Individual at Kingston

INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING
THE DEATH OF A MAN AT HMP KINGSTON
IN SEPTEMBER 2006
Report by the Prisons and Probation Ombudsman for England
and Wales
July 2007
This is the report of an investigation into the death of a man in September 2006. He
was a life sentence prisoner at HMP Kingston. He was found dead in his single cell
with two plastic bags taped over his head. He was aged 64.
I offer my sincere condolences to his family and friends.
The investigation was led by one of my colleagues. My thanks also go to a number
of clinicians at Portsmouth City Primary Care Trust, particularly to the chair of the
review panel that assessed the clinical care given to the man while in custody.
I am grateful too for the assistance my colleagues received from the staff and
management of Kingston prison. I also acknowledge the help of Hampshire Police
who carried out their own enquiry into the man’s death and readily shared their
information with me.
The greatest number of self-inflicted deaths in prison occur in local prisons and
amongst those recently received into custody. This man was representative of a
different group of prisoners: those long into their sentences who seem to feel that
they have no prospect for release. I have little doubt that his anticipation of a ‘knock
back’ from the Parole Board was a major factor in his apparent decision to take his
own life.
During his years in custody, the man had been subject to formal suicide and self-
harm monitoring and support on six occasions. However, in the immediate period
prior to his death he was seen to be in a very good mood. Although it is counter-
intuitive, as I report later in this document an improvement in mood immediately
before a self-inflicted death has been recognised in the literature on suicide, and has
been found in a number of my investigations.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2007
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CONTENTS
SUMMARY
THE INVESTIGATION PROCESS
HMP KINGSTON
Life Sentence Prisoners
Suicide and Self Harm Monitoring Procedures
Healthcare Centre
Psychiatric Services
Drug Strategy
Roll Checks
Unlocking of Prisoners
Follow-up to Deaths in Custody
KEY FINDINGS
ISSUES
Roll Checks
Town Visit – September 2004
Anti-Bullying
Suicide and Self Harm Monitoring Procedures
Medical Care
Emergency Response
Cell Furniture
Events following the Death
RECOMMENDATIONS
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SUMMARY
This is the report of an investigation into the death of a prisoner at HMP Kingston.
On the morning of 25 September 2006, he was found in his cell at HMP Kingston
with two plastic bags taped over his head. Staff decided that resuscitation was futile
as there were no signs of life. This was confirmed by the doctor who said that rigor
mortis had started to set in.
The post mortem concluded that the cause of death was asphyxiation.
The man was a life sentence prisoner and had been in prison since 1988. He had
been resident at Kingston since September 2003. By September 2004, he had
progressed through the lifer system to a point where he was granted permission to
transfer to a prison with open conditions. However, on one occasion, he was
believed to be under the influence of alcohol or drugs after an escorted visit which
placed his progression in jeopardy.
Staff opened an ACCT form on 14 June 2006. (This is a document designed to co-
ordinate the care and observation of a prisoner who is vulnerable to suicide or self-
harm.) It was closed on 26 July when staff were content that he was no longer
vulnerable to suicide or self-harm.
On 13 September 2006, his case was reviewed by the Parole Board. The occasion
when he was thought to have misused drugs or alcohol had affected his status and
the Board decided that he should remain in closed conditions. He had not formally
been notified, but he told his personal officer that he knew the outcome.
Staff and prisoners remember him as humorous, likeable and frail man. However,
he did have a reputation for being grumpy and for complaining.
My report includes a total of nine recommendations. A further 14 have been made by
the clinical review panel.
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THE INVESTIGATION PROCESS
1. The investigation was conducted by one of my colleagues. He visited HMP
Kingston and saw key locations including the healthcare centre and the wing
where the man was located.
2. The investigator issued notices to staff and prisoners, inviting anyone with
information relating to the man’s death to make themselves known. He spoke
to a number of prisoners who responded to the notice.
3. The investigator also spoke to the Chair of the Independent Monitoring Board
(IMB), a representative of the local branch of the Prison Officers’ Association
(POA), one of the prison chaplains, and various other members of staff
including the Safer Custody Manager. He formally interviewed a number of
prison staff and healthcare professionals involved in the events surrounding the
man’s death. In addition, the investigator spoke informally to other staff and to
prisoners.
4. The prison gave the investigator full access to all the documentation
surrounding the man’s time in prison. The police also provided copies of the
documents and statements in their possession.
5. One of my family liaison officers spoke on the telephone to the man’s brother.
He gave a little background information, but had no specific issues to raise.
Indeed, the man’s death had resurrected such unhappy memories that his
brother did not feel able to be involved in the investigation. However, he would
welcome a copy of my investigation report.
6. The review panel for Portsmouth City Primary Care Trust (PCT) undertook a
clinical review of the man’s care while in prison.
7. Following the publication of the draft report the Prison Service Area office
commissioned its own investigation, and the report has been amended in the
light of their feedback.
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HMP KINGSTON
8. HM Prison Kingston was built in 1877 to a radial design. It currently serves as
a specialist prison for life sentence prisoners. One wing is for prisoners who
have reached category C. The prison holds a maximum of 192 prisoners. On
the day of the man’s death, the prison was full.
9. The overall establishment rating is four (four being the highest and one the Formatted: Bullets and
lowest). This rating is established from a number of factors, including Numbering
performance against area targets, Prison Service National Standards and
independent inspection by Her Majesty’s Chief Inspector of Prisons (HMCIP).
10. In relation to Prison Service National Standards, the establishment attained a
rating of ‘Good’ for non-security and security, which were marked as 88% and
87% respectively during the most recent audit in November 2005. Suicide
awareness and self-harm procedures were also rated as ‘Good’, achieving a
mark of 84% compliant with the relevant standard.
11. Following an inspection in December 2005, HM Chief Inspector, reported that
Kingston had improved considerably and had a senior management team that
was clear about its role and purpose. Relationships between prisoners and
staff were relaxed and friendly. However, the Chief Inspector said there was a
lack of positive engagement, such as personal officer work, and of interaction
with prisoners while out of their cells. For example, bullying for medication was
an acknowledged problem, but the queue for medications was virtually
unsupervised during HMCIP’s inspection.
12. The Chief Inspector noted that managers had tackled a significant problem with
illegal drugs and were about to cut down on the over-prescribing which had led
to trading in opiate-based medications. Healthcare had suffered from slow
engagement by Portsmouth PCT, and the Chief Inspector said that the prison
required both stronger clinical leadership and the development of chronic
disease management clinics and mental health work to support the needs of its
ageing and long-stay population.
13. My investigator found that some progress has been made by the prison and the
PCT in response to the findings and recommendations of the Chief Inspector.
14. In common with many prisons, Kingston issues prisoners with a pre-packed
breakfast meal. This is collected with the previous evening meal and is
intended to be eaten by the prisoner in his cell before the cells are unlocked in
the morning. The breakfast is packed in a clear and un-perforated plastic bag,
which typically contains cereal, milk, bread roll, butter, preserves, sugar and
tea/coffee.
Life Sentence Prisoners
15. Following sentencing, life sentence prisoners are advised of the minimum
period that they must serve before they can be considered for release on life
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licence. This is often referred to as the tariff. No life sentence prisoner can
expect to be released before they have served the minimum sentence period.
16. Life sentence prisoners are initially moved to a ‘First Stage’ centre. During this
time the prisoner’s Life Sentence Plan (LSP) is developed. The LSP is a tool
that assesses the risk factors that contributed to crime. The LSP is written and
targets are set, aimed at reducing the risk of re-offending.
17. Once the risk factors are identified and the appropriate courses are agreed, the
prisoner can then move to a ‘Second Stage’ prison that offers the appropriate
courses and environment for the individual to progress through their plan.
Kingston is one such ‘Second Stage’ prison.
18. Regular risk assessments are carried out in order to assess a lifer’s progress in
reducing the likelihood of re-offending. A Parole Board panel reviews whether
prisoners are ready to progress to a lower category prison, including open
conditions (Third Stage), or release.
19. Once released, the lifer is supervised by the Probation Service. Although the
supervisory element of the licence may eventually be cancelled, they remain
liable to recall to prison for the rest of their natural life.
Suicide and Self Harm Monitoring Procedures
20. Prison Service suicide and self-harm procedures are set out in Prison Service
Order (PSO) 2700. The Assessment, Care in Custody and Teamwork (ACCT)
system is used when a prisoner is identified as being vulnerable to self-harm or
suicide. (ACCT replaced the former F2052SH process, and is a significant
advance upon it.) The aim of the system is to enable staff from all disciplines to
work together with the individual, creating a safe and caring environment,
where distress is minimised and those prisoners who are distressed feel they
are able to ask for help. It should identify individual need and offer
individualised care and support before, during and after crisis.
21. Staff are taught to recognise the signals that a prisoner who is in distress may
display. When a member of staff is concerned they may raise an ACCT
document which triggers a care planning process. The prisoner is encouraged
to talk about their problems, which staff attempt to reduce using a care plan
combined with extra support and possibly increased observation.
22. The PSO says at annex B that, when an ACCT is opened, the manager of the
unit where the prisoner resides must:
• decide, in consultation with healthcare staff, whether to manage the prisoner
on the residential unit or refer initially to the Healthcare Centre (HCC), and
document reasons;
• ensure that, where available, prisoners on an open ACCT have been offered
the opportunity to talk to a Listener and/or Samaritan; [Listeners are
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prisoners trained by the Samaritans, and provide a confidential listening
service.]
• ensure a case review is held within 24 hours, and document a summary of
the review and agreed care plan.
23. A care plan must be drawn up and agreed by all involved, including the
prisoner. Multi-disciplinary case reviews must be held as necessary, including
in the event of a further act of self-harm. The ACCT should be closed following
a case review when the prisoner appears to be coping satisfactorily. The case
review will agree after-care or follow-up requirements.
Healthcare Centre
24. Portsmouth City Primary Care Trust took over the commissioning of healthcare
at Kingston in April 2005. Under this arrangement, Kingston managed the
delivery of healthcare, having a non clinical manager in place, supported by a
lead nurse. The PCT employed a nurse and a healthcare assistant, but had no
managerial responsibilities for Kingston. In May 2006, the PCT decided to take
on the full provision of healthcare, with effect from 1 October.
25. Provision includes 24 hour doctor on call cover, but no in-patient facility.
Prisoners requiring 24 hour nursing cover are either transferred to local
hospitals or another prison with such provision. Additional services include a
psychiatrist, visiting dentist, pharmacy, GP surgeries and nurse triage. Two
doctors from a local practice attend Kingston for two hour sessions on Monday,
Wednesday and Friday.
26. If emergency medical assistance is required, then the member of staff detailed
radio call-sign ‘hotel’ responds, taking the emergency equipment bag with
them. They assess the situation and commence any emergency treatment,
before deciding on the next course of action. The person detailed as ‘hotel’ is
available throughout the day and is contactable from the communications room
via the UHF radio. On 25 September 2006, this was the duty nurse.
27. Since the death of this man, the PCT are making number of key changes.
From 1 October, the PCT provider arm has taken on full management of the
service and a clinical nurse manager has been employed. Healthcare service
times have been extended and the issuing of some of the opiate based
medication is now supervised. There is improved communication between the
healthcare team and the rest of the prison. The Clinical Governance and
Medicines Management groups are well established. Additionally, a review of
the GP cover and of the mental health services provision is planned.
28. The above developments are part of ongoing work to support the prison
healthcare action plan. These are monitored as part of the quarterly prison
healthcare service reviews within the PCT commissioning process.
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Psychiatric Services
29. Psychiatric services include a community psychiatric nurse (CPN). She is
commissioned by the PCT as a Mental Health Gateway Worker, delivering
mental health support to prisoners. She works at the prison from Tuesday to
Friday and has a typical caseload of around 15 prisoners. She attends the
Suicide Prevention Team meetings and is a member of the local safer custody
group.
30. The CPN is clinically supported by a general consultant psychiatrist who holds
a clinic at the prison every week. There had been difficulties obtaining regular
psychiatric services for the weekly morning clinics. There was no provision
between March and August 2006 inclusive, due to an unfilled position.
However, a consultant psychiatrist is now in post.
Drug Strategy
31. There is a multi-disciplinary approach to tackling the problem of drug use in the
prison. Detection involves drug dog searches, cell and area searches and
Mandatory Drug Testing (MDT). Throughcare includes one-to-one working with
a drug worker and support from the Counselling, Assessment, Referral, Advice
and Throughcare (CARATs) team. The prison also offers voluntary drug
testing to monitor progress, group-work, a helpline to Narcotics Anonymous,
auricular acupuncture, and other medical support. All grades of staff at
Kingston are trained in drug awareness.
32. Prisoners are identified from their reports and interviews, as well as positive
MDT results. There are arrangements with the Healthcare Centre at HMP
Winchester for the transfer of prisoners who require detoxification.
Roll Checks
33. The following instructions are extracted from the security section of the Prison
Officer training manual, with regard to the roll checks:
• Count the prisoners in their cells and get a response.
• This means that you physically check the presence of the occupants in
every cell. You must ensure that you receive a positive response from
them by knocking on the door and await a gesture of acknowledgement.
• If you fail to get a response you may need to open the cell to check. The
purpose of this check is to confirm that the prisoner has not escaped, is not
ill or dead.
34. Kingston’s Local Security Strategy 2.06 for Routine Roll Checks came into
effect on 19 March 2004. It requires that roll checks are conducted at least four
times every 24 hours when night staff handover in the morning, prisoners are
locked up at lunchtime and teatime and the end of the day at 8.00pm. Night
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staff conduct additional roll checks when they come on duty, at 6.30am the next
morning and at any other time as instructed by the manager in charge during
the night. Every roll check must result in a response from the prisoner, and if
no response is forthcoming, staff are instructed to seek assistance.
Unlocking of Prisoners
35. The following instructions with regard to the unlocking of prisoners are also
extracted from the security section of the Prison Officer training manual:
“The locking up and unlocking of prisoners is a fundamental task of a prison
officer:
• Stand back away from the door when opening observation port cover and
check that the window insert is intact and not broken.
• Place palm of hand, with fingers spread over the observation port.
• Withdraw the additional security bolts on the cell door if there are any,
checking that the bolts and retaining brackets are in good condition.
• Place the hand on the door handle and take a firm hold.
• With the other hand insert the key into the lock and rotate it to the stop
position, in an anti-clockwise direction.
• Holding the key in the stop position turn the door handle in an anti-
clockwise direction.
• Remove the key from the lock and push the door slightly open.
• Remember to always keep the keys out of sight of prisoners.”
Follow-up to deaths in custody
36. PSO 2710 gives instructions on action to be taken following a death in custody,
including the support arrangements for staff and prisoners. The PSO says that
priority must be given to communicating the facts about the death to prisoners
and staff. It says it may be useful to issue a written statement to prisoners to
defuse rumour and myth, but that this will depend on local judgement. Any
prisoner who may have been particularly affected by the death should be
offered support.
37. A record should be kept of all those entering the area where the prisoner died.
There should be an immediate post-incident debrief (a ‘hot debrief’) of staff
involved before they go off duty. A senior member of staff should act as a de-
briefer and a duty care team member identified and, if necessary, called in on
duty (PSO 2710, Chapter 5.)
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KEY FINDINGS
May 1988 to September 2003
38. In May 1988, the man was arrested and charged with murder. He appeared in
court, was remanded in custody and taken to HMP Lewes. Following
reception, he settled well into prison life with no apparent problems. However,
it was noted that he was a carrier of hepatitis B and that he was addicted to
Valium. A Valium reduction plan was prescribed. In March 1989, he was
sentenced to life imprisonment at Lewes Crown Court. Following sentence he
returned to HMP Lewes.
39. In May 1989, he was moved to the Lifer Unit at HMP Wormwood Scrubs where
the LSP was written. The main risk factors identified were drug and alcohol
abuse, the use of violence and his offending lifestyle. Whilst in custody he
completed a number of offending behaviour courses including:
• Drug Rehabilitation
• Cognitive Behaviour
• Alcohol Awareness
• Reasoning and Rehabilitation
• Health and Safety
• Life Skills
• Assertiveness
An ongoing target was that he should remain free of adjudications, drugs and
alcohol.
40. In September 1993, he transferred to HMP Kingston and while he was there he
had weekly sessions with the CARATs drugs team. In October 1994, a
F2052SH was opened. This was because he told staff that he could not take it
and that he was struggling with life in prison. The F2052SH was closed on the
same day.
41. The man transferred to HMP Bristol on in December 1994. In August 1996, a
further F2052SH was opened because he had self-harmed and told staff that
he was on a hunger strike. This F2052SH was closed two months later. In
November 1996, he transferred to HMP Swaleside.
42. The man transferred to HMP Grendon in February 1998. Just over two years
later (June 2000), a third F2052SH was opened because he talked about his
suicidal intent. This one was closed in July. Whilst still at Grendon, a fourth
F2052SH was opened in October 2001 and closed two days later. This time,
he had talked about being depressed.
43. In November 2001, he made a progressive move to HMP The Mount.
However, in February 2003, a fifth F2052SH was opened. The man had made
superficial lacerations to his wrist but taken a large overdose which was
considered to be a serious suicide attempt. (He had taken a week’s supply of
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medication.) This coincided with the negative feedback from a parole review.
This F2052SH was closed on in March.
44. In May 2003, the man had served his tariff (15 years). He was transferred - for
what proved to be the final time - to HMP Kingston in September 2003.
45. During his time in prison, he had a number of health concerns which are
explored more fully in the clinical review. They include the after effects of a
road traffic accident in 1972, hand problems, back pain, tinnitus, hepatitis B and
C, hernia repair, weight loss, food refusal, poor mental health, medication use
and misuse, and substance misuse.
46. Entries in his prison records depict him as a man who was very skilful in getting
his own way, particularly with medication. Staff describe a grumpy, but likable
old man, who had a good but very dry sense of humour. It appears that he was
a vocal complainer and always had an ‘axe to grind’. The man was repeatedly
warned about the untidiness of his cell, which was dirty and cluttered. I have
no doubt that he was a challenging man to manage.
September 2003 to September 2004
47. The first 12 months the man spent at Kingston following his transfer were
relatively uneventful. He appeared to settle well and with no apparent
problems. His drug test samples were negative as they had been for a few
years.
48. On first arrival at Kingston, he was in possession of a TENS pain relief
machine. This is a battery powered electrical unit which uses electrodes
placed onto the skin to deliver electrical impulses to the nerves. It is used to
provide pain relief by blocking pain signals to the brain. At some point, the
machine broke (the record is unclear when) and was not replaced. Records do
not indicate what, if any, relief or benefit he got from the machine.
49. Shortly after he arrived at Kingston, he was introduced to his personal officer.
His personal officer would keep an eye on him, as well as keeping a record of
events in his history sheet and contributing to review boards, assessments, etc.
The man and his personal officer maintained a fairly reasonable working
relationship.
50. Also within a few days of arriving at Kingston, the man met a prisoner he had
known more or less since entering custody as a lifer but whom he had not seen
for a few years. The fellow prisoner told my investigator that he was surprised
by the deterioration in the man’s physical condition. He said the man was frail
and struggled to walk and carry his own meals.
51. The man had his first escorted town visit on 10 June, whilst at Kingston prison.
No concerns were raised and the officer complimented his behaviour,
politeness and consideration.
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52. In July 2004, the Parole Board Panel considered his case and recommended
that he was suitable for Open Conditions, and awaited final confirmation of the
decision. The man provisionally requested a transfer to HMP Leyhill so that he
could consider release to a suitable hostel in the area. Plans were made for
him to have an escorted visit there in September.
September 2004 – May 2005
53. On 14 September, the man and the escort officer left Kingston at 8.30am to go
to Leyhill, but did not arrive until 2.40pm. The officer reported that their journey
was delayed by a traffic accident, bad weather, getting lost and frequent stops
because of the man’s health. The Area Office investigation discovered that
when the man and the officer reached Leyhill, the principal officer who received
them decided that the visit should be postponed because of the man’s poor
mobility and because of the time needed for the return journey. In the course
of the return journey another stop was made so that they could use a
supermarket toilet.
54. The escort officer searched him on the wing when they got back to Kingston,
and has prepared a statement for the Area Office in which he states that the
man did not appear to be under the influence of alcohol and had none in his
possession.
55. The same day the results of a parole review were confirmed and the man was
not to be released, but would progress to ‘Stage Three’ and was eligible for
open conditions. He was told the result of the parole review at 6.30pm after he
returned from the visit and the officer noted that the man appeared “a bit down”
and had not had a good day as it was a long journey and his back had troubled
him so that he could not get out of the car at Leyhill.
56. Less than an hour later, at 7.45pm, the man went to the wing office and staff
noticed that his speech was slurred and he was unsteady on his feet. He
asked to go to the main prison to see a principal officer, but was persuaded to
return to his cell. At 11.00pm his behaviour had become disruptive and he was
segregated overnight, suspected of being under the influence of alcohol or
drugs. He was examined by a doctor who determined that he was under the
influence of drugs.
57. The next day an officer asked other prisoners whether there was alcohol on the
wing, and a prisoner directed him to the man’s cell where he handed over a
bottle of lemonade. The prisoners said that the man had been drinking from
the bottle before he was removed from the wing. The bottle was subsequently
handed to officers searching cells. Later in the day one of the officers
searching cells was approached by a prisoner who said that he had removed a
bottle of lemonade from the man’s cell and handed it into the office.
58. Subsequently the man underwent a urinary drug screen, which produced a
negative result. He later alleged that he had been set-up by his escorting
officers whom he said had taken him to a pub. In protest, he refused food for a
short time. The allegations were investigated by the prison but there was no
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evidence to substantiate them. I have not myself investigated the matter
further and have relied on the prison records and the Area Manager’s
investigation.
59. The Area Manager has concluded that from the information available there was
no evidence that the man was under the influence of either alcohol or drugs. In
particular there are no records of any adjudications arising from the incident,
nor any entries in his medical records.
60. From February 2005 onwards, drug tests on him were positive on eight
occasions. They include four findings for opiates, three for cannabis, four for
benzodiazepines and one for amphetamines. The medical records state that
he was prescribed opiates and benzodiazepines for pain relief.
61. In February 2005, evidence suggested that he had been punched. It is
speculated that he was being bullied for his medication. However, there was a
concern that he was selling his medication, possibly to obtain other drugs.
62. In April 2005, the man was told that he was on the waiting list for a transfer to
HMP Ford, a category D open prison. The same day, he told his personal
officer that he had had his medication stolen and was being bullied. However,
he refused to give further information and said that he did not want any action
taken. He simply wanted his medication replaced. He made similar allegations
in May.
May 2005 – June 2006
63. For the next 12 months, he appears to have been relatively stable. His last
mandatory drug test was conducted in March 2006, and he tested positive for
opiates and benzodiazepines, which was consistent with his prescribed
medication.
64. A prisoner told my investigator that during May 2006 the man had said to him
that he was feeling fed-up, saw no future and wanted to die. The prisoner said
that he felt the same, and they had a discussion about a suicide pact and
decided they would overdose on heroin. Although the man appeared to mean
what he said, he said he did not take this too seriously, particularly as it was not
discussed again.
65. A psychology report, dated 31 May, recorded that it was difficult to recommend
further offending behaviour courses, given the number he had already attended
and his general ill health.
66. A self-harm document (ACCT) was opened on 14 June after he told a wing
officer that he was having thoughts of suicide, and that he had told friends not
to grieve for him as he could no longer cope.
67. That afternoon a wing officer assessed the man as part of the ACCT process.
He said that he was feeling suicidal and low in mood for a number of reasons:
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• his deteriorating medical condition
• he claimed that he was being bullied for his medication
• he did not feel safe around young prisoners
• his perception of injustice following his unsuccessful town visit in
September 2004
• the fact that he was still in prison over three years beyond his tariff date.
Despite this, he said that he had no intention of committing suicide, as he said
he had the coping skills not to do so. He said that he wanted to be released
from prison.
68. On 15 June, the first multi-disciplinary case review was carried out where much
of the above was repeated. Additionally, the man said that he was not eating
on a regular basis. A care plan was developed to help him cope with the things
that were troubling him. During the review, he was reminded that the Listener
scheme was available to him. The ACCT document shows that he asked to
see particular Listeners frequently. However, if one of them was not on duty
and another Listener was offered, he would refuse to see them.
69. The same evening the man told a prison officer that he was concerned about a
psychologist’s report written for his forthcoming parole review. The officer
discussed the points of concern and attempted to reassure him. He also
pointed out that the man was doing his cause no good by not eating properly.
70. On 16 June, the CPN assessed him. He was described as being low in mood
and “rambling and jumping from subject to subject” in his conversation. The
man said that he had not eaten for eight days and that he intended to stop
drinking. This was a protest against the prison’s interpretation of events
surrounding the town visit in September 2004 and his positive drug tests. The
CPN was unable to finish the assessment because limited time was available.
However, she was not sufficiently concerned that the assessment needed to
continue and decided to finish it the next day. Later that evening, the prison
officer found that the man was chatty and generally in a good mood.
71. The CPN saw him again the next day to finish the assessment. Afterwards,
she was concerned for his mental health. Additionally, he said that he would
kill himself should his physical health become too bad for him to cope with.
The CPN thought that he might benefit from being located in a prison with 24
hour healthcare facilities and a referral to the healthcare centre for further
assessment, but did not write either suggestion in his medical records.
72. A healthcare assistant spoke to him on 21 June. He said that he felt like
ending his life, and mentioned that he was thinking of cutting himself. Again
there is no note of the conversation in his medical records. He said that he was
still drinking copious cups of tea with sugar, but that he was not eating.
However, he said that he was eating a biscuit with his medication.
73. The man saw the governor on 23 June and was able to discuss his grievances.
Although he did not settle all the issues, the governor made assurances that he
would look further at the unresolved issues. Since the draft report was
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published, the Area Manager has investigated the outcome of the meeting, but
has found no evidence that it took place.
74. The same day, the man was again reviewed by the CPN. The man was
described as confused, said he was not eating and was constipated. The CPN
formed the opinion that he was suffering from toxic confusion. She discussed
this with the doctor and the man was given an enema which the CPN thought
would improve his condition.
75. A second multi-disciplinary case review took place in June where the man
talked about his current feelings. He told staff that he would not be eating until
he had a satisfactory answer from the governor. It was noted that he was
taking fluids and was collecting his breakfast pack on a daily basis. He was
encouraged to eat, and healthcare agreed to monitor his weight and
medication. He was told that staff would check him closely.
76. Also in June, the man was issued with a copy of the dossier that was to be
considered by the Parole Board in September. He appeared happy to have
this dossier. His personal officer told my investigator that, in the build up to the
parole hearing to consider the possibility of him transferring to open conditions,
the man was visibly apprehensive and quieter than normal, and spent a little
more time in his cell. Despite this, he was not acting in a way that cause his
personal officer to be concerned about him.
77. The Area Manager has noted that his medical records contain an entry that the
healthcare assistant, in agreement with the doctor, said that he could use his
night medication during the day if he needed to. He said that he had
deliberately self-harmed by burning the top of his left arm with a cigarette. He
would not let anybody see the burn.
78. Healthcare staff audited the medication that the man had in his possession on
the morning of 30 June. There were discrepancies in the Nitrazepam that he
could not account for. It was clear that he was under the influence of sedative
medication.
July – September 2006
79. At 12.35pm on 5 July, the man was discovered with self-harm scratches on
both of his wrists. The medical records describe them as deep wounds caused
by a razor blade, which were oozing blood. He was treated and placed in a
‘safer cell’ overnight. That afternoon, the ACCT document was reviewed. (This
is mandatory following any incidence of self-harm.) During this review he said
that he was going to kill himself, but later he assured the review team that he
would not do so. The man once again said that he was awaiting an answer
from the governor.
80. Healthcare staff again audited the medication that the man had in his
possession on 5 July. On this occasion, he had no medication and said that he
had taken it all. He refused to discuss the issue further. However, this was not
treated as an overdose, simply that the medication had been used quicker than
16
it should have been. The Area Manager has been unable to locate the man’s
medication records and so it is unclear what had been dispensed, and
assumed that healthcare thought it insignificant.
81. A wing officer brought the man a bowl of soup and a roll. Half an hour later, he
said how much he enjoyed the meal and asked for more soup and another roll
which the officer supplied.
82. On 6 July, as there were discrepancies with his in-possession medication, he
was told that he must collect his medication from the medical room hatch rather
than being allowed to collect it weekly. The man was not happy about this and
complained regularly. His personal officer thought that this was because he did
not have control of the medication, rather than it being physically demanding for
him to collect it. The man said that his objection was due to the sleeping
medication being issued at 4.00pm. As a result, he would sometimes be
asleep at 5.30pm, but awake again at 3.00 or 4.00am.
83. The same day, the man told a prison officer that he was being bullied by four
prisoners and supplied the three names that he knew. This was dealt with
under the anti-bullying policy. That evening, his personal officer spent about 20
minutes with him and found him to be in a better frame of mind and chatty.
84. On 8 July, the man told staff that he was now eating properly and feeling more
positive about the future. The ACCT document was further reviewed by a
multi-disciplinary team on 9 July. This review included his personal officer.
The review was earlier than planned as the man appeared to be more positive
in his outlook. He said he felt a lot better and was not going to self-harm or
attempt to commit suicide. The Area Manager has advised that his medical
records for 9 July describe the wounds as caused by a razor blade and that
they were oozing blood.
85. On 12 July, a multi-disciplinary case conference reviewed him for the fifth time.
He appeared a little confused, but said that he was eating and drinking
regularly. Physically, he was unkempt, dirty and had strong body odour. He
said that he had been struggling with his pain, as his medication had been
reduced and that was still waiting for an answer from the governor. He was
referred to healthcare, to the CPN and to the consultant psychiatrist for
assessment.
86. The man fell over on the wing on 17 July. As he was suffering with pain in his
hip and was taken to the local Accident and Emergency Department. He was
treated and returned to the prison that afternoon.
87. On 18 July, he appeared to be quite jolly. The ACCT document was again
reviewed on 19 July. The review team was not multi-disciplinary on this
occasion, as there was no input from the Healthcare Centre. He confirmed that
he was eating and had no thoughts of suicide or self-harm.
88. The CPN saw him on 20 July, and found that he was still a little confused but
had improved his appearance and cleanliness.
17
89. The ACCT document was reviewed on 26 July. This seventh review was the
last one, as the multi-disciplinary team, including his personal officer, decided
that the document could be closed. At the review, he said that he had been
having problems with another prisoner who had now been moved from
Kingston. This made him happier. He said he was not being bullied any more
and had no intention of committing suicide or harming himself. The man was
made aware of the support network available and the ACCT was closed.
90. On 27 July, he had a conversation with a wing officer and said that he was
unhappy with the way healthcare was treating him – in particular, the fact he
had to collect his medication rather than being allowed to keep it in
possession. He complained that he had to take his night medication at 4:00pm,
supervised at the medication hatch, rather than being trusted to take it at
9:00pm in his cell.
91. The man was reviewed by the CPN on 11 August. He still presented as being
confused, but was generally calmer. He said he was tearful in the mornings.
He discussed the forthcoming Parole Board review and felt that he was likely to
be released on licence.
92. The man was reviewed again by the CPN on 18 August. He presented as low
in mood, but thought it was because he was in pain. The man again said that
he felt he was likely to be released on life licence.
93. On 24 August, following a cell search, he was found guilty at an adjudication for
being in-possession of medication that was not prescribed to him. The same
day, he was assessed by the consultant psychiatrist. He said that he was no
longer tearful and that his mood was generally better.
94. A post closure ACCT interview was conducted by the PO and his personal
officer on 6 September. The man said that he was very disappointed and
angry that he was not allowed his sleeping tablets in possession. Whilst the
reviewers concluded that he was not at risk of suicide or self-harm, they felt
that his health, mobility and state of mind were deteriorating. A decision was
made to refer him to be assessed for a transfer from Kingston to a prison with a
healthcare centre offering inpatient facilities. The PO made a referral to
healthcare on 11 September.
95. The Parole Board hearing took place on 13 September and afterwards it was
recorded in his records that he felt it went well, but he was resigned to staying
in category C conditions. The Board concluded that he should remain at
Kingston, pending further work on anger management and a period free from
substance misuse. Both he and his personal officer presumed that events
surrounding the town visit when he was found to be intoxicated were a key
factor in the Parole Board’s decision. The man expected formal notification of
the Board’s decision in about 14 days.
96. The Parole Board had previously concluded that he remained a significant risk,
and had judged that he was not suitable for transfer to an open prison. The link
18
between his use of alcohol and illegal drugs and his offending behaviour was a
major factor in these decisions.
97. The man was seen and assessed by the consultant psychiatrist on 14
September. During the assessment, he complained of a disturbed sleep
pattern which he attributed to having to take his sleeping medication
(Nitrazepam) at 4:00pm. He assured the doctor that he would not have this
medication taken from him, and that he would use it responsibly at 10.00pm
each night.
98. The consultant psychiatrist agreed to a four week trial period. The consultant
psychiatrist told my investigator that he discussed this decision with the duty
nurse. However, the duty nurse told my investigator that she found out after
the consultant psychiatrist had left the prison, and did not have the opportunity
to discuss it with the doctor. The duty nurse consulted other healthcare
colleagues and, for reasons of practicality, decided that the man would collect a
single dose of night medication at the hatch when taking other medicine at
4.00pm. He would then have to return the next day with the empty foil packets
to receive that evening’s dose. The man returned the empty foils on a daily
basis, and his cell was checked weekly.
99. Formal notification of the Parole Board’s decision was not received until after
the man had died. But during a conversation with his personal officer on 16
September, he was clear that he thought the result would be negative.
100. His personal officer last saw him on 21 September. It was about lunchtime and
he was in the queue for medication. He was again complaining about having to
collect his medication rather than keep it in his cell. Looking back, his personal
officer remembers him being perfectly normal that day. Even with the benefit of
hindsight, nothing strikes her as different about him in any way.
101. Later that day, the consultant psychiatrist attended the prison to see the man
as planned. However, he did not attend and the doctor was unable to locate
him (the doctor did not have security clearance and therefore could not carry
keys). Normally the doctor relies upon the CPN to find prisoners, but she was
not in the prison and nobody else was available. Regrettably, the doctor was
unable to carry out the assessment.
102. A fellow prisoner who was in the cell next to the man’s cell, told my investigator
that three or four prisoners (including himself) would help him with the
collection of meals and cleaning as he was unsteady on his feet.
103. The prisoner said that the man would regularly talk about committing suicide,
and said this was because he was unhappy about the care he was receiving
from healthcare. He had not taken the man’s comments seriously, saying that
the man had “cried wolf” too often. The last time he remembers the man
talking about suicide was around 21 or 22 September. He said that he told a
male member of staff but could not remember which one. Allegedly, the officer
told him that he would tell healthcare. I have found no other record of this
conversation, nor of any action being taken.
19
24 September 2006
104. A prison officer knew the man reasonably well and saw him around lunchtime
when she came on duty. She remembers that he was perfectly normal and
said “hello” to her.
105. At 3:00pm, the duty nurse attempted to audit the medication that the man had
in his possession. On this occasion, his cell was so untidy that the audit was
abandoned without finding any medication.
106. A prisoner saw the man in his cell in the afternoon and found that he was acting
normally. He did not think that the man was in any way vulnerable. Another
prisoner, who had been acting as a Listener for the man regularly saw him that
afternoon as a friend. He told the police that when he saw him he was his
normal self, and he had left him with no concerns.
107. At 4.00pm, the duty nurse issued him with his medication. Apart from his
regular complaint about not being allowed his medication in possession, she
told my investigator that there was nothing different about him that day, and
she was not concerned about him.
108. About 4.15pm, another prisoner saw him in his cell for about 15 minutes. He
told my investigator that the man seemed to be the happiest that he had seen
him. They had a bit of light hearted banter together whilst the man ate two
sardine rolls. The fellow prisoner left the man in his cell, as it was time for the
prisoners to be locked in for the evening. He was not left with any suspicion
that the man was vulnerable to suicide or self-harm.
109. The fellow prisoner had been at Kingston for about three months and had built
up a friendship with the man, spending a lot of time in his cell chatting. He was
young and more mobile than the man, and would help him by collecting his
meal and making sure he had what he needed before he was locked in his cell.
He would also ensure that the man remembered to collect his medication.
110. At about 8.00pm, the wing officer checked the roll on D wing by checking each
cell and verifying the number of prisoners on the wing. This is a counting
procedure and not a welfare check. It takes place at the beginning and end of
each shift to ascertain the number of prisoners being handed over to the next
shift. Whilst not checking in any great detail, the officer remembers that the
man was sitting on his bed but cannot recall what he was doing.
111. One Senior Officer (SO) and two prison officers were on duty overnight. The
evening roll check was completed by both of the officers. Neither could
remember who checked the man’s cell, but neither recalled anything unusual
about the roll check. Overnight, the staff heard nothing unusual on D wing and
were not called to the man’s cell for any reason.
25 September 2006
20
112. During the morning roll check, a prison officer counted D wing prisoners at
5.50am. He could not remember anything specific or suspicious about the
man’s cell, only that there was enough natural light to establish that there was a
prisoner in the cell.
113. At 7.00am, another officer conducted a further roll check of the prison. The
natural light was low, so the officer briefly switched on the light in each cell,
verified the prisoner was present, and continued around the wing. At the man’s
cell, the officer put the light on, saw a hand on the sheets and, having verified
that the man was present, switched the light off and moved to the next cell.
When the roll check was complete, he returned to the centre and signed the roll
check document confirming that he had seen 192 prisoners.
114. At 7.45am, the duty SO gave permission for staff to unlock all of the cell doors,
and the wing SO unlocked all the cell doors on D1 landing. To do this, the wing
SO simply opened the lock and left each door open about four inches. He did
not open any of the observation flaps or look into the cells. When he opened
the man’s cell, he opened the door without resistance and moved on to the next
cell. The wing SO told my investigator that some staff open the observation
flap and look inside the cell, but his practice is not to do so.
115. Once the wing was unlocked, the SO remained on the landing until he was
content that the wing was operating normally. About three quarters of the
prisoners came out of their cells, but the man did not. This was not a surprise
to the SO, as he knew that the man would stay in bed until he had to go to the
medical hatch. Once the wing was settled, the SO went to the security
department where he normally worked.
116. A fellow prisoner passed the man’s cell and pushed the door open a little and
realised the bed was blocking the door. He said that the man did this regularly,
although the Area Manager states that there is no evidence of previous
occasions. He told the man that he had a tea kit for him and threw it on to the
edge of his bed. He then left the cell assuming that the man was lying in.
117. Another fellow prisoner also went to the man’s cell, as he did every morning, to
ensure he was out of bed and ready to collect his medication. The door was
unlocked, but not opened more than a few inches. When he pushed the door it
was clear to him that there was an obstruction and the door would not open
beyond six or seven inches. He looked through the cell observation flap and
noticed that there was something wrong as he could not get a response. On
closer inspection, he realised that there was a plastic bag covering the man’s
head. He immediately went to alert the duty SO.
118. At about 7.49am, the duty SO and two officers were in the prison centre (this is
where the ends of the wings meet and provides a good all round observation
point). The prisoner approached and asked the duty SO if anybody had
checked on the man, as he could not get a response from him. He did not
mention the plastic bag.
21
119. Two officers went to the cell and could not open the door. The first officer
pushed harder against the door and was able to open it sufficiently to see that it
was blocked by the bed and a painting easel. The second officer beckoned for
the duty SO to attend, and then went to healthcare where she found the duty
nurse
120. The staff at the cell managed to move the bed back enough for the first officer
to enter the cell and completely remove the obstruction. Once in the cell, staff
could see that the man had two of the breakfast pack plastic bags over his
head. They were taped around his neck with a roll of brown parcel tape. He
was lying on his back, with the covers pulled up to his chest by his hands,
which were visible over the covers. The duty SO raised the alarm using the
radio system.
121. The duty nurse was in the healthcare centre and, before the radio alarm was
raised, she was alerted to a problem by the second officer. The nurse did not
know what the problem was, but from the officer’s demeanour realised it was
urgent. However, the nurse did not enquire into the nature of the problem and
did not take the emergency response bag with her.
122. At the same time that staff gained entry to the cell, the duty nurse arrived. The
nurse checked him for signs of life, but could not find any. The nurse was
certain that the man was dead and decided that any attempts at resuscitation
would be futile.
123. Soon afterwards, paramedics arrived at the cell, and confirmed the assessment
made by the duty nurse. At about 8:15am, a doctor arrived at the cell and after
an examination certified that the man had died. The doctor told my investigator
that the man’s body was in the early stages of rigor mortis.
Events following the death
124. The wing SO secured the cell door with a security lock, and the cell was treated
as a potential crime scene until the police arrived. The SO told my investigator
that he looked through the observation flap. Even in the improved light, he
struggled to see the bag on the man’s head. He said that observation was
made difficult by the untidy condition of the cell, particularly as many objects
were piled around the bed.
125. The staff involved submitted comprehensive statements to the governor,
providing a detailed account of the discovery and management of what had
occurred. Other paperwork was completed subsequently to record events in
accordance with the local contingency plans for a death in custody.
126. At 10.00am, all staff involved attended a hot de-brief which was chaired by the
duty governor. Staff were able to talk through the sequence of events and
were offered support.
22
127. The prisoner in the cell opposite the man who died told the police that the man
regularly said, “I might as well get it over and done with; I’m going to die in here
anyway.”
128. On a number of occasions during his time at Kingston, he was warned that his
cell was in an unacceptable condition. On his first visit, my investigator looked
at his cell before it was cleaned and found it very dirty and untidy. There was
property piled around the cell, with no apparent control of its volume exerted by
the prison.
129. There was no formal announcement of the man’s death and staff learnt
principally by word of mouth.
130. The post mortem concluded that the man died from asphyxia. It also showed
there were no defensive marks or evidence that a third party had been
involved. The police investigation also confirmed that there are no third parties
involved and that there are no criminal issues.
131. The man had no next of kin registered, but the prison knew that he had a
brother so the duty governor asked the police to trace him. The police found
his address and were able to inform him of the man’s death. His brother
explained that they were not close. The prison was asked to make funeral
arrangements locally.
132. Photographs were taken of the cell as part of the police investigation. The area
manager described the photographs showing the man’s hand outside the bed,
placed on his chest, in front of the brown tape used to seal the plastic bag
round his neck and head. The police investigation established that the plastic
bags that he used were those supplied by the kitchen with the breakfast packs.
The bags are un-perforated, measure 18 by 24 inches, and are of a slightly
frosted appearance.
133. The tape that was used to secure the plastic bags around his neck was the inch
and a half wide brown parcel tape used by prisoners in the workshops. This
tape is not issued to prisoners, but is not an item that is separately controlled
and accounted for. As he did not go to the workshops, the police could not
establish how he was in possession of the tape.
134. Some of the prisoners whom my investigator spoke to said that the man was
being bullied by healthcare staff into taking his medication in front of them,
rather than later in his cell. Others told my investigator that he was unhappy
with his medical treatment. The man’s fellow prisoner and friend said that it
was the worst prison healthcare he had seen in 21 years. In contrast, another
prisoner said that he has confidence in healthcare at Kingston, and that he was
treated very well.
135. My investigator was also told that the man was too infirm to collect his meal
unaided, but that prisoners would assist him as staff would not. There is a stair
lift, but it had been broken for a long period of time. When my investigator
checked, the stair lift was working. Prisoners told my investigator that they
23
thought he should have been in a specialist environment for the elderly or in
full-time healthcare.
24
ISSUES
Roll Checks
136. The fact that the man was discovered by another prisoner, after two different
officers had checked the cell to count the roll and a senior officer had unlocked
the cell door, is both surprising and disappointing. National instructions are
clear; the officer must gain a response from the prisoner. However, in common
with many prisons, custom and practice seems to have developed at Kingston
into officers simply checking the roll and not that the prisoners are alive. (The
motive is a benign one: to avoid disturbing prisoners unnecessarily.)
137. National guidelines instruct staff to open the door observation flap, and check
inside a cell before opening it. Again, custom and practice at Kingston has
developed into some staff not opening door flaps in order to provide prisoners
with privacy. The wing SO did not open the flap to look inside the cell before
opening the door.
138. If any of the three members of staff had completed the tasks as they should
have been done, then the low levels of light in the cell would not have been a
factor in failing to see the plastic bags on the man’s head.
139. I acknowledge that the man was likely to have died by the time the wing officer
conducted the roll check at 5:50am. However, in other circumstances the
opportunity to save a life could be lost.
The governor should remind all staff of the expected standards when they
conduct a roll check and when they unlock prisoners. These procedures
need to be monitored by managers regularly.
Town Visit – September 2004
140. There is no doubt that the man felt that he was the victim of injustice when he
was thought to be intoxicated after the town visit in September 2004. At the
time, he denied being drunk. However, he later claimed that the escorting staff
had taken him to the pub thus setting him up. The governor at the time
investigated the man’s claim, but could find no supporting evidence.
141. I have not enquired into this matter further. However, it is clear that the incident
became a major factor in his mind and one that would inevitably affect his
future. On the very day of the town visit, he was told that he would be able to
move to open conditions. This was never formally rescinded, but I suspect he
knew that in practice it was unlikely that he would be transferred to an open
prison in the foreseeable future. It appears that his strategy was to throw some
doubt on the events surrounding the town visit.
142. Whatever actually occurred during the town visit, it was a great concern to him
and the focus of much of his suicidal vulnerability. However, it appears that the
prison handled his persistent denial and counter allegations seriously, and with
patience and professionalism.
25
Anti-Bullying
143. Kingston prison’s local Anti-Bullying Strategy is a comprehensive policy
document which is consistent with national policy. The man complained on a
number of occasions that he was being bullied for medication. There is
contrasting information that suggests that he was actually selling his
medication.
144. On 6 July 2006, he told a prison officer the names of three prisoners whom he
said were bullying him. This was investigated and dealt with appropriately
using the local policy.
145. The prison and the PCT both acknowledge the observations made by HMCIP
when the Inspectorate witnessed bullying in the queue for medications.
However, my investigator found that the queue was properly supervised and
did not witness any bullying.
146. Some prisoners told my investigator that the man was bullied by healthcare
staff into taking his medication. It is well documented that he said his
medication was being stolen, but that he did not want to have control of his
medication taken away. It appears that he had to be encouraged to take his
medication at the hatch, but I judge this to have been appropriate.
Suicide and Self Harm Monitoring Procedures
147. Kingston’s local Suicide Prevention Strategy is another comprehensive policy
document, again consistent with national policy. An ACCT document was
properly opened when the man threatened to commit suicide on 14 June 2006.
The ACCT was closed on 26 July when he had appeared to improve. My
investigator also assessed the five F2052SH documents and found that that
were all appropriately handled by the individual prisons.
148. Observations and assessments made in the ACCT are to a good standard. All
were multi-disciplinary, with the exception of the sixth case review on 19 July.
All reviews explored the issues that were concerning him and concluded with
appropriate care plans and observation levels being set. I consider that the
ACCT document was managed very well. It provides clear evidence that the
man was cared for.
149. The build-up to the Parole Board hearing was clearly having an effect on his
state of mind. This was also the case in February 2003 when at The Mount.
On that occasion, following a negative parole result, he had cut his wrist and
taken a week’s supply of medication in an apparently serious suicide attempt.
However, the link between Parole Board decisions and the man’s risk of self-
harm does not seem to have been made by the prison prior to his death.
150. After the Parole Board hearing on 13 September 2006, I have little doubt that
the man realised that he was not going to progress quickly to open conditions
or to eventual release on licence. This was despite the fact that he had already
served three years and four months beyond his tariff.
26
151. I think it very likely that this realisation, coupled with his increasingly frail health,
increased the risk of suicide. However, to the staff and prisoners around him,
he appeared to be coping. In fact, it is suggested in the clinical review that the
good mood observed in the immediate period prior to his death was an
indicator that he had already made the decision to kill himself. An improvement
in mood immediately before a self-inflicted death is a recognised phenomenon
in the literature on suicide, and has been found in a number of my
investigations.
152. When the man did not attend for his appointment with the visiting psychiatrist
on 21 September, a nurse or discipline officer should have located him and,
with his agreement, accompanied him to the Healthcare Centre. By missing
this assessment with the visiting psychiatrist, an opportunity may have been
lost to identify the state of his mental health and any suicidal ideation.
The PCT should ensure that there is a follow up procedure when
prisoners do not attend for appointments. The procedure must establish
a reason for the prisoner not attending and make provision for a repeat
appointment if required.
153. In the psychiatrist’s view, because of his personality traits and long history of
self harming and suicidal behaviour, the likelihood of him completing suicide (in
prison or following release) would always be considered to have been high.
According to the doctor, at the time of his death the man displayed several risk
factors for deliberate self harm and suicide:
• His personality traits suggest that he had poor coping skills at times of
stress and tended to be impulsive.
• There were significant stresses in his life including chronic back pain,
tinnitus and ongoing bullying by other prisoners. In addition, he had been
expecting bad news from the Parole Board about his future and felt a sense
of betrayal by the prison.
• In the months leading up to his death, the man displayed a fluctuating
mental state with episodes of confusion, frank psychosis and clear
evidence of a depressive disorder, associated with suicidal thoughts and
self harm behaviours. He had lost a lot of weight and was becoming
increasingly physically frail.
Psychiatric Care
154. Although he had a long history of drug and alcohol abuse, the man was
prescribed medication that was potentially addictive. No single health
professional was overseeing this aspect of his care, leaving potential for abuse
and exploitation by other prisoners.
155. There is no clear care pathway for patients needing tertiary psychiatric care. In
the community, a General Practitioner seeing a patient with depressed mood,
27
suicidal thoughts, profound weight loss, self neglect and psychotic symptoms,
including hallucinations and delusions, would be strongly requesting urgent
assessment and possible inpatient psychiatric care.
156. The psychiatric assessment provided for him is not comparable to that he
would have received in a standard community mental health team outpatient
clinic. A comprehensive risk assessment document would have been
completed, as would a full mental state examination. Particularly on a first
psychiatric assessment, a written summary of the interview would have been
sent to the referring agency, generally the patient’s doctor.
157. The quality of the assessments by the CPN was good. She clearly
documented her findings, quite often using the man’s own words. She
appeared to have developed a good therapeutic rapport with the man.
158. Why the consultant psychiatrist made no comment on the man’s psychotic
symptoms remains unclear. Presumably, the CPN would have mentioned her
concern regarding his mental state in her referral to the doctor and subsequent
conversations with him.
159. If psychotic symptoms had been confirmed and enduring, the possibility of
prescribing anti-psychotic medication would have been an option.
The PCT should ensure that there are appropriate assessments and
mental health pathways in place to plan and provide effective mental
health care and support.
Medical Care
160. Medical records were generally poor and not to the standards expected by the
professional regulatory bodies, and there was no audit procedures for the
monitoring of standards of clinical entries. The Nursing and Midwifery Council
(NMC) sets standards for entries in nursing notes. These include the need to
properly identify who is making the entry.
161. The entries made by the CPN were of a good standard and were legible. They
demonstrated both a thorough assessment and a clear conclusion and
management plan. The entries made by the Health Care Support Worker
(HCSW) were excellent in form and legibility. But other nursing note entries did
not meet the NMC standards and were generally too brief.
162. The doctor’s entries made in the man’s clinical record are not of a satisfactory
standard. The entries are often difficult or not possible to decipher, at least in
part. Both written and computer entries are too brief, and are not sufficient to
provide evidence of adequate history taking or examination.
163. Communication at the time of the man’s death within the healthcare team and
with mental health professionals was ineffective. As a result of poor
communication and a failure not to look back at recent clinical entries, the
concerns of the CPN and the PO went unnoticed.
28
164. During the course of his food refusal, and while on the ACCT document, the
man lost 12lb. This was a significant amount of weight loss for an already thin
and frail man. The Healthcare Centre does not have a formal procedure for
monitoring food refusal. The absence of a written food refusal policy is likely to
lead to inconsistent care.
165. A TENS machine should have been obtained and provided for him. He was on
large doses of a strong opiate painkiller and the use of this medication was a
concern because of its potential for misuse and the resultant risk of bullying.
166. Evening medication had either to be given in-possession, or taken under
supervision at 4:00pm. It is not reasonable to expect patients to take sleeping
medication at 4:00pm.
The PCT should review the nursing hours available in the prison, so that
evening medication may be supervised at more appropriate times.
167. Requests for the man’s transfer from Kingston appear to have gone unheeded.
Given that from March to August inclusive there was no visiting consultant
psychiatrist at the prison, the onus was very much on the doctors to back up
the CPN.
168. Serious concerns were documented by the CPN on four occasions. On 12
June 2006, she believed that the man was unfit to be held in Kingston and that
he should be transferred to the healthcare wing at Winchester for 24 hour
health care.
169. Following the entries by the CPN, subsequent GP entries show no recognition
of her concerns, nor does there appear to be a response to her requests for a
GP review of the man’s physical health.
The head of healthcare should ensure that appropriate follow up action is
taken when a prisoner is referred to healthcare for assessment.
170. Given the fact that from March to August 2006 inclusive there was no visiting
consultant psychiatrist at the prison, the onus was very much on the GPs to
provide a medical input to mental health provision to back up the Mental Health
Gateway Worker.
The head of healthcare should ensure that alternative arrangements are
made if there is a shortage in the provision of mental health in reach
services.
171. The man claimed that he was being bullied for his medication. However, there
is security information that he was selling his medication, intelligence that may
be validated by the fact he was failing his drug tests. I am unable to say what
happened to his medication, but it is manifest that the man was not taking it as
prescribed.
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172. When it became apparent that the man was not taking his medication, it was
appropriate that he was no longer allowed to retain it in his possession.
However, it was not reasonable to expect sleeping medication to be taken at
4:00pm. The subsequent decision to allow the man his sleeping medication in-
possession, on a daily basis, was therefore entirely appropriate. Since his
death, I am pleased to see that the prison and the PCT have extended the
treatment times to allow medication to be given in the evenings.
The head of healthcare should ensure that doctors do not make decisions
about whether a prisoner is allowed to keep medication in their
possession without consulting other members of the multi-disciplinary
team.
173. Prisoners have expressed differing views on the quality of healthcare provision
at Kingston. From the evidence, documentation and findings of the clinical
review, it appears that the healthcare team were working hard to provide a
decent service for prisoners. In general, I judge that they are moving in a
positive direction.
Emergency Response
174. Once staff were alerted to the man’s condition, staff responded immediately
and appropriately. The wing officer acted quickly in locating the duty nurse.
However, the officer did not tell the nurse the nature of the emergency. The
nurse realised that the matter was urgent but did not enquire as to its nature.
Consequently, the duty nurse responded without any emergency equipment.
175. Whilst I acknowledge that it made no practical difference in this case, a practice
of not taking the emergency bag to urgent calls is not supportable. It must
become established practice for emergency equipment to be taken to all
emergency calls.
The head of healthcare should ensure that nurses called to an emergency
situation take the emergency bag with them.
176. The decision not to attempt resuscitation was appropriate and consistent with
national guidelines.
Cell Furniture
177. The untidy condition of the man’s cell was unacceptable. I acknowledge that
he was told to clean his cell on a number of occasions, but his refusal to
maintain a tidy cell appears to have been ignored. It may be that he felt unable
to clean the cell, due to his physical ill-health. But in that case staff ought to
have made alternative arrangements. In any event, the prison ought to have
actively reduced the volume of property that he was allowed to keep in his cell.
178. When it became clear that it was not possible to assess whether or not he was
hoarding his night medication, the giving of this medication in-possession
should have been discussed with the visiting psychiatrist or one of the GPs,
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with a view to discontinuing it. In any event, a comprehensive cell search
should have been conducted by the discipline staff.
Events following the man’s death
179. The man was found dead on the third anniversary of his arrival at Kingston. I
can see nothing that indicates this was anything other than a coincidence. I
have not been made aware that the date was significant to him in any way.
180. PSO 2710 requires that the holding of a hot debrief. This took place and it
appears that all staff involved were able to contribute. Support to officers,
healthcare team members and other prisoners was also given.
181. The reports submitted to the Governor by staff were detailed and
comprehensive. This was both helpful to my investigator and prevented some
staff being interviewed needlessly.
182. The wide availability of plastic bags in the Prison Service is not normally a
concern. However, this is the second death my office has investigated which
has resulted from asphyxiation using such a bag. I note that the bag in this
case was not perforated. It would be circumspect for the Director General to
consider the safety implications of the bags used in prisoners’ wastebins and
breakfast packs. The man was also able to obtain parcel tape from a prison
workshop, although the means by which he did so are unknown.
The Director General of the Prison Service should commission a short
review of the types of plastic bag that are readily available to prisoners
and the safety implications thereof.
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RECOMMENDATIONS
National
1. The Director General of the Prison Service should commission a short review
of the types of plastic bag that are readily available to prisoners and the safety
implications thereof.
The recommendation is partially accepted by the Prison Service.
Since the publication of the draft report, I have been advised that the Safer
Custody Group carried out a review in July 2004, and concluded that
restriction of one means of self inflicted death usually leads to greater use of
alternatives. Unless an individual ACCT plan determines that plastic bags
should not be supplied to a prisoner, they would not be singled out by
automatic removal of items such as plastic bags, which may increase the
incidence of bullying of vulnerable prisoners.
Local
2. The governor should remind all staff of the expected standards when they
conduct a roll check and when they unlock prisoners. These procedures need
to be monitored by managers regularly.
This recommendation has been accepted. A notice has been issued to staff
and all line managers have been informed of their responsibility to ensure that
staff carry out their duties correctly.
Healthcare
3. The PCT should ensure that there is a follow up procedure when prisoners do
not attend for appointments. The procedure must establish a reason for the
prisoner not attending and make provision for a repeat appointment if
required.
The recommendation has been accepted and the healthcare team is
developing a process which will be completed by August 2007. A record is
now kept of all prisoners who fail to attend healthcare appointments.
4. The PCT should ensure that there are appropriate assessments and mental
health pathways in place to plan and provide effective mental health care and
support.
The recommendation has been partially accepted and the Service Level
Agreement with the Mental Health Team is under review, for completion by
August 2007. The Primary Care Trust have established a weekly psychiatric
clinic, part time clinical psychologist and increased the service provided by the
psychiatric nursing service.
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5. The PCT should review the nursing hours available in the prison so that
evening medication may be supervised at more appropriate times.
The recommendation has been accepted and the nursing hours extended to
6.00pm. Evening medication is now dispensed between 5.30 and 6.00pm,
and all prisoners are assessed to determine whether they can hold their own
medication.
6. The head of healthcare should ensure that appropriate action is taken when a
prisoner is referred to healthcare for assessment.
The recommendation is accepted.
Agency nurses are being trained to use the same recording system as those
employed by the PCT. All nurses are being provided with triage and physical
assessment training. The introduction of a nurse led service has also
improved the doctor’s documentation.
7. The PCT should ensure that alternative arrangements are made if there is a
shortage in the provision of mental health in reach services.
The recommendation is accepted.
Alternative provision is available from the AMH Crisis team or duty psychiatrist
to cover the absence of any of the usual practitioners.
8. The head of healthcare should ensure that doctors do not make decisions
about whether a prisoner is allowed to keep medication in their possession
without consulting with other members of the multi-disciplinary team.
The recommendation is accepted, and team meetings and handovers have
commenced.
To reduce the risk of prisoners being bullied for their medication, a system
has been introduced to reduce the amount of opiate medication in circulation.
Prisoners take their morning dose in the presence of a trained duty nurse and
collect their evening dose at tea time.
9. The head of healthcare should ensure that nurses called to an emergency
situation take the emergency bag with them.
The recommendation is accepted.
All nurses employed by the PCT have now completed Basic Life Support
(BLS) training and BLS will continue until the paramedic or doctor confirms
death. The emergency bag has been re-stocked and portable oxygen
supplied.
The response to all Serious Adverse Events now follows the PCT policy and
prison staff have been advised to contact the on call PCT manager if a
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situation occurs outside healthcare hours. The healthcare hours have been
extended from 7.30am to 4.30pm, and are now 7.30am to 6.00pm.
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