HC Deb 21 May 1984 vol 60 cc801-8

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Douglas Hogg.]

12 midnight

Mr. Andrew F. Bennett (Denton and Reddish)

I am grateful for the opportunity to raise the need for a public inquiry into the death of Alan Tschelebinski in Strangeways prison, Manchester in January 1983.

I had hoped that the Minister of State, Home Office, who is to reply to the debate, would agree to such a public inquiry. Although nothing can be done for Alan or his parents, we ought to learn the lessons of this tragedy and ensure that nothing like it happens again.

I should have preferred a public inquiry, because I have to criticise many of the individuals who dealt with Alan during the last few minths of his life, and the problem with an Adjournment debate is that it does not give such individuals the opportunity to defend their actions and explain themselves. A public inquiry would give them the chance to explain why they behaved as they did.

A public inquiry would also give us a chance to look at how, once again, the police complaints procedure has not worked. There has been a whitewash over the way in which the police dealt with a mentally ill individual. In addition, a public inquiry would have given us an opportunity to look at the prison medical service, which was not adequate to meet Alan's needs during his eight days in prison.

I shall briefly outline what happened to Alan between 1976 and his death in 1983. While working at Portwood brush works, he contracted TB. Before that, although he had suffered mild epileptic fits at school, he had not had any major problems. However, while being treated for TB at Marple Dale hospital, he suffered a severe attack of grand mal and fairly soon thereafter the first instance of his being violent to other people occurred when he attacked another patient.

However, after that, it was possible for Alan to return home and, although life was fairly difficult for him there, he managed to hold various jobs. In the end, in 1979, it was arranged for him to go into St. Thomas' hospital, Stockport for a short period because of some of the difficulties at home. The social services department arranged for him to go first to Simon house and then Chaucer house — short-term accommodation in Stockport.

Unfortunately, following a case conference at Chaucer house, Alan jumped from a first-floor window and sustained cuts and injuries that resulted in his having to be taken to Manchester royal infirmary. It was felt that he could not be discharged back into the community, but adequate accommodation for him was not available at Stepping hill hospital, Stockport. He was transferred to Prestwich hospital, where considerable investigations were conducted into his epilepsy and into the possibility that he had a cerebral tumour. Extensive investigations were carried out at Salford royal infirmary and Bootham park hospital in York.

For most of the time that Alan was at Prestwich, his behaviour seemed to respond to treatment and, although there was one outburst of violence in late 1981, when he atacked a nurse, it was hoped in 1982 that he could be returned into the community in Stockport.

Unfortunately, there was an apparent lack of liaison between Prestwich hospital and the social services department at Stockport. Nothing happened for a long time, and during that period Alan began to complain that the staff at Prestwich hospital were teasing him. He became very dissatisfied. Eventally it was arranged that he should be moved from Prestwich hospital to the Stepping hill hospital at Stockport, and he went there in November 1982. From that date he appears to have gone to the local police station on two occasions to complain about the treatment that he had received at Prestwich hospital. The doctors at Prestwich believe that he was exaggerating in his complaints.

Alan returned home over the Christmas period of 1982. He was going out from Stepping hill hospital with the agreement of the staff, and he did so on a number of occasions. On the Wednesday after Christmas he left his home and his parents assumed that he was returning to the hospital. However, it is alleged that he returned to Prestwich hospital to look for a nurse against whom he had a grudge. At any rate, he believed that he had a grudge against the nurse. Having failed to find the nurse, he set fire to a car belonging to the nurse. He then returned to the Stepping hill hospital and on the following day, Thursday 30 December, the police interviewed him at the hospital as part of their inquiries into the burning of the car. Following that, he was taken to Bury court, where he appeared on the Friday without his parents being able to be present at the court hearing. He was remanded to Strangeways prison and eight days later he died in prison in pretty poor circumstances.

I believe that a public inquiry should address itself to why the police, when they arrested him at Stepping hill hospital, did not inform Alan's parents that they were arresting him. I have a letter that was sent to me in May 1983 by Chief Superintendent Halliwell of the Bury division, in which he makes it clear that he did not tell the parents because he did not believe that he had a duty to do so. He wrote: I would advise you that, of course, Mr. Tschelebinski is an adult and there is no requirement on the police to notify his parents under these circumstances. I accept that there is no duty on the police to inform the parents of an adult that their son or daughter is the subject of their inquiries, but I understood that it was clear practice — it is to be incorporated in the Police and Criminal Evidence Bill—that when there is any doubt about the mental condition of an adult it is the duty of the police to inform the parents.

It was clear to the doctor who was treating Alan at Stepping hill hospital that it was necessary for his parents to be informed. He makes it clear that the nursing staff at Stepping hill hospital impressed upon the police that they believed that Alan's parents should be told and supplied to the police medication for Alan's condition so that he could be properly looked after. The charge nurse was left with the clear understanding that the police would inform Alan's parents of his position.

The police claim that in taking Alan to Bury he told them that he did not want his parents informed. They believed that it was more reasonable to listen to Alan than to his doctor and the charge nurse who was treating him.

When I asked the Minister to consider the holding of a public inquiry, he decided to refer the issue to the Police Complaints Board. There have been considerable discrepancies between what the doctors have said and the police. It was made clear to the police that Alan's parents should be informed. There are discrepancies between what emerged at the inquest and what subsequently emerged when the reporting officer reported to the Police Complaints Board.

I shall read a letter from the solicitors which makes it clear that at the inquest it emerged that the police did not appreciate Alan's condition. The letter states: After the burning of the car, the Police evidence was that they went to Stepping Hill Hospital to arrest him and they denied any knowledge of his psychiatric condition. They maintain that they were introduced to Mr. Tschelebinski in the Hospital waiting room and no mention was made to them that he had been brought from the psychiatric ward. I find this extremely hard to believe, as also I disbelieve all their protestions that they had no knowledge of his mental condition. It is quite clear from the information I have, and which I put to the Police, that this man suffered from epilepsy and also had a serious mental condition and in common parlance, he was completely mad. It would appear that the Magistrates were certainly unaware of his medical history when they remanded him to Strageways and it seems unlikely, in my experience, that they would have done this had they been fully aware of the facts. The Police denied, in their evidence, any suggestion whatever that he had shown any tendencies of insanity and yet it came out later at the inquest, after the Police Sergeants had finished their evidence, that when he arrived at the prison he had a card with him asking the prison authorities to watch him as he was 'violent'. Therefore the Police clearly had an inkling of his medical condition. It is important that the police complaints investigator should have interviewed Alan's parents—which he did—and also the magistrate's clerk at Bury to find out what the police said then, and checked on the evidence at the inquest. I have reason to believe that he did not do that. I hope that when the Minister replies he will confirm whether or not that happened.

The police did not inform Alan's parents on the Thursday and, of particular importance, at about 9 o'clock on Friday morning, half an hour before Alan was due to appear in court, they phoned his parents, who pointed out that it was impossible to get from Brinnington, Stockport to Bury in half an hour. Instead of postponing the case, the police decided to proceed without the parents. It is unfortunate that the magistrates were not provided with all the information and remanded Alan in Strangeways. It is clear from medical evidence that he should not have been put into the conditions that he was at Strangeways.

When Allan arrived at Strangeways he experienced what no one should experience in British prisons. The evidence at the inquest continues: On the day after his arrival at Strangeways he was transferred to a bare cell i.e. a cell with no furniture, bare brick walls and a concrete floor and only a mattress on the floor. This was allegedly for his own safety and he was stripped naked and left in this cell from about the second day until the date of his death. At first he apparently refused food but later he began to eat. He was said to have caused the bruising and injuries to himself by `running against the cell walls'. From the Pathologist's evidence these bruises had in fact occurred some days before his death and they were consistent with this behaviour. He is also said to have spent most of his time lying on the cell floor, latterly in his own excreta. The prison doctor maintains in his evidence that he had a full medical record from the hospitals and that the hospital at Strangeways was a proper place for his detention rather than a secure mental ward. The doctor also maintains that the doctors were competent to treat such a person, even though they had no padded cells or any place to detain him in order to prevent him injuring himself. By way of excuse, they said that their padded cells had been destroyed in a recent fire and that they were using temporary accommodation in the prison.

In addition to that, the prison authorities refused to allow his parents to visit him during his few days in prison. They said that he was too ill to have visitors, in spite of the fact that his mother had dealt with him on many occasions when he was suffering from fits and might well have been the one person who could calm him down. She certainly could have impressed on the prison authorities that they should treat him differently.

There is a major need for an inquiry so that we can find out why the police failed to inform the parents, and satisfy ourselves that the police did riot give one story to the police complaints board and a different one at the inquest. We must also discover why the magistrates at Bury remanded someone to a prison when, had they examined even briefly the charge sheet, they would have realised something about his mental background and would at least have taken into account the fact that Strangeways was an inappropriate place. If the medical officer of Strangeways genuinely had all the medical background on Alan that he claimed at the inquest he had, he, too, should have realised that Strangeways was not the sort of place where, especially in view of the damage to other prison accommodation, Alan could be looked after properly. Finally, we must know why, when it was clear that Alan was in such a bad condition, the medical officer did riot move him to a secure mental hospital that might have had appropriate accommodation for him.

I realise that in 15 minutes I can only sketch the problems of a tragic case. hope that the Minister can answer some of the questions tonight, but, far more, I hope that the Minister will be prepared to have a public inquiry, or some form of inquiry, where all the people involved in this tragedy can be questioned, where lessons can be learnt, and where we can ensure that no one else suffers in this way.

12.15 am
The Minister of State, Home Office (Mr. Douglas Hurd)

The hon. Member for Denton and Reddish (Mr. Bennett) has brought to our attention a terrible personal tragedy, and anyone who examines the matter must share with him a sense of tragedy and express real sympathy to the family of Mr. Tschelebinski. I make no criticism of the hon. Gentleman for raising the matter in this way. It is natural that he should do so. He asks for an inquiry, but we must take into account the fact that Mr. Tschelebinski's death has already been inquired into by inquest and that the role of the police in the matter has been investigated, and a report made to the independent Police Complaints Board.

The hon. Gentleman covered many aspects of the case, and to complement rather than contradict what he said I should set out the events as we have them. On 29 December 1982 the Bury division of Greater Manchester police received a complaint from a member of the staff at Prestwich hospital that his car had been set on fire. Following police inquiries, Mr. Tschelebinski was arrested the following day at Stepping Hill hospital, where he had been a patient for about three weeks. He appeared before Bury magistrates' court on 31 December, when the prosecution requested a remand in custody, which was granted.

Mr. Tschelebinski was received at Manchester prison the same day, where he was examined on reception by a medical officer, who noted his medical history and called for his previous medical records from Prestwich arid Stepping Hill hospitals. In view of Mr. Tschelebinski's epileptic condition and his previous attempt at suicide, the medical officer arranged for him to be admitted to the prison hospital and prescribed medication. At first, Mr. Tschelebinski was very disturbed in his behaviour and also refused food and would not take his anti-epileptic medication regularly. Probably as a result of this refusal he had several epileptic fits on 4 and 5 January, and was given injections to control him.

By 6 January Mr. Tschelebinski had begun to show some signs of improvement. The medical officer had arranged for him to be seen by a consultant psychiatrist from Prestwich, who saw him on 6 January. Meanwhile, with constant nursing care, Mr. Tschelebinski's condition began to improve, and he started to take his medication regularly. He was taking fluids and eating a small amount of his meals. By 7 January he was considered to be much improved, more approachable, speaking to staff and taking a full diet and regular medication. When Mr. Tschelebinski's cell was unlocked at 7.45 on the morning of 8 January staff noted that he had defecated on the floor of his room. When the other inmates had been attended to, the hospital staff returned to give Mr. Tschelebinski his medication and breakfast. At this point he was cooperative, spoke to staff, and took both his medication and breakfast.

At about 8.55 am Mr. Tschelebinski's cell was unlocked again so that he could be given a bath and his room cleaned. The staff found him on the floor apparently dead. The officer who found him immediately cleared his mouth of food and instituted artificial respiration and external cardiac massage, which was continued with the help of other officers, and the medical officer was called.

Those resuscitation attempts were unsuccessful and the medical officer pronounced Mr. Tschelebinski dead at about 9.25 am. The inquest into the death was held at Manchester on 28 April 1983. I need not go into the medical evidence, because there is no dispute about it. The jury returned a finding of death by misadventure. In accepting the finding the coroner added that no blame could be placed on the prison staff.

I shall deal with the points made by the hon. Gentleman. It is perhaps logical that I should deal chronologically with the criticisms that he makes of the role of the police. He argued that the police were at fault in failing immediately to notify Mr. Tschelebinski's parents of the fact that he was in custody, despite having told the nursing staff that they would do so.

I understand that the Police Complaints Board was satisfied from the investigation report that in not informing Mr. Tschelebinski's parents the officer was complying with Mr. Tschelebinski's own wishes that they should not be notified. The offer to notify his parents was made by another police officer when he was taken to the police station, and was refused. He changed his mind about their being informed on the morning of 31 December, shortly before his court appearance, and they were then immediately contacted.

The hon. Gentleman suggested that the police were nevertheless under an obligation, despite that expression of his wishes that his parents should not be informed, to notify them, and in correspondence the hon. Gentleman has referred to the judges' rules. The relevant passage is concerned with cases of doubt as to whether the person can understand the questions put, or where he appears likely to be especially open to suggestion.

The Police Complaints Board investigation found that though it was plain that Mr. Tschelebinski had had previous psychiatric problems, at the time of his arrest he was considered by his consultant to be fully aware of his actions and fit to be charged and detained. In those circumstances, the board agreed that there was no obligation on the police to inform Mr. Tschelebinski's parents, against his wishes. As the hon. Gentleman is aware, the criticism made in the course of the investigation and endorsed by the Police Complaints Board was that, having come to that conclusion, which the board thought was justified, the arresting officers failed to inform the hospital that they were not, as they had undertaken to do, contacting the Tschelebinskis.

The board was satisfied from the investigating officer's report that the arresting officer was made fully aware of Mr. Tschelebinski's status as an informal patient at Stepping Hill hospital, receiving treatment for epilepsy, and of his previous mental history.

The police informed the prosecuting solicitor of Mr. Tschelebinski's earlier treatment for mental illness, and that information was given to the magistrates. I understand that it was that information that led the clerk of the court to recommend Mr. Tschelebinski's remand to a "place of safety", which was to be the hospital wing of Strangeways prison.

The clerk showed the reasons for his remand in custody to be the seriousness of the offence, defendant's mental condition and confirmed that Strangeways prison was the authorised establishment to receive prisoners on remand.

The hon. Gentleman asked me about the conduct of the investigation, and he has implicitly criticised the board's report. He is aware, because he is experienced in these matters, that Ministers have been given no power by Parliament to intervene in any way in the investigation of complaints against the police or in the consideration by the Police Complaints Board of investigation reports. The Police Complaints Board is not under the control of Government. It has been deliberately set up by Parliament otherwise.

As the hon. Gentleman also knows, the Police and Criminal Evidence Bill, which received its Third Reading last week, changes that procedure so that the new Police Complaints Authority can itself supervise the investigation of complaints as defined by the Bill. I hope he will agree that that will be a change for the better in the procedures that we are discussing.

The hon. Gentleman also suggested that the magistrates' court was in error in not sending Mr. Tschelebinski to a psychiatric hospital instead of to a prison. As the hon. Gentleman knows, I cannot comment on the decisions of the court. As he also knows, because it has emerged in correspondence which he originated, in our judgment a magistrates' court has no power to order a remand to hospital in circumstances such as those of Mr. Tschelebinski's case.

The hon. Gentleman asked why Mr. Tschelebinski was put in a bare cell without clothes. When the medical officer examined him on reception he noted that he was generally disturbed, that he had made an attempt at suicide before and that he was an epileptic. To minimise the danger of self-injury, Mr. Tschelebinski was put in a room from which the furniture had been removed, but which contained a number of mattresses. His clothes were also removed to prevent any suicide attempt. I am told that the room was adequately heated and that he was given a blanket. As I think my chronology of events shows, he was under regular supervision by hospital staff.

Unfortunately, despite those precautions, Mr. Tschelebinski sustained some injuries. On 5 January he was found to have a laceration to the back of his scalp, and on 6 January bruising on his knees and elbows was noted. He was given medical treatment, his condition gradually improved and the risk of self-injury decreased

As the hon. Gentleman said, Mr. Tschelebinski's mother telephoned several times to ask about her son's health and was advised that he was not in a fit state to be visited. As in any case of a relative wishing to visit a prisoner who is in a disturbed state, that advice was given after medical staff had considered the possible effects of a visit in those circumstances on both the patient and the visitor.

That is the sequence of events in this tragic case. Obviously, we have looked carefully at all the information that has come to us from the various sources that I have described. As the hon. Gentleman has taken up a number of other cases—I do not say similar cases, because I recall none in my experience with quite the same elements of tragedy — he will be aware that hindsight is a powerful force in discussions of this kind. In fairness to all concerned, we have to consider whether those involved took reasonable decisions in the light of the circumstances at the time and the knowledge that they had or could reasonably have been expected to have at that time.

Against that test, we have considered very carefully the information available to us and the results of the different inquiries that have already been made—the inquest and the Police Complaints Board investigation. As I have said, we have no powers to intervene in or comment on the Police Complaints Board report. With regard to the prison, where jurisdiction is different, we see no reason to differ from the conclusion of the coroner, who made it clear that in his view no blame attached to prison staff for Mr. Tschelebinski's unexpected and sudden death.

Therefore, while recognising fully, and indeed sharing, the sense of tragedy that came through in the hon. Gentleman's speech, I do not think that he established the case for a public inquiry.

Question put and agreed to.

Adjourned accordingly at twenty-eight minutes past Twelve o'clock.