Individual at Hull

Investigation into the circumstances surrounding the
death of a man in the custody of
HMP Hull in March 2008
Report by the Prisons and Probation Ombudsman for
England and Wales
November 2008
Final Report
This is the report of an investigation into the death of a man found hanging in his cell
at HMP Hull on 14 March 2008. Following staff efforts to resuscitate the man, he
was transferred to a local hospital where he died the following day.
I pass on my condolences to the man’s family and friends for their loss. I trust that
this report addresses the questions that they have about his care in prison.
The investigation was carried out by one of my investigators. I am grateful to the
clinical reviewer who was appointed by Hull Teaching Primary Care Trust to examine
the man’s clinical care. I would also like to thank the Governor of Hull. The Head of
Residence and the appointed investigation liaison officer offered my investigator
excellent support throughout the investigation process.
I raise concerns about alcohol detoxification, information sharing and the treatment
of self harm. The man seemed to settle in well, but was subject to suicide prevention
measures for one week, following an episode of self harm. The measures were lifted
three days before he died.
My report contains eight recommendations for the prison to take forward, including
one intended to strengthen suicide prevention measures, five for healthcare delivery,
one for the bail information office and one for the Governor to consider in relation to
emergency response procedures.
Jane Webb
Deputy Prisons and Probation Ombudsman November 2008
Final Report 2
CONTENTS
Summary
The Investigation Process
HMP Hull
Key Events
Issues
Recommendations
Final Report 3
SUMMARY
The man was admitted to a local mental health unit to assess his mental state
following an attempted overdose on 13 February. His family described him as an
alcoholic and by his own admission he was a “heavy drinker”. On 18 February, he
was discharged from the unit, drank whisky and committed his alleged offences.
Police took the man into custody where he remained for two days, until he was
remanded to HMP Hull on 20 February, following a court appearance. This was his
second time in custody. His first experience of prison was a short sentence in open
conditions in 2000.
During his first reception healthscreen at Hull, the man laughed with staff about how
he had ended up in prison. He told them he took the overdose on 13 February so
that he would be sectioned and receive treatment for his alcoholism. He said he had
no intention of harming himself. The man’s manner was cheerful according to the
nurse leading the healthscreen, although the observing nurse felt that he was
masking his anxiety. She noticed no signs that he was withdrawing from alcohol.
The lead nurse assessed that the man was not at risk of suicide or self harm but
made a mental health referral.
The next morning the man saw the doctor for his secondary health check. The
doctor assessed him as having no mental or physical health needs. He did not think
that the man was at risk of self harm or suicide. The mental health assessment took
place later that day. Again, the primary care mental health team leader did not
identify any mental health problems and the man assured her that his alcohol misuse
issues had been dealt with at the mental health unit earlier in the month. In fact, the
man had yet to undergo a clinical detoxification. The team leader decided that he
needed no further mental health supervision.
The man went through his induction and settled well on the wing. His solicitor wrote
to the Bail Information Office to try to secure a hostel placement so that he could
spend his time awaiting trial in the community, rather than in prison. The Bail
Information Office did not receive the correspondence in time for a court hearing on
27 February, so the hearing was adjourned until 4 March.
The adjourned videolink hearing went ahead on 4 March (a court appearance where
the defendant appears by video conferencing facilities rather than in person). The
man was refused bail on the grounds that he had failed to address his alcohol
misuse needs. Another hearing was scheduled for 18 March. The man was upset
by the videolink hearing. He took an overdose of what he thought were 32
paracetamol tablets (in fact it is likely that they were two sanitising tablets and a
number of sweets). He alerted staff that he had taken an overdose and was taken to
be examined by a nurse. The nurses on duty were not convinced that the man had
taken an overdose. They checked his pulse, blood pressure, temperature and pupil
dilation. They did not refer him to hospital or take a blood test and no mental health
referral was made. He was checked by a nurse later that night, who could find not
physical symptoms of an overdose.
Officers started suicide prevention measures. During the night the man shaved his
eyebrows off, but no mention is made about this in his records. The suicide
Final Report 4
prevention measures continued for a week, during which time no further concerns
were raised. Following a review, the suicide prevention measures were stopped.
The man was visited by his solicitor on 12 March. The solicitor had no concerns
about his wellbeing following their meeting. Two days later, a prisoner who had
become friends with the man on the wing went to see him in his cell. He was
hanging from the metal bracket supporting his toilet. The prisoner could not support
the man’s weight on his own and called for assistance. Another prisoner came to the
cell and helped to support the man’s weight.
Officers on the wing heard shouting and made their way to the cell. They took over
from the prisoners, thanked them and asked them to leave. Officers cut the ligature
around the man’s neck and the cord that was bound around his wrists. They started
resuscitation efforts until healthcare staff arrived within minutes. Nurses continued to
resuscitate until the paramedics arrived. The paramedics administered adrenaline
and the man showed signs of life. He was transferred to the local hospital, where he
remained unconscious until he died the following morning.
Final Report 5
THE INVESTIGATION PROCESS
1. I appointed an investigator from my office to conduct the investigation into the
circumstances surrounding the man’s death. The Head of Residence
immediately organised for the man’s prison records to be copied and sent to my
investigator. Notices were sent to the prison to invite prisoners and staff to
contact my office with any information they thought was relevant to the
investigation. There was no response to these notices.
2. The investigator was unable to open the investigation within the customary
three days and visited the prison on 2 April to meet staff and collect additional
information. She met the Deputy Governor and her investigation liaison officer.
During this visit, she also met the Detective Constable leading the police
investigation. (All deaths in custody are subject to an initial police investigation
before I can continue with my investigation.) The Detective Constable
confirmed that the police were not treating the death as suspicious and were
happy for my investigation to go ahead. I am grateful to the police for sharing
relevant information with my investigator.
3. A Clinical Governance Manager was appointed by Hull Teaching Primary Care
Trust (PCT) to conduct a review into the clinical care that the man received
while he was at Hull. I would like to thank the clinical reviewer for her co-
operation with the investigation process and for the comprehensive review
which has been so valuable to this report.
4. After a thorough review of the paperwork, the investigator arranged to visit Hull
to interview staff and prisoners. She contacted the man’s cellmate who had
been transferred to Durham prison, and conducted a telephone interview with
him.
5. One of my family liaison officers contacted the man’s brother, the listed next of
kin. He discussed his concerns about the man’s care at Hull and suggested
that my family liaison officer contact the man’s daughters. My family liaison
officer, accompanied by my investigator, visited the man’s daughters and wife
who expressed concern about the treatment that he received for his substance
misuse. They were also anxious to discover why the man was not subject to
suicide prevention measures when he died. I have examined these issues in
the report.
6. Following her meeting with the family, the investigator was joined by the clinical
reviewer to conduct joint interviews with officers and healthcare staff. She
interviewed another of the man’s cellmates who was still at Hull. My
investigator wrote to the man’s solicitor for information about the outstanding
criminal matters. I am sincerely grateful for the information that he provided for
the investigation in his written response. The clinical reviewer joined my
investigator for follow-up interviews at the end of May. My investigator then
conducted telephone interviews with the members of the Bail Information
Office.
Final Report 6
HMP HULL
7. Hull is a local prison that serves the Yorkshire and Humberside Area. As with
all local prisons, it is under constant pressure to accommodate the large
numbers of prisoners that make up its ever-changing population.
8. Her Majesty’s Chief Inspector of Prisons carried out her last full inspection in
November 2005. Hull has changed considerably since the time of that
inspection due to the closure of a much-criticised unit. At that time, the Chief
Inspector found that “the healthcare centre provided a good service”.
9. In her examination of the substance misuse resources at Hull, the Chief
Inspector focussed on the increasing support available to prisoners who used
drugs rather than alcohol. She concluded that the policy was still under
development and training needs of staff were beginning to be addressed. The
Integrated Drug Treatment Service (IDTS) unit opened in September 2007.
Predominantly for the treatment of prisoners withdrawing from drugs, those
going through alcohol detoxification are also supervised on the unit. It is a
discrete wing with extra healthcare staff, where only prisoners going through
detoxification are located and receive additional support.
10. The Measuring the Quality of Prisoner Life (MQPL) survey, carried out in
November 2007, found a small majority of prisoners negative about
relationships between prisoners and staff. This was in contrast to the
Independent Monitoring Board’s finding, in its annual report for 2006/7, who
found staff “dedicated and loyal”. A number of prisoners who participated in the
MQPL survey expressed frustration at the lack of employment opportunities.
The Inspectorate found “the overall quantity of purposeful activity remained
insufficient, with prisoners spending too long locked up in their cells”.
11. The man’s death was the first apparently self-inflicted death at Hull in 2008. At
the time of writing, no other prisoner has died by apparently self-inflicted
means, although there have been four deaths by natural causes so far this
year.
Final Report 7
KEY EVENTS
12. The man was remanded to Hull on 20 February, following a court appearance
at North Lincolnshire Magistrates court. A self-harm warning form was
completed by court staff. It recorded the man’s attempted overdose on 13
February and that he had made statements of intent to self-harm. Court staff
passed the form to escort staff, who, in turn, passed the form to an officer
working in reception. The reception officer signed the warning form to
acknowledge its receipt. It was filed in the man’s wing history and a copy taken
for his clinical record.
13. While the man was in reception, two other officers completed a cell sharing risk
assessment. The purpose of the assessment is to determine whether it is safe
for a prisoner to share a cell. They referred to the Prisoner Escort Record
(PER) and warrant. As discussed, there was an asterisked message on the
warrant, “*PLEASE NOTE – DEFENDANT IS VULNERABLE*”. However, the
officers did not mention the man’s highlighted vulnerability on the cell sharing
risk assessment. Once the relevant section was completed, the form was
passed to the nurse in the first night centre for her counter-signature as the
healthcare professional on duty that evening.
14. The Head of Healthcare has set up a system whereby any documents that
indicate a prisoner’s vulnerability must be faxed through to her in the healthcare
centre by reception officers. The man’s warrant was duly faxed through to her.
Although she could not specifically remember the warrant, she told my
investigator that she would have checked the man’s records to see if any action
had been taken by staff. The Head of Healthcare said that she would have
been satisfied to see a referral had been made for a mental health assessment
and so taken no further action.
15. The man’s first reception healthscreen took place at 8.40pm. (A first reception
healthscreen is an assessment of the immediate mental and physical health
needs of a prisoner.) The healthscreen was held in a private room on the first
night centre so that there was confidentiality. The first night nurse completed
the healthscreen. A newly appointed nurse observed the interview as a training
exercise. The first night nurse said that the healthscreen normally takes about
15 minutes and involves the prisoner answering a number of set questions
about their mental and physical health.
16. She recorded that the man had been treated at a local mental health unit for an
“alcohol detox”. The man told the first night nurse that he took the overdose on
13 February following his wife’s instructions in order to be admitted to a
psychiatric unit for treatment for his alcohol misuse. (He retracted this version
of events in his final letter.) He told the nurse that he “had no intentions at all”
of self harm. The man explained that he drank whisky after being discharged
from a local mental health unit and then he committed his offence. The first
night nurse did not refer him for further work with his substance misuse. When
asked why she had not referred him in interview for this investigation, she said:
Final Report 8
“Because I didn’t feel like he was withdrawing. They usually have to have
some, showing some signs of withdrawal before … if he had seen the doctor
would have identified that, if had some of the signs, the doctor would have
referred him on.”
17. Following the man’s healthscreen, the first night nurse referred him for a mental
health assessment. She could not specifically remember why she made the
referral, but on checking his records during interview, said it was likely to be
due to the recent discharge from the mental health unit and an outstanding
appointment. The first night nurse also made a referral to the doctor to check
the man’s hypertension.
18. The self harm warning form from the court staff accompanied the man into his
first reception healthscreen, as did the records from his short time in police
custody. During the screening, the first night nurse signed the self harm
warning form and confirmed that she had not opened an ACCT document.
(ACCT stands for Assessment, Care in Custody and Teamwork and is the
system used to identify and support prisoners at risk of suicide or self-harm.)
She was satisfied that the man was not at risk of self harm at that time. She
described the man as relaxed and joking about how he had ended up in prison.
He said that he had been forced to take the overdose on 13 February and he
had no intention of further self-harm. He made good eye contact and his body
language was relaxed. The newly appointed nurse’s impression was that the
man’s laughter was masking anxiety. However, she was satisfied that this
would be addressed by the mental health team.
19. After the completion of the healthscreen, the first night nurse turned to the cell
sharing risk assessment. In response to the question, “Following the self-harm
assessment have any concerns been raised?”, the nurse indicated that they
had not. She went on to write, “no evidence of risk to self/others”. The man
was assessed as being a low risk and was located in a residential shared cell in
the first night centre. During interview, the first night nurse said she would not
normally look at a warrant, so she did not see the asterisked message about
his vulnerability. The man told her that he was not at risk of self harm and so
she recorded that there were no concerns.
20. Unbeknown to staff, the man had been in the local mental health unit for a
period of assessment. Although he was given medication to stabilise him
through the assessment, it was not a formal detoxification. When asked during
interview whether she thought the man’s drinking on the day of his discharge
reflected the success, or otherwise, of his apparent detoxification, the first night
nurse said, “it obviously didn’t work did it”. When asked how she would have
found out what happened to the man at the local mental health unit, she said
that she would not have been able to find anything out that night. The nurse
explained that often healthcare staff have to go on “face value” about what is
wrong with a prisoner. However, she did have access to police records that
documented his inebriated state at the time of his offence and subsequent
arrest. On this occasion, she said that the man showed no signs of alcohol
withdrawal, which she described to my investigator as “shaking, sweating, pins
and needles, things like that”.
Final Report 9
21. The following morning, the man had a health check with a doctor employed
through an agency to provide a doctors’ service to the prison. He started
working in mid-February and so had been working at Hull for about a week
when he carried out the man’s assessment. All prisoners see a doctor when
they arrive at prison for a health assessment. During this routine appointment,
the man told the doctor that he had successfully completed a detoxification
programme at the local mental health unit. The doctor noticed no signs of
alcohol withdrawal and did not discuss the man’s alcohol misuse with him any
further. The man explained that he had been taking antidepressants and
antihypertensives for high blood pressure, but that he had taken nothing over
the last ten days. The man said that he felt much better and preferred not to
take medication. The doctor found “no physical or mental health issues”. The
doctor told my investigator that he did not request the man’s medical records
from the local mental health unit because the man did not present with any
worrying symptoms that required treatment. In the doctor’s opinion, the man
was not at risk of self-harm. Although the doctor was not familiar with the
ACCT process, but he said he would have asked for the man to be admitted to
the inpatient healthcare centre for constant supervision or referred him for a
mental health assessment if he was concerned that he was at risk to himself.
The doctor noticed that the man was due to see the mental health team for an
assessment later that day.
22. The Team Leader for the Primary Mental Health team carried out a mental
health assessment the same day, following the first night nurse’s referral. She
also found no evidence of mental health problems. During the assessment, the
man, “reported a history of problems following what he described as being
given large amounts of medication and alcohol by his wife. After treatment in
hospital he now feels a new man”.
23. The primary care mental health team leader explained to my investigator that
the primary care mental health team use a specific assessment form to assess
a prisoner’s mental health. She said that a prisoner can be offered between six
and ten weekly sessions with the primary care mental health team and are
constantly reviewed during that time. The mental health assessment examines
a prisoner’s level of risk, mood, cognitive ability and whether the prisoner is
suffering from severe and enduring mental illness. She described the first
assessment as “a screening process built up through a process of discussion”
with the prisoner. The team leader said that in order to assess risk, she looks
at a prisoner’s body language. She explained indicators of risk might be as
follows: “no eye contact, they appear to be in a withdrawn state, they appear to
be unhappy, they appear to be distressed in some way or no communication as
well”.
24. The primary care mental health team leader said that if a prisoner is showing
symptoms of withdrawal, her team would refer them to the substance misuse
team on the IDTS unit. Only after a formal detoxification could her team be
usefully involved in a prisoner’s care. She remembered carrying out the man’s
mental health assessment. She said:
Final Report 10
“… at the time I saw him he was quite happy and cheerful really. I
remember him talking about how he had, he had an alcohol problem and
had just recently been in hospital … and had quite positive thoughts for the
future at that point in time and I didn’t determine any risk at all and no risk of
suicide”.
25. When the man spoke to her about his use of alcohol, she said, “he talked about
that as if it wasn’t current and as if it was a long time before”. Following her
assessment, the team leader was satisfied that the man was not in need of
further support from the primary care mental health team.
26. The man’s solicitor wrote to my investigator with details of the contact his firm
had had with the Bail Information Office, throughout the man’s time at Hull. The
original bail application requested release to the man’s parents’ address and
was refused because it would have been too close to the alleged victim’s home.
The prosecution’s solicitors indicated that they would not oppose a bail
application to an address outside his home area. On 21 February, after the
man’s remand to custody, the firm sent a letter to the Bail Information Office
asking that a hostel place be found.
27. There are two Bail Information Officers working at Hull. One of the officers said
that she did not receive the letter from the man’s solicitors until it was faxed
through on 27 February, after checking his records. Nevertheless, meeting a
Bail Information Officer is part of each prisoner’s induction process. The Bail
Information Officer could not specifically remember her initial meeting with the
man on 21 February, but there is a record of it having taken place. The
purpose of the meeting was to establish if he had any bail needs, and as the
man did not have a bail address, the Bail Information Officer identified that he
needed either supported housing or a hostel placement. She said that there
was “nothing alarming” about the meeting. It is not the role of the Bail
Information Officer to discuss a prisoner’s substance misuse needs, apart from
establishing if there are any. The man denied any problems with alcohol.
28. While he was on the first night centre the man completed the five day induction
programme to familiarise him with the rules and regimes of the prison. As part
of the induction assessment, he had an interview with a CARATs worker. (The
Counselling, Assessment, Referral, Advice and Through Care Services is a
nationwide treatment programme for prisoners who have misused drugs or
alcohol.) Officer Norrie confirmed that the man was told about CARATs and
how the workers could support him for his alcohol misuse. The man had no
recorded contact with CARATs during his time at Hull. Due to the nature of his
charges, the man was not given access to the pin phone system or a first night
telephone call. According to Prison Service Order (PSO) 4400, the Governor
must take steps to ensure that communication from prisoners charged with an
offence under the Protection from Harassment Act 1997 is effectively
monitored.
29. Once the man had completed the induction programme on 26 February, he
moved into the main area of the prison, to a shared cell on C wing. He shared
this cell with another prisoner who said that they got along well. My investigator
Final Report 11
spoke to the other prisoner during the course of the investigation. He described
the man as “an alright guy”, who smoked a lot. The prisoner said that he
respected the man as an older prisoner and looked after him. Although the
man did not leave his cell very much, the prisoner said he had no problems with
other prisoners and got along well with staff.
30. The man was scheduled to appear at court via videolink on 26 February. When
his solicitors contacted the Bail Information Office to discover whether they had
found a hostel placement, they were informed that the office had not received
the original request for a bail address sent on 21 February. The solicitors faxed
the letter again. The videolink hearing was adjourned, due to the lack of a
proposed bail address. Despite this exchange, at around 3.00pm the next
afternoon, the Bail Information Office faxed the man’s solicitor’s to ask advice
as to whether a bail application was to be made on the man’s behalf. The
solicitors again faxed the Bail Information Office on 27 February, requesting
that a hostel placement be found. The solicitor made it clear that the
prosecution were prepared to agree bail, as long as the hostel placement was
away from the area where the alleged victim lived. They attached a case
summary of the man’s alleged offence and previous convictions.
31. During interview, the Bail Information Officer explained that as soon as possible
after the initial bail information meeting, she contacts a prisoner’s solicitor to
find out whether they intend to make a bail application, and determine what the
prisoner’s bail needs are. The Bail Information Officer wrote a letter and faxed
it to the Man’s solicitors on 26 February asking whether he needed a bail
application. She said that this would have been her earliest opportunity to
contact the solicitor due to her workload at that time. The Bail Information
Officer said that she had not received the letter from the solicitor dated 21
February that crossed in the post as she sent the fax. Once the solicitor
received her fax, they faxed through a copy of the letter already sent by post on
21 February.
32. A list is kept in the Bail Information Office with all of the contact numbers for bail
hostels in the area. The Bail Information Officer said that she called all of them
and there were no spaces available. Even if there had been any spaces
available, she thought it would have been unlikely that a bail hostel would have
given the man a place. She said that bail hostels usually only accept high risk
prisoners and his criminal history meant that he was considered a low risk
prisoner. However, in any event there were no hostel spaces on 27 February,
which is why she then decided that the man should be referred to ClearSprings.
(ClearSprings is a private company commissioned by the Home Office to
provide supported accommodation for people leaving prison.) ClearSprings
take low risk prisoners who appear in certain courts in a specified area. The
man came into the ClearSprings catchment area, and they were prepared to
look at an application from him. The Bail Information Officer did not have time
to complete the man’s application for ClearSprings herself and left a request for
her colleague, the other Bail Information Officer, to complete it on her behalf
when he returned from leave on 3 March.
Final Report 12
33. Upon his return from leave, the second Bail Information Officer was clearing his
backlog and asked his colleague, a probation worker in the Public Protection
Office, to interview the man for the ClearSprings application. The probation
worker had previously completed bail hostel applications, although it was not
part of her core function at the prison. The probation worker remembered
going to the wing to speak to the man in an interview room at about 2.30pm on
3 March. She told my investigator that the man “appeared fine” and was co-
operative with the application process. She went through the form and asked
all the required information. The man wanted to talk to her about the
circumstances of his alleged offence but she said that she brought him back to
the task in hand. The probation worker said that she would never tell a prisoner
whether they were likely to get a hostel placement or not, because it is not the
Bail Information Officer’s decision and she would not want to raise their
expectations. According to the probation worker, she returned back to the Bail
Information office and passed the completed application form to the second Bail
Information Officer. The second Bail Information Officer said that it was the
probation worker who faxed the application form to ClearSprings, but her
recollection was that the second Bail Information Officer must have done it.
The application form, completed by the probation worker, was faxed to
ClearSprings without the necessary case summary. ClearSprings rejected the
application on the grounds that the man was in denial of his alcohol needs.
When the man’s solicitor contacted ClearSprings, they were told that the
application was rejected because the required case summary was missing from
the application.
34. Meanwhile, the man had settled on the wing. Officers described him as a quiet
prisoner, who did not leave his cell much, even during periods of association.
He appeared at a Magistrates Court via videolink on 4 March. He told his
cellmate that he was expecting to be released to a bail hostel. The solicitor
thought this was a reasonable assumption at this time. The case was further
adjourned until 18 March. Again, the prosecution assured the man’s solicitor
that they would have no objection to bail, as long as hostel placement could be
organised.
35. The man’s solicitor spoke to him in a private booth after the videolink hearing.
In his letter to my investigator, he wrote:
“[The man] was more upset and annoyed by the presence of his wife’s sister
than his further remand. [I] recall explaining to him that whilst there had
been problems with the bail hostel referral, it seemed that a final decision
was very close in that regard and that should the prosecution be as good as
their word once they had an address away from the area then bail ought to
be a formality. [I] also explained to [the man] that his wife’s sister was
perfectly at liberty to be in court during the hearing and that her presence
made no difference in the way in which that case was going to be dealt
with.”
36. Although the solicitor recognised that the man was upset, he was not unduly
concerned about his wellbeing during the interview. He told my investigator
Final Report 13
that he did not think it necessary to speak to a member of prison staff about
what had happened that day.
37. The man was remanded back into custody until 18 March. The prisoner who
he shared his cell with at that time told my investigator that the man changed
after this court appearance. He said that he was made angry by his wife’s
sister during the hearing. He told the other prisoner that if it was not for his
support, he would kill himself. The prisoner said that although staff at Hull were
approachable, he did not tell them about the man’s threats of suicide. He said
that he did not think that the man was making a serious threat to harm himself.
38. At about 7.30pm, the man was in his cell when he called over an officer. He
said that he had taken 32 paracetamol tablets and two other tablets that he did
not recognise. (These tablets were sanitising tablets from a dispenser on the
wing.) The man was not prescribed paracetamol tablets. The officer took the
man to the first night centre where the first night nurse and the newly appointed
nurse who had seen the man on reception were on duty. The newly appointed
nurse was the first to examine the man and was concerned about him. She
checked the man’s blood pressure, temperature, pupil dilation and pulse, all of
which were normal. She said that she was worried that the man had taken an
overdose but also did not see any physical symptoms.
39. The newly appointed nurse sought advice from the first night nurse, who
examined the man and said that she did not think that he had taken an
overdose. She would expect the man to have a stomach ache, slurred speech
and be sweating. She said that he just seemed angry about the videolink
appearance. The first night nurse did not make a mental health referral or take
a blood sample. The newly appointed nurse said she would have liked to take
the man to outside hospital but thought that the matter was “taken out of my
hands … as though I’d lost control and someone was totally overruling anything
that I said”. The newly appointed nurse did not express her concerns at the
time. When she handed over to the night shift, the first night nurse instructed
the nurse on the night shift to check if any symptoms had developed. When
she checked the man, the night nurse also found no evidence that he had
taken 32 paracetamol tablets. The clinical reviewer explains that there is a
“lack of early symptoms” following a paracetamol overdose and recommends
that a patient is “transferred to hospital urgently”.
40. The officer told my investigator that the man thought that these tablets were
paracetamol tablets. However, when the officer returned to the man’s cell to
search for evidence of what he had taken, there was no physical evidence that
he had taken any paracetamol tablets. Instead, the officer found wrappers for
mints sweets, which he thought the man may have mistaken for paracetamol
tablets. Nevertheless, following the man’s reported overdose, the officer raised
a Concern and Keep Safe form, in accordance with ACCT procedures. He did
not sign or date the form. The man told this officer that, “he was going to do
something bad, and he could not cope any more. He also stated he was going
to hang himself.” It was agreed that an officer should have a conversation with
the man every morning and afternoon and irregular observations were to be
Final Report 14
made throughout the night shifts. The man was given a letter explaining the
ACCT process.
41. The prisoner sharing a cell with the man remembered him shaving off his
eyebrows that night. When he asked him why he had done it, the man could
not explain. The prisoner said he understood that his bizarre behaviour was
because he was upset about the videolink. No mention is made of the man’s
eyebrows in his ACCT record.
42. The following morning, an ACCT assessor completed an ACCT assessment
interview. Officers receive special training to become ACCT assessors. This
was the ACCT assessor’s third ACCT assessment and she told my investigator
that she was confident with the process. The man told the ACCT assessor that
all of his problems “related to his wife”. He blamed her for his imprisonment
and repeated his accusation that she had, “been overdosing him with
depression pills and alcohol”, (that he later retracted). When the man was
asked to describe the last 48 hours and what might have led to him self-
harming, he talked about the videolink appearance. He said “it all got too much
for him” but that he did not want to die. It was just a bad day and he had other
family to think of. He told the ACCT assessor that “he could not see it
happening again”. The man said that he got on well with his cellmate and had
no problems about approaching staff for help.
43. The ACCT assessor attended an ACCT case review later that day. A senior
officer (SO) chaired the review. The man said he felt fine after having a long
conversation with the prisoner he shared a cell with. He told the officers that he
had no intention of self-harming. The man was identified as being a low risk of
self harm or suicide but the ACCT document remained open, to be reviewed on
12 March.
44. Later that afternoon, the prisoner sharing with the man moved cells. During his
conversation with my investigator, he explained that he was concerned about
sharing a cell with someone who was talking about suicide and did not think he
could cope with that pressure. Another prisoner was moved into the man’s cell.
The cellmate heard from other prisoners that the other prisoner had been
moved because he was suspected of bullying the man. There are no security
records to support this, and no entry was made in the man’s wing file or the
wing’s observation book to this effect. The other prisoner’s security record
shows no intelligence was received about bullying throughout his time in prison.
An officer recorded that the man was associating well with other prisoners and
getting on well with his new cellmate.
45. One officer on the wing recorded that he had a “good chat” with the man on 7
March. The man said that he was “fine and dandy” and had made the decision
to move forward with his life, once the court case and sentence were out of the
way. He told the officer he was, “going to move to a new area and start again”.
Four days later, an officer had another conversation with the man, who asked
when he was going to be taken off the ACCT document. The officer recorded
that he had “no concerns at present”.
Final Report 15
46. According to the man’s family, he met his solicitor on 11 March. His family
understood that he told his solicitor “if you don’t get me out of here, I’ll do
something stupid”. The solicitor confirmed that there was no meeting that day,
but his colleague visited the man on the afternoon of 12 March.
47. An ACCT case review was chaired by the same SO as chaired the previous
review on 12 March at 11.15am, a few hours before the man’s legal visit. The
man attended the review and was “in good spirits”. The man remained
unemployed at that time, but during this review agreed to make use of the
employment opportunities in the prison. The ACCT document was closed. The
post closure interview was scheduled for 20 March.
48. A colleague of the man’s solicitor visited him for one and a half hours that
afternoon:
“[My colleague] from our office saw [the man] at Hull Prison on 12 March in
the afternoon. He spent an hour and a half with him and took a full
statement from him. … [My colleague’s] assessment of [the man] was that
he seemed perfectly normal if not cheerful and gave him no cause for
concern as to his welfare. He made no comments during that interview
about intending to harm himself.”
49. Another prisoner on C wing described himself as the man’s friend. He told
police that when he saw the man on 13 March, he was “cheerful, happy and
relieved that he had someone to talk to regarding the problems with his
wife/partner”.
50. Every morning at 7.45am, prisoners are unlocked for a period of exercise.
There are seven officers and one senior officer working on the wing during the
morning shift. Every prisoner is unlocked but it is their decision as to whether
they choose to exercise or not. They return to their cells at 8.15am. Prisoners
who attend work and education are allowed out of their cells to make their way
to their respective activities. At about 10.00am, all other cells are unlocked and
prisoners associate on the wing or carry out domestic tasks like changing
laundry or cleaning their cells for the morning until about 11.20am.
51. At around 10.40am on 14 March, an officer was conducting accommodation
fabric checks in each cell on the fourth landing of the wing where the man was
located. (Daily accommodation fabric checks are performed by officers to
check that the cells are secure.) The officer regularly works on C wing and
knew the man. He remembered going into the man’s cell. The man was sitting
on the bed drinking tea or coffee. The officer asked him if he was alright and
he said, “yeah, I’m okay”. The officer said “there was nothing apparent to
trigger any concerns”. The cellmate told my investigator that other prisoners
had noticed the man leaving his cell six or seven times that morning, looking
around and then returning to his cell.
52. The man’s friend had just finished showering at 10.57am and made his way to
the man’s cell to visit him. When he walked into the cell, he saw the man’s foot
sticking out from behind the toilet screen. The man’s friend called his name but
Final Report 16
got no response. He noticed the man had been sick. He bent down to check
the man and saw him hanging with a shoelace around his neck, attached to a
low level toilet bracket. The prisoner tried to lift the man and release the
pressure from the lace. The man’s hands were also tied behind his back with a
piece of nylon cord. (The cord was the same material used to bind bundles of
newspapers for distribution on the wing.) The prisoner could not manage to lift
the man and so he pressed the cell bell to raise the alarm. He shouted at other
prisoners to help him, but those nearby seemed to be in a state of shock. He
approached a larger prisoner who he thought would be able to support the
man’s weight. The other prisoner followed the man’s friend into the cell. The
other prisoner supported the man’s weight with his right arm, while trying to
release the pressure of the ligature with his left hand.
53. An officer was working on the third landing of the wing when he heard prisoners
shouting. He immediately made his way to where the noise was coming from,
one landing up. The officer arrived within seconds. He entered the cell and
saw the man on his knees with a ligature around his neck, being supported by
two prisoners. Two officers and an SO followed the first officer into the cell. A
principal officer (PO) was behind them and stayed in the cell doorway. The first
officer assisted to support the man’s weight. Another officer reached over to
the ligature and cut it with his anti-ligature knife. One of the prisoners pointed
out that the man’s hands were tied together. The female officer used her
ligature knife to cut the nylon cord around his hands. The officer who cut the
ligature and the SO lowered the man to the floor, ready to start cardio-
pulmonary resuscitation (CPR). One of the prisoners recalled that he tried
without success to find a pulse. The two prisoners were thanked for their
efforts and asked to leave the room.
54. The female officer and the SO could not find a pulse. The man was not
breathing and the female officer noticed that his lips were blue. The SO started
chest compressions and the female officer started mouth to mouth
resuscitation. The first officer to the cell made a Code Blue radio call, which
means medical emergency – breathing difficulties. The PO requested an
ambulance over the radio. This was within minutes of the earlier radio call.
55. The Senior Staff Nurse was on A wing when she heard the Code Blue radio
call. A wing is close to C wing and the senior nurse immediately made her way
to C wing with the first night nurse who was nearby. In the meantime, the PO
instructed the first officer to collect the emergency grab bag from the staff
office. Another officer was asked to collect the defibrillation kit from A wing,
about one minute away from C wing.
56. The nurse detailed to respond to emergencies that day was attending a non-
urgent medical situation on B wing when she heard the radio call. The senior
nurse and the first night nurse reached the man’s cell first, about three minutes
after he was found hanging. The senior nurse took over chest compressions.
Shortly afterwards, the emergency response nurse arrived at the cell. The first
night nurse had retrieved the oxygen from the emergency bag and passed it to
the emergency response nurse. The emergency response nurse took over
from the female officer and inserted the ambubag into the man’s mouth to give
Final Report 17
him oxygen. The nurses applied the defibrillator during their resuscitation
attempts but it advised not to shock. The nurses continued for around 20
minutes, until paramedics arrived at about 11.20am. The paramedics inserted
a tube into the man’s throat and injected adrenaline into his arm. They found
that his heart had started again for a short while and compressions were
started again. More adrenaline was injected. The man’s condition was
stabilised and he was transported to the local hospital.
57. The ambulance left Hull at 12.05pm and arrived at the hospital five minutes
later. The man was taken straight to Accident and Emergency to continue his
treatment. At 12.25pm, hospital staff discovered a note in the man’s pocket.
The envelope was addressed to his wife. On the reverse of the envelope the
man had written that he wanted to go to the university. Subsequently, my
investigator has learned that this referred to his long-standing wish to donate
his body to science. The man was not explicit in his letter about his intention to
die. He said his “sickness, headaches and toilet problems” were coming back
and that he was fed up all the time. He also wrote that he suffered from cold
sweats most days. He apologised to his wife for telling lies about her and
asked for her forgiveness. The police collected the note an hour after it had
been discovered, as part of their evidence gathering exercise. The man had a
computerised tomography (CT) scan and then returned to the Accident and
Emergency Department.
58. Although the Head of Security was not the Duty Governor on 14 March, he
offered to help liaise with the man’s family. The governor said that the prison
wanted to make sure that the family were notified as quickly as possibly
because of the man’s critical condition. Ordinarily, the prison would elect their
own representatives to visit the family, but it was decided to ask the local police
to inform the family. Unfortunately, the wrong house number was given to the
police and this resulted in a delay in breaking the news to them.
59. The governor was notified when the man’s brother had arrived at the hospital.
He went to speak to him personally because he thought it was appropriate that
a governor was present to receive the family and answer any questions. He
took the man’s brother to a quiet room in the hospital and explained what had
happened. The man’s parents then arrived and he took them to one side and
gave them the same explanation. The man’s family went to his bedside. The
governor arranged for the escorting prison officer to stand outside the hospital
room. The man had no restraints on him. Two uniformed police officers were
stationed outside of the hospital room.
60. A bed watch log was started by the two escorting officers, just as they were
informed that the man was to be transferred to the Intensive Care Unit at about
2.30pm. The bedwatch log was started as the escort record finished. Another
officer took over the bedwatch at 7.15pm. The man’s family continued to arrive
throughout the night and stayed with him. At 6.05am, the family were informed
that the man had passed away, although his death had not been pronounced
by a doctor. Shortly afterwards, they left the hospital. A hospital doctor
pronounced the man’s death at 6.45am.
Final Report 18
61. The bedwatch officer contacted an officer in the command suite at the prison at
8.00am to notify her of the man’s death.
Prisoner Support
62. Once staff had arrived at the man’s cell, the prisoners were thanked and asked
to leave the cell. I am pleased to see the prisoners’ efforts were appreciated
and they were appropriately asked to leave the cell, while staff continued with
resuscitation efforts.
63. The prisoners who attended the cell commended staff’s efforts to resuscitate
the man. The man’s friend told police, “the officers and myself did everything
we could to save him and [officers] acted very professionally in trying to revive
him”.
64. The police interviewed the man’s friend and the prisoner who assisted him
shortly after the man was transferred to hospital. The police also analysed the
bindings around the man’s wrists to ensure that there had been no third party
involvement in his death. They were satisfied that the binding was tied by the
man himself. The police concluded that there were no suspicious
circumstances surrounding his death.
65. When the man was transferred to hospital, two of the officers who attended the
emergency went to speak to the two prisoners who assisted to tell them what
had happened. The man’s cellmate was intercepted on his way back from
education. He remembered alarms going off while he was in his morning class
but did not know what had happened. When he got back to the wing, an SO
took the cellmate into a private office to explain that the man had been taken to
hospital and his prognosis was not good.
66. After the man’s death, the Governor issued a notice to prisoners, which was
posted around the prison. The cellmate organised a collection for some flowers
to be sent to his funeral. With the help of an SO, the cellmate also circulated a
condolence book for prisoners to express their sympathy, which was sent to the
man’s daughters.
67. A memorial service was held in the prison chapel in the days following the
man’s death. The family heard that the service had been cancelled, however, it
went ahead, despite low attendance.
Staff Support
68. All staff, including healthcare staff, involved in the resuscitation efforts were
invited to a hot debrief after the man had left the prison on 14 March. (A hot
debrief is a meeting to give staff the opportunity to share their feelings following
involvement in a traumatic incident.) Officers told my investigator that they
found it helpful to go through what had happened. The female officer raised
her concern that she performed mouth to mouth without a face mask and was
issued with one during the meeting.
Final Report 19
69. Other staff learned of the man’s death when they next came on shift. There
were notices posted around the prison. Prison Service staff said they felt well
supported by the welfare team, who also attended the hot debrief. However,
healthcare staff said that they were not allowed to access support from the
Prison Service welfare service and were not clear who to go to. They sought
support from their colleagues and found that this was effective. Although I
make no formal recommendation, the Head of Healthcare will wish to ensure
that staff are aware of the support services available from Hull Teaching PCT.
Family Liaison
70. As explained above, the man’s family were informed of his death by the local
police and there was some delay in doing so, due to confusion with the house
number. Prison Service Order (PSO) 2710 suggests that it is good practice for
a representative of the prison to break the news. (PSO 2710 governs the
prison’s response to a death in custody.) In this case, I think the prison were
right to ask the local police to break the news on their behalf because the
priority was for the family to get to the hospital as soon as possible. The delay
is regrettable. The prison offered to pay reasonable funeral expenses in
accordance with PSO 2710.
71. When my investigator and my family liaison officer met the man’s daughters
and his wif, they had several concerns that they wanted the investigation to
address. They were worried about the nylon cord that the man used to bind his
hands together. They were surprised that such material was readily available
to prisoners on the wing. My investigator discovered that the cord was likely to
have been the material used for the distribution of newspapers on the wings.
There are no security restrictions on this material.
72. The man’s family were also worried that he was only subject to suicide
prevention measures for one week during his time at Hull. They said that he
was good at masking his anxiety, but expected staff to look beyond his
immediate presentation and identify that he was at risk of suicide. My
investigator asked the first night nurse, the doctor and the primary care mental
health team leader to describe the non-verbal signs that they look for when
assessing a prisoner’s risk of self-harm. The man did not speak with his
cellmate with whom he had formed a good relationship, about suicide or
thoughts of self harm. With hindsight, it is likely that the man was at risk of self
harm at the time staff made their assessments. However, staff looked for
appropriate body language and presentation and I do not think that their
assessments were unreasonably made. I explore this matter at greater length
later in the report.
73. The man’s family were also concerned that he told his solicitor explicitly that he
was going to kill himself after the court hearing on 4 March. My investigator
spoke to the officer on duty in the videolink office that day. She said that she is
trained in ACCT procedures and would open an ACCT document if she thought
a prisoner was at risk of self harm or suicide. She could not recall any prisoner
who was particularly distressed on 4 March. The family asked my investigator
to find out whether the solicitor spoke to any member of staff about the man’s
Final Report 20
suicide threat. In his letter to my investigator, the man’s solicitor said that he
did not think that the man was at risk of suicide after that hearing, although he
was upset by a relative’s presence. Therefore, the solicitor did not have any
concerns to pass on to staff.
74. The man’s family are worried that his mental health and substance misuse
needs were not formally identified and properly addressed at Hull. In some
respects, I share their concern and will go on to examine the treatment that he
received in more detail below.
Final Report 21
ISSUES
Should the man have been in prison?
75. The man first applied to be bailed to his parents’ address. The application was
refused on the grounds that the address was too close to the alleged victim. At
this early stage, the prosecution indicated that they were unlikely to have any
objection to the man being bailed to an address outside his local area.
76. When the man’s solicitor wrote to my investigator, he was concerned that the
Bail Information Office had not effectively dealt with the man’s bail hostel
application. He wrote:
“What we can say however is that this is a case where [the man] would have
been granted agreed bail had the hostel referral process run more smoothly
than it did. If he had been bailed to a hostel whether [the man] would have
gone on to harm himself is a matter for conjecture.”
77. Prison Service Order (PSO) 6101 sets out mandatory requirements for Bail
Information Schemes in prisons. The aim of the schemes is, as follows:
“Prison-based schemes target defendants who have failed to secure bail at
their first court appearance and could benefit from assistance in applying for
bail at their second or subsequent appearance.”
78. The first letter of 21 February requesting that the Bail Information Officer locate
a hostel placement went missing. I am prepared to accept that these things
happen, however regrettable the consequence. However, I am concerned
about the apparent inefficiency of the referral on 4 March. PSO 6101 says:
“Bail Information Officers … must identify risk factors and areas of need and
ensure that relevant information is included in the referral to [the service
provider] and in the bail information report to the court.”
79. A link to the bail referral form is annexed to the Order. The form has a list of
required information. Emboldened in the centre of that list is ‘Case Summary’.
There is a warning at the bottom of the form that it must be faxed by 3.00pm
with the accompanying information for a referral to be considered for that day.
The case summary was not attached to the bail application.
80. The man’s bail application was ultimately refused due to his outstanding alcohol
needs. These needs were not identified or treated at Hull. I am satisfied that
the Bail Information Office’s inefficiency did not fatally affect the man’s bail
application. However, I am concerned about the resources and the apparent
miscommunication around the man’s bail application.
The Governor must assess and, where necessary, improve the efficiency
of the bail information office.
Final Report 22
Clinical Care
Clinical Review
81. Hull Teaching PCT commissioned a Clinical Governance Manager to review
the clinical care that the man received while he was in custody. The clinical
reviewer had access to the man’s medical records and conducted joint
interviews with my investigator. The clinical reviewer also called for the records
of the man’s time at the local mental health unit, the week before he was taken
into custody.
82. The clinical reviewer concluded that the first reception healthscreen, the
doctor’s assessment and the mental health team leader’s assessment were
“timely, appropriate and comparable to services within the community”. The
clinical reviewer does not discuss the assessment of the man’s substance
misuse needs in her review. However, she was concerned that the man’s
medical records do not appear to have been requested from his community
practice.
83. She was concerned about the treatment that the man received after his alleged
overdose on 4 March and in particular that there was no mental health referral.
She makes one recommendation about patient records and four about the
response to his alleged paracetamol overdose. I agree with the clinical
reviewer’s recommendations and commend them to the prison and the Primary
Care Trust for further attention. I have considered the clinical reviewer’s
findings in the next sections of my report.
Why did the man not receive any treatment at Hull for his alcohol misuse?
84. The man arrived at Hull three days after he had been discharged from the local
mental health unit. He told staff that he had undergone a detoxification
programme and felt like a “new man”. The first night nurse was aware that the
man had drunk whisky on his release and was drunk when he was taken into
police custody. The man’s inebriation was well-recorded by police and the first
night nurse acknowledged that she saw the police medical documents. During
her interview with my investigator, the nurse conceded that the detoxification
programme “obviously didn’t work”, if he got drunk immediately on his
discharge. Still, she made no referral to the doctor for detoxification. Despite
the evidence available to her, she took the man at his word because he
presented as relaxed and gave her no cause for concern.
85. The doctor said that he could see from his entry in the medical record that the
man had told him he had undergone a successful detoxification from alcohol.
The doctor saw no signs of alcohol withdrawal, such as sweating or shaking.
He said that he referred to the first reception healthscreen to inform the
assessment. When asked his opinion about the man’s drinking upon discharge
from his apparent detoxification at the local mental health unit, the doctor said
that he could not remember seeing that in the screen and that it was
concerning. He did not recall seeing the first night nurse’s handwritten entry in
the medical record, which sets out the events of 18 February more clearly. The
Final Report 23
doctor said that he has contacted a prisoner’s doctor during a secondary
healthscreen to verify the medical history if he had reason to doubt that the
prisoner was giving him an accurate account of his needs. He did not contact
the man’s community doctor or the local mental health unit because he had no
reason to doubt that the man had not been through a successful detoxification.
When asked what resources there were for prisoners going through an alcohol
detoxification, the doctor said that if he thought that the man required an
alcohol detoxification programme, he would have referred him to the substance
misuse team on the IDTS unit. (IDTS is a discrete unit where prisoners who
are detoxifying from drugs and alcohol are accommodated for the duration of
the detoxification programme.)
86. In the final letter that he wrote to his wife, the man described the symptoms he
was experiencing, “Something’s not right again? Started to sweat most days
and nights. (Cold Sweats).” He said that he had “headaches, sickness and
toilet problems”. All of these symptoms are classic symptoms of alcohol
withdrawal. Withdrawing from alcohol is not only physically painful but it can
affect a person’s mental state.
87. I am concerned that vital medical history was not known to the prison to inform
the man’s care. I understand that each healthcare professional was qualified to
make their own judgement about the man’s mental health and substance
misuse needs based on how he presented to them at the time of their
assessments. However, this case is a reminder of the importance of verifying a
prisoner’s medical history. I appreciate that even if the records were requested
from the man’s GP or directly from the local mental health unit, they would not
have arrived in time to inform these assessments. I am surprised that no one
contacted the local mental health unit to verify the treatment that he received so
shortly before he reached the prison. I am equally surprised the man’s medical
records were not called for, despite a system for their retrieval being in place. I
agree with the clinical reviewer’s recommendation:
The Head of Healthcare must strengthen the system whereby a
prisoner’s’ medical history is requested from the relevant community
service provider, if any substance misuse, physical or mental health
needs are identified during the initial healthscreens.
88. During interview, the Head of Healthcare explained that the man could have
been admitted to the IDTS unit at Hull. There the man would have received a
clinical detoxification. His treatment would have been observed by the staff on
the IDTS, who include nurses and healthcare assistants. The Head of
Healthcare acknowledged that the man would not have received support from
CARATS had he been admitted to the IDTS unit, as CARATS at Hull do not
support prisoners going through an alcohol detoxification, only those detoxifying
from illegal substances. In fact, she said that there were no psycho-social
resources available for prisoners going through alcohol detoxification. She
believed that no national funding had been allocated for such resources.
89. The Deputy Governor told my investigator that the prison were aware of a lack
of resources for prisoners undergoing alcohol withdrawal. With that in mind,
Final Report 24
the prison has already met with local healthcare services to develop a pilot for
the Alcohol for Good Lives (AFGL) programme. The Deputy Governor said that
the pilot was in its early stages when the man was in the prison. As he had not
been identified as in need of alcohol detoxification, it is doubtful whether he
would have received such a programme. None of the healthcare staff
interviewed during the investigation seemed to be aware of the pilot. They all
expressed concern at the lack of psycho-social resources available to help
prisoners going through alcohol withdrawal.
The PCT should provide support mechanisms for prisoners going
through alcohol withdrawal.
I am pleased to note that the PCT have advertised for a substance misuse
specialist nurse since the man’s death.
Were the man’s mental health needs met in prison?
90. The first night nurse referred the man for a mental health assessment because
she knew he was going to miss an appointment at the mental health unit due to
his remand to custody. She thought that he might have had ongoing mental
health needs. She did not ask for the man’s medical records from the mental
health unit because she had made a mental health referral and thought the
doctor would see the man the next morning. She told my investigator that the
doctor or the primary care mental health team would request the man’s
community records if they were needed to inform his ongoing care.
91. The doctor’s assessment took place on the man’s first morning in Hull. During
interview, the doctor said:
“what I have entered in my records is that he didn’t have any physical or
mental health issues. That means that I would have seen him face to face
and I would have assessed that he wasn’t depressed, he must have been
having good eye contact and talking normally and he mentioned about
having a successful detox, alcohol detox recently at that time and he said
that he’s trying to stay away from alcohol till that point when I saw him.”
92. The doctor went on to say that he could see from the man’s medical notes that
he was due for a mental health assessment later that day. He told my
investigator that he did not normally have access to a prisoner’s records at the
time of a secondary healthscreen. He said that he would have a copy of the
first reception healthscreen, but that is a brief summary of the prisoner’s
immediate medical needs. The doctor assessed the man on the basis of his
presentation at interview and what he said during the secondary health screen.
He had no concern for the man’s mental health.
93. All mental health referrals go to the newly established Primary Care mental
health team who carry out a review within 24 hours of prisoners who have just
arrived at Hull. The team leader was scheduled to work in the reception and
induction area of the prison on 21 February. She remembered the man’s
mental health assessment and described him as being “happy and cheerful”
Final Report 25
throughout their interview. She completed a Primary Health Questionnaire
(PHQ) 9. Despite the first night nurse’s note on the referral form, the team
leader said she was not aware of how recent the man’s alcohol problems were
and got the impression from him that his stay at the mental health unit was a
long time before his arrival at the prison. She said that she did not request the
man’s medical records from the mental health unit because she did not
consider that he needed further mental health supervision.
94. No mental health referral was made following the man’s apparent overdose on
4 March. The officer who raised the concern and keep safe form did not make
a referral. The first night nurse did not consider it a serious act of self-harm and
did not think it necessary to make a mental health referral. The newly
appointed nurse felt that the situation was out of her control, but she also
mistakenly thought that the man was being seen by the mental health team
following his referral at the first reception healthscreen. The ACCT assessor
did not make a mental health referral following her assessment of the man as
part of the ACCT process. This is in spite of the PHQ9 form being attached to
every new ACCT document, for officers to consider whether there were any
outstanding mental health issues. The ACCT assessor said that she was sure
that the man did not have any mental health issues. She said that if she was
concerned, she would have telephoned the healthcare centre and asked for
someone to make a mental health assessment.
95. It is a matter of concern that the man was not referred for a mental health
assessment following his attempted overdose. In fact, it was likely that he
swallowed a number of mints, believing them to be paracetamol tablets. That
the act of self harm caused no physical damage does not diminish the intention
that the man had to harm himself. When the mental health team leader learned
of the man’s attempted overdose, she was concerned that he had not been
referred for a mental health assessment. The Head of Healthcare was
surprised and concerned that no referral was made at that time. I agree with
the clinical reviewer that staff awareness of mental health processes should be
improved:
The Head of Healthcare and Governor must support the Head of the
Primary Care mental health team in promoting awareness among all staff
of the mental health referral system.
Was the medical response to the man’s alleged overdose attempt
appropriate?
96. I have already discussed the fact that no mental health referral was made
following the man’s alleged attempted overdose on 4 March. It appears that he
did not actually take paracetamol tablets because only wrappers for
confectionary were found in his cell. However, it is likely that he believed it was
a genuine attempt to overdose. The newly appointed nurse was the first
healthcare professional to examine him and she took his blood pressure, pulse
and measured his pupil dilation and temperature. However, as a relatively new
member of staff, she sought advice from a more experienced nurse in the
prison setting, the first night centre nurse. At that point, the newly appointed
Final Report 26
nurse described the situation as being taken out of her control, although she did
not raise this at the time. The first night centre nurse assessed the man’s
manner, discovered that he did not have a stomach ache and concluded that it
was unlikely that he had taken the overdose.
97. The first night centre nurse is an experienced nurse in the prison health
setting. I am concerned that the man’s substance misuse needs were not
identified at first reception, and am not satisfied his alcohol problem was
sufficiently explored. I am particularly concerned that the first night nurse did
not effectively treat his apparent overdose on 4 March and did not make a
subsequent mental health referral. The man approached staff following this
overdose attempt. This was the only time he showed any vulnerability in
prison. This may have been a crucial missed opportunity.
98. The clinical reviewer expressed her concern about the assessment of the
man’s condition. She commented particularly on the fact that his blood was not
tested and the lack of policies and protocols at Hull for dealing with an alleged
paracetamol overdose. I commend the following recommendations made in
her review to the PCT:
Development of multi disciplinary procedural guidelines are required to
emphasise to staff current best practice in the care of patients presenting
with an alleged self induced poisoning.
99. I am pleased to learn that such policies are already in development. At the time
of writing the draft report, they are being considered by the PCT ready for full
implementation later this year.
All patients who allege to have taken an overdose who do not require
immediate transfer to the hospital should be monitored until the self
induced poisoning can be confirmed or discounted.
100. The family had the opportunity to comment on a draft of this report before it was
finalised. They were concerned that the man’s next of kin were not contacted
by the prison after he had allegedly taken an overdose. They also asked why
staff did not chase up the man’s medical records. My investigator asked the
clinical reviewer to look at this matter as far as healthcare staff were concerned.
The clinical reviewer responded as follows:
“The PCT in Hull held no records for [the man]. No records were
requested following the alleged overdose attempt as at that time the staff
did not perceive an overdose had occurred and did not refer him for
further treatment. Previous medical records would not have his changed
his care as they may still not have been in receipt, it can often take
several weeks for a GP to send on health records. Immediate care is
determined by assessment of the patient at the time regardless of
previous notes.”
I am concerned that the family were not contacted following an apparent
episode of self harm. Officers opened an ACCT document in order to monitor
Final Report 27
the man’s level of risk to himself. I hope that the Governor will work with the
Head of Safer Custody to remind staff of the importance of involving a
prisoner’s family at times of crisis. Even where the prisoner does not want staff
to contact their family, efforts should be made to encourage the prisoner to
make contact himself.
Did staff respond appropriately when the man was found in his cell?
101. As soon as the prisoner shouted for assistance, officers made their way to the
man’s cell. They appropriately took over the situation from the two prisoners
and asked them to leave.
102. The female officer did not have a face mask, but continued with mouth to mouth
resuscitation. I am concerned that staff do not routinely have pocket face
guards for their own protection. There is no requirement for staff to carry
pocket face guards, although it is recognised by the Prison Service as “good
practice”.
The Governor should consider issuing all staff with pocket face guards to
carry with them at all times.
103. The paramedics continued resuscitation attempts and transferred the man to
hospital. The clinical reviewer expressed no other concerns about the
emergency response to the man’s discovery.
Should the man have been subject to suicide prevention measures?
104. The man arrived in custody on 20 February with a suicide and self harm
warning form, a Prisoner Escort Record and a court warrant. All three
documents flagged his vulnerability. The escort record and the self-harm
warning form both explicitly referred to his overdose on 13 February. However,
an ACCT was not opened by officers on reception or the nurse, following her
first reception healthscreen.
105. During interview, the first night centre nurse described the man as “quite jolly
really, didn’t seem apprehensive”. She said that she had a long conversation
with him and the newly appointed nurse, observing the healthscreen, about
how he had “ended up in prison”. The first night nurse said he made good eye
contact, seemed relaxed and caused her no concern. The nurse told my
investigator that she does not look at court warrants as part of the
healthscreen, but did look at his escort record and the suicide and self-harm
warning form. She asked the man about his overdose. He told her that he was
forced by someone else to take a number of pills in order to get admission to
the local mental health unit. He had wanted to go through an alcohol
detoxification. The two nurses believed the man’s account of the overdose.
The first night nurse did not think he intended to take his own life. She asked
him if he had any ongoing thoughts of self-harm, which he denied. Taking into
consideration his relaxed demeanour, the first night nurse was satisfied that he
was not at risk of self harm or suicide.
Final Report 28
106. The newly appointed nurse was concerned at the man’s level of anxiety but
was satisfied that he would be seen by the mental health team, because the
first night nurse had made a referral. The newly appointed nurse told my
investigator that she had not received ACCT training. She started work at Hull
in January 2008 and her induction had consisted of observing staff until she felt
ready to perform healthcare tasks by herself. At the time of her interview in
May, she still felt unprepared to do first reception healthscreens. I am surprised
that newly appointed nurses do not routinely receive ACCT training.
107. The doctor assessed the man the next morning. When my investigator
interviewed him, he could not specifically recall the assessment, but referred to
the entry he made in the man’s medical record. He said that he was not
concerned that the man was at risk of self harm or suicide. He had not
received training in ACCT procedures, but would have either admitted the man
to the healthcare inpatients’ unit for constant supervision or made a mental
health referral, if he was concerned about his level of risk. I am concerned that
a medical professional involved in the assessment of prisoners at such a
vulnerable time of their custody was not familiar with the suicide prevention
measures in place at the prison.
The Head of Healthcare and Governor should ensure that all permanent
healthcare staff undergo ACCT training this financial year and that
agency staff are briefed on suicide prevention systems before they carry
out healthcare assessments.
108. The Primary Care Mental Health Team Leader carried out a mental health
assessment later that morning. For the assessment, she had access to the
mental health referral from the first night nurse and the entries detailed on the
electronic medical information system (EMIS). She found the man to be “quite
happy and cheerful really”. She said that he felt “a lot better and quite relieved”
to have undergone a successful detoxification. When my investigator asked
the team leader how she can tell whether someone is at risk of suicide or self-
harm, she said:
“We’re looking really around body language at that time. You know it’s often
the case that somebody who may be saying they don’t feel suicidal, that
often those what you’re picking up is on the body language and maybe
there’s no eye contact, they appear to be in a withdrawn state, they appear
to be unhappy, they appear to be distressed in some way or no
communication as well.”
The mental health team leader did not think the man was at risk of self harm.
109. Three healthcare experts with experience of working with prisoners did not
consider the man at risk of suicide or self harm. When my investigator met the
man’s family at the beginning of her investigation, they asked her to look into
why his risk was not identified. With the benefit of hindsight, it is clear that the
man was capable of hiding his anxiety and it is possible he hid his true feelings
from the first night nurse, the doctor and the mental health team leader. The
man was consistent in his story about the circumstances surrounding the
Final Report 29
overdose attempt on 13 February. His final letter to his wife is the first
indication that this story was not true. The man admitted that he had lied to
staff and his solicitor in the letter that was found on him by hospital staff. The
information made available to my investigator about the man’s time at the local
mental health unit paints a clearer picture of a man in crisis. The erratic
behaviour that led to his remand was not known to staff assessing him in his
first few days at Hull. Such behaviour is an indicator of risk. On balance, while
it is regrettable, I cannot say it was unreasonable for staff not to have opened
an ACCT document given the facts available to them at the time of their
assessments. It must also be borne in mind that two weeks passed following
the healthscreen without any indication that the man was at risk of self harm.
110. The man did not express any concern or anxiety in the intervening days to
warrant a reassessment of his level of risk. On 4 March, he approached an
officer on the wing, claiming that he had taken a significant number of
paracetamol tablets and some sterilising tablets. The first night nurse checked
the man for the physical symptoms of a paracetamol overdose. The clinical
reviewer subsequently advised that no such symptoms would normally be
evident for some time after an overdose. She did not think that the man had
taken the overdose because he was not experiencing any stomach pain or
dizziness. The first night nurse recalled that the man was apologetic and rather
embarrassed to have taken the pills. She did not think he was at risk of self-
harm or suicide at the time. Despite being unsure whether the man had taken
paracetamol tablets, the officer who took him to see the nurse subsequently
raised a Concern and Keep Safe form, the first stage of the ACCT process.
The newly appointed nurse, still not trained in ACCT procedures at this point,
remembered feeling anxious about the treatment the man had received
following his alleged overdose. She felt that the situation had been taken out of
her hands. However, she did not express this to anyone at the time.
111. An ACCT assessment was carried out the next day. The ACCT assessor
thought that the man had reacted to a bad videolink appearance and the risk he
posed to himself had probably decreased as he calmed down. She attended
the first ACCT case review, together with an SO and the man. The SO chaired
the review as he was the manager for the wing that morning. He did not know
the man from the wing but used the ACCT assessment and the man’s
presentation during the case review to inform his judgement. He agreed with
the ACCT assessor that the man was probably no longer at risk to himself, but
kept the ACCT document open as a precaution. The man was told about
support available to him through the Listeners and his personal officer. (A
Listener is a prisoner who has been trained by the Samaritans to support
prisoners through periods of crisis.) He was to be checked every shift and at
irregular intervals throughout the night. An ACCT ongoing record was kept and
showed staff’s regular interactions with the man. No concerns were reported
during the week after his self harm attempt.
112. As scheduled, a follow-up ACCT case review took place on 12 March, chaired
by the SO again. The only other member of staff present was another officer
from C wing. The decision was made to close the ACCT. The SO
remembered the man being “upbeat” during the meeting. The man talked
Final Report 30
about taking employment at the prison. Although he is not trained in mental
health, the SO drew on his many years of custodial experience to assess the
man and felt that he was no longer at risk.
113. During the seven days the ACCT was open, the man’s personal officer, (the
female officer who attended the emergency), was not at work. (A personal
officer is a point of contact for a prisoner for any queries or concerns.) Nor did
he access the Listeners. However, the SO thought that he was no longer at
risk of self harm. Given his presentation at the case review and the facts
available to the SO at the time, the decision was again, regrettable but
reasonable. I am concerned that no healthcare staff were invited to attend the
meeting. According to ACCT guidance, case reviews should be multi-
disciplinary. The attendance of a healthcare staff member might have alerted
the mental health team to the man’s self harm attempt.
114. The family were concerned that the man had been visited by his solicitor the
day before his ACCT document was closed. They thought he might have
reacted badly to the visit. They were worried that the information about the
solicitor’s visit was not properly considered by the staff who closed the man’s
ACCT document. During interview, the SO confirmed that he did not know that
the man had a recent legal visit. They did not discuss any matters relating to
his legal representation.
115. In fact, the man’s solicitor confirmed to my investigator that a colleague from his
office saw the man on the afternoon of 12 March. The ACCT case review took
place at 11.15am, before the legal visit took place. In his account of the legal
visit, the man’s solicitor wrote:
“[A colleague] from our office saw [the man] at Hull Prison on 12 March in
the afternoon. He spent an hour and a half with him and took a full
statement from him. … [my colleague’s] assessment of [the man] was that
he seemed perfectly normal if not cheerful and gave him no cause for
concern as to his welfare. He made no comments during that interview
about intending to harm himself.”
116. Even if the SO had been aware of the man’s forthcoming legal visit, he gave no
cause for concern during that interview. If the legal visit had affected the man’s
state of mind, he gave no indication of it to his cellmate or staff on the wing.
117. In conclusion, it is unfortunate that the man could not communicate his feelings
to staff. The final letter that he wrote to his wife demonstrated his feelings but
recognised that he had lied about his circumstances, particularly surrounding
his attempted overdose on 13 February. The man appears to have been expert
in hiding his anxiety and staff were unable to discern his true state of mind.
Conclusion
118. The man’s family told my investigator that he was good at hiding his feelings.
He masked his anxiety throughout his time at Hull. However, opportunities
were missed for simple information sharing which might have improved the
Final Report 31
care that he received. Healthcare staff in the first two days did not refer to each
other’s entries thoroughly enough and did not gain a full understanding of his
substance misuse needs. The way that the man presented himself to staff as
cheerful meant that this might have made no difference to the outcome in this
case, but may make a difference in future cases.
119. However, I am satisfied that staff appropriately assessed the man’s body
language and looked for signs of alcohol withdrawal at the time of his reception.
The man showed no signs of risk to himself until 4 March when an ACCT
document was opened, to be closed a week later after due consideration of his
presentation at the review meeting. A mental health referral should have been
made following this attempted self harm. Sadly, the man died three days after
the ACCT document was closed.
Final Report 32
RECOMMENDATIONS
1. The Governor must assess and, where necessary, improve the efficiency of the
bail information office.
The Prison Service partially accepted this recommendation. Their response was:
“We have two full time bail information officers who see every unconvicted
prisoner who comes into Hull prison. To enhance this, group meetings are
now being carried out on A wing. Reports are sent to the courts and referrals
are made for accommodation when not available.”
2. The Head of Healthcare must strengthen the system whereby a prisoner’s’
medical history is requested from the relevant community service provider, if any
substance misuse, physical or mental health needs are identified during the initial
healthscreens.
The Prison Service accepted the recommendation and have put into a place a
random audit to ensure compliance.
3. The PCT should provide support mechanisms for prisoners going through alcohol
withdrawal.
The PCT accepted this recommendation and recruitment processes for a
specialist alcohol misuse/substance misuse nurse are underway.
4. The Head of Healthcare and Governor must support the Head of the Primary
Care mental health team in promoting awareness among all staff of the mental
health referral system.
The recommendation was accepted. In response, the prison wrote:
“Increased staff training and awareness of service. Service specification to be
included on induction of new staff and Primary Care Mental Health to discuss
service at team meetings and governance forums.”
5. Development of multi disciplinary procedural guidelines are required to
emphasise to staff current best practice in the care of patients presenting with an
alleged self induced poisoning.
The recommendation was accepted and at the time of response, a draft of the
guidelines were out for consultation.
6. All patients who allege to have taken an overdose who do not require immediate
transfer to the hospital should be monitored until the self induced poisoning can
be confirmed or discounted.
The recommendation was accepted and has been incorporated into the policy
document.
Final Report 33
7. The Governor should consider issuing all staff with pocket face guards to carry
with them at all times.
The prison accepted this recommendation and have placed an order for face
masks.
8. The Head of Healthcare and Governor should ensure that all permanent
healthcare staff undergo ACCT training this financial year and that agency staff
are briefed on suicide prevention systems before they carry out healthcare
assessments.
The prison partially accepted this recommendation, writing:
“Due to staff turnover and service requirements, may not be feasible for ALL
staff to complete within this financial year. Scoping to be completed to
ascertain which staff require training and all new staff to receive training on
induction, all other staff who have not received training will be followed up
once scoping complete”.
Final Report 34