s death, and reported that the early indications were
that he had taken his own life.
48. The Chaplain informed the man’s parents that their son had died sometime
between 11.00am and 12.30pm. The Chaplain was also the prison family liaison
officer appointed to deal with any family issues. The Governor wrote a letter of
condolence to the family the same day. The police subsequently appointed their
own family liaison officer who maintained contact with the family.
49. A post mortem was carried out at the hospital. It found that the man had died as
a result of asphyxia caused by constriction of the neck.
Murder investigation
50. During the last week in April, the police interviewed a number of prisoners at
Lewes as well as the cellmate’s ex-girlfriend and her friend. Statements provided
to the police indicated that he had said that he intended to kill the man and make
it look like suicide, that he had a fascination with killing someone, and he had
been playing games of pain with him. One prisoner said that he thought he had
heard the cellmate laugh between 11.40 and 11.50pm on 23 April. (There is no
evidence that any of this information had been communicated to prison staff
before the man’s death.)
51. The cellmate was arrested by the police on 27 April. During questioning, he
initially described how he had found the man hanging. He denied elements of the
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statements other witnesses had made. During the night, however, when he was
being monitored under suicide prevention procedures, he was heard saying that
he may or may not have killed the man. He returned to Lewes on 28 April. That
evening he told prison staff that the man had not committed suicide but that he
had killed him. He admitted to having strangled him and then attempted to make
it look like suicide. He signed a record of these admissions, written by a senior
officer, which he later retracted. On 3 May, he was re-arrested on the basis of
this further evidence. Following an interview in which he offered no comment, he
was charged with the man’s murder.
52. On 20 May 2008, at Crown Court, the cellmate was found guilty of the man’s
murder. He was sentenced to life imprisonment.
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ISSUES
53. The man was murdered by his cellmate. Although it became evident during the
murder investigation and subsequent trial that the cellmate had expressed to
others ideas about killing the man, there is no evidence that prison staff were
informed. The evidence suggests that the cellmate only expressed these ideas in
the few days and the afternoon immediately before the murder, and they had not
been considered a serious intent by the individuals he told.
54. Prior to the murder, prison staff thought that the man and his cellmate got on well
together. The officer told the Ombudsman’s investigator that the cellmate had
not told her he had any problems with the man or was contemplating killing him.
Neither had the man given any indication that he was worried about his cellmate.
She could not recall anything unusual about either of them the day before the
murder and said that she would never have thought the murder was going to
happen. I am satisfied that there is evidence that the man had considered him to
be a supportive cellmate.
Cell Sharing Risk Assessments
55. The officer said that approval for the man and his cellmate to share a cell would
not have been given had anything in their cell sharing risk assessments given
cause for concern. The man’s CSRA continued to assess him as low risk whilst
his cellmate’s assessment was medium risk. However, CSRAs tend to be very
individualised assessment documents. They primarily assess whether an
individual prisoner poses a risk to a cellmate, based on their individual
characteristics. They do not ordinarily consider the ongoing relationship between
prisoners sharing a cell. In this case, the man’s last CSRA review undertaken on
20 January, before he began sharing a cell with his cellmate, contained a note
questioning whether prison intelligence had any information regarding risk. At
that point there would have been nothing of any particular relevance. The
cellmate’s CSRA identified him as a medium risk and he was considered to be
more of a risk to himself. However, by late February, prison intelligence was
questioning the man’s interest in his cellmate’s ex-girlfriend.
56. There is no evidence recorded that these questions led to any review of either
their cell sharing risk assessments. I consider that this kind of intelligence
information should have led to a formal review of both their CSRAs, taking
account of any potential relationship dynamics between the prisoners sharing the
same cell. However, I accept it is doubtful, given the positive evidence presented
to prison staff of their friendly relationship, that a review might have led to a
change in assessment of cell sharing. Nevertheless, undertaking such a review
might have led to staff being more alert and aware of any small indications of
changes in the relationship between the two. I therefore make the following
recommendation to the Governor of Lewes.
The Governor should ensure that any security and intelligence information
relating to a prisoner’s interests in the personal affairs of his cellmate
should lead to a formal Cell Sharing Risk Assessment review.
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Care and Support Unit reviews
57. I am satisfied that the procedures and processes for segregation in the Care and
Support Unit at Lewes fulfil the requirements of PSO 1700. The CAS unit
provides a different form of support for prisoners and is not a normal segregation.
It has a much higher staff ratio than on normal location, allowing for work with
prisoners toward normal integration on the wings. The reviews of the man’s
progress demonstrate precisely the positive achievements that he was making.
58. However, as with my comments above in respect of CSRAs, the reviews tend to
be very individualised assessment documents which fulfil the function of
continued authorisation for segregation. They tend not to contain much
assessment about the relationships between either prisoners sharing a cell, or on
the unit generally, other than generalised summaries such as ”mixes well with
others”. I believe that a more staff intensive unit providing support should record
more detailed assessment of prisoner relationships. This would form part of the
planning system to allow prisoners on the CAS under good order or discipline to
return to normal location. As I am aware that the CAS unit closed some time ago
I do not make a formal recommendation on this matter.
Critical incident debrief and employee support
59. My investigator found that prison and healthcare staff responded quickly and
professionally to the alarm raised for the man. It is clear that they did all they
could to assist him until the paramedics took over. Processes to secure the area
and inform all the relevant personnel were followed through, including effective
liaison with the police.
60. A hot debrief took place following the incident and a member of the care attended
to provide support to staff. It appears that all appropriate follow up actions were
carried out after the man’s death.
Family Liaison
61. Although I have been unable to establish the details, I am satisfied the man’s
family were informed of his death as soon as possible. The Governor referred to
follow up support being available through the Chaplain, who was also the prison’s
FLO, in the letter of condolence sent to the man’s parents on the day of his
death. However, the murder investigation clearly took precedence and the police
appointed their own family liaison officer.
62. I note that a new Prison Service and Police Service protocol “Prison, Probation
and Immigration Related Deaths in Custody – A Protocol for Police
Investigations” is due to be published which will set out how the respective
services will work together when an investigation is being conducted into the
possible murder of a prisoner. This should help to clarify all the appropriate
responsibilities and roles for each service. In particular, it should ensure a
clarification of the relative roles of police family liaison and the Prison Service’s
family liaison responsibilities.
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CONCLUSION
63. It appears that both the man and his cellmate were content to share a cell
together on the Care and Support Unit. I can find no evidence to suggest that he
feared for his safety whilst sharing the cell with his cellmate. Staff on the unit did
not identify any concerns relating to either man that may have led to them
reconsidering their CSRA. Had the prisoners who were interviewed by the police
or the cellmate’s girlfriend believed that he actually intended to kill the man, it is
likely that they would have informed staff. Tragically, it seems that the threats to
kill him were not taken seriously. If they had taken action on this information I
believe his death could have been prevented.
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RECOMMENDATIONS
The Governor should ensure that any security and intelligence information
relating to a prisoner’s interests in the personal affairs of his cellmate should
lead to a formal Cell Sharing Risk Assessment review.
In response to the recommendations, the National Offender Management Service
(NOMS) drew attention to inaccuracies in paragraphs 22, 36 and 58, relating to the
requirement to review CSRAs. These errors have been amended.
NOMS also asked if we would reconsider the recommendation in the light of the
inaccuracies. Given that the recommendation calls for a review in the light of new
information rather than a requirement for routine review, this recommendation will
stand.
As requested, the protocol referred to in paragraph 65 has been clarified by insertion
of the full title - Prison, Probation and Immigration Related Deaths in Custody – A
Protocol for Police Investigations. The protocol has been drawn up between the
National Offender Management Service (NOMS), UK Border Agency, Youth Justice
Board and the Association of Chief Police Officers (ACPO).
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