Never get arrested and sent to prison at the weekend

Never get arrested and sent to prison at the weekend -that would have been good advice for Waleed Ali

Waleed Ali did not have much luck in life. Even as a child he had never been right, he heard things and had never been sent to school. He had been taken prisoner to Iraq as a young Kurdish man and possibly tortured. By 2022 he was in London and was being cared for by his family here. His doctors recognised potential PTSD and a learning disability, and depression. He was taking serious doses of antipsychotic and anti-depressive medications but still reported depression.

One Friday in October 2022 he met his ex-partner and her small child in the street and was fortunately prevented from doing her serious harm when passers by intervened. The police who arrested him immediately appreciated that something was wrong. He made strange noises, tried to take off his trousers, and at times he appeared quite absent. Sensibly they took him to St Mary’s Hospital.

There, he shouted about wanting to kill himself and again he ‘checked out’ from time to time but was judged not so ill as to be sectioned and was therefore released back to the police. The doctors could not see the records for Mr Ali’s long history of mental illness and had no background to follow up. Medical records are not easily available between GPs and hospitals. Mr Ali could not describe his medical history or his medication.

At the police station he was charged with attempted murder and placed under constant watch in his cell because his behaviour was so erratic. He lay on the cell floor, attempted to pull out his toenails, and appeared vacant at times. Officers described odd noises. He spent his last night in this police cell.

The nurses in the police station were so worried that they reported to the mental health team at the Westminster Magistrates Court that Mr Ali needed constant supervision because he was at such high risk of suicide and self-harm. So far so good, this team at the Magistrates Court were experienced, they knew that the prison and court system effectively closed down at the weekend, and they knew that everyone should be on high alert - they had a defendant moving to Court and Prison on a Saturday who was a danger to himself and possibly to others. A nurse was so worried that she reported in person to the SERCO custody team to alert them and then she emailed the Wandsworth Reception and mental health teams warning them that a person at high risk was going to arrive tomorrow.

Failures in prison transport

When defendants are moved, whether from the police station to court or on to prison, there is vital paperwork that must be completed and which must be read. This is known as the Person Escort Record or PER. The front pages are the most important, they show the risks the person may be to himself or others, and the levels of observation and care that must be taken. Without completing and/or accessing their PER, a defendant should not be moved.

Sadly, this is where the system started to fail. A flood at another Magistrate’s Court that Saturday morning meant that double the number of cases were suddenly going through the Westminster Court creating a degree of chaos. On top of this, SERCO and HMPPS were slowly transitioning from a paper PER to a digital PER system and this had still not yet fully bedded in.  Neither of the two staff of the SERCO van moving Mr Ali to court or then on to Wandsworth Prison read the digital PER as they apparently couldn’t access this on their handheld equipment. They weren’t able to access paper copies either as the printer in the Police Station wasn’t working. Neither did they watch him on their CCTV in the van. Shockingly in the inquest, the jury watched 40 minutes of Mr Ali in obvious distress, howling, becoming vacant, and rolling his eyes, trying to pull at his toes. When the van got to the prison SERCO staff made no report of any risk or strange behaviour. A SERCO senior manager of the Transport division confirmed that Mr Ali should never have been moved in a van without the transport team having access to and reading his PER which would have alerted them to his high level of risk. They should have completed a SASH (a suicide and self-harm paper form) which would have been handed in at the prison reception and should have immediately triggered action to prevent Mr Ali from harm.  They should have put him in Cell1 in the van where they would have seen what was happening. But this is not what happened.

Failures in Wandsworth Prison

At the prison, more mistakes were made. While the digital PER could be read, the junior officer on Reception didn’t have easy access to a terminal. As a result, Reception had got into the habit of relying on the warrant from the Court which put Mr Ali in their custody, the handovers of the SERCO team to find out about the new arrivals and any SASH forms.  In Mr Ali’s case there was no spoken handover or SASH form. The primary concern of the SERCO team was handing over the property bags, not the men. The prison officers on Reception therefore relied on the warrant, even though the Digital PER was available and would have clearly shown that this was a prisoner who was self-harming or suicidal. Unfortunately, the warrant contained a mistake in Mr Ali’s date of birth and, while the nurse on Reception thought him odd, she could not trace his medical history or his GP notes, it being Saturday afternoon, and nothing could be done to find his medical records until Monday morning. She thought him fit to share a cell.

Mr Ali ended up, with no medication, in a cell for two on Saturday evening, having arrived in the prison just after 5pm. His cell mate did not like the look of him, and it was mutual, but the door was closed on them. Mr Ali became increasingly disturbed, his behaviour was again very erratic, and he was making the same strange noises. This was not going down well with his cell mate and eventually there was a row. Mr Ali rang the cell bell several times and asked to change cells but was told that this would have to be dealt with in the morning. The cell mate took the top bunk and went to sleep. He woke and put on the light at about 9.00pm to find his vape. He saw Mr Ali had hung himself. He rang the cell bell and waited for the officer to come. Despite some quick thinking and bravery from an officer who went into the cell alone to cut Mr Ali down before more help arrived, he could not be revived. He had been in Wandsworth just 4 hours.

It is worth noting that Mr Ali had badly attacked a woman in the street the previous day, but no SERCO staff or prison staff knew that precautions might be necessary to protect themselves or their colleagues. The failure to read his PER, to assure themselves that they had his notes, and to understand the risks he carried had serious consequences not only for Mr Ali but could have been equally serious for other prisoners and SERCO employees and HMP Wandsworth officers.

This tragic saga was triggered by Mr Ali’s actions happening on a Friday, when the courts were over busy and he could not be ‘processed’ until Saturday, until a flood meant that this was not a normal Saturday when normally ‘nothing much happens” and because the people who can trace NHS records were not at work.

But add to this the sloppiness, poor training and reliance on new digital systems that in reality don’t work as well as the old paper forms. This led to men like Mr Ali being moved across London without any understanding of the risks they posed, prisoners processed through the reception of the prison, again with no appreciation of their history, or what any other experienced teams who had met and worked with them had said. There was no sharing of knowledge.

It was a mess, and Mr Ali died. The jury came to a verdict of suicide.

Now it is for SERCO to convince HMPPS that its staff do not move people without reading their notes; that each member of staff knows their job and its responsibilities and does a reliable hand over to the next team.

 It is for the prison to ensure that its staff are better trained, and read the history and the emails in their in-box from concerned parties and always open the correct procedures as soon as they see a hint of suicidal behaviour or thoughts.

It is for the medical teams to get to grips with the strange modern notion that people fall ill, commit crimes, and generally live their lives seven days a week and that a service that leaves on a Friday at four and wakes up on a Monday at ten does not work well at all.  We need to be able to trace medical records 24/7 in hospitals and prisons -the consequences of failure are too painful.

A postscript: When he was in First Night, Mr Ali was given a PIN which would have enabled him to ring his brother, who was his main carer. He couldn’t however as he didn’t know his brother’s number which was in his phone which had by this time been locked away. Could a call have saved him? We will never know. WPIC has suggested to the Governor and Head of Safety that a relative’s number could be recorded on the prisoner NOMIS system at the Reception desk as this would then be available to any officer or member of the healthcare team. The Governor has approved this move and has also put it forward to the regional safety board.