UK: Severin complaint "fully justified"
01 May 1999
On 8 March, a damning report by the Parliamentary Ombudsman into the death of Kenneth Severin in Belmarsh prison was finally published. It followed a complaint made on behalf of Kenneth's family by INQUEST, the organisation that since 1980 has campaigned in support of bereaved families following a death in custody.
Kenneth Severin died while being restrained by prison officers in November 1995. The inquest held into his death in January 1997 recorded an open verdict with positional asphyxia following restraint as the cause of death. However, an inquest has a very narrow remit and it is manifestly not a public inquiry. It is concerned primarily with the medical cause of death and consequently the range of issues of concern to the family could not be properly explored. INQUEST's concern about the evidence that emerged at the inquest about the ill treatment and subsequent death of a mentally ill man in prison led the group to write to the Prisons Ombudsman as the independent body that can investigate complaints against the Prison Service.
INQUEST requested that they investigate this case because of the serious issues that needed to be explored. The Prisons Ombudsman replied, indicating that while he was very sympathetic to our request he could not investigate the complaint. Firstly, because part of the case concerned the clinical judgement of doctors, which is specifically excluded from his remit, and secondly and potentially more importantly he had no remit to investigate complaints about a prisoners' treatment from third parties which rules out the family of the deceased. INQUEST has raised with the Home Secretary whether the remit of the Prisons Ombudsman should be widened so that he can accept complaints about prisoners' treatment from third parties ie: the families of those who die in custody.
With no other mechanism available, INQUEST complained to the Parliamentary Ombudsman on the family's behalf through the Woolwich MP, John Austin. The Parliamentary Ombudsman looks into misfeasance and maladministration in public office.
The complaint highlighted issues about prison health care, the treatment of the mentally ill in prison, the use of strip cells, the lack of communication between discipline and medical staff. It also exposed failings at a national and local level to ensure that prison officers were properly trained in the dangers of control and restraint. It also raised concerns about the failure of the Prison service to disclose to the family the internal inquiry report.
In a highly critical report the Ombudsman expresses particular concerns about prison health care and the treatment of a mentally ill man. He found that Mr Severin's death had followed an incident that should have been treated as a problem requiring medical advice but was treated as a routine disciplinary issue.
"Mr Severin received no more care than would have been accorded to a prisoner in the main prison despite the fact that he was mentally ill and had accordingly been located in the health care centre. I conclude that a combination of inadequate health care staffing and inadequate communication between non-health care and health care staff denied Mr Severin medical consideration at the time when he most needed it, and allowed less well judged approaches to the situation to prevail. That merits my strongest criticism."
The report also criticised failings at a local and national level within the Prison Service to ensure that prison officers were properly trained in the dangers of control and restraint:
"... the [Prison Service] were slow to alert prison Governors fully to the danger of positional asphyxia; they failed to translate such warnings as they gave into adequate instructions for their training staff, and the training arrangements at Belmarsh failed to keep officers up to date regarding such limited modifications as were made. The result was that in 1995 Mr Severin was dealt with in the same way as he would h