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C.993/97
Mishandling by the Prison Service (PS) of the relocation of a prisoner under restraint
Summary
Full report
Background
Investigation
Findings
Conclusion
Summary of case
In November 1995 a prisoner died of positional asphyxia following restraint; his family complained to the Ombudsman about his treatment by prison staff. The Ombudsman found that his death had followed an incident which should have been treated as a problem requiring medical advice but was treated as a routine disciplinary problem, and that the procedures which had come with that approach had been applied with insufficient appreciation of the danger they posed. Those failings had been largely attributable to operational shortcomings on the part of PS in the form of, respectively, inadequate local arrangements to ensure that incidents involving prisoners in the prison's health care centre were managed by health care staff, and inadequate local and national arrangements for training regarding the risk of positional asphyxia following restraint. The Ombudsman concluded that it must remain a matter for speculation whether the prisoner's death would have occurred in the absence of those failings. He noted that since the death much work had been done by PS both locally and nationally to improve matters, but more remained to be done.
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Full report
1. Miss C complained about the way in which HM Prison Service (PS) dealt with the affairs of her brother, Mr D, who died while in custody at HM Prison, Armley (HMP Armley) and that administrative failures within the prison contributed to his death. Miss C also complained that PS refused to release a copy of the report of their internal inquiry into her brother's death.
2. The investigation began in February 1995 once the former Commissioner had obtained comments from the Director General of the PS after the referral of the complaint by the Member. I have not put into this report every detail investigated by the Commissioner's staff but I am satisfied that no matter of significance has been overlooked.
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Background
3. The procedures applying to the reception of prisoners into prison in 1993 were set out in PS Standing Order 1A and included specific requirements aimed at the prevention of suicide. On a prisoner's arrival a medical officer would assess whether the prisoner was regarded as being at risk of attempting suicide, order preventive measures, where appropriate, and make a full record of the assessment and any instructions given to staff. That assessment would, at the time of Mr D's admissions to HMP Armley, have been carried out under Circular Instruction 20/1989 (see paragraph 4) which stressed the crucial importance of prisoners receiving a thorough health check on arrival in prison. It was for the manager of each prison wing to ensure that the medical officer's instructions were recorded in the wing observation book and that those instructions were carried out by staff. Standing Order 1A also required that the Governor, or a member of staff appointed by the Governor, should interview a prisoner no later than the day after reception and that prisoners be interviewed as soon as possible after reception by a probation officer.
4. Circular Instruction 20/1989 contained PS's strategy for the identification and support of those regarded as potentially suicidal. Those instructions provided indicators on the assessment of risk, which included previous suicide attempts or self injury, a history of psychiatric problems, depression, drug or alcohol abuse. If a prisoner was assessed as high risk or at some risk (the latter including cases where there were a number of risk indicators but no clear indication that the prisoner was feeling suicidal, or where the prisoner appeared anxious or sad but was not clinically depressed) a form F1997 should have been completed and passed to the manager of the prisoner's wing (paragraph 3). Staff who came into contact with prisoners on reception were advised to be alert to indications of risk and to respond promptly. Furthermore, all prison staff were held responsible for referring to the medical officer (by completing form F1997) any prisoner that showed signs of being at risk.
5. The medical officer may recommend that a prisoner be placed in shared accommodation. At the time of Mr D's admission to HMP Armley, that recommendation should have been recorded on form F1997 (if one had been completed), on the prisoner's cell card, in the register held in reception, in the observation book held on the prison wing and on the computerised Local Inmate Database System (LIDS). The entry in the wing observation book was dependent on an entry having been made on the prisoner's cell card. A list of the names of those prisoners for whom forms F1997 had been completed (paragraph 4) and who required shared accommodation was available from LIDS. PS initially told the Commissioner's staff that LIDS could not identify recommendations for shared accommodation when form F1997 had not been completed but later provided an extract from LIDS which showed that a "CC" (communal cell) recommendation had been included on Mr D's record. Circular Instruction 20/1989 also advised that prisoners placed in shared accommodation because they were regarded as at risk should not be left alone unintentionally after the transfer or discharge of a cellmate.
6. Prison staff undertake patrols during the night at HMP Armley. "Pegging" is an electronic method of recording visits to certain sites at set intervals. A prisoner who wishes to contact staff on patrol can push a lever from inside the cell which causes a metal indicator (known as a tally) to fall into a projecting position outside the cell. Staff on duty in the prison wings do not have routine access to LIDS and rely on the wing observation book for any special instructions about prisoners.
7. Probation officers working at HMP Armley do not routinely record telephone calls and keep a written record only of what they regard as crucial information. Information on security matters or details of a prisoner's self-harm would be made known to prison staff but other matters are divulged on a "need to know" basis to respect the confidentiality of prisoners' affairs.
8. Under Standing Order 1A (paragraph 3) cash and property brought into prison by a prisoner will be taken from him as soon as possible and stored or sent out of the prison. At the time of Mr D's admission, prisoners newly arriving at HMP Armley were not given cash or canteen privileges for several days. All prisoners' mail is opened by prison staff to check enclosures but not all mail is read before it is passed on.
9. Under section 13 of the Coroners Act 1988 where, on application under the authority of the Attorney-General, the High Court is satisfied that because new evidence or facts have been discovered it is necessary or desirable in the interests of justice that an inquisition on an inquest previously held concerning a death should be quashed and another inquest should be held, the High Court may order another inquest into the death and quash the inquisition on the first inquest. The investigation of the commencement and conduct of inquests are not within the Commissioner's powers, as set out in the Parliamentary Commissioner Act 1967, and I refer to such matters only to put in context the actions of PS.
10. Under paragraph 3(v) of Part I of the Code of Practice on Access to Government Information (the Code), which came into force on 1 April 1994, bodies within the Commissioner's jurisdiction are obliged to release, in response to specific requests, information relating to their policies, actions and decisions and other matters relating to their areas of responsibility, unless that information is exempt from disclosure under one or more of the exemptions at Part II of the Code.
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Investigation
11. 1993
Mr D was admitted to HMP Armley on 12 March 1993. The reception assessment completed by the medical officer recorded that Mr D had answered "No" to the question, "Have you ever been depressed, deliberately injured yourself or attempted suicide?". He confirmed that he had taken drugs. The medical officer noted that he was "not depressed, not suicidal". Mrs B, Mr D's mother, said later that at that time she had contacted a probation officer working outside PS as she was concerned about a suicide attempt made by her son in 1992. That probation officer later told the inquest that was held into Mr D's subsequent death (paragraph 17) that he recollected that Mrs B had been concerned about Mr D's general lifestyle and that he had not understood there to be any concerns about self-harm. He said that when he had visited Mr D in prison on 22 March he not shown any sign that he intended to harm himself. That probation officer also told the inquest that he had been due to visit Mr D again after his subsequent readmission to HMP Armley (see paragraph 12) but, as it took a week and a half to arrange appointments, he had not had the opportunity to do so.
12. Mr D was released from HMP Armley on 2 April and was readmitted on 18 June. A prison officer noted on that occasion that, on entry to prison, Mr D had "dashes" on his wrist. (Mrs B later told the Commissioner's staff that Mr D had cut his wrists some weeks earlier and scars were evident; that was confirmed by the pathologist at the subsequent inquest.) The same medical officer that had seen Mr D in March undertook the reception assessment. Mr D answered "Yes" to the question, "Have you ever been depressed, deliberately injured yourself or attempted suicide?", and said that that had been in 1992. He also confirmed that he had taken drugs, most recently three days earlier. The medical officer noted that he had "felt depressed" in 1992 but was "OK now". She further noted that Mr D was not suicidal but recommended "C/C" (that he be located in a communal cell); she did not complete form F1997 (paragraph 4). Mr D did not tell the medical officer that his general practitioner (GP) had referred him to a consultant psychiatrist and that he was waiting for an appointment. (At the inquest the medical officer said that she had not carried out a physical examination during her assessment, that the practice of examining prisoners for signs of drug abuse had been discontinued, that she had recommended a communal cell because Mr D had mentioned a psychiatric problem in 1992, that there was no routine enquiry about a prisoner's contact with his or her GP and that Mr D's assessment had taken about five minutes.) The communal cell recommendation was entered in the reception register and on LIDS. PS later told the Commissioner's staff that Mr D's cell card had disappeared after his death and staff could not remember whether the communal cell recommendation had been entered on it. No recommendation was entered in the wing observation book and no special watch instructions were issued.
13. Mr D was located in a shared cell for the nights of 18/19 to 21/22 June. On 22 June the prisoner sharing the cell was discharged and another prisoner, whom I call Mr X, moved into Mr D's cell. According to Miss C, Mr X later told her (see paragraph 22) that he had been told by prison officers that Mr D was not to be alone in a cell because he had tried to commit suicide. Mr X also told Miss C that he had been present when Mr D had received a letter from his solicitor saying that bail had been refused and that Mr D had "been devastated" by that news. (At the inquest a police officer said that he had been told by prison staff that Mr D had been refused bail.) Also on 22 June Miss C telephoned the prison probation officer (a different probation officer from the one that had visited Mr D on 22 March (paragraph 11)), who had known Mr D for several years, expressing concern about her brother. Miss C said that she had told him that she had found a noose hanging in her brother's flat and that the family were concerned about his state of mind. The probation officer later said that that telephone call had been made on behalf of Mrs B who was worried because Mr D had not been in contact with her. The probation officer agreed to talk to Mr D, which he did on the same day, and then telephoned Miss C to say that Mr D did not appear to be emotionally distressed. I have seen no record of Miss C's telephone call or of the probation officer's discussion with Mr D among the papers provided by PS.
14. On 25 June Mr X was discharged and Mr D was left alone in his cell. Prisoners returned to their cells at 2000 hours, pegging (paragraph 6) started and finished at 0545 hours the next morning. The officers on duty subsequently said that there had been no problems during that night, that Mr D had not operated his tally (paragraph 6), that they had not been aware of the communal cell recommendation and that no such instructions had been entered in the observation book. Mr D was found dead in his cell on the morning of 26 June.
15. On 27 June an allegation was made by a prisoner that Mr D had been bullied by another prisoner. The next day a report was made by a prison officer that prisoners had alleged that he (the prison officer) had been aware that Mr D intended to commit suicide. Also on 28 June the Coroner and the Governor of HMP Armley were formally notified of Mr D's death. The report to the Governor said that the communal cell recommendation for Mr D had been recorded in the reception register, on LIDS and on his cell card. The next day another prison official, in his report to the Governor, said that he had noted the communal cell recommendation on LIDS. He said that he had been advised that that could have been for a number of reasons and not necessarily because a prisoner was regarded as at risk of self-harm. He felt that that was an unsafe practice and suggested that, at minimum, all recommendations for communal cell placements be noted in the wing observation book (paragraph 3). He said that where prisoners were regarded as at risk of self-harm a form F1997 must be completed.
16. The Coroner's Office were told by a prison governor (whom I call officer A) on 1 July 1993 that there was evidence to suggest that Mr D had been bullied by other prisoners (paragraph 15). On 6 July officer A completed his report of the internal inquiry held by HMP Armley into Mr D's death; he had examined Mr D's medical records, determined his movements within the prison and what pastoral care he had received and investigated the events surrounding his death. Officer A had also investigated reception, cell allocation and night patrol supervision procedures within the prison. In the course of the investigation he had interviewed prison staff but had not talked to any of the prisoners who had shared a cell with Mr D (one was still in prison but others had been discharged). Officer A had interviewed the prison officer whom prisoners had said had been aware of Mr D's intention to commit suicide (paragraph 15); the allegation had been denied by that officer. Officer A had also considered whether Mr D had been bullied by other prisoners and had notified the Coroner's Office that there was evidence to support that allegation. Officer A noted that the bullying appeared to have resulted from Mr D approaching other prisoners for cigarettes as he did not have access to cash and canteen privileges (paragraph 8). Although officer A said he found the reception procedure at HMP Armley to be "archaic and dehumanising" he said that Mr D had shown no sign of suicidal tendencies or depression on arrival at HMP Armley; his investigation had not revealed why Mr D's communal cell instruction had not been followed up correctly. Officer A said that there might have been a case of neglect by staff in not ensuring that continuity of a communal cell placement was maintained or that Mr D might have "slipped through the safety net". He made a number of recommendations to improve procedures for the reception of prisoners, to introduce "safety net" procedures for those prisoners for whom a communal cell placement had been recommended but no form F1997 completed, and to review other prison procedures.
17. On 13 July the then Member of Parliament wrote to the Governor at HMP Armley for confirmation that a full inquiry would be conducted into the death of Mr D and that the report of the inquiry would be sent to him. The Governor replied on 15 July saying that the internal inquiry and the report were confidential to PS but that he would make evidence available to the Coroner. On 23 July the then Member recommended to Miss C that she wait to see what information emerged at the inquest which was eventually held on 29 November. I have seen a copy of the transcript of the proceedings and note that evidence was taken from Mr D's GP, the prison's medical officer, prison and police officials and the probation officer who had visited Mr D on 22 March 1993 (paragraph 11). The verdict of the jury at the inquest was that Mr D had killed himself.
18. On 2 December the solicitor who had instructed Counsel appearing for Treasury Solicitor and the Home Office at the inquest prepared his report on proceedings. He commented that he was surprised that little emphasis had been placed on the failure of HMP Armley to make sure that the communal cell recommendation made by the medical officer had been carried out and that the Coroner had not drawn attention to the evidence that Mr D had been bullied.
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19. 1994
On 9 February 1994 the then Member asked the Home Secretary, through a Parliamentary Question, that a copy of the report of the prison inquiry into Mr D's death be made public. That request was refused by the Director General of PS who said that it was not PS's practice to publish such reports as disclosure might undermine their effectiveness. He said they could release Mr D's prison medical records. On 15 February Miss C requested a copy of those records and asked whether Mr X, or the occupants of the cells adjacent to Mr D's cell, had been asked for information as part of the inquiry, why the recommendation that her brother be placed in a communal cell had not been entered in the wing observation book, and why a medical examination was not undertaken when Mr D was admitted to HMP Armley. PS replied on 21 February enclosing Mr D's records and saying they were looking into the questions she had raised; they offered a meeting to discuss the family's concerns. On 22 February the then Member asked the Home Secretary, again by a Parliamentary Question, how the publication of inquiry reports would undermine their effectiveness. The Director General replied on the same day saying they had reviewed the policy on disclosure of information to a deceased prisoner's family and decided that documents made available to the Coroner might be given, on request, to the next of kin in advance of an inquest. They would not, however, publish reports of internal investigations or make them available to the Coroner for two reasons.
"First, given the closed and potentially volatile nature of the prison environment publishing reports into prison incidents could cause problems for the day to day management of the prison. Knowledge within the prison of their contents and conclusions could, for example, lead to reprisals or disruption in the working relationships between staff. Second, the prospect of publication could discourage witnesses from cooperating with the inquiry and from being totally candid in the information they give to it. If they knew their identities were to be revealed, they might be at risk of being treated as informers. This could make it more difficult for the Prison Service to discover the truth..."
20. On 25 February the then Member, in a further Parliamentary Question, asked the Home Secretary if he would, at the request of Members, deposit copies of reports of internal investigations into suicides in prisons in the Library of the House of Commons. The Home Secretary declined to do so as internal investigations were reviews which PS carried out for their own management purposes.
21. On 26 April Miss C, other family members and their solicitor, met PS representatives. I have seen a note prepared by the PS after that meeting in which they regarded the discussion as having met the family's concerns. However Miss C subsequently told Members of Parliament who pursued the case and later the Commissioner's staff that Mr D's family had been far from satisfied with PS's answers to their questions. On 3 May and 8 June Miss C's then Member of Parliament wrote to the Director General of PS asking that a copy of the internal inquiry report be made available. The Director General replied on 13 June along the same lines as his letter of 9 February to the first Member (paragraph 19).
22. On 24 June a governor at HMP Armley wrote to Mr X to say that Mr D's family wished to contact him concerning Mr D's death. He sent a copy of the text of the letter to Miss C; she noted on that copy that PS had taken a year to write to Mr X despite her repeated requests. (The Director General later told the Commissioner that HMP Armley had no record of those requests.) Mr X contacted Miss C and they met on 27 June. According to a record of that discussion, which was not signed by Mr X, he said that he had found aspects of Mr D's behaviour disturbing. He said he had not told prison officers about Mr D's behaviour as they had first told him that Mr D should not be in a cell on his own; that was why he (Mr X) had been moved from his cell to share with Mr D. Mr X had not known that Mr D had died before the Governor had written to him. (It has not been possible to interview Mr X during the course of the investigation.).
23. On 14 November the Member who referred the complaint to the Commissioner's predecessor wrote to the Home Secretary saying that he felt it would be beneficial to Mr D's family and PS if the results of the inquiry into Mr D's death were made public. On 24 November the Minister of State at the Home Office, in reply to a Parliamentary Question from the Member again asking that reports of internal inquiries into deaths in custody be made available, said he would discuss the matter with the Director General of PS. The Member referred Miss C's complaint to the Commissioner's predecessor on 25 November 1994. Miss C considered that the inquest verdict was flawed as evidence had not been sought from Mr X about Mr D's behaviour while they had shared a cell and, had that evidence been heard, the jury would have reached a different decision (paragraph 17).
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24. 1995
The Director General, in his comments to the former Commissioner on the complaint, accepted that Mr D should not have been left alone in his cell on the night of 25/26 June 1993 and said that since Mr D's death new procedures had been introduced throughout PS for the care and support of those regarded as at risk of suicide or self-harm. Those instructions remind staff that, where a prisoner is placed in shared accommodation because he or she is regarded as at risk, a procedure must be in place to ensure that the prisoner is not left alone following the transfer of a cellmate. The Director General also said that the report of the internal inquiry into Mr D's death had not been made public as those that had given information had done so on the understanding that it would remain confidential. On 3 May the Minister of State replied to the Member's letter of 14 November 1994 (paragraph 23) apologising for the delay and saying that PS had re-examined their policy and recommended that, in future, reports of internal investigations into self-inflicted deaths in custody would be made available to the Coroner. On 31 May Miss C wrote to the Member commenting on the letter from the Home Secretary. She said it was unfair that copies of reports were to be sent to the Coroner but not to the deceased's family and that the meeting in April 1994 (paragraph 21) had not provided answers to the questions raised by Mr D's family.
25. On 26 October I asked the Permanent Secretary of the Home Office whether PS's policy of refusing to release reports of internal enquiries had been reviewed after the introduction of the Code (paragraph 10) and how, in general terms, the Home Office and PS would respond to a complaint made under the Code that a request for information contained in an internal inquiry report had been unreasonably withheld. In reply on 19 December the Permanent Secretary said that he understood PS's policy was not to release reports of internal inquiries on the grounds that they were internal documents and because their disclosure could prejudice security in prisons. He said that requests would be considered on an individual basis and that PS would need to consider whether the nature of the report justified it being withheld under the Code.
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Findings
26. Since the original requests for disclosure of the internal inquiry report to Mr D's family, there have been significant developments in PS's general policy on making available information relevant to and contained in such reports. Specifically, documents made available to the Coroner may now be given to the next of kin on request (paragraph 19) and it appeared from the Minister's letter of 3 May 1995 that internal inquiry reports themselves are now (paragraph 24) made available to the Coroner. In the light of those initiatives, it was not clear to me why the Permanent Secretary should argue, as he did during my investigation (paragraph 25), that internal inquiry reports might be exempt from disclosure under the Code in response to individual requests. That did not seem to me to be consistent with the decisions to make available information in the circumstances I have described and I put that point to the Permanent Secretary and to the Director General. In reply they said that internal inquiry reports were made available to the Coroner for reference, not as evidence and did not form part of those documents which were automatically disclosed. The Director General said that with hindsight it was apparent that PS had not made explicit in Ministerial correspondence the caveats which surrounded the disclosure of internal inquiry reports and that he understood how the advice contained in the correspondence of 22 February 1994 (paragraph 19) and 3 May 1995 appeared inconsistent. Whatever HO and PS now say about how they should have advised the then Minister between November 1994 and May 1995, the Minister's letter of 3 May to the Member did not contain any of the restrictions which HO and PS maintain were intended. I cannot be confident that that interpretation provides a reliable basis for replying to requests to disclose information from internal inquiry reports in the future even though the present Director General has said that PS are to review their investigation procedures, including the possible disclosure of inquiry reports. That matter does not affect the report into Mrs B's specific complaint and I shall continue to pursue my concerns with HO and PS as a separate matter.
27. I have considered whether PS have acted reasonably in continuing to withhold from Miss C or Mrs B a copy of their internal inquiry report into Mr D's death. I concluded that there is little to justify such a continued refusal especially as PS have already made the majority of the information contained in the report known to Miss C or to the Coroner or in evidence at the inquest into Mr D's death. While the Code contains no assurance that pre-existing documents, as opposed to information, will be made available I saw no reason why those parts of the reports which concern information already known should not be made available. Where information contained in the report is not in the public domain but can be provided in such a way that it does not endanger individuals or prison security then there would seem no reason why that should not also be disclosed. I therefore asked the Director General whether PS would now disclose the report sought by Miss C and her family. He said that PS's review (paragraph 26) required considerable thought and extensive consultation both within PS and with other departments and agencies, that he felt it would be unwise to prejudge the outcome of that review and that he remained unable to agree to disclose the report to Mrs B. I am disappointed with the Director General's decision and hope that he will keep Mrs B's request under review. However I have seen a copy of PS's inquiry report and I can say that it contains no information which has not been disclosed in this report or given in evidence at the inquest into Mr D's death. Mrs B has therefore the information she sought, albeit not a copy of the inquiry report, and I consider that that has met, in spirit at least, the requirements of the Code.
28. My investigation revealed a catalogue of errors and omissions by prison staff when dealing with Mr D. At the time of his admission to HMP Armley in 18 June 1993, the medical officer's recommendation that Mr D be placed in a communal cell had been entered in the reception register and on LIDS. Mr D had been placed in a communal cell from arrival in HMP Armley until the night of 25/26 June and at least some officers must have been aware of the communal cell recommendation. However that recommendation does not appear to have been known to staff on Mr D's wing. No entry was made in the wing observation book but that entry would have been dependant on an entry having been made on the prisoner's cell card (paragraph 5). Since Mr D's cell card has been unaccountably lost, I have not been able to confirm without doubt whether the communal cell recommendation had been recorded on it. I cannot say whether Mr D's tragic death would have been avoided had he not been alone in his cell on the night of 25 June but what is clear is that the medical officer had recommended that Mr D be placed in a communal cell and that had not happened. That merits my strongest criticism.
29. PS instructions recommend that staff in contact with prisoners on reception into prison should be alert to signs that a prisoner might be at risk of suicide or self-harm. A prison officer noted the scars on Mr D's wrists (paragraph 12) but, as the medical officer later said at the inquest, no medical examination was carried out. It is unfortunate that the reception assessment at HMP Armley was not more thorough; the most cursory of examinations would have revealed signs that Mr D had made a recent suicide attempt. At least three of the main risk factors were present in Mr D's case - previous suicide attempt, a history of depression and drug abuse. Miss C has said that she telephoned the prison probation officer after finding evidence in Mr D's flat that suggested he intended to harm himself but that officer has said that he had not understood there to be concerns that Mr D would attempt to harm himself. There seems to me to have been at least prima facie evidence that Mr D was at risk but lack of communication between prison staff and a failure to follow procedures resulted in that risk being unrecognised. Those shortcomings merit my strongest criticism. Although the Director General agreed that three main risk factors were present he said that a large proportion of those entering prison might have those symptoms and that they would not, in themselves, have automatically resulted in the raising of a form 1997. He said that identifying those at risk of self-injury required sensitive judgments which had to be made on the basis of a range of factors and without the benefit of hindsight. I welcome PS's new procedures (paragraph 24) which should go some way to ensure that those who should be in a communal cell are appropriately and safely accommodated. However, I remain concerned about the arrangements for the medical assessment of prisoners arriving at HMP Armley. The short time allowed for those assessments cannot fulfil PS's own recommendation that all prisoners receive a thorough health check (paragraph 3). I asked the Director General what steps he intended to take to improve arrangements. In reply he said PS had recognised for some years that the local facilities at HMP Armley for medical examination and admission procedures were inadequate; seven million pounds of capital funding had been provided to build an upgraded gate lodge, visits and reception area and that that work would start in 1997/98. In addition, prisoners arriving at HMP Armley are now examined by full-time prison doctors who are better placed to prescribe appropriate facilities within the prison and to follow through their recommendations. The Director General also said that in August 1994 new standards governing the assessment of prisoners' physical and mental health needs on their first reception into prison had been issued. All prisons had been given up to three years to ensure that local policy and practice reflected that standard and PS's Director of Health Care would be arranging for the implementation of all health care standards at local level to be properly audited and reviewed.
30. I turn now to officer A's investigation (paragraph 16) of Mr D's death. It seems to me that he made insufficient effort to determine the point at which the procedure for ensuring a consistent approach to the recommendation that Mr D be located in a communal cell had broken down. Having failed to identify the source of the procedural breakdown, he could not then recommend a remedy which would prevent a recurrence. However, I welcome officer A's recommendations that arose from the inquiry and I have seen evidence that those have been either implemented or actively considered within HMP Armley.
31. Although I do not doubt the sincerity of Miss C or any other member of her family, I cannot accept without doubt the information provided to Miss C by Mr X (paragraphs 13 and 22). During my investigation I have also found significant differences in the accounts of telephone conversations between Miss C and Mrs B and the probation officers who had had contact with Mr D (paragraphs 11 and 13) and in the absence of any independent corroborating evidence I cannot now determine what was said on those occasions. Similarly, I cannot comment on PS's apparent delay in meeting Miss C's requests to contact Mr X as HMP Armley have no record of them (paragraph 22). That calls into question the standard of record keeping at HMP Armley and I put it to the Director General that greater care needs to be taken by all prison officials in recording contact with a prisoner's family. Without at least a record of such contact the potential for confusion and conflict between prisoners, a prisoner's family and prison staff will be high. In reply the Director General said that, in order to minimise such confusion as occurred in Mr D's case, the Governor of HMP Armley had decided that families will be notified of a point of contact who will be responsible for providing information and responding to their queries. There also seemed, from the evidence given at the inquest, to be some confusion about the arrangements for probation officers to visit prisoners (paragraph 11) in HMP Armley. Visits by probation officers should not be unnecessarily delayed by the prison and I asked the Director General to review current procedures and publicity on that matter. In reply he said that in 1993, as now, visits by probation officers were not normally booked more than a week in advance because the movement of prisoners transferring elsewhere, being released on bail or being released by the courts led to an excessive number of cancellations. Most visits were booked 2-4 days in advance but, if a probation officer mentioned any concern about a prisoner, that information would be passed promptly to a senior prison officer, or to the duty governor, to arrange an early visit and to enable wing or health care staff to talk to the prisoner that day about his situation. The Director General added that field probation officers with such concerns would normally talk direct to the probation officers working within the prison.
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Conclusion
32. The Director General apologised for the shortcomings on the part of PS and outlined the procedural improvements which had, or were taking place, throughout PS. The Director General continued to refuse to disclose a copy of the internal inquiry report saying that that policy was under review and that he could not prejudge the outcome. However I have seen a copy of PS's inquiry report and I can say that it contains no information which has not been disclosed either in this report or given in evidence at the inquest into Mr D's death. Mrs D has therefore the information she seeks. I regard that, together with the Director General's apologies and procedural improvements, to be a satisfactory outcome to a justified complaint.
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