Individual at Birmingham

Investigation into the circumstances surrounding the death
of a man at HMP Birmingham in December 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
July 2007
This is the report of an investigation into the circumstances of the death of a man at
HMP Birmingham in December 2005. The man was found hanging in his cell in the
High Dependency Unit. He had been in custody for almost five months at the time of
his death.
I extend my sincere condolences to the man’s family and friends for their loss.
The investigation was carried out by two of my colleagues. I would like to thank the
Governor of Birmingham, and his staff for their help. I am sorry that it has taken longer
than I would have liked to complete this report, but that reflects the seriousness of the
matters raised by the man’s death.
The man had suffered from depression and anxiety for many years and he was also
agoraphobic. Due to these conditions he found it difficult to be in a standard prison
wing. It was for this reason that he was located in the High Dependency Unit, where he
seemed to settle quite well.
The man was treated by a number of different clinicians while in Birmingham. Among
other professionals involved in his care, the man was seen by a consultant psychiatrist
from the local mental health trust. The man twice told the psychiatrist that he had
thoughts of suicide, but this information was not shared with anyone else involved in his
care.
The independent clinical review, commissioned as part of this investigation, is extremely
critical of the man’s care and treatment. As well as criticising poor or absent
communication, the review also draws attention to the erratic prescribing and supply of
his medication.
Following the man’s death, three letters were found in his cell addressed to his family,
the prison Governor and police. In one of these letters, the man spoke bitterly about
how he was affected by the delays and interruptions in the provision of his medication.
He indicated clearly that it was this that led to him to decide to take his life.
This ranks amongst the most disturbing cases I have encountered in the two and a half
years that I have held responsibility for the investigation of deaths in prison custody. I
am much influenced by the findings of the clinical review which highlights significant
deficiencies in the delivery of care to the man. And in retrospect, the conclusion seems
inescapable that he should have benefited from the support and monitoring he would
have received under the ACCT procedure.
2
I have made 18 recommendations. One is about how a family is told about a death in
custody. The remaining 17 recommendations are all about healthcare provision.
This version of my report, published on my website, has been amended to remove the
name of the man who died and those of staff, prisoners and organisations involved in
my investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2007
3
SUMMARY........................................................................................................ 5
INVESTIGATION PROCESS............................................................................ 7
HMP BIRMINGHAM.......................................................................................... 8
CARE FOR PEOPLE AT RISK OF SELF-HARM OR SUICIDE........................ 9
EVENTS LEADING UP TO THE MAN'S DEATH.............................................. 10
THE DISCOVERY OF THE MAN'S DEATH...................................................... 15
DEALING WITH SIMULTANEOUS EMERGENCY INCIDENTS....................... 16
LETTERS FOUND IN THE MAN’S CELL.......................................................... 17
AFTER THE MAN’S DEATH............................................................................. 18
ISSUES FROM THE CLINICAL REVIEW AND ITS CONCLUSIONS............... 19
FINDINGS AND CONCLUSIONS...................................................................... 21
RECOMMENDATIONS..................................................................................... 24
FAMILY RESPONSE TO REPORT................................................................... 28
4
SUMMARY
In July 2005, the man was received into HMP Birmingham having been convicted of
several offences, including three counts of blackmail. He was sentenced to three years
and nine months imprisonment later that month.
On arrival at Birmingham, the man had a standard healthcare assessment to explore his
past medical history, his current health needs, his use of prescribed medication and
whether he had any thoughts of self-harm. The man said that he was concerned about
his mental health and that he had previously been treated for depression, anxiety and
paranoia (several days later, the man also revealed that he suffered from agoraphobia).
Among other prescribed medicines, the man said that he was receiving diazepam (for
anxiety).
The man’s condition of agoraphobia made it very difficult for him to settle in the
standard prison wings – it was noted that he would not go on exercise, association or
visits. Having spent six weeks in standard location, the man was moved to the High
Dependency Unit (HDU) which offers accommodation and support to prisoners who
have difficulty coping within the prison environment. All of the evidence shows that the
man benefited from being in the HDU and he was able to associate with the prisoners
there to some extent.
Another adverse effect resulting from the man’s agoraphobia was that he was not able
to receive visits in the prison’s visiting hall. To help with this problem, arrangements
were made for the man to receive several visits in the prison chaplaincy.
The overall delivery of healthcare to the man has been criticised strongly in the
independent clinical review. National protocols advise that prolonged use of diazepam
should be avoided and that abrupt withdrawal of that medicine should also be avoided.
The doctors involved in the man’s care planned from an early stage to reduce and then
stop his diazepam, but the management of this plan was poor and the man often
suffered delays and interruptions in receiving the drug.
As well as criticism of the prescribing and dispensing of medication, the clinical
reviewers describe the man’s healthcare delivery as being patchy and disorganised with
no obvious long-term treatment plan. Comment is also made that no one person
maintained an overview or took responsibility for his package of care. One of the
reasons behind that comment was the lack of information sharing between the clinicians
involved – such clinicians included GPs and locum GPs, prison nurses, the prison
community mental health team and consultant psychiatrists from the local mental health
trust. On two separate occasions, the man indicated to a consultant psychiatrist that he
was thinking of taking his life, but this information was not passed on.
During roll check on the morning of 6 December, the man was found hanging in his cell.
Healthcare staff attended as well as ambulance paramedics. Resuscitation was not
attempted as it was clear he had died some time before he was discovered.
5
I have made 18 recommendations. One recommendation relates to notifying families
about deaths in custody. The remaining 17 recommendations all concern healthcare
provision.
6
INVESTIGATION PROCESS
1. The investigation was opened on 7 December 2005 when my colleagues visited
HMP Birmingham. They met the head of safer custody and the duty governor on the
day of the man’s death. They also met two members of the Independent Monitoring
Board (IMB) and a representative of the Prison Officers’ Association (POA). One of my
colleagues informed them of the nature and scope of the investigation. Notices were
issued for staff and prisoners notifying them of the investigation. My colleagues
subsequently interviewed a number of staff who had dealings with the man.
2. At the time of their visit, a community mental health team leader, was unavailable
for interview. The mental health team leader, along with other clinicians involved in the
man’s care, was later interviewed for the purpose of the independent clinical review
commissioned by Heart of Birmingham Teaching Primary Care Trust (PCT).
3. One of my family liaison officers contacted one of the man’s sisters to inform her
of the investigation. My investigator and family liaison officer visited the man’s sister
and her husband at their home.
4. The man’s sister said that her brother suffered from agoraphobia and depression.
Medication helped him deal with these conditions, although he still found it difficult to be
in public places even to the extent of not feeling able to attend family gatherings and
weddings. The man’s sister received a letter from her brother about a week after he
had gone into prison telling her that he was not receiving any medication. She
telephoned the prison and spoke to a nurse who advised asking the man’s GP to fax his
prescription. When the man’s sister spoke to the GP, she said she would send a letter
to the prison with details of her brother’s clinical condition. After a fortnight, the man
said he was receiving some medication, but it was coming in ‘dribs and drabs’. He said
he was finding this extremely difficult to deal with, as it was leading to him having dark
thoughts and thoughts of suicide. The man’s sister wrote to the Governor and she also
contacted one of the chaplains about her concerns.
5. The man’s sister said that the way she heard of her brother’s death was difficult.
She said that she was at work when she received a telephone call from the chaplain
who said that he needed to speak to her, and asked her to come into the prison. She
said that it would not be very convenient, so he asked her if they could meet at her
home and if she could have a friend with her. The man’s sister asked the chaplain if her
brother was dead. He did not directly answer her question, but did say that she was
making things very difficult for him. The chaplain and one of the prison governors then
went to the house.
6. The man’s sister told my investigator and family liaison officer, that she was
horrified when she found out, after his death, that her brother had never been subject to
special monitoring for those judged at risk of suicide.
7
HMP BIRMINGHAM
7. HMP Birmingham is a local prison built in 1849 for adult male prisoners. It
serves the Crown and Magistrates' Courts of Birmingham, Stafford and Wolverhampton
and the Magistrates' Courts of Burton, Cannock, Litchfield, Rugeley, Sutton Coldfield
and Tamworth.
8. Birmingham has recently undergone a period of considerable change as a result
of a multi-million pound investment programme, which has added new workshops,
educational facilities, a new healthcare centre and gymnasium. The prison holds
around 1,400 prisoners.
9. In May 2004, Birmingham received an unannounced inspection from Her
Majesty’s Chief Inspector of Prisons (HMCIP). The report issued by HMCIP following
the inspection indicated the need for some development, but it also reported that:
‘… the overall picture is of a prison that has fundamentally changed for the better
over the last four years … Birmingham is an example of what can be done by a
committed and determined Governor …’
10. In June 2005, Birmingham started using the ACCT (Assessment, Care in
Custody and Teamwork) process for the monitoring of prisoners judged to be at risk of
self-harm or suicide. ACCT has been designed to replace the F2052SH process.
8
CARE FOR PEOPLE AT RISK OF SELF-HARM OR SUICIDE IN PRISON
11. It has long been recognised that being in custody can cause some people to
think of harming or even killing themselves. Prison staff are trained in how to assist
prisoners who are at risk of suicide or self-harm and all prisoners are asked whether
they have any such thoughts when they first arrive in prison.
12. For many years, the system for supporting prisoners who were struggling to cope
with their problems was managed through the ‘Self-Harm At-Risk’ Form – the F2052SH.
Starting in 2005, the F2052SH began to be replaced with a new system to help identify
and plan care for prisoners at risk of suicide or self-harm. The replacement is known as
the ACCT Plan (Assessment, Care in Custody and Teamwork). ACCT encourages staff
to work together to provide individual care to those prisoners judged to be at risk.
13. Prison Service Instruction (PSI) 18/2005 introduced ACCT and it contains both
guidance notes and mandatory instructions. Among the mandatory instructions is the
following:
‘Prior to commencing use of ACCT in their establishment Governors … must
ensure they have complied with the actions listed at Appendix B.’
14. Among other actions listed in Appendix B to PSI 18/2005 is the following:
‘… Governors … must ensure that … all staff in contact with prisoners … (… not
only residential/discipline staff, but other staff such as … healthcare … and
mental health in-reach) are familiar with ACCT …’
9
EVENTS LEADING UP TO THE MAN’S DEATH
15. The man was received into Birmingham in 22 July 2005. At that stage he had
been convicted on a number of counts of blackmail and three lesser offences. He was
still awaiting sentencing. As part of the standard prison reception process, the man
received a First Reception Health Screen assessment. During that assessment, the
man reported to the nurse that he was receiving several prescribed medications
including diazepam. When asked whether he had any health concerns, the man said
that he was concerned about his mental health and had received treatment for
depression, anxiety and paranoia. He denied having any thoughts of self-harm.
16. Following his initial health screening, the man received a more detailed
psychiatric assessment which was conducted by a registered mental health nurse
(RMN). The man was asked whether he had any self-harm or suicidal ideas. The man
said that he did have such thoughts, but had no concrete plans for following them
through. The RMN noted on the screening form that the man should be referred to a
psychiatrist.
17. For his first five days in Birmingham, the man remained in D-Wing, which acts as
the prison’s reception centre. Later in July, the man was transferred to M-Wing, which
is a standard prison wing.
18. Two days later, the man was seen by a prison doctor. He reported that he
suffered from agoraphobia (a fear of public places). The doctor noted that the man’s
GP had confirmed that he was receiving a number of prescribed medicines, including
diazepam, and that he had been receiving these medicines for at least a year. The
doctor noted that a referral should be made for the man to be seen by a psychiatrist.
19. In early August, the man asked to speak to the duty governor. The duty governor
noted that the man’s main concern was his mental health state and his anxiety about
being in large crowds. The man mentioned taking his own life although he also said
that he had never previously made any such attempt, nor ever harmed himself. The
man asked to be placed on Prison Service Rule 45 for his own safety. At interview, the
duty governor said that he thought he might have spent 10 or so minutes speaking with
the man. Given the man’s declaration that he had no history of self-harm or suicide
attempts, the duty governor did not consider it appropriate to open an ACCT form.
Instead, the duty governor thought that the most appropriate option was to arrange for
the man to be reviewed by the mental health team within the next 24 hours.
20. Following on from the arrangement made by the duty governor, the man was
seen the next day by the community mental health team leader.
21. Ten days later, the man was seen by a locum psychiatrist from Birmingham and
Solihull Mental Health Trust. The psychiatrist made a lengthy note of her consultation
with the man, which included him saying that:
10
‘He feels he will not survive this sentence …’
The psychiatrist noted that her plan was to seek the opinion of another psychiatrist.
22. In early September, the man transferred to Birmingham’s High Dependency Unit
(HDU). This unit was originally located in A-Wing before being relocated to C-Wing in
early October 2005. The HDU holds up to 15 prisoners, all of whom find it difficult being
in a standard prison wing. The reasoning behind the man’s referral to the HDU was that
he:
‘Seems to have issues surrounding being around many people/large spaces.
Won’t go on exercise/association/visit due to amount of people.’
23. The referring officer’s comment on why it was thought that the man would benefit
from being in the unit was:
‘Smaller space. Less people to attempt to interact with (staff and prisoners).’
24. A week later, Birmingham’s Governor received a letter from the man’s sister and
another from his partner. The letter from the man’s sister referred to a letter she had
received from her brother in which he said that he was feeling suicidal. The man’s
sister spoke about her brother’s depression and condition of agoraphobia, which she
said was making his time in prison very difficult to cope with. The letter from his partner
mentioned the same issues as his sister. On the same day that these letters were
received, the community mental health team leader went to see the man and he made
the following entry in the man’s medical record:
‘… Visit to explore the issues that the man is struggling with. All seems to
revolve around his medication. He is asking for further diazepam despite having
had reducing dose and then discontinuation of prescription. The man continues
to receive setraline and propranolol.’
25. The community mental health team leader went back to see the man the next
day when he made the following note:
‘Return visit to ensure that the man received his medication last night … all was
ok … for discussion [with] Prison GPs.’
26. Two days later, the psychiatrist made the following entry in the man’s medical
record:
‘I had a discussion with the community mental health team leader … today with
regard to this patient. We discussed our concerns for his well-being and
management. The prison has a policy regarding the reduction/cancellation of
benzodiazepines due to the addictive potential. Unfortunately, this has been a
major part of the man’s maintenance for several years. He has disclosed his
11
disagreement with the planned reduction of diazepam. He already sees
catastrophe resulting from this proposal … [Plan]: … To discuss (second opinion)
with a doctor … To follow-up next week.’
27. The man was seen by another psychiatrist in September, whose opinion included
that the treating clinicians should continue reducing the dose of diazepam.
28. In line with her plan, the psychiatrist saw the man once more following the
assessment made by the second psychiatrist. This consultation took place at the end of
September, when this psychiatrist noted that the man had:
‘… daily thoughts of suicide …’
The psychiatrist’s plan included for the man’s diazepam to continue to be reduced and
for him to have a further psychiatric review two weeks later.
29. An officer told the investigators that he started working in the HDU when it was
first opened (this was around the end of 2003). The officer said that the process leading
to a prisoner being located into the HDU started with wing staff recognising that one of
their prisoners might gain from a transfer. The referral is followed up by an officer from
HDU visiting the prisoner and explaining how the unit operates. It is then for the
prisoner to decide whether or not he wishes to join the unit. The officer said that he had
been the officer who visited the man at the time he was in M-Wing. The officer found
the man to be a polite and well mannered individual. After moving to the HDU, the man
said that he was glad to have moved to the unit because he found it difficult facing
crowds of people. It suited him being in a unit with a smaller number of people.
30. The officer said that the man only had one close prisoner friend in the HDU.
Although the man had no other close friends, he never had problems with any of the
other prisoners. The officer said that he spoke a lot with the man – the comparatively
small number of prisoners in the HDU compared to a standard wing meant that officers
had more time to sit down to talk. The man would talk about ordinary things, such as
about his family.
31. The officer said that, other than that the man was concerned about his
agoraphobia, the only matters that seemed to concern him were relating to his
medication. Each time the man complained about his medication the HDU staff would
inform medical staff.
32. The officer said that the man’s death had shocked him. The man had never said
anything to make him think that he might have been at risk.
33. Another officer has also worked in the HDU since it first opened. He described
the man as a quiet person, but one who did communicate with staff and had no difficulty
in bringing to their attention any problems he was having. This officer said that the man
fitted in well in the unit and seemed to have no problem mixing with the other prisoners.
12
The man tended to associate with just one or two other prisoners and this would mainly
be with them visiting him in his cell. However, the man would come out onto the landing
and would play the occasional game of pool. The man’s dislike of crowds and public
spaces made it difficult for him to receive visitors in the visiting area. To help the man
with this, arrangements were made for him to receive some visits in the chaplaincy.
34. This officer also said that the man’s main problem seemed to be his medication.
The unit staff would usually contact the community mental health team leader and he
would come to the unit to see the man.
35. This officer said that speaking from the staff’s point of view, the man was a
popular prisoner. Staff thought he was getting the best out of the unit. He went on to
say that the man’s death hit staff very hard as they felt they were offering him good care
and that he was happy with it.
36. A third officer works in the HDU two days per week. On the other days, he works
elsewhere in C-Wing. This officer gave similar evidence to the other two officers about
how the man settled into the unit, about how he interacted with staff and other
prisoners, and about how shocked all the staff were at the man’s death.
37. The chaplain said that his first contact with the man had arisen after he received
a telephone call from the man’s sister. She told him that her brother was having
problems with family visits. The chaplain went to see the man who explained that he
had difficulty in dealing with situations where there were a lot of other people around.
He found the visiting area difficult and even had problems walking along prison
landings.
38. The chaplain arranged for the man to receive a family visit in the chaplaincy. The
man’s sister, the man’s partner and a friend attended. At the end of the visit, the
chaplain informed the man’s sister that she should write to the prison Governor to ask
for special dispensation for the man to continue receiving visits in the chaplaincy. The
man had one more family visit in the chaplaincy, but he died before arrangements for a
third visit had been completed. The chaplain had a number of conversations with the
man’s sister in connection with the arrangements for these visits.
39. The chaplain said that the man mentioned problems with his medication in every
conversation they had. The chaplain made enquiries and was told that the man was
receiving the right medication. In none of their conversations did the man make any
threats that he would kill himself.
40. A prisoner in the HDU said that he worked as a cleaner in the unit. He made a
point of befriending the man, who seemed reluctant to come out of his cell. As the man
got used to the HDU and the people in the unit, he began to find it easier to come out of
his cell. Other prisoners would visit the man in his cell. The man would say hello, but
did not really bond with many people.
13
41. The prisoner said that the man had a lot of problems with his medication. His
diazepam dose was lowered with a view to ending it, but the replacement medication he
was given did not help and he was clearly not well.
42. The prisoner said that he and the man had had several conversations about
death. The man was worried about his impending court case and mentioned that he
had two houses which he thought were at risk of being re-possessed. The man had an
idea that if he took his life the houses would be safe. On a separate occasion, the man
had spoken about death and suicide but not in a way that made the prisoner think that
the man was intending to take his life. The final occasion had been on the day before
the man died. The man showed the prisoner a diagram he had drawn of a noose, but
the man was joking with the staff that day and told the prisoner that he would deny
having any suicidal thoughts if his friend were to report anything. In any case, the
prisoner himself did not think that the man would do anything. The prisoner said that he
noticed a decline in the man’s mood in the final two weeks of his life. But he did not see
a particular trigger point to suggest or indicate that the man would take his life.
43. The prisoner said that the staff in HDU put in a lot of time to support prisoners.
They tried hard with the man and managed to get him to start using the gym. They also
badgered healthcare to try to resolve the problems the man was having with his
medication.
14
THE DISCOVERY OF THE MAN’S DEATH
44. An officer support grade (OSG) said that she started a night shift in C-Wing at
8.30pm in early December. The first thing she did was to count all the prisoners in the
wing. Four or five of the prisoners were subject to special monitoring, as they were
judged to be at risk of self-harm or suicide and the OSG had to check each of these
prisoners five times per hour. In addition to carrying out these checks, the OSG also
had to respond to any prisoners pressing their cell call bells. The man was not one of
the prisoners who pressed their call bells.
45. Before her shift ended on the following morning, the OSG was required to count
the prisoners in C-Wing. She commenced this count sometime between about 5.50am
(according to her interview with the investigator) and 6.10am (according to her
contemporaneous written statement). When the OSG reached the man’s cell, she
found that he had placed paper over the observation panel in his door. The OSG
banged on the door and called to the man to remove the paper. The man did not
respond. The OSG was carrying a cell key, but this was contained in a sealed pouch
which is only to be opened in the case of a clear emergency. The OSG interrupted her
count of prisoners and went to tell a senior officer (SO) about the man’s cell.
46. The SO was the assistant Night Orderly Officer for that night. At about 5.25am
that morning, an emergency occurred in which a prisoner had allegedly taken his cell
mate’s drugs. From the prisoner’s appearance, it seemed to the SO that he might well
have taken an overdose. The nurse in attendance agreed and so arrangements were
made to send the prisoner to outside hospital as quickly as possible. At about 6.15am,
the OSG reported the problem with the man’s cell. At this time the SO was in the midst
of helping to take the other prisoner to a taxi to send him to hospital. The SO told the
OSG that he would deal with the man once he had finished with the other prisoner.
47. Another officer who started work at 6.30am that morning began counting the
prisoners. When he arrived at the man’s cell, which was at around 6.50am, he found
that the observation panel was covered. The officer unlocked the cell door and saw the
man by the window suspended by a ligature. The officer blew his alarm whistle and
then supported the man’s weight as he began to untie the ligature. Other staff arrived at
this point and, once the ligature was freed, the man was lowered to the floor. The
officer said that the man’s body was cold to the touch and rigor mortis had started to set
in. The officer checked the man for presence of a pulse, but he found none. No
attempts were made to try to resuscitate the man as it was clear that he was already
dead. A nurse, who responded to the whistle alarm, described the man’s body as being
very cold.
48. Ambulance paramedics arrived at around 7.15am. Their report, following
examination of the man’s body, confirms that rigor mortis had set in.
15
DEALING WITH SIMULTANEOUS EMERGENCY INCIDENTS
49. As noted, on the night, the SO was the assistant Night Orderly Officer. (Because
of its size, Birmingham employs both a Night Orderly Officer and an assistant.) The SO
explained at interview that his responsibility was to supervise the main parts of the old
prison containing A to J wings. Two further wings and the healthcare unit are based in
the new part of the prison. But the assistant Night Orderly Officer can only gain access
to that part of the prison after the Night Orderly Officer has released the double locks
that, for security reasons, separate the two sections. The SO said that it was at about
6.15am that the OSG reported to him that the man had blocked the observation panel
on his door. At that time in the morning, the Night Orderly Officer would have been
disengaging the double locks around the prison ahead of the arrival of the day staff and
the beginning of a new day.
50. Birmingham’s head of operations, told the investigator that, at night time, the
assistant Night Orderly Officer has to prioritise when simultaneous incidents arise. The
head of operations said that, in the case of more than one obvious emergency, he
would expect the assistant Night Orderly Officer to ask the Night Orderly Officer to help.
In such circumstances, a duty such as disengaging the double locks can be postponed.
The head of operations went on to say, however, that a blocked observation panel is
not, in itself, an emergency. Although prisoners are told that they should not do this, it
is common for them to do so to gain some privacy.
16
THE LETTERS FOUND IN THE MAN’S CELL
51. Following the man’s death, three letters were found in his cell within which he
discussed his decision to take his life. One letter was addressed to the prison
Governor, the police and his family. A second letter was addressed to the man’s
mother and family. The third letter was addressed to his partner.
52. In the letter addressed to the prison Governor, the police and his family, the man
spoke about his treatment in prison. He complained about having to wait two weeks
before he started to receive any medication, and about constant delays in the issue of
his medication once it had been prescribed. Sometimes these delays would be three or
four days, once it was much longer than that. He also complained about the decision to
wean him off one of his medicines – diazepam. He wrote that he was calmed by
diazepam and that this drug stopped his mind from racing, helped him to avoid suicidal
thoughts and helped him to sleep. It was, he wrote, the problems of medication that
eventually led to him refusing medication and his decision to take his life. The man also
claimed in this letter that, on about five occasions, he had told the community mental
health team leader, the psychiatric nurse, that he would kill himself. The man also
referred to the landing officers to whom he sent his thanks for helping when they could.
He added that he had been careful to withhold from them anything that could have
made them suspicious about his plans.
53. In the letters to his mother, family and partner, the man repeatedly spoke of the
love he felt for them and apologised repeatedly for the action he was going to take.
17
AFTER THE MAN’S DEATH
54. The man’s nominated next-of-kin was his sister. The news of the man’s death
was broken to her by one of the prison chaplains, who had had contact with her in
connection with the man’s family visits.
55. The chaplain, together with one of the prison governors went to the man’s sisters
home at around 10am, but they found that no-one was in.
56. The chaplain and the governor then returned to the prison and the chaplain
telephoned the man’s sister at her place of work. He asked her to visit the prison and,
when she said it was not convenient for her to leave work at that time, he asked her to
return to her home. The man’s sister realised that the news was bad and asked him
directly if her brother was dead. However, the chaplain did not want to tell her of her
brother’s death by telephone and so made arrangements to go back to her house to tell
her in person.
57. The man’s family took up an offer for them to visit the prison to see the man’s cell
and they met some of the staff in the HDU. The family was told that Birmingham would
pay the funeral costs.
58. The staff involved in finding the man were offered the opportunity to speak with
members of Birmingham’s care team. The same opportunity was offered to the staff
and prisoners in the HDU unit.
18
ISSUES FROM THE CLINICAL REVIEW AND ITS CONCLUSIONS
59. Following the man’s death, Heart of Birmingham Teaching PCT commissioned
an independent investigation into his care and treatment from an ex-Director of Public
Health and an ex-NHS manager. Their review, which appears at annex A, is extremely
detailed and contains significant criticism of many aspects of the man’s care and
treatment. In their chronology of events, the reviewers itemise around 20 separate
occasions when there were failures or omissions in the delivery of care to the man. The
most frequently occurring omission related to delays and interruptions in the prescribing
and administration of medicines to the man. Poor communication between the different
clinical teams responsible for the man’s care and treatment is also subject to severe
criticism.
60. The reviewers reached the following conclusions:
The man had a history of mental disorder and frequently expressed suicidal
ideas. His family warned the prison of his vulnerability and of his need for
family support. His history and his obvious distress should have triggered the
ACCT process, leading to a multidisciplinary review and a management plan
(CAREMAP). Unfortunately, nobody saw fit to invoke the ACCT process so
there was no overall management plan.
The man’s healthcare was patchy and disorganised with no one person
maintaining an overview or taking responsibility for his package of care. His
health needs were mainly to do with his mental health problems but because
there was no formal contract or service level agreement between the Primary
Care Trust and the Mental Health Trust nobody took overall responsibility. He
was seen on an ad-hoc basis by a number of mental health professionals but
there was no obvious long-term plan for his treatment and communication with
the primary care team was poor or absent.
His primary care was equally patchy and he saw a bewildering number of
nurses, GPs and locum GPs. Communication between the various health
professionals was hindered by the frequent absence of the Inmate Medical
Record and medication charts and the general disorganisation of the medical
records system.
The system for prescribing and dispensing medicines was also disorganised.
Prescriptions went missing and there were frequent gaps between
prescriptions. Although there is no formal policy on the prescribing of diazepam
within the prison, doctors were actively discouraged from prescribing it (this is
discussed further in the main body of the clinical review). Eventually, following
a period of erratic and variable supply, a decision was made to wean the man
off the drug even though he had been taking it for about 18 months and he was
psychologically reliant on it.
19
We may never know the reasons why the man committed suicide but the
disorganised healthcare, the confusing array of health encounters and the
chaotic treatment regime must be considered as possible contributory factors.
20
FINDINGS AND CONCLUSIONS
61. When the man arrived in HMP Birmingham in July, he received a health screen
interview during which he denied having any thoughts of self-harm. However, he
reported having concerns about his mental health, said that he had received treatment
for depression in the past, and reported that, among other prescribed medicines, he
was receiving diazepam. When the man was seen by a prison GP one week later, he
reported that he suffered from agoraphobia.
62. The man spent the first six weeks of his time at Birmingham in standard prison
locations. It was noticed during this time that he was finding it difficult being with so
many other people and that he would not go on exercise or association. After an
assessment to gauge his suitability, the man was transferred to the High Dependency
Unit (HDU).
63. All of the evidence – from staff, from a prisoner friend of the man’s, and from his
letters to he family and others – indicates that he settled well in the HDU. He clearly
remained reserved, but he kept his door open to allow other prisoners to visit him in his
cell. He also played the occasional game of pool, and was described as observing the
goings-on in the wing while standing at the doorway of his cell. In one of his final
letters, the man said that the landing staff had done their best to help him and that he
withheld from them anything that could have made them suspect that he was planning
to take his life.
64. Besides its impact on the man’s involvement in activities on the wing, another
effect of the man’s agoraphobia was that he found it difficult to receive visits in the visits
hall. To help with this, one of the chaplains, arranged for the man to receive some visits
in the chaplaincy.
65. In contrast to the complimentary remarks in his letter about the landing officers,
the man was highly critical of his clinical care and treatment. Within the man’s medical
records there is an entry about him saying that he was pessimistic about his chances of
surviving his prison sentence. Another entry reports him saying that he was having
daily thoughts of suicide. On this point, the clinical review concludes that both the
man’s own comments and those made in writing to the prison by his family should have
triggered the opening of an ACCT document. Had an ACCT document been opened,
one of the outcomes would have been improved sharing of information between the
clinical and non-clinical staff responsible for the man’s welfare. This would have
resulted in landing officers being made aware of comments the man had made about
having thoughts of suicide.
66. The fact that no ACCT form was opened has led the clinical reviewers to
question how effectively ACCT training and awareness has been rolled out through the
prison. It is the responsibility of the Governor to ensure that all those who have contact
with prisoners, including those such as visiting psychiatrists, are aware of ACCT.
Recommendations on this issue are made in this report.
21
67. Another conclusion made in the clinical review is that the man’s healthcare was
patchy and disorganised. The clinical reviewers point out that nobody took overall
responsibility for his care and that there was no obvious long-term plan for his
treatment.
68. Beyond his repeated apologies to his family for the action he was about to take,
and his expressions of love for them, the strongest theme emerging from the letters the
man left after his death was the problem he was having with receipt of medication. The
clinical reviewers confirm that the prescribing and dispensing of medication for the man
was indeed disorganised, with frequent gaps between prescriptions. The reviewers
point out that the man was psychologically dependent on one of his medicines, namely
diazepam, but the supply of that medicine was also erratic before the decision was then
made to wean him off it. (The clinical review includes two recommendations about
policy and practice in prescribing diazepam.)
69. The clinical reviewers’ final conclusion is that the man’s disorganised healthcare
provision must be considered as a possible contributory factor leading to his decision to
take his own life. The content of his final letters supports that conclusion.
70. The man’s death was discovered when the officer went into his cell at 6.50am.
However, over half an hour earlier the OSG found that the man had covered his cell
door observation panel. She reported this to the SO, the assistant Night Orderly Officer.
He told her that he would deal with the matter after dealing with the problem he was
facing at that moment. The problem of the moment was a prisoner who it seemed had
taken an overdose and who needed to be transferred to outside hospital urgently.
Birmingham’s head of operations has explained that it is common for prisoners to cover
their observation panels, so finding an obscured panel does not, in itself, constitute an
emergency. I agree that it was entirely appropriate for the SO to have prioritised the
two problems in the way he did. In any case, descriptions of the man’s body when
found indicate that he had died some hours earlier.
71. Upon the man’s death, the chaplain and one of the governors went to the man’s
sister’s home to break the sad news to her in person. As it was a weekday, and as both
the man’s sister and her husband are employed, no-one was at home. The chaplain
then telephoned the man’s sister at work and asked her to visit the prison – although he
did not tell her why he was asking her to do so. When the man’s sister said that it was
not particularly convenient for her to leave work at that particular time, the chaplain then
asked her to return to her own home, to ensure that she was in company with a friend,
and that he would visit her there. Unsurprisingly, the man’s sister guessed that her
brother was dead and she asked the chaplain if that was the case. She says he replied
that she was making things difficult, and could she return to her home as he had asked.
72. Bearing the responsibility for breaking the news of a death in prison custody is
not an easy or an enviable duty. Help and advice for those asked to carry out this task
is contained in the guidance supplementary to Prison Service Order 2710. It was
22
entirely appropriate, and in line with the guidance, for the chaplain and the governor to
have visited the man’s sister’s home to break the news in person. Unfortunately, the
guidance is silent on the approach to take in the case that no family members are found
to be at home when the visit is made. It was with the very best of intentions that the
chaplain then telephoned the man’s sister at her place of work, but from the words
exchanged in their conversation it was hardly surprising that she guessed what had
happened. In this case, the chaplain had established a relationship with the man’s
sister through his involvement in arranging family visits for her brother. Given the
existence of such a relationship, a better approach when the chaplain telephoned the
man’s sister might have been for him to have been candid about why he was contacting
her. He could then have arranged a follow-up visit to her home in person.
I recommend that the Governor arranges a review of Birmingham’s contingency
plans for notifying families about deaths in custody – in particular to consider
alternative approaches when the initial visit to the family home proves
unsuccessful.
23
RECOMMENDATIONS
The following recommendations were made in the draft version of this report. The Prison
Service’s response is included in italics following each recommendation:
1. I recommend that the Governor arranges a review of Birmingham’s
contingency plans for notifying families about deaths in custody – in particular to
consider alternative approaches when the initial visit to the family home proves
unsuccessful.
Recommendation accepted: The establishment will look at alternative
approaches when the initial visit to the family home proves unsuccessful,
breaking the news by telephone would always be used as a last resort.
2. The records management system should be overhauled and improved so that
the Inmate Medical Record is always available for every healthcare interaction.
Ideally, a computerised medical record should be introduced, consistent with that
used in the rest of the NHS.
Recommendation accepted: Filing clerk appointed. A new policy has been
implemented to improve the management of medical records.
3. A summary of the previous primary care medical record should be obtained
as a matter of routine for all prisoners entering HMP Birmingham. If, at reception
screening, a prisoner is identified as having ongoing care from his GP, the
transfer of records should be expedited (by fax or e-mail).
Recommendation partially accepted: Logistically difficult for all records.
Arrangements are in place to access primary care records for prisoners who are
receiving on going care from their GP. This is expedited by fax with a hard copy
to follow.
4. If a prisoner has received specialist care for an ongoing condition, the details
of that care should be obtained from the relevant specialist.
Recommendation accepted: Policy developed and implemented for both Primary
Care and Mental Health Services to obtain information regarding the patients
management from the relevant specialist.
5. All healthcare staff, including visiting specialists, should be trained in record
keeping.
Recommendation accepted: Record keeping training forms part of an annual
rolling programme.
6. The quality of record keeping should be regularly audited.
24
Recommendation accepted: The quality of all clinical records is subject to
regular audit.
7. There should be a clear policy on the use of diazepam and other similar drugs
within the prison. The policy should take into account the security implications
of such drugs but should also be ‘patient centred’ and allow individual clinicians
some discretion.
Recommendation accepted: Policy has been developed in line with BNF
guidance. This policy is being expanded to manage the specific issues of
benzodiazepines in substance misuse. Clinicians have the discretion to deviate
from the guidance should a clinical need dictate. Target for completion is
January 2007.
8. If a doctor decides to prescribe a reducing dose of diazepam, the regime,
should be in line with good prescribing practice e.g. as described in the British
National Formulary.
Recommendation accepted: As above. Target for completion is January 2007.
9. A ‘repeat prescribing’ system should be established so that prisoners with
chronic conditions who are receiving long-term medication can obtain their
medicines easily and with no gaps.
Recommendation accepted: Prisoners with a chronic condition have all
medication recorded in their individual patient medication record which is held as
a computerised record in pharmacy. The dates that the medication is next due is
highlighted as the current prescription is dispensed to ensure later doses are not
missed.
10. Whenever a prisoner does not receive his supervised medication the reason
should be investigated and appropriate action taken.
Recommendation accepted: The nurses who administer supervised medication
will note when prisoners do not attend at the hatch for their medication and
inform pharmacy who will then inform the GP. If a prisoner refuses more that
three doses the above protocol is followed.
11. The Primary Care Trust and the Mental Health Trust should agree a detailed
contract/service level agreement for the provision of mental health services
within the prison. The contract should set out the expectations and
responsibilities of each party. It should clearly state the criteria for receiving
continuing specialist mental health treatment and make provision for the
provision of primary mental health care to those who do not meet these criteria.
25
Recommendation accepted: Service level agreement signed. Discussions with
the commissioner regarding development of primary mental health services
commenced and funding identified. Development of agreed pathways and full
implementation of the care programme approach by March 2007.
12. The PCT and the Mental Health Trust should make every effort to provide
continuity of care within the prison.
Recommendation accepted: Agreement at the Prison Partnership board for the
appointment of a single Director for Prison Health who will have overall
managerial responsibility and accountability for Prison Health. Appointment is out
to advert. Target for completion is March 2007.
13. Communication between the primary care team and the mental health team
should be improved. It might be helpful to hold joint meetings/case conferences
to allow the teams to discuss the joint management of individual patients.
Recommendation accepted: Appointment of the Consultant Psychiatrist who hold
weekly multidisciplinary case conferences. GPs hold a daily ward round.
14. All healthcare staff, including visiting specialists should be trained in the use
of the ACCT system.
Recommendation accepted: A proportion of the staff have already received
training a rolling program is being implemented to ensure that new staff are
trained and there is an annual update for all staff. Target for completion is March
2007.
15. Trigger criteria for initiating ACCT should be agreed and applied consistently
throughout the prison.
Recommendation accepted: Integral aspect of the ACCT document.
16. Whenever a healthcare worker sees a prisoner who reports suicidal feelings
this should be documented and an ACCT plan considered. If the decision is
made not to initiate ACCT, the reasons for this should be recorded. Even if an
ACCT plan is not opened, the healthcare worker should consider whether or not
to inform a prison officer.
Recommendation accepted: As above. Record keeping training program
developed. Standard of clinical records subject to regular audit.
17. All primary healthcare staff should be trained in resuscitation techniques.
This training should be updated regularly and a register of training maintained by
the Healthcare Manager.
26
Recommendation accepted: This is an integral aspect of training and is subject
to regular audit by the Nurse Manager. Central electronic data base held of all
training need and delivery.
18. A full set of emergency equipment, including resuscitation equipment, should
be carried when responding to emergency alert calls.
Recommendation accepted: A full set of emergency equipment is located on
every wing and checked on a regular basis.
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FAMILY RESPONSE TO REPORT
In response to the Ombudsman’s draft report the man’s family wished to add their own
recommendations. These were:
1. That there should be monitoring by an independent person of any prisoner who has
expressed suicidal thoughts and/or where concerns have arisen.
(It is felt that were such an independent monitor in place, this tragedy would have been
avoided)
2. An Advocacy Service should be established for use by prisoners in such a
vulnerable position.
(Again, it is felt that if such a service was available in a case like this to address the
concerns that were clearly being expressed in the lead-up to the death, the death could
have been avoided)
3. There should be a minimum level of information made available to prisoners as to
who to turn to when he or she is getting nowhere in progressing issues of concern.
(It is felt that the deceased clearly felt that he had no-one to turn to)
28