3. Memorandum submitted by INQUEST
PRISONS AND OVERCROWDING
INTRODUCTION
INQUEST is the only non-governmental organisation
in England and Wales that works directly with the families and
friends of those who die in custody to provide an independent
free legal and advice service to bereaved people on inquest procedures
and their rights in the Coroner's Court. We provide specialist
advice to lawyers, the bereaved, advice agencies, policy makers,
the media and the general public on contentious deaths and their
investigation. We also monitor deaths in custody where such information
is publicly available and identify trends and patterns arising.
INQUEST is unique in working directly with the
families of those who die in all forms of state custody—in
which we include deaths in prison, young offender institutions,
secure training centres, immigration detention centres, police
custody, while being detained or in contact with the police, shot
by the police or following pursuit, and those detained under the
Mental Health Act.
We have accrued a unique and expert body of
knowledge on issues relating to deaths in custody and seek to
utilise this towards the goal of proper post-death investigation
and the prevention of custodial deaths. INQUEST has been at the
forefront of working alongside bereaved people to bring the circumstances
of the deaths into the public domain and under public scrutiny
and to hold the relevant authorities to account. We have reported
our concerns about custodial deaths and their investigation at
a national and international level.[9]
INQUEST has been frustrated by the failure to
learn the lessons from deaths occurring in different custodial
settings and the lack of joined up learning between agencies.
In our view this has resulted in more deaths occurring because
of the failure to approach this serious human rights issue in
a holistic way. Many of issues arising from deaths in custody
need to be fed into the wider agenda for social inclusion of government,
local authorities and voluntary sector. Many of the deaths which
occur are part of a pattern which impact on policies on combating
racism, drug and alcohol use, homelessness, mental health, crime
prevention and policing.
To this end we recommend the setting up of a
Standing Commission on Custodial Deaths which would bring together
the experiences from the separate investigation bodies set up
to deal with the police, prisons, hospital deaths and the others.
Such an over-arching body could identify key issues and problems
arising out of the investigation and inquest process following
deaths and it would monitor the outcomes and progress of any recommendations.
It could also look at serious incidents of self-harm or near deaths
in custody where there is a need to review and identify any lessons.
Arising from this it would develop policy and research, disseminate
findings where appropriate and encourage collaborative working.
Lessons learned in one institution could be promoted in the other
institutions, best practice could be promoted and new policies
designed to prevent deaths could be drafted and implemented across
all the institutions. It would play a key role in the promotion
of a culture of human rights in regard to the protection of people
in custody.
The Standing Commission should also have powers
to hold a wider inquiry where it sees a consistent pattern of
deaths. Such an inquiry could give voice to and a platform for
examination of those broader thematic issues and those issues
of democratic accountability, democratic control and redress over
systemic management failings that fall outside the scope of the
inquest. One of its functions would also be to lay the past to
rest and assisting the process of effecting real and meaningful
change.
This submission details current concerns arising
from our casework and monitoring of the investigation and inquest
process following deaths in prison. Many of these deaths raise
concerns about inhuman and degrading treatment and systemic failings.
INQUEST highlights the following issues arising
from prison deaths:
— a disturbing number of self-inflicted
deaths in prison of people who had a known previous psychiatric
history;
— the rise in the number of youth deaths
and in particular of remand prisoners, and the need for an understanding
of the needs of young people;
— deaths of children in penal custody—both
Youth Offender Institutions and Secure Training Centres;
— ongoing concern about the deaths
of women in custody;
— the link between prison deaths and
inadequate or inappropriate health care;
— the increasing number of drug related
self-inflicted deaths in prison of prisoners who are not given
treatment and support for drug withdrawal;
— the stereotyping of black people
with mental health problems;
— the use of prison as a "place
of safety" for those with serious mental health problems;
— the number of deaths taking place
in segregation units particularly of those at risk of suicide;
— the number of self-inflicted deaths
which occur within Health Care Centres;
— the need for a reduction in the use
of imprisonment for vulnerable people, Prisoners with mental health
problems are often a risk more to themselves than to others as
the increasing catalogue of self-inflicted deaths in prison reveals;
— inadequate policies to deal with
bullying;
— lack of training in suicide prevention
and awareness—training in suicide prevention is no longer
mandatory;
— inadequate attention to health records,
failure to share paperwork that identifies an individual's high
risk of self-harm or suicide, lack of communication between staff
within the prison;
— there has been a pattern of failure
to acknowledge self harming behaviour as an expression of distress
which has often led to such behaviour being treated as a discipline
problem and for clearly distressed people to be placed in segregation
rather than receiving appropriate care;
— continuing problems with cell design,
access to ligature points—in particular cell bars;
— the need for diversion schemes for
those suffering from mental health, drug and alcohol problems;
— the failure of the Prison Service
to implement recommendations made by HM Chief Inspector of Prisons;
— problems with the investigation and
inquest system in particular the delay in holding inquests which
as the only public forum in which these deaths are subjected to
public scrutiny frustrates the learning process;
— the limited scope of the inquest
and the fact that it can not consider sentencing policy and allocation;
— there is no central monitoring or
publication of jury findings and coroners recommendations following
prison death;
— the failure of the Prisons and Probation
Ombudsman reports to take into account evidence from inquests
and jury findings/coroners recommendations.
INQUEST currently has 166 open prison death
cases within its caseload. We highlight a number of these cases
that illustrate our concerns.
This year (2005) a number of inquests have taken
place into the deaths of women in prison where juries have highlighted
serious issues of concern regarding the treatment and care of
women withdrawing from drugs, the regime and the conditions in
which they were held.[10]
In June two inquest verdicts were returned into the deaths of
Tina Bromley who died on 4 January 2004 aged 37 at HMP
Edmunds Hill and Sue Stevens who died in HMP Durham on 21 February
2003 aged 48. Both juries found significant failings in the
prison service in relation to the care of these two vulnerable
women, one with a history of drug problems and one with a long
mental health history. In the case of Tina Bromley the lack of
communication regarding her detoxification regime was criticised
as was moving her from a shared cell to a single cell. The jury
at the Sue Stevens inquest criticised the prison for unsatisfactory
planning of her move from HMP Holloway to HMP Durham resulting
in an inadequate assessment of her self-harming tendencies.
Emma Levey HMP Downview died on 4 November 2004
Emma was 24. The jury at her inquest found that
she took her own life whilst the balance of her mind was disturbed.
They added that "Emma repeatedly requested further psychiatric
care but was unable to receive this as Downview had no regular
psychiatrist . . ." In fact the psychiatrist had left the
prison in August and had not been replaced. The jury heard that
because of health service re-organisation the GP at the prison
could not access any consultant psychiatric advice from the NHS.
Louise Giles—HMP Durham died on 20 August
2005
Louise is one of four women to have taken their
own lives in prison this year. Louise Giles had a long history
of self harm whilst outside prison (approx 20 overdose attempts
between the ages of 13 to 19). On entry to Newhall prison in October
2002 she self harmed and tried to kill herself on 40 separate
occasions. She was remanded to HMP Durham where again the same
pattern of self harm and suicide attempts emerged. On the 20 August
2005 aged 20 she was found dead with a ligature around her neck.
In September 2005 Chief Inspector of Prisons, Anne Owers, called
for the remaining women prisoners in Durham to be moved as a matter
of urgency. A number of women had already been moved after a previous
report in May 2004 recommended the closure of Durham's women's
unit. Ms Owers urged urgent action to ensure "that women
prisoners are no longer held in such isolated and alienating conditions".
It was in this isolated and alienated condition that Louise Giles
died.
Karen Fletcher—HMP Holloway died on 28 October
2005
30 year old Karen Fletcher was found hanging
at 7.27 pm in an ordinary cell at HMP Holloway. She was transferred
to Whittington Hospital but pronounced dead at 8.29 pm. Karen
was serving a life sentence for arson. At the time of her death
Karen was on an open FS2052SH/ACCT.
Daniel Nelson—HMYOI Doncaster died on 20
September 2005
Daniel Nelson was 18 years old and died at HMYOI
Doncaster whilst in the Health Care Centre. He was admitted to
the Health Care Centre on the 11 September due to the fact that
he believed that staff were going to hang him. He stated that
he would do it first before the staff could do anything to him.
On 13 September he was found to have made a ligature from his
bedding. On the same day he made another out of his t-shirt. He
was then put on a F2052SH. On the 14 September he cut his arms.
On the 16 September he was found to have made another noose from
a tee shirt. He remained paranoid and agitated up to the time
of his death and it is believed that he was having a nervous breakdown.
There was some psychological assessment and he was prescribed
medication. It is not clear as to who he saw for the assessment
but it was not a consultant psychologist and the levels of medication
he was given are unclear. He was however due to see a consultant
psychiatrist in the week of his death. However he was found dead
in the early hours of the 20 September. He was still on a 15 minute
watch at the time of his death.
Sam Elphick HMYOI Hindley died on 15 September
2005
17 year old Sam Elphick was found hanging in
HMYOI Hindley. He had been identified as being at risk of suicide
and self- harm. He was the 29th child to die in the custody of
the state since 1990. INQUEST's concerns about the failure to
learn the lessons from child deaths resulted in a highly successful
campaign for a public inquiry into the death of 16 year old Joseph
Scholes who died in HMYOI Stoke Heath in March 2002. This public
inquiry call is widely supported by MP's and lords and the Parliamentary
Joint Committee on Human Rights. Since his death another five
children have died in penal custody. The judicial review into
the Government's failure to set up an inquiry is now taking place
on 30 November and 1 December 2005.
Anthony Mola—HMP Durham died on 13 June
2005
23 year old Anthony Mola had been diagnosed
with schizophrenia in his teens. He was arrested on 10 June following
an altercation with police and taken to the police station and
from there to hospital suffering with severe injuries. On 13 June
he was remanded to Durham Prison for threats to kill. He smashed
up his cell in the health wing and was taken to the segregation
unit. He started a fire in his cell. It was 20 minutes before
the cell door was opened by prison officers with the Fire Brigade
in attendance. Anthony was found under his bed and was taken to
hospital where he died of smoke inhalation.
Vincent Shem HMP Wandsworth died on 14 February
2005
The jury in the inquest into the death of 32-year-old
Vincent Shem, a Ghanaian man who was found hanged in HMP Wandsworth
on 14 February 2005 found that he had been found hanging by a
bed sheet. During the three day inquest the jury heard evidence
on how Vincent spent long hours locked in his cell with nothing
to occupy him. It was also noted that there was little interaction
between prison officers and prisoners due to staff shortages and
overcrowding. Indeed none of the prison officers who gave evidence
could even recall having spoken to Vincent during the three weeks
he was in prison.
Brian Carter—HMP Shrewsbury died on 4 March
2004
34 year old Brian Carter was remanded to HMP
Shrewsbury prison for murder. At 13.30 hours on 4 March 2004 he
was discovered hanging from cell window bars. The key findings
of the jury who were asked if his death was contributed to by
any defect in the system found that:
— We believe that by not having access
to historical and current individual GP and prisoner records that
an accurate and reflective assessment could not be made on initial
screening that highlighted any risks that may have been previously
identified. This could have lead to a suitable monitoring programme
and appropriate treatment.
— We believe that access to the bars
within the window arrangement in the cell creates the most obvious
opportunity for self harm.
— We would like this risk to be assessed
with a view to control measures being put in place to remove access
to the grill and bars.
HM Coroner for Shrewsbury, Mr Ellery announced
he would be writing to the Minister of Prisons raising key issues
including:
— The provision of up to date medical
records from both inside and outside prison at the time of medical
assessment. He also called for consideration being given to the
practical difficulties in getting this information and how these
problems could be overcome. He also asked for the harmonization
and computerisation of all medical and prison records to allow
easier risk assessment.
— Consideration should be given to
the creation of a unique prison number for an individual whenever
and wherever he or she is in the prison system.
Marcus Downie died in HMP Chelmsford 11 May 2002
The jury in the inquest into the death of Marcus
Downie found that "he took his life while suffering from
schizophrenia". They found that "the system for ensuring
that Mr Downie actually received and took his medication was unsatisfactory".
Marcus, who was 20 years old was a diagnosed schizophrenic and
had been prescribed anti psychotic medication. He had only been
on remand for one month (pending sentencing for road traffic offences)
before he was found hanging in his cell in the segregation unit.
The inquest examined key issues including:
— The monitoring of the mentally ill
and how and when they take their medication.
— How the cell bell system is implemented.
— The appropriateness of the segregation
block for young offenders.
— Risk assessment of the vulnerable
in HMP Chelmsford.
The coroner said she would be raising issues
of concern with the Prison Service.
Jason Thompson—HMP Swansea died on 1 November
2004
Jason Thompson was 26 when he hung himself in
HMP Swansea on 1 November 2004. Before he went into prison Jason's
social worker and his psychiatrist stated that his mental health
problems were severe. At the time of his arrest Jason indicated
to the police that he had been having suicidal thoughts. Despite
his mental state, his suicidal thoughts and the fact that his
remand warrant stated that he "appeared very unwell and might
be a suicide risk" he was remanded into Swansea prison on
4 October 2004. On being told this news he self harmed whilst
in court and a FS2052SH was opened on his arrival at the prison.
He stated to a prison doctor that he was claustrophobic and would
rather die than remain in custody. Between the 5 to the 18 October
Jason made six suicide attempts all of which involved him tying
a ligature around his neck. Jason's behaviour was becoming increasingly
disturbed—he shaved his head, refused to eat anything other
than tree fallen food, barricaded his cell, assaulted a PO with
a meat pie and wrote slogans on his shirt. On two separate occasions
CPNs suggested that Jason was displaying symptoms of psychosis.
Instead of focusing on the root cause of such extreme behaviour
Prison Staff continue to see Jason as a petulant, difficult and
manipulative prisoner attempting to play the system. During Jason's
time in prison in the midst of his self harming he was placed
several times in the segregation unit. He would later be found
hanging in his cell on a normal wing having been removed off suicide
monitoring. The inquest is yet to take place.
October 2005
STATISTICS ON DEATHS IN PRISON
Source for all statistics: INQUEST monitoring and
casework.
Figures correct at 31 October 2005 and refer to England
and Wales.
ALL DEATHS IN PRISON 2000—DATE
Classification
| 2000 | 2001 |
2002 | 2003 | 2004
| 2005 | Total |
Self-Inflicted | 82
| 73 | 96 | 93 |
95 | 63 | 502 |
| Non-Self-Inflicted | 57 | 50
| 57 | 77 | 107
| 61 | 409 |
| Homicide | 3 | 1
| 0 | 1 | 2 |
1 | 8 |
| Awaiting Classification | 0 |
0 | 1 | 1 | 4
| 14 | 20 |
| |
| | | |
| |
CHILD (14-17) AND YOUTH (18-21) DEATHS IN PRISON 2000-DATE
Classification | 2000
| 2001 | 2002 |
2003 | 2004 | 2005
| Total |
Self-Inflicted (18-21) | 15
| 12 | 14 | 13 |
6 | 10 | 70 |
| Self-Inflicted (14-17) | 3 |
3 | 2 | 0 | 0
| 2 | 10 |
| Non-Self-Inflicted | 0 | 0
| 2 | 2 | 0 |
0 | 4 |
| Homicide | 2 | 0
| 0 | 0 | 0 |
0 | 2 |
| Awaiting Classification | 0 |
0 | 0 | 0 | 1
| 1 | 2 |
| |
| | | |
| |
There were also two child deaths in Secure Training Centres
in 2004, one self-inflicted and one involving control and restraint.
BLACK AND MINORITY ETHNIC DEATHS IN PRISON 2000—DATE
Classification | 2000
| 2001 | 2002 |
2003 | 2004 | 2005
| Total |
Self-Inflicted | 8
| 5 | 8 | 8 |
11 | 11 | 51 |
| Non-Self-Inflicted | 1 | 2
| 1 | 6 | 9 |
6 | 25 |
| Homicide | 1 | 0
| 0 | 0 | 1 |
0 | 2 |
| Awaiting Classification | 0 |
0 | 0 | 0 | 0
| 2 | 2 |
| |
| | | |
| |
DEATHS OF WOMEN IN PRISON 2000—DATE
Classification | 2000
| 2001 | 2002 |
2003 | 2004 | 2005
| Total |
Self-Inflicted | 8
| 6 | 9 | 14 |
13 | 4 | 54 |
| Non-Self-Inflicted | 1 | 1
| 2 | 1 | 7 |
2 | 14 |
| Awaiting Classification | 0 |
0 | 0 | 0 | 0
| 1 | 1 |
| |
| | | |
| |
NB. Figures in the three above tables are included in the
table of all deaths.
9
The Ashworth Inquiry 1992; United Nations Committee on the Elimination
of Racial Discrimination 1996 and 2000; Council of Europe Committee
on the Prevention of Torture 1997; Home Affairs Select Committee
on Police Complaints and Discipline 1997; United Nations Committee
Against Torture 1998; Inquiry into the death of Steven Lawrence
1998; Health Select Committee into Adverse Clinical Incidents
and Outcomes in Medical Care 1999; Health Select Committee Inquiry
into the Provision of Mental Health Services 2000; Attorney General's
review of the role of the Crown Prosecution Service in deaths
in custody 2002; Fundamental Review of Coroners' Services 2002;
Joint Committee on Human Rights-deaths in prison 2002; Independent
Inquiry into the death in psychiatric care of David Bennett 2003;
Joint Committee on Human Rights Inquiry into Deaths in Custody
2003 and 2004. Back
10
See press releases on Styal prison deaths www.inquest.org.uk Back
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