Individual at Brinsford

Investigation into the death of a man
at HMYOI Brinsford in March 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2008
This is a report of an investigation into the death of a man. The man was just 19
years old when he took his own life in his cell at HMYOI Brinsford. He had been in
custody there for just two weeks.
I would like to offer my sincere condolences to the man’s family on their tragic loss.
I must also apologise for the delay in issuing this report. The Primary Care Trust
who had responsibility for completing the clinical review rightly wanted to produce a
thorough and comprehensive document. Unfortunately, this took much longer than
expected to complete.
The investigation was undertaken by my two of my colleagues. We would like to
thank the Governor of Brinsford and his staff for their participation and assistance.
South Staffordshire Primary Care Trust undertook a review of the man’s clinical care.
I must also thank them for the review.
In tragic circumstances, I have been impressed by the compassion and
professionalism demonstrated by the officers who discovered the man in his cell and
attempted to resuscitate him. I am also impressed by the care and dedication
displayed by Senior Officer in charge of the prison wing on which the man died, and
by the Safer Custody team who work hard to try to prevent tragedies of this nature.
However, I must also record that valuable information regarding the man’s mental
state was neither noticed nor acted upon by Brinsford. If it had been, I am sure he
would have been monitored more closely and a more urgent referral made for a
mental health assessment. It is also a concern that the man did not receive the
medication that the prison’s doctor said he had prescribed for him. These issues are
considered in more detail in this report and in the clinical review.
I make a total of 12 recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2008
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CONTENTS
Summary 4
The Investigation Process 5
HMYOI Brinsford 7
Key Findings 9
Issues 19
Recommendations 23
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SUMMARY
The man was discovered in his cell at HMYOI Brinsford early in the evening in March
2007 with a ligature tied around his neck. He had used a cord from a stereo, which
he had borrowed from another prisoner that afternoon. Despite the efforts of staff,
he could not be revived. He was just 19 years old when he died.
The man lived with his partner and was a father to three young children. Whilst he
was at Brinsford, he remained in touch with his partner and other members of his
family through regular telephone calls and letters. He also received visits, but he
experienced problems with visiting orders for his mother which he brought to the
attention of wing staff.
The man had been in custody previously. He arrived at Brinsford in March 2007
after being remanded into custody by the Crown Court for a number of relatively
minor offences. He was unable to be bailed, as he had previously received a
suspended sentence which was revoked when he allegedly committed the new
offences.
Throughout his time at Brinsford, staff were concerned about the man’s mental
health, and an ACCT document (used to monitor prisoners at risk of suicide or self
harm) remained open from 12 March until the day he died. The staff involved in
opening and reviewing his ACCT took care to ensure they interacted with him and
checked on him regularly. They made him aware of the support available, and one
Senior Officer in particular spent time with the man to help him sort out some
problems.
Staff in healthcare also spent time with the man but, although they too were
concerned about his mental health, they did not raise an urgent mental health
referral, instead making a routine one. The man was still on the waiting list when he
died. Had any member of the healthcare been aware of a probation report which
said that the man had tried to take his life on two previous occasions, I believe they
would surely have taken a different and more urgent approach.
The staff who found the man tried valiantly to resuscitate him. He was pronounced
dead by the prison doctor at 8.29pm.
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THE INVESTIGATION PROCESS
1. I appointed two investigators to conduct the investigation on my behalf.
Notices were issued to both prisoners and staff, inviting anyone who might
have information on the man’s death to make themselves known to the
enquiry. However, no additional witnesses came forward.
2. My investigators were given access to all the man’s prison records, including
his medical records and police statements. They were also given copies of
personal letters written to the man from his partner, along with transcripts of
telephone conversations between them and between the man and other
members of his family.
3. My investigator visited Brinsford in March 2007 to open the investigation and
visit the cell where the man died. All the prison documents were forwarded to
her within two weeks of her visit.
4. My investigators visited Brinsford on 24 and 25 May to carry out interviews.
Due to staff sickness, they were not able to interview everyone they wanted,
so returned to the prison on 27 June to carry out the remaining interviews.
5. My investigators used Brinsford’s own tape recording machine to record
interviews with staff, but this broke down on a number of occasions. This
meant that handwritten notes needed to be taken. However, these were
forwarded to staff for agreement in the usual way. Notes of the interviews
with prisoners were also taken by hand (which is usual practice) and
forwarded for their agreement as a true and accurate record.
6. A number of staff remained on sick leave throughout this investigation.
However, I believe that police statements taken on the night the man died and
shortly afterwards have provided the investigators with sufficient information.
7. One of my Family Liaison Officers contacted the man’s partner and his
father’s partner by telephone. The Family Liaison Officer explained the role of
the Prisons and Probation Ombudsman and asked whether there were
concerns or questions they would like my investigators to consider.
8. The family raised several issues. They were concerned at the length of time it
had taken for them to be informed of the man’s death. (There was a delay of
approximately six hours before the Prison Governor and his Family Liaison
Officer arrived at the home of the man’s mother.) They asked that my
investigators consider how the ACCT process was managed. They also told
my Family Liaison Officer that they had not been informed that the prison
would contribute to the cost of the funeral until after they had already applied
for financial assistance from the Department for Work and Pensions.
9. The family also believed that the man should not have been allowed a stereo
in his cell as he had not earned this through the Incentives and Earned
Privilege Scheme. They believed that staff should have been alerted to the
fact that he had a stereo as he was playing loud music. The family also
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questioned whether the man had been on an ACCT document at the time of
his death. They were also concerned that he was being bullied when he first
went to Brinsford and that some prisoners had been trying to take a watch
from him. The man’s partner asked why he had not been allowed to make a
telephone call around 4.30pm on the day he died.
10. Another question was whether the man saw a doctor whilst at Brinsford and
whether he was prescribed medication for his depression. Finally, when the
family were given the man’s possessions, they included a sheet of paper
which was headed a self assessment check list. One of the questions on the
checklist asked “How do you feel today” and the man had ticked “Very Low”.
The family believe the man completed the checklist the day before he died
and want to know whether staff had seen it. My investigators asked prison
staff about this and were told that the checklist was for the individual’s
personal use and would not have been seen by anyone else.
11. A clinical review of the man’s health care whilst in custody was undertaken by
South Staffordshire Primary Care Trust. As part of this review the prison’s
doctor and Charge Nurse were interviewed. (The Charge Nurse was one of
the staff members who remained on sick leave throughout this investigation.)
The clinical review team held an initial meeting on 31 July to review
information and evidence about the man’s care. Further meetings were held
on 24 October and 22 November 2007.
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HMYOI BRINSFORD
12. HMP and YOI Brinsford is situated north of Wolverhampton in Staffordshire
and shares a large site with HMP Featherstone. The prison was opened in
1991 and cares for both juveniles (those aged 15-17 years) and young
offenders (18-21 years).
Induction wing
13. The purpose of the induction wing is to house new prisoners before they are
located on to a main wing, to provide them with information about the prison,
and let them know what help is available. It is also where staff can identify
prisoners who are vulnerable or at risk, and provide them with advice or take
appropriate action, for example opening an ACCT document.
Assessment, Care in Custody and Teamwork (ACCT)
14. ACCT requires any member of staff who identifies concerns about a prisoner
at risk of suicide or self harm to take action and to record those actions. The
ACCT document should be available to all staff where the prisoner is located,
including workshops and visits. Within 24 hours of an ACCT being opened,
the prisoner is seen by an assessor and has a case meeting review. ACCT
reviews are held at appropriate intervals and are attended by the prisoner and
a case manager, together with other members of staff.
Healthcare
15. Brinsford’s healthcare centre is located on the ground floor of a two-storey
building shared with the induction, throughcare, support unit (ITSU). It has a
24 hour in-patient healthcare facility. Doctor cover is available five days a
week, with an out-of-hours service commissioned by the Primary Care Trust.
A mental health in-reach team works closely with healthcare staff.
Listeners
16. A number of prisoners at each prison are trained and supported by the
Samaritans to be Listeners and to offer peer support. Other prisoners can
speak to Listeners in confidence about any issues that affect them. Listeners
are bound by confidentiality rules, like the Samaritans, and are unable to
disclose any details about conversations they have had (unless it is a matter
which threatens the security of the prison).
Anti-bullying Strategy
17. Brinsford has a specific anti-bullying manager, albeit with other duties. An
anti-bullying protocol called BRAVES (Brinsford’s Reducing Aggression and
Violence Effectively Strategy) has been established and meetings are held
monthly. At these meetings, staff review incidents of bullying, consider
causes of bullying and analyse statistics and trends. All Senior Officers are
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trained to be aware of signs of bullying, and to carry out investigations which
they report back on at the meetings.
Prison Service Orders (PSOs)
18. PSOs are issued to every prison and detail the mandatory action to be taken
regarding specific issues.
Offender Assessment System (OASys) Reports
19. OASys reports are assessments completed by the Probation Service in
advance or after a court appearance. Each report provides information
regarding the offence, and personal details (including accommodation,
financial status, education, relationships and lifestyle), and produces a risk of
harm summary. In the case of man who is the subject of this report, the
OASys assessment included that he was at risk of suicide as he had taken an
overdose a few weeks beforehand. The man also recounted to the probation
officer how he had taken a car with the intent of driving it into a wall in an
attempt to take his own life.
Incentives and earned privileges scheme (IEP)
20. The Prison Service introduced the IEP scheme in 1996 to encourage and
reward good behaviour. There are three levels: basic, standard and
enhanced. Incentives include access to in-cell television, more private cash
to spend, wearing own clothes, more time out of cell and community visits.
Each prison sets its own criteria for prisoners to obtain each level.
Independent Monitoring Board (IMB) Report
21. The local Independent Monitoring Board’s report for 2005-2006 acknowledged
that Brinsford held vulnerable prisoners and that the prevention of self harm
and suicide was a significant challenge for everyone. The report referred to
the successful introduction of the ACCT approach and was impressed at the
number of staff who had received ACCT training. The Suicide Prevention
Strategy had been revised and used as an example of good practice for other
prisons. The Board reported that the Suicide Prevention Team met on a
monthly basis and was well attended by both internal and external agencies.
A cross-section of ACCT plans were reviewed for quality and accuracy each
month. The IMB also noted that Brinsford had forged a constructive
relationship with the Samaritans (something which also impressed my
investigators) and that the Listener scheme had been re-launched. The IMB
commended the small team of staff who contributed to this area of work.
Her Majesty’s Chief Inspector of Prisons Report
22. The last inspection of Brinsford by HM Chief Inspector of Prisons, Ms Anne
Owers, was in 2007. In her subsequent report, Ms Owers said Brinsford was
struggling to provide appropriate levels of safety and decency.
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KEY FINDINGS
23. The man arrived at HMYOI Brinsford in March 2007 from the Crown Court.
This followed his conviction at the Magistrates’ Court in January 2007 for
several offences. It was the man’s second time in prison, having previously
served a sentence at Ashfield YOI.
First reception
24. The man attended a first reception health screen on 9 March, where he
informed the healthcare assistant, that he had been seen by a psychiatrist
seven months previously for stress. The man said he had been prescribed an
antidepressant (Fluoxetine) and sleeping tablets (Diazepam) to relieve his
symptoms. He told the healthcare assistant that he had stopped taking the
medication approximately three months previously, as he had started to feel
better.
25. On page eight of the first reception health screen document, the healthcare
assistant indicated that the man should be referred to the doctor. In her
interview for this investigation, the healthcare assistant recalled that the man
had appeared quite tearful and upset and was worried about being away from
his family. The healthcare assistant explained to the man the help and
support that would be available to him at Brinsford, including the purpose of
an ACCT document. The man told the healthcare assistant that he did not
feel suicidal and did not need to be on an ACCT, but if he needed any help he
would speak to someone. He was then located onto the induction unit.
Healthcare involvement
26. The man was seen in healthcare, following the healthcare assistant’s referral,
on 10 March at 7.20pm by a Registered General Nurse (RGN). The nurse
noted in the Inmate Medical Record (IMR) that the man seemed very
depressed and tearful and that he was missing his family and children. The
man told the nurse that he felt he needed to resume taking his anti-
depressants and sleeping tablets, and the nurse made a written referral in the
IMR for him to be seen by the prison doctor. The nurse also gave the man
some herbal tablets to help him settle that night.
27. There is an entry in the IMR the next day by the prison’s doctor (who was the
on call doctor). The entry is quite difficult to read but, with clarification from
the doctor at interview, I understand it says that the man had been on “anti-
depressants seven months ago, that he was not sleeping – on fluoxetine as of
today”. (The clinical review has said that urgent attention should be paid to
improving the standard of legibility. I agree.) When the doctor was
interviewed by the clinical reviewers on 17 September, he said that this entry
was in fact a prescription that he had made out for the man. It is unclear from
the entry that this was the doctor’s intention as it was recorded in the
Significant Events and Health Issues page of the IMR. The man did not
receive this medication.
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28. The man was seen again by the healthcare assistant on 12 March. He
passed her as he was being escorted through healthcare and asked to have a
word. The healthcare assistant recalled that they went to the staff room to
talk. The man told her that he was having trouble coping and that he wanted
to speak to his partner. The healthcare assistant arranged some credit to be
put on his Pinphone account so he could speak to her. The man also told the
healthcare assistant that he was having thoughts of harming himself. The
healthcare assistant immediately opened an ACCT document and referred the
man to be seen by the Charge Nurse at Brinsford. The healthcare assistant
recorded her account of this conversation in the IMR.
29. The Charge Nurse saw the man the next day and made an entry in the IMR.
He noted that the man was low in mood and very stressed. The man also told
the Charge Nurse about his previous medication and agreed to forward the
name of the psychiatrist he had seen. (In fact, he did not return with this
information.) However, in the ACCT document it is noted that he was a
patient of a psychiatrist in the community. No steps were taken to find out
further information from the man’s community doctor. Neither the ACCT
document, nor the OASys report, was ever forwarded to anybody in
healthcare. Brinsford have subsequently said that the OASys report would
not have been accessed as the man was subject to judicial review. In normal
circumstances the prison does not work with OASys on any offender who is
not sentenced.
30. The Charge Nurse said that the man should be referred to the Staff Nurse for
a full mental health assessment. The Charge Nurse noted that an ACCT
document had been opened for the man, but that he had denied any intention
of self harm or suicidal thoughts. At no point, however, were any members of
healthcare involved in reviewing his ACCT plan. The Charge Nurse made a
further entry in the IMR on that day. It says he called into the induction wing
to see the man, but he was having a visit at the time.
31. The Charge Nurse’s impression was of a man who was having some difficulty
adapting to prison life. Although the man said he had no major concerns, the
nurse completed a routine referral form for a mental health assessment by the
Staff Nurse. This referral would normally take between two and five weeks
and the Charge Nurse did not feel an urgent referral (which would take no
more than two weeks) was necessary. The Charge Nurse said at interview
there was nothing to suggest the man had any predominant mental health
issues. Had he been aware or seen the OASys document he may have made
an urgent referral.
32. There were no further entries in the IMR until a retrospective entry was made
by another nurse after the man’s death. There is no evidence to suggest that
the man was ever assessed by the Staff Nurse.
ACCT plan and ongoing record of events
33. The ACCT document was opened on the man by the Healthcare Assistant on
12 March. The Temporary Senior Officer (T/SO) who was the unit manager on
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the Induction wing was responsible for discussing the man’s ACCT plan with
him. On page three of the ACCT form, the healthcare assistant had
highlighted the concerns she had about the man. The healthcare assistant
noted that the man had been thinking of harming himself since being in
custody and was very low in mood. It was noted that he should be seen by a
mental health nurse due to his previous condition and medication.
34. The T/SO devised an immediate action plan with the man. The plan noted
that he would prefer to be located in a shared cell. The T/SO considered
moving the man to the vulnerable prisoners unit, but thought it best to give
him the opportunity to settle on normal location rather than be located on a
unit with prisoners who were segregated because of the nature of their
offences. The T/SO also noted that the man should have three recorded
conversations daily with staff and three recorded observations throughout the
night. There were no set times for the interactions to avoid the man being
able to predict when they would take place. The man was also given access
to the telephone to speak to his partner and father. The T/SO explained the
work of the Samaritans and the support that was available to the man at
Brinsford. The T/SO noted an immediate intervention was that the man
should be seen in healthcare for an assessment as he had stopped taking his
antidepressants three months earlier.
35. The T/SO then carried out the mandatory tasks explained on page four of the
ACCT document. She organised the man’s case review, referred him to
healthcare for assessment and briefed staff. She also recorded in the unit
observation book the requirements for the conversations and observations he
was to have. Finally the T/SO logged the ACCT document. Prison staff noted
on 12 March in the on-going record part of the ACCT document (as part of the
interactions and observations of the man) that he said that he was feeling fine
and seemed upbeat.
36. An officer carried out an ACCT assessment interview with the man the
following day (13 March). The man talked about what he believed his
problems were. These concerned missing his family and the fact he had
stopped taking his antidepressants. He said he had no thoughts of self harm,
but contradicted this by saying he had had thought of hanging himself.
However, he said he had not acted upon these thoughts because of his
children and that they and his partner were his reason for living. The officer
noted that the man’s immediate plan was to look at ways to cope with
boredom (such as visiting the gym, education and association), to ensure he
received visits and letters, and to be assessed in healthcare with a view to
reviewing his medication.
37. The T/SO also saw the man on 13 March, about 15 minutes after his ACCT
assessment with the officer. The man told her that he felt okay, but had had
thoughts of hanging himself the previous two days. He agreed that he was
aware of the support available to him. He said he felt nervous about his
transfer out of the induction unit and onto a wing. It was agreed that the man
would stay on the Unit for another night, although this was also due in part to
the lack of spaces on the wings.
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38. The T/SO also completed a caremap on page 13 of the ACCT document.
Two issues were noted for action. The first was that the man should be
assessed in healthcare and be referred for a mental health assessment. The
second was to contact his solicitor with a view to applying for bail. Both
actions were completed later that day. The solicitor told the officer who
completed the ACCT assessment that the man would not be eligible for bail,
but it is unclear whether she passed this information onto him. The
assessment of the man in the on-going record for the rest of the day was that
he was interacting well with staff and seemed happy in a shared cell. He
appeared cheerful when he returned from a visit and, when asked, said he
was fine.
39. The next day (14 March) the man was transferred from the induction unit to
the first night unit. As part of the ACCT process, the T/SO completed a
review on page 14 of the document. At this review, the T/SO reviewed the
man’s level of risk as low. The T/SO also recorded that the man had thought
of harming himself and had reservations about locating onto a wing. The
T/SO asked that the man’s progress and transition onto the wing should be
monitored and warned that he might be a target for bullies because of his
stammer. (This is not something that the man ever appeared to complain
about, and does not seem in practice to have been an issue.)
40. In the on-going record for 14 March, a member of staff noted that the man
was given a phone call to his solicitor who told him he would not be able to
have bail. The note says that the man, “has accepted this with problem”. (I
assume this should have read without problem.) It was also noted that at
12.20pm the man chatted with staff about a transfer. He said he had no
thoughts of self harm and had appeared chatty and upbeat. However, by
4.20pm that afternoon the man had told staff he was feeling low and wanted
to see someone in healthcare. He was told he could do so the next morning,
although there is no entry in the on-going record to suggest that this
happened.
41. Later that evening, another member of staff spoke to the man. Although the
entry is not annotated clearly (very few members of staff wrote their names
rather than simply initialling their entries), it would appear that the staff
member was a SO. The entry says that the SO had allayed some of the
man’s fears that he would come to harm if allowed to mix with other prisoners.
The man said that his confidence had received a massive boost and they had
agreed to sort out his canteen (purchases from the prison shop) and phone
call issues the next morning. There is no earlier entry to explain what these
issues were, but the man had got into debt through borrowing tobacco and it
was likely that he was using his canteen to repay the debt.
42. It was noted on 15 March that the man said he had no problems and seemed
content. It was also recorded that his canteen problems had been sorted out
and his phone call had “been done”. On 16 March, the man told staff he had
no problems and seemed relaxed and settled.
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43. On 17 March, the SO who had spoken with the man on 14 March made an
entry in the on-going record section of the ACCT document. He noted that
the man’s mother had telephoned the prison and was concerned that her
son’s mood seemed very low. The SO spoke to the man who told him that he
had been verbally intimidated (he gave no further details). He also discussed
how he had become in debt to another prisoner through borrowing tobacco.
The man commented on his Ben Sherman watch, which he seemed to be
concerned about, although he denied that anybody had asked him for it. The
SO said he would investigate the matter and speak to the man again the next
day. (The SO would investigate the issues and also report back to the anti-
bullying meeting as part of the BRAVES protocol.) An entry later that evening
said that the man seemed better after his conversation with the SO and would
be alright overnight.
44. The man’s second ACCT case review was held the next day (18 March). He
had been transferred from E1 wing onto G1 (although it is not clear from
prison records why he was moved) and appeared much happier. The SO
wrote in the on-going record of the ACCT document that the issue with the
tobacco debt had been resolved. He noted that the man had been upset
about it. They also spoke about the man’s watch and the SO advised him to
store it away rather than keep it in his possession. The man said he planned
to do this and told his family that he had done so. The man’s Prisoner’s
Property Record does not show that he put the watch into store, although an
undated annotation on the record says “Ben Sherman Watch 01564170 Not
on card”. This may suggest that the watch was in fact stored away.
45. The man also told the SO that he had no thoughts of self harm at that
moment. The SO encouraged him to telephone his partner and mother at the
earliest opportunity. The SO noted that the man had seemed a little tearful
after speaking to his partner, but had said he was okay. The SO thought that
the man should remain on the ACCT plan (the next case review was due on
25 March).
46. The man continued to be monitored on the ACCT. On 19 March, he said he
had no thoughts of self harm and was okay. The next day, he told an officer
he felt down and was given a phone call. On 21 March, he interacted well
with peers and did not speak about self-harming.
47. There was nothing else recorded of note until 22 March at 12.15pm when the
SO made a further entry in the on-going record. He said that the man had
appeared to be very tearful and said he did not think he could cope in prison.
They discussed the fact that the man could not be transferred until he had
been sentenced and how much he was missing his family. The SO recorded
that the man appeared more settled after their conversation and he had
advised him to consider speaking to the landing Listeners. The man replied
that he was not interested in doing so at that time, although he did actually
speak to one of the Listeners later that day. Although the Listener was unable
to disclose the exact nature of their conversation, he said at interview that the
man was crying when he first spoke to him but seemed better by the end of
the conversation. The Listener said he was shocked when he heard that the
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man had taken his own life. He had seemed okay at lock up that day and
thought their conversation had helped him.
Events of 23 March 2007
48. There is an entry in the on-going record in the ACCT form which says that the
man was unlocked at 7.45am on 23 March 2007 and had seemed to be in a
good mood. When asked by an officer how he felt, he replied that he felt
alright and he was given a phone call. Phone records show that he made 16
telephone calls that day. He made a call at 7.45am which lasted three
minutes and 26 seconds. He made another call to the same number at
10.20am, but phone records show there was no reply. The man made a
further six calls between 10.20am and 11.14am, but only the final call
appeared to connect. It lasted 31 seconds. The man made eight calls to his
partner’s mobile phone between 10.21am and 11.13am. Only one call to this
number at 10.46am appeared to connect. It lasted for 23 seconds. Phone
records show that on five of these calls the person receiving the calls hung up
and the caller hung up three times. The man’s partner said that she kept
losing her mobile phone connection, as she was in a poor area for reception.
A fellow prisoner at Brinsford said at interview that he had heard a rumour that
the man had an argument with his family on 23 March. He had not witnessed
this himself.
49. The man was spoken to by a prison officer at 11.05am as part of the three
daily interventions written into the ACCT document. An entry was made in the
ACCT that he seemed alright and there were no problems or concerns.
Another officer spoke to the man at 1.00pm when he stated he was fine and
seemed content. At 2.30pm, the man spoke to another officer about a visiting
order (VO) for his mother. It seemed that the man had missed the opportunity
of a visiting order when he moved wings, and had effectively missed a week’s
worth of visits. His mother had telephoned the prison to try to clarify the
situation. The officer wrote that the VO would be issued the next day and the
man seemed satisfied. That is the last entry made in the ACCT document.
50. From the interview with the Senior Officer in charge of the wing it is possible
to account for the rest of the man’s day. The SO said that an officer had
spoken to her as he was concerned that the man’s cell-mate had gone to
court and this meant that the man would be alone. The officer had arranged
for the man to spend time out of his cell cleaning the landing, interacting with
other landing cleaners (who were also trained Listeners) and using the
telephone. The man’s last call was made at 11.14am and lasted 31 seconds.
51. The officer wanted to check with the SO in charge of the wing that she was
content for the man to spend the lunchtime alone in his cell. The officer had
spoken to the man and asked him how he felt and whether he was going to do
anything silly. The man replied, “No, I wouldn’t do that”. Based on this
information, the SO confirmed that the man could have lunch on his own.
After lunch, the man had been seen back out on the landing and again he had
used the telephone (although there is no printout of any calls being made on
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the phone records). Some of the prisoners whom the man talked to were
Listeners, although he did not speak to them in that capacity.
52. Another prisoner told the investigation that he heard the man call out from his
cell for an officer at about 4.30pm. The prisoner went to the man’s cell and
said there were no officers on the wing. The man said he wanted to make a
telephone call and the other prisoner told him he would have to wait until that
evening. The prisoner said that the man had seemed happy with that. (It is
probable that the time the other prisoner recalls is incorrect as the man was
unlocked until 4.50pm and the other prisoner was not unlocked for the gym
until 5.30pm.)
53. At 4.45pm, the SO in charge of the wing had another conversation with the
officer about whether the man should be in a cell on his own. His cell mate
had not returned from court (in fact he did not return to Brinsford at all). As
the man had seemed to be in quite a jovial mood, had responded positively to
all the interactions with staff during the day, and had already spent the
lunchtime alone in his cell, the SO agreed that the man could go back into his
cell until tea time. The SO would then reconsider what to do after tea if his
cell mate still had not returned from court. Before the man returned to his cell
at 4.50pm, he asked the other prisoner if he could borrow a stereo from him
as he had two in his cell. The other prisoner also lent him a CD. (Borrowing
the possessions of another prisoner is commonplace but against Prison
Rules. Any items found in a prisoner’s cell during a cell search that do not
appear on their property card should be removed. However, staff would not
have known that the stereo in the man’s cell was unauthorised until or unless
they read his in possession property card and carried out a cell search.)
54. At approximately 5.30pm, the other prisoner and the Listener, who were
located in the cell opposite the man, were unlocked early so they could go to
the gym. The officers and the SO in charge then began to unlock the rest of
the landings in their usual order to allow the prisoners out to collect their tea.
G1 landing, where the man was located, was the last to be unlocked.
55. The SO came to the man’s cell at about 6.30pm. She looked through the flap
in the door before unlocking it and saw that he appeared to be hanging. The
SO immediately entered the cell, followed by another officer. The SO told the
investigation that the man was almost sitting on the floor, with his legs
outstretched towards the door. He had tied an electrical cable from the stereo
to the frame of the bunk bed and had attached the other end around his neck.
The SO called out for someone to raise the alarm whilst she and the officer
went to cut the man down.
56. The officer supported the man’s body, while the SO cut the ligature using her
anti-ligature fish knife (a specially designed knife carried by all front-line staff).
In the meantime, another officer had taken the SO’s radio to make a call for
urgent medical assistance and request an ambulance. The first nurse to
arrive at the scene recalled at interview that a call was made for a medical
emergency over the radio. However, the location of the cell with the
emergency was incorrect and she ran to the wrong location before being re-
15
directed to the man’s landing. At interview, the nurse said her colleagues in
healthcare had not been aware of the emergency as they had not heard the
call. One colleague had not been issued with a pouch to hold the radio, and
the other’s radio battery was flat.
57. The SO in charge of the wing and the officer who had entered the cell with her
placed the man on the floor and the SO checked for breathing and a pulse but
found neither. The SO confirmed at interview that she held a current first aid
qualification. Rigor mortis had not set in and the SO began attempts to
resuscitate the man. She placed a mask over his mouth and she and the
officer commenced cardio pulmonary respiration (CPR). The officer began
working on chest compressions whilst the SO concentrated on mouth to
mouth resuscitation. They worked at a ratio of two breaths to every 15
compressions. (The universal recommended ratio is two breaths to every 30
compressions, although a ratio of 2:15 is suggested by some authorities when
two people are involved in the rescue attempt.) There were no defibrillators
located on the wing, although there may have been one in healthcare.
Access to a defibrillator might have been helpful, as it would have indicated to
the SO whether the man had a shockable heart rhythm.
58. When the nurse arrived at the cell she volunteered to take over the mouth to
mouth resuscitation from the SO who was visibly tiring. Three officers had
arrived at the cell shortly after the SO and the first officer on the scene had
entered the cell. One of those had used the SO’s radio to request medical
assistance, another relieved the first officer on the scene and took over
administering chest compressions from him. The nurse, who had been
suffering from a heavy cold and had run a distance of about a quarter of a
mile to the man’s cell, began to tire so the SO took over the mouth to mouth
resuscitation again.
59. The third of the three officers to arrive at the cell heard over the radio that an
ambulance was on its way so went to wait for it at the gate, ready to escort it
through the prison. The first response team arrived within a few minutes. The
paramedics relieved the officers and continued with the attempts at
resuscitation. Another ambulance crew arrived about ten minutes later and
brought equipment with them. They continued to work on the man for
approximately another half an hour but were unable to revive him.
60. The prison’s on call doctor arrived at the prison at 8.10pm where he was
escorted to the man’s cell. The doctor examined the man’s body and
confirmed there were no vital signs. He pronounced death at 8.29pm.
61. Whilst staff were trying to resuscitate the man, other prisoners began to make
some noise as they had not been unlocked for tea and were not aware of
what was going on. Staff told the prisoners that there was an emergency and
the officer who had escorted the ambulance arranged for those who worked
on the servery to be unlocked to plate up the meals for the others. Officers
then delivered the meals to their cells. From interviews, it does not appear
that staff specifically explained to prisoners what had happened to the man, or
16
checked whether they were alright when they did this, as they were unsure
whether it would be appropriate.
62. Staff were asked to remain at the prison while the police took statements from
them. The Coroner’s Officer also arrived later that evening. At around
11.00pm, the Governor held a de-brief. At interview, staff spoke of being
expected to arrive for the normal duty the next day - despite staying late that
evening and the traumatic experience of the man’s death.
63. The prison’s Family Liaison Officer, a Principal Officer (PO), the Governor and
the prison Chaplain left the prison at approximately 1.00am to visit the man’s
next of kin to break the news of his death. The PO had advised the Governor
that this information should be given by them rather than the local police.
Unfortunately, there was a considerable delay in leaving the prison as the PO
was the designated person who had to assist the police and wait for the
Coroner’s Officer to arrive. With hindsight, it would have been sensible for
another member of staff either to have attended to the police or to have
visited the man’s family.
64. The man had named his mother as his next of kin and it was agreed that the
PO, the Governor and the Chaplain should visit her personally. They were
met by local police at about 2.00am and escorted to the man’s mother’s
home. They arrived there at 2.10am. After breaking the tragic news, they
gave her information about the PO’s role and about procedures and details of
associations who deal with bereavement. An offer was made to pay for the
man’s funeral and to accompany his mother to visit her son in the Chapel of
Rest. They also told the man’s mother that she and other family members
were welcome to visit Brinsford to lay flowers in the cell where the man died.
The Governor agreed to put all this information in a letter. (He did so on 23
March, but the letter did not reiterate all the information including the offer to
pay for the man’s funeral.) The man’s mother said she needed to go to tell
the man’s father what had happened and, at her request, the prison’s
representatives did not accompany her. They left her house at 2.30am.
65. A further critical incident de-brief was held a week or so later. Staff at
interview commented on how well they had been supported by members of
the Care Team but felt less supported generally by senior managers. In
particular, my investigators were told that staff were asked to return to duty as
soon as this de-brief finished, before refreshments were served and before
staff had an opportunity for an informal talk about what had happened.
66. A post mortem was held on 28 March. This concluded that the man died as a
result of hanging and that the marks on his neck were consistent with a
ligature. There was no other evidence of external violence or of any pre-
existing disease that would have contributed to his death. The cause of
death was asphyxia by hanging.
67. The PO rang the man’s mother on 2 April. He enquired whether the prison
could help with the cost of the funeral. The man’s mother said she was
having problems with the cost and gave the PO the details of the funeral
17
directors. The PO rang the man’s partner on 5 April. He asked whether she
wanted to visit the prison and meet some of the prisoners who had known the
man. The PO also explained that the Governor had agreed to pay for the
man’s funeral and that, as soon as they had paid the invoice, the funeral
directors would reimburse any deposit the family had made. The man’s
partner said she would pass on this information to the man’s mother. She
said she would also consider visiting Brinsford after the funeral, but could not
think about it then. The man’s funeral was held on 10 April.
18
ISSUES
Clinical issues
68. The man told wing and healthcare staff involved that he had stopped taking
his prescribed anti-depressants and sleeping tablets about three months
before he arrived at Brinsford as he had begun to feel better. He asked for
the prescription to be renewed. On 11 March 2007, he had an appointment
with the prison doctor who recorded that he was to receive some medication.
However, the doctor did not complete a prescription chart to alert healthcare
staff to his intentions. The clinical review says that the completion of this
documentation is the responsibility of the prescribing doctor. After making
further enquiries, the clinical reviewers confirmed that no prescription was
ever received in the dispensing pharmacy.
The Primary Care Trust should review the actions of the prison doctor.
They should also ensure that prescriptions for any medication are
completed on the correct documentation.
69. The clinical review also found that standards of record keeping were poor and
inconsistent. The review says that urgent attention should be paid to
improving the standards and legibility of the documents in the interests of both
prisoners and professionals. My investigators found this also to be the case
when non-healthcare staff annotated other documents such as the on-going
record in the ACCT.
The PCT should ensure the standard of documentation is improved in
prison records, for example the use of abbreviations, and all entries
made in prison documentation should be signed with a legible and
printed signature.
The Governor should consider ways of improving the standard of
documentation in prison records.
70. The Charge Nurse made a mental health referral for the man, but he
remained on the waiting list until the day he died. Another referral was also
made by the T/SO Unit Manager. If either had been aware that the man had
tried to take his own life on two previous occasions (from information in the
OASys report) a more urgent referral would surely have been made. It can
only be assumed that the report was kept with the man’s core record and filed
away, despite the valuable information it contained. The clinical review found
that there were no formal protocols in place for such referrals, nor any clear
guidance on how to prioritise referrals and on the acceptable length of time to
be on a waiting list for a referral.
The Governor should ensure that prisoner’s documentation is checked
for incidents of previous self-harm and that this information is passed to
the appropriate department.
19
71. There was no defibrillator on the wing where the man died. If staff had had
access to, and been trained to use the machine, the SO would have been
able to detect whether the man had a shockable heart rhythm before
commencing CPR.
Staff should be trained to use, and have access to, defibrillators on the
wings.
72. The clinical review concluded, after consideration of the records, their
investigations and associated paperwork, that the man received a level of
care equivalent to that received in the community, with the notable exception
that he did not receive the anti-depressants that the prison doctor said he
prescribed for him. The clinical review says that the Primary Care Trust must
take action to address this matter.
A review of the Out of Hours service provider should be carried out to
ensure that appropriate documentation is completed and that correct
processes are in place for writing prescription charts. Also that entries
made in the IMR meet national record keeping standards.
73. The clinical review makes a further recommendation concerning a service
review of Brinsford’s Primary Mental Health Service. This does not directly
relate to the circumstances of the man’s death and has been addressed
separately to the Chief Executive of the Primary Care Trust as have three
examples of good practice.
ACCT
74. The ACCT document was opened when staff first became concerned about
the man. The documentation and reviews were carried out appropriately, as
was the level and frequency of interactions and observations. However, some
actions did not appear to be followed up, for example when the man
requested to be seen by someone in healthcare on 14 March. It is also not
clear whether the officer who carried out the ACCT review on 13 March told
the man that he would not be eligible for bail (although he was told this
himself after he had spoken to his solicitor). No healthcare staff were ever
involved in the ACCT reviews. This would have provided some cohesion
between the healthcare and the wing staff who were responsible for
monitoring the man.
The Governor should ensure that actions noted in an ACCT document
are followed up by staff.
The Governor and PCT should review the input of the healthcare team
into ACCT reviews, in particular when a patient is awaiting a mental
health assessment.
75. The actions taken by the officer and the SO on 23 March show that they were
concerned about the man and carefully thought through their actions. The SO
decided to allow the man to have lunch in his cell alone and the officer kept
20
him out on the wing to interact with staff and other prisoners, including those
who were Listeners. As the man had seemed fine, the SO made a
considered judgement that he could be locked up alone again at tea-time. As
this had already been the case at lunch, and given that the man had seemed
okay and had been interacting with staff and discussed a visiting order for his
mother, it was not unreasonable for the SO to make this decision. It is to their
credit that the SO and the officer thought through the decisions based on what
they believed to be in the man’s best interests. (I have been impressed
generally by what I have learned of the SO’s professionalism, and the
Governor may wish to consider if this should be formally recognised in some
way.)
Bullying
76. I have found no evidence to suggest that the man was bullied because of his
stammer whilst he was at Brinsford. It is unclear whether he was ever asked
for his watch by other prisoners and, although he mentioned that he had been
verbally intimidated, he gave no further information. The man’s family believe
that he was having trouble with relationships with other prisoners but, aside
from two issues about his watch and the debt he was in, he did not discuss
this with staff. The SO who made an entry on to the man’s ACCT on 14
March spent time talking to him about this and gave him advice which seemed
to help. The debt issue also appeared to be resolved, again with help from
the SO.
Prison radios
77. At interview, the first nurse on scene spoke of the difficulties healthcare staff
had experienced with prison radios. On the evening that the man died, her
healthcare colleagues were unaware of the emergency as they did not have
radios. One person did not have a radio because there were no pouches
available and the other’s battery had gone flat. The nurse recounted another
occasion when she worked a nightshift with no radio as the battery was flat as
it was in the replacement she was given. I am pleased to learn that the
Governor has already taken steps to rectify this matter.
All staff, including healthcare staff, should be issued with working radios
and pouches. The Governor should remind staff of the importance of the
correct use of codes and other information in emergency situations.
The man’s self assessment checklist
78. The man’s family raised as a matter of concern a checklist which was
returned to them with his property. This document had not been forwarded to
my investigators to consider as it was amongst his possessions and not
amongst any prison documentation. On the checklist, the man had assessed
himself as feeling very low and his family believe this was completed on the
day before he died although this is not certain. If the form had been issued to
the man and he was meant to return it to a member of staff, then clearly he
did not do so. Unless the checklist had been shared with staff they could not
21
be expected to act upon it. However, it is clear to see from other prison
records that the man’s mood varied frequently and that staff were already
monitoring him through the ACCT.
Informing the family
79. My investigators were concerned at the length of time taken to inform the
man’s mother of his death. Whilst there is always the need for liaison and co-
ordination at the prison after a death, consideration of the needs of the
bereaved family should be foremost in people’s minds. If the PO who was the
designated Family Liaison Officer was, as he said at interview, fully occupied
with escorting and liaising with police and then awaiting the Coroner’s Officer,
arrangements should have been made for another member of staff to take
over this role to allow the PO and the Governor to visit the family.
The prison should ensure that the family of the deceased is notified of
the death at the earliest opportunity.
Support for staff
80. At interview, a number of staff voiced concern about the level of care they
received after the man’s death. Most spoke of being kept at the prison until
late on the day he died, with an expectation that they report for their shift the
next day. Brinsford have since said that the Duty Governor and the Care
Team arrived on the unit very quickly and that staff were told if they had to
stay late to speak to the police they would not need to return first thing in the
next morning. One officer spoke of the arrangements for the critical de-brief,
where staff were told to return to work immediately after it ended without time
for an informal chat and refreshments. I am not sure if this was coincidence,
but I note that a number of staff who were involved in attending to the man’s
death then began an absence of long term sick leave.
All staff involved in a death in custody should be offered appropriate
care and support by senior managers, as well as the Care Team, and
time given for a thorough de-brief afterwards.
Support for prisoners
79. Staff seemed uncertain about the best way to inform prisoners about what
had happened to the man. It seems likely that his death would have had an
impact on some prisoners, especially those with whom the man spent time.
Staff should have been briefed on how best to ensure they felt supported.
Prisoners who are affected by a death should be made aware of the
support available to them, whether it be through the chaplaincy, wing
staff, Listeners or Samaritans, and given the opportunity to talk.
22
RECOMMENDATIONS
To the Governor
1. To consider how the standard of documentation in prison records can be
improved.
2. To ensure that prisoner’s documentation is checked for incidents of previous
self-harm and that this information is passed to the appropriate department.
3. To ensure that actions noted in an ACCT document are followed up by staff.
4. To ensure all staff, including healthcare staff, are issued with working radios
and pouches. To remind staff of the importance of the correct use of codes
and other information in emergency situations.
5. To ensure that the family of the deceased is notified of the death at the
earliest opportunity.
6. To ensure all staff involved in a death in custody are offered appropriate care
and support by senior managers, as well as the Care Team, and time is given
for a thorough de-brief afterwards.
7. To ensure prisoners who are affected by a death are made aware of the
support available to them, whether it be through the chaplaincy, wing staff,
Listeners or Samaritans, and given the opportunity to talk.
To the Governor and the Primary Care Trust
8. Staff should be trained to use, and have access to, defibrillators on the wings.
9. To review the input of the healthcare team into ACCT reviews, in particular
when a patient is awaiting a mental health assessment.
To the Primary Care Trust
10. The Primary Care Trust should review the actions of the prison doctor. They
should also ensure that prescriptions for any medication are completed on the
correct documentation.
11. The PCT should ensure the standard of documentation is improved in prison
records, for example the use of abbreviations, and all entries made in prison
documentation should be signed with a legible and printed signature.
12. A review of the Out of Hours service provider should be carried out to ensure
that appropriate documentation is completed and that correct processes are in
place for writing prescription charts. Also that entries made in the IMR meet
national record keeping standards.
23