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So what does "visit allowed, visit cancelled mean"?

Maurice had a visit booked this week which was approved in advance by the wing governor.

All the arrangements were made and the visitor turned up at the appointed time.

Entry to the prison was then refused on the grounds that the visitors details were " not on the system" .

The visitor in question has visited Maurice in the same prison on previous occasions!

Out of interest what ID did the visitor take to the failed visit.

Why was it not possible to put the person details on the system.

Was this the first visit during Maurices latest imprisonment?

Hopefully a little insight into these answers will avoid other visits being turned down at the prison gates

Perhaps it might be worth me explaining my previous questions and thoughts - On Cardiff Prisons visiting page (www.insidetime.org/info-visitorsinfo.asp), they state that visitors records are deleted when a prisoner is released. So it would seem that each detention requires  the visitors details to be uploaded onto their system as a "new" visitor on the first visit to Maurice during that period of him being in prison.

From the page it says that on the first visit photo ID and proof of address is required, after that its just biometric / photo id. What they dont seem to make clear is that the first visit rule applies for each time Maurice is held.

VISITING INFORMATION

Booking Procedure

Automated system. Visitors book

Booking Phone No.

029 2092 3327

Booking Opening Time

Mon-Fri: 09:00-16:00

Minimum Booking Notice

1 weekday

Booking Email Address

Socialvisits.cardiff@hmps.gsi.gov.uk

Min Age Unaccompanied

18

Search Procedure

Rub down, metal detector & passive drugs dog

Visitors 1st Visit ID

Photo ID and proof of address

Subsequent Visit ID

Biometrics but take photo ID

Visitor Adult Age

14 - Adult ID required

Child Visitor ID

Passport, Birth Certificate etc.

Disabled Facilities

Full access; wheelchair accessible tables

Parking

Multistory opposite prison. Disabled park on yellow lines outside main gate

Hand In Money on Visit

No

Hand In Other Items

No

Book next visit on Visit

Phone in Visitors' Centre

Back to Top

VISITING CENTRE

Opening Times

12:30 (08:45 on Saturdays)

Refreshments

Hot & cold drinks and snacks plus vending machines

Toilets

Yes, with disabled access and baby changing facilities

Disabled Facilities

Full access including toilets

Child Facilities

Minimal, unsupervised

Refundable Locker Deposit

£1

Booking the visit

Any newly convicted prisoner will have a reception visit automatically placed onto the visitor bio-metrics system. Thereafter, the number of visits applicable to any prisoner (through the IEP scheme) is automatically created.

The prisoner does not send out Visiting Orders. If you wish to visit you should either telephone or email and if the prisoner has a visit available this will be booked. Visits are booked on a first come first served basis.

You can book for a maximum of 3 adults and a reasonable number of children (under 14).

There is a telephone in the Visitors' Centre which goes directly to the Visit Booking Clerk where you can book your next visit.

Booking by Email

Socialvisits.cardiff@hmps.gsi.gov.uk

Email a request to the Email booking address.

You should include the prisoner's full name and prison number.

The full name, date of birth and address of everyone who wishes to visit.

You should get a reply/confirmation the following morning.

Click Here to download Prison Service Instruction on visit booking services.

Arriving at Cardiff

You should book in at the Visitors' Centre outside the main prison.

Make sure you have your ID. If you booked by Email take a copy of the confirmation.

You can get refreshments, rest and freshen up in the Visitors' Centre before moving to your visit.

It is a good idea to arrive as early as possible at the Visitors' Centre (opens 12:30) to get a low number to move earlier to the Visit Room. If you arrive after 14:20 you will be refused admission.

Click Here to download Prison Service Instruction on Acceptable Identification for visitors.

Moving to the Visit Room

All visitors are given a number. These numbers are called out for visitors to transfer to the Visit Room.

Searching

All visitors to Cardiff are subject to searching.

Searching is done by staff of the same gender although male visitors may be searched by female staff unless they object.

As well as a rub down and check with a metal detector, Cardiff use a passive drugs dog. If you have a child who is frightened of dogs you should inform staff - the dogs are trained not to bark or jump up. Young children are normally searched by female staff.

Sometimes visitors might be asked to remove religious headwear. This will be done in a private area with staff of the same gender; the visitor will be given time to refit headwear,

Cardiff use a biometric system and photograph all visitors aged 14 and above. This system helps speed up the visitor processing system. If you have any concerns about being photographed you should contact the prison before your visit. Photographs are only used for the purposes of visits and are removed when the prisoner leaves the prison. Young children are not photographed.

Is this what happened on the abortive visit? Did the person take and offer the photo ID and proof of address, was it the first visit for this period of imprisonment?

I doubt that they help matters by making this clear - why would they? It might help Maurice...

Still if people know and go prepared then that stuffs their awkwardness.

Cat Lady,

The Wing Governor went to see Maurice, in his cell, an action almost unheard of in the Prison system and he gave Maurice his assurance that the visit would go ahead!

Now either the WG. is involved in this deception or, more likely one of his minions has either failed to carry out the order to enter the visitors details on the system or one of them had deliberately deleted those details. As you say there seems to be a proceedure for doing that within the prison system. I would say though, that although there may be a local option to remove the details, it is extremely unlikely that our information hungry government would allow any information of this nature to be permanently lost.

They spy on everyone all the time!

Guido - I agree with your comments about data retention. But surely its the access to the information that is the issue I doubt the gate minion would have access to historic data. That would be an admission that they retain rather than delete it.

Unfortunately they hold the keys and generate the hoops we have to go through. I guess the real test of this matter is this:

1: Was it the persons first visit to Maurice during his CURRENT period of detention?

2: Did the person take photographic ID and proof of address?

If the answer is yes for the above questions then serious questions can be asked as to why the person was not allowed - following the Wing Governor saying that the visit could go ahead.

Out of curiosity why did the wing governor need to approve the visitor and go and see Maurice to confirm that/ Surly that happening is another almost unheard of action.

Was the visitor regarded as a contentious visitor?Perhaps regarded as a journalist or threat to the prisons security?

There can't be many other reasons to refuse Maurice a visitor

Call from M Kirk 6 Dec. 13:

www.onetruemedia.com/shared

The above comment should read Sat. 7 Dec. 13:

Call received from Maurice Kirk Sat. 7 Dec. 2013:

www.onetruemedia.com/shared

MK’s call from Friday 6 Dec. 2013:

www.onetruemedia.com/shared

The call of 7th does through more light on the visit and why it was discussed by the wing governor and Maurice.

I find it rather disturbing that Maurice says he has had NO visitors for two months, that is either social or legal visits.

How many of the group that support him have tried to visit during that time? Was Maurice in the punishment block for any of the two months? If he was then he would not be allowed visitors but if not and people other than the witness he had arranged to see have tried to visit him and been refused then that needs some serious thought and questions asking.

Of course Kirk knows that all he has to state in summing up his civil claim is that he "relies upon his crown court jury trial manchine gun acquittal case" and they lose.

But they don't want that and need to keep him (unlawfully) locked and docked into constant and ongoing criminal matters ...

He is currently "Kidnapped" because the 3 requisite signatures needed to lawfully and even legally hold him [anyone in fact in this country] in prison are not to be found on any document or parchment that they could nor can they dare to produce.

The three required signatures are those of the Judge, the prosecuting barrister and THE DEFENCE BARRISTER.

Wake up Sabine and stop your 'only' throwing of dirt at the UK's busted judicial system - when the European Courts of justice are as equally corrupted and busted.

There; the whole story not half of it (Sabine) with a hidden agenda of pro-EU blinkers on. But hey that's what Marxists do.

The EU judiciary are as independent of the EU parliament as are the UK's judiciary from the UK's parliament - NOT AT ALL. They are interdependent upon one anothers existance.

Hanging is too good for em.    

Call from Maurice Kirk 11 Dec 13 - he has been assaulted again in HMP Cardiff, he states - at the court hearing yesterday MK was refused his reading glasses so he couldnt read anything - he couldnt hear anything [was the audio in the court room evern working properly for this hearing?] - every request made to the judge was refused, he couldnt even call witnesses, he alleges - a complete farce of a hearing by all accounts but nothing new regarding the targeting of Maurice Kirk:

www.onetruemedia.com/.../view_shared

Very worrying call from MK this afternoon - who is now fearing for his life:

www.onetruemedia.com/shared

..and im glad you find these calls "interesting" Cat Lady.. I guess this is all a bit like Coronation Street to you. .who exactly ARE YOU??

Lets hope that HMP Cardiff have learnt from its past mistakes and do start to listen to Maurice's concerns: I copy below the content of a previous report( www.ppo.gov.uk/.../105-09-Death-of-a-male-prisoner(1).pdf)

Investigation into the circumstances surrounding the death of a man at HMP Cardiff

Report by the Prisons and Probation Ombudsman

for England and Wales

June 2011

2

This version of my report, published on my website, has been amended to remove the names of the man who died and those of staff and prisoners involved in my investigation.

This is the report of an investigation into the death of a prisoner at HMP Cardiff who died on 19 October 2009. The man was 40 years old. He came into prison just over eight weeks before he died. The man had been remanded in custody after being charged with the murder of his partner. The evidence suggests that the man took an overdose of pain relief medication. Letters to his family and friends discovered after his death also suggest that he intended to take his own life. I would like to offer my sincere condolences to the man’s family and those affected by his death.

The man passed away in his sleep and was discovered by fellow prisoners after his cell was unlocked during the morning of 19 October. The prisoners raised the alarm and staff discovered that the man had been dead for some time. It appears that, during the evening of 18 October and the morning of 19 October, the man was not observed at the appropriate levels for prisoners who are located in healthcare. Also there was a discrepancy between a statement written by a member of healthcare staff and the closed circuit television (CCTV) record of events. As a result, the former Governor of HMP Cardiff commissioned an internal disciplinary investigation and the staff concerned were officially reprimanded.

The investigation was undertaken by my two of my investigators. I am grateful for the assistance they received from staff at HMP Cardiff, especially the Head of Safer Custody, who has since retired. I would be grateful if the Governor would pass on my thanks. Staff from Healthcare Inspectorate Wales reviewed the man’s clinical care and I appreciate their assistance.

After receiving the toxicology report following the man’s death, South Wales Police opened an investigation into the circumstances of his suspected overdose. I postponed my investigation until their enquiries were complete. I apologise for the considerable delay issuing this report and any additional distress this may have caused to the man’s family and staff at Cardiff. This was caused by the suspension of the Ombudsman’s investigation while the police conducted their own investigation, and the late receipt of the clinical review.

The clinical review concludes that the man’s clinical care was not comparable to that available in the community. I note the issues highlighted in the clinical review and I endorse the recommendations. These include a review of healthcare systems at Cardiff, carrying out secondary healthcare assessments and ensuring that care plans are put in place. I make recommendations of my own relating to administration of medication, staff being aware of trigger points for prisoners who are subject to selfharm monitoring and the interaction between officers and prisoners when cell doors are unlocked.

Jane Webb

Acting Prisons and Probation Ombudsman June 2011

3

SUMMARY

The man was born in 1969 and was 40 years old when he died in the healthcare centre at HMP Cardiff on 19 October 2009.The man had been remanded into custody by a local Magistrates’ Court on 21August 2009 for the murder of his partner. He arrived at HMP Cardiff the same day.During his first reception health screen interview, it was recorded that the man had previously been treated for deep vein thrombosis and had a history of alcohol dependence. He had also been prescribed medication for acute anxiety and pain relief. Although the man had previously tried to harm himself, the initial reception health screening record did not note that he should be referred for a mental health assessment. Additionally, a secondary health screen assessment did not take place as these are not routinely undertaken at Cardiff.

On 4 September, the man attempted to cut his throat. A self-harm observation and support regime was started but was stopped on 8 October, when the man appeared more accepting of his situation and the risk of self-harm was thought to have reduced.During the night of 18 October and the early morning of the following day, staff made visual checks of the man. However, they were not at the level of frequency set for prisoners in the healthcare centre and no further checks were made after 6.20am on 19 October. The man’s cell was unlocked just after 8.00am, but it was only several minutes later that fellow prisoners raised the alarm after finding him unresponsive. Paramedics attended the prison and confirmed at 8.50am that the man had died.

After the man died, the prison activated its death in custody contingency plan. The police visited the prison and found no suspicious circumstances. A post mortem examination was unable to confirm the cause of death. However, toxicology reports submitted to the Coroner after the post mortem confirmed that the man died as a result of the effects of dihydrocodeine (a prescribed pain relief medication) and tramadol (a pain relief medication that was not prescribed to the man). Letters were also later discovered, addressed to the man’s family and friends, which suggested that he intended to take his own life.

The former Governor of Cardiff was concerned about the actions taken by staff on 18

and 19 October. After viewing the closed circuit television (CCTV) footage of events

surrounding the man’s death, she commissioned an internal disciplinary

investigation. Following the investigation, two members of staff were officially

reprimanded.

The clinical review carried out by staff from Healthcare Inspectorate Wales (HIW),

considered the care provided for the man. In HIW’s view, the quality of care given to

the man was not equivalent to what he would have received in the community. HIW

makes five recommendations for service improvement. I understand that the prison

health partnership is considering the findings from the review and is developing an

action plan to address them.

4

I make three recommendations. HMP Cardiff should review the procedures relating

to observation checks of prisoners whilst they are in the healthcare centre. Staff

should be aware of trigger points for prisoners who are subject to self-harm and

suicide observation procedures. Additionally, when a healthcare cell door is

unlocked, the member of staff should interact with the prisoner to ensure that there

are no immediate medical issues that may need attention.

5

THE INVESTIGATION PROCESS

1. The investigation was opened on 21 October 2009 by one of the Ombudsman’s

investigators. Notices were subsequently issued to both staff and prisoners at

HMP Cardiff, informing them of the investigation process and giving the

opportunity to contact my investigator if they felt that they could provide any

relevant information. In the event no one came forward.

2. The investigator also studied all the relevant prison records relating to the

man. They included his main prison record and his medical records.

3. Staff from Healthcare Inspectorate Wales (HIW) reviewed the man’s clinical

care. The purpose of this review is to establish whether the care which he

received in prison was comparable with what he would have been offered in the

community. I am grateful to HIW for undertaking such a thorough review,

which was received on 18 November 2010.

4. The investigator and an Assistant Ombudsman visited HMP Cardiff on 10

November, 7 and 8 December and 1 February 2010. They discussed aspects

of the man’s treatment with staff and interviewed eight members of staff. The

investigator returned to Cardiff on 4 March, and met a prisoner who had been

in the healthcare centre.

5. After receiving the toxicology report, which suggested that the man died of an

overdose, South Wales Police began an enquiry into the care he received. The

officer leading the enquiry asked that my investigation be suspended until their

investigation, and any subsequent court proceedings, were concluded. In

return, the police agreed to share the information they gathered, including the

witness statements. The police investigation was closed in July 2010 when the

Ombudsman’s investigation resumed.

6. The investigator contacted Her Majesty’s Coroner to inform her of the nature

and scope of my investigation and to request a copy of the post mortem report.

Upon completion, this report will be sent to the Coroner to assist her enquiries

into the man’s death.

7. One of the Ombudsman’s Family Liaison Officers contacted the man’s mother

who was listed as his next of kin. She discussed the purpose of the

investigation and gave the man’s mother the opportunity to raise any concerns

or questions that the family wanted to be addressed. The investigator and

Family Liaison Officer later met the man’s mother. She mentioned that her son

had been close to three prisoners, one of whom was still in custody at Cardiff.

She also raised the following matters:

• Menacing correspondence received by the man from his dead partner’s

family.

• Why prisoners and not officers discovered that the man had died.

• What medication was being prescribed to the man, how this was

administered and what measures are in place to ensure that prisoners

are not able to stockpile their medication.

6

• The man’s appearance when he was found.

The investigator has addressed the issues raised by the family within the

report. I hope this helps them better understand the events leading up to the

man’s death. The solicitors representing the man’s family received a copy of

my draft report. They declined to raise any comments, on behalf of the man’s

family, in response to the findings, preferring instead to raise matters directly

with the Coroner at the inquest.

7

HMP CARDIFF

8. Cardiff prison is located very close to the city centre. Originally built in 1827, it

has undergone extensive refurbishment. The establishment is what is

commonly referred to as a local prison which generally means that it is used to

accommodate remand prisoners, although there are also a number of

sentenced prisoners.

Healthcare

9. In May 2008, the healthcare unit at Cardiff moved into a purpose built, 22 bed,

two storey building. It provides 24 hour nursing care and is commissioned by

Cardiff and Vale University NHS Health Board. All prisoners undergo a health

screening during the first night reception process upon arrival at Cardiff.

10. Mental health services are provided by an in-reach team and two registered

mental nurses. In addition there is an occupational therapist and a psychiatrist

who cover seven sessions each week. Two of the sessions provide tertiary

care for those who are assessed as a high risk. There is one full time doctor

and one part time doctor who are contracted to provide general practitioner

services. The doctors provide 13 sessions each week including Saturday

mornings. Out of hours doctor cover is provided by a local surgery.

11. Within Cardiff healthcare, there is a CCTV system with a number of video

cameras each capable of recording images on to a computer system. The

images can be played back as necessary and provide a detailed account of

movement along the majority but not all of the ground floor.

12. Additionally, although not connected to the man’s death, there are two specially

designed cells which are adjacent to each other. Both cells have a camera

which record images on to a video recording system. Whenever a prisoner is

deemed to be at high risk of suicide or self-harm, an officer sits outside the cell

and observes the prisoner. If there are two prisoners in the adjacent cells, then

two officers sit outside, each watching the prisoner who they are responsible

for. Unlike the normal cells, the doors are not solid and have vertical bars

instead. Covering the bars is a clear perspex sheet allowing observation into

the cell. The officers are seated directly opposite the cell door.

Care Team

13. Each prison has its own care team. Care team staff are drawn from all areas of

the prison and trained specifically to help and support prison staff. Following

any serious incident, they provide an invaluable role to any member of staff

who requires support.

Assessment, Care in Custody and Teamwork (ACCT) procedures

14. ACCT procedures are pivotal in the management of any prisoner thought to be

at risk of suicide or self-harm. The ACCT document is the principal tool for

assessing, monitoring and managing any prisoner through a period of crisis.

8

ACCT procedures can be initiated by any member of staff, irrespective of grade

or discipline. The ACCT form itself contains instructions and guidance for its

use.

15. If a member of staff has reason to believe that a prisoner is at risk of self-harm

or suicide, he or she must open an ACCT form immediately. The following

further actions must also be completed:

• A ‘Concern and Keep Safe’ form must be opened immediately. The

purpose of this form is to determine the main issues causing the prisoner

to be at risk of self-harm or suicide.

• An immediate action plan must be compiled within one hour of the ACCT

form being opened. The purpose of the immediate action plan is to

consider and record the most appropriate environment and regime

required to support the at-risk prisoner prior to the first case review. The

plan should be drawn up within an hour of the ACCT form being opened.

• An assessment interview must be conducted with the at-risk prisoner by a

trained assessor within 24 hours of the ACCT form being opened. The

purpose of this interview is to examine in depth the reasons behind the risk

posed by the prisoner. The details of the assessment then inform the

initial case review.

• An initial case review must be conducted within 24 hours of the ACCT

form being opened. The review panel must, in conjunction with the at-risk

prisoner, agree a care and management plan - or ‘caremap’ - setting out

goals or the prisoner to achieve, with the help of staff, in order to reduce

his risk.

• Thereafter, regular multi-disciplinary case reviews must be convened,

each involving the at-risk prisoner, so that his risk can be monitored and

his caremap updated.

16. The ACCT form can be closed once those involved in the prisoner’s care, as

well as the prisoner himself, are content that the risk has reduced to the point

where formal monitoring is no longer necessary. A post-closure review, once

again involving the prisoner and a multi-disciplinary panel, must be convened

within an appropriate interval.

Performance Rating

17. Prisons in England and Wales are assessed for performance by the National

Offender Management Service (NOMS). For public prisons, NOMS use a

combination of the Prison Performance Assessment Tool (PPAT, which looks

at 33 indicators) and the public prison weighted scorecard (which looks at a set

of 44 indicators). Each establishment is then given a rating between one and

four (one being “serious concerns” and four “exceptional performance”). For

the last four quarters, HMP Cardiff has been given a rating of three (or “good

performance”).

9

Independent Monitoring Board

18. Each prison has an Independent Monitoring Board (IMB). IMB members are

independent and unpaid. They monitor day-to-day life in their prison and

ensure that proper standards of care and decency are maintained. In the most

recent published annual report, covering the period from September 2008 to

August 2009, the IMB said they found Cardiff to be a well run establishment,

with good relationships between staff and prisoners. They also considered that

ACCT documents were being used appropriately to help prisoners who were

thought to be at risk of harming themselves.

19. The IMB report states that there: “are still concerns about prisoners with mental

health issues being held in the mainstream prison which is not designed to

meet their need”. The report added that the Board were aware of the financial

constraints which had affected both uniformed and administrative staff and

hoped that the effects would not be detrimental to the positive work being

carried out.

Her Majesty’s Chief Inspector of Prisons

20. In January 2008, Dame Anne Owers, the former Chief Inspector, carried out an

announced inspection of the prison. There was an unannounced short followup

inspection in July 2010, but the report of that inspection has not yet been

published. In the introduction to her 2008 report, Dame Anne said the prison

suffered from all the difficulties of an overcrowded and pressurised prison

system. She went on to say the prison was essentially safe and that prisoners

were more likely to report feeling safe than at other local prisons.

21. Of particular note, Dame Anne commented that:

“Anti-bullying procedures had improved since the last inspection, but it

was disappointing that the enthusiasm of the safer custody manager

had not communicated itself to those staff responsible on a day-to-day

basis for supporting those at risk of self-harm.”

22. Dame Anne found that not all staff had been trained in the use of the ACCT

procedures, and she recommended that training should be fully implemented.

Similarly, she recommended that all staff receive anti-bullying training. In

general, the quality of completed ACCT documents was good.

23. Dame Anne said that, overall, her report reflected the positive work being done

at Cardiff, in spite of the pressures and difficulties within the prison system.

She added that the prison’s strengths were its local links and ethos along with

the support it has been able to obtain from the Welsh statutory, private and

volunteer organisations.

Police investigations of deaths in custody

24. With all deaths in prison custody, the police are notified by the prison as soon

as the death is discovered. In the first instance, the police treat the area as a

10

potential crime scene and, as part of their investigation, note the names of

everyone involved and those who have been in contact with the body.

Additionally, they note the identity of all those entering and leaving the

cordoned area. It is only when the police are satisfied that the death is not

suspicious that the Ombudsman’s investigators are allowed to begin their own

investigation.

Previous investigations of deaths in custody

25. The investigator reviewed the Ombudsman’s reports for deaths at Cardiff.

While none of the circumstances of those investigations are similar to this,

previous recommendations have also mentioned that improvements should be

made to record keeping.

11

KEY EVENTS

26. The man was in 1969 in South Wales. On 21 August 2009, he was remanded

into custody by a local Magistrates’ Court for the murder of his partner. The

man arrived at HMP Cardiff on the same day. It was not the man’s first

experience of being in custody, but his previous convictions had only led to

short custodial sentences. Prior to coming into custody the man received state

benefits as he was unable to work due to ill health.

27. At the man’s first reception health screen interview, it was recorded that he had

a history of alcohol dependence and had been prescribed medication for acute

anxiety and pain relief. It was also recorded that he had been treated for deep

vein thrombosis and had used illicit drugs. The man was also a smoker. On

his arrival at Cardiff, the man provided details of his doctor and mentioned his

on-going health problems. Neither the HIW nor my investigator could find any

evidence of his medical records being requested or followed up.

28. During his first reception health screen, the man admitted that he had

attempted to harm himself in the past, although he said he had “no thoughts of

self-harm at present”. There was no record of the man being referred for a

mental health assessment despite being charged with murder1 and him

reporting that he had tried to previously harm himself.

29. Unlike most other prisons, Cardiff does not routinely undertake a secondary

health assessment within 72 hours of admission. This meant that further

opportunities for care planning and investigation of healthcare issues were

missed. (The secondary health screening is a general health assessment and

should be offered to every prisoner in the week following arrival in custody.

This assessment is equivalent to a primary care assessment when registering

with a doctor in the community. It provides an opportunity for gathering further

health information, health education and promotion and, importantly, checking

how a prisoner is settling in.)

30. Due to the nature of his offence, the man was initially admitted to the

healthcare centre for observation. On 26 August, the man moved to the

induction wing where he underwent a short alcohol detoxification programme.

31. The man was prescribed the following medication: propranol (for anxiety),

amytriptyline, mirtzapine and trazodone (for depression), carbamazepine (for

alcohol withdrawal), flucloxacillin (an antibiotic), zopiclone (for insomnia), and

gabapentin and dihydrocodeine (for pain relief). The medication was

dispensed to the man every day. My investigator was told by healthcare staff

how medication is administered. A prisoner is asked to get a drink and is then

given their medication which is taken in front of the member of staff.

1 Part 2 of the First Reception Health Screen form clearly states in bold capital letters: “If charged with

murder or manslaughter, refer for mental health assessment”.

12

32. During the period from 26 August until 4 September, the man complained to

staff of feeling nauseous and sweating. There was no evidence in the records

of medical observations being undertaken during this period.

33. The man was taken to Crown Court on 27 August and was due to return to

court on 6 November.

34. Around 6.00pm on 4 September, staff discovered the man lying on his bed

having cut both his wrists and his throat. The following entry was made by a

nurse at the prison in the man’s medical record:

“He told me that he was missing his partner (he is accused of her

murder), and that he hadn’t done a good enough job of killing himself

and that he would try again when he had the chance.”

35. A letter from the man to his mother was also found by staff. He wrote:

“Just a few lines to say I’m very sorry for what I’ve done. I can’t go on

without … [the man’s partner] mum I loved her more that I can imagine.

I don’t want to go on without her any more.”

36. The man was taken to the Accident and Emergency (A&E) department at a

local hospital. After his injuries were treated, the man was seen by a Specialist

Psychiatric Registrar. She wrote that in her view: “Incident of self-harm as a

reaction to the circumstances and consequences of the index offence. Risk of

further harm is high in view of this”.

37. The Specialist Psychiatric Registrar suggested that the man’s amytriptyline be

stopped, as it “can be serious in overdose if he secretes it”. The doctor agreed

the proposed plan with a consultant psychiatrist and that “meds [medicines] can

be continued if they can observe him/supervise meds”. The man returned to

the prison later that same night and was admitted to the healthcare centre.

38. As the man was identified as an ongoing suicide risk, an Assessment, Care in

Custody and Teamwork (ACCT) self-harm observation and support regime was

started at 6.35pm on 4 September.

39. As part of the ACCT process, an assessment interview was undertaken, on 5

September, by a member of the Safer Custody team at Cardiff. At section 3 of

the Record of Interview he noted that: “The man stated that he had no previous

incidents of self-harm in his life. The man had always been able to cope

without the use of self-harm”. At section 4 it was recorded that the man had

“no history of anxiety attacks, and no history of auditory or visual hallucinations.

States no problem with sleeping and eating a full diet”.

40. Following the interview it was recorded that the man was to “remain on

continuous observation level in healthcare, and to be further assessed by a

Safer Custody Manager and psychiatric services. Locate in camera/gated cell”.

The Action Following Assessment Form was completed at 9.50am on 5

September and noted that “the man is assessed high risk due to sentence”.

13

The need for an urgent referral to psychiatric services was also noted and the

date and time for the next review was set for 9.00am on 7 September. A care

and management plan (Caremap) was drawn up and four goals and related

actions were established. Each of the goals related to keeping The man safe

and the related actions were:

• Locate in a safe camera cell continuous watch in healthcare.

• Ensure cell staff are aware of the observation and interaction level

and the recording of these levels.

• Supervise shaving at all times. Remove all sharp objects including

cutlery when not in use.

• To be assessed by psychiatric services.

The Caremap makes no reference to the recommendation made by the

Specialist Psychiatric Registrar in respect of medication being continued under

supervision.

41. A care plan was also drawn up healthcare staff on 5 September and this

recorded the nursing action as follows:

• One to one over weekend.

• No sharp objects or in possession medication.

• Contact on call psychiatrist at the local hospital to come and assess

the man.

• Review safer custody.

• Establish therapeutic relationship.

• Allow time to ventilate feelings.

• Ensure any medications are given.

• Review with GP as soon as possible.

No reference is made in the care plan to cleaning or checking the man’s wounds.

The care plan was to be reviewed on 7 September but this did not take place.

There were no further reviews of the care plan or any additions or amendments

after 5 September.

42. At the first ACCT case review held on 7 September, it was recorded that the

man was still located in the healthcare centre under continuous observation2.

The following was written in the record of the case review:

“The man describes feeling more settled this morning, with mood being

stable, looking towards the future. The man has been in contact with

his mother by telephone over the past few days, which has made him

realise the effects this incident would have on family members. The

man now feels the self-harm was a silly act, which he now regrets. The

2Whenever a prisoner is deemed to be at high risk of suicide or self-harm, an officer sits outside the

cell and continually observes the prisoner. Unlike the normal cells, the doors are not solid and have

vertical bars instead. Covering the bars is a clear perspex sheet allowing observation into the cell.

The officers are seated directly opposite the cell door.

14

man continues to state the self-harm was offence related, and now has

to come to terms with this issue.”

43. During the review it was decided that as the man’s mood had improved, the

level of observations was to be reduced from continuous to intermittent (up to

four times an hour) level and that he was to stay in the healthcare centre for

further assessment.

44. At the second ACCT case review it was recorded that the man was in “good

spirits” and was coming to terms with what had happened to him. It was

recorded that:

“The man stated that it had all come on top at one time and it would

never happen again. The man expressed no thoughts, plans or intent

to perform any other acts of self-harm now or in the future.”

45. During the morning of 11 September, The man was taken back to hospital for

an outpatient appointment with a Consultant Oral and Maxillofacial Surgeon.

This was to review the wound to his neck. He returned to prison the same day.

In his letter dated 22 September, the consultant wrote:

“Sutures have now been removed and the wound is clean and healing

well. He has some loss of sensation in the region of the wound and in

light of this a review appointment in three months time has been

arranged.”

46. Around 9.15pm on 11 September, the following entry was made in the man’s

medical record: “requesting further medication states staff are ignoring him

because of his charge”. On the following day, 13 September, it was recorded

that the man was: “still complaining about his medication and that we re not

taking him seriously”. HIW is not clear from the records what the man’s exact

concerns were about his medication.

47. The man’s partner’s funeral took place on 15 September. He received

bereavement support from staff and a visit from the chaplain. The man was

also visited by his mother and brother. At his ACCT review the following day,

16 September, it was noted that the man was having a difficult day after the

funeral of his partner. A psychiatrist was not at the meeting and there was no

evidence that a psychiatric report was prepared or considered at the ACCT

review. The following was written in the record of case review:

“The man was tearful and remorseful at what he had done … the man

is now coming to terms with his situation and he has no further

thoughts of self-harm and his risk level has been reduced to low.”

48. During the evening of 16 September, it was recorded in the medical record that

the man had asked for medication to help him sleep. He was prescribed

zopiclone (a medication for insomnia) despite having slept well the night before.

15

49. The following entry was made in the medical record on 17 September:

“Demanding sleepers [sleeping tablets] again … Says he needs them due to

him feeling anxious. Advised to discuss with psychiatrist”. On the following

day, 18 September, it was recorded that the man was: “still demanding

sleepers and something to make me less anxious … Remains somewhat

belligerent but has not been aggressive”.

50. On 21 September, the man was seen by a consultant psychiatrist. However,

they did not seem to be made aware of his repeated requests for medication to

help him sleep. The following entry was also made in his medical record:

“Stating that was fine until approached by staff re[garding] possible

move back to F wing … received letter which he perceived to be

threatening (from family of wife) and this has worried him.”

51. During the afternoon of the following day, 22 September, the fourth ACCT case

review was held. It was recorded that the man felt that it was too early for him

to leave the healthcare centre as he would not feel safe and might harm

himself. He told staff about the threatening letter he had received and his risk

level was assessed as “raised”.

52. Despite his risk level being raised, the frequency of checks made on the man

after 22 September appear to have been ad-hoc with wide variation in the time

between checks. The timings also mirrored the checks made on the two days

prior to the risk level was assessed as being “raised”. For example, on the

following day, 23 September, it was recorded that checks were made at:

2.20am, 6.15am, 8.30am, 10.00am, 11.50am, 3.10pm, 5.40pm, 8.20pm

and11.40pm. On 22 September, checks were made at: 2.25am, 5.30am,

7.30am, 11.45am, 3.00pm, 6.00pm, 8.20pm and 11.30pm and, on 21

September, checks were made at: 2.40am, 6.00am, 7.30am, 9.00am, 12.00pm,

2.10pm, 6.30pm, 8.30pm and 11.30pm.

53. The man’s mental health and medication was reviewed by a consultant

psychiatrist on 23 September. The consultant noted the man’s history of

depression and suggested that he should be prescribed mirtzapine (a

medication used to treat depression) 15 milligrams initially to be increased to

30 milligrams. It was also noted that the man had received threats (the letter

mentioned above) and was concerned that he might be injured. The medical

record indicated that although the man had no plans to harm himself this “may

vary depending on events/other stresses”. It was also recorded that the man

could leave the healthcare centre and move to a wing in the main prison “when

the threats to harm him have been addressed”.

54. On 24 September, the man gave a urine sample for mandatory drug testing.

Three days later (on 27 September), the following entry was made in the man’s

record: “Settled day requesting a move to normal location as he feels he wants

to move on and attend education”. However, on the following day, 28

September, he was recorded as threatening to harm himself (deliberate selfharm

- DSH) if discharged from the healthcare centre.

16

55. The man told the prison doctor on 30 September that he was not happy to take

the increased dose of mirtzapine. The psychiatrist was advised and he saw the

man on the following day, 1 October. Following his consultation it was decided

to stop the mirtzapine and prescribe propranol (a beta blocker used to assist

with treatment of hypertension and anxiety) instead.

56. Around 9.15am on 6 October, the man was taken to the segregation unit. He

had failed the mandatory drug test two weeks before, and was taken there

pending an adjudication hearing3. The following entry was recorded in the

ACCT document: “Now located in [cell] P1-28 awaiting adjudication, seemed

relaxed and was quite talkative in route over from H/care [Healthcare]. Seems

fine”. At the adjudication it was decided that the man’s punishment of

confinement to his cell for seven days should be suspended. He returned to

the healthcare centre at around 10.15am that same day.

57. The ACCT document was closed on 8 October when the medical assessment

identified that the risk of self-harm had reduced and that the man had come to

terms with his situation. The post closure monitoring caremap required:

• The mainstay in the healthcare centre until at least 20 October.

• He should be observed four times a night.

• He should be provided with written information of the interventions or

contact points and how to access them.

The man was also seen by a consultant psychiatrist the same day. It was

recorded that he had “on-going problems since stopped amytriptyline” and his

mood was low. Trazodone (an anti-depressant) was prescribed and it was also

recorded that the man was “adamant that would not repeat act DSH/suicide”.

58. On 9 October, the man was again seen by a consultant psychiatrist and the

following entry was made in his medical record: “still to be considered a

suicidal risk ... still believes he is at risk from wife’s family because of letter he

has received and threats to his mother”.

59. The ACCT post closure review was conducted by a member of the Safer

Custody team on 15 October. The Safer Custody Manager at Cardiff saw the

man three days later, on 18 October. He wrote the following entry in the man’s

record:

“The man continues to describe himself as settled within health care…

The man is waiting to take part in the Christmas church play and

seems most motivated by this. The man states he has no thoughts of

self-harm, feels he is beyond this now.”

60. Around 9.00pm on 18 October, the CCTV recording shows a nurse dispensing

medication to the man which is confirmed by the treatment chart. The nurse

also made a visual check of the man at 10.04pm and 11.52pm that night and

3 Adjudication - An internal hearing into breaches of prison discipline caused by prisoners. It can also

be referred to as "being on a charge".

17

4.55am and 6.21am on 19 October. His colleague, an officer who was also

based on healthcare centre on the same shift, did not go near the man’s cell

during this period.

19 October 2009

61. When interviewed as part of this investigation, the nurse confirmed that there

are three levels of observation. Level 1 is constant watch, level 2 is high level

observations and level 3 is normal observations. The nurse said that he

believed that the man was on level 3 observations. However, when prisoners

are located in the healthcare centre the observation levels should be

intermittent. The nurse defined as this as prisoners being observed four times

an hour. When interviewed the nurse said:

“As far as I was concerned the man was on normal obs (observations)

… we do rounds three or four times an hour. In the course of doing the

rounds we had a couple of people on the inpatient facility who would

often tend to stop and have a chat. One person in particular who’s

noted for spending lots of time talking to staff and you know if you’re

doing a round you’re going to spend ten minutes talking to him which

obviously will knock the next check going round then back a little bit.”

62. When asked about issuing medication, the nurse said:

“I tend to take my time doing the medication round. So I tend to

actually have a chat to the ones I give medication to. My routine

basically is to give them medication first, watch them taking it and then

start talking to them so obviously if they’re going to palm4 it then its

much more difficult to do so but certainly I’d no concerns about the

man taking his medication. … I normally ask them to get a drink of

water first, get them to come perhaps with a drink of water. I put the

medication into a pot which then goes in their hand and they take it by

the hatch in front of me and then we can have a bit of a chat at the

same [time].”

63. The nurse confirmed that he had not seen any indication that the man intended

to take his own life. The nurse said:

“Certainly for the last couple of weeks [before his death] he appeared

to be quite bright and cheerful. He had come to terms with the

situation he was in. He was in for murder I believe. … Certainly in the

last two or three weeks that I’d been with [the man] he appeared to be

quite positive and as I said come to terms with the situation. There

was no obvious evidence of suicidal ideation with him to my knowledge

anyway.”

4 Palm – This is when a prisoner does not ingest/take their medication but instead hides it in their

hand or mouth. The medication can then be thrown away, stock piled or sold to other prisoners.

18

64. The CCTV footage showed that, at 7.39am on 19 October, two nurses

dispensed medication from the mobile trolley. It appeared that one of the

nurses gave medication to a number of prisoners, including the prisoner in the

cell next door to the man. At no time did any healthcare staff attempt to give

medication to the man or look into his cell.

65. However, according to a statement completed by of the nurses for the

Governor after the man’s death, at around 7.45am he opened the man’s

observation hatch in the cell door. The nurse wrote, in his statement, that as

the man appeared to be asleep he decided to administer his medication once

his cell was unlocked. The man’s treatment chart shows the morning dose of

prescribed medication appeared to be signed for by a member of staff. The

nurse’s written statement did not match the CCTV record which showed that,

after 6.21am, no member of prison staff checked the man or tried to give his

medication to him.

66. The CCTV recording shows that at 7.41am, cleaners and vulnerable prisoners5

were unlocked. Seven minutes later, the cleaners were seen putting cartons of

milk through the cell door hatches (including the man’s cell) which my

investigator has confirmed was the usual practice. At 8.06am, the vulnerable

prisoners went back to their cells and the other prisoners on the healthcare

centre were unlocked. An officer unlocked the man’s cell door but did not look

inside.

67. At around 8.13am, two prisoners in the healthcare centre, went into the man’s

cell but were unable to obtain a response from the man. They immediately

informed staff that they thought that the man was dead. In his statement to the

police, one of the prisoners said:

“As I got closer, I saw what appeared to be sick on the pillow next to

the man’s mouth area. At this point I thought something might be

wrong with the man. I then approached the man closer and touched

his left arm, which was furthest from the mattress. His arm felt cold

and his skin tone appeared to be grey. At this point I did suspect he

was dead.”

68. The Inpatient Manager and a Health Care Assistant (HCA) went to the man’s

cell. They found the man lying on his right hand side on his bed. In her written

statement completed soon after the death, the HCA wrote:

“I observed the inmate lying on his bed. He was lying on his side

facing the wall. He was covered with a blanket with his shoulders

exposed. A small amount of blood was visible on his pillow. Both

myself and [the Inpatient Manager] checked for radial and brachial

pulse [pulses found at the wrist and elbow respectively] but this was

absent upon touching I noted that his skin was cold and he was rigid.”

5 Vulnerable prisoners - Prisoners who are separated from the general population of the prison. This

can be due to a number of reasons including: the nature of their offence, publicity surrounding their

case and trouble coping with being in prison.

19

69. When interviewed for this investigation, the Inpatient Manager said:

“I actually called the man, I called his name to see if he was asleep.

Because he looked as though he was fast asleep, the covers were over

him, he was lying on his right side, he looked like he was just asleep. I

called him, there was nothing, no answer. I went around to him and I

went to sort of like shake his shoulder like … you are waking

somebody up and I called his name. But as soon as I touched him he

was ice, it was very icy and as I sort of put my hand on him it was like

his whole body moved, it wasn’t [just] his shoulder, he was very rigid. I

looked over, he was very sort of mottled, his eyes were closed. There

was blood and that, only a little bit but it was around his nose and

mouth. I checked for a pulse in the neck and on his wrist. There was

nothing at all, he was so cold.”

70. When staff discovered that the man had died they summoned immediate

assistance by using an emergency alarm bell rather than using the prison radio

system or telephone. An ambulance was called at 8.31am. The paramedic

arrived at the cell shortly afterwards and pronounced at 8.50am that the man

was dead.

71. Other prisoners were immediately told of the death and they were also asked

whether they required anything or wanted to speak to a Listener. (Listeners are

trained by Samaritans to provide confidential emotional support to fellow

prisoners in distress.) All the prisoners who were on ACCT monitoring were

reviewed.

72. The head of Safer Custody, a Chaplain and the Deputy Governor told the

man’s mother of his death later that morning at around 11.00am. A member of

staff from the Safer Custody Team was appointed as the prison’s family liaison

officer. He kept in contact with the family and assisted with the funeral

arrangements. Cardiff also offered financial assistance with the costs of the

funeral. The man’s funeral took place on 29 October and the service was

conducted by the Chaplain. The man’s mother later told my family liaison

officer that she had appreciated the help and support she received from prison

staff in the period following her son’s death.

73. After a death, prison managers must hold a “hot debrief”. This is a meeting of

all the staff who were involved in finding and attempting to resuscitate the

prisoner. The meeting should focus on reassurance, information sharing and

how staff can support each other. After he returned from visiting the man’s

family, the Deputy Governor held a hot debrief in the early afternoon of 19

October. It is not clear who attended as some staff were still being interviewed

by the police at that time. During the meeting it was thought that the man might

have died of natural causes but that this would need to be confirmed by the

Coroner. The only areas of concern raised at that time were the importance of

preserving evidence in the cell for the police and the use of the emergency

alarm bell to summon assistance.

20

74. After the man’s death, letters to his mother and a friend were found in the

internal postal system. In the man’s letter to his friend he wrote:

“I’ve got things in place. I just want you and … to be my bearers, and

pop up to see my mum every so often like you promised my friend. I’ve

even got the music sorted …, you know me … I like to be organised.”

75. In the man’s letter to his mother he wrote:

“I’m sorry about everything mum I’ve really put you through the mill

haven’t I. This is the last time mum no more crap off me anymore.

Just get through this and its all plain sailing, don’t worry about me

cause I’ll be up there with [his partner] and my dad. I had to do it mum

couldn’t go on anymore without her.”

76. The man’s mother and brother visited the prison on 11 November to visit his

cell. His belongings were handed to the family before they left.

77. Due to concerns raised by the Head of Safer Custody about the checks on

prisoners not being carried out correctly by staff in the healthcare centre and

the fact that nurse’s statement did not match the CCTV record, the former

Governor of HMP Cardiff decided, after discussing the issues with my

investigator, to commission an internal disciplinary investigation. It was

conducted by a Governor from HMP Usk. Following the internal investigation,

disciplinary action was taken against two members of staff.

78. The post mortem examination was unable to establish the cause of death. The

interpretation of a subsequent toxicology report, dated 25 November 2009,

suggests that the concentrations of tramadol (a pain relief medication, 7.52

milligrams per litre) and dihydrocodeine (10.6mg/L) were high and consistent

with a recent overdose of the drugs. (Therapeutic concentrations of tramadol

are usually less than 1 mg/L and deaths attributed to the drug are normally

associated with concentrations of greater than 6mg/L. Deaths attributed to

dihydrocodeine alone are typically associated with concentrations greater than

2-3 mg.)

79. The man had only been prescribed dihydrocodeine. Only one other prisoner on

the healthcare centre was prescribed tramadol. He was later interviewed by a

detective from South Wales Police but stated that he had not given his

medication to the man. Neither the detective nor the investigator were able

establish the source of the non-prescribed medication. The inquest into the

man’s death was completed on 10 May 2011. The jury concluded their

narrative verdict with the following comment:

”The man was intent on taking his own life. Full adherence to prison

policies and protocols may not have prevented him from doing so.

However, in this instance, failure to follow the procedures and protocols

reduced the likelihood of preventing the man from taking his own life.”

21

ISSUES

Concerns raised by the man’s family

80. As mentioned earlier in the report, the man’s mother met the investigator and

the family liaison officer. The family gave them a letter sent to the man dated

15 September (the date of his partner’s funeral). The letter was allegedly from

the man’s partner’s father, and consisted entirely of a lyric from the song

“Sympathy for the Devil”.

81. The man’s family wondered whether the implied threat in this letter was noted

by staff when checking correspondence. They wondered whether the issue

was discussed with the man when he received the letter. The family also

wanted to know how the sender was able to address the letter using the man’s

prison number.

82. The man told staff in the healthcare centre about the letter, and he also

mentioned it at his ACCT review meetings. The following entry was written in

the man’s medical record on 21 September: “… received letter which he

perceived to be threatening (from family of wife) and this has worried him”. The

man raised the issue of risk of retribution again when he saw the Head of Safer

Custody on 18 October. The Head of Safer Custody intended to ensure that

this issue was considered when the man moved from the healthcare centre to

normal location.

83. I conclude that action was being taken to deal with the letter and the implied

threat therein, as part of the decision making process about where the man

would be located in the prison. However, it is not clear how the letter came to

be addressed to the man with his prison number. The investigator was unable

to find a satisfactory response to this question.

84. The family were also concerned that a prisoner, and not a member of prison

staff, discovered that the man had died. The investigator informed the family

that the Governor of HMP Cardiff shared these concerns and had

commissioned an internal investigation of the actions taken by staff. The

investigator also agreed to clarify the sequence of events on 18 and 19

October.

85. When interviewed as part of this investigation, the nurse declined to comment

on the discrepancy between his statement to the Governor and the CCTV

footage.

86. I consider that the observation procedures employed by staff in the healthcare

centre at Cardiff were poor. The man was not checked as frequently as

required for a prisoner located in the healthcare centre (intermittent, which is

described as four times an hour). He was only checked four times by a nurse

during the period from 8.00pm on 18 October and 6.30am on 19 October. No

checks were made by his colleague. The man was also not checked after

6.30am on 19 October. The nurses on duty the next morning did not issue any

medication to the man. Although it was suggested in a written statement that

22

this was because he was asleep, the CCTV record clearly shows that the

nurses did not go near the man’s cell. The officer who unlocked the man’s door

but did not interact with him and therefore did not realise he had passed away.

87. According to the records it would appear that the nurse did not carry out the

actions described in his statement to the Governor. I am pleased that an

internal disciplinary investigation was carried out and that action has been

taken to review the procedures for observing prisoners in the healthcare centre.

I am content that the matter has been dealt with and the issues raised were

addressed promptly.

88. As mentioned previously, after the man’s cell was unlocked, it was not

discovered that he had died until two prisoners raised the alarm. I find this

unsatisfactory. Checks on the man had failed to take place as they should

have done and, when found, he appeared to have been dead for some time.

89. Whilst I could find no written requirement in Cardiff’s local roll check procedures

that staff should check prisoners for signs of life when they unlock the cell, I

believe that they should ensure the wellbeing of prisoners when they do so. I

recognise that, in this case, the man was already dead and such a check would

not have altered the outcome. However, by not checking his wellbeing, a dead

man was left in an open cell unattended for nearly ten minutes. Had the two

prisoners not gone in and found the man, it is possible this would have been

much longer. This is clearly unacceptable. The Prison Officer Entry Level

Training (POELT) manual states:

“Prior to unlock, staff should physically check the presence of the

occupants in every cell. You must ensure that you receive a positive

response from them by knocking on the door and await a gesture of

acknowledgement. If you fail to get a response you may need to open

the cell to check. The purpose of this check is to confirm that the

prisoner has not escaped, is ill or dead.”

From the interviews and CCTV footage, it is clear that this procedure was not

followed.

The Governor of HMP Cardiff should review the procedures for unlocking

prisoners and ensure that when a cell door is unlocked the member of

staff interacts with the prisoner to ensure that there are no immediate

issues that may need attention.

90. As mentioned previously, when it was discovered that the man had passed

away, staff used an emergency alarm bell instead of using the prison radio

system. Following the hot debrief and information discussed at interview I

believe that this matter has now been resolved internally at Cardiff.

Clinical care

91. As noted, a review of the man’s medical care was undertaken by staff from

Healthcare Inspectorate Wales (HIW).

23

92. The review found that many aspects of the care provided to the man had been

“questionable and flawed”. As mentioned previously, opportunities were

missed which could have helped to identify his risk of self-harm and to ensure

more timely care and treatment. Following his first self-harm attempt on 4

September, ACCT procedures were put in place. However, HIW judges that

the man’s care appeared to have been “fragmented” and that there “was a lack

of care planning by healthcare staff and inconsistent nursing input”.

93. Despite the man confirming that he had taken a drug overdose in the past and

that he suffered from anxiety, he was not referred to the mental health team for

assessment following his admission to Cardiff. The man was on remand for the

murder of his partner and this made a referral for a mental health assessment

all the more important (Page 2 of the First Reception Health Screen form

clearly states in bold and capital letters: “If charged with murder or

manslaughter, refer for mental health assessment”). HIW believes that had

appropriate, and required, action been taken, and the man referred for a mental

health assessment, his first suicide attempt might have been averted.

The Head of Healthcare at HMP Cardiff should make sure that regular

audits are undertaken of key documents such as the First Reception

Health Screen form to ensure that they are being completed correctly.

Such reviews are important in relation to highlighting gaps and

identifying related training needs.

94. HIW also notes that, on arrival at Cardiff, the mansard that he had various

health problems, including alcohol misuse and acute anxiety. However, no

record has been found that this was confirmed with his community doctor, or

that his medical records were ever requested.

The Head of Healthcare at HMP Cardiff should put mechanisms in place

to ensure that all available information about the medical and mental

health history of a prisoner is obtained.

95. Her Majesty’s Chief Inspector of Prisons (HMCIP) ‘Expectations’ document6,

against which it assesses prisons in England and Wales, expects that prisons

will undertake a second healthcare assessment within 72 hours of admission.

Such assessments provide an opportunity for a more detailed assessment of

healthcare issues and needs. Cardiff does not undertake second assessments

as a matter of routine and neither the staff from HIW nor my investigator found

any evidence of the man being offered such an assessment.

The Head of Healthcare at HMP Cardiff should ensure that secondary

healthcare assessments are made part of the routine procedures for

prison admission. These assessments should include a full medical

assessment with urine and bloods being screened.

6 HMCIP, ‘Expectations: Criteria for assessing the conditions in prisons and the treatment of

prisoners’, 2009., Section 4, Expectation 28

24

96. As mentioned previously, the man was put onto a detoxification programme

after he arrived at Cardiff. However, there was no evidence of a care plan

being put in place or of general observations being undertaken prior to his

attempt to harm himself on 4 September. The man had complained to the

prison doctor on 26 August of nausea and sweating but routine clinical

observations were not started. He moved from the healthcare centre to normal

location on the same day but no rationale was set out in the records provided to

the investigator and HIW.

Assessment Care in Custody and Teamwork

97. Following his first self-harm attempt, an on going record of significant events,

conversations and observations was put in place and ACCT review meetings

were held. A Caremap, which was initially completed on 5 September, was

developed and updated in a timely manner following each ACCT review

meeting. An urgent referral to psychiatric services was also made. However,

the clinical review highlights a number of anomalies that led HIW to believe that

the ACCT process and psychiatric support were not effectively linked.

98. The psychiatrist who assessed the man immediately following his self-harm

attempt on 4 September, stated in his report that he should no longer take

amitryptyline as it “can be serious in overdose if he secrets it”. The

psychiatrist also stated that “meds can be continued if they can observe

him/supervise meds”. While the medication was stopped immediately, there is

no reference in the man’s medical records for the need to observe or supervise

him when he was taking his medication.

99. Some of the information documented as part of the first ACCT review interview

does not accord with information already gathered about the man’s history from

the First Reception Health Screen and the psychiatric assessment undertaken

on 4 September. Specifically, the interview note records that:

“The man stated that he had no previous incidents of self-harm in his

life” and that the man had “No history of anxiety … attacks … States no

problems with sleeping.”

100. The man’s medical records provide very little evidence of nursing observations

and care. HIW are surprised by this given that the man’s amitriptyline had

been stopped immediately after his hospital admission and side effects due to

withdrawal from this medication should have been expected. Under normal

circumstances, patients are weaned slowly off medication such as

amytriptyline.

101. The care plan was not amended or added to after it was drawn up on the 5

September. This is in contrast to the Caremap which was updated immediately

after each ACCT review. It is important that when a prisoner has more than

one need, for example detoxification and self-harm, that complementary care

plans are in place. The Caremap cannot and should not replace the need for a

care plan which should cover the health needs of the patient in greater detail.

25

The Head of Healthcare at HMP Cardiff should ensure that care plans are

in place for those prisoners with on-going health problems to ensure that

holistic care is provided.

102. The Safer Custody Team at Cardiff manages all Assessment, Care in Custody

and Teamwork (ACCT) cases. Members of the team review prisoners and,

when ACCTs are closed, they closely monitor the prisoner to ensure that they

remain actively supported. However, the recommendations made at ACCT

reviews regarding the level and frequency of observations do not appear to

have been complied with. The psychiatrist did not attend all ACCT reviews and

it is unclear to whether discussions were always supported by an up to date

psychiatric assessment.

103. A number of records completed between 11 and 14 September refer to the fact

that the man was complaining about his medication and was unable to settle.

No consideration was given to the fact that the man may have been suffering

from symptoms of withdrawal from amitriptyline. A note of a ward round

assessment undertaken by the psychiatrist on 14 September indicated that he

was not appear to have been made aware of the man’s request for “sleepers”

and unhappiness with his medication. It is understandable that there should be

concern over the man’s repeated request for medication to help him sleep.

However, staff did not appear to have been aware or sensitive to the fact that

the man’s partner’s funeral was due to take place on 15 September and

refused to give him medication on the proceeding evening. There is no record

that alternative discussion/counselling was provided.

104. It is important that trigger points are recorded on ACCT documents. The use of

ACCT is covered in Prison Service Order (PSO) 2700, “Suicide and Self Harm”.

At section 4.10.1, it is noted that people accused of homicide are at particular

risk of harming themselves, and those accused of homicide of a family member

or domestic partner present “an exceptional risk of suicide”. The PSO states

that “Care of such prisoners will require close monitoring of trigger points, for

example during any trial or around key anniversaries”. The funeral of the victim

should be considered as such a trigger point, and the information shared

among staff. The man’s request for medication around the time of the funeral

should have alerted staff to a heightened risk, which should have been

recorded on the ACCT document.

The Governor of HMP Cardiff should ensure that trigger points are

accurately recorded on ACCT documents, and that staff are aware of the

increased risk that can occur at these points.

105. At the third ACCT review it was decided to reduce the man’s risk of self-harm to

“low” and allow him to move out of the healthcare centre. However, a

psychiatrist was not at the meeting and there was no evidence of a psychiatric

report being prepared and considered at the ACCT review. Despite the man’s

risk level being assessed as “raised” at the fourth ACCT review, the frequency

of checks after 22 September appear to have been ad-hoc, with wide variation

in the time between checks.

26

106. On 8 October, the fifth and final ACCT review took place, and the monitoring

procedures were closed. The man’s risk was assessed as “low” and he was to

remain in the healthcare centre until at least 20 October. Observation levels

were reduced to four times a day and night. However, it was noted that

healthcare normal observation levels were intermittent (defined as up to four

times an hour). The caremap was amended to reflect the decision to close the

ACCT and an initial post closure review date was set for 15 October. A

psychiatrist was not at the review meeting and again there was no evidence of

a psychiatric report being made available for discussion and consideration.

The last psychiatric assessment was undertaken on 1 October, when the man’s

medication was changed.

107. Staff continued to support the man after the ACCT was closed to ensure that

he did not have further concerns. He was engaging with staff and making

arrangements to be involved in the Christmas play. There were no indications

that he intended to harm himself. Therefore, staff were very surprised when

they discovered that he died and initially thought that his death was natural

causes. It was only after the discovery of the letters he had attempted to post

to his friend and mother that it was thought that he may have taken his own life.

108. However, according to the medical records in the days leading up to his death,

the man’s behaviour appears to have become more difficult and he was

reported as agitated, surly and uncooperative. No consideration appears to

have been given to the fact that he may have been exhibiting signs of

withdrawal from mirtzapine or other medication. The reviewer suggests that

the man may have been exhibiting signs of withdrawal from dihydrocodeine.

The concentration of this drug was 10.6mg/L in the post mortem femoral blood.

Fatalities attributed to dihydrocodeine are typically associated with blood

concentrations greater than 2-3mg/L.

109. The clinical reviewer at HIW concludes that important medical information was

not always shared and that psychiatric reports were not always available at

ACCT reviews. HIW considers: “the level of nursing input to be wanting” and

that “the man’s complaints about his medication were not taken seriously

enough by healthcare staff”. HIW does not think that staff properly escalated

concerns about the man’s constant requests for sedatives and the issues that

intermittently arose about his behaviour. Links between the man’s behaviour,

changes to his medication and possible anxiety and depression do not appear

to have been made.

110. HIW also drew attention to the lack of a referral for mental health assessment

upon the man’s admission to HMP Cardiff and that the warning given by the

specialist psychiatric registrar (on 4 September) appears to have gone unheeded.

The registrar clearly identified a risk of the man secreting his

medication and therefore recommended that he was observed while taking his

medication. While it is clear that the man was given his medication it is not

clear whether he was observed taking it. Although he had taken an overdose

of tramadol, which he obtained from an unknown source, the clinical review

states: “… we should not let this issue divert us from the fact that the amount

27

of dihydrocodeine in his femoral blood indicates that he would have died from

the amount of this medication alone”.

The Head of Healthcare at HMP Cardiff should ensure that appropriate

safeguards are in place when medicines are given to prisoners.

111. HIW also states that the Head of Healthcare has a key role to play in ensuring

the provision of good healthcare to prisoners at HMP Cardiff. HIW states that it

is the responsibility of the Head of Healthcare to:

“… to know the strengths and weaknesses of all her staff, to ensure

established processes and requirements are complied with and to

know on a daily basis the challenges staff are facing with regard to

individual patients.”

The Head of Healthcare at HMP Cardiff should undertake a full review of

the systems and processes in place for care planning, undertaking

observations and the recording and escalation of concerns. The Head

of Healthcare should also be required to demonstrate how she ensures

that staff are properly trained, appraised and supported.

28

CONCLUSION

112. The man arrived at HMP Cardiff on 21 August 2009 after being charged with

the murder of his partner. Two weeks later he attempted to take his own life

and was subsequently placed on an ACCT self-harm monitoring regime. This

was closed on 8 October when the risk of harm had appeared to have reduced.

On morning of 19 October, The man was discovered dead in his bed in the

healthcare centre at Cardiff.

113. In light of the findings of my investigation and the clinical review, I conclude that

the care provided to the man was not appropriate. Observation checks were

not carried out, which led to the discovery of the man’s death a number of

hours after he had died. The systems for the issuing of medication were not

robust. Some healthcare staff did not ensure that the opportunity to hoard

medication was minimised. A poor approach to this procedure, where

prisoners were not observed taking their medication, created an environment

where medication could be retained. The medication could then be hoarded to

be sold on to other prisoners or to be used in attempts of self-harm. I am

disappointed that some healthcare staff adopted this approach and hope that

the issuing of medication procedures is reviewed in light of this poor behaviour.

I make eight recommendations.

29

RECOMMENDATIONS

1. The Governor of HMP Cardiff should review the procedures for unlocking

prisoners and ensure that when a cell door is unlocked the member of staff

interacts with the prisoner to ensure that there are no immediate issues that may

need attention.

Accepted - The Local Security Strategy (LSS) point 8.02 has been amended to

instruct staff to obtain a response from prisoners when carrying out roll checks.

2. The Head of Healthcare at HMP Cardiff should make sure that regular audits are

undertaken of key documents such as the First Reception Health Screen form to

ensure that they are being completed correctly. Such reviews are important in

relation to highlighting gaps and identifying related training needs.

Accepted - Bi-monthly audits will be completed by the Practice Manager to

ensure the first reception screen form is being completed correctly. Any training

needs will be identified and addressed.

3. The Head of Healthcare at HMP Cardiff should ensure that all available

information about the medical and mental health history of a prisoner is obtained.

Accepted - The Head of Healthcare will ensure that systems are in place to

obtain all available information about the medical and mental history of a

prisoner, particularly in complex cases.

4. The Head of Healthcare at HMP Cardiff should ensure that secondary healthcare

assessments are made part of the routine procedures for prison admission.

These assessments should include a full medical assessment with urine and

bloods being screened.

Accepted - All prisoners to be offered a secondary health assessment and this

includes assessment of their physical and mental health needs. Bi-monthly

audits will be carried out to ensure this practice is in place.

5. The Head of Healthcare at HMP Cardiff should ensure that care plans are in

place for those prisoners with on-going health problems to ensure that holistic

care is provided.

Accepted - Bi monthly audits will be carried out by the in patient manager to

ensure care plans identify patient needs. The audit will monitor that the care

plans are holistic and are evaluated regularly.

6. The Governor should ensure that trigger points are accurately recorded on ACCT

documents, and that staff are aware of the increased risk that can occur at these

points.

Accepted - A Governor’s Order to be issued to remind staff of the importance of

including trigger points on ACCT documents. (Particularly ACCT Assessors and

30

case managers). Wing managers should remind staff during morning briefings,

prior to unlock of important trigger points.

7. The Head of Healthcare at HMP Cardiff should ensure that appropriate

safeguards are in place when medicines are given to prisoners.

Accepted - Administration of medication will be carried out in line with the MMC

Administration of Medicines Policy. The In-Patient Manager will carry out bimonthly

audits to monitor compliance.

8. The Head of Healthcare at HMP Cardiff should undertake a full review of the

systems and processes in place for care planning, undertaking observations and

the recording and escalation of concerns. The Head of Healthcare should also

be required to demonstrate how she ensures that staff are properly trained,

appraised and supported.

Accepted - A full review of systems and processes for care planning, undertaking

observations and the recording and escalation of concerns will take place by the

Head of Healthcare, supported by the In-Patient Manager, Pharmacy Lead,

Mental Health Lead and Head of Safer Custody. All Staff will receive a

comprehensive induction. All staff will have an appraisal which is reviewed and

identify any training needs. This will be audited by the performance team biannually.

Clinical supervision will be made available to staff.

BRILLIANT, BRILLIANT, BRILLIANT, Cat Lady!!!

Maurice said the website really makes a difference! He gets somewhat special treatment as only 'high up officers' are supposed to talk to him now...

All in all, he feels like 'mission accomplished'.

Let's hope we'll see him OUTSIDE soon - and not too damaged as a consequence of having been assaulted and not getting medical treatment (just like Melissa, I'm afraid...)

If Kirk gets out and runs with that Marxist *** - yet again - good bye.

Bouncing off of Cat Lady eh Sabine - maybe she's one of your 'created' for a purpose pseudo attack dogs - seeing how your other attack dogs have all been silenced of recent!!!

You and your Sisterhood of friends - eh Sabine.

Maurice has ALWAYS been promoting himself the cause of 'litigants in person' and thus supported many others as McKenzie Friend.

These are the two common denominators for my 'cross-issue linking', Cat Lady.

It is a known and recorded fact on the web 'that has a memory' Sabine - that Victims - "amuse" you while your real priorities and interests lie elsewhere.

How telling a comment was that some years ago?

And by the way aren't you also noted and timelocked on the web thingy to be adept at 'attaching' yourselfie [pics of you inc] to many other people's good causes and cases in order to big yourselfie up ... [many of them having suffered further detriments] and to lead others away from 'matters' which governments don't like to address?

The term 'McKenzie Friend' and those who 'still use it' in respect of helping others in court is a worn out term. McKenzie Friends who know little if nothing about the true tricks being played out in court system are as useful as chocolate teapots.

Good points Whistleblower. I have spent a lot of time reading Maurice’s blog, yet I can’t once find a reference to him acting as a McKenzie friend.

I do however wonder if Sabine’s claims are perhaps very clever – such claims would remove from Maurice the future choice for him to use someone as a Mckenzie friend.

I base that reasoning on the conditions described within the practice guidelines set down by Lord Neuberger of Abbotsbury, Master of the Rolls  and Sir Nicholas Wall, President of the Family Division (12 July 2010).

courtwithoutalawyer.co.uk/mckenzie%20friends%20practice%20guidance%202010.pdf

It would seem that a strong argument for a Judge not allowing support for someone via a “Mckenzie friend” would be that the person is competent to act for themselves if acting as a “Litigant in Person”

To quote the practice guidance:

13) A litigant may be denied the assistance of a MF because its provision

might undermine or has undermined the efficient administration of

justice. Examples of circumstances where this might arise are: i) the

assistance is being provided for an improper purpose; ii) the assistance is

unreasonable in nature or degree; iii) the MF is subject to a civil

proceedings order or a civil restraint order; iv) the MF is using the litigant

as a puppet; v) the MF is directly or indirectly conducting the litigation; vi)

the court is not satisfied that the MF fully understands the duty of

confidentiality.  

A strong argument against Maurice being allowed a McKenzie friend to assist him in Court would seemingly be that “Maurice has helped others as a McKenzie Friend in Court” and is therefore at such a level of understanding that such a “Friend” is not necessary to allow the hearing to proceed fairly.

Sabine – you push the services of McKenzie Friends, may I ask how many times you have yourself acted as one in a Court Room?  Your numerous websites and blogs remain silent on that. Yet on one of your blogs you state how you were excluded from helping someone on the grounds that you do not understand confidentiality.

mckenzie-friends.co.uk/.../learning-by-doing-how-to-assist-litigants-in-person-as-mckenzie-friend-a-lesson-for-us-and-the-courts

I quote below:

“LEARNING by DOING: how to assist Litigants in Person as McKenzie Friend – a lesson for us and the Courts

This is the Practice Guidance that shows that I should NOT have been kicked out of Lincoln County Court yesterday.

Our introduction letters got us in as McKenzie Friends, but we didn’t get ‘right of audience’. As ‘web publisher’, I knew I wouldn’t, for I was told once before that - You don’t understand confidentiality”

Pray explain Sabine – why would a McKenzie Friend need “rights of audience” rather than the simple right to provide assistance to a defendant in the agreed way of a McKenzie Friend? It rather implies that you wanted to present the case as a "lawyer" yet went there knowing that you had little chance of being allowed to even help as a McKenzie Friend due to your past track record.

WHY PUT THE DEFENDANT THROUGH THAT? Surely it increased the defendants stress level beyond belief.

My own thoughts are that rather than wanting to help the defendant you aimed to seek publicity for yourself.

I feel that is also (but in a very clever way) what you are trying to do with respect to Maurice – and all at Maurice’s expense.

I could not help but notice this letter on one of your websites. The content is of assistance to Maurice:

From: Hunter, Patrick [NOMS]

29 May 2012

Dear Ms McNeill

Thank you for your further email of 1 May concerning the above subject.

With regard your comments on the treatment of remand prisoners, under

British and International law imprisonment of defendants on remand should

not deprive them of any normal rights and freedoms as citizens, except

where this is an inevitable consequence of imprisonment of the courts

reason for ordering their detention and to ensure the good order of the

prison.  Unconvicted prisoners therefore enjoy certain rights and

privileges that are not available to convicted prisoners.

Those held in custody but not convicted should not be deprived of any of

their rights, except where this is an inevitable consequence of

imprisonment.  Any limitations on their activities should be only the

minimum necessary in the interests of security, efficient administration,

good order and discipline, and the welfare and safety of all prisoners.

As far as possible remand prisoners are kept separate from convicted

prisoners, and are entitled to a number of rights and privileges, subject

to security and operational needs, including wearing their own clothing,

buying extra reading and writing material, and not being required to work

unless they wish to.  They may receive as many letters as they wish and

are also entitled to send out two free (Statutory) letters at public

expense each week and may continue to carry out business activities.  They

may also be attended by their own doctor or dentist, at their own

expense.  However, with regard their access to and the use of the PINphone

system they are treated in the same way as convicted prisoners and there

are no special provisions provided.

In respect of the way remand prisoners are treated in other countries such

as Germany, this is not a matter for me or my Unit to comment on but

should you wish to pursue this point I would suggest that you contact

officials within the Justice Policy Group of the Ministry of Justice.

Regards

Patrick Hunter

Offender Safety, Rights and Responsibilities Group

National Offender Management Service

Post Point 4.16, 4th Floor,

Clive House

70 Petty France

London

SW1H 9EX

Tele: 0300 047 5718

Call from MK this morning Sun 15 Dec. 2013. See:

butlincat.wordpress.com/.../from-maurice-kirk-14-dec-13

It turns out that during the farcical court hearing on Tuesday 10 Dec. 13, when MK was denied his legal paoers for the hearing, and so much more, the "learned judge" had a transcript of the recording from the 7 cctv cameras located at the scene in front of him all the time.

Good to hear that Maurice is making a bail application.

I have known and seen Maurice act as McKenzie Friend for the Musas.

I have acted as McKenzie Friend and web publisher for Maurice, ever since his emails were blocked from Cardiff courts and I submitted documents on his behalf. His authorisation dates 25 October 2010.

There are a million and one ways of 'assisting' as McKenzie Friend. Visiting him (and others) in prison is one of them. Not only in writing and signing documents. Go to victims-unite.net/our-cases-as-stories and you'll find lots of 'veteran victims' who have helped each other. Maurice as no. 23: victims-unite.net/our-cases-as-storiesviolent-physical-attacks/maurice-kirk/

I came in late. You may also visit the video where Maurice, Norman and whistleblower came to my meeting at the House of Lords. edm1297.info/.../tackling-the-serious-oppression-of-hm-subjects

I do wish you could turn your suspicion / negativity into trust / positivity. If not, it can't be helped.

Sabine - I will take the definition of a "McKenzie Friend" as per the definition stated in the CPR.

It is widely held as:

Part I – Reasonable assistance from a McKenzie Friend

2) There is a presumption in favour of permitting a personal litigant to have reasonable assistance from a layperson, sometimes called a McKenzie Friend,. Personal litigants assisted by McKenzie Friends remain litigants-in-person. McKenzie Friends have no independent right to provide assistance. They have no right to act as advocates or to carry out the conduct of litigation. In McA v McA [2006] 10 BNIL 63[2], Master Redpath held that a McKenzie Friend may be allowed a right of audience in very exceptional circumstances.

What McKenzie Friends may do

3) McKenzie Friends may:

i) provide moral support for personal litigants;

ii) take notes with the permission of the judge;

iii) help with case papers;

iii) quietly give advice on any aspect of the conduct of the case which is being heard.

What McKenzie Friends may not do

4) McKenzie Friends may not:

i) Conduct the litigation, acting as the personal litigant’s agent in relation to the proceedings;

ii) Manage the personal litigant’s cases outside court, for example by signing court documents; or

iii) Exercise a right of audience by addressing the court, making oral submissions or examining witnesses unless this has, in very exceptional circumstances, been authorised by the court.

It is a criminal offence to exercise rights of audience or to conduct ligitation unless properly qualified and authorised to do so by an appropriate regulatory body or with leave of the court. The very exceptional circumstances in which a McKenzie Friend can apply for rights of audience or to conduct litigation are set out in paragraphs [14-18] below.

Confidentiality

5)  A McKenzie Friend must observe strict confidentiality in relation to any documents they have sight of and any information they hear in relation to the proceedings. Breach of such confidentiality will usually amount to a contempt of court, giving rise to sanctions including a fine and imprisonment.

Exercising the Right to Reasonable Assistance

5) While personal litigants ordinarily have a right to receive reasonable assistance from McKenzie Friends the court retains the power to refuse to permit the giving of such assistance. The refusal may occur on initial application or at any time during the hearing.

6) A personal  litigant may be denied the assistance of a McKenzie Friend or a particular McKenzie Friend because its provision might undermine or has undermined the efficient administration of justice. Illustrationss of circumstances where this might arise, which are not exhaustive, are:

i) the assistance is being provided for an improper purpose;

ii) the assistance is unreasonable in nature or degree;

iii) the McKenzie Friend is subject to an order such as a civil proceedings order or a civil restraint order or has been declared to be a vexatious litigant; by a court in Northern Ireland or in another jurisdiction of the United Kingdom;

iv) the McKenzie Friend is using the case to promote his or her own cause or interests or those of some other person, group or organisation, and not the interests of the personal litigant;

v) the McKenzie Friend is directly or indirectly conducting the litigation;

vi) the court is not satisfied that the McKenzie Friend fully understands and will comply with the duty of confidentiality.

7) The following factors are NOT of themselves sufficient to justify the court refusing to permit a McKenzie Friend to assist a personal  litigant:

(i) The case or application is simple or straightforward, or is, for instance, a directions or case management hearing;

(ii) The personal litigant appears capable of conducting the case without assistance;

(iii) The personal litigant is unrepresented through choice;

(iv) The other party is not represented;

(v) The proposed McKenzie Friend belongs to an organisation that promotes a particular cause;

(vi) The proceedings are confidential and the court papers contain sensitive information relating to a family’s affairs

.............................

I would imagine that you would face difficulties with respect to 6(iv)

iv) the McKenzie Friend is using the case to promote his or her own cause or interests or those of some other person, group or organisation, and not the interests of the personal litigant;

On that basis I can not see why a Judge would allow you to act as a "McKenzie Friend" for Maurice. You widely cross reference cases for publicity.

I could not find any references in Maurices blog's to you acting in Court for Maurice as a "McKenzie friend" Please enlighten us as to when and where you helped Maurice in Court in the role of McKenzie friend?

With respect to the Musa's - when and where did Maurice appear in Court and gain acceptance by the Judge as their "McKenzie Friend"?

I feel that your interpretation of the role of "McKenzie Friend" have defined and accepted it. has gone way beyond how the law Courts defined a "McKenzie Friend"

Does this not devalue the whole ethos and idea of a McKenzie Friend"

Why not try and describe such help as "lay help and support" rather than trying to brand everything as "McKenzie Friend" activity?

I can not see for a second any mechanism that allows a "Mckenzie friend" any more rights or ability to seek audience with a Court, prepare and offer legal documents or to indeed submit documents on anyone behalf than one of Santas elves!!

Why not brand such help with another more apt label such as "Association of lay helpers to Litigants in person" rather than devaluing the recognized, valuable and well defined role of a McKenzie Friend within a Court room.

Unless devaluing and removing the mechanism for "McKenzie Friend" support in a Court room for a litigant in person is what you want to do?

Its not about turning negativity into positivity on my behalf, but trying to look at practical ways to help MAURICE rather than treating him as pawn in a political long game.

Don't you think reminding Maurice of the statement that you obtained from Patrick Hunter would have been constructive. It clearly states a remand prisoner may continue to run their business. Apply that to Maurice's legal plight and difficulties getting his cases to move forward whilst he is prison.

I have read the last two comments by Sabine and Cat Lady; and I have only a few brief comments to make for the moment.

Sabine your knowledge of conducting litigation in the courts is miserable and I am warning you that you are 'yet again' attempting to name someone via your self-promoting of edm's. That someone has never made the mistake of promoting themselves personally off of the back of Maurice and has always tried to remain nameless on his site [see: many postings to that effect going back some years]. That someone knows only too well that it is 'the case before the court and that case only' which is of relevance. There are too numerous a list of people who have gone into court pretending to be McKenzie style caseworkers - who then destroyed the cases by promoting their issues off of the back of the person in the case before the court. e.g. In the History of Maurices cases a certain person PC continually over many years always managed to pump his name and his issues very slyly into several paragraphs of documents in Maurices cases. Maurice was warned time and time again [for over a year and a half] to get that persons 'self-promotion' out of his paperwork. Did Maurice ever learn or listen to what he was told.

It is a known fact that certain attack dogs of Sabines - named and smeared an individual - on this site - WHY? Was there some pact to steer Maurice away from him and keep him in the pack of dunderheads - who know diddly squat about the real dirty games that go on in the courts?

You yourself Sabine are known to have banned many people on your own sites 'because they DARED TO CHALLENGE YOU' - and your misguided belief about how things are done and how people can wins cases - without being represented by bloody actors from the legal fraternity. There are times to expose things on the net and there are times to keep yeur gob shut to win the longer game.

Sabine you are about 15 years behind many others out there of knowledge of the law and of the procedures of it and more importantly of how to go about beating the bent judiciary [And their lesser but conspiring but suborned to the judges fools in the CPS and police] - by using their very own procedures and processes to make them look like the turkeys that they have become. Perhaps Sabine you are 'tasked' with keeping many victims from actually getting their justice. Maurice has been led a merry dance since his acquittal - and he shares some of the blame for that as well.

Cat Lady - of what you have put up there is further that I could write about but save for now - the issue of confidentiality.

The legals love to use confidentiality - to keep people coralled like sheep. But when legals make mistakes - I will not be cowed nor craven by their clauses of confidentiality or pathetic threats of contempt - when matters of criminality and fraud arise in a case and the contempt is of the courts itself and where the court has brought itself into disrepute with the administration of justice.

btw - Maurice never stood up and argued a sausage in court in the M case - he was wrongly encouraged to do things by a certain person - who then bigged herself up on her sites - isn't that right Sabine?        

Quote - Sabine:-

"... came to my meeting at the House of Lords."

"my meeting" ...? A perfect example of Sabine's Narcissisism.

And what a waste of time your meetings have been. Save that every issue was kicked firmly into the long grass - Mitchel MP - On the gravytrain as is Hemming MP.  

More documents received from Maurice at

www.butlincat.wordpress.com

- scroll down - with more to follow.

Would some one please confirm Maurice's CURRENT status at the prison.

1: Is he held on remand

2: Is he held as a convicted prisoner

3: If he is now held serving a sentence as a convicted prisoner, when was the date of conviction and what was the sentence.

This information is important as if Maurice is held on remand his rights to certain things are much greater than if he is convicted.

As far as I am aware he is still on remand for the charge of breaching a restraining order.

The two bit trial he had last week was for a different matter he said he arrested a prison security guard the guard said he was assaulted by M. The Judge chose to believe the guard and M got 12 weeks.

That sentence will have been served by now so he is still on remand until the 12th January next year when he will face yet another trial for breaching the never served and draft restraining order as they like to call it.

News just in,

Apparently Maurice has been moved, today at 5 o'clock, from  his cell on E wing to the punishment block. This will of course deprive him at a stroke, of the priveledges which it has taken him so long to get access to.

Furthermore, he went to visit the doctor this morning and was shown on the computer, in front of a prison officer, that there is no record of the brain scan that he had at the University hospital of Wales on the 28th November, the same brain scan that showed his brain to be healthy, in direct contravention to the made up psychiatric evidence abused by the court so far.

There are two possible explanations for this:

The first is that there may be some kind of computer glitch preventing the record from showing on the prison computer.

The second is that persons unknown have deliberately interfered with his medical record in order to prevent the exposure of the truth.

This is otherwise known as perverting the course of Justice!

South Wales Police are in total meltdown - if what was aired on national television tonight at 7 pm about the Ian Watkins [paedo] case is taken into account. The IPCC are investigating that SWP clearly knew of Watkins' activities as far back as 2008.

Maybe the SWP and its lawyer in chief 'Oliver twist the truth' from  Dolmans were more interested in 'shutting up the bigger threat to SWP back then' - but now they have to contend with both issues.

Watkins is to be sentenced at Cardiff tomorrow - an opportunity perhaps for some legal protests - 'Release Maurice Kirk' posters to be held up outside the court [criminal court building]?

Extremely worrying call from MK received today at 16.56 pm, with another from 9 oclock this moring, with 5 letters [the rest to follow] received today 17 Dec., one being a reply from South Wales Police Authority =

butlincat.wordpress.com/.../5570