An independent investigation into the death of a woman, who was encouraged to kill herself by other inmates, has revealed concerns about a culture of bullying at HMP Eastwood Park.
Jessica Whitchurch, who was known as Jess to her family, died at Southmead Hospital two days after she was found hanged in her cell, on May 18, 2016, at the age of 31.
Jess, from Nailsea, was one of seven women to die at Eastwood Park in 2016, of which three died as a result of self-inflicted injuries.
An inquest into her death heard she had tried to take her own life, with a damning conclusion identifying the “multiple failures” that contributed to her death.
An investigation into her death has now been completed by the Prisons and Probation Ombudsman. It reveals a culture of bullying and drug abuse at the Kinnon Unit, where Jess was detained. The unit was facing staff shortages – with many people working there openly reluctant to be placed on the unit – and rising levels of staff sickness.
As a detoxification unit – where many prisoners with alcohol and substance abuse issues are initially placed to ‘detox’ at the start of their sentences – Kinnon was known by staff to have “always had a difficult prisoner group”, according to the report.
With staff struggling to cope with conditions in Kinnon unit, the report compiled by the ombudsman – who describes the “underlying culture of bullying” as “pervasive” at the prison – recommended the deputy director for the women’s estate should also assess the broader implications of the circumstances of Jess’ death not just for Eastwood Park, but other prisons too.
What led Jess to take her own life?
Jess, who had been diagnosed with complex social anxiety disorder, was remanded in custody on September 7, 2015, for attempted robbery, battery, and damage to property. When she died, she was just two months away from completing her prison sentence.
Her time in prison
She had served previous sentences at Eastwood Park, and was known to have a history of substance misuse and had been frequently monitored under suicide and self-harm prevention procedures.
During her time in prison, she had been involved in a number of incidents with staff and prisoners, and had faced disciplinary hearings for her treatment of staff and diversion of her medication.
Attendance at group counselling sessions
Despite remaining on the Kinnon unit, she was accepted as an outpatient into a programme for those with personality disorders, based on Unit 10, and attended weekly counselling sessions and group work. She applied to move to Unit 10, however was denied in April 2016 – a month before her death – but continued to access the service.
Incidents of bullying begin
Meanwhile, she began to face bullying in Kinnon, which reportedly began in March 2016 after she argued with another prisoner about drugs. Following the confrontation between the women, she was moved from ‘A spur’ to ‘B spur’ on March 6.
Subjected to a “campaign of bullying”
Later that month, she was accused of shredding another prisoner’s clothes to pieces, and the next day a group of inmates from her old spur banged on the dividing door between the two sections, whilst each wearing torn sections of a pair of Jess’ trousers.
After the incident, an internal investigation found that Jess had been subjected to a “campaign of bullying”, during which prisoners were encouraged to spread rumours about and intimidate her.
Two prisoners made allegations of sexual assault and harassment against her, which were found to be malicious.
From March 17, after she told a psychiatrist that she felt unsafe and the bullying had intensified, she was escorted by a member of staff whenever she left Kinnon Unit.
Attempts to self-harm
During her time at the Kinnon unit, Jess had made a number of attempts to harm herself, and had been placed under self-harm and suicide observation measures accordingly.
On May 12, just eight days before she passed away, she made an attempt to harm herself after her purchases from the prison shop were stolen – however said that she had not intended to kill herself.
Staff monitored her for five days, until May 17, when her mood reportedly was seen to improve.
May 18 – first seen to be upset before lunch
On May 18, Jess was reportedly found to be upset before lunch, however a psychiatrist who spoke to her “was not worried she was at imminent risk of harming herself”, and said Jess had told her she had support from her sisters.
A supervising officer was also satisfied that she was not at risk of harming herself.
Jess involved in fight and attempted to harm herself
A short while later, Jess was involved in a fight on the unit, and afterwards attempted to harm herself at around 12.15pm.
The supervising officer and another officer spent ten minutes talking to her, which the report states that “although in the context of a busy prison, this is a significant amount of time, it is actually a short period within which to be certain of a person’s level of risk”.
Decision made to place her on self-harm and suicide monitoring
The decision was made to place her on self-harm and suicide monitoring, during which she was to be checked on twice an hour.
The supervising officer who made the decision said she knew Jess was “quick to lose her temper and self-harm impulsively”, but was equally quick to calm down and did not have a history of repetitive self-harm.
Prisoners shout at Jess to take her own life
Once all the prisoners had been returned to their cells, the other inmates on the spur began banging and shouting, goading Jess into taking her own life.
Amongst their taunts, they were heard telling Jess to “do it proper so we know you are dead”.
Just one inmate refrained from taking part.
‘Brighter’ after conversation with staff about her sisters
Jess was examined by a nurse and a healthcare assistant, who found her crying in her cell.
The healthcare assistant knew Jess from her previous sentences, and struck up a conversation with her about her sisters, of whom she had pictures on her wall.
During this conversation, she reportedly appeared to brighten up.
Jess found lifeless in her cell
The final self-harm and suicide monitoring check on Jess took place shortly before 1pm. Just 30 minutes later, she was found hanging and lifeless in her cell.
Despite the efforts of prison officers, nurses, and paramedic, she could not be revived.
Disturbingly, the report reveals that prisoners on the unit continued to shout unpleasant things during the resuscitation attempt.
Jess passes away two days later in hospital
Two days later, on May 20, 2016, she passed away in hospital, surrounded by her family.
What have her family said?
The report repeatedly makes reference to Jess’ relationship with her sisters, who had supported her whilst she was in prison. She had pictures of them on the walls of her cell, and addressed the short note she left before her death to them.
One of her sisters, Emma Gardiner, said: “As far as we’re concerned, we’ve not heard of any changes that could have helped Jessica, or any other woman in a similar position.
“We’ve always maintained that her death was caused by the way she was treated in prison, not just by the other inmates but the staff there too. It wasn’t safe then, and I doubt that it is now.
“Since Jessica’s death we have been working to make sure that lessons are learnt, and other families are not put in the same awful position as we have had to deal with. There needs to be a major overhaul, and I hope that the report goes some way toward making those changes a reality.
“The fact remains that her death was avoidable, the care she received was inadequate, and prisons like Eastwood Park should accept that they need to do much, much better. She was failed, completely.”
What were the investigation’s findings?
Despite the incidents of bullying from fellow inmates that haunted her final weeks, the ombudsman report states first of all in its findings that the care Jess received from staff was of a “good level”.
It states: “There is evidence of a caring approach from staff of all disciplined and good efforts were made to work out what was best for her.
“Ms Whitchurch’s personality disorder often made relations with prisoners and staff difficult. Sadly, she appears to have got to a point where she could no longer cope.
“She left a suicide note for her sisters to the effect that she was sorry but she could not carry on.”
With regards to the assessment of Jess’ level of risk on May 18, the report outlines a number of concerns about the frequency of staff checks on vulnerable residents.
When considering the judgement call of the supervising officer who decided that Jess should be checked on twice an hour in her final hours at Eastwood Park, the ombudsman said that the decision was understandable due to the staff member’s knowledge of Jess’ character. However, it is also pointed out that “while a prisoner’s presentation and history is important and reveals something of their level of risk, it is only one piece of evidence in judging risk.
The report also calls on the ‘benefit of hindsight’ following the decision to monitor Jess twice a hour and, crucially, ultimately finds that “a period of constant supervision or at least a much higher number of checks over the lunchtime period was appropriate to ensure Ms Whitchurch’s safety”.
Between September 2015 and May 2016, Jess was placed under ACCT (Assessment, Care in Custody and Teamwork) review – a process that is used in response to concerns that an individual may be a risk of self-harm or suicide. In the process of investigating Jess’ death, it was found that a medical professional had never attended an ACCT first case review, which is a mandatory requirement.
Shockingly, her medical notes reveal that here was no record of any engagement between mental health staff and the ACCT process during Jess’ reviews, and some reviews took place with just one member of staff present – going directly against the ‘Teamwork’ element of the process itself. The ombudsman has noted this as “poor practice”.
Jess’ experience of bullying is also outlined in the findings of the report. The ombudsman has stated they they are “satisfied that the events on A spur in March were investigated and dealt with promptly and sanctions to the perpetrators were applied appropriately”, however describe the bullying directed toward Jess on B spur as “less clear cut”.
Ultimately, the report states: “We are satisfied that the relationship between Ms Whitchurch and the other prisoner [who Jess had previously described herself as ‘struggling a little’ with] was not straightforward and that Ms Whitchurch did not appear obviously vulnerable or a victim of bullying on B spur”.
The decision not to move Jess to Unit 10 as she’d requested was found to be satisfactory, as she had “not demonstrated the required period of stable behaviour” that would permit her to leave Kinnon Unit.
What did the investigation reveal about bullying and drug culture at HMP Eastwood Park?
The ombudsman’s investigation has revealed a number of concerns surrounding the bullying and drug culture at the prison, in particular on the “difficult” Kinnon Unit – concerns that were also revealed into a previous death on the unit.
These include issues with staff shortages, as perceived by the staff themselves, which had resulted in worries about the medication hatches not being policed properly in order to prevent the diversion of drugs and the resultant bullying.
It was also found that officers were stretched due to the high number of prisoners subject to suicide and self-harm monitoring on the unit, meaning that it was difficult to make sure prisoners were safe. There were a significant number of new staff working on the unit at the time who had been significantly impacted by the deaths, and staff sickness levels had increased.
Some staff were reportedly vocal about their unwillingness to work there at all.
The report states that the safety and management of the unit is a “cause for concern”, however it also raises questions into the management of the prison as a whole, and its ability to manage ‘challenging behaviours’ across all areas. For example, it was reportedly unclear where inmates involved in bullying may be in the prison.
It is these that lead to the ombudsman’s conclusion – that the investigation has given rise to implications that could be felt not only at HMP Eastwood Park, but beyond to other prisons. It is recommended in the report that the Deputy Director of the Woman’s Estate oversees the investigation itself.
What does the report say about the prison?
The report itself states that Jess was the second prisoner at Eastwood Park to take her life in May 2016.
The investigation into the first death also revealed a culture of bullying and drug taking – issues present in both cases. The two incidents were the first self-inflicted deaths at Eastwood Park since 2007.
The investigatory report makes reference to an inspection that was carried out in November 2013 – at which time HMP Eastwood Park was found to have a good relationship between staff and prisoners. Comprehensive measures to limit bullying and violence were in place, security procedures were found to be proportionate, and the number of positive results in drugs tests was very low.
The main security concern was the smuggling of drugs into the prison, with some prisoners claiming that medication had been traded, but inspectors found no evidence of a substantial problem.
The Independent Monitoring Board (IMB), which is made up of unpaid volunteers from the community, found in its latest annual report – dated October 2015 – that despite staffing issues, the prison was generally “safe, secure, and decent”.
However, they did raise concerns about an increasing number of self-harm cases, and a lack of analysis of the reasons for it. There had been delays in completing two wing refurbishments, which were said to have unsettled the regime of the prison.
It was also reported that staff had struggled to control the number of illicit drugs circulating in the prison.
Most people who are thinking of taking their own life have shown warning signs beforehand.
These can include becoming depressed, showing sudden changes in behaviour, talking about wanting to die and feelings of hopelessness. These feelings do improve and can be treated.
If you are concerned about someone, or need help yourself, please contact the Samaritans on 116 123.
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