Individual at Acklington

Investigation into the circumstances surrounding the
death of a man at HMP Acklington
in August 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2008
The man was 29 years old when he died in August 2007 in his cell at HMP
Acklington. He was found hanging. My investigator and I offer our sincere
condolences to the man’s family and friends for their sad loss.
I wish to thank the Governor of Acklington for making the necessary facilities and
information available to my investigator, and for the assistance of the Liaison Officer.
In the course of the investigation, I also asked for a clinical review to be carried out
into the care and treatment the man received in custody. I am grateful to the clinical
reviewer for his assistance.
The man had been returned to prison earlier in 2007 after breaching his parole
licence conditions. At the time of his death, he was being monitored under the
Prison Service’s suicide and self harm support and monitoring procedures. I believe
these procedures were being operated properly and that, short of a one-to-one
watch, all that could reasonably be done to support and monitor him was done. On
what was known at the time, I do not judge that a one-to-one watch would have been
justified
My report shows that the man had been treated for mental illness and had fabricated
stories about the deaths of close relatives and a girlfriend. I make two
recommendations to the prison authorities.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2007
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CONTENTS
Summary
The Investigation Process
HMP Acklington
Key Findings
Issues
Conclusions
Recommendations
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SUMMARY
The man was released on licence from prison on 6 March 2007. Unfortunately, he
breached the licence conditions and this resulted in him being taken back into
custody on 4 May.
For the purposes of this report I have concentrated on the period from when he
returned to prison. It had been recognised by the doctor assessing him following his
reception back into custody that he appeared mentally stable but somewhat
depressed.
On 29 July 2007, the man handed a note to a member of prison staff. He had written
that he was suffering from anxiety and depression over the death of his brother,
whom he said had killed himself in prison, and also his uncle’s murder. He wrote that
he felt suicidal. The member of staff opened a suicide and self harm monitoring and
support document. Observations began immediately, followed by an assessment
meeting. During the meeting the man said that his mother had died and that his
family blamed him for her death. He also referred later to an ex-girlfriend, saying that
she too had killed herself in prison.
Nine days later, on 7 August 2007, the man was meant to receive a visit from a
friend but the visitor did not arrive. Recognising that this concerned him, a manager
authorised a telephone call to find out why the visit had not gone ahead. After
making the telephone call, he appeared much happier.
Later that evening, as part of the suicide and self harm monitoring procedure, an
officer went to the man’s cell to check on him. When he arrived, he saw the man
hanging from the window bars. The officer immediately entered the cell and cut him
down. He summoned assistance and began to administer first aid whilst waiting for
assistance from other prison staff.
Shortly afterwards, ambulance staff arrived. After carrying out their own checks,
they stopped any further attempt to resuscitate the man. The prison doctor arrived
later and confirmed that the man had died.
Following the man’s death, it became evident that he had fabricated the stories
about the family deaths. In fact, his mother contacted the prison directly to find out if
it were true that he had died. Sadly, she had first learned of her son’s death from a
friend.
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THE INVESTIGATION PROCESS
1. Following notification from the Prison Service that the man had died in HMP
Acklington, the investigation was allocated to one of my investigators. He
contacted the prison’s Liaison Officer and arranged to travel to the prison and
open the investigation the following day.
2. On 9 August, the investigation into the man’s death formally opened at the
prison when the investigator chaired a meeting with prison managers and
representatives of Northumberland Primary Care Trust. At the meeting was
the Deputy Governor, an Officer representing the Prison Officers’ Association,
the Head of Care for Northumberland Care Trust), the prison’s Clinical Team
Leader, the Community Psychiatric Nurse and the prison’s Liaison Officer.
3. The investigator was briefed about what had occurred. Following the
meeting, he was shown the cell where the man had been found. From the
information supplied, the investigator identified which staff he wished to
interview and arranged to return to the prison at a later date. A number of
interviews were recorded on tape, whilst others were carried out less formally
and not taped.
4. On 23 August, my investigator returned to Acklington. He interviewed the
officer who found the man hanging and also spoke to an offender supervisor
who works at the prison. Before leaving the prison, the investigator met the
Deputy Governor and fed back to him progress on the investigation. The
Deputy Governor welcomed the feedback.
5. The investigator returned to the prison on 3 September to complete his
interviews with staff.
6. The same day, one of my family liaison officers (FLO) telephoned the man’s
mother. The FLO explained my role and offered the man’s family the
opportunity to meet her and the investigator. The purpose of the meeting was
for the family to contribute towards my report and ask any questions they
would like me to examine. The mother decided that she did not require a visit.
However, she did ask a few questions that I am pleased to say my report has
been able to answer.
7. On 5 September, the investigator completed his interviews at Acklington.
Before leaving the prison, the investigator met the Deputy Governor and fed
back the findings of the investigation. These included one urgent finding. The
Deputy Governor thanked the investigator and told him that the feedback
would be dealt with.
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HMP ACKLINGTON
8. Acklington prison is a category C establishment situated near the village of
Acklington, close to Morpeth in Northumberland. It was built on the site of a
former RAF base and accommodates convicted adult male prisoners with a
mixture of prisoners including men serving life sentences. Additionally, about
half the population are vulnerable prisoners and/or sex offenders. The prison
can hold a maximum population of 871 prisoners. It provides employment in
subjects such as farms and gardens, education and a variety of workshops.
On 21 January 2006, the prison unlock roll was 849.
9. Between Monday and Friday, prisoners are unlocked in the morning at
7.55am. They are locked up for the night at 7.15pm. At weekends, the prison
is unlocked at 8.30am. On Saturday, it is locked up at 7.15pm. On Sunday,
the prison is locked up for the night at 5.20pm.
Anti-ligature knives
10. Staff in contact with prisoners are issued with specially designed knives,
commonly known as fish knives. They are designed to be used in an
emergency and assist the removal of a ligature. They have a concealed
blade that is placed against a ligature and pushed forward to cut it without
harming the prisoner.
Addressing Substance Related Offending (ASRO)
11. ASRO is a community based drug programme. The equivalent programme
that runs in prisons is known as PASRO.
Code blue
12. Code blue is a local procedure at Acklington used to alert the communications
room staff that someone is experiencing breathing difficulty. The radio
operator in turn alerts healthcare staff and they attend carrying the correct
emergency equipment.
Counselling, Assessment, Referral, Advice and Throughcare (CARATS)
13. The Counselling, Assessment, Referral, Advice and Throughcare (CARATS)
service supports prisoners who have a history of drug or alcohol abuse. The
CARATS service can be accessed by an intermediary service or by the
prisoner referring himself.
Healthcare
14. Acklington does not have 24 hour medical cover on site. Outside of
healthcare opening times, medical assistance is provided by an on call doctor,
or the emergency service. The Healthcare opening times are weekdays from
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7.30am to 7.45pm, Saturdays from 8.30am to 7.45pm, and Sundays 8.30am
to 5.30pm.
Her Majesty’s Chief Inspector of Prisons
15. In April 2003, Her Majesty’s Chief Inspector of Prisons made an unannounced
follow up inspection of the prison. The inspection found that Acklington was
largely a safe prison. However, the Chief Inspector’s report does comment on
suicide prevention and anti-bullying training, highlighting the need for more
extensive training especially for permanent night staff.
16. Three years later in December 2006, HMCIP carried out an announced
inspection of the prison. In the introduction to her report, she says that she
was disappointed to find that, despite raising concerns over three years earlier
about extending the prison, those concerns had gone unheeded. The report
states that the expanded prison had not only failed to provide sufficient
purposeful activity places, but had struggled to sustain a safe and decent
environment.
17. The report acknowledges that there were few incidents of self harm. It also
describes commendable examples of care for those at risk.
18. The introduction to HM Chief Inspector’s report acknowledges that a new
group of senior managers had been transferred into the prison. She
recommends that emergency resuscitation equipment and emergency
assistance should be immediately available to all staff and prisoners.
Independent Monitoring Board (IMB)
19. Each prison has its own IMB made up of volunteers from the community. The
Board’s role is to ensure that the prison is properly run and that prisoners are
treated decently. Each Board produces an annual report for the Secretary of
State.
20. In their most recent annual report (covering the period to 30 June 2006), the
Acklington IMB raised concern about the general condition of the prison with
the exception of the newer accommodation. The Board did not identify any
concerns relating to suicide and self harm. Their report said that, on the
occasions when a death had occurred at the prison, the Board had been
properly notified. They also reported that staff and prisoners had been
supported.
Listeners
21. In common with most prisons, Acklington has a Listener scheme, under which
the Samaritans train selected prisoners to offer support for any prisoner who
is feeling vulnerable and at risk. The scheme is confidential and any prisoner
can ask to speak to a Listener at any time of the day or night. Prisoners can
access a Listener easily by speaking to a member of staff. During the hours
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that prisoners are locked in their cells, anyone wishing to speak to a Listener
can make the request from the staff on duty.
22. Also available to Listeners is a co-location suite, which is a cell that has been
specially designed to accommodate two Listeners and a prisoner in crisis. It
is not normally occupied and is ready for use at any time of day or night. The
suite is available for any prisoner deemed to require support and allows them
to speak in private to two Listeners.
Multi-Agency Public Protection Arrangements (MAPPA)
23. The MAPPA is a formal partnership between police, probation, prisons and
other statutory and non-statutory agencies which assesses and manages
offenders in order to minimise the risk of serious harm they may pose to the
public. There are four core functions:
• identification of offenders with the potential to commit serious violent
and sexual offences
• sharing relevant information between agencies
• assessing the risk of serious harm
• managing that risk.
24. Offenders who come within the MAPPA remit are classified according to the
nature of the risk and its management. The higher the risk, the higher the
level at which they are managed. Level one offenders are managed by one
agency, usually the police or probation service. Level two offenders are
managed jointly by all the MAPPA agencies, and level three offenders are
managed by the Multi-Agency Public Protection Panel (MAPPP) which is
made up of senior managers from the MAPPA agencies.
Night state 10.00pm – 6.00am
25. Night state is when the prison is fully locked up for the night and staffing levels
are at a minimum. There is often just one night patrol officer per wing, or on
occasions between two wings. Their role is to monitor the security of the wing
and prisoners.
26. At night time, as well as officers and Operational Support Grades (OSGs),
there is a Senior Officer (SO) on duty. The SO is responsible for the prison
and, in the event of an incident, staff refer to the SO for advice and
instructions. If necessary, the SO in turn will refer to the on call duty governor
for advice.
27. During night state, no one can gain entry to the prison or leave it without the
night manager’s permission. The night manager has to override the in built
security systems to allow anyone to enter or leave the prison before 6.00am
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when the security systems disengage. It is only in exceptional circumstances,
or when the duty governor requires entry, that night state would be broken.
28. During night state, it is not normal to unlock a cell unless the night manager
has sufficient staff in place to deal with any situation. Night patrol officers do
not carry security keys and are therefore unable to move freely around the
prison. They do however carry a cell door key in a sealed pouch secured to
their uniform belt. If it is felt necessary to enter a cell in the event of a life
threatening situation, the night patrol officer breaks the pouch seal to obtain
the key. However, in the first instance, the officer must summon assistance
and only enter a cell on their own if safe to do so.
29. Unlike the night patrol officers, the night manager does carry security keys
and is able to move freely about the prison. The manager will usually visit
each of the wings during the night and check on the welfare of the staff and
ensure they are carrying out their duties correctly
Patrol state
30. Patrol state describes the arrangements when prisoners are locked into their
cells during the day, for example during staff meal times. In patrol state, it is
only the prisoners’ cells that are locked whilst other parts of the prison may be
functioning normally. There may be at least one officer patrolling the wing
and quite often two. The patrol officer deals with any cell call bells, and
checks those prisoners on Assessment, Care in Custody and Teamwork
(ACCT) documents. Additionally, patrol officers monitor the security of the
wing, carry the normal prison security keys and, if necessary, access most
parts of the prison including individual cells.
Police investigations of deaths in custody
31. With all deaths in prison custody, the police are notified by the prison as soon
as the death has been discovered. In the first instance, the police treat the
area where the person is found as a potential crime scene and, as part of their
investigation, note the names of everyone involved and those who have been
in contact with the body. Additionally, they note the identity of all those
entering and leaving the cordoned area. It is only when the police are
satisfied that the death is not suspicious that my investigators are allowed to
begin their own investigations.
Previous deaths at Acklington
32. Since my office took over the responsibility for investigating all deaths in
prison custody on 1 April 2004, there have been four apparently self-inflicted
deaths at Acklington (including that of the man who is the subject of this
report) and eight due to natural causes.
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Prison staff
33. There are three levels of uniformed prison officer grades. Prison officers form
the largest part of the uniformed staff. They are the front line supervisory staff
with whom, in the majority of cases, prisoners have first and most contact.
34. Senior officers (SOs) are the first grade of managers and act as a reference
point for prison officers. SOs are responsible for the day to day management
of their area, supervising staff and dealing with issues raised by prisoners.
35. Principal Officers (POs) are the highest managerial rank of the uniformed
staff. They supervise the uniformed staff and have operational responsibility
for the prison.
36. Operational support grades are also uniformed members of staff. They are
issued with security keys, and carry out a number of tasks but not the full
range of duties given to an officer.
PSO 2700 Assessment, Care in Custody and Teamwork (ACCT)
37. ACCT requires staff to identify any concerns, take action, and document those
actions for prisoners identified as at risk of suicide or self-harm. The
document should be available to all the staff where the prisoner is located.
Within 24 hours of the document being opened, the at-risk prisoner will be
seen by an assessor and have a case review meeting. The meeting draws up
a care and management plan, known as a CAREMAP, and a member of staff
is nominated as the case manager. Wing managers take on the role of case
manager, oversee the management of the ACCT document and attend case
reviews.
Release on licence
38. All prisoners sentenced to more than 12 months’ custody are considered for
release on licence, which means they are supervised by the Probation
Service until the expiry date of their sentence. There are standard conditions
for all licences that include:
• keep in touch with the probation officer in accordance with any instructions
that may be given
• receive visits from the probation officer at their place of residence
• only undertake approved work
• not travel outside the United Kingdom
• be well behaved, not commit any offence and not do anything which could
undermine the purposes of supervision, which are to protect the public,
prevent re-offending and help successful resettlement into the community.
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39. Further conditions can be added by the Secretary of State if they are deemed
necessary for an individual.
40. If a licensee breaks any of their conditions, they are deemed to have
breached their licence and the probation officer submits a report to the
Secretary of State (in practice, the Ministry of Justice acts as the Secretary of
State’s agent) who has the authority to revoke it. When the licence is
revoked, the person is subject to arrest by the police and return to the nearest
prison.
Resuscitation equipment
41. Healthcare at Acklington has two emergency response bags. The bags
contain the necessary equipment for suitably qualified staff to use to protect
life.
42. There are five automatic defibrillators located around the prison. Four are
situated in dispensary rooms situated in the accommodation units, whilst the
fifth is held in healthcare. Defibrillators monitor the activity of the heart and
inform the user on what action to take with the patient. As well as
defibrillators, mouth to mouth facial masks are available and situated in unit
offices.
Roll checks
43. Roll checks are carried out to confirm the individual wing totals correspond to
the prison total. Whenever a roll check is done, the officer has to see the
prisoner is in the cell but is not required to confirm that the prisoner is alive.
Some roll checks are carried out very early in the morning when it would be
inappropriate to wake the prisoner to check if he or she is alive. However, if
the prisoner is subject to ACCT monitoring, the officer must confirm that the
prisoner is alive. During normal observations, if the officer has any doubt
about the condition of the prisoner or is unable to see the occupant, they must
seek assistance immediately and, if necessary, enter the cell. Roll checks are
carried out at midnight, 6.00am, 7.30am, lunchtime, 4.00pm and 9.00pm.
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KEY FINDINGS
44. On 16 December 2005, the man was sentenced at the Crown Court to 30
months imprisonment. He had been found guilty of being involved in the
supply of drugs. After receiving his prison sentence, he was taken to HMP
Durham.
45. Durham is known as a local prison, which simply means that its main function
is to serve the local courts. Once a prisoner has been remanded into custody
or sentenced to imprisonment they are taken to a local prison. Following
assessment, and subject to the security category, a convicted prisoner may
be transferred to another establishment. On 1 February 2006, the man was
transferred from Durham as a category C prisoner and taken to Acklington.
46. On 23 August, as part of his sentence plan, the man was transferred to HMP
Haverigg where he stayed for two months. He returned to Durham on 10
October, remaining there until 6 March 2007 when he was released on
licence.
47. Due to the nature of his offences, the man was being managed in the
community under the MAPPP high risk arrangements. He went into
supported accommodation provided by Northumbria Probation Area.
(Supported accommodation is shared accommodation supported by the local
drug treatment team.) The man’s release was supervised by a probation
officer of the Northumbria Probation Area.
48. The clinical reviewer notes correspondence in the man’s medical record from
the consultant psychiatrist of the district hospital. The doctor wrote about
increased concern by the mental health team following the man’s release from
prison, and his own assessment of his condition on 1 May 2007. The
assessment revealed increasing mental stress with marked suicidal thoughts.
The doctor prescribed Olanzapine and Diazepam and planned to review him a
week later.
49. In the meantime, whilst at the supported accommodation, the man was given
Subutex (the active ingredient of which is buprenorphine, a drug prescribed to
assist drug users overcome the effect of opiate withdrawal). Probation
records show that, in the early days, the man co-operated with the Subutex
programme and was regarded by his supervising officer as making a real
effort to end his drug habit. He progressed so well that his supervising officer
supported an application for him to be given a placement on the ASRO
programme due to start later that month.
50. Unfortunately, the man’s life style became chaotic when once again he
returned to drugs. He got himself into debt and, on 3 May 2007, telephoned
his probation officer to tell her he was being threatened because of the money
he owed. He told her he had used cocaine on more than one occasion and
owed £240. The man went on to say that he would kill himself if he was not
given alternative accommodation.
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51. His probation officer told him to inform the police about the threat, and to go
to a local homeless persons unit as they could provide him with emergency
accommodation. At that point, he became angry and threw a fire extinguisher
through a window. Two police officers dealing with an unrelated matter saw
what he had done. They arrested him and took him to the police station
where he was charged with criminal damage.
52. As the man was still on licence and subject to MAPPP, an urgent referral was
made by the Probation Service to the Early Release and Recall Section (then
part of the Home Office, now part of the Ministry of Justice) which
recommended an emergency recall to prison. The reason for recall was that
the man had breached his licence conditions. Additionally, he was considered
to be a risk to members of the public and to himself. The following day (4
May), the Home Office confirmed his licence had been revoked and he was
returned to Durham prison.
53. The clinical reviewer notes that, whilst in Durham, the man was placed on a
detoxification programme. He was also given an assessment for his ongoing
asthma condition. The clinical reviewer notes that the man’s suicidal thoughts
and depression appeared to resolve when he began the detoxification
programme, and there was no need for further psychiatric assessment. The
man continued with a gradual reduction in the programme with reduced
medication.
54. On 8 June, the man referred himself to the prison’s CARATs team. Once
again he was regarded by his supervising officer as making a determined
effort to get away from drugs.
55. On 23 July 2007, the man telephoned his probation officer at her office. He
had been told that he would not be able to join the PASRO programme at
Durham because he was to be transferred to Acklington. The probation officer
noted in the probation record that he was upset about being unable to join the
programme.
56. Two days later, the man left Durham and transferred to Acklington. The
clinical reviewer notes that assessment of his physical and mental health
revealed that he had mild to moderate asthma which was disturbing his sleep.
The man was required to continue using an inhaler and inhaled steroids.
During the reception procedure at Acklington, he told the officer that he did
not want to be located onto Foxtrot (F) or Golf (G) units due to previous
problems. After completing the reception documentation, he was allocated to
Delta (D) unit.
57. The duty SO spoke to the man after he arrived at Acklington. The SO had
known the man from a previous sentence. He told my investigator that the
man said he was unhappy at being recalled to prison. The man told him that
he was having problems with his girlfriend, and he had been recalled for a
trivial reason.
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58. The duty SO told my investigator that he did not think that the man was
depressed, but could see that he was unhappy. He added that the man was
concerned about being back in prison as he thought his girlfriend would end
their relationship. The man told the SO that he had a child. He asked the SO
for writing paper, but did not say whom it was he wanted to write to. The duty
SO presumed from the conversation that the man was going to write to his
girlfriend.
59. The following day (26 July), the man was seen as part of the normal reception
procedure by the prison’s medical officer. The clinical review shows that the
doctor assessed the man’s physical and mental health. The doctor arranged
for a routine asthma review which revealed ongoing mild to moderate asthma
requiring inhaled steroids. His mental state appeared stable, although
somewhat depressed. The detoxification programme continued with a
gradual reduction in medication and sleeping tablets overseen by the doctor.
60. At some stage the man wrote a note asking to see the Principal Officer (PO).
The note, which he handed to the prison officer on 29 July, said he suffered
from anxiety and depression. He said he was having problems over the death
of a brother and the murder of an uncle. The man went on to write that he
had tried to talk to Listeners on a previous sentence, but implying that they
told other prisoners of his problems. The man added that he felt suicidal and
asked to move to another cell to be closer to someone he knew. Finally, he
added that he wanted to see a doctor.
61. After reading the note, the first prison officer opened an ACCT document the
same day. (the officer is a trained ACCT assessor.) She described the man
as being low in mood. In the assessment section, the officer noted that the
man’s problems related to the death of his brother who he said had died in
HMP Frankland. He also referred to an ongoing trial relating to the apparent
murder of his uncle.
62. The man told the first prison officer that he had last harmed himself in April
2007, not intending to kill himself but instead to relieve pressure. He said that
his previous attempts to kill himself were by hanging, but he had also cut his
arms and throat not intending to end his life. The prison officer asked the man
how depressed and suicidal he felt. She described him as shaking his hands
to indicate that the decision was evenly balanced.
63. The officer noted that the man said he was taking medication because he
had been hearing voices but said he had not heard them since. (The entry
does not note what the voices were saying to the man.) The man also told
the officer that his mother was dead. He said that his family did not support
him as they blamed him for her death.
64. As soon as the ACCT assessment had been completed, the first prison
officer, the wing SO, and the man met to discuss the action plan. The wing
SO wrote the assessment and arranged an appointment with a community
psychiatric nurse (CPN) on 2 August. He also asked probation staff to identify
the date of the man’s licence recall review. The wing SO arranged for the
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man to remain in his current cell, which he occupied alone, so that he could
speak freely to his cousin in a cell opposite his.
65. After completing the ACCT case review, the wing SO arranged a further case
review for 2 August. Finally, the wing SO wrote on the front cover of the
ACCT document noting his instructions regarding the level of observations.
He wrote that the man should be seen three times during the night, with three
conversations during the day, emphasising the need for staff to speak to him
at least once in the morning, afternoon and evening.
66. As part of the investigation, my investigator met the PO and asked her how
well she knew the man. She said that she had known him for about four
years. She described him as depressed and said he once told her that he
had often thought about suicide. The investigator asked if she had spoken to
him about the note, and she said she had not. She added that she was not
on duty when the note was received, and was satisfied that her staff had dealt
with it correctly. However, she did speak to the SO who dealt with it in her
absence.
67. The PO said the wing SO told her that the man had asked to move to another
unit to be closer to a friend. The man told the SO that he did not trust the
Listeners to respect the confidentiality of conversations with them. The PO
said that the man had raised concern about Listeners on a previous sentence
and believed it was paranoia on his part. The PO told the investigator that she
had not discussed the man’s concerns with the Listeners. She said that other
staff had said he was happy to be back in prison. She added that her
impression was that the man felt he had more support in prison than in the
community.
68. One day later (30 July), the man was interviewed by a member of the
probation team. He explained the recall process but told the man the review
date had not been set. The officer noted in the ACCT document that the man
had a good understanding about the process.
69. The ACCT document shows that the man had settled down and appeared in
good spirits. However, on 31 July the ACCT document notes that the man
was angry because his name was not on the medication list. The nurse
dealing with treatments corrected the error and the man later apologised for
his behaviour. The ACCT document shows that the man settled down again.
70. On 2 August, the man was seen by the CPN. After interviewing the man, the
CPN wrote a summary of the meeting in the ACCT document. They
discussed his personality disorder and alternatives to self harm behaviour.
The CPN noted that the man did not have thoughts or plans of suicide at that
time. They agreed that the man should ask to see a CPN whenever he was
stressed rather than harm himself. The CPN also referred him for remedial
gymnasium.
71. My investigator met the CPN and asked him to describe the man’s mood. He
said the man did not appear to be suffering from “clinical depression”, but was
15
instead in low mood. The CPN explained that Acklington has a local policy of
providing extra gymnasium activities for prisoners with mental health
problems. He said it was the man who told him that he had a personality
disorder, and not his own diagnosis. After ending the meeting with the man,
the CPN arranged to see him again a week later on 9 August.
7 August
72. The first wing officer is a permanent member of D unit staff. He had known
the man for some time during various prison sentences. Although unaware
that the man had been released on licence, he did know that he had returned
to the prison after breaching the conditions of his licence.
73. At interview, the wing officer described the man as someone who did not
cause staff any problems. He said the man got on with most of the staff. The
officer went on to say that the man would very rarely go to education classes
or workshops, preferring instead to remain on the unit.
74. After arriving for duty at 1.30pm on 7 August, the officer went directly to D unit
where he worked in the afternoon as an induction officer. He told the
investigator that he did not see the man until approximately 5.00pm, when he
was unlocked to collect his evening meal and medication.
75. During the afternoon, the man was meant to receive a visit from his girlfriend
but she did not arrive. The wing officer said the unit SO asked him to allow
the man to telephone her in order to find out why the visit did not take place.
He added that the man had no money available to use the prisoners’
telephone and, because he was on ACCT, the SO agreed to him being
allowed to use one of the prison telephones.
76. The wing officer told the investigator that the man appeared to be in a low
mood. He took him to an office and, before he was allowed to speak to his
girlfriend, he explained who he was and asked if she would take the call.
After she agreed to receive the call, the officer handed the telephone to the
man. (Because he was using an office telephone, the officer was required to
remain with him). The wing officer heard the man ask his girlfriend why she
had not visited. Although the officer did not hear the reply, he said the man
accepted her answer. The man went on to tell her that he had a parole
hearing due. He also asked if she would book another visit for the following
Saturday (11 August). Again, the wing officer did not hear the reply. After
about two minutes, the man ended the call telling his girlfriend that he loved
her.
77. The wing officer described the man as being much happier after he had
spoken to his girlfriend. The man told the officer that she was going to try and
visit him on the Saturday, and thanked him for allowing the call. Once he had
left the office, the officer made an entry in the ACCT document noting the
telephone call.
16
78. Although the officer was not present at the time, he knew that the man had
had a disagreement with a nurse about his medication. The man had been
prescribed sleeping tablets, but the prescription had expired which meant the
nurse was unable to supply the tablets. At 6.45pm, the second wing officer,
one of the unit staff, recorded in the ACCT document that the man had
applied to healthcare for more tablets.
79. At 7.15pm, the wing officer made a further entry in the ACCT document noting
that the man had been on association all evening. (Association periods allow
prisoners to meet with other prisoners socially.) He added that the man was
concerned at not being given sleeping tablets.
80. Five minutes later at 7.20pm, the wing officer began locking prisoners up for
the night. In interview, he remembered that the man was the last person on
the landing to be locked in his cell. After locking the prisoners, the wing
officer completed his work by counting the landing roll. He recollected seeing
the man lying on his bed, watching television. The wing officer returned to the
unit office to record his landing roll and to wait for the arrival of another officer,
who was coming on duty early that evening, to allow him to leave.
81. The duty officer arrived for duty at approximately 7.45pm. Although he was
not due to be on duty until 8.45pm, he had agreed with the first wing officer to
take over early so that he could leave the prison. The duty officer told my
investigator that he went straight to D unit where he met the wing officer. He
said the wing officer told him that the man was being monitored under ACCT
and that he had spoken to him about 30 minutes earlier (7.15pm). The duty
officer went on to say that the wing officer told him the man had been
expecting a visit that afternoon from his girlfriend but she had not arrived. He
also told him about the telephone call.
82. At approximately 8.40pm, the duty officer went to what he believed was the
man’s cell to check on him. He looked into the cell and saw a prisoner whom
he thought was the man lying on his bed, watching television. The officer
returned to the wing office and made an entry in the ACCT document, noting
what he had seen. Once the duty officer had made the entry, he realised that
he had been to the wrong cell. After checking the unit roll board to confirm
the correct cell, he went straightaway to the right one, cell D1-7. I understand
that the exact location of prisoners subject to ACCT is noted in the unit diary
for the information of all staff.
83. When the duty officer arrived at the cell a few minutes later, he lifted the
observation panel. After switching on the internal cell light, he saw the man
hanging from the window bars. At interview, he said he could see his face
which he described as being discoloured. He said he could see his eyes were
wide open and that he looked to be seated. The officer said he saw that the
ligature was secured to the window hinge.
84. The duty officer immediately unlocked the cell door, and at the same time
removed his anti-ligature knife from its holder. He lifted the man up to take
the pressure off his neck and cut the ligature using the knife. He then placed
17
the man onto the floor and loosened the ligature. The duty officer checked for
any sign of breathing and a pulse, but did not detect anything. As he was the
only member of staff in the D unit at that time, he then ran to the office to raise
the alarm. Rather than use a prison radio, he used the emergency telephone
number (222) to alert the communications room operator (the OSG) that there
was a code blue emergency on D unit. After raising the alarm, the duty officer
went straight back to the man and began to administer Cardio Pulmonary
Resuscitation (CPR).
85. The prison radio communication log shows that, at approximately 8.45pm, the
OSG received an emergency telephone call telling him of the code blue. He
immediately informed the rest of the staff on duty via the prison radio, asking
for all available staff to go to D unit. The OSG also telephoned for an
ambulance via 999. Additionally, he sent a message to the on call Duty
Governor via pager, asking him to contact the prison urgently. Unfortunately,
the pager did not respond correctly so another OSG, who was also in the
communications room, telephoned the Duty Governor.
86. In the meantime, the duty officer continued with CPR alone until he was joined
by the third wing officer who had responded to the radio message. The duty
officer told him to go back to the unit office to collect a resuscitation mask,
while he continued with CPR. After collecting the mask, the third wing officer
assisted the duty officer with CPR. Between them, they alternated the chest
compressions and breathing until other staff arrived.
87. When the duty officer made the emergency call, the night manager (the duty
SO) was also in the communications room. The duty SO issued a code blue
message via the prison radio asking all available staff to go to D unit. He too
went to D unit where he saw the duty officer and the third wing officer carrying
out CPR. At interview, the duty SO described how he supervised what was
happening, explaining that other staff arrived and assisted. He said mouth to
mouth resuscitation was being administered via a plastic mask placed over
the patient’s face. (The mask has a tube in it, which the rescuer blows air
through.) He said the officer was having difficulty getting any air into the
man’s lungs and that his chest was not rising. The duty SO described the
man’s skin colour as pale, his lips blue, and his eyes open.
88. The duty SO told my investigator that he did not know if a defibrillator was
available in the prison, saying he presumed that if one were available it would
be in healthcare.
89. Meanwhile, the second prison officer was in Bravo (B) unit, a short distance
from D unit. She was relieved at approximately 8.55pm by a night patrol and
went directly to D unit to offer assistance. When she arrived, she went to the
man’s cell and saw the officers carrying out CPR. She told my investigator
that she took over CPR from the duty officer. She described the man’s pupils
as fixed and staring. She said his skin colour was becoming darker. The
second prison officer checked the man’s mouth for any sign of obstruction, as
it was apparent to her that his mouth was full of liquid and air was not getting
18
into his lungs. As the staff were unable to see any blockage, they continued
CPR until the ambulance staff arrived.
90. At 8.59pm, the ambulance arrived and was escorted to D unit. The second
prison officer said the ambulance staff placed an oxygen mask over the man’s
mouth and attached an electrocardiograph (ECG) machine to his body. The
ECG equipment did not show any sign of life. She said the ambulance staff
then attached a defibrillator to the man to administer an electric shock, but it
too was unsuccessful. As the man had not responded to the shock or CPR,
the ambulance staff stopped any further attempt to resuscitate him and
concluded that he had died.
91. When all attempts to resuscitate the man had been unsuccessful, the on call
prison doctor was contacted at home at 9.10pm and asked to attend. The
doctor was told what had occurred and asked to make his way to the prison to
certify that the man had died.
92. In contrast to the recollections of the others interviewed, the duty SO believed
CPR had continued until the doctor arrived. My investigator asked him if he
was certain that his account was correct as other staff had told him CPR
stopped soon after the ambulance staff gave the electric shock. The duty SO
then doubted that his memory of events was correct. I am satisfied that CPR
did stop once the ambulance staff said the man had died.
93. At 9.25pm, the on call Duty Governor arrived. Fifteen minutes later, the
doctor telephoned the prison to tell them he was on his way. A few minutes
later, the communications officer received a telephone call from a police
officer telling him that the police were also on their way to the prison.
94. At 10.25pm, the prison doctor arrived and went directly to D wing. After
carrying out his own checks, he confirmed that the man had died. The
ambulance staff, having received confirmation that the man was dead, packed
their equipment away and left the prison at 10.42pm. The doctor left a few
minutes later.
After the man’s death
95. Police officers arrived at about 11.30pm and initially treated the area where
the man had died as a potential crime scene. After satisfying themselves that
no one else was involved in the man’s death, they left the prison shortly
before midnight. During a search of the man’s cell a handwritten note was
found. The note simply said, “Phone [name withheld] my uncle I’m happy
gone. Thanks.”
96. At 1.47am the following morning, undertakers arrived at the prison and left
with the man’s body shortly afterwards at 2.20am. After meeting with his staff,
the Governor and the Deputy Governor left the prison. Once they left, the
prison was locked and placed in night state.
19
97. The first wing officer returned to the prison in the morning. When he arrived,
he met the duty officer in the street who told him that the man had been found
hanging during the night and had died. The wing officer did not believe the
news, but when he went into the prison he realised it was true. The officer
said that one of the governors took him to one side and told him what had
happened. The governor arranged for the care team to offer support. The
wing officer said the care team were helpful and was satisfied with the level of
support available in the prison.
98. Following the man’s death, the Deputy Governor arranged for the prison care
team to be on hand and available to any member of staff. Additionally,
managers at all levels made a conscious effort to speak to those directly
involved and provide further support. All open ACCT documents were
reviewed.
99. Managers and staff spoke to prisoners, telling them what had happened.
Listeners were briefed and were asked to assist staff in supporting prisoners.
Contacting the man’s next of kin
100. When any prisoner is received into prison they are asked to identify their next
of kin. This is then recorded in the prisoner’s record. Following the man’s
death, his prison record was checked. The record showed that he had first
given the name of a woman who at the time was a prisoner at Low Newton.
At some stage, the details were changed to another woman whom he
described as his girlfriend. Having obtained her address, police officers in the
area visited and asked her to telephone the Deputy Governor. The man’s
girlfriend telephoned at about 1.00am, and he broke the news to her. She told
him that she had spoken earlier to the man, and he had not given any
indication of what he was about to do.
101. Later that morning, the Deputy Governor received a telephone call from the
police and was told that the man’s girlfriend did not want to be regarded as
the man’s next of kin. This left the Deputy Governor in a quandary, as he had
no further details of who could be contacted. The prison liaison officer decided
to contact the man’s probation officer to see if she knew of anyone who could
be told of the death. Whilst trying to contact the probation officer, the Deputy
Governor received a telephone call from the man’s mother. She said she had
been told by a friend that her son had died and she wanted to know if it was
true.
102. The prison liaison officer had originally been told that the man’s mother was
dead. However, after confirming her identity, he told her what few facts he
had available at that time. He arranged for the prison’s family liaison officer,
and the chaplain to visit her the following day.
20
ISSUES
Assessment, Care in Custody and Teamwork (ACCT)
103. Once the man handed a note to prison staff telling them that he was suicidal,
an ACCT document was opened. He was assessed very quickly and a
suitable support plan written. The case review shows that the decisions taken
were acted on in a timely fashion. I am satisfied that the ACCT document
was opened as quickly as possible and also that the man was monitored
correctly.
Clinical care
104. The clinical review describes the man as a rather immature young man, with
a long history of drug abuse. He had experienced frequent episodes of self-
harm and shown previous suicidal intent, and this was immediately
recognised at Acklington. The doctor adds that the man was placed
appropriately on ACCT monitoring, with no significant depression or suicidal
risk identified.
105. The clinical reviewer concludes that the standard of care was consistent with
accepted NHS medical and prison practice. He adds that there were no clear
organisational deficiencies that could have been implicated in the man’s
death. The doctor commends the ACCT procedure at Acklington for its
person- centred approach. Although he does not make a recommendation,
he believes that a comprehensive integrated healthcare IT system might
make the assessment of health and prison care easier.
Resuscitation
106. In the eleven previous investigation reports into deaths at Acklington, I have
not identified any similarities to this case other than staff training. I have
previously said that consideration should be given to providing first aid training
for all staff who have contact with prisoners. In the man’s case, I extend the
recommendation regarding first aid training to include the use of a defibrillator.
CPR
107. The duty SO gave a different account of the length of time CPR was carried
out. Contrary to others, he said it continued until the doctor arrived. After
being told that his account differed from other witnesses, he began to doubt
that his recollection was correct. I am satisfied that CPR did continue until the
ambulance staff took over, and it was they who stopped any further attempt to
resuscitate the man after the electric shock failed. (I should emphasise that I
am satisfied that the SO’s account was a simple mistake and not intended to
mislead. No criticism of him is intended or to be inferred.)
21
Face Masks
108. Whilst attempting to resuscitate the man, the staff used a face mask to blow
air into his lungs. The mask is designed to allow the user to blow air in
through a one way valve, whilst at the same time being protected from any
liquid that may come from the patient’s mouth. It is intended to be used in
close contact.
109. In contrast to the face mask, the ambulance staff attending to the man used
an Ambu bag. The equipment has a mask that fits firmly over the patient’s
mouth and air is pushed in by squeezing a bag. Unlike the face mask, it is not
a close contact piece of equipment.
110. My investigator spoke to the healthcare manager about the face mask and the
risk posed by body fluids being accidentally transmitted to the resuscitator.
The manager immediately recognised the benefit of Ambu bags and placed
an order for Laerdal masks to be supplied. (Laerdal masks are similar to
Ambu bags and offer greater protection to the person using them.) I welcome
and commend his action.
Defibrillator
111. My investigator asked staff involved in trying to resuscitate the man whether
they had considered using a defibrillator. He was told that a defibrillator was
available, but that it is locked in healthcare. Other than the night manager, no
one else has access to it. The night manager said he did not know where it
could be found.
112. When ambulance staff were trying to resuscitate the man, they connected
their defibrillator to his body. The automated equipment told them to shock
him, but this was unsuccessful. Although I cannot say with any certainty what
the outcome might have been had a defibrillator been used by prison staff, I
am bound to wonder if an earlier intervention might have had a positive effect.
113. After speaking to the healthcare manager, it was evident to my investigator
that there are five defibrillators available across the prison, one of which is on
D unit. However, I understand that it was generally believed that prison
officers had no interest in learning how to use them and therefore they had
not been made available to anyone other than medical staff. My investigator
spoke to a member of the local Prison Officers’ Association and asked if
officers were reluctant to use the equipment. He said not, but went on to
explain that no time had been made available to train the staff in their use.
114. Whatever the situation, I urge the Governor to find a way through the problem,
which from my own investigations does not appear to be an issue in any other
prison. I make the following recommendation:
The Governor should consider training all staff in the use of
defibrillators and make the equipment accessible. The Governor should
22
ensure that, at night, the night manager is not the only person trained to
use the equipment.
Emergency Gate Override System
115. In an emergency, it is essential that the vehicle gates are capable of being
opened to allow movement in and out of the prison. During the day, the gate
staff can open and close the gates freely. However, in night state when the
gate security systems have engaged, this is not possible without overriding
the system.
116. In Acklington’s case, the only person who can override the system during
night state is the night manager. The night manager, who may be at the
scene of an incident, must leave the area and first go the security department.
After unlocking a safe, the night manager obtains the override key and breaks
a seal to remove the key from its pouch. The night manager has then to leave
the security department and go to the gatelodge where he or she can override
the security systems.
117. The night manager told my investigator that he had five officers on duty at
night, but none had access to the override key. The night manager was
assisting with CPR when the ambulance arrived, but by the time it was leaving
the automatic gate systems had engaged. Had the man been alive and
requiring emergency transfer to hospital, the night manager would have had
to leave him to override the gate security systems.
118. A further scenario to consider was what the situation would be if it were the
night manager himself who collapsed. My investigator judged that this
required urgent rectification and fed back his views to the prison liaison officer
immediately.
The Governor should, as a matter of urgency, ensure that at least two
people are on duty during the night who are trained and capable of
overriding the gate security systems.
Family contact
119. Although quickly contacted, the person identified by the man as his next of kin
did not want that responsibility. With no other family details available, efforts
were made to speak to the man’s probation officer.
120. In the meantime, the man’s mother (whom he had said had died) rang the
prison and spoke to the prison liaison officer. After confirming that he was
indeed speaking to the man’s mother, the liaison officer gave as much
information as he had to hand.
121. I am satisfied that the prison did everything possible to ensure the next of kin
was told as soon as possible about the man’s death. They were not to know
that the person listed as next of kin would withdraw. Neither were they to
23
know that the man had, for whatever reason, incorrectly told prison staff that
his mother was dead.
122. I have been pleased to learn that the prison’s family liaison officer and
chaplain subsequently went to tell the mother what had occurred.
Additionally, I am pleased that the prison has offered to assist the family with
funeral costs.
123. My own family liaison officer has also contacted the man’s mother. The
mother told her that the prison have been extremely helpful and have returned
the man’s possessions to her.
Support for Staff and Prisoners
Prisoner Support
124. At a management meeting held the morning after the man’s death, the Deputy
Governor reminded all managers of the need to ensure prisoners were given
the correct information. He asked for Listeners to be told about what had
happened. In addition, he issued a notice to all prisoners telling them that the
man had died. The PO and a governor spoke personally to a friend of the
man. Additionally, all open ACCT documents were reviewed. Staff unlocking
prisoners for the day ensured they were aware of what had happened. Not
surprisingly, I understand that the prisoners were calm and subdued.
Staff Support
125. When my investigator arrived at Acklington on 9 August, it was evident that
arrangements had been put in place by the Deputy Governor to support staff
affected by the man’s death. He found notices clearly displayed around the
prison reminding them about the services of the local care team, and a
separate notice telling staff when a member of the Prison Service Staff Care
and Welfare would be present.
126. I also understand that, on the night the man died, the prison care team were
contacted and quickly made support available to staff. Additionally, one
member of the team arrived at the prison in the early hours of the following
morning to relieve the care team who had been working through the night.
24
CONCLUSIONS
127. I conclude that, although the man was being monitored under the ACCT
arrangements, he kept his true intentions very close to himself. He had often
talked of suicide and clearly he had a number of mental health problems.
However, unless a prisoner is subject to constant supervision (where a
prisoner is supervised by a designated member of staff on a one to one basis,
remaining within eyesight at all times and within a suitable distance to be able
to physically intervene quickly), there will always be an opportunity for any
prisoner to seriously harm themselves. I do not believe that the man
warranted a one-to-one level of observations, and am satisfied that the prison
did everything that was reasonable to protect him.
128. The evidence shows that ACCT monitoring was being carried out within the
correct time scales. The man was monitored at 7.15pm, and it was as a result
of an extra check that he was discovered hanging at 8.40pm. I am satisfied
that ACCT monitoring was appropriately carried out.
129. It was only after his death that it became clear that the man had fabricated
stories, telling prison staff that his brother had hanged himself in prison. He
also told them that his girlfriend had committed suicide in prison. Additionally
he told staff that his mother had died and his uncle had been murdered. All of
these stories were untrue.
130. In the aftermath of the man’s death, I judge that Acklington properly met all its
responsibilities to the man’s family, to its staff, and to other prisoners, so far
as it was able.
131. My investigation has revealed some weaknesses in Acklington’s night-time
arrangements. However, I commend the speedy actions of the Healthcare
Manager in recognising the benefits of Laerdal masks and placing an order for
them to be supplied.
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RECOMMENDATIONS
1. The Governor should consider training all staff in the use of
defibrillators and make the equipment accessible. The Governor should
ensure that, at night, the night manager is not the only person trained to
use the equipment.
The Governor has not accepted the recommendation
2. The Governor should, as a matter of urgency, ensure that at least two
people are on duty during the night who are trained and capable of
overriding the gate security systems.
The Governor has accepted the recommendation.
26