Individual at Chelmsford

Investigation into the circumstances surrounding the death
of a man at HMP Chelmsford on 20 March 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
April 2006
This is the report of an investigation into the death of a man who died in the
segregation unit at HMP Chelmsford on 20 March 2005. The man cut himself
with a razor blade that he had been given by staff when he had asked to be
able to shave. When he was discovered bleeding, and although the timings
are inexact, I conclude there was an unacceptable delay before his cell was
opened.
I wish to offer my sincere condolences to the man’s family for their loss. He
was on remand at the time of his death. His mental health status, and the
different views taken about it by clinical and non-clinical staff, is at the heart of
this tragedy.
This investigation was conducted by one of my Senior Investigators. Both he
and I are grateful to the Governor and his staff at Chelmsford for their help
and co-operation during this investigation.
A clinical review was undertaken by the Chelmsford Primary Care Trust into
the medical care that Mr Hampson received. I am grateful for their report. I
was very disappointed that Chelmsford’s Medical Officer, did not fully co-
operate with my investigation.
This is a report that makes very uncomfortable reading. In an investigation
that has revealed serious shortcomings in respect of F2052SH procedures,
completion of the segregation safety algorithm, and other matters, one vision
haunts me. It is of a F2052SH review being conducted in a cell with the
prisoner actually hiding under his bed.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2006
Contents
Summary
Investigation methodology
The person this report relates to.
HMP Chelmsford
Events prior to the man’s death
Events surrounding the man’s death
Events after the man’s death
Clinical review
Findings and conclusions
Recommendations
Summary
1. The man was remanded into custody at HMP Chelmsford on 4 March
2005. He had cut himself whilst in police custody and was immediately
placed on a F2052SH booklet and housed in the Healthcare unit.
2. He was started on a short (5 day) detoxification programme having
tested positive for benzodiazepines. But he was unhappy that he was
not given methadone.
3. During the afternoon of 8 March, a smashed TV was found hidden under
the man’s bed. He denied damaging it but was placed on disciplinary
report. A few minutes later, the Medical Officer discharged him from the
Healthcare unit.
4. The man transferred to B wing the following morning. Later that
afternoon, he punched an officer in the face who had responded to his
cell bell. He was moved to the segregation unit and made the subject of
a ‘three man unlock’.
5. The man’s behaviour became more and more odd. Despite being on an
open F2052SH, he was given 17 days cellular confinement for the two
offences of breaking his television and assaulting a member of staff.
6. Staff became concerned about his mental state but knew that he was
due to see the Consultant Psychiatrist. He began hiding under his bed
with the mattress on top of him. He told officers that people were
coming to get him and kill him.
7. The man was seen by the Consultant Psychiatrist on 18 March, but he
found no evidence of current mental illness. He remained on the
segregation unit and continued to display bizarre behaviour.
8. Just before lunchtime on 20 March, the man asked to be given a razor
so that he could shave. An officer gave him a disposable razor with his
lunch. At 12.24 pm, the man pressed his cell bell. When the officer
attended, he saw him staggering around his cell having apparently cut
his left wrist.
9. A number of other officers arrived outside the cell, including two nurses.
The man was on the blood-covered floor and the cell was entered. The
man was taken out of the cell and resuscitation was attempted. He was
pronounced dead at 2.15 pm.
10. The investigation has revealed a number of serious failings. I make nine
recommendations.
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Investigation methodology
11. The investigation was opened at HMP Chelmsford on 23 March 2005.
The Governor and his staff produced the man’s core record and a large
number of other documents for examination. Notices were distributed
around the prison notifying staff and prisoners of the investigation.
12. A number of prison staff were formally interviewed along with a prisoner
who was in the Segregation Unit at the time of the man’s death.
13. My investigator met with officers from Essex Police on 24 May to discuss
the case.
14. Her Majesty’s Coroner was contacted to inform her of the nature and
scope of my investigation and to request a copy of the Post Mortem
report. Upon completion, this report will be sent to the Coroner to assist
in her enquiries into the man’s death.
15. My investigator arranged a meeting with the man’s mother and step-
father at their solicitors’ office on 18 April 2005. Also at the meeting was
a representative from the organisation INQUEST.
16. My investigator summarised the events surrounding the man’s period in
custody and his death, as he had discovered them during his
investigation so far. He was able to clarify a number of matters for the
family and noted a number of concerns that they had. A more
comprehensive list of questions was included in a letter from the
solicitors the following day.
17. With the agreement of Her Majesty’s Coroner, a number of documents
relating to the man’s time at Chelmsford were disclosed to the family’s
solicitors in line with this office’s disclosure policy,
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The person this report relates to
18. The man was 32 years old when he died. He had two sisters and a
brother. He excelled at sports, especially swimming, and had a love of
art. He worked as a window fabricator for a short while before giving it
up to concentrate on his art.
19. In the early 1990s, the man was in a long term relationship from which
he had a daughter.
20. In 2000, one of the man’s sisters died tragically. This had a profound
effect on him as he was unable to come to terms with her death.
21. The man had a drug dependency problem for over ten years. In the
past, he had used heroin intravenously but more recently had been
prescribed methadone. He also used cannabis and ecstasy. Prior to his
death, the man’s doctor was treating him for depression, alcoholism and
drug addiction.
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HMP Chelmsford
22. HMP Chelmsford was built in 1828 as a county gaol. Since 1987, it has
been used as a category B local prison and young offender institution.
23. Two new house blocks and a purpose-built sports facility were opened in
1996 to relieve overcrowding. During 2000, Chelmsford converted one
of the wings to house more young people. The new Healthcare Centre
was formally opened in July 2004.
24. In the introduction to her report on an unannounced inspection of
Chelmsford in August 2004, HM Chief Inspector of Prisons says:
‘This report of Chelmsford prison and young offender institution records
an establishment continuing to make progress. This is all the more
impressive because Chelmsford has had a difficult history, both in terms
of inadequacies in its care for prisoners and its troubled industrial
relations.
Chelmsford remained a reasonably safe establishment. Various
supporting procedures had been improved since our last inspection,
including those for induction, anti-bullying, reducing drug supply into the
prison, mandatory drug testing and detoxification.
However, we were concerned that there had been an increase in the use
of force, segregation and special cells – the reasons for which were not
entirely apparent. This concern was heightened because the segregation
unit was badly in need of refurbishment, although we noted that staff
prisoner relationships in the unit were constructive and reviews and care
plans for difficult prisoners were excellent.’
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Events prior to the man’s death
25. The man’s parents said that he was at their house on 3 March 2005. His
behaviour caused them such concern that they called the local police.
The officers who responded were about to leave when the man insisted
that they take him to prison. He was told that he had not done anything
to make that necessary. The man promptly punched one of the police
officers in the face. He was arrested. Whilst in police custody, he
attempted to cut his wrists and was placed on a self-harm watch.
26. On 4 March, the man was transferred from the police station to
Southend Magistrates’ Court to answer the charge of actual bodily harm
on the police officer. He was handed over to the private escort company
(Premier Custodial Group) who checked him every five or ten minutes.
27. At court, a suicide/self-harm warning form was completed based on
information supplied by the Community Psychiatric Nurse (CPN) at the
court. The Premier escort officer completing the form noted the following
information: ‘Believed to be withdrawing from illicit drugs (heroin/crack)
Methadone user. Appears to be acutely psychotic, drug induced
psychosis. Believes he is going to be abducted and killed.’ Checks
every five minutes were indicated.
28. The man arrived at HMP Chelmsford at 4.30 pm, having been remanded
in custody until 7 March. The committal warrant from the court had a
hand written note on it stating, ‘MDO CJMHT report attached. Risk self-
harm.’ The CPN at court, had written the report. He identified that the
man had had three admissions to psychiatric hospitals since October
2004, the last being on 24 February 2005. He stated that the man
presented as suffering from a drug induced psychosis, with clear
paranoid delusions. He said that the man was a risk to both himself and
others as a result of his delusional beliefs. He recommended that he be
remanded into custody until 7 March when a further assessment could
be made, adding that it would enable a decision to be taken as to
whether the man would require hospital treatment in an environment with
some degree of security.
29. During his First Reception Health Screen at Chelmsford, the man denied
having any suicidal or self-harm thoughts when he was asked. He
claimed to have been prescribed Cipramil (an anti-depressant),
methadone and tablets for his drinking. He was referred to see the
Detox nurse.
30. At 7.25 pm, a self harm at risk form F2052SH was opened in Reception.
This form is designed to record the reasons why a prisoner is felt to be at
risk, the proposed means of support during the crisis period and a place
to record, at stipulated intervals, observations of the prisoner throughout
the risk period.
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31. The nurse who opened the form decided to admit him to the healthcare
centre within the prison, noting that he should be in single
accommodation and requesting Mental Health Team input. The level of
supervision was set as ‘regular’. Chelmsford’s Suicide Awareness
Policy – Operational Instruction ‘Annex B’ states: ‘At risk prisoners in a
single cell, or on their own in a double cell, should be seen by staff at
irregular intervals of no more than one hour.’ The supervision recorded
on the F2052SH was frequently more than an hour apart, sometimes
several hours.
32. A Samaritans telephone was to be made available to the man upon
request.
33. The man was urine tested for drugs on 5 March. He tested positive for
benzodiazepines but not for methadone or opiates. He was put onto a
short detoxification program, consisting of lofexidine and a nine day
course of diazepam. He was assessed by the Detox nurse and given a
second urine test. That test proved positive for opiates. No satisfactory
explanation for the discrepancy between the two tests has been
presented.
34. A psychiatrist saw the man on 6 March when it was noted on the
F2052SH that the man was not suicidal and there was no evidence of
acute mental illness. A review of the F2052SH was planned for later in
the week.
35. At 5.26 am on the morning of 7 March, the man called out to the night
officer who came to check on him. He said there would be dramas at 7
am as people were coming to get him, calling him a ‘nonce’. He was
rocking on his feet but claimed to be feeling alright. He went to court
later that morning without incident. The man was remanded into custody
until 21 March and returned to healthcare.
36. At 3.15 pm on 8 March, a smashed TV was found in the man’s cell under
his bed. He denied being responsible. The security report of the
incident says that a shard of glass wrapped in a towel was found under
the bed. The shard of glass is referred to as a weapon. There is no
mention of the fact that the man was on an open F2052SH. The report
of the incident in his medical record refers to the man being somewhat
annoyed that he did not get his methadone detox. There is no mention
of the shard of glass in either the medical record or the F2052SH.
37. The man was seen by Chelmsford’s Medical Officer, at 3.30 pm. His
written F2052SH discharge report states in the summary of in-patient
stay, ‘Settled, No mental illness. No s/harm ideation. On a brief detox at
present.’ In the recommendation section, the doctor wrote, ‘Normal
management plan. May become upset when detox ends though.’
38. At 9 am on 9 March, the man was moved to B wing. An entry in the
F2052SH booklet at 3 pm reads, ‘Threats to cut up. MO adamant not
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coming back to HCC at present. Insists detoxing methadone.
Rationalised manipulation – cited by Lyn Booth MHT.’
39. At 5 pm, an officer answered a cell bell at the man’s cell. When the
officer opened the door, the man punched him in the face. As a result,
he was moved to the segregation unit on A wing. A case conference,
attended by a senior manager, should have been held immediately in
order to take account of events leading up to the decision to segregate
and to develop a specific care plan for the man whilst in segregation.
There is no evidence that this was done, contrary to Chelmsford’s
Suicide Awareness Policy Statement.
40. A Segregation Safety Algorithm form is a document that has to be
completed whenever a prisoner is to be moved into segregation. It
consists of five sections. Part A is a yes/no flow chart designed to show
any healthcare reasons against segregation. That part is completed by
a registered nurse or doctor within two hours of the prisoner being
placed in segregation or before a punishment of cellular confinement at
adjudication. Part B records the name of the duty governor informed
and the time. Part C shows the decision made by the duty
governor/adjudicator. Part D has a short list of actions to be taken if the
prisoner is to be segregated, and part E has space for the name of the
duty governor, the signature and the date and time. The process is
referred to as ‘being fitted’ i.e whether the prisoner is ‘fit’ for segregation
mentally and physically. An algorithm form was initiated by a nurse and
she completed part A of the form. The remainder of the form was not
completed.
41. On 10 March, the man was made the subject of a three man unlock
because he apparently continued to threaten violence toward staff.
(Three man unlock meant that three officers needed to be present before
his cell could be unlocked.)
42. A F2052SH review was held with the man present. It was noted that he
was completely pre-occupied with the need to get more drugs whilst
detoxing. He stated that he would ‘lose it’ without treatment. He also
said that he had no thoughts of self-harm and that he would never get
through the detox. The support plan was to discuss the detox issues
with healthcare staff and the doctor, offer support from the chaplaincy
and use of the Samaritans phone. The review team did not set an
observation interval, but as the man was being held in the segregation
unit he should have been observed every hour as a minimum. A further
review was scheduled for 17 March.
43. Later that morning, a governor grade officer held the adjudication for the
man’s two offences of smashing his TV and assaulting an officer. She
was unaware that the man was on an open F2052SH. During the
adjudication hearing, the man became verbally abusive and when he
moved towards the governor he was restrained and removed from the
adjudication room. The hearing continued in his absence.
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44. A healthcare nurse who happened to be on A wing, was given a set of
algorithm forms to complete at 10.35 am by the adjudicating governor
before she gave her punishment. The nurse knew that the man had
been on a F2052SH but did not know if he still was. The man was not
present when she completed the form. She answered ‘no’ to the
question asking if the prisoner was on an open F2052SH. The governor
was subsequently unable to correctly complete section C of that form.
45. The man was punished for smashing the TV with seven days cellular
confinement and another ten days for the assault on the officer, making
17 days in total.
46. An un-timed entry later that day in the man’s medical record states,
‘Spoke to on A wing appears quite hyper. Rude and abusive, decision
by medical officer and myself (detox nurse) to curtail treatment as it is
enhancing his anxiety.’
47. Just before 1 am on 11 March, the man began pacing his cell and
banging the door. When spoken to, he said he was OK. At 1 am, an
entry in the F2052SH states, ‘Smashing up cell. Informed Oscar 1 via
comms phone.’ The 1.10 am entry in the A wing staff observation book
states, ‘banging and pacing around his cell, smashed vanity board.
Oscar 1 informed and came over and calmed him down.’
48. At 6.30 am, the man began to bang his cell door with the vanity board.
He was again calmed down. At 6.45 am, he began shouting. He was
spoken to by an officer and said that people were ringing the jail and
saying that they wanted to kill him. The officer assured him that was not
the case. The man appeared to accept that and sat on his bed.
49. At 8.00 am, when he was asked why he had declined hot water and
exercise, the man said that people were looking at him through
binoculars. The officer concludes an entry in the F2052SH with ‘Very
strange’. At 10 am, the man rang his cell bell - for no reason, he said.
50. At 8.45 pm that evening, the man asked to be let out of his cell and
seemed very confused. At 9.25 pm, he was seen lying under his bed.
He came out and told the officer that an armed response unit was
outside intending to get him out.
51. A governor’s entry for 12 March states, ‘Still displaying strange paranoid
behaviour although a little more coherent today.’ When the governor did
his rounds the following morning, the man told him that a particular
officer and he were going to be shot.
52. The next entries of significance begin at 3.15 pm on 13 March when the
man was abusive to a nurse who had come to see him. At 7.30 pm, he
rang his cell bell and told the officer that the prison was surrounded by
armed police. There are then numerous entries throughout the night
8
with the man distressed and lying under his mattress on the floor and
continuing to shout about armed forces coming.
53. The Governor’s rounds entry for 14 March states, ‘Displaying strange
behaviour traits, writing on mattress. To be seen by psychiatrist.’ The
entry for 15 March states, ‘Found under bed. I have concerns with this
prisoner’s state of health and will discuss this with healthcare staff.’ My
investigator found no record of any subsequent discussion.
54. An entry in the A wing staff observation book dated 16 March reads, ‘still
displaying bizarre behaviour. Psychiatrist coming to see him on Friday.
Currently prisoner refusing to wear clothing. Staff are continuing to try
and work with him but uncooperative.’
55. At 6.10 am on 17 March, the man rang his cell bell. The records say that
he asked for all nine prison officers hiding in the office to get him a ‘burn’
(cigarette) before he was shot in the head. Later that morning, the man
was seen by a governor in the segregation unit. He was acting bizarrely
and told the governor that all the staff were going to Broadmoor.
56. At 11 am, the man was hiding under his bed and refused to come out of
his cell for his F2052SH review. A Senior Officer decided to hold the
review in his cell with the man still under the bed. The man said that he
was praying. The review noted that he was due to see the psychiatrist
the next day and that he had another 17 days on cellular confinement
(CC). (In fact, he only had another ten days of his punishment left.) The
review team persuaded the man to have a shower. The support plan
was for A wing staff to support the man to complete his punishment,
referral to the psychiatrist, and use of the Samaritans phone.
57. At 3 pm, the man’s mother and his stepfather visited him. It was a
closed visit, meaning that he and his visitors were separated by a glass
partition. The man was dressed, but looked dishevelled and distressed.
At times, he talked loudly about people going to shoot him. A governor
was passing through the segregation unit and saw the visit taking place.
He noted how distressed the man’s parents were by the visit. The
governor arranged for the man’s parents to meet with him after the visit.
They were very concerned about the state that the man appeared to be
in. The governor reassured them that the man was now in the best
place to be taken care of. He advised them that he was to see a
psychiatrist the next day. His parents also believed that he told them
that the man was being checked every 30 minutes and was on a three
man watch.
58. The governor denies saying the man was on a 30 minute watch and
believes that the family misheard him when he mentioned that he was on
a three man unlock. The governor was told of the circumstances of the
man’s arrest. No information from that conversation was written down or
passed on to others. Later that night, the man was in his cell sitting on
the floor with a blanket over his head.
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59. The following day, 18 March, the man was seen by a Consultant
Psychiatrist. In his report, he notes that the man was initially quite
uncooperative and guarded. The man admitted to being distressed as
he had thought his mother and stepfather were dead, so he was
shocked to see them. The man denied that he had behaved in any odd
manner, for example having his hair standing on end or lying under his
bed. He admitted to using heroin and methadone outside of prison. The
man stated that he was causing havoc in the prison because he wanted
to stay in healthcare, but that he was now going to behave well in A
wing.
60. The psychiatrist noted that he elicited no abnormal beliefs or thoughts
and that the man denied having an abnormal mood. He decided that the
man had no current ideas of self-harm or suicide nor could he detect any
feature suggestive of any current mental illness.
61. During his interview with my investigators, the psychiatrist agreed that,
prior to his meeting with the man, he had been able to read the notes
and comments on his Medical Record and F2052SH. He had also read
the report written by the CPN from the Criminal Justice Mental Health
Team at court. Unfortunately, the CPN had dated the letter incorrectly
as 4 March 2004 and not 2005. Even though the text in the letter makes
it clear that the events mentioned took place in 2005, the psychiatrist
disregarded the information as he believed it referred to events over a
year earlier.
62. The psychiatrist’s report in the man’s Medical Record gave no diagnosis
or plan for his continued care. During interview, he told my investigators
that maybe the man had a ‘borderline personality disorder’ and that,
even if he was suffering from a drug induced psychosis, he would have
expected the effects to have worn off by time he saw him.
63. The man went back to his cell in the segregation unit and continued to
display unusual behaviour, sitting on the end of his bed praying, lying
under his bed with the mattress on top of him, and talking about angels.
The observation book notes that he was awake all night, talking rubbish
and making a lot of noise. The man continued to talk to himself, pace
his cell etc until about 11.20 pm on 19 March, when he appeared to be
asleep.
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Events surrounding the man’s death
64. At 11.17 am on the morning of 20 March, the man pressed his cell bell.
When Officer One and two other officers responded, the man asked to
be given a razor as he wanted to have a shave. He was unshaven, and
had been for some time. Despite knowing that the man was on an open
F2052SH, originally opened because he had superficially cut his wrists
whilst in police custody, and being aware that he had been exhibiting
bizarre behaviour for some time, the man was promised a razor with his
lunchtime meal. The officers were also aware that he had been seen
two days before by the psychiatrist, although no report of that
consultation was available to the Segregation staff as it was only
documented in his ‘confidential’ Medical Record. Healthcare staff had
not passed relevant information on to those caring for the man in the
segregation unit.
65. The man’s cell was unlocked about 11.50 am and the three officers gave
him his lunch and a plastic disposable razor. The issue of the razor was
not documented. During his interview, Officer One told my investigators
that he had given the man the razor. He knew that he was on a
F2052SH and that it was for ‘cutting’ but said that the form did not say
not to give him a razor.
66. At 12.24 pm, the man pressed his cell bell again. Officer One responded
within seconds and immediately shouted the alarm when he looked into
the cell. He saw the man staggering around the cell, a bloody handprint
on the wall and a lot of blood on the cell floor. The man was apparently
naked from the waist down.
67. Other officers arrived at the cell. A Senior Officer saw the man moving
around the cell and grunting. He called to the man a number of times to
ask where the blade was and for him to pass it out. The SO said in
interview that he was assuming it was a razor blade at that time. At
some point, the man apparently said, "I don’t know where it is.” My
investigators believe that the man’s reputation for violence and
unpredictability was the major reason the cell was not entered
immediately.
68. Other officers were arriving, including two nurses from healthcare. By
this time the man was writhing on the floor of the cell. Some of the
officers were in the process of putting on protective clothing (overshoes
and white paper suits) to protect themselves from the blood.
69. In the absence of any exact evidence, my investigators have had to rely
on the timings provided by staff who were present. Within a few minutes
of the man pressing his cell bell, a governor grade, a Principal Officer, a
Senior Officer, three A wing officers, an officer who had gone onto the
wing at lunchtime and two nurses from Healthcare were at the cell. The
estimates of the time taken to enter the cell vary from three to fifteen
minutes. An officer was tasked with keeping a log and he recorded entry
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at 12.35 pm, nine minutes after the man pressed his cell bell. It should
be noted that the officer also records the time of responding to the man’s
cell bell as 12.30 pm, which was incorrect.
70. The SO and Officer One said during interview that, when they looked
into the cell, the man was on his feet. The other officers said they saw
him on the floor. The first Healthcare nurse, who arrived at the cell a few
minutes later, saw the man on the blood-covered floor. She saw that no
blood was coming from the wound on his wrist and no movement. The
second nurse said that an ambulance would be required as soon as
possible and the PO contacted the control room at 12.29 pm to request
one. In interview, the first nurse admitted that when she told the
governor that they should go in she believed that the man was dead.
71. The second nurse opened the cell door and then she and two officers
entered the cell. They brought the man out into the corridor to give them
more room to work. He was placed on a blanket and the second nurse
and an officer performed Cardio Pulmonary Resuscitation (CPR). They
had just administered a shock from the defibrillator when the ambulance
crew arrived at 12.50 pm. A paramedic arrived five minutes later. The
ambulance crew and the paramedic took over CPR from the prison staff
but without success. The man was pronounced dead at 2.15 pm.
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Events after the man’s death
72. The governor remained on A wing and continued to supervise events
and facilitate the police response. The other officers involved were told
to go and wait in the command suite. They found the suite locked,
however, and they ended up waiting in the boardroom. All of the officers
interviewed spoke of the length of time, by some estimates almost two
hours, before a debrief took place. During the time they were in the
boardroom, they had no idea what was happening although they were
provided with refreshments.
73. The officers were complimentary of the care team’s response. The
possible impact of the man’s death on the other A wing prisoners was
not overlooked. A member of staff was instructed by the governor to
patrol the wing to keep an eye on the other prisoners. A general review
of other prisoners on F2052SHs was conducted as is standard practice.
Each prisoner on A wing was spoken to, in order to gauge any reaction
to the death.
74. Chelmsford has a Governor’s Order which outlines the procedures to be
followed after a death in custody. My investigators were content that the
staff actions following the man’s death were in accordance with that
policy.
75. After some trouble identifying the man’s mother’s address, the governor
who had been at the cell went and informed her personally of her son’s
death. When he was interviewed, my investigators noted how deeply
the man’s death had apparently affected him.
76. When my investigator met with the man’s parents, his mother was
unhappy with some of governor’s answers to her questions.
77. As part of the investigation, my investigators wanted to interview
Chelmsford’s Medical Officer, as he had made a number of decisions
and documented entries relating to the man’s care. He refused to co-
operate with my investigation despite a personal request to do so by the
prison Governor. His main reason for not co-operating appeared to be
the mistaken belief that my investigators, and by implication, the
Ombudsman’s office, were not entitled to have access to the man’s
Medical Record. (Prisoners’ Medical Records are one of the documents
that are required - and always made available - at the start of an
investigation into a death.) Chelmsford’s Medical Officer is employed by
a private company, which in turn is contracted by the local Primary Care
Trust to provide the services of a Medical Officer at Chelmsford. The
doctor also declined to co-operate with the person who was preparing
the clinical review for the Primary Care Trust.
78. As the result of my investigators giving feedback on the investigation to
the Governor, a Governor’s Order was issued on 1 April 2005. It stated,
amongst other things, that prisoners in the segregation unit on F2052SH
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booklets should only be allowed supervised shaves.
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Clinical Review
79. The clinical review of the man’s medical care whilst he was at
Chelmsford was undertaken by the Chelmsford Primary Care Trust. The
reviewer was able to take part in the interviews with staff and had access
to a copy of the documentation supplied by the prison, including the
man’s Medical Record.
80. In her report the reviewer makes a number of recommendations, most of
which are reflected in my own recommendations at the end of this report.
She has included recommendations about the requirement for accurate
and contemporaneous record keeping by Healthcare staff, F2052SH
observation levels, and a medical emergency coding system, amongst
others.
81. The reviewer also asked the Section Head for Substance Misuse at
Prison Health, for an opinion. She specifically wanted his views on the
clinical management of the man’s substance misuse. He makes two
recommendations with which I concur and have included amongst my
own.
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Findings and Conclusions
F2052SH and the man’s behaviour
82. There were concerns about the man’s mental condition before he arrived
at Chelmsford, and his behaviour once there only added to them. Every
officer interviewed commented on his bizarre behaviour in one form or
another. He was placed on the F2052SH booklet upon arrival and
admitted to Healthcare. It was known at that time that he had recently
self-harmed by cutting himself and had lately (and not for the first time)
been a patient at the local mental hospital.
83. No specific observation intervals were set in the F2052SH, only ‘regular’
supervision. That is contrary to Chelmsford’s own Suicide Awareness
Policy which stipulates ‘irregular observations intervals of not more than
an hour’ for a prisoner on a F2052SH alone in a cell. On 9 March 2005,
there was an interval of six hours between entries on the F2052SH and
several other large gaps on other days.
84. From the evidence of the written records, the man appears to have been
seen as manipulative, disruptive and possibly dangerous, rather than
unwell and a potential self-harmer. An example is the smashed TV
incident on 8 March. There was no mention of the shard of glass
wrapped in a piece of towel, either in his Medical Record or the
F2052SH. As the man was on the self-harm watch for cutting himself, I
am concerned that the glass shard was only seen as a potential weapon
rather than as a possible means of self harm. I also note that the fact he
was on a F2052SH booklet was not included in the Security Information
Report. Within 15 minutes of the smashed TV being discovered, the
medical officer had decided that the man should leave Healthcare and
go onto normal location. I question the appropriateness of this decision
given the man’s history of mental instability.
85. The man continued to exhibit behaviour recognised by staff as strange
and bizarre. The F2052SH review on 17 March was actually held in his
cell as the man was hiding under his bed and refusing to come out.
Although he was eventually persuaded out and later agreed to take a
shower, I do not believe that holding a F2052SH review in those
circumstances was decent or acceptable.
86. The impression gained from reading the documentation and the staff
interviews is that the prison and the man were in a ‘holding pattern’,
waiting for the Consultant Psychiatrist to make his assessment and tell
the prison what to do with the man. However, the psychiatrist ended his
report by stating that he could detect no feature suggestive of any
current mental illness. I am in no position to make my own clinical
assessment and must defer to his professional judgement. I simply note
that it was at odds with the observations being made on a daily basis by
non-clinical staff.
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87. Whatever the man’s exact mental condition, the fact is that staff were
looking for guidance on how best to deal with a prisoner they found
difficult and who was exhibiting bizarre and challenging behaviour. The
doctor’s assessments on 6 March and 8 March, and that of the
Consultant Psychiatrist, on 18 March, all concluded that the man did not
have a current mental illness. However, the Consultant Psychiatrist
could not have taken full account of the man’s medical history in coming
to this view, as he believed that the contents of the report by the CPN
referred to events over a year previously instead of less than a month
before.
Segregation and Adjudication
88. Rightly, Prison Service policy is that prisoners on open F2052SH
booklets should only be placed in a segregation unit in exceptional
circumstances. I am all too conscious of the number of deaths to have
occurred in segregation since I started investigating all deaths in prison
custody some 18 months ago. That said, I do understand why some
such prisoners end up in segregation and the pressures on prison staff
who are required to care for prisoners who, for a variety of reasons,
cannot be located within the general prison environment.
89. In the man’s case, there was no case conference before he was placed
in the segregation unit, contrary to the prison’s Suicide Awareness
Policy. That policy also states that the decision to locate at-risk
prisoners in the segregation unit must be for as short a time as possible,
and the temporary nature of the segregation should be reflected in the
care plan. Again, that was not done. In addition, adjudicators should
consider, for prisoners on an open F2052SH, the implications of
imposing punishments such as cellular confinement. But in this case,
the adjudicating governor was unaware of the man’s self-harm status
and gave a total of 17 days cellular confinement. Clearly, it is vital that
the adjudicator should be in possession of all the facts and
circumstances relating to a prisoner and the alleged offence. Only then
can a proper assessment be made and suitable punishment given.
90. The Segregation Safety Algorithm form was not properly completed on 9
March when the man first entered the segregation unit. On 10 March,
the nurse incorrectly completed the algorithm form required by the
adjudicating governor, by ticking the box stating that he was not on a
F2052SH. That error led to the governor completing the remainder of
the form incorrectly. There is no evidence, therefore, that the man was
properly fitted for the segregation unit, either initially or at the
adjudication stage.
Issuing a razor
91. My investigators discovered that, at the time of the man’s death, it was
policy in the Healthcare unit only to allow supervised shaving for
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prisoners on open F2052SH booklets. However, that policy did not
apply in the segregation unit. The Governor has since implemented
such a policy for the segregation unit. It is for consideration whether the
policy should apply throughout the prison, and whether other jails should
be made aware of it. I acknowledge that the universal adoption of
supervised shaving for all prisoners on open F2052SH’s would not be
feasible or justified. My concern is focused especially on those with a
known history of cutting as a form of self-harm. The decision to give the
man a razor over the lunch period on 20 March was not risk-assessed in
any way.
92. Within minutes of the man pressing his cell bell at 12.24 pm on 20
March, there were nine members of staff outside the cell. Too much
emphasis was placed on him using the blade from the razor as a
weapon and on protection from blood contamination. Much of the time
that officers were looking at the man through the cell door window, he
was writhing on the floor. His loss of blood was obvious, leading to one
of the nurses believing that he was already dead when the cell was
finally entered. The log records the time of entry as 12.35 pm, nine
minutes after the man alerted staff. Whilst acknowledging the concerns
for staff safety, the number one priority should be the preservation of life.
It was apparent that he had seriously self-harmed and I believe there
was an unacceptable delay before entering the cell.
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Recommendations
93. The Governor should ensure that staff receive any necessary
training in relation to Chelmsford’s Suicide Awareness Policy and
the requirements of any self-harm documents.
Accepted – 1.All staff are currently being trained in the new Assessment,
Care in Custody and Training (ACCT) procedures. This is mandatory
training which, forms part of their SPDR objectives.
2. The establishments Suicide Awareness Policy is available and
displayed in all areas for guidance to staff.
Target Completion Dates: 1.Currently on going with a target date of May
2006. This will be included in staff SPDRs for 2006 / 07. 2.Immediate
94. The Governor should remind staff of the priority to preserve life
and consider further training for wing staff, on actions to be taken
on the discovery of apparent death or serious self-injury, as per
PSO 2710.
Accepted - The Governor will publish a Governors Information Notice
(GIN) in line with PSO 2710. This will form part of all staff SPDR’s for
2006/07 as a generic objective. All staff must sign to say that they have
both read and understood the notice.
TCD: GIN 067/05 published December 2005.
GIN 067/05 will also be included in all staff SPDRs for 2006 / 07 as a
generic objective. Target May 2006.
95. The Governor should ensure that provisions are in place so that
any Adjudicator is fully briefed on the circumstances relating to the
alleged offence and any other factors likely to have an impact on
the punishment decision, including whether there is an open
F2052SH.
Accepted - Adjudication paperwork now stamped to indicate an open
F2052SH. The Adjudicating Governor receives the information
regarding the circumstances of the offence as part of the enquiry
process. The Wing conduct report also indicates an open F2052SH.
This is verbally read out to ensure all present are aware.
Governors Order 068/05 re: Adjudication Daily Report Log (ADRL) now
published inline with recommendation. The ADRL will provide the
adjudicator with the following information i.e. name, number, status,
charge, F2052SH, any other concerns prior to an adjudication taking
place. The purpose of this is to ensure that the adjudicator is aware of
prisoner’s circumstances before conducting the adjudication.
TCD: Completed
96. The Governor should consider whether his Order 008/05, relating to
the issue of razor blades to prisoners on open F2052SH on the
segregation unit, should be made policy throughout the prison.
Considered but not accepted - Each individual should be risk assessed
separately based on their individual needs and situation. This
recommendation was discussed at our local Safer Custody Meeting
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(21/12/05). It was considered to be unrealistic to monitor this policy
effectively across the prison due to the high number of prisoners moving
through the establishment, and also due to the fact that razors are
currently issued to prisoners daily, twice as required, as part of the
prisons decency agenda. A blanket policy restricting access to razor
blades would be a disproportionate response in relation to both risk and
resource cost. Individual case management is the right approach and is
likely to be more effective and defensible.
TCD: ongoing
97. The NOMS Safer Custody Group should consider whether further
advice should be offered to all prisons on the issuing of razor
blades in light of this report.
Partially accepted - SCG has no plans to highlight this issue in isolation
although the revised PSO 2700 will seek to strengthen the current policy
on items in possession by cross referencing to ACCT plans and
individualised care.
All cases should be treated individually, this is a key part of ACCT.
98. The Governor and Primary Care Trust should consider whether the
contract with the Medical Officer should be discontinued in light of
his decision not to cooperate fully with this investigation.
Following discussions with PCT, Care UK, the Health Care Manager and
the Governor the decision has been made not to terminate the doctor’s
contract
99. Any specialist advisors giving a medical opinion on a prisoner
should be encouraged also to propose a plan to deal with
challenging behavioural problems, even if there is no diagnosed
mental illness.
A multi disciplinary approach is required when managing prisoners who
are displaying behavioural and discipline problems.
The Prison Lead GP would liase with the assessing psychiatrist in the
case of a prisoner displaying challenging behaviour as part of a team
approach towards the overall care of such a patient. Any specialist
opinion expressed by the Prison Lead GP or psychiatrist should be used
as part of a team orientated multidisciplinary approach in caring for such
prisoners.
TCD – immediate and ongoing.
100. Patients with co-existent mental health and drug problems should
be considered for longer term detoxification to limit the potential
for exacerbation of their psychiatric symptoms in accordance with
local community policies.
Accepted - Detoxification for patients is based on the Government
Publication “Drug and Misuse Dependence, Guidelines on Clinical
Management”. Patients with any dual diagnoses are seen and reviewed
regularly at present to formulate individualised plans towards achieving
successful detoxification and treatment of any mental health issues. This
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is currently done in conjunction with the mental health team and visiting
psychiatrist. This will formally be adopted into the Local Drug Strategy
\and Protocols currently being updated.
101. Prisoners arriving at Chelmsford with a declared drug problem
should normally be offered urine testing and a specialist substance
misuse assessment the same evening.
Partially accepted - Prisoners at present are currently ‘scored’ using a
formalised system which allows nurses in reception to clinically and
objectively assess their need for immediate intervention with any
detoxification, medication or symptomatic relief. As many prisoners
have been treated with detoxification in police custody immediately prior
to coming into prison they often do not present signs of withdrawal. We
therefore adopt a broader approach to this through the system we
currently employ as outlined above. This allows a more accurate
assessment on a more individualised basis for each prisoner and is safe
and effective. At present we do not have sufficient resources in place in
the evenings in reception to achieve the testing of urine on reception.
New Staff profiles will be introduced on 8 January 2006 and a new staff
rota introduced. Once the new profiles have settled we will undertake a
‘pilot’ programme for urine testing in reception based on existing staffing
levels. Pilot programme will commence 13 February 2006 and will be
reviewed one month after.
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