all credits: Garden Court Chambers
published April 2009
Any news updates on this case will be listed at the foot of this item
In March 2009, An inquest jury concluded that a catalogue of serious failings at HMP Leeds caused or contributed to the death of 25 year old remand prisoner Mohammed Mudhir who was found hanged in the segregation unit of the prison on 21st August 2005 while the balance of his mind was disturbed. He was remanded into HMP Leeds in June 2005.
His inmate medical record (IMR) indicated that he was a vulnerable person, who had a history of depression since childhood, and two years previously had experienced thoughts of self harm. Whilst in prison he was moved to the segregation unit on 18th August 2005. Three days later he was found dead in his cell.
From the 17th August there was evidence that Mohammed’s mental health was deteriorating. Prison officers were concerned when they saw what they thought to be blood on his sweatshirt. When they asked Mohammed if he was injured he refused to engage or speak with them. The prison officers then asked a Registered Mental Nurse to conduct an assessment. Although she saw cuts to his arms she failed to open a self harm form (otherwise known as an ACCT form) despite not knowing how the lacerations had come about. She admitted that she failed to look at the IMR.
A prisoner by the name of Daniel Jones reported that Mohammed had expressed suicidal thoughts. He also saw lacerations to Mohammed’s wrists. Mr Jones said that he reported this to a prison officer. Yet no action was taken.
Another prison officer reported that during the afternoon of 18th August Mohammed was talking ‘incomprehensible nonsense’; yet again no action was taken to help Mohammed. Later that evening, Mohammed was noted to have covered up the windows, lights and spy hole to his cell.
Fearing that he was in the process of self harming/suicide, prison officers entered the cell with a ligature knife, whereupon Mohammed attacked an officer. The officer struck Mohammed with a baton and restrained him.
The officers reported that during the restraint, Mohammed showed incredible strength and was impervious to pain. The officers used pain compliance control and restraint techniques on Mohammed and were surprised when he did not utter a sound or respond to this force. One officer gave evidence to the effect that in his 20 years service he had not seen anything like this.
Mohammed was then conveyed to a special camera cell in the segregation unit. This basic cell only contained a toilet and a mattress on a raised plinth. A nurse, Nurse Nuttal a General Registered Nurse, who came to assess his fitness for segregation saw “small lacerations to his wrists” which were consistent with self harm injuries yet despite the fact that she got no explanation from Mohammed as to these injuries, she failed to open a self harm form (ACCT).
Contrary to PSO 1600 which states that a prisoner should only be in the special cell for the shortest amount of time necessary which could be as little as 20 minutes with periodic reviews by a Governor, Mohammed was detained there for 18 hours without review. The total amount of staff contact time with Mohammed during this period was less than 90 seconds. He was offered no water; this again was contrary to PSO 1600 which states that prisoners should be treated with dignity, fairness and respect.
The deputy governor, Mr Denton, when asked why Mohammed had been kept in the special cell for so long, and in this manner, could not provide an explanation. He was also asked whether he was concerned that Mohammed had been noted to be drinking from the toilet. He said, of course, as this was a possible indication of serious mental health problems. He agreed with the suggestion that “one would not treat a dog in the way Mohammed had been treated.”
Despite prisoners in the segregation unit being particularly vulnerable, the segregation unit at HMP Leeds was staffed by unqualified and untrained staff. Mohammed was observed by two such auxiliary officers over night. One directly observed Mohammed drinking water from the toilet, the other officer was told that this had occurred.
Neither took any action, not even asking him if he was okay or needed a drink. One OSG, Lewis, when asked if this concerned her, said no, because she had seen prisoners drinking from the toilet before and when she drew this to the attention of senior managers, they did nothing about it.
Mohammed’s time in the segregation cell was captured on CCTV. This showed him to be:
Further, both the Nurse and the Doctor failed to carry out the required assessment of Mohammed for his fitness and suitability to be in the special cell and the segregation unit. Neither knew of their obligations under the Prison Service Orders.
The Doctor was unaware of the following when he went to Mohammed’s cell:
Had he known about the above, he said he would have:
a) Opened an ACCT
b) Had him transferred out of the segregation unit
c) Had a mental health assessment done on Mohammed
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