Individual at Acklington

INVESTIGATION INTO THE DEATH OF A MAN AT HMP ACKLINGTON ON
26 FEBRUARY 2005
REPORT BY THE PRISONS AND PROBATION OMBUDSMAN FOR
ENGLAND AND WALES
JULY 2005
This is the report of an investigation into the death of a man, who died on 26
February 2005 having been taken ill at HMP Acklington. Because the cause
of his death was unclear, my office carried out a full investigation into its
circumstances.
I would like to take this opportunity to add my condolences to those already
expressed by my Family Liaison Officer, to the sister of the deceased, and to
those who knew him. They have lost a loyal and faithful brother and friend.
The man who is the subject of this report had a number of chronic health
conditions, which appear to have been properly treated by the prison’s
healthcare department. There were occasions early in his time in custody
when he experienced periods of depression. However, there were no
indications that this was the case in February 2005, and I am satisfied with the
prison’s monitoring of his mental health. Similarly, although some
arrangements for prisoners to hold their own medication were inadequate,
there is no suggestion that the prison’s practices should have been
implemented any differently for the deceased.
Nevertheless, there were aspects of the prison’s response to his being found
unconscious that were inadequate. Whilst they do not appear to have been
significant for this particular man, it is vital that the lessons are learnt.
I have been assisted greatly in this investigation by a doctor who carried out a
prompt review of the man’s healthcare whilst at the prison. I am pleased to
see that the doctor makes no recommendations about the work of the
healthcare centre. However, like most prisoners and indeed like people
outside prison, the man held his own supplies of medication. Proper
safeguards for prisoners in this position are not in place as they should be.
My thanks are due to the Governor of Acklington, and to his colleagues, for
their assistance with the investigation. They have responded willingly to the
changes brought about by my office’s investigation arrangements and this is
much appreciated.
Stephen Shaw CBE
Prison and Probation Ombudsman
July 2005
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CONTENTS
Summary 4
Background 5
HMP Acklington 6
Conduct of the investigation 8
Key findings 9
Recommendations 17
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SUMMARY
1. The man was 66 years old when he died at hospital on 26 February 2005.
He had been found in his bed unconscious the same day at Acklington
prison. He had suffered with several chronic medical conditions prior to
his arrest and sentence.
2. The man’s health conditions were stabilised by long term medication,
which he kept in his own possession. The risks of keeping his own tablets
were considered when he arrived at the prison and were deemed to be
out-weighed by the benefits. He was a man who took positive steps to
meet his own health needs and holding his own medication was a part of
this.
3. Before transfer to Acklington in April 2004, the man had disclosed that he
feared being bullied by other prisoners and had said that he was
depressed. However, he appeared to have benefited from the transfer and
there had been no more indications that he felt under pressure. Education
and wing staff described him as a quiet man and the Sentence Planning
Board set comprehensive and realistic objectives.
4. The man was allocated a single cell when he arrived at Acklington and
kept it for eight months until December, when he was reduced to standard
level on the Incentives and Earned Privileges Scheme because he refused
to attend a treatment programme. He then shared his cell with his cell-
mate until his death and there were no indications of any problems that the
move might have caused.
5. When the man died it was thought by the hospital and prison that it was as
a result of natural causes. However, the first post mortem found that he
had consumed an excessive amount of medication and a second post
mortem was ordered. The second post mortem has confirmed that his
death was due to natural causes, and that the large number of tablets he
had consumed were in an undigested state and so did not contribute to his
death.
6. This report considers whether there were any indications that the man was
at risk of harming himself which should have been noticed and responded
to by staff. It also considers the treatment of his long term physical
symptoms and whether any other actions should have been taken.
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BACKGROUND
7. The man was born in 1938 and was 66 years old when he died on 26
February 2005 in hospital. He was a single man, and had cared for his
mother until her death in the mid 1980s. He owned his own home, but
it was sold when he was convicted and he had said that he would have
no fixed abode on release. He worked until he was remanded in
custody in January 2004. The Probation Service prepared a
comprehensive assessment of the man before he was sentenced. He
was described as suffering from angina and glaucoma, and had had a
brief period of depression in 1984. He told Probation that he had no
history of self harm, and confirmed this when he was first remanded in
custody.
8. The man was subsequently convicted on 13 April and sentenced to five
years imprisonment. On 1 July, the Appeal Court increased his term to
six years. It was his first conviction and his first experience of prison
life. Initially, he was held at Preston, but transferred to Durham where
he was allocated a ground floor cell because of his angina. From
Durham, he was moved almost immediately to Acklington. It was at
Acklington that he was found unconscious in his bed on 26 February,
transferred to hospital and died later that day.
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HMP ACKLINGTON
9. HMP Acklington is a Category C prison for convicted adult male
prisoners with an operational capacity of 882, which includes almost
400 spaces for vulnerable prisoners. The prison opened in 1972.
10. The man’s cell was situated on the ground floor of C Wing which is in
one of the wings for vulnerable prisoners. It has the capacity to hold 83
prisoners but, on the day he died, there were only 82 present. One of
these prisoners was subject to the F2052SH monitoring procedures,
which are put in place for prisoners who are considered to be at risk of
suicide or harming themselves. The average age of prisoners on C
Wing at the time of the man’s death was 45 years. The man shared his
cell with a prisoner who was a few years younger than he was but who
was also in poor health.
11. Prisoners in the wing live in dormitory conditions and in double cells.
There are 12 cells in the spur where the man lived. Each prisoner has
a key to his own cell and uses a shared bathing and toilet area within
the spur. There is a locked metal gate at the end of the spur, with an
office from which staff can see the corridor through the middle. Each
prisoner has a single bed, table and wardrobe, together with a lockable
bedside cupboard for the storage of valuables and medication.
12. The evening routine includes a regular roll call at 7.30pm to confirm
that all prisoners have been seen, after which the prison goes into
“patrol state” when C wing prisoners are locked in their spur and staff
numbers are reduced. When the night staff arrive on the wing, they are
given a hand over by the staff going off duty together with a sealed
packet containing cell keys to be used in an emergency. In the
morning, the day staff are also given a hand over and a further roll
check is carried out before the night staff go off duty. The weekend
routine is for prisoners to be unlocked from 8:40am and served
breakfast. C wing prisoners are called to the spur gate, which is
unlocked for them to collect their meal from the servery.
13. The prison’s healthcare is provided by Northumberland Primary Care
Trust, who employ nurses during the day, seven days a week. They
work with a medical officer, providing out patient care and weekly or
monthly administration of medication to prisoners who have been
assessed as capable of keeping it in their own possession. They
administer medication to other prisoners, when either they are
considered to be incapable of taking their medication without
supervision or the medication itself is unsuitable to be held in their cell.
Prisoners who require in patient nursing are transferred to outside
hospital or to another establishment.
14. Her Majesty’s Chief Inspector of Prisons (HMCIP) carried out an
unannounced inspection of Acklington in April 2003. Her report
described a ‘safe prison’ and went on to record that ‘the low levels of
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self harm and the absence of self inflicted deaths reflect well on the
proactive approach taken by staff’. However, the Inspectorate
highlighted concerns about the needs of older prisoners, and those with
health conditions requiring a level of care that could not be provided at
Acklington. At the time of this investigation, the clinical team leader
was exploring the possibility of introducing clinics for specialist
conditions such as those experienced by older people.
15. The most recent audit of Acklington by HM Prison Service’s Standards
Audit Unit was in November 2004. It assessed four discrete areas:
Decency and Health, Organisational Efficiency and Effectiveness,
Regimes and Safety. The report identified concerns about the quality of
support plans for prisoners who were considered to be at risk of suicide
or self harm. The report also focussed on the management of
medicines, and the Primary Care Trust plans to develop a policy for
medication held in possession. At the time of this investigation, the
work had yet to be completed.
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CONDUCT OF THE INVESTIGATION
16. Initially, my office was advised that the man’s death was likely to be
due to natural causes. The subsequent results of the post mortem
meant that interviews with staff and others were required and so the
initial arrangements were altered. The investigation into the man’s
death began with a meeting with the Governor and a representative
from the Independent Monitoring Board on 21 March 2005. Notices
were displayed to announce the investigation and invite prisoners and
staff to contact the investigator. One prisoner asked to speak to the
investigator but later withdrew the request as he was moving to another
prison.
17. Interviews were conducted with 11 staff, including those who knew the
deceased, those involved when he was found ill on 26 February, and
those responsible for the running of various aspects of prison life. A
meeting was held with the Primary Care Trust’s Clinical Team leader,
who works full time at the prison, and two of her managers, together
with the governor responsible for liaison between the prison and Trust.
The man’s cell-mate was also interviewed.
18. Informal conversations took place with the prison’s chaplain, and with
two members of staff in the art department where the man attended
classes.
19. Prison records, including medical records, were also made available
together with relevant prison policies and procedures.
20. One of my office’s Family Liaison Officers has had telephone contact
with the bereaved family and friends.
21. A Clinical Review was commissioned from Northumberland Primary
Care Trust and was carried out by a doctor.
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KEY FINDINGS
Events prior to 26 February
22. The man was remanded in custody to Preston prison in January 2004.
He was charged with offences committed over many years. His legal
advisors initiated the Poor Coper Risk Assessment because he was of
pensionable age, not in good physical health and it was his first time in
prison. At the time, the man expressed fears about his personal safety
as he said that he was conspicuous amongst the other prisoners and
was frightened of being attacked. He was given Vulnerable Prisoner
(VP) status because of his age and the nature of his offences. This
status continued throughout his time in prison.
23. A First Reception health screen was carried out on 17 January and this
confirmed the earlier assessment of the man’s physical and mental
health. It was good practice that a Well Man assessment was carried
out. The man had angina, glaucoma, diverticular disease and a hernia.
24. The man transferred to Durham in early February. On 8 February, he
expressed concerns for his personal safety because of the nature of
the charges and said that he was feeling low. It was arranged for him
to see a Listener (a prisoner who has been trained to work by the
Samaritans). Consideration was given to opening an F2052SH, but it
was not thought to be necessary. Medical assessments that month
described him as fit and well, but he later asked to see the Medical
Officer because of his heart condition. On 10 March, he again asked to
see the doctor because he felt unwell and his condition was further
reviewed on 10 April.
25. On 20 April, the man was assessed as fit for transfer from Durham to
Acklington. It was noted that he held his own medication for an
ongoing heart condition. The same day, the Durham records note that
he said he was being bullied because of his offences and that other
prisoners were shouting at his door. The records state that action
would be taken once the culprits were identified.
26. The man’s home probation officer completed the OASys assessment
on 21 April. This is the assessment tool used to describe all aspects of
an individual’s circumstances. It stated that there was no risk of self
harm or of attempts at suicide. The man was described as an
intelligent and eloquent man, but one who was manipulative.
27. The man transferred to Acklington on 23 April and the First Reception
procedure was repeated. In response to questioning about self harm,
he said that he had considered it in February that year and had felt
depressed both inside and outside prison. He said that he had not
recently considered suicide and neither had he received treatment for
depression. He was referred to a Registered Mental Nurse for
assessment. This was carried out the following week when he said
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that he had previously mentioned suicide at court when he thought he
was threatened with a lengthy sentence. There were no further
occasions when suicide or self harm was mentioned by the man.
28. Prisoners at Acklington hold their own medication unless specific risks
are identified, mainly for the individual prisoner but sometimes due to
the type of medication. The arrangements are referred to as In
Possession (IP). The arrangement has been in place for about two and
a half years since prison healthcare providers were advised to
replicate, as far as possible, the conditions in the community. In this
case, the man signed the Medication Agreement the day that he
arrived at the prison. Amongst other things, the Agreement stated that
he agreed not to save up or hoard medication and to take it as
prescribed for the prescribed duration. He held his own medication for
the rest of his time at Acklington and there were no concerns about his
safety. He collected it from healthcare staff each month and stored it in
the lockable cupboard in his cell.
29. Throughout the time that prisoners at Acklington have held their own IP
medication, the prison has not had a policy for its administration,
although there are many implications for the day to day routine. IP
medication has considerable benefits for prisoners like the man who
died, who are able to take responsibility for their own health needs,
particularly when they have a long term health condition.
Correspondence from the man in his medical record suggests that he
did just this. For example, he wrote to healthcare when he needed new
glasses and to follow up medical tests. Holding his own medication
also meant that he did not have to queue to collect it each time a dose
was required, which might be time consuming and tiring.
30. However, there are also implications for procedures such as Cell
Searches, Cell Sharing and Safer Custody and these should be
considered jointly by discipline and healthcare staff. Policies for IP
medication should take account of, and link with, other relevant prison
healthcare and security policies, including national policies. It is good
practice, when introducing any change to a service, that all resulting
effects are monitored. This has not happened at Acklington and no
information was available about whether any adverse incidents had
taken place since IP medication was introduced. However, an
additional cell search would be ordered if a member of staff suspected
that a prisoner was stockpiling medication. In addition and where
possible, a prisoner thought to be at risk of suicide or self harm would
be located in wing where the access to medication was reduced.
The Governor and Primary Care Trust should develop a
comprehensive policy for In Possession medication to include
risk assessment for suitability, storage and compliance with
treatment regimes. The policy should be audited on a regular
basis to ensure its effectiveness.
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31. On arrival at Acklington, the man was allocated to H wing. The wing
has single cells and is the part of the prison used to accommodate new
arrivals. He was given Enhanced Prisoner status under the Incentives
and Earned Privileges Scheme (IEPS) on 13 May, meaning that he
was entitled to additional association time with other prisoners each
day and one more visit per week. H wing contains cells for enhanced
prisoners and the man was able to remain on that wing. His medical
record for the following month states that he was coping at the time, but
was still melancholic about being in prison at his age.
32. Because of his age, the man was not employed at the prison, and he
was eligible to use the Education department’s classes. He attended
art classes three times a week and the teachers in the department said
that he enjoyed completing individual course work. He was not a man
who asked for help with his work, but would wait for a teacher to
approach him. The staff described him as a quiet and studious man,
who worked hard and was a decent and fine artist. His art work
improved considerably, but the teachers said that he never felt it was
good enough.
33. A Sentence Planning Board took place on 3 December which identified
objectives for the man’s prison sentence. It also considered whether
he was at risk of suicide or self harm and the judgement was that he
presented as low risk. Although the man told the Board that he was
unhappy about being in custody, he said that he would not harm
himself. He had had issues when settling into prison life and had used
a Listener, but he said that it had not been helpful to him. The prison’s
support network was explained to him, including the chaplaincy team
and he said that he was coping without it. The Board recommended
that the man undertake the Sex Offender Treatment Programme
(SOTP) and continue with education classes. The Board’s record was
comprehensive and complete, and set realistic and achievable targets
which were being delivered.
34. However, the man declined to attend the SOTP, as he said that his
offences were committed many years ago and did not think he
presented any risk of further offending. Because he refused to attend
the programme, he was reduced to standard level on the IEPS.
Consequently, on 9 December he was moved to C wing and allocated
to a double cell, which he shared with his cell-mate and where he was
subsequently taken ill.
35. Later that week, the man’s medical record state that he said that he
was feeling stressed and worried all the time. There are no more
entries in the medical record until those of 26 February.
36. There are few entries relating to the man in the C wing observation
book, but there is one for 24 January 2005 when he reported his cell-
mate as having overdosed on his own medication. The records for this
incident were requested by the investigators but were not available.
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37. The two men continued to share a cell and it was the man’s cell-mate
who alerted staff to his condition on Saturday 26 February. He told the
investigators that the man was unusually late going to bed on the
Thursday beforehand as he was writing papers for many hours.
However, he said that they went to bed as usual on 25 February and
he did not hear anything during the night.
Events of Saturday 26 February
38. An Officer and an Officer Support Grade (OSG) carried out the routine
roll check of C wing at 6:00 am on Saturday 26 February. This is done
by opening the flap in the cell door to confirm that the prisoners are
present.
39. At 7:30am, they handed over to a “guesting” officer, meaning that it
was not his regular place of work in the prison. The guesting officer
told the investigators that there was nothing of significance regarding
the man in the night staff report. He repeated the roll check before the
night staff left the wing, and rang the information through to the Detail
office.
40. The guesting officer remained alone on the wing until 8:30am, when a
second officer was to begin his shift. Of the two officers, the guesting
officer was the more experienced but the second officer knew the wing
better and there is no protocol that gives either responsibility over the
other. Both were carrying keys, and the second officer carried cell
keys, but neither carried a radio. A third officer was present as he was
carrying out voluntary drug tests.
41. The man’s cell-mate has given a statement to the police and to the
investigators from the Ombudsman’s office. This confirms that he was
woken on the Saturday morning by the man’s alarm clock. In interview
with the investigation team, he described the deceased as a man of
regular habits, who routinely set his alarm and got up quickly after it
rang once or twice. He said that this routine did not vary at the
weekend. On 26 February, the alarm rang as usual but the man did
not silence it and his cell-mate said that he eventually reached to turn it
off himself. Some time later he woke again and heard the man snoring.
He said that he got out of his own bed and tried to rouse him by
shaking his shoulder. He heard that his breathing was noisy and saw
what he thought was blood coming from his mouth on to the pillow. He
rang the cell bell and then went to the spur gate from where he could
talk to staff.
42. The cell-mate confirmed that the second officer came to the gate and
he told him that the man had been taken ill and that he could not wake
him. In his statement for the prison, the second officer said that he
arrived at the wing at about 8:25am in time to start his shift at 8:30am.
He told the investigators that the cell call bell rang at the panel whilst
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he was taking his jacket off. The panel indicated the cell bell that had
rung. He went to the spur gate where he spoke to the cell-mate who
expressed concern about the man and said that he could not wake him
up. He returned to the office to collect a colleague, the guesting officer,
as the prison was still in patrol state and officers are instructed to patrol
in pairs. The two officers then went to the cell, and saw the man lying
on his back in bed. In his police statement, the second officer said that
there was what he thought was vomit on the pillow and blood by the
man’s mouth and nostril. He said that the man’s breathing was
laboured and the officers tried unsuccessfully to wake him. Neither the
second officer nor the guesting officer had an up to date first aid
qualification and neither officer was aware of whether the other was
qualified. They did not attempt first aid.
Consideration should be given to providing first aid training for all
staff who have contact with prisoners.
42. The officers returned together to the office intending to ask for
healthcare to be contacted. They left the man unaccompanied and the
second officer said that another prisoner, a landing cleaner who could
be trusted, was asked to wait at the cell door.
The officers should be instructed that a sick prisoner should not
be left unaccompanied.
43. In his statement to the Ombudsman’s investigators, the second officer
said that when he and the guesting officer returned to the office, the
voluntary drug-testing officer said that the Communications room had
already been telephoned. However, in the second officer’s statement
to the police, made shortly after the incident, he said that he had
actually asked the voluntary drug-testing officer to make contact, which
is what the voluntary drug-testing officer says happened.
44. The second officer and the guesting officer returned to the cell, and the
second officer said that the man remained on the bed and his breathing
could be heard. He said that they tried to rouse him again but failed
and again they returned together towards the office to see if healthcare
staff were in sight. They then returned for the third time to the cell.
The man was described as making a snoring noise, his breathing was
noisy with his chest rising and falling. The second officer said that he
thought that the matter was quite urgent.
45. In interview, he said he thought that he himself telephoned the
Communications room the second time but did not consider using the
radio to summon assistance even though he thought that there would
be one in the office. Although the clinical review states that the time
between the cell-mate alerting staff and medical assistance arriving
was not significant to the man, it could be critical to another prisoner.
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The Governor should review arrangements to ensure that staff are
trained and equipped to recognise an emergency and call for
immediate assistance using the standard prison emergency
procedures.
46. At about 8:50 am, a Senior Officer (SO) completed his routine duties on
A wing. He left to do the same on B wing, where the staff informed him
that they thought that there was an incident on C wing. The SO went
immediately to C wing and to the cell where he assessed the man’s
condition. He said that, although he does not have a medical
background, he recognised that the man had medical needs and he
was informed that healthcare staff were on their way. The Senior
Officer said that he told the second officer to stay in the cell, whilst he
ensured the smooth running of the wing. He ordered the other
prisoners to return to their cells, allocated the cell-mate to another cell,
ensured that those prisoners who were being monitored for suicide or
self harm were checked and that breakfast was served. The cell-mate
told the investigation team that his own medication was untouched and
remained in his possession.
47. The voluntary drug-testing officer said in interview that there was a
further telephone conversation between the wing and the
Communications room. He recalled a Principal Officer (PO), who was
the Orderly Officer in charge at the time, telephoning to ask if
healthcare staff had arrived. The PO told the investigation team that
the voluntary drug-testing officer then said that the man was coughing
up blood, but he did not detect any urgency in the call and so was not
surprised that the information came by telephone rather than radio. In
interview, the voluntary drug-testing officer said that the fact that a
second telephone call was made should have been an indication that
he viewed the situation as urgent.
48. This call coincided with healthcare staff arriving on duty at the gate and
collecting their radios. The first nurse, who arrived with the second
nurse, told gate staff that they would see the man when they gave
treatments at 9:30am, which is carried out either in the healthcare
centre or the wing, depending on the numbers of staff on duty on the
day. The routine for treatments is that prisoners make their own way
there. The first nurse said that at this point the information she had
been given led her to believe that the man was capable of walking to
treatments independently. The Principal Officer was still on the
telephone to the voluntary drug-testing officer and relayed the first
nurse’s decision to him. The voluntary drug-testing officer’s response
was that this would not be soon enough and that the man required
urgent medical attention. The PO said that he informed the
Communications room of the voluntary drug-testing officer’s opinion
and the radio was used to redirect the nurses to the wing. The PO told
the investigation team that he then went to the wing as he realised that
the situation was more serious than he had first thought.
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49. The first nurse went first to B wing to collect the emergency response
bag and the second nurse went straight to C wing, where she found the
man lying on his back, with laboured breathing and dried blood around
his nose. She placed him in the recovery position, checked that his
airway was clear and requested wing staff to make an immediate
request for an ambulance. The first nurse arrived with the bag, which
contained resuscitation equipment, and oxygen was administered. The
nurses said that he did not respond to stimuli but his pulse continued
and they considered that he had suffered a massive stroke.
50. The PO stated that the ambulance arrived at about 9:00 am and the
paramedics went to the cell to join the nurses. The man was placed on
a stretcher and an electro cardio graph was carried out.
51. The PO remained on the wing after the ambulance arrived. As Orderly
Officer, he was in charge of the running of the establishment and
reported to the Duty Governor for the day. He was not involved in the
arrangements for the other prisoners as he was aware that the SO had
made arrangements for the wing’s operation. The Duty Governor had
arrived at the prison at about 9:00am to be informed of events and that
an ambulance had been called. He carried out an assessment of any
risks arising from man’s departure from the prison and then went to the
wing.
52. The man was placed in the ambulance at about 9:30am, but its
departure was delayed for ten minutes whilst more treatment was
given. Because he was so poorly, he was not strip searched and no
restraints were in place. Two officers accompanied the man in the
ambulance. At about 9:45am after the departure of the ambulance, the
Duty Governor contacted the man’s sister to inform her of his condition.
53. After the ambulance left the prison, The PO returned to the Detail office
to arrange for staff to provide a bed watch at the hospital. He also
spoke to the second officer and the guesting officer to inform them that
they should have used the radio to summon assistance.
54. An officer who was assigned to the bedwatch has given a statement to
the police to confirm that he was alone on the assignment because the
severity of the man’s condition meant that another officer was not
required. He remained outside the room whilst hospital staff gave
treatment. At 12:20pm he was informed of the man’s death, and then
telephoned the PO to let him know. The family were contacted by the
Duty Governor and given the information soon after 1:00pm. It was
only after the man died that the cell was isolated.
55. Initially, it was thought that the man had died due to natural causes and
the prison put the appropriate procedures into place. A de-brief
meeting was not held and no arrangements were made to monitor the
well being of staff involved with caring for the man, although the Duty
Governor spoke to them informally. The Duty Governor told the
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investigation team that one of his duties was to evaluate the
management of the incident and he said that the PO had advised him
that, in his view, officers should have used the radio to summon
assistance and used the Code Blue sign. The officers involved were
informed of this at the time and the Duty Governor said that the matter
would be considered further following completion of the Ombudsman’s
investigation.
56. A post mortem investigation took place and identified that significant
quantities of medication had been consumed. A second post mortem
was requested and has concluded that the man died from pneumonia.
The report confirms that he had consumed excessive quantities of
naproxen tablets, but that these were in an undigested state.
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RECOMMENDATIONS
1 Consideration should be given to providing first aid training for all staff
who have contact with prisoners.
2 The Governor and Primary Care Trust should develop a
comprehensive policy for In Possession medication to include risk
assessment for suitability, storage and compliance with treatment
regimes. The policy should be audited on a regular basis to ensure its
effectiveness.
3 The second officer and the guesting officer should be instructed that a
sick prisoner, such as the deceased, should not be left
unaccompanied.
4 The Governor should review arrangements to ensure that staff are
trained and equipped to recognise an emergency and call for
immediate assistance using the standard prison emergency
procedures.
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