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AR — HMP Norwich

Serious Self-Harm Incident 25 October 2018 4 learning points Investigator Mark Boother

The report of the independent investigation conducted by Mark Boother into the incident of life-threatening self-harm involving ‘AR’ at HMP Norwich on 25 October 2018 is published here.  Also published is the response to the investigation from His Majesty’s Prison and Probation Service (HMPPS). ‘On 25 October 2018 ‘AR’ was discovered hanging in his cell at HMP Norwich. Staff administered first aid, including CPR, before paramedics arrived and ‘AR’ sustained a serious and long-term brain injury and resides in a nursing home.

Key findings

AI-generated summary
The investigation found no significant failings in the management of AR prior to the incident or in the immediate staff response to his self-harm, which was prompt and life-saving. However, HMP Norwich demonstrated significant failings in its post-incident procedures, including the failure to conduct a required investigation, mishandling of crucial evidence like AR's letters, poor record-keeping, and inadequate review of the incident in Safer Custody meetings.

Learning points

4 extracted
Learning point 1 · Link to learning point Addressed to: HMPPS policy

Learning point · source text

HMPPS should update PSI 15/2014 (which has an expiry date of 02 April 2018). Consideration should be given to: • requiring governors to complete any simple investigation within three months of the incident, or provide an update on the progress of the investigation at three monthly intervals • facilitating the dating of all documents and annexes that require completion
Learning point 2 · Link to learning point Addressed to: HMP Norwich communication

Learning point · source text

HMP Norwich should ensure that there is an awareness of the contents of property returned to prisoners next of kin, and that such returns are handled sensitively
Learning point 3 · Link to learning point Addressed to: HMP Norwich policy Accepted

Learning point · source text

HMP Norwich should review its record keeping procedures to ensure documents are stored in a way that they can be retrieved and produced on request
HMPPS Response
The proforma guide for staff being developed by HMP Head of Safer October
Norwich will include a section on the correct procedures for Custody 2023
gathering all documentation (digital and hard copy) regarding HMPPS
the prisoner involved in a life-threatening incident.
Documentation will be gathered and co-ordinated by the Safety Group
Safer Custody Department. HMPPS
All relevant documentation will be carefully logged and
entered into a hard copy file. They will also be scanned and
archived onto the computer record for ease of transmission
to other interested parties.
Separately, the Safety Group will provide the prison with a
list of relevant documents that should be gathered for an
incident that will be investigated under Article 2.
Learning point 4 · Link to learning point Addressed to: HMP Norwich safety Accepted

Learning point · source text

HMP Norwich should formally include a standing item on the safer custody meeting agenda to review progress on outstanding simple investigations.
HMPPS Response
HMP Norwich will add this issue to the Safer Custody Head of Safer October
meeting agenda as a standing item to ensure timely and full Custody 2023
completion of all investigations that take place following any HMPPS
serious incidents.
Weekly Safety Intervention Meetings (SIM) are chaired by
the Safer Custody Governor and are well attended by the
wider multi-disciplinary team. Key information around
ongoing incidents and investigations is routinely shared
during the SIM.

Case details

Establishment HMP Norwich
Responsible body HMP Norwich
Incident date25 October 2018
Incident typeSerious Self-Harm
Investigator Mark Boother
Learning points4

Documents

Investigation Report HMPPS Response IAPDC Page

Learning point themes

policy (2) communication (1) safety (1)