Individual at Blakenhurst

Investigation into the circumstances surrounding the
death of a prisoner at HMP Blakenhurst
in January 2006
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2006
This is the report of an investigation into the circumstances of the death of a prisoner
who died in his cell at HMP Blakenhurst in January 2006. Following post mortem
examination, the cause of the man’s death was recorded as hanging.
I extend my sincere condolences to the man’s family and friends.
The man who is the subject of this report had been in prison for approximately two
months, having been remanded to HMP Blakenhurst on 17 November 2005.
I would like to thank the Governor of Blakenhurst at the time of our investigation. I
am also grateful to those members of his staff who assisted us, particularly the senior
officer who acted as a liaison officer for the investigation team. I have found the
prison’s efforts in liaising with the man’s family to have been both sensitive and
respectful.
I am also grateful to Redditch and Bromsgrove Primary Care Trust for their clinical
review of the man’s medical care whilst he was at Blakenhurst. The findings of the
clinical review have informed this report.
With the benefit of hindsight, it is possible to argue that staff should have
implemented the Prison Service’s formal suicide and self harm prevention
procedures (ACCT) in respect of this man. However, in facing serious charges and a
breakdown in his personal relationships, and exhibiting signs of depression, the man
did not appear to be so different from a very large number of prisoners in the Prison
Service’s care. Not all the relevant information was in one person’s hands, but even
if it had been I do not think one can say with certainty that an ACCT form would have
been opened. Generally speaking, the staff at Blakenhurst have emerged well from
this report and I do not believe the decision not to open an ACCT can be criticised -
notwithstanding the tragedy that actually occurred.
I make three recommendations and draw a number of other matters to the
Governor’s attention.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2006
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Contents
Summary 4
The investigation process 7
The prisoner 8
HMP Blakenhurst 9
The events leading up to the man’s death 10
20 January 2006 18
Discussion of the issues 23
Findings and conclusions 29
List of recommendations 33
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Summary
1. The man who is the subject of this report was remanded to the custody of HMP
Blakenhurst on 17 November 2005. He was facing two charges involving
serious sexual offences.
2. On his arrival at the prison the man was given Rule 45 protection, meaning that
he would be located on a wing for prisoners who might be vulnerable to attack
by others. He spent his first night in the Segregation Unit and was located in a
shared cell on a houseblock the following day.
3. Both a first reception health screen and a secondary health screen were carried
out for the man on his first day at the prison, as was a cell sharing risk
assessment. The health assessments raised no issues of concern regarding
his physical or mental health.
4. The man was seen by a prison doctor on 5 December when he described
feeling depressed and low. He was prescribed anti-depressants for 14 days.
On 11 December, the prison was contacted by the man’s former partner who
told a member of the control room staff that the man had indicated in phone
calls and letters that he might harm himself. The control room staff passed this
information to officers on the man’s wing who immediately spoke to him. Two
officers asked him whether he had any intentions of harming himself, which he
denied. He also declined the offer to speak to one of the Listeners (prisoners
who are trained by the Samaritans to offer confidential support). The man told
the officers that he felt his medication was not working properly and the officers
made arrangements for him to see a doctor the following day.
5. The man saw another prison doctor on 12 December. During this consultation
his medical records were not available. The man’s anti-depressant medication
was changed and he was referred to see the prison psychologist for a non-
urgent assessment. The man was placed onto the waiting list but he died
before an appointment was available for him.
6. On 14 December, a Healthcare Nurse (HCN) (who was also a registered mental
health nurse) visited the man’s wing to conduct an assessment for him. He was
not on the wing at the time and the HCN left a note for him to contact her, but
he did not. On 21 December, the man returned to see the same doctor he had
seen on 12 December. As a result of this consultation his medication was
increased. The man’s medication was not “in possession” and his treatment
chart shows that from 27 December his compliance with taking his medicine
was beginning to deteriorate. By 8 January, he was rarely attending to take his
medication.
7. The man appears to have found being in prison difficult from as soon as he
arrived. Those who knew him described his quiet and occasionally withdrawn
nature. It appears that his demeanour deteriorated at some point shortly after
the start of January. Although several members of staff who interacted
regularly with the man noticed the lowness of his mood, no-one felt concerned
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that he might harm himself and the procedures for caring for a prisoner at risk of
self harm or suicide (ACCT) were not instigated.
8. The man told staff that he needed to get out of his cell more often. At some
point during the days just prior to his death, arrangements were made for him to
work in the prison industries rather than attending education lessons as he had
been doing up until that time. He was due to start working in the industries the
following week.
9. At approximately 7.45am on Friday 20 January, the man went to the treatment
hatch on the houseblock to collect his medication. This was dispensed by a
HCN. On returning, he chatted briefly to his cell mate, who was just getting
ready to leave and go to industries. Neither the HCN nor the man’s cell mate
noticed anything out of the ordinary about him that morning.
10. A fellow houseblock prisoner was due to see the man for a tutorial session that
morning. At about 10.25am, he asked one of the wing officers to open the
man’s cell. The officer looked through the observation hatch and saw that the
man was suspended from a bed sheet that was attached to the hinge of the
cupboard high up on the cell wall. He called “code yellow” over his radio (the
code used at Blakenhurst to indicate an immediate threat to life) and entered
the cell. The officer could not find a pulse in the man’s wrist and quickly
realised that he would not be able to lift him down on his own and so left the cell
to fetch help.
11. Several members of staff were already on their way to help, having heard the
“code yellow” call. The officer who had opened the cell door was joined by two
other officers and a senior officer (SO). Between them they supported the
man’s weight and tried to release the sheet from around his neck. One of the
prison’s HCNs who was responsible for attending to emergencies that day
responded to the call along with another HCN. They arrived at the cell within a
few minutes and found the officers still attempting to release the man from the
sheet. He was released shortly afterwards and the two HCNs commenced
Cardiopulmonary Resuscitation (CPR) as soon as the man had been placed on
the floor. The HCN responsible for attending emergencies requested a
defibrillator and asked for an ambulance to be called. Other members of
healthcare staff arrived shortly afterwards and CPR was continued until the
paramedics arrived at the cell at 10.44am. The paramedics were unable to
obtain any output from the man and one of the prison doctors certified his death
at 10.50am.
12. The police were called and officers from West Mercia Constabulary arrived at
the man’s cell at 11.50am. At about 2.30pm, the Governor asked one of the
prison’s governors to break the news of the man’s death to his family. The
governor did this along with one of the prison’s chaplains and an officer from
West Mercia Constabulary.
13. A search of man’s cell following his death revealed a letter that he had written to
his former partner outlining his intention to take his life.
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14. I make three recommendations. The text also refers to a number of other
matters the Governor will wish to consider.
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Investigation process
15. Two of my senior investigators visited Blakenhurst and met with the
Governor, a member of the Independent Monitoring Board and the Head
of Healthcare.
16. Notices were issued to staff and prisoners informing them of the
investigation and inviting comment.
17. My investigators were provided with unrestricted access to the man’s
prison records, including his medical records. A copy of the post mortem
report into the man’s death was kindly provided by HM Coroner.
18. Formal and informal interviews were conducted with prison officers,
members of healthcare staff and prisoners.
19. One of my family liaison officers wrote to the man’s parents to explain the
purpose of the Ombudsman's investigation and to ask them to contact
her with any questions they might have had. My family liaison officer
also telephoned the man’s former partner who raised some issues that
she wished the investigation team to consider. She wanted to know
whether the prison had responded appropriately to her phone call to
them on 11 December and whether the emergency response to try to
save the man had been adequate. She also wanted to know whether
staff at the prison were trained to identify those who may be at risk of
suicide or self harm.
20. My family liaison officer wrote to the man’s former partner to confirm that
her concerns had been passed onto the investigation team. The man’s
parents did not contact my family liaison officer to express any additional
concerns.
21. The investigation team liaised with Bromsgrove Primary Care Trust
(PCT) who undertook to conduct a clinical review of the man’s medical
care whist he was at Blakenhurst. The findings and recommendations of
the PCT’s review have informed this report.
22. Both the man’s family and the Prison Service received a copy of my draft
report and both have had the opportunity to comment on its content.
Their comments are included in the text where relevant
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The prisoner
23. The man who is the subject of this report was 39 years old when he was
remanded into the custody of HMP Blakenhurst. He had been living with
his partner and her children and his son from a previous relationship.
He worked as a welder. Although he had previously spent time in
custody for minor offences, he had not been in prison since 1987.
24. The man is described by those who knew him as articulate and
intelligent. He was determined and focused and had been training to run
in a marathon. During his time at Blakenhurst, he formed friendships
with several other prisoners who commented that he was finding it hard
to come to terms with being in prison and was distressed that his
relationship with his partner had broken down.
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HMP Blakenhurst
25. HMP Blakenhurst is a category B local prison, meaning that it holds a
combination of sentenced prisoners and those on remand. The prison
serves the West Midlands area and holds just over 1,000 prisoners.
Blakenhurst is divided into five houseblocks which are sub-divided into
three spurs. One of these spurs is a unit for vulnerable prisoners and
holds approximately 75 prisoners. The prison’s inpatient Healthcare
Centre has 21 beds and services are commissioned by Redditch and
Bromsgrove PCT.
26. Blakenhurst was last inspected by HM Chief Inspector of Prisons in
November 2005. The report into this unannounced inspection
(published February 2006) concluded that the prison had greatly
improved its approach to promoting a safe custodial environment and
preventing self harm. It also commented on the improvements to
healthcare and mental health services.
27. Seven prisoners took their own lives at Blakenhurst between January
2003 and July 2004. This man’s death is the first apparently self inflicted
death at the prison since then.
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The events leading up to the man’s death
28. The man was remanded from Magistrates’ Court into the custody of
HMP Blakenhurst in November 2005. He was facing two charges of a
serious sexual nature.
29. On arrival at Blakenhurst, the man was offered Rule 45 protection (this
means that he would be located on a wing especially for prisoners who
are vulnerable to attack from other prisoners, usually because of the
nature of the offence they are accused of). The man accepted Rule 45
protection and was subsequently located on a houseblock. He spent his
first night in Blakenhurst’s Segregation Unit and was located on the
houseblock the following day. It is unclear why this man was not located
onto this houseblock on the day he arrived at Blakenhurst, but it is
possible that he was placed into the Segregation Unit while a cell was
identified for him.
30. A first reception health screen was carried out that day by a Registered
Mental Health Nurse (RMN). The man reported no previous history of
mental health or physical health concerns. He had no history of
substance misuse, and just a minor skin condition likely to be eczema
was identified. The plan of action from a healthcare perspective was
that no immediate action was required and he was suitable for normal
location work and all cell occupancy. A secondary health screen was
also carried out for the man on 17 November. Again, no issues of
concern were recorded.
31. Also on 17 November, a cell sharing risk assessment was carried out.
This concluded that the man presented a low risk of harm to others and
he was subsequently located in a shared cell.
32. On 25 November, the man was assessed by a member of healthcare
staff (whose identity could not be established by the investigation team)
and was found to be fit to attend court. The man had contact with
medical staff again on 5 December when he saw one of the prison
doctors. During the consultation, he discussed feeling depressed and
low and said that he was experiencing headaches. He was prescribed a
routine anti-depressant, Fluoxetine, 20mg for 14 days.
33. On 6 December, the man was visited by his solicitor. She told the
investigation team that, as the committal papers had not been received
by that stage, there had been a limited amount of preparation for the
case. The solicitor explained that she had felt the same concerns for the
man as she would for anyone facing such serious charges. However,
she had specifically asked him how he was coping and he had replied
that he was managing to hold things together for the sake of his son.
The solicitor said that a bail application had been scheduled for 16
January in the event that the man’s committal papers had still not
arrived. However, the papers did arrive some time before that and a
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letter was sent to Wolverhampton Crown Court on 13 January to
withdraw the bail application.
34. On 10 December, one of the regular houseblock officers made an entry
in the man’s wing records. The entry indicated that he was a quiet and
timid prisoner who might be vulnerable to bullying or conditioning by
other prisoners and he needed to be monitored. On the following day,
11 December, the officer made a further entry. It read as follows:
“Ref phone call from Comms that [the man] has threatened to kill
himself via letters and phone calls to his wife and children.”
35. The officer who made the entry told the investigation team that, following
the call from the communications room, he and another wing officer went
to speak to the man immediately. They spent some time in the wing
office with him and asked him how he was feeling and if he was
experiencing any difficulties or was feeling low. The officers asked the
man if he would like to speak to a Listener or someone from the
chaplaincy but he declined. The officer went on to explain that he and
the other officer specifically asked the man whether he was thinking
about self harm, explaining that his partner had contacted the prison to
raise her concerns. The man maintained that he was not considering
harming himself but that he did think that the anti-depressant medication
he was taking was not working properly.
36. One of the officers made a telephone call to the healthcare centre while
the man was still in the office and asked for an appointment to be
arranged for that afternoon. He was told that it would not be possible
but that he could be seen the following day. The officer recalled that the
confirmation slip for the appointment time arrived later that afternoon
and he personally took it to the man.
37. Both of the officers who spoke with the man that day explained that they
had been trained in how to use the Prison Service’s procedures for
caring for those at risk of suicide or self harm. The Assessment, Care in
Custody and Teamwork (ACCT) process requires that, if a member of
staff believes a prisoner to be at risk of suicide or self harm, then ACCT
procedures are instigated. Both officers felt confident that they would
have instigated these procedures for the man if they had thought it
necessary. He had not given them any reason for concern during their
conversation with him.
38. Following this conversation with the man, one of the officers made the
following entry into his wing record:
“Spoke with [the man] with reference to the telephone call from
his wife. [The man] states he has no intention of self harm or
killing himself. He also stated that he is receiving medication
for, as he puts it, split personality, which is not working. We
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have arranged with Healthcare to take a look at his medication
and for him to be assessed.”
39. On the following day, 12 December, the man was seen by another
prison doctor. A note was made in his medical records that he was
experiencing headaches and panic attacks and that the medication he
had been given the week before did not appear to be working. He
explained that he had been prescribed Venlaxafine a week previously.
The man’s medical records were not available during this consultation
and he was mistaken about his earlier prescription: he had in fact been
prescribed Fluoxetine. The clinical reviewer comments that this
medication would not have started to take effect until 7-14 days after he
began to take it.
40. The doctor made some notes about the man’s history, including that the
headaches had started approximately three years earlier and that he
had previously been involved in a road traffic incident. The doctor
changed his medication to Stelazine, 2mg for 10 days, and also 10mg of
Propanolol. The doctor also made a note to refer him to the prison’s
psychologist. There is no reference made to the man having feelings of
depression or having thoughts about self harm or suicide. The doctor
completed the referral for the psychologist the following day, indicating
that the man’s need for assessment was not urgent and documenting
the reasons why he had been referred. These included his anxiety,
headaches and panic attacks. Again, no reference was made to self
harm or suicidal thoughts.
41. The prison’s psychologist told the investigation team that she had never
assessed the man. She explained that she received referrals to see
individuals either verbally in the Multi Disciplinary Mental Health meeting
on Friday lunchtimes or via a standard referral form. As the psychologist
does not work full time at the prison, these would be left in her in tray.
For referrals which have not been identified as urgent (as was the case
for this man) the individual would be placed on a waiting list. The
psychologist told the investigation team that it would not be unusual for a
non-urgent patient to wait for 6-8 weeks before they are seen.
42. On 14 December, a Healthcare Nurse (HCN) made an entry in the
man’s medical records indicating that she had been to the houseblock
and attempted to see him. The HCN is a Registered Mental Health
Nurse and had intended to carry out an assessment. When she got to
the houseblock, the man was at education and so she did not speak to
him and instead spoke to officers on the wing (who have not been
identified). She asked the officers if they had any further concerns
regarding the man’s mental health and was told that they did not. The
HCN advised the officers to ask for a referral for the man to see
someone if any further problems arose. In interview, the HCN told the
investigation team that she left a note for the man in his cell, asking him
to get in touch if he wanted to speak to someone from the Mental Health
In-reach Team. She explained that she then made a note in her own
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diary to review the man’s medical records at a later date. The HCN
explained that, when she checked the man’s medical records some time
later, she observed that he had been seen by a doctor and so was
satisfied that he was engaging with medical staff and any further issues
would be picked up. She could not remember exactly when she had
done this.
43. It has not been possible to establish who contacted the HCN as no
written referral was made requesting that the man be seen by the Mental
Health In-reach Team. The clinical reviewer’s investigations indicate
that Healthcare frequently takes such referrals verbally from wing staff
and that these are not always recorded, logged or prioritised. It seems
highly likely that the houseblock staff contacted Healthcare by
telephone, although no members of staff the investigation spoke to
remembered doing this.
44. The man failed to attend a medical appointment on 16 December. It
appears from the clinical reviewer’s investigations that this appointment
had been arranged as a follow up to the man’s appointment with the first
prison doctor on 5 December, and was not related to his appointment
with the second doctor on 12 December.
45. On 21 December, the man saw the second prison doctor again. The
doctor increased the man’s prescription of Stelazine from 2mg twice a
day to 5mg. The Stelazine was a ‘not in possession’ prescription.
Initially the man attended on the majority of days for his twice daily dose.
However, from 27 December 2005 his compliance with taking
medication deteriorated, resulting in him taking his medication only once
a day.
46. Further notes were made in the man’s wing record around this time. On
17 December, a wing officer wrote “No problems, keeps himself to
himself.” On 24 December, one of the officers who had spoken at length
with the man on 11 December noted that he was “Quiet and very much a
loner. Staff are to be vigilant around him.” The officer explained that
this comment had been intended to alert other officers that they should
be aware of how quiet and insular the man was, and to try and
encourage him to talk.
47. A week later, on 31 December, another wing officer made an entry into
the man’s wing record. He observed him to be a very quiet and
respectful prisoner who was very polite to staff and who spent a lot of
time in his cell. He noted that he seemed “settled”. Similarly, on 7
January an officer noted that the man was very quiet and shy but had
settled well and that there were no concerns that week.
48. Around this time, one of the prison’s chaplains had frequent contact with
the man. The chaplain explained to the investigation team that the man
came to evening communion fairly regularly and that she could
specifically remember him coming to communion on the two Tuesdays
13
prior to his death (Tuesday 10 and 17 January). On Tuesday 10
January, the communion was attended by only two prisoners; the man
who is subject of this report and another prisoner from the Houseblock.
On that evening, the chaplain asked if the two men would like to write
down any thoughts they might have and offer them as a prayer to God.
The man asked that his prayer only be read out if something were to
happen to him. The chaplain, the man and the other prisoner had an
open discussion about what he had meant by that comment and whether
he was intending to harm himself. He said that he had only been talking
metaphorically. The other prisoner who had attended the communion
that evening told the investigation team that he had taken the man’s
comment to be an indication of his low mood and had not felt that he
was intending to harm himself.
49. The clinical reviewer notes that by 8 January the man was rarely
attending for his medication. On 11 January, he was seen by a doctor
and complained of anxiety attacks. He said that he had not had any
suicidal thoughts and it was agreed that he would return a week later.
50. The prisoner who attended communion with the man who died told the
investigation team that he spoke to him very regularly. The two men
would play cards and both often attending evening congregation. This
prisoner had been encouraging the man to get involved in a scheme in
which prisoners help other prisoners to improve their basic skills in
English and maths, known as “Toe by Toe” (I am myself a strong
supporter of Toe by Toe). The prisoner told the investigation team that
some time during the week or so before his death, the man who died
had asked one of the officers if he could speak to a Listener. (These are
prisoners who are trained by Samaritans to offer a confidential support
service to other prisoners in crisis.) The prisoner explained that the man
had not been provided with a Listener and had been met with an
unsympathetic response from the officer. The prisoner provided the
name of the officer who he believed had turned down the man’s request.
The investigation team interviewed this officer who explained that he had
no recollection of ever having spoken to the man and certainly not of him
asking to speak to a Listener. The staffing detail for the week preceding
the man’s death indicates that the officer was not working on the
houseblock during that period.
51. During this time, the only Listener on the houseblock had been
suspended from his duties and there was therefore not a resident
Listener on the wing.
52. An entry in the man’s wing record on 14 January seems to indicate a
change in the way he was presenting on the wing. One of the wing
senior officers (SO) noted the following:
“Needs more things to do during the day as it has been noted
that his mood is starting to deteriorate. He is a bright prisoner
who needs to be using his brain more.”
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53. On 16 January, the man appeared in court. His solicitor explained to the
investigation team that the purpose of this appearance had been to
apply for bail. However, as has already been highlighted, as the man’s
committal papers had been received by this date, his application for bail
had already been withdrawn and his appearance at court would have
been unnecessary. The man’s cell mate commented that he had found
this experience stressful and had felt frustrated by it.
54. During the early part of the week beginning Monday 16 January, the
man received some news in his education class which seemed to upset
him. One of the teachers at Blakenhurst, told the investigation team that
he had been told that the Thursday afternoon teaching sessions were
going to be abandoned due to financial difficulties. The teacher
explained that while most of the prisoners affected were disappointed
and complained, the man who is the subject of this report went very
quiet and seemed genuinely upset at the prospect of one of the classes
being cancelled. He explained to the teacher that he wanted to be out of
his cell as much as possible and seemed anxious that he needed to be
busy all the time. Because of this, he had taken the decision to go back
to working in industries rather than attending education. It appears that
the man had originally swapped from industries to education as he did
not like being in the noisy, crowded environment. However, he felt that
at least going back to working in industries would get him out of the cell
more. He also felt that the manual hard work in being in industries
would help alleviate his insomnia.
55. The man attended evening communion again on Tuesday 17 January.
The chaplain told the investigation team that she had been concerned
for him on that night and he had appeared very quiet and withdrawn.
Worried by this apparent decline in his mood, she went to the
houseblock and discussed her concerns with officers there. She
explained that it was not her impression that the man was suicidal but
rather that he was struggling to cope with the pressure of his impending
court case. The chaplain could not remember which officers she spoke
to. In addition to speaking to staff on the man’s Houseblock, she left a
note for a volunteer who worked at the prison to go and see the man and
see how he was. The volunteer did so and reported back to the chaplain
that the man had seemed okay and had been talking about his plans for
the future.
56. The teacher told the investigation team that he had talked about the man
who died to the officers on the houseblock several times. His afternoon
teaching sessions with the prisoners on that houseblock took place in
the teaching room located on the landing so he regularly saw the landing
staff. He explained that he had spoken to staff on occasions to try and
organise for the man to spend more time out his cell in the mornings. It
was the teacher’s impression that these conversations had never
achieved much and that the man continued to find it difficult to cope with
the amount of time he spent in his cell in the mornings.
15
57. Following his conversation with the man regarding the cancellation of
one of the afternoon teaching sessions, the teacher recalled speaking to
the houseblock officers (he could not recall which officers by name)
about man’s reaction and of his concern for him. He discussed the
possibility of instigating ACCT procedures for the man and asked for
their advice. The officers said that they did not personally feel that they
had reason to be concerned that the man would harm himself but
encouraged the teacher to open ACCT procedures if he had concerns.
Having discussed the issue, the teacher did not feel there was cause to
be specifically concerned about the man harming himself and he took no
further action.
58. The SO who made the entry in the man’s records on 14 January told the
investigation team that he believed he could recall talking to the man on
the morning of Wednesday 18 December. He explained that he was
mindful of the previous entry he had made in the man’s wing record and
had gone to check on how he was doing. The man had asked about the
possibility of a job on the wing in order to get out of cell more. The SO
explained that there were no jobs available at that time but that he would
be kept in mind if anything came up. He talked to the man about his
disappointment with the cuts to education classes and considered that
he seemed to be quite down. The SO told the investigation team that he
specifically asked the man whether he was thinking about harming
himself and he stated that he had absolutely no intention of doing so.
The SO did not make a note of this conversation in the man’s wing
record.
59. Also on 18 January, the man was seen by the triage nurse and was
referred to see the doctor about his panic attacks and insomnia. He was
seen by a prison doctor who he had not seen before. He described
experiencing generalised anxiety attacks but stated that he had not
experienced any psychotic episodes or suicidal thoughts. The doctor
recorded the man’s poor compliance in relation to anti-depressant
medication, altered his prescription to Escitolopram 10mg and
encouraged him to take his anti-depressants. The doctor at this stage
was under the impression that the man was being seen by both the
psychology service and a RMN, neither of which was true.
60. The man’s cell mate described him as quite a ‘down’ person who did not
talk about his problems. He described how the man found it hard to be
locked up in the cell, especially when he was on his own. He explained,
however, that even though the man hated being locked in the cell he
would sometimes stay in there even when the door was unlocked and he
was free to go onto the wing.
61. Another prisoner who spoke regularly to the man described him as an
unhappy person. He explained that the man had talked to him about the
charges he was facing and had expressed his upset at the effect it was
having on his former partner and son. This prisoner told the
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investigation team that the man had once said that if he had had a gun
he would take his own life. He had believed him to be telling the truth
and considered that he was depressed. The prisoner had not relayed
this conversation to anyone or approached a member of staff to express
his concerns for the man.
62. The man’s relationship with his partner had broken down since his
imprisonment. In addition to distress at the breakdown of his
relationship, it appears that he was finding the separation from his son
very hard to cope with and was distressed about how his son was being
affected by the charges he faced.
63. On 19 January, the man’s solicitor wrote to advise that he was to cease
all contact with his former partner as she was a potential prosecution
witness. It has not been possible to establish whether the man received
this letter before his death. Given the time it would take for the letter to
have been processed by the prison, it seems unlikely that he would
have.
17
Friday 20 January
64. The man’s cell mate told the investigation team that the man had
appeared to be his normal self on the morning of his death. The man
was the first out of bed and to make a cup of tea, which was usual. At
approximately 7.45am, he went down to the treatment hatch on the
ground floor landing of the houseblock to collect his medication. The
medication was given to him by a Healthcare Nurse. The HCN who was
giving out medication that morning told the investigation team that he
asked each of the prisoners collecting medication a few questions, such
as “Did you have an okay night?” and “How are you feeling this
morning?” He does not recall anyone having specific problems that
morning and noticed nothing of concern when he spoke briefly to the
man.
65. The man arrived back at his cell some time just before 8.00am. The
man’s cell mate was just about to leave to go to work in industries and
had a brief conversation before he left. The man said he was looking
forward to Monday as he said he would be working in industries from
then and so would be out of the cell in the morning. He said that he
would clean the cell that morning as it was his turn. The man’s cell mate
then said goodbye and left the cell. The investigation team discovered
that there was some confusion over whether the man was actually due
to start work in industries on that morning. The teacher believed that
that he should have been and one of the wing officers confirmed that he
was on the list to start on that day. However, the man told the wing
officer with the list that he wanted to start from the following Monday, an
intention he then reiterated to his cell mate as he left the cell that
morning.
66. The prisoner who attended communion with the man was due to see him
during the morning to discuss the man’s plans to become a Toe by Toe
tutor. He told the investigation team that, at about 8.45am, he saw the
man going into his cell and called to him that he would see him later that
morning. He does not recall whether the man answered but he gave
him a “thumbs up” and went into his cell. The wing officer who had the
list for those attending industries recalled that it was about 09.10am
when he locked the man back in his cell.
67. The prisoner who was due to see the man about Toe by Toe had
another prisoner to see that morning. He asked the wing officer if he
would unlock this other prisoner so that they could have their tutorial.
The officer told the investigation team that he believed this would have
been at approximately 10.00am. After this first session was finished, at
approximately 10.25am, the prisoner asked to see his second Toe by
Toe prisoner; and he and the officer made their way to the man’s cell.
68. The officer explained that he and the prisoner made their way to cell B2-
13, the man’s cell. Before opening the door, the officer opened the
observation flap and saw the man hanging from the locker at the back of
18
the cell, suspended by a sheet that was wrapped around his neck. The
officer called “code yellow” on his radio. (In Blakenhurst, code yellow is
a term used to alert other staff that there is an immediate threat to life
and that urgent assistance is required.) The officer entered the cell and
saw that the man had wrapped what appeared to be an entire bed sheet
around his neck and had managed to secure it in the locker by wedging
it inside the hinges of one the doors. He felt for the man’s pulse in his
wrist but could find none. The officer told the investigation team that,
due to the man’s colour and appearance, he feared he was already
dead. However, his priority was still to remove the ligature from around
his neck and to begin emergency first aid.
69. The locker from which the man had suspended himself was very high
and the officer explained that he could see immediately that he would
not be able to release the man from the ligature without assistance. He
appeared to have stood on a chair to reach the top of the locker and
have then stepped off it or kicked it away. One of his feet was still partly
resting on the chair. The officer estimated that he was in the cell for
about 20 seconds before he took the decision to leave the cell and go to
the nearby office to summon help. He left the cell, locking it behind him,
and began to make his way to the office some 20 yards away. He did
not get as far as the office before other members of staff were already
making their way towards him. He called to them that he needed their
help and turned back towards the man’s cell. The officer went back into
the cell, along with two officers and a senior officer (SO). The officer
who had found the man and the SO supported his weight while one of
the other officers attempted to untie the ligature. The thickness of the
sheet made it impossible to cut through it with an anti-ligature knife
(known as a ‘fish knife’) although the SO and one of the officers both
attempted this. One of officers went back to the office and called for
another SO who was in the Detail Office to ask for his assistance. The
SO made his way to the houseblock, arriving as the other officers were
still attempting to cut the man down.
70. Two Healthcare Nurses were working together in the Healthcare Centre
when they heard a ‘code yellow’ call over the radio. One of the HCNs
was the nurse responsible for attending any emergencies that day, and
the other was the HCN acting as the member of medical staff to support
her. The HCN who was responsible for immediate response noted in
her police statement that she received the code yellow call at
approximately 10.25am. She responded to the radio message and
confirmed that she was on route to the houseblock. The other HCN
went with her, taking the emergency bag with him. It took the two HCNs
about two minutes to reach the houseblock. On arriving at the man’s
cell, the two nurses saw that three officers were attempting to release
him from the ligature. One of the HCNs helped the officers and they
managed to untie the knot and unravel the sheet from around the man’s
neck. He was placed onto his back, with his head towards the door of
the cell. The emergency response HCN asked for a defibrillator
machine to be brought to the cell and then took out a pocket mask and
19
began to carry out Cardiopulmonary Resuscitation (CPR). She also
requested that an ambulance be called.
71. One of the prison’s Principal Officers (POs) was designated as Oscar
One that day, meaning that he was responsible for the operational
running of the prison and of managing any incidents that occurred. As
part of the protocol following a member of staff making a ‘code yellow’
request, the officer acting as Oscar One is notified of the location of the
incident by the Control Room. As the PO was making his way around
the house blocks that morning, he was alerted that a ‘code yellow’ had
been called from an officer in the houseblock and so he immediately
made his way there. He estimated that it took him no more than a
minute to arrive at the houseblock. The PO arrived at the man’s cell at
the same time as another officer. He instructed the officer to start a log,
which he duly did. The PO responded to the HCN’s request for an
ambulance and contacted the Control Room over his radio. He gave
brief details of what had happened and requested that a call be made for
an emergency ambulance. The Control Room log indicates that a call
for an ambulance was made at 10.32am.
72. The emergency response HCN administered mouth to mouth whilst the
other HCN started chest compressions. Another HCN, who was in the
Healthcare Centre, estimated that she heard the radio call requesting
the defibrillator just before 10.30am. She and a Healthcare Assistant
(HCA) made their way to the houseblock and arrived within a few
minutes. On arrival she prepared the defibrillator and instructed the
HCNs to stop CPR while she attached this to the man. She was not
able to attain any output and so the CPR continued. A further HCN had
heard the ‘code yellow’ message on her radio and so made her way to
the houseblock. On arriving, she found that the man was already being
attended to by other healthcare staff and so assisted by passing
equipment.
73. The PO acting as Oscar One told the investigation team that, within
approximately 20 seconds of arriving at the man’ cell, he requested that
the duty governor also attend. The Control Room log indicates that a
call was put out requesting that the duty governor attend the houseblock
at 10.37am.
74. The prison’s nurse sister was in the Healthcare Centre and was told by
another member of healthcare staff that her help was needed. The
officer completing the log noted that that the sister arrived at the man’s
cell at 10.38am. The sister took over CPR and asked for all of the non-
emergency staff to leave the cell. Because of size of the cell and where
the man was positioned on the floor, the officers who had arrived at the
cell first remained at the back of the cell whilst the medical staff attended
to him.
75. The paramedics arrived at the prison at 10.40am and at the man’s cell at
10.44am. CPR had been carried out continually until they arrived and
20
took over, some twenty minutes after he had been found. They were
unable to obtain any output. One of the prison’s locum doctors was
asked by the Healthcare Manager if he could certify the man’s death.
He did so at 10.50am.
76. The PO told the investigation team that, when he arrived on the
houseblock , staff were locking prisoners behind their doors. He
instructed staff to continue with this. The prisoner who had been waiting
to see the man for his Toe by Toe session (and had been outside the
man’s cell when he was discovered) had realised quickly that something
very serious had happened to the man. He told the investigation team
that the officer had told everyone to get behind a cell door immediately
and that prisoners had done so. He explained that members of the
chaplaincy came to see him and talked to him until his cell mate came
back from industries a little later in the morning.
77. The man’s cell mate described how he had come back from industries
late that morning and that he was not sure why there had been a delay.
When he tried to make his way to his cell, he was stopped by an officer
and taken to the shower block where the officer explained what had
happened. He said that he was regularly checked on by staff and also
had the chaplain to talk to.
78. The paramedics left the prison at 11.05am. It appears from the Action
Checklist completed by the duty governor that West Mercia
Constabulary had been contacted at 10.45am and arrived at the man’s
cell at 11.50am.
79. The duty governor led a ‘hot debrief’ at 11.30am in the prison chapel.
The debrief was widely attended by both discipline and healthcare staff
who had been involved in trying to save the man that morning. The
debrief was minute and staff were reminded of the availability of
members of the Care Team to offer them support, and of the need to be
mindful of the effect the man’s death might have on prisoners.
80. The governing Governor asked one of the other governors to break the
news of the man’s death to his family. This governor estimated that he
was asked to do this at approximately 2.30pm. The man’s records had
already been consulted and had shown his next of kin to be his parents.
The governor had not been trained in family liaison and had never
previously broken the news of a death. He consulted Prison Service
Order 2710, which provides guidance. The prison has its own Family
Liaison Officer’s guidelines which contain an information gathering
checklist. This was completed by one of the prison’s chaplains and
included information about the man and his family circumstances as well
as the known details about his death. In addition, a risk assessment
was completed, including any known information about the family or
neighbourhood that prison staff needed to be aware of. Nothing of this
nature was recorded. It had been decided that the governor and the
chaplain (whose communion the man had attended) would go to visit the
21
man’s family together and that they would be accompanied by a police
officer from West Mercia Police. They waited approximately half an hour
for an officer to arrive and take them to the man’s parents’ address,
arriving there at 4.00pm.
81. The governor explained that, on arriving at the man’s parents’ home, he
broke the news of his death. The governor was aware that the man had
a son and his parents explained that he now lived with the man’s former
partner. The man’s parents asked that the governor and the chaplain
break the news to the man’s son. Agreeing to do this, they were aware
that the man’s son was young and that they did not want to tell him of his
father’s death without him being accompanied by an adult. With the
assistance of the police officer, they were able to locate the man’s
former partner and asked for her to return home as they had needed to
break some news to her and the man’s son. After they had done so, the
governor, chaplain and the police officer left the house, explaining that
one of the prison’s senior officers would be acting as their family liaison
officer (FLO) and that he would be visiting them soon.
82. The senior officer appointed as the prison’s family liaison officer
contacted the man’s parents and former partner and has maintained
regular contact with the family. The man’s family asked the prison
chaplain to carry out the service at his funeral, which she did. The
prison covered the costs of man’s funeral.
83. A subsequent search of the man’s cell revealed that he had written a
letter to his former partner, outlining his intention to take his life. It is not
clear when this letter was written.
22
Discussion of the issues
84. I note that this man spent his first night in the prison in the Segregation
Unit. In all likelihood, this was because he was on Rule 45 protection
and was awaiting a place on the houseblock. I share the view,
expressed by HM Chief Inspector of Prisons in her report of February
2006, that it is not appropriate for prisoners who have been afforded
Rule 45 protection to be located in the Segregation Unit for this reason.
The appropriateness of the man’s assessment by Healthcare staff
85. The initial assessment of the man’s health was carried out appropriately.
In the two months between his arrival at Blakenhurst and his death, he
was seen by several different members of healthcare and his medication
for depression was altered three times in the space of six weeks. The
clinical reviewer recommends a consensus about the treatment of
depression to be established, in consultation with prison pharmacists
and prison GPs. The reviewer suggests that this should include a
review of appropriate evidence based medication and the length of time
needed for the chosen drug to be effective.
86. The clinical reviewer also concludes that there is a need for improved
sharing of relevant information between wing staff and medical staff. I
note that, when the Registered Mental Nurse was requested to see the
man on 14 December, she was unaware that information had been
received suggesting that he could have been intending to harm himself.
The clinical reviewer also recommends a review of the referral process
to the mental health team with the aim of establishing a robust system
with clear referral criteria. This would involve the creation of an audit
trail allowing healthcare professionals to track the progress of patients
and preventing patients being lost in the system. In addition, the
reviewer recommends that a policy should be established which would
remove the onus on the patient to re-engage with the Mental Health In-
reach Team when they may be experiencing episodes of mental
distress1.
87. I fully endorse the reviewer’s recommendation that there is a need for a
more robust system for recording, prioritising and monitoring prisoners
who are brought to the attention of the Mental Health In-reach Team.
However, I also consider that healthcare staff should be reminded of
their right to review the contents of a prisoner’s wing file if they believe
this would be relevant to their duty to care for the prisoner as a patient.
In the Registered Mental Health Nurse’s case, she could have quite
reasonably requested to see the man’s wing file in order to gain an
understanding of why he had been referred for an assessment.
1 I note that, in their response to the draft version of this report, the Prison Service said they believed
the clinical reviewer’s report confused the two groups of staff responsible for dealing with prisoners
with mental health problems. The Prison Service advised that those with severe and enduring mental
health problems fall into the remit of the In-reach staff. Those with less acute mental health needs are
cared for by the in-house Registered Mental Health Nurses (RMNs).
23
88. The clinical reviewer notes that, although the majority of entries in the
man’s medical records were legible, this was not the case for all entries
and some were not signed or dated.
89. The clinical reviewer also makes the following recommendations:
• A common formulary for prescribing anti-depressants should be
maintained, and monitored by prison medical staff at defined intervals.
• If a referral from the wing is received and contact cannot be made, this
should be recorded in the Inmate Medical Record (IMR) and also within
the prisoner’s wing records.
• If staff have been concerned that a prisoner may be at risk of self harm
but subsequently make a decision not to instigate ACCT procedures for
a prisoner, it should be clear from the prisoner’s records why that
decision has been made.
• A formal process for monitoring referrals to the forensic psychologist
should be in place and prisoners on the ‘waiting list’ should be reviewed
on a regular basis by the multi disciplinary team to identify if their needs
have changed.
• Care should be taken when a prisoner’s medical records are not
available, especially if significant alterations to medications are being
made.
• The standard of record keeping in prisoners’ medical records should be
regularly audited against relevant guidelines.
90. The clinical reviewer indicates that more consideration should perhaps
have been given to instigating ACCT procedures for the man, as he was
demonstrating depression, anxiety and had reportedly made suicide
threats. I consider that any one of the members of staff who was aware
of his low mood would have been justified in opening an ACCT for him.
However, there was a lack of information sharing between healthcare
staff, Mental Health In-reach staff and discipline staff. This appears to
have resulted in no one person being aware of all the significant factors
affecting the man’s state of mind and therefore his risk of harming
himself. While in hindsight it would seem that ACCT procedures should
have been initiated, the man’s presenting symptoms were not such that
the decision not to have done so can be criticised.
The care of man by other prison staff
91. The houseblock accommodates some 70-80 prisoners. For much of the
time during the day, the wing is staffed by two officers. There are
officers available if they are needed on an adjacent houseblock and
there is also a senior officer responsible for supervising both
24
houseblocks. The houseblock where the man died does not operate a
personal officer scheme and staff explained to the investigation team
that prisoners are happy to approach any member of staff. The quality
and frequency of entries in the man’s wing record tends to suggest that,
despite there being few members of staff on the wing, the officers made
efforts to interact with him and to document many of the specific
conversations of note.
92. Many other members of staff, including those from Chaplaincy,
Healthcare and Education, also interacted with this man and may have
had cause to make entries in his wing records. It should be considered
good practice to encourage staff from all disciplines to share information
in this way. It can only assist in informing staff about individual prisoners
and help raise awareness about those who might be at risk of self harm.
93. Both the chaplain and teacher who saw the man regularly spoke to
officers on the houseblock about their concerns for this man, although
neither specifically had concerns about him harming himself. Discussing
worries about individual prisoners with other members of staff is to be
encouraged. The chaplain and the teacher both felt confident that they
would have instigated ACCT procedures if they had felt it appropriate.
However, neither considered that the man had intentions of harming
himself, rather that he was struggling to cope with his upcoming court
case and the pressures of being in prison.
94. The man’s former partner asked the investigation team to consider
whether staff are appropriately trained to identify those who may be at
risk of suicide or self harm. During their training on how to use the
ACCT system, staff are trained to look for both the physical and
behavioural changes that may indicate that a person is vulnerable to
harming themselves. Staff are also trained to respond to prisoners who
may be experiencing distress by talking openly with them, as well as by
observing changes in behaviour and attitude.
95. The man’s former partner was also concerned about whether the
information she passed onto the prison on 11 December was dealt with
appropriately. The investigation team found that, once the information
was received by a member of staff in the prison’s Control Room, the
information was swiftly communicated to staff on the houseblock. The
wing officers, on receiving the information from the Control Room, took
entirely appropriate action. They spoke at length with the man and, in
obtaining a doctor’s appointment for him, attempted to help him address
difficulties he was having with his medication. Both officers felt satisfied
that the man did not intend to harm himself, but that they would have felt
confident to instigate ACCT procedures if they had felt it necessary.
Attempts to help the man spend more time out of cell
96. As is the case for many prisoners, the boredom and stress of being
locked in a cell was something this man found hard to cope with. He
25
had decided that he would stop attending education as it did not afford
him enough time out of his cell and was due to start in industries on the
Monday following his death. In addition, arrangements had been made
for him to become a tutor on the Toe by Toe programme which would
mean more time out of his cell.
97. The investigation team were told by some of the prisoners that it was
extremely rare for the houseblock prisoners to be given exercise outside.
They were told that exercise was given at least several times a week but
that it sometimes coincided with the hour in the afternoon when
prisoners wanted to take showers and collect their meal. It was
explained that pressure on staff numbers meant that this was sometimes
unavoidable. Manifestly, prisoners should be given the opportunity to go
outside for exercise without having to forsake their meal or shower.
Nevertheless, there seem to have been efforts made to find
opportunities for the man who is the subject of this report to spend more
time out of his cell through involving him in other activities.
98. Other prisoners who were friends with the man commented on his
quietness and occasional unwillingness to come out of his cell even
when he was able to do so.
The man’s access to support
99. A fellow prisoner who played cards with the man told the investigation
team that he had asked an officer to speak to a Listener a week or so
before his death. The prisoner named the officer who be believed had
refused to get a Listener for him. I have found no evidence to suggest
that this was the case. Indeed, the officer in question was not working
on the houseblock at the relevant times.
100. It was brought to the attention of the investigation team that there had
been no resident Listener on the houseblock for some weeks. One of
the houseblock prisoners explained that, while in theory Listeners from
anywhere in the prison should be able to support a prisoner on the
houseblock, in practice there was a reluctance to engage with prisoners
on that wing because of the nature of their alleged offences. Whilst it
has not been possible to establish whether the number of Listener
referrals reduced on the houseblock after their Listener was suspended,
it is clearly of benefit to the residents to have access to a Listener who
also lives on the wing.
101. The man who died appeared to be finding it very hard to cope with the
breakdown of his relationship, a situation which is sadly not unusual in
prison. He spoke of his distress to individual prisoners, and members of
prison staff including the chaplain were aware that he was finding the
stresses of prison hard to cope with. When the prison was contacted by
the man’s former partner on 11 December about concerns about his
intentions to harm himself, the staff involved acted swiftly and with
sensitivity.
26
Response of staff on 20 January
102. On the morning of the man’s death, staff responded swiftly and
appropriately to try to save him. Each member of staff the investigation
team spoke to about the use of ‘code yellow’ understood what it meant
and how to respond. All the members of staff who tried to save the man
had been trained in suicide awareness and understood the importance
of releasing the ligature from around his neck. The two officers who
were first to arrive and help the man had received heart start training in
the past two years, and all officers are equipped with anti-ligature knives.
103. The first two Healthcare Nurses arrived at the man’s cell within minutes
of hearing the ‘code yellow’ call. They took the emergency bag with
them and asked for a defibrillator machine as soon as they arrived and
realised it would be needed. An ambulance was also requested.
Further healthcare staff arrived very quickly and the senior nurse took
over resuscitating the man until the ambulance staff arrived some 12
minutes after they had been called.
104. The Principal Officer who was Oscar One that day estimated that he
arrived at the man’s cell within a minute or so of hearing the ‘code
yellow’ call. He ensured that a log was kept. He also kept the duty
governor informed of what was happening.
105. Following the man being pronounced dead at 10.50am, the duty
governor held a hot debrief for staff. The debrief appropriately drew
attention to the possible needs of staff who had been involved in trying
to save the man, but also highlighted the need to be sensitive to
prisoners’ reactions to his death.
106. The investigation team interviewed the majority of the staff who were
involved in trying to save the man on the morning of 20 January. All of
those they spoke to spoke favourably of the help and support they had
received following this tragic death. However, the man’s teacher, a
member of staff who knew the man well but who was not involved in
trying to save him that morning, felt that it was unfortunate that he was
not offered support as he would have welcomed it.
Suicide prevention at HMP Blakenhurst
107. The recent report following an unannounced inspection by HM Chief
Inspector of Prisons noted that safer custody is a priority for Blakenhurst,
and that a range of initiatives have resulted in a significant reduction in
incidents of self harm. The investigation team found that the staff they
spoke to demonstrated a good level of awareness of the ACCT
procedures and were confident about instigating them if necessary.
108. The investigation team were told about Blakenhurst’s Insiders scheme
by one of the prisoners who co-ordinated the work. The scheme aims to
27
provide a support and information service both to newly arrived
prisoners and to those who may need specific help. The Listener and
Insider schemes were talked of favourably by prisoners, but there was a
clear concern about the absence of a Listener on the houseblock.
Family Liaison
109. Once the governor who was asked to break the news of the man’s death
to his family was aware that he would be making this visit, he took
appropriate steps to ensure that this was done as quickly as possible.
He did this without jeopardising his or his colleague’s safety. The prison
has developed its own local guidance for staff when delivering the news
of a prisoner’s death, and has also produced a useful information pack
to be given to bereaved families. The governor and the chaplain worked
closely with the police to ensure that they did not deliver such sad news
to the man’s son inappropriately, and their sensitivity in this matter is
commendable. The governor was not aware that he was going to break
the news of the man’s death to his family until almost four hours after he
died. Whilst no criticism is made of the governor’s actions in preparing
to break the news to the man’s parents, it is noted that it would have
been desirable for them to have been visited before 4.00pm, some five
and a half hours after his death.
110. I have found the prison’s family liaison officer’s efforts in liaising with the
man’s family to have been sensitive and timely.
Could this man’s death have been prevented?
111. It is not possible to know whether a specific event triggered the man’s
decision to take his own life or for how long he had considered it. It is
evident that he frequently spent time alone in his cell and that the
morning of 20 January would not have been his first opportunity to
attempt to take his life. It is not clear whether the man had received the
letter sent by his solicitor on 19 January indicating that he could not
contact his former partner, but this seems very unlikely.
112. It appears that many of those staff and prisoners who regularly came
into contact with the man were aware of his distress. However, given
the severity of the charges against him and the deterioration of his
personal circumstances, his state of mind appeared to others to be
understandable. Other than his comment about a gun to a fellow
houseblock prisoner, he never appeared to give any indication that his
distress would lead him to harm himself.
28
Findings and recommendations
113. It is not appropriate for prisoners on Rule 45 protection to be located in
the Segregation Unit on their first night in custody and I suggest that
steps are taken to prevent this happening.
114. The man was clearly finding his time in prison difficult to cope with. He
was facing very serious charges and his relationship had broken down
as a result. He did appear to talk to some prisoners and staff about his
difficulty in coping. But, with the exception of one prisoner who by his
own admission did not tell staff about his concerns, none of those whom
he confided in considered that he was in danger of harming himself.
Rather, it was believed that his expressions of despair were simply
indications of how low he was feeling at the deterioration of his personal
life and the prospect of his upcoming court case.
115. The man had frequent contact with healthcare staff at the prison and had
been prescribed anti-depressants. Taking into account the findings of
the clinical reviewer, I consider that there were missed opportunities to
engage with him in a way which might have helped him to address his
depression and anxiety. Although he came to the attention of the Mental
Health In-reach Team and had been referred for an appointment with the
prison psychologist, inadequate referral and monitoring systems
resulting in his ‘slipping through the net’.
116. I recommend that consideration is given to the following findings,
as outlined in the clinical review:
• A consensus about the treatment of depression should be
established in consultation with prison pharmacists and prison GPs.
This should include a review of appropriate evidence based
medication and the length of time needed for the chosen drug to be
effective.
The Prison Service accepted this recommendation locally. They
responded that: “The appointment of a clinical lead will enable a
protocol to be drawn up regarding the prescribing of anti-
depressants. This will be forwarded to the drug and therapeutic
committee for agreement.”
• There should be a review of the referral process to the mental health
team with the aim of establishing a robust system with clear referral
criteria. This should incorporate the creation of an audit trail to allow
healthcare professionals to track the progress of patients and
safeguard against patients being lost in the system. A policy should
be established which would remove the onus on the patient to re-
engage with the Mental Health In-reach Team when they may be
experiencing episodes of mental distress.
29
The Prison Service accepted this and advised that: “A new system
had been established to monitor referrals and ensure an appropriate
professional sees the patient. A system to be developed to give the
patient the necessary information to enable them to re-engage with
the mental health team following discharge from that period of care.
Those with severe and enduring mental illness will remain on the
patient list until discharged from the establishment.”
• A common formulary for prescribing anti-depressants should be
maintained, and monitored by prison medical staff at defined
intervals.
The Prison Service accepted this recommendation and commented:
“A formulary is being developed which will encompass anti-
depressants and all other medications.”
• If a referral from the wing is received and contact cannot be made
then this should be recorded in the IMR and also within the prisoner’s
wing records.
This was also accepted by the Prison Service: “Notice to be issued to
all staff regarding appropriate documentation.”
• If staff have been concerned that a prisoner may be at risk of self
harm but subsequently make a decision not to instigate ACCT
procedures, it should have been clear from the prisoner’s records
why that decision has been made.
In accepting this recommendation, the Prison Service commented: “A
notice is to be issued to all staff regarding appropriate
documentation.”
• A formal process for monitoring referrals to the forensic psychologist
should be in place and prisoners on the ‘waiting list’ should be
reviewed on a regular basis by the multi disciplinary team to identify if
their needs have changed.
The Prison Service accepted this recommendation and stated the
following: “Referrals discussed at weekly multi-disciplinary meeting.
All referrals should be generated by another healthcare professional.
The patient will remain on the referrer’s caseload until seen.
Outstanding referrals to be subject to review on a bi-weekly basis
initially. This process to be reviewed after two months and reduced
to monthly if appropriate.”
• Care should be taken when a prisoner’s medical records are not
available, especially if significant alterations to medications are being
made.
This was accepted by the Prison Service.
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• The standard of record keeping in prisoners’ medical records should
be regularly audited against relevant guidelines.
The Prison Service accepted this and commented that:
“Documentation audit to take place at three-monthly intervals.
Defensible documentation training to be delivered as per training
plan.”
117. The houseblock is a large wing, but despite this man being a quiet and
apparently introverted person, wing staff were caring and appear to have
engaged with and monitored him. It appears that the majority of
significant interactions between the man and the wing staff were
appropriately documented in his wing record. However, staff other than
the discipline staff also had significant conversations with the man and
none of those was recorded either in his records or in the general wing
observation book. I acknowledge that on a large wing, staffed by only
two officers, there are practical limits to the amount of information that
should be recorded. However:
I recommend that all staff are reminded of the importance of
sharing information about prisoners and that they are encouraged
to read prisoners’ wing records and the wing observation book. All
staff should also be reminded of the importance of documenting all
significant interactions with prisoners in their wing records and,
where appropriate, the wing observation book.
The Prison Service accepted this recommendation and noted:
“Residential managers have been reminded of the importance of
communication and monitor staff compliance. Safer Custody staff
monitor ACCT forms to ensure proper recording, particularly relating to
meaningful interaction with the prisoner.”
118. As a point of note, prisoners should be afforded the opportunity to take
outside exercise everyday and the timing of this should not routinely
coincide with other essential daily tasks such as taking a shower or
collecting an evening meal.
119. On the morning of 20 January, the response to the finding of this man
was timely and well handled with all staff aware of the procedures to
follow. As a housekeeping point, I would suggest that some thought be
given to whether it is possible to find a way to identify those members of
staff who may be affected by a prisoner’s death but who may not be
immediately obvious as being in need of support.
120. The prison’s proactive approaches to developing a safe environment
and reducing suicide and self harm, such as the Insider and Listener
schemes, are to be commended. However, it is inappropriate not to
have a resident Listener on a wing whose population are, by definition,
vulnerable to feeling isolated and in need of support.
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I recommend that a suitable prisoner is identified and trained to act
as a Listener for the houseblock and that this is actioned as a
matter of urgency.
The Prison Service accepted this recommendation and confirmed that a
Listener has now been trained and appointed on the houseblock.
121. The man’s family were told of his death in a sensitive manner and the
prison’s Family Liaison Officer has maintained regular contact with the
family. I would, however, emphasise the need to inform a family of a
prisoner’s death as soon as is possible.
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Recommendations
1. I recommend that consideration is given to the following findings, as
outlined in the clinical review:
• A consensus about the treatment of depression should be established in
consultation with prison pharmacists and prison GPs. This should include a
review of appropriate evidence based medication and the length of time needed
for the chosen drug to be effective.
• There should be a review of the referral process to the mental health team with
the aim of establishing a robust system with clear referral criteria. This should
incorporate the creation of an audit trail to allow healthcare professionals to
track the progress of patients and safeguard against patients being lost in the
system. A policy should be established which would remove the onus on the
patient to re-engage with the Mental Health In-reach Team when they may be
experiencing episodes of mental distress.
• A common formulary for prescribing anti-depressants should be maintained,
and monitored by prison medical staff at defined intervals.
• If a referral from the wing is received and contact cannot be made then this
should be recorded in the IMR and also within the prisoner’s wing records.
• If staff have been concerned that a prisoner may be at risk of self harm but
subsequently make a decision not to instigate ACCT procedures, it should be
clear from the prisoner’s records why that decision has been made.
• A formal process for monitoring referrals to the forensic psychologist should be
in place and prisoners on the ‘waiting list’ should be reviewed on a regular basis
by the multi disciplinary team to identify if their needs have changed.
• Care should be taken when a prisoner’s medical records are not available,
especially if significant alterations to medications are being made.
• The standard of record keeping in prisoners’ medical records should be
regularly audited against relevant guidelines.
2. I recommend that all staff are reminded of the importance of sharing
information about prisoners and that they are encouraged to read
prisoners’ wing records and the wing observation book. All staff should
also be reminded of the importance of documenting all significant
interactions with prisoners in their wing records and, where appropriate,
the wing observation book.
3. I recommend that a suitable prisoner is identified and trained to act as a
Listener for the houseblock and that this is actioned as a matter of
urgency.
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