Investigation into the attempted suicide of Mr L D
Date of Interview: Name of Interviewer/s: Name of Interviewee: Male 31 July 2006 Stephen Shaw, Prisons and Probation Ombudsman and Ali McMurray Ex Governor G Davies For the benefit of the tape and those who may listen to it in due course, it is just about quarter past two on Monday 31 July 2006. Present in the room are: Stephen Shaw, Prisons and Probation Ombudsman Ali McMurray, Assistant Ombudsman. Gareth Davies, Ex Governor of Pentonville. Well thanks very much Gareth. Before we put the tape on I shared with you the way I was conducting the investigation and emphasising that this a formal interview that will be disclosed to Mr D s representatives and eventually become part of the public record of the investigation. Could you just confirm for the tape that you are happy to proceed having been told the nature of the investigation and having chosen to come without a representative or pal. I am content. Well that is very nice of you. Can we do some simple things first, again just for the record. Would you mind sharing with us your career within the Prison Service, when you joined, where you have served, taking us right up to date? I joined the Prison Service in I am trying to think now 1980, in September 1980 having been a soldier for quite a long time. My first posting was actually quite simply to Pentonville where I was Assistant Governor. From there I went to Albany also as an Assistant Governor. In those days you did about seven years as an Assistant Governor as a sort of apprenticeship. My second tour AG post was Albany which was then in the High Security system. From there I went to Wandsworth as Head of Residence and then I did a staff job for an Area Manager when the Area Manager system first was invented for East Anglia. From there I went to be Deputy Governor of Wormwood Scrubs and from there
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to be Governor of Canterbury. I then had a job as Head of MSSU for a couple of years before going to Stephen Shaw: Gareth Davies: Stephen Shaw: Gareth Davies: Stephen Shaw: Gareth Davies: Stephen Shaw: Gareth Davies: Stephen Shaw:. MSSU? Management Selection and Succession Unit and then went to Pentonville. And what was the date you first went to Pentonville? June 2000. And you served at Pentonville as Governor for what period? Until February 05 with six months secondment to Iraq. And this again, do you recall the exact dates you were in Iraq, I imagine it is not the sort of thing you forget? You never forget it. I went to Iraq on December and left on June, I think 12th 04. And during the period we are interested in, that is to say at the end of 2001, do you recall who the members of your senior management team at the time? Yes at that stage, Ruth Kringle was the Deputy Governor, the Head of Residence oh my goodness his name has gone Gary Monaghan, Head of Security was Mike Posely, Doctor was, the Senior Medical Officer was Dr Yisa. The Head of Healthcare was actually a Principal Officer at that stage acting up called John Attard and the developments in healthcare were in his remit. I think that really was the SMT really. Now as you know we are investigating the circumstances surrounding the near suicide of LD on 27 December 2001. Do you have any recollection of Mr D at all? I could recall the incident. but before the incident do you have recollection of having come across ? No not in any, well not in any memorable way.

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The chances are that you would have come across him because he was in healthcare and you would have gone to healthcare on your rounds? Yes, I couldnt put a face to the name. No, no, well tell us about what you recall of the incident? Pretty much, the way these things hit you, there had been a serious attempt at suicide. I always viewed hanging as a cold dread really because it is a signal that it was pretty serious and we were developing at that stage a CPR resuscitation team. It hadn'reached the full operational t state that it finally arrived at but it was still about and that was run by. he was the SO in the yes, Peter Hayward. Peter Hayward yes, and that was being developed by Peter at that stage and probably Mr D owes his life to the fact that it existed in the light of events, you know. A double edged thing but basically they were operating on medic, paramedic type principals, intubation, CPR oxygen, very quickly all bagged up ready to run and go somewhere where somebody had tried to himself serious harm. That was in many respects all I remember about the incident that the CPR team had been successful and in fact subsequent reports I received were that it had been completely successful. Were you on duty at the time? I think I was yes, I think I was. And what would have been the practice for a nurse in a serious incident within the prison? They would deal with it as a sort of paramedic emergency. We would be informed that it was going on, didnt all rush there, largely because all you would do is get in the way and the fact is the Governor arriving on the scene tends to make people a bit stiff and they might not operate as well as if you are not there. So I would be receiving reports, the reports would be, There has been an incident, the CPR team are there, the ambulance is on its way, he has gone to hospital. I mean it would be a series of reports in that way. Then

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there would be a hot debrief normally done by Peter Hayward and probably John Attard, I cant recall. There is a hot debrief. Stephen Shaw: Gareth Davies: And this is sufficiently unusual in the event that you would remember it or was this ? it is the fact that he didnt die. I have known one other case like that, I am sure there are lots more but I have known one other case like that which I investigated at Dover, with better results I must say, but basically it was the fact that it was one of the first times that the CPR team really had brought somebody back, as it were. And did you share that view that it was only because of the establishment of this Hotel 9 resus team that the man had survived, did you share that with others? I dont think I did really because no one actually asked. It still remained a near miss and we were still working on the team and one thing I have learned is it is better that when you are not absolutely sure that it was that incident, that issue which is, say keep the (inaudible) out of the way and I am fairly confident that it was because of the team that it was early days, in the light of what happened subsequently and the other years that I was at Pentonville I would say it was the team, at that time I was. just thought it might be. And the idea of having a group of staff specially trained up and kitted out to be able to give paramedic aid very very speedily, did that find favour with the powers that be? It did eventually. Peter Hayward had already worked up the idea when I arrived there. I was quite interested in the idea. I had seen something similar in America where they have quite high level resuscitation equipment, largely because they have a lot of very old prisoners and so he was pushing at an open door with me. We eventually worked it up to. under John Attards guidance and leadership and Peters as well, Peter remained as instructor and so on until Peter was detached from Pentonville to London area to spread it across the London area, attached on temporary promotion, I mean it was actually.
. I should never ask the question you dont know the answer to, but I dont know the answer to this question at all, has it spread it across the other London prisons? I believe it has but I. otherwise Peter has been wasting his time and I cant see the Area Manager putting up with that. I think it will have spread but I would need to check that. And in terms of after Mr D goes to hospital you have no further involvement in management of the incident, debriefing of staff, commendations of staff, visits to talk to staff or prisoners, none of that? No I didnt have any involvement there. And I think we have covered enough of. you have no other recollection of Mr D as the sort of prisoner he was, his behaviour hadnt come to your ?. only what I subsequently read, I have no real. sources you are reading is Carole Drapers report or anything else? Carole Drapers largely because that is the only thing that is about. Well can I move on then to talk about Pentonville itself, and as I say we are mostly interested in the state of the prison at the end of 2001 but perhaps it might be helpful if you talk about your first impressions of the prison when you first returned there as Governor, I think you said a year earlier? Pentonville had actually been given a full inspection in 1999 a few months before I became Governor and in general the report was extremely good and in fact I was slightly disappointed when I got there to find that things werent as good as the Inspectorate in my view, there was some extremely good areas, the residential function was well controlled, decent, things going ahead in the way that the Prison Service was going on at that time which was generally improving. The operational side of it was pretty poor. We had had an audit once again just before I got there, and there were really weird things going on, like at one stage the works department were cutting our own keys and things like that, which is just absolutely unbelievable but

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that was what was going on, and so there were lots of huge things wrong with the place. That aside, it convinced the Inspectorate that it was a prison which was wanting to get ahead and having a go and I think that is why it got a good report. The one area the Inspectorate seriously criticised to the extent that it was, you know, really serious criticism was healthcare centre. The healthcare centre was in what I would have called when I was an AG there, R wing which used to the be trials wing and which I was (inaudible) for actually and it was, I mean you knew exactly what it would be like. It was a Pentonville cell block at the end of C wing and it was separated from the rest of the prison by what we used to call the Goering edition because C wing had been bombed during the war right in the middle of it which gave us a gymnasium, which wasnt an enormous wing and R wing was beyond there. It was when I first saw it, filthy, absolutely filthy. I. it was on. traffic light red as requiring some special attention and I think it was the last prison to come off traffic light red which was Stephen Shaw: Gareth Davies: Stephen Shaw: Gareth Davies: there were a number of healthcares in similar situations yes, I think there were about a dozen I think so, about that order and they were all the same type of prison, I think Birmingham and Pentonville were the last two. It was in a disgusting state and I began to look for reasons why this should be and if you look at the timing of this you could see that the 99 report would have reported well into 2000 when the report come out and in fact the report really only came out just before I became Governor and so we are then looking at eighteen months later and we should therefore, as you would expect, be beginning to see some improvements and indeed we were but we were starting from an extremely low base. What we had done and what I had discovered was that we had an entirely nursing staff with very few prisoners officer actually worked in healthcare and Peter was one, but there were very few and whereas nurses are very good at healthcare and medical work, and so on, their institutional skills actually nowadays are not very good at all, so issues such as keeping the place clean it seems such as scrubbing out for people who cant really look after themselves very well, cleaning schedules, all that sort of

issues, the basic Florence Nightingale stuff, if you wish, was not being done well at all and I came to the view that it actually needed prison officers to do this and so I increased the number of prison officers. Literally, they were straight prison officers. They were not healthcare staff at all in any shape, form although a lot of them subsequently became healthcare staff and I selected acting Principal Officer, there was this chap called John Attard and he, with Peter Hayward supported by Gary Monaghan who was his boss began to spring clean the place - literally deep cleaning. Issues such as prisoners walking around the landing with no shoes on, were tackled, the hot plate was properly administered, generally the wing cleaners went into prisoners who were mentally ill and cleaned out their cells twice a day and because basically they werent really capable of looking after themselves, so we started on that sort of basic Matron agenda, if you wish. (In fact John Attard was not pleased to be call Matron!) So that is where we started. Stephen Shaw: Gareth Davies: And you started in 2000 you would say, some months after you became Governor? I should think, around about October 2000 we were beginning to know what we were doing and this is about a year after that, so we like a lot of things you make huge advance and then you stall a bit, and in fact that is what happened and we were rolling along at a sort of even, but acceptable, it still was not. it was still a high risk place. and we were trying to work up plans to develop a new healthcare centre specifically for the purpose. The existing healthcare centre at Pentonville was condemned. It was still there, occupying a huge acres of space in Pentonville, but it had been condemned. It was completely useless as a healthcare centre in modern times. It was an Edwardian building I think, early Edwardian building. Two wings and a bit in the middle which you had to go upstairs and along to get from one end to the other, it was full of asbestos, it was soaking wet. There was the earliest isolation cell ever built inside a prison, was in this hospital and it, if you went to see it out of interest, it was three inches deep in water. It was a terrible place - the corridors, you couldnt push trolleys down them. But this was occupying quite a huge space and I wanted it to be razed to the ground and build a new healthcare centre on the site. Huge trouble with English Heritage because it was a Listed Building of course and so we had all of this sort of difficulty to deal with. Our eyes had

really gone into this sort of period of time. Now Paul Boateng was the Minister at the time and he certainly was very interested in healthcare at Pentonville, took a deep personal interest in it and eventually he authorised the money on the strength of the improvements we had made that far and in fact the new hospital opened about a month before I left Pentonville, boom, boom. Stephen Shaw: Gareth Davis: Stephen Shaw: Gareth Davies: Stephen Shaw: Gareth Davies: But at the end of December 2000 you are still in R wing, in the struggle for and you are still on red traffic light.? Oh yes, yes. I dont think we got off red traffic light until about probably 2004. And do you think that that traffic light judgement was a fair one? Yes. It was a high risk place. A high risk place, define what was it that made it such a high risk place? The building was not really good for what it was doing. It had a culture of couldnt care less, certainly from a lot of nursing staff. From nursing or discipline staff? The nursing staff. The discipline staff were hand picked and I would have taken any of those staff anywhere really. But at the end of 2001 you had nursing staff who you judge now, couldnt care less? Yes I sacked three of them eventually, I mean well there is no need to go into these other cases but they were similar, they were cases of lack of care or lack of moral courage in some respects, where prisoners have been seriously damaged because they hadnt done their, or they hadnt even tried to do their job. That is really the issue and that was the culture in a number of the staff, that the prisoners got in the way of them earning their money really and it was a I find it a very disappointing attitude and I was quite ruthless about it if I am at it. I did actually sack three healthcare staff, nurses.
But if I said that it was a potentially unsafe place for prisoners, is that too strong? That is fair. I felt much more comfortable the moment I got the discipline staff in there because at least I knew then the institutional procedures would be followed because they were that kind of officer and that is why they had been picked to go there and Attard was that kind of leader. That is why he had been picked to go there. But I mean it was trying to bail out a leaky boat and if we start looking at. there are some figures which I remember because they burned in my brain, the sort of figures when I started at Pentonville and the figures when I finished there, and they dont really alter that much except they just get more and more intense, we would. about 43,000 movements through reception at the time per annum which probably is the highest in the UK and if it is the highest in the UK it is probably the highest in Europe. We are going back nine and a half thousand new numbers per annum. Of those, thirteen percent would have acute psychiatric disorder, which is normally defined as requiring treatment in a secure unit, sixty five percent, ninety five percent had high psychiatric morbidity normally caused by drug induced psychosis, sixty five percent had educational levels below key skills level 1, sixty five percent will have taken a Class A drug within such a time before we could detect it when they came in, so that is three days. This is the state the place was in, not the state, this was the pressure that the prison was under. I think that what you had to be sure of if we were in this state was a) this high risk particularly with the high level of psychiatric illness we were dealing with, the healthcare operated efficiently and according to the way I thought it was supposed to be operating, because quite frequently you think things are operating in a certain way and you go down and you check for yourself and you find that they are not, and that was why I wanted sort of to put a firmer hand on the way it was run. I gently told the Doctor, SMO he was a marvellous SMO, a lovely man, deeply concerned about prisoner welfare, absolutely I didnt think he had the managerial skills to run this difficult operation, and there was a slight bit of head banging in which we resolved a period of time when I made it clear to him that John Attard, who I by then had promoted temporarily to Grade F, cant remember whether it was Grade F then or G5, I dont know, he was the Manager and the Doctor would be getting on with this

medicine and his clinical practices and so on and so forth but Attard ran the wing, ran the healthcare centre. Stephen Shaw: Gareth Davies: Again I need to know just when the timings of this, would this be June 2001? About then, but certainly Attard was in there pretty quickly after I got there and I think I finally bit the bullet about who was managing the healthcare centre into 2001 it would be, I couldnt give you the month, it would be earlyish. And gradually to be honest, they got better, they got better. All the time that we are trying to make these improvements of course we are moving in the Prison Service towards assimilation to the National Health Service which was a difficult managerial exercise in itself, if you imagine super imposing that on top of a failing healthcare centre, it was challenging and I know that the Private Care Trust at Islington who had Pentonville and Holloway to look after, were daunted by it all. Again that characterisation of it as a failing healthcare centre, is it fair to apply that to December 2001? We are still on the red light then. I think by that stage prisoners in the healthcare centre were being treated as decently as prisoners in the rest of the prison. Go on. Well I mean that is to say something isnt it, you send someone to the healthcare centre and they get less decent treatment than if they are in the main wings. Because the main wings could be pretty rough and ready but generally Pentonville has a reputation of being relatively benign. It has a benign staff culture, comes from when they used to look after all the dossers, nothing macho about looking after a dosser and you are duty bound to look after them and that culture has been maintained, I think. But in the healthcare centre it wasnt there at all, that culture wasnt there at all, these were just people who were paid. One of the good things we did, and it is very difficult to put actual timescales on this, I would have to go and get the Governors journal and read back through them but basically, when we actually began to get the community psychiatric nurses into the main wings of the prison, we were then quite able to say to wing staff, Healthcare centre is not a place where you dump
difficult prisoners, it is care in the community fellas, they live on the wings, we have got community psychiatric nurses available to you and they will refer people that need to go into healthcare should they ever require it. And in fact they went immediately back into their sort of looking after the meths drinkers type mode, and they looked after these guys perfectly well once they knew that, you know, there was somebody that they could take advice from, so that was a real breakthrough, which cut the numbers of beds we required in the healthcare centre. We shut dormitories in the healthcare centre and turned them into workshops. This would be 02, I would think, beginning of, so we were getting close to that period of time. And we actually were getting regime into the healthcare centre so it was like climbing a long gymnasium rope actually, but I mean, you know, we moved, still going up. Stephen Shaw: One of the aspects of management of the healthcare centre again not linked to Pentonville was the reliance upon agency nurses, was that a strength or weakness? A great weakness. A great weakness and the reason is of course that agency nurses are frequently are aware of the prison procedures - very much so because they are probably healthcare nurses from another prison, but they would not apply your procedures, they might apply another prison procedure or the hospital where they normally work procedures, but the fact is it is it didnt work particularly well, largely because they are not of the prison Given that they also cost a whole lot of money and what happens is the funding for healthcare is dragged off into agency nursing and so you need new equipment, you need new dental drill or you need something like that, you cant have one because you spend all your money on agency nursing. This was something that John Attard was particularly hot on, so we cut the number of beds in the healthcare centre, we made it a rule that only Attard the Deputy Governor or me could order agency nurses, so we had a firm control on that budget. Strange enough having a control on the budget also gave us control on the staffing of the healthcare. We got a much better grip of it, looking at the profiling, and so and so forth, we had you remember added. I had applied to healthcare, I think there were eleven discipline officers to go into the healthcare centre which is fair amount of money to be applying, but it needed it and I wasnt at all, never ever considered, sort of stealing back again. So agency nurses

were bad in two ways, one is they are not of the place, they dont follow the procedures, they are knackered Stephen Shaw: Gareth Davies: Stephen Shaw: because they are doing it as a second job? Thats right and they cost a lot of money which comes out of the healthcare budget. Whether generally or specifically, were you conscious of any particular problems of staff shortage over. this is say when Mr D attempts to kill himself is just after Christmas 2001, but were you conscious of any particular staff shortages over the Christmas period or no different from any other prison? Christmas periods and Bank Holiday periods actually contrary to popular belief we are not short of staff. I cant, I dont know what day Christmas fell on that year, we could look it up, but if you find, unless you find it is a Saturday or Sunday you have always got plenty of staff because the prison is profiled for Tuesday or whatever the Christmas day is, and therefore you are knocking off staff at the levels of the staff that you require and obviously we trim regimes and we dont have staff on duty unnecessarily on these days but the fact is the prison Bank Holidays are always properly staffed because they can be and generally that staffing issue is over the Christmas period will last for certainly the week between Christmas and New Year. Is there anything else you want to say about healthcare? I am going to move on to self harm and suicide prevention in a moment. Is there anything else we havent covered, I mean is there anything you wanted to know more about healthcare that Gareth wants to ?. we were successful I mean in improving it, I mean we did reach the stage where we were allowed the money for the new healthcare centre which was 7,000,000 We visited the new healthcare centre and it is just incomparable as a building. We were also conscious of what the Chief Inspector said, as you say, the 1999 reports where he refers to healthcare as a disgrace and I couldnt remember the word I knew it was pretty bad
. I didnt want to be leading the witness. 1999 it was a disgrace and by 2002 Chief Inspector is talking about good regime activity in the healthcare centre although I think nobody would pretend that the building and the facilities were appropriate. I mean manifestly they were inadequate for the purpose, probably for any purpose but it is interesting what you said about the numbers going through, the extent of psychiatric morbidity, which is the contrast of between what you have got and comes from the catchment area. Pentonvilles catchment area is the A1 up as far as Hertfordshire, round to the Thames to the East out as far as Barking area, Essex. It contains four of the poorest boroughs in the United Kingdom, you know, the old East End, it is a pretty tasty catchment area. Anyway further invitation. Is there anything Ali where you think I should have asked about healthcare? I would be interested in how it felt as a department if you like whether, once John Attard took over, whether staff were working in a sort of purposeful way or whether they remained in a sort of chaos or ? Initially there was a huge friction and I remember one day Doctor Yisa bursting into my office whilst I was in a meeting, shouting, Get him out of my healthcare centre, I cant stand it, get him out, he is causing all kinds of bother and I knew who he was talking about and Doctor Yisa will remember this as well I am sure, but I asked Doctor Yisa to leave me alone whilst I was in my meeting and I would speak to him when he calmed down and what had occurred was that, I referred to it in passing earlier, John Attard had been standing on the landings and seen a prisoner going to get his lunch and he had no shoes on. So he stops him as a good Principal Officer would and says, Where are your shoes, go and put your shoes on. The prisoner replies, he hasnt got any shoes, so John collars the Charge Nurse and says, Why hasnt this man got any shoes, get him some shoes perfectly reasonable thing for a Principal Officer to ask. I dont get shoes, I am a nurse, and John being the sort of bloke he is put this right straightaway and says, Do what you are told, basically, and this led to a big us and them. In the end there was the discipline officers became more nurses and the nurses became more institutional with one or

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two or three exceptions which I dealt with in a different way, but initially it was very unpopular because people dont like being told they cant run a wing, they are not getting it right. Ali McMurray: And processes in terms of admin and storing and keeping the records and referrals to outside agencies, were those all in place and working properly? Always very fragile I thought, there was a whole, there was a culture of piles of records had been moved about from earlier on and a number of occasions we would have a huge search because a prisoner is due to go to court and we couldnt find his IMR and it had been picked up on a bottom of pile of books, it was chaotic, that was chaotic. And referrals to outside agencies? That went quite well, I mean Yisa was particularly good at that sort of thing and we had cultivated, I forget the name of the hospital now, a psychiatric hospital where we could, and that was one of his great strengths. one of Yisas strengths was actually the control of self harm, he was rightly obsessed with it. Thank you. That leads me into questions about suicide prevention and what have you. The Visitors report for the period in question, the period of 2001, says about suicide prevention that there was little training and that mandatory procedures were not always followed. What was your take on the management of suicide prevention at the time? It wasnt as bad as I had a very bad
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SIDE TWO Stephen Shaw: Before we turned over the tape I was referring to the then Board of Visitors annual report 2001 which had said, I am paraphrasing here, suicide prevention - there was little training in place and that mandatory procedures were not always being following, and you indicated some dissent from that? Yes the suicide prevention training was relatively new on the block at this stage, certainly to the extent in which people follow it now, but it was mandatory and you know, sometimes I used to wonder what the BoV I thought I was doing, if they thought I was just ignoring Prison Service orders and not doing the training that the staff were supposed to do. Perhaps sometimes they couldnt do it as fast as they would have liked but the fact was the suicide prevention training packages were always full and going ahead. The only time we had serious trouble with training was with the training of Listeners, and we had some difficulty getting the courses to run full and to be completed. That was normally as a result of the trainer and falling out of the course. I dont mean falling with the course but falling out of the course for some reason and we did get very low on Listeners at one stage. The 2052 procedures in a big local are an enormous administrative burden. They are detailed, they are bureaucratic, they require reviews, they require constant monitoring of staff entries and it represented a fairly major cultural change to write sensible things down in the 2052SH. I dont mean, when I say sensible, I dont mean that people wrote stupid things down in the 2052s. One officer did and he was fired as a result. The appears to be sleeping, it would, in this era would have been a not unusual comment in the 2052, which of course is absolutely useless and so again staff to realise that this was not the way you go about it. When you do your mandatory training you tell them about the system. It is a quantitative issue. The qualitative issue i.e. the quality of the entries, is a cultural issue and that takes a lot longer and it is all very well for people to go and look in books and say, this is rubbish, this isnt done, that has not been done, this is not properly done, so forth, easy, easy cheap shots. Achieving the changes you are after is not easy and the question of driving, driving and driving the Dep was responsible for suicide prevention and a little mental blank here yes, appointed a full time Senior Officer, I think probably towards

the end of 2001 again who checked all 2052s every day, brought to my attention things which werent right. Also Duty Governors checked all 2052s every day. We had difficulty maintaining the reviews, three day reviews that was just so burdensome. Stephen Shaw: Gareth Davies: to that extent the. may be right if yes, if they were to say things like, sometimes the initial reviews were not completed, I would, yes but basically we proceeded not as threadbare as that. The reviews or at least the impression I have of the reviews is that they were not multi disciplinary, the prisoner wouldnt always be present would they? That is about it, it isnt an administrative problem, multi disciplinary, when do you have them, where do you have them, pressure comes to different areas of the prison at different times and you have to do a lot of them, so unless you actually have a review team operating fully, and we were never generously staffed. It wasnt idleness, it was literally practicability. Well let me ask a question related to resource question and we mentioned Dave Leane before and I had said that we managed to retrieve the interview today to Carole Draper some four years or more ago, where he was asked the question about the process of putting people on a permanent watch and what he said was, Only a doctor could do it and it was all to do with money. Do you have a recollection of what the process was for putting somebody on permanent watch and whether it is true that it is all to do with the resource constraint? This actually links to agency nurses issues because to put somebody on a close watch, you required an agency nurse. Essentially the nurse would do the job? Yes He or she would sit there looking at the prisoner all day.? That is right and in fact I thought it was. it took me a long time to work my way around this, because it was a very
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sensitive area and I had other fish to fry, but I thought that somebody sitting in a chair looking glassy eyed through a t window into a dormitory which we didn'like anyway was not the best use of anybodys time, although it was effective, if we look at the outcomes and suicide prevention despite what the BOV says, was reasonably effective compared with other jails of its size and type. Big money issue which is why the doctor controlled it himself and why he wanted dorms, if you speak to Dr Yisa he would tell you he likes dorms because dorms actually assist in suicide prevention. Dont quite know where I am going now but Stephen Shaw: well I am just trying to clarify on the. is Mr Leane right in saying that it is always the doctor who decided whether somebody could be on constant watch or not? I think probably it was always the doctor but not because he was the only one who could but because it fell to him. I see. Do you recall the, described as the semi furnished cell, cells, I think there were two of them, AS1 and AS2? Mr D was held in one of those cells for a period before his death. Do you recall why those cells were used, what you thought about the conditions within them? I wasnt very happy about them. I could see, they were being used as crutches in a way, it was the only solution that people to when they were worried about somebody. I didn'like them at all. They presented as a safe place but I t dont think they addressed the problems, does that make sense? It does, but I prefer it to be in your words rather than in mine. Well I think that is the way I would do it, that is what I would say. I was reluctant to take this crutch away because when you are trying to change things there is the issue of business continuity and what you dont want is to change things ostensibly for the better and the outcome gets worse. So in many respects the fact that Pentonville had a reasonably good outcome from the point of view of suicides, relatively low compared with other places, I didnt want to have better procedures and worse outcome. So these particular cells were considered to be amongst other things why we had such good outcomes. I was very reluctant therefore at that stage to take these things away because they could have let

go of the rope completely and we would have had worse outcomes. Stephen Shaw: Gareth Davies: Stephen Shaw: Again I prefer it be your words rather than mine, what do you recall of the physical conditions in AS1? Very, very sparse, very sparse indeed, almost like a special cell in the segregation unit, not permissible nowadays. Well just take me down that road as well. So what we are saying is at that time in Pentonville you were reliant upon putting people into conditions akin to a strip cells because they were safe in the sense that you couldnt put a ligature anywhere but apart from that there wasnt very much you could do, but that in your judgement you would not be allowed to do that today? No, I know you wouldnt. what the orders are now, as you would expect me to. I dont know, I think that I mean that wouldnt apply, we must be careful not applying todays standards to, not ancient history, but nevertheless five years ago long time in the prisons. I mean I remember that at Albany we had a padded cell and things change, the ways of dealing with issues change, I think with this particular problem the biggest advance was the introduction, was the community psychiatric nurses onto the wings and you now get a much more community response, more support, which is huge support rather than absence of ability to hurt oneself, you get support which helps you. But at the time in Pentonville we have in the healthcare centre Mr D but actually other people too who are known to be at risk of self harm. I dont have the numbers of the exact time, and presumably could get them at some point, but significant numbers in healthcare would have been on open 2052SHs. Aside from using the anti suicide cells for people who are in acute distress, what practically could I have done if I had been one of Mr Attards bright young things come into work on healthcare, what practically could I have done to work with those at risk? We did do a lot. It is, if you remember, if you reach the stage where you are really depressed and I have, I might have
been slightly clinically depressed at some stages of my life, but I mean what happens is, I believe that you cant think of anything positive about yourself at all, and all the positive things that have happened in your life are diminished to the point of invisibility by this huge amount of the negative things which are flying around you like bats. Unfortunate term, but you know what I mean. If, therefore, you improve decency and control and options, choice and interest, cleanliness, all these things you are actively supporting an optimism, so even the guys in the cells really who could not look after themselves had cleaners come in and do for them twice a day, people were properly dressed or decently dressed, people got good food, basic things, the discipline staff talked to the prisoners a lot more than the nurses oddly enough. That is the kind of thing. Stephen Shaw: Gareth Davies: Stephen Shaw: Gareth Davies: But you didnt have day centres or.? ahhh we did, we did. It wasnt a very good day centre because it was a bit fragile in our delivery of it. But more some days centre? Yes some days centre. They have got certainly fantastic space now in the new healthcare place for a day centre. We got rid of the dorms as I was saying as we got rid of a number of beds in the healthcare centre and we turned one of the dormitories into a day care centre and we employed an art therapy teacher, and she, well she did very very good work. This is at the relevant time? Yes So there was art therapy, do we know if there was anything else? There was work. It was simple work of, it had to do with putting files together. I cant remember if it was for the Prison Service or not but they actually put cardboard file covers and put a tag through them and so on. It was pretty sort of rudimentary work, but it was work. They also got PE. So that. this is quite important to press to get an idea of what, I dislike the word regime, but what was going on.?

John was definitely building a regime. have you spoken to John? I havent, no He could. he has got a photographic memory, he could detail almost on a daily basis what was happening. I want to ask you some final questions relating to Carole Drapers investigation report. That is all I had on self harm and suicide, so I dont know again if Gareth wants to say anymore I havent asked about or if Ali, other things I should have asked? No specific questions but just a sense of how under control things felt in the healthcare centre from suicide self harm point of view? If you are asking me if I went to bed every night confident that I would not receive a phone call at some stage telling me that somebody had killed themselves, I would say, I couldnt say that at any stage. It was terrifying and numbing actually. Sometimes it is very difficult really to explain to people how physically it hits you and I was always terrified of it. Thank you. And I mean you had in your charge hundreds of very vulnerable people? Yes when you work it out, thirteen percent of nine and a half thousand is over a thousand. Its lots, yes. Okay, unless. have you got anything you want to. Oh, no. no. Well look we are onto you will be pleased to know, onto the last set of questions which are related to Carole Drapers, I was going to say, report but actually reports because she conducted a number of investigations at the same time. Amongst the things she draws attention to perhaps I will take them one at a time, just for your comments on, she was

Ali McMurray;

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critical of the quality of post incident care of staff, do you think that was fair comment? Gareth Davies: Yes and no. It is an odd service, the Prison Service and we have our caring system and lots of screws would prefer to use that system in private than in a big blaze of glory after a big incident. I think we would offer a kind of care we would offer would be when you actually, Do you know that there is a care team and if you are feeling down about things, you know where to find them. There is one on duty, or two on duty actually, and they are a good team. But because we didnt do it with a blaze of trumpets, flashing lights, doesnt mean to say it wasnt happening. Some of the other things she says, I think we have covered, but we might as well do just for the record, she said that specialist referrals to psychiatrists, specialist ones always have been? Well I mean we used to reckon that we were doing quite well for a local London well that is the standard isnt it, you. so I think we know specifically what happened in respect of Mr D but in general using the benchmark of a London local prison . well let us not mince words. The way that care in the community as devised by the National Health Service has become care in prisons and we dont really want to know about these things hate using that term, these people, sorry, about prisoners, it is a national disgrace actually and if you start looking at the figures who I have talked to earlier on, I talked about education, I talked about mental illness, the prison officer used to detoxify three thousand prisoners per annum which is more that the National Health Service in the whole of South of England and obtaining psychiatric care for mentally ill prisoners in prison was very, very very difficult, that depended upon all kinds of favours and deals to be cut between the SMO and psychologists, psychiatrists I am sorry, in various psychiatric hospitals around London and it is a disgrace. But within that context, which is not very good, we did alright as well as anybody. A couple of other things again I think we have covered them. She talked about healthcare documentation getting, going

lost, going astray, was there a particular problem on file handling.? Gareth Davies: Stephen Shaw: I think I have already covered that, it was chaotic. Chaotic and she says of the 2052SH review she noted not only no involvement of prisoner to which I refer to, but no involvement of probation. Was probation strong or weak at the time? At the time it was weak, it became stronger. And overall Carole Draper produced I say a series of reports. Do you think they were fair, how should I read them? I know Carole very well indeed. We were Assistant Governors together at Pentonville. She knows her way round big locals. She knows where to look but sometimes I thought she concentrated on things which were easy to find out against a bigger picture and I cant criticise her overmuch because she is doing a job, but I did think that sometimes, not doing it deliberate, she made things a little bit worse than they appeared, appear worse than they are. Okay, so well, again I dont want to put words in your mouth, but it sounds as if you didnt really welcome these reports? You can read them selectively, I can read a report. I did welcome the report because they tell you as Governor what is happening two or three levels below your span of control and this is important information because I have always worked on the principal you check on how effective you are being by checking two levels down, not one level down, two. If you get down, somebody is going to tell you what has happened three or four levels down independently, that is really valuable, so I do value these reports. But I sometimes wish she didnt emphasise things which are relatively, not so important, but relatively unimportant compared to some of the major issues. And were you involved in any way in drawing up the action plan based on her reports? Some I would be, certainly not all of them
And do you have any recollection, I mean we have the action plan, but do you have any recollection of what was involved that you did have? It would be something that I would delegate generally, I would think probably to, I have a sneaky feeling that Ruth wasnt it is awful because I cant remember the suicide prevention co-ordinator, not co-ordinator Governor really which would be Ruth. she would deal with the action plan and I would stamp it basically, not stamp it, checked that it was okay. Checked it was okay, we agree on that. That is my all my questions. Again you are more than welcome to talk about anything else you think we should have asked you about or anything you want to say? I am sorry my memory isnt better. Your memory is extraordinary by the standards of the other people we have interviewed, your memory is extraordinary. Because it is a very important area and it was exercising us very severely at the time. You can see I cant even remember who the suicide prevention chief was, I am sure it was Ruth, I am sure it was. Ali is there anything I should have asked? No not that I can think of. Well in that case we might as well be formal about it and say that the time is now fifteen thirty and the interview is closed.