Individual at Lewes

Investigation into the circumstances surrounding
the death of a man
at HMP Lewes in December 2005
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2006
This is the report of an investigation into the death of a man in December 2005 at
HMP Lewes. He died as the result of a cut to the left internal jugular vein apparently
by his own hand. The man was 48 years old.
My colleagues and I would like to extend our condolences to his family and to those
touched by his passing.
The investigation was undertaken by two of my colleagues. I would like to thank the
Governor of HMP Lewes and his staff for their ready participation in the investigation.
I am particularly grateful to the Security Governor who acted as the establishment’s
Liaison Officer with the investigation team.
The Head of Healthcare at HMP Lewes was identified Sussex Downs and Weald
Primary Care Trust (PCT) to undertake a review of the man’s clinical care, and I
greatly appreciate her assistance. I judge her review as both comprehensive and a
fair representation of the clinical services at HMP Lewes. However, as the clinical
reviewer is the Head of Healthcare at Lewes prison, I wonder if it was appropriate for
the PCT to ask her to undertake the review. Colleagues in Prison Health may
consider this is a matter on which guidance should be offered to all PCTs with a
prison in their area.
This report makes three recommendations, all based on the clinical review. It also
refers to police information relating to the man’s risk of suicide that the Coroner may
wish to explore in more depth.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2006
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CONTENTS
Summary
The Investigation Process
HMP Lewes
Events prior to 11 December 2005
Events on 11 December 2005
Events after 11 December 2005
Issues
Recommendations
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SUMMARY
The man was born on 6 September 1957. He was 48 years old when he died at
HMP Lewes, apparently by his own hand, in December 2005. Having been charged
with committing a serious sexual offence, his trial was due to start the following day
at the Crown Court.
The man had first been remanded into custody from the Magistrates’ Court on 18
April 2005. At the court he had been seen by a Forensic Community Mental Health
Nurse who concluded that the man was at risk of self-harm or suicide. A self-harm
warning form was completed by a senior custody officer at the court identifying the
risk.
The man was received at HMP Elmley where, during his First Reception
Healthscreen, he denied any thoughts of suicide or self-harm.
The only notes in his medical record from Elmley are that he fell from his bed or a
chair on 26 April and hit his right lower ribs which were sore. He was taken to the
local hospital with a request from the prison’s medical officer that the hospital assess
him for possible complications of the rib injury and to check his cardiovascular
system. He was discharged later the same day with ibuprofen tablets for the injury.
The discharge letter also indicates that he underwent an ECG examination.
On 5 May, the man did not attend a doctor’s appointment, but no reason was noted
and it is unclear what the appointment was for. He remained at Elmley until he
appeared at the Crown Court on 22 July 2005, following which he was remanded to
HMP Lewes. On reception at Lewes, he again denied he had any thoughts of self-
harm or suicide. He did not come to the attention of staff and the only notes in his
medical record are that he missed sick parade on 30 August and again on 1
November. He complained of indigestion on 13 September, for which he was
treated and he was signed off work that day.
While he was at Lewes, there is no evidence that he gave any indication to anyone
else that that he had suicidal thoughts. Nevertheless, it would seem from comments
made by his wife that he found it difficult to cope with prison life and his children
expressed concern to her about his wellbeing following a visit. Judged overall, his
time at Lewes was entirely unremarkable. However, the fact that police information
that he had been downloading articles about suicide from the internet at the time of
his arrest was not known by prison staff may have led them to underestimate the
risk.
The clinical review concludes: “it is my opinion that healthcare staff, prison officers
and paramedic staff acted appropriately when responding to the emergency and
when they attempted to resuscitate the man.” However, the clinical reviewer has
identified a number of areas where improvements could be made to the systems of
recording and to some procedures. She makes a number of recommendations,
three of which I have endorsed.
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THE INVESTIGATION PROCESS
1. My investigators studied all relevant prison records relating to the man. These
included his main prison record, his medical records and statements from prison
staff.
2. Sussex Downs and Weald Primary Care Trust identified a General Manager and
Head of Healthcare at HMP Lewes, to carry out a review of the man’s clinical
care. I am grateful for this review being undertaken in a most timely manner.
3. My investigator contacted Her Majesty’s Coroner to inform him of the nature and
scope of my investigation and to request a copy of the Post Mortem report. This
recorded the cause of death as hypovolaemic shock leading from a haemorrhage
caused by a cut to the left internal jugular vein. Ischaemic heart disease was
found to be present but did not contribute to his death. Upon completion, this
report will be sent to the Coroner to assist him in his enquiries into the man’s
death.
4. One of my family liaison officers met with the man’s wife (the couple had
separated) in the company of one of my investigators. She told them of her
concerns which are considered later in this report. The wife said that that when
two of their four children visited their father in prison, they noticed deterioration in
him. They reported that he had become withdrawn and depressed and had lost
weight. The wife asked why this was not noticed and acted upon by prison staff
and why he was not placed on suicide watch or given the opportunity to speak to
someone. She was also concerned that, on the morning after his death (the day
of the planned trial), news of the man’s death was reported on the local radio
station and teletext. She was not happy with the prison’s explanation that they
had to inform waiting press at court. In addition, a front page report in a local
newspaper had made reference to her marriage and she wanted to know where
the press had got the information from. She also asked where the man’s mobile
telephone and bank card were as they had not been returned. I hope this report
and the clinical review provides her with answers to her questions.
5. My investigators discussed aspects of the man’s treatment with staff at Lewes
and the clinical reviewer.
6. Six members of staff were interviewed during the course of the investigation.
They were offered the opportunity of being accompanied by a work colleague or
Trade Union official.
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HMP LEWES
7. Lewes prison was built in 1853. It is a local prison which houses trial/remand and
sentenced adults. In March 2002, Lewes lost the court commitment to receive
and hold young offenders, although a small group of prisoners aged under 21 are
held on remand as a facility to the local courts in the Sussex area. The prison
has now opened a large wing (F Wing) to accommodate vulnerable prisoners.
The prison has an operational capacity of 558.
8. The provision of healthcare within HMP Lewes is the responsibility of Sussex
Downs and Weald Primary Care Trust. Primary care is delivered by medical staff
and registered nurses, and the healthcare centre has the opportunity to draw
upon the range of healthcare services within the local NHS Trust. Medication is
administered on a weekly and/or monthly basis to those prisoners who have been
assessed as suitable to safely manage their own medication. It is administered
on a daily basis to other prisoners, when either they are considered to be at risk
or the medication is unsuitable to be held in their cell.
9. There is an in patient ward with 18 beds and a constant watch cell. This is
staffed by registered nurses and provides for both the physical and mental health
needs of those patients requiring 24 hour primary nursing care.
10. In a full announced inspection in 2003, Her Majesty’s Chief Inspector of Prisons
(HMCIP) described HMP Lewes as a good local prison, but expressed concern
about the lack of services for vulnerable prisoners and suggested they be moved
to a more appropriate site and their places taken by short-term prisoners,
requiring resettlement in the locality. An unannounced follow-up inspection in
August 2005 found that many of the recommendations from the 2003 inspection
had been implemented, and the prison had continued to improve in a number of
areas - with the exception of vulnerable prisoners, for whom provision remained
extremely limited. Managers and staff across the prison have put much effort into
addressing the issue of suicide and self-harm and Lewes had been a pilot for the
Prison Service's new suicide and self-harm prevention measures.
11. As a result, most of the recommendations in the earlier inspection report had
been implemented and the rate of self-harm was much reduced. HMCIP also
concluded that other aspects of safety had improved (concerns about the
segregation unit and first night arrangements had been addressed, positive drug
test levels were low and detoxification arrangements were excellent). HMCIP
noted, ‘Lewes had sustained the respectful staff–prisoner relationships which
were identified in the 2003 inspection. This went some way to mitigating the
limitations of the old and occasionally inadequate accommodation which was,
nevertheless, well looked after and clean.’
12. There have been four other deaths at Lewes since April 2004, three from natural
causes and one apparently self inflicted death. There are common issues
between the death of the man who is the subject of this report and one of the
natural cause deaths, to which I shall refer later in this report.
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EVENTS PRIOR TO 11 DECEMBER 2005
13. My investigators were told by the Coroner’s Officer that when the man was first
arrested he had 43 pages printed from the internet on how to commit suicide. He
appeared before the Magistrates’ Court on 18 April 2005. The Prisoner Escort
Record (PER) from the Police Station to the Magistrates’ Court did not mention
the internet pages. Part A of the PER, completed by the custody assistant had
the ‘other’ box ticked for concerns, but there were no details recorded of what this
might refer to. The man was not noted to be at risk of self-harm or suicide.
14. A psychiatric report was completed at the Magistrates’ Court by the RMN, which
noted the man was agitated and distressed and believed he would not survive
prison due to the nature of the alleged offences and his previous employment as
a police officer. The report also noted that, since his arrest, he had a poor
appetite and problems sleeping. Night sleeping tablets had been prescribed for
him. He had expressed a desire to kill himself. The RMN considered there was
a high risk of him committing suicide. A self-harm warning form was completed
by a senior custody officer at court. That day the man was remanded in custody
to HMP Elmley. The PER for the man’s transfer between the Magistrates’ Court
and HMP Elmley appears to have gone missing.
15. A full Induction was completed at HMP Elmley, which included a First Reception
Healthscreen completed by the staff nurse. She saw the self-harm warning form
forwarded by the Court and has noted it on the healthscreen. She recorded that
the man had no thoughts of self-harm. When my investigators spoke to her, she
could not recall completing the healthscreen or whether she had specifically
asked the man about the psychiatric report. In fact she could not recall whether
she saw the psychiatric report, although she agreed that she must have been
aware of the concerns about him as she signed the self-harm warning form. She
explained that she would normally see a psychiatric report if one had been
completed.
16. The staff nurse said it would appear that she did not have any concerns about the
man’s wellbeing as she did not open a self-harm warning form (F2052SH). She
said she had referred him to the safer custody officer, using a standard memo,
due to the potential risk of self-harm because of the nature of his charges and the
fact that he was an ex-police officer. This memo was not found in the man’s
paperwork. She reiterated that she was not sufficiently concerned to put him on
a F2052SH, and the idea of the memo is to identify those prisoners who
potentially could be at risk of self-harm or suicide but have not given any specific
indication of that intention.
17. A Secondary Health and Well Person Assessment was carried out which was
unremarkable. It is not clear who completed this form and there is no entry made
in the man’s medical record. A cell share risk assessment was completed by the
wing. This noted that the man was a Rule 45 prisoner (vulnerable prisoner
status) and stated that he had no thoughts of self-harm and had been
misunderstood. There was no mention of the psychiatric report. The man was
considered a low risk of sharing a cell with others (that is, he was considered
suitable for multi-cell location).
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18. The man was transferred to HMP Lewes on 22 July, following his appearance at
the Crown Court. The PER completed for his transfer between Elmley and the
Crown Court shows he was on constant watch at 7.35am, but there are no further
details. No suicide or self-harm warning box was ticked. There is no PER now
available for his transfer between the Crown Court and Lewes Prison. When he
arrived at Lewes, he underwent a standard induction programme. The Induction
Audit Checklist shows that he had a legal aid interview, chaplaincy interview, bail
information interview and a PE induction.
19. The induction checklist also notes that a healthscreen interview was completed
by a nurse, but there is no written record of what took place. In interview, a wing
nurse said he vaguely recalled triaging the man when he arrived at Lewes but
again there is no documentary evidence of this. The Head of Healthcare
explained that the policy is that all prisoners, including transfer prisoners, should
have a full reception healthscreen. There is no evidence that this happened in
the man’s case. The Head of Healthcare explained that, since she has been in
post (January 2006), she has tried to make improvements to all healthcare
services, including reception screening and follow-ups. She said that, prior to
January 2006, it would appear that when healthcare staff were under pressure in
reception, they briefly reviewed previous healthscreens from other
establishments without undertaking a new one.
20. A cell share risk assessment was completed by the duty officer. The man
answered ‘no’ when asked if he had previously been subject to a F2052SH. The
officer considered he was a medium risk (that is, there was no immediate risk to
others of him sharing a cell with somebody else, but the situation would need to
be reviewed regularly). It was noted that the man said he would share a cell with
a ‘mature, sensible, clean person.’
21. The man requested Rule 45 status due to his previous employment as a police
officer and the nature of his alleged offence. He was transferred to the
Vulnerable Prisoners Unit under Rule 45 on 25 July.
22. On 5 August, a wing officer spoke to the man about the psychiatric report which
had been forwarded to Lewes by Elmley. It is not clear when this was forwarded
by Elmley, but a note records that it was received at Lewes on 5 August. The
officer was asked to talk to the man about the report. In interview, the officer said
he did not see the psychiatric report, but as far as he was aware it said that the
man was vulnerable and could be at risk of self-harm. The entry in the man’s
core record by the officer notes: ‘spoke to the man about psychiatric report and
issues about self-harming, he has not got a clue why the report has come from
the Magistrates’ Court, does not feel suicidal or like self-harming. No issues.’
23. On 30 August, there is a note in the man’s medical record that he did not attend
sick parade. There is no record of what action, if any, was taken as a result. It is
not clear either why the man was receiving medical attention.
24. On 13 September, it is noted in the man’s medical record that he was suffering
from indigestion and was vomiting, and he was signed off work.
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25. On 1 November, there is another note in his medical record that he did not attend
sick parade. Again, there is no record of any action taken as a result and no
record of why the man was receiving medical attention.
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EVENTS ON 11 DECEMBER 2005
26. On 11 December 2005, at approximately 4pm, the first landing officer went to
lock the man’s cellmate back into the cell. He said he looked through the
observation hatch and, as he could not see anything, he unlocked the door and
pushed it open. He looked down at the threshold of the door and noticed blood
on the floor. He then saw the man sitting in a chair at the back of the cell, with
his back to the sink, facing his bed. He could not see very clearly as it was dark
in the cell, with the only light coming from the landing. He shouted for help, as he
could not use his radio because the battery was dead. He saw the second
landing officer running towards him he entered the cell. The second landing
officer saw the prison officer making his way to the cell and told him to get
medical help.
27. The second landing officer arrived at the cell door and immediately went and
pressed the general alarm located approximately two cells away. He then re-
entered the cell. The man had a cut to the left side of his neck. The first landing
officer fetched some gloves from the second landing officer. The second landing
officer had a sealed emergency medical pouch, which included one pair of
gloves, which he had obtained from healthcare years previously. It is not clear
what else was in the medical pouch.
28. The prison officer radioed for medical assistance and collected the First Aid Box
and the Emergency Intervention Bag from the wing office. Both landing officers
carefully laid the man flat on the floor. The second landing officer checked the
man’s airway, while the first landing officer performed chest compressions.
29. At around 4.05pm, the wing nurse responded to the emergency call and arrived
with emergency equipment. The second prison officer arrived at the same time.
The man was moved within the cell to ensure more space to continue
resuscitation. Both landing officers then left the cell. The wing nurse continued
with the resuscitation, along with the second prison officer. The wing nurse told
my investigator that it proved difficult to obtain good chest compressions and
airway breathing initially. He changed masks and airways until eventually he
administered mouth-to-mouth resuscitation effectively. During this time he said
that he noticed two lacerations, one on the left side of the man’s neck and
another on his larynx, and he placed some gauze swabs on the wounds to stop
the bleeding. He found a toothbrush handle, which had a blade welded to it and
he placed it on a plate by the sink.
30. The principal officer (PO) who was the orderly officer at the time of the man’s
death, called for an ambulance by radio at approximately 4.05pm. At
approximately 4.11pm, the Sussex Ambulance Paramedics arrived and took over
the management of the man’s airway, while the wing nurse and the second
prison officer took it in turns to perform heart massage. The paramedic crew then
intubated and cannulated the man, while administering 1200mls of Hartman’s
solution and adrenaline. (Hartman’s solution is used to replace essential fluids
lost from the body.)
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31. After approximately another 20 minutes, the paramedics decided to transfer the
man to the Accident and Emergency (A&E) Department at the local hospital. He
left the prison by ambulance at approximately 4.55pm. Resuscitation was
continued by the paramedic crew, the second prison officer and a senior officer
(SO), in the ambulance until approximately 5.11pm.
32. The man was pronounced dead on arrival at the A&E Department at
approximately 5.17pm.
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EVENTS AFTER 11 DECEMBER 2005
33. The duty governor contacted the man’s daughter on her mobile telephone, and
also spoke to his wife. Later that night, he visited the man’s wife and children to
offer condolences and support. He was also able to give some more detail about
the circumstances and a contact number for the coroner's office.
34. A letter of condolence was sent to the man’s wife by the Governing Governor on
19 December. Flowers were sent by the prison and they contributed towards the
cost of the funeral. The chaplain and a governor acting as the prison family
liaison officer attended the man’s funeral on behalf of the prison.
35. The post mortem recorded the cause of death as hypovolaemic shock leading
from a haemorrhage caused by a cut to the left internal jugular vein. Ischaemic
heart disease was found to be present but did not contribute to his death.
36. Staff who were interviewed agreed that the support offered by the Post Incident
Care Team after the man’s death was very good. They found the hot debrief, on
15 December, very useful. The second prison officer told my investigators that
the prison offered to pay for massage for his shoulder as he pulled some muscles
whilst performing CPR.
37. Following the concern expressed by the man’s wife, the governor who was at the
time the family liaison officer for the prison made enquiries into the press release.
The following is the direct wording that was passed to him as a result (I note it
does not give any indication of the man's former occupation or of the location of
his family and was issued after the man’s family had been told of his death): ‘We
can confirm the death in custody of a man at HMP Lewes (DOB). The man was
discovered in his cell by staff at 16:00hrs on Sunday 11 December, he appeared
to have cut his own throat. Staff immediately attempted to resuscitate him and an
ambulance was called. However he failed to recover and was pronounced dead
at 17.17hrs. Every death in custody is a tragedy, and our sympathies are with
the family and friends of the man at this time. The Police, Coroner and Next of
Kin have been informed. As with all deaths in custody, the Prisons and Probation
Ombudsman will conduct an investigation.’
38. The press notice also includes the following: ‘If asked: “The man was on remand
for rape, and had been in custody since 18.04.05. He was not on an open ACCT
form. He was from East Sussex.” If asked what the man used to cut his throat:
‘We cannot comment further as this is now subject to an investigation by the
Prisons and Probation Ombudsman.’”
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ISSUES
Clinical Care
39. The clinical review was undertaken by the healthcare manager on behalf of
Sussex Downs and Weald PCT. She concluded that the healthcare staff, prison
officers and paramedic staff acted appropriately when responding to the
emergency when they attempted to resuscitate the man. However, the clinical
reviewer drew attention to a number of issues concerning standards of record
keeping and assessing prisoners’ mental and physical health needs. She has
made a number of recommendations which I endorse.
40. It is not clear from the reception induction checklist completed at Lewes what
form of reception healthscreen the man had when he was transferred from
Elmley. This meant that staff did not have a clear picture of his current health
status.
The Healthcare Manager must ensure that all prisoners new to the prison or
transferred from another prison are given an appropriate healthscreen and
followed up, and that a system of clinical audit is developed to ensure staff
compliance.
41. The man refused to attend a medical appointment at Elmley and did not attend
sick parade on two separate occasions at Lewes. There is no record of any
follow-up or reasons for why he refused or failed to attend. There does not
appear to be any routine process at Lewes for following up and establishing
reasons for non-attendance. This was mentioned as an issue in a previous
investigation of a death from natural causes at HMP Lewes.
Where a prisoner refuses to attend an appointment, a reason for refusal
should be sought and documented in the medical records, signed by the
patient and witnessed by staff. Refusals to attend should be brought to the
attention of a Senior Nurse.
42. The clinical review also indicates that it is sometimes difficult to decipher who
has made the entries in the medical records, as there are only signatures, names
are not printed and there is no covering signature sheet available. This was also
mentioned as an issue in a previous investigation of a natural cause death at
Lewes.
The healthcare manager must remind staff to print their name next to their
signature in medical records. A signature sheet must also be available for
cross referencing official documents if required.
43. I agree with the clinical reviewer’s conclusion that healthcare staff, prison officers
and paramedic staff acted appropriately when they responded to the emergency
and attempted to resuscitate the man. The prison’s contingency plans for dealing
with a death in custody were followed. However, the first landing officer could not
call for assistance by radio because his radio batteries were not charged.
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Sharing information
44. It is of concern that several Prisoner Escort Records have either gone missing or
were not completed when the man was moving from prison to court and from
court to prison. Furthermore, on the occasions that PERs could be evidenced
they were often incomplete. Such records are a key tool for the sharing and
transfer of information between departments and organisations.
45. Good record keeping helps inform the care process and ensure the continuity of
care and management of an individual. It also enables early detection of
changes in a prisoner’s demeanour or mental health and therefore assessments
and interventions to be put in place in a timely manner.
46. It has been identified by the Coroner’s Officer that the man was received into
police custody with information downloaded from the internet about suicide. It is
of great concern that this information was not passed onto the escort staff and to
the Prison Service. As this is a matter concerning the police, I have judged it to
be outside my remit. However, the Coroner may wish to explore this matter in
more detail as part of the inquest procedures.
47. I am concerned that the psychiatric report prepared by the RMN at court was not
seen by one of the wing officers when he was asked to talk to the man about
those issues on 5 August. It would certainly have been beneficial for him to have
seen the report before he spoke to the man.
Risk of suicide and self-harm
48. The man denied that he had any thoughts of suicide or self-harm when he arrived
at Elmley and later when he was transferred to Lewes. He did not give staff at
either prison any cause for concern. However, he was a vulnerable prisoner, in
view of his alleged offence and his previous occupation as a police officer and
this had been identified by a RMN at court.
Contact with the man’s family
49. The man’s wife was concerned that news of her husband’s death was reported
on teletext and the radio shortly after she had been told. This followed the
procedures set out for a death in custody, which include the routine publication of
a press notice including details of offence. This is standard practice for the
Prison Service’s National Operations Unit, and is usually done when it is
confirmed that the family have been informed of the death, as was the case here.
I think these procedures are proper given the necessary public interest in any
fatality occurring in a closed institution. However, it would clearly be helpful for
next of kin to be advised at an early stage that a press notice will be issued, as
details of the death may appear in the media which may be distressing for the
family. It might also be useful to suggest that next of kin may want to contact
other family members quickly. I understand that staff in Prison Service
Headquarters are currently working to resolve this issue.
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50. My investigators have tried to locate the man’s mobile telephone and bank card.
There is no trace of the items at Lewes and the police have no record of them
either.
Conclusion
51. The man died from an apparently self-inflicted cut to the left internal jugular vein
while in custody at Lewes. From comments made by his wife he was a well
loved father but he was struggling to cope with prison life and two of his children
expressed concern to her about his wellbeing following a visit. His time at Lewes
was unremarkable; it appears he was very quiet and rarely associated with other
prisoners.
52. During his time at Lewes, there is no evidence that the man gave any indication
that he had suicidal thoughts. However, the fact that police information that he
had been downloading articles about suicide from the internet at the time of his
arrest was not known by prison staff may have led them to underestimate the
risk.
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RECOMMENDATIONS
HEALTHCARE
The Healthcare Manager must ensure that all prisoners new to the prison or
transferred from another prison are given an appropriate healthscreen and
followed up, and that a system of clinical audit is developed to ensure staff
compliance.
Where a prisoner refuses to attend an appointment, a reason for refusal
should be sought and documented in the medical records, signed by the
patient and witnessed by staff. Refusals to attend should be brought to the
attention of a Senior Nurse.
The healthcare manager must remind staff to print their name next to their
signature in medical records. A signature sheet must also be available for
cross referencing official documents if required.
The Prison service has accepted all the recommendations.
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