An inquest jury sitting before HM Coroner for West Yorkshire, David Hinchliff, today concluded that a catalogue of serious failings at HMP Leeds caused or contributed to the death of 25 year old remand prisoner Mohammed Mudhir who was found hanged in the segregation unit of the prison on 21 August 2005 while the balance of his mind was disturbed.
Mohammed Mudhir's family was represented by Leslie Thomas of Garden Court Chambers and Kate Maynard of Hickman and Rose Solicitors.
Mohammed Mudhir, age 25, was remanded into HMP Leeds in June 2005.
His inmate medical record (IMR) indicated that he was a vulnerable person, who had a history of depression since childhood, and two years previously had experienced thoughts of self harm.
Whilst in prison he was moved to the segregation unit on 18 August 2005. Three days later he was found dead in his cell.
From the 17 August there was evidence that Mohammed's mental health was deteriorating.
Prison officers were concerned when they saw what they thought to be blood on his sweatshirt. When they asked Mohammed if he was injured he refused to engage or speak with them.
The prison officers then asked a Registered Mental Nurse to conduct an assessment. Although she saw cuts to his arms she failed to open a self harm form (otherwise known as an ACCT form) despite not knowing how the lacerations had come about. She admitted that she failed to look at the IMR.
A prisoner by the name of Daniel Jones reported that Mohammed had expressed suicidal thoughts. He also saw lacerations to Mohammed's wrists. Mr Jones said that he reported this to a prison officer. Yet no action was taken.
Another prison officer reported that during the afternoon of 18 August Mohammed was talking 'incomprehensible nonsense', yet again no action was taken to help Mohammed.
Later that evening, Mohammed was noted to have covered up the windows, lights and spy hole to his cell. Fearing that he was in the process of self harming/suicide, prison officers entered the cell with a ligature knife, whereupon Mohammed attacked an officer. The officer struck Mohammed with a baton and restrained him.
The officers reported that during the restraint, Mohammed showed incredible strength and was impervious to pain. The officers used pain compliance control and restraint techniques on Mohammed and were surprised when he did not utter a sound or respond to this force. One officer gave evidence to the effect that in his 20 years service he had not seen anything like this.
Mohammed was then conveyed to a special camera cell in the segregation unit. This basic cell only contained a toilet and a mattress on a raised plinth.
A nurse, Nurse Nuttal a General Registered Nurse, who came to assess his fitness for segregation saw "small lacerations to his wrists" which were consistent with self harm injuries yet despite the fact that she got no explanation from Mohammed as to these injuries, she failed to open a self harm form (ACCT)
Contrary to PSO 1600 which states that a prisoner should only be in the special cell for the shortest amount of time necessary which could be as little as 20 minutes with periodic reviews by a Governor, Mohammed was detained there for 18 hours without review. The total amount of staff contact time with Mohammed during this period was less than 90 seconds. He was offered no water, this again was contrary to PSO 1600 which states that prisoners should be treated with dignity, fairness and respect. The deputy governor, Mr Denton, when asked why Mohammed had been kept in the special cell for so long, and in this manner, could not provide an explanation. He was also asked whether he was concerned that Mohammed had been noted to be drinking from the toilet. He said, of course, as this was a possible indication of serious mental health problems. He agreed with the suggestion that "one would not treat a dog in the way Mohammed had been treated."
Despite prisoners in the segregation unit being particularly vulnerable, the segregation unit at HMP Leeds was staffed by unqualified and untrained staff. Mohammed was observed by two such auxiliary officers over night. One directly observed Mohammed drinking water from the toilet, the other officer was told that this had occurred. Neither took any action, not even asking him if he was okay or needed a drink. One OSG, Lewis, when asked if this concerned her, said no, because she had seen prisoners drinking from the toilet before and when she drew this to the attention of senior managers, they did nothing about it.
Mohammed's time in the segregation cell was captured on CCTV. This showed him to be:
- Pacing the cell in circles
- Praying incessantly
- And drinking out of the toilet
Further, both the Nurse and the Doctor failed to carry out the required assessment of Mohammed for his fitness and suitability to be in the special cell and the segregation unit. Neither knew of their obligations under the Prison Service Orders.
The Doctor was unaware of the following when he went to Mohammed's cell:
- Lacerations to his wrists
- That Mohammed had been drinking from the toilet
- Mohammed's bizarre behaviour prior to his arrival in the segregation unit
- Mohammed's mental health history as contained in the IMR
Had he known about the above, he said he would have:
a) Opened an ACCT
b) Had him transferred out of the segregation unit
c) Had a mental health assessment done on Mohammed
He agreed that the fact that Mohammed was drinking out of the toilet, was an important indicator of mental health deterioration
An officer falsely endorsed the segregation unit compact (the document containing the rules of the unit) indicating that Mohammed had refused to sign the document. This was despite the fact that the CCTV shows that no officer went to Mohammed's cell with this compact throughout the duration of his time on the unit and therefore he was never given the document. When confronted with the CCTV evidence, the officer had no explanation. Mohammed was not given the basic items that the other segregation prisoners were given such as flasks of hot water. He did not eat any food for his first 40 hours on the segregation unit.
During the afternoon of 19 August, Mohammed was moved from the special cell into an ordinary, single cell in the segregation unit. This cell was not safe. Despite the fact that it was designated for single accommodation, it contained a bunk bed which Mohammed eventually hung himself from. When the number two governor was questioned as to the justification of a bunk bed in the designated single segregation cell, he could provide no explanation or justification.
He agreed that a bunk bed provided obvious ligature points for somebody mindful to self harm. He also accepted that the prison service, for a number of years, were aware that cells should endeavour to be free from ligature points. The presence of an unnecessary bunk bed was an obvious failing in this risk assessment.
Within (hours) of being placed in this unsafe cell, Mohammed was found dead, on the morning of 21 August 2005, having suspended himself from the top bunk.