Jonathan Palmer
PFD Report
Partially Responded
Ref: 2017-0173
Coroner's Concerns (AI summary)
There was no effective system for families to provide crucial health information for prisoners, nor assurance of its dissemination. Ineffective control of contraband (Spice) inflow posed significant health risks within the prison.
View full coroner's concerns
_ There Is no effective system by which the family of a prisoner can input Information they deem relevant to a prisoner's health needs and be assured this will be disseminated to relevant teams within the prison, with appropriate records being maintained in order to be able to demonstrate this has been done_ Families can be a source of valuable medical information, particularly, where GP records have not been obtained and the individual himself may not be a reliable source. It would be beneficial to have a clear, publicised conduit for a family to provide relevant medical information to a specified department: The Inquest was informed that a single point of contact has now been established, but it remains unclear whether comprehensive records of all contacts will be maintained, or whether this will result in the timely dissemination of information to those with a role in the prisoner's welfare, such as healthcare staff, RAPt or the chaplains. As the Personal Officer scheme appears to have been abandoned at HMP Wandsworth there is no alternative individual for a concerned family to approach The steps taken to control the inflow of contraband material into the prison (such a8 the illicit drug known as Spice) , appear Ineffective Insidious substances such as Spice can mimic the symptoms of psychotic illness and jeopardise life when unpredictable reactions occur to those using it. Spice is also likely to adversely affect discipline within the prison, create the potential for intra prisoner bullying (arising from drug debts) and stretch already depleted healthcare resources_ In order to combat this menace, steps should be taken to identify the entry points in order that they can be more effectively controlled and those involved, deterred_
Responses
Action Taken
A Safer Custody Learning Bulletin has been issued regarding receiving emergency calls and sharing risk information from families, Samaritans, and others. HMP Wandsworth conducts searches of all visitors and prisoners after visits and uses various methods for prisoner searches, including a new body scanner. Mail and property are searched, and a policy on property was updated in 2016. (AI summary)
A Safer Custody Learning Bulletin has been issued regarding receiving emergency calls and sharing risk information from families, Samaritans, and others. HMP Wandsworth conducts searches of all visitors and prisoners after visits and uses various methods for prisoner searches, including a new body scanner. Mail and property are searched, and a policy on property was updated in 2016. (AI summary)
View full response
Dear Mr McLoughlin, Inquest into the death of Jonathan David Palmer Thank you for your Regulation 28 Report dated 31 May 2017, addressed to then Governor of HMP Wandsworth, at the conclusion of the inquest into the death O1 Jonathan David Palmer on 19 November 2015. Your report has been passed to the Safer Custody and Public Protection Group in Her Majesty's Prison and Probation Service (HMPPS the agency that has replaced NOMS) , which is responsible for sharing learning from deaths in prison custody. HMPPS works hard to learn lessons from deaths in custody and in particular looks to recommendations from the investigations by the Prisons and Probation Ombudsman (PPO) and the findings of inquests to help us identify areas for improvement would like to thank You for drawing our attention to the matters of concern that you raised in your report and will seek to address each in turn: Your first point is that there was no effective system by which the family of a prisoner can report their concerns about prisoner's health needs and be assured that this information will be disseminated appropriately In October 2016 the NOMS Safer Custody Group issued a Safer Custody Learning Bulletin titled 'Receiving Emergency Calls: facilitating the sharing of risk information by families, Samaritans and others' (Annex F): The bulletin is directed at all Safer Custody Teams_ Custodial Managers Reception/First Night Teams, Operations/Communication Room Teams and all staff whose duties may include receiving an emergency call from concerned families, the Samaritans or others_ It states that 'All prisons should have processes in place enabling anyone with concerns about prisoner's risk (to themselves or others) at any time to make contact quickly with an identified member of staff equipped to ensure that appropriate action is taken '
It goes on to say that it is essential that contact can be made with establishments 24 hours day, seven days a week, and that calls are answered promptly It states that families should be provided with contact details which can be used in an emergency: At HMP Wandsworth; a Governor's Order has been issued to all staff, stating that contact with prisoners' families must be recorded on the National Offender Management Information system (NOMIS): This is to ensure dissemination of information to all departments including healthcare You also expressed concern at what appeared to be ineffective steps taken to control the inflow of contraband material into the prison_ HMP Wandsworth now has a robust multi-pronged approach in place to address this_ Drug supply prevention is a continual challenge for all prisons and particularly a large inner city prison such as HMP Wandsworth: New psychoactive substances (NPS) present another aspect to this issue which the prison service was struggling with at the time of Mr Palmer's death NPS remain challenge as they can be easily disguised (e.g: sprayed on to writing paper) although dogs are now trained in their detection and mandatory drug testing kits can now also detect NPS In house training has promoted greater awareness and vigilance amongst staff but many of the supply routes remain the same In order to disrupt entry routes of illegal items and contraband, HMP Wandsworth now conduct searches of all visitors prior to the visit and search prisoners after visits_ There are varying methods of prisoner searches, including rub-downs, full strip searches or using the prison'8 new body scanner: The BOSS chair (which identifies whether a prisoner has secreted items anally) and metal detection wands are also available tools in the search for contraband items_ Mail and property sent to prisoners is searched and dogs are used wherever possible_ An X-ray machine is used for property and policy on property was updated in 2016, clarifying what prisoners are allowed to have in their cell, thus reducing available hiding places and means of trafficking Drones are now a major threat to prison security with drone deliveries to Wandsworth extremely prevalent until September 2016, when a combination of police support; technological developments and more effective internal measures (intelligence gathering, disrupting particular prisoners, rapid response searches and windows) led to a massive reduction_ Since September 2016, there has been only one intelligence report relating to drones HMP Wandsworth has seen significant success identifying corrupt staff and volunteers in the last year: Several staff have been permanently excluded with one significant find of contraband leading to an ongoing police investigation. Finally, in the next year the prison is due to change to a "smoke free" environment This will be a massive challenge but once implemented will mean that any form of smoking is banned, making it much more conspicuous and easier for the prison to tackle NPS meaning more effective control and deterring those involved. the the fixing
hope this response provides you with reassurance that HMPPS recognises the importance of the concerns you have raised: Thank you again for bringing these matters to our attention:
It goes on to say that it is essential that contact can be made with establishments 24 hours day, seven days a week, and that calls are answered promptly It states that families should be provided with contact details which can be used in an emergency: At HMP Wandsworth; a Governor's Order has been issued to all staff, stating that contact with prisoners' families must be recorded on the National Offender Management Information system (NOMIS): This is to ensure dissemination of information to all departments including healthcare You also expressed concern at what appeared to be ineffective steps taken to control the inflow of contraband material into the prison_ HMP Wandsworth now has a robust multi-pronged approach in place to address this_ Drug supply prevention is a continual challenge for all prisons and particularly a large inner city prison such as HMP Wandsworth: New psychoactive substances (NPS) present another aspect to this issue which the prison service was struggling with at the time of Mr Palmer's death NPS remain challenge as they can be easily disguised (e.g: sprayed on to writing paper) although dogs are now trained in their detection and mandatory drug testing kits can now also detect NPS In house training has promoted greater awareness and vigilance amongst staff but many of the supply routes remain the same In order to disrupt entry routes of illegal items and contraband, HMP Wandsworth now conduct searches of all visitors prior to the visit and search prisoners after visits_ There are varying methods of prisoner searches, including rub-downs, full strip searches or using the prison'8 new body scanner: The BOSS chair (which identifies whether a prisoner has secreted items anally) and metal detection wands are also available tools in the search for contraband items_ Mail and property sent to prisoners is searched and dogs are used wherever possible_ An X-ray machine is used for property and policy on property was updated in 2016, clarifying what prisoners are allowed to have in their cell, thus reducing available hiding places and means of trafficking Drones are now a major threat to prison security with drone deliveries to Wandsworth extremely prevalent until September 2016, when a combination of police support; technological developments and more effective internal measures (intelligence gathering, disrupting particular prisoners, rapid response searches and windows) led to a massive reduction_ Since September 2016, there has been only one intelligence report relating to drones HMP Wandsworth has seen significant success identifying corrupt staff and volunteers in the last year: Several staff have been permanently excluded with one significant find of contraband leading to an ongoing police investigation. Finally, in the next year the prison is due to change to a "smoke free" environment This will be a massive challenge but once implemented will mean that any form of smoking is banned, making it much more conspicuous and easier for the prison to tackle NPS meaning more effective control and deterring those involved. the the fixing
hope this response provides you with reassurance that HMPPS recognises the importance of the concerns you have raised: Thank you again for bringing these matters to our attention:
Sent To
- HMP Wandsworth
- Home Office
Response Status
Linked responses
1 of 2
56-Day Deadline
29 Sep 2017
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Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 30 November 2015 an investigation was commenced into the death of Jonathan David Palmer ("Mr Palmer') . On 18 2017 concluded the investigation at the end of an 8 Inquest, sitting with a jury: The Jury returned a Narrative conclusion:
Circumstances of the Death
On 3 June 2015 Mr Palmer was brought to HMP Wandsworth on remand prior to a trial which was listed to commence on 23 November 2015. On19 November 2015 at approximately 1400 hours Mr Palmer's Ilfeless body was discovered suspended from a ligature in his cell He was declared dead at 14.58 hours, after resuscitation efforts were abandoned. The Inquest found the cause of death to be Ia Hanging_ In the period between June and November 2015 Mr Palmer had exhibited bizarre and violent behaviour_ The prison and medical staff attributed his behaviour to the effects of an illicit drug, Spice. Mr Palmer's family (including his two brothers who were also held on remand and shared a cell with him for part of the time) were convinced that he was experiencing a developing psychotic illness In addition to his pre-existing psychiatric conditions The Narrative conclusion returned by the jury did not make a finding on the balance of probability as to whether his behaviour prior to his death should be ascribed to the misuse of illicit drugs, an emerging psychotic illness or a combination of the two. Mr Palmer's community GP records were not obtained and hence those responsible for his assessment and treatment in the prison from June 2015 onwards, had little information available as regards his previous medical history: Relevant aspects would have included his suicidal ideation in earlier years and the diagnosis of a major depressive illness, approximately four months before he was remanded in prison_ May day
Mr Palmer's family gave evidence that they endeavoured to make the prison aware of their concerns about his mental health in numerous telephone calls to safer custody, RAPt and the prison chaplains, as well as posting documents to the prison governor; but the records available from chaplains and others did not enable the Inquest to determine the date, nature and value of all of the information alleged to have been sent to the prison. Evidence taken at the Inquest indicated that Mr Palmer admitted at various times to having smoked Spice The Jury did not; however, find causal link between any illicit drug usage and the death: One prisoner asserted in the course of his evidence that contraband material is smuggled into the prison by corrupt individuals, but the investigation of this matter was outside the scope of the Inquest
Mr Palmer's family gave evidence that they endeavoured to make the prison aware of their concerns about his mental health in numerous telephone calls to safer custody, RAPt and the prison chaplains, as well as posting documents to the prison governor; but the records available from chaplains and others did not enable the Inquest to determine the date, nature and value of all of the information alleged to have been sent to the prison. Evidence taken at the Inquest indicated that Mr Palmer admitted at various times to having smoked Spice The Jury did not; however, find causal link between any illicit drug usage and the death: One prisoner asserted in the course of his evidence that contraband material is smuggled into the prison by corrupt individuals, but the investigation of this matter was outside the scope of the Inquest
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe that the Secretary of state for the Home Department and /or the Governor of HMP Wandsworth have the power to take such action_
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.