A warning that this Newscast contains information which some readers may find distressing.
It is impossible to remove all risk from the Isle of Man Prison but one death in custody is one too many.
That’s what the prison governor has told Manx Radio following the culmination of a series of inquests into the deaths of serving prisoners.
The three men had all taken their own lives, in similar circumstances, between 2020 and 2023.
Tessa Hawley has this episode of Newscast:
[Music] Hello, it's Tessa, one of the news editors here at Manx Radio, back with another episode of Newscast. Now, before we start, I want to give you a trigger warning. This newscast contains information about death and in particular suicide, which some of you may find distressing. Today, we're going to be talking about deaths in custody. Earlier this month Manx Radio was in court for the inquest into the death of serving prisoner Christopher Corkill. His inquest was the third to be held after three men took their own lives in similar circumstances between 2020 and 2023. At the 46-year-old's inquest, a jury recorded a verdict of suicide. He was found dead in his cell at the Isle of Man prison on the 24th of February 2023. Mr Corkill's death followed that of fellow prisoners Craig Anderson in 2022 and Khan Douglas on the 31st of March 2020. In May 2022, at the inquest into the death of Mr Douglas, a jury concluded the 29-year-old had died by suicide whilst the balance of his mind was affected, which was contributed to by neglect. Shortly after those court proceedings concluded, the Department of Home Affairs released a statement saying, "Death in custody are rare in the Isle of Man, and the Department takes its responsibilities under the custody act seriously." Immediately after Khan's death, work began to make improvements that would reduce the possibility of another family having to endure this loss. The coroner has been informed of this work and the ongoing efforts to ensure that those who are in custody at the Isle of Man prison continue to be kept safe, particularly those who are most vulnerable. However, on the 25th of November 2022, Mr Anderson was found dead in his cell at the Isle of Man prison. The jury at the 28-year-old's inquest in February this year concluded that he died by suicide whilst the balance of his mind was also disturbed. Delivering a narrative verdict, Jorah's noted that whilst there was no neglect, there had been a missed opportunity to render care that could have made a difference to the outcome. Mr Anderson's death and that of Mr Cawkill three months later sparked independent investigations by the prisons and probation ombudsman. They were instigated by the DHA and started in April 2023, and the PPO reports, which are dated January 2024, were released publicly in May and July this year. Mr Douglas' death was not reported on as part of this process as his inquest had already concluded by this time. The PPO found that at the time of Mr Anderson and Mr Cawkill's deaths, the prison had not made sufficient changes or responded to the learning from the death of Mr Douglas in 2020. It also found the management of prisoners at risk of self-harm or suicide was inadequate, a mental health provision was inadequate and unsafe. There were also unsafe practices noted in relation to the issuing of medication, as well as a lack of clinical governance and quality oversight dedicated to prison health care. Fifteen recommendations were made within the report, including the need for a review into provision of mental health services, a prison population health needs assessment and the stopping of unsafe medication practices. The PPO investigation followed a separate inspection from his Majesty's Inspectorate of Prisons, which was undertaken between February and March 2023. Again, at the request of the DHA, inspectors visited the Derby facility, where they found many missed opportunities and poor systems of accountability. It was the first inspection since 2011 and 14 areas of concern were identified. Government was told six of these should be treated as priorities, which required immediate attention. A follow-up review was conducted between the 30th of April and the 2nd of May this year, where the inspectors found encouraging improvements with good or reasonable progress made against nine of the concerns. HMIP found that governance and oversight of many critically important areas of accountability had improved. There had also been considerable effort by prison leaders to improve the care of those at risk of suicide or self-harm, and inspectors found individuals to be well supported. The HMIP report also noted that the prison health care team had been placed in special measures in December 2023, following the deaths in custody. Special measures are an internal governance mechanism designed to ensure any incident or issue that's identified as extremely challenging and/or high risk, is afforded a level of attention, resource and leadership in order to facilitate positive change. Paul Moore is Monkscare's Deputy Chief Executive and Director of Nursing and Governance. He told Monks Radio he believes as a result of the tragic deaths and the investigations that have followed offender health care will be changed permanently for the better. Special measures is a mechanism, an internal mechanism that we have inside Monkscare for providing a period of intensive support to a service that is experiencing some challenge. It was my call really to put the prison health care service into special measures in December last year after we were in receipt of the findings of both the inspector of prison's report and also the findings of the prison and probation ombudsman. Both those reports were quite significant in that they revealed a lot of aspects of care that we needed to work on and develop, and the scale of that change and the capacity to deliver that change felt to me as though we needed to put some intensive support into the team to enable that change to take place as quickly as possible. From reading those reports it definitely did flag a lot of issues within how the health care was running within the prison. I guess the question would be why had things been allowed to go so wrong? I don't think I would say that they were allowed to go wrong. I think it's a very challenging environment to operate in and since I joined the team at Monkscare we've been focused on improving the offender health care service, but against a backdrop of some difficulty, particularly difficulty in terms of culture, particularly difficulty in terms of recruitment, retention and the stability of the workforce and the leadership in particular meant that even though we were working on some of those problems we weren't able to gain the level of traction that we needed in the timescale that we wanted. So I think it's fair to say we weren't allowing it to happen. We were trying to improve the situation but circumstances were getting bigger than we were. Do you think things have genuinely improved now? In short yes, but I don't think that's the end of the journey by any stretch of the imagination. So I think special measures have allowed us to get phase one of an offender health care improvement plan off the ground and I think that represents the foundation for what has to come next. We're still going to have to do quite a bit of work on offender health care improvement to continue to modernise, to continue to build the workforce and the capability of that workforce, to focus in particular on something called the principle of equivalence, which is ensuring that from a health care perspective, offender or otherwise you have the same level of access to health care as you might expect if you were not in custody. So it's the beginning of something rather than the end of something. Would you say that you are confident that the prison health care team is going in the right direction? I have no hesitation in saying that the offender health care team alongside the prison officers and the leadership team inside the prison gives me enormous confidence that we are in a much better place than we were and have the ability to confront the challenges that lie ahead for us, you know, to deal with offender health care need, but also offender health care need in the context of a rising prison population. I think we have a good team. We have a different way of working together, much more open, much more collegiate and I think that got an awful long way to being able to tackle some of the problems that lie ahead. It's deeply regrettable that they took their own lives, but these are sentinel events, they lead us down a path to learn things from those events and there have been many lessons from these cases that we've been dealing with recently and with the insight of the inspector and the ombudsman. It's allowed us to apply a focus on the prison that we might not have been able to do and therefore I think it's been enormously helpful at changing permanently the way we do offender health care on the other man. Now it's understood the coroner of inquest will make a number of recommendations as part of the coronial process following the conclusion of the inquest into the death of Mr Anderson and Mr Corkill. Prison governor and head of the prison and probation service Leroy Bonic gave evidence at the latter. He told the jury there was a deep commitment to preventing further tragedies. Mr Bonic also highlighted a number of changes and developments to policy and procedures which have been sparked by the inspections. This included moving away from the previous fault of five system which were open for people at risk of self-harm or suicide to a new one called ACT, assessment, caring custody and teamwork and the introduction of trauma training. Mr Bonic told Monks Radio whilst improvements have already been made for the better, it's impossible to remove all risk from the prison environment. One death is one death too much as you know I was questioned at length to understand with regard to that and you know unfortunately in my 34 years as you know we've seen deaths each time in prison but you know we need to work with the systems we've got with those prisoners and continue to you know save God you know there well being. Are you confident that the prison is a safe place? Most definitely yes it is a safe place yes. When we talk about mental health obviously that was a big focus of the reports and it's been a big focus of the inquest. They did say that they didn't think that the mental health provision in the prison was equivalent to what people would get in the community. What reassurance can you give people that that is an area that's had real focus and that actually things have improved in regards to mental health for the better. I meet with you know the deputy of Monkscare you know by monthly in terms of some of those special measures were in. Now as I said in you know during the inquest I believe you know they have more opportunities within the prison to access mental health you know we have a GP that's on five days a week. We have the other services coming we have a mental health nurse she's not full-time but have access and can do a triage and signpost them to individuals in terms of you know what treatment is needed. What I would say is that you mirror that about getting an appointment in the community and I say differently. People would maybe perceive that prisons by their very nature are sort of locked down and staff have oversight and control over everything but it is impossible to remove it. You can never eliminate risk 100% as I say one is one too many but you know certainly my experience of 34 years prisoners you know I talked about always find a way unfortunately what we have to do is recognize that these individuals are in distress and and work through that with them. The phrase lessons will be learned it's such a used phrase it's from maybe such an overused phrase but in these cases moving forward now will lessons be learned? Well so I'm at the helm most definitely and you know the staff always strive to do better in terms of their you know their daily job in terms of looking after prisoners which you know I'm proud of the staff and the way they go about their work and they despite the trauma that it has caused some individuals you know they come back the following day and do a great job. You can find links to all of the reports that I've mentioned at maxradio.com they're lengthy and they are worth a read. There's also details of local organizations that provide advice and support to anyone struggling with their mental health on the website as well. Thank you for making it to the end of the maxradio newscast you are obviously someone with exquisite taste. May I politely suggest you might want to subscribe to this and a wide range of maxradio podcasts at your favourite podcast provider so our best bits will magically appear on your smartphone. Thank you. you. [BLANK_AUDIO]
