James Thomas

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Independent investigation into
the death of Mr James Thomas,
a prisoner at HMP Risley, on 20
August 2017
A report by the Prisons and Probation Ombudsman
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Thomas was found unconscious in another prisoner’s cell at HMP Risley on 17 August
2017. He was taken to hospital but died on 20 August of severe brain injury due to lack of
oxygen. He was 36 years old. I offer my condolences to Mr Thomas’s family and friends.
Other prisoners said that Mr Thomas had been smoking psychoactive substances (PS)
when he fell unconscious, and it appears highly likely that illicit drug use played a part in
Mr Thomas’s death. He had a history of self-harm, substance and alcohol misuse but had
successfully completed an alcohol dependency programmes in custody before relapsing
on release. After recall to custody about two months before his death, he began to use
psychoactive substances (PS).
I am concerned that Risley’s approach to Mr Thomas’s illicit drug use was over-punitive
and was not balanced by supportive measures (such as referral to substance misuse
support services) or by recognition of his personal vulnerability. As a result, Mr Thomas
experienced a very restricted regime, with no television and little time out of his cell, in the
weeks before his death and this may have made him more, rather than less, likely to use P
to alleviate boredom.
Like many prisons, Risley faces significant problems controlling the supply of and demand
for PS and other drugs. I am concerned that individual prisons are being left to develop
local strategies which risk being ill-formed, overly punitive or unable to draw on the
learning of others. In my view, there is now an urgent need for national guidance on the
best measures to combat this serious problem. We have previously made a
recommendation to this effect to the Chief Executive of HM Prison and Probation Service.
We have also written to the Prisons Minister setting out our concerns at the number of
drug-related deaths in custody.
I hope that the learning from this and similar investigations informed HMPPS’ Drug
Strategy which I was pleased to see published in Spring 2019.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister CB
Prisons and Probation Ombudsman July 2019
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 11
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Summary
Events
1. On 10 May 2013, Mr James Thomas was sentenced to eight years and three
months imprisonment for attempted robbery. He was released on licence from HMP
Humber on 6 April 2017 but he was recalled to custody four weeks later after
breaching his licence conditions. He was moved to HMP Risley on 19 May.
2. On 27 July, Mr Thomas was found under the influence of psychoactive substances
(PS). The prison GP wrote to him outlining the dangers of PS but he was not
referred to the substance recovery service for support. His level of privileges under
the incentives and earned privileges (IEP) scheme was reduced to basic, he was
placed on Tackling Anti-Social Behaviour (TAB) monitoring and charged with a
disciplinary offence under prison rules.
3. On 17 August, Mr Thomas told a substance recovery worker that he had smoked
PS but wanted to stop. He said the basic regime meant he did not have a television
and he was using PS because he was bored. She said she would bring some word
puzzles the next day to occupy his mind.
4. At about 5.20pm on 17 August, a prisoner told an officer that Mr Thomas needed
staff assistance. The officer found Mr Thomas in another prisoner’s cell lying on his
back, unresponsive. The officer radioed a medical emergency code and began
CPR. Healthcare staff and ambulance service staff attended and continued
resuscitation. Mr Thomas’s heart responded and he was taken to hospital but did
not regain consciousness. Medical tests showed he had suffered serious brain
injury due to lack of oxygen. Mr Thomas was pronounced dead at 5.27pm on 20
August.
Findings
5. Mr Thomas received limited help for substance misuse from the drugs and alcohol
recovery service at Risley. At the time of Mr Thomas’s death, clinical healthcare
services and substance misuse support services used separate information
recording systems. This meant that although he was a client, substance recovery
workers did not know he had twice been found under the influence of PS. Since
October 2017, however, the substance recovery team has had access to the clinical
information system, and we have not, therefore, made a recommendation about
this.
6. We are concerned that Risley took a variety of disciplinary actions against Mr
Thomas but these were not balanced by supportive measures to tackle his illicit
drug use (for example, referral to support services or recognition of his
vulnerability).
7. Sanctions applied to reduce the supply of illicit drugs at Risley showed insufficient
distinction between users and dealers. The cumulative effect of sanctions under
disciplinary procedures, TAB (usually used for victims or perpetrators of bullying
rather than drug use) and IEP meant that Mr Thomas experienced a very limited
regime. Paradoxically, this may have made it more likely that Mr Thomas would use
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PS to alleviate the boredom caused by such a regime. We are concerned that the
lack of effective and intelligent managerial oversight led to inflexible use of
punishments on minimal information and was not tailored to Mr Thomas’s individual
needs.
Recommendations
• The Governor of HMP Risley should ensure that staff are aware of their
responsibilities in operating the Tackling Anti-Social Behaviour and Incentives
and Earned Privileges strategies in relation to illicit drug use and that measures
taken are proportionate to the individual prisoner.
• The Governor of HMP Risley should ensure that staff always make a referral to
drug treatment services when a prisoner is found to be under the influence of
PS.
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The Investigation Process
8. HMPPS notified us of Mr Thomas’s death on 20 August 2017
9. The investigator issued notices to staff and prisoners at HMP Risley informing them
of the investigation and asking anyone with relevant information to contact her. One
prisoner made contact.
10. The investigator visited Risley on 24 August and 21 September 2017 and on 11
January and 5 February 2018. She obtained copies of relevant extracts from Mr
Thomas’s prison and medical records.
11. The investigator recorded interviews with nine members of staff and one prisoner.
She also spoke to several officers while visiting D wing and a CGL recovery service
manager. One prisoner declined to be interviewed and one member of staff did not
make himself available for interview.
12. In February 2018, the investigator spoke to the Governor about the inconsistencies
of TAB monitoring, the disciplinary approach to illicit drug use and missed
opportunities in maintaining substance misuse support.
13. NHS England commissioned a clinical reviewer to review Mr Thomas’s clinical care
at the prison. He interviewed five members of staff jointly with the investigator.
14. The investigation was suspended in February 2018 while we awaited toxicology
results and a cause of death. The investigation was resumed in July 2018.
15. We informed HM Coroner for Cheshire of the investigation. The coroner gave us the
results of the post-mortem examination. We have sent the coroner a copy of this
report.
16. One of the Ombudsman’s family liaison officers contacted Mr Thomas’s brother, to
explain the investigation process and to ask if he had any matters he wanted the
investigation to consider. He asked what had happened to his brother about three
weeks before his death as he had not contacted their mother since that time, which
had been unusual. He described his brother as very gullible and vulnerable to drug
use because he would readily do anything anyone asked him to do.
17. Mr Thomas’ brother was given a copy of our initial report. He did not make any
further comment. HMPPS also received a copy and did not identify any factual
inaccuracies.
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Background Information
HMP Risley
18. HMP Risley is a medium security prison on the outskirts of Warrington, holding
convicted men. Primary care healthcare services are provided by Bridgewater
Community NHS Foundation Trust, mental health services are provided by Greater
Manchester Mental Health Trust. Drug and alcohol misuse services are provided by
CGL Recovery Service (Change, Grow, Live).
HM Inspectorate of Prisons
19. The most recent inspection of HMP Risley was in June 2016. Inspectors reported
that almost two-thirds of prisoners said it was easy to obtain drugs, compared to
40% in comparable prisons. There was evidence that the availability of
psychoactive substances (PS) was undermining prisoner well-being and was a
major challenge to the prison’s stability, but the problem was being confronted with
some meaningful work. There were not enough full-time activity opportunities and
the regime was restricted. Inspectors said there was a reasonable strategic action
plan to tackle this. Healthcare was adequate. Substance misuse services were
good and the range and content of interventions was excellent and delivered by a
skilled drugs team.
20. Most prisoners said the incentives and earned privileges scheme had not helped
them to change their behaviour. The number of prisoners on the basic level of IEP
had trebled since the last inspection in 2013 and there was not enough focus on the
underlying causes of poor behaviour. Inspectors noted that oversight was
inadequate and they were not confident that reviews for prisoners on the basic level
were sufficiently robust or that behaviour improvement targets were set and
implemented appropriately.
Independent Monitoring Board
21. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to March 2017, the IMB reported
that a reduction in staffing levels had impacted on the running of the prison. It
described Risley as a safe environment despite the lack of drug detection dogs and
high levels of substance misuse which caused disruption.
Previous deaths at HMP Risley
22. Mr Thomas’s was one of three deaths at Risley in 2017. The previous death of a
prisoner in March 2017 was attributed to synthetic cannabinoid (PS) toxicity and we
were concerned in that case at the apparent ease with which PS could be obtained.
We have since investigated a death in March 2018 which also appears to have
involved psychoactive substances.
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Psychoactive Substances (PS)
23. Psychoactive substances, previously known as ‘legal highs’ are an increasing
problem across the prison estate. They are difficult to detect and can affect people
in a number of ways including increasing heart rate, raising blood pressure,
reducing blood supply to the heart and vomiting. Prisoners under the influence of
PS can present with marked levels of disinhibition, heightened energy levels, a high
tolerance of pain and a potential for violence. Besides emerging evidence of such
dangers to physical health, there is potential for precipitating or exacerbating the
deterioration of mental health with links to suicide or self-harm.
24. In July 2015, we published a Learning Lessons Bulletin about the use of PS and its
dangers, including its close association with debt, bullying and violence. The bulletin
identified the need for better awareness among staff and prisoners of the dangers
of PS; the need for more effective drug supply reduction strategies; better
monitoring by drug treatment services; and effective violence reduction strategies.
25. HMPPS now has in place provisions that enable prisoners to be tested for specified
non-controlled psychoactive substances as part of established mandatory drugs
testing arrangements. Testing has begun, and HMPPS continue to analyse data
about drug use in prison to ensure new versions of PS are included in the testing
process.
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Key Events
26. On 10 May 2013, Mr James Thomas was sentenced to eight years and three
months imprisonment for attempted robbery and sent to HMP Manchester. He
moved to HMP Everthorpe in June 2013 and began an alcohol dependency
programme. In March 2014 he was transferred to HMP Humber and continued
addressing his offending behaviour.
27. In March 2017, Mr Thomas’s application for parole was approved. On 9 March, he
discussed with his offender supervisor how he would handle a temptation to drink
on release. He was adamant he would be able to have only one drink as he knew
that returning to Approved Premises (formerly known as a probation hostel) under
the influence of alcohol would risk recall to prison. On 6 April, Mr Thomas was
released from prison.
28. He failed to return to the Approved Premises on 7 May and his offender manager
was unable to contact him. He returned on 9 May and a breathalyser test indicated
that he had been drinking alcohol. His licence was revoked for missing a probation
appointment, failing to reside in the AP, failing to make contact and alcohol misuse.
He was taken into custody by the police and on 10 May, he was returned to HMP
Manchester.
29. Mr Thomas told a healthcare assistant (HCA) during an initial health screen that he
had cut his right wrist three weeks before as he suffered from Post-Traumatic
Stress Disorder due to experiencing sexual assault as a child. He said he had not
harmed himself in prison for several years and did not have current thoughts of
suicide or self-harm. The HCA referred him to the mental health team. He was
given an alcohol screening test to gauge his level of alcohol dependence. As he
showed mild to moderate signs of withdrawal, he was referred to a doctor for a
detoxification assessment.
30. Mr Thomas saw a locum GP on 10 May. He told the GP he had been drinking three
litres of cider a day in the community and had ‘sniffed’ some cocaine the previous
week. He prescribed a Librium detoxification programme to begin the following day.
31. On 11 May, Mr Thomas saw a substance misuse practitioner. He told her he had
drunk three three-litre bottles of cider every day between the period of his release
and his recall to prison. He said he did not take PS, had taken cocaine recently and
was not known to mental health services but would like to be as he had
experienced childhood trauma. She noted that he had a stutter and referred him to
the mental health team regarding the abuse he had experienced.
32. Mr Thomas was monitored by substance misuse healthcare staff for five days.
Although Mr Thomas told a nurse practitioner, that he felt the detoxification had
finished too quickly, the nurse recorded that he was satisfied that there were no
clinical concerns and that Mr Thomas appeared stable and did not raise any
immediate mental health concerns. On 18 May, another nurse reviewed Mr
Thomas’s notes and assessed he was medically fit for transfer to another prison.
He was transferred to HMP Risley on 19 May.
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HMP Risley
33. On reception at Risley, a nurse carried out a new prisoner health check. She noted
Mr Thomas’s history of deliberate self-harm and referred him to the mental health
team due to his history of anxiety and depression linked to past trauma. On 23 May,
after discussion of his case at the single point of referral meeting, he was referred to
CGL, the drug and alcohol service, and placed on the waiting list for counselling. He
was discharged from the mental health in-reach service.
34. On 23 May, Mr Thomas’s offender manager in the community, completed a recall
assessment of Mr Thomas’s risks of offending and harm on OASys, the offender
management system used by prison and probation services. She noted that he
spoke with a stutter and had been bullied at school, partly due to his speech
impediment. She assessed that that he was prone to being easily led by his peer
group due to his learning disability, pronounced stutter and his experience as a
victim of bullying in the past. She noted he was easily influenced by others and
would try to impress those he chose to associate with. He appeared vulnerable and
would let others take advantage of him, which would place him at risk of re-
offending.
35. On 8 June, a prison GP saw Mr Thomas at a routine GP appointment following
transfer. The prison GP told the investigator and clinical reviewer at interview that
Mr Thomas had presented as happy to engage, alert with good eye contact and no
thoughts of self-harm or suicide, but the results of two questionnaires he completed
showed he had mild to moderate depression and anxiety. He prescribed an
antidepressant and arranged to see Mr Thomas in four weeks’ time.
36. On 6 July, a prison GP saw Mr Thomas who appeared well with no obvious signs of
depression or thoughts of self-harm. He did not make a follow-up appointment and
explained to Mr Thomas he could request one if he needed to. The prison GP did
not repeat the questionnaires, which he said would be his usual practice, as he was
confident that Mr Thomas did not present with any significant depressive symptoms.
37. The CGL substance recovery co-ordinator, met with Mr Thomas on 5 June. He told
her he did not use drugs but had problematic alcohol use as he used drinking to
cope with traumatic events he experienced as a child. He said he could cope in
prison but struggled without boundaries and support. She gave him a booklet on
alcohol to complete in his cell and return. Mr Thomas returned it partially completed
on 20 July with a note saying he needed help with completing it.
38. On 27 July, a Supervising Officer (SO) found Mr Thomas in his cell apparently
under the influence of PS. A nurse examined Mr Thomas and found his pupils were
enlarged, slow to react and he appeared to be under the influence. Due to his
speech impediment she did not consider it fair to determine whether his speech was
slurred due to the effect of PS or not. She wrote in his clinical records that she
would liaise with a doctor as to whether Mr Thomas was suitable to keep
antidepressant medication in his cell.
39. A SO placed Mr Thomas on report for breaching Prison Rule 51, paragraph 5, on
the grounds that he “intentionally endangered the health and safety of others or was
reckless as to whether health or personal safety was endangered” and also
downgraded him from entry level to basic, the lowest level of IEP. He also initiated
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Tackling Anti-Social Behaviour (TAB) monitoring and wrote on the monitoring
booklet that it was for “4 weeks min”. The SO submitted an intelligence report but
did not refer Mr Thomas for substance misuse support.
40. The SO did not make himself available for interview so we do not know why he
initiated TAB monitoring (which is usually used for perpetrators or victims of
bullying) in response to Mr Thomas’s drug taking.
41. On 28 July, a GP reviewed the nurses note about Mr Thomas possibly being under
the influence of PS. He decided that Mr Thomas could continue taking an
antidepressant and issued a standard letter to him warning of the dangers of using
PS.
42. Mr Thomas’s disciplinary hearing took place on 29 July. The record of the hearing
states that Mr Thomas refused to attend but said, “I’m guilty,” and that the hearing
proceeded in his absence. The SO and nurse’s accounts were read out. The senior
manager who conducted the hearing wrote in the record that he took into account it
was Mr Thomas’s first finding of guilt. He imposed a punishment of 28 days
stoppage of earnings at 50%, 28 days loss of association, no access to gym for 28
days and no television for 28 days.
43. A SO conducted a TAB review on 3 August. She did not record whether Mr Thomas
attended the review or who else was present. She noted that on 1 August Mr
Thomas was not wearing his basic prison uniform so he would remain on the basic
regime and be reviewed in a weeks’ time. She set a behavioural target for him to
wear the basic kit at all times.
44. On 10 August, the SO held another TAB review. She recorded that Mr Thomas did
not attend due to the wing being locked down. As Mr Thomas was observed by staff
not wearing his basic uniform on 7 August, the SO said he should remain on basic
and be reviewed on 17 August. The SO acknowledged to the investigator that the
entries written by her and other officers in Mr Thomas’s TAB document were limited
in detail.
45. On 12 August, an unnamed officer wrote in Mr Thomas’s TAB booklet “under
influence again!”. An intelligence report submitted on the same day named Mr
Thomas as one of up to 12 prisoners who went into a cell on D wing on 11 July and
appeared to be under the influence of PS. He was not placed on report or referred
to substance misuse services.
46. Mr Thomas’s substance recovery worker, arranged to see him on 15 August but
they were unable to meet as the wing was locked down, so she spoke to him
through his door. He said he was okay and the meeting was rearranged for 17
August.
17 August 2017
47. A SO reviewed Mr Thomas’s behaviour on 17 August. She recorded that Mr
Thomas was not present at the review but did not say why. In response to his
alleged use of PS on 12 August, failure to wear the correct clothing and turning up
late for roll checks, she decided that TAB monitoring would continue.
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48. At 10.30am, the CGL substance recovery co-ordinator, met with Mr Thomas,
noticed that he was wearing prison clothing and asked why. He replied that he was
on basic for smoking PS. She told the investigator she was unaware before this that
he had been downgraded to basic or that he had been suspected of PS use. They
discussed harm reduction and his areas of risk which were boredom, being easily
led by others and managing triggers and cravings. Mr Thomas said he was smoking
PS twice a week. They agreed that he would aim to stop smoking it for the week as
he hoped to be off basic the next week. She said she would bring some word
puzzles the next day to counter boredom as she had run out of them. He agreed to
attend weekly alcohol and PS groups (these are group sessions designed to raise
awareness of the effects of PS and offer harm reduction advice) and she made the
referrals and returned at 3.45pm to give him a relapse prevention booklet which he
accepted.
49. A prisoner on D wing, told the investigator that Mr Thomas and two other prisoners
entered his cell at about 4.40pm when staff unlocked the wing in the afternoon for
association (a period of time when prisoners are free to visit each other’s cells). The
prisoner said they all smoked PS with a pipe. He described Mr Thomas as a
vulnerable person who did not have many friends. Mr Thomas would chat with him
and seemed friendly but had not been in his cell before. He thought he came
because of the two prisoners he was with.
50. The prisoner recalled feeling ‘high’ and then passing out. He said when he woke up,
another prisoner was lying on his bed and Mr Thomas was lying on his back on the
floor with his eyes open. The prisoner on the bed checked Mr Thomas’s pulse and
said he thought he was dead. He told another prisoner to get an officer and they
both left his cell.
51. An officer was approached by a prisoner on D wing who said a prisoner needed
some help. The officer went upstairs to cell 2-08 North accompanied by two other
officers. They found Mr Thomas lying on the cell floor in a crucifix position with three
or four prisoners in the cell, one of whom said Mr Thomas had hit his head. An
officer asked them to leave and checked for Mr Thomas’s pulse but could not find
one. An officer radioed an emergency code and began CPR with another officer. An
officer remained outside the door to prevent prisoners trying to get back in the cell.
52. Shortly before Mr Thomas was found, a prisoner on B wing had collapsed after
suspected PS use. An ambulance had been called at 5.15pm but was stood down
after the prisoner recovered consciousness. An officers request for an ambulance
was, therefore, initially confusing for the ambulance service.
53. A nurse was the first healthcare member of staff to arrive. She put defibrillator pads
on Mr Thomas’s chest but no shock was advised. Paramedics arrived with an
emergency doctor and managed to detect a heartbeat. Mr Thomas was stabilised
and was taken to hospital. He did not regain consciousness and died on 20 August
at 5.30pm with his family present.
Contact with Mr Thomas’s family
54. A senior manager contacted Mr Thomas’s mother to say that her son had been
taken to hospital. A Family Liaison Officer (FLO) was appointed to ensure that Mr
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Thomas’s family were able to visit him in hospital. The prison contributed to the cost
of the funeral in line with national guidelines.
Support for prisoners and staff
55. After Mr Thomas’s death, staff involved in the emergency response had the
opportunity to discuss any issues arising and to offer support. The staff care team
also offered support.
56. The prison posted notices informing prisoners of Mr Thomas’s death and offering
support. Staff reviewed all prisoners assessed as being at risk of suicide or self-
harm in case they had been adversely affected by the death.
Post-mortem report
57. Mr Thomas died as a result of a hypoxic brain injury (serious brain damage as a
result of a lack of oxygen to the brain). He did not suffer a head injury. Toxicology
tests did not detect PS or alcohol. However, this may be because Mr Thomas was
in hospital for three days before his death, allowing time for illicit substances to pass
through his system. The pathologist concluded “it is highly likely that after
consuming Spice [PS] he suffered a cardiac arrest due to a fatal synthetic
cannabinoid.”
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Findings
Effective communication between information systems
58. Mr Thomas received limited help for substance misuse, partly because he did not
disclose his PS use immediately to his recovery co-ordinator. In addition, the
system for picking up new referrals relied on CGL’s attendance at the prison’s
morning meeting to learn about any prisoner found under the influence the day
before.
59. At the time of Mr Thomas’s death, clinical healthcare services and substance
misuse support services used separate information recording systems and CGL
staff would have to ask a member of the healthcare team to access SystmOne (the
healthcare system) on their behalf, which was not always practical. This meant
healthcare staff were unaware of Mr Thomas’s contact with substance misuse
support services.
60. Although Mr Thomas was a CGL client, substance recovery workers did not know
Mr Thomas had twice been found under the influence of PS as they did not have
access to other information recording systems and it was not mandatory to notify
them if a prisoner was discovered using or under the influence of PS. It was only
when Mr Thomas’s recovery co-ordinator noticed he was wearing different prison
clothing and asked why that she found out Mr Thomas had been downgraded to
basic as a direct result of PS use.
61. Since October 2017, the substance recovery team has access to SystmOne, the
clinical information system. This is a positive and long overdue development.
Illicit substances
62. Risley told us they held monthly drugs strategy meetings to discuss intelligence and
identify areas of weakness around the prison to prevent the trafficking of drugs.
While we accept that Risley has a drugs strategy in place and staff are working hard
to implement it, it is clear that more needs to be done to reduce the supply and the
demand for PS.
63. We recognise that this is a serious problem across much of the prison estate, not
just Risley. In our view there is an urgent need for national guidance to prisons from
HMPPS about best practice in reducing the supply of and demand for drugs,
including PS. We have raised our concerns with the Prisons Minister and with the
Chief Executive Officer of HMPPS who has committed to producing a national
strategy for dealing with illicit drugs in the autumn of 2018.
Risley’s response to use of psychoactive substances
64. We are concerned that staff took a variety of disciplinary actions against Mr Thomas
but these were not balanced by supportive measures to tackle his illicit drug use (for
example, by referral to support services) or recognition of his vulnerability.
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65. On the first occasion Mr Thomas was thought to be under the influence of PS, staff
chose a punitive approach of charging him under prison disciplinary rules and
placing him on the basic IEP level. It was the first time since Mr Thomas began his
sentence in 2013 that he had been placed on report and we question whether his
punishment was proportionate.
66. The cumulative effect of a combination of sanctions under disciplinary procedures,
TAB and IEP meant that Mr Thomas experienced a very limited regime from 27 July
until his death. Mr Thomas’s offender manager recognised that being bored placed
him at risk of further offending behaviour. The loss of association, gym, television
and half of any earnings stripped him of most, if not all, opportunities to use his time
productively and may have increased the likelihood that he would fill the void by
using PS.
67. We do not understand why Risley used TAB procedures for prisoners found taking
PS. TAB procedures are usually initiated for the perpetrators or victims of bullying.
In this case they appear to have been used in the same way as the IEP system to
address poor behaviour.
68. Risley’s IEP policy dated December 2015 says that the basic regime has no
minimum or maximum time scales and that clear and realistic targets should be
discussed with the prisoner to assist them to progress. However, Mr Thomas’s TAB
booklet had a minimum time of four weeks written on the cover and, with the
exception of the review which took place on the same day he was found
unconscious, the reviews were perfunctory.
69. We note that a SO said at interview that prisoners could see their TAB
documentation if they wished, but never asked to do so. Although Mr Thomas was
shown in the documentation as having attended the TAB reviews, he does not
appear to have been invited to any of the reviews. There were a series of missed
opportunities to involve agencies, such as CGL recovery co-ordinators or his
offender manager, to introduce a rehabilitative aspect into Risley’s approach to the
use of PS. In our view, the lack of effective and intelligent managerial oversight led
to inflexible use of punishments on minimal information and was not tailored to Mr
Thomas’s individual needs.
70. In addition, the punitive approach was not balanced by supportive measures to help
Mr Thomas tackle his drug misuse. Although he was on the waiting list for
counselling to explore his childhood trauma, he did not receive it in the three
months he was at Risley. His family and his offender manager considered he was
vulnerable, eager to please and easily led but there is no evidence that any action
was considered to support Mr Thomas in this respect.
The Governor of HMP Risley should ensure that staff are aware of their
responsibilities in operating the Tackling Anti-Social Behaviour and
Incentives and Earned Privileges strategies in relation to illicit drug use and
that measures taken are proportionate to the individual prisoner.
The Governor of HMP Risley should ensure that staff always make a referral
to drug treatment services when a prisoner is found to be under the influence
of PS.
12 Prisons and Probation Ombudsman
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Inquest
12. The inquest, heard in August 2024, concluded that Mr Thomas’s death was drug
related.
Prisons and Probation Ombudsman 13
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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