In my role within the Civil Liberties team at Hudgell Solicitors I spend a significant amount of time reviewing circumstances surrounding deaths in custody – work which has highlighted common failures across the prison service to protect inmates from avoidable harm, leading to lives being needlessly lost.
My clients are no different to any others who turn to us in cases relating to the loss of a loved one.
They are families who have lost someone unexpectedly and have been left wanting answers about what went wrong. They are still coming to terms with the fact they’ll never see their loved ones again and look to us to provide specialist legal support.
From the many cases I have been involved in over the past 18 months, it has become strikingly obvious that there are common failings which run across the prison service, failings which leave prisoners at extra risk, and all too often result in the loss of life.
Cases have included prison officers failing to carry out basic welfare checks on inmates who were known to be vulnerable and at risk; we have even investigated a case where records suggested checks had been completed when in fact they hadn’t.
In another officers were found to have failed to follow procedures requiring them to record a verbal response from a prisoner when carrying out welfare checks, assuming them to be asleep when in fact the prisoner was slipping into unconsciousness.
Such failings are totally unacceptable and represent a clear breach of a prisoner’s rights. The most common examples we see include:
- Complacency over care –Prison staff become almost ‘immune’ to the challenging behaviour of inmates, such as the impact of drug use or repeated threats to harm themselves. This complacency often leads to staff failing to react in an appropriate manner when red flag signals call for action and where life is in danger. We currently act for the family of a prisoner where a Prison and Probation Ombudsman (PPO) Independent Investigation found staff had become ‘complacent’ with his threats to take his own life. He was found dead in his cell.
- Failure to follow set procedures – Many prisoners are placed on dedicated welfare plans due to being classed a potential risk to themselves. We have seen cases where these checks have either not been carried out or not been carried out in time, leading to fatal consequences. In one case in which we supported a family, a prisoner was meant to be checked at two hourly intervals as he was known to be at risk of self-harm, but CCTV footage showed that 18 required observations were not carried out over two days, despite written records suggesting they had been completed.
- Poor communication and record keeping – A key aspect of the prison officer role is communication and the accurate and appropriate handover of information between shifts. We have seen many cases where the concerning behaviour and mental state of prisoners, which has been escalating, has either not been recorded sufficiently on paperwork, not communicated between shift changes, or just not read by staff taking over shifts, resulting in a failure to take appropriate action. We also see many failings regarding information provided on prisoner welfare when inmates are transferred from one prison to another, leading to gaps in their specific care plans in their new environment, at a time when they may be extra vulnerable given they are in new surroundings.
- Failures to establish appropriate care plans – Any prisoner identified as being at risk of suicide or self-harm must be managed through the Assessment, Care in Custody and Teamwork (ACCT) process. This requires certain actions to be taken within different time frames, to ensure that the risk of suicide and self-harm is reduced. Any staff member who receives information, including from family members or external agencies, or observes behaviour which may indicate a risk of suicide or self-harm, is required to consider opening an ACCT. Sadly we see many cases where this does not happen, denying the prisoner vital support from a multidisciplinary team established to support them until they are no longer considered to be at risk.
- Failure to provide appropriate healthcare – Poor healthcare is a continuing issue in prisons and is often linked to a ‘complacent’ approach from staff. We represented the family of a man who died as a result of bleeding from an ulcer in his intestine, two days after telling a prison nurse that he had an ulcer and that he believed it was about to burst. The nurse admitted that she should have escalated this to a GP, but she did not. An inquest into his death found failings in medical care, including prison officers not referring him to hospital when he was found to have vomited blood, and failing to initiate a ‘Code Blue Call’ when he was found struggling to breathe in his cell.
Of course, we recognise the role of prison officers is not an easy one, and in fact can be hugely challenging. They face difficult situations and challenging individuals on a daily basis, but this is why following procedures is key to the role they do.
Prison is meant to be a system to reform and rehabilitate, and prisoners are entitled to certain standards of care. Serious issues across the service need tackling now.
When families see a loved one sent to prison, but due to negligence they never get to see them walk out, there needs to be answers and accountability. It is a role I have been proud to take on for so many.
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Our death in custody solicitors are some of the most experienced in the country – and are proud of their strong track record of achieving the best possible outcomes for clients.
If you’d like to discuss how we would pursue a case on your behalf, please get in touch and talk to us in complete confidence. Call 0808 2316071 today.