Crown Censure of HM Prison Service

Date:

13 February 2012

Release No:

COISE/1302

The National Offender Management Service (NOMS) today was subject to a formal Crown Censure from the Health and Safety Executive (HSE) after the death of a prisoner at HMP Bullingdon in Bicester, Oxfordshire.

On 26 September 2006, Daniel Rooney (also known as John Hughes) was awaiting sentence. At about 7.45pm he was found by a prison officer with a noose around his neck trying to tie it around a light fitting. A senior officer identified that Mr Rooney was at-risk of suicide and/or self-harm and as part of the additional support measures he was placed in a cell which was identified to be a 'safer cell' at about 8pm.

During the following 40 minutes he was observed by prison staff on three separate occasions the last of which was between 8.40pm and 8.45pm when he was found hanging with a ligature, made from his bedding and fixed to a shower rail support bracket. The bracket had been fitted to the wall using screws strong enough to support a ligature made from bedding in the cell. The brackets should have been attached to the wall with fixings that were not as strong to support the ligature used by Mr Rooney. The Post Mortem gave cause of death as "Hanging".

Examination of the 'safer cell' after the death identified several points where ligatures could be attached. Investigations conducted by the Prisons and Probation Ombudsman and the Coroner were unable to prove when the shower rail was installed, who installed it, who authorised its installation or who checked it had been fitted in an appropriate way in a 'safer cell'.

NOMS accepted the Crown Censure after explaining the actions it had taken and continues to take to prevent a similar occurrence at HMP Bullingdon and other prisons.

HSE's director for its Southern Division, Heather Bryant, who took the Censure hearing said:

"This was an unnecessary tragedy and shows that all refurbishment programmes need to be adequately controlled. The standard in this cell was far below what is appropriate for those vulnerable prisoners in a safer cell."

HSE's investigating inspector, Matthew Lee, said:

"NOMS is fully aware of issues relating to self-inflicted deaths of prisoners. In the years 2007 - 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 Crown Censure found that on the date of Mr Rooney's death, NOMS did not comply with Section 3(1) of the Health and Safety at Work etc Act 1974 and Regulation 5(1) of the Management of Health and Safety at Work Regulations 1999.

Notes to editors

1. The Health and Safety Executive is Britain's national regulator for workplace health and safety. It aims to reduce work-related death, injury and ill health. It does so through research, information and advice; promoting training; new or revised regulations and codes of practice; and working with local authority partners by inspection, investigation and enforcement. www.hse.gov.uk
2. Section 3(1) of the Health and Safety at Work etc Act 1974 states: "It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected thereby are not thereby exposed to risks to their health or safety."
3. Regulation 5(1) Management of Health and Safety at Work Regulations 1999 states: "Every employer shall make and give effect to such arrangements as are appropriate, having regard to the nature of his activities and the size of his undertaking, for the effective planning, organisation, control, monitoring and review of the preventive and protective measures."
4. While the provisions of the Health and Safety at Work etc Act apply to Crown bodies, including departments and agencies, Crown immunity means such bodies are excluded from the provisions for statutory enforcement, including prosecution and penalties. HSE enforces health and safety law in relation to Crown bodies in Great Britain.
5. A list of censured Crown Bodies is published online and in the HSE annual report.

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