Individual at High Down

Investigation into the circumstances surrounding the
death of a man at HMP High Down
on 11 December 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2009
This is the report of an investigation into the death of a man, a remand
prisoner who was found hanging in his cell at HMP High Down on 11
December 2007. The man was 20 years old. He had been at High Down
since 31 October and was awaiting trial for murder.
I offer my sympathies to the man’s family, friends and all those affected by his
loss.
The investigation was conducted by two of my investigators. A clinical review
into the care received by the man while he was in prison was undertaken by
an Independent Health Clinician for the Surrey Primary Care Trust (PCT). A
psychiatric report, written by a doctor in psychiatry, was also commissioned
by the PCT to assist with this investigation. Although these reports were
somewhat delayed, I am most grateful to the health clinician for the Surrey
PCT and the psychiatrist doctor for conducting their respective reviews. I am
also grateful to the Governor and staff of High Down, especially the Governor
for her assistance and co-operation during the investigation process.
The man had had previous contact with mental health services. There had
been periods in his short life when he experienced depression and paranoia,
and he had abused alcohol. He also had a history of harming himself and had
notably done so only two days before being taken into prison custody. When
he arrived at High Down, an ACCT document was opened and the man was
admitted into the healthcare in-patients unit immediately. He was
subsequently transferred to a wing, but his mood remained low and he
reported hearing voices. He continued to express a desire to take his own
life, and his eating pattern was very disturbed, although he made no actual
attempts at self harm or suicide until the morning of his death.
I conclude that the man received a generally good level of individual care and
support at High Down, and I commend staff for their attempts to improve the
man’s outlook on life. I also make nine recommendations, primarily covering
healthcare processes, self harm monitoring procedures and family liaison. I
note that following the man’s death, the prison healthcare in-patient unit
carried out a review of its procedures. I hope the findings of my report, along
with their own review, will be acted upon swiftly to improve the level of care
given to prisoners in healthcare.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2009
CONTENTS
Summary 5
The Investigation Process 6
HMP High Down 9
Key Findings 13
Issues 28
Conclusion 33
Recommendations 34
SUMMARY
The man arrived at HMP High Down on 31 October 2007, having been
remanded in custody awaiting trial for murder. He had previously served
custodial sentences in three other establishments. His longest period in
custody had been at HMP&YOI Reading.
Upon his arrival at High Down, it was noticed that the man was very
withdrawn and isolated. When examined by the healthcare staff in reception,
he admitted that he had harmed himself only two days earlier. Scars on his
forearms confirmed this. The man was immediately transferred to the in-
patient healthcare unit, where an Assessment, Care in Custody and
Teamwork (ACCT) document was opened to ensure he was monitored and
supported against self-harm. He was placed under constant observation.
The man remained in the healthcare unit for approximately three weeks,
during which time the observations were reduced to once an hour. He
received a great deal of support and care from healthcare staff whilst on the
unit including regular assessments by the nursing staff and psychiatrist.
However, his mood remained low, his interaction with others was minimal,
and he regularly told staff that he intended to take his own life.
When the man was relocated to a residential wing, his ACCT remained open
and wing staff continued to monitor him. It was hoped that having more
access to facilities such as education would help improve his mood and
interaction with others. However, he showed little improvement. The man did
attend a music club and was later allowed to have a guitar in his cell, which
appeared to help. However, his verbal expressions of a desire to take his
own life continued.
Throughout the day on 10 December 2007, and leading into the early hours of
the morning on 11 December, the man was checked by the staff on duty. He
gave no particular cause for concern to any of the staff (including the night
Officer Support Grade (OSG), who had a brief conversation with him before
the man appeared to go to bed). He was then checked at regular intervals.
When the man was checked at around 4.15am by the OSG, he appeared to
be standing up at the back of his cell. The OSG turned the cell light on and
saw the man hanging from his wardrobe. He raised the alarm, and staff
attempted resuscitation. A first response paramedic attended the prison,
quickly followed by an ambulance crew.
Although the man had not responded to the attempts at resuscitation, the
paramedics believed that, because of his young age, there was still a
possibility that he might survive. He was taken to hospital where resuscitation
efforts continued. However, soon after arriving, the doctors declared the
man’s death.
After the man was taken to the hospital, staff found letters and
correspondence in his cell. He left information for friends and family which
explained that he had intended to take his own life. My report includes nine
recommendations and two examples of good practice.
THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened by one of my
investigators on 19 December 2007 when he visited HMP High Down.
He met the Governor and some of his staff. Notices of the investigation
and terms of reference had already been sent to the prison; these invited
anyone with any information to contact my investigators. No prisoners
came forward to be interviewed.
2. My investigator also met representatives of the Prison Officers’
Association and the Head of Healthcare. He visited the in-patient unit
and house block 1, where the man had lived, and met a representative of
the Independent Monitoring Board. My investigator returned later to
conduct interviews, accompanied by my second investigator.
3. A clinical review was commissioned from Surrey PCT to assess the
man’s medical care. This also included a psychiatric review. I am
grateful to the health clinician and to the psychiatrist for their respective
reports.
4. One of my Family Liaison Officers (FLOs) made contact with the man’s
mother and father, informing them of my investigation. The following
issues were raised in relation to their son’s death, and I hope I have
addressed them fully in my report:
• The man’s family believe that he was clearly unwell when he went into
prison. He was very depressed, would not talk to anyone and would
not make any eye contact. They noticed this on their visits to see him
in prison. The prison had identified this and put him on 15 minute
observations. The man’s mother believes that these observations were
reduced. At the time of the man’s death he had not been checked for
one hour and 20 minutes.
• The family also believe the man may have deliberately negotiated his
way off the healthcare unit, knowing that he would not be observed as
frequently by wing staff.
• The man’s mother explained the difficulty she has had contacting the
prison FLO on the number that was provided. She was aware that the
FLO had a period of annual leave but was concerned that they had
waited a long time for the man’s belongings to be returned.
• The man’s mother said that the way in which the prison handled the
matter of the funeral costs had caused the family distress. The prison
did not offer any assistance at first. Only when the man’s mother
broached the subject did the prison offer financial assistance up to
£2,000. The man’s mother had received quotes for the cost of the
funeral, the cheapest of which was £3,279. She therefore spoke to the
prison again to request assistance to cover this amount and was
informed that the Governor would consider it. The man’s mother said
that the prison eventually agreed to meet the full funeral costs, but that
they had taken a week to make this decision. During this time, she
was very distressed as the family could not move the man’s body or
hold his funeral.
5. The man’s family read our report and shared a number of the concerns
raised in my investigation. Although these do not lead to factual
changes the report, I am grateful for them sharing their views with us. In
particular the man’s father had concerns that the man was treated as an
adult in an adult system despite having a much younger mental age. He
feels that if the prison service had involved the man’s parents in his care
they could have learned more about his issues and hence been better
able to meet his needs. He feels strongly that self-reporting was not
reliable and additional information could have been sought.
HMP HIGH DOWN
6. HMP High Down opened in September 1992. It was initially a core local
prison (able to take top security category A prisoners) but in 2003 it
became a category B prison. It routinely holds approximately 750
prisoners. Each house block has three spurs (A, B and C) and each
spur is broken down into three levels, 1 being the lower level, 2 the
middle and 3 the upper level. There is a gate at the end of each spur.
7. House block 5 opened on 26 November 2007, which was followed by
house block 6 in 2008. With the introduction of the new house blocks,
the prison now holds 1103 prisoners. As part of the building work, a new
education block has been added, which is now open. There is also work
in progress to improve the kitchen and the reception area. High Down’s
regime includes education, catering, workshops and painting and
decorating courses.
8. The healthcare centre has 23 in-patient beds, all in single cells,
supported by 24-hour nursing cover. A range of primary care services is
also available for prisoners. Four of the healthcare cells have gates
rather than doors to allow staff to observe the patients in those cells
more closely. There is a day area where the patients can watch
television and relax. Twice a week, a member of the education staff
attends the day centre and provides activities for the men.
Independent Monitoring Board (IMB) report
9. IMB members are appointed to each prison by the Secretary of State for
Justice. They are not members of the Prison Service, nor are they part
of the prison’s management team. They are required to report annually
to the Secretary of State, highlighting good practice and any areas of
concern.
10. The IMB’s report for High Down for the period 2006-07 emphasised the
increasing range and mix of prisoners in the establishment, some of
whom they believed were inappropriately placed in a local prison. They
also commented on the difficulties caused by reduced funding and
overcrowding. Despite this, however, they believed that High Down was
well run, with “the vast majority of staff committed to providing a secure,
fair and decent regime for prisoners”. There had been particular
emphasis in building good relationships between staff and prisoners.
11. In the section headed “Safer Custody”, the IMB commented specifically
on the delivery of the ACCT process. Although the system was well
established and used, the quality of certain ACCT observations was
described as “variable”. However, the Board emphasised that this and
other matters involving safer custody were being addressed in a co-
ordinated and focussed way.
Her Majesty’s Chief Inspector of Prisons’ report
12. The most recent inspection of High Down by Her Majesty’s Chief
Inspector of Prisons was an announced inspection in May 2006. Her
report of her findings included the following:
“High Down, along with all local prisons, is under tremendous
pressure as a result of the growth in the prison population. Despite
this, the establishment had made considerable strides in a number
of areas.
“Healthcare services were good in all areas except dentistry, and
action to change the dentistry provider had begun. Primary care
and GP clinics were delivered on the wings, and nurses were based
there throughout the working day. An impressive array of visiting
professionals supported these core staff. Mental health services
were very good, with a coordinated strategy aimed at providing the
best care either in the inpatients’ facility or on the wings. The joint
working between the in-reach team and the primary mental health
team was particularly impressive. Prisoners residing in the
inpatients unit were appropriately occupied in a day-care centre.
“There was a good suicide prevention policy document in place.
Monitoring entries in ACCTs were generally good, although case
reviews were poorly attended and the timing of some night entries
was too predictable.”
13. Her Majesty’s Chief Inspector recommended that checks by night staff
on prisoners subject to open ACCT documents be frequent and
unpredictable, and that case reviews should be attended by
representatives of all departments that have regular dealings with the
prisoner.
Previous PPO investigations into self-inflicted deaths at High Down
14. There had been three previous apparently self-inflicted deaths in High
Down, before that of the man, since my office took responsibility for
investigating all deaths in prison custody in 2004. None of the
recommendations made in the first two reports are relevant to this
investigation.
15. The third death occurred in May 2007. My investigator made eight
recommendations, of which two relate to the provision of mental health
services at High Down, and three to the ACCT monitoring process.
However, my findings were not shared in full with the Prison Service until
January 2008
Assessment, Care in Custody and Teamwork (ACCT)
16. ACCT has been introduced at all prisons as a documented process to
monitor and support prisoners assessed as at risk of suicide or self
harm. (The previous system was known as the F2052SH procedure.)
Once placed on ACCT, the prisoner is observed at intervals determined
by their perceived level of risk and observations continuing during the
day and the night.
17. Each prisoner is assessed within 24 hours and then reviewed further at
intervals decided on an individual basis. The ACCT guidance says that,
to be effective, the review should involve the people who know the
person at risk or are involved in their care.
18. Amongst other things, the ACCT guidance states that prisoners should
be cared for in a safe environment. It is for the case review team to
decide the most appropriate place to locate an individual prisoner.
Canteen
19. Prisoners can obtain various foodstuffs and other items from the prison
shop. (This is known as canteen.) They also have access to kettles and
are provided with a weekly tea pack, bread and other food items.
Prisoners use money from their prison cash account to purchase
canteen items.
Cell Sharing Risk Assessment (CSRA)
20. In order to make sure that unsuitable prisoners do not share cells (for
example, a racist prisoner and one from a visible ethnic minority), a cell
sharing risk assessment form is completed by reception staff when a
prisoner first arrives at the prison.
Counselling, Assessment, Referral, Advice and Throughcare (CARATS)
21. Organisations specialising in the treatment of substance abuse have
drugs workers based in most prisons. CARATS workers can run
programmes, offer counselling and support, and arrange referral on
release. Access to CARATS is voluntary.
Induction
22. Having gone through the prison reception process, prisoners at High
Down are generally located onto the induction wing where facilities and
the regime of the prison are explained. After a suitable period on the
induction wing, they are re-allocated to a regular residential wing.
Peer advisors and Listeners
23. In common with most prisons, High Down uses experienced prisoners to
operate as peer advisors and Listeners. Peer advisors welcome new
prisoners, highlight any concerns and explain the processes the
newcomers will encounter in the early days of custody. Listeners assist
those prisoners who require additional support at any time in their period
in custody. (They are provided with training from the Samaritans to
support them in this role.) Confidentiality is a critical feature of the
Listeners’ role.
Mental Health In-Reach
24. The In-Reach team offers a mental health service for all prisoners who
have enduring mental illnesses. They also treat and support prisoners
who have mental health problems, offering intervention in crisis
situations. The team supports prisoners who are on ACCT documents,
and attend most ACCT review meetings.
Personal officer
25. Every prisoner is assigned a personal officer. Their role is to meet on a
regular basis and to discuss any issues or concerns the prisoner may
have. High down operates a risk based personal officer scheme, which
targets the more vulnerable prisoners as well as those with offending
behaviour needs that mean they would benefit from this service. Any
prisoner can request a personal officer, if they feel that it would help
them.
Reception
26. On arrival at HMP High Down, all paperwork is checked before prisoners
are taken off the escort vehicle. Staff check warrants to ensure they
have the correct prisoners in custody, and then set up the necessary
records. The prisoner is taken from the vehicle and booked in by the
senior officer on the front reception desk. Details of the prisoner and
their offence are taken, together with any known or identified concerns.
27. All prisoners see the first night in prison officer, reception officers and the
nurse on duty. During this process, staff obtain address and next of kin
details. Prisoners are full searched, their property is logged, and they
are health screened, before being placed in a holding cell ready for
locating staff to take them to a wing.
Roll check
28. The roll check is the physical count of the number of prisoners on each
wing within a prison. Roll checks occur on a number of specified
occasions during the day and night, and staff must sign that the roll is
correct
Sealed key pouch
29. The High Down night order instruction describes the sealed key pouch
as follows:
“Sealed key pouches containing a cell key are distributed to all
night staff patrolling units holding prisoners. They are to be used
to gain entry into cells at night in an emergency in order to attend to
a prisoner whose life is in danger.
“On discovering a life threatening incident, staff must raise the
alarm by contacting the Control Room. The night patrol officer
must decide whether aid is required immediately, or whether any
delay may result in a very serious harm or death. If the latter is the
case, the officer should break open the sealed pouch and use the
key to open and enter the cell. If the life threatening situation is a
self harm incident involving a ligature, the cut down scissors must
be used whenever possible.”
KEY FINDINGS
The man’s previous prison sentence
30. The man served a ten week custodial sentence at HMP&YOI Reading
from 27 October 2006. On his arrival, a risk assessment was completed
which noted that the previous day he had tried to find arteries on his
arms and cut them with a razor blade. He had also previously made
violent attempts to self harm and was currently experiencing suicidal
thoughts and anxiety.
31. He was assessed by a psychologist on 27 October and 7 November
2006. The man said he was not sleeping well, had little appetite for food
and experienced low concentration levels. He said he had made five
previous attempts at self harm and had a suicide plan.
32. During the psychologist’s assessment, the man avoided eye contact and
spoke in a quiet and monotonous tone. His speech was fluent and there
was no evidence of thought disorder. He was subsequently diagnosed
as suffering from a reactive depression with anxiety, but showed no clear
evidence of psychosis.
33. An ACCT document was opened and the man said that he would ask for
help if he had any further thoughts of self harm. He was also prescribed
sufficient sleeping medication for one week. A further appointment was
made for him to be assessed again by the psychologist on 10 November.
The man declined to attend the planned session, preferring to play the
piano in the prison chapel. He was released from Reading soon
afterwards.
Arrest and charge
34. The man was arrested and charged with murder on 30 October 2007.
He remained in police custody overnight, where he was subject to a
constant suicide watch after admitting that he had recently self-harmed.
The following morning, the man was placed into the custody of the escort
contractor, Reliance Custodial Services (RCS), to be escorted to
Portsmouth Magistrates’ Court for his hearing.
35. The man arrived at court at 10.25am. The police had completed the
PER (Prisoner Escort Record) Part B escort record and handed it to the
RCS staff. It was noted that the man had been identified as being at
high risk of self harm, was violent and possibly had a mental condition.
He remained at court for the entire day and was checked at regularly
intervals by the RCS staff. Throughout the day, it was noted that the
man was quiet and did not eat the meals that were provided. It was also
noted that there was evidence of recent cutting and self harm as he had
marks on his arms. The man was later remanded into the custody of
High Down.
The man’s arrival at HMP High Down
36. The man arrived at High Down at 5.35pm on 31 October and went
through the normal prison reception screening process. He was quiet
throughout and failed to make eye contact with staff whilst they
conducted their assessments of him. It was noted that he had been
charged with murder and that he was at risk of self harm. The man’s cell
sharing risk assessment (CSRA) document noted that he should be
placed in a single cell because of the risk he might pose to others.
37. The Senior Staff Nurse was on duty in reception when the man arrived
and interviewed the man as part of the reception screening process.
The Nurse told my investigators that, as well as working in the prison, he
is a Registered Mental Health Nurse (RMN) working as a psychiatric
nurse in the community.
38. The Nurse said that, during the examination, the man said he had self
harmed only days before being received into custody. It was a serious
act of self harm, although he said he had no intention of taking his life.
He also said he had a history of overdosing. The Nurse described the
man’s mood as “extremely low” and said he made no eye contact. Given
the seriousness of the man’s self harm attempt, the Nurse decided to
open an ACCT document. He considered that the man was at high risk
of self harm and felt that he should be admitted into the healthcare in-
patients unit for further observation. The ACCT and CSRA document
were noted to this effect.
39. The man was later transferred from reception to the healthcare unit at
6.50pm. He was interviewed by two Registered General Nurses (RGNs)
on his arrival. They confirmed that the man had no medication in his
possession and offered him the use of a telephone and access to the
Listener service. His mood was again noted as being “extremely low”.
He remained withdrawn, made no eye contact and exhibited very low
self esteem. The man said that he had not eaten or had a drink for two
days. He was placed in a gated cell on level one observation (constant
watch), with a full assessment scheduled for the following day.
40. In interview with my investigators the healthcare in-patient manager, said
that when the man arrived in the healthcare unit the staff were
concerned about him because he seemed “depressed and isolative”.
The unit had a psychiatrist who attended the prison twice a week, and
the in-patient manager ensured that a referral was made for the man to
be assessed.
41. Throughout the man’s first night, the duty healthcare assistant observed
and engaged in conversation with him. At around 11.00pm, the man had
some tea and toast. Later he talked about his home life and friends.
The following morning, the man spoke for an hour with the healthcare
assistant. He talked about his offence and what had happened. The
man said he had no intention of self harming until after the verdict in his
case. Should he be found guilty, he said he would kill himself in prison.
42. The man gave a number of reasons why he would kill himself and said
that his life would not be worth living. The healthcare assistant
continued to engage in conversation with him, offered him support and
encouraged the man not to take his life.
43. The man’s mood was still low the following morning (1 November 2007).
His interaction with staff was minimal and he remained in his cell
watching television. An ACCT assessment interview was conducted by
an RGN at 11.25am. The man told the nurse that he had had a difficult
childhood and had self harmed for a number of years, the last time being
only two days ago. He admitted “there is a presence who makes him
commit acts of self harm” and tells him,”not to eat or drink”. He did not
wish to socialise with others, preferring to be alone. The man said he
would self harm, although he did not know exactly when and this was
dependent on the “voice or presence”. He added that he could not serve
a long term sentence and would “end it all”. The man had given the
nurse permission to obtain his medical details from HMP&YOI Reading
and she contacted them accordingly.
44. Immediately following the man’s ACCT assessment interview, an ACCT
review was conducted. The in-patient manager, an RGN and the man
himself were present. The review concurred with the Registered
General Nurse’s assessment. An urgent referral to the prison
psychiatrist was made for the following morning.
45. Details from the man’s inmate medical record (IMR) were received by
fax from Reading. They gave information relating to the man’s mental
health both before and whilst he was in Reading’s custody. He had been
placed on an ACCT document and had had contact both with a
psychiatrist and a psychologist. The man had also complained of
hearing voices whilst in his cell and it was noted that he was becoming
paranoid.
46. As the day progressed, the man appeared more settled. He ate his
lunch and dinner. In the evening, his behaviour was described by
healthcare staff as “isolative and monosyllabic”. He remained on level
one observation.
47. From 2 November onwards, the man’s behaviour showed little change.
He made no attempt to harm himself but his interaction with staff
remained minimal. His observation level was reduced from level one to
level two (regular observations). It was noted in the man’s ACCT
document that on the evening of 3 November he remained quiet and
withdrawn. He refused his evening meal but said he was okay and had
no thoughts of self harm.
48. On 4 November, he was assessed by another registered general nurse.
The man said he felt uncomfortable with adults as he had had a difficult
childhood and, although he did not want to kill himself, he felt no
emotion.
49. On 5 November, healthcare staff noted in the man’s IMR that he was not
eating. The man said he was not hungry and had already eaten an
apple and had a drink. The In-Patient Manager told my investigators that
the in-patient unit was a supportive and trusting environment. Staff
believed that the man was not eating because he was depressed, and
they were trying gradually and gently to encourage him to eat. The In-
Patient Manager asked all staff to monitor the man’s food and fluid
intake.
50. The psychiatrist conducted an assessment. The man made poor eye
contact and appeared depressed, but was able to smile on a few
occasions and said he had no thoughts to harm himself. The psychiatrist
wrote that the man should remain in the healthcare unit for further
assessment. Later that evening (5 November), the man’s mood was still
noted as quiet. He spoke to a member of staff and said that since he
had been in prison he had had no contact with anyone from outside.
With his permission, the man’s mother was telephoned and told that the
man would welcome a visit from her. His eye contact and engagement
with staff was a little improved and he repeated that he had no current
thoughts of harm. That night it was reported that the man slept well.
51. The man remained on level two observations. He refused food at times
and stayed in his cell a lot of the time. Staff continued to try to engage
him in conversation but generally the man’s mood remained low. He
was given the opportunity to attend education classes and association
with other prisoners to try to get him to leave his cell but he refused,
opting to watch his television.
52. The man’s second ACCT review took place on 7 November. The In-
Patient Manager, an Officer and the man were all in attendance. The In-
Patient Manager noted that the man remained withdrawn and was
unwilling to socialise or speak with others. The man said he was still
hearing voices. The offer of support continued and he remained on level
two observations.
53. On the morning of 9 November, the man was escorted to court for a
hearing. After this, for reasons not clear from his prison records, the
man was initially taken to Reading and then back to High Down. On his
return to High Down that afternoon, he was assessed by an RMN. The
man made no eye contact and was unresponsive to her questions. He
admitted hearing voices of unseen people commanding him to kill
himself. He also admitted to having suicidal thoughts all the time. He
had not been prescribed any medication. It was noted that a ligature had
been found in the man’s property when it was searched at Reading. An
RMN Nurse said that the man’s mood was low and he was considered to
be a risk of self harm. His ACCT document remained open and he was
again placed on constant watch.
54. The following day, during a routine ward round, the man was seen again
by the psychiatrist. On this occasion, the man said his aim was to be
dead by the age of 21. The psychiatrist noted that it was possible that
the man was suffering from a personality disorder. She recommended a
referral to the prison doctor for the following week as well as out-patient
follow up by herself.
55. Around lunch time on 10 November, a further ACCT interview was
conducted. It was noted that the man had a history of self harm, had
complained of command hallucinations, and had described experiencing
intermittent paranoia. The man was “isolative”, his speech was quiet and
his eye contact was elusive. The man also did not appear to
comprehend the seriousness of what he had been charged with. The
man said he had previously had contact with mental health services. A
referral back to the psychiatrist was noted on his records. Although it
was not recorded at this review, it appears that the man’s level of
conversation and observation was level 2.
56. On 11 November, an Officer noted that the man refused breakfast and
did not come out of his cell. He managed to get the man out of his cell in
the afternoon, and took him to a private office in an attempt to engage
him in conversation. They spoke for about 20 minutes. The man was
not very forthcoming and said again that his goal in life was “to be dead”
before he was 21. He claimed he had previously attempted to take his
life but failed. The Officer noted that he had already contacted the man’s
mother to enquire about his behaviour. She had confirmed that the man
had at times acted strangely and would sit in his bedroom for hours upon
end. When the Officer ended their meeting, thanked him. The Officer
then passed this information on to the nurse on the unit.
57. The following morning, no concerns were raised about the man. He had
a visit in the afternoon and afterwards seemed calm and settled. Staff
noted that he was quite chatty.
58. A Registered General Nurse spoke with the man on 13 November. He
was still quiet and was not socialising much with others. However, he
did speak with her and his eye contact was good throughout their
conversation. He told the nurse that he had no current thoughts of self
harm.
59. At the ACCT review on 14 November, the man was still low in mood. He
said that he was having regular thoughts about the abuse he had
suffered in the past. He reiterated his intention to kill himself but said he
had no way of doing it. His ACCT document remained open and his
monitoring continued.
60. Despite the man’s isolation, staff thought that he appeared calm and
more settled. On 15 November, the level 2 observations were
discontinued after an ACCT review. Thereafter, the man occasionally
joined other prisoners for association. No self harm concerns were
noted. However, a Senior Officer (SO) carried out a further cell sharing
risk assessment (CSRA) and noted that the man believed his situation
was “hopeless”. The man expressed not only a desire to die but also to
harm others. He was to be assessed by the mental health team and
encouraged to interact with others on the wing.
61. An entry by the psychiatrist in the man’s IMR on 19 November showed
that he missed his appointment because he was having a visit.
However, the general feedback from staff was that he was more stable
and there was no evidence of increased threats to harm himself. A plan
was made to transfer the man to a single cell in a house block. He was
to receive out-patient follow up care from the psychiatrist. Over the next
couple of days, the man’s behaviour was settled and no cause for
concern was reported.
62. On 21 November, the man was assessed by the Mental Health In-Reach
team and the SO noted that:
“After assessment it appears the behaviour he displays is his
normal behaviour outside and although very introverted and quiet
there is no evidence of mental health issues.”
63. The SO carried out a further CSRA on 21 November. The man’s risk
level remained high and it was noted that he did not like being in prison
nor in the in-patient unit. In respect of his mental health needs, the man
was to be seen as an out-patient in the psychiatrist Doctor’s clinic and
was encouraged to interact with others on the wing.
64. As well as the man and In-Patient Manager, two other members of staff
attended the ACCT review on 21 November. This was expected to be
his last review before he was discharged from the healthcare unit. The
man still maintained his intention to harm himself and end his life. He
said he would take his life whether he was located in the healthcare unit
or not and was just waiting for the “opportunity to do it”. Despite staff
encouragement to get him to interact with other prisoners and staff, the
man told the review members that he had no future.
65. The In-Patient Manager told my investigators that there was no
operational pressure to discharge the man from the healthcare unit. As
time passed, and following discussions with staff at ward rounds, they
felt that his quiet and introverted behaviour was part of his normal
personality.
66. The man’s ACCT entries show an intermittent pattern of engagement
and isolation from everyone. The entries suggest that he was gradually
more settled towards the end of his stay in the healthcare in-patient unit.
67. At the ACCT review on Friday 23 November, the In-Patient Manager
broached with the man the possibility of relocating to a residential wing.
The man had refused a request two days earlier, but on this occasion he
had no objection and said he no longer had any thoughts of self harm.
The In-Patient Manager said the man would be followed up by the In-
Reach team and psychiatrist after he left the healthcare unit.
68. The In-Patient Manager noted that the man should remain in a single cell
as the risk to others was greater than to himself. He discussed the
proposal with other staff, including nurses, the in-patient team and the
psychiatrist. The In-Patient Manager completed a discharge plan to be
given to the staff on house block one stating that the man had a
personality disorder, was low in mood, was not receiving any medication,
and was being monitored by an ACCT document.
69. At interview with my investigators, the Mental Health In-Reach Manager,
said that the man had not been formally referred at any time to the In-
Reach team. Nor was he being supported by the In-Reach team,
although he was assessed in the healthcare unit by the psychiatrist who
was affiliated to the team.
70. Later in the evening of 23 November, the man was moved to house
block one. An ACCT review was held at 7.35pm, attended by another
SO, an Officer and the man himself. The man was quiet and gave one
word responses to questions from the SO, his new case manager. He
also ate no food that evening.
71. At interview with my investigating officers, the SO said that she was very
concerned with the man’s demeanour. He said he had no plans of self
harming but was in shock at his predicament. He again mentioned
hearing voices and wanted to play the piano which was located in the
chapel. This request had previously been declined as he was in the
healthcare unit. The SO said she would look into the man’s request.
The man added that he had no wish to attend work or education.
72. The SO told my investigators that, because of her concern about the
man, and because she did not know him well, she increased the
observations to hourly overnight. She was also aware that he would be
in a single cell. Following the ACCT review she contacted the healthcare
unit to see what further information she could gain about the man. The
similarities in the man’s behaviour in healthcare and the house block
were confirmed by staff in both units.
73. The man refused breakfast and lunch on Saturday 24 November but,
although not very communicative, he did collect his evening meal. On
Sunday morning, he again declined breakfast and lunch and said he was
happy to sit in his cell watching television. He collected his evening meal
but refused to come out of his cell for association. A Nurse was
informed of the man’s behaviour and made a referral to the ln-Reach
team.
74. A nurse from the In-Reach team saw the man on Monday 26 November.
His conversation was very limited, although he said that he had no
suicidal or self harm thoughts. The man was advised about the various
coping mechanisms he could use. He was thereafter to be monitored by
the house block nurse.
75. In general, staff found it difficult to have any communication with the man
who invariably answered with one word answers. Principal Officer (PO)
who was on duty on 27 November, attempted to have a conversation
with the man and managed to “get a couple of giggles”. The man told
him that he was concerned about mixing with other prisoners as he was
from a middle class background and would not fit in. The PO asked
whether he felt like harming himself, but the man did not answer. He did
say, however, that he would not “do anything” that night. An
arrangement was made for the man to see a Listener to try and
persuade him to associate more with the other prisoners.
76. On 28 November, another Officer had a long chat with the man about
how he was finding prison life. He again said he felt he did not fit in
because of his background. He had received letters and money from his
parents, but did not want to speak to them on the telephone. The man
also said that he was waiting to hear from his solicitor. The Listeners
and Samaritans schemes were explained once more, and the man was
reminded that he could talk to staff at any time about any worries. He
told the Officer that he had pronounced thoughts of self harm and agreed
he would make an effort to come out of his cell when she was next on
duty (which was to be Saturday 1 December).
77. At interview with my investigators, the Officer said that the man
appeared very “withdrawn and lost”. She described him as someone
who made minimal eye contact and gave one word responses when
spoken to. He also rarely came out of his cell. The Officer said there
were occasions when she repeatedly had to ask the man to come out to
collect his meals.
78. A Principal Officer took the initiative to contact the man’s solicitor on his
behalf as he believed this would help the man. The solicitor confirmed
that she had received the man’s letter and planned to make a legal visit
on 13 December. It was noted the next day that the man was making
friends on the wing and asked if he could speak to two other prisoners in
their cell. This was agreed to. Staff also told the man he would be able
to join the music club in the chapel.
79. On 30 November, the man attended the chapel to play in the music club.
He spent an hour and half playing the piano and guitar. He also had a
visit from his parents. Later that evening, an SO held an ACCT review
meeting with the man which lasted about one hour. No other staff
attended. The SO recorded that the man was a lot more talkative and
maintained better eye contact during their conversation. He said that he
had enjoyed the music club that morning. He told the SO that he had his
own guitar at home and asked if it was possible for it to be brought in for
him. He also asked if the education department could provide him with
drawing and art materials to use in his cell. (A few days later the man
was provided with an art set for his drawing and he said he would
consider attending art classes in the education unit.)
80. When asked about his intention to self harm, the man told the SO that he
had originally planned to kill himself on his 21st birthday (11 June 2008).
He said that, because he was in prison, this was no longer possible.
Nevertheless, he felt that he could not cope with a long sentence. The
man said he still experienced thoughts of self harm and, although he had
no set plan or timescale, said he still intended on taking his life.
81. On 1 December, the man again declined all meals and association.
Staff found it difficult to engage him in conversation. An Officer tried to
convince him to eat but the man said that he was not hungry. The next
day, he again refused his breakfast and lunch but collected his evening
meal.
82. At around 3.00pm on 6 December, staff allowed the man to telephone
his mother to tell her she would be allowed to bring his guitar into the
prison on her next visit. Following this conversation with his mother, the
man spoke to the officer on duty and said he was okay and was “just
getting used to the place”. He also said he felt that the “staff were
smothering him”. Later that evening, although the man collected his
evening meal, he remained in his cell.
83. The man’s next ACCT review was on 7 December, again conducted by
an SO. The man initially was quiet, made no eye contact and gave
closed responses to questions asked. However, his mother was bringing
in his guitar the following day and he said he was looking forward to this.
He was now occupying some of his time in his cell drawing. In respect of
his self harming, the man said there was no change in how he felt.
84. Another SO also spoke with the man about his comment that staff were
smothering him. The man said he did not feel uncomfortable and
accepted that staff had to check on his wellbeing. He maintained that he
had suicidal thoughts, although the SO felt that he seemed less specific
about them than he had done in the past. The man did not collect his
evening meal, saying he was not hungry. The SO gave him a packet of
biscuits to eat in his cell.
85. The man again failed to collect his breakfast the following morning
(Saturday 8 December), and did not leave his cell. When the man was
checked, staff recorded that he was subdued and made no conversation.
He was encouraged to eat and staff made a note to keep an eye on him.
At lunchtime, and having seen the man emerge from his cell, staff again
checked upon him. He was sleepy and said he was not interested in
lunch. Later in the afternoon, the man had a visit from his family. Staff
spoke to him on his return and noted that his mood was much better.
86. On 9 December, the man received his guitar. Again he did not eat lunch
or his evening meal, but remained in his cell playing his guitar and
watching television. When asked how he was, the man said he was
“fine”.
Monday 10 December
87. No real change in the man’s behaviour was reported on 10 December.
He remained in his cell all morning but engaged with staff during their
checks. For the most of the day, the man appeared to be sleeping or
watching television in bed. Staff spoke to him at lunch time and during
evening association and on both occasions the man said he was okay.
He once more declined to leave his cell to collect any of his meals.
88. At 8.15pm that evening, an Officer Support Grade (OSG) began his night
duty on house block 1. All prisoners had already been locked in their
cells for the night. The OSG collected his folder containing an anti-
ligature knife (known as a fish knife because of its shape), torch and
pouch of keys (cell keys within a sealed pouch for emergency use only)
from the orderly office. He also received information about those
prisoners on open ACCT documents, and received a verbal handover
from the officer on the wing. He was not informed of any concerns.
89. When the OSG checked the ACCT documents, he noticed that the man
had been placed on an hourly watch. Although not unusual, he thought
that this level of observation was high and checked with the Orderly
Officer on duty, who confirmed that this was correct. He then
commenced his normal duties which included checking on all those
subject to ACCT procedures.
90. At interview with my investigators, the OSG said that, although he had
not been ACCT trained, he understood the principles behind it. Upon
checking the man’s cell at 8.30pm, he noticed him sitting on his bed
watching television. The OSG asked the man if he was okay to which he
nodded in response.
91. When the OSG checked the man at 10.30pm, he observed the man
writing at his desk. Seeing a guitar in the cell, he engaged in a brief
conversation with the man about it. When the man was checked at
11.30pm, he was standing up arranging paperwork that was on his bed.
Again the man responded by nodding his head at the OSG who asked if
he was okay.
92. At 1.00am, the OSG shone his torch through the cell observation panel
of the man’s cell as the cell light was switched off. The man appeared to
be in bed asleep and the OSG had no concerns about him. Further
checks were logged at 2.00am and 3.00am, with the man appearing to
remain asleep.
93. The OSG started patrolling the wing again at 4.15am. He arrived at the
man’s cell and again used his torch to look in to the cell. On this
occasion, he noticed that the man was out of bed and apparently
standing up. The battery went flat as the OSG shone the torch from the
man’s feet to his head. The OSG said he immediately turned the cell
light on. He saw the man hanging from his wardrobe by a white ligature
which was tied around his neck. He described the man as looking pale,
with saliva coming from his mouth.
94. The OSG used his radio and alerted the control room to a ‘Code 1’
emergency (the code for prisoners with chest pains, hanging, or an
immediate threat to life). He also requested Hotel 2 (a call for the
healthcare officer on duty). An ambulance was requested by the control
room.
95. The OSG told my investigators that he did not go into the cell because
he had been told that he should not do so unless two officers were
present. He had not been trained in first aid. When other staff arrived,
the OSG made his way to the office to replace the batteries in his torch
and continue his duty.
96. A fourth SO said he responded to the Code 1 emergency call. Three
Officers also made their way as quickly as possible to house block 1.
One Officer told my investigating officers that he arrived at the man’s cell
within 45 seconds of the call. As one of only two cell key holders (the
other being a SO) he opened and went into the cell with another Officer.
Both officers saw the man hanging. An SO immediately contacted more
staff to assist and appointed others to escort the ambulance when it
arrived.
97. An Officer told my investigators that the man had made a plaited rope
and tied it around the wall cupboard in the corner of the cell. Another
Officer cut the ligature with his fish knife. The Officer supported the
man’s body and the two officers then laid the man on the floor. One
Officer said that the man’s lips had curled back and he was cold.
98. Another Officer also responded to the emergency call. At interview, she
told my investigating officers that she arrived at the man’s cell as the
other two officers were supporting the man’s body. She assisted and
moved the cell furniture so that the man could be laid flat on the floor.
She then checked to see if the man had a pulse but found none.
99. The officers were about to commence cardio pulmonary resuscitation
(CPR), when a Nurse arrived. One Officer said this was about 20
seconds after he had arrived at the cell. The Second Officer left the cell
and made her way to the main gate to meet the paramedics. It was a
cold night and, en-route to the gate, she experienced difficulties
unlocking a number of the outside gate locks because of the freezing
temperatures.
100. At interview, the Nurse told my investigators that he responded to the
emergency call at 4.23am. He immediately made his way to house block
one, en route meeting the SO who explained that a prisoner had been
found hanging.
101. They arrived at the cell and saw the man lying on the floor with his head
towards the cell window. The Nurse immediately checked the man for
signs of life. He was pale in colour and cold. Salivation fluid was also
leaking from the right side of his mouth. The man had no pulse or blood
pressure and was not breathing. The Nurse told my investigators that, in
his opinion, the man showed no signs of life. Nonetheless, he
commenced external cardiac compressions.
102. At interview, another Nurse told my investigators that, on hearing the
radio call, he collected the red emergency bag (which contains
equipment to aid resuscitation) from the healthcare unit and made his
way to house block 1. He arrived at the man’s cell within two minutes.
Whilst the other Nurse carried out cardiac compressions, the newly
arrived nurse inserted an airway, connected an ambu bag (an artificial
breathing aid) and set up the oxygen supply. This Nurse also carried out
a full assessment of the man and concurred with the other Nurse that he
showed no signs of life.
103. An Officer met the paramedic from the fast response unit at the prison
gate at 4.35am. At 4.43am, a SO received a telephone call from the
main prison gate informing him that an ambulance crew with two
paramedics had also arrived. The officer was at the time in the process
of escorting the first response paramedic through the prison. She told
my investigators that she had to deliver the paramedic to the man’s cell
first, before she could return to collect the ambulance crew.
104. An SO said that night staffing levels are much reduced compared to
those of the day shifts. He said that it was inevitable that there was a
delay before the ambulance was escorted through the prison as staff
were already in the midst of escorting the first paramedic. Staff on duty
told my investigators that the ambulance crew were verbally aggressive
with them because of the delay.
105. Another Officer was on duty that night and received a telephone call
from an SO informing him of an emergency on house block 1. The
officer had been unaware because the batteries in his radio were flat.
He made his way as quickly as possible to the man’s cell arriving at the
same time as the first response paramedic.
106. When the paramedic arrived at the cell, he was briefed by the two prison
nurses. The paramedic then continued to examine the man and
attached a portable defibrillator which continued to instruct the user not
to shock, meaning there was no cardiac activity. The paramedics asked
the SO to make contact with the ambulance paramedics to ensure they
brought a stretcher and a 12 inch ECG lead to the cell.
107. When the ambulance paramedics arrived at the cell, they discussed
what action to take next with the first response paramedic. Two nurses
left the cell to make their entries in the man’s medical record.
108. One of the officers told my investigators said that the paramedics said
they intended to continue to attempt resuscitation on the man as he “was
a young lad”. They meant by this that, given the man’s age, they
believed there was a possibility he could be revived. The man was
transported into the ambulance and taken to the Epsom Hospital. A
fourth SO said that, although the prison staff believed that the man was
already dead, the ambulance crew were not forthcoming with any
information about his condition. He therefore instructed an Officer to
accompany the man in the ambulance, none of the paramedics having
officially pronounced his death.
109. The second Governor was the duty governor responsible for the prison
on the night of the man’s death. He told my investigators that he was
contacted at home at around 4.40am by the prison’s communications
officer. The officer explained that the man had committed an act of self
harm by suspending himself with bed linen around his neck from his cell
cupboard. Resuscitation was being attempted. The Governor made his
way into the prison. On the way, he was updated by the Officer who was
instructed to accompany the man in the ambulance on the man’s status
and told that the man had been taken to hospital.
110. The ambulance crew left the prison and continued to try and resuscitate
the man on route to Epsom Hospital. When they arrived, a team of
doctors were on hand to take over and the man was immediately taken
into a room where resuscitation continued. The Officer told my
investigators he watched the doctors try to revive the man. He was
eventually pronounced dead at 5.42am.
111. The police arrived at the hospital soon afterwards and were updated on
events. The Officer contacted the prison to inform staff of the man’s
death.
After the man’s death
112. As the second Governor’s journey took approximately 40 minutes, he
telephoned the control room again for an update before arriving at the
prison. On this occasion he was told that the man’s death had been
pronounced at the hospital. The SO had instigated the prison’s death in
custody contingency procedures and contact was being made with the
appropriate agencies.
113. The police arrived at the prison at 6.00am, as did the Governor. The
man’s cell had already been sealed awaiting their arrival. The Governor
then spoke to a number of staff and assisted the police. Instructions
were given to collate the man’s records including details of his next of
kin.
114. At around 7.10am, arrangements were made to review all the other
prisoners who were currently on an open ACCT. The Governor made
arrangements for the night duty staff to congregate in the orderly office
so that they could complete incident reports. This was followed by a hot
debrief meeting at 7.45am. The officer arrived back from the hospital in
time to attend. Staff were given the opportunity to go through the events
of the night, and support was offered.
115. Another SO arrived on duty to be informed of the man’s death that
morning. She told my investigating officers that, as the prison’s family
liaison officer (FLO), she immediately obtained the man’s next of kin
details. Within an hour and accompanied by a fourth Governor, she left
the prison to inform the man’s family of his death. When they arrived,
they were met by the man’s mother and stepfather. The man’s mother
told the SO that the man had said he would take his own life. She was
concerned that he had done so with the strings from the guitar that she
had recently brought into the prison for him. The SO was able to confirm
that the man had not used the guitar strings.
116. At interview, the SO told my investigators that they gave the man’s
parents as much information as possible, including the coroner’s details
and prison contact numbers. The family were also offered the
opportunity to visit the prison.
117. The SO said that the man’s parents asked for further information about
funeral costs and the return of his property. The SO said that she told
the family that the prison would offer financial assistance for the funeral.
118. The man’s parents were originally informed by this SO that the prison
would pay up to £2,000 towards funeral expenses. The family later told
the prison that the cost of the man’s funeral amounted to £3,279 and
asked if the prison would be able to contribute further. The matter was
passed to the Governor of High Down. I understand there was a delay
of a week before the full payment was authorised.
119. The SO and two other members of staff attended the man’s funeral. At
that stage, the man’s personal property had not been returned to his
family. The SO told them that she would make arrangements for the
property to be returned as soon as possible. Due to her annual leave,
she was unable to do so the following week, during which time the man’s
family again enquired about the return of his property. No arrangement
had been made in the SO absence to return the property. On her return
from leave, the SO arranged for the man’s property to be returned.
Letters found in the man’s cell
120. After the man’s death, a number of letters were found in his cell. The
majority were dated 6 December 2007, and were addressed to friends
and family members expressing his wish to distribute his belongings to
specific people. He made it clear that it was his intention to kill himself,
and referred to longstanding issues to do with his lifestyle and
relationship difficulties. The man also mentioned that he believed he
would be sentenced to 25 years in prison.
Post Mortem
121. The conclusion of the post mortem examination was that the cause of
the man’s death was hanging.
ISSUES RAISED IN THE INVESTIGATION
Clinical care
122. On arrival at High Down, the man was immediately located in the
healthcare unit and an ACCT document was opened. Further to this, he
had contact with and was monitored by a number of healthcare staff.
The clinical reviewer notes that this included the man being assessed by
the visiting prison psychiatrist during three ward rounds.
123. The psychiatrist was a member of the mental healthcare In-Reach team.
However, the man was not referred to the In-Reach team for a
secondary assessment. The In-Reach Manager confirmed to my
investigators that it was clear from the entries in the man’s ACCT plan
that a referral was intended. However, one was not made and so no
follow up action took place in spite of the team being part of the ward
rounds.
The Head of Healthcare should ensure that all follow up actions in
ACCT plans are carried out.
124. The clinical reviewer highlights that prisoners should be seen by
members of the In-Reach team after being specifically referred to them,
and not simply on an ad hoc basis when the team happen to be present.
This would clarify the position in respect of in-reach involvement and
follow-up. In particular, there would be no need for a separate referral to
in-reach for follow-up when a patient is discharged from healthcare.
125. The clinical reviewer also comments that, in the community, mental
health teams benefit from all referrals entering the system in the same
way. It might be helpful if this approach were adopted by the Mental
Health In-Reach team who provide secondary psychiatric services to the
prison population.
126. At the time of my investigation, prisoners assessed by a member of the
In-Reach team were seen as a referral to the team rather than to
individual members (such as the psychiatrist). I am pleased to learn that
the healthcare unit has recently reviewed its procedures, and this
practice has now been changed so that any patient admitted to the unit
for inpatient care will be allocated a named nurse and has a full mental
health nursing assessment within seven days of admission. Any patient
admitted with a mental illness will be automatically referred to the In-
Reach team. I therefore do not make a formal recommendation.
127. The clinical reviewer also considers that the In-Reach team would
benefit from the input of a psychologist.
The Head of Healthcare should ensure that the revision of their new
procedures relating to referrals and discharge from the In-Reach
team is promulgated to all relevant staff.
The Head of Healthcare should review the benefits of having a
psychologist within the In-Reach team.
Relocation of prisoners from the healthcare in-patient unit
128. Upon being relocated to the normal prison house block, the man was not
subject to a detailed planning process that would have assisted wing
staff to identify any signs of deterioration. Staff did not receive clear
guidance about what to observe and when to ask for further intervention
or assessment. The prison healthcare manager confirmed to my
investigators that it was their expectation that prisoners discharged from
the healthcare unit should receive a routine check within a week.
Unfortunately, this did not occur when the man was discharged because
of staff shortages. The unit had no further contact with the man once he
was moved to the wing.
129. It is beneficial for there to be a multidisciplinary approach to prisoner
aftercare, as well as a formal review, so that appropriate staff have an
opportunity to input into the prisoner’s care. As part of the healthcare
review since the man’s death, all patients’ discharge plans now include
an offer of an out-patient appointment.
ACCT monitoring
130. So far as they could judge, my investigators found that staff accurately
reported their observations and interactions with the man. At the time of
his death, he was expected to be monitored every hour. However, there
was an interval of one hour and 20 minutes between the final two
checks.
131. The clinical reviewer notes that an hourly frequency can provide an
opportunity for an individual to self harm between observations. In fact,
this is true of any level of observations short of constant. However, as
the Chief Inspector of Prisons has noted in her most recent inspection
report on High Down, checks by night staff on prisoners subject to open
ACCT documents should be frequent and unpredictable. This is to avoid
the prisoner being able to predict when he is going to be observed by
staff. Had the man been checked upon 20 minutes earlier (say at
4.00am), it is far from certain that the outcome would have been
different. However, the Governor will wish to assure himself that night-
time ACCT checks are being carried out appropriately.
The Governor should review the timeliness of night-time ACCT
observations.
132. The issue of observations aside, it is clear from this investigation that
many staff tried to improve the man’s mood by engaging him in
conversation. I am also impressed by the decision to allow his mother to
bring in the man’s guitar and let him keep it in his cell.
The Governor should commend the relevant staff named in this
report for their efforts in offering support and care to the man.
133. At interview with my investigators, the healthcare manager said that the
ACCT documentation was only used by prison staff. I do not know if this
view is shared by others, but all staff should be reminded that the ACCT
process works best when everyone contributes, with entries made by
wing, health and in-reach staff.
134. The OSG on duty the night the man was found hanging was not trained
in ACCT procedures although he was aware of the principles behind it. I
recommend that all staff who have contact with prisoners receive at least
basic training on the ACCT document.
The Governor should provide ACCT training for all staff who have
contact with prisoners.
Night duty staff
135. A number of issues came to light during this investigation relating to
night staff. An OSG’s torch failed to work because the batteries were flat
when he arrived at the man’s cell. The batteries also failed in an
Officer’s radio (the main means of communication). As a result, he was
not immediately aware that an emergency had been reported elsewhere
within the prison. Equipment failures can have a significant impact on
the speed of response to incidents. Steps should be taken to ensure
that all prison radios and torches are fit for purpose at the beginning of
staff duty.
The Governor should ensure that radio and torch batteries are
regularly changed to avoid their failure whilst staff are on duty.
136. When the man was first discovered, an OSG did not enter the cell. He
observed the man in what was considered a life threatening position,
hanging by a ligature and with saliva was coming from his mouth. The
prison’s night procedures say that “saving life is paramount and aid must
not be delayed whilst waiting for support staff to arrive”. However, they
also state that personal safety is to be considered before entering a cell.
The OSG told my investigators that his instructions from his senior
managers were that he should never enter a cell unless two officers are
present.
137. The night procedures require staff to make a judgement about when to
enter a cell in emergencies. Staff must decide whether they think a life is
in danger, and whether they believe there to be a risk to the security of
the prison. I have now conducted many investigations in which staff
across the prison estate have had to make such a decision. On some
occasions they have entered the cell; on some occasions they have not.
I have been loath to deploy the certainty of hindsight when considering
the reasonableness or otherwise of those decisions.
138. Nor do I criticise the OSG’s actions in this instance. In any event,
assistance arrived at the man’s cell very quickly and I believe it unlikely
the OSG’s decision to stay outside the cell had any detrimental impact
on the events that followed. The OSG was not first aid trained and
would have been limited as to what he could have done for the man
without further support.
139. However, it would be wise for the Governor to review the night
procedures to ensure there are no avoidable ambiguities. In particular, I
note that the OSG has said that his instructions were never to enter a
cell alone (in contradiction to the formal policy).
The Governor should review the night procedures and ensure that
all night staff are aware of what is expected of them.
The Governor should review the level of first aid training amongst
night duty staff and where necessary ensure such staff receive
additional training.
Emergency Services
140. Prison staff reported to my investigators that the ambulance crew were
unhappy about the delay before they were escorted to the man’s cell. It
is perhaps inevitable that delays can sometimes occur during the night
state when there are reduced staffing levels. I am pleased to note that
the clinical reviewer has already addressed this matter with the
ambulance service.
A familiarisation exercise has already been carried out by the
ambulance service regarding prison procedures for emergency
vehicles, particularly at night when staffing levels are reduced. I
note this as good practice.
Funeral expenses
141. Support for funeral costs is addressed in Prison Service Order (PSO)
2710. The PSO says that the prison should:
“… offer to pay reasonable funeral expenses or, if the family want
particularly expensive arrangements, offer a contribution. £3,000 is
the sort of figure considered reasonable in 2005-2006 but not to
quibble over small sums. This offer should be made irrespective of
whether the family is entitled to claim a grant from the Social Fund.”
142. My investigator found that the family liaison officer was unaware of the
information in this PSO. This led to the wrong information being given to
the family which resulted in an unnecessary delay in payment being
authorised for their expenses. I believe that the delay in dealing with this
matter has contributed to the family’s sense of disappointment with the
prison and make the following recommendation.
The Governor should ensure that all family liaison officers are
aware of the current PSO guidance and the information is explained
to the next of kin as soon as practicable.
CONCLUSION
143. The man was a young man who had a history of self harm and mental
health difficulties, and had expressed an intention to take his own life
well before entering Prison Service custody at HMP High Down. When
he was received at High Down, on remand for murder, he spent three
weeks in the healthcare unit where he was assessed and monitored as
part of the healthcare unit regime and by virtue of being on an open
ACCT. He then spent a further three weeks on a mainstream prison
wing where he seems to have been well supported by wing based staff.
Aware of the man’s talent for playing musical instruments, staff managed
to engage him in some musical activities within the prison. In spite of
this, the man’s outlook on life remained unchanged and he maintained
his intention to take his own life throughout his short stay in custody.
144. It appears that the man did not believe that things would improve, and
the letters found in his cell after his death support this view. I do not
believe that there were actions that prison staff could reasonably have
been expected to have taken that would lead to a different outcome.
RECOMMENDATIONS
1. The Head of Healthcare should ensure that all follow up actions in ACCT
plans are carried out.
2. The Head of Healthcare should ensure that the revision of their new
procedures relating to referrals and discharge from the In-Reach team is
promulgated to all relevant staff.
3. The Head of Healthcare should review the benefits of having a
psychologist within the In-Reach team.
4. The Governor should review the timeliness of night-time ACCT
observations.
5. The Governor should review the level of ACCT training amongst all staff
who have contact with prisoners.
6. The Governor should ensure that radio and torch batteries are regularly
changed to avoid their failure whilst staff are on duty.
7. The Governor should review the night procedures and ensure that all
night staff are aware of what is expected of them.
8. The Governor should review the level of first aid training amongst night
duty staff and where necessary ensure such staff receive additional
training.
9. The Governor should ensure that all family liaison officers are aware of
the current PSO guidance and the information is explained to the next of
kin as soon as practicable.
Good practice
10. The Governor should commend the relevant staff named in this report for
their efforts in offering support and care to the man.
11. A familiarisation exercise has already been carried out by the ambulance
service regarding prison procedures for emergency vehicles, particularly
at night when staffing levels are reduced.
The Prison Service has accepted seven of the recommendations and partially
accepted the remaining two. Their action plan is attached as an annex.