An inquest offers an unusual window into Manchester's death-ridden prison

'Who was to blame, whose fault was it?'

Sep 17, 2022

By Jack Dulhanty

By the time they started CPR, he was already dead. Grey skin, blue lips, eyes fixed in their sockets. Paul Anthony Johnstone died in cell 305 of I-wing in HMP Manchester, the prison we all know as Strangeways. We don’t know what caused him to die, but we do know that procedures were in place to help him, and those procedures were not followed.

Normally, prison deaths are associated with violence, self-inflicted or otherwise. In the past five years, 33 people have died in HMP Manchester, that’s about one every two months (civil servants at the Ministry of Justice refer to prisons like Strangeways as “cluster sites”, one source told me). In the government data, deaths are recorded by year, month and cause of death. There’s homicide, self-inflicted, natural causes.

But then there’s Johnstone’s: other.

These are sometimes called “unclassified deaths,” where the cause is unclear, and investigation is required. Often, these deaths come down to a failure of systems designed to prevent deaths or help in life-threatening emergencies.

The two most urgent emergency calls in prison are code blue and code red. Code blue should be called when a prisoner is unresponsive or having trouble breathing. A code red is basically the same, but also entails heavy bleeding.

Officers who find prisoners in these conditions are meant to radio central command, say the relevant code, and specify the wing and cell number. It triggers a response from emergency services from outside and inside the prison, giving the prisoner the best chance of receiving effective care.

HMP Manchester photographed by Christopher Furlong. Photo via Getty.

Since Johnstone died, there have been 20 more deaths in HMP Manchester, five of which are registered as “other”. Experts say this is because a prison’s utmost priority is imprisonment, above all else. “Ultimately, prisons are not hospitals,” says Andrew Neilson, director of campaigns at the Howard League of Penal Reform. “They have healthcare units and healthcare staff in them, but they're primarily institutions that are there to punish people.”

Prison deaths are a big problem in the UK — a “national scandal” according to the charity Inquest. According to a document produced by researchers at University College London (UCL) in 2019, “over the last decade, the number of prisoner deaths has almost doubled, as has the number of prisoners who self-harm.” In 2007/8, there were 166 deaths in prison custody. By 2017/18, it was 325.

But HMP Manchester has significantly more prison deaths than average. In 2021, the rate of death across the UK prison population was 4.7 per 1000 prisoners; by our estimation, based on the prison’s size, in HMP Manchester it was 11.2 deaths per 1000 prisoners, more than double the national rate.

Johnstone died on the 2nd of January 2019, within a week of arriving. We’re writing about him now because his inquest has finally been completed.

On the day, Johnstone woke up early for a meeting with a therapist. He had been in HMP Manchester for six days, on I-wing, the prison’s drug treatment wing. Johnstone had a long history of drug use. As a teenager, he began smoking cannabis, then discovered ecstasy, and later crack cocaine and heroin.

When he arrived in the prison, he told his GP he had been using crack cocaine and heroin daily, and so was put on a detoxification programme that involved being given controlled doses of methadone.

The therapist said Johnstone appeared drowsy but engaged. After the meeting, he went to collect his medication and was back at his cell by 9am. Derek Hulme, Johnstone’s cellmate, thought he had looked clammy and tired in the days before his death.

A few hours went by and the men went for lunch. They took it back to their cells, but Johnstone didn’t eat much. He said he was going to get on his bunk. Hulme lay and watched TV for a while. Just after 1pm, he stood up to change the channel and saw Johnstone hadn’t moved: he was lying on his front, arms up around his pillow, his face tucked into the crook of his left arm.

“I just thought he was sleeping,” said Hulme, later. He lay back down for another 15 minutes or so before checking again on Johnstone. He was now grey. He tried to rouse him: “Andy,” he said. He thought he was called Andy; he had always called him that. In the six days they shared a cell, Johnstone never corrected him.

The emergency cell bell for I-305 was activated at 1:44pm. Officer Thompson, a man with a lean red face, was just off lunch. He saw the cell bell light up and went to the third landing of I-wing. Thompson had been in the job just over a year and it was his first time responding to this kind of incident.

When he looked through the hatch he could see Hulme sat on the bottom bunk, trying not to think about what might be happening, or had already happened, right above his head.

“Can you look at my padmate? He’s not moved for a while.”

Thompson came into the cell and looked at Johnstone.

“Is he breathing?”

“I haven’t got a clue.”

Thompson entered the cell at 1:47pm. Within the next seven and a half minutes, Johnstone died.

Code Blue

When a prison officer starts work, they are given what’s referred to as an “emergency response in custody” card — an ERIC. The card outlines the signs that would mean an officer should call a code blue or code red. Thompson’s card was in the wallet in his bag, which was at the end of the wing. After asking Hulme if Johnstone was breathing, Thompson tried to rouse him but couldn’t. He was unresponsive, but Thompson detected a pulse in his neck.

At that point, he should have called a code blue, but he didn’t.

Instead, he backed out of the cell and looked below him. Through the landing's metal grating he saw his colleague, officer Wardle. Thompson called down for help. Wardle came up and also detected a faint pulse, this time in Johnstone’s wrist, but failed to rouse him.

He should have called a code blue, but again, he didn’t.

Instead, he stayed in the cell while Thompson ran to the nurse at the bottom of the wing. But the nurse was there for cases of substance misuse, not emergency response. She told Thompson to radio Hotel 1, which he did at 1:50pm.

The city skyline showing HMP Manchester. Photo by Anthony Devlin via Getty Images.

That day, Danielle Spirou was the emergency response nurse on call for the entire prison. She was on the neighbouring H-wing when she received Thompson’s call, but couldn’t hear him clearly because of poor signal. She asked him to repeat himself, which he did: an unresponsive prisoner in cell I-305. But he didn’t say code blue.

The I-wing, as the drug treatment wing, often has cases of unresponsive prisoners. So a report of one didn’t give Spirou enough pause to take the emergency bag with her. Instead, she took a pulse oximeter and a blood pressure band.

In the meantime, another prison officer named Rawcliffe was now in cell I-305 with officers Thompson and Wardle. Rawcliffe also detected a pulse, found Johnstone unresponsive, but didn’t call in a code blue. The three officers moved Johnstone into the recovery position, still on the top bunk.

Before starting work at HMP Manchester, all three men had taken ten-week training courses that included training in CPR. Yet, none of them attempted it, instead opting to wait for people with “more medical knowledge”, to quote Thompson, to deliver basic life support. Also, neither Wardle nor Thompson recall being shown how to properly take a pulse during their training.

Spirou got to the cell at 1:54pm. Seven minutes and thirty-three seconds had passed since Thompson first found Johnstone unresponsive. Spirou found no pulse, called an ambulance and radioed for extra assistance from the prison healthcare team. In effect, she called a code blue, although she didn't say the words.

She then asked the officers to take Johnstone down from the top bunk so she could commence CPR, for which patients need to be on a hard surface. The officers said no, saying that the three of them couldn’t get Johnstone — a large man, weighing about 90kg, or 14 stone — over the bunk’s guardrail and onto the ground safely. A report by the Prisons and Probation Ombudsman said the officers referenced prison policy that warned against this — but it later transpired that no such policy exists.

So Spirou got on the bunk and began delivering CPR. It was ineffective; Johnstone’s eyes were now fixed in their sockets. Two more nurses arrived, as well as extra prison officers responding to radio contact from those already there. Spirou had one of the nurses go to collect the emergency bag that would have already been there had a code blue been called.

The officers, now five in number, brought Johnstone down from the top bunk and proper CPR began. Spirou also attached the defibrillator and another nurse gave Johnstone oxygen. It wouldn’t be until around 2:25pm, 40 minutes after he was found unresponsive, that paramedics arrived at Johnstone’s cell. They pronounced him dead at 2:46pm. He was 37 years old.

‘Unfair and inhumane treatment’

“Dr Carter, could you please slow down?” asks Zak Golombeck, Manchester’s Area Coroner. Dr Naomi Carter is the first witness to give evidence in the inquest into Johnstone’s death. The inquest requires a jury — seeing as it is investigating the death of someone who died in custody, and the cause is unclear — but the jury aren’t keeping up with Dr Carter.

To be fair, it’s a tricky report: Carter couldn’t determine Johnstone’s cause of death. His heart appeared normal, with no signs of a heart attack. There was no sign of bleeding on the brain. There was some patchy bleeding on the lungs and some oedema, a build-up of fluid, but this could have occurred after his death. His cause of death was logged as “1A: unascertained”.

Julie Evans, a toxicologist, found that while cocaine, methadone, THC, olanzapine (for schizophrenia) and mirtazapine (for depression) were found in Johnstone’s system, there hadn’t been any recent excess of drugs that could have caused his death. Although Johnstone was a long term user of cocaine, a cardiotoxin that can cause arrhythmia in the heart, and his two anti-psych prescriptions could have similar effects, it remained only a possibility that these contributed to his death.

A prison officer in the rotunda area of HMP Manchester in the year 2000. Photo by Phil Noble for PA Images via Getty Images.

In fact, by day two of the inquest, the phrase “cause of death” is abandoned altogether. A professor in interventional cardiology discusses ventricular tachycardia — where the heart's pumping chamber beats too quickly to function — as a mode of death. At one point, two jurors fall asleep.

The real crux of the inquest is whether the delay in calling a code blue contributed to Johnstone’s death. In the seven and a half minutes between Thompson finding him unresponsive and Spirou entering the cell, Johnstone’s pulse was detected by three people. But despite being unresponsive, the call wasn’t made to bring in medical help and start any kind of life support.

In the end, this is seen as only possibly contributing to his death. Because the actual cause of death is unknown, there’s no way of knowing when whatever killed him occured, so it can’t be said for certain whether prompt CPR would have made any difference. In a statement, HMP Manchester’s leaders say they “admit a failure not to call a code blue,” but add: “this wasn’t causative of Mr. Johnstone’s death”.

In an analysis of 61 inquests in relation to prison deaths, filed between January 2018 and December 2019, the charity Inquest found that 19 raised issues in relation to healthcare, staff training and staffing levels. “The staffing of prisons has not been at the level the prison service would want,” says Neilson.

Working in prisons is a stressful, underpaid job. Staff are currently being balloted for strike action, and the prison service has seen huge numbers of staff leave since the start of the pandemic.

This inevitably impacts the treatment of prisoners. In a report published last month by the Independent Monitoring Board, it was found that fluctuating staffing levels at HMP Manchester have “caused unfair and inhumane treatment in various ways”.

When Golombeck asked Thompson and Wardle (the former still working at the prison, the latter now a constable in Bolton) why they didn’t call a code blue, they cited distress and a lack of experience. They both accept that one should have been called.

A few seats down from me are Jackie and Anthony, Johnstone’s sister and father. They both listen intently. Anthony’s face is perpetually screwed. When Golombeck rises, he stands bolt upright like he’s in the army.

The jury finds the cause of death to be unascertained and gives the narrative conclusion that the delay in emergency care possibly — not probably — contributed to Johnstone’s death. When Golombeck offers his condolences, Anthony murmurs “thank you, sir” almost to himself.

He and Jackie both wonder how within such a short space of time, Johnstone came to die. He had spent eight years in one prison and got out, then spent six days in another and died. How does that happen? They never really find out.

The way it treats its prisoners

“Who was to blame, whose fault was it?” asks Aleksandr Goryanchikov, the protagonist of Dostoyevsky’s prison novel, The House of the Dead. Goryanchikov is reflecting on the waste of talent all around him, the men “uselessly buried within those walls”.

It’s to Dostoyevsky that many people attribute the most famous line we have about incarceration — that a society “should be judged not by the way it treats its outstanding citizens, but by the way it treats its criminals.” The other popular version of the quote goes: “The degree of civilisation in a society is revealed by entering its prisons.”

It’s also been attributed to Churchill, Disraeli and Mandela, but it’s doubtful that any of them said it, and anyway: which one of us can say we really know how our prisoners are being treated?

Most of us never enter prisons or hear what is going on inside their walls. The prison service, and the Ministry of Justice that runs it, are notorious for their lack of transparency — they make it difficult for journalists to speak to inmates or for campaign groups to work out what is really going on. There is a "lot of secrecy in the MOJ and the prison service and that needs to stop", said John Podmore a few years ago, and he should know as a former prison inspector and former governor of Brixton, Belmarsh and Swaleside prisons.

The same UCL researchers I quoted earlier in this story say that inadequate complaints systems and patchy record keeping mean that when things go wrong in prisons, “it is rarely thoroughly investigated”. It’s only when something goes so badly wrong that it results in a criminal trial or an inquest that we gain a momentary peek inside our vast and creaking carceral system.

As the figures from last year show, the death of Paul Johnstone was no exception and the mistakes that could have prevented his demise seem to have prompted no great reform of prison practice or public outcry. And perhaps that is the key here.

Who is to blame for the way we treat our prisoners? In some sense, we all are. “The indifference of the public and the media towards the well-being of prisoners has resulted in a lack of public sanctions on government decisions,” say the UCL researchers, who note that there is usually “little media interest” in the issue of prison reform.