‘Discharged: Dead’ – Deaths in Custody and the Scandal of Ignorance

By Mark Leech

(Updated 12th October 2019)

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 Worcestershire.

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 his 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.

The fact is that lessons that should be learnt from each death in custody 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.

Last week (9th October 2019) the Prisons and Probation Ombudsman, Sue McAllister, published her latest 2018/2019 annual report. In it she set out her bitter disappointment that despite the increasing number of deaths in custody, into which her office carries out an investigation into each one, the fact is that no-one take a blind of bit of notice of any of the recommendations she makes to reduce deaths in custody

“We continue to make the same recommendations repeatedly, sometimes in the same establishments and, often, after those recommendations have previously been accepted and action plans agreed to implement them. Where the same failings are identified time and again, organisations must address those barriers which exist, whether they are structural, cultural, attributable to insufficient resources or to other things.”

It is a complaint I have been making for years, and I been criticised for seemingly misunderstanding the roles that certain officials have to play, and for critically pointing out that not only are far too many of the Ombudsman’s recommendations ignored, but worse the Independent Monitoring Boards (IMBs) in each prison are complicit in this because they fail to mention in their annual reports the true facts of deaths in the prisons that they monitor – treating them as events that are seemingly 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.

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 just cut and pasted from one annual report to the next, with only the often increasing numbers changed from one year to the next.

A recent Report PPO published into yet another death in custody was 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 – meaning 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 at all.

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 it ought to be mandatory that such a death is always made public – this is the United Kingdom, not North Korea.

The PPO should make public that they are investigating the death with an online list of all current PPO fatal incident investigations. It can of course be anonymised, there are sensitivities of next of kin and the judicial process of an Inquest to consider, 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 – and the fact that it never is sits uneasily with any organisation that promotes itself as independent.

In short: the concealment has to stop. I recently conducted a search of our Fatal Incident database, it contains details of all the PPO Fatal Incident Reports and I searched how many reports the PPO had issued on deaths in custody where they had been forced to repeat recommendations that they had made previously but which had been ignored – recommendations, lest we forget, that had to be repeated because a further death in similar circumstances had occurred; the result was almost 100 cases that ran to some six pages.

Unless we learn the lessons of why so many die in custody, unless we are open and transparent about deaths, immediately acknowledging publicly 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 fact is that prison officials will continue with their final tragic task of stamping 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 and Managing Director of Prisons Org UK
Twitter @prisonsorguk
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