AA — HMP & YOI Holloway
Ana was 21 years old when she attempted suicide on 2 May 2004 at HMP & YOI Holloway. She was discovered by staff suspended by a ligature in a shower room. Ana was taken to hospital where her condition stabilised but subsequent medical tests revealed that Ana had sustained substantial brain damage as a result of the incident. A detailed internal investigation by the Prison Service was carried out into the circumstances of Ana’s attempted suicide.
Key findings
Learning points
We recommend that assessments for transfer to psychiatric care are made much more quickly than in Ana’s case. We endorse the recommendation in Lord Bradley’s 2009 report on people with mental health problems or learning disabilities in the criminal justice system that the Department of Health should develop a new minimum target for the NHS of 14 days to transfer a prisoner with acute, severe mental illness to an appropriate healthcare setting.
A Prison Transfer Project is seeking to help commissioners to effect transfers within a maximum period of 14 days, building on Lord Bradley’s earlier review of mental health and learning disability in the criminal justice system. The new standard mental health contract covering secure mental health services also refers to the 14-day transfer, supporting closer monitoring of local performance. In addition, the Prison Transfer Project will deliver a joint training package for Prison Service and NHS staff to increase understanding and appropriate use of the national transfer procedure by clinical and non-clinical staff in the Prison Service and NHS. It will also help prisoners, as well as clinical and non-clinical staff in both the Prison Service and NHS, to increase understanding of and confidence in the transfers and remittance process. Responsibility for delivering effective transfers lies at local level. It is important that commissioners, provider organisations, offender health teams, individual establishments and Area Managers work closely together in regions and clusters to ensure delays are minimised.
We recommend that when prisoners believed to be at risk are allowed to work, they should undertake tasks in the company of other prisoners rather than alone and that staff should supervise their work as much as possible.
Positive regimes enable prisoners to engage in activities which reduce distress and potentially reduce rates of suicide or self harm. PSO 2700 Suicide Prevention and Self Harm Management, (introduced 2007), requires staff to deliver appropriate and suitably risk assessed in and out of cell activity for prisoners managed under ACCT procedures. It is for the Case Review Team, including the prisoner, to determine what tasks or activities will be undertaken, where they will be undertaken and the levels of supervision required in each case.
We recommend that training in suicide prevention is undertaken by all staff who come into contact with prisoners and that the training is refreshed on a regular basis with managers having responsibility for ensuring continued understanding and compliance with the areas covered.
With the implementation of ACCT all staff in contact with prisoners are required to undertake training in ACCT – Foundation. This course provides an introduction to the NOMS suicide prevention and self harm strategy and guidance on the operation of the ACCT process. There is a requirement for refresher training to take place no later than every 3 years.
We recommend that clearer guidance is produced on what kind of immediate internal inquiry should be undertaken following acts of serious self-harm, what evidence should be collated and retained and what form of action planning should be set in place as a result.
Chapter 13 of PSO 2700 Suicide Prevention and Self-Harm Management recommends that an internal investigation is carried out into the circumstances of serious self-harm. It makes provision for the retention of required documentation. OSRR will consider whether additional guidance is required as part of the revision of PSO 2700 which is due to be completed by April 2011.
We recommend that a dedicated liaison officer be appointed for any Independent Investigation. The person appointed should report directly to the Governor for the duties performed in this role and should be allowed sufficient time away from normal duties to be able to perform to an acceptable standard and to provide the necessary assistance to the investigation. S/he should have the necessary authority to require the assistance of other staff in providing information requested by the investigation.
OSRR will issue guidance to prisons when an independent Article 2 investigation is commissioned. This will include a request that the prison Governor appoints a liaison officer to assist the investigation. It will be for the prison Governor to determine how best to manage the role of liaison officer within their establishment.
In addition we recommend that the prison should take a proactive role in providing necessary written information so that, in general, the investigation is in the position of reviewing the documentation and deciding which of that supplied is relevant rather than trying to determine what documents may be available that may be relevant and useful.
As part of the guidance issued to prisons, a suggested list of documents that may be relevant to the investigation and should be collated will be included. The guidance will also ask the prison to consider whether there is any other documentation and/or information that be relevant to the investigation and which should be brought to the attention of the investigator.
We recommend that urgent priority is given to developing and implementing a system of assessing the needs of remand prisoners and those with short periods to serve and a fully functioning Personal Officer scheme.
NOMS is currently reviewing its reception policy which will in principle include an instruction for prisoners arriving at a prison to be interviewed to discover information about their needs and risks, and any other relevant information. Prisoners received into a prison will go through the reception process, including various assessments in relation to their mental and physical health. If it is their first time in the prison they will be located on the First Night Centre (FNC) where they will receive their induction to the prison. Each prison has in place an induction scheme which can be varied in response to the needs of prisoners, and a means to assess these needs. Induction caters for different types of prisoners and situations and arrangements may vary to reflect local circumstances. The NOMS policy is set out in PSO 0550 Prisoner Induction and paragraph 4.6 sets out that an induction for remand prisoners must take account of their status. Whilst the PSO is being reviewed this element will be retained in the new document. The personal officer scheme is currently under review and NOMS continues to encourage its officers to act as role models and provide support to prisoners in their care.
We recommend that more effective models of clinical care are developed for prisoners with diagnosed mental illness and that ways are found to ensure that diagnostic assessments undertaken for the courts are swiftly and systematically used to inform decisions about day to day medical care in prison.
In January 2006, HMCS issued instructions to all criminal courts to attach a copy of any medical/psychiatric assessment/report to custodial warrants to ensure that prison reception officers were in a position to make early assessments regarding risk. This approach was endorsed by the Senior Presiding Judge. A cross Government Health and Criminal Justice Programme is currently underway to improve health and social care services at various points of an offender’s contact with the criminal justice system (prison, police, courts and probation). Alongside planned work on the scoping of court liaison and diversion services to ensure that people are not sent to prison unnecessarily, this programme is seeking to reduce the delay in producing court psychiatric reports by producing national templates and guidance. It is also seeking to improve the quality of data, records and information sharing across the criminal justice system in support of continuity of assessment by scoping IT system requirements to support a whole pathway approach. This builds on the current roll-out of the first national clinical IT system for prisons, which is nearing completion. The Government is currently undertaking a review of major ICT programmes and therefore elements of this programme may be affected. The programme will work closely with the Ministry of Justice on their forthcoming ‘Rehabilitation Revolution’ Green paper and review of sentencing reform.
We recommend that stronger efforts are made to assemble and substantiate basic information about prisoners’ next of kin and family situation, particularly where young offenders are concerned.
NOMS is in the process of reviewing its reception policy and will include an instruction to record a prisoner’s next of kin’s name and contact details where a prisoner is willing to disclose details.
We recommend that policy on the sharing of medical information in the prison setting is clarified and a training programme established to ensure staff understand its implications.
In addition to response to recommendation 3 In 2005, the Department of Health and HM Prison Service issued guidance to all prisons (‘Safe and Secure’) for managing and sharing information across health and criminal justice systems. In addition, and relating to the ongoing prison health IT programme to ensure the availability of electronic health information to support continuity and excellence of clinical care in the prison estate, there is an offender health information governance board which is managing the development of new policy to improve the appropriate sharing of health information in the criminal justice settings. The NHS code of confidentiality applies to all clinical information held on prisoners and there is an ongoing process to ensure the criminal justice systems understand the requirements of this code and the associated legal framework. The training requirements for health and security staff is a matter for local clinical governance systems and prison governors.
We recommend that the banning of visitors should be a last resort and in the case of young offenders the implications of such bans are taken into account before imposing them. Prisoners should be told of bans and avenues of appeal made known to visitors and prisoners when bans are imposed.
NOMS is currently undertaking a review of the management and implementation of security of visits which includes the decision to ban any visitor. The issues raised in this recommendation will be considered as part of the review, however, the discretion to ban visitors in order to maintain safety, order and control within our prisons will be retained.
We recommend that physical as well as mental health is fully assessed during periods subject to suicide and self-harm monitoring and that consideration is always given to the most appropriate location for a prisoner, in particular whether a move to a dormitory is desirable and the outcome of such consideration recorded.
Between 2000-07 HMPS conducted a series of wide ranging reviews of its suicide prevention and self harm management procedures. The National Review resulted in the development of a new system of individualised, care planning for at risk prisoners. In 2004, this new system, Assessment, Care in Custody and Teamwork, (ACCT), was piloted at a number of establishments, prior to national roll out between 2005-08. HMP Holloway introduced ACCT in May 2005. ACCT introduced a multi-disciplinary case management approach to supporting prisoners identified at risk of suicide or self harm. ACCT differs from the F2502SH (the previous self-harm care planning system) in its overall approach to prisoners. It focuses on an individual assessment, uses accountable case managers and assessors, encourages flexible care, and sets up clear systems to deal with post-closure and post-release care. Since Ana’s attempted suicide, the management of at risk prisoners has fundamentally changed. The ACCT Assessment requires staff to consult health staff for information related to risk factors. Where risk factors are identified the Case Manager is responsible for ensuring the appropriate follow up actions are taken, this includes referrals for physical health assessments. Case reviews must include the key people involved in the prisoner’s care. This includes non residential staff who may also be in contact with the prisoner/trainee, such as the healthcare staff where appropriate and relevant to the individual’s care. Where attendance in person at the review is not possible, written or verbal reports can be submitted for consideration. A key element of the ACCT process is the involvement of the prisoner and it is expected that they are present at their case reviews and are consulted about their care. Where concerns have been raised about an individual prior to the ACCT Assessment taking place, an Immediate Action Plan is completed. This requires specific consideration about where the prisoner can be safely located. Location of at risk prisoners is a key element of their care and forms part of the considerations for the Case Review. Decisions in relation to at risk prisoners are taken by the Case Review Team and are recorded in the ACCT document.
We recommend that the adequacy of staffing levels is reviewed particularly in respect of the needs of women at weekends. We also recommend that stronger efforts are made to ensure residential units are not deprived of staff because of bed watches.
Prison Governors review their staffing levels to ensure that they are able to deliver a prison regime. The potential number of bedwatches would be a consideration when the staffing reviews are conducted. Only in exceptional circumstances would the regime be reduced to resource a bedwatch. Bedwatches are usually covered by staff working additional hours.
We further recommend that Holloway agrees a minimum staffing level and takes action when the level in any area and/or at any time is not reached.
HMP Holloway has an agreed minimum staffing level (MSL). The prison Governor will undertake a review of the MSL by the end of 2010 and will take into account the findings and recommendations from the investigation report.
Case details
| Establishment | HMP & YOI Holloway |
| Responsible body | HMP & YOI Holloway |
| Incident date | 2 May 2004 |
| Incident type | Attempted Suicide |
| Learning points | 14 |