No violation of Art. 2;Violation of Art. 3;Violation of Art. 13;Non-pecuniary damage - financial award;Costs and expenses partial award

The applicant is the mother of PERSON who , on DATE , at DATE , died from asphyxia caused by self - suspension whilst serving a sentence of CARDINAL months’ imprisonment at FAC .

The immediate circumstances surrounding PERSON death are inevitably obscure , since he took his life while alone . For the rest , the parties have in the main accepted the facts as established by the ORG and these are reproduced below in Section A. The medical reports concerning PERSON state of health prior to his death are summarised in Section B.

From DATE , PERSON received intermittent treatment in the form of anti - psychotic medication for a condition which it appears was first diagnosed whilst he was serving a DATE prison sentence for assault . It appears to have been reported by PERSON that he was diagnosed as suffering from paranoid schizophrenia . Following his release from prison in DATE , PERSON general practitioner continued the prescription of anti - psychotic medication .

His medical history included symptoms of paranoia , aggression , violence and deliberate self - harm , and his behaviour was sometimes unpredictable . In DATE , shortly before he was admitted to prison , he had received treatment at FAC following CARDINAL incidents in which he had injected himself with overdoses of insulin . Following the first incident , on DATE , it was noted that he was complaining of paranoia . Diagnoses of borderline personality disorder and paranoid schizophrenia were made and it was noted that he had a history of frequent episodes of deliberate self - harm . He was discharged after DATE on a prescription of anti - psychotic medication . The second incident , on DATE , was associated with the breakdown in his relationship with his girlfriend . The admission notes recorded as diagnoses “ Personality disorder . Paranoid psychosis . Suicide threats ” . He discharged himself on DATE .

On DATE he was admitted to FAC , having been remanded in custody following an assault on his girlfriend . On admission , he was received by the prison ’s health care centre for observation and assessment , having mentioned a history of suffering from paranoid schizophrenia .

On DATE , when the medical notes recorded that there had been no evidence of schizophrenia DATE , an attempt was made to transfer him from the health care centre to ordinary location . DATE he was re - admitted to the health care centre because he had been kicking at his cell door and appeared paranoid to prison staff . The explanation provided by PERSON was that he had taken some cannabis which had “ tripped him out ” and made him paranoid , shaky and tense . Subsequently , on DATE , he was discharged to ordinary location having been assessed as fine , with no psychiatric symptoms , cheerful and coping . By the evening , he was complaining that he was “ cracking up ” . He was advised to “ calm down and think positively about going to court DATE ” . In the event , on DATE , he was released on bail .

PERSON was re - admitted to FAC GPE on DATE , having been convicted of the assault on his girlfriend and sentenced to CARDINAL months’ imprisonment . He was again received by the prison ’s health care centre for observation and assessment . On DATE PERSON , the prison ’s senior medical officer , consulted PERSON , the consultant psychiatrist who had been treating PERSON before his admission to prison . PERSON advised that PERSON had a personality disorder with anti - social traits and that under stress he disclosed some fleeting paranoid symptoms . PERSON concurred with the medication which Dr PERSON had prescribed ( thioridazine ) and suggested a clopixol injection with chlorpromazine . He also advised that PERSON should be treated symptomatically .

On DATE PERSON barricaded himself inside the ward room of the health care centre in protest against his proposed transfer to ordinary location . On DATE , following an adjudication concerning the incident , the governor imposed a suspended punishment of CARDINAL ORG extra imprisonment . On DATE he was discharged to ordinary location but re - admitted to the health care centre the following evening after his cell - mate reported that he was uptight and had fashioned a noose from a bed sheet which he was keeping under his bed . On his return to the health care centre , he was placed in an unfurnished cell and put on a TIME watch . The entry in his medical notes for DATE records :

“ Brought to ORG at TIME ... states he will hang himself . A noose has been made out of strips of sheets . In conversation with PERSON , [ says ] he is under pressure from kitchen workers who have stated they will contaminate his food etc . The look of relief on his face was great when I told him he will have to stay here . ”

A subsequent entry , on DATE , records “ owes on wing hence ca n’t cope [ with ordinary location ] ” .

On DATE it was decided that PERSON should be assessed by the prison ’s visiting psychiatrist , PERSON . On DATE , before he had been assessed , a further attempt was made to transfer him to ordinary location . He was re - admitted to the health care centre the following day . The entry in his medical notes for DATE records :

“ Brought to treatment room shaking and hyperventilating . Declined any further medication . Unable to cope . Admitted to health care centre for observation and assessment . Seen at TIME . He says he felt panicky and paranoid in main prison . He felt he was going to be attacked . He felt he might have to defend himself . Located in single cell on lower landing . ”

On DATE PERSON was assessed by ORG , who did not consider that it was currently necessary to transfer him to a hospital for psychiatric treatment , but prescribed a change in his medication , and recorded in his medical notes :

“ He is an old patient of mine who suffers from a mild , chronic psychosis . He is not usually violent , although he is easily stressed and then can be unpredictable . ”

He also recommended that PERSON should have no association until the panic / paranoia subsided .

On DATE the question of moving PERSON to ordinary location was again raised with him . The entry in his medical notes for CARDINAL DATE records :

“ He does not feel fit for [ ordinary location ] as he is afraid he might be injured , further mention of paranoia by him . To remain in a single cell . ”

In the course of DATE his mental state was noted to deteriorate , with evidence of aggression and paranoia . PERSON , who had no psychiatric training , considered that the change in medication might be responsible and therefore prescribed a return to his previous medication . At TIME PERSON assaulted CARDINAL hospital officers , CARDINAL seriously . Following the assault , he was placed in an unfurnished cell within the health care centre and put on a TIME watch . It is not known how long the watch was kept in place .

On DATE PERSON , who had CARDINAL months’ training in psychiatry as a senior house officer , certified PERSON fit for adjudication in respect of the assault and fit for placement in the segregation unit within the prison ’s punishment block . He recorded in PERSON medical notes for CARDINAL DATE :

“ Calm and rational . No sign of mental illness . Slept well , feels relaxed . Claims he was frustrated DATE and this is why he attacked the officer . Fit for normal cellular confinement in punishment block . ”

DATE , PERSON , the prison ’s deputy governor , ordered PERSON to be placed in segregation in the punishment block under Prison Rule CARDINAL . PERSON considered segregation appropriate , as PERSON behaviour was unpredictable and he posed a threat to staff . No date appears to have been given for his release from segregation .

Whilst in segregation , PERSON would have been locked up TIME each day . Although the segregation unit was visited DATE by a doctor , the prison chaplain and the prison governor , PERSON would , in contrast to location within the health care centre or the main prison , have had minimal contact with staff , and none with fellow prisoners .

On DATE , following his transfer to the segregation unit , PERSON requested a “ listener ” ( a prisoner trained by the Samaritans in the counselling of inmates who may be suicidal ) . At TIME Mr Gill , CARDINAL of the prison ’s hospital officers , was contacted after PERSON had indicated to prison officers on the segregation unit that he was feeling suicidal . The medical notes record :

“ Went to see [ PERSON ] . DATE raised [ ( a form completed for the referral of an inmate , perceived to be a suicide risk , to the medical officer ) ] . Listener in cell with inmate . Reassurances given that he is not suicidal but tense , agitated [ and ] needs to talk it over . Will get [ medical officer ] to see when he attends later . ”

At TIME , however , PERSON was threatening to harm himself and was therefore transferred to an unfurnished cell in the hospital wing and put on a TIME watch . It remains unclear how long this watch was maintained .

At TIME attempted to speak to PERSON through his cell door . Whilst noting that he appeared very agitated and distressed , and claimed to be hearing voices and thinking he was PERSON , PERSON doubted that he was suffering from any psychotic illness . PERSON medical notes record that he spent the greater part of the night banging on and kicking his cell door , shouting obscenities and making threats to prison staff . On CARDINAL DATE PERSON recorded in PERSON medical notes :

“ TIME denying he is suicidal . Verbally abusive to staff . Some bruises from hitting door . This man is a considerable hazard to staff and has become obnoxious to other hospital inmates due to his behaviour . He is unpredictable and has made threats to his life . He has been placed on Rule CARDINAL . I have explained to him that his remaining in the [ unfurnished ] cell is in order to assess his attitude in TIME . I will increase chlorpromazine to CARDINAL mg ORG and resume PERSON and chloral nocte . He says he will not take medication . ”

The medical notes for CARDINAL DATE record :

“ TIME – very much better in attitude . Slept well . Requests to return to [ the segregation unit in the punishment ] block . Agreed . ”

PERSON was duly returned to the segregation unit . A note in the segregation unit ’s occurrence book for CARDINAL DATE records :

“ PERSON [ was ] brought in from the hospital . Seems slightly more lucid than before , however still needs watching . At tea time PERSON asked to [ talk to a listener ] as he stated he felt he was ‘ going into one’ , which I took to mean kicking off ... staff beware . ”

The medical notes record at TIME :

“ Troublesome in block . Given extra chlorpromazine . Seemed to calm down after a chat . If he is talking suicidally TIME then unfurnish his block cell and review ‘ mane’ [ query , in TIME ] . ”

Save for a short note on CARDINAL DATE that at “ TIME clopixol CARDINAL mg given ” , no further entry was made in PERSON medical notes from the CARDINAL DATE until his suicide on DATE . PERSON , who had no psychiatric training , saw PERSON in the course of routine TIME visits to the segregation unit on CARDINAL to CARDINAL and DATE to CARDINAL DATE . She recalled :

“ ... We had the cell door open on the majority of occasions . I recall there may have been CARDINAL time when I spoke through his glass window ... but that was because they were short of staff . He had the opportunity to talk to me .

We discussed his medication . He never mentioned any feelings of depression to me or not coping . On the whole PERSON appeared calm and with it with me . He appeared clear and not disturbed . I also checked with the staff as to his behaviour through the day , and they replied that there was nothing that concerned them . ”

The occurrence book of the segregation unit records , however , on CARDINAL DATE :

“ PERSON abusive , aggressive and offering violence to staff . Relocated to [ cell ] CARDINAL for a quietening down period . PERSON phone call to solicitor at TIME re assault on H / O Dent . On return [ from phone call ] to ACARDINAL [ landing ] states he will behave himself . Relocated to [ cell ] CARDINAL . ”

The entry for CARDINAL DATE records :

“ PERSON refused cup of tea . PERSON there was something out in it . When told that there was nothing out in it he decided to drink it . He is starting to act very strange . Staff to be aware . ”

The entry for CARDINAL DATE records :

“ PERSON seen by doctor . Refused medication . Staff to still offer medication . To be logged if taken or refused . ”

Following the entry on DATE there is reference to the fact that on CARDINAL , DATE and DATE he accepted his medication . Thereafter there is no reference to PERSON in the occurrence book until his suicide on DATE .

In a letter to his mother , dated CARDINAL DATE , he complained that his state of mind was not very good .

On CARDINAL DATE Dr Bradley assessed PERSON to be fit for adjudication in respect of his assault on the CARDINAL prison officers on DATE . The record of the adjudication contains the certification by the doctor that he was fit for adjudication and for cellular confinement . The doctor added the following observations :

“ At the time of the alleged offence Mr PERSON was receiving medication for a chronic psychiatric problem and he had had a recent change in medication . ”

The adjudication took place on DATE , DATE after the events concerned . PERSON was found guilty of assault . In mitigation , he told the deputy governor , PERSON :

“ I suffer from a split personality disorder . I have been in and out of institutions all my life . I now have a chance to make good . My mum has booked a holiday in GPE . I have behaved myself . ”

The deputy governor said that he noted what the applicant said but that he was facing extremely serious charges . He awarded DATE in prison together with CARDINAL days’ loss of association and exclusion from work in segregation in the punishment block . At that point , PERSON had DATE to go before his expected release . The sentence had the effect of delaying his release from DATE until DATE pursuant to the applicable provisions , he had been entitled to release after CARDINAL of his DATE sentence , with account also being taken of time spent in detention on remand .

Shortly after the adjudication , PERSON was seen by the chaplain , who recalled in his evidence at the inquest that PERSON had been unhappy about the decision and had said : “ I was thinking of kicking off , but I do n’t think I will . ” The chaplain stated that at no stage did PERSON indicate that he might take his own life .

At CARDINAL the following morning , on DATE , PERSON was seen by PERSON who recalled that he seemed calm , polite and relaxed . He was then seen by the deputy governor , PERSON , who later described him as having been in a highly agitated state , but relaxing when he was informed that his right to buy tobacco had not been suspended .

NORP In TIME PERSON was visited by a friend , PERSON , whom he had known for DATE . M.T. , who saw PERSON for TIME , found him to be disappointed that he had an additional twenty - eight days to serve in prison , but otherwise in good spirits and , when PERSON left , as looking forward to his next visit the following DATE . Prison officer PERSON , who returned PERSON to his cell following the visit , recalled that PERSON was very talkative and appeared to be in high spirits .

Prison officer PERSON , who saw PERSON at or TIME , recalled that he seemed all right and asked if he could use the telephone at TIME Mr PERSON agreed , but in the event it does not appear that PERSON was allowed out of his cell to make the call . According to the evidence given later at the inquest , Mr PERSON , who was on duty on landing ACARDINAL – the segregation block DATE , was absent in the toilet for TIME from TIME On his way from the toilet to assist on landing ACARDINAL , he noticed that the cell call indicator for landing ACARDINAL was depressed . The call buttons in each cell lit up indicators on each landing to ensure that if an officer was not present on CARDINAL landing , the light could be seen by officers on other landings . There was no noise issuing from the indicator as it seemed that someone , a prisoner or prison officer , had de - activated the buzzer , access being possible to the system from each landing . Mr PERSON called to another officer to accompany him and immediately went to PERSON cell and proceeded to open it . He estimated that a minute went by between seeing that the light was on and opening the cell door .

At TIME on CARDINAL DATE , PERSON was discovered by the CARDINAL prison officers hanging from the bars of his cell by a ligature fashioned out of a bed sheet . At TIME he was pronounced dead .

At some point before he committed suicide , PERSON had depressed the call button in his cell . It would not have been possible for him to depress the call button whilst suspended . It was Mr PERSON ’s evidence at the inquest that PERSON must have depressed the call button during TIME when he was using the staff toilets since the light on the landing , which would have indicated that the call button had been depressed , was not on when he left .

In an undated letter , received by PERSON after DATE , PERSON wrote :

“ As you will well know I am in prison for assault on [ PERSON ] , which I received DATE . I can not take much more . I have seen PERSON in here he wrote me up for some new tablets fenzodine white tablets like white smarties . I just went mad on them , and ended up on assault on CARDINAL staff . I am asking you if you can give me treatment when I get out and get me better . I was using drugs in PERSON as well , I feel very unstable but the doctor will not help me at all . I need help please could you send the Governor a report on me , I ca n’t take much more . ”

On DATE , at the inquest before a coroner , the jury recorded a verdict of death by misadventure and that the cause of death was asphyxiation by hanging . Evidence was submitted in public proceedings by CARDINAL witnesses , CARDINAL of whom gave oral testimony . The witnesses included the applicant , the prison officers on duty who had discovered PERSON body , the police inspector who had investigated the death , the deputy governor of the prison , a number of prison hospital officers and the senior prison doctor , the prison chaplain and PERSON , who had visited PERSON on DATE he died . Statements were submitted by these persons , as well as by PERSON and PERSON .

On DATE the applicant was granted legal aid limited to obtaining further evidence and counsel ’s opinion on the merits and quantum of damages in a potential action against ORG in respect of the treatment of her son and the conditions of his detention .

In a report dated CARDINAL DATE , PERSON , the consultant forensic psychiatrist instructed by the applicant ’s solicitors , expressed his opinion that PERSON , as a prisoner suffering from paranoid schizophrenia , was unfit to be placed in segregation in the punishment block and that the failure of the prison authorities to accommodate him in the hospital wing was an important contributory factor to his death ( see paragraph CARDINAL below ) .

In an opinion dated DATE , counsel advised in the light of the psychiatrist ’s report that , notwithstanding the grave breach of duty by ORG in keeping PERSON , a mentally ill prisoner , in a punishment cell without any proper medical monitoring , an action in negligence under LAW ( LAW Act DATE would not succeed since there was no evidence that PERSON had suffered any injury of a kind in respect of which a cause of action could be maintained . He was already mentally ill and there was no indication that he suffered any worsening in his condition , or developed any new condition as a result of his confinement . Mere distress was insufficient , and the fact of his death was not such as to constitute in LANGUAGE law an injury in respect of which a cause of action lay . In respect of proceedings under LAW DATE , counsel advised that , since PERSON was over DATE when he died , the applicant did not qualify for bereavement damages and there were no dependants who might be able to pursue a claim . To the extent that the applicant might have incurred any funeral expenses , these were not sufficient to justify the support of legal aid . The effect of this advice was to prevent the applicant from pursuing any contemplated litigation since , in the light of the advice , legal aid would be withdrawn .

By a letter of CARDINAL DATE , the applicant was informed by ORG that they were considering whether to discharge her legal aid certificate given counsel ’s opinion that she had no reasonable prospect of success . By a decision of DATE , ORG discharged her legal aid certificate since it was unreasonable in the circumstances that she continue to receive assistance .

Dr PERSON , GPE , GPE , a consultant forensic psychiatrist at ORG , prepared a report at the request of the applicant ’s solicitors , on the basis of materials from the inquest , PERSON prison medical record , his medical notes from ORG and his general practice medical record . He had had no contact with PERSON before his death . His report included the following :

“ Family and personal history

There is a family history of psychiatric disorder , in that his maternal grandmother is said to have died in a mental hospital , his mother suffered a severe depressive illness after the cot death of PERSON ’s younger brother and his father is described as an alcoholic who was occasionally violent .

PERSON ] childhood was disturbed and unhappy . His parents separated when he was about a DATE old . His mother suffered from severe , intermittent depression throughout his childhood . His behaviour at school was disruptive , including fighting and truancy . He is said to have been in care at various times from DATE , and spent time in foster homes , detention centres and approved schools . His work record was poor , consisting of occasional short - term manual work . A report by PERSON ( dated CARDINAL ) states that he tended to stop jobs because of paranoid thoughts .

His disturbed behaviour continued after leaving school . He is said to have spent times in GPE at DATE as a rent boy and convictions included breach of the peace ( DATE ) , car theft and breaking into a jewellers ( age CARDINAL y. ) , convictions relating to fighting at DATE and a conviction for ORG DATE after stabbing his sister ’s boyfriend .

Psychiatric history

He is said to have been diagnosed as suffering from paranoid schizophrenia when he was aged DATE ( in DATE ) , whilst he was serving a prison sentence for the offence of G.B.H. He had paranoid thoughts and was started on treatment with cloxipol ( anti - psychotic medication ) .

Whilst serving his prison sentence , he is said to have spent a brief spell in PERSON prison , where he was told that his paranoid schizophrenia was too severe for him to get involved in group therapy .

In DATE , he was discharged from prison and continued clopixol until it was changed to depixol ( a similar , injectable , anti - psychotic medicine ) by his FAC ...

His first admission to a psychiatric hospital was to PERSON , GPE , ... in DATE .

From CARDINAL.CARDINAL.CARDINAL until CARDINAL.CARDINAL.CARDINAL , he was admitted to ORG . He had taken an overdose , injecting himself with insulin . He was also complaining of ‘ paranoia’ . The admission summary lists the diagnoses as ‘ borderline personality disorder’ and ‘ paranoid PERSON . It also notes his history of ‘ frequent episodes of ORG ( deliberate self - harm)’ . The discharge summary also noted that he was ‘ unable to cope living on his own’ ... and that he was disruptive on the ward ... It was noted that ‘ there did not seem to be too much evidence for his paranoia’ , but he was discharged on CARDINAL different types of anti - psychotic medication ( including a fortnightly injection ) and an anti - depressant . ...

From CARDINAL until CARDINAL , he was admitted to ORG , after taking an overdose following the breakdown of his relationship with his girlfriend . The summary of this admission lists the diagnoses as ‘ Personality disorder . Paranoid psychosis . Suicidal threats.’ Shortly after taking his own discharge , he was arrested for the assault on his former girlfriend which led to his prison sentence . ...

Opinion

PERSON suffered from paranoid schizophrenia . He appears to have developed this illness in DATE ... After his discharge from prison in DATE , he maintained fairly regular contact with psychiatric services and his FAC and for most of this time , was being given an injectable anti - psychotic medication . Among the psychiatrists who saw him , there appears to be general agreement about the diagnosis of schizophrenia .

I note that he was also given diagnoses of personality disorder and substance abuse at various times . There is evidence to support the diagnosis of personality disorder . However , none of the psychiatrists who saw him appear to have doubted the additional diagnosis of schizophrenia and all continued his treatment with anti - psychotic medication . The significance of the diagnosis of personality disorder is that he would have been a more difficult patient to look after , than the average patient with schizophrenia .

Schizophrenia is a serious and long lasting mental illness that may be controlled to a greater or lesser extent by medication but is not cured by that medication . Self - harm , suicide and violence are recognised complications of schizophrenia . Many of the symptoms which Mr PERSON showed in the time leading up to his death are recognised symptoms of schizophrenia , including paranoia , hearing voices , disturbed sleep , aggression , ambivalence and thoughts of self - harm . These symptoms can have other causes but , in the case of a patient known to suffer from schizophrenia , it would be usual to assume that the symptoms were due to the schizophrenic illness . It is impossible to make any reliable distinction between symptoms which are due to schizophrenia and those which are due to an individual ’s personality .

The diagnosis of schizophrenia has important implications . The management of the condition is primarily the responsibility of doctors , as the normal prison rules can not be expected to cope with persons whose mental state is grossly abnormal , without guidance from doctors . The following comments are therefore made with reference to what would constitute an acceptable standard of care for a person with schizophrenia .

From the evidence I have seen , the standard of medical record keeping was inadequate on CARDINAL occasions . CARDINAL CARDINAL.CARDINAL.CARDINAL , the management plans changed from continuous observation in the prison ORG , and a decision to seek the opinion of a visiting psychiatrist ( PERSON ) , to a decision to transfer Mr PERSON to ordinary location . There is no information in the medical notes to explain this decision . On CARDINAL , Mr PERSON was stating to staff that he intended to hang himself and a noose had been found in his cell . Given this evidence of serious suicidal intent , it would be good practice to record in the medical notes the reason for discontinuing the higher level of observation and returning to normal location .

There is no entry in the medical notes for DATE leading up to PERSON death . Given that the entries up to this point record disturbed and unpredictable behaviour and threats to his life and threats of violence to others , there were good reasons for monitoring his mental state regularly and there is no record to show that this was done .

Following the visit and assessment by ORG on DATE the evidence I have seen suggests that the standard of care received by PERSON fell below that which he was entitled to expect . PERSON confirmed that Mr PERSON suffered from ‘ mild chronic PERSON and recommended adding a new form of anti - psychotic medication to his existing regime of anti - psychotic medication . A recommendation was also made on DATE that Mr PERSON not be allowed association until his panic / paranoia had subsided . PERSON ( who had previous knowledge of the patient ) also noted that the patient was not usually violent .

On DATE ( CARDINAL ) , his mental state was noted to deteriorate with evidence of paranoia and aggression . The change in medication recommended by PERSON was then reversed . On DATE , PERSON concluded that there was no sign of mental illness and pronounced Mr PERSON fit for normal cell location in the punishment block .

With the benefit of hindsight , it is apparent that Mr PERSON was not fit to be located in the punishment block . CARDINAL things run throughout his medical notes . CARDINAL is his fear of being located anywhere other than the hospital , the second is his tendency towards suicidal behaviour . I believe that the failure to accommodate him in the hospital wing was an important contributory factor to his death .

In my opinion , it is not possible to justify the reversal of the change in medication recommended by PERSON , without further reference to PERSON ( or another psychiatrist ) . PERSON clear opinion was that the patient was suffering from a psychosis and that the correct treatment was a change in anti - psychotic medication . Dr PERSON ’s advice was not followed consistently . For example , PERSON concluded on DATE that there was no sign of mental illness , despite PERSON opinion of DATE and the evidence in the medical notes of paranoia and aggression on CARDINAL . It is most unlikely that the type of mental illness documented by PERSON ( described as chronic ) would have disappeared completely within DATE .

On the evidence I have seen , I believe that PERSON was incorrect in his judgment ( that there was no mental illness present on DATE ) and that , as a doctor without psychiatric qualification , he should not have taken a different course of action from that recommended by the psychiatrist . ”

Dr Reveley , a second consultant psychiatrist instructed by the applicant ’s solicitors , expressed her opinion on the basis of the inquest proceedings and medical records , including the notes from prison and ORG . She had never met or treated PERSON . Her report included the following :

“ Opinion

I am of the view that PERSON suffered from paranoid schizophrenia , paranoid type as defined by the ICD-CARDINAL classification of Mental and Behavioural Disorders DATE . CARDINAL of the essential features of this disorder is presence of delusions in the context of a relative preservation of cognitive functioning and affect . The individual suffering from this disorder is therefore generally able to describe the typical examples of hallucinations . Examples of the most common paranoid symptoms included delusions of persecution , grandiose delusions , hallucinatory voices that threaten the patient , hallucinations of taste and smell . There is ample evidence that PERSON suffered from such symptoms during his final prison sentence . Violence and self - harm are often associated with this condition , as indeed they were in the case of PERSON . ORG , CARDINALth edition DATE draws attention to this finding : ‘ The persecutory themes may predispose the individual to suicidal behaviour , and the combination of persecutory and grandiose delusions with anger may predispose the individual to ORG

PERSON was also variously diagnosed as suffering from substance abuse and personality disorder . Neither of these diagnoses is inconsistent with paranoid schizophrenia and they often coexist with that condition . It is also clear PERSON was consistently treated with anti - psychotic medication , and that the prison medical staff impliedly accepted a diagnosis of psychosis by continuing to treat with anti - psychotic medication . Indeed he specifically received a diagnosis of ‘ mild chronic ORG while in prison . Any diagnosis of psychosis is always of the utmost significance . There are CARDINAL main psychiatric conditions that lead to psychosis : schizophrenia , manic depressive disorder and substance abuse ( e.g. ecstasy , ORG , amphetamines , alcohol , and sometimes cannabis ) . It may be impossible to distinguish between the individual psychotic disorders when someone is first seen by a psychiatrist , and uncertainty about a patient ’s diagnosis may remain for DATE . But having said this , there is almost never any disagreement among psychiatrists about whether a patient is psychotic . Indeed psychotic symptoms can be successfully treated with anti - psychotic drugs even where there is some diagnostic confusion about the classification of the psychotic state . The evidence is that the prison medical staff while accepting that there was no formal diagnosis of his mental disorder , continued to treat his psychotic symptoms with anti - psychotic medication . ...

PERSON was treated with anti - psychotic medication while in prison . On account of the medication his condition is , apparently , maintained by this medication with the exception of the isolated flare - ups . These isolated incidents are regarded by the prison doctors as discrete episodes of bad behaviour . When there is no observable episode , PERSON appears to have been regarded as mentally well , or at least sufficiently well to be punished by segregation . This is in my view to adopt a dangerously over - simplified view of mental disorder . The analogy would be with someone with a fever who is given fever reducing drugs , and thereafter put outside on a cold DATE ’s day on the principle that he is showing no signs of a temperature . In such circumstance no - one would be surprised if there were a recrudescence of the fever . In PERSON case there was a failure by the prison authorities to recognise a fundamental psychiatric truth when they found him fit for the punishment block . They were assessing the mental state of a heavily medicated individual whose underlying problems were being maintained and masked by that medication . ( Despite the finding that he was sufficiently normal for the punishment block I note that there was no indication in the notes that his medication should be discontinued ) .

Because PERSON is adjudged to be well , he received no nursing care on the punishment block . Nursing care is not just about the administering of medication . It is vital to the successful management of mental illness , not least because the nurse is a trained observer and can react quickly and effectively where there are indications that an individual ’s mental state is a cause for concern . Nursing is primarily the process of looking after physical or emotional needs of patients with the aim or restoring , improving , maintaining , or promoting well - being . The notion of punishment is incompatible with the goals of nursing DATE and indeed with all medical care .

An acceptable level of care in the management of PERSON condition during this period would have included a close monitoring of the medication as regards dose and side effects ; a close monitoring of his mental state as regards symptomatology , and as regards any increased risk of self - harm or suicide . There is no evidence that adequate monitoring of this type was performed during DATE of his life .

This is particularly surprising in the context of his earlier problems which included self - harm and violent outbursts and given that there had been a number of changes in the medication prescribed during the time he spent in FAC .

The nature of schizophrenia is such that there are remissions or periods of less florid symptomatology where the positive symptoms , i.e. those associated with a distortion of normal functioning , are not exhibited . During such periods the so - called negative symptoms may continue to be in evidence . Negative symptoms are symptoms that reflect a diminution or loss of normal functioning . They include affective flattening ( immobility of feature , unresponsiveness , poor eye contact and reduced body language ) , alogia ( poverty of speech which is often manifested by brief , laconic , empty replies , often accompanied by a diminution in the number of thoughts which is reflected in decreased fluency and productivity of speech ) , avolition ( an inability to initiate and persist in goal - directed activities ) and anhedonia ( loss of interest and loss of pleasure in life ) . These negative symptoms account for a substantial degree of morbidity associated with the disorder . They are particularly common in the prodromal ( before episode ) and residual ( after episode ) phases of the disorder , and can often be very severe in their own right . ...

It is my view that PERSON was recognisably at a very high risk of deliberate self - harm or suicide . This risk would have been evident even if he had not been placed on the punishment block during DATE of his life . It has been shown that , compared with the general population , people who deliberately harm themselves experience CARDINAL times as many stressful life problems in DATE before the act . The events are various but a recent quarrel with a spouse , girlfriend , or boyfriend is particularly common and other events include separation from or rejection by a sexual partner , and a ORG appearance . CARDINAL of all people who harm themselves are suffering from a Personality disorder . Several studies agree that there are a number of factors that seem to distinguish patients who go on to repeat deliberate self - harm . These include previous psychosis , personality disorder of the anti - social type , criminal record , alcohol or drug abuse , lower social class , and a history of unemployment . It is also significant that among patients who have been involved in an earlier episode of deliberate self - harm , the suicide rate in the subsequent DATE is CARDINAL times greater than in the general population .

As regards the risk of completed suicide , studies show that prisoners have a higher suicide risk than the general population , and that CARDINAL in CARDINAL of all those suffering from schizophrenia end their own lives , and that CARDINAL of all those who take their own lives are being treated with psychotropic drugs . ( The above statistics are taken from ORG , ORG , DATE , and are widely accepted . )

It is not possible to quantify precisely what the degree of risk as regards self - harm or suicide was for PERSON , It is my opinion that he was recognisably in one of the very highest risk groups and that following his removal to the punishment block it was more likely than not that there would be some episode of self - harm during the period of his seclusion . This being the case , I am of the view that the failure to recognise this risk meant that his treatment during DATE of his life fell substantially below acceptable standards of care . ...

Individuals with paranoid delusions can often be helped by psychological support , encouragement and assurance . During treatment best results are achieved if doctor / nurse maintains a good relationship with the individual , and is dependable and avoids letting the patient down . He should show compassionate interest in the individual ’s delusions , but without colluding in them , or condemning them , and most importantly without ignoring them . The treatment PERSON received in the punishment block fell far short of this model .

In my view the way in which PERSON , an individual suffering from paranoid schizophrenia , was treated , was likely to arouse in him feelings of hopelessness , fear , anguish , and inferiority . The circumstances of his imprisonment on the punishment block were humiliating , debasing and degrading , and had the effect of undermining his will to cope with , and battle against , his psychotic illness . His will to resist the illness was cumulatively undermined and resulted in the taking of his own life . The prison regime to which he was subjected disregarded his basic right as an ill person to be medically treated and properly cared for and thereby broke his will to endure imprisonment . LAW declares that ‘ Any act or advice which could weaken physical or mental resistance of a human being may be used only in his interest’ . The acts performed and the advice given by medical staff in respect of PERSON treatment were manifestly not in his interest . What he suffered during DATE of his life was likely to have been terrifying , and I use that word advisedly , in its original sense of instilling terror . I have treated many paranoid schizophrenics and I have never doubted their capacity to believe absolutely in the apparent threats created by their delusions . A punishment that requires a psychotic individual to face those threats alone and without proper medical support is wholly unacceptable , and in my view constitutes an inhuman and degrading punishment . ”

In a report dated DATE , PERSON , the prison ’s senior medical officer , in response to the psychiatric reports obtained on behalf of the applicant , stated as follows :

“ These reports were compiled upon the documentary evidence available to the doctors and to my knowledge neither of them had the opportunity to see or examine Mr PERSON . The medical weight of their reports must therefore be significantly diminished . These reports were prepared over a year ( Dr PERSON ) and DATE ( Dr PERSON ) after the death of PERSON .

The historical data given in both reports was compiled from other documents and originally probably would have come from Mr PERSON himself or his mother – the basis of most medical histories comes directly from the patient without ascertaining their veracity . On reception Mr PERSON gave a history of schizophrenia – no specific symptoms of schizophrenia were observed from his reception onwards during his time in custody on remand or when convicted .

From comments by PERSON and PERSON upon entries in ORG ( IMR ) – I prescribed Clopixol because PERSON was so adamant that he wanted it and was helped by it , and because PERSON had suggested it be tried , ‘ if he does n’t do so well’ . It was prescribed not as an anti - psychotic but as a tranquilliser on the basis of the above . My conversation with PERSON and my prescribing PERSON are in fact separate entries in the IMR and it is important to refer to the original IMR entries rather than my witness statement . I recall I was reluctant to prescribe PERSON because of the paucity of symptoms and signs of psychosis . As far as I can recall , PERSON gave no reason why he did not want to continue his NORP except that he received no benefit from it and he was adamant that he felt better on PERSON and PERSON . It is important to note that I do not recall that he had experienced any side effects due to ORG which might have limited my prescribing PERSON . Both PERSON and PERSON put great weight upon his medication indicating a diagnosis – this was not the case . The dosage of PERSON commented upon in Dr PERSON ’s report was indicated to me by PERSON .

The symptoms noted on CARDINAL were quite reasonably thought possibly to be due to the change in medication and Dr. PERSON indicated that he return to his previous medication . PERSON attended the prison for DATE sessions DATE at that time and was our only visiting psychiatric resource . PERSON implied that because PERSON PERSON was unwilling to go to the main prison on DATE he should have been kept in the hospital . Were unwillingness to leave an indication of continuing location in the hospital we would have a totally static population .

In the IMR for CARDINAL the entry was made by a Hospital Officer not a Doctor . ORG , PERSON , has no formal psychiatric training . We did not have , at that time , any psychiatrically qualified nurses . Please see my entry for DATE , ‘ owes on the wing hence ca n’t cope’ . The reports do not refer to this . If he owed on the wing it is highly likely that he would be threatened with food contamination , this would represent reality rather than paranoia , and there is always the possibility that the noose was made so that he could return to the sanctuary of the hospital . A prepared noose is enough indication in itself for hospitalisation and TIME watch irrespective of mental state rather than implying a disturbed mental state in itself as described by Dr GPE .

The entry for CARDINAL in the IMR , “ to assess DATE ” , was cancelled by my hand probably fairly soon after it was written ( most likely on DATE same pen ) . The interpretation of this was that there was no indication that he needed to see PERSON and that he was well and symptom - free . He was noted fit for work and gym . No contemporaneous record was made because there was nothing of import to note .

It is appropriate here to observe that while there is an agreed paucity of notes at some ( and only some ) stages of the IMR ... nil entries may be taken as indication that no abnormality or overt disorder was present .

On the segregation wing all prisoners are medically screened before adjudication and the range of punishments known to the doctor . The duty doctor does the round in the segregation unit before the Governor attends there so that any new inmates located there can be medically checked prior to the Governor ’s adjudications . All inmates in the segregation unit are seen every day by the duty doctor . If an inmate in the segregation unit becomes ill so that hospital care is indicated he is promptly transferred to the hospital . A diagnosis of a mild chronic psychosis is not a contra - indication per se for transferring to the segregation unit – indeed the daily visits by the Governor , Doctor and Chaplain provide a greater degree of observation and care than possible on the main wings . I do not think that Mr PERSON would have been continuously an in - patient in a psychiatric hospital were he in the community . I must agree that the segregation unit generally is not conducive to mental well - being but all prison medical staff are trained in and are highly aware of the effects of imprisonment and segregation and review each inmate on the segregation unit DATE with this in mind . The duty doctor ’s DATE visits to the segregation unit to assess Mr PERSON ’s medical state included judging whether his medication level was appropriate and whether he was a suicidal risk . Dr PERSON ’s implication that medical staff connive with the ‘ authorities’ to punish is totally untrue . We provide medical care and our ethical stance is concerned with this and this alone . We hold ORG meetings regularly at which our ethical stance is clearly outlined . This is something I know we all care about passionately and is the cornerstone of the medicine all of us practise here .

I am not of the opinion that PERSON suffered from paranoid schizophrenia . This is based on my own observations and Dr Roberts’ doubt about his diagnosis ( and he was the Psychiatrist who had observed him as an in - patient the most recently prior to his reception ) . We did not have a patient , ‘ known to suffer from PERSON , ( Dr PERSON ) . He was known to us via Dr PERSON information as a patient suffering from , ‘ personality disorder , anti - social , under stress , some fleeting paranoid ORG . PERSON appeared quite normal most of the time during his periods of custody and observation .

Self - harm , suicide and violence are recognised complications of personality disorder . Only the self reported paranoia and hearing voices are symptoms of schizophrenia . There is ample evidence that PERSON ’s episodes of paranoia were intermittent and transitory . ( Dr PERSON described , ‘ episodic paranoia’ , and Dr PERSON , ‘ isolated flare - ups’ ) , linked to the taking of illicit substances . From the IMR , “ says he has had cannabis which tripped him out and made him paranoid’ . ...

Mr PERSON was afraid of being on ordinary location but not of being in the segregation unit . This supports a theory that he had real and not imaginary fears for his safety on the wing , especially in the light of him telling me ‘ he owed’ . Nevertheless Mr PERSON was always admitted to the hospital when he had a ‘ flare - up’ . Dr PERSON ’s analogy of mental illness and a fever is neither appropriate nor convincing .

There is no clear description of delusions , in fact their description is vague except , ‘ thinking he is Jesus’ . I did not find any continuity of a strongly held delusional system .

It is clear from the IMR that Mr PERSON had long periods when he did not display any symptoms or signs of mental illness and he was therefore at these times mentally well . Being well there were no contra - indications to being located in the main prison or segregation unit .

It was notable that PERSON did not display the signs that PERSON describes for us , i.e. immobility of features , unresponsiveness , poor eye contact , reduced body language , alogia . This was further evidence to us that he did not suffer from a florid psychosis .

Overall , from the CARDINAL reports prepared , I find the evidence for a florid psychosis to be slim . PERSON is not a forensic psychiatrist and appears unfamiliar with prison medical care . Her comments are emotive rather than objective .

PERSON was known to us as an impulsive , self - harming and aggressive man who periodically had episodes when he described paranoid feelings and vague delusional symptoms . There is no evidence to support the diagnosis of schizophrenia with which he strongly self - labelled himself . His disturbed episodes and death may well have been the sequel to drug taking in the main wing , consequent upon which were threats of reprisal . ”

Dr PERSON , instructed on behalf of the Government , stated , inter alia , as follows :

“ Opinion

It has been asserted that by the complainant and the CARDINAL psychiatrists ( PERSON and PERSON ) that have reviewed the case that PERSON was wrongly diagnosed , his symptoms overlooked and that he was placed in situations which would inflame his condition . Both doctors concluded that PERSON suffered from schizophrenia and that much of his behaviour could be explained by this . Having made this diagnosis they say his fears and anxieties must have been due to an underlying delusional state . This is an assumption based on the belief that PERSON was schizophrenic . On the basis of their assumption that PERSON was seriously mentally ill it is also asserted that the prison should have anticipated his suicidal tendencies and taken better precautions and not subjected him to the privation of the punishment block .

The prison was not staffed by consultant psychiatrists . The doctors there would very properly rely on the opinion of the ORG specialists who had been caring for their inmates before imprisonment . The diagnosis given to them by PERSON ’s latest psychiatric specialist ( PERSON ) was of ‘ personality disorder , antisocial in GPE , and that PERSON was liable to ‘ fleeting paranoid ORG when under stress .

It is true that Dr PERSON had also treated PERSON in the past and had described him as suffering from ‘ a mild chronic PERSON . This is not a specific diagnosis but a general description . In any case PERSON did not consider PERSON so ill as to require treatment in psychiatric hospital . He indicated , like PERSON , that PERSON would have short lived periods of psychosis ( and panics ) at which time he would need special care and treatment . He recommended that PERSON not be given association until recovered from his ‘ panic and paranoia’ . This recommendation seems to have been met .

The staff in GPE proceeded along the lines outlined by PERSON giving the medication he recommended in the hope of reducing PERSON ’s symptoms e.g. his volatility , his poor response to stress and his tendency to transient psychotic periods . They also admitted PERSON to the ORG when his condition appeared to deteriorate .

Much of PERSON ’s behaviour can be understood as manipulative to escape the pressures of the ordinary wings into the relative peace of the ORG . There is no evidence that the fears he expressed about being attacked on the wings were not understandable or even reasonable ones . There is no reason , given Dr Roberts’ diagnosis , not to accept PERSON ’s account at face value . Where there were episodes which might have been psychotic ones ( e.g. when he claimed to be PERSON and hearing voices ) he was taken into the ORG and appeared to recover quickly as PERSON indicated he would .

In the end PERSON seemed to accept the regime of the punishment wing and settle down . The observations we have all support that this was so . PERSON obviously was initially angered by the punishment given out on CARDINAL.CARDINAL.CARDINAL though he seemed to have overcome his anger . There was no evidence that he had become psychotic . His worries ( CARDINAL ) about his access to the shop being stopped by the governor were perfectly understandable . It is not necessary to postulate mental illness to explain them . I conclude that the medical management of PERSON during his stay in GPE prison was perfectly reasonable particularly given the opinion of PERSON . We do not know what PERSON intended on TIME of CARDINAL . The pattern was very similar to previous life threatening attempts with a warning to others so he might be saved . Perhaps he had decided that he could not or would not face a further period on the punishment block and that he would demonstrate this by the attempt during which he would be saved and returned to the ORG . I do not think anyone could have anticipated what he did or when he did it . My only criticism would be that at the very end scissors to cut the ligature were not available on the punishment wing . ”

Section CARDINAL of the Prison Act DATE required each prison to have a medical officer who , according to Rule CARDINAL of the Prison Rules DATE promulgated by the Secretary of ORG , was responsible for “ the care of the health , mental and physical , of the prisoners in that prison ” .

Rule CARDINAL provided :

“ ( CARDINAL ) The medical officer shall report to the governor on the case of any prisoner whose health is likely to be injuriously affected by continued imprisonment or any conditions of imprisonment . ...

( CARDINAL ) The medical officer shall pay special attention to any prisoner whose mental condition appears to require it , and make any special arrangements which appear necessary for his supervision and care .

( CARDINAL ) The medical officer shall inform the governor if he suspects any prisoner of having suicidal intentions , and the prisoner shall be placed under special observation . ”

Health care within prisons was also governed by LAW , which defined the responsibilities and duties of the members of a prison health care team . LAW provided :

“ The initial medical assessment of all prisoners to the health care centre on or shortly after reception into prison , or as a result of concern about their mental state , should include consideration of special arrangements needed for their supervision to prevent attempts to harm themselves or commit suicide . Where it is considered that special supervision is medically indicated the medical officer will order supervision in CARDINAL of the following forms :

( a ) continuous supervision , in which the prisoner is observed by a designated officer who remains constantly in his or her presence ; or

( b ) intermittent supervision in which the prisoner is observed by a designated officer at intervals of not TIME . ”

ORG also issued its own guidelines . At the relevant time , these were in the form of Circular Instruction CARDINAL/CARDINAL providing guidance , inter alia , relating to staff responsibilities , action on reception , referral and assessment during custody and preventative measures in respect of prison suicides . Circular Instruction CARDINAL/CARDINAL defined the task of ORG as being

“ to take all reasonable steps to identify prisoners who are developing suicidal feelings ; to treat and manage them in ways that are humane and most likely to prevent suicide ; and to promote recovery from suicidal crisis ” .

The central element of this system was the suicide referral form ( FCARDINAL ) . Wing managers ( senior prison officers ) transmitted referrals to the prison medical officer who decided whether any suicide prevention measures should be taken . Following criticism by the Chief Inspector of Prisons in his report “ Suicide and Self - Harm in Prison Service Establishments in GPE and GPE ” , new guidelines were issued in DATE Instruction to Governors CARDINAL/CARDINAL . This required , inter alia , a specific Self - Harm / At Risk form ( FCARDINALSH ) to be used where a prisoner was identified by any member of staff as needing special care due to the risk of suicide or self - harm . This enabled the observations of all personnel in contact with the prisoner to be recorded and was intended to provide a comprehensive and ongoing record of the prisoner ’s state of mind . A case review by the key personnel involved in the prisoner ’s care ( for example , the senior medical officer , a governor grade and the senior wing officer ) was to take place before the prisoner was taken off ORG At Risk form .

Under sections DATE and CARDINAL of LAW DATE , any prisoner suffering from a serious mental illness might be transferred to a hospital for detention and treatment .

Rule CARDINAL of the Prison Rules DATE , pursuant to which PERSON was placed in segregation , required the prison governor to remove a prisoner from segregation in the event that a medical officer so advised on medical grounds . Rule CARDINAL(CARDINAL ) provided that no punishment in cellular confinement was to be imposed unless a medical officer had certified that the prisoner was in a sufficiently fit state of health .

There was no requirement under statute or the Rules for a prison to be staffed by a medical officer with psychiatric qualifications . The medical officer did have discretion to request a psychiatric opinion when considered appropriate ( Rule CARDINAL ) .

In an article published in ORG ( DATE , vol . CARDINAL , “ Inpatient care of mentally ill people in prison : results of a DATE ’s programme of semistructured inspections ” ) , the medical and nursing inspectors of Her Majesty ’s Inspectorate of Prisons stated , inter alia :

“ The quality of services for mentally ill prisoners [ fall ] far below the standards in ORG . Patients’ lives [ are ] unacceptably restricted and therapy limited . The present policy dividing inpatient care of mentally disordered persons between the prison service and the ORG needs reconsideration . ”

Under the Prison Rules DATE , a prisoner could be confined in a prison ’s segregation unit or punishment block under CARDINAL provisions .

Under Rule CARDINAL , a governor had the power to segregate a prisoner where this appeared desirable for the maintenance of good order or discipline or in his own interests . This was limited to DATE , after which any extension had to be authorised by a member of ORG or the Secretary of ORG .

Under Rule CARDINAL(CARDINAL)e , the governor had the power to punish a prisoner convicted of a disciplinary offence by ordering CARDINAL days’ cellular confinement in the punishment block .

The conditions of prisoners segregated in a prison ’s punishment block have been considered by the Chief Inspector of Prisons and Lord Justice PERSON , who carried out an inquiry into the prison system .

In his DATE report “ A Review of the Segregation of Prisoners under Rule CARDINAL ” , the Chief Inspector of Prisons commented :

“ ORG inmates were held in very restricted conditions ... They were usually located in the area of the prison called the segregation unit or punishment block , alongside inmates who were there under punishment ... They were generally subjected to much the same sort of regime as the prisoners under punishment , except that they were allowed a few extra privileges . They were locked up on their own in a cell for nearly the whole day ; only coming out to have an TIME ’s exercise walking round a yard , to collect their meals , to empty their chamber pots and to have an occasional shower . These excursions perhaps helped to break the monotony but usually did not provide them with much social contact . Opportunities to talk with fellow inmates were very limited and their relationships with staff were often antagonistic or distant ... [ paragraph CARDINAL ]

... removal from association can involve the loss of various opportunities and advantages in addition to the obvious deprivation of human contact . The decision to segregate should therefore always be taken with care but especially so when the inmate concerned has not directly requested segregation . Accordingly , decisions to impose segregation on unwilling prisoners should be subject to particularly strong and effective safeguards . ” ( paragraph CARDINAL )

He added that segregation “ can entail living under an impoverished and monotonous regime which may even be psychologically harmful ” .

Lord PERSON , in his report “ Prison Disturbances ” , DATE , Cm CARDINAL , stated :

“ While segregation under LAW is not intended to be a punishment , the use of the Rule will almost invariably adversely affect the inmate who is made subject to it . In most establishments anyone segregated under LAW will be subjected to regime restrictions very similar to those undergoing punishment . ” ( paragraph CARDINAL )

Although there is no obligation on the governor or ORG to consult a doctor before initiating segregation , the governor is obliged to discontinue it if so advised by a medical officer on medical grounds ( Rules CARDINAL and CARDINAL of the DATE Rules ) .

DATE . If a prisoner has a complaint in relation to the conditions of his imprisonment or an adjudication , he may use the “ remedies and complaints ” system .

If the complaint relates to conditions of detention and can not be resolved informally , the prisoner may make a formal application which will be recorded and a senior member of staff will discuss the matter with the prisoner usually within DATE . If the prisoner remains dissatisfied , he then completes a request / complaint form to be considered by the governor , who usually replies within DATE . The prisoner may then appeal to the Area Manager of ORG .

A complaint about an adjudication is submitted immediately to the Area Manager .

NORP In either case , if the prisoner is dissatisfied with the decision of the Area Manager he may make an application for judicial review or make a complaint to ORG .

Since DATE , prisoners who have exhausted the internal complaints system appeal to ORG , who may make recommendations to ORG if he upholds a complaint . He can not quash or overrule a ORG decision .

In his DATE report for DATE , ORG stated , in respect of the complaints system :

“ CARDINAL . ... the ORG ’s service DATE and indeed ORG internal requests / complaints system – is working well with regard to complaints about relatively formal and non - urgent topics . Prisoners generally know the well - established procedures for dealing with grievances about disciplinary adjudications and property loss and are willing to wait while the somewhat lengthy complaint processes are worked through .

The situation is very different for most other categories of complaint . Assaults , refusal of temporary release , the imposition of closed visits ... all these are matters which prisoners want resolved immediately . They are also issues for which the request / complaints procedures may superficially appear to be inappropriate or issues which prisoners are afraid to raise with staff within the prison . Certainly , the relatively lengthy and formalised process of complaint to the governor ( taking a DATE plus ) , an appeal to ORG ( taking DATE ) and an ORG ’s investigation ( taking DATE and sometimes more ) will not commend itself to a disaffected prisoner wanting immediate redress . ”

Case - law establishes that the High Court enjoys jurisdiction to grant judicial review of a decision either to segregate a prisoner pursuant to Rule CARDINAL of the Prison Rules DATE or to punish him pursuant to Rule CARDINAL ( NORP v. Deputy Governor of FAC , ex parte GPE [ DATE ] CARDINAL Appeal Cases CARDINAL ) . The court would review the matter in accordance with the well - established principles of administrative law , namely , whether the decision was perverse or irrational , whether the decision was made by reference to irrelevant factors or without regard to relevant factors , or made for an improper purpose , in a procedurally unfair manner or in a manner which breached any governing legislation or statutory instrument . However , the court of review can not substitute its own decision on the merits of the case for that of the decision - making authority .

A prisoner able to prove that his conditions of confinement have caused him injury , physical or psychiatric , resulting from the negligence of the prison authorities may claim an award of damages . If a prisoner is assaulted , he may maintain an action for assault , even in the absence of proof of physical injury . Damages may be awarded for any indignity or humiliation suffered , while exemplary damages may be awarded where the court concludes that there has been “ oppressive , arbitrary or unconstitutional action by the servants of the government ” ( PERSON v. PERSON [ DATE ] Appeal Cases CARDINAL ) .

An action for the tort of misfeasance in public office may also be maintained if there has been a deliberate or dishonest abuse by a public officer through the purported exercise of a power otherwise than in an honest attempt to perform the relevant function . It includes performance of an act which the official has no power to perform with the object of injuring the claimant or where he knew he had no authority to perform it and actually foresaw that it could cause harm to the claimant or an identifiable class to whom the claimant belonged . “ Harm ” is not limited to physical or psychiatric damage .

DATE . Following the death of a prisoner and regardless of the cause , an inquest must be held pursuant to section CARDINAL(CARDINAL)c of LAW DATE . Such inquests must be held with a jury ( section CARDINAL(CARDINAL)a ) . The coroner is the independent judicial officer charged with inquiring into deaths of various categories . His duties have been judicially defined :

“ It is the duty of the coroner as the public official responsible for the conduct of inquests , whether he is sitting with a jury or without , to ensure that the relevant facts are fully , fairly and fearlessly investigated . He is bound to recognise the acute public concern rightly aroused where deaths occur in custody . He must ensure that the relevant facts are exposed to public scrutiny , particularly if there is evidence of foul play , abuse or inhumanity . ” ( NORP v. GPE , ex parte PERSON [ DATE ] Queen ’s Bench CARDINAL ( Court of Appeal ) CARDINAL )

Rule CARDINAL of the Coroner ’s Rules allows the parent of a deceased person to examine witnesses at an inquest either in person or through counsel or a solicitor . There is , however , no legal aid for representation at inquests . Nor at the time of the inquest in this case was there any right to disclosure of documents .

Under LAW of the Coroner ’s LAW and Rule CARDINAL of the Coroner ’s Rules , proceedings and evidence at an inquest must be directed solely to ascertaining

– who the deceased was ;

– where the deceased came by his death ;

– when the deceased came by his death ;

– how the deceased came by his death .

No verdict may , however , be framed in such a way as to appear to determine any question of the criminal liability of a named person or civil liability .

The scope of an inquest has been described judicially as follows :

“ ... It is noteworthy that the task is not to ascertain how the deceased died , which might raise general and far - reaching issues , but ‘ how ... the deceased came by his ORG , a far more limited question directed to the means by which the deceased came by his death .

... I further consider that [ previous judgments ] make it clear that when ORG stated that CARDINAL of the purposes of an inquest is ‘ to allay rumours or suspicions’ this purpose should be confined to allaying rumours and suspicions of how the deceased came by his death and not to allaying rumours or suspicions about the broad circumstances in which the deceased came by his death . ” ( Sir PERSON , ORG , NORP v. the Coroner for GPE and GPE , ex parte PERSON , DATE , unreported )

“ The cases establish that although the word ‘ how’ is to be widely interpreted , it means ‘ by what ORG rather than in what broad circumstances ... In short , the inquiry must focus on matters directly causative of death and must , indeed , be confined to those matters alone ... ” ( ORG , ORG , NORP v. Coroner for LOC of GPE , ex parte PERSON and Others ( DATE ) CARDINAL Justice of FAC )

“ ... it should not be forgotten that an inquest is a fact finding exercise and not a method of apportioning guilt . The procedure and rules of evidence which are suitable for CARDINAL are unsuitable for the other . In an inquest it should never be forgotten that there are no parties , no indictment , there is no prosecution , there is no defence , there is no trial , simply an attempt to establish the facts . It is an inquisitorial process , a process of investigation quite unlike a trial ...

It is well recognised that a purpose of an inquest is that rumour may be allayed ; But that does not mean it is the duty of the Coroner to investigate at an inquest every rumour or allegation that may be brought to his attention . It is ... his duty to discharge his statutory role – the scope of his enquiry must not be allowed to drift into the uncharted seas of rumour and allegation . He will proceed safely and properly if he investigates the facts which it appears are relevant to the statutory issues before him . ” ( Lord Lane , ORG , NORP v. GPE , ex parte PERSON ( DATE ) CARDINAL Solicitors’ Journal CARDINAL )

A person who suffers injury , physical or psychiatric , in consequence of the negligence of another may bring an action for damages for that injury . An exacerbation of an existing condition constitutes such injury . Upset and injury to feelings resulting from negligence in the absence of physical or psychiatric damage or exacerbation do not entitle a plaintiff to damages . Any personal - injury action maintainable by a living person survives for the benefit of his estate and may be pursued after his death .

Claims arising from the death of an individual caused by negligence are brought under LAW DATE or LAW ( LAW DATE . The former enables those who were financially dependent on the deceased to recover damages for the loss of support ; the scheme is compensatory and , save for the sum of MONEY for bereavement awarded to the spouse of a deceased or parent of a deceased child under CARDINAL at the time of death , damages are awarded to reflect the loss of support . The latter enables damages to be recovered on behalf of the deceased ’s estate and may include any right of action vested in the deceased at the time of his death together with funeral expenses .

According to the case - law , the common law imposes a duty of care on prison authorities in respect of those in their custody . The prison authorities have a duty to exercise reasonable care in the prevention of injury and harm and a duty to provide medical care . This duty extends to the protection of a mentally ill prisoner against committing suicide . In GPE v. the Chief Constable of Greater Manchester [ DATE ] CARDINAL All England Law Reports CARDINAL , the custodial authority was held liable for failing to prevent a suicide .

In Commissioner for the Police for the LOC v. PERSON [ DATE ] CARDINAL Weekly Law Reports CARDINAL , concerning the claims of the deceased ’s spouse under LAW , ORG confirmed that even in the case of a prisoner of apparently sound mind the authorities remain liable for a negligent failure to prevent his suicide , although in such a case the liability is shared with the deceased because of his voluntary act . Respect for personal autonomy did not preclude that steps be taken to “ control a prisoner ’s environment in non - invasive ways calculated to make suicide more difficult ” ( p. CARDINAL - B ) .

As regards the standard of care , in ORG [ DATE ] CARDINAL All England Law Reports CARDINAL , which concerned , inter alia , whether a continuous as opposed to a TIME watch should have been in place on a mentally ill prisoner at the relevant time , PERSON held that the duty to take reasonable care of such a prisoner

“ should not and does not expect the same standard across the entire spectrum of situations , including the possibility of suicide , as it would in a psychiatric hospital outside prison . The duty is tailored to the act and functions performed . ”

However , more recently , in ORG , DATE ) , ORG held in relation to the provision of ante - natal care to a pregnant woman :

“ We are concerned with a remand prisoner , a high risk pregnancy . I can not regard PERSON as authority for the proposition that the plaintiff should not , while detained in GPE , be entitled to expect the same level of ante - natal care , both for herself and her unborn infants , as if she was at liberty , subject of course to the constraints of having to be escorted and , to some extent , movement being retarded by those requirements . ”


Violation of Article 1 of Protocol No. 1 - Protection of property

Alvina Gyulumyan;Corneliu Bîrsan;Egbert Myjer;Elisabet Fura;Ineta Ziemele;Josep Casadevall

The first applicant was born in DATE and lives in GPE ( GPE ) . The second applicant was born in DATE and died in DATE .

On DATE the applicants’ property , comprising flat no . CARDINAL and appurtenant land situated in GPE , Intrarea PERSON no . CARDINAL , was seized by GPE no . CARDINAL/CARDINAL , following their decision to leave the country . No compensation was paid . No copy of the decision to seize the property was sent to the applicants .

On DATE company ORG , a ORG - owned company responsible for the management of property belonging to the ORG , sold the flat to the then tenant , ORG , under PERSON no . LANGUAGE .

On DATE the applicants brought court proceedings for restitutio in integrum and seeking to have the sale by the ORG declared null and void .

On DATE the applicants lodged an application with the administrative authorities for restitution in kind of the property under Law no . CARDINAL/CARDINAL governing immovable property wrongfully seized by the ORG . So far they have not received any answer .

On DATE ORG Instance allowed the applicants’ action in part . In the operative part of the judgment it held , inter alia , that there were no grounds for rescission of the sale by the ORG , but ordered ORG to allow the applicants to take possession of the flat and the appurtenant land . The court compared the property titles , finding that the seizure had been unlawful but that ORG had made the purchase in good faith .

On DATE ORG allowed an appeal by ORG and by company ORG and , in the operative part of the judgment , varied the judgment of the first - instance court by dismissing the applicants’ action for recovery of the property . In its reasoning , the court considered that the first - instance court had been requested by the applicants to assess whether the seizure was null and void because they had not been sent a copy of the seizure decision , and that therefore the lower court should not have analysed the lawfulness of the seizure of its own motion . ORG also considered that the failure to inform the applicants of the seizure did not affect its validity and that the applicants had no valid property title .

On DATE ORG , in the operative part of a final decision , dismissed as groundless an appeal on points of law by the applicants . In the reasoning of the judgment the court considered that although some of the ORG criticisms were well - founded , in particular regarding the misinterpretation of the law by ORG when it found that ORG had exceeded the limits of the request made by the applicants , those criticisms did not constitute grounds for amending the previous judgment in accordance with LAW , but only for removing its reasoning . Therefore , in the reasoning part of its decision , ORG considered , in line with the findings of the first - instance court , that the ORG had no valid title and that therefore the applicants had never lost their right of property . However , the court reasoned that as the applicants had not contested ORG ’s good faith in their appeal , ORG had correctly dismissed their claim for recovery of the property .

NORP The relevant legal provisions and jurisprudence are set forth in the judgments GPE v. GPE ( [ ORG ] , no . CARDINAL , § § CARDINAL - CARDINAL , ECHR CARDINALVII ) ; PERSON and Others v. GPE ( no . MONEY , § § DATE , ORG CARDINALVII ) ; ORG v. GPE ( no . CARDINAL , § § CARDINAL - CARDINAL , ECHR CARDINALXII ( extracts ) ) ; and PERSON v. GPE ( no . CARDINAL , § § CARDINAL , DATE ) .


Preliminary objection allowed (non-exhaustion of domestic remedies);Violation of Art. 5-3;Remainder inadmissible;Non-pecuniary damage - finding of violation sufficient;Costs and expenses partial award - Convention proceedings

The applicant was born in DATE and lives in GPE .

On DATE the applicant was arrested and brought before an investigator who decided to remand him in custody on charges of sexual assault allegedly committed against a minor on DATE , an offence punishable with DATE imprisonment under LAW of LAW . The investigator 's decision was confirmed by a prosecutor .

On DATE the investigator conducted searches in the applicant 's home .

On DATE the applicant was released .

In the course of the investigation a number of witnesses , the alleged victim and the applicant were heard and several forensic and medical reports were drawn up .

On DATE the investigator submitted his conclusions to the prosecutor , proposing that the applicant should be indicted for sexual assault .

On DATE ORG referred the case back to the investigator instructing him to undertake further investigation as to whether the applicant had raped the same girl on DATE , as alleged by her .

Since the alleged victim had changed her address and could not be located , the investigation could not proceed and was suspended on DATE .

NORP In DATE the case file was transmitted to the district police in GPE with instruction to continue seeking the alleged victim 's address . It appears that as of DATE , the date of the latest communication received from the parties , the investigation remained suspended .

The relevant provisions of LAW ( “ ORG ” ) concerning decisions on pre - trial detention and the NORP authorities ' practice at the relevant time are summarised in the ORG 's judgments in several similar cases ( see , among others , the ORG v. GPE [ ORG ] , no . ORG , § § CARDINAL , ORG CARDINAL-II ; PERSON v. GPE , no . GPE , § § DATE , DATE ; and ORG v. GPE , no . CARDINAL , § § DATE , ORG ORG ( extracts ) ) .

A legislative amendment that entered into force on DATE introduced a possibility for an accused person to request that his case be brought for trial if the investigation has not been completed within DATE in cases concerning serious offences and DATE in all other cases ( Article CARDINALa CCP as in force until DATE ) . In accordance with section CARDINAL of the transitory provisions to the DATE amendment , that possibility applies with immediate effect in respect of investigations opened before DATE . In DATE , Article CARDINAL was superseded by ORG CARDINAL and CARDINAL of the new ORG , which have the same wording .

The procedure under those provisions is as follows . The accused person must submit a request to the relevant court which has DATE to examine the file . It may refer the case back to the prosecuting authorities or terminate the criminal proceedings . If the case is referred to the prosecutors , they have DATE to file an indictment with the trial court or to terminate the proceedings failing which the court is under a duty to terminate the proceedings against the accused person who had filed the request .

The DATE amendment was introduced in ORG with the reasoning that it was necessary to secure observance of the right to trial within a reasonable time as guaranteed by the ORG .