Prisoner hanged himself despite being placed in safe cell… The HSE issued a formal Crown Censure against the National Offender Management Service (NOMS) after a prisoner died in unusual circumstances at HMP Bullingdon in Bicester, Oxfordshire.
On 26 September 2006 the prisoner concerned was awaiting sentence when a prison officer observed him with a noose around his neck attempting to tie it to a light fitting. He was subsequently identified as a suicide risk and placed in what prison authorities regarded as a safe cell.
The prisoner was checked on by prison staff three times while he was in the safe cell but on the third occasion he was checked on his body was found hanging with a ligature made from the bedding in the cell and attached to a shower rail support bracket. The screws used to fix the bracket to the wall were sufficiently strong to support the ligature and the post-mortem verdict on the prisoner’s cause of death was simply described as “hanging”.
The investigation into the death found that there were several areas in the safe cell where a ligature could have been attached. However the Prisons and Probation Ombudsman and the Coroner were unable to determine when the shower rail bracket was attached nor who attached itm authorised its installation or checked if it was appropriate for a safe cell.
Matthew Lee, HSE’s investigating inspector, said:
“NOMS is fully aware of issues relating to self-inflicted deaths of prisoners. In the years 2007 – 2009 the average number of self-inflicted deaths in prisons was 69 per year. The most common method was by hanging, which represented 91 per cent of all self-inflicted deaths. As such, the defendant should have had a more robust system for ensuring the risk was adequately controlled at HMP Bullingdon.
“Staff on duty at the prison at the time of the death were clearly under the impression that they had placed Mr Rooney in a safer cell which, so far as was possible, was ligature free”
Heather Bryant, HSE director for its Southern Division, took the Censure hearing against NOMOS. She commented:
“This was an unnecessary tragedy and shows that all refurbishment programmes need to be adequately controlled. The standard in this cell was far below what is appropriate for those vulnerable prisoners in a safer cell.”
The Crown Censure found that NOMS failed to comply with Section 3(1) of the Health and Safety at Work etc Act 1974 and Regulation 5(1) of the Management of Health and Safety at Work Regulations 1999.
After accepting the Crown Censure NOMOS pledged to take all necessary actions to prevent the likelihood of this kind of tragedy occurring in the future.