Source · Article 2 investigation

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

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 HMPPS policy

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 HMP Norwich communication

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 HMP Norwich policy Accepted

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 HMP Norwich safety Accepted

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 date	25 October 2018
Incident type	Serious Self-Harm
Investigator	Mark Boother
Learning points	4

Documents

Investigation Report HMPPS Response IAPDC Page

Learning point themes

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