D E T E R M I N A T I O N
by
SHERIFF NIGEL MURRAY PATON
in Inquiry into the circumstances of the
death of
DANIEL THOMAS CREW
Under the Fatal Accidents and Sudden
Deaths Inquiry (
APPEARANCES
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For the Crown: |
Mr Macari, Procurator Fiscal Depute |
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For the Crew Family: |
Mrs Crew |
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For the Scottish Prison Service: |
Mrs Martin Brown, Solicitor, of |
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For the Prison Officers Association |
Mr Anderson, Solicitor, of Levy McRae, Solicitors |
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[1] My determination is as follows.
Summary of findings
[2] Daniel Crew, who was 21 years
old, was sentenced to two months' imprisonment at
[3] A fatal accident inquiry was
held, and required to be held, by virtue of section 1(1)(a) of the Fatal
Accidents and Sudden Deaths Inquiry (
Place and time of death
[4] With respect to section 6(1)(a)
of the 1976 Act, Daniel Crew, who was born on 16 January 1985, died between
1900 and 2100 hours on 12 September 2006 in cell 3.26, Hermiston House,
HM Prison, Edinburgh.
Cause of death
[5] With respect to section 6(1)(b)
of the 1976 Act, the cause of Daniel Crew's death was suspension by ligature.
Reasonable precautions
[6] With respect to section 6(1)(c)
on the 1976 Act, there are no reasonable precautions whereby Daniel's death
could have been prevented.
Defects in system of working
[7] With respect to section 6(1)(d)
of the 1976 Act, there were no defects in any system of working which
contributed to Daniel's death.
Other facts relevant to the circumstances of Daniel's death
[8] With respect to section 6(1)(e)
of the 1976 Act, there were no other facts that had a bearing on Daniel's
death.
Recommendations
[9] There are no recommendations for
changes to practices or procedures which could have altered the course of
events. The following matters, however,
should be given consideration:-
(1) Whether clarification is required about the
use of the addiction assessment form in HM Prison, Edinburgh in relation to
alcohol detoxification. (See paragraphs
61 and 62.)
(2) Further training or instructions in
relation to clear communications and use of codes in emergencies in HM Prison,
Edinburgh. (See paragraphs 70 to 80.)
(3) How the Scottish Court Service, in
consultation with, for example, the Judiciary, Reliance and the Scottish Prison
Service, might best ensure that social enquiry, psychiatric and other medical
reports tendered to the court at sentence are transmitted to the prison or
detention centre when an offender is sentenced to a term of imprisonment. (See paragraphs 85 to 88.)
(4) Whether procedures on admission in relation to
establishing medical prescriptions require revision. (See paragraphs 96 and 97.)
Place, time and cause of death
[10] At about 1900 hours on
[11] At about 20.30 (according to the
prison incident log in Crown production no. 21), a fellow prisoner entered
Daniel's cell, no. 26 on level 3 in Hermiston House and found him hanging in
his cell at the lavatory door. He called
residential prison officer (RPO) Stephen Rooney for help. Mr Rooney said he heard that call at about 20.30. He found Daniel Crew lying on the floor in
the cell doorway and tried to find signs of life. He shouted for staff for assistance. RPO Scott Thomson responded. He called for a nurse. RPO John Grieve also responded. He went to the cell, and then radioed the
control room (ECR) for a nurse and an ambulance. He shouted to RPO Dunn at the officer's desk
on level 3 to confirm that nurses and an ambulance were on their way. Mr Rooney and Mr Grieve carried out
cardiopulmonary resuscitation (CPR) which they were trained to do. They did not find any sign of life. Within five minutes practitioner nurses Carol
Brand and Claire Anderson arrived. Nurse
Anderson thought that she received the call to attend at about 20.20. That is the time recorded by her in the SPS
physical care records (Crown production no. 22). They took over CPR in which they were
trained. They arrived with Security
Intelligence Manager, Edward Maley, who assisted. They found no signs of life. Nurse Anderson attached a defibrillator but
could not use it because no heart rhythm was detected. They continued CPR until the paramedics
arrived at the cell which was at 20.59 according to the prison incident log in
Crown production no. 21. Paramedic
Lesley Conway asked what had happened and was told that Daniel had been found
hanging at about 20.25 and that no heart rhythm had been found. She found no heart rhythm and pronounced life
extinct at 21.00 hours: see Crown production no. 29 (patient report form). An ECG was carried out at 21.10 which
produced a flat line indicating no sign of life: see Crown production no. 28.
[12] Professor Gerhard Kernbach-Wighton,
the Consultant Forensic Pathologist at
[13] Since no signs of life were ever
detected by the prison officers who reached Daniel, or the nurses who reached
him shortly after, which was at about 20.30, I think one can conclude that
Daniel had died by 20.30. He was alive
at 1900 hours when he was seen making a telephone call on the CCTV
footage. He must therefore have taken
his own life between 1900 hours and 2030 hours.
[14] Professor Kernbach-Wighton
confirmed that death was by ligature.
Daniel appeared to have used a strip of towel, which is seen in
photographs 5 to 7 in Crown production no. 31.
A prisoner is given two towels at a time for his use.
[15] It has not been possible to
ascertain why Daniel took his own life.
There seemed to have been some concern that CCTV footage showed someone
entering his cell before he was found, but on investigation it transpired that
a prisoner was visiting a cell next to Daniel's. I have read carefully the transcript of
Daniel's telephone call to his girlfriend in Crown production no. 26, but
nothing in it indicates that he felt he had nothing to live for. He does describe the prison as a "shit-hole"
with "a lot of junkies" and that it was "murder in here". His girlfriend does not appear to be quite as
enthusiastic about their relationship as he was. When he says he loves her she says "I
know". He asks if she will come up from
[16] There was a suggestion that
Daniel was being bullied. A prisoner
came forward on
Reasonable precautions
[17] I do not think that there are
any reasonable precautions that could have been taken which were not taken
whereby Daniel's death might have been avoided.
Steps taken by the prison
[18] The steps taken by the Scottish
Prison Service (SPS), and Saughton Prison in particular, to ensure a prisoner's
wellbeing and to try to ascertain the prisoner's concerns and identify risks,
are impressive.
[19] On arrival at the prison Daniel
was interviewed by a prison officer. In
accordance with the SPS Act 2 Care Suicide Risk Management Strategy (Crown
production no. 10) a prison officer completed the first part of the reception
risk assessment document (Crown production no 11). Among a number of answers to questions,
Daniel answered that he was not feeling suicidal and that he did not feel that
he might hurt himself. It was indicated
that he showed no signs of anxiety. The
prisoner officer identified no apparent risk.
It was one of the duties of the prison officer to look for signs of and
assess a risk of suicide or self-harm.
[20] Next, on admission, the prisoner
sees a nurse. The nurse, Fiona Rose,
completed the health care records nursing assessment form (Crown production no.
6, and health care risk assessment part of the risk assessment document (Crown
production no. 11). It was part of the
nurse's function to look for signs of and assess a risk of suicide or
self-harm. Daniel indicated that he was
on painkillers and sleeping tablets and had had psychiatric treatment; he had
last taken drugs (Cocaine) two years ago and did not have a drink problem. He told nurse Rose that he did not feel
suicidal and did not feel like hurting himself.
She considered that he was slightly anxious, but presented no apparent
risk at present. She indicated in her
evidence that the length of the interview depended very much on the
circumstances, but generally lasted about 15 minutes. She had no cause for concern about
Daniel. The nurse then makes an entry in
the SPS physical care records (Crown production no. 22). Nurse Rose recorded that Daniel "presents no
particular medical issues at this time" and queried whether he was prescribed
painkillers and sleeping tablets as he indicated. Daniel signed a form (Crown production no. 8)
which is a consent sent to the general medical practitioner to release relevant
medical information to the prison. For
reasons of doctor-patient confidentiality, such a consent would be required.
[21] Next the prisoner has a one to
one talk with a peer supporter, that is a prisoner who is a "meeter and
greeter" at reception. That person is
expected to pass on any concerns to staff.
It is thought that a prisoner might be more likely to be open with a fellow
prisoner than with a prison officer.
[22] On admission a prisoner is given
a copy of the induction booklet. The
version current on Daniel's admission is in Crew production no. 10. Daniel appears to have been given a copy: see
admissions data in Crown production no. 15.
The booklet is revised at regular intervals and the current version is
Crown production no. 17. The document
provides information, among other things, about visits (page 8), the family
contact development officer (page 9), the anti-bullying policy and the listener
and Samaritan schemes. A listener, a
prisoner, is on duty every day in the prison, one in the morning and one in the
afternoon, to offer support to fellow prisoners to solve problems. They are trained by the Samaritans and offer
confidentiality in line with Samaritan protocols.
[23] After passing through reception,
on admission, a prisoner is allocated to a landing or level and a cell in
Hermiston House. There is another peer
supporter there, a "meeter and greeter", on each landing who speaks to the new
prisoner. He also is expected to pass on
any concerns to staff.
[24] Within 24 hours of admission the
prisoner must be seen by one of the prison doctors who work as GPs in the prison. Daniel was seen the day after his arrival, on
[25] Dr Vyas considered that there
was no danger in prescribing Chlordiazepoxide to someone who had had a head
injury. What Daniel was described was a
therapeutic dose; it would cause no problems if taken by someone who did not have
an alcohol problem. The dose was 10 mg
as can be seen from the prescription sheet no. 1 in Crown production no.
25. There would be no problem in
prescribing Amitriptyline as well even if it were not required.
[26] So far as Amitriptyline is
concerned, Dr Vyas appears to have contacted Daniel's GP, Dr Ross, and
ascertained that 12 tablets of Amitriptyline (50 mg) were last issued to Daniel
on
[27] Dr Briggs described
Amitriptyline as primarily an anti-depressant but that Daniel's prescription
was very low for depression. The drugs
had other uses such as a sedative to help sleep or as a painkiller such as to
reduce migraines. (One notes that Nurse
Rose had recorded that Daniel told her that he was prescribed painkillers and
sleeping tablets.) Dr Briggs thought that
50 mg was consistent with use to help sleep.
In his opinion, if Daniel took a week's supply he would not come to any
harm although he might become unwell. He
confirmed that Amitriptyline and Chlordiazepoxide could be combined without
risk. Professor Kernbach-Wighton also
confirmed that there was no danger in prescribing these drugs together; and
that they were not contributing factors to Daniel's death.
[28] Within 72 hours of admission a
core screen document (Crown production no. 12) must be completed. In this document, completed on 6 September,
Daniel did not disclose any problems; he did not want to discuss anything with
a prison social worker. He did not say
anything which caused concern that was noted.
He did not mention that he had a problem with drugs or alcohol, but
stated that he would like to stop smoking.
[29] Nurse Rose said that if she had
been aware of the statement in the social enquiry report (in Crown production
no. 20) that Dr Ross, Daniel's GP, felt that custody "would be very harmful to
Mr Crew's mental well-being", that would have made her more inclined to look
into Daniel's mental health background.
On its own, however, the statement would not necessarily indicate to her
that he should be put on ACT as a prisoner at risk. She might have referred Daniel to the mental
health team to see how he was coping.
[30] In fact, as it happens, Daniel
was seen by a mental health nurse, Norma Brown.
She had 15 years' experience, was a registered mental nurse and a
trained community psychiatric nurse.
Apparently Mrs Crew had telephoned the prison, and spoken to a family
contact development officer. Nurse Brown
said that she received a request from Hall staff because Daniel's mother had
called and was concerned at how he was coping in prison. Nurse Brown checked with Hall staff who said
that Daniel seemed to be coping well given that he had never been in prison
before. She interviewed Daniel privately
in an office on level 3 in Hermiston House on 9 September for, she thought, about
20 minutes. She recorded the interview
in SPS mental health records (Crown production no. 23) and the fact that the
interview had taken place was recorded in the physical care records (Crown
production no. 22). She found Daniel to
be bright and appropriate. He said he
had been drinking to excess when at liberty.
His mood appeared to be at a good level.
He said he was coping quite well given that he had not been in prison
before, and it was not as difficult as he had expected. He expressed no problems. In evidence Nurse Brown said that she asked
him if he had any mental illness to which he replied "no". If he had mentioned any, she would have
contacted those concerned in his treatment.
She said she asked him if he had had any contact with psychiatric services
and he said that he had not. There was a
contradiction in that she was aware of a reference to psychiatric treatment in
the admission risk assessment and physical care records. So she asked him about the mental health
treatment that he had had. He said that
this was when he had received his head injury (in 2005). She saw no evidence of mental illness. It was not appropriate to put him on
ACT. Nurse Brown said she would not put
a person on ACT just because a person had had psychiatric treatment. From this, and from the evidence of Dr Sharp,
the Consultant Psychiatrist at Huntlyburn House, Melrose, it is apparent that
having psychiatric treatment does not necessarily mean that one has thoughts of
self-harm or suicide.
[31] I asked Nurse Brown if she would
be surprised to learn that Daniel did not mention that he had been interviewed
by two psychiatrists within the last six weeks of his interview with her, that
is on 27 July and 15 August. She said
that she would have expected him to have mentioned it as a contact with
psychiatric services. A prisoner, she
said, might not mention it if he did not want them to know or if he was
concerned what the consequences might be if he did mention it.
[32] Mrs Crew was concerned at the
Inquiry that, on admission, Daniel exhibited factors which were indicative of
self-harm or suicide which are mentioned in the Act 2 Care Strategy (Crown
production no. 10). These were, she
said, the first time in prison, mental health problems, unemployment, anxiety,
headaches and sleep problems. The
impression I got from Nurse Rose and Nurse Brown is that one had to look at the
whole picture, not any particular factor.
From their interviews with Daniel they could not see any cause for
concern.
[33] Mrs Crew was critical of the
fact that whereas the prison officer noted no anxiety, Nurse Rose noted that
Daniel was slightly anxious. Nurse Rose
did not seem to consider this a contradiction.
She said sometimes a prisoner will say something different when speaking
to a man than when speaking to a woman.
[34] On the information available to
the prison, there does not seem to me to have been anything that should have
led those who interviewed him, or the prison authorities, to conclude that
Daniel was at risk.
[35] There was a query about the
presence of alcohol in Daniel's post-mortem sample. Pauline Lax, the forensic toxicologist who
analysed the sample, thought that alcohol would be produced in the blood as a
result of post-mortem microbial production but was less likely to be so
produced in urine. The alcohol present
(7 mg in 100 ml) was very low and was more likely to have originated from the
consumption of alcoholic drink. She
thought it would have been taken less than a week before (ie taken while Daniel
was in prison). Professor Kernbach-Wighton,
on the other hand, said that the presence of a higher concentrate of alcohol
was more likely to be found in urine rather than blood as a result of
post-mortem microbial production.
Pauline Lax said that she could not exclude the possibility that the
alcohol in the urine was the result of post-mortem microbial production. In the light of that and Professor Kernbach-Wighton's
evidence, I conclude that the very low concentration of alcohol in the urine
sample was the result of post-mortem microbial production. It was not the result of Daniel having
consumed alcohol in prison before his death.
Information from outside agencies at the time of Daniel Crew's admission
to prison
[36] A social enquiry report had been
requested by the court and was available when Daniel was sentenced on
[37] The author of the report, Lisa
Grieve, was in training as a social worker at the time she wrote the
report. She became a social worker in
December 2006. She said, in evidence,
that Daniel came to the social work office with his mother and Liddy Hall, a
volunteer advocate with the Borders Independent Advocacy Service. Liddy Hall was with him during the
interview. Miss Grieve said in evidence
that Daniel was not easy to assess. He
did not want to communicate, did not answer readily, or gave the shortest
answer possible. Daniel mentioned the
brain injury and that his behaviour was affected by it. He did not mention that he had psychiatric
problems or treatment. He did not say
anything about self-harm or suicide.
Miss Grieve contacted his GP, Dr Ross, who told her about Daniel being
assessed by Dr Sharp and that he was not receiving any psychiatric treatment
and was told that he should stop taking drugs and alcohol. Miss Grieve did not contact Dr Sharp. Daniel denied to Miss Grieve that he had a
problem with either drugs or alcohol.
Miss Grieve could not remember exactly what Dr Ross said about custody
being harmful to Daniel's mental well-being.
Dr Ross did not mention self-harm or suicide. Liddy Hall did not mention self-harm or
suicide. Miss Grieve said that she came
from that area of belief that prison was harmful to anybody and that she could
have written that statement regardless of any psychiatric problem. Notwithstanding that statement, Miss Grieve
had no concerns about the likely effect of custody on Daniel. If she had had a concern about self-harm or
suicide she would have mentioned it explicitly in her report.
[38] After that interview Mrs Crew
wanted to speak to Miss Grieve alone to which Daniel consented. Later Daniel withdrew his consent and became
agitated, and the discussion was terminated.
An interview with the parent of an offender over 18 would occur only if
the offender consented, Miss Grieve said.
Mrs Crew did not mention, according to Miss Grieve, self-harm or
suicide. Mrs Crew put to Miss Grieve in
cross-examination that she had told her about Daniel misusing his medication,
an incident when he had cut his arms with a blade, an incident when he refused
medical help for an injured foot, and had shown her an image on the digital
camera of Daniel having cut his face (a photograph which is in Crew production
no. 9). Miss Grieve had no recollection
of being told these things and had never seen the photograph before.
[39] Zoe Brydon, who was not a social
worker, is a criminal justice officer who represented the social work
department at court. She has been doing
that work for 18 months. She was in
[40] Miss Brydon said that if she had
been aware of a sign of risk, or had any concerns about risk, or if anybody
mentioned concerns such as a member of the family, the defence solicitor,
police or the custody officers (Reliance) she would complete the SPS suicide
risk identification court form (SPS production no. 2). If the form is completed it is given to
Reliance and accompanies the offender to prison. She did not fill up the form and did not send
it. She did not do so because she did
not identify a risk. She could not
remember Daniel, but said in evidence that if there had been an indication of
suicidal or self-harm tendencies, she would have filled in the form. In not sending the form she would not have
thought that there would have been a risk.
She would have spoken to him because the social enquiry report mentioned
mental health problems, that is the assessment by Dr Sharp and Dr Ross's
comment about Daniel's mental well-being.
Any conversation with Daniel would only have lasted a couple of minutes.
[41] If there were no indications of
risk, but there was something in the social enquiry report or, for example,
mention of self-harm some years before, it was Miss Brydon's practice to fax a
letter to the prison. In this case she
faxed a letter (Crown production no.32) at 16.41 on 4 September to the social work
department at Saughton Prison stating that Daniel had some mental health
problems due to a head injury. She
waited until she had the confirmation of the transaction report. She did not usually seek confirmation of
receipt by the social work department and did not do so on this occasion.
[42] It is apparent that neither the
social worker who wrote the social enquiry report, nor the community justice
worker in court, had any concerns or saw any signs of Daniel having thoughts of
self-harm or suicide and they were not aware of any. I recognise that they were both relatively
inexperienced; but it is also apparent that Daniel did not say anything to them
that raised concerns.
[43] Dr Sharp, a Consultant
Psychiatrist since 1995 and a psychiatrist for 20 years, is based at Huntlyburn
House in
[44] In July 2006 Daniel was referred
again by his GP for psychiatric assessment after cutting his face (see the
photographs in Crew production no. 9). This
was the occasion that Liddy Hall described in evidence as very important to
Daniel because he wanted help and treatment for his problems. When he was refused admission to Huntlyburn,
she said that Daniel did not feel that anyone believed him about his condition,
that that distressed him and that he felt what was the point.
[45] The truth of the matter appears
to be rather different. Daniel was
interviewed by Dr Mohamed Abou El-Alamein.
Although Dr El-Alamein was the most junior psychiatrist with only four
or five months' experience, his assessment of Daniel appears to be similar to
that identified by all the other mental health professionals who had seen him
previously. In the letter from the
psychiatrist to Dr Ross on
[46] In his letter to Dr Ross of
[47] Dr Sharp was asked by Daniel's
solicitor for a report for Daniel's sentencing diet on
[48] He had no psychiatric disposal
to recommend. I do not know if this
report was referred to by Daniel's solicitor in her submissions at the
sentencing diet, or whether it was produced to the court; there is no evidence
that it was. It may not have been
because there was no psychiatric or other recommendation. Had it been, it would not have disclosed any
risk of suicide or self-harm. Dr Sharp
did not mention in it Daniel's previous threats of suicide or self-harm.
[49] Dr Sharp said in evidence that
there was not a possibility of self-harm or suicide at that time; if he had
though that there was a serious possibility he would have mentioned it in his
report to the defence solicitor. Daniel
appeared to have plans for the future which was a positive sign. In his view Daniel's self-harm thoughts were
related to his alcohol misuse (that is, they occurred when he was drunk)
because after a few days (that is, when he was not drinking), they
receded. In any event his self-harming
was superficial. His disturbed behaviour
was different from serious and persistent suicidal attempts. Daniel did not have a personality
disorder. He would not have considered
it necessary to contact the prison about risk because Daniel was like any other
young man with similar problems.
[50] Dr Sharp considered that Daniel
had to deal with his drug and alcohol problem before anything could be done
about his underlying problems. It was
very difficult to do anything when Daniel did not accept that there was a
problem. It seems to me that those
underlying problems were rather more social than psychiatric: Daniel was
described by Dr Sharp as a troubled, unhappy young man struggling to find a
role in life and sustain relationships.
[51] None of the mental health
professionals who saw Daniel seemed to identify a suicide risk.
[52] Liddy Hall said that Daniel
spoke to her about suicide from time to time and she had a fear about his
suicidal tendencies. She wrote to
Daniel's GP about him trying to harm himself and told Dr Sharp of her
fears. Liddy Hall wrote a report for
Daniel's solicitors (Crew production no. 1) for the court appearance on 4
September. She said she raised her
concerns about suicide in this report.
That report was primarily dealing with Daniel's head injury and the
contact that Liddy Hall had with Maxine Kinnaird of the Headway Group. Daniel's lack of engagement could be due to
his head injury, it was stated. Maxine
Kinnaird was said to recommend assessment at somewhere like the Robert Ferguson
Unit at the
[53] Dr Sharp did recall Liddy Hall
mentioning the Robert Ferguson Unit to him.
He had worked at the
[54] Mrs Crew was critical of the psychiatric
report written by Dr Sharp for Daniel's solicitor because it did not mention
instances of self-harm, his mother's concern about Daniel's suicide thoughts,
his referral to the crisis team (when he was seen by Dr El-Alamein on
[55] As I have mentioned, it is not
known that the sheriff was shown the psychiatric report obtained by the
solicitor; and one was not sought by the court.
Even if the report had made such references, one cannot know what the
sheriff would have done. The evidence of
Dr Sharp indicates that he would not have had concerns about current self-harm
or suicidal risk; and I have mentioned why he did not say anything about it in
his report to the solicitor. No one who
assessed Daniel in the week before he died had any concerns.
[56] The only reference to Headway is
in Liddy Hall's report for the defence solicitor (Crew production no. 1) and
the comments recorded from Maxine Kinnaird in that report. Those do not mention concerns for Daniel's
safety. I have already dealt with Liddy
Hall's comment about Daniel's safety in her report in paragraph 52 above.
[57] Daniel was seen between 2004 and
2006 by a consultant neurologist, a psychologist and a number of
psychiatrists. From the records in Crown
production no. 27 and the evidence of Dr Sharp, Daniel appears to have denied
suicidal ideation. The advice was that
Daniel should make use of a referral to community drug or alcohol services, but
he appears not to have wanted to take that up.
A number of these professionals, including his GP, considered that Daniel
was heading for a custodial sentence if he did not change his behaviour.
[58] Had the social enquiry report,
Dr Sharp's report of 31 August 2006 and Liddy Hall's report of 4 September been
available to the staff at the prison who assessed Daniel, those reports would
not have disclosed anything that would have raised a concern about a risk of
suicide or self-harm by Daniel.
Furthermore, the social worker and Dr Sharp did not mention any concerns
because there were none.
Defects in any system of working
[59] There were no defects in any
system of working that I have been able to identify.
HM Prison, Edinburgh
[60] According to Mr Stuart Wright,
the prison officer in charge of induction, a cell sharing risk assessment form
(see Crown production no. 16) should have been completed on admission by the
reception officer, the nurse and the Hall prison officer. The purpose of this is to identify whether a
prisoner is at risk of harm or suicide to himself or of harm to others if on
his own cell or if sharing a cell. There
does not appear to have been one completed for Daniel; if it was, it was not
produced. Daniel was in fact in a cell
on his own. No risks to himself were
identified on his admission. While this
form should have been completed, there was no evidence that it not having been
done contributed in any way to Daniel's death.
[61] There was a question raised as
to whether an addiction assessment form (Crown production no. 7) should have
been completed. It would be signed by
the nurse. Nurse Rose said it would not
be completed for someone given alcohol detoxification. The form itself, 1 notice, appears designed
for drugs. Dr Vyas at one point thought
it should have been completed, though at another seemed to suggest it was not
required if just a straightforward detoxification drug programme was prescribed
to combat the symptoms of alcohol withdrawal.
There was no need to complete it for drugs because Daniel did not
indicate he had a current drug problem.
Where such a form is completed, the prisoner is referred to the
addictions team. Associated with this
form is the taking of a urine test. Dr
Vyas seemed to think that this would always be done, but Nurse Rose thought it
would only be done if a drug addiction were disclosed. Daniel did not disclose that he had a current
drug addiction and was not being treated for one.
[62] Daniel told Dr Vyas on 5
September that he had an alcohol problem.
Dr Vyas prescribed Chlordiazepoxide for detoxification. It was not apparent that Daniel required anything
more than the prescribed detoxification drug regime. There was some confusion about whether the
addiction assessment and the referral to the addictions team should be made
when dealing with alcohol detoxification.
It may depend on the degree of alcoholism. While there is nothing arising out of this
which contributed to Daniel's death, the system might be looked into to see if
there is clarification required about when the procedure is to be used if at
all in relation to alcohol.
[63] There is also a prisoner's
supervision form (Crown production no. 13) to be completed at admission. This is not concerned with the risk of harm
but with security. It is not clear if
such a form was completed in respect of Daniel, as none was produced; though in
the core screen document completed on 6 September (Crown production no. 12) it
is recorded that Daniel's PSS level was "low" i.e. he required minimum
supervision and restrictions. One
imagines that this could not be recorded without an assessment document being
completed. If this form had not been
completed, the failure to do so did not contribute in any way to Daniel's
death.
[64] In Crown production no. 11, the
ACT reception risk assessment document, it is not possible to decipher the name
of the prison officer who prepared the reception risk assessment. The printed name and signature are just
squiggles. There will be occasions when
it will be important to identify that person.
While this failure did not contribute to Daniel's death, I think in
future the name of the officer completing that part of the risk assessment
document should be clearly legible.
[65] Mrs Crew was critical of the
shortness of the interviews at admission by the nurse and the doctor. The length of time will depend on the circumstances,
including the number of admissions to be seen.
A prisoner is seen by two different members of staff separately and
independently at admission (prison officer and a nurse) and by a third, a
doctor, within 24 hours. He is also seen
by two meeters and greeters, though I accept that these are not professionals
there to assess risk. It has to be borne
in mind that assessing risk is not something done only at admission. An ACT document can be raised at any time by
any person working in the prison and in contact with a prisoner. All staff are trained with Act 2 Care
Strategy, and within 24 hours of an ACT document being raised a case conference
is held at which the prisoner is present.
The strategy document (Crown production no. 10) points out that assessment
on admission is a "one-off" snapshot and emphasises that it is vital for all
staff to look for signs of risk throughout a prisoner's period of custody.
[66] I do not think that the prison
can be criticised for the length of the interviews in the admission process.
[67] Mr Wright, the induction
officer, formulated the induction course at Saughton Prison. It is for prisoners serving sentences from 30
days to life. On admission prisoners
receive the induction booklet (Crown production no. 17 and Crew production no.
10). Prisoners are involved in its
contents. It is a précis of the material
covered on the induction course. Mr
Wright tries to update the booklet quarterly.
Prisoners also receive an invitation on the preceding Thursday or Friday
of the start of the course, which is on a Monday, to attend the course. The induction course always starts on a
Monday and lasts for five days. The
course is presented by an induction officer and two prisoners; other members of
staff also take part. It is compulsory
to attend the start of the course. After
that a prisoner can decline to attend.
If he does so, he signs a disclaimer.
Daniel signed a disclaimer on 11 September (Crown production no. 14)
which was a Monday. This would have been
the first day of the course that he attended, he having been admitted to the
prison the previous Monday afternoon.
When someone signs a disclaimer, the induction officer would try to
encourage the prisoner to attend. He
would also ask the meeter and greeter on the prisoner's level in the Hall to
speak to him to try to persuade him again.
It is not known if this happened in Daniel's case. Mr Wright was on leave at the time and had no
dealings with Daniel.
[68] Mr Wright mentioned that the
induction unit at Saughton Prison had been referred to as a centre of
excellence in the October 2006 report by Her Majesty's Chief Inspector of
Prisons, Dr Andrew McLellan. The prison
was the most advanced in relation to induction of prisoners.
[69] Mrs Crew thought that attendance
at the whole induction course should be compulsory. As was explained by the deputy governor,
Christine McGeever, a prisoner who was made to attend a course that he did not
want to attend could be disruptive, spoil it for others and would not get
anything out of it for himself. For
these reasons I do not think attendance at the whole induction course should be
made compulsory.
Communications and emergency codes
[70] Mr Grieve said that, when he put
out the call for a nurse and an ambulance, he used the term "code red". He understood since that there were two
unofficial codes "red" and "blue", the former used when there was blood and the
latter when there was a breathing problem.
A number of members of staff who were called to the scene thought that the
codes were unofficial. The deputy
governor thought that these codes were official, the purpose of the different
codes being to forewarn staff as to the type of emergency.
[71] It was apparent from all the
witnesses from the prison that it made no difference which code was used. Both were treated as an emergency, and the
nurses confirmed that they took the same equipment to the scene whichever code
was used.
[72] Paramedic Lesley Conway said
that she received an emergency call from ambulance control at 20.34 about a
male prisoner with cut wrists. Crown
production no. 30 contains a printout of the record of the emergency 999
call. It contains the statement in
answer to the question "What's the problem?"
"MALE CUT HIS WRISTS". It also
mentions that the male was conscious and breathing, although a few lines later
it is recorded that consciousness and breathing were unknown. The emergency appears to have been given an
"amber" dispatch code by the ambulance service.
Miss Conway indicated that she would not know whether the emergency was
given a red (immediate response) or amber code.
She was based, and was, at
[73] It may be, as the result of a
code red being used, that confusion arose about the nature of the emergency in
this case. A code red which suggests
blood, would be more consistent with cut wrists than with use of a ligature.
[74] In this case it is clear that
use of the term "code red" rather than "code blue" did not affect the response
to the emergency in this case. Staff in
the prison responded to it immediately and the nurses arrived with the
necessary equipment including oxygen and CPR equipment. The ambulance service and crew responded as
quickly as they could.
[75] I can quite understand that
prison staff would wish to use a code rather than call out the details of the
emergency. It is quicker and avoids disquieting
other prisoners. The use of "code red"
rather than "code blue", however, did not contribute to the death of Daniel.
[76] Mrs Crew said it should be
possible to make a 999 call from all telephones in the prison and not to have
to go through the control room. She said
it would save time. There is also the
issue of maintaining accuracy of information when more than one person is
involved in passing on a message.
[77] It was not entirely clear
whether it was possible to make an outside call from the officer's desk on
level 3. It is certainly not possible
from every telephone. It does not necessarily
follow that it would save time to make a 999 call from the officer's desk. I can envisage circumstances where it would
be quicker to ask the control room to do it, thus freeing up an officer for
other duties. I can understand that the
more people who are contacted to pass on a message, the more possibilities
there are for the message to become garbled.
There are other ways of ensuring that that does not occur. In this instance nothing done affected Daniel's
death.
[78] I can also envisage security
problems if an outside call for an emergency could be made from any
telephone. It would mean that all
telephones could be accessible to prisoners as well.
[79] Mr Macari for the Crown,
submitted that clear and accurate communication is essential and that there was
a training issue to be considered. I
agree.
[80] I think that if there are to be
emergency codes, it should be clear to all prison staff what they are and when
each is to be used. Consideration should
be given to dealing with this and the issue of passing on accurate information
in training or by some other means.
[81] There was some concern expressed
by Miss Conway about the time it took to get to Daniel from the prison
gates. She received the call at 20.34
(see Crown production no. 30 and the patient report form which she
completed (Crown production no. 29)).
According to her it took 14 minutes to get to the prison (which she did
not record). She appeared to rely on the
time it had taken on previous occasions to determine the time it took. That would take the time to 20.48. She noted the time she got to the patient as
20.55 (Crown production no. 29). Therefore,
it took seven minutes to get to Daniel from the prison gates. She thought that the time it takes to get to
a patient in the prison should be looked at.
She was critical of the time it took to get the vehicle through the four
gates of the prison entrance. She did
not think there was a sense of emergency at the prison.
[82] The prison incident log (Crown
production 21) in which times are derived, where possible, from CCTV or the
gate/ECR log, indicates that the ambulance arrived at the prison at 20.55 and
that paramedics reached the patient at 20.59.55. According to that log the time from the gate
to the scene was therefore just under five minutes. Lesley Conway accepted that it could have
been five minutes. One wonders whether
the time she noted as the time at patient (20.55) was not in fact the time of
arrival at the prison which she would have had time to record; although she
said it was the time that she arrived at the patient. Nurse Rose said it would take about five
minutes; Mr Rooney thought that that was quite quick because the scene was about
the furthest from the gate one could get.
[83] The deputy governor said that
the gate staff would look out for the ambulance so as to open the gate
quickly. In fact Lesley Conway could not
remember whether the gate was already half open when she arrived. One can understand that one gate has to be
closed before the next is opened. The
deputy governor was surprised that one officer had to walk from gates 3 and 4
(which had to be operated manually in order to open and close them) as Miss
Conway said had happened. That may have
been because there were not enough staff to deploy, said the deputy governor.
[84] I do not think that there was
any critical time lapse in the ambulance crew getting to Daniel. The evidence suggests that it was about five
minutes which was judged to be about right as the time it would take. If Daniel was found to have no signs of life
at 20.30 he would have been dead long before the ambulance arrived at the
prison. Lesley Conway acknowledged that
this was probably so.
Court reports
[85] Both Miss Grieve and Miss Brydon
understood that the practice was that social enquiry reports accompanied
prisoners to the prison. It appears that
Daniel's social enquiry report did not accompany him to prison. The court warrant committing him to prison in
Crown production no. 20 has the words "COPY SOCIAL ENQUIRY/COMMUNITY
SERVICE/PSYCHIATRIC/MEDICAL REPORTS ATTACHED" crossed out by a line drawn
through them. In joint minute no. 3 it
is agreed that the clerk of court stated that she believed she would have
attached the social enquiry report to the warrant but could not explain why
those words were struck out of the warrant.
I do not see how, or why, they would have been crossed out if the social
enquiry report had been attached to the warrant.
[86] It was clear from prison staff,
including the deputy governor, that reports are not always attached to the
warrant. They provide useful information
for the prison in dealing with and caring for a prisoner, not just in relation
to information about risk of self-harm or suicide.
[87] The procurator fiscal suggested
that the wording on the warrant should be amended so that it was clear whether
a report had been "prepared". If the report was not attached, but it
appeared that a report had been prepared, the prison could make enquiries to
obtain it. Mrs Crew thought that all
such reports should always be sent to the prison.
[88] I think the better course is to
ensure that any social enquiry, medical or other report produced to the court
for sentence accompanies the prisoner to the prison. There is not a statutory requirement for that
to be done, but it is regarded as best practice. I think that the
Daniel Crew
[89] Daniel was the youngest of four
sons. He lived in the Borders. Growing up he loved football and was very
interested in motor bikes and cars.
Never academic, Mrs Crew said he saw his future as a mechanic and
started a mechanic's course. He dropped
out after a year. Like many teenagers,
she said, Daniel chose a new circle of friends who had different standards and
values and hence he got involved with drugs and alcohol and was unable to see
how they were affecting him and his lifestyle.
Liddy Hall helped him twice to obtain his own accommodation in Hawick
with which he could not cope. He
returned to living at home but there appeared to be friction at home because
his parents were concerned about his drinking and abuse of drugs which he would
not accept. It is clear that his parents
were beside themselves in trying to get Daniel to see his problems and in
trying to get help for him. By the time
he was sent to prison on 4 September he had already 11 previous
convictions mostly for breach of the peace.
He did not make use of probation.
He did not want to co-operate with social workers, the psychiatrists or
make use of community addiction services.
He was described by professionals with whom he came in contact as
immature, not taking responsibility for his behaviour and its consequences, as
confused, aggressive and threatening. He
sometimes walked out of interviews when his mother contradicted his denials of
his problems. Dr Sharp said that Daniel
could be a sheepish likeable young man.
Liddy Hall referred to his sensitive and caring side; but if something
he wanted did not work he reacted badly.
He would get into fights, being willing to take someone on.
[90] A picture emerged of a young man
who not only did not want to take responsibility, but denied he had a problem
and did not want to talk about it. His
brother, Richard Crew, said that he would keep himself locked up, that is he
would keep his thoughts to himself.
[91] In her submissions Mrs Crew said
that his family failed him, the system failed him and the professionals failed
him. I have not found any evidence that
anybody failed him. Daniel could not
have had a more supportive family; and I find no evidence of Daniel being
failed by "the system" or by any of the professionals with whom he came in
contact. Daniel was offered support and
help by and from psychiatrists and other health professionals. Sadly, I think Daniel failed himself by not
taking responsibility.
[92] Mrs Crew considered that
Daniel's profile, which she listed in her submissions, was one which, had it
been known to the prison, would have alerted staff to treat him as at
risk. The profile was: age range 18-24
high risk, history of drug and alcohol abuse, mental health problems, serious
head injury, headaches and sleeping problems, unemployed, in prison for first
time, self-harming, depression, anxiety, disbelieved by professionals, no hope,
low self-esteem. There is no evidence
that Daniel was disbelieved by professionals; he would not take their
advice. The prison staff were not aware
of the mental health problems, the self-harming and depression. As I have already mentioned, none of the four
members of the prison staff who interviewed him saw signs of risk; the
psychiatrists who assessed him saw no signs of risk; but some evidence for hope
was noticed. No one who looked for signs
of risk detected any.
Other factors relevant to the circumstances of Daniel's death
[93] None of the points with which I
deal under this head had any bearing on Daniel's death. I consider it appropriate to mention them
because they were raised.
Documents sent to the prison by fax
[94] Mrs Crew thought that any
information sent to the prison by fax, such as the letter faxed by Zoe Brydon
to the Social Work Department in the prison (see paragraph 41 above) should be
confirmed by the recipient so that it was known not only that it had been sent
but that it had been received. I think
that that is probably a good idea: just because it is sent does not mean that
it has been received.
Learning difficulties
[95] Mrs Crew considered that there
was a failure to notice an indication of a learning difficulty or anxiety with
Daniel because he put the wrong date on two forms. These were the consent to obtain medical
information from his GP (Crown production no. 8) and an "in possession"
medication document (Crew production no. 5).
Anyone can put a wrong date down; and I think the month in the second document
could in fact be a "9". I have already
dealt with the question of anxiety. I do
not think the putting of the wrong date was an indication that Daniel was at
risk or that he could not read the induction booklet.
Prescription and supervision of medicine in prison
[96] Mrs Crew was critical of the
fact that Daniel could be prescribed Amitriptyline by Dr Briggs without him
having seen the patient and when it had not been prescribed by his GP since
[97] It appeared from the evidence
that Dr Vyas decided not to prescribe it; although there is no record that he
contacted the GP or did not prescribe it, whereas Dr Briggs said he was asked
to contact the surgery because it had not been done. It may be because what was prescribed by Dr
Briggs was not harmful, that he erred on the side of prescribing rather than
not. Consideration should be given as to
whether procedures in relation to establishing prescriptions on admission to
prison require revision.
[98] Mrs Crew argued that all
medicines in prison should be supervised.
It was apparent that the Chlordiazepoxide was supervised in that Daniel
had to go to the medical centre to take that medicine. The Amitriptyline and the vitamin B and
Thiamine tablets were unsupervised, that is he was given the tablets in the Hall,
and he could take them to his cell and take them when required. Dr Vyas said that there were spot checks made
in relation to medicine that was unsupervised.
[99] As was pointed out by Mrs Martin
Brown for the Scottish Prison Service, outside prison there are medicines that
patients are allowed to take home to administer unsupervised. It may be, of course, that a prison is a
rather different environment which may require more supervision than would be
necessary outside prison. The vitamin B
and Thiamine were vitamins. The
Amitriptyline was a therapeutic dose which, if he had taken all seven pills,
could not have done Daniel harm. I do
not think, therefore, that it was necessary that the medicine should be
supervised. I think it is perhaps going
too far to say that all medication and vitamins should be supervised.
Staffing level in the prison
[100] Mrs Crew criticised the
staffing level on level 3 in Hermiston House as being too low. There would be four or five officers on
duty. There are 65 cells on the level
with room for 80 prisoners. That means
there would be one officer to 16 to 20 prisoners. There was no evidence that that was
inadequate. There was no evidence that
the number of staff on duty had any bearing on Daniel's death.
Whether the ambulance was delayed
[101] Mrs Crew said that the
ambulance to be sent to the prison was stood down before the call was
reclassified as an emergency. No one
from the ambulance control gave evidence about Crown production no. 30. The paramedic, Lesley Conway, could not, as
she did not usually see such a document.
I think Mrs Crew has read too much into, or misunderstood a particular
entry in, the transcript.
[102] The number of the emergency
call in relation to Daniel, given when the call was received at 20.32.43, was
"1673097". At 20.34.02 the transcript
appears to list what the availability of ambulances was. There is no mention in that list of Lesley
Conway's ambulance, the call sign of which on the first page is given as
"LIV495". The entry at 20.34.14 "LIV495
Stood Down from Call: ROU 1673012" suggests to me that Lesley Conway's
ambulance was stood down from or had finished a different call. There is no entry before that indicating that
Lesley Conway's ambulance was allocated to Daniel's emergency before the "stood
down" entry. The ambulance could not be
stood down from a call to which it had not yet been allocated. Lesley Conway's ambulance was allocated to
the call at 20.34.15. That is also the
time that Lesley Conway recorded in Crown Production no. 29 that she received
the call. I suspect that "ROU" stands
for routine and "1673012" is the number given to the call to which that entry
relates which is not the same number as the call number given to the emergency
call from the prison. There is no
question of a delay in an ambulance being sent out to the emergency.
Other points raised
[103] Mrs Crew criticised the fact
that medical staff did not appear to be available 24 hours a day in the
prison. This is outwith the remit of the
Inquiry, as Mrs Crew understood. Nursing
staff were on duty when Daniel was found.
There were two passing references to the availability of medical staff
during the night. I do not know what the
night arrangements are and they were not gone into during the Inquiry. I cannot possibly comment on this issue.
[104] Mrs Crew was surprised that
some witnesses did not recall times, conversations and other facts. Mrs Crew would, of course, know a great deal
about her son and his involvement with a number of people. Those who were dealing with Daniel would have
a number of other individuals to deal with as well as Daniel. It would not be possible for everyone with
whom Daniel came into contact to remember every detail in the way that Mrs Crew
did.
[105] Mrs Crew was critical of the
fact that after Nurse Brown had interviewed Daniel she received no call from
the prison to say that her telephone call had been followed up and what the
result was. She did mention in her
submissions that she had had a telephone call at some point from a prison
officer whose name she cannot remember who telephoned her with certain
information. She informed him of her
concerns that the family had had no message or request about a visit or for
clothes for Daniel. He said he would
take the time to deal with it. He
subsequently telephoned again to suggest a visit. Since those duties are the responsibility of
the family contact development officer it may well be that it was such an
officer who did in fact make contact with the family.
[106] Mrs Crew was also concerned
that information was given to the press before formal identification of Daniel
by members of the family. The deputy
governor, Christine McGeever, said that this was dealt with by the press office
at SPS Headquarters, and not by the prison and she was unable to give any
explanation. The deputy governor did say
that the press office was not informed until the police had advised that the
next-of-kin had been informed of the death.
While a deceased person must be identified, I do not think that it has
to be by a member of the family.
[107] Mrs Crew complained that the
family was overlooked in the days after Daniel's death. Mr and Mrs Crew were given two telephone
numbers to contact and they had difficulty making contact. I can understand how the family might feel. Following such a tragedy there is a great
deal for the prison staff and the police to do in making enquiries, and
gathering and collating information. In
the doing of that I can understand how the family might feel left out. I think sometimes there can be a reluctance
to give out pieces of information as they become available until the whole
picture is clear and the pieces of information can be confirmed. Were a family to be given a piece of
information at an early stage which subsequently turned out to be wrong there
would no doubt be criticism for the wrong information being disclosed. The deputy governor explained that after a
death in prison, families are now referred to the Chaplaincy team in the
prison.
[108] Mrs Crew was concerned that
little information came to light about Daniel's last day in prison. It would not be possible, it seems to me, to
record everything that every prisoner did in the course of each of his days in
prison. Obviously certain events would
be recorded such as attending a course, receiving a visit or making a telephone
call which could subsequently be traced.
[109] There were graffiti in Daniel's
cell. Graffiti in cells are common. I was informed that daily checks are carried
out, and prisoners are encouraged to clean them off. If offensive, graffiti can be painted
over. Richard Crew, one of Daniel's
brothers, wrote a letter to the procurator fiscal mentioning the graffiti on
the walls in Daniel's cell and on his bedding.
It is not known how much graffiti were present when Daniel was placed in
the cell. There was no evidence that the
graffiti affected Daniel's mental state.
[110] An envelope was found in
Daniel's cell, but no letter. DI Thomson
said that an envelope, or piece of paper, was found with the name 'Jen' and a
telephone number written on it. He was
given the envelope by Mrs Crew. Richard
Crew said there was an envelope in the cell with the name and address of
Daniel's girlfriend written on it. He
took it and gave it to his mother. There
was no letter in it. There was no
evidence that a letter had been removed.
[111] Mrs Crew was critical of the
fact that, as a party litigant, she was not able to obtain witness statements
from the procurator fiscal, and the witness list which was produced gave her no
clue as to the identify of the witnesses, what their roles were or what their
evidence might be about. I do not know
if the problem about witness statements may be regarded as similar to that in
criminal cases in which such statements are given to defence solicitors, but
not to accused persons representing themselves.
In relation to the witness list most of the witnesses were just
identified by name with an address being care of the prison. It might be possible to give more of a clue
as to whether the individuals on the witness list were, for example, prison
officers, persons who had dealings with the deceased or were involved in
attempting to resuscitate him. These
points were not gone into in the Inquiry, and there will be a number of issues
to consider in relation to them. For
those reasons I cannot make a recommendation, but they may bear some
examination and consideration in the procurator fiscal's office.
Post-Inquiry letter
[112] Mr and Mrs Crew sent me a three
page typed letter dated
[113] Firstly, it had not been
possible to contact one of Daniel's relatives before information had been
passed on to the media and it was mentioned on radio and television. I do not think I can comment on this as it
was not a matter with which the Inquiry is concerned. As a general rule I am not sure that it is
possible to withhold information from the press until every family member has
been informed.
[114] The other matter was the
circumstances in which the family was refused legal aid. Again this is a matter with which the Inquiry
was not concerned. The question of legal
aid for the family of a deceased to be represented at a fatal accident inquiry
is a matter to be taken up by a constituent with his or her Member of the
Scottish Parliament.
WITNESSES
who gave evidence at the Inquiry
(in order of appearance)
John Grieve, Residential Prison
Officer, HM Prison, Edinburgh.
Steven Rooney, Residential Prison
Officer, HM Prison, Edinburgh.
Dr William Briggs, MB, ChB, MRCGP,
DRCOG, DCCH, Medical Officer, HM Prison,
Edward Maley, Security Intelligence
Officer, HM Prison, Edinburgh.
Claire Anderson, Admissions Advice,
HM Prison,
Lesley Conway, Ambulance Paramedic,
Christine McGeever, Deputy Governor,
HM Prison, Edinburgh.
Dr Clifford Sharp, MB, ChB, MRCPsych,
Consultant Psychologist, Huntlyburn House,
Dr
Pauline Lax, BSc, FRP, Forensic Scientist, Forensic Alliance
Ltd.
Fiona Rose, Registered Nurse, HM
Prison, Edinburgh.
Norma Brown, Mental Health Nurse, HM
Prison, Edinburgh.
Stuart Wright, Induction Officer, HM
Prison, Edinburgh.
Lisa Grieve, Social Worker, Scottish
Borders Council.
Zoe Brydon, Criminal Justice Officer,
Scottish Borders Council.
Professor Gerhard Kernbach-Wighton, MD,
DRM, SFM, PhD, FGS, LegM, FRS Med, FFOSS, FGS TrafM, FGS, EtLM, Consultant
Forensic Pathologist, University of Edinburgh.
Richard Crew, St Boswells.