Individual at Leicester

Circumstances surrounding the death on 17 May 2005 of a man
after he attempted to hang himself on 12 May at HMP Leicester
Report by the Prisons and Probation Ombudsman for
England and Wales
August 2006
This is the report of an investigation into the death of a man who died at a local
hospital on 17 May 2005. He had been taken there from HMP Leicester after
attempting to hang himself in his cell on 12 May. The man was convicted but
awaiting sentence at the time of his death.
This investigation was conducted by two of my Investigators. I would like to
extend my thanks to the former Governor and his staff at Leicester for their help
and co-operation during this investigation.
The Eastern Leicester Primary Care Trust was asked to carry out a Clinical
Review into the medical care that the man received.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2006
Contents
Summary
Investigation methodology
The subject of this report
HMP Leicester
Events prior to the man being found hanging
Events surrounding the man’s hanging
Clinical review
Findings and conclusions
Recommendations
Summary
1. The man who is the subject of this report was remanded into custody at
HMP Leicester on 4 May 2005 by Loughborough Magistrates’ Court. It
was noted on the reception documentation that he stated that he was
anxious and depressed and had stomach problems. He denied any
thoughts of harming himself.
2. The nurse who completed the First Reception Health Screen ticked the
box on the form for the man to be assessed by the in reach mental health
team. That assessment was never completed. The man was assessed
as suitable to share a cell on the First Night Centre (FNC).
3. On 9 May, the man was seen by a doctor. He complained of diarrhoea,
and a stool sample was taken and sent for analysis at the local hospital. It
was again noted that he was feeling anxious and depressed.
4. The man returned to Loughborough Magistrates’ Court on 11 May, where
he was convicted and remanded to Crown Court for sentencing. He was
worried about the effect that might have on his mother and the fact that his
wife and children wanted nothing more to do with him. That night, he sat
up talking with his cell mate. The cell mate listened but thought the man
would feel better in the morning.
5. The following morning, both the man and his cell mate went to Healthcare.
The man saw the practice nurse and complained of anxiety caused by
diarrhoea and its implications in prison. The consultation was cut short
when the man said that he needed to use the toilet.
6. About 9.30 am, the man was returned to the wing where he may have had
a shower before being locked back in his cell. At 10 am, when his cell
mate returned to the cell and asked a member of staff to open the cell
door, they saw the man hanging from the cell window bars behind a
makeshift curtain.
7. The alarm was raised and other officers responded swiftly. The bed sheet
he had used as a ligature was undone and he was moved into the corridor
where Cardio Pulmonary Resuscitation (CPR) was started. Paramedics
arrived at 10.20 am and took control of his medical care. At 10.37 am, the
man was transferred to the local hospital. He died at 8.30 pm on 17 May
2005.
Investigation methodology
8. The investigation was opened at HMP Leicester on 19 May 2005. The
Governor and his staff produced the man’s core record and a large
number of other documents for examination. Notices were distributed
around the prison notifying staff and prisoners of the investigation. A
number of prison staff were formally interviewed. A serving prisoner was
also interviewed, as was the man’s cell mate who had been released from
custody.
9. My investigators also met with the investigating officer from Leicester
Police to discuss the case.
10. The Eastern Leicester Primary Care Trust was contacted. In line with
Department of Health requirements, they agreed to carry out a Clinical
Review of the medical care that the man received whilst he was in
custody.
11. Her Majesty’s Coroner was contacted to inform him of the nature and
scope of my investigation and to request a copy of the Post Mortem
report. Upon completion, this report will be sent to the Coroner to assist in
his enquiries into the man’s death.
12. One of my family liaison officers contacted the man’s wife and his mother.
Neither wanted a personal visit from the FLO or the investigators at that
time, but both raised their concern about his death over the telephone.
They both felt that the prison had not done enough to support the man’s
depression.
The subject of this report
13. The man was born in 1957. He was married with two children and lived in
Leicester until the time of his death.
14. He was first convicted of a criminal offence in the early 1970’s,
subsequently appearing at court and being convicted on a further three
occasions. He had never received a custodial sentence, his offences
having been dealt with by way of Community Rehabilitation Orders and
other non-custodial penalties. The man had been in prison on remand on
one previous occasion.
15. The man was convicted of a sexual offence in May 2005 and was awaiting
sentence at Crown Court when he attempted to hang himself. He was 47
years old when he died.
HMP Leicester
16. HMP Leicester is an early Victorian prison. The main living
accommodation is a long rectangular cell block with four landings. Most
cells have two occupants although some have been converted into
dormitories. In cell electricity is currently being installed in all living units.
Whilst this investigation was taking place, some alteration work and
rewiring, including the installation of in-cell electricity, was taking place in
the First Night Centre.
17. The prison was last inspected by Her Majesty’s Chief Inspector of Prisons
in July 2003 when it was noted that Leicester was three months into a five
year action plan.
18. Since April 2004, there has been six deaths at Leicester: four self inflicted,
one from natural causes and one homicide. Action plans drawn up as the
result of the investigations into two of the deaths have not yet been
completed. Insufficient healthcare staff was cited as the main reason for
the delay in implementation.
19. In the latest Prison Performance Ratings for the first quarter 2005/6,
Leicester rated level 3 of 4. That level is defined as ‘Meeting the majority
of targets, experiencing no significant problems in doing so, delivering a
reasonable and decent regime’.
Events prior to the man being found hanging
20. The subject of this report arrived at HMP Leicester on 4 May 2005 having
been remanded into custody by Loughborough Magistrates’ Court. The
Prisoner Escort Record (PER) form, which was initiated at Loughborough
Police Station, listed under medical risks: headache, stomach problems
and depression. Nothing was ticked in the Security or Other sections, nor
was there any mention of risk of self harm or suicide.
21. The man’s First Reception Health Screen form was completed by a nurse
on 4 May. She noted on the form that he suffered from depression and
anxiety and required a mental health assessment. The man told the nurse
that he had received treatment for depression and had been an in-patient
in 1985. He said that he had never received any medication for mental
health problems. He claimed never to have harmed or tried to harm
himself and denied any thoughts of suicide or self harm. The details of the
man’s GP were recorded, as was the fact that he suffered from asthma
and was allergic to penicillin. At the end of the form the nurse ticked the
box ‘Refer to GP’ and signed the form.
22. During her interview, the nurse told my investigators that she believed
that, as she had ticked the box on page two of the form indicating that a
mental health assessment was required, the doctor would then complete a
referral form. In fact, on 4 May, the procedure according to the deputy
healthcare manager was that the nurse should have completed the
referral form or if the forms were completed late at night the healthcare
assistant should go through the forms the following day and action any
referrals. The man never had a mental health assessment.
23. A reception officer completed the Cell Sharing Risk Assessment form. In
section one, he ticked that he had received the PER form, the Warrant
and the man’s previous convictions. During interview, the officer admitted
that he was not in possession of those documents at that time. In section
two of the form, a yes/no answer is required to the question: Does the
prisoner have any previous convictions (including attempted) for the
following …? A list of offences follows, two of which the man had
convictions for, yet the no box was ticked. The third question in that
section asks if the current offence is one of the offences on the list. The
man’s current offence was on the list but again the no box was ticked.
Alongside these and other questions on the form are boxes marked
‘Source’. The intention is that the completing officer enters the source of
the information into the box: either D for documents, I for inmate/prisoner
or S if staff are asked. None of the Source boxes on the form is
completed.
24. The officer said during his interview that all of the information came from
the man but he forgot to complete the source boxes. When he asked the
man what his alleged offence was, he replied, “Oh, I can’t remember.”
That interaction appears typical of the whole interview. The officer asked
the questions and accepted at face value whatever the man replied.
When the officer later discovered that the current offence was on the list of
offences, he did not alter the form. The man was assessed as a low risk
and suitable for cell sharing using the Cell Sharing Risk Assessment.
25. The man was put into a cell on the First Night Centre (FNC). The FNC is
a group of cells set aside to house new prisoners when they first enter
Leicester. The new prisoners then undergo an induction process before
moving on to other parts of the prison. The stay in the First Night Centre
can often extend to over a week due to the lack of accommodation
elsewhere in the prison.
26. As part of the induction process, the man was seen the following day by a
healthcare assistant. She completed the Second Reception Health
Screen form and noted that the man was fit only for light duties and unfit
for sport. She also referred him to the GP’s morning surgery on Monday 9
May regarding blurred vision, depression, itchy hands and scalp, constant
headaches and loose stools. There is no record of the man being given
any medication, although the doctor who saw the man during the
reception process, said in interview that he made sure he was given some
loperamide for his diarrhoea. There is no documentary evidence to show
this ever having been prescribed or issued.
27. On 5 May, the man was also seen by the Chaplain, had a resettlement
interview and a probation remand interview as part of the induction
procedure. Later that afternoon, the man telephoned his wife. She
promised to send some money for him but refused to visit.
28. The man was seen by a doctor at morning surgery on 9 May. During her
interview the doctor said that he presented with a number of problems all
relating to anxiety. She prescribed a shampoo for his itchy scalp,
Paracetamol for his tension headaches, Propanadol, a beta-blocker, to
help calm him, and Zolpidem to help him sleep. She arranged for a stool
sample to be taken and sent to the local hospital for analysis. The doctor
also noted that she did not have the man’s medical records from his own
GP. She wrote a letter requesting the medical notes which was faxed to
the GP that day. The GP replied by fax that he needed the man’s consent
before he could release them to the prison. During interview, the prison
doctor agreed that the GP was correct and that the healthcare assistant
should also have faxed a copy of the man’s consent which he signed on 4
May. The man’s medical notes were never obtained from his GP.
29. The doctor noted on the medical record that the man should have an In
Reach (mental health) referral. She said that it is usual for prisoners at
Leicester to be seen within seven to ten days of the request. The doctor
said that she was not sufficiently concerned about the man’s mental health
to open a F2052SH self-harm booklet.
30. The man returned to Loughborough Magistrates’ Court on 11 May where
he was convicted and remanded into custody to await sentencing at
Leicester Crown Court on 8 June. His change of status was not notified to
healthcare and, as stated in the clinical review, there is no consistent
mechanism for communicating such information. The man’s cell mate
said that the man was very ‘down’ when he came back as he was hoping
to be released on bail. The cell mate said that either that night or possibly
the night before, the man asked a member of staff if he might see a
Listener. (A Listener is a prisoner who has volunteered to be trained by
the Samaritans and is then available to other prisoners in time of crisis.)
The cell mate said that the officer said he would see what he could do.
31. There were three Listeners available on those nights, so there was no
reason why the man’s request to speak with a Listener, if indeed he did
ask, could not have been arranged. My investigators have spoken to the
officers on duty, of whom the request could have been made, but none of
them recalls such a request.
32. The man’s cell mate also said that, during the evening of 11 May, the man
said, `You know what, do me a favour. When I’m asleep if you kill me’
(sic). The cell mate said that he knew that the man was feeling very down
about the court case, but felt that by the morning he would be alright
again. He also thought that the man was too worried about his health to
really think about killing himself.
33. On the morning of 12 May, both the man and his cell mate went to
healthcare. The man saw the practice nurse at about 9.30 am. She noted
that he was pale and anxious about his diarrhoea. She explained to him
that they needed to await the results of the stool analysis before a proper
diagnosis could be made. The man then said that he needed to go to the
toilet and the nurse told him that he could come back if he so wished. She
did not see him again. The nurse noted the fax from the man’s GP
regarding consent, and during interview said that it was her intention to
discuss the matter with the prison doctor.
34. A healthcare officer took the man back to the wing and, as is usual
practice, let him onto the Centre and called out to notify the staff that a
prisoner had returned. He did not put him back into his cell. The
healthcare officer did not notice anything unusual about the man’s
behaviour as they walked back.
35. The Centre cleaner saw the man shortly after he arrived back, at around
10 am, and the man asked him for some soap so that he could have a
shower. The man walked with the cleaner to where the soap was kept,
and the last the cleaner saw of him was the man walking back towards his
cell. It has not been possible to confirm if he took a shower or not.
Events surrounding the man’s hanging
36. About 10 am, the man’s cell mate returned to the First Night Centre and
looked into the cell. He noticed that the television was on but the cell light
was off. He did not see the man, but saw that the sheet, which had been
placed on the window as a makeshift curtain by a previous occupant, was
down so as to cover the window and that there was a shadow behind it.
The cell mate asked a wing officer to let him into the cell. The cell mate
went to the back of the cell and pulled the curtain aside. He saw the man
hanging from the window bars by a bed sheet and shouted for staff.
37. An officer came to the cell door and shouted for more staff to attend. An
officer entered the cell and took hold of the man and held him up so as to
relieve pressure on his neck. The cleaner and another officer entered the
cell. The cleaner helped to hold the man up while the officer attempted to
cut through the twisted sheet with a ‘fish knife’. Upon hearing the general
alarm on the radio, the control room asked for Hotel 4 (Healthcare
emergency response) to attend the scene. The Senior Officer (SO)
arrived in the cell and told the cleaner to leave. He also tried to cut the
sheet without success. Eventually, they managed to untie the knot
nearest the man’s neck and he was placed onto the cell floor.
38. At 10.06 am, three nurses were at the cell.
39. One of the nurses and the SO began Cardio Pulmonary Resuscitation
(CPR). At 10.08 am, an ambulance and the attendance of the Senior
Medical Officer (SMO), were requested. After a short time, they moved
the man out into the corridor and screens were placed around. CPR was
continued until the SMO arrived at 10.13 am. He examined the man and
could not detect a pulse or signs of breathing. CPR then continued with
the Healthcare Manager taking over the chest compressions from the SO.
40. The paramedics arrived at 10.20 am and connected the man to a cardiac
monitor. The SMO obtained an intravenous access and administered a
dose of adrenaline. A saline solution was administered followed by
another dose of adrenaline. About 10.27 am, cardiac output was shown
on the monitor and chest compressions were stopped. Assisted breathing
was continued and the man was then transferred by ambulance to the
local hospital. The man was unconscious and escort handcuffs were not
used either en route to the hospital or at any time whilst he was there.
41. Two notes written by the man were found in the cell. They contained a list
of things that he would no longer be able to do and expressed his feelings
of isolation and despair.
42. The man had placed a healthcare request to see the Triage Nurse dated 5
May into the applications box. The application boxes should be emptied
every night by the night staff. The man’s note was found at the bottom of
the box at 10.50 am on 12 May. It is not possible to say with certainty
when the request was put into the box.
43. A hot-debrief was held at the prison to give the staff involved the chance
to talk through what had occurred. They were also offered the services of
the care team. Prisoners who were on open F2052SH booklets and the
prisoners on the First Night Centre were spoken to in order to gauge any
reaction to the man’s apparent suicide attempt.
44. The man’s family were notified of his condition and were able to visit him
whilst he was at the hospital.
45. The man did not recover consciousness and was pronounced dead by at
the local hospital at 8.30 pm on 17 May 2005.
46. My investigators spoke to the solicitor who had represented the man at
court on 4 and 11 May. She said that the Judge had expressed concern
in open court that the man was at risk. My investigator contacted the
Judge but he does not recall considering the man to be at risk. He said
that on 4 May there was a discussion which took place regarding the
change in sentencing arrangements from 1 April 2005, the man’s previous
convictions and the potential length of the sentence he would receive if
convicted. The sentencing would be heard at Crown Court and the
sentence could potentially be indeterminate. The Judge believed that the
man would have been aware of this conversation and the possible
ramifications. The man’s solicitor did not pass on any concerns about his
safety to either the court or prison staff.
Clinical review
47. The Eastern Leicester Primary Care Trust (PCT) is responsible for
commissioning the provision of healthcare at HMP Leicester. On 25 May,
my investigator told the PCT of the man’s death, and they conducted a
Clinical Review into the medical care that he had received whilst at
Leicester and the local hospital in accordance with the agreement
between the Home Office and the Department of Health. The PCT is
required to conduct a significant untoward incident report under its own
internal procedures.
48. The Clinical Review concludes that in the main the man’s healthcare
management at Leicester was appropriate. The report states that there is
no evidence that different actions by healthcare staff would have resulted
in a significantly different outcome.
49. The report has made a number of recommendations and two observations
of good practice in his report.
Findings and conclusions
50. The subject of this report arrived at Leicester on Wednesday 4 May,
complaining of a number of medical conditions. He was seen briefly by a
doctor as part of the reception process. The doctor says that he ensured
the man was given medication for his upset stomach, but my investigators
have not found documentary evidence to support this. The following day,
the man was booked in to see a doctor at the morning surgery on Monday
9 May.
51. The request to obtain the man’s medical notes from his GP was declined
because a signed consent form had not been faxed to the GP’s office. No
further attempt was made to obtain the notes, although it is likely that
practice nurse would have done so later on 12 May.
52. A nurse completed the First Reception Health Screen when the man
arrived. She ticked the box requesting a mental health assessment but
mistakenly believed that the doctor would note the box and arrange the
referral. The procedure for referral for a mental health assessment is not
clear and needs to be properly documented and training given. All officers
involved in the reception process should be aware of the correct
procedures to be followed.
53. The reception officer completed the Cell Sharing Risk Assessment
(CSRA) form for the man on 4 May. The completion of the form and the
information obtained was not of the standard to be expected. Whilst the
poor completion of the form had no detrimental effect in this case, the
CSRA form is an important document designed to protect prisoners and
create a safer prison environment. Officers completing such
documentation should be diligent in their questioning and recording.
54. As previously noted, the man’s change in status from a remanded to a
convicted prisoner was not notified to healthcare staff. If it had been, any
change in his mood might have been picked up. However, it should be
remembered that the man was not on a F2052SH and there is no record
of it being noted in Reception that the man was ‘low’ or depressed when
he arrived back at Leicester.
55. Overall, my investigators found Leicester to be a well run establishment
with a good number of dedicated and caring staff. The officers involved
when the man was found hanging responded quickly and professionally. I
have no doubt their efforts gave the hospital doctors the best chance of
saving his life.
56. Although I am critical of some record-keeping, and the fact that the
mental health assessment had not been completed before his death, I
have no evidence that his attempted hanging could have been foreseen
or, for that reason, prevented.
57. Contrary to information given to my investigators whilst carrying out the
investigation, the healthcare manager, states in the prison’s response to
my report that there was no formal procedure for referral for a mental
health assessment in place at the time and that subsequent actions to be
taken are open to interpretation. As can be seen from the preceding
pages the reception nurse clearly believed a procedure existed. This
confusion should be addressed as a matter of urgency.
Recommendations
Operational
Records & record keeping
58. Staff should be reminded of the importance of accurate record keeping to
ensure a holistic multi-disciplinary approach to prisoner care and support.
59. Service Response: ACCEPTED – Staff Information Notice to be published
reminding staff of requirement to keep accurate records, and maintain
high quality Cell Sharing Risk Assessment documents. Target date for
completion 28/2/06.
Health
59. The Governor and PCT should ensure that health staff involved in the
reception process by completing the First Reception Health Screens,
understand the referral process for obtaining specialist support and
advice, and work as part of the multi-disciplinary team.
60. Service Response: ACCEPTED - Appropriate training for Health staff in
reception procedures, screening and referrals, to be integral part of the
HMP Leicester Healthcare specification submitted to the PCT for
commissioning. Target date for completion 28/2/06
61. The Governor and the PCT should ensure that robust procedures are put
in place with regard to the referral process for obtaining specialist support
and advice, and that all staff are aware of those procedures.
62. Service Response: ACCEPTED – Referral forms to be made available to
all HCC staff in Reception. 2nd Screening to pick up any further referrals
on First Night Centre. Procedures in place where referral forms go direct
to mental health nurses. Target date for completion 31 July 2006
63. The Governor and PCT should ensure that there is a clear protocol for any
change in a prisoner’s status as the result of a Court appearance to be
communicated to Healthcare staff during the Reception process.
64. Service Response: ACCEPTED - Governor’s Order to be published,
stating that prisoners are not to leave Reception until they have been seen
by Healthcare staff and for Reception staff to be made aware of need to
inform Healthcare of any change in a prisoner’s status. Target date for
completion 28/2/06.
65. All items on the prison action plan are now completed.