Individual at Birmingham

Investigation into the circumstances surrounding the
death of a man at HMP Birmingham
in August 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2008
This is a report of an investigation into the death of a man who was 32 years old. He
was found hanging in his cell at HMP Birmingham on 18 August 2007. He had been
in custody there for three months.
I would like to offer my sincere condolences to the man’s family on their loss.
I must also apologise for the delay in issuing this report. The first clinical review
raised issues that needed to be clarified and it took some time for a more
comprehensive clinical review to be commissioned, completed and forwarded to my
investigator. However, I must also acknowledge delays within my own office that
reflect the heavy caseload faced by my investigators. I am all too aware that it is
nearly a year since the man died and that his family and representatives have
anxiously awaited the outcome of this report.
The investigation was undertaken by one of my investigators. We would both like to
thank the Governor of Birmingham and his staff for their participation and assistance.
We are particularly indebted to the prison’s liaison officer.
Three healthcare professionals were involved in conducting clinical reviews and I
thank them sincerely for this. However, I have mentioned on previous occasions that
I believe clinical reviews should not be carried out by staff who are responsible for
the delivery of healthcare at the prison concerned. I again draw this to the attention
of those in the Department of Health responsible for prison healthcare.
I believe that both wing and healthcare staff were trying their best to ensure that the
man received the care he needed. However, it is unfortunate that a breakdown in
communications meant that he did not receive an appointment to see a psychiatrist
or community psychiatric nurse whilst at HMP Birmingham, and nobody ever
checked that he had. It is of course impossible to say whether the outcome would
have been different had the man spoken to somebody.
My report shows that the man gave away his belongings shortly before he was found
hanging. This is a phenomenon that I have encountered in other investigations, and
I think it can be said to be a clear indicator of increased risk. The Prison Service’s
Safer Custody and Offender Policy Group may wish to offer advice to all
establishments on this matter.
I make four recommendations to the Governor.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2008
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CONTENTS
Summary
The Investigation Process
HMP Birmingham
Key Findings
Issues
Recommendations
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SUMMARY
The man was remanded into custody at HMP Blakenhurst on 18 May 2007. He
transferred to HMP Birmingham, following a court appearance, on 24 May.
The man was in the process of completing a drug detoxification programme when he
left Blakenhurst. However, after assessment by a doctor in healthcare at
Birmingham, it was found that he was suffering from mild opiate withdrawal and
should be treated for his symptoms.
During his time at Birmingham, the man rarely came to the attention of staff. He was
a quiet and polite man, who spent time with a small circle of other prisoners and
attended education classes.
On 13 July 2007, the man self harmed. An Assessment, Care in Custody and
Teamwork (ACCT) document (which is used to monitor and support prisoners
thought to be at risk of self harm) was opened that day and it remained open until
eight days before his death. It came to light during this investigation that this was not
the first time he had tried to harm himself, but it is uncertain whether staff were
aware of these instances until after his death.
On 10 August, an ACCT case review was held to determine whether the man should
continue to be monitored and assessed. The review panel decided that the ACCT
should be closed as he told staff that he had no problems and wanted the document
to be closed. A further review to check his progress was planned for 24 August.
In the early hours of the morning of 18 August, staff on A wing were alerted by frantic
banging on the door by the man’s cell mate. On arrival, his cell mate told staff that
the man was hanging. Upon entering the cell, they saw that he was suspended from
a ligature made from a bed sheet which was tied around his neck and the bars of the
window. Despite the efforts of staff, the man could not be revived. He was
pronounced dead by paramedics at 3.14am.
My report includes four recommendations.
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THE INVESTIGATION PROCESS
1. I appointed one of my investigators to conduct the investigation on my behalf.
Notices were issued both to prisoners and to staff inviting anyone who had
information relating to the man’s death to make themselves known to the
investigator. However, no additional witnesses came forward.
2. My investigator was given access to all the man’s prison records, including
his medical records and police statements. All of these documents were
forwarded to my investigator within a week of her initial visit on 23 August
2007.
3. My investigator visited HMP Birmingham to carry out taped interviews with
staff and an untaped interview with a prisoner on 16, 17, 24 and 25 October.
She also visited the cell where the man died.
4. One of my Family Liaison Officers (FLOs) contacted the man’s next of kin
(his brother) to explain the role of the Prisons and Probation Ombudsman
and to offer him the opportunity to participate in the investigation process.
The man’s brother raised some concerns and asked that my investigator
consider these as part of the investigation.
5. The man’s brother believed that the man’s personality changed when he
went to prison, that he had become mentally unwell and had harmed himself
by cutting his wrist a few weeks before he died. He believed the man should
have seen a psychiatrist and felt that his concerns about his brother’s mental
health were not taken seriously by prison staff. The man’s brother said he
mentioned these concerns to a staff member when he visited the prison on
13 July. The man’s brother had also heard that the man had been told that
two of his friends had been arrested and imprisoned. He wanted clarification
of why the man was told this, as it was not the case.
6. The man’s brother instructed solicitors to take forward these and other
concerns on behalf of the family. The solicitors subsequently wrote to my
investigator and she has been in correspondence with them to answer their
questions.
7. A clinical review of the man’s healthcare whilst he was in custody at
Birmingham was undertaken by the former head of healthcare at the prison,
on behalf of the local Primary Care Trust (PCT). As this review did not
address all of the questions raised by my investigator, a further review was
undertaken by a member of staff, also from the healthcare department at
Birmingham. A third clinical review was completed by a doctor, acting clinical
lead at Birmingham. This was forwarded to my investigator on 16 May 2008.
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HMP BIRMINGHAM
8. HMP Birmingham is a large Victorian prison first built in 1849. It is a category
B local prison for adult male offenders and holds 1,450 prisoners. A recent
programme of refurbishment has provided new workshops, educational
facilities, a new healthcare centre and gymnasium, as well as improvements
to existing facilities. The prison has 11 accommodation units which are a
mixture of Victorian four-landing wings from a centre point and more recent
residential houseblocks.
A wing
9. A wing can accommodate 147 prisoners. These are mainly prisoners on
remand or awaiting sentencing.
Anti-ligature knives (fish knives)
10. Anti-ligature knives, also known as ‘fish knives’ or ‘cut down tools’, are
specially designed to cut ligatures.
Assessment, Care in Custody and Teamwork (ACCT)
11. ACCT requires any member of staff who identifies a prisoner they believe to
be at risk of suicide or self harm to take action and to record those actions.
The ACCT document should be available to all staff where the prisoner is
located, including workshops and visits. Within 24 hours of an ACCT being
opened, the prisoner is seen by an assessor and has a case review meeting.
ACCT reviews are held at appropriate intervals and are attended by the
prisoner and a case manager, together with other members of staff.
Counselling, Assessment, Referral, Advice and Throughcare (CARATS)
12. There are drug workers based in most prisons from organisations specialising in the
treatment of substance abuse. CARATS workers can run programmes, and offer
counselling, support and referral to rehabilitation centres to prisoners and on
release. Access to CARATS is voluntary. A Charter of Rights and Responsibilities
for prisoners who use the CARATS service is included as an annex to this report.
Drug Strategy
13. HMP Birmingham has a Drug Strategy that was published in March 2006.
The objective is:
“To reduce the harm suffered by individual prisoners misusing drugs,
encouraging awareness and behavioural change whilst in custody that
can be sustained on release”
The Strategy says:
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“There will be systems in place to identify, assess and support
prisoners with a drug misuse problem and which recognise the specific
needs of particular groups including those from ethnic minorities.”
The Drug Strategy Committee has clear terms of reference and meets on a
monthly basis to monitor and evaluate the effectiveness of drug services.
The committee is formed of a multi-disciplinary team, including governor
grades and CARATS workers.
Foreign National Prisoners
14. HMP Birmingham has a Foreign National policy. Its aim is to provide equality
of treatment for foreign national prisoners by identifying and addressing their
specific needs, ensuring that they receive the same care and have the same
access to all prison facilities and information that is offered to all prisoners.
15. The Foreign Nationals Committee meets bi-monthly to discuss any issues or
concerns. These issues are also raised at the Race Relations Management
meeting. Birmingham uses Language Line, a telephone support service
(available 24 hours a day, 365 days a year) to interpret information for
prisoners who do not speak, or speak little, English.
Healthcare
16. The provision of healthcare is the responsibility of the Primary Care Trust.
Primary care clinics are delivered by doctors. The primary healthcare team
comprises doctors and nurses, and there is an in patient facility (which has
34 beds) staffed by registered mental health nurses and discipline officers
during the day and a nurse and discipline officer at night.
Keys for night staff
17. Operational Support Grades (OSGs) who are on night duty are given a
sealed pouch containing a cell key. The local prison strategy (annexed to
this report) gives instructions as to when an OSG can break the seal on the
pouch and use the key. There are 15 numbered pouches and each wing has
two pouches containing keys for use at night in an emergency. Not all night
staff carry cell keys because of the threat to the security of the prison.
Listeners
18. A number of prisoners at each prison are trained and supported by the
Samaritans to be Listeners and to offer peer support. Other prisoners can
speak to Listeners in confidence about any issues that affect them. Listeners
are bound by confidentiality rules, like the Samaritans, and are unable to
disclose any details about conversations they have had (unless it is a matter
which affects the security of the prison).
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Independent Monitoring Board (IMB) report
19. The IMB is made up of local lay people appointed to each prison by the
Secretary of State. They are not members of the Prison Service, nor are
they part of the prison’s management team. They are required to produce an
annual report to the Secretary of State for Justice, highlighting good practice
and flagging up areas of concern. The Birmingham IMB’s report for the
period 1 July 2006 to 30 June 2007 acknowledged problems created by
overcrowding, lack of purposeful activity for prisoners, relationships between
staff and prisoners and a failing personal officer scheme. With regard to
healthcare, the IMB had concerns that there was still no primary mental
health provision. The Board continued to have concerns that prisoners with
mental health problems, and who in their opinion should not be in prison,
were located in healthcare. The IMB also said that, although funding had
been available for some months, substance misusers received no better
support and care than they would have the year before.
Her Majesty’s Chief Inspector of Prisons report
20. The HM Chief Inspector of Prisons made an announced inspection of HMP
Birmingham in February 2007. The subsequent inspection report noted that
the prison had seen significant change over the previous five or six years,
including a considerable amount of new building work.
21. Overall, inspectors were disappointed with what they found at Birmingham
and attributed this partly to the pressures of an overcrowded prison system.
However, the Chief Inspector’s report said that the prison was not responding
“proactively and robustly” to the challenges it now faced and that some of the
old culture was “reasserting itself”. Nevertheless, it was a credit to staff and
managers that the prison remained a much better place than when inspected
in 2000.
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KEY FINDINGS
22. The man was remanded into custody at HMP Blakenhurst on 18 May 2007.
Whilst there, he began a detoxification programme for withdrawal from
opiates. He left Blakenhurst on 23 May 2007 to attend Birmingham
Magistrates’ Court. He spent the night in police custody before he was
moved to HMP Birmingham on 24 May. He had been charged with drug-
related offences and was found guilty on 13 August. He was awaiting
sentencing when he died.
First reception
23. A Prisoner Induction Checklist showed that the man was seen by healthcare
on the day he arrived at Birmingham. The note made in his Inmate Medical
Record (IMR) says that the man had received detoxification medication whilst
he was detained in police cells the night before, had no thoughts of self harm
or suicide and should be referred to “detox and GP for script”.
24. The man was also seen in the Detoxification and Treatment Unit where a
staff member completed a Withdrawal Monitoring Chart and noted that there
were no typical detoxification symptoms such as rhinorrhoea (sniffing),
agitation or restlessness, shivering, lactorrhoea (watery eyes), nausea and
vomiting, piloerection (hairs standing on end), diarrhoea or stomach cramps.
It was also noted that the man had last used heroin (although Blakenhurst’s
medical record records this as opium use rather than heroin) a week before,
was not on any prescribed medication and did not have any current physical
or psychiatric problems. The recorded actions for the man were that he was
to drink plenty of fluids to avoid dehydration, that he was to be offered
symptomatic relief for his withdrawal and would be referred to the detox
doctor’s clinic. (This meant he should receive medication to treat the
symptoms of his drug withdrawal, such as episodes of diarrhoea and aches
and pains, when or if they occurred.)
25. The man had also been risk assessed for sharing a cell, been issued with a
smoker’s pack, a Pin number so he could use the prison’s phones, and had
been allowed a two minute telephone call. The Cell Sharing Risk
Assessment noted that he had a history of drug use and was currently
dependent on drugs. It was also noted that he spoke limited English. He
was assessed as a low risk and fit to share a cell with another prisoner.
26. The man also attended a “Day One Interview” intended to assist staff in
assessing whether a prisoner is at risk of self harm and to highlight any
issues or problems a new prisoner might have. During this interview it was
noted that the man said he spoke English, was a “drug addict” who had last
used opium that month, was expecting to receive medication for
detoxification, and had never committed an act of self harm.
27. The staff member who conducted the interview also noted that the man did
not feel that he would self harm at that time and had never suffered or been
9
treated for depression or any mental health problems. He had, though,
recently suffered bereavement, as his father had died in April.
25 May to 12 July
28. On the man’s second day at Birmingham, the Induction Checklist shows that
he met the prison doctor, a CARATS worker, an officer working with foreign
national prisoners and also with the prison chaplain. The prison doctor noted
that the man had “no ongoing medical problems”, had last used opium ten
days before and was on lofexidine (for drug withdrawal) whilst at Blakenhurst.
The doctor wrote that the man should be treated “symptomatically” (treated
for his symptoms due to drug withdrawal).
29. An officer who works with foreign national prisoners also saw the man on 25
May. My investigator spoke informally to this officer during her visit to
Birmingham. The officer said that approximately 17 per cent of prisoners at
Birmingham were foreign nationals. He recalled that he and the man had
discussed the issue of deportation as this was concerning him, but it was
unlikely he would have been removed due to his nationality. The officer said
he told the man he would see him again once he had been sentenced.
30. The man also attended a “Day Two Interview”. At this interview he
expressed slight concern at being in prison but did not feel he was at risk of
harming himself.
31. The man was also seen on 25 May by a CARATS worker, who completed a
Drug Intervention Record. It was noted that the man presented no issues
that required immediate attention such as vulnerability, a history of self harm
or special health needs. It was also recorded that he had last used opium on
15 May, and that he was not currently receiving any treatment for his drug
use. The CARATS worker summarised the meeting by saying that the man
spoke limited English and had “very little reading and writing” and wanted to
attend education classes to improve his skills. The CARATS worker wrote
that she had referred the man to a Drug Intervention Programme for support
once he had been released from prison. They also discussed minimising
harm, overdose and tolerance levels.
32. The CARATS worker saw the man again on 2 July. She noted that he was
“fine”, was adamant that he would not use drugs again and did not require
any further intervention. She completed a Comprehensive Substance
Misuse Assessment on the same day. In a section entitled “Summary of
physical and mental health” she recorded “no evidence shown of either
physical or mental health issues”. There is no further record of the man’s
meeting with CARATS after 2 July.
33. Until 13 July, there is little else in the man’s prison records of note. He
attended court on 20 June, 28 June and 10 July. He was described in the
wing history sheet as a polite individual who had settled in well and seemed
to socialise with a small number of other prisoners. He visited healthcare on
10
26 June complaining of heartburn and was prescribed omperazole to relieve
this. He attended education classes and seemed to be progressing well.
34. My investigator spoke to a prisoner who gave an insight into the man and
how he had been feeling. The prisoner said that the man tended to ask other
prisoners about what length of sentence he could expect and that this was
weighing on his mind. He also remembered that the man had often said he
was going to kill himself, because of the possible length of his sentence and
for other reasons relating to his offence.
35. The prisoner recalled an incident (although he was not sure when it took
place) when he shared a cell with the man. The man had attempted to
swallow a bottle top. However, he asked the prisoner to help him as he was
choking and he smacked the man on the back until the top came out.
However, the man did the same thing about 15 minutes later and the prisoner
said he told him that if he did it again he would alert staff. The prisoner said
he told officers about this the next morning but they just laughed. He could
not recall their names. The prisoner said that he asked to change cells
shortly after this incident and did so. On the day the prisoner moved, the
man collected his stereo from reception and gave it to him. He said he did
not need it as he was going to kill himself.
36. The prisoner, who was sharing a cell with the man when he died, was
released from Birmingham before my investigator was able to interview him,
but he gave a detailed statement to the police. In this statement, he recalled
meeting the man when they attended the same education classes. The man
told him that he had tried to harm himself and attempted suicide and that he
thought he might receive a 20 year sentence. The cellmate remembered that
the man had always seemed very sad and spent a lot of time sleeping or with
his friends.
13 July – The man’s act of self harm
37. On 13 July 2007, at approximately 10.00am, the man made a cut to his left
wrist with a blade from a razor. The cut was deep and measured about four
centimetres. He was seen at 10.14am by a doctor who referred him to the
Accident and Emergency Department of the local hospital for treatment and
to assess any tendon injury. He left the prison at 11.30am and returned from
the hospital at 4.41pm later that day.
38. An officer had opened the ACCT document before the man was taken to
hospital. The officer noted in the Immediate Action Plan that the man should
be located on A2 landing and initially placed on five observations an hour.
The ACCT document travelled with the man to hospital where the
observations were carried out.
39. The man’s brother had a pre-booked visit the same day. A Principal Officer
(PO) was called to the Visitors Centre following a call from a member of staff
who worked there. They had checked that local prison computer system and
seen that the man had been taken to hospital and so would not be available
11
for the visit. The man’s brother appeared very distressed because he was
concerned about the man’s health due to a number of telephone calls he had
received from him that week. Before he left for the Visitors Centre, the PO
checked the man’s computerised prison record and confirmed that he had
been taken to hospital that morning. As he was still there, he was unable to
receive the visit.
40. The PO met the man’s brother for approximately 40 minutes in the Visitors
Centre along with the Centre’s Customer Services Manager. They began to
tell him that the man had harmed himself and was in hospital. The man’s
brother immediately asked whether he was dead. The PO explained what
had happened and asked why he had questioned whether the man had died.
His brother said that at a previous court hearing the man had told his solicitor
he intended to take his own life. He also said that the man had harmed
himself on several occasions and had a substance misuse history. The PO
asked whether he had advised anyone of this, but his brother said he had not
as he had expected the solicitor to say something. The PO assured the
man’s brother that the information would be passed on to the relevant
departments in the prison. He gave him his direct office telephone number in
case he had any further concerns or the man repeated this intention to him.
The man’s brother also called his wife during the meeting to obtain the man’s
solicitor’s number so he could speak to them about his concerns.
41. After his meeting with the man’s brother, the PO returned to the prison and
rang A wing. He spoke to a Senior Officer (SO) and asked whether an ACCT
document had been opened for the man. The SO confirmed that it had. The
PO then telephoned the treatment room in healthcare and asked them to
book a psychiatric referral for the man. The PO confirmed to my investigator
that he had previously made psychiatric referrals by telephoning healthcare.
However, healthcare told my investigator that they only accept written
referrals and would not accept a telephone request. A copy of the Initial
Referral Process procedures was viewed. It does not say that referrals must
be made in writing.
42. The solicitor’s first contact was also on 13 July 2007 when following the call
from the man’s brother they rang the prison. They initially spoke to
somebody in the Discipline Office who transferred the call to the chaplaincy.
There was no answer, so a message was left on the answerphone. They
next telephoned the duty governor, but did not record whom they spoke to.
During this conversation they were informed that the man had harmed
himself and been taken to the local hospital.
43. My investigator asked the man’s solicitor whether they had alerted the prison
of any concerns about the man. They responded in writing, including copies
of all notes of telephone conversations. There is no record of any contact
between the solicitors and the prison about the man’s mental health or any
health concerns prior to 13 July.
44. The solicitors also forwarded a copy of a fax they sent to the prison on 13
July asking for information about the man and whether he had committed
12
suicide. This fax appears to have been sent after the man’s brother met the
PO and indicates that he was still unsure exactly what had happened to his
brother.
45. An officer said at interview with my investigator that he was the duty ACCT
assessor on 14 July. The ACCT assessor met the man and they talked
about why he had harmed himself. The man told him that he was worried
about receiving a long sentence and being deported back to his home
country, and that his father had recently died. He also told the ACCT
assessor that he had been thinking of harming himself for about two weeks
and had told his brother and solicitor that he intended to do so. However, he
said he had not intended to kill himself and his actions had scared him. The
ACCT assessor noted that the actions on the ACCT plan for the man were
that he was to continue to attend education classes, remain in contact with
his brother, and be assessed by a Community Psychiatric Nurse (CPN).
46. A further case review was held on 14 July, and attended by the ACCT
assessor, a second SO and the man himself. It was recorded that the man
should be seen by the doctor and a CPN and this was to be arranged on 17
July. It was also noted by the second SO on the Caremap part of the ACCT
that the man wanted to see the CPN as he kept thinking about receiving a
long sentence. This appointment was to be arranged by wing staff on 17
July. The next ACCT review was due on 20 July.
47. His brother visited the man approximately three days after he had harmed
himself. At this meeting the man would not stop talking and his brother
believed he was mentally ill. (This was the last time he saw the man as he
stopped accepting visits three weeks before he died.)
48. Whilst at Birmingham, the man received co-amoxiclav (an antibiotic) and
ibuprofen for five days from 18 July. This was for the cut to his wrist. He was
also prescribed paracetamol from 19 July, and given it daily from 20 July to
10 August. The man was also prescribed omperazole (an antacid) for
heartburn, which he was given from 20 July to 9 August, and had a five day
prescription for zopiclone (sleeping tablets) from 19 to 23 July.
49. On 20 July, a case review was attended by a third SO, an officer and the
man. The SO noted that the man was not very communicative and the man
said he thought he was mentally ill. It was noted that a referral was made to
the doctor, but there are no further details.
50. The man’s solicitor informed my investigator that they had a legal visit with
their client on 25 July. The man had seemed “volatile, confused and
emotional”. This information was not relayed to the prison.
51. The next case review was held on 27 July, and attended by the first SO, the
ACCT assessor and the man himself. It was noted that he seemed in good
spirits and denied telling his cell mate he intended to kill himself. There was
no mention of whether he had yet seen a doctor or CPN.
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52. It is recorded on the medication chart that the man was given paracetamol
for flu-like symptoms on 2 August, and again for wrist pain on 5 August.
53. On 3 August, another case review was held. This was attended by a fourth
SO, the ACCT assessor and the man. It was recorded that he seemed in
good spirits and had no thoughts of self harm.
54. After a further legal visit on 3 August, the solicitor noted that the man seemed
much more alert than on the previous occasion but that he remained at risk
of harming himself if he were to receive a lengthy custodial sentence. The
man still had stitches in his cut wrist and told the solicitor that he felt he had
let his family down and so had decided to commit suicide. He also said that
his bouts of anxiety and depression were as a result of having to go “cold
turkey” in the prison.
55. A final case review was held on 10 August, and was attended by the second
SO, two officers, and the man. It was recorded that the man said he had no
problems and wanted the ACCT closed. He also asked to move to share a
cell. The ACCT was closed and a review was to be held on 24 August.
There was no mention of his referral to a doctor or a CPN, or a note to chase
up whether an appointment had been made. The ACCT assessor said at
interview that he knew the man had seen a doctor, but was unsure about a
CPN. There is no note in the man’s on-going record in the ACCT to say he
had been seen by anyone from healthcare other than to receive painkillers
for his wrist or a sleeping tablet. Nor is it recorded in his Inmate Medical
Record (IMR) that he ever saw the doctor or a CPN after the ACCT was
opened.
56. The last time the solicitor saw the man was in the court cells on 13 August.
An interpreter was present for this meeting. The man’s wound was still
visible and he discussed this at length with the interpreter in his own
language. A translation was requested but the interpreter said that the man
was feeling very depressed and under pressure.
57. There is no evidence to suggest that the solicitor raised any concerns about
the man’s mental health to anyone at the prison.
Events of 18 August
58. The man’s cellmate recalled in his statement to the police that the man had
seemed unusually happy on the night of 17 August. They had spent the
evening watching television and then slept from approximately 11.00pm. The
cellmate said he woke up in the early hours of the morning to go to the toilet
(which is separated by a low partition). As he looked towards the man’s bed,
he saw that it was empty. He turned towards the cell window to see that the
man appeared to be hanging from a green bed sheet attached to the window.
The cellmate said that he thought by the man’s appearance that he had died.
He immediately pressed the cell bell and frantically began kicking the door.
14
59. An Operational Support Grade (OSG), who was on night duty on 18 August,
was in the office on A wing at approximately 3.00am when she heard loud
banging on a cell door. She followed the banging and this led her to the cell
shared by the man and his cellmate. The OSG looked through the
observation panel and could see that the man was suspended from a ligature
and that his cellmate was frantic. The OSG immediately raised an urgent call
for Oscar Two (the code for the senior officer in charge of the prison at night)
and Hotel Two (the code for healthcare) to attend. By the time the OSG had
radioed through the call, three officers had arrived at the cell door, alerted by
the noise.
60. My investigator asked the OSG why she did not immediately break the seal
on the pouch she was carrying and open the cell door. She said that,
although OSGs carry a pouch containing cell keys, it is prison policy not to
open cell doors and that is the duty of a more senior officer or a response
team. The prison forwarded an extract from a local strategy which instructs
staff when they are permitted to open a cell door. The relevant section says
that cell doors must not be opened by a staff member at night when they are
on their own, unless they judge that they can save life by doing so and are
not endangering the lives of other prisoners or the security of the prison. In
any such instance, the control room must be informed and an emergency
alarm must be raised. The strategy also states that, under normal
circumstances, no cell will be opened at night unless there are three
members of staff present (one of these being Oscar Two).
61. Of the three officers who had arrived at the cell, officer one was in the library
when he heard the banging on the cell door. He followed officer two up to
the man’s cell. When they arrived at the door, the OSG told them that
somebody was hanging. Officer three also heard the banging and made his
way quickly to the cell door.
62. Officer two looked through the observation panel and tried to speak to the
man’s cellmate who was obviously distressed. Neither Officer one or two
had a cell key as they attended as response officers and did not carry a full
set of keys (in line with the prison policy). They waited a matter of seconds
for officer three to arrive and open his sealed pouch to take out his key.
Officer three struggled to break the seal on the pouch and Officer one had to
use his fish knife to break the seal.
63. As officer three opened the door, the cellmate pushed past and rushed out of
the cell. Officer three attempted to calm him down whilst the other two officer
entered the cell. Officer two attempted to lift the man to relieve the pressure
of the ligature and Officer one cut the ligature with his fish knife. They then
laid the man on a bed. In interview, officer one recalled that the man felt cold
to the touch. Officer two remembered that the man appeared pale and
clammy and his eyes seemed glazed. Officer one checked for signs of life,
but could not find the man’s pulse. Officer two touched the man’s eyeball to
see if there was any reaction, and also shone his torch into his eyes, but
there was none.
15
64. Officer two began to administer Cardio Pulmonary Resuscitation (CPR) by
carrying out chest compressions in an attempt to resuscitate the man. He
continued to do so until a nurse arrived a few minutes later. The officers did
not attempt mouth to mouth resuscitation as the man’s tongue appeared
swollen and filled the whole of his mouth, making it difficult to find his airway.
65. The nurse was on the Centre on the wing and had heard the banging on the
cell door. She made her way to the cell, picking up a bag of emergency
equipment on the way. The bag contained a cylinder of oxygen, resuscitation
aids and a defibrillator. When the nurse arrived at the cell, the man was lying
on the bed. She checked for his pulse, but found none. His eyes were open
and his pupils were fixed and dilated. His fingernails were blue and he
appeared to be discoloured. The nurse attempted to insert an airway, but
was unable to do so as the man’s jaw was stiff and she could not open it.
The nurse administered oxygen with a face mask. At this point, officer one
left the cell to call for an ambulance.
66. The SO whose role was as the Night Orderly Officer and Oscar Two (officer
in charge of the prison) that morning, responded to the emergency call and
arrived at the man’s cell at 3.05am. He found officer two and the nurse
carrying out CPR.
67. The nurse applied the pads of the defibrillator to the man’s chest and
switched the machine on. The defibrillator advised “no shock” which meant
there was no shockable heart rhythm and indicated that he had already died.
68. The nurse and officer two continued with CPR until the paramedics arrived
approximately 15 minutes later. The paramedics put their own defibrillator
onto the man, but again it showed no shockable heart rhythm. Upon
examination, they noted that he was cold, cyanosed (a blue colour to the
skin) and that rigor mortis had set in around the jaw area. The paramedics
pronounced him dead at 3.14am.
69. The cellmate meanwhile, was very distressed and officer three took him to
the end of A wing landing, away from the cell. The cellmate was shaking and
began vomiting. Officer three took the cellmate to the Care Suite on C wing
to sit with two Listeners. When the nurse left the man she went to see his
cellmate. She found him with the Listeners, sitting on the floor sobbing. He
refused to speak to the nurse and seemed frightened. A number of actions
were taken in support of the man’s cellmate.
70. The Deputy Governor rang the man’s brother during the day on 18 August
and asked whether someone from the prison could visit him. His brother
realised something was wrong and asked if the man had died. The Deputy
Governor confirmed that he had. It was agreed that he and other prison
representatives would visit the man’s brother the next day. At 9.00am on 19
August, three members of staff visited the man’s brother. An aunt and uncle
were also present. The Deputy Governor explained to them what had
happened and that the prison would appoint a Family Liaison Officer whom
16
the man’s family could contact if they had any questions. The prison also
offered to contribute towards funeral expenses.
71. Staff directly involved in the discovery and attempted resuscitation of the man
were asked by my investigator if they had felt supported, had been invited to
attend a de-brief, and offered the opportunity to speak to the Care Team.
There was a mixed response from staff. Some had been offered support
services but had declined, whilst others, in particular officer two, appear to
have been overlooked. The OSG attended a de-brief on the morning of 18
August, and spoke to a member of the Care Team, but nobody else had
spoken to her since then. My investigator judged that some of those involved
still seemed distressed about what had happened. However, the man’s
cellmate appeared to have been well looked after by staff.
72. A post mortem was carried out on 20 August, the cause of death was
recorded as hanging.
73. Staff were not aware that the man had given away some of his possessions
until a senior officer (SO) from the Security Department was called to A wing
on 26 August to confiscate the man’s stereo from the prisoner. The prisoner
had visited reception that morning to ask for it to be recorded on his property
card. When asked how he came by the stereo, he told officers that the man
had given it to him two weeks earlier and said that he did not need it as he
was going to hang himself. When asked why he had not reported this to
staff, the prisoner told my investigator he had told staff on several occasions
but they had laughed at the information. (Two officers from security told my
investigator that the prisoner said “I just didn’t” when asked why he did not
inform anyone about what the man had said.) The prisoner also recalled that
the man gave his flip-flops to another prisoner. The prisoner did not tell
anyone about this.
74. On 5 September 2007, the Police requested a sample of the man’s blood to
be tested for the presence of alcohol, commonly abused drugs
(amphetamine, ecstasy, opiate drugs, methadone, benzodiazepines,
ketamine and metabolites of cocaine and cannabis) and over the counter
medication. The results showed that he was not under the influence of
alcohol, any commonly abused drug or any medication when he died.
17
ISSUES
Clinical care
75. His brother spoke to my Family Liaison Officer and his own legal
representatives about questions he had regarding the man’s treatment in
prison. The overwhelming concern of his brother - and one shared by my
investigator - was that he was not seen by a CPN despite the need being
recognised by the PO and those involved in the man’s ACCT reviews. The
man’s brother thought that the man had become mentally unwell whilst at
HMP Birmingham.
76. The PO told my investigator he contacted healthcare after his meeting with
the man’s brother to book a referral for the man to see a CPN. He said he
telephoned healthcare and always made referrals that way. It is also
recorded in the ACCT document during the case reviews that the man
needed to see a doctor and a CPN. The wing staff wrote in the ACCT
document that an appointment was to be made on 17 July, but there is no
evidence that this was followed up.
77. Healthcare told the investigator that they never received a referral from any
member of staff. Their practice was only to take written referrals and there is
no evidence that a written referral was ever made. The prison has
recognised the breakdown in this system and that prisoners could slip
through the net.
78. The Clinical Lead from Birmingham acknowledges this problem in her clinical
review dated 16 May 2008. The referral policy was decided in January 2007
by the Mental Health Team and the information was disseminated to prison
staff via the Suicide Prevention Group. In an attempt to clarify and simplify
the situation, the Clinical Lead writes that the case manager involved in the
ACCT process will in future take responsibility for acute mental referrals. The
Suicide Prevention Group will be tasked with informing all staff of this
arrangement.
The Governor should ensure that a system is put in place to identify
prisoners who need to be referred to the mental health team and that
checks are made to ensure that prisoners attend appointments.
79. His brother also expressed concern about the man’s withdrawal from drugs
and his detoxification once he arrived at Birmingham. Whilst he was at
Blakenhurst, he was on a detoxification programme and had been prescribed
medication as he was diagnosed with severe opiate withdrawal symptoms.
This is documented in the Prescription and Administration Record Chart
raised at Blakenhurst. The man was prescribed lofexidine (for opium
withdrawal) and zopiclone (to help him sleep), which he began to take on 19
May until his last recorded dose administered at Blakenhurst on 22 May. The
Prescription Record (which is annexed to this report) indicates that the man
should have received lofexidine for 11 days until 29 May, and zopiclone for
seven days until 25 May. He spent the night of the 23 May in police cells,
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and was prescribed medication for his withdrawal that night. His
detoxification came to an abrupt end when he transferred to Birmingham and
before he had completed the whole programme.
80. When the man was assessed in healthcare at Birmingham on 25 May, it was
noted in the IMR that he had been taking lofexidine whilst at Blakenhurst and
that he should be treated “symptomatically c/o diarrhoea & aches & pains”.
In other words, the doctor was aware that the man had been prescribed
lofexidine which he had last taken at Blakenhurst on 23 May but judged that
he displayed no physical signs of opiate withdrawal. The doctor thus decided
that his withdrawal symptoms should be treated symptomatically. This meant
that he would be given medication for symptoms such as diarrhoea or aches
and pains incurred as a result of his withdrawal, rather than being given
medication for the withdrawal. The clinical reviewers seem to agree that this
was the correct course of action to take with the man.
81. The Clinical Lead writes in her clinical review that the man was “suffering
from fairly mild opiate withdrawal” and that, when he was assessed by the
Detoxification Treatment Unit, he displayed none of the symptoms associated
with withdrawal. There is no evidence that medical staff did not assess the
man correctly at Birmingham, but it may be the fact he spoke limited English
meant he was unable to fully explain to staff how he was feeling.
82. The ACCT document was opened immediately after the man harmed himself
and regular reviews took place. However, a member of healthcare did not
take part in any case review. It is good practice that they should, especially
when a prisoner’s mental health is a concern. There was also a lack of
continuity amongst staff who assessed him. I understand it is not always
practicable for the same staff to carry out reviews, but it would be helpful if
the case manager at least had sight of all of the reviews for a particular
prisoner.
The Governor should remind staff that, whenever possible, a member of
healthcare staff should be present at an ACCT review. If a member of
healthcare is unavailable, then a note about the prisoner should be
forwarded by healthcare, in good time for the review.
83. It is also evident good practice that, when actions are noted on an ACCT
document, they are followed up at the next review. As I have shown, it was
noted in two ACCT reviews that the man should by seen by a CPN and that
an appointment should be made on 17 July. However, there is no record that
this was ever followed up by staff.
The Governor should satisfy himself that robust procedures are in place
to ensure that all actions noted in an ACCT document are followed up
by staff. Also, prisoner records should be checked to inform staff
carrying out ACCT reviews whether the prisoner has any significant
court appearances pending, for example the start of a trial.
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Local night strategy procedures
84. Staff seemed unclear about when they are permitted to enter a cell in an
emergency. The OSG said she thought she was not allowed to enter the
cell. Officer two also held this view.
The Governor should ensure that staff are aware and fully understand
the local night strategy procedures, particularly relating to unlocking a
prisoner whose life may be in danger.
Aftercare for staff
85. There was a mixed response from staff when asked by my investigator about
the support they received after the man’s death. Some staff appeared to
have been overlooked.
The Governor should implement a procedure to ensure that all staff
involved in a death in custody are aware of the support available to
them and that they are supported by the Care Team and senior
managers should they need it.
Aftercare for the man’s cellmate
86. The cellmate was clearly traumatised after discovering his cell mate hanging.
I believe he was treated with care and respect by staff concerned. Out of
respect for his right to privacy, I have not included the details in this report.
Further question from the man’s brother
87. His brother believed that the man had been told that two of his friends
had recently received a prison sentence. This was untrue and his brother
wanted to find out if, and why, the man was told this. My investigator could
find no evidence of this, and was unable to answer this question.
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RECOMMENDATIONS
1. The Governor should ensure that a system is put in place to identify
prisoners who need to be referred to the mental health team and that checks
are made to ensure that prisoners attend appointments.
2. The Governor should remind staff that, whenever possible, a member of
healthcare staff should be present at an ACCT review. If a member of
healthcare is unavailable, then a note about the prisoner should be forwarded
by healthcare, in good time for the review.
3. The Governor should satisfy himself that robust procedures are in place to
ensure that all actions noted in an ACCT document are followed up by staff.
Also, prisoner records should be checked to inform staff carrying out the
ACCT reviews whether the prisoner has any significant court appearances
pending, for example the start of a trial.
4. The Governor should ensure that staff are aware and fully understand the
local night strategy procedures, particularly relating to unlocking a prisoner
whose life may be in danger.
5. The Governor should implement a procedure to ensure that all staff involved
in a death in custody are aware of the support available to them and that they
are supported by the Care Team and senior managers should they need it.
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