The Queen (on the application of Mrs Pearl Scarfe, Julie Barber and Jamie Blyde) v Governor of HMP Woodhill and Another Inquest (Intervener)
| Jurisdiction | England & Wales |
| Judge | Mr Justice Garnham |
| Judgment Date | 23 May 2017 |
| Neutral Citation | [2017] EWHC 1194 (Admin) |
| Docket Number | Case No: CO/5343/2016,CO/5343/2016 |
| Court | Queen's Bench Division (Administrative Court) |
| Date | 23 May 2017 |
[2017] EWHC 1194 (Admin)
Lord Justice Irwin
and
Mr Justice Garnham
Case No: CO/5343/2016
IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
DIVISIONAL COURT
Royal Courts of Justice
Strand, London, WC2A 2LL
Heather Williams QC & Adam Straw (instructed by Deighton Peirce Glynn) for the Claimant
James Strachan QC & Emma Price (instructed by Government Legal Department) for the Defendant
Written intervention by Heather Williams QC & Jesse Nicholls (instructed by Hickman & Rose) for INQUEST
Hearing dates: 7 th April 2017
Approved Judgment
Introduction
This is a judgment of the Court to which we have both contributed.
By these judicial review proceedings, the Claimants seek to challenge what they describe as " the Defendants' failures to comply with their public law, common law and article 2 ECHR duties to protect prisoners at HMP Woodhill from suicide", failures which they contend are " ongoing". The relief they seek is a declaration that the Defendants have breached those duties and an order requiring them to comply with the mandatory provisions of national prison policy.
The context for this challenge is what is agreed to be the very high rate of self-inflicted death at HMP Woodhill. The Claimants are three persons with a close interest in the arrangements for suicide prevention at that prison. Pearl Scarfe is the mother of Ian Brown, a prisoner who committed suicide in his cell in HMP Woodhill on 19 July 2016. Julie Barber is the sister of Ian Brown. Jamie Blyde is the brother of Daniel Dunkley who was found suspended by ligature in his cell at the prison on 29 July 2016, and who died on 2 August 2016 as a result of the injuries he sustained. Mr Blyde was himself detained at HMP Woodhill until recently and could be returned there in the future. He has been placed under observation due to concerns about his risk of suicide or self-harm. It is accepted that all three claimants have sufficient interest to bring these proceedings.
We have received helpful written submissions from an intervener, the organisation "Inquest". Inquest is a small, independent charity which, amongst other things, provides free advice to people bereaved by a death in detention or custody. Those submissions were prepared by Heather Williams QC and Jesse Nicholls. When leading counsel originally instructed by the Claimants was unable to conduct the case, Ms Williams took over that role. It has been accepted by all concerned that that was entirely appropriate. We are grateful for Ms Williams' assistance, in both her capacities, and for that of counsel for the two Defendants, James Strachan QC.
In addition to the declaratory relief to which we have referred, the Claimants seek an order under CPR 54.20 transferring the civil claim for damages relating to Ian Brown's death to the Queen's Bench Division. We do not understand that application to be disputed and, subject to further submissions that may be made when this judgment is handed down, we are minded to make an order in those terms.
The Common Ground and the Issues
A remarkable feature of this case is the extent of the agreement between the parties. There is agreement as to the essential factual background, the circumstances of the deaths at HMP Woodhill, and the obligations on the Defendants. There is a considerable measure of agreement between the parties as to the applicable legal principles.
Also agreed are the national policies which apply. We set out below the relevant parts of Prison Service Instruction ("PSI") 64/2011 entitled " Management of Prisoners atrisk of harm to self, to others and from others (Safer Custody)" and PSI 03/2001 relating to responses to medical emergencies.
It is possible, in addition, to set out in relatively short compass the applicable legal principles because the difference between the parties is largely on matters of emphasis.
The substantive differences between the parties relate to whether the deficiencies identified in the various reports to which we have referred below amount to "systemic" failings by the prison authorities, and the extent to which the identified problems at HMP Woodhill are capable of solution by means of an order of this Court.
The Investigations
It is common ground that there have been eighteen self-inflicted deaths in HMP Woodhill since 2013. There were five self-inflicted deaths at the prison in 2015 and seven in 2016. These represent both the highest rate, and the highest number, of self-inflicted deaths in any prison in the entire prison estate.
At the time of the hearing of this claim, 11 of the deaths had been subject to an inquest. Inquests in respect of the other deaths were yet to take place. Because they all occurred at the same prison, all the inquests were conducted by the same Coroner, HM Senior Coroner for Milton Keynes, (with the exception of one inquest which was conducted by an assistant coroner for that region). In each case, as required by The Coroners and Justice Act 2009, the Coroner sat with a jury. Each jury has produced determinations in which they have answered questions posed by the Coroner. Following a number of the inquests, the Coroner produced a " report to prevent future deaths" (or "PFD report"), pursuant to paragraph 7 of Schedule 5 of the Act.
Subsequently, reports have been produced by the Prisons and Probation Ombudsman for England and Wales ("the PPO") in respect of each of the deaths. The PPO frequently conducts investigations and produces reports on deaths in prison. The reports are detailed, independent and authoritative. They provide descriptions of the circumstances of the relevant death and make relevant recommendations to the prison authorities. We have seen reports in respect of 13 recent self-inflicted deaths.
The Prison has, without exception, accepted all the recommendations made by the Coroner and the PPO about the need for compliance with Prison Service Instructions relevant to suicide prevention
Based on those reports, we set out below, by way of example only, a short summary of the circumstances of six of the deaths at HMP Woodhill. None of this is in dispute.
The Circumstances of the Deaths
Inevitably, the detailed circumstance of each death at HMP Woodhill prison are different. However there are significant similarities between many of them. The following five cases all occurred in 2015 or 2016.
Daniel Byrne died on 27 February 2015 after hanging himself in his cell the previous day. The inquest jury concluded that there had been a failure by both healthcare staff and prison officers to carry out an adequate risk assessment for self-harm and suicide, and a failure to carry out the first "ACCT" case review adequately. (Some of the requirements of "ACCT" or "Assessment, Care in Custody and Teamwork" are considered further below).
The PPO found there was a failure to assess and manage Mr Byrne in accordance with the requirements of PSI 64/2011. Staff had failed to consider a number of risk factors identified in the instruction, and had wrongly based their assessment of Mr Byrne substantially on his presentation. It was said the ACCT Assessor failed to review Mr Byrne's records, that the 'care-map' contained inadequate measures to reduce risk and that the response to finding Mr Byrne hanging was too slow. The PPO noted
" we are concerned that many of the same issues have been repeated in a number of our investigations including this one. In six cases investigated in 2013 and 2014 we found that staff had failed to identify or properly assess the risk of suicide and self-harm in newly arrived prisoners".
The PPO recommended that the Governor should ensure that there were effective operating procedures in the prison reception and that all staff understood the procedures for identifying prisoners at risk of suicide and self-harm, and for managing and supporting them.
Ian Brown committed suicide by hanging in his cell on 19 July 2015. The jury at the inquest concluded there was a failure to carry out the ACCT procedures and reviews. The PPO found there were shortcomings in the ACCT process, including the fact that his ACCT had been closed without a multi-disciplinary review.
Simon Turvey died by hanging on 29 December 2015. The coroner's PFD report indicated that
" the family of Mr Turvey was not aware of the arrangements for the family to notify the prison if they had concerns as to his welfare. If they had known of the telephone line to report concerns they would have used it."
The PPO noted that, during a telephone call overheard by staff, Mr Turvey had been upset and tearful, had indicated he had contemplated suicide and had spoken about being unable to cope.
Thomas Morris died by hanging on 26 June 2016. The PPO expressed concern that the timings of checks made on Mr Morris by staff were predictable, and about the adequacy of ACCT care-maps. He said that the Governor
" should ensure that prison staff manage prisoners at risk of suicide or self-harm in line with national guidelines, including setting levels of observations which are appropriately adjusted as the perceived risk changes and these changes are irregularto prevent the prisoner anticipating that they will occur and setting care-map actions which are specific and meaningful, aimed at reducing prisoner's risks and are actively followed up".
As noted above Daniel Dunkley died from hanging on 29 July 2016. The jury at the inquest into his death concluded that there was a failure to carry out appropriately the ACCT procedures and reviews, and in particular that there was...
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