Christopher Corkill

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Christopher
Corkill, a prisoner at Isle of Man
Prison, on 24 February 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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© Crown copyright, 2024
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
My office does not have any jurisdiction in the Isle of Man but was invited by the CEO of
the Department of Home Affairs, Mr Dan Davies, to conduct this investigation. PPO
investigations are undertaken to assist prisons in ensuring the standard of care received
by those within remit is appropriate. Our recommendations should be focused, evidenced
and viable. This is especially the case if there is evidence of systemic failure.
Mr Christopher Corkill was found dead in his cell at Isle of Man Prison on 24 February
2023. He had suffocated himself by placing a plastic bag over his head. He was 46 years
old. I offer my condolences to Mr Corkill’s family and friends. This is the third self-inflicted
death at the prison since March 2020.
Mr Corkill had a history of self-harm and was supported by suicide and self-harm
prevention measures, known as Folder 5, when he first arrived at Isle of Man Prison in July
2022. However, we found no evidence that staff could have reasonably identified that his
risk of suicide had increased before he died.
The clinical reviewer found the overall care provided to Mr Corkill by Manx Care was not
equivalent to that which he could have expected to receive in the community.
Mental health services within Isle of Man Prison were found to be inadequate, unsafe, and
not equivalent to what is available in the wider community. Despite Mr Corkill’s history of
mental health issues, and recent self-harm before he entered prison, he was never
referred for a mental health assessment. This was a significant failing. Mr Corkill also had
a number of chronic physical health issues. There were no care plans, and he was not
adequately monitored.
When Mr Corkill was discovered, he had been dead for some time. We have identified a
number of factors that should be addressed to improve the response during a medical
emergency.
Our investigation identified other issues fundamental to the care of prisoners. The
Department of Home Affairs and Department of Health and Social Care need to support
the Governor and Manx Care to improve staffing levels, governance, oversight and
management of risk and the need to develop clear protocols and guidance to support staff
in undertaking their duties to improve safety.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman January 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 6
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 12
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Summary
Events
1. On 23 July 2022, Mr Christopher Corkill was remanded to Isle of Man Prison,
charged with drug offences. On 29 July, he appeared in court and was sentenced to
34 months and 20 days imprisonment. Mr Corkill had been to prison before.
2. Mr Corkill had a long history of substance misuse and mental health issues. He had
been diagnosed with schizophrenia, drug induced psychosis and had a history of
self-harm and attempted suicide. In the month before he was remanded, Mr Corkill
had made significant cuts and burns to his arms. He also had some chronic
physical health issues, including heart failure.
3. Mr Corkill was supported by the prison's suicide and self-harm prevention measures
(known as Folder 5) on one occasion, when he first arrived at Isle of Man Prison.
There was nothing obvious in his demeanour in the weeks before he died to
suggest his risk of suicide had increased.
4. At 7.52am on 25 February, an officer unlocked Mr Corkill’s cell for him to collect his
medication. The officer looked into the cell, saw Mr Corkill lying on his bed and
moved on. The officer returned to the cell four minutes later and discovered Mr
Corkill lying unresponsive on his bed, with a plastic bag over his head. The officer
radioed for assistance and prison and healthcare staff responded. Paramedics
declared Mr Corkill’s death at 8.09am.
Findings
5. Mr Corkill’s was the third self-inflicted death at Isle of Man Prison since March 2020,
and we found that the prison had not made sufficient changes or responded to the
learning from the previous deaths.
6. We found, as did HM Chief Inspector of Prisons, the management of prisoners at
risk of suicide and self-harm was inadequate. Too much emphasis was placed on
staff/prisoner relationships and prior knowledge of the person. Mr Corkill was
subject to Folder 5 procedures when he first arrived, the management of which was
poor; there was no assessment, no medical report and no caremap.
7. The clinical reviewer found that the mental health provision at Isle of Man was
inadequate, unsafe and the care Mr Corkill received was not equivalent to that
which he could have expected to receive in the community. Despite Mr Corkill’s
significant mental health history, previous self-harm, and requests to see the mental
health team, he was never referred and assessed. We found there was confusion
and a lack of understanding about the referral process.
8. Mr Corkill did not receive equivalent care for his physical health issues. Despite his
chronic conditions, there were no care plans and no formalised process to assess
and review him.
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9. We identified unsafe practices regarding the issuing of medication, a lack of clinical
governance and quality oversight dedicated to prison healthcare and an insufficient
response to Mr Corkill’s death from Manx Care.
10. The immediate response when Mr Corkill was found unresponsive was inefficient,
largely because the prison has no specific emergency response policy. Similarly,
the lack of clear guidance for staff led them to attempt to resuscitate Mr Corkill
despite clear signs of death.
11. We found that it was inappropriate that Mr Corkill’s body was not placed back into
his cell after he was declared dead.
12. We also have concerns about how Mr Corkill’s family were informed of his death
and staff support following it.
Recommendations
• The Department of Health and Social Care and Manx Care should review the current
provision of mental health services at Isle of Man Prison and provide a dedicated
mental health service, which is sufficiently resourced to meet the needs of the
population.
• Manx Care should undertake a systemic population health needs assessment across
Isle of Man Prison to determine the prevalence of mental health conditions and need.
• Manx Care should ensure there is a long-term conditions monitoring register and clinic.
• Manx Care should ensure there is a dedicated lead pharmacy provision at Isle of Man
Prison and there is a prescriber available every day, even if that is for remote
prescribing.
• Manx Care should ensure that patients who come in with complex and high-risk
medication (as per the RCGP guidance) have a medication review when they arrive at
the prison.
• Manx Care should implement electronic medication administration records.
• Manx Care should have a dedicated clinical governance lead responsible for prison
healthcare at Isle of Man Prison to ensure practice is compliant and underpinned by
national guidance, legislation and evidence-based practice.
• The Serious Incident Review Group of Manx Care should always complete an
investigation following a death in custody.
• The Governor should introduce a clear protocol to staff for effectively communicating a
medical emergency.
• The Governor and Manx Care should ensure that there is clear joint guidance for all
staff, and check their understanding, about the circumstances in which resuscitation is
inappropriate in accordance with European Resuscitation Council Guidelines.
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• The Governor should consider establishing a protocol with the Isle of Man
Constabulary to ensure that following a death in custody the deceased’s body is moved
back into their cell for dignity, if there is no suspicion of a crime.
• The Governor should ensure that the prison complies with its own policy for contacting
the families of deceased prisoner and that they have adequately trained family liaison
officers.
• The Governor should ensure in the event of a death in custody, prisoners’ in-cell
telephones should be disconnected immediately to avoid families being notified before
the prison have an opportunity to break the news.
• The Governor and Manx Care should ensure that all relevant staff, irrespective of
status, position, or experience, are able to attend a debrief following a death in custody
and that they receive appropriate aftercare support.
• The Department of Home Affairs should consider immediately commissioning an
independent investigation in the event of any future non-natural deaths at Isle of Man
Prison.
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The Investigation Process
13. The Isle of Man Department of Home Affairs asked the PPO to conduct an
independent investigation into the circumstances surrounding the deaths of two
prisoners, Mr Corkill’s death in February 2023 and another man in November 2022,
who had died in similar circumstances. There had been a third similar death in
March 2020, but this was not investigated as the inquest had already concluded
(the Coroner provided details of the inquest findings). The PPO were formally
commissioned to investigate on 17 April 2023.
14. The investigator issued notices to staff and prisoners at Isle of Man Prison informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
15. The investigator visited Isle of Man Prison on 2 May 2023. She obtained copies of
relevant extracts from Mr Corkill’s prison and medical records. She visited the wing
where he lived, reception, healthcare and met with senior managers.
16. The PPO commissioned a clinical reviewer to review Mr Corkill’s clinical care at the
prison. The investigator and clinical reviewer interviewed 18 members of staff and
two prisoners in June 2023. They interviewed the prison Governor and General
Manager for Integrated Mental Health Services on 6 July.
17. The investigator and clinical reviewer met with the Governor and separately with
Manx Care in July, to provide feedback on the investigation and share the emerging
findings so they could act before the publication of the PPO report.
18. We informed The High Bailiff, Her Worship Coroner for Isle of Man of the
investigation. The Coroner gave us the results of the post-mortem examination. We
have sent the Coroner a copy of this report.
19. The investigator contacted Mr Corkill’s brother and partner to explain the
investigation and to ask if they had any matters they wanted us to consider.
Mr Corkill’s brother asked:
• Why are plastic bags still available when a previous review into a death said they
should all be removed?
• What was known about Mr Corkill’s history of suicide attempts?
• Are prisoners checked as they should be while subject to enhanced monitoring as
part of the suicide prevention measures?
• Why was Mr Corkill discovered by another prisoner and not a member of staff?
• Why did Mr Corkill’s partner find out about his death two hours before the prison
made contact?
• Why did the prison not make any direct contact and why was communication from
the prison, police and Department of Home Affairs poor?
• Did Mr Corkill leave a suicide note?
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Mr Corkill’s partner asked:
• Why were plastic bags available, given there had been previous deaths at the
prison by this method?
• Why was she informed of Mr Corkill’s death via a message from another prisoner?
• Why there was no other contact from the prison and no condolence letter.
20. Mr Corkill’s brother and partner received a copy of the initial report. They did not
highlight any factual inaccuracies.
21. Isle of Man Prison received a copy of the report. They identified some factual
inaccuracies, and the report has been amended.
22. Manx Care also received a copy of the report. They identified a number of factual
inaccuracies within the PPO and Clinical Review reports. We have made some
amendments to the reports as a result. Other points raised were not factually
inaccurate and our findings were based on the information provided to us from
documentation and interviews. Manx Care did not provide an action plan for the
recommendations specific to healthcare at Isle of Man Prison but provided a copy of
their Offender Healthcare Improvement Plan.
23. We note that the Prison Healthcare Team has been placed in ‘special measures’ by
the Executive Director of Nursing. This is an internal governance mechanism
designed to ensure any incident or issue that is identified as extremely challenging
and / or high risk is afforded a level of attention, resource, and leadership in order to
facilitate positive change. He commenced special measures meetings on 15
December 2023, and these will continue on a weekly basis until such time Manx
Care can be assured that adequate progress has been made against Manx Care’s
Offender Healthcare Improvement Plan.
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Background Information
Isle of Man Prison
24. Isle of Man Prison is in the Jurby parish of the Isle of Man. The prison is operated
by the Isle of Man Prison and Probation Service (part of the Department of Home
Affairs) and is the only prison on the island, holding up to 138 prisoners. All
prisoners at Isle of Man Prison are located in single cells equipped with a toilet and
washing facilities. The design of these cells means there no ligature points. There
are two wings that accommodate remand and convicted prisoners, as well as wings
for female prisoners, and vulnerable prisoners. There is also a care and separation
unit (segregation).
25. Manx Care (equivalent to the NHS in England) have provided healthcare at the
prison since April 2021. Prior to that date services were provided by the Department
of Health and Social Care (Isle of Man). Healthcare is provided between 7.30am
and 5.30pm Monday and Friday and until 8.30pm Tuesday, Wednesday, and
Thursday; at weekends between 8.30am and 5.30pm. There is no inpatient facility.
A GP attends twice a week and a psychiatrist once a week.
HM Inspectorate of Prisons (HMIP)
26. The most recent inspection of Isle of Man Prison was in March 2023. Inspectors
reported that the quality of staff/prisoner relationships was a strength. Prisoners
were treated with respect and lived in decent conditions. However, governance and
oversight of many critically important areas of accountability, were weak.
27. Inspectors found the management of prisoners at risk of suicide and self-harm was
inadequate. Interventions or responses were often disproportionate, risk averse and
too often lacked sufficient focus on care for individuals or their well-being. There
was poor understanding of risks and how to manage them, including those
associated with the management of prisoners in their early days and those at risk of
suicide or self-harm (similar findings were found in the previous HMIP inspection in
2011). Inspectors found the monthly safer custody meetings were unstructured.
28. After a suicide in March 2020, and another similar death in November 2022, the
prison formulated an action plan, but inspectors considered some of the actions to
be unnecessarily risk averse. Prisoners with a history of self-harm were monitored
irrespective of risk. Folder 5s (suicide and self-harm prevention measures) focused
on monitoring rather than the promotion of wellbeing and did not address why
prisoners felt like self-harming. Some lacked care plans and multi-disciplinary input
and case management was inconsistent. Observations were recorded on the
prisoners record rather than the Folder 5 and there was no system to monitor these
prisoners when they left the wing or travelled outside of the prison, for example to
hospital or court.
29. Inspectors found 98% of prisoners had a named Custody Support Officer who met
with them regularly. Most prisoners said their CSO took an interest in their
wellbeing. There was good access to Samaritans, but there was no Listeners
Scheme (prisoners trained by Samaritans to support their peers).
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30. The Care Quality Commission (CQC) carried out an inspection with HMIP. Clinical
governance of health services in some areas was weak. They identified substantial
staff shortages in 2022, and gaps in management, nursing and other professions
had impaired delivery of healthcare services by Manx Care. The professional
oversight and management of medicines and pharmacy services was inadequate.
31. Inspectors noted that there had been recent organisational restructuring, funding
cuts and the retirement of experienced leaders resulting in a leaner senior
management team. 40% of officers had less than two years’ experience. These
changes had been unsettling and almost three-quarters of staff said morale was
low. Inspectors said that senior officers were not visible on the wings, but the
Governor was committed to change.
Independent Monitoring Board
32. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to March 2022, the IMB expressed
their concern that Isle of Man Prison was the only facility on the island for those
prisoners with significant mental health issues, which was neither safe nor suitable.
They reported that prison staff worked tirelessly to monitor and care for prisoners
with mental health needs but were not trained to do so. They described the situation
as ‘an accident waiting to happen’. The IMB acknowledged progress has been
made with mental health pathways, although they were not yet in place, and urged
the Minister and Government Departments to support and fund this provision within
the prison.
33. The IMB noted that attendance at the monthly safer custody meeting was lower
than desired and attributed this to low staffing levels. They found overnight
concerns monitoring had increased, possibly due to staff being more aware and
observant and noted this to be a quick and effective safety net to flag individuals’
risk which is used as an early intervention prior to starting Folder 5 procedures.
Previous deaths at HMP Isle of Man
34. Mr Corkill was the third prisoner to die at Isle of Man Prison since March 2020. The
previous deaths were both self-inflicted and all three deaths had similarities, not
least the method of suicide. We have identified issues with the management of
suicide and self-harm prevention measures, mental health provision, early days in
custody and the emergency response.
Folder 5 – suicide and self-harm prevention measures
35. Folder 5 is Isle of Man Prison’s system to support prisoners at risk of suicide or self-
harm. The purpose of a Folder 5 is to try to determine the level of risk, how to
reduce the risk and how best to monitor and support the prisoner. Guidance on
Folder 5 procedures is set out in the Self-harm and Suicide Prevention Policy and
Procedures dated 5 May 2022.
36. After an initial assessment of the prisoner’s main concerns, levels of supervision
and interactions are set according to the perceived risk of harm. Checks should be
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irregular to prevent the prisoner anticipating when they will occur. There should be
regular, multidisciplinary review meetings involving the prisoner every 48 hours. As
part of the process, a caremap (a plan of care, support, and intervention) is
completed. The Folder 5 should not be closed until all the supportive actions have
been completed and the risk is assessed to have reduced. Observations are
recorded separately on the prisoners’ electronic prison record.
Assessment, Care in Custody and Teamwork
37. Assessment, Care in Custody and Teamwork (ACCT) is the care planning system
HM Prison Service uses to support prisoners at risk of suicide or self-harm. The
purpose of the ACCT is to try to determine the level of risk posed, the steps that
staff might take to reduce this and the extent to which staff need to monitor and
supervise the prisoner. Checks should be made at irregular intervals to prevent the
prisoner anticipating when they will occur.
38. Part of the ACCT process involves assessing immediate needs and drawing up
support actions to identify the prisoner’s most urgent issues and how they will be
met. Staff should hold regular multidisciplinary reviews and should not close the
ACCT plan until all support actions are completed. Guidance on ACCT procedures
is set out in Prison Service Instruction (PSI) 64/2011 on safer custody.
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Key Events
Background
39. On 23 July 2022, Mr Christopher Corkill (known as Peanut) appeared in court
charged with drug offences and he was taken to Isle of Man Prison. Mr Corkill had
been to prison before. On 29 July, Mr Corkill was sentenced to a total of 34 months
and an additional 20 days for breaching a previous licence.
40. In the month before he was imprisoned, Mr Corkill was under the care of the Mental
Health Crisis Response Team. He was described as extremely paranoid, hearing
voices and had visual hallucinations. He also self-harmed by cutting and burning his
arms. Mr Corkill was due to have an operation to have an implantable defibrillator
fitted (due to heart failure) but the procedure was deferred as his arms were
infected.
41. Mr Corkill had a long history of substance misuse. He was diagnosed with
schizophrenia, drug induced psychosis and had a history of self-harming and
suicide attempts. Mr Corkill also had a number of physical health conditions
including heart failure, angina, chronic obstructive pulmonary disease (COPD), high
blood pressure and eczema. Mr Corkill was prescribed medications to manage his
physical health issues. In addition, he was prescribed medication for anxiety
(diazepam), an antidepressant (mirtazapine), medication that controls neuropathic
pain that also treats anxiety (pregabalin) and an antipsychotic (risperidone).
Arrival at Isle of Man Prison
42. When he first arrived at the prison, Mr Corkill was managed under the prison’s
suicide and self-harm procedures, known as Folder 5, as his person escort record
(PER – a document that accompanies all prisoners when they move between police
stations, courts and prisons which sets out the risks they pose) outlined his recent
self-harm. Mr Corkill was insistent that he had never attempted suicide and had no
thoughts of doing so. Mr Corkill was initially observed every half an hour, which was
reduced to hourly the next day.
43. During his initial healthscreen, Mr Corkill’s medical history was noted and that he
was under the care of the Drug and Alcohol Team (DAT). Mr Corkill was allowed to
have his GTN spray in possession (to treat angina and chest pain), but he had to
collect all other medications daily. Mr Corkill’s blood pressure was high. He was
examined the next day and an electrocardiogram (ECG – a test to check the heart’s
rhythm) was completed. Although his blood pressure remained high, we found no
evidence that staff reviewed the ECG results or planned to continue monitoring him.
Between 23 – 26 July, Mr Corkill was given his medication without a prescription,
via a transcribed medication record (when staff copy previous prescriptions) created
by nurses at the prison.
44. Prison staff had no concerns about Mr Corkill when he arrived. He appeared settled
on the wing, mixed well with other prisoners, and raised no issues, other than a
request for a more comfortable mattress. Folder 5 observations were reduced to
three a day. The Folder 5 assessment and caremap were never completed.
45. On 26 July, Mr Corkill appeared in court and pleaded guilty to all offences. No bail
application was made, and he returned to Isle of Man Prison. Although there is an
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entry in Mr Corkill’s prison record that he left the prison, there is nothing in the
record to detail what happened at court or that anyone checked on Mr Corkill’s
wellbeing or if his court appearance and guilty status had impacted upon his risk of
suicide or self-harm.
46. On 28 July, an officer was assigned as Mr Corkill’s Custody Support Officer (CSO -
a named point of contact to provide support to prisoners and help solve any issues
they may have). Mr Corkill said his only concern was about his partner being made
homeless as the tenancy for their property was in his name. The officer contacted
the resettlement team to provide advice and support to Mr Corkill. He met with Mr
Corkill regularly. He facilitated contact with the resettlement team to help him sort
issues regarding his housing and finances. Mr Corkill worked in the prison laundry
before he asked for a wing-based job, as he found the laundry work too strenuous.
47. On 29 July, Mr Corkill appeared in court and was sentenced. He told staff that he
was expecting double the sentence he received and was pleased with the outcome.
Later, at a Folder 5 review, Mr Corkill told staff that he did not require support
through the Folder 5 process, and they agreed to close it. A post-closure review
was scheduled for 5 July. This is an error and should have read 5 August. A post
closure review was never completed.
48. On 12 August, Mr Corkill submitted a complaint that he had not been seen by a
doctor, despite being at the prison for a month, and felt weak and dizzy. He also
said he had not been seen by the mental health team and felt at an ‘all time low’
and wanted to be treated fairly ‘as he would if he was in the community’.
49. On 20 August, Mr Corkill had an ECG and an entry in his medical record noted that
it was handed to a consultant psychiatrist specialising in substance misuse working
with DAT. The ECG results are not documented in his medical record nor if a GP
reviewed them. On 22 August, Mr Corkill complained of chest pain and was placed
on the GP waiting list. The same day, a GP at Isle of Man Prison noted that there
was nothing recorded in Mr Corkill’s medical record that he was experiencing chest
pains, no acute concerns and that he was waiting for a cardiology appointment. Mr
Corkill was to be monitored, but there is no evidence he was. On 24 August, a
nurse recorded that Mr Corkill required an ECG and that his cardiology follow up
appointment needed to be chased, but there is no evidence either was done.
50. On 7 September, Mr Corkill met with a DAT keyworker. He said that he felt much
better than he had in the community and his mood was stable. Mr Corkill said his
physical health had also improved but said that he had not seen a GP since his
arrival in prison.
51. On 18 September, Mr Corkill had his clinical observations taken, which were all
within normal parameters. He told the nurse he had not seen a GP since his arrival,
and he was placed on the GP waiting list. On 20 September, he was examined by a
GP at Isle of Man Prison, who noted all his clinical observations were within normal
range and that his chest was clear, but that it was over a year since he had been
seen by cardiologist.
52. The same day, Mr Corkill met with his DAT keyworker. They discussed his
substance misuse, harm reduction and relapse prevention. They agreed to meet in
a month.
53. On 22 September, Mr Corkill was placed on report for being in possession of
prescription medication and for having excessive vapes which belonged to another
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prisoner; staff were concerned he was trading on the wing. On 26 September, he
was found guilty of breaching the prison rules and given a total of 14 days cellular
confinement, loss of television, loss of association and 50% stoppage of earnings
as a punishment. He spent his cellular confinement in the prison’s Care and
Separation Unit (CSU). There is no evidence he was seen by healthcare staff while
segregated, other than to dispense his medication.
54. On 6 October, Mr Corkill asked for nicotine lozenges, but was told he would not get
these until Monday. (There was a supply issue. An order was made on 5 October
with an estimated delivery date of 10 October. Healthcare staff only supply
lozenges to prisoners signed up to a smoking cessation programme). He was
unhappy and made threats to harm himself by swallowing batteries. Mr Corkill was
briefly moved to a camera cell while his cell was made safe, including having his
radio removed. He later said that he would never harm himself and was just
frustrated that he was not given the nicotine lozenges. No other issues were
recorded, and Mr Corkill moved back to B Wing on 9 October. He was told that he
had been sacked from his laundry job. Over the next few weeks Mr Corkill complied
with the wing regime and was employed as a cleaner.
55. On 26 October, Mr Corkill met with his DAT keyworker. He explained he had been
segregated for having too many e-cigarettes. They agreed to meet in two weeks.
56. On 12 November, the CSO met with Mr Corkill for a CSO contact. He noted that Mr
Corkill was quiet and difficult to engage in conversation, but said he was pleased to
be working on the wing as a cleaner. They met again several times over the next
month and no issues were recorded.
57. On 23 November, Mr Corkill was seen by healthcare staff as prison staff reported
he had been vomiting blood. However, healthcare staff quickly established this was
not correct and he had heart burn. Mr Corkill told the nurse that he was very
anxious because of his cardiology history. Initially his blood pressure was raised,
but a short time later was within normal range. The nurse saw him later that evening
and again the next day. Mr Corkill was given Gaviscon to relieve his heart burn and
he told the nurse that he felt better.
58. On 18 December, Mr Corkill was seen by a psychiatrist from the DAT, and he said
that he was happy on his prescribed medication and no changes were made.
59. On 24 December, following a cell search, Mr Corkill was placed on report as he was
found with a tampered vape and a milk carton that had been repurposed as a ‘bong’
to smoke drugs. The adjudication was adjourned until after Christmas.
60. On 5 January, Mr Corkill failed a mandatory drug test which showed that he had
used opiates, cannabis, and gabapentin. He was placed on report, but these
charges were later dismissed as staff did not complete the documents in the correct
time frame.
61. On 6 January Mr Corkill was awarded a total of 21 days cellular confinement, as
well as loss of his other privileges, as punishment for having the tampered vape and
bong. Mr Corkill spent his cellular confinement in the CSU. Throughout this time, Mr
Corkill was described as polite, compliant, and caused no problems. There is no
evidence he was seen by healthcare staff while in the CSU, other than for his
medications to be dispensed. On 26 January, Mr Corkill returned to B Wing.
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62. On 1 February, the CSO visited Mr Corkill for a CSO contact. He was sleeping and
did not want to be disturbed. He noted that Mr Corkill slept a lot and was often
difficult to engage in conversation. He told Mr Corkill to let him know if he had any
issues and said he would visit him again the following week.
63. On 14 February, the CSO completed his monthly CSO report for Mr Corkill. He
noted that Mr Corkill slept most of the day which made it hard to have effective
sessions with him, that he was quiet and hard to engage in conversation but that he
caused staff few problems and was polite. This CSO entry was the last recorded
event in Mr Corkill’s prison record.
64. Mr Corkill’s partner visited him 15 times during this sentence, the last visit was on 5
November. Between 17 February and 21 February, Mr Corkill made five calls to his
partner, totalling around 28 minutes. The investigator listened to these calls. Mr
Corkill said he was concerned that he had not been able to speak to her in the
previous couple of weeks and that his ‘mind had been going overtime’. His partner
explained that her phone had been broken. Mr Corkill told his partner that he loved
her, and he had been panicking, had felt depressed and was worried something
was wrong with their relationship.
65. During their last conversations on 21 February, Mr Corkill’s partner explained that
she had been unable to visit him as she had to work. The phone kept cutting off and
Mr Corkill’s partner said her phone was ‘playing up’. The call ended with Mr Corkill
saying he was ‘sound.. plodding along’. There is nothing of concern within these
telephone calls, although at times the conversation was stilted. Mr Corkill did not
attempt to use his phone again. He had £9.28 credit remaining on his account. (All
prisoners’ telephone calls, except those that are legally privileged, are recorded,
and prison staff listen to a random sample.)
66. On 23 February, at around 4.52pm, Mr Corkill’s cell was unlocked and, a few
minutes later, he left and collected his evening meal. He left his cell again at
5.04pm, spoke to Officer A and returned a minute later. (The officer was on long
term sick leave for the duration of the investigation and could not be interviewed). At
5.18pm, an officer locked Mr Corkill in his cell for the night. At 8.26pm, another
officer completed a routine check of all prisoners. She recalled Mr Corkill was sitting
on his bed and raised his hand to acknowledge her. Because he was not subject to
special monitoring Mr Corkill was not checked again during the night.
25 February
67. At 7.14am, Officer A started the early morning routine check. He arrived at Mr
Corkill’s cell two minutes later, looked through the observation panel, and continued
his duties.
68. CCTV shows that at around 7.52am, Officer B went to Mr Corkill’s cell to unlock him
so he could collect his medication. He looked through the observation panel, saw
Mr Corkill lying on his bed and unlocked the door before moving on to the next cell.
He said good morning as he usually did and believed he got a response from Mr
Corkill, but in interview accepted he must have been mistaken. Other prisoners had
been unlocked and were on the landing. He returned to Mr Corkill’s cell at 7.56am.
He pushed the door open and looked in, he saw Mr Corkill had a clear plastic bag
over his head. He used his radio to request assistance and pressed the general
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alarm. Other prisoners on the landing looked into Mr Corkill’s cell from a few metres
away but did not enter.
69. Officer B went back into Mr Corkill’s cell. He was lying on his bed with a plastic bag
over his head, secured by a dressing gown cord. He shouted Mr Corkill’s name and
shook his ankle, which he described as ice cold. Staff responded. They removed
the plastic bag, moved Mr Corkill to the landing outside his cell where there was
more space and started cardiopulmonary resuscitation (CPR). A nurse quickly
responded with emergency medical equipment, followed by another nurse. They
attached a defibrillator to Mr Corkill which indicated he had no shockable heart
rhythm. The second nurse was unable to insert an airway, as Mr Corkill’s jaw was
clamped shut due to rigor mortis. Other prisoners had been locked away in their
cells and their observation panels closed.
70. Isle of Man Ambulance Service records show that an ambulance was requested at
7.56am. Paramedics arrived at the scene at 8.00am. Mr Corkill’s death was
declared at 8.09am.
71. The second nurse sat with Mr Corkill’s body until staff covered him with a sheet and
placed screens around him to preserve his dignity. Mr Corkill’s body remained on
the landing. Police attended the scene at around 8.36am, and Mr Corkill’s body was
removed at 12.19pm.
72. Mr Corkill did not leave a suicide letter.
Contact with Mr Corkill’s family
73. Isle of Man Constabulary broke the news of Mr Corkill’s death to his family. The
family did not receive a condolence letter and there was no offer of assistance
towards funeral costs, which was held on 31 March 2023.
Support for prisoners and staff
74. After Mr Corkill’s death, there was not a collective debrief for all staff involved in the
emergency response as there should have been. Senior managers did speak to
people individually, but not everyone felt supported. The staff care team and prison
psychologists also offered support.
75. The prison posted notices informing other prisoners of Mr Corkill’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Corkill’s death. The
prison does not have a Listeners Scheme (prisoners trained by Samaritans to
support other prisoners), but Samaritans attended the prison and offered support. A
memorial service was held on 5 April 2023.
Post-mortem report
76. The post-mortem report concluded that Mr Corkill’s death was due to plastic bag
suffocation and ligature compression of the neck. Toxicology results showed only
his prescribed medication and did not find any illicit substances.
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Findings
Management of Mr Corkill’s risk of suicide and self-harm
77. Mr Corkill had a long history of substance misuse, metal health issues, and had
previously self-harmed. We found that in the weeks leading up to his death, Mr
Corkill gave no indication that he was at imminent risk of suicide or that staff could
reasonably have foreseen his actions. Staff and his friends on the wing said that he
appeared no different from usual and did not disclose how he was feeling. After his
death, his friends discovered that he was having some personal issues.
78. In their recent inspection, HM Inspectorate of Prisons found that the management of
prisoners at risk of suicide and self-harm was inadequate. We also found the
approach to the prevention and management of suicide and self-harm at Isle of Man
Prison relied heavily upon good staff/prisoner relationships, and previous
knowledge of the individual, rather than there being an evidenced based
assessment of the risks and triggers that might increase risk. Staff had not been
sufficiently trained and the process for supporting prisoners at increased risk relied
on monitoring rather than addressing the needs of the prisoner to reduce that risk.
This was evident in how Mr Corkill was managed when he first arrived at Isle of
Man Prison.
Folder 5 procedures
79. Prison staff started Folder 5 measures on 23 July 2022, when Mr Corkill first arrived
at Isle of Man Prison, due to his recent history of self-harm. However, there was no
Folder 5 assessment, which should have been completed within 24 hours, no
medical officer report and no caremap. There were frequent observations recorded
and detailed entries in Mr Corkill’s prison record during the time he was on a Folder
5, but we found too much emphasis was placed on Mr Corkill’s assertion that he
had no thoughts of suicide or self-harm, rather than assessing and understanding
other objective factors that impacted on his risk and the ongoing stressors in his life.
The Folder 5 was closed on 29 July, but the post closure review scheduled for 5
August, was never completed.
80. Although a prisoner’s presentation can reveal something of their level of risk, it is, at
best, only a reflection of their state of mind at the time that staff assess their risk (if
even that) and should be considered as one piece of evidence. It is critical that all
risk factors are considered to ensure that a prisoner’s level of risk is judged
holistically.
81. Isle of Man Prison did not have an effective training programme. Staff who
completed and managed Mr Corkill’s Folder 5 had not been trained to complete the
Folder 5 assessment and nobody had been trained as a case manager. Most staff
had either not received refresher training or not recently and some staff had never
had any specific Folder 5 training, except for observing a colleague. Reviews were
set for every 48 hours, regardless of risk and need so there was no consistency
with regards to chairing the review. The caremap which should be used to record
the specific issues that led to the opening of a Folder 5 and what actions would be
completed to reduce the risk was absent and there was no managerial oversight to
ensure compliance with the Folder 5 process.
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82. Isle of Man Prison had been reviewing the Folder 5 process for some time and had
intended introducing a bespoke Custody Care Plan. However, during the PPO
investigation the Head of Isle of Man Prison and Probation Service and prison
Governor decided the prison would adopt the newest version of the ACCT process
used in England and Wales which was already well established. The
implementation of ACCT is set out in a comprehensive Prison Service Instruction
(PSI) 64/2011 Management of prisoners at risk of harm to self, to others and from
others (Safer Custody).
83. On 10 July, HMPPS Safety Team visited Isle of Man Prison for four days to deliver
ACCT training. During this training week 79% of prison officers were trained and
100% of healthcare, education, and Bidvest Noonan escort staff. In addition, seven
staff were trained as ACCT assessors and five as case coordinators. Four staff
have also been identified to attend HMPPS Learning and Development Team to
complete the train the trainer for ACCT assessors to ensure ACCT training can be
delivered to those not able to attend the initial training, or new starters. Any officer
promoted to SO will attend to be trained as a case co-ordinator.
84. The decision to implement ACCT is a positive step forward. The ACCT process will
replace the Folder 5 from 1 October 2023. Given that Isle of Man Prison has
already made the decision to adopt the latest version of ACCT procedures and
training has already taken place, with the provision for ongoing training, we do not
make a separate recommendation. HMIP are due to return to the prison in April
2024 and will provide feedback to Isle of Man Prison on how the new system has
been implemented.
Availability of plastic bags
85. In response to the death in March 2020, the prison removed plastic bags from
reception and the induction unit. Following the second death, they stopped using
plastic bags to deliver prisoners’ canteen. Since Mr Corkill’s death, all plastic bags
used on the wings have been removed, except for those used in the bins situated
on the wing landing which were swapped on a one for one basis. We do not know
why all three men had used this method, but it was suggested by most people
interviewed, including other prisoners, that this was a chosen method simply
because it had been effective previously. Not including the deaths at Isle of Man
Prison, between January 2020 and October 2023 the PPO has been notified of and
began investigations into 297 self-inflicted deaths in the prison estate within
England and Wales. Six of these (or 2%) were classified as suffocation using a
plastic bag.
86. The ongoing availability and use of plastic bags at the prison was questioned by the
bereaved families. The cells in Isle of Man Prison had few, if any, ligature points
and we know that if a person is intent on taking their own life, they will find a way.
We consider that a blanket approach to the management of suicide and self-harm
risk is not helpful and should be based on individual circumstances and factors. If a
prisoner is identified as at risk of suicide or self-harm, then the removal of plastic
bags should be considered as part of the management plan.
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Clinical care
87. While there cannot be a direct comparison, the objective of the clinical review is to
establish if Mr Corkill received clinical care equivalent to that he would have
expected to receive in the community. To provide a meaningful conclusion on
equivalence of care, the clinical reviewer focused on whether there was equity of
access to healthcare within the prison compared to the Isle of Man community
(given Manx Care provide both services) and compared with healthcare provision
delivered within prisons in England and Wales.
88. The clinical reviewer produced two reports: an overview of healthcare services
provided by Manx Care, and one specifically reviewing Mr Corkill’s care. These
reports should be read in conjunction with the findings in this report. The clinical
reviewer has made a number of recommendations, which we have not repeated in
our report but should be actioned by the Department of Health and Social Care and
Manx Care.
Mental health
89. We found that the mental health services provided within Isle of Man Prison are
currently inadequate, unsafe, and not equivalent to what is available in the wider
community and within other comparable prisons in England and Wales.
90. Mr Corkill was never referred to the mental health team, which was a significant
failing. He had been under the care of the Crisis Response Team in the community
prior to his imprisonment and had a long standing severe mental health condition.
But, contrary to National Institute of Health and Care Excellence (NICE) guidelines,
he did not get access to mental health services during his time in prison. The
clinical reviewer therefore concluded that the mental health care Mr Corkill received
at Isle of Man Prison was not equivalent to what he would have received in the
community.
91. During his time at Isle of Man Prison, Mr Corkill asked to be referred to the mental
health team, he even wrote that he wanted to be treated fairly ‘as he would if he
was in the community’. The current referral process is an electronic form, completed
by healthcare staff, which is emailed directly to the Integrated Mental Health Service
(IMHS). However, we found no evidence a referral had been made for Mr Corkill.
Healthcare staff, prison staff and prisoners told us that accessing mental health
services within the prison was difficult and waiting lists excessive. However, the
General Manager of the Integrated Mental Health Service said that referrals from
the prison were low and that there were no waiting lists.
92. The General Manager confirmed that a referral was never received for Mr Corkill.
We were unable to establish why a referral was not made or why his mental health
was never fully assessed. During the investigation, we were also told by healthcare
staff that a prisoner can either be under the care of the mental health team or DAT,
but not both. He confirmed that if it was clinically appropriate, a prisoner can be
under the care of both services.
93. There were many missed opportunities to assess and engage Mr Corkill about his
mental health. The clinical reviewer concluded that the confusion over Mr Corkill’s
referral to the mental health team reflected poor understanding of the process, poor
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communication between services and poor integrated working. We therefore make
the following recommendations:
The Department of Health and Social Care and Manx Care should review the
current provision of mental health services at Isle of Man Prison and provide
a dedicated mental health service, which is sufficiently resourced to meet the
needs of the population.
Manx Care should undertake a systemic population health needs assessment
across Isle of Man Prison to determine the prevalence of mental health
conditions and need.
Physical health
94. The clinical reviewer concluded that the physical health care Mr Corkill received at
Isle of Man Prison was not equivalent to what he would have received in the
community.
95. Mr Corkill had a number of significant health issues, and he was especially anxious
about his heart condition. These were not monitored in line with NICE guidelines
and there were no care plans in place. Mr Corkill submitted a complaint around
three weeks after he arrived, asking to see a GP as he had chest pains. However,
the GP concluded, without examining Mr Corkill, that he did not need to be seen.
We find it difficult to understand why he was not physically examined given the
seriousness of his underlying health conditions. While Mr Corkill was monitored on
an ad-hoc basis, this was not formalised as part of a care plan We make the
following recommendation:
Manx Care should ensure there is a long-term conditions monitoring register
and clinic.
Medication
96. Governance around medication, in particular medications that are deemed a high
risk in prison settings, was poor. Manx Care do not use The Royal College of
General Practitioners (RCGP) guidance for ‘safer prescribing in prisons’ dated
2019.
97. Mr Corkill had been prescribed psychotropic medication for his mental health, and
medications for his physical health issues, before entering prison. However, when
he arrived at Isle of Man Prison the clinical reviewer found that the reasons for
these medications were not fully ascertained or understood. He was never seen for
a face-to-face review of his medications while in prison. Between 23 July and 26
July, Mr Corkill was given his medication without a prescription, via a transcribed
medication record created by prison nurses. We were told that nurses felt they had
to transcribe in the prisoners’ best interests, so they did not go without their
medication. This is not lawful prescribing and against the Nursing and Midwifery
Council prescribing code (NMC - professional standards of practice).
98. On the morning that Mr Corkill died, a nurse dispensed medication and signed to
say it had been given to him when he was already deceased. We were told that
because Mr Corkill had so much medication, and always collected it, this was a
quicker way of dispensing it. Although the nurse accepted signing for medications
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that have not been collected was not the correct protocol, he said it was common
practice and, concerningly, did not consider this posed a major risk. We found there
was a level of complacency based on familiarity, rather than there being a
fundamental approach to safety. This is unsafe clinical practice and against the
NMC code for contemporaneous record keeping.
99. During the investigation we raised our concerns with Manx Care and were assured
these practices had now stopped. Despite these reassurances and to ensure
medications are administered correctly we make the following recommendations:
Manx Care should ensure there is a dedicated lead pharmacy provision at Isle
of Man Prison and there is a prescriber available every day, even if that is for
remote prescribing.
Manx Care should ensure that patients who come in with complex and high-
risk medication (as per the RCGP guidance) have a medication review when
they arrive at the prison.
Manx Care should implement electronic medication administration records.
Governance of healthcare services
100. We found healthcare staff morale was low. Staff felt frustrated by the lack of
response from senior managers when issues were raised and how long processes
took to change. We were provided with the Manx Care governance structure and
there appeared to be a lack of dedicated clinical governance and quality oversight
dedicated to prison healthcare. The approach to making changes around clinical
governance and healthcare policy seemed to be largely reactive after an event,
rather than it being a proactive approach with a drive for continuous evaluation and
improvement. We found there were evident layers of complicated bureaucracy
when it came to clinical governance and making changes to the healthcare system.
We were not assured that there were clear lines of responsibility within the
governance and executive structure.
101. There was evidence of good clinical practice by individual members of healthcare
staff who worked on goodwill and dedication. However, we found that the
importance of promoting staff wellbeing and resilience was not given the priority it
deserves, with an overall lack of support, supervision, and training. Healthcare staff
said that there were no regular team meetings and that they did not have clinical
supervision. We were told that this issue related to recruitment challenges, staff
turnover, sickness, and several senior management changes. Throughout our
investigation the healthcare manager was required to leave her duties to help on an
operational level due to staffing issues. While this addressed an immediate issue,
this took her away from the strategic responsibilities. We found there is not enough
resilience within the healthcare system. We make the following recommendation:
Manx Care should have a dedicated clinical governance lead responsible for
prison healthcare at Isle of Man Prison to ensure practice is compliant and
underpinned by national guidance, legislation and evidence-based practice.
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Serious incident investigation
102. Manx Care undertakes a 72-hour review following a death in custody. However, not
all incidents go on to have a comprehensive serious incident investigation. The
decision whether a serious incident investigation is conducted is made by the
Serious Incident Review Group of Manx Care.
103. After the death in November 2022, we were told that initially it was not going to be
investigated because it was deemed that there were no obvious acts or omissions
that contributed to his death. This decision was challenged, and his death was then
investigated. However, following Mr Corkill’s death the decision was made that an
investigation was not required and was not completed. We found this decision
difficult to understand given that the previous death was eventually subject to a
serious incident investigation.
104. Manx Care’s policy for ‘incident reporting, investigation and learning’ dated 2021,
states that a serious incident can be defined as ‘an unexpected or avoidable injury
which results in serious harm’. A self-inflicted death in prison is without question a
serious event, resulting in the ultimate harm to the individual. Without investigating
the circumstances surrounding a death, it is difficult to understand how a decision
can be reached that there are no acts or omissions relating to the healthcare
provided to the prisoner. Our investigation has highlighted significant issues that
could and should have been identified sooner. We make the following
recommendation:
The Serious Incident Review Group of Manx Care should always complete an
investigation following a death in custody.
Emergency response
Communicating the emergency
105. Isle of Man Prison do not have a policy on communicating a medical emergency.
When Mr Corkill was discovered, an ‘urgent’ message was radioed before Officer B
pressed the general alarm. Some staff thought an urgent message was for a
medical emergency, other staff said this was for any significant incident and other
staff did not know what an ‘urgent’ call signified. Staff did respond quickly, including
healthcare staff. An ambulance was requested with very little delay, because staff
recognised the seriousness of the situation, not because there was a clear policy in
place.
106. PSI 03/2013, Medical Emergency Response Codes, which is used within UK
prisons, sets out the actions staff should take in a medical emergency. Two distinct
codes are used: code blue if a person is unresponsive or not breathing, and code
red if there is significant blood loss or burns. It contains mandatory instructions for
Governors to have a protocol to provide guidance on efficiently communicating the
nature of a medical emergency, ensuring staff take the relevant equipment to the
incident and that there are no delays in calling an ambulance. It says that if a
medical emergency code is called over the radio, an ambulance must be called
immediately.
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107. We found that staff did not have any clear guidance on effectively communicating
when there is a potentially life-threatening medical emergency. We recommend the
following:
The Governor should introduce a clear protocol to staff for effectively
communicating a medical emergency.
Resuscitation
108. In September 2016, Professor Sir Bruce Keogh, National Medical Director at NHS
England wrote to Heads of Healthcare for prisons and Immigration Removal
Centres in England and Wales introducing new guidance to support staff on when
not to perform cardiopulmonary resuscitation. This guidance was designed to
address the issue of inappropriate resuscitation following a sudden death in a
prison and was taken from the European Resuscitation Council Guidelines 2015
which state, “Resuscitation is inappropriate and should not be provided when there
is clear evidence that it will be futile”. We were told that Manx Care Governance
Team were not aware of this guidance, despite it being published in 2016.
109. Officer B told the investigator that he believed Mr Corkill was already dead when he
discovered him. The second nurse said she observed that Mr Corkill showed signs
of rigor mortis, which occurs some hours after death. When paramedics arrived,
they also recorded there were obvious signs of death, and that rigor mortis was
present. We understand the commendable wish to attempt and continue
resuscitation until death has been formally recognised, but staff should understand
that they are not required to carry out CPR in these circumstances. Trying to
resuscitate someone who is clearly dead is distressing for staff and undignified for
the deceased.
110. Isle of Man Prison do not have a policy or guidance on when it is not appropriate to
start CPR. We were told by all those we interviewed that they were required to
commence CPR until a doctor or paramedic declared death which was reflected in
guidance from 2015 which stated that staff should continue CPR ‘irrespective of the
length of time they (the prisoner) was thought to have been lifeless’. We were
unable to establish what informed this guidance and it was suggested it was based
on personal, moral, and ethical views of those involved in writing the policy,
although it was ratified by the Policies and Procedures Committee of the
Department of Health and Social Care.
111. Manx Care had identified the need for guidance on when it is not appropriate to
commence CPR after the first of the three self-inflicted deaths in 2020, which was
again highlighted after the second death. When Mr Corkill died, staff again thought
they needed to commence CPR when it was not appropriate. During interview in
June 2023, the Care Quality and Safety Coordinator Manx Care said that new
guidance was being drafted which was in the process of being agreed. Given this
was three years since the first death and seven months after the second death we
do not understand why this guidance was not given greater priority. Had the
guidance been published sooner, the trauma staff experienced would have been
reduced, and the indignity for the deceased avoided.
112. Manx Care responded to feedback during the investigation about the need to
expedite and publish revised guidance. The new guidance was agreed in June
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2023, and which reflects that issued in England and Wales in September 2016.
However, it is directed to Manx Care staff and is not joint guidance for both
healthcare and prison staff. We make the following recommendation:
The Governor and Manx Care should ensure that there is clear joint guidance
for all staff, and check their understanding, about the circumstances in which
resuscitation is inappropriate in accordance with European Resuscitation
Council Guidelines.
Events after Mr Corkill was declared dead
113. The Death in Custody Policy reviewed on 1 December 2022 by the Deputy
Governor, states that following a death the body must be moved in accordance with
the protocols previously agreed with the police and Coroner. We requested a copy
of this protocol, but it was not provided.
114. After the paramedics declared that Mr Corkill had died, his body was covered with a
sheet and screens were placed around him. Prisoners remained behind their doors.
Mr Corkill’s body was left lying on the landing for around four hours before it was
collected by a private ambulance. All staff interviewed said that they believed Mr
Corkill’s cell, and the landing area, was a ‘crime scene’ and they could not move Mr
Corkill’s body until the police had given their authority. Isle of Man Prison do not
have any specific death in custody contingency plans on what to do in the event of
a death in custody, so were guided by the police.
115. The investigator contacted the Acting Detective Chief Inspector for Major and
Specialist Investigations and Intelligence Departments from Isle of Man
Constabulary, to ask if there was guidance or policy on returning the deceased to
their cell. She explained that the police would always request that a body is left in
situ as best practice, to prevent any further disturbance of forensic evidence in a
suspicious case as far as reasonably possible and to rule out any third-party
involvement. She said this was standard practice in any sudden death, but the
context of a prison death had not been specifically considered.
116. We found it was inappropriate and distressing that Mr Corkill was not moved back
into his cell. There was no suspicion a crime had been committed. Staff had already
entered Mr Corkill’s cell when he was discovered and moved him to the landing, so
it would not have made any significant difference if his body had been sensitively
placed back into the cell. Prison managers reflected that they were very conscious
of the time it had taken to remove Mr Corkill’s body, which was also an issue in the
two previous deaths. Despite this issue being identified, this had not prompted any
discussion with the Isle of Man Constabulary regarding establishing an agreed
protocol following a death in custody. We make the following recommendation:
The Governor should consider establishing a protocol with the Isle of Man
Constabulary to ensure that following a death in custody the deceased’s body
is moved back into their cell for dignity, if there is no suspicion of a crime.
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Informing Mr Corkill’s family
117. The Death in Custody Policy states that it is essential following a death that prison
staff work openly with bereaved families, that the prison must inform the next of kin
and any other person reasonably expected to be informed and that it was good
practice to appoint a dedicated family liaison officer (FLO).
118. Isle of Man Constabulary broke the news of Mr Corkill’s death to his family before
the prison had an opportunity to do so and Mr Corkill’s partner found out via a
telephone call from another prisoner. Isle of Man Prison did not attempt to make
any further contact with Mr Corkill’s family or partner. They did not consider
contributing towards the cost of his funeral (in England and Wales the prison
contributes up to £3,000 towards funeral costs) and did not send the family a
condolence letter.
119. The visiting prison chaplain is a qualified FLO at Isle of Man Prison and had
undertaken his training at the HMPPS training centre. Although the Governor said
he knew the prison chaplain was FLO trained, the Deputy Governor did not. The
Deputy Governor said he believed the decision for the police to inform Mr Corkill’s
family was made because they were unaware there was a trained FLO at the
prison. The Governor said he was aware that the FLO knew Mr Corkill’s family, and
had been in contact with them, and passed messages to them from the prison
about collecting his belongings. This contact was established as the FLO knew the
family rather than in an official capacity as prison FLO. The Governor accepted that
greater efforts could have been made to contact Mr Corkill’s family and a
condolence letter should have been sent.
120. We found that contact with Mr Corkill’s family should have been more considered.
Utilising a trained FLO to visit a family in person to break the news, with a senior
prison manager, should be an expectation, in line with the prison’s own Death in
Custody Policy. There needs to be a better understanding by senior managers of
the need to ensure families are notified as soon as possible and provided with
appropriate support. We make the following recommendation:
The Governor should ensure that the prison complies with its own policy for
contacting the families of deceased prisoner and that they have adequately
trained family liaison officers.
The Governor should ensure in the event of a death in custody, prisoners’ in-
cell telephones should be disconnected immediately to avoid families being
notified before the prison have an opportunity to break the news.
Staff support
121. Giving staff the opportunity to collectively discuss an incident and reflect on all
aspects of how it was managed is fundamental to providing the prison with
feedback on any issues that need to be addressed. It also provides those directly
involved with an opportunity to process events. This is also stipulated in the Death
in Custody Policy.
122. Although staff involved in the emergency response were spoken to individually after
Mr Corkill’s death by the operational manager, there was not a collective debrief as
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there should have been. The staff care team and the TRiM manager (trauma risk
management for staff) contacted staff and support was offered by a prison
psychologist.
123. Many staff involved in the emergency response said that support after Mr Corkill’s
death could have been better, they did not feel sufficiently supported by managers
and were expected to return to a normal regime too quickly. The second nurse who
had also responded when the previous prisoner died said she was not expected to
return to her duties immediately, but her colleague was. We were provided with a
copy of the Death in Custody Contingency Plans dated 2019, during the
consultation period. These plans are outdated and do not reflect the current
expected response following a death in custody. This meant staff were being
reactive on the day in a situation that was not common. While we accept that the
prison does not have many deaths, there should have been a proactive response
after the previous death in March 2020 and contingencies reviewed and agreed so
senior staff understood the expectations. We make the following recommendation:
The Governor and Manx Care should ensure that all relevant staff,
irrespective of status, position, or experience, are able to attend a debrief
following a death in custody and that they receive appropriate aftercare
support.
Isle of Man Prison response to deaths in custody
124. There was no independent investigation into the circumstances surrounding the
death in March 2020. We understand that the prison conducted an internal
investigation and they responded to the findings at the conclusion of the inquest.
Changes were made to practice and processes at Isle of Man Prison; plastic bags
were removed from reception and the induction wing, anyone with a history of
suicide or self-harm was placed on a Folder 5 when they arrived at the prison and
PER forms were sent to all managers. However, we found that these changes did
not result in improved management of those at risk of suicide or self-harm.
125. The PPO was commissioned to complete an investigation into the two most recent
deaths, following the HMIP Inspection that took place between 27 February and 10
March 2023. There are many similarities in all three self-inflicted deaths. Although
some of the learning in this report had already been identified by the prison and
Manx Care, the healthcare providers, this has not resulted in the change we would
have expected to see. We therefore recommend:
The Department of Home Affairs should consider immediately commissioning
an independent investigation in the event of any future non-natural deaths at
Isle of Man Prison.
Governor to Note
Safer Custody Meeting
126. Isle of Man Prison holds a monthly Safer Custody Meeting (SCM). The Self-harm
and Suicide Prevention Policy and Procedures document dated 5 May 2022, sets
out who is required to attend, including the Deputy Governor, who is chair, the Safer
Custody Principal Officer (PO) and Healthcare Manager. The objectives of the
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meeting include the monitoring, delivery, and quality of the Folder 5 procedures. We
found, as did HMIP, that governance and oversight of this critically important area
was poor.
127. The investigator requested copies of SCM minutes between June 2022 and June
2023. There were no minutes for July or December 2022. The Deputy Governor
said that the meetings may have been rescheduled for staff to attend and that they
were not cancelled but ‘postponed… so one meeting is counted as two, effectively’.
Of the ten meetings that did take place between these dates, the healthcare
manager only attended three meetings (10 January, 9 February, and 20 June
2023). A prison officer from Safer Custody also attended just three meetings (8
September, 9 February and 20 June 2023). There was no specific mention in these
meetings of Mr Corkill’s death and no mention of the PPO investigation.
128. While we understand that there is a daily briefing and staff exchange information
about those prisoners where there are concerns, the SCM should be a priority for
the prison. We found that the information recorded lacked meaning. The meetings
were only monthly and attendance often poor from critical areas.
129. During the investigation we raised our concerns with the Governor. Since 24 June,
the prison has now introduced a weekly Review of Complex Cases (RoCC)
meeting, the implementation of which is set out in the new Complex Case Strategy,
and all staff have been informed and advised on how to make a referral. Attendance
by the senior leadership team is mandatory, as well as representatives from across
the prison. The RoCC aims to ensure that risk information is accurately recorded,
and relevant information is shared with all prison and probation staff, as well as
external agencies to ensure the safety and well-being of prisoners. Given the prison
has already taken action to address this issue, we do not make a separate
recommendation, but the Governor must ensure the newly introduced RoCC is
audited to ensure compliance with the prisons new protocol.
Prison record
130. Isle of Man Prison use the Prisoner Information Management System (PIMS) an
electronic record where all contacts and events are recorded. We found that entries
in Mr Corkill’s record were frequent and detailed. However, each time a prisoner
comes into custody, a new record is created for them. This means that information
recorded on earlier sentences is not so easily accessible, resulting in potentially key
information about risk being overlooked. We would encourage the Governor to
consider reviewing the process for creating new prisoner records for those who
have previously been in custody.
Listeners Scheme
131. Isle of Man Prison do not have a Listeners scheme. The first Listener scheme was
introduced in 1991 and Listeners are in almost every prison in the UK. Listeners are
selected prisoners who have been specially trained by Samaritans to provide
support to their peers. The visiting chaplain said the prison would be keen to
introduce Listeners at Isle of Man Prison, but there was a reluctance from
Samaritans on the island to deliver training. While we understand the population is
very small and many prisoners would not be serving sufficiently long sentences to
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justify training, this should be further explored. The Governor should consider this
further.
Body Worn Video Cameras
132. Body Worn Video Cameras (BWVC) are not currently used in Isle of Man Prison.
BWVC’s are an important source of evidence for PPO investigations, and wider
learning for prisons following an incident. HMPPS staff are required to wear BWVCs
and require prison staff to activate them during any reportable incident, including
medical emergencies. The Department of Home Affairs should consider this.
Healthcare to Note
Medical records
133. We found the clinical records system at Isle of Man Prison (and across the island)
was disjointed, cumbersome and not fit for purpose. The prison, hospital, mental
health team, and GP surgeries all have separate recording systems that do not link
up. This means that information is either having to be duplicated across systems, or
more concerningly significant information about care and clinical need is not shared
that is vital to the care of prisoners (and residents on the island).
134. We were told that various reviews of the medical record system had taken place
and that consideration of implementing one system to record all clinical contacts
was being considered but that this had been ongoing for ‘years’. We would urge the
Department of Health and Social Care and Department of Home Affairs to urgently
review the need for a medical record system that is fit for purpose and support
Manx Care in introducing one electronic record keeping system to provide a more
cohesive, safer means of sharing patient information.
Prisons and Probation Ombudsman 25
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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