Prison ombudsman's report into death of Whitemoor inmate ahead of inquest makes recommendations for health care and night time cell checks
PUBLISHED: 14:56 31 October 2018 | UPDATED: 14:56 31 October 2018
An inquest is to be held next month into the death of a prisoner at Whitemoor who was the sixth inmate to die at the top security jail in a three year period.
The Prison and Probation Ombudsman Nigel Newcomen has already published his own findings into 51-year-old Adrian Glover’s death in February of last year but now the matter will be heard at a formal inquest at Peterborough Town Hall.
In the prelude to his report Mr Newcomen said Glover was the sixth prisoner to die at Whitemoor since August 2014, three previously from natural causes and two, he noted, were self-inflicted.
“We have raised concerns in previous reports about delays in calling an ambulance in emergencies and in paramedics attending cells,” he .concluded.
Glover was found dead in his cell at HMP Whitemoor on February 12, 2017, and Mr Newcomen set out to find whether the prison had provided appropriate medical support to someone they knew had suffered mental health issues.
“Staff appropriately managed Mr Glover under suicide and self-harm prevention procedures after his arrival at Whitemoor, but these procedures were subsequently ended,” he said.
“Staff continued to make efforts to support him but I consider that staff should have identified that he was once again at risk of suicide or self-harm shortly before he died and put in place formal protective measures.
“I am also concerned that his mental healthcare was inadequate and that there were some deficiencies in the emergency response.”
In July 2011, Glover, of Coventry, was jailed for 12 years for the attempted murder of his ex-girlfriend by repeatedly stabbing her in the chest.
He had admitted a charge of attempted murder; one doctor told the trial it was “‘pure luck’’ his former partner didn’t die.
Mr Newcomen’s report says that Glover was monitored under suicide and self-harm prevention procedures, known as ACCT, a number of times.
On August 1, 2016 he was released on licence but, on November 2 he was recalled to HMP Birmingham.
On December 18, 2016, Glover was one of ten prisoners moved to HMP Whitemoor after a major riot in Birmingham.
An officer started ACCT procedures in January as he was concerned that Glover stayed in his cell, refused meals and did not take his medication. Glover moved to C wing, a quieter wing, and ACCT monitoring stopped shortly afterwards. The mental health team saw him and a GP prescribed an antidepressant.
On February 9, Glover was assessed for an offending behaviour programme. He did not want to take part and told the member of staff who assessed him that he had been struggling in the past few days. The member of staff told an officer who spoke to him. Mr Newcomen said: “He denied feeling low and said he was simply unwell. The next day, the officer spoke to Mr Glover again after he did not collect his meals.
“Mr Glover said he felt under the weather, but would be fine. On February 11 another officer noted that Mr Glover had refused his morning medication, refused his meals and stayed in his cell all day and that another prisoner was concerned about him. The officer spoke to the wing manager who spoke to Mr Glover that afternoon.
“He was in bed and said he felt under the weather and wanted to remain locked up. “They decided ACCT monitoring was unnecessary.”
Two night staff decided to check on Glover a few extra times. He was seen at 8.05pm and 9.45pm. At the next check, just after midnight, an officer saw Glover at the back of the cell and was concerned. He did not have a radio so ran to the office to obtain the radio. He called a medical emergency code blue at 12.03am. An ambulance was called three minutes later.
The officer went back to Glover’s cell and when a dog handler arrived at 12.05am they unlocked the door and entered.
Other staff arrived and gave Glover chest compressions until a nurse, manager and supervising officer arrived a few minutes later. A first response car arrived at Whitemoor at 12.11am and a paramedic attended Glover’s cell at 12.20am.
At 12.28am the paramedic pronounced that Glover had died.
Mr Newcomen’s report goes into some detail about the prison regime and the circumstances surrounding the care Whitemoor would have expected to provide for Glover.
He was critical in his report about procedures to monitor him and said there was a delay in staff calling an emergency code blue because night staff shared a radio and the officer who found Glover did not have a radio with him.
“There were some deficiencies in the emergency response (a delay of three minutes in calling an ambulance and an officer waited two minutes for other staff to arrive before going into the cell,” he said.
“While it is unlikely that these changed the outcome for Mr Glover, such delays could be critical in other circumstances. The clinical reviewer considered that Mr Glover’s mental healthcare was not equivalent to that which he would have received in the community.”
The ombudsman made a series of recommendation about the monitoring and management of prisoners considered to be at risk.
He said they needed to understand their responsibilities and the need to share all relevant information about a prisoner’s risk.
A number of other recommendations about sharing of information and training were set out in his report and accepted by prison authorities.
And he said the governor should ensure radios are issued to all night staff so they can promptly raise the alarm in an emergency.
Mr Newcomen also called for guidelines to be followed that outlined “that preservation of life is paramount and cells may be entered during night for this purpose, following a dynamic risk assessment”.
“The governor and head of healthcare should ensure appropriate mental healthcare for prisoners at all times,” he said.