A former prison warder has been cleared of the involuntary homicide of a prisoner who died by suicide under his watch, after a magistrate noted that he could not see the patient because a CCTV camera was incorrectly positioned.
Magistrate Kevan Azzopardi ruled that “constant watch” care was the responsibility of the nursing staff and not the warder, Philip Zammit, 66, from Qrendi, who could not monitor the patient over a small black and white monitor connected to a CCTV camera that did not cover the entire cell.
The magistrate noted that the positioning of the camera and the monitoring station had been upgraded after the incident.
The inmate, 45-year-old Richard Paxton, was found hanged in his cell at the Forensic Ward of Mount Carmel Hospital on January 9, 2016. Despite nurses and doctors administering CPR for 40 minutes, Paxton was declared dead.
An internal inquiry held by the Home Affairs Ministry had concluded that there were no administrative shortcomings but that some employees had fallen short of what was expected of them.
Paxton was on level one supervision, which means that he was meant to be under 24-hour supervision. According to internal procedures, someone on constant watch must be at arm’s length from the staff assigned to watch him when outside their cell, and monitored through CCTV when inside it.
However, the court heard how the CCTV cameras did not cover the entire cell Paxton was in, because the camera was placed over the door. Even the window was not covered entirely by the camera. The court was told that although workers had flagged this to the prison authorities, nothing was done.
Paxton died beneath the camera, with his back to the cell door and therefore, out of the camera's line of sight. This was a blind spot and only his hand could be seen in the footage.
When a nurse realised that his hand was not moving and he was not answering when spoken to, he went to Zammit to ask him to open the cell.
Magistrate Azzopardi noted that Zammit could not be held responsible for other people’s shortcomings. The blind spots in the CCTV coverage of Paxton’s cell and the unclear picture on the four-inch monitors were not his responsibility.
“The court is perplexed on how a person who had already attempted suicide was not only placed in a cell which was not fully covered by the CCTV camera, but was placed in a cell with a door having a large enough hole in it to be used by a person with suicidal tendencies to in fact commit suicide,” Magistrate Azzopardi said.
The positioning of the CCTV camera and the monitors were subsequently changed, the court noted, adding that it was “shameful” that a tragedy had to happen for the prison management to take action on the complaints it had been receiving about the camera position and small monitors.
By the time the court conducted an on-site visit of the cell, as part of the case brought against Zammit, the camera's positioning had already been changed.
Magistrate Azzopardi, however, noted that the cell’s door had not been changed and the hole used by nurses and wardens to peep through was large enough for anyone to attempt suicide. He recommended that this be changed “immediately”.
The court said Zammit, who had been a prison warder for 21 years, could not be held responsible for the shortcomings of other people.
It also said that Zammit could not be held responsible for a rope that Paxton had hidden somewhere, noting that the cell had not been searched while the prisoner was there.
The magistrate said that constant watch supervision was the nurses’ responsibility, not Zammit’s, who was responsible for order inside the prison facility. He therefore ruled that Zammit was not negligent in the carrying out of his duties and cleared him of all charges.
Lawyer Arthur Azzopardi and Jacob Magri were defence counsels.