Dr Bob Johnson 7 February 2003 page 1 re Charles Bronson 2

CONFIDENTIAL Friday, 7 February 2003

GENERAL MEDICAL REPORT

on Charles Bronson BT1314
(formerly Peterson, currently Ahmed)
Full Sutton Prison, York Y041 1PS
born 6 December 1952 aet 50

by Dr Bob Johnson

Member of Royal College of General Practitioners,
P 0 Box 235 York Y01 7YW www. jnf.org.uk
GMC speciality register for psychiatry
reg. num. 0400150

formerly Head of Therapy, Ashworth Maximum Security Hospital, Liverpool
Consultant Psychiatrist, Special Unit, C-Wing, Parkhurst Prison, Isle of Wight MRCPsych (Member of Royal College of Psychiatrists), MRCGP (Member of Royal College of General Practitioners). Diploma in Psychotherapy Neurology & Psychiatry (Psychiatric Inst New York), MA (Psychol), PhD(med computing), MRCS, DPM, MRCS. Approved under Section 12(2) of the Mental Health Act 1983.

Solicitors Peter Boddy Solicitor 28A Duke Street Darlington Co Durham DL3 7AQ tel 01325 25 43 48

I examined the above on Thursday, 6 February 2003, in the prison stated and found as follows.
I am sending a copy of this report directly to the above, as is my invariable custom, though at his special request, via his solicitors as noted.

contents of this report

GENERAL MEDICAL OVERVIEW 2
1 legal considerations 3
1.1 considerations of trust 3
1.2 the medical record as evidence of lack of trust 3
1.3 considerations of conflict of interest ,.5
2 injury damage still untreated 6
3 evidence that the injury damage was caused by assault 6
4 is there a sub-culture of `automatic prison brutality'? 7
MY BACKGROUND 8
EXPERT DECLARATION 8
MY OPINION AND RECOMMENDATION 9

GENERAL MEDICAL OVERVIEW

This is an unusual case is several respects. Firstly this is the first occasion a High Court Order, or its equivalent, has been required for me to gain medical access to a patient. Secondly there is clear medical evidence of damage arising from injury which has not been receiving the appropriate medical attention it so obviously urgently needs. Thirdly there is disturbing evidence that these injuries were caused by a deliberate assault of prison staff upon this patient while he was under their care. And finally, and perhaps most troubling of all, there is the suggestion of an under-culture of physical brutality which may run something as follows - if a prisoner smashes prison property (as here the shower room) then the prison staff `are expected to' smash the prisoner. This latter of course is a most serious allegation which would require more time and resources to establish than are available to me at this time. However the very possibility of its existence would, in my view, warrant it being investigated by the highest authorities, so that they can determine whether or not such a climate of brutality did operate on this occasion, and just how widespread it might be if it did. The legal team instructing me might consider sending copies of this report to the Governor of the prison, the Director General of the Prison Service, the Home Secretary, the Chief Inspector of Prisons, the Prison's Ombudsman and others whose statutory duty it is to uphold the highest standards of care in our prisons, which represent a rather obvious basis by which our very civilisation can and should be judged.

1 legal considerations

As I understand it, the fact that I was permitted to examine this patient, after earlier strenuous prohibitions, relies on the fact that the Human Rights Act entitles the individual to a doctor of his choice. The fact that in the absence of such extensive legal endeavours this report would simply not have been possible - the prison service almost glibly prohibiting my visit - this reflects poorly on the statutory duty of the prison service to care for those for whom it is responsible.

1.1 considerations of trust

The stand taken by my legal team receives immediate and ample justification from my medical findings. A patient needs first and foremost to trust their doctor - in the absence of trust, medical practice evaporates, as here. Charlie Bronson refused to have his lacerations stitched by the prison medical staff - what clearer indication could there be that a stable trustworthy doctor-patient relationship is the sine qua non of medical practice. No trust between both parties leads inexorably to no treatment. Both parties are thereafter wasting their time.

In a superficial sense, blame for refusal by a patient of treatment offered, in this case suturing of an obvious wound to the thumb and elsewhere, can readily be laid at the patient's door. However since all medical practice since the dawn of time has relied upon a robust doctor patient relationship, then the medical staff of the prison must bear a measure of responsibility for the failure of that bond to materialise, as here. Again the prison medical staff do not operate in a cultural vacuum - I have worked for five years in Parkhurst Prison so I am well aware of the pressures on professionals working in prison, endeavouring to maintain the highest standards of their profession. Thus the responsibility for the manifest failure of medical care is shared among all three parties here - the patient, the doctors, and the prison ethos for which the prison governor, the prison staff and indeed the prison service as a whole is clearly responsible. I see little value in allocating percentages of blame in this respect to each of these three parties - suffice it to say that the failure of a therapeutic medical context should be entirely unacceptable in this age, and steps should be actively taken to remedy this medical disaster area.

1.2 the medical record as evidence of lack of trust

Evidence that there is some justification on Charlie's part not to trust the prison medical staff comes from a review of his medical record. Here we see clear entries dated as follows

4 1 03 "smashed up shower block this a.m. multiple lacerations to both hands. Inmate refused examination and treatment.
5 1 03 "injuries - abrasions / contusions to Left front-temporal area less to Right ditto.
Hands Right ?? bony injury - needs X ray
         Left 2.5 cms and 1.5 cms laceration to thumb Refuses suture"

The second entry, dated 5 1 03 records extensive injuries to his head. There is no record of where these came from. Obviously they are unlikely to have arisen from the patients own actions, unlike the injuries to his right hand which he used to smash the window and the basin.

No full medical history is recoded here, no suggestion that these head wounds were inflicted by others and not by the patient. The medical record is incomplete, and seriously so. The reason why it is incomplete is readily deduced - were the prison doctors to document actions entailing staff violence, then the doctor's working-life would become decidedly difficult. Siding with the prisoner against the prison staff is not a comfortable position - there is thus clear evidence in the deficiency of this medical record of a conflict of interest operating inside the medical profession. This in itself is readily registered by the patient, who here withdraws his trust.

Thus Charlie's refusal to trust the medical staff has some justification since they show themselves in these medical records to be less than 100% on the patient's side - perhaps inhouse medical staff would find this difficult or impossible to achieve. Where medical personnel cannot for whatever reason, put their patients' interests first, then medical practice fails, as here. If prisons concentrate heavily on punishment, then treatment, which is its antithesis, takes a back seat, as here.

I have a relationship of trust with this man, built up since I first examined him on 5 July 1991. As evidence of this, I had no trouble in obtaining a urine sample - and entering the result for the first time in his medical record. It occurs to me that this is the first occasion when the entry of a normal urine test result is of such medical significance.

Confirmation of this breakdown in medical care comes from the following. The patient and the patient's wife both assured me that he had been passing blood in his urine following his injuries. If I knew of this most ominous symptom, why is there no record of it in his medical notes ? Again the answer reflects on the parlous quality of the doctor patient relationship. No doctor can practice medicine in the absence of a clear history from the patient - indeed medical skill and expertise consists largely in successfully eliciting significant clinical items from troubled individuals.

Here a combination of the three factors mentioned eliminates entirely the medical consideration of this dire symptom. Since the doctors do not know about it, have no access to it, cannot raise enough of a trustworthy relationship to acquire it - they cannot offer treatment, nor, inexorably can Charlie receive any possible medical assistance with it. Here then is clear evidence of a break down in medical care, arising from three sources mentioned, but nevertheless resulting in a complete vacuum of care for this individual at this time.


1.3 considerations of conflict of interest

I would wish to emphasise that I have some measure of sympathy for the doctors in this matter. I know what attempting to provide medical services in a prison can entail. However, there is clearly a conflict of interest here - preserving amicable relations with colleagues among the prison officers, while endeavouring to conduct an ethical medical practice requires support and diplomatic skills which are not generally included in the medical curriculum.

Where these two powerful factors conflict, as here, then one or other must suffer. Thus where the prison staff appear to be the cause of the medical problem, then only by confronting this thorny issue can the doctor hope to gain the patients trust, and thereby access to the vital symptoms on which alone medical practice can progress.

Here as the medical records clearly show, this particular nettle was not grasped, the whole issue of possible staff violence is simply ducked, placing this particular patient in a dire condition, with an untreated kidney injury of major clinical significance. Again timely intervention of legal procedures may well have circumvented an dire outcome that no one could possibly wish for.
Bronson 2 2 injury damage still untreated

In examining this patient, it was clear that damage still remained from his injuries. He told me he was deaf in his left ear. This again has not been recorded in the medical record. There is a clear possibility that this deafness arose from injuries received. He needs urgent examination of his ear drum, something that was quite inappropriate for me in a confined cell, with 6 officers standing at one end. He needs a full ENT evaluation, with inspection of his ear drum. He also needs a full set of hearing tests.

He gives a clear history of continuing pain in his back, this is so severe it has prevented him for exercising since the date of his injury. This is a major setback, since exercise for this man is vital to his mental health. When I examined his abdomen, t clearly observed that his Left kidney was enlarged, it was swollen to a larger size than it should have been. It was also tender - again a serious medical indication of major kidney damage.

Enlargement of the kidney, taking into account the clear history of haematuria, or passing blood in the urine for some 5 days after the injury is entirely consistent with a diagnosis of bleeding internally. He requires urgent investigation. He may even require an operation to relieve the possible haematoma, or accumulation of blood within the capsule of the kidney.

Failure to record the least suggestion of traumatic kidney disease is obviously of the gravest medical significance. Happily the legal processes enabled me to exercise the already fruitful medical relationship I have with this man, to elicit this potentially lethal symptomatology, hopefully in time to limit long term damage to his kidney. I need scarcely add that were both kidneys to suffer such damage (of which I have no evidence to date) then the outcome could be dire indeed.

3 evidence that the injury damage was caused by assault

Charlie clearly used his Right hand to smash the window and the basin. He did not use his left hand for this. However it is his Left hand, especially his Left thumb which suffered most severely. Accordingly this is a medical indication to look for a different origin for the injuries to his. Left hand. His Left thumb in particular, as his medical record shows was split from top to bottom. When I examined him, there was a longitudinal scar running the full length of his left thumb. There would appear to be only one possible explanation for this, namely that his thumb was crushed, possibly under a boot. Certainly the scar I examine yesterday is entirely consistent with his thumb being powerfully stamped upon.
This conclusion is further bolstered, not only by the patient's clear history of being assaulted but also of there being clear photographic evidence to confirm this. I was myself prevented from my explicit wish to photograph Charlie's current condition. Nevertheless several references have been given to me that photographs taken at the time clearly show boot marks on his head. I have not, as yet, seen these photographs myself, the urgency of the medical considerations means I am completing this report before seeing them, however I am assured that this is the case both by his wife who has seen them, and his solicitor also. There is only one way that boot marks can appear on the scalp.

4 is there a sub-culture of 'automatic prison brutality' ?

I did not put this point directly to Charlie, but I am sure he would take it as read that his smashing up the shower room lead directly to his being injured. For the record, he tells me that on the day in question, he was told by staff that he would be denied his 1 hour exercise on that day because the locks were frozen. Later he says, witnesses saw the locks being readily used without difficulty.° He tells me that the staff said this in order to watch a TV programme.

He was frustrated by this, and smashed up the shower room. Clearly this is an immature thing to do, but given his recent history, mentioned further below, then his manifest lack of making progress in the system must be taken into account.

Were Charlie's allegation that his exercise hour had earlier been denied him on that day, then the staff should bears some measure of responsibility for his subsequent outburst - not 100% of course, but when dealing with violent and potentially dangerous prisoners, arbitrary changes of the rules should be avoided at all reasonable costs, as again I know full well from my 5 years work in Parkhurst Prison. And where they are changed, then care should be taken to explain fully the reason for this disadvantage to the prisoners, an explanation that should make at least some sense, otherwise an understandable air of grievance is likely to be raised.

He tells me again of his fear of being jumped upon whenever he is out of his cell. Indeed this fear is of a size that means he is frightened of being killed. Given the extent to which he has already suffered kidney damage, perhaps this is not so far fetched after all.

Again a further happy outcome of the legal intervention in this case, is that his fear in this regard is now reduced by the certain knowledge that he will be able to invoke outside medical assistance of his own choice, backed, if need be, by High Court Action. This greatly reassures him. It shows him that there is a wider authority that can be applied even in a Segregation Block than the say-so of the local prison staff.

MY BACKGROUND

I have been medically qualified since 1961 when I became a Member of the Royal College of Surgeons. I had intensive training in general medicine and general surgery, and was responsible for performing some 30 appendicectomy operations. I am a Member of the Royal College of General Practitioners and have been since 1974.


For almost 22 years I was a Principal in a General Medical Practice, much of that time as a single handed General Practitioner. I devised a system of recording symptom data from general practice from which I gained a PhD in medical computing from UMIST in the University of Manchester in 1980.

EXPERT DECLARATION

I. I understand that my primary duty in-writing reports and in giving evidence, is to the Court or other Statutory Bodies, rather than to the party who engaged me.
2. I have endeavoured in my reports and in my opinions to be accurate and to have covered all relevant issues concerning the matters stated which I have been asked to address.
3. I have endeavoured to include in my report those matters, which I have knowledge of or of which I have been made aware, that might adversely affect the validity of my opinion.
4. I have indicated the sources of all information I have used.
5. I have not, without forming an independent view, included or excluded anything
which has been suggested to me by others (in particular by my instructing solicitors).
6. I will notify those instructing me immediately and confirm in writing if for any reason
my existing report requires any correction or qualification.
7. I understand that:
(a) my report, subject to any corrections before affirming as to its correctness, will form the evidence to be given under affirmation
(b) I may be cross-examined on my report by a cross-examiner assisted by an expert
(c) I am likely to be the subject of public adverse criticism by the judge if the Court concludes that I have not taken reasonable care in trying to meet the standards set out above
8. I confirm that I have not entered into any agreement where the amount or payment of my fees is in any way dependent on the outcome of the case.

MY OPINION & RECOMMENDATION

MY OPINION AND RECOMMENDATION

I have had cause to examine this man on several occasions now, notably on 5 July 1991. and it really is little short of disgraceful how little has been done to rehabilitate him. I reported in May 2002 on a substantial change in his underlying personality problems, as evidenced also by his marriage to a highly supportive wife. Surely he should now be expecting to move on to conditions of more normal prison life, and eventually taking such steps as are necessary for his sensible eventual release.

As this particular episode demonstrates we have managed to build up a level of trust which is not easy given all the circumstances. This fact alone argues in favour of allowing me to continue to treat this man over a period of time. It is highly significant that as I was discussing his general situation, he spontaneously asked me if I would undertake to see him, say, monthly in order to continue the treatment we had started many years ago, and which he has requested in writing on almost a yearly basis since.

He has clearly indicated his preference for me as his doctor. Does this preference have weight in law ? A prison doctor would have a huge mountain to climb to reach the level of trust we now enjoy. We have a history of a developing relationship - a positive history. Sadly the prison doctors he has met have a similar length of history, though rather less fruitful, as the present episode so clearly shows.

My pattern of counselling or treatment has a measure of uniqueness in itself- every psychotherapist like every artist, brings his or her own unique flavour to what they do. Charlie Bronson has clearly stated that he likes my `brand' - perhaps some legal way may be found for me to answer his continued requests.

IT IS MY CONSIDERED OPINION that Charles Bronson suffers from severe injuries, notably damage to his Left kidney, and his left ear.

MY RECOMMENDATION is that these two medical conditions be given urgent and expert medical attention from an ENT specialist, and from a renal expert. If these are not undertaken within 7 days, then I would have no hesitation in advising my legal team to return to the High Court for assistance.

On the wider issues, it is clear to me, and has been for some time, that the current policy of moving him on, at random, with no notice from one maximum security wing to another, for shorter or longer periods, apparently at whim, is entirely counterproductive. This is not only on medical grounds, humanitarian grounds, but also on simply pragmatic grounds.

This man states that his recent marriage has helped stabilise him. Has the prison service capitalised on this ? Has it encouraged this family relationship to flourish ? Have they expedited increased contact between this husband and his wife and step daughter ?

Surely it is time to combine humanitarian strategies with prison security strategies. It must be obvious that to build a measure of permanence into this man's prison stay together with increased contact with his new family, must surely make the prison staff's job easier.

Is this a case where legal, penal and medical strategies can come together to stabilise this man's condition for the first time in his 26 years in custody?

If I can assist in any other way, I should be more than happy to do so.

Dr Bob Johnson Friday, 7 February 2003
Consultant Psychiatrist, P 0 Box 235 York Y01 7YW www.jnf.org.uk
GMC speciality register for psychiatry reg. num. 0400150


formerly Head of Therapy, Ashworth Maximum Security Hospital, Liverpool
Consultant Psychiatrist, Special Unit, C-Wing, Parkhurst Prison, Isle of Wight


MRCPsych (Member of Royal College of Psychiatrists),
MRCGP (Member of Royal College of General Practitioners).
Diploma in Psychotherapy Neurology & Psychiatry (Psychiatric Inst New York), MA (Psychol), PhD(med computing), MBCS, DPM, MRCS. Approved under Section 12(2) of the Mental Health Act 1983.