PPO Publishes Report into Death in Custody from Heatstroke

“Serious failings” must be addressed after a man died from heat stroke after being held in a police van and a stuffy court cell on one of the hottest days in 40 years, a watchdog said.

Rafal Sochacki, a 43-year-old Polish national arrested on an extradition warrant, died in Westminster Magistrates’ Court on June 21 2017.

On Tuesday 2nd July a jury in an inquest into his death concluded it was most likely caused by him being subjected to excessive heat, according to the Prisons and Probation Ombudsman (PPO).

After the ruling PPO Sue McAllister published an independent report into the death, identifying “serious failings” which should be addressed.

The van taking Mr Sochacki from Wood Green police station to the court stopped at Charing Cross police station on the way, the PPO report said.

He spent 50 minutes in his cell in the vehicle with the engine and air-conditioning turned off, according to the report.

Temperatures in central London reached over 30C (86F) on June 21 2017 and was regarded as the hottest June day in London for 40 years.

The air-conditioning at Westminster Magistrates Court in Marylebone had not worked for weeks.

Portable air-conditioning units provided staff with some relief from the heat but did not effectively help detainees in cells, the PPO said.

Mr Sochacki arrived at the court “drenched with sweat” and within three hours he was “behaving bizarrely”, picking and pulling at his clothing or shouting and hitting his cell door.

Some two hours later, he was found unresponsive and later died at the court, despite attempts to resuscitate him.

His body heat reached at least 39.6C (103F).

Mr Sochacki died of cardiovascular collapse caused by hyperthermia (severe heat stroke) and hypertensive heart disease, the PPO said.

Ms McAllister will now meet government bodies responsible for court transfers and detention as well as private contractor Serco to discuss changes that need to be made.

She said: “I am very concerned that there were inadequate contingency plans when the court’s air-conditioning failed.

“Our investigation also found deficiencies in the way staff managed Mr Sochacki during his transfer to and time in a cell at Westminster Magistrates’ Court.

“We found some apparent non-compliance by Serco staff in delivering their contracted service and we have drawn this to the attention of both Serco and those responsible for the management of their contracts at HM Prison and Probation Service (HMPPS) and HM Courts and Tribunals Service (HMCTS.)”

Julia Rogers, Serco managing director for justice and immigration, said: “Any death in custody is a tragedy and our thoughts are with the family and friends of Mr Sochacki.

“We are pleased the coroner found that our officers had carried out their duties properly and did everything they could to help Mr Sochacki.

“We have been working closely with the Ministry of Justice (MoJ) and already agreed new procedures to manage extreme temperatures in our vehicles and in the court custody suites.

“The MoJ will also be providing us with a new specialist heat sensory device, that was not previously required, to trial in the custody suites.”

A MoJ spokesman said: “Our thoughts remain with Mr Sochacki’s loved ones and we apologise for our failings in this case.

“Lessons have been learnt from this tragic incident.

“We have established clear procedures when court cells reach set temperatures and when there are excessive delays in collections, and all of our buildings now have ready access to a defibrillator.

“We will continue to learn from this and ensure we are doing everything possible to keep those in custody safe and well.”

The Prisons and Probation Ombudsman wrote in their report:

Mr Rafal Sochacki died of cardiovascular collapse caused by hyperthermia (severe heat stroke) and hypertensive heart disease in a court cell at Westminster Magistrates’ Court on 21 June 2017.
He was 43 years old.
The circumstances of Mr Sochacki’s death are very disturbing. On the way to court he spent 50 minutes parked in an unventilated escort vehicle and was then held for nearly five hours in an unventilated court cell on one of the hottest days of 2017. The court’s air conditioning was not working and police estimated that the temperature in Mr Sochacki’s cell was between 34⁰C and 40⁰C at the time of his death.
I am very concerned that there were inadequate contingency plans when the court’s airconditioning failed. Staff were aware that the temperature in the cells was excessively hot and it is unacceptable that Mr Sochacki and other detainees were left in those conditions for hours.
Our investigation also found deficiencies in the way staff managed Mr Sochacki during his transfer to and time in a cell at Westminster Magistrates’ Court.
We found some apparent non-compliance by Serco staff in delivering their contracted service and we have drawn this to the attention of both Serco and those responsible for the management of their contracts at HMPPS and HMCTS.

Read the Report

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.

Prison: Deaths, Assaults and Self-Harm – and the facts no amount of spin can conceal

 

By Mark Leech

 

 

Look, I get it.

When your back is against the wall and you’re up against it, when every single piece of evidence shows no matter what you do it stubbornly isn’t working, there is a real temptation to find virtue in anything.

But there is no virtue to be found in the latest safety in custody quarterly statistics, where every single one of the key indicators show a continuing annual rise in deaths, violence and self-harm.

Just look at the plain, stripped-of-spin, painful facts.

  • In the 12 months to March 2019, that’s just four weeks ago by the way, there were 317 deaths in prison custody, up 18 from the previous year – of these, 87 deaths were self-inflicted, up 14 from the previous year.
  • Self-harm incidents rose to 55,598 in 2018, a new record high.
  • Incidents requiring hospital attendance rose to a record high of 3,214 in 2018 and the number of self-harm incidents requiring hospital attendance increased by 5% on the previous year to 3,214.
  • Assault incidents increased to 34,223, a record high level in 2018.
  • Annual assault incidents reached a record high of 34,223 incidents in 2018, a 16% increase from 2017.
  • Assaults in the October to December 2018 quarter show a 5% increase on the same quarter of the previous year.
  • The proportion of assaults on staff continue to rise. The proportion of assaults on staff increased to 30% of all incidents in 2018, an increase from 29% in 2017, and a steady increase from 20% between 2008 and 2011.
  • The proportion of assaults on staff (38%) in female establishments in 2018 was higher than in male establishments (29%).
  • In the 12 months to December 2018, there were 3,918 serious assault incidents, up 2% from the previous year.
  • While serious prisoner-on-prisoner assaults decreased by just 1% since the previous year, serious assaults on staff rocketed by 15% (to 995) in the same period.

Now you tell me what has anyone who can read, talk and walk upright, got to applaud here?

When every single indicator across the quarter is at a higher figure than 12 months ago – often reaching yet more ‘new record highs’ – I find nothing to applaud at all.

But Prisons Minister Rory Stewart did.

Indeed despite the reality that every single annual indicator on deaths, assaults and self-harm showed increases, Rory made a video.

In it he managed to keep a straight face while celebrating the fact that, as he saw it, we have turned a corner, there is now light at the end of the tunnel, the signs of success are there he said, and we should all take comfort from the fact that he has it all under control.

No he doesn’t.

It’s one thing to mistake a swallow for the arrival of Summer, but it’s insane to look at these figures and say a single grain of sand means we’ve all arrived on a beach in Ibiza and it’s now Party Time.

No its not.

You can’t look at one quarter’s figures in this custodial world and make presumptions or try and extrapolate it into the future – especially when every single key annual indicator is still on the rise.

This is not a world where exact science works at all.

The prison population is constantly changing,  it’s fluid, it’s a world where there are people with mental illnesses, addictions, learning difficulties, impulsive behaviour issues, gang allegiances, where skilful manipulators and sophisticated fraudsters are at work.

It’s a place where there isn’t and never has been a one size fits all solution to anything.

It’s a world where when you think you’ve got something cracked the whole thing goes tits up proving you haven’t cracked it at all .

Exactly 25 years ago six Exceptional Risk Category A prisoners escaped from the ‘impregnable prison within a prison’ Special Secure Unit at Whitemoor prison, having managed to acquire a gun and ammunition they shot one prison officer and made it out of the unit over two walls and through a fence to short-lived freedom on the other side – the later Woodcock report revealed they’d also managed to smuggle into the SSU one pound of Semtex high explosive.

What seems calm and controlled one minute can blow up in your face the next – and then drop back down again as if nothing has happened just minutes later.

It’s a world where people aren’t afraid of consequences, being sent to prison doesn’t bother them – they’re already there – and they’ve largely spent a lifetime sticking two fingers up to authority and saying ‘fuck you’ whatever may then befall them.

You can take nothing for granted in this custodial world – and certainly not the fragile seeds of hope that even on the best view these figures do not represent.

I know,  I spent 14 years in prison,  during a prison career of riots and roof-top protests, segregation, ghost trains, and 62 different prisons until one day I arrived at Grendon Underwood where the healing process started, where for once I was treated with decency and respect and where my head was taken off and screwed back on the right way round and I haven’t looked back.

But in 61 other prisons it was ‘them and us’ – and consequences were irrelevant; which is why telling the public that the Government has doubled the sentence for assaults on prison officers may appear like progress, but in the real world of prison it’s utterly meaningless – neither prevention nor cure work here, only reasoning succeeds in the end.

I don’t doubt at all that Rory Stewart and David Gauke have the best of intentions but they are political animals, they have a concave view of the world in which they tell lies for a living – no disrespect, it’s just what politicians do – they call it putting a spin on things but to many people it’s just lying.

Yes, the 10 Prisons Project has had some success, I don’t deny that, it was inevitable and it would be strange if the investment in those prisons didn’t see cleaner wings, brighter landings, fresher environments and progress – but there are another 108 prisons where that simply isn’t the case; in fact there are another 108 prisons where things are going from bad to worse and no amount of spin or fresh paint can conceal it.

Don’t take my word for it, just go to the IMB web site and just read the latest annual reports just published.

IMB at HMP Durham: ….The prison has seen large increases in the use of force, assaults, death in custody and illegal use of drugs

IMB at HMP Haverigg …. widespread use of Psychoactive Substances (PS), not only with respect to those addicted to its use but on the general prison population, staff and also on the overall regime.

IMB at HMP Channings Wood …. decline in both the safety and well-being of the prisoners and in the physical condition of their surroundings with a significant increase in the use of the drug Spice and a serious deterioration in the state of the men’s living blocks.

IMB at HMP Hewell say the prison isn’t even fit for the 21st Century – 20 years after we entered it, widespread use of illicit drugs and mobile phones….

And so it goes on.

A splash of spin and a coat of paint can’t conceal reality – Queen Victoria thought the world smelt of fresh paint because, wherever she went, ten feet in front of her was a man with a paint brush; but had she turned the corner, had she gone off-tour, she would have collided with a reality where filth, stench and danger were obvious to anyone who cared to look.

Well, I care to look.

I want to be optimistic, I want to see progress, but equally I refuse to be deceived and distracted by political spin from the reality of a prison world that is, on the statistical facts, one where in terms of violence, death and self-harm it is getting worse not better.

When we’ve had 12 months not 12 weeks (and we haven’t had a single week across all four key indicators yet let’s not forget) of falling figures on deaths, self-harm and assaults in our prisons, when anecdotal evidence matches the figures and confirms that control has been regained and retained then – and not until then – we can say that progress has genuinely been made; rather than just a second-rate video that frankly was as risible to watch as it was as laughable to listen to.

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

HMP Durham: Must Address Violence, Drugs and Deaths says Inspectors

HMP Durham, a heavily overcrowded prison, was found by inspectors to have significant problems with drugs and violence and worryingly high levels of self-harm and self-inflicted and drug-related deaths.

Durham became a reception prison in 2017. Around 70% of the 900 men in the jail were either on remand or subject to recall and over 70% had been in Durham for less than three months. On average, 118 new prisoners arrived each week. Significant numbers of prisoners said they arrived at the jail feeling depressed or suicidal. Self-harm was very high.

Peter Clarke, HM Chief Inspector of Prisons, said: “Our overriding concern was around the lack of safety. Since the last inspection in October 2016, there had been seven self-inflicted deaths, and it was disappointing to see that the response to recommendations from the Prisons and Probation Ombudsman (which investigates deaths) had not been addressed with sufficient vigour or urgency.

“There had also been a further five deaths in the space of eight months where it was suspected that illicit drugs might have played a role.” Drugs were readily available in the jail and nearly two-thirds of prisoners said it was easy to get drugs; 30% said they had acquired a drug habit since coming into the prison. “These were very high figures”, Mr Clarke said, though the prison had developed a strategy to address the drugs problem.

The leadership, Mr Clarke added, was “immensely frustrated by the fact that they had no modern technology available to them to help them in their efforts to stem the flow of drugs into the prison. We were told that they had been promised some modern scanning equipment but that it had been diverted to another prison.” The scale of the drugs problem and related violence meant that technological support was urgently needed.

Since the last inspection at Durham in 2016, violence had doubled and the use of force by staff had increased threefold, though some of the increase in force may have been due to new staff who were not yet confident in using de-escalation techniques. Governance of the use of force had improved.

Mr Clarke added: “There were some very early signs that the level of violence was beginning to decline, but it was too early to be demonstrable as a sustainable trend.”

Alongside these concerns, inspectors noted “many positive things happening at the prison.” These included the introduction of in-cell phones and electronic kiosks on the wings for prisoners to make applications, which had “undoubtedly been beneficial”. The disruption caused by prisoners needing to be taken to court had been reduced by the extensive use of video links.

A new and more predictable daily regime had recently been introduced, increasing access for men to amenities such as showers and laundry on the wings. “For a prison of this type, the time out of cell enjoyed by prisoners was reasonable and it was quite apparent that, despite its age, the prison was basically clean and decent,” Mr Clarke said. It was also good that the leadership saw new staff as an opportunity to make improvements, not an inexperienced liability.

Overall, Mr Clarke said:

“There was no doubt that there was an extent to which HMP Durham was still going through the process of defining, refining and responding to its role as a reception prison. The very large throughput of prisoners gave rise to the risk that taking them through the necessary processes could predominate over identifying individual needs and ensuring favourable outcomes. However, the prison was aware of this risk. The most pressing needs are to get to grips with the violence of all kinds, make the prison safer and reduce the flow of drugs. Only then will the benefits flow from the many creditable initiatives that are being implemented.”

Mark Leech, Editor of The Prisons Handbook for England and Wales said:

“Apart from security, safety must be the primary function of any prison but the number of deaths at Durham, and particularly the failure to implement the recommendations of the Prisons and Probation Ombudsman designed to reduce deaths in custody, is deeply worrying.

“Only yesterday I wrote an open Letter about this issue to the Ombudsman, and this report reinforces the point that prisons must have the resources to implement PPO recommendations otherwise what is the use of them in the first place?”

Prisons minister Rory Stewart said: “We are determined to install full airport-style security with the right dogs, technology, scanners and search teams to detect drugs.

“We will install the technology in Durham and we will be rolling it out across our local prisons. Tackling drugs is vital for reducing violence.”

Deaths in Custody: The Noose Around The Ombudsman’s Neck

pdf version

open letter from Mark Leech The Editor of The Prisons Handbook for England and Wales, to The Prisons and Probation Ombudsman

 

Dear Sue,

Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation.

Did you bother reading each of those words – or notice I had inserted a number in one of them?

Actually, I didn’t, but you went back anyway and read them again; right?

Unfortunately, that isn’t what happens to the ‘Recommendations’ you make in your Fatal Incident Reports into deaths in custody; people don’t go back and read them again.

When you set out your ‘Recommendations’ designed to learn lessons and reduce deaths in custody, no one takes a blind bit of notice of them – and, what’s worse, your Office ignores the fact they’re ignored too.

Tragically you’re not alone in looking the other way. Independent Monitoring Boards (IMBs) in whose prisons these deaths take place, and to whom monitoring the implementation of these Recommendations should be a priority, ignore them too. Year after year, they simply airbrush them out of their Annual Reports as if they have never been made; I will return to this shortly.

Every single Prisons Ombudsman that’s gone before you in the last 25 years at least had the excuse that they’ve never unlocked a prison cell door and found a prisoner swinging dead with a noose around their neck; but as a former Prison Governor you don’t have the luxury of that excuse. You know exactly what it’s like: the shock, horror, frantic attempts at resuscitation, and the wave of utter devastation that then descends on the whole prison afterwards.

Yet, despite that personal experience deaths in custody keep happening and frequently too; as I write this we are six weeks into 2019 and already 20 people have died in our prisons – 17 of whom have seemingly taken their own lives, and eight definitely have.

Your Office still keeps investigating these deaths, still keeps writing their reports, still keeps making recommendations, and still does absolutely nothing when, time after time, those recommendations are ignored – lamentably this week you’ve done it again.

John Delahaye was 46 years old when he was found dead in his cell at Birmingham Prison on 5 March 2018; let me remind you of the catalogue of errors that lead up to it.

Ten weeks before his death Mr Delahaye was taken from Birmingham prison and admitted to hospital almost certainly having taken an insulin overdose; he returned to prison 24 hours later.

In your report into his death published this week, you write:

“When Mr Delahaye returned to Birmingham on 1 January following this overdose, there was no handover between hospital and prison healthcare staff and prison healthcare staff did not know he had returned to prison until the next day. 

I am also concerned that suicide and self-harm monitoring procedures (known as ACCT) were not started until the day after he had returned to prison. In addition, I have concerns about the way the ACCT procedures were managed when they were started. Staff did not effectively investigate why Mr Delahaye had taken the overdose and healthcare staff were not involved. The ACCT was closed prematurely two weeks later, with little having been done to identify or mitigate Mr Delahaye’s risk to himself. This was compounded by the fact that Mr Delahaye was discharged from mental health services after just one appointment.

I am concerned to be repeating recommendations to Birmingham about suicide and self-harm prevention procedures. [emphasis added]

“It is very difficult to understand why Mr Delahaye was allowed to have his insulin back in his possession less than a month after his overdose. I am concerned that NHS guidelines were not followed when this decision was made. 

“I also have serious concerns about the way staff at Birmingham conducted roll checks and unlocks. When Mr Delahaye was found on the morning of 5 March, he had clearly been dead for some time and it seems possible that no member of staff had seen him for more than 13 hours.

“This needs to be rectified urgently. 

“Staff also failed to use an emergency code when they found Mr Delahaye unresponsive. Although this did not affect the outcome for Mr Delahaye, it could make a critical difference in other cases.” 

Now, take a moment to look too at the Birmingham Prison IMB Annual Report published just 10 weeks ago and covering the period in which Mr Delahaye died in the prison. Neither his name, the circumstances of his death, nor the fact that your repeated recommendations had been ignored, are ever mentioned; not even once – they’re airbrushed out of existence; small wonder then why so many consider the IMB as completely and utterly useless?

I would remind you that your Office is not investigating the loss of someone’s property here, but the loss of someone’s life; yet it consistently fails to understand this vital distinction.

I accept the fact you are new to this role, and while there are those who say that as a former Prison Governor you are not the right person to be holding this critical Independent Office, I’m not yet one of them. I think your experience as a Governor means you know where to look, what questions to ask, what answers to demand and having opened cell doors and cut dead people down you know exactly how important all this really is.

The question is: when will we see action from your Office and not just words that everyone, including IMBs, totally ignore?

Yours sincerely,

Mark Leech

Editor: The Prisons Handbook for England and Wales

@prisonsorguk

Recent PPO Fatal Incident (Death in Custody) Reports

The Prisons & Probation Ombudsman has published the following self-inflicted death in custody reports in the last seven days.

Mr Robert McLoughlin was found hanging in his cell at HMP Leeds on 20 February, and died in hospital five days later, on 25 February, never having regained consciousness. He was 32 years old. I offer my condolences to Mr McLoughlin’s family and friends. Although Mr McLoughlin was subject to Prison Service suicide and self-harm monitoring procedures at the time of his death, I am concerned that the prison did not properly address or mitigate his risk factors. Had the suicide and self-harm monitoring procedures operated more effectively, staff might have made more informed decisions about how best to support him. I am concerned that I have repeatedly criticised the management of suicide and self-harm at Leeds and note that the Chief Inspector of Prisons has raised similar concerns. It is essential that the lessons from Mr McLoughlin’s tragic death are quickly and effectively acted upon.

Full report.

Mr Mark Doyle was found hanged in his cell on 22 March 2017 at HMP Pentonville and died in hospital six days later. Mr Doyle was 45 years old. We offer our condolences to Mr Doyle’s family and friends. The investigation into Mr Doyle’s death found deficiencies in the management of the ACCT process, specifically in assessing risk and delivering appropriate levels of observations. Control room staff did not immediately call an ambulance when the emergency was raised. Faulty cell bells were not reported and were not checked daily as required. We are troubled that mental health staff did not consider all available information in considering Mr Doyle’s referral. There have been six self-inflicted deaths at Pentonville since 2016. We are very concerned to repeat in this report recommendations that have been made in previous investigations into deaths at Pentonville. Given these concerns, the Prisons Group Director for London and Thames Valley should commission a review on the operation and management of the ACCT process at HMP Pentonville. As part of this review, he should, in particular, assure himself that HMP Pentonville has effectively implemented all PPO recommendations following self-inflicted deaths at the prison in the last five years and provide a report to me outlining progress within 3 months of receiving this report.

Full report.

Mr Jack Denison died of sepsis and pneumonia at hospital on 31 May 2016, while a prisoner at HMP Wymott. He was 86 years old. I offer my condolences to Mr Denison’s family and friends. Mr Denison was a frail man with several health conditions which healthcare staff managed well. I am satisfied that his care in prison was equivalent to that he could have expected to receive in the community and healthcare staff could not have prevented his death. Although it did not affect the cause of death, I am concerned that poor communication between HMP Garth and Wymott resulted in Mr Denison missing vital hospital appointments. There was no medical input to the security risk assessment when Mr Denison was taken to hospital and managers gave insufficient consideration to the impact of his health on his level of risk. It is also a concern that Mr Denison’s next of kin details were not updated when he arrived at Wymott.

Full report.

Mr Gary Lines was found hanged in his cell at HMP Northumberland on 18 September 2015. He was 44 years old. I offer my condolences to Mr Lines’ family and friends. Prison staff had begun suicide and self-harm prevention procedures when Mr Lines harmed himself on 13 September, but case reviews were not multidisciplinary and healthcare staff were not involved. No one checked Mr Lines’ community prescription from the time he arrived in prison on 8 August and he was not prescribed antidepressants, which he said he needed to help drive off suicidal thoughts, until the day before he died. While I consider it would have been difficult to predict that Mr Lines was at high and imminent risk of suicide, I am concerned that a lack of effective information sharing and consideration of his risk factors led to his risk being underestimated and a low level of observations. On the morning he was found hanged, I am not satisfied that staff checked Mr Lines’ wellbeing effectively.

Full report.

Mr John Duffey was found hanged in his cell at HMP Liverpool on 16 July 2016. He was 44 years old. I offer my condolences to Mr Duffey’s family and friends. Mr Duffey was a military veteran with a diagnosis of post-traumatic stress disorder and depression. He had a long history of illicit drug use and alcohol abuse. The investigation found deficiencies in the operation of suicide and self-harm prevention procedures at the prison. I am concerned that this is not the first time that I have found suicide and self-harm prevention procedures to be inadequate at Liverpool. However, I do not consider that staff at Liverpool could have predicted that Mr Duffey intended to take his own life when he did and, therefore, could not have prevented his actions. Fellow prisoners said that Mr Duffey was a regular user of ‘Spice’, a new psychoactive substance, that he was being bullied and was in debt for drugs, but the investigation found no evidence to corroborate these claims. Nevertheless, I note the ease with which Mr Duffey appeared to have been able to acquire illicit drugs at Liverpool and the prison needs to increase its efforts to combat the risks posed to prison safety particularly by new psychoactive substances.

Full report.

Did prisoners take their lives because they could no longer face violent, drug-ridden jail? – Chief Inspector

Peter Clarke, HM Chief Inspector of Prisons, has asked whether prisoners in HMP & YOI Nottingham took their own lives because they could no longer face life in the violent, drug-ridden jail.

In one of the most disturbing inspection reports in recent years, Mr Clarke posed the question in relation to eight apparent self-inflicted deaths between inspections in February 2016 and January 2018, part of an “appalling and tragic” picture of suicide and self-harm in Nottingham.

The formal cause of death in those cases will be decided by inquests but Mr Clarke said: “For too long prisoners have been held in a dangerous, disrespectful, drug-ridden jail. My fear, which may prove to be unfounded, is that some could face it no longer and took their own lives.”

HM Inspectorate of Prisons (HMIP) inspected the East Midlands jail in 2014. That was, like the vast majority of inspections, an unannounced visit. Safety then was assessed as poor, the lowest grade. The following inspections in 2016 and 2018 were, unusually, announced in advance. Despite this, safety was yet again found to have remained at a poor assessment. This spurred Mr Clarke to invoke the first ever use of a new ‘Urgent Notification’ protocol, which requires the Secretary of State for Justice, publicly, to take personal responsibility for improving a jail with significant problems. This centred on a “dramatic decline” at Nottingham and a “persistent and fundamental lack of safety”.

Mr Clarke said: “This prison will not become fit for purpose until it is made safe. It was clear from our evidence that many prisoners at Nottingham did not feel safe.” Inspectors identified disturbing findings:

  • Forty per cent of prisoners in the inspection survey said they felt unsafe on their first night in the jail; 67% that they had felt unsafe at some point during their stay; and 35% that they felt unsafe at the time of the inspection. Well over half reported bullying or victimisation.
  • Reported violence had not reduced since 2016, with 103 assaults against staff in the six months before the inspection. In the same period, there were nearly 200 incidents of prisoners climbing on the safety netting between landings. Inspectors said the overall level of disorder “contributed to a tense atmosphere at the prison.”
  • Well over half of prisoners said drugs were easily available and 15% had acquired a drug problem since entering the prison.
  • Use of force by staff had increased considerably since 2016 with nearly 500 incidents in the six-month period prior to the inspection, yet governance and supervision of such interventions were weak.
  • Just under half of prisoners had mental health needs and a “very high” 25% – 116 prisoners – were under psychiatric care. A quarter of prisoners said they felt suicidal on arrival in Nottingham.
  • Levels of self-harm were far too high, with 344 occurrences recorded in the six months up to the inspection.

Not surprisingly, Mr Clarke said, “in a prison which could be defined by the prevalence of drugs and violence, the level of suicide and self-harm was both tragic and appalling. Since our previous visit, eight prisoners had taken their own lives, with four of these tragedies occurring over a four-week period during the autumn of 2017.  Just a few short weeks after this inspection, a ninth prisoner was believed to have taken his own life.

“We were concerned that some repeated criticisms related to these deaths made by the Prisons and Probation Ombudsman (PPO) (which investigates prison deaths) had not been adequately addressed. For example, cell call bells were still not being answered promptly.”

Mr Clarke added: “We do not claim that the prison had been completely inactive in the face of these challenges. A new violence reduction strategy had been prepared in late 2017… However, this work was fitful and had yet to have an impact.” The prison also had a drug supply reduction policy, though it was not embedded and was not effective.

Inspectors also acknowledged an increase in staff numbers in recent months, though they noted that “too many staff were passive, lacked confidence in dealing with issues or in confronting poor behaviour, and prisoners did not yet see them as reliable or able to deal with the many daily frustrations they faced.”

Health care was reasonably good, and there were plans to improve mental health provision. Daily routines were more predictable and more activities were available for prisoners. There were also “some creditable efforts to prepare men for release”.

The prison governor assured inspectors they had understood the scale of the problems. Mr Clarke said: “I am hopeful that the Urgent Notification will galvanise Her Majesty’s Prison and Probation Service (HMPPS) to provide the support the prison needs to make it an acceptable environment in which to hold prisoners. If this is to happen, there will need to be levels of supervision, support and accountability that have been absent in the past.” The HMPPS action plan drawn in response to the Urgent Notification in January 2018 promised “much that is welcome in terms of review, audit and analysis. However, this must all be translated into tangible action to improve the day-to-day experience, safety and well-being of prisoners. Unless this happens, I fear that progress will be neither substantial nor sustainable.”

Overall, Mr Clarke said:

“This was yet again a very poor inspection at Nottingham that left me with no alternative but to bring matters directly to the attention of the Secretary of State by invoking the urgent notification procedure. The record of failure, as set out in this report, cannot be allowed to continue.”

Michael Spurr, Chief Executive of Her Majesty’s Prison & Probation Service, said:

“We published an immediate response to the Chief Inspector’s concerns on 14 February and have today published a comprehensive plan setting out the practical actions we are taking to improve conditions at HMP Nottingham. Drug testing has been increased, specialist staff are working with vulnerable prisoners and safety is the absolute priority for the Governor and staff every day. We have strengthened management arrangements, are providing external support and will monitor progress closely over the coming months.”

A copy of the full report, published on 16 May 2018, can be found on the HM Inspectorate of Prisons website at: www.justiceinspectorates.gov.uk/hmiprisons

Prison Deaths From New Psychoactive Substances Rises To 79 Says Ombudsman

spice

The number of prisoner deaths in which the use of new psychoactive substances (NPS) may have played a part has now risen to at least 79, said Prisons and Probation Ombudsman (PPO) Nigel Newcomen. Tonight (11/7/2017) he addressed the All-Party Parliamentary Group on Penal Affairs at the House of Lords.

Looking back at his six-year tenure, and discussing the rise in self-inflicted deaths in prisons, Mr Newcomen said the prison system was yet to emerge from a crisis. He discussed major themes that have emerged from his investigations and studies into deaths in custody that need to be acted upon, and mentioned the problem of mental ill-health among prisoners, which needs to be better recognised by staff and, if recognised, better managed.

 

Nigel Newcomen said:

“As well as mental ill-health, another contributory factor to the increase in suicide in prison is the epidemic of new psychoactive substances. My researchers have now identified 79 deaths between June 2013 and September 2016 where the deceased was known or strongly suspected to have taken NPS before death or where their NPS use was a key issue during their time in prison. Of these investigations, 56 were self-inflicted deaths.

In the past, Mr Newcomen has highlighted the four types of risk from NPS:

  • a risk to physical health – NPS use may hasten the effects of underlying health concerns;
  • a risk to mental health, with extreme and unpredictable behaviour and psychotic episodes, sometimes linked to suicide and self-harm;
  • behavioural problems, where the NPS user has presented violent or aggressive behaviour, which is often uncharacteristic for that prisoner; and
  • the risk of debt or bullying, as the use of NPS often results in prisoners getting into debt with prison drug dealers.

Nigel Newcomen said:

“Establishing direct causal links between NPS and the death is not easy, but my investigations identified a number of cases where my clinical reviewers considered that NPS led to psychotic episodes which resulted in self-harm. In other cases, NPS led to bullying and debt of the vulnerable, also resulting in self-harm.

“NPS is a scourge in prison, which I have described as a “game-changer” for prison safety. Reducing both their supply and demand for them is essential.

“But neither mental ill-health, nor the availability of NPS wholly explain the rise in suicides in prison. Every case is an individual tragedy with numerous triggers. And, in such complex circumstances, the safety net of effective suicide prevention procedures is essential. Unfortunately, too often my investigations identify repeated failings in prison suicide prevention procedures.”

Mark Leech editor of The Prisons Handbook said: “This further rise in prison deaths attributable to NPS is deeply concerning, it shows that despite a range of measures introduced by HMPPS, and a Thematic Review by the Chief Inspector of Prisons in December 2015, these dangerous drugs continue to cause deaths inside our prisons.

“Research shows that synthetic cannabinoids, usually known as Spice or Black Mamba, form the only category of illicit drugs whose use by prisoners is higher in prisons than in the community, 10% compared to 6%, and there is no easy answer to it – many of those who take NPS say they do so for reasons of boredom one solution therefore is to resource the Prison Service to deliver the active purposeful regimes that have been steadily stripped away since 2010.”

The Prisons Handbook: Further reading and research on NPS can be found at the following links

■ NPS in Prisons – a Toolkit for Staff: http://www.nta.nhs.uk/uploads/9011-phe-nps-toolkit-update-final.pdf

■ Drug Misuse: Findings from the 2015/16 Crime Survey for England and Wales https://www.gov.uk/government/statistics/drug-misusefindings-from-the-2015-to-2016-csew

■ Changing patterns of substance misuse in adult prisons and service responses. A thematic review by HM Inspectorate of Prisons https://www.justiceinspectorates.gov.uk/hmiprisons/ wp-content/uploads/sites/4/2015/12/Substance-misuseweb-2015.pdf

■ Adult substance misuse statistics from the National Drug Treatment Monitoring System (NDTMS)1st April 2015 to 31st March 2016 http://www.nta.nhs.uk/uploads/adult-statistics-from-thenational-drug-treatment-monitoring-system-2015-2016[0].pdf

■ HM Chief Inspector of Prisons for England and Wales Annual Report 2014–15 https://www.justiceinspectorates.gov.uk/hmiprisons/wpcontent/uploads/sites/4/2015/07/HMIP-AR_2014-15_TSO_ Final1.pdf

■ HM Chief Inspector of Prisons for England and Wales Annual Report 2015–16 https://www.justiceinspectorates.gov.uk/hmiprisons/wpcontent/uploads/sites/4/2016/07/HMIP-AR_2015-16_web-1. pdf

■ Spice: the bird killer (User Voice May 2016) http://www.uservoice.org/wp-content/uploads/2016/05/ User-Voice-Spice-The-Bird-Killer-Report-Low-Res.pdf

■ Project NEPTUNE guidance, 2015 www.neptune-clinical-guidance.co.uk/wp-content/ uploads/2015/03/NEPTUNE-Guidance-March-2015.pdf

■ Harms of Synthetic Cannabinoid Receptor Agonists (SCRAs) and Their Management. Novel Psychoactive Treatment UK Network NEPTUNE http://neptune-clinical-guidance.co.uk/wp-content/ uploads/2016/07/Synthetic-Cannabinoid-ReceptorAgonists.pdf

■ Ministry of Justice press release, 25 January 2015 www.gov.uk/government/news/new-crackdown-ondangerous-legal-highs-in-prison

■ Centre for Social Justice, ‘Drugs in prison’, 2015 http://www.centreforsocialjustice.org.uk/library/drugs-inprison

■ EMCDDA, European Drug Report 2015: ‘Trends and developments’, June 2015 www.emcdda.europa.eu/publications/edr/trendsdevelopments/2015

■ Drugscope, ‘Not for human consumption: an updated and amended status report on new psychoactive substances and ‘club drugs’ in the UK’,2015 http://www.re-solv.org/wp-content/uploads/2015/06/Notfor-human-consumption.pdf

■ PHE, ‘New psychoactive substances. A toolkit for substance misuse commissioners’, 2014 www.nta.nhs.uk/uploads/nps-a-toolkit-for-substancemisuse-commissioners.pdf

■ Home Office, ‘Annual report on the Home Office Forensic Early Warning System (FEWS). A system to identify new psychoactive substances (NPS) in the UK’, September 2015 https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/461333/1280_EL_FEWS_Annual_ Report_2015_WEB.pdf

■ Global Drug Survey 2016 https://www.globaldrugsurvey.com/past-findings/theglobal-drug-survey-2016-findings/

A copy of the speech can be found on the PPO’s web site from 14 July 2017. Visit www.ppo.gov.uk.