Discharged: Dead – When Truth Falls Through The Trap Door

 

By Mark Leech FRSA. Editor: The Prisons Handbook

I remember it all like it was yesterday – and I doubt I will ever forget.

The 23rd May 1985 was a bitterly cold day in Dartmoor prison as the howling wind whistled off the local Tors and I found myself once again shivering as I walked alone Midnight Express style around a small caged exercise yard in the E.Hall punishment block of a prison built to hold Napoleonic prisoners of war 200 years before.

I was serving 56 days’ solitary confinement, completely my own fault, having just spent two weeks protesting about the change in parole policy by the then Home Secretary Leon Brittan, on the roof of Long Lartin Maximum Security prison in Evesham.

In the cage next to me was a young man called David Greenhow, 23 years old, with learning difficulties, his hair matted with mucus he occupied the cell next to mine and I would often hear him screaming in the night.

That day he spent his hour of exercise standing against the wall of the cage rocking backwards and forwards – he was in E.Hall for repeatedly kicking his cell door in the main prison, he couldn’t explain why, and the Governor had responded by placing him in the E.Hall punishment block for what was euphemistically called the ‘Good Order and Discipline’ of the prison.

We never spoke that day, not once, I asked him how he was but he never responded, his ceaseless rocking backwards and forwards left me with the impression of a young man more in need of help than punishment, and I continued my circular walk lost in my own thoughts against the biting Dartmoor wind.

It was three hours later when I heard the first Officer shout, followed by the stampede of feet to the cell next door. Urgent voices rang out ‘Get the Minuteman’ – the resuscitation machine – but by the time that arrived 20 minutes later from the hospital at the other side of the prison, David Greenhow was beyond help.

His young life ended there, dangling from a ripped bed sheet that he had tied around the cell window bars. This young man, with his whole future stretching out before him, had chosen to take his own life rather than face the anguish of going through even one more day.

That evening the police arrived, they spoke only to prison officers and stayed long enough to rule out foul play. According to the later Inquest Report what were then called the ‘Board of Visitors’, but are today known as Independent Monitoring Boards (IMB) – the supposed ‘watchdogs’ of the public interest – never attended that night. The Chairman, according to the report, had been telephoned at home and advised of the death but seemingly saw no reason to drive the 20 miles from his home in Plymouth to the prison; the man was dead, so what?

Even a century ago, at least in Reading Gaol, the Chaplain called.

At 11pm as I looked through the drill hole in the centre of the spyhole fitted into my cell door I watched as David Greenhow’s lifeless body, wrapped in a green blanket and strapped to a wheelchair, was pushed along the landing outside my cell door to a waiting ambulance on what was to be his final journey in this world – a trip to the hospital mortuary.

David Greenhow was just one of many I have seen choose death over life to prison suicide over the years, it’s hard for those who have not experienced the devastation of despair that descends on a prison wing after someone has taken their own life to explain it, but there is a silence that wasn’t there before, some people talk in hushed whispers while others resort to morbid comedy to cope: “He was too young to be hanging around bars anyway.”

I’ve heard it all – but every death in custody is an event that I never forget and it is to this day what focusses my attention and drives me to confront the horrors of lives needlessly lost which are simply written off as par for the prison course by those who should know better.

Recently some on social media have criticised me for focussing on this, for not understanding, they assert, ‘the issues’; for seemingly misunderstanding the roles that certain officials have to play, and for critically pointing out that too many of today’s IMBs fail to mention in their annual reports how deaths in custody in the prisons that they monitor are treated as events unworthy of any real attention.

They’re wrong: I do understand, and too well as only someone who has been through it too many times can do.

The fact is that lessons that should be learnt from each death are not only routinely ignored, but the very fact that they are ignored is itself shamefully unworthy of any acknowledgement or note.

For every death in custody in England and Wales the Prisons and Probation Ombudsman (PPO) conducts an investigation, attempting to learn lessons to prevent the next death. They make a plethora of well-intended recommendations designed to prevent repetition, pointing out where things went wrong, how events may have turned out differently if the rules, regulations, practices, procedures, policies and previous identical recommendations made for the second, third and fourth time had been followed.

But they’re not followed; indeed they are almost routinely ignored, without consequence to those who ignore them, but not to those who later die needlessly when they may have been saved.

In IMB annual reports every year, and I read them all, so often the text relating to the number of deaths that have occurred in the prisons these IMBs ‘monitor’ are cut and pasted from one annual report to the next, with only the often increasing numbers changed from one year to the next.

Today, as I write this, 29th June 2019, the PPO published yet another death in custody report, this time into the death by hanging of 30 year old James Turnbull at HMP Durham. In that report the PPO again points out to HMP Durham the failures to implement the same recommendations in respect of Mr Turnbull’s death that the PPO had made previously to Durham Prison – and which like so many before it remain ignored and not implemented.

Mr James Turnbull was found hanged in his cell on 23 December 2017 at HMP Durham. He was 30 years old. Mr Turnbull experienced a severe decline in his mental health in the weeks before he died. His transfer to a psychiatric hospital had been approved and he was awaiting a bed space when he died. The investigation found there was a delay in arranging a psychiatric assessment for Mr Turnbull. If he had been assessed more promptly, it is possible he may have been transferred to hospital earlier where he could have received appropriate treatment. 

Staff managed Mr Turnbull under suicide and self-harm prevention procedures (known as ACCT) when his mental health declined. Initially, they did this well. However, I am concerned that staff wrongly assessed his level of risk and stopped ACCT procedures prematurely. They restarted ACCT procedures on 20 December, after Mr Turnbull told them he had been thinking of ways to hang himself, but worryingly, stopped them just over 24 hours later. I am concerned that despite Mr Turnbull’s continued paranoid behaviour, his pending transfer to psychiatric hospital and a recent stated intention to take his life, he was not being monitored under ACCT procedures when he died. Previous investigations at Durham have identified similar deficiencies in assessing prisoners’ risk and managing ACCT procedures. The Prison Group Director needs to satisfy himself that staff at Durham are properly applying ACCT procedures to protect prisoners at risk of suicide and self-harm. 

Why were the recommendations by the PPO of failures in the past to carry out the mandatory suicide and self-harm procedures correctly at Durham not implemented – and why were these later criticisms even required at all?

Durham is a prison with a shocking record of suicides – precisely perhaps because the lessons and PPO recommendations are neither learned nor implemented. But the failure to implement death in custody recommendations is not something the IMB at Durham found worthy of any note at all – indeed they imply that all is well when it clearly isn’t.

In the latest HMP Durham IMB annual report, covering the period November 2017 (a month before Mr Turnbull died) to October 2018 and published in March 2019, this is what they say:

“Over the last year deaths in custody have increased from 7 (2017) to 11 (2018). Out of the 11 deaths this year, no Coroner’s report is available. The Board have been informed promptly of these deaths and where possible have observed the initial actions and subsequent investigation. All Prison and Probation Ombudsman (PPO) reports have been monitored by the Board and discussed with the Governor. The prison action plans have been monitored accordingly. “

Not a single word about the death of Mr Turnbull, indeed none of the 11 prisoners who died at Durham during this year warrant any specific mention at all. There is nothing, not a word, about the criticism of the PPO and the prison’s failure to implement previous recommendations – and the fact is they must have known when writing their annual report because every prison and its IMB are given the contents of PPO Reports within weeks of a death, and often well over a year before the report itself is made public.

Instead the Durham prison IMB just make the risible claim that PPO reports have been monitored; what on earth does that even mean?

This isn’t just happening at Durham, this is a nationwide problem where IMBs fearful of rocking the Ministry of Justice’s ‘boat’ prefer silence to sanction, concealing from the public whose loved ones have died in their jail, how their deaths might have been prevented if the prisons they monitor had implemented recommendations made previously and ignored.

This problem was made more obvious recently when Anne Owers, the Chair of the National IMB Management Board, issued her first National IMB Annual Report on 5th June 2019. Because this report is merely a rehashing of the flawed IMB annual reports from Boards around the country, this too made no mention at all of any failures, by any prison, to implement PPO recommendations on deaths in custody.

Indeed when you read this report, which others who ought to know better have commended, you will find that the word ‘death’ or ‘deaths’ in this 56 page report appears just once, as a passing reference only, on page 11.

This lamentable fact was forcibly brought home in the Ministerial Response to the National IMB Annual Report when the Prisons Minister, Robert Buckland QC, responded formally to the Report on 28th June 2019 – in which he failed to mention even once, the subject of deaths in custody.

It is not just IMBs and Ministers who are to blame for this, the independent Prisons and Probation Ombudsman are themselves complicit in this concealment – and it starts right on Day One.

The PPO is advised immediately there is a death in custody. But they make no announcement about it, they conceal what deaths they are currently investigating and they have absolutely no mechanism in place for monitoring the implementation of their recommendations at all – which is why prisons ignore them with impunity and without consequence.

That concealment is supported by both HM Prison and Probation Service and the Ministry of Justice, neither of whom make public when someone has died in their care; they leave that to journalists to discover when news ‘leaks’ out days or weeks later – if at all.

The PPO is the first to trumpet its alleged independence, it makes much of it in every report they publish, but the fact is that this is little more than a mirage.

When a person dies in the custody of the State the PPO should announce they are investigating, there should be an online list of current investigations, it can be anonymised, there are sensitivities of next of kin to be considered and the judicial process of an Inquest to consider too, I understand all that. But the very fact they are investigating a death in custody, where it happened, when it happened, male or female and the age of the deceased should be made public – this is the United Kingdom, not North Korea.

This concealment has to stop.

I recently conducted a search of our Fatal Incident database, it contains all the PPO Fatal Incident Reports and I conducted a search of how many reports the PPO had issued on deaths in custody where the PPO had been forced to repeat recommendations that had been made previously but ignored – recommendations that had to be made again when further death in similar circumstances had occurred; the almost 100 cases runs to some six pages.

Unless we learn the lessons of why so many die in custody, unless we are open and transparent about deaths, acknowledging immediately when they occur, unless the PPO can put in place a robust mechanism for monitoring the implementation of their recommendations – and IMBs can be honest about when that implementation just isn’t happening – then people will continue to die, perhaps needlessly, in our prisons.

And, just like 35 years ago when 23-year-old David Greenhow was being driven out of the gates of Dartmoor Prison for the final time, the facts is that prison officials will continue to stamp the front of far too many prisoners’ records with the brutal self-explanatory text: “Discharged: Dead”.

Mark Leech FRSA, is the Editor of The Prisons Handbook for England and Wales.