The National Offender Management Service (NOMS) has received a formal Crown Censure following the death of an inmate at a prison in Bicester, Oxfordshire.
On 26 September 2006, HMP Bullingdon inmate Daniel Rooney, who was also known as John Hughes, was awaiting sentence for burglary. A senior prison officer identified him as being at risk of suicide or self-harm, and that evening he was transferred to a ‘safer cell’.
Staff regularly observed him for 40 minutes. However having been left unsupervised for five minutes an officer returned to find him hanged by a ligature, made from his bedding that had been fixed to a shower rail.
The HSE wasn’t notified about Mr Rooney’s death until 2007, after an inquest had concluded and it only received primacy for investigation in 2010. The subsequent inquiry found that the shower rail should have been secured to the wall using lighter fixings (i.e. not strong enough to support a person’s weight). There were also several other points in the room where ligature could have been attached.
The NOMS was unable to provide the HSE with any information about when the rail was installed, or by whom. It also admitted failing to test the strength of the fixings to ensure they could not support ligature.
HSE investigating inspector Matthew Lee said: “NOMS is fully aware of issues relating to self-inflicted deaths of prisoners. Between 2007 and 2009 the average number of self-inflicted deaths in prisons was 69 per year. The most common method was by hanging, which represented 91 per cent of all self-inflicted deaths. As such, the defendant should have had a more robust system for ensuring the risk was adequately controlled at HMP Bullingdon.
"Staff on duty at the prison at the time of the death were clearly under the impression that they had placed Mr Rooney in a safer cell which, so far as was possible, was ligature-free."
The NOMS pleaded guilty on 13 February to breaching s3(1) of the HSWA 1974, and reg.5(1) of the MHSWR 1999. As the organisation is a crown body it can’t be prosecuted and it instead received a Crown Censure – a formal recording of a decision by the HSE that it failed to comply with health and safety law.
Following the censure, HSE head of operations for the South, Mike Wilcock, told SHP that he feels it is important that the Executive continues to highlight cases of this nature despite the pressure of budget cuts. He said: “We treat Crown bodies the same as commercial organisations, and it is right and proper that we apply the law. A censure is a proper use of our resources in my view, as it highlights a serious safety failing.”
