Individual at Hull

Investigation into the circumstances surrounding the
death of a man
at HMP Hull in March 2007
Report by the Prisons and Probation Ombudsman for
England and Wales
December 2007
This is a report into the circumstances of the death of a man at HMP Hull, in March
2007. He was found in his cell early on Sunday morning when a staff member
noticed that the observation hatch on his cell had been blocked. Despite staff
attempts at cardio pulmonary resuscitation and the attendance of paramedics, he
was pronounced dead at 3.08am. He was 27 years old.
I offer my sincere sympathy and condolences to the man’s family and friends for their
loss.
The investigation was carried out on my behalf by two of my colleagues. A clinical
review of the man’s healthcare at HMP Hull was undertaken by Hull Teaching
Primary Care Trust. I am grateful for the comprehensive and timely report.
I would like to thank the Governor of Hull and his staff for their co-operation and
assistance with this investigation. Particular thanks go to the principal officer who
was a most efficient liaison officer, for his help throughout the investigation process.
The man had been at HMP Hull for just a few days. He had been arrested following
the alleged breach of a restraining order, but was adamant that he was not guilty of
the offence. The man accordingly felt aggrieved and this sense of injustice was a
constant theme in his conversations over the phone to family and friends. In a note,
he wrote the phrase, “I’m innocent” and then outlined the words with dotted lines. In
another he said that he could not take any more. It seems that the idea of spending
any further time in prison in these circumstances was something he could not
endure.
Emma Bradley
Prisons and Probation Deputy Ombudsman December 2007
2
CONTENTS
Summary 4
The Investigation process 6
HMP Hull 7
Key findings 8
Issues 15
Recommendations 21
Annexes
1. Documents considered during the investigation
2. Clinical Review
3. ACCT from August 2006
4. Instruction sheet for ACCT observations in use at Hull
5. Transcripts of interviews
3
SUMMARY
The man was born on in 1979 and died in the early hours of a Sunday morning in
March 2007, at HMP Hull. He grew up in Hull and, as an adult, lived and worked in
the city. He was separated from his wife with whom he had one child.
In June 2006, the man’s wife obtained a restraining order against him. The following
month he was sentenced to 12 months imprisonment for driving offences. He initially
went to Hull, but in August was told he was being transferred to a more distant
prison. He then took an overdose and told staff that he did not know what else to do.
Staff opened an ACCT plan to give him additional support through the crisis. An
ACCT document describes the problems facing a prisoner at risk of harming himself
and implements a plan to give him the support he needs to help him through a period
of crisis. They also arranged for his transfer to be changed to HMP Everthorpe,
which was much closer to Hull. The following day, the man moved to Everthorpe.
In November, the man’s relationship with his wife broke down and he again took an
overdose, for which he was treated in the healthcare centre. Staff opened a new
ACCT, which remained in place until 26 November. In January 2007, the man was
released from prison.
In early March, the man was arrested by the police and charged with breaching the
restraining order. He was received into Hull later the day and was interviewed by a
number of staff during the reception process. They noted his high daily consumption
of alcohol and previous self-harm attempts, both inside and out of prison. However,
none of them felt that the man was at risk of harming himself at that time.
The man was then allocated a shared cell in the induction wing. As a result of his
charges, the man was subject to the restrictions imposed by the Protection of
Harassment Act 1997, as laid out in Prison Service Order (PSO) 4400.
The following morning, the man was assessed by the doctor who prescribed an
alcohol detoxification programme. The doctor was concerned at his low mood and
his thoughts of suicide. She appropriately opened an ACCT plan, which remained in
place for the rest of his time in Hull. When an ACCT assessor interviewed the man
later that morning, the man said he was very angry at being in prison, because he
was totally innocent of the charges. He was convinced that when he returned to
court in a week’s time, he would prove his innocence and be released. He was also
very eager to contact his solicitor. However, in line with PSO 4400, he was not
allowed to use the telephone until the numbers he had given were checked. PSO
4400 relates to prisoners convicted of, or charged with, offences under the
Protection from Harassment Act 1997. It sets out a range of measures to prevent
such prisoners from Harassment Act 1997, from continuing to harass their victims
while in prison
On Friday afternoon, he was able to use the telephone and over the next 24 hours,
he made a number of phone calls. Most of them related to his appearance in court
the following week. The entries made in the ACCT plan show that the man spent
most of Saturday afternoon sleeping or watching television.
4
At 2.34am on Sunday, staff entered the man’s cell because the observation flap had
been covered up and there was no response to their calls to clear it. The man was
found suspended from the light fitting. Staff cut the ligature, laid the man on the floor
and called for assistance. They then began cardio pulmonary resuscitation (CPR).
The duty nurse attended and continued the resuscitation attempt. An ambulance
and two paramedics arrived 15 minutes later. Sadly, none of the efforts made to
resuscitate the man were successful and he was confirmed dead at 3.08am. The
Governor and a family liaison officer visited the family at 6.40am to break the news
of the man’s death.
5
THE INVESTIGATION PROCESS
1. The investigation was opened at HMP Hull on 14 March 2007, by two of my
colleagues. Notices were issued informing staff and prisoners about the
investigation and inviting anyone with information to come forward. All
documents relating to the man were made available, including the records from
his previous period of imprisonment. The investigators also met members of the
Prison Officers’ Association and Independent Monitoring Board (IMB).
2. In accordance with my Terms of Reference an independent clinical review of the
man’s health needs, whilst he was in custody at HMP Hull, commissioned from
Hull Teaching Primary Care Trust (PCT). The review can be found, in full, at
Annex 2.
3. One of my family liaison officers contacted the man’s family. The family were
concerned about a previous occasion when the man had harmed himself and
whether there were records of what happened. My report deals with this issue in
paragraphs 10 to 13.
6
HMP HULL
4. HMP Hull opened in 1870 and is now a Category B adult male and Young
Offender local prison serving the courts in East and North Yorkshire and North
Lincolnshire. There are nine residential units. The maximum number of
prisoners that can be held is 1,071, and the certified normal accommodation is
812.
5. In March 2004, HM Chief Inspector of Prisons carried out an announced visit and
reported that the prison was providing a largely safe and decent environment.
Additionally, the prison was given a full Standards and Security Audit in 2004 and
has been rated “good” in both areas.
6. Hull has implemented the Assessment, Care in Custody and Teamwork (ACCT)
approach to helping and monitoring prisoners at risk of self-harm. The key aims
of ACCT are to create a safe and caring environment, to identify prisoners’
individual needs and to offer individualised care and support before, during and
after a crisis.
7. Hull operates both the Insider and Listener scheme. The role of an Insider is to
welcome newly arrived prisoners, highlight any concerns they may have, and to
explain the processes they will encounter in the early days of custody. Listeners
assist those prisoners who require additional support at any time during their
period in custody.
8. PSO 4400 relates to prisoners convicted of, or charged with, offences under the
Protection from Harassment Act 1997. It sets out a range of measures to prevent
such prisoners from Harassment Act 1997, from continuing to harass their victims
while in prison. Prisoners subject to PSO 4400/1 are prevented from making
unauthorised contact with certain identified individuals. The restrictions of the
Public Harassment Act 1997 means that the prison tries to balance security and
good order with protection of the public and the prisoner’s need to maintain family
ties.
7
KEY FINDINGS
9. The man had some previous petty offences on record, mainly related to driving.
The majority of these had been dealt with by way of driving bans and fines.
However, after failing a community service order he served a short sentence
between January and May 2001. The man’s records did not contain a list of
previous convictions, so it is not known whether that was his first time in prison.
10. A pre sentence report written by a probation officer, in 2006, details the man’s
excessive use of alcohol and his disturbed emotional state. She also recorded
that the man had previously attempted suicide, in 2005, by taking an overdose of
his grandfather’s pills. The man said he saw his doctor after this attempt, but it is
unclear if any diagnosis was made regarding depression or poor mental health.
The man confirmed at the time that he had made no further attempts at self-harm
or suicide.
11. In 2006, the man was sentenced to 12 months imprisonment for further driving
offences and was taken to HMP Hull. Following usual procedures, a cell sharing
risk assessment was completed. On the assessment form, staff recorded,
“ACCT last time in prison. Family probs - now sorted”. An Assessment, Care in
Custody and Teamwork (ACCT) plan is a monitoring and assessment process,
used to observe and support more closely those prisoners at risk of harming
themselves. No further mention of this ACCT plan is made in the man’s prison
records.
12. The following month, the man was told that he was going to be transferred to
another prison. He had applied to go to a nearby prison, but was allocated to one
he felt was too far away. In August, he took an overdose of his prescribed
medication, but was discovered by staff before any harm was done. The man
told staff that he had taken the pills because the new prison was too far away for
his wife to visit, given her poor state of health. The man was taken to the
healthcare centre where he was examined by a doctor. Staff opened an ACCT
plan and the man then returned to his cell on D wing. Staff monitored him during
the night and in the morning he was interviewed and assessed by a member of
staff. The man said that he had been “very low” the previous day and had not
known what to do. Staff arranged for his transfer to be changed to HMP
Everthorpe - a fifteen minute car journey from Hull. This resolved the issue and
the ACCT plan was closed. The doctor then examined the man again and said
that he was fit enough to be transferred. The next day, the man was taken to
Everthorpe.
13. On 17 November, the man told staff that his relationship with his wife had broken
down. Staff then opened another ACCT plan. The following day he took an
overdose of 12 ibuprofen pills and eight paracetamol and was treated locally in
the healthcare centre. The ACCT remained open until 26 November. The man
was released in January 2007.
14. The man was arrested in early March 2007, charged with assaulting his wife and
having contravened a court order imposed in June 2006. A risk assessment
carried out by the police identified that the man was taking medication but no
8
record was made of what it was. Also noted was the fact that he had tried to
harm himself in the past, having taken an overdose during a previous time in
prison. The police also recorded that the man said he had been drinking all night.
15. A prisoner escort record (PER) accompanies every prisoner as they move
between police custody, the courts and the prison system. It is used to highlight
any immediate concerns staff may have about the prisoner in their care and pass
that any relevant historical information to the next agency who might deal with
them. The man’s PER form highlighted self-harm, as well as drug and alcohol
issues. He was remanded in custody for a week.
16. In Hull, the man gave his mother as his next of kin and supplied her contact
details. He also said that he had previously spent a year in prison for a drink
driving offence and had been released from HMP Everthorpe in January 2007.
He then confirmed that he had been remanded for one week. The duty senior
officer completed the harassment notification on the reception form as required
by PSO 4400.
17. The man was then seen by an officer who completed the first section of the Cell
Sharing Risk Assessment (CRSA). He indicated that he had seen the man’s
PER and the warrant information. He noted on the form that the man replied no
when asked about drug or alcohol issues. In answer to the question ‘is there any
evidence of the prisoner being subject to previous suicide watch’, the officer
ticked the ‘no’ box. He then ticked the box that said the man was a low risk. In
the space available to make any other comments, the officer wrote ‘no concerns’.
18. However, the answers that the man had given the officer were different from the
information on the PER form, especially in relation to alcohol use and previous
self-harm attempts. The officer told my investigators that unless he has evidence
to support what is recorded on the other documents he uses the information
given by the prisoner to complete the CSRA. He explained that the CSRA and
the PER are sent to the induction unit with the prisoner, so both are available to
the induction wing staff.
19. The man then went to the first night centre on A wing. He was seen by a nurse
who completed the health care section of the CSRA, section 3. She noted the
man’s history, as given on the PER form. She indicated that no concerns had
been raised as part of her assessment, writing, ‘no concerns at present’. The
nurse then completed the man’s First Reception Health Screen. She noted that
the man had been remanded for one week, on a charge of harassment. Again,
the man told her he had been in prison before, having been released from
Everthorpe earlier that year. The man reported no concerns regarding his
physical health and the nurse noted that he ‘looks fit and well, good weight for
height’.
20. When asked about substance misuse, the man disclosed that he drank about two
pints of vodka a day, along with 15 cans of lager. He confirmed that he had last
had a drink the day before. He also said he smoked cannabis daily. The nurse
noted that although the man had admitted to a serious alcohol problem, he was
9
not suffering any withdrawal symptoms at that time. She then referred him to the
substance misuse team to assess his alcohol dependency.
21. In the section covering mental health, the man said that, in the past, he had been
prescribed Prozac and amiltriptyline for his mental health. He said that he had
tried to self-harm both in prison and the community, the last time being at
Everthope two months previously, where he had taken an overdose. The nurse’s
summary of the man read, ‘low in mood due to current circumstances, states no
thought of self-harm at present despite’. The man asked the nurse for some anti-
depressants to help lift his mood. She said that she would refer him to the doctor
the following morning and they could discuss it then.
22. The CSRA was then signed by an officer on the induction wing. He ticked the
box which indicated that the man should be ‘located as normal’, meaning he was
deemed suitable to share a cell. At interview, the induction officer explained that
he went though all the prison paperwork and rules and regulations with the man.
This included the A wing First Night Centre and the Induction Unit questionnaire.
He also recorded that the man said he had been in prison before. When asked if
he felt like harming himself, the man answered no and also said he had no other
concerns. He also asked the man if he had any other concerns and the man
answered ‘no’. It is also recorded on this form that the man was issued with a £1
phone credit. It is regular practice to issue this on a prisoner’s first night. It
allows them to contact their friends and family to let them know where they are.
However, the man was subject to the provisions of Prison Service Order 4400.
23. The man had been charged with harassment and checks were necessary before
permission to use the phone was granted. He should therefore not have been
issued with a phone credit at this time. When the reception officer spoke to my
investigators, he explained that although he had signed the form to say this
phone credit had been issued, in reality it had not been credited to his account
and this was merely an administrative error. He also made a note in the man’s
wing file, saying that an initial induction briefing had been given to the man and
he had raised no concerns. He noted that the £1 phone credit had not been
issued because of the harassment charge, but a phone call had been made on
the man’s behalf.
24. We know from other documents that the man was not cleared to use the phone
until two days later. We also know that a phone call was made to the number the
man provided for his next of kin, to let them know where he was. The
observation records for prisoners serving their first night in custody show that the
man was checked every hour throughout that first night at Hull.
25. At 9.50 the next morning, the man was seen by the duty doctor. She noted in the
man’s medical record that he had been abusing alcohol. As part of the alcohol
withdrawal assessment, she recorded that his hands were moist and he had a
visible tremor. She prescribed a standard detoxification regime. She also wrote
that he appeared ‘depressed, very low and was thinking about suicide’ and that
he had attempted suicide last year while in prison. She then opened an ACCT
document to ensure that the man would have the additional support that he
needed.
10
26. After the doctor had registered her concern, the man was seen by the wing senior
officer who drew up an immediate action plan. As part of this plan, he arranged
for the man to remain in a double cell on A wing, but stipulated that he would be
checked hourly by the staff. He suggested that the man should use the Listeners
and Samaritan services. He also encouraged him to keep in touch with his
friends and family by telephone. There does not appear to have been any
recognition that the man had not yet been cleared to use the phone.
27. The senior officer then held an assessment interview. The man told him that he
was struggling to cope with his withdrawal from alcohol. He said that he did not
feel he should be in prison, as he had not committed the offence of which he had
been accused. The man told the senior officer that in the past he had taken an
overdose of painkillers, but had not attempted self-harm recently. He had done
this as his marriage was breaking up and he had felt low. The man said, on
these occasions, he had wanted to die. The senior officer noted that although the
man was low, he was discussing his situation openly and making good eye
contact. He said the man had described his situation as ‘bleak’ and added a lot
would depend on his forthcoming court appearance.
28. The senior officer’s summary of the interview reflected the man’s upset at finding
himself in prison. He said the man had a history of self-harm and had admitted
that he did not know how he would cope if he was returned to prison after his
court appearance. It was agreed that the observations and monitoring should
continue. The senior officer also noted that the man said he was close to his
mother and was expecting a visit from her that day. The man then said he was
receiving medication to help him with his withdrawal from alcohol.
29. There are several entries in the man’s ACCT record that day, in which staff detail
the daily interactions and observations. Staff reported that he had taken all his
meals, was talkative and, when asked, told staff he was fine. It was also
recorded that he was chatting amiably to his cell mate. An entry at 7.30pm
shows that an officer had telephoned the man’s grandfather, who said he would
arrange for the man’s mother to visit.
30. The following day, the man’s medical record shows that he was reviewed by a
member of the substance misuse team. During the review, the man said that
prior to coming into prison he had been drinking in excess of 50 units of alcohol a
day. He had been doing so every day for the previous eight years, with the
exception of his periods in custody. He also said that he had numerous overnight
admissions to Accident and Emergency units due to collapsing in the street from
excessive alcohol.
31. Again, the entries in the ACCT document showed him talking to staff, chatting
with his cell mate and apparently fine. However, later that day one of the
chaplaincy team noted in the record that he had spoken with the man for about
15 minutes. The chaplain said that he had been asked to see the man by a
member of staff. Before he went to the cell, he spoke to an officer in the wing
office. The officer told him that the man would probably ask for his help in
making a telephone call, but that was not yet possible as he was subject to PSO
11
4400. When the chaplain spoke to the man, it was indeed the man’s over-riding
concern. He said that he urgently needed to contact his solicitor. The chaplain
pointed out that it was about 4.30pm on a Friday afternoon so there would
probably be nobody in the solicitor’s office. The man just repeated that he
needed to speak to his solicitor that day and it was not right that he could not.
The chaplain wrote in the ACCT that the man was shaking and was very agitated.
By this time, he had been cleared to use the telephone. However, the man had
given only three numbers for checking. None of these were for his solicitor so, he
could not call direct. The man’s telephone records show that the first time he
used the phone was on 9 March at 3.34pm. He dialled his mother’s number, but
received no reply.
32. At some point during the day, the man wrote a series of notes to his family saying
that he was innocent and he could not take being in prison when he had not done
anything. One note appeared to be a draft letter to his solicitor asking him to
obtain information to help refute the charge against him. There is no evidence
that he subsequently sent a letter based on this draft. The notes are all dated at
the bottom, but there is no time on them. They were found in his cell, after his
death.
33. The following day, at 8.30am, the man’s cell was opened so he could collect his
medication. An officer later wrote in the man’s ongoing ACCT record that he
spoke very quietly and appeared low in mood.
34. The man made three phone calls that morning. The first was to his mother and
they talked for over six minutes, discussing his case. The record of the call
shows that he was upset and angry. He told her that he was struggling to deal
with things and had been put on ‘a watch’. He said “I felt like doing myself in
because of something I hadn’t done”. He repeated the phrase, “I shouldn’t even
be here!” a number of times. He also mentioned that he had not been able to
make a phone call to his solicitor. She reassured him that she was in contact
with his solicitor and would be in court to support him on the following
Wednesday.
35. He then telephoned his cousin at 11.16am. His cousin was not home, so the
man spoke briefly to his cousin’s girlfriend. The man then redialled his mother’s
number and spoke to her for a further three minutes. He checked that his mother
had arranged to visit him and again they spoke about his case. The man told his
mother that he had been unable to call his solicitor because of the harassment
allegation. His mother again reassured him that she had been in contact with his
solicitors and was due to visit their office the following Tuesday, the day before
the man was due back in court. The man mentioned that he had asked staff
several times for a phone call to his solicitor during the previous two days. He
said he was told to make a written application to see his solicitor.
36. The man was seen by several other staff members that day, who all recorded
that at various times he was watching television, talking with his cell mate or
sleeping. At 8.00pm, the man was checked by one of the OSGs, who wrote, ‘He
is sound tonight, he stated no problems’.
12
The night of the man’s death
37. At 8.30pm, the officers on night shift came on duty and at 9.00pm the prison went
into night patrol state. The night orderly officer (radio call sign Oscar1) was the
most senior officer on duty in the prison. He was assisted by two officers whose
call signs were Oscar 2 and Oscar 3. The wings were patrolled by Officer
Support Grade (OSG) staff, as is usual. There was a duty governor on call.
38. During night patrol state, only Oscar 1 carries a full set of keys to unlock all gates
and cells. Oscars 2 and 3 also have keys that allow them to move through the
prison. Wing staff and nurses do not have access to keys allowing them free
access around the prison and have to be escorted. Oscar 2 told my investigators
that when he is Oscar 2, he usually carries a cell key and he did so on that night.
The OSGs are each issued with a cell key in a sealed pouch for use in
emergencies. The staff instructions are that during the night state, a cell may
only be unlocked by a single member of staff where there is, or appears to be,
immediate danger to life.
39. Two OSGs were responsible for patrolling and checking the prisoners. As part of
the handover from the day staff, one did a roll check and made a note of the
prisoners who had to be checked during the night, including those on ACCT
plans. The man was to be checked once during every 60 minute period. (Such
checks are ‘at irregular intervals’ rather than every hour, on the hour.) The other
OSG carried out the checks up to 11.00pm and then the first took over. He told
my investigators that when he checks a prisoner he opens the observation flap
on the cell door and looks in. He does not move on until he is satisfied that the
man he is checking is ‘settled, content and okay’. When he checked the man at
1.00am, he was writing and appeared settled.
40. The next time the OSG went to check the man was about 2.30am. When he
opened the observation flap he realised that contrary to prison rules, it had been
covered from the inside. Therefore he could not see the man or his cellmate.
The OSG shouted through the door for the men to uncover the flap but there was
no reply. He kicked the door to attract their attention and called the man’s name,
again without reply. He then shouted to the cellmate, but still got no reaction.
The OSG told my investigators that he thought the men were playing a game and
were having a laugh at the staff. He told the men that unless the flap was
uncovered he would put them on report. When there was still no reply, he went
upstairs to get advice from Oscar 2.
41. Oscar 2 decided to accompany the OSG to the man’s cell. When there was still
no response from the men in the cell, Oscar 2 unlocked the door. As the staff
entered the cell, the towel that had covered the flap fell to the floor. The officers
then realised that the man was directly in front of them and was hanging from the
light fitting. Oscar 2 immediately lifted the man up, while the OSG used his anti-
ligature knife to try to cut the man down. When he was unable to do this, Oscar 2
took over. The OSG then summoned help over the radio by saying that there
was a ‘Code Blue’ at the man’s cell. This told everyone that it was a medical
emergency that involved someone with breathing difficulties. Oscar 2 succeeded
in releasing the sheet from the light fitting and the two officers lowered the man to
13
the floor. Oscar 2 began mouth-to-mouth resuscitation, while the OSG performed
chest compressions. When the staff entered the cell, the cellmate was asleep in
the top bunk, but he woke up as staff went to the man’s aid.
42. When the OSG called the Code Blue, all staff who were carrying radios heard it.
The OSG who was on duty in the communications room and he recorded the call
as being made at 2.34am. Oscar 1 immediately went to A wing. On his way, he
called Oscar 3 and told him to collect a nurse from the healthcare centre and
escort her to the man’s cell. When the duty nurse heard the call, she collected
the emergency equipment bag and went to the gate at the entrance to the
healthcare centre, to wait for an escort. Oscar 1 arrived at the man’s cell and
realised that he was in a very serious condition, so he told the communications
OSG to call an ambulance. The time was 2.39am.
43. At 2.40am, the nurse arrived. She immediately checked for a pulse, but could not
find one. She also noted that the man’s pupils were fixed and dilated. She took
over the compressions from Oscar 2. As she worked, she noticed the cellmate
sitting on the top bunk and she asked staff to take him out of the cell. The staff
continued with CPR for a further ten minutes until the paramedics arrived. One of
the paramedics took over the breathing from Oscar 2. She and the nurse worked
together for a further fifteen minutes. However, they decided that nothing further
could be done for the man and the paramedics pronounced him dead at 3.08am.
44. The Governor one of the family liaison officers visited the man’s mother and
grandfather to beak the news of his death. The man’s mother told my family
liaison officer that she was very grateful for the information the prison family
liaison officer had provided and for her continuing care and support to the family.
14
ISSUES
Cell Sharing Risk Assessment (CSRA)
45. A number of staff interviewed the man in reception on the morning of his arrival.
An officer spoke to the man as he completed several of the necessary forms,
including the CSRA. This questionnaire aims to identify any risk a prisoner may
pose to another prisoner, to help officers allocate new prisoners to a cell. The
assessment is usually completed by both healthcare and discipline staff.
46. The officer asked the man the questions on the first part of the form and ticked
the relevant boxes. However, a number of the man’s answers were different to
the information contained on the PER form. The officer recorded what the man
told him, rather than using the information on the PER form. He told my
investigators that the PER form was attached to the CSRA before it was sent to
the induction unit. He did not want to copy out a lot of information from the PER
form onto the CSRA and expected the induction staff to read both documents.
Reception staff often have to interview many prisoners in a fairly short space of
time and it is time-consuming to transfer information from one document to
another. Similarly, the induction unit also accept many new prisoners onto the
unit at a time.
47. Where the PER form highlights important information about a prisoner, especially
if it is at odds with information on the CSRA, it would be helpful for the reception
officer to draw attention to it and if necessary, question an individual further. This
could be achieved by making a brief note in the section of the CSRA for
observations and concerns. That way, induction unit staff would be alerted to the
importance of information on both the PER form and any other documents
accompanying the prisoner.
The Governor should ensure reception staff draw attention to any
conflicting information when completing the CSRA.
ACCT
48. When the duty doctor saw the man on the morning of his first full day in Hull, she
was concerned about both his physical and mental health. Physically, he was
beginning to suffer the effects of alcohol withdrawal. The doctor therefore
prescribed medications for a standard detoxification programme. When she
asked whether he had self-harmed in the past, or if he felt like doing so at
present, the man’s reply caused her to open an ACCT plan.
49. When an ACCT plan is opened, a case manager is appointed and staff must also
draw up an immediate action/support plan. Within 24 hours, a full assessment
must take place. The wing senior officer drew up the action plan and carried out
the assessment shortly after the doctor passed the ACCT document to him. The
speed with which this was done is commendable. Hull has added an additional
page to the booklet that contains all the information, assessments and
observations. It contains instructions to staff. The instructions emphasise the
15
quality that is expected and examples of both good and poor entries are given. A
copy of the instructions appear at Annex 5
I commend as good practice, the information sheet used at Hull that
describes and gives examples of what makes a good entry in an ACCT
plan.
50. That said, staff do not appear to have considered contacting the man’s family to
include them in his support plan. PSO 2700 Suicide and Self-harm Prevention
states in paragraph 3.4.3, “After consultation with the prisoner, the nominated
next of kin must be notified, unless:
a. There is a clinical reason not to, or
b. If aged 18 and over, the prisoner does not consent, or
c. The prisoner’s support plan indicates otherwise.”
There is nothing on the record to show that staff considered encouraging the man
to include his family in his support plan.
The Governor of Hull should remind staff of the requirement, in PSO 2700,
to consider involving the family in the support of a prisoner on an ACCT
plan and introduce an audit of records to establish compliance.
51. The senior officer who assessed the man told my investigators that during their
conversation, the man was focussed on his court appearance the following week.
He was convinced that the evidence would prove his innocence and that he
would be freed. The senior officer’s concern was that if the man returned to
prison, he would be at heightened risk of self-harm. The senior officer therefore
decided to keep the ACCT open until after the court date. He scheduled the next
review of the ACCT for the day after the man was due to return to court. It would
have been helpful to other staff if the information about his court date had been
noted on the section for triggers/warning signs.
The Governor of Hull should remind staff to enter triggers such as court
appearances in the relevant section of the ACCT.
Access to phone cards
52. When the man arrived at Hull, the reception officer asked him during the
reception interview whether his family knew where he was. When the man said
no, the officer telephoned the man’s grandfather on his behalf. The man faced a
charge of harassment and so was not permitted to use the telephone until the
numbers he wished to call had been cleared. The process to approve the
numbers involved checking them to ensure that they did not belong to people he
was banned from contacting. It took staff two days to carry out the checks and
the man was not able to use the telephone until then. I find two days to check the
man’s telephone numbers to be a reasonable length of time.
53. However, on arrival, the man d had asked, as a matter of urgency, to contact his
solicitor, to discuss the charges against him and the evidence that he was
convinced would prove his innocence. He was very frustrated at not being able
16
to contact them immediately. In a letter dated on his third day in prison, ‘between
14.30pm and 17.00pm’ found in his cell after his death, he protested at being
unable to use the telephone. He spoke to a chaplain about this the same
afternoon and by the end of the conversation he was shaking.
54. My investigators raised the issue of the man’s great desire to speak to his
solicitor with one of the wing senior officers. He said that it would be almost
unheard of for staff to allow a prisoner to use an office telephone to contact their
solicitor. Prisoners who need to speak to their legal representative have three
ways of doing so. They can make an application for a letter which they can then
send to the solicitor. They can also get the number put on their list of approved
PIN phone numbers or they can ask a family member to contact the solicitor.
The man did not have enough time before the court date to make the application,
receive the legal letter, send it to his solicitor and then wait for a reply. Neither
had he given the solicitor’s number for his PIN phone, so he could not use that
method of contact.
55. However, once he was able to speak to his mother, he was able to ask her to
deal with the solicitor on his behalf. Given that the man was on an ACCT plan
and the imminence of his next court date, it seems unduly stringent not to
consider making an exception, to help put his mind at rest. The Governor may
wish to consider whether, in cases such as the man’s, a legal aid fax could be
offered or a system put in place for contact to be made using an official
telephone.
Medical Care
56. The clinical review was undertaken by a member of Hull Teaching Primary Care
Trust (PCT). He concluded that the clinical care the man received in prison was
at least as good as the care he would have received had he been in the
community. He said that the drug detoxification programme that the man was
prescribed was appropriate and all ACCT procedures were completed in a timely
manner. However, he highlighted three learning points.
57. Some of the forms in the man’s medical record were incomplete. They did not
have all the personal details filled in and in one case the person completing the
document did not initial or date the form.
The Prison Health Partnership should take steps to ensure the healthcare
staff adhere to the guidance on records and record keeping, issued
variously by the General Medical Council, the Nursing and Midwifery
Council and the Royal Pharmaceutical Society of Great Britain.
58. The other two points relate to assessing the seriousness of previous self-harm
attempts. The reviewer suggests that it would be good practice for healthcare
staff to go further in gathering information than the current First Reception Health
Screen form requires. He proposes that staff should not simply ask prisoners
about the incidence of recent serious self-harm attempts. They should also ask
for details and record how serious the attempt was. That way, staff could
develop a profile of what triggers that prisoner to harm himself. Similarly, he
17
suggests the setting up of a risk protocol to record prisoners who were at risk and
how serious the risk was. The assessment could then help prioritise referrals to
the Mental Health Inreach Team. Whilst not making an official recommendation,
the Head of Healthcare may wish to consider adopting these practices as a
means of further identifying and supporting prisoners who are at risk of self-harm.
59. Two further healthcare issues came to light when looking at the attempt to
resuscitate the man. These concern healthcare staff who work night shifts. My
investigators interviewed the nurse who went to the man’s aid after the Code
Blue call. The Staff Nurse is an agency nurse who often works at Hull. She is a
Registered Mental Nurse (RMN), which means that her area of expertise is caring
for people with mental health problems. However, at Hull she sometimes
performs more general duties, including dealing with men in poor physical health.
On the night the man died, there were two nurses on duty and both were RMNs.
The Head of Healthcare should ensure that, wherever possible, one of the
night shift nurses is a Registered General Nurse to ensure an appropriate
skill mix of staff.
60. The nurse responded to the Code Blue as part of her duties as Hotel (H) 1, the
response nurse. When she heard the call for assistance, she asked her
colleague to fetch the defibrillator that is kept the healthcare centre. A
defibrillator is a machine that supports the treatment of patients who experience
sudden cardiac arrest, by delivering a shock to the heart. The nurse’s colleague
could not find the machine and even if she had, the nurse was not very confident
in using it. However, this did not adversely affect the treatment that the man
received.
The Head of Healthcare should ensure that all night duty nurses, whether
permanent or agency staff, are trained in CPR, including the use of the
defibrillator.
Finding the man
61. The documents that detailed finding the man revealed two different times -
2.10am and 2.34am. Having examined the apparent discrepancy, I am content
that there was no delay in staff attending the man and attempting to resuscitate
him.
62. The officers and nurse who found the man and went to his aid all estimated the
time that they became involved. When asked, none of them said they had made
a note of the time or looked at a clock or watch. Understandably, their immediate
concern was to tend the man. The staff who gave the time as 2.34am, used the
time recorded in the control room log.
63. The OSG on duty in the control room that morning said that as soon as he heard
the Code Blue call on the radio, he looked at the clock above his desk. The time
was 2.34am and he entered this on the log. He gave a very clear account of his
actions after hearing the call and he was sure that the time was accurate. During
the investigation my staff checked the clock. It was accurate and in a very
18
prominent position. On balance, I conclude that the man was found at 2.34am,
somewhat later than the estimates of the first staff on the scene.
The man’s cellmate
64. In the first few days after the man’s death, concerns were expressed about
whether his cellmate had been involved in any way. There was a rumour in the
prison that the two men had taken drugs obtained from another prisoner. A
second rumour was that the cellmate had told an officer that he had helped the
man cover the observation flap. The cellmate was released on bail a few days
after the man’s death and my investigators did not have an opportunity to speak
to him as he left no onward address.
65. At the time of writing this report, the post mortem report was not available.
However, the toxicology report showed that the man had not used alcohol or
drugs, other than the medication he was taking for the detoxification programme.
Therefore, the first rumour was clearly untrue.
66. My investigators spoke to a number of staff about whether the cellmate had
known the man’s intentions and had helped to cover the observation flap. When
the OSG checked the man at 1.00am, he was writing and appeared settled. The
OSG was not able to say where the cellmate was, as his attention was on the
man. At 2.34am, when he entered the cell with Oscar 2, they were only vaguely
aware of the cellmate. The OSG assumed that he must have been in his bed
because he was not in their way. Oscar 2 said that the cellmate was in his bed
when they entered the cell and when they started to move about, the noise woke
him up. He then appeared disoriented and shocked by what was happening.
67. After the man’s death, prison managers were informed of the rumour of the
cellmate’s involvement. My investigators spoke to three members of staff in an
attempt to identify the source of the information. A senior officer told my
investigators that she heard a female officer and other officers discussing the two
rumours the day after the man’s death. Three days later, she realised that this
had not been officially reported and she then submitted a security information
report. Prison managers then passed the information to my investigators and the
police liaison officers. No further issues have been raised by the police. The
female officer said that she had spoken about the rumour that the cellmate knew
what the man had planned to do, but that was all. She said that the whole prison
was talking about this rumour. However, she said that she had not heard the
rumour that the two men had taken drugs or that the cellmate had helped by
covering the flap.
68. When my investigators asked one of the A wing managers, about this, he
expressed surprise and said he had not previously heard the rumour. Certainly,
no officer had reported that the cellmate had admitted assisting the man. The
manager was very clear that all he had heard after the man’s death was some
prisoners talking to each other, questioning whether it was possible to sleep
through such an event. He did not hear officers talk about it until senior
managers questioned the officers concerned. The senior managers then passed
the matter to my investigators. My investigators could find nothing concrete to
19
link the cellmate to the man’s actions. The rumour may well have started as
speculation about whether it is possible for someone in the same cell to be
unaware of a cell mate taking such action. Therefore, I conclude that this was
simply speculation.
Conclusion
69. The man who died was a young man who was obviously labouring with his
addiction to alcohol and the difficulties of a relationship which was breaking
down. He was also struggling to accept being back in prison under
circumstances which to him felt unjust and flawed. His anger at being in prison
was equalled by the conviction that his innocence would be proved when he
returned to court. Sadly, he did not live long enough to set out his case.
20
RECOMMENDATIONS
The Governor should ensure reception staff draw attention to any
conflicting information when completing the CSRA.
This recommendation was accepted. All staff are to be made fully aware of the
requirement to cross reference information contained on the Prisoner Escort
Record (PER) form when completing the Cell Sharing Risk Assessment (CSRA).
The Governor of Hull should remind staff of the requirement, in PSO 2700,
to consider involving the family in the support of a prisoner on an ACCT
plan and introduce an audit of records to establish compliance.
A detailed response was not provided for this amended recommendation.
The Governor of Hull should remind staff to enter triggers such as court
appearances in the relevant section of the ACCT.
This recommendation was accepted. The importance of trigger points in ACCT
documents forms part of the training module, and the daily management of the
ACCT document. All open ACCTs are subject to a full assessment by trained
assessors within 24 hours of opening and identified triggers, if appropriate, noted.
The Prison Health Partnership should take steps to ensure the healthcare
staff adhere to the guidance on records and record keeping, issued
variously by the General Medical Council, the Nursing and Midwifery
Council and the Royal Pharmaceutical Society of Great Britain.
This recommendation was accepted. All healthcare staff have been issued with a
copy of the Nursing and Midwifery Council (NMC) guidelines on record keeping,
and training around this subject is now part of the performance review of each
member of staff. Since April ’07, a phased introduction of electronic patient
records has been started, which will ensure all entries are legible.
The Head of Healthcare should ensure that, wherever possible, one of the
night shift nurses is a Registered General Nurse to ensure an appropriate
skill mix of staff.
At the time of issuing the final report, a response had not been supplied by the
Prison Service.
The Head of Healthcare should ensure that all night duty nurses, whether
permanent or agency staff, are trained in CPR, including the use of the
defibrillator.
This recommendation was accepted. All nurses including bank nurses are
included in the yearly training performance reviews. Basic life support training is
mandatory for all nurses. However, the nurse in question has undertaken this
training and it is her responsibility to bring any issues in regard to her own
confidence to the attention of her line managers.
21
Good practice
I commend as good practice, the information sheet used at Hull that
describes and gives examples of what makes a good entry in an ACCT
plan.
22
ANNEXES
1. Documents considered during the investigation
Core Record
Custody File
Security File
Medical Records
Records from the man’s previous period of imprisonment
23