Individual at Rochester

Investigation into the death of a young man
at HMYOI Rochester on 22 September 2004
Report by the Prisons and Probation Ombudsman for
England and Wales
July 2006
This is the report of an investigation into the circumstances of the death of a
young man in HM Young Offender Institution Rochester on 22 September
2004. He was found hanging in his cell just after 10 pm that night. Efforts by
staff and paramedics to resuscitate him sadly failed. He was only 19 years
old.
This report reveals how a series of mistakes and errors of judgement led to
this tragic outcome. The man died while he was not lawfully held in custody.
My investigation team comprised two Assistant Ombudsmen, a Senior
Investigator, an assistant investigator and a governor from HMP Swaleside.
An independent review of the man’s medical care in prison was commissioned
from the Medway Primary Care Trust. Unfortunately, that report was not
complete at the time of writing.
The Investigation Team would like to thank the former Governor and his staff
at HMYOI Rochester for their assistance and co-operation during the course
of this investigation. We are also indebted to the investigating officer from
Kent Police for his very helpful involvement in the early stages of the
investigation. I regret the delay in completing this report. This has been
caused by several factors outside my office’s direct control.
I have made a considerable number of recommendations, reflecting the
seriousness of any young person's death and especially one that occurs in the
circumstances described in this report.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2006
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CONTENTS
Summary
Investigation methodology
HMYOI Rochester
The subject of this report
The young man’s family
Events prior to the man’s death
22 September 2004
Evaluations and conclusions
Recommendations
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Summary
The young man who is the subject of this report was sentenced to a total of 12
months imprisonment in January 2004 for offences of violence and failing to
surrender to his bail. He had been at HMP Chelmsford since 10 December
2003 and returned there upon sentence.
On 16 January 2004, the young man was transferred to HMYOI Rochester
where he quickly settled into the routine of prison life. As part of his support
plan, he had a number of one to one counselling sessions with a
psychotherapist who worked for a charity called Starting Point, based in
Maidstone. It was during these sessions that an attachment began to form
between the young man and his counsellor.
The young man was released on licence on 9 June 2004 and went to live at
an approved premises in Essex. A month later, he received a warning letter
for returning late to the hostel, and at the end of July he was given a final
warning letter. On 29 August, he returned to the premises late. Feeling that
he would be sent back to prison, he packed his bags and left. When he
missed an appointment with his Probation Officer on 1 September, the
Probation Service notified the Early Release and Recall Section at Prison
Service Headquarters with a view to having his licence revoked. The young
man's licence was due to expire on 9 September.
His licence was revoked on 9 September 2004 and his details were listed on
the Police National Computer for him to be arrested and returned to custody.
There was no information making it clear that he could not lawfully be held in
custody once he was returned to a prison because his licence had been
revoked on the day it expired.
Unknown to the authorities, the young man had been living with his counsellor
at her house in Sussex since he left the approved premises in Essex.
On 21 September 2004, a concerned neighbour called Sussex Police to the
counsellor’s address just after midnight. They could not find anyone but later
that morning the counsellor arrived at Eastbourne District General Hospital
with injuries she claimed had been inflicted by the young man. When police
returned to her house at 10.47 am, they found him hidden in the loft. He had
a large number of apparently self-inflicted cuts to his body. The Police
Officers arrested him after a struggle and he refused medical treatment both
at the address and later at hospital.
The police decided to return the young man to prison and question him at
another time regarding the assault on his counsellor and, after a number of
telephone calls, he was taken back to HMYOI Rochester. Once there he
calmed down and allowed his injuries to be treated. The young man told the
prison staff that he was happy to be there but would have killed himself if the
police had not got to him in time.
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A Self harm at Risk Form (F2052SH) was opened for him and it was decided
that he should be checked every 30 minutes. He was put into cell C4-224 on
C wing at 8.15 pm. At 9.45 pm, the Night Patrol Officer noticed that the cell
observation panel in the cell door had been obscured. Other officers were
called and the cell was entered. The officers found the young man in bed but
noticed a torn strip of bed sheet hanging from the cell window. The strip was
removed and the watch was increased to every 15 minutes.
At 11.10 am the next morning, 22 September 2004, Healthcare and prison
staff carried out a case review in relation to his self-harm risk. The young man
was present at the review and it was decided that he should be checked
hourly from then on.
At 9 pm that night, the Night Patrol Officer saw the young man apparently
writing on some paper in his cell. When he looked into the cell again at 10
pm, he saw him hanging by a strip of torn bed sheet from the cell window.
Further assistance and an ambulance arrived but, despite efforts to
resuscitate him, the young man died. The young man had left two suicide
notes, one to his sister and one to his counsellor.
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Investigation methodology
1. The investigation was opened at HMYOI Rochester on 24 September
2004. The Governor and his staff produced the young man’s Core Record
and a number of other documents for examination. Notices were issued to
staff and prisoners informing them of the investigation. My investigator,
was shown around the prison and discussed the circumstances of the
young man’s death with the Governor and his deputy. On subsequent
visits, the investigation team requested and were given other documents
and conducted interviews with prison staff.
2. A Family Liaison Officer (FLO) from the Ombudsman's office contacted
the young man’s family and offered them the opportunity to meet with that
officer and an investigator to offer support, discuss the purpose of the
investigation and to raise any concerns or questions that they would like
explored and addressed. A meeting took place on 2 November with the
young man’s sister. The FLO also contacted the counsellor who agreed to
meet with the FLO and an investigator to discuss her involvement and
offer any support. That meeting took place on 23 November 2004.
3. I asked Medway PCT to carry out a clinical review of the healthcare
received by the young man whilst he was in prison. A doctor was asked to
prepare a report. Copies of the paperwork were delivered by hand to the
doctor and a discussion about the case took place. Several phone calls to
the PCT and the doctor have been made but no report has been
forthcoming.
4. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of my investigation and to request a copy of the Post
Mortem report. Upon completion, I will send this report to the Coroner to
assist him in his enquiries into the death of this young man.
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HMYOI Rochester
5. H M Young Offender Institution Rochester is a closed establishment
that holds sentenced young men between the ages of 18 and 21 years
who are serving less than four years imprisonment. The prison is able to
accommodate 392 young men. During our investigation, the population of
the prison was around 371.
6. The prison has a mixture of single and double accommodation cells
contained on three Victorian wings and a further residential unit of single
cell accommodation, which is used as an Induction Unit. This Induction
Unit (C wing) was the unit where the young man was accommodated on
21 and 22 September 2004.
7. HMYOI Rochester had a new Governor in the same week that the
young man died. He is placing a high priority on developing a
performance culture, improving and developing the regime for prisoners
and the environment for staff and visitors.
8. Rochester recently achieved a good rating in their Standards Audit
inspection. The Security Audit was due to be held in March 2005. There
have been no recent inspections by HM Chief Inspector of Prisons. The
last inspection was in August 1999 when the prison was used for different
purposes, housing adults, Immigration Act detainees, and young
offenders, while C wing was used to house sex offenders under going
treatment programmes.
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The subject of this report
9. The subject of this report was born in 1984 in Dublin, Ireland. He was only
19 at the time of his death. He had an elder brother and two elder sisters. His
parents separated when he was three. His mother suffers from schizophrenia
and his father was given custody of him. The young man's elder sister left
Ireland when he was seven, eventually settling in Essex.
10. The young man would stay with his mother from time to time and, in his
sister's opinion, became adept at 'working the system' from an early age by
observing his mother's involvement with Social Services. He truanted from
school and did not complete his primary education, a fact his sister says did not
raise much concern in Dublin. Despite that, he was a talented painter and
musician.
11. At the age of 17, the young man went to live with his sister and started an
apprenticeship with a local engineering company. He enjoyed the work and
was doing well. The job brought money and with that the ability to buy alcohol.
At a training course about six months into his apprenticeship, he got into a fight
with another employee and was sacked.
12. The young man obtained a job at a nightclub in Colchester, which he
enjoyed. Alcohol abuse was a problem for him and his inability to control his
consumption of it lost him the job.
13. After staying with his sister and then with his brother and his girlfriend, a
local housing association gave him a flat.
14. His sister was aware that the young man had self-harmed on two previous
occasions. The first time he had taken an overdose of his brother's child's
eczema medication. He became very drowsy and was taken to Casualty but
suffered no lasting effects. The other occasion was when he had cut his wrists
prior to a court appearance in December 2003. He had explained to her that it
had been an attempt to obtain a psychiatric assessment to avoid being sent to
prison. She said it was a typical example of him trying to use the 'system' to his
advantage.
15. His sister was aware of the young man's relationship with his counsellor. It
was probably the first serious relationship he had experienced. The young man
was particularly impressed that she was a counsellor. He had said that he was
very much in love with her. In his sister’s opinion, her brother was completely
obsessed with the counsellor. His sister showed my investigator the young
man’s mobile telephone and the text messages on it both to and from the
counsellor professing their love for each other.
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The young man’s family
16. The young man’s sister said that her parents did not have any
questions or concerns regarding his death. They have visited Rochester
with her and her other brother. Her parents were impressed with the
establishment and the staff. His sister explained that they had been
expecting something much worse, assuming that all prisons were like the
prison in Dublin. The Governor had shown the family around the prison
and allowed them time in the cell that the young man had occupied. They
have no complaints about the way staff treated them.
17. His sister said that she had not known about the torn up bed sheet
being found in his cell the day before he died. She was also concerned
about the time that he had died, as she was worried that he had wanted to
be found. She was reassured when my investigator said that it looked as if
the young man had killed himself shortly after 9 pm knowing that staff
would not be returning until 10 pm.
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Events prior to the young man’s death
18. The subject of this report had been convicted of a number of minor
assaults, public order and damage offences dating from November 2002
until December 2003 for which he had received community rehabilitation
orders. He had remained at liberty partly in light of an assessment report
for Colchester Magistrates’ Court prepared by a Consultant Psychiatrist.
19. The young man had told the psychiatrist that he had self-harmed from
the age of 13 and had ‘died twice’ and had to be resuscitated in hospital,
once from cutting his wrists and once from an overdose. He also said that
he cut himself frequently when distressed. This information which came
from the young man is more extreme than the information supplied by his
sister to my investigators.
20. On 9 December 2003, the young man was arrested for failing to
answer his bail on 1 December. A doctor saw him at the police station and
noted scars from apparently self-inflicted cuts to his face and wrists. At
Colchester Magistrates’ Court the following day, he was seen by a
member of the Criminal Justice Mental Health Team who noted numerous
old cuts to the young man’s face, wrists, chest and stomach. His strong
suicidal ideation and intention was also noted, as well as the young man
threatening to further self-harm if remanded in custody.
21. The Court remanded him into custody on 10 December 2003 and he
was sent to HMP & YOI Chelmsford. The committal warrant has a hand
written note on it stating, ‘N.B serious risk of self-harm + suicide. Suicide
watch to be implemented.’
22. Chelmsford opened a F2052SH booklet upon his arrival at the prison.
The concerns of the Court staff were noted and he was put into a double
cell as well as being given access to ‘Listeners’ and the Samaritans'
phone. (Listeners are prisoners who volunteer for training by the
Samaritans to provide support to other prisoners.) The young man
remained in a shared cell throughout his time at Chelmsford. His Cell
Sharing Risk Assessment (CSRA) assessed him as a medium risk,
defined as 'no immediate risk but the situation will need to be reviewed
regularly'.
23. During his First Reception Health Screen he said that he had cut
himself deliberately many times in the past and had attempted suicide by
overdosing, hanging and cutting his wrists. On the same page of the form,
he declared that he was feeling neither suicidal nor having thoughts of self-
harm. He also said that he was not using drugs. It must be understood
that the prisoner supplies the information for this form and, at the time of
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completion, the nurse usually has no means of verifying that information.
Despite his replies he was kept on the F2052SH booklet.
24. On 22 December 2003 at 2.20 am, the young man made cuts to both
his forearms requiring sutures and the application of Steri-strips. He was
placed on a 15 minute watch for a short time. The self-harm is not referred
to again on the F2052SH and there appears to have been no review after
the incident. Furthermore, at the review on 30 December it is not
mentioned.
25. The young man attended Colchester Magistrates’ Court on 9 January
2004 and was sentenced to 12 months imprisonment. He returned to
Chelmsford but was transferred to Rochester on 16 January to serve the
remainder of his sentence. The Senior Officer (SO) in charge of the
reception area that day completed a Cell Sharing Risk assessment form.
He noted that the offence that the young man was in custody for was ABH
and that he had a homophobic tattoo on his chest. The young man also
said that he did get angry and frustrated quickly and that it was immature
behaviour relating to his family. The SO ticked NO to the entire list of anti-
social behaviour in section 2 of the form. Nothing appeared to have
changed since 10 December 2003, yet the young man was identified as a
high risk of harm to others and therefore allocated a single cell.
26. There had been no incidents of self-harm since 22 December and the
young man stated that he was not feeling suicidal and was keen to come
off the F2052SH booklet. His case was reviewed on 20 January 2004 and
the booklet closed. As part of the prison's continuing support, he was
referred to Starting Point, a charity working with young and adult offenders
and their families, for counselling.
27. The young man began to attend one to one counselling sessions in the
Healthcare unit with a psychotherapist who worked for Starting Point. His
first session was 28 January and he had a session almost every week until
2 June 2004. There was a total of 18 sessions.
28. His counsellor had been a volunteer counsellor at Rochester for
Starting Point since August 2002. In October 2002, the Health Care
Manager, sent a memo to the Deputy Governor regarding concerns about
a young prisoner and the way that prisoner behaved around female staff
generally and the counsellor in particular. The young man had been
observed inappropriately crowding the counsellor’s personal space
following a counselling session. The healthcare manager wanted to move
the venue closer to where other staff would be able to monitor and
supervise the sessions. It would seem the counsellor reluctantly agreed.
29. During interviews, three people who saw the sessions conducted by
the counsellor told my investigators that they had cause to voice concerns
to the healthcare manager. These concerns centred on her sitting close to
her clients during the sessions and the fact that some clients knew quite a
lot about her family and personal life, which staff felt was inappropriate.
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The healthcare manager did not either raise those concerns with the
counsellor or investigate further.
30. In February 2004, Rochester considered the young man for release on
Home Detention Curfew (HDC) but on 26 February it was refused. The
reasons for refusal were that he had previously failed to surrender to bail,
previously offended whilst on bail and had two findings of guilt at
adjudication. The most recent adjudication was on 11 February when he
had refused to go to work. Previously, fermenting liquid (an attempt to
make alcohol) was found in his shared cell at Chelmsford.
31. The remainder of his time at Rochester passed without incident and the
counselling sessions continued.
32. On 9 June 2004, the young man was released on licence under the
Automatic Conditional Release (ACR) scheme, having completed half of
his sentence. He lived at an Approved Premises in Essex. That was not a
condition of his licence but he was required live where “reasonably
approved by (his) supervising officer and notify him/her in advance of any
proposed change of address.” His licence was due to end on 9 September
2004.
33. The Deputy Manager of the premises described the young man as a
cheeky, charming, irritating, young man who would make you frustrated
one minute but the next he would be bouncy and happy again. She said
that the premises were run as a “tight ship” but staff would bend over
backward trying to make a difference to the lives of residents.
34. The young man was very anxious all of the time he was at the
approved premises. He wanted to get his licence over successfully but
was worried that he would be recalled and this became more and more of
an issue for him. After the slightest misdemeanour, he would ask, “I’m not
going to be recalled am I?”
35. On 28 July 2004, following his involvement in a fight, the Assistant
Chief Officer (ACO) sent the young man a Final Warning letter. Although
the staff would have been warned that this was coming, the young man
was not required to open it in their presence and his reactions were not
observed.
36. The Deputy Manager said that, on the afternoon of 29 August, the
young man had been feeling very wound up. She spoke to him and lent
him a cd telling him to play it in his room and relax for an hour or so. He
was exhibiting a high level of anxiety as he often did, wanting his licence to
end so that he could rejoin his family and rebuild his life. The Deputy
Manager did not see him again.
37. That night, the young man returned to the approved premises 40
minutes late for curfew. When he asked if he would be recalled, the
member of staff on duty said he could not say what would happen but he
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would have to report it up the line and it would be for others to make the
decision.
38. However, at 2.50 am on the morning of 30 August, the young man's
room was found to be empty. He had taken his belongings and left the
premises. There was no condition of residence. If there had been, when
staff found the young man was absent after curfew they would have
contacted the stand-by Manager who in turn would have discussed the
situation with the stand-by ACO. If it was thought that there was significant
risk to the public, then the Early Release and Recall Section in the Prison
Service would be contacted immediately. In this case, the supervising
officer was informed as she retained responsibility for managing the
licence.
39. The Deputy Manager said that during the period that the young man
was absent, she had several telephone conversations with his sister who
was very concerned about him. She urged the sister to tell him to return
and he would not be recalled. She described, “constant telephone calls
back and forth” to the sister but she did not speak directly to the young
man. If he had returned, every effort would have been made to avoid
having him recalled, as the end of his licence period was so close.
40. As it was, Monday 30 August was a Bank Holiday, and the supervising
officer was not in the office again until Tuesday 31 August. The young
man had left a message on her answerphone to tell her of his intention to
return to Ireland and saying he was at Holyhead. The supervising officer
was a Trainee Probation Officer and, before making a decision about what
action to take, she consulted her line manager and the approved premises.
She confirmed that there were no plans to breach him at present, although
there would be if he went to Ireland, and that the hostel would take him
back if he returned. She could not get through directly to the young man
on his telephone so left a message for him, urging him to return.
41. The young man was in breach of his licence by failing to inform the
supervising officer in advance of a change of address but he had an
appointment to see the supervising officer the following day, 1 September.
With the approval of the Senior Probation Officer, she decided to give the
young man the opportunity to contact by waiting until then to see if he
reported. When he failed to do so, he was further in breach of his licence
and steps were taken to inform the Early Release and Recall Section
(ERRS).
42. The young man was not considered a high risk to the public. The
information was not processed as an urgent case, and immediate recall
was not requested. If it had been, the ERRS would have acted more
quickly. (Immediate recall is requested only if there is considered to be a
high risk to the public or self by the offender.)
43. The young man had been serving a 12 month sentence. Sentences of
12 months up to, but not including 4 years, fall under Automatic
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Conditional Release (ACR) procedures. Prisoners are automatically
released on licence at the halfway point of their sentence, assuming they
do not get earlier release through Home Detention Curfew. The licence
period runs from the day of release to the three-quarter point of their
sentence. The remaining quarter is not under supervision, but the person
is ‘at risk’ of having to serve that portion of their sentence if they are
convicted of a further offence during that period.
44. The young man's period on licence started at 00:01 hours on 9 June
2004 and lasted until 00:00 on 9 September 2004. In practice, prison
establishments cannot release a prisoner at midnight on the day that their
licence expires and so release them instead at some time during the day
before.
45. My investigation team met with several members of ACR Section in
Croydon and were told of the normal recall procedures and timescales set.
The target number of days from receipt of a fax instigating breach
proceedings to receiving a reply from the Parole Board is five working
days. This equates to one day to receive the request from probation, one
day to draft reasons for the Parole Board to consider, one day to send the
paperwork to the Parole Board and two days for the Parole Board to
convene, consider and communicate their result back to ACR section. The
licence revocation is normally issued the same day that the results are
received back from the Parole Board.
46. On 2 September, the Probation Service sent a fax to ACR section in
Prison Service Headquarters saying that the young man had breached his
licence conditions and that they were therefore instigating recall
procedures. The fax was sent at 11am. No action was taken that day by
ACR section.
47. On 3 September, the fax was booked in and identified as requiring ‘fast
track’ procedures. The reasons for the Parole Board to consider were
drafted. No further progress was made over the weekend of 4 and 5
September.
48. On Monday 6 September, the application for licence recall was sent to
the Parole Board for approval. The Parole Board sat on 7 September and
approved the recall. The results of the Parole Board are normally sent to
ACR section the following day. These were duly e-mailed on 8 September
at 09:00 to the head of ACR section who then copied them to team leaders
at 09:42. Caseworkers in the team are then informed of the results. The
identified caseworker was not in the office that day; he was working at
another office in central London. No one picked up his work and no one
processed the young man’s licence revocation. The failure to act on the
Parole Board's decision meant that ACR Unit did not meet their target of
five working days to process a Licence Revocation. More importantly in
this case, it meant that when the licence revocation was issued on 9
September, there was no longer any time left to serve in prison custody
before his original licence expired.
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49. On 9 September, the caseworker returned to the office and completed
the licence revocation for the young man. The revocation was sent to
Scotland Yard and noted on the Police National Computer in the normal
way. There was no note on the Licence Revocation indicating anything
unusual about this revocation. The revocation notice stated, “the
Secretary of State hereby revokes the licence issued on 9/6/04 in respect
of …….. and recalls him to prison... signed on behalf of the Secretary of
State 9/9/04.” The revocation paperwork explicitly states that the named
individual is being recalled to prison. There was no way that police
detaining the young man, nor a receiving prison’s reception staff, could
identify that the Licence Revocation had been issued on the same day the
initial period on licence expired and that therefore there was no lawful
period left to serve in custody.
50. It is now known that the young man and the counsellor had met up
shortly after his release from Rochester and had spent a lot of time
together thereafter. He had been with the counsellor during 29 August and
the early hours of 30 August. Having returned late to the approved
premises in Essex and fearing that he would be ‘breached’, the young man
telephoned the counsellor. She collected him and took him to her house in
Sussex.
51. The counsellor allowed the young man to stay with her at her house.
She says that they were in love and he was there as her partner. He lived
with her and her children until his arrest.
52. Just after midnight on 21 September 2004, Sussex Police received a
telephone call from the counsellor’s neighbour. She was aware that a
young man was living with her and was concerned for her safety. Police
attended the address and saw signs of a disturbance but neither the
counsellor nor the young man were present. Later that morning, the
counsellor contacted the police from Eastbourne District General Hospital,
where a motorist who found her after she had fled her house had taken
her. She told the police that the young man had assaulted her.
53. At 10.47 am on 21 September, Police Officers returned to the
counsellor’s address and eventually found the young man hiding in the loft.
They saw blood and pieces of razor blade around the house. The young
man was bleeding from multiple apparently self-inflicted cuts to his arms
and torso. The Officers managed to detain him after a struggle and,
realising that he required medical treatment, called an ambulance. He
refused to let the paramedics treat him. He was eventually taken to
Eastbourne Hospital where he again refused treatment and had to be
restrained. Eventually he allowed some rudimentary bandages to be
applied and the Police Officers took him to Eastbourne Custody Unit
arriving just after 1pm.
54. The young man was kept in the police van because of his volatile
behaviour whilst the Custody Officer contacted both Lewes Prison and
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Feltham YOI in an effort to return him to custody as required by the licence
revocation. Lewes refused because of his age. Feltham would have
accepted him if he had been arrested in London, but as he was in Sussex
suggested that he be returned to Rochester.
55. It should be noted that the licence revocation document did not indicate
that the prisoner should have been taken to a prison, immediately issued a
new licence, and released. Nor that any detention upon arrival at the
prison would be unlawful. The entry on the Police National Computer
regarding the licence recall merely gave a telephone number at ERRS to
contact. When contact was made, the officers were not made aware of the
situation relating to the young man’s licence, but were faxed a copy of the
licence revocation notice. The notice carries no information about when
the licence expires.
56. The Custody Officer at Eastbourne telephoned Rochester and spoke to
an Administrative Officer (A.O) who works in the Custody Office. Her main
job is to carry out the sentence calculations and confirm discharges. She
does not have the authority to agree to accept prisoners so she rang
Reception and spoke to the SO. He told her to tell the police to bring the
young man and asked the AO to get his back record brought to Reception.
The investigation team were told by the Deputy Governor that, at
Rochester, such a decision should have been made by the Orderly Officer.
Once the young man arrived, the decision to let him stay was taken by a
more senior officer.
57. The young man arrived at Rochester about 4 pm. He was taken to
Reception and into the medical room. He stated that he would have killed
himself if the police had not arrested him. Shortly after the Deputy
Governor attended and spoke with the Police Officers and the young man.
He said that everyone looked tired, the young man was dishevelled and
dirty and already being treated by a Healthcare Officer. The Deputy
Governor believed that the young man had been taken to Lewes and
Feltham before arriving at Rochester. The young man was calm and
stated that he was happy to be back at Rochester. The Deputy Governor
says that he then decided on compassionate grounds that the young man
should stay.
58. The nurse opened a F2052SH at 5.45 pm stating on the form, ‘……..
was brought into Rochester under Police escort, with numerous self
inflicted cuts to both arms, upper body, face and neck. Says he is happy
to be here but would have killed himself if the Police had not got to him in
time.’ At 5.50 pm, she made another entry in the healthcare assessment
section, ‘States he is happy to be here and will not self harm again.’ At
that time she also decided that he should be housed on C wing and in a
single cell.
59. The police had documented a total of 14 injuries to the young man’s
body, a few scratches but mostly cuts of varying length and depth. It was
decided that two of the cuts would require suturing by the prison doctor.
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The doctor gave the young man 10 mg of Olanzapine, a mild anti-
depressant that he had previously been prescribed at Rochester. Another
SO saw the young man when he was in the healthcare unit at about 6.30
pm as his cuts were being sutured. The officer spoke with him for about
30 minutes during which time he was calm and stated that he did not
intend to kill himself nor cause himself further harm. He also
acknowledged that he would have to serve the remainder of his sentence.
The young man thought that he would remain in custody for a further three
months.
60. The doctor made an entry in the F2052SH booklet at 7.45 pm stating,
‘Multiple lacerations to trunk and forearm. Did it 03.00 hrs today. States
“was drunk” at the time. No self harm, suicidal intent.’ She also ticked the
box for him to return to a Residential Unit as opposed to the Admit to
Health Care Centre option. In the case of Rochester, which does not have
the facility to offer in-patient care, prisoners need either to be transferred to
nearby HMP Elmley, which has 24 hour Healthcare, or to a NHS Hospital.
The Healthcare staff at Rochester are on duty until 9 pm.
61. The reception SO said that, even though a formal Cell Sharing Risk
Assessment was not carried out, he remembered that the young man was
assessed as a high risk previously and would have assessed him so
again. As a ‘high risk’ prisoner, the young man would not have been put
into a shared cell.
62. The second SO then made some entries in the F2052SH booklet that
had been opened. He wrote, ‘This prisoner had several serious self harm
wounds that needed stitching by the duty doctor, there were slashes and
cuts all over his torso, arms, forearms, neck and face. Police took him to
hospital for treatment but he refused.’ He then listed his decisions about
how the young man was to be managed on the F2052SH:
° 30 minute watch until seen by outreach team for review.
° Prisoner to be kept in a single cell until reviewed
° Samaritans phone to be made available when requested.
63. During interview, the reception SO admitted that neither a First
Reception Health Screen form nor a Cell Sharing Risk Assessment were
completed for the young man. These are important documents normally
completed shortly after a prisoner’s arrival in Reception. The former asks
a prisoner a number of questions about his health, state of mind and other
medical or addiction problems he may have, the latter is used to consider
the level of risk of putting the prisoner in a cell with another person.
64. The young man was allowed to make a telephone call whilst in
Reception at 8.10 pm. He rang the counsellor’s mobile number, which her
ex-husband answered. It is believed that he told the young man not to call
again and hung up.
17
65. At 8.15 pm, the young man was put into cell C4-224 on C wing, the
induction wing. The cell is on the top landing at the end of the spur,
furthest from the stairwell and the wing office. The windows in the cell
have secondary glazing which slides open to allow access to the small top
windows that can be opened by use of the metal finger loop handles.
There had previously been two notice boards fixed to the walls of the cell.
These had been removed but the curved brackets, about three inches
long, two top and two bottom, had been left. The metal bed was bolted in
place and there was a fixed metal sink and toilet. A small wooden table, a
wood and metal chair and a wooden cabinet with a television on top
completed the furniture. There is no evidence to suggest that any
consideration was given to which cell the young man was put into, other
than what was available.
66. At 9 pm, the Officer Support Grade (OSG), the Night Patrol, looked into
the cell. He was looking out of the window. The OSG asked the young
man if he was ok and he replied “Yes”. At 9.30 pm, when the OSG went to
recheck the young man as required by the F2052SH protocol in place, he
saw that he was in bed, apparently asleep but that the inspection window
in the cell door was partially blocked. He contacted the night duty SO by
radio to inform him of the situation.
67. The SO arrived on C wing shortly afterwards with other officers. The
SO saw that the window had not been completely blocked but it made
viewing into the cell difficult. The SO spoke to the young man, who
appeared asleep, through the door. He got no verbal response, although
he did move. The SO unlocked and entered the cell and spoke to the
young man, who was very sluggish. He told him that the window had to be
kept clear and the young man just grunted in reply. The SO pulled the
blanket down to the young man’s waist to check his injuries and, noting
that all appeared in order, he turned to leave.
68. It was at that point that he saw a torn piece of bedding hanging from
the window. It was about one inch wide and about four feet long and had
been wedged between a wooden batten that was part of the window and
the wall. Although it was not fixed securely to anything, The SO realised
that it could be used as a ligature for self harm and removed it from the
cell. He did not attempt to speak to the young man about his find. Back in
the C Wing office he wrote up the incident in the F2052SH booklet and
appropriately increased the watch to be kept on the young man to 15
minutes. There were no further incidents that night.
18
22 September 2004
69. The young man woke shortly after 8.15 am on 22 September. At 8.45
am, he was asked to get ready to go to Healthcare. He was non-
communicative and at 9.15 am a nurse and a health care worker (HCW)
went to his cell. The nurse, who knew the young man fairly well, explained
that they had to do a case review. She says that he was unwilling to go
over to Healthcare but willing to talk to them. He said he was very tired
and they agreed to return at 10 am.
70. At 10 am, an officer wrote in the F2052SH booklet, ‘Remains
uncommunicative and will not get up.'
71. The nurse and the HCW returned to the young man’s cell at 10.30 am
and they persuaded him to get out of bed and co-operate. He did not go
to Healthcare. There is no mention of this interaction with him in the
F2052SH booklet.
72. A short while later, a F2052SH case review was held in the SO’s office
on C wing. The nurse was present along with a Principal Officer (PO), an
SO, the HCW and the young man. All of the staff say that he presented
well during the review, acknowledging why he was there and generally
taking part in the process. When asked specifically about the ligature
found the previous night, he said that he had done it out of boredom and
shrugged it off. He said that he had assaulted his girlfriend and cut himself
quite badly. The young man said that alcohol played a big part in the
events. He did not divulge who his girlfriend was. The young man said
that he wanted to be at Rochester, he felt safe and that he knew he had
support there. During the review, he was asked about his first night phone
call and he said that he had telephoned his girlfriend. He said that he had
not spoken to her as her ex-husband had answered. He said that he
asked the ex-husband to pass on a message to say that he was sorry. He
did not refer to the call again.
73. The nurse wrote up the case review in the F2052SH booklet at 11.10
am. In the summary she wrote, ‘Tied a ligature to the window as was fed
up about the situation with his girlfriend.' The review team decided on the
following support plan for the young man:
° F2052SH to remain open following protocol
° To be observed hourly when in cell
° Wing to arrange phone call to sister
° Outreach to visit and support daily
° Aware of Samaritans phone if needed during the night.
74. Meanwhile, the AO in the Custody Office was processing the twelve
sets of documents for the new prisoners who had come to Rochester the
previous day. She now believes that the young man’s file had been placed
into his back record the previous night in reception and had been sent to
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Security. She attended a meeting in the late morning and, when she
returned to her desk at lunchtime, the young man’s file was there.
However, her work schedule is to process the new intakes in the morning
and discharges and other work in the afternoon. She placed his file into
her morning tray to be processed the following day. The AO officially had
48 hours to process the file and she would have been within that time limit.
No one at the prison was therefore aware that the young man could not
lawfully be held in custody. He should have been released with a new
supervision licence.
75. The Healthcare staff told the Deputy Governor that the young man’s
girlfriend was his Counsellor. The police had notified the staff. The Deputy
Governor decided that he needed to speak to the young man about that
and sometime during the afternoon he and a Principal Officer (PO) spoke
to him in his cell. The Deputy Governor explained that the prison was
aware of whom his girlfriend was and that she would be excluded from the
prison in her official capacity. However, he said that if she wished to visit
him as a friend that would be allowed. The young man was apparently
very non-committal about that but generally was calm, chatty and
compliant. The Deputy Governor thought that he looked a lot better than
when he had seen him the previous evening. The young man said,
“Thanks for keeping me, I am feeling OK.”
76. The Deputy Governor has said that, due to the confidentiality of the
issue regarding the counsellor, he did not make an entry in the F2052SH
booklet.
77. Also during the afternoon, Sussex Police contacted the prison and told
them that the young man had written ‘F*** your clients’ on a wall at the
counsellor’s house. No Security Information Report (SIR) was generated
as the result of this information. A wing officer made an entry on the wing
book stating that the young man was to be accompanied at all times whilst
off C wing, except when on visits. The reason was the possibility of him
wanting to harm other prisoners who had been counselled by his
counsellor, out of jealousy. This entry was dated but not timed. A later
entry added by the PO read, 'This young man is not to try to contact his
ex-girlfriend who is allegedly a possible victim.’ Again, the entry is not
timed.
78. During the rest of the afternoon, the young man took some exercise
and had some time to associate with other prisoners. He told staff that he
was fine and that he knew that there might be some consequences of his
actions against his girlfriend.
79. At 6.50 pm, an outreach worker was on C wing and the young man
asked to see her. She spoke with him for a few minutes during which he
expressed concern for the counsellor and started talking about how guilty
he felt about everything. The outreach worker, who knew the young man
well, told him that she would see him later in the week. An hour later, he
was out on the wing for association before lock-up for the night.
20
80. At 9 pm, the night patrol OSG looked through the observation panel
into the young man’s cell and saw that he was writing on something. He
had a pen in his hand. He asked how he was and he replied, “Yes I’m
fine,” and gave the officer the ‘thumbs up’ sign. It now seems likely that he
was writing out his suicide notes.
81. Probably after that check, the young man broke off one of the window
openers and used that to remove the wooden surround to one of the
window panes. He then took the pane out completely. He placed it out of
sight at the head of the bed and put the pieces of wood and the window
opener in the cabinet by the door.
82. At 10 pm, the OSG again looked into the cell. He saw that he was
hanging from the window at the rear of the cell, and appeared lifeless. The
officer walked back to the stairwell so as not to alert the other prisoners.
He used his radio to notify the control room that he had a ‘hanging’.
Believing there was nothing he could do to get the young man down, the
officer returned to the wing office. As he arrived, the night SO and other
officers came onto the wing.
83. As they got to the cell, another officer who had been on patrol joined
them. They saw that the young man was hanging from the window, his
lips were blue and there was no movement. An officer opened the door,
and the SO held the young man to relieve the pressure on his neck and
asked for someone to use the scissors to cut him down. It was then that
they realised that the OSG had brought the First Aid green box from the
wing office, not the cut down green box. An officer ran to get the scissors
from the cut down box in the wing office. Meanwhile, the first officer used
his lighter to burn through the ligature and the young man was moved onto
the floor in the corridor as it afforded more space in which the officers
could work. The officers commenced Cardio Pulmonary Resuscitation
(CPR).
84. The Control Room staff had telephoned at 10.08 pm for an ambulance
that arrived at 10.26 pm. It had been delayed for a few minutes as the
crew had gone to HMP Cookham Wood, the women’s prison on the same
estate. The crew then spent some time looking for HMYOI Rochester,
before being directed by their radio controller.
85. When the Paramedics arrived on C wing, they noted from observing
the young man’s skin colour that the CPR was ineffective. In the opinion
of one of the Paramedics, he had been dead for about 30 minutes. They
attached an automatic defibrillator and got a ‘No signs of life’ read out. A
larger machine was then taken from the ambulance and attached so that a
readout could be obtained. It was left in place for 10 minutes after which
they completed a life extinct form.
86. The young man’s body was screened off, the police were called and his
cell sealed.
21
87. The young man had written two suicide notes. One was to his
counsellor, saying sorry for everything including what he was about to do
and professing his love for her. There was a similar note to his sister but
asking her to contact the counsellor and to tell her he loved her.
88. Various senior staff came into the prison as a result of the young man's
death, including the new Governor. A de-briefing session was held about
3 am. Members of the Care Team also attended. All of the staff
interviewed were happy with the level of support offered that night and
subsequently.
89. A notice was displayed where staff collect their keys announcing the
young man 's death. Some staff thought that was not the best way to learn
of the tragedy but could not think of a viable alternative.
90. The prison complied with the contingency plans for a death in custody.
91. The Governor made contact with the young man's family and invited
them into the prison. The family made a trip from Ireland to the prison and
spent some time in the young man's cell and on C wing. When my
investigators spoke with his sister, she said that the family were very
happy with the Governor's response and the way they had been treated.
22
Evaluations and conclusions
Licence revocation
92. The only person who was aware that issuing the Licence Revocation
on 9 September meant that the young man could not be held in prison
custody was the case worker in the ACR unit. He did not communicate
that fact.
93. Given the unusual circumstances, it is surprising that the case worker
did not seek further guidance on dealing with the young man’s revocation
from his line manager and/or the head of unit.
94. Neither the police detaining the young man, nor HMYOI Rochester’s
reception staff, could reasonably have been expected to know or find out
that he could not lawfully have been held in prison on 21 September.
95. The young man took his own life on 22 September, before the Custody
Office at Rochester had calculated his revised release dates (when it
would have become apparent that he should not have been in custody).
96. Whether the young man would have been held in custody by the police
in connection with the assault cannot be known, but the likely outcome
would have been for him to be interviewed and then bailed pending a full
statement being taken from the counsellor.
The young man’s acceptance at Rochester
97. When the young man arrived at Rochester on 21 September 2004, he
was tired, dishevelled and in obvious need of medical attention.
Unfortunately, Rochester is not used to receiving prisoners directly from
either the police or the courts, and was not prepared for it. His arrival
caused confusion and consternation.
98. There was confusion over who had actually agreed to him being brought
to Rochester. The reception SO told the Custody Office AO to tell the
police to bring him. He did not have the authority to do so. When the
young man arrived, a number of staff of various ranks came to see him.
The Deputy Governor spoke to him and agreed that he stay, on
compassionate grounds, after the young man had said that he wanted to
be at Rochester.
99. The young man had 14 self-inflicted injuries visible on his body, some of
which required suturing. He told staff that he would have killed himself if
the police had not arrested him. Rochester does not have 24 health care
cover. Anyone requiring in-patient care or likely to require medical
attention after 9 pm is transferred to HMP Elmley or the local hospital.
100. Despite the presence of a number of senior staff and members of the
healthcare team when the young man arrived, some of the standard prison
23
forms were not completed. These included the First Reception Health
Screen and the Cell Sharing Risk Assessment. The result is that I have to
rely mainly on post death memories regarding his medical condition.
There is no documented record of why he was not put into a shared cell
despite being on an open F2052SH.
101. Rochester has not had a self-inflicted death of a prisoner for a number
of years and this may have led to a high degree of confidence amongst
staff. My investigators found a typical response to be, ‘well we must be
doing something right.’
The cell
102. With the absence of any documentary evidence to tell me how a
decision was made with regard to which cell the young man was to be
placed in, it appears that he was put into the only available cell, C4-224 on
C wing. C wing has four landings on two spurs each with 16 cells on two
floors. The cell was at the far end of one of the first floor landings.
Consequently, he was as far from the wing office as it is possible to be on
C wing. Rochester's own Suicide Prevention Policy & Strategy Document
(SPPSD) states, 'At risk prisoners should be located in cells which
facilitate good supervision, i.e. near wing office.'
103. The interior of the cell had numerous ligature points, including several
hooked brackets on the wall. The young man was able to remove part of
the metal window mechanism, which itself has a finger pull loop to which a
ligature could be tied, and used it to remove the wooden window frame
surround. He then removed the plastic windowpane. The window has
secondary glazing and by sliding it open it is possible to tie a ligature to the
aluminium crossbar, which is what he did.
104. The cell in which the young man was placed was unsuitable for a
prisoner on an open F2052SH booklet.
F2052SH booklet
105. The purpose of this booklet is to inform staff that there are concerns
about a prisoner who may be at risk of self-harm, to record support plans
and details of case reviews, and to record observations and interactions
with the prisoner. It is a tool intended to help prevent incidents of self-
harm or suicide.
106. On his first night in Rochester, observations were increased on the
young man from once every 30 minutes to once every 15 minutes after a
ligature was found hanging from the window in his cell. The increase was
necessary, but prisoners on intermittent supervision should be checked at
least five times an hour at irregular intervals. The checks must not be
spaced at regular, and therefore predictable, intervals. The OSG noted his
observations every 15 minutes, which meant that the timing of his checks
was predictable.
24
107. What has been written in the F2052SH is generally of a good standard.
However, I am concerned that two significant interactions with the young
man on 22 September were not recorded in the booklet, namely the visit
by the nurse and HCW at 10.30 am and the afternoon visit by the Deputy
Governor and the PO.
108. There is a need for further staff training in connection with the
F2052SH and its use.
F2052SH Case Review
109. The case review was held in an office on C wing after 10.30 am, The
notes of the review were written by the nurse at 11.10 am; the time it
began is not recorded.
110. The young man presented well at the review; he was animated and
took part in the review process. That is at odds with how he was
presenting up to that time. The 10 am entry on the booklet reads,
'Remains uncommunicative and will not get up.'
111. The review team was not aware at the time that his girlfriend was a
counsellor at Rochester, but they did know that he had assaulted her quite
badly and would most likely face charges as a result.
112. The team was aware that during the previous night his watch level had
been increased from 30 minutes to every 15 minutes, and that this
increase was made after a torn bed sheet ligature had been found
attached to the window in his cell. The young man said that he was fed up
about the situation with his girlfriend and had made the ligature out of
boredom. The team were aware that he was in a single cell, and had self
harmed quite badly just prior his arrest by the police the day before.
113. There is no record of the decision making process to explain why at the
end of the review his watch was changed from every 15 minutes to hourly.
During interviews with the review team, it became clear that staff had an
honestly held belief that the young man was not at an imminent risk of
committing suicide. I fear that they may have lent too much weight to the
way he presented himself during the review. The nurse and HCW had
seen him twice within the two hours before the review when he presented
in a much less communicative and animated manner.
114. Given the self-harm cuts that the young man had arrived with, the
uncertainty of the situation with his girlfriend, the uncertainty over how long
he would be held in custody, whether he was facing further charges and
his ligature of the previous night, the decision to lower his watch to hourly
observations is difficult to justify. I am not clear what further behaviours
the young man could have demonstrated to warrant a closer watch, other
than an actual suicide attempt.
25
Response to the discovery of the young man hanging
115. The decision whether a lone officer should enter a prisoner's cell at
night is left to his or her judgement and as such I make no comment on the
OSG’s decision in this case. He correctly communicated the information to
the control room staff and, by the time he had returned to the wing office,
the other officers had arrived. Cutting the ligature was delayed by the
OSG bringing the wrong green box back to the cell. The first aid box did
not contain scissors. Rochester's SPPSD in relation to Night Orderly
Officers says, 'Ensure all wing patrol staff carry ligature scissors and
laederal masks.' None of the officers on duty had a means to cut the
ligature but one officer reacted quickly and burnt it through with his lighter.
116. The use of the same green plastic boxes for different emergency
situations leads to confusion.
117. Although summoned in good time, the arrival of the ambulance crew
was delayed by their inability to find HMYOI Rochester. According to the
paramedics, the young man was probably dead when he was first
discovered so the delay may not have been significant in this case but
could be in the future.
The young man’s counsellor
118. The Healthcare Manager,was interviewed in relation to the counsellor’s
role within Rochester and specifically with regard to any staff concerns
about her. He acknowledged the memo submitted in October 2002 which
raised concerns about the way a prisoner was behaving at her sessions.
That concern was dealt with appropriately.
119. He also agreed that several members of his Healthcare Team had
voiced concerns to him regarding the counsellor’s sessions. When asked
what those concerns had been, he replied, "Their concerns were about the
smartness of the young lads as they came over, the amount of care that
they’d put into preparing themselves to actually come to interview. One
point, their use of aftershave, if you like, when they came over. The
relative position of the counsellor and her client within the room and her
sitting posture within the room."
120. Apart from passing the counselling room a little more frequently, the
healthcare manager did not take any further action regarding the concerns
raised by his staff, except to tell them to submit anything objective 'on
which he could act' to him in writing.
121. In interview, he was asked, "In terms of Healthcare staff then having
observed her, any more concerns about observations of what she was
doing or how she was sitting and that sort of thing?" He replied, "Those
actually did rattle on, yes, they did, reasonably persistently but again,
nothing objective that one could get a handle on."
26
122. The counsellor was in a position of trust counselling vulnerable young
men like this young man. Whilst staff did not submit their concerns in
writing to the healthcare manager, any worries about her professionalism
or suitability for her role should have been documented and passed to the
prison's senior management for discussion as to what action to take.
27
Recommendations
National
123. The Prison Service should consider whether to add an attachment
sheet to the Licence Revocation Notice for use in exceptional
circumstances. This additional page could be used to alert police and
prison staff to unusual circumstances, such as when there is no period left
to serve in custody.
124. The Prison Service should review its guidance to staff concerning
officers entering cells alone at night in emergency situations such as a
hanging.
125. The ERRS should review its procedures to ensure that, when a
member of the ACR casework team is not in the office, another member of
the team follows up their work.
Local
126. Healthcare staff should ensure that the decision making process
concerning a patient’s care is evidenced in the medical record in
accordance with the standards of record keeping required by the Nursing
and Midwifery Council.
127. The Governor should remind all staff that any prisoner on an open
F2052SH booklet is allocated a cell and observation level commensurate
with the risk of self-harm they exhibit.
128. The Governor should remind staff of when and what type of entries to
make in the F2052SH booklet.
129. The Governor should review the contents of the Suicide Prevention
Policy & Strategy Document, and consider which staff should carry ligature
scissors.
130. The Governor should remind staff completing F2052SH case reviews
of the need to consider all of the circumstances surrounding a prisoner in
crisis and not to place undue weight on any one factor, such as the
prisoner himself stating that he is ‘okay’.
131. The Governor should arrange for the various emergency boxes in the
prison to be more readily identified by using different colours.
132. The Governor or his representative should liaise with the local
ambulance headquarters to ensure crews are aware of the location of the
prison.
133. The Governor should consider whether there is a case for a disciplinary
investigation regarding Healthcare Manager for failing to take proper action
28
about concerns raised by his staff about the counsellor. (The Governor
has responded to this recommendation when commenting on a draft
version of this report: I would not accept this recommendation, as I believe
that the proper action, without proof, was taken.)
29