Individual at Birmingham

Investigation into the circumstances surrounding the
death of a man
at HMP Birmingham in 2010
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2011
This is the report of an investigation into the death of a man, a prisoner at HMP
Birmingham. He died in March 2010, having been discovered in his cell with a
ligature around his neck. He was 36 years old and had been in prison for nine days.
I offer my sincere sympathy and condolences to his family and friends.
The investigation was carried out by my colleague. A review of the man’s medical
care in custody was carried out by the clinical reviewer on behalf of the local Primary
Care Trust (PCT). I am most grateful to him for his assistance.
I would also like to thank the Governor and staff of Birmingham for their co-operation
during the course of the investigation. I am especially obliged to two members of
staff for their help in liaising with the investigators.
The man had served in the Marines for ten years and was said to find it difficult to
come to terms with aspects of his war service. Having been arrested on 1 March for
the attempted murder of his partner the day before, he remained in police custody for
the next three days. He was assessed as a high risk of suicide by the local hospital
and also told the police he felt suicidal. This information was not passed to the
prison. On 4 March, he appeared at Magistrates Court and was remanded to HMP
Birmingham. While at court, a nurse assessed him as at risk of suicide and
fortunately this information was appropriately forwarded to the prison.
On arrival at the prison, a reception officer and a nurse interviewed him. Due to the
information from court and her own assessment of him, the nurse made an urgent
referral to the mental health team but did not herself believe he was at risk of suicide.
Later that evening, another nurse from the mental health team assessed him and
concurred with his colleague’s view. Suicide prevention measures were not started.
It is my opinion that they should have been put in place to safeguard his welfare and
I make a recommendation in this regard.
Following an initial delay obtaining his records from his community general
practitioner (GP), he was assessed by a detoxification doctor and received the
appropriate treatment to help him stop misusing heroin. However, in the morning of
13 March, he was discovered hanging in his cell and subsequent attempts to
resuscitate him were unsuccessful.
Officers and nurses responded quickly to the situation. Nevertheless, I make
recommendations regarding the introduction of a code system to be used in
emergency situations, annual first aid training for officers and more clarity in
determining who should call an ambulance, since there was a delay of 22 minutes
until this occurred. I also ask the Governor to consider the appropriateness of family
liaison arrangements and to ensure that prisoners receive the visits to which they are
entitled.
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.
Thea Walton
Acting Deputy Ombudsman November 2011
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CONTENTS
Summary
The investigation process
HMP Birmingham
Key findings
Issues
Conclusion
Recommendations
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SUMMARY
The man was arrested in the early hours of 1 March for the attempted murder of his
partner the day before. He remained in police custody for three days and told the
police medical examiner that he felt suicidal and had intentionally taken a heroin
overdose the day before his arrest. During this time, he also attended hospital
where he was assessed as highly suicidal. Crucially, this information was not
passed to the prison and remains the subject of a misconduct investigation by the
Professional Standards Department at West Midlands Police.
On 4 March, he appeared at Magistrates Court. While in the court cells he was
assessed by a nurse, who was concerned about him and completed a suicide and
self-harm warning form which accompanied him to the prison. On arrival at the
prison, an officer and two nurses assessed him. None of them believed he was at
risk of suicide and therefore suicide prevention measures were not started. He had
been in prison before.
I have considered the reasonableness of this decision and whilst it is clear that he
denied he was feeling suicidal, it is my belief that suicide prevention measures
should have been started at this stage. He had expressed an intention to kill himself
whilst at court earlier in the day and was facing a serious charge of violence against
a partner. The National Offender Management Service’s own research indicates that
facing this type of offence increases a person’s vulnerability to suicide or self-harm.
Over the following few days, he was assessed by the detoxification doctor and was
treated for his drug misuse. Staff did not have any concerns regarding his risk of
suicide or self-harm. Late in the evening on 11 March he called staff to his cell as he
said he had accidentally fallen over and hit his head on the sink. Staff had no
concerns about his mental state at the time and he remained in the cell on his own.
However, letters written by him, which were found in his cell after his death, describe
this injury as occurring as a result of a failed suicide attempt and that he intended to
try to kill himself again the following evening.
At 7.55am two days later, he was found hanging in his cell. Staff responded quickly
and professionally in their resuscitation efforts although I make a recommendation
regarding first aid training. I also suggest the introduction of a code system to be
used by staff in the event of an emergency. An ambulance was not requested for 22
minutes after he was found, seemingly since all the staff assumed that one of their
colleagues had already made the request. I do not believe that ambulance staff
would have been able to save him. Nevertheless, a lack of clarity about who should
call an ambulance has been an issue in previous deaths in Birmingham and I am
disappointed to repeat the recommendation. The paramedics arrived at 8.30am and
pronounced him dead one minute later.
Following his death, the Governor went to his mother’s home to tell her the news,
while the police simultaneously visited his partner. However, due to police advice
that it was not appropriate for the victim of the alleged offence to act as next of kin
and the family’s feelings towards his partner at the time, she was not subsequently
contacted by the prison. I remain unconvinced that this was an appropriate decision,
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especially following his partner’s letter to the Governor expressing her concerns
about his death.
Despite trying to book a visit to see him from the day he was remanded, his mother
was unable to do so until 18 March. Indeed, he did not receive any visitors during
the nine days he was remanded. I therefore make a recommendation that the
Governor ensures the system at Birmingham allows prisoners to have the visits to
which they are entitled.
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THE INVESTIGATION PROCESS
1. The investigation was allocated to a senior investigator on 15 March 2010.
On her behalf, two days later, another senior investigator and an assistant
ombudsman opened the investigation at HMP Birmingham and issued notices
announcing the investigation to staff and prisoners. The notices included an
invitation to those who wished to submit information related to the man’s
death to make themselves known to the investigator. No one came forward
as a result.
2. The investigator was given access to his prison files, including his medical
record. She went to Birmingham on 11, 12 and 27 May to interview staff.
Another senior investigator interviewed three prisoners on her behalf. She
submitted a number of questions to a member of healthcare staff via email.
She also spoke to the Reliance Custodial Services Area Manager regarding
his care whilst he appeared in court. The Independent Monitoring Board
(IMB) and the Prison Officers’ Association (POA) did not have any specific
issues to raise with her.
3. A clinical review of the management of his health needs in custody was
carried out by the clinical reviewer on behalf of the local PCT. He
accompanied the investigator to some of the interviews on 11 and 12 May.
4. One of my family liaison officers wrote to both the man’s partner and his
mother in April, to explain the investigation process and invite them to raise
any issues they wished the investigation to address. Both she and the
investigator met his partner and her mother on 23 April. His partner raised the
following issues:
• She said the court and police were aware of recent suicide attempts by
him. She therefore wanted to know what information was passed onto
the prison and what precautions were put in place as a result by the
prison?
• What psychiatric assessments were completed on him?
• She had heard that two prisoners had asked to be moved into the
same cell as him but he was on his own. Why was this the case?
• What checks were made on him throughout the night before he died,
what time was he found and what attempts were made to resuscitate
him?
• She understood from police that he had a wound on his neck when he
died which had required stitches. How did this injury happen and who
had treated it?
• Why did he not have any visitors?
• Why was there a delay in her finding out about his death later that day
and why was there no contact from the prison apart from a very brief
letter from the Governor?
• Given that she was the victim of his alleged offence, why was he
allowed to write to her and was his mail checked?
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5. The investigator and family liaison officer also visited the man’s mother and
brother on 13 May. They raised the following issues:
• What information had the police given to the prison regarding his risk of
suicide? If this was insufficient, what action was being taken?
• Were prison staff aware that he had been hospitalised due to taking a
heroin overdose the week before he went into prison?
• Why was his cell still locked two months after his death?
• Did he use the broken hatch on his door as a ligature point?
• Why was it so difficult to book a visit to see him?
• Why were suicide prevention measures not started following his suicide
attempt the night before he died?
• Why did it take three to five days for letters to be delivered to him?
6. I have attempted to answer the questions above in the report. The man’s
mother and partner received a copy of my draft report as part of the
consultation process. The partner made written representations in response
to the findings of the investigation. My Senior Family Liaison Officer, together
with an investigator, visited the partner and mother who raised additional
issues, including a number concerning his clinical care.
7. I have considered the issues raised and referred the clinical matters to the the
local PCT. Both my own and the PCT’s response have been addressed
outside of this report in separate correspondence. This has been sent to the
man’s partner and mother and other stakeholders with this final report.
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HMP BIRMINGHAM
8. Built in 1849, Birmingham is one of the largest prisons in the country,
accommodating a maximum population of 1,450 adult male sentenced and
unsentenced prisoners. It accepts prisoners from local courts and its main
function is to hold prisoners who are awaiting sentencing, being held on
remand or facing a trial. Originally a Victorian prison, in recent years it has
expanded and modernised.
9. Birmingham is a category B prison. On arrival into prison, prisoners are risk
assessed and given a category based on their offence and the risk that they
pose to the public should they escape. Category B prisoners are those for
whom the highest security conditions are not necessary but for whom escape
must be made very difficult.
10. Healthcare is provided by the local Primary Care Trust (PCT). The PCT
contracts Birmingham and Solihull Mental Health Trust to provide mental
health services within the prison, including staffing and running the 34 bed in-
patient unit.
11. The former Chief Inspector of Prisons completed a full and unannounced
inspection of Birmingham in December 2009. She found that:
“ … while some progress had been made, there was still a considerable
amount to do to ensure a safe, decent and effective prison … There was a
good senior management attention to safer custody, though some of the
operational aspects of support for prisoners at risk of suicide needed
strengthening.”
12. The most recent annual report published by the Independent Monitoring
Board (IMB) at Birmingham covers the year from July 2007 to June 2008.
(The IMB at each prison is made up of members of the public who are both
independent and unpaid. They monitor the day-to-day life in their local prison
and ensure that proper standards of care and decency are maintained.)
13. The Board noted that the personal officer scheme was not functioning well,
something the former Chief Inspector of Prisons also drew attention to. The
IMB praised the safer custody team’s efforts.
14. The National Offender Management Service is responsible for the
management of prisons in England and Wales. Every three months it
publishes an assessment of each prison’s performance against 34 measures.
Prisons can gain a rating of between one (serious concerns) and four
(exceptional performance). Birmingham has scored two (requires
development) for the last four quarters.
15. The Ombudsman assumed responsibility for investigating deaths in custody in
2004. Since that time, this office has investigated 28 other deaths at
Birmingham, of which ten were apparently self-inflicted. Most recently, there
have been nine deaths at the prison since December 2009 (including that of
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the man), of which four were apparently self-inflicted. A common theme to
emerge from these recent and some earlier investigations was the lack of a
proper code system when officers needed to communicate with colleagues
over the radio net in an emergency. Another similarity is a delay requesting
an ambulance, which was an issue in deaths in 2008 and 2010. I repeat my
recommendations in this regard.
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KEY FINDINGS
16. In the months before the man’s arrest, his partner said that his mood had
become increasingly bizarre and erratic and he had lost two stone in weight.
The clinical reviewer notes that he was being prescribed methadone by his
general practitioner (GP) during this time, which he did not want to disclose to
his partner. His GP described him as, “well dressed, putting on a brave
positive face, but not very forthcoming with the truth about his inner feelings”.
He was not communicative during appointments with his GP, who believed
that he did not disclose many of his concerns and it was difficult to gain his
trust.
17. On 10 February, he told his GP that he was not sleeping, had a poor appetite
and was losing weight. He also said he had relapsed to heroin misuse and a
drug test indicated he had also misused crack cocaine. He failed to go to
subsequent appointments with his GP but continued to collect his methadone
prescription.
1 to 4 March, in police custody
18. On 1 March 2010 at 1.20am, he was arrested for attempting to murder his
partner the day before. Later that morning, whilst in police custody, he
became disoriented, struggled to speak and said his face felt numb. He was
taken to hospital by ambulance and returned to the police station that evening
at 5.20pm, having been deemed fit to be detained.
19. Further information about his hospital admission came to light after his death.
On 29 March, his GP surgery received an undated discharge letter, via fax,
from a nurse at the hospital. It said that the police had brought him to the
hospital’s Accident and Emergency Department after he attempted suicide the
day before. The date of admission is not specified but my investigator has
confirmed with West Midlands Police Professional Standards Department that
only one admission to hospital is noted in his police custody record, that of 1
March.
20. His mental health in the hospital was assessed as having depressive
symptoms with a high risk of suicide and the nurse wrote that he:
“regretted he did not succeed in killing himself, and had nothing left for
himself in the future. He said there is no point in working and repeated
no point in living anymore. Objectively, actively expressed suicide
ideation, feeling of hopelessness and not looking forward to the future.”
The nurse indicated that the home treatment team would visit him in hospital,
prior to discharge, to devise a treatment and management plan. There is no
evidence that this occurred and it is not known if the nurse passed this
information to the police.
21. Over the next two days, 2 and 3 March, he was kept in police custody and
interviewed regarding the alleged offence on a number of occasions. He told
10
the police that the night before his arrest he had injected £50 worth of heroin
in order to take his own life. He tested positive for opiates and cocaine. He
also said that he had taken an overdose of paracetomol five years ago but
had known at the time that he would not die. He denied the offence stating
that he and his partner had tried to commit suicide by hanging themselves in
their home. He also told the police medical examiner that he felt suicidal.
4 March, appearance at Magistrates Court
22. He was taken from the police station to Magistrates Court, arriving around
8.00am. The first five sections of the Person Escort Record (PER) had
already been completed by the police. (The PER is a form that accompanies
each prisoner between police station, court and prison. It provides information
about the prisoner’s needs and the risk he poses to others and himself.) The
police had noted that he was violent and concealed weapons but that there
was no other known risk. The box indicating a risk of suicide or self-harm was
not ticked and no information about his suicide threats was recorded on the
form.
23. Having been placed in a cell at court, he was checked every 30 minutes by
officers from Reliance Custodial Services. My investigator spoke to the
Reliance Area Manager, who said that the police had sent a fax regarding him
to the Reliance control room, as is routine. It was flagged with markers for
mental health, suicide or self-harm, drugs and weapons and entered onto the
Reliance computer system. She told my investigator that the PER form and
fax to the control room are not routinely cross-referenced as the warning
markers often vary between the two.
24. Staff at the Magistrates Court added the information to the board in the court
cells by his name. No other information regarding his risk of suicide was
passed from the police to Reliance staff.
25. Community Psychiatric Nurse (CPN) A was working in court that morning.
Having noted the information on the board that the police had concerns about
his mental health and risk of suicide and self-harm, the nurse assessed him in
his cell at 10.20am. The Reliance Area Manager said that, had the CPN
relied solely on the information on the PER form, he would not have
interviewed him. During the CPN’s assessment, he was tearful and upset,
speaking of his intention to harm or kill himself given the opportunity. The
nurse did not diagnose him with any other mental illness.
26. The nurse was also concerned about his reaction to the alleged offence.
Although he reported no history of self-harm during their conversation, the
nurse recommended that he should be constantly observed by staff whilst he
was in court custody. He was placed in an observation cell, which has a full
glass door and is watched by two escort officers. The CPN recorded his
assessment on a suicide and self-harm warning form, which accompanied
him, along with the PER, to the prison.
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Thursday 4 March, HMP Birmingham
27. Following his appearance in court, he was remanded to HMP Birmingham and
arrived around 2.30pm. This was not his first time in prison, although it was
the most serious offence he had been charged with. Officer A signed section
seven of the suicide and self-harm warning form to indicate that it had been
received.
28. Officer B was working on the front desk of reception that day. Whilst he told
the investigator that he could not remember him specifically, he was
responsible for opening the cell sharing risk assessment (CSRA) at the front
reception desk. (The CSRA assesses the risk of harm a prisoner presents to
a cellmate if they are required to share a cell.) When completing his section
of the CSRA, the officer said he would also have had the PER, suicide and
self-harm warning form and warrant, with details of the alleged offence,
available to him.
29. During the assessment, Officer B noted details of his previous convictions and
current alleged offence. Since the officer had the suicide and self-harm
warning form, he said that he specifically asked him if he had any intention in
this regard, which he denied. Knowing the non-verbal signs of a risk that a
prisoner might harm himself, such as a lack of eye contact, the officer did not
have any concerns about him. He disclosed that he was “currently addicted to
drugs and on methadone”. The officer assessed him as presenting a low risk
of harm to others and suitable to share a cell. He gave his mother’s details as
his next of kin.
30. Officer B then gave his paperwork to Nurse A, who was responsible for
completing the healthscreen in reception. The nurse said that each
healthscreen is conducted in a private room and the interview takes about ten
minutes. The purpose is to obtain a prisoner’s GP details and gather
information about any physical or mental health issues and drug or alcohol
misuse, as well as their history or current feelings of self-harm or suicide.
31. He told the nurse that he had misused heroin in the past and was being
prescribed methadone (a heroin substitute) and citalopram (an anti-
depressant) in the community before his remand. She passed this information
to Prison Doctor A who prescribed one week of citalopram until this
prescription was confirmed with his GP. The doctor also prescribed five days
of zopiclone (a benzodiazepine derived sedative), which is standard practice
for drug misusers when they first come into prison to help counteract any drug
withdrawal symptoms.
32. The nurse said that he was mainly concerned that his partner, who worked for
the NHS, would be able to access the information they discussed. She
assured him that his information would remain confidential. The nurse
referred him to the detoxification team due to his disclosure regarding drug
misuse. He named his partner as his next of kin and this was noted in the
health record, while his mother remained noted as next of kin in the reception
paperwork.
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33. Nurse A said she had read the suicide and self-harm warning form, but he
repeatedly denied any thoughts of suicide or self-harm. He told her that he
was “fine” and would ask for help if he needed it. However, despite his
assertions, she still had concerns since she observed he was not making
good eye contact and appeared “withdrawn and down”. She said because of
this, and the form she had received from court, she made an urgent referral
for him to be seen by the mental health team that evening. She said that she
was not sufficiently concerned to begin the Assessment, Care in Custody and
Teamwork (ACCT) procedures. (ACCT is the suicide prevention system used
by prisons to identify and support prisoners who are thought to be at risk of
self-harm and/or suicide.)
34. The nurse completed the healthcare section of the CSRA and also assessed
him to be a low risk of harm to others. He was then offered a shower and a
telephone call before he moved to D wing, the first night centre. It is not
known if he telephoned anyone at this point. His CSRA was signed off as low
risk to others by the allocating officer. (Despite requests by my investigator,
staff at Birmingham have been unable to confirm whether he was located in a
single or double cell and, if he shared, who his cell mate was. This is also the
case following his subsequent cell moves. This is because the new computer
system can only link prisoners to cells, but not to each other.)
35. As a result of Nurse A’s referral to the mental health team, at around 8.00pm
he was assessed by a Registered Mental Nurse (RMN). The nurse no longer
works at the prison and was not available for interview by my investigator.
The following assessment is taken from the nurse’s notes in the medical
record.
36. He denied the alleged offence and said he had never had any mental health
problems. He related some difficulties with his partner and said due to
frustration on the night of the alleged offence he had tied a noose around his
neck and jumped from the balcony. He said he had not meant to kill himself
but wanted to show his partner how it felt when someone acted in that
manner.
37. The RMN assessed that he:
“appeared to be functioning well mental health wise but is concerned
with his case and the risk of losing his livelihood. He reiterated that he
does not intend to end his life nor does he have any thoughts of
deliberate self-harm … He has however expressed he might need
psychological input in a an attempt to ventilate his concerns … he
states he does not want to be perceived as someone with mental
illness fearing it might impact negatively on the court process … He
presented as settled in mental state at time of interview but there are
possibilities of his mental health deteriorating due to thoughts of the
nature of his charge.”
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38. The nurse did not start the ACCT measures either. He referred him to a
forensic mental health nurse who assesses the mental health of every
prisoner charged with murder or attempted murder. She works at the prison
three days a week and normally interviews prisoners within seven to 14 days
of them being referred. She did not have the opportunity to assess him before
he died.
Friday 5 March
39. The following day, 5 March, he was interviewed by an officer as a continuation
of the induction process. Having denied any thoughts of suicide or self-harm,
he said he was not concerned about being in prison and had no problems
after spending his first night in custody. He again gave his next of kin details
as those of his partner. He was also interviewed by the resettlement
department, to whom he denied having any housing concerns. He was
moved to another cell on the same wing. My investigator has been unable to
establish why this happened.
40. Prison Doctor B works within the Integrated Drug Treatment Service (IDTS) in
the prison and provides clinical care for prisoners with drug and alcohol
problems. He assessed him later that morning, who told him that he had last
misused heroin three days ago, along with unprescribed benzodiazepines.
The doctor recognised his drug withdrawal symptoms. He tested positive for
methadone, morphine, cocaine and benzodiazepines. His treatment and
prescription of methadone was confirmed over the telephone with the
Swanswell community drug project. The doctor prescribed methadone and
diazepam (used to treat anxiety and insomnia), which he said he had been
taking illicitly and so the doctor wanted to gradually wean him off it.
41. The doctor also discussed the alleged offence with him and reassured him
regarding his concerns about the confidentiality of their appointment. The
doctor described his mood as “normal” and “affable”, with good eye contact.
He disclosed that he had harmed himself years ago but did not have any
current intention to do so.
42. The doctor was unaware that Prison Doctor A had prescribed citalopram to
him the night before. However, he said this would not have affected his
assessment since he knew that the mental health team were already involved
in his care and had completed their assessment the day before. The doctor
had access to the assessment which was in the medical record.
43. Later that day, he was interviewed by a worker from the Counselling,
Assessment, Referral and Throughcare service (CARATs, the prison drug
misuse service) team. He told the CARATs worker that he had last misused
heroin on 28 February (the day of the alleged offence). This is slightly
different to the date he gave to Prison Doctor B, but does not seem significant
in the circumstances.
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6 – 10 March
44. Although he could not yet be moved to the detoxification wing since it was full,
he received his medication each day from the nurses who visited D wing. No
significant events were recorded on 6 or 7 March.
45. On 8 March, the Offender Health Administrator sent a fax to his GP to obtain
further details regarding his medical history. She deals with routine requests
and works standard weekday office hours, apart from Fridays when she
finishes work at 1.30pm. She explained that, due to the number of new
prisoners daily at Birmingham, it was likely that she did not start processing
the request for his records until Friday 5 March or Monday 8 March. She
would have to ensure that she had received his signed disclosure form, as
well as details of his community GP before requesting the information. She
said a delay of around four to five days to request the records would be
expected.
46. However, if a doctor in reception or elsewhere urgently needed the community
GP records, this request would not be processed by herself. The prison
doctor would contact the appropriate surgery directly themselves. Later that
day, he asked a nurse for a reduction in his methadone prescription which she
agreed to discuss with Prison Doctor B.
47. His partner gave my investigator a copy of a letter he wrote to her, dated 8
March. From the letter, it is clear that he found it difficult to cope in prison and
wrote that he “just wants to die”. He wrote a similar letter the following day in
which he says “Fact. My mind is made up. I love you and cannot live without
you”. He told her that he had made her his next of kin. She did not contact
the prison since she had told the police that he was highly suicidal and
expected that the information would have been passed to the prison. His mail
was not being monitored by staff who were unaware of the contents.
48. On 9 March, he moved to a cell on the induction wing, N wing. His CSRA was
reviewed by an officer and he remained assessed as a low risk of harm to
others. He asked for a reduction in his methadone prescription since he
wanted to be weaned off it completely.
49. The fax sent by the Offender Health Administrator was received by the
community GP surgery at 10.43am that day. Surgery staff told the clinical
reviewer that they replied the same day with a summary of his medical history.
Despite requests, my investigator has been unable to gain access to this
response and it is not clear whether the prison received it.
50. On 10 March, Prison Doctor B assessed him and agreed to a slight reduction
in his methadone prescription. The doctor had tried to dissuade him from
reducing his methadone intake after such a short time in custody. However,
he told him that he had only been prescribed methadone for around four
months in the community and did not want to take it in the long-term. The
doctor described him as “determined, focussed and positive” and gave him no
cause for concern.
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51. He wrote a letter to his family at 7.20pm that evening which was found in his
cell after he died. He said that he “cannot go on” and will “watch over you”.
He tells his family to “be strong and remember to celebrate my life and not
mourn my death”. He also wrote to his mother that he has “waited from the 8
March so it would not fall on your birthday”.
Thursday 11 March
52. He appeared at Crown Court for a preliminary hearing. He left the prison at
around 7.15am and returned at 1.50pm. The PER which accompanied him
indicated that there were no concerns in relation to suicide or self-harm.
53. My investigator listened to a recording of a telephone call he made to his
mother around 6.30pm that evening. He said he had been in court, and they
went on to discuss other practicalities which had arisen because of his arrest,
such as the location of his car. He did not voice any intent to harm himself
and talked about the future. (This is also true of earlier telephone calls he had
made to his mother on 7 and 10 March, which my investigator also listened
to.)
54. He wrote another letter to his partner in which he says “all I think of is ending it
all”. He says he tried to “end it” last night and woke up on the floor with “scuff
marks on the floor”. Staff were unaware of this attempt since he did not bring
it to their attention.
55. That evening, at 11.46pm, he rang his cell bell. (Each cell has a bell to be
used by prisoners in the event of emergency or if they require staff attention.)
Officer Support Grade (OSG) A was working on N wing on his own. He went
to the cell two minutes later and looked through the observation hatch. The
man had blood on his head and told the OSG that he had slipped over and hit
his head on the sink. The OSG immediately used his radio to request the
assistance of Oscar Two, Senior Officer (SO) A, and Hotel Two, Nurse B.
(Oscar Two and Hotel Two are the emergency response radios which are
carried by the nurse and SO on duty during the night.)
56. The OSG carried on talking to him through the hatch to ensure that he
remained conscious and was not losing too much blood. The nurse and SO
arrived around five minutes later. As is standard procedure at night, the SO
requested permission to go into the cell from the control room. This was
given, and the nurse and SO went into the cell together. The OSG remained
outside the cell.
57. Nurse B said when she went into the cell she noticed a “considerable amount”
of blood on the left side of his head and blood on the sink. She also said that
he was “alert, oriented and talking”. The nurse cleaned his head and treated
the wound on his chin with Steri-strips. (Steri-strips are thin adhesive strips
which are used to close small wounds.)
16
58. He told the nurse that he had got up to go to the toilet, twisted his ankle and
fallen over. This seemed a plausible explanation to her. She checked for any
symptoms of a more serious head injury and completed a report of injury to
prisoner form. She noted that he “reports falling in his cell but unclear how
injuries occurred”. By this she meant that he could not explain exactly how he
had cut his chin or bumped his head. She said this would be normal if he had
been unconscious for a short period.
59. She had no other concerns about him and said that he “was chatting
throughout, he was bright, didn’t appear upset or anything like that and he
was just very compliant with treatment”. As with every unexplained injury, she
said that she considered whether he had inflicted it himself. When asked, he
denied this. Since she found his explanation plausible, she did not consider
him to be at risk of suicide or self-harm.
60. Once he had been treated, the SO locked his cell and informed the control
room. The nurse gave the SO the form she had completed regarding his
injury, which he put in the inbox in the safer custody office. She left the wing
and made a note that she would review him in an hour to confirm that there
were no signs of head injury.
Friday 12 March
61. At around 1.20am, the nurse returned with the SO and completed her review
of him. She had no further concerns and told him he would be reviewed again
later that morning but, if he felt any other symptoms in the meantime, he
should inform staff. He told her he felt “fine” and wanted to go to sleep. She
described his mood as “bright, chatty and pleasant”. She had no further
contact with him.
62. The OSG checked him at hourly intervals throughout the night, firstly by
talking to him through the hatch but, after he had fallen asleep, by checking
that he was breathing. (The checks of his wellbeing were good practice on
the part of the OSG.) The OSG recorded what had happened in the wing
observation book and gave a verbal handover to the day staff at 7.00am, at
the end of his shift. Nurse B also gave Nurse C a verbal handover at this
time, requesting that she review him later that day. The nurse then went off
duty and left the prison.
63. At 9.35am he moved to M wing, the detoxification wing. This is where all
prisoners who are prescribed methadone or Subutex (a heroin substitute)
should ideally be placed. They will remain here until they stop taking this
medication. However, as SO B explained, the wing is usually full so new
prisoners often have to wait until a space becomes available. This accounts
for the delay of a few days before he was able to move to the wing.
64. Just over an hour later, he was reviewed by Nurse C, following his injury the
night before. The nurse checked his head and chin and took his blood
pressure. He reported no further symptoms but wanted to see Prison Doctor
B. The nurse therefore spoke to the doctor and made an appointment for him
17
later that day. She did not have any concerns that he was at risk of self-harm
or suicide since she thought that his explanation of the injury was believable
and she described his mood as “bright and happy”.
65. He had remained in contact with his ex-partner, who was the mother of his
two children. In a letter to her dated 12 March, which was found in his cell
after his death, he wrote that he tried to take his own life the previous night but
the shoelace snapped and he hit his head on the sink. He also made it clear
that he could not face a long sentence and wanted to die. He wrote that he
wanted a single cell, so when they put him in a double cell, he was difficult to
his cellmate and so they were separated. He also referred to seeing his ex-
partner the following week when she was due to visit, saying that “it would be
the last time he would ever need money”. Again my investigator has been
unable to confirm who he was sharing a cell with and there is no note of
anyone being moved from his cell in the wing history sheet.
66. He wrote to his partner the same day, again stating that he had tried to
commit suicide the night before and he “was devastated I was still alive”. He
added “I am going to try again tonight”, referring to making her his next of kin
and his wish to be cremated.
67. On another sheet of paper recovered from his cell after he died, he has
seemingly weighed up the consequences of taking his life. He listed the
issues in his life which included losing his children, losing his partner,
upsetting her family, having no plans, facing a long prison sentence, putting
his partner through a trial and not being strong enough. He also wrote, under
a column labelled “positives” that he would be able to meet his “nan” and
watch over his partner, children and family.
68. At his appointment that afternoon, he asked Prison Doctor B if he could be
weaned off methadone, since he did not want to take the drug for long. The
doctor noted in the medical record that he remained “motivated, focussed and
well oriented”. The doctor agreed to further reduce his dose of methadone at
the end of the current prescription. The doctor told my investigator that he did
not notice the wound on his chin, nor did he have an opportunity to review the
paperwork regarding the injury before their appointment.
69. At Birmingham, personal officers are allocated according to the cell in which a
prisoner is placed. (The personal officer scheme allocates a named officer to
each prisoner who they can approach for advice or to resolve complaints.)
During the nine days that he was in Birmingham, he changed cells four times.
My investigator was told that he would not have had the opportunity to get to
know a particular personal officer. He did have a named personal officer
following his transfer to M wing but she did not have the opportunity to
introduce herself.
70. Officer C works on M wing. He first met the man around 2.30pm, after he had
returned from his doctor’s appointment. The officer described their
conversation as “jovial” and said he was happy because the doctor had
18
agreed to start reducing his methadone prescription. He said he did not like
being on the detoxification wing and hoped to move in about a week.
71. As was routine on Fridays, he was locked in his cell between 3.00pm and
4.00pm, while medication was issued. The prisoners were unlocked and
served their evening meal at 4.00pm. At around 4.45pm Prisoner A asked
two officers if he could move into his cell as they knew each other from
outside the prison. The man was in a double cell on his own at that time. The
prisoner told my investigator that he was concerned about him as he had
known him for a long time and thought that he was not his “usual self”.
However, he did not believe that he would harm himself and says he would
have told staff if he thought this was the case.
72. Officer C said that such requests are frequent and, because they were
finishing serving dinner and preparing to lock the prisoners into their cells for
the 5.00pm roll check (count of prisoners), they were too busy to deal with it.
The officer said that the prisoner did not give him any reason to think he was
worried about the man’s welfare or that the request was urgent. He therefore
told him that he would deal with his request the following day. The officer said
neither the prisoner nor the man himself gave him any reason to be
concerned that the latter would harm himself.
73. The officer said that he and the prisoner spoke about the conversation the
next day, after the man’s death, and the prisoner acknowledged that he had
not expressed the urgency of his request which he now regretted. In a letter
to my investigator, the prisoner wrote that he had always found Officer C to be
a “firm, but fair” officer and believed that if it had not been nearly 5.00pm, the
officer would have moved him into the man’s cell that day. He also regarded
the other officer as a “fair and pleasant” officer.
74. Prisoner B, overheard Prisoner A’s request. He told my investigator that he
never thought the man would “go that far”. He said he seemed “chatty and
had a normal life”. He thought maybe he put “a front” on things to hide his
feelings.
75. Prisoner A said that as a result of his concerns about the man’s anxiety, he
spoke to a Listener. (Listeners are selected prisoners who are trained by
Samaritans to provide confidential emotional support to fellow prisoners who
are in distress.) The Listener immediately talked to the man but told my
investigator he did not have any concerns about his welfare. He had not got
the impression from Prisoner A that he was concerned about any risk of
suicide or self-harm, more that he was anxious. The man confirmed that he
would like the prisoner to move into his cell with him, which the Listener
repeated to the prisoner. The Listener told the investigator that he found
officers on the wing to be reasonable and willing to move prisoners as
appropriate. He said he had always been able to access help when he
needed it.
76. Prisoner C on M wing, knew the man from outside prison and felt it was clear
that he was at risk of suicide. However, he did not talk to staff about this. He
19
spoke to him during the evening and said he would talk to him again the
following day. He also said that he did not believe he should have been in a
cell on his own but that, earlier in the day, he had said that he did not want a
cellmate. Prisoners were locked back in their cells at 5.00pm and a roll check
was completed. A further roll check took place at 8.00pm.
77. Nurse D began work at 9.00pm that evening. A member of staff told her that
the man had not received his medication at 5.00pm since his drug chart had
not been available on the wing. All the drug charts for M wing prisoners are
kept on the wing but, since he had moved wings earlier that day, his drug
chart had mistakenly not been moved with him.
78. At around 11.00pm that evening, the nurse managed to confirm his
medication with the nursing staff on his previous wing. He had received his
methadone earlier in the day but was waiting for his prescription of diazepam
and citalopram. The nurse therefore asked OSG B to unlock his observation
hatch so she could give him his medication at around 11.30pm. They went to
the cell to find that the lock was not working on his hatch so the nurse could
open it without a key. He took the medication. (The nurses’ response to the
earlier medication omission was good practice.) Having had a brief
conversation with him about his medication, which lasted less than a minute,
the nurse did not assess that there was any reason to be concerned for his
welfare and described him as “calm”. In the medical record she noted he,
“had good eye contact, engaged well in conversation, appeared physically
and mentally stable”. He had no more contact with staff overnight.
The man’s death
79. Around 5.00am, OSG B completed the checks of all the cells on M wing,
including that of the man, and nothing untoward was reported. Officer D
began his shift at 7.45am, and received a verbal handover from the OSG who
said that there had been no problems overnight. The officer then started to
complete his checks of all the cells. When he got to the man’s cell ten
minutes later, he looked through the observation hatch and saw that he was
hanging from the back of the door.
80. The officer said he immediately radioed the control room with a message for
urgent assistance that he had found someone hanging and asked for Hotel
Two to come to the cell. The control room log indicates that they received an
initial message for “urgent assistance” from Officer D, with no details of the
hanging. Not all the staff who responded to the call were aware they were
attending a hanging. An emergency code system was not in place in the
prison at the time.
81. Officer C was on the landing below the officer and heard his call for
assistance. He immediately went to the cell and the officers unlocked and
tried to open the door. This was difficult as he had threaded the ligature,
which was part of a bed sheet, round the top corner and hinge of the door. He
was in a sitting position, almost touching the floor behind the door. (His
brother understood that the broken hatch had been used as a ligature point. I
20
can confirm that this was not the case and, furthermore, SO B said that he did
not think it would be possible to do so, due to the way the hatches open.)
82. Officer D managed to put his arm round the door and used his cut-down tool
to cut the sheet. (Cut down tools are provided for cutting ligatures. Staff in
closed and semi-open prisons who have contact with prisoners are issued
with and must carry their own tool.) Both officers went into the cell and Officer
D noticed a plastic bin which had been turned upside-down and placed by the
corner of the door. He assumed he had stood on the bin before hanging
himself.
83. Both officers were trained in first aid a number of years ago but had received
no annual refresher training since that time. They thought that he was slightly
stiff but warm to the touch. The officers laid him on the floor and Officer D cut
the ligature from his neck. He had also tied part of a bed sheet round his
hands. Both officers tried to find a pulse. SO B had also arrived at the cell by
this stage and, having initially thought he could detect a pulse, realised that
this was not the case. The SO had not received recent first aid training either.
84. Officer C went outside the cell, since it was cramped, and checked over the
radio that healthcare staff were on their way to the cell. He again requested
urgent assistance and said that they had found a prisoner hanging. He
confirmed that whilst there is no code system at Birmingham, but if staff hear
the words “urgent assistance”, they immediately go to the requested place.
He asked if anyone had an ambubag (used to aid resuscitation) but no one
did. He therefore began chest compressions at the ratio of five chest
compressions to two breaths. (This ratio is incorrect, which I deal with later in
my report.)
85. Two nurses (Oscar Two) and (Oscar Fifteen – the emergency back-up radio)
were in the general office together when they heard the request for urgent
assistance. They immediately went to the cell and, on the way there, were
told by an officer that he had stopped breathing. Nurse E turned back to get
the defibrillator and oxygen while Nurse F continued to the cell. (A defibrillator
is a portable electronic device which measures electrical activity in the body
and advises on the action to be taken.)
86. Nurse F arrived at the cell about three minutes after the initial call for
assistance, and the SO then stepped outside the cell to give her more room.
As Officer D continued with chest compressions, the nurse tried to insert an
airway into the man’s throat, which was difficult since his tongue had swollen.
The nurse said that his hands were cold to the touch and he looked purple.
She tried to use an ambubag to administer breaths but this was difficult as his
neck was slightly stiff. The nurse asked Officer D to cut his clothes so that
she could apply the defibrillator and also cut the sheets which he had used to
tie his wrists together. The officer was then relieved from doing chest
compressions by Officer E and he too left the cell.
87. Nurse E had arrived at the cell two minutes after Nurse F. She attached the
defibrillator to him which advised that they should continue cardio pulmonary
21
resuscitation (CPR). The nurses and Officer E continued rotating between
completing chest compressions and administering breaths.
88. SO C had just arrived at the prison at around 8.00am and picked up the Oscar
Three radio when he heard the call for assistance on M wing. Oscar Three is
responsible for responding to any emergencies which happen on the East
side of the prison. Oscar One (held by Principal Officer (PO) A) is in charge of
the whole prison and Oscar Two (held by PO B) is responsible for responding
to emergencies on the West side of the prison. The SO went first to his office
to leave his belongings and collect his belt (to which his cut-down tool was
attached), then he went straight to M wing. On arrival, around five minutes
later, he saw the nurses were already trying to resuscitate the man and he
therefore remained outside.
89. The Duty Governor and PO B also arrived at the cell around this time. They
were responsible for managing the emergency. They checked that an
incident log was being completed, informed the governing Governor of the
situation and checked on staff welfare.
90. At 8.17am, which was 22 minutes after he had been found, SO C asked how
much longer the ambulance would be by telephoning the control room from a
wing office. The control room told him that an ambulance had not been
requested. The SO therefore asked control to call one immediately. The
paramedics subsequently arrived at 8.30am and took over CPR. They
attached their defibrillator to him, which advised that nothing more could be
done for him and they pronounced his death one minute later.
After the man’s death
91. The Duty Governor asked SO B to ensure that all the prisoners were
immediately told by wing staff what had happened . All those on open ACCTs
were reviewed that morning.
92. The governing Governor held a hot debrief at 9.45am which 12 members of
staff attended. (A hot debrief is a meeting for staff to discuss any lessons
learned and their feelings following serious events such as deaths in custody,
hostage situations or escape attempts.)
93. There are three family liaison officers (FLOs) at Birmingham. Due to their
high workloads at the time of the man’s death, the Governor appointed himself
as the FLO. The man had named both his mother and partner’s as his next of
kin. Following a conversation between the Governor and the police after the
death, he decided to treat his mother as next of kin. The police thought that it
would be inappropriate for his partner to act as next of kin given that she was
the victim of the alleged offence.
94. The Governor therefore agreed with the police that they would tell the man’s
partner of his death at the same time as he told his mother. The Governor
went to the mother’s home immediately after the hot debrief, but only his
brother was there. The brother telephoned his mother, who insisted that the
22
Governor tell her the news over the telephone. She returned home a short
while later. (In the meantime, the police had also told the man’s partner of his
death.) I am told that any delay in giving the news was due to the Governor
having to ensure that issues at the prison had been adequately dealt with,
travelling to the home and then waiting for the man’s mother to return.
95. The Governor gave the family the direct telephone line to his secretary and
also his personal telephone number so that he could be contacted by them 24
hours a day. He said he received one telephone call from the man’s brother
requesting information about where to view him following his death. One of
the prison FLOs contacted the family to offer to assist with the funeral
expenses and two FLOs from the prison attended the funeral.
96. At the time of the death, the Governor said the family were upset with his
partner, blamed her for his death and did not want her to be involved in the
funeral arrangements. He decided to respect these wishes, rather than
further upset the family by contacting her. He said she was not informed of
the funeral arrangements for this reason. The police were also concerned
that the ex-partner and mother of his two children blamed the man’s partner
for his death and presented a risk to her. The Governor said that he did not
want to worsen this situation either.
97. On 17 March, the man’s partner wrote to the Governor making it clear that
despite the alleged offence, she did not want to be excluded and believed she
had been listed as his next of kin. She was particularly concerned that she
had received a number of letters from him stating his intention to commit
suicide. She had not contacted the prison as she thought he would be safe
there and wanted to know what measures had been taken to protect his
welfare. It is clear from the letter that she was distressed.
98. The Governor replied to the letter on 15 April, writing: “Thank you for your
letter, dated 17 March, 2010, the contents of which have been noted”. The
letter was signed by his secretary. The Governor had no further contact with
her.
99. A further debrief for staff was held two weeks after the death. All the staff said
they were happy with the support and care they had been offered, apart from
one OSG who felt that more could have been done to check on her welfare.
Nurses E and F reported that, since they were the only permanent nurses on
duty that day, they had to keep the emergency response radios which they
found difficult in the circumstances. Nurse F questioned whether agency
nurses could also be tasked with holding the emergency response radios and
being in charge of prison keys.
100. At the time of writing, the post-mortem report was not yet complete. However,
I understand the doctor responsible has given the provisional cause of death
as hanging. The man’s partner said she had heard from the police that he
had a wound on his neck requiring stitches. She wanted to know how this had
happened. None of the staff my investigators spoke to had noticed a wound
on his neck. It may have been confused with the wound on his chin but, until
23
the post mortem is complete, I am unable to comment further and the
question can be resolved at the inquest.
101. I have not had sight of the toxicology report but have been told that he tested
positive for methadone, diazepam and citalopram which were all within
therapeutic levels and had been prescribed to him. Mirtazapine (an anti-
depressant) was also found in his system at a therapeutic level, although it
had not been prescribed to him and it is not clear where he got it from. He did
not test positive for any other drugs or alcohol.
102. The man’s mother asked my investigator why his cell had remained locked for
two months after his death with his belongings inside. The cell did remain
locked for this time, although there does not seem to be a particular reason
other than to ensure that all investigations had been completed. His
belongings were taken to the Governor’s office very soon after his death.
They remained in the Governor’s charge until the prison received the police
and coroner’s permission that they could be returned. (I understand her
concern but the matter is outside the Terms of Reference of this investigation
and should be addressed to the police and coroner.)
24
ISSUES
Information sharing about the man’s risk of suicide
103. On 1 March, police took the man to the Accident and Emergency Department
at hospital where he was assessed as highly suicidal. The clinical reviewer
comments:
“The discharge letter with this information was not faxed to the man’s
GP until 29 March. No date was on the letter. This discharge letter
was not communicated to HMP Birmingham as a result of this failure.
The nurse, in the discharge letter, states she was going to liaise with
the Home Treatment team but this did not happen probably as a result
of being in custody.”
104. I welcome the clinical reviewer’s recommendation to the hospital liaison
psychiatry department regarding the timeliness of information sharing in
relation to a patient’s risk of suicide.
105. Whilst it is unclear whether the police had access to this assessment, they did
have other significant information about the man’s risk of suicide. He had told
the police medical examiner that he felt suicidal. He had also said that he
tried to kill himself when committing the alleged offence and again by taking a
heroin overdose shortly afterwards. The suicide and self-harm warning
marker was ticked on a fax sent by police to the Reliance Head Office on 4
March and was subsequently annotated on the board in the cells at
Magistrates Court when he appeared there. Because of the warning marker,
he was assessed by a CPN based at the court and again assessed as at risk
of suicide. A suicide and self-harm warning form was appropriately completed
and forwarded to the prison.
106. However, the police failed to record that he was a risk of suicide on the PER.
They also failed to pass on any of the above information in relation to his
recent suicide attempts and current feelings in this regard. My investigator
spoke to a Detective Inspector in the Professional Standards Department at
West Midlands Police. He said that the police had made an error by not
sharing this information and that a misconduct investigation had been started
as a result. At the time of writing, this investigation is ongoing. As the
investigation by West Midlands Police falls outside of my remit, I am unable to
comment further and trust that this matter will be effectively investigated by
the police.
Delay requesting the man’s medical records from his community doctor
107. He arrived at Birmingham on Thursday 4 March. That evening, Prison Doctor
A prescribed citalopram and zopiclone. The following day, he was assessed
by the detoxification doctor and prescribed methadone (a previous
prescription confirmed with the local community drug project) and diazepam.
25
108. A fax was received by his GP surgery five days later, on 9 March, requesting
his medical history. The prison’s offender health administrator said it was
likely that she did not make the request for his records until a few days after
he arrived. She explained that because of the volume of new prisoners, a
delay of around four to five days to request the records would be expected.
However, if the community records were urgently needed, there was provision
for the prison doctor to approach the community surgery directly.
109. Whilst the GP said they replied on 9 March, I have not seen evidence of their
fax in his medical record and he was prescribed citalopram until he died.
Medication was therefore seemingly issued to him without any confirmation
from his community GP. He had not previously been prescribed citalopram,
as he claimed to the prison doctor. The clinical reviewer was concerned by
the delay obtaining the doctor’s records and I endorse his slightly amended
recommendation that:
The Head of Healthcare should ensure that requests for medical
information from the community doctor are made within one working
day of a prisoner’s arrival, particularly when the prison doctor expects
to prescribe medication.
Did staff miss any signs that the man was at risk of suicide or self-harm?
110. He was arrested in connection with an offence of violence towards his partner.
Offences of this nature are recognised as likely to increase the risk of self-
harm. He was in the custody of the police and prison for 12 days during which
time he was assessed by numbers of custody and healthcare staff. Their
opinions varied about the risk he presented to himself, as did the steps they
took to ensure that the information was passed on.
111. Following his arrest on 1 March, he was admitted to hospital and discharged
later that day. He told the nurse at the hospital that he regretted not killing
himself the day before and said that he had nothing left to live for. He was
assessed as a high risk of suicide.
112. He also told the police medical examiner that he felt suicidal and had tried to
commit suicide twice the day before. This information was not forwarded to
the prison and the suicide and self-harm marker was not ticked on the PER.
113. He was assessed by a CPN at the Magistrates Court who noted on a suicide
and self-harm warning form that he was tearful, upset and described his
intention to harm or kill himself, given the opportunity. This form accompanied
him to the prison and those who subsequently interviewed him that day had
access to it.
114. Officer B was the first at the prison to assess him. The officer did not have
any concerns regarding his state of mind and he denied any intention of
harming himself. However, this initial interview took place at the front desk
and therefore was not private. In such situations it seems less likely that he
would disclose any personal issues or concerns he was having. I note that
26
following the last inspection of Birmingham, the former Chief Inspector of
Prisons reiterated one of her previous recommendations that such interviews
should take place in a private room. I would also ask the Governor to ensure
that the necessary arrangements are made for this to happen in future.
115. Officer B followed Birmingham’s suicide and self-harm management policy,
which states that when a prisoner arrives with a self-harm or suicide warning
form this must be passed by the reception officer to the healthcare screener,
who was Nurse A. She interviewed him for about ten minutes in a private
room. Although he again denied any intention to harm himself, she was
concerned that he did not make eye contact and noted he appeared
“withdrawn and down”. Whilst she did not have sufficient concerns to start
monitoring under the ACCT process, she did make an urgent referral to the
mental health team for a further assessment.
116. I have considered the reasonableness of the nurse’s decision and believe that
she should have started the ACCT support measures. Whilst I must be
careful not to apply the benefit of hindsight, she knew that earlier in the day he
had clearly stated his intention to kill himself given the opportunity. He was
facing a serious charge of attempted murder against his partner and appeared
withdrawn and down to the nurse. Regardless of his assertions that he was
now “fine” and given that the early period in prison is known to be one of
particular vulnerability, observations made under the ACCT process would
have been a safeguard to check and observe his mental state.
117. Birmingham’s suicide and self-harm management policy states that staff must
be aware of the high suicide or self-harm risks associated with those charged
with violent offences against a family murder or murder. He fell into both of
these categories. The policy also states that often prisoners will “conceal their
intent” to harm themselves.
118. As a result of the nurse’s urgent referral to the mental health team, he was
assessed a few hours later by a RMN. Again, he denied any thoughts of
suicide or self-harm, although he did tell the nurse that he had tied a noose
round his neck and jumped from his home balcony on the night of the alleged
offence. He claimed that this was not an attempt to commit suicide but as a
demonstration to his partner to show how it felt when someone acted in that
manner. Regardless of his intentions, this represented an admission of risky
behaviour which could have resulted in his death. He also told the nurse that
he did not want to be perceived as someone with a mental illness as he
feared this could impact negatively on his court case. This may therefore
have been a reason for him to hide his true intentions.
119. Whilst it has not been possible to establish whether the RMN had access to
the suicide and self-harm warning form, he did have access to the medical
record where Nurse A had made an entry regarding the form and her
assessment of him. The RMN therefore knew that he had previously stated
his intention to kill himself. Given this and his other admissions to the nurse
regarding hanging himself on the night of the offence, it again seems
27
advisable that the nurse should have opened the ACCT procedures,
regardless of his assertions that he felt “fine”.
120. The clinical reviewer concurs with my view, recommending that:
“An ACCT should have been opened as there was clear evidence of a
suicide attempt and mental health assessment within 24 hours of
arrival to HMP Birmingham.”
121. The following day, he was interviewed by an officer as part of his induction
and again denied any feelings of suicide or self-harm. He was also assessed
by the detoxification doctor who did not have any concerns for his welfare.
Prison Doctor B described him as:
“sort of not giving anything away, cheerful and all that, talking on and
on, concerned about his family, concerned about this outside. Then
we’re not sort of thinking how are you yourself kind of thing. I mean
that probably was a facade.”
122. He wrote the first of several letters to his family and friends on 8 March stating
his intention to commit suicide. (I deal later in my report with my concern that,
despite his offence, his mail was not being monitored by prison staff.) None of
the letters were read by prison staff and so they were unaware of their
contents. However, they make it clear that he hid his true intentions from staff
and seemed determined to end his life.
123. In the evening of 11 March, he injured himself, telling staff that he had fallen
over and hit his head on the sink. However, in letters to his partner and ex-
partner he said that this was an unsuccessful attempt to commit suicide.
Nurse B had treated him following the cut to his chin and asked him directly
whether the cut was as a result of him harming himself. He denied this and
the nurse had no further concerns about him. She completed a report of
injury to prisoner form (F213). He was appropriately reviewed throughout the
evening. The following day he was assessed by Nurse C who again had no
concerns about his welfare, describing his mood as “bright and happy”.
124. Birmingham’s violence reduction strategy states that every unexplained injury
must be investigated. This includes incidents where prisoners say they have
fallen out of bed or where the individual’s explanation lacks credibility or the
injuries do not support their account. The investigation process involves the
injury being reported on a F213 form which is then followed up by the safer
custody team. They will then complete an Unexplained Injury Investigation
Form and the incident will also be reported to health and safety staff for them
to investigate as an accident. The injury will then be investigated by the
residential SO, in consultation with the security department, safer custody and
a violence reduction officer.
125. I am satisfied that Nurse B complied with Birmingham’s violence reduction
strategy and his injury would have been investigated. It is impossible to
determine what the outcome would have been. However, both nurses said
28
they did not consider that he was at risk of self-harm or suicide. The clinical
reviewer concludes, “in an ideal world this injury should have been assessed
as a possible suicide attempt if the risk had been highlighted”.
126. On balance, given that he had not been subject to ACCT measures, I do not
find it unreasonable that both nurses did not assess there to be a risk of self-
harm at this stage. From their point of view, this was an isolated incident,
without precedent, he appeared cheerful and they found his explanation
plausible. They would also have known that the injury would have been
further investigated under the violence reduction strategy.
127. He moved to the detoxification wing on 12 March. He was apparently initially
put in a double cell with another prisoner, although it has not been possible to
confirm this with the prison. The information comes from a letter he wrote to
his ex-partner in which he said he was deliberately difficult to the other
prisoner who was therefore moved from the cell. There is no record of this in
the wing history sheet.
128. I have considered whether to make a formal recommendation in this regard.
Records of cellmates and explanations for cell moves are especially important
as they cannot be determined from the computer system. It would seem
prudent that the wing observation book and prisoners’ history sheets are used
to record when cell mates are moved or do not get on. The Governor will wish
to ensure that staff are reminded of their responsibilities.
129. Later that day at around 4.45pm, Prisoner A asked two officers if he could
move into his cell, since he was concerned about him. However, having
spoken to both officers, that prisoner and other prisoners who were present, it
is my impression that Prisoner A did not give the officers any reason to think
that his request was urgent. He himself told my investigator that he did not
think the man was a risk of suicide. The officers said they were unable to
move him at present but would consider his request the following day. In the
circumstances and given the information with which they were presented, this
seems like a reasonable decision.
130. In conclusion regarding the signs that the man was at risk of harming himself,
it is clear that staff had a very difficult task to assess him. He was seemingly
an easy-going and polite prisoner, who claimed that he had no thoughts of
self-harm or suicide. He convinced several nurses, a doctor and numbers of
discipline staff that he was coping within the prison environment. He was also
concerned that any discussions regarding his mental health would be
disclosed to his partner or affect his trial.
131. His letters make clear his determination to hide his true feelings from staff and
his intention to kill himself. Furthermore, crucial information regarding his risk
of suicide from the police and psychiatric department at a local hospital was
not forwarded to the prison in a timely manner. This would have enabled staff
at the prison to gain a more accurate reflection of his mental state. However,
particularly following his initial arrival at the prison, there was evidence to
suggest he was at risk of suicide and in my opinion an ACCT should have
29
been opened. It is impossible to determine whether this would have led to a
different outcome. I recognise that the reception staff assessed him seven
days before his first attempt to harm himself in prison. Nevertheless I make
the following recommendation:
The Governor should satisfy himself that all staff are familiar with the
suicide and self-harm management policy. In particular, they should be
fully aware of indications of a risk of self-harm or suicide and start ACCT
measures where appropriate.
Treatment for drug misuse and administration of prescribed medication
132. On his first night in prison, he was prescribed five days of zopiclone to lessen
any drug withdrawal symptoms he was experiencing. The following day, he
was assessed by the detoxification doctor and tested positive for methadone,
cocaine, benzodiazepines and morphine. He was prescribed methadone.
Despite no spaces being available on the detoxification wing, records indicate
that he received this prescription as directed.
133. The clinical reviewer comments regarding the prescription of
benzodiazepines:
“HMP Birmingham staff had been told by the man himself that he was
also taking illicit benzodiazepines. His urine confirmed the
benzodiazepines but this was taken on 5 March the night after
receiving benzodiazepines in reception. Although this was a
reasonable clinical decision the picture was confused by the
administration of sedation the night before causing positive urine.”
134. The clinical reviewer recommends that prisoners should be tested for drugs in
reception before any medication is administered, especially sedatives. I agree
with the clinical reviewer that, where possible, a drug test should be
conducted by the nurse in reception, prior to any drugs being prescribed.
However, if a prisoner is experiencing withdrawal from drugs, their needs
must be prioritised, rather than delaying to allow for a drug test. Therefore, I
do not make a formal recommendation in this regard but suggest that the
Governor and Head of Healthcare ensure that drug tests are completed at the
earliest opportunity and in reception, where time and resources allow.
135. Following requests from him, the doctor agreed to reduce his methadone dose
from 40mls to 35mls on 10 March. The clinical reviewer notes that “This is a
very conservative reduction within the bounds of good practice”. He was
moved to the detoxification wing on 12 March. Whilst he makes no criticism of
Prison Doctor B’s practice, I note that the clinical reviewer makes an
additional recommendation to the local PCT with regards to the appraisal
system for prison medical staff.
136. The man’s prescription charts could not be found on 12 March when the
nurses were due to dispense his medication. Therefore, he did not receive his
diazepam or citalopram medication until 11.00pm that evening. However,
30
none of the nurses or the doctor my investigator spoke to believed delays in
administering medication were a frequent problem. In this case, the charts
were found and he was given his medication, albeit late. Furthermore, the
clinical reviewer and doctor believed that the delay in his medication by six
hours would not have had a significant impact on his physical or mental well-
being. The clinical reviewer considered, “This is unlikely to have had an
adverse affect on his mental state, and he would have felt very comfortable
after the dose.”
Code system for emergencies
137. There was no code system in place for first responders to use in the event of
an emergency. The staff involved all thought that a code would have helped
them in different ways. Nurse F thought that a code system would be useful
since it would help healthcare staff to know what equipment to carry to the
emergency. She explained that, whilst they always take the general
emergency bag to any request for assistance, if they knew, for example, that a
prisoner had stopped breathing they could also collect oxygen on their way.
138. Conversely, Nurse E said she did not think a code system would have an
effect on the equipment healthcare staff took to emergencies. However, she
did think that it would be useful so that she could psychologically prepare for
emergency situations.
139. SO C told my investigator that it would have been useful for him to have had
more information initially. Had he known the emergency was a hanging rather
than a violent incident, he would have gone straight to M wing rather than
going to his office first to leave his belongings. Furthermore, a code system
could alert the communications room to call an ambulance. The clinical
reviewer also thought that a code system would be useful.
140. The Governor said that he had previously considered introducing a code
system at Birmingham but that when he spoke to the nursing management at
the time about this they did not think it would be beneficial. He subsequently
became convinced of the advantages of such a system and, when my
investigator spoke to him in May 2010, was in the process of introducing
emergency codes.
141. However, my investigator made further enquiries to see if this had been
completed in August 2010. The Head of Safer Custody said that Birmingham
had decided not to implement a code system. This was on the basis that all
equipment was contained in one emergency bag and therefore managers had
agreed that a radio call of “emergency assistance” was sufficient. However,
this bag does not include a defibrillator (although there are nine secondary
first aid bags around the prison) and there are other advantages of having an
emergency code system. For example, staff are more psychologically
prepared to know what type of incident they are responding to. It may also
help to make it clear when an ambulance needs to be called, which was an
issue in the man’s death and is discussed further later in the report.
Investigations following deaths at Birmingham in 2006 and 2008 also
31
encouraged the introduction of a code system. I therefore make the following
recommendation:
The Governor implements a code system to notify responding staff
about the nature of an emergency.
First aid training and equipment carried by staff
142. Having discovered the man hanging, Officer D wanted to use an ambubag to
aid CPR and prevent any risk of infection when conducting mouth to mouth
resuscitation. He was not aware of any staff having been issued with them.
The officer said he would be keen to carry an ambubag or other resuscitation
aid if they were provided by the prison and I therefore suggest that the Head
of Healthcare looks into the feasibility of this equipment being offered to staff.
143. Neither of the two officers or SO who found the man and started CPR had
been recently first aid trained. Staff are trained when they first start working in
the prison but there is no system in place for regular refresher training in basic
life support. Officer D incorrectly believed that the current recommended ratio
of chest compressions to breaths to be five to two. Since 2005 the
Resuscitation Council has recommended a ratio of 30 compressions to two
breaths. The clinical reviewer was also concerned about the lack of training
available for staff and I therefore make the following recommendation:
The Governor should consider providing annual CPR training for all staff
in contact with prisoners.
144. Nevertheless, I believe that the officers generally reacted quickly and
professionally when they found the man. The nurses arrived at his cell within
minutes and Officer D continued to assist them with CPR until Officer E took
over. Due to the delay calling an ambulance, these members of staff had to
continue the resuscitation attempt for 30 minutes until the paramedics arrived.
They should be commended for their efforts in this regard.
145. Staff were content with the debriefs held after the man’s death and were
generally satisfied with the support offered. However, Nurses E and F had to
keep the emergency response radios which, understandably, was difficult for
them. Nurse F suggested that agency nurses, as they are all registered,
could also be tasked with holding the emergency response radios and being
in charge of prison keys. I would ask the Governor and Head of Healthcare to
consider this.
Calling an ambulance
146. Despite my positive remarks about several aspects of the response when the
man was found hanging, I am concerned about the arrangements for calling
an ambulance. The clinical reviewer was also concerned about the delay in
calling an ambulance and recommended that staff are reminded that anyone
32
can call an ambulance and staff responding to an emergency should not
assume someone else has done so.
147. Officer D discovered him at 7.55am. An ambulance was not requested until
8.17am, a delay of 22 minutes. The officer believed it was the control room’s
responsibility to call an ambulance or request more information if they needed
it from those at the cell. He said that since he had communicated that there
had been a hanging, he thought the control room would have automatically
requested one and it was not his responsibility to do so. However, the control
room log states only that he requested urgent assistance. Some other staff
had also been unaware they were responding a hanging.
148. Officer C was unsure whose responsibility it was to call an ambulance but
knew that he could have requested one himself. However, he said he was
occupied with trying to enter the cell and checking for signs of life. Shortly
afterwards, he was asked to complete the routine incident log (of the people
entering and leaving the cell) and he therefore assumed that someone else
had requested the ambulance.
149. Both Nurses E and F said they assumed that the officers who first discovered
the man would have called an ambulance, since he was hanging and not
breathing. On reflection, they said that they should have checked that this
had been done when they arrived at the cell.
150. Other staff said they thought that either the nurses or the first officers to the
cell would have called an ambulance.
151. An operational order issued at Birmingham on 5 May 2009 regarding medical
emergencies states that:
“The officer (or other person) supervising the incident scene may
request that an ambulance is called, prior to the arrival of Hotel Two,
Oscar One or Oscar Two if they believe that the prisoner’s condition is
sufficiently serious to warrant doing so. This is particularly important
where the prisoner appears to be unconscious and/or not breathing.”
152. I am aware that a recommendation was made in this regard in 2008, which
was accepted by the prison. A delay requesting an ambulance is apparently
an issue for another death earlier in 2010. On this occasion I do not believe
that the earlier arrival of an ambulance would have altered the outcome for the
man. This may not be the case in other circumstances and I am concerned to
have to repeat my recommendation here. I therefore make the following
recommendation.
The Governor should remind staff of the contents of his operational
order dated 5 May 2009, emphasising that any member of staff can
authorise the calling of an ambulance in an emergency and staff
responding to an emergency should check that this has been done at
the earliest opportunity.
33
Contact with the man’s family
153. When he first got to Birmingham, he told the reception officer that he would
like his next of kin to be his mother. After his death, the Governor appointed
himself as the FLO, as he considered that the other three trained FLOs were
already working to their full capacity. Whilst it is unusual for a governing
Governor to appoint themselves as the FLO, I am satisfied that the man’s
mother was given adequate support and the opportunity to contact the
Governor should she have wished to do so.
154. However, he also gave his partner’s details as next of kin on two occasions.
Following his death, the Governor spoke to police who did not believe it was
appropriate for his partner to act as next of kin since she was the victim of the
offence. He therefore decided to go to the man’s mother’s house to break the
news, while the police simultaneously went to see his partner. This seems a
reasonable decision and eliminated the possibility of the partner finding out
about his death from a third party.
155. Following the news, the family were initially upset with his partner and did not
want her to be involved in funeral arrangements. Furthermore, the police had
assessed that his ex-partner presented a risk to her since she blamed her for
his death. Due to this and the victim issues involved, the Governor therefore
attempted to avoid antagonising the situation further by contacting her but
would treat his mother as his sole next of kin.
156. The man’s partner wrote to the Governor on 17 March outlining her concerns
about his care. She received a one line reply to her letter, nearly one month
later, which was signed by the Governor’s secretary. It was clear from her
letter that she did not want to be excluded by the prison, despite being the
victim of the alleged offence. It was also clear from the man’s letters how
seriously he had regarded his relationship with his partner. He wrote about
his intention to marry her and that he had made her his next of kin.
157. When my investigator and FLO visited her on 23 April she appeared
vulnerable and had been further distressed by being excluded by the prison.
She had questions, such as when he had been discovered, which my
investigator was able to answer immediately. She also had a number of
issues that she wanted to raise and had not been given the opportunity to do
so until this point. They have already been detailed in this report.
158. She said she found the Governor’s response to her letter particularly
upsetting, due to its brevity and lack of answers to questions she had raised.
It compounded her feelings of being excluded by the prison. She also found it
insulting that it had not been signed by the Governor himself. The Governor
said he had forwarded her letter to the police officers involved in the man’s
death. He felt unable to elaborate further in his letter due to her being the
victim of the offence and the advice he had received from police. However,
the police did not allocate a family liaison officer in the case and therefore she
was left, as she described it, feeling “isolated”.
34
159. National prison guidance for liaison with bereaved families recognises the
term “family” to include those:
“chosen as well as biological and can include: husbands, wives,
partners, significant others, parents, siblings, children, guardians and
others who have had a direct and close relationship with the
deceased.”
The guidance recognises that the FLO will need to take a flexible approach to
who is regarded as family, as well as dealing with family “at odds amongst
themselves”. They may have to deal with several branches of a family all with
equal rights to information and use the services of more than one FLO in
“extreme circumstances of family division”.
160. The Governor clearly had a finely balanced decision to make, given the
family’s feelings towards the man’s partner at the time and the victim issues
involved. However, it is clear from her letter written four days after he died
that she wanted to be involved by the prison. It is my opinion that, particularly
from this time, she should have been contacted by the prison. This could
have been by a different FLO, as suggested in the guidance above or by the
Governor himself. Indeed, by the time my investigator met the man’s mother
on 13 May, she had resolved some of her negative feelings about the partner
and they had visited his grave together.
161. I also believe that the Governor’s reply to the man’s partner’s letter could have
been quicker and more personal so as not to compound her feelings of being
insignificant as far as the prison were concerned. Whilst it is likely many of
the issues she had raised could not have been answered at this stage,
perhaps more explanation of why this was the case and letting his partner
know that the letter had been forwarded to the police would have been helpful
for her to know.
162. The Governor did not complete a family liaison log since he said his memory
is systematic and he therefore did not need to write his decisions down.
Birmingham’s family liaison policy states that:
“The Family Liaison Officer must ensure that all contacts they have
with the family are recorded. This information will be required for the
investigation and will enable the Governor, FLO Co-ordinator and
others to keep up to date and direct the future strategy.”
No doubt the Governor acted with the best of intentions when he took on the
family liaison role. However, in light of his decision not to involve the man’s
partner, I make the following recommendation:
Following a death in custody, the Governor ensures that national and
local guidance available to FLOs is followed and that the prison involves
all branches of a family as appropriate.
35
Letters to the man
163. The man’s mother questioned why it took three to five days for letters to be
delivered to him. The Duty Governor said that this was not an excessive
amount of time given Royal Mail’s delivery schedules and subsequent
processes within the prison before mail is delivered to each prisoner. He was
not aware of any issues which delayed mail being received by prisoners.
164. Since she was the victim of the alleged offence, the man’s partner asked why
he had been allowed to write to her. Birmingham’s policy for reading mail
states that only those prisoners who pose a threat to children, have been
remanded for or convicted of an offence under the Protection From
Harassment Act or of sending obscene mail will have their mail automatically
routinely read. The policy does not refer to adult victims and the Governor
may wish to consider whether it should be included. In addition, if the victim,
police, probation services, social services or member of the public who no
longer wants contact writes to the prison, they will restrict this mail. She had
not made any such request. Therefore he would only have been subject to
the random reading of five percent of his mail, as is the case with all
prisoners.
Visits to the man
165. The man’s mother said that from 4 March she repeatedly tried to book a visit
to see her son. When calling, the telephone line repeatedly went unanswered
or was cut off. After a few days she therefore sent an email to the visits
department, to which they replied but told her they did not have any visits left
for that week (commencing 8 March). The earliest visits they could offer her
were on 17 or 18 March. She therefore booked a visit for the evening of 18
March. His ex-partner had also booked a visit for this day.
166. The visits booking scheme is run by an external company who control all the
telephone and internet booking requests. The prisoner must first of all provide
a list of people whom he wishes to visit him. On 5 March, he applied for his
ex-partner, children, mother and father to be able to book visits. These
names were entered on the computer system and forwarded to the company.
Those wishing to visit then have to telephone the visits booking line or make
an email request, as his mother and ex-partner did.
167. The Duty Governor confirmed that this system could be quite slow and a new
computer had been ordered for the visits team. He said a visit could be
prioritised if the person was put through to the duty governor. The Governor
said that he thought the visits system had improved since the man’s death but
acknowledged that the visits slots were full on most days.
168. As a new prisoner, he was placed on a standard regime under the Incentives
and Earned Privileges (IEP) scheme. (IEP rewards and encourages
prisoners’ good behaviour and has three levels – basic, standard and
enhanced.) Birmingham’s visits policy says that unconvicted prisoners on
standard regime are entitled to three hours worth of visits per week.
36
169. Even though he was an unconvicted prisoner, he did not receive any visits in
the nine days he was in prison. Given that the first days in custody are known
to be a period of increased vulnerability for prisoners and, in some instances
family contact can be a protective factor, this is particularly concerning. He
shared his suicidal thoughts with his family but was unable to see them face to
face. Had he been able to talk to them, circumstances may well have been
different, and he may have been reassured. His family must now live with the
distress of losing him, yet having been unable to see him between the alleged
offence and his death. I therefore make the following recommendation:
The Governor ensures that the visits booking procedure is satisfactorily
functioning and those wishing to book visits are able to do so in line
with Birmingham’s visits policy. Further, the Governor should ensure
that the arrangements for new prisoners are satisfactory.
37
CONCLUSION
170. The man’s behaviour had become increasingly erratic and he had lost a lot of
weight in the months leading up to his arrest for the attempted murder of his
partner. The circumstances of this offence in itself was cause for concern with
regards to the risk of suicide he presented. There were also other indications
of an intention to harm himself which did not get passed to the prison either by
the police or a local hospital.
171. It is clear that once he arrived at Birmingham, he made every effort to conceal
his true feelings from staff and other prisoners and was convincing in this
respect. Whilst staff described him as “cheerful” or “likable”, his letters to his
family and friends indicated a man who was deeply distressed and talked of
ending his life. One piece of paper found in his cell after he died, listed his
concerns as losing his children, losing his partner, upsetting her family, having
no plans for the future, facing a long prison sentence, putting his partner
through a trial and not being strong enough. From his letters, it is apparent
that he had made two unsuccessful suicide attempts in the two nights before
he eventually died. Despite attempting to book visits, his family did not have
the opportunity to see him face to face.
172. Whilst it is difficult to assess a prisoner’s true intentions if they tell staff that
they have no thoughts of suicide, there were indicators and information
available to staff which, I believe, meant that suicide and self-harm prevention
measures should have been started when he first went to prison. However, it
would be complete speculation as to whether these measures would have
allowed him to disclose his true feelings and intentions. It is also impossible
to determine whether they would have had any success in preventing his
death.
38
RECOMMENDATIONS
1. The Head of Healthcare should ensure that requests for medical information from
the community doctor are made within one working day of a prisoner’s arrival,
particularly when the prison doctor expects to prescribe medication.
NOMS accepted this recommendation and responded:
“Work has already commenced in this area.”
2. The Governor should satisfy himself that all staff are familiar with the suicide and
self-harm management policy. In particular, they should be fully aware of
indications of a risk of self-harm or suicide and start ACCT measures where
appropriate.
NOMS accepted this recommendation and responded:
“Work has already commenced in this area.”
3. The Governor implements a code system to notify responding staff about the
nature of an emergency.
NOMS did not accept this recommendation and responded:
“HMP Birmingham have reviewed their emergency response procedures and are
confident that the system in operation is now clear; known to all staff and fit for
purpose.”
4. The Governor should consider providing annual CPR training, such as Heartstart,
for all staff in contact with prisoners.
NOMS responded:
“Due to the size of the staffing population at HMP Birmingham it is felt that that
providing all staff with annual CPR training is unachievable. Training is provided
to staff, however, the risk associated with emergency first response is mitigated
by 24 hour healthcare staff and qualified first aid trained staff within the
establishment. In addition nurses on nights are located centrally and are
therefore able to attend incidents quickly.”
5. The Governor should remind staff of the contents of his operational order dated 5
May 2009, emphasising that any member of staff can authorise the calling of an
ambulance in an emergency and staff responding to an emergency should check
that this has been done at the earliest opportunity.
NOMS accepted this recommendation and responded:
“Work has already commenced in this area with an update operational order.”
39
6. Following a death in custody, the Governor ensures that national and local
guidance available to FLOs is followed and that the prison involves all branches
of a family as appropriate.
NOMS responded:
“This recommendation is already complied with at HMP Birmingham. This
particular case involved multiple next of kins and a decision was made that they
believe was defensible based on the information available at that time and
intended to not antagonise individuals at what was obviously a difficult time. The
decision was also made following consultation with the Police. Information
received anecdotally may indicate a different action may have been taken but this
is with the benefit of hindsight and new information coming to light, i.e. the
partner of the man and his family dealing with their differences. This decision was
taken with the Staffordshire police and HMP Birmingham feel it was the most
appropriate decision at the time.”
7. The Governor ensures that the visits booking procedure is satisfactorily
functioning and those wishing to book visits are able to do so in line with
Birmingham’s visits policy. Further, the Governor should ensure that the
arrangements for new prisoners are satisfactory.
NOMS accepted this recommendation and responded:
“This will be reviewed by the Head of Operations and incorporated into the local
death in custody action plan.”
40