Individual at Isle of Wight

Investigation into the death in October 2006
of a man who was a prisoner at HMP Albany
Report by the Prisons and Probation Ombudsman for
England and Wales
May 2007
This is the report of an investigation into the death of a man who was a prisoner at
HMP Albany. The man was found hanging in his cell at the prison in the early hours
on the morning of 23 October 2006.
I extend my condolences and those of my colleagues to the man’s family. I know
that his passing will have caused much grief for his family and friends, and I hope
this report goes some way to answering the questions they may have.
This is the first apparently self inflicted death that I have had to investigate at Albany
since my office started investigating all deaths in prison custody in April 2004.
The investigation was undertaken on my behalf by one of my investigators. In
addition, a clinical review was conducted by the Isle of Wight NHS Primary Care
Trust. I am most grateful to the doctor who completed the review. I am also
indebted to The governor and staff at Albany for their cooperation and assistance
with my investigation. I would particularly like to thank the Head of Security and the
Governor’s secretary.
It is evident from my investigation that the man who died was a quiet man who, for
the most part, kept himself to himself. He was respectful and friendly to both staff
and prisoners and appeared generally settled at Albany. However, due to
circumstances mostly beyond his own control, it is apparent that the man who is the
subject of this report had much on his mind during the last few weeks of his life.
Although no one can be sure of the reasons why he appears to have taken his own
life, I believe that the domestic problems he was experiencing at the time were a
substantial contributory factor.
Stephen Shaw CBE
Prisons and Probation Ombudsman May 2007
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CONTENTS
Summary
The Investigation Process
HMP Albany
Key Findings
Issues
Recommendations
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SUMMARY
The man who died was received into custody on 27 October 2004 at HMP
Dorchester. Prison documents noted that the man had a history of depression and
self harm but recorded that he was not suicidal at the present time. The man was
admitted to the healthcare centre overnight before being located on the vulnerable
prisoners’ wing.
On 28 October, the man told staff that he had cut himself. In response to his actions,
staff at Dorchester began monitoring and supporting the man under arrangements
for prisoners who are thought to be at risk of suicide or self harm. On 4 November,
he was transferred to HMP Albany.
During the reception process at Albany, it was noted that the man suffered from a
“mental condition” and was vulnerable. During a consultation with a medical officer
on 5 November, it was recorded that he had been depressed but had no suicidal
thoughts at that time. At a case review on 10 November, the decision was taken that
the man’s risk of self harm had reduced sufficiently for the special monitoring and
support arrangements to be ended.
Between December 2004 and September 2006, the man appears to have led a quiet
and untroubled life at Albany. There is little in his prison record to suggest
otherwise. However, on 29 September 2005 during a cell search, a large quantity of
paracetamol tablets was found in his possession.
On 9 September 2006, the man received news that his wife had been involved in a
car accident on her way to visit him. On 24 September, he learned from his parents
that his wife had not been involved in an accident but was seeing somebody else.
Because of the man’s record of self harm, staff were informed.
In the weeks leading to his death, the man made a number of calls to his parents
and his wife.
On 21 October, the man wrote a last will and testament, along with a number of
other letters that were found in his cell after his death. The man spoke with his
mother for the last time on the morning of 22 October. It was noted by an officer on
the wing that the man was laughing and joking with other prisoners that day.
In the early hours of 23 October, the man was found hanging in his cell. Emergency
life saving assistance was given, but the man was pronounced dead by paramedics
at 5.30am.
My report makes a number of recommendations to the Governor at Albany.
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THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened by one of my
investigators.
2. Notices announcing the investigation were issued to both staff and prisoners
informing them of the investigation and its terms of reference. These were
displayed around the prison and invited staff and prisoners to contact the
investigators should they wish to do so.
3. My colleagues visited Albany and were given full access to all areas of the
prison. They met with a number of governors as well as with members of the
Independent Monitoring Board. My investigators also made themselves
known to two representatives of the local branch of the Prison Officers’
Association. The investigators obtained documentation relating to the time
that the man spent at both Albany and his local establishment, and
interviewed a number of staff and prisoners who had had contact with him.
During their visit to Albany, my investigators also met with a Police Liaison
Officer and a Detective Sergeant from the Hampshire Constabulary.
4. I commissioned a clinical review from the Isle of Wight NHS Primary Care
Trust, and one of their doctors kindly completed this on their behalf.
5. My investigator and one of my family liaison officers met with the man’s
parents at their home in November 2006. The man’s parents raised a
number of issues with my family liaison officer and investigator. I trust that my
report will address these matters satisfactorily and any other questions that
the man’s family may have.
6. A copy of this report will be sent to the Coroner to assist him with his
enquiries.
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HMP ALBANY
7. Albany is a category B training prison built on the outskirts of Newport, Isle of
Wight, in the early 1960s. It was previously part of the high security estate.
Albany holds sex offenders and other vulnerable prisoners, and operates as
an assessment centre for the core sex offender treatment programme.
8. Up to 526 prisoners can be held at the prison. The principal accommodation
comprises five four-storey cell blocks designated A to E wings. (These wings
are identical and hold a maximum of 88 prisoners in single cells. There is no
in cell sanitation. However, prisoners have access to sanitation at night by
the use of electronic unlocking.) In May 2003, a unit holding 80 category C
prisoners was opened; each of the cells in this unit has in cell sanitation.
9. Health services at Albany and at the other two prisons on the Isle of Wight are
delivered by the Isle of Wight NHS Primary Care Trust. Healthcare at Albany
is based on primary care and operates from 8.00am to 9.00pm daily.
10. Albany was last inspected by Ms Anne Owers, HM Chief Inspector of Prisons,
on 25 October 2005. She reported that Albany remained an essentially safe
establishment and had improved the availability of purposeful activity. Ms
Owers’s comments about healthcare provision were less favourable. She
said:
“Although progress had been made since the last inspection in some
healthcare areas, many had either stood still or regressed. The
perception of patients we spoke to was that healthcare generally had
deteriorated and was poor. This was in contrast to the last inspection
when 53% of prisoners in our survey thought that healthcare was good
or very good.”
11. The death of the man subject to this investigation is the first apparently self
inflicted death to have taken place at Albany for a decade. My office has
investigated six deaths from natural causes at the prison since April 2004, the
most recent being in October 2005.
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KEY FINDINGS
12. The man who died at Albany was sentenced to twelve years imprisonment at
Crown Court in 2004. He was received into custody at Dorchester prison later
that day. The Prisoner Escort Record (PER – a form that accompanies staff
on all escorts and provides a chronological record of the escort and also
advises staff about the risks of an escort or transfer) recorded that the man
was at risk of suicide/self harm, that he was taking medication and that he
suffered from depression. A Suicide Self Harm Warning Form was also
completed by escort staff. This recorded the man’s history of depression and
self harm. I note that staff at the local prison did not fully complete this form,
although the man’s history of depression was recorded on several other
documents.
13. During the reception process at the local prison, a personal summary sheet
(F2050 – Page 1) was completed and the man’s personal details were
recorded by staff. The man gave his mother’s name and address as his next
of kin and also as the person to be notified in an emergency. A Cell Sharing
Risk Assessment (CSRA – a form used to assess the level of risk that a
prisoner would be to other prisoners when sharing cells) was also completed
by staff. It was recorded on the CSRA that the man was “not suicidal at
present”. Nevertheless, due to the length of his sentence, he was to be
admitted to the healthcare centre overnight. The following day, the man was
placed on the vulnerable prisoners’ wing under Rule 45. (Prisoners who have
committed an offence of which other prisoners disapprove are frequently
segregated from the remainder of the population under Rule 45.)
14. As part of the reception process, all prisoners entering prison are given a first
night reception health screen. This is based upon information given by the
prisoner himself. The nurse who conducted the man’s assessment at the
local prison noted that he had recently seen a doctor for neurological damage
and depression, and was receiving amitriptyline and fluoxetine. (These drugs
are primarily used in the treatment of depression. However, in lower doses I
understand that they can be prescribed to alleviate pain.) The nurse noted
that the man had suffered from a nervous breakdown seven to ten years
previously, and that he had attempted to self harm five years before. The
man was currently taking 20mg of fluoxetine for the treatment of his mental
health problems. Another health screen, completed the following day, noted
no concerns.
15. Shortly after midnight on 28 October, the man rang the bell in his cell in order
to tell staff that he had cut himself. Healthcare staff attended and superficial
lacerations made to his right wrist were cleaned and dressed. During his
treatment, the man complained to staff that he had not received his fluoxetine
for three days.
16. The man was seen by a doctor at the local prison later that day. In addition to
noting some of the man’s general medical issues, the doctor recorded that the
man’s mental condition was stable, that he had minimally self harmed the
previous evening, that he denied any thoughts of self harm and that he was
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not clinically depressed.
17. Staff completed the relevant documentation in light of the man’s attempt to
self harm, and opened an F2052SH booklet on him and he was monitored
hourly. (An F2052SH is a document used by the Prison Service to monitor,
support and assess those prisoners at risk of self harm. It has recently been
replaced by the Assessment Care in Custody Teamwork form – (ACCT).)
Nursing staff noted in the booklet that there was a clinical risk of self harm and
that the man had a poor level of coping. During a case review on 30 October,
the man spoke of a recent family visit and news of a possible appeal. He
described himself as feeling vulnerable and talked of his history of self harm
and depression. The man remained on hourly observations.
18. On 3 November, an entry by an officer in the man’s wing history sheets noted
that he was:
“… seen for transfer. Still not very happy after OCA [Observation,
Classification and Allocation – the prison department that arranges
transfers] informed him, due to family reasons and [the man] thinking
he would stay at [the local prison] until appeal is heard.”
19. On 4 November, the man was transferred to HMP Albany. His PER form
noted that he had a mental condition, was vulnerable and was on an open
F2052SH. The CSRA form completed upon his arrival at Albany noted that it
was the man’s first time in prison, and that he was:
“A very private man who has been shell shocked with what has
happened over last month.”
20. At approximately midday on 4 November, the man was seen by a nurse at the
prison. She wrote in his IMR [Inmate Medical Record] that he was upset but
had no feelings of self harm, and that he seemed calm when spoken to. The
nurse noted the man’s neurological problems and gave him a dose of his
prescribed medication. She told the man that he needed to attend the
medication hatch for further medicines. The nurse also recorded on the
CSRA that it was the man’s:
“First time in prison therefore never shared a cell, prefers to be alone.
On an open 2052. When in [local prison] self harmed 28 October
2004.”
21. An entry in the man’s wing history sheets on 4 November records that he was
very concerned about the future, had started his appeal process and
completed his induction. It was also noted that he had concerns about his
wife who had recently sold their house and whom the man was helping to
move abroad.
22. On 5 November, the man was seen by the prison doctor, who recorded:
“Transferred from [Dorchester]. Has an appeal ongoing. Has been
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depressed and had one episode of self harm. No suicide thoughts
now. Gives a good account of himself, has ongoing medication – see
chart.”
23. At an F2052SH case review held at Albany on 10 November, it was recorded
that the man was taking his medication regularly, and that he was feeling a lot
better and beginning to settle in. It was noted that the man was hopeful about
his appeal and in the meantime was getting on with his sentence. The
decision was taken to close the F2052SH booklet.
24. On 11 November one of the prison doctors at Albany, wrote to the man’s GP
in his local town requesting information about the neurological disorder from
which he had suffered.
25. Between December 2004 and September 2006, the man appears to have led
a quiet life at Albany. There is little on his prison record to suggest otherwise.
General entries on his wing history sheets and other information suggest that
the man kept himself to himself, was respectful towards staff and associated
well with other prisoners. Comments noted on his record include: no
problems to report, no cause for concern, and that everything was okay. On
14 December 2004, an officer recorded that the man was “a quiet man but not
afraid to ask staff for help if he needs it.”
26. On 29 September 2005 during a cell search, staff found 98 Paracetamol
tablets in the man’s cell. The tablets in excess of those that had been
prescribed to him were removed and returned to the healthcare centre. The
Security Information Report (SIR) completed by staff about the discovery said
that, with his history of self harm, possession of such a quantity of painkillers
was a matter of concern. The report suggested that wing staff and healthcare
staff keep an “eye on this prisoner”.
27. On 9 September 2006, an entry in the man’s wing sheets noted:
“Wife in accident on way to visits. Given phone call to [local] hospital,
wife discharged herself, at home now. Phoned home all ok at
moment. Poss[ible] phone call tomorrow.”
28. On 23 September, staff attempted to phone the man’s wife as she had not
turned up for a visit and was not answering the phone. On the following day
(24 September), it was recorded that the man:
“Got in touch with his mother and father. They told him his wife was
not involved in an accident (ref entry 9-9-06) … said she was seeing
someone else. Has taken this news badly but had a long talk to him
and he says he is now alright. But be aware has record of self harm.
Staff informed.”
This was the last entry made on the man’s prison record.
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29. During the week leading to his death, the man made a number of telephone
calls to his wife and parents. On 18 October, he spoke with his wife twice.
During their conversation, the man implied that he had taken an overdose of
his medication and spoke of his fears that he would receive a “Dear John”
letter from her. (A “Dear John” letter is one in which a prisoner is told that his
relationship with his wife or partner is at an end.) The man also spoke with
his parents that day.
30. Early on 19 October, the man spoke briefly to his wife. He attempted
unsuccessfully to contact her again at around lunchtime. At 1.15pm, the man
spoke with his friend. During the call, the man asked about his wife, indicating
that he believed she was conducting an affair with another man. When asked
by his friend how he was doing, the man said that he was doing as best he
could. He added:
“Don’t really see much point in going on much longer, but there we go.”
The man’s friend told him that he should “hang on in there”.
31. At 1.36pm on the same day, the man spoke with his mother again. He asked
her to drive past his wife’s address in order to confirm whether or not she had
moved out. The man expressed concern to his mother that his wife was
spending unauthorised amounts of his money by the use of his credit cards.
The man spoke with his mother later and she confirmed that his wife was still
living at their home. That evening, the man spoke with his parents once
again. He said he would draw up a list of possessions that remained in his
home and that he wanted back. The man made several unsuccessful
attempts to contact his wife during the afternoon and evening of 19 October.
32. On 20 October, at about 1.37pm, he left a message on his wife’s mobile
phone saying that he would call her back later that day. The man made
further, unsuccessful, attempts to contact his wife that afternoon. At 5.01pm
the man spoke with his mother.
33. Throughout 21 October, the man attempted on numerous occasions to
contact his wife by phone. At 10.59am, he rang his mother. They spoke
generally of things that had been going on and about the man’s wife. The
man told his mother that he had compiled a list of possessions he wanted to
be collected from his home, and that he had put this list in the post to her.
The man spoke with his father at 4.00pm. During this conversation, the man
talked of a letter that he had received from his wife earlier that day. The letter
said that, due to the problems she had been experiencing whilst he had been
in prison, she was no longer able to continue with their relationship. The man
told his father that she had met a “new man”. He also said that, as their
landlord was going to evict her from their home in December, he would need
to move his possessions from the property.
34. The man wrote and addressed a last will and testament, dated 21 October, to
his solicitors. This was one of the letters removed by the police from the
man’s cell after the discovery of his body. The other letters were addressed
10
to his parents and wife. I understand that the police removed the letters
before prison staff were able to read their contents. As a the man’s parents
did not receive their son’s “last will and testament” along with the other letters
until some time after his death.
35. The man spoke with his mother for the last time on Sunday 22 October at
8.57am. They again talked about his wife. The man concluded the call by
saying that he would speak with his mother again the following Tuesday
afternoon.
36. An officer on B wing said that the man was laughing and joking with other
prisoners on the Sunday evening.
37. My investigators spoke to a number of staff and prisoners at Albany who knew
the man. The officer who had seen the man laughing and joking described
him as a:
“quiet individual, no problems whatsoever, polite, respectful.”
Another officer from B wing described the man who died as:
“A very polite, mature person, always polite, seemed jovial with
staff and to his peers.”
An instructor at Albany described the man as a hard working individual who
was trustworthy and who volunteered to do additional unpaid work in the
workshops.
38. However, it is also clear from what my investigators were told by both staff
and prisoners (and in light of correspondence between the man and his wife),
that about three months before the man’s death he began to experience
substantial marital problems. The man often spoke about these difficulties to
other prisoners and they preyed on his mind. These difficulties culminated in
the “Dear John” letter that the man received from his wife on 21 October.
39. Approximately two weeks before his death, the man spoke with a fellow
prisoner. This fellow prisoner told my investigators that the man who is the
subject of this investigation had told him how he believed his wife was leading
him a “merry dance”. The fellow prisoner said that he was also aware that the
man had received a “Dear John” letter from his wife and that he was upset
about this. The fellow prisoner said that he had been shocked on learning the
news that the man had apparently taken his own life. He said that there had
been no warning and nothing appeared to be wrong with the man, whom he
described as being upbeat and positive about his forthcoming appeal. Other
prisoners who knew the man who died spoke similarly of their experience and
knowledge of him.
40. An OSG confirmed with my investigators that on the evening of 22 October, at
approximately 8.00pm, he completed a roll check of the wing, checking
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numbers and noting that there was nothing out of place. The OSG said that
this was the last time that he saw the man alive.
The discovery of the man’s body
41. At approximately 5.03am on the morning of 23 October, whilst carrying out the
morning roll check, the OSG checked the man’s cell. He said that, on looking
through the cell door, he could see what appeared to be the man sitting under
the window. In his incident report, the OSG said that he could see a fine cord
leading down towards the man’s neck and immediately tried to gain a
response from him. The OSG told my investigators that, seeing blood coming
from the man’s nose, he ran downstairs to the wing office, leaving the gates
behind him open. On reaching the office, the OSG said that he telephoned
the control room (Comms) to obtain assistance from the night orderly officer.
(During night shifts in prison, the night orderly officer is more commonly
known as Oscar 1 and his deputy as Oscar 2). An entry in the control room
log at 5.06am records that:
“Informed inmate 5253 Hanging in cell. Ambulance called.”
42. The OSG told my investigators that, upon the arrival of other officers, call
signs Oscar 2 and Oscar 1, a few minutes later they left the wing office to
return to the man’s cell. The OSG said that he took the emergency self harm
response kit with him. On arrival at the man’s cell, the OSG said that the door
was electronically unlocked by control room staff. (Unfortunately there is no
definitive record as to when the cell door was unlocked. The entry in the
control room log simply records that at 5.06am the man had been found
hanging in his cell.) The OSG explained that, on entering the cell, Oscar 1
and Oscar 2 raised the man slightly so they could cut the ligature from the
man’s neck.
43. When asked during interview if he was aware of any guidance with regard to
entering cells at night, the OSG said that he was not. He went on to say that
during training he was told that he was unable to enter a cell on his own
anyway, and that only Oscars 1 and 2 could do so.
44. Oscar 2 told my investigators that, at about 5.00am when he was just about to
check the alarm bells, a message came from the control room to attend B
wing as soon as possible. (Albany does not have a code system of alerting
staff to the type of incident they are about to attend.) Oscar 2 said that, on
reaching the B wing office, he was met by the OSG who advised him of the
suspected hanging on the 4th landing. Oscar 2 said that it was about two
minutes from the time he received the original emergency call to when he
reached the man’s cell.
45. Upon arriving at the cell, Oscar 2 said he looked through the flap, suspecting
that the man had hanged himself. He said that Oscar 1 then looked in, and
on doing so immediately contacted the control room, requesting that the cell
door be unlocked electronically. On entering the cell, Oscar 2 said that he
assisted in cutting the man down, and confirmed that it was at this time that
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Oscar 1 called for an ambulance before commencing cardio-pulmonary
resuscitation (CPR).
46. Oscar 1 was in the centre office at around 5.00am when a call to attend B
wing was received from the control room. Oscar 1 said that it took about two
minutes to get from the centre office to the man’s cell, adding that Oscar 2
was about twenty seconds in front of him. Oscar 1 said that on reaching the
cell he immediately asked the control room to unlock the cell door
electronically.
47. Oscar 1 assisted the other officers present in cutting the man down. He then
checked for a pulse and any signs of breathing. He explained to my
investigators how he tried to give the man mouth to mouth resuscitation alone,
but was unable to do so as the man’s jaw was shut tight and he could not
open his mouth. Oscar 1 said that he proceeded to give chest compressions
and attempted to administer oxygen through the man’s nose instead. He said
that he continued with CPR, but as there were no signs of life he placed the
man in the recovery position and waited for the arrival of paramedics.
48. According to the control room log, the ambulance arrived at Albany at 5.22am,
and the paramedics were in attendance at the man’s cell at 5.25am. The man
was pronounced dead by the paramedics at approximately 5.30am.
49. As well as the last will and testament written by the man on 21 October, a
number of other letters were discovered in his cell after his death. These
included two letters to his mother and father, and one each to his brother,
sister and wife. One of the letters to his parents was written on the afternoon
of Sunday October 22. The man wrote in it about how he had lost everything.
In part of the letter, The man said:
“I have to go and get my tea now and I hope they don’t see how upset I
am. I got some funny looks but that’s all.”
50. My investigators spoke with prisoners who occupied cells on either side of the
man, asking if they had heard anything unusual that night. One of the
prisoners said that he had heard a bang in the early hours of the morning,
describing it like a chair falling over. The other prisoner said he heard nothing
in the night other than voices on the landing at about 5.30am.
51. A governor told my investigators that a hot-debrief took place that morning
and was attended by a number of staff who had been involved in the
discovery of the man. A review of all prisoners on open ACCTs was also
completed. Staff who had attended the man were offered the facilities of the
prison’s welfare team.
52. At 10.20am, a chaplain from Albany informed the man’s parents, by
telephone, of their son’s death. A governor along with the chaplain visited
the man’s parents at their home that afternoon. On the following Friday (27
October), the man’s parents visited Albany with other family members and
saw the cell in which their son had died. During the visit, the man’s family
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also met with some of his friends on the wing. The man’s parents spoke to
my family liaison officer and investigator positively about the help and support
received from staff at the prison, in particular from the chaplain and Head of
Security. The prison made a significant contribution towards the funeral
expenses.
Clinical Review
53. The clinical review was undertaken by a doctor on behalf of the Isle of Wight
Primary Care Trust. I summarise the doctor’s findings in the paragraphs
below.
54. During his time in prison, the man had been extensively investigated for
orthopaedic and neurological symptoms and his care was equitable with that
expected in the wider community. There was no evidence to suggest that the
man did not have access to healthcare in Albany.
55. In February and July 2006, the man probably complained of pain rather than
depression. Extensive investigations were made between 2002 and 2004 into
the man’s orthopaedic and neurological symptoms. During his time at Albany,
the man had been able to undertake daily living activities satisfactorily.
56. Prescription and commonly abused drugs were not found in above therapeutic
levels in the man’s blood taken during the post mortem and were not,
therefore, directly involved in his death.
57. The attending paramedics acted appropriately in not attempting to resuscitate
the man.
58. The care provided to the man for his depression was broadly equitable with
that provided in the community, but there was room for improvement. In
addition, the doctor commented on the need for the PCT’s clinical governance
department to review the operation of the VISION system at the prison.
(VISION is the system that electronically records prisoners’ healthcare notes
and their contact with healthcare staff at the prison.)
59. The doctor makes four recommendations:
The primary care service for the Isle of Wight prisons should be asked
to produce a policy on the prescribing and review of prisoners on
antidepressant medication, including a consideration of who is best
placed to undertake reviews by the end of August 2007.
That a screen [on the VISION system] should be set up to structure the
review of patients prescribed antidepressants for moderate to severe
depression. The screen should be implemented with suitable training
for staff by the end of October 2007.
That the operation of the VISION system should be reviewed by the
PCT’s clinical governance department by end of December 2007.
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That the scheduling and calling of prisoners for mental health and other
primary care return visits should also be reviewed by the end of March
2008.
60. The doctor also concluded that consideration should be given to the training
of prison staff in resuscitation and that the management of prisoner held
medication should be reviewed.
Post Mortem Report
61. A post mortem was conducted on 24 October. It gave the cause of death as
hanging.
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ISSUES
62. Just after 5.00am on the morning of 23 October, the OSG noticed that
something was wrong when he checked the man’s cell. The OSG returned
immediately to the wing office in order to phone for assistance, remaining at
the office until help arrived. Upon the arrival of Oscars 1 and 2, all three
members of staff returned to the man’s cell, taking with them the emergency
self harm response kit. On confirming that the man was in need of urgent
assistance, his cell was unlocked by the control room.
63. Section 7 of Albany’s local instructions sets out guidance for staff who
discover a prisoner who has attempted to self harm during the night. It says
that:
“Night Operational Instructions must make clear, that if a cell must be
unlocked, two members of staff must be present, except in an obvious
emergency where there is an immediate danger to life.”
64. It is clear that the members of staff who attended to the man in the early hours
of 23 October did so in accordance with the locally approved policy.
However, the locally approved policy relating to the entering of cells at night
appears to be at odds with the local suicide prevention policy. Both lack
clarity in explaining to officers the requirements of the relevant Prison Service
Orders.
I recommend a review of sections 7 and 8 of Albany’s local instructions
(attempted suicide and death in custody) with particular focus on the
circumstances in which a cell may be unlocked during the night and the
staffing level that is required.
65. Of the staff who attended to the man, only Oscar 1 had received up to date
first aid and CPR training. Oscar 2 had received training approximately five
years previously, and the OSG had undergone first aid training in previous
employment. Given the evidence of Oscar 1 that the man’s jaw was locked
and that he showed no vital signs, I believe that nothing further could have
been done to save the man’s life even if all the staff had had up to date
training in CPR. However, in view of the low levels of staff on duty at night,
and the absence of any healthcare staff, I make the following
recommendation.
I recommend that the Governor gives consideration to training all night
duty OSGs in basic CPR techniques.
66. During the investigation, my staff learned that a defibrillator of the type which
can be used by the general public and which requires no formal training
before use, is kept in the healthcare centre at Albany. My investigators asked
a number of officers about the defibrillator. Many were not aware of it. Others
were aware of it but were unsure as to how it could be accessed.
I recommend that the Governor in conjunction with the Healthcare
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Manager considers the training of night staff in the use and location of
the defibrillator.
67. My investigators noted that the post incident log was not begun until the
arrival of the Duty Governor at 5.55am. In addition, the incident log kept by
the control room had been poorly completed.
I recommend that the Governor reminds all staff of the importance of
completing accurate, timely and comprehensive logs.
68. Overall, I cannot say that there were any obvious signs that staff should have
picked up that the man was planning to take his life. In fact, on the evening
before his death he was seen laughing and joking with other prisoners. There
can be no way of telling if this was a deliberate attempt by the man to mislead
staff and prisoners as to his intentions or whether he was at peace with the
decision he had made.
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RECOMMENDATIONS
I recommend a review of sections 7 and 8 of Albany’s local instructions
(attempted suicide and death in custody) with particular focus on the
circumstances in which a cell may be unlocked during the night and the
staffing level that is required.
Accepted
I recommend that the Governor gives consideration to training all night
duty OSGs in basic CPR techniques.
Not Accepted – HMP Albany said that their current arrangements ensure that
all Senior Officers are trained in first aid. They say that Night Orderly Officers
are always Senior Officers and current arrangements ensure that the first on
scene is first aid trained. Given I am simply asking for a review of this matter,
I hope that Albany will reconsider its rejection of this recommendation.
I recommend that the Governor in conjunction with the Healthcare
Manager considers the training of night staff in the use and location of
the defibrillator.
Partially Accepted – The local Primary Care Trust will be contacted in order to
seek advice on minimising the risk during the State A night period by the end
of April 2007.
I recommend that the Governor reminds all staff of the importance of
completing accurate, timely and comprehensive logs.
Accepted
Clinical Review Recommendations
The primary care service for the Isle of Wight prisons should be asked
to produce a policy on the prescribing and review of prisoners on
antidepressant medication, including a consideration of who is best
placed to undertake reviews by the end of August 2007.
Accepted
That a screen [on the VISION system] should be set up to structure the
review of patients prescribed antidepressants for moderate to severe
depression. The screen should be implemented with suitable training
for staff by the end of October 2007.
Accepted in Principle – By October 2007 HMP Albany will recruit suitably
qualified psychiatric nurses to ensure that reviews are completed.
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That the operation of the VISION system should be reviewed by the Isle
of Wight’s PCT clinical governance department by end of December
2007.
Accepted in Principle – On behalf of the Primary Care Trust, HMP Albany will
bring this recommendation to their attention.
That the scheduling and calling of prisoners for mental health and other
primary care return visits should also be reviewed by the end of March
2008.
Accepted
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