Individual at Lincoln

Investigation into the circumstances surrounding the
death of a prisoner at HMP Lincoln
on 12 May 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
September 2007
This is the report of an investigation into the death of a man who was found hanging
in his cell at HMP Lincoln on 12 May 2006. Despite valiant efforts by prison staff to
save his life, he was pronounced dead shortly after arrival at hospital. He was 30
years of age.
I would like to extend my own and my colleagues’ sincere condolences to the man’s
family and to all those affected by his death.
The investigation was carried out on my behalf by two investigators from my office.
A clinical review of the man’s death was conducted by a doctor from the West
Lincolnshire Primary Care Trust. I am most grateful to the Governor and staff at
Lincoln for their co-operation and assistance during my investigation.
This report, as are so many from my office, is focused on the death of a young man
with a history of mental ill health and substance misuse. During his time in prison,
the man was moved from one establishment to another, often spending only days in
one jail before being moved on to another. Consequently, no proper assessment of
his needs could be made. Treatment such as this is often detrimental to those with
mental health problems. I draw attention to my concern that some of the
establishments where the man was located were either unaware of, or unable to help
with, his problems.
As is the case in a significant proportion of the apparently self-inflicted deaths I
investigate, the man who is the subject of this investigation had reported auditory
hallucinations.
There was a failure to recognise the man’s self-harm status when he was received at
Lincoln, and I also criticise the apparent use of a Post-it note (now missing) to record
important security information.
Nevertheless, my report concludes that the man was generally well treated during
his time at Lincoln. The clinical reviewer reports that the man had been assessed
thoroughly and frequently by appropriately qualified and competent staff at the
prison. He concludes that the man’s death could not have been foreseen or
prevented.
My report includes a number of recommendations about processes that had no
direct bearing upon the man’s death but which could be improved.
Stephen Shaw CBE
Prisons and Probation Ombudsman September 2007
2
CONTENTS
Summary 4
The Investigation Process 6
Background 7
HMP Lincoln 8
Key Findings 9
Issues 23
Recommendations 27
3
SUMMARY
On 8 September 2005, the man who is the subject of this investigation was sent to
HMP Highdown on remand, having been arrested for assault. Staff at Highdown
noted that the man had a history of psychiatric problems, and had previously
attempted to take a drug overdose, but had no thoughts of self harm.
Several weeks later, on 21 October, the man was transferred to HMP Lewes, and
then a week later he was moved to HMP Belmarsh where he remained until 7
December, when he was sent back to Lewes. At Lewes Crown Court on 7
December 2005, the man was sentenced to twelve months in prison with a two year
extended licence.
On 19 December 2005, the man was moved to HMP Wandsworth. A risk
assessment recorded no concerns with regard to his mental health. However, as a
consequence of staff concerns, an Assessment, Care in Custody and Teamwork
Care Plan (ACCT) was opened on 11 January 2006. It was closed the following day.
(The ACCT document describes the problems facing a prisoner at risk of harming
himself and implements a plan to give him support and help him through a period of
crisis.)
On 16 January, the man was transferred to HMP Edmunds Hill. During the reception
process it was recorded that he had mental health needs and heard voices in his
head. However, it was noted that he had no thoughts of self harming.
On 13 February, the man attempted to hang himself with his stereo lead. As a
consequence, an F2052SH was opened by staff at the prison. (An F2052SH was a
document used to assess and observe prisoners at risk of self harm. It has since
been replaced by the ACCT process but was in use at Edmunds Hill and many other
prisons at the time.) He was placed on 24 hour supervision (constant watch).
On 16 February, the man was transferred to HMP Bedford for further assessment.
Whilst at Bedford he was assessed by a community psychiatric nurse who
diagnosed him with a personality disorder. He told nursing staff that he had
attempted to hang himself because his parole had been refused, but denied any
thoughts of self harm at that time.
The man was transferred to Lincoln, on an open ACCT document, on 2 March 2006.
However, during the reception process, reception and healthcare staff failed to note
that he was on an open ACCT and therefore at risk of self harm.
The man’s records note that he immediately settled into the regime at Lincoln and
commenced work in the tailors’ workshop. However, on 8 March, he requested a
repeat prescription for diazepam and was referred to the mental health team. Two
days later, he told staff that he was unable to attend work that day because of his
mental health problems.
On 14 March, the man was seen by a nurse who recorded that he heard voices in
his head telling him to kill himself, and that he saw visions of cutting his wrists and
hanging. The nurse immediately opened a F2052SH and the man was seen by the
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prison doctor later that day. Over the following weeks, the man was in constant
contact with healthcare staff, and received significant input from the mental health in
reach team at the prison.
The man was taken off the F2052SH on 27 March. However, two days later he was
found in his cell having made cuts to both his wrists. An F2052SH was immediately
opened and the man was located in the healthcare centre, where he continued to
have significant contact with primary healthcare and mental health professionals. On
27 April 2006, the F2052SH document was closed.
The man was moved from the healthcare centre to normal location on 29 April.
Whilst on E wing, he continued to have contact with the mental health nurse and
visiting general psychiatrist at Lincoln.
On the afternoon of 12 May 2006, the man was discovered by his cell mate hanging
in his cell, and the alarm was raised. Staff attended to the man and efforts were
made to resuscitate him. Sadly, he was pronounced dead shortly after arriving at
Lincoln County Hospital, across the road from the prison.
5
THE INVESTIGATION PROCESS
1. Two investigators from my office, carried out the investigation into the man’s
death. Notices were issued to staff and prisoners informing them of the
investigation and its terms of reference, and inviting them to contact the
investigators should they wish to do so.
2. My colleagues visited Lincoln and were shown the healthcare unit where the
man spent most of his time in the prison, as well as the cell on E wing in
which he apparently took his own life. The investigating team met with the
Governor of Lincoln and a representative of the Independent Monitoring
Board. They also made themselves known to a representative of the local
branch of the Prison Officers’ Association. The investigators reviewed the
man’s prison record, health care records and other documentation. They
interviewed a number of staff at the prison.
3. A clinical review was completed by a doctor from the West Lincolnshire
Primary Care Trust. Interviews with medical staff were conducted jointly by
my investigators and the clinical reviewer.
4. My investigator spoke with Lincolnshire police. The police confirmed that
they had no concerns with regard to the circumstances of the man’s death.
My investigator also contacted the Coroner’s office, and a copy of this report
will be sent to the Coroner to assist him with his enquiries.
5. One of my family liaison officers contacted the man’s family at the beginning
of the investigation. The man’s mother contacted another of my family
liaison officers at the end of November 2006. The man’s mother expressed
her concern that her son had been taken off diazepam abruptly. She also
questioned why he had not been on ‘suicide watch’ at the time of his death,
having self harmed in previous weeks.
6
BACKGROUND
6. In 1998, the man sustained a serious head injury in an assault and spent
time in hospital. He received help under Section 3 of the Mental Health Act
for the ongoing mental health problems he suffered. He was prescribed
anti-psychotic and anti-depressant medication whilst in the care of his local
psychiatric hospital.
7. The man subsequently started to self harm. Occasionally, he would
experience suicidal thoughts and he used illicit drugs, prescribed drugs and
alcohol to deal with his feelings. By the time of his late twenties he was a
poly drug user with ongoing psychological problems, and he experienced
difficulties in controlling his emotions.
8. Between 3 and 7 September 2005, the man carried out three separate
offences whilst under the influence of alcohol. He was arrested and
remanded in custody until 27 October. This was his first time in prison. He
was initially sent to HMP Highdown.
9. The man was moved around the prison estate frequently before finally being
transferred to Lincoln on 2 March 2006.
10. At Lincoln, the man continued to experience difficulties handling his
emotions which affected his ability to work and participate in prison life. He
remained fairly reclusive and found it hard to socialise and interact with
others.
11. The man became eligible for parole on 8 March 2006. However, the Parole
Board felt that his mental health problems and tendency to self harm placed
him in too vulnerable a position to be released early on licence. The Board
said that this was compounded by the difficulty his probation area was
having in finding suitable accommodation for him on release. The man was
told that the Parole Board had rejected his application for release in April.
12. The man died on the afternoon of 12 May 2006, apparently at his own hand.
He was aged 30.
7
HMP LINCOLN
13. HMP Lincoln is a category B, local adult male prison. Built in 1872, the
prison receives prisoners direct from the courts across the East Midlands. It
also receives serving prisoners transferred in from other establishments and
has an operational capacity of 490.
14. The prison holds mainly remand and convicted prisoners serving short term
sentences and a relatively small number of life sentence prisoners. The
prison is divided into four residential units, a segregation unit, a first night in
custody wing (FNC) and a healthcare unit for both inpatients and
outpatients.
15. The most recent inspection report by Her Majesty’s Chief Inspector of
Prisons (HMCIP) was published in November 2005. It described Lincoln as
a prison in recovery, working towards restoration of normal functioning and
a good standard of regime. However, the report found that Lincoln was still
underperforming in some crucial areas.
16. Lincoln’s reception process was heavily criticised by HMCIP for the lack of
privacy it gave to prisoners being interviewed for cell sharing risk
assessments. The induction process was similarly criticised for assessing
prisoners within hearing distance of others, and for rushing its delivery of
information about the prison’s facilities and regimes. The HMCIP report also
commented that improvements needed to be made to the anti-bullying
strategy, and to self harm and suicide procedures.
17. HMCIP found that healthcare provision had improved and that, despite
being understaffed, the inpatient facility was a safe and therapeutic
environment with a decent standard of care in evidence.
8
KEY FINDINGS
8 September 2005 to 2 March 2006
18. On 8 September 2005, the man was sent to HMP Highdown having been
arrested and charged by police. A psychiatric report prepared by the Court
Division Team said that the man was well known to psychiatric services. He
had been admitted to a medium secure unit seven years previously for
schizophrenia, and had a history of personality disorder. The assessor
recorded that the man’s current diagnosis was one of borderline personality
disorder and alcohol abuse, that he was a risk to others when intoxicated,
and that he complained of suicidal thoughts.
19. Upon reception, the man’s personal details were entered in his prisoner
record. However, no contact details were entered for next of kin, or
someone to contact in case of emergency.
20. A first reception health screen (a process used to assess the physical and
mental health of a prisoner on admission to prison) indicated that the man
had psychiatric problems and a Suicide Self-Harm Warning Form (used to
indicate a prisoner’s likelihood of self harm) indicated that he had made
previous attempts to overdose on medication. However, during his prison
induction on 12 September, it was noted that the man had no thoughts of
suicide or self harm but suffered from panic attacks. In his clinical review on
behalf of Lincolnshire Primary Care Trust, the clinical reviewer notes that the
man was seen by a psychiatrist on 23 September who diagnosed substance
misuse, chronic low self esteem and features of borderline personality. As a
consequence the man was given a reducing dose of diazepam as well as
mirtazapine and olanzapine, with follow up from a psychiatric nurse and
doctor. Two weeks later, the man was further prescribed zopiclone and it
was noted on his medical records that he was “mentally stable, no evidence
of psychosis or paranoia.”
21. The man was moved to HMP Lewes on 21 October, and it was again noted
on his prison records that he had a personality disorder. As a consequence,
he was referred to the mental health in-reach team for an assessment. The
assessment cited previous instances of drug and alcohol abuse, but
concluded that he had no suicidal ideation present and seemed stable at
that time.
22. Five days later, on 27 October, the man was transferred to HMP Belmarsh
and was located in healthcare the following day. When assessed by staff
during an exit plan, he was noted as having difficulties in asserting himself
and as being bullied by other prisoners, but there were no self harm issues.
In his review, the clinical reviewer notes that the man was seen by a
psychiatrist on 1 November, and it was recorded that he was feeling
agitated, uncomfortable and unhappy.
23. On 7 December, the man was moved back to Lewes. A cell sharing risk
assessment (a document used to ascertain the level of risk that a prisoner is
9
to others and to himself) was completed by a member of reception staff. It
was recorded that the man had mental health problems and that staff should
monitor his behaviour. It was indicated that he was of medium risk to other
prisoners. The same day he was sentenced at Lewes Crown Court to
twelve months imprisonment with a two year extended licence.
24. Twelve days after being admitted to Lewes, the man was transferred to
HMP Wandsworth. A risk assessment recorded no concerns with regard to
his mental health, and nursing staff indicated that following the self harm
assessment no concerns had been raised. However, on 11 January 2006,
an ACCT document was opened. It was closed the following day. In his
review, the clinical reviewer records that healthcare staff noted on 13
January that the man felt the medication he had been on had not been
working or helping him. He complained of insomnia, panic attacks, and that
he was hearing voices which were more like his own thoughts than anything
else.
25. Several days later, on 16 January, the man was moved to HMP Edmunds
Hill. During reception, it was noted that he had mental health needs and
that he was full of “thoughts” and had voices inside his head. However, it
was recorded that the man had no thoughts of self harming. In his review
the clinical reviewer notes that the following day he was seen by a mental
health nurse who, concerned that he was hearing voices, arranged single
cell accommodation for him. On 27 January, it was noted that the man was
still apprehensive and thought that something bad was going to happen to
him.
26. On 13 February, the man tried to hang himself with his stereo lead. An
F2052SH was opened, the man was placed on a constant watch, and he
was seen by a doctor. The clinical reviewer notes in his report that it was
decided to place the man on 24 hour supervision, that he should be seen by
a psychiatrist for a complete review of his medication, that he should also
see the mental health in-reach team, and that he would benefit from
cognitive behavioural therapy. On 15 February, the man complained about
being on olanzapine, wanting to be treated with quetiapine instead.
27. On 16 February, the man was transferred to HMP Bedford for further
assessment. A letter from healthcare at Edmunds Hill confirmed that, once
the man had been assessed, they would be happy to accept him back. The
F2052SH opened at Edmunds Hill was closed and an ACCT opened in its
place. The clinical reviewer notes that the man was assessed by a
community psychiatric nurse (CPN) and diagnosed with personality
disorder. The man told the CPN that he had attempted to hang himself
because his parole had been refused, but reconsidered his actions as he did
not want to die. He was reviewed further on 17 February and denied any
thought disorder or self harm ideation at that time. (It is not apparent to
what part of the parole process the man was referring.)
28. The man was informed by his probation officer on 21 February, that he
would not be eligible for home detention curfew as originally advised
10
because he had been sentenced with an extended licence, making him
ineligible. The clinical reviewer notes that, on the same day, during an
assessment by a specialist registrar in psychiatry, the man said he had
considered hanging himself because parole had been refused. However, an
entry in his medical records, on 22 February, noted that he had tied a
ligature around his neck because of bullying and because he owed money
on the wings.
29. The clinical review says that the man was further seen by a CPN on 27
February. At that meeting it was recorded that there was no evidence of
any thought disorder and, although the man had expressed some concerns
with regard to his parole, no further acts of self harm had been attempted.
There was no self harm ideation expressed.
30. Although the man had said he wanted to return to Edmunds Hill, he was
transferred to HMP Lincoln.
The man’s time at HMP Lincoln
31. The man arrived at Lincoln on 2 March. Part of the reception process
included the completion of a cell sharing risk assessment (CSRA) which, as
well as recording the risk that he could have been to others when sharing a
cell, also said whether or not he was at risk to himself. The man arrived at
Lincoln on an open ACCT document. The Prisoner Escort Record (PER)
noted this and a previous PER form, kept in his record, also said that he
suffered from “self induced psychosis”. Nevertheless a senior officer (SO) in
reception at Lincoln, completed the CSRA and recorded that the man had
never shown any signs of anti-social behaviour or abused drugs or alcohol.
He also recorded that the man was not currently dependent on drugs, was
not on an open F2052SH/ACCT, and that there was no previous evidence
that he had been.
32. During his interview with my investigators, the SO from reception was
unable to recollect whether or not the open ACCT document had arrived
with the man. The SO also said that, when filling out the CSRA, reference
would not normally be made to the PER form. He said that, if four or five
prisoners were being processed at one time, it would not be possible to
have all the relevant documents on the desk together. At a prisoner
induction board review later on 2 March, another officer endorsed the
comments made by the SO in reception.
33. During their visit to Lincoln, my investigators visited the reception area of the
prison and noted it was generally small and cramped. The desk used to
interview prisoners upon first reception was small and located in the corridor
only feet away from the main entrance to the unit. It was in a position where
any interview completed would have been heard by other prisoners waiting
to be processed. The investigators noted that the location of the reception
centre, in the old administration block of the prison, placed considerable
constraints on the level of facilities available to newly received prisoners.
11
34. After being interviewed by reception staff, the man saw a nurse from
healthcare who completed the medical part of the CSRA form. During her
interview with my investigators the nurse said she did not remember
receiving an ACCT document from reception staff that day, and as a result
noted on the CSRA form that there were “no concerns at present”.
However, the nurse wrote in the man’s continuous clinical record, “mental
health issues, no drug misuse and has previous self-harm/overdose.
Asthmatic – referral completed.” The prescription of mirtazapine and
olanzapine, which had been previously prescribed to the man, continued at
Lincoln. However, the planned reducing dose of diazepam, 5mg, was not
continued beyond the seven day dose that had been prescribed by the
medical officer at Bedford on 25 February.
35. Later on 2 March, the man was seen in the first night centre where Risk
Assessment for Labour, Inmate Work Suitability Questionnaire and New
Reception Security Assessment forms were completed. There are no
further entries in the man’s prison record until 6 March when he completed a
wing application asking for a transfer back to Edmunds Hill, saying that he
should have been transferred there from Bedford. The man was advised by
staff that he had been sent to Lincoln due to population pressures, and
when his paperwork arrived they would process his application details. The
following day, 7 March, the man made an application to be transferred to
Highdown in order that he could be closer to his family. There appears to
have been no response from the prison to this request.
36. On 6 March, the man commenced work in the tailors’ workshop. On 8
March, he was seen in the healthcare triage unit where he requested a
repeat prescription of diazepam. He was referred to the mental health team.
The man was also seen by a CARAT worker that day, and discussed with
her his recent drug use, his expectation of release in the near future and
that parole was an issue for him.
37. On 10 March, it was recorded in the man’s wing history sheets that he had
not caused any problems on the wing or in the tailors’ workshop. However,
on 12 March, he told staff that due to mental health problems he would be
unable to attend work that day. The man’s wing sheets note that staff
contacted healthcare who advised that he should remain on the wing until
seen by the mental health nurse on 14 March.
38. On 13 March, the man made an application for Change in Labour, saying
that he would rather attend education than work in the tailors’, because his
medication made him unable to use the machinery there. The man appears
to have received no response to his application.
39. On 14 March, the man was seen in healthcare by a nurse. She recorded
that the man felt as if his head would explode, that he heard voices telling
him to kill himself, and that he saw visions of cutting his wrists and hanging
himself. She said that the man was still awaiting contact from the mental
health in-reach team at the prison. The nurse opened an F2052SH citing
suicidal thoughts and the visions that the man was having. The clinical
12
reviewer notes in his review that the healthcare doctor wrote in the man’s
medical notes later that day:
“complains of paranoia, delusions, illusions (pictures on walls taking to
him) and auditory hallucinations ordering him to hang himself.
Descriptions of above just unconvincing. Accurately describes panic
attack with tension in head and palpitations. I suspect this is his main
problem currently.”
40. The man was seen again by a nurse on 15 March. The nurse noted on his
medical records:
“there is no current clinical indication for a need to change from
olanzapine or any clinical requirement for the reintroduction of a
benzodiazepine which he is also requesting. Message left with in
reach team as this man is on CPA.”
Another nurse who attended a review of the man’s F2052SH, also noted
that he was hearing voices telling him to hang himself because he wanted
different medication. At a further F2052SH review on 20 March, it was
recorded that the man still had problems with his medication. Although he
had become more settled, he occasionally still heard voices but these were
not aggressive.
41. The man wrote a letter to the healthcare doctor on 16 March requesting a
change in his medication. On 17 March, the man put in a wing application
for a transfer further south, saying that he had been told that he could go to
HMP Stocken as soon as spaces became available. Lincoln’s response
informed the man that the prison was given spaces at random and that he
would be put on the list for transfer.
42. In an entry of 22 March, the healthcare doctor noted that the man was
finding it difficult to leave his cell due to paranoid thoughts and that he
wanted to go back onto quetiapine and diazepam. The man said that
olanzapine made him feel drowsy.
43. Later that day, the man was seen by a mental health nurse from the mental
health in-reach team. The nurse noted that the man had been attacked
numerous times in the community and had been previously admitted to
hospital where he was diagnosed with drug induced psychosis. The man
told the nurse that he was currently feeling low in mood and motivation, was
unable to concentrate and experienced disturbed sleep. He said that he
had experienced visual and auditory hallucinations previously during drug
induced psychosis. The nurse recorded that there should be a planned
medication change to risperidone and trazadone, as the man was adamant
that olanzapine and mirtazapine were ineffective. During her interview with
my investigator, the nurse said that the man was, “generally, quite sort of,
chatty and happy to engage in conversation.”
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44. The man’s F2052SH was reviewed again on 27 March. It was decided to
close the booklet. The review coordinator recorded that the man presented
himself in a positive manner. He had some concerns about his medication
but no thoughts of self harm. However, one of Lincoln’s probation officers
recorded on the man’s probation notes that although he had reported no
thoughts of self harm he was struggling to cope in custody.
45. On 29 March, the man was found in his cell on B wing having made cuts to
both his wrists. He was transferred to the healthcare unit for treatment and
an F2052SH was opened by a senior officer. The mental health nurse, who
had previously seen the man on 22 March, recorded in his medical record
that he had razor blade injuries to both wrists. He was anxious and coping
poorly due to his personality disorder. She said the man was worried about
his probation report and that he was repeatedly asking for his medication to
be changed. He could not cope on the wings and was thinking about self
harm. As during her first contact with the man, the nurse confirmed that he
was “quite happy to speak to me about what had happened and how he was
feeling at the time.” The man remained in the healthcare unit for further
assessment and observation and was given access to both Listeners and
the Samaritans.
46. The mental health nurse saw the man again the following day. She wrote in
his medical record that he had said he had planned to self harm, waiting for
his cell mate to return to work in order to use his razors. The man told her
he believed he should be prescribed diazepam. The nurse recorded that
she told him repeatedly that this was not appropriate. She said that he
continued to ask for a change to his medication, but was told he needed to
continue taking it for it to be effective.
47. The probation officer at Lincoln completed the man’s parole assessment
report on 31 March. She wrote that she was unable to support his early
release on licence.
48. On 1 April, the healthcare in-patient manager chaired the first review of the
man’s re-opened F2052SH. He recorded that the man was happy to chat,
was more positive and felt safe in healthcare. The man was said to be
unhappy with his medication and only wanted diazepam. It was said that he
was near to his parole review and wanted a transfer to a category C
establishment. During interview, the healthcare in-patient manager told my
investigator that at the review the man appeared withdrawn, an observation
that has been confirmed by a number of staff at Lincoln. Nevertheless, the
in-patient manager found him willing to talk and sensed that the man was
relieved to be in the healthcare centre.
49. In his clinical review, the clinical reviewer observes that the man:
“was assessed by a specialist registrar in psychiatry on 5 April 2006.
Her notes run to three sides. She noted that he had taken many
overdoses in the past, had previously been detained under the Mental
Health Act, and had been admitted to psychiatric hospitals as a
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voluntary patient. His current presentation is that he was having panic
attacks, occasional thoughts about harming self, especially at night,
and that he was thinking about hanging himself. She decided to
increase the dose of risperidone, and prescribed venlafaxine and
zoplicone. He was to begin cognitive behavioural therapy and anxiety
work with the in-reach staff.”
50. Further reviews of the man’s F2052SH took place on 6, 14 and 20 April
2006. On 6 April, it was noted that there had been no change since the last
review and that he was eating and sleeping well. He was to remain in
healthcare for further assessment. On 14 April, it was noted that the man
said that he wanted diazepam for his panic attacks, and produced a diary
that stated repeatedly he was having thoughts of self harm. On 20 April, it
was recorded that the man should remain in healthcare for continued
assessment, that he was still hearing voices telling him to self harm, and
that it had been agreed to continue his level 1 observations.
51. The man had kept the diary referred to above as a consequence of a
suggestion by the psychiatrist. It records the man’s feelings from 6 April
until the last entry on 18 April. He recorded anxiety, panic attacks, hearing
voices and thoughts of suicide on a regular basis. His last entry said he was
suffering from really bad panic attacks that morning and felt like cutting his
wrists. The man mentioned wanting a change to his medication in his diary.
52. On 10 April, the man’s outside probation officer submitted her parole
assessment report. She too said she was unable to recommend parole for
the man. On 11 April, he was again seen by the mental health nurse who
recorded that he was a bit brighter and was hoping for a positive Parole
Board outcome early the following week.
53. A number of entries in his medical record over the following days recorded
that the man had become more settled on the unit. On 18 April, the mental
health nurse noted that he was still awaiting his Parole Board decision. She
wrote that the man, “States he wants to change his medication AGAIN.
Advised him that this is not necessary or appropriate at this stage.”
54. In his clinical review, the clinical reviewer notes that the man was:
“reviewed by the specialist registrar in psychiatry on 19 April 2006.
She says that he was claiming that voices all night were telling him to
kill himself. He was constantly thinking about what has happened, and
he feels guilt attacks. He was having panic attacks two to three times
per day, and felt that everyone hated him. She decided to increase his
venlafaxine, add diazepam, and reduce risperidone.”
55. Entries on the man’s medical records over the coming days record that
there were no problems and that he remained settled on the healthcare
centre. On 26 April, the man was seen again by the healthcare doctor. He
noted that the man was settled but was still quite paranoid and was hearing
15
voices from the television. He also wrote that the man was considering a
move to E wing and that he should remain on level 1 observations.
56. On 27 April, the man was seen again by the mental health in-reach nurse.
She noted the man’s intention to move forward with his life and that he
wanted a move to E wing in order to attend education. She said that the
man felt brighter from going out to the exercise yard in the sunshine.
57. That day also saw the man’s final F2052SH review. The review coordinator,
the in-patient manager, wrote that the man remained settled in healthcare
and was hopeful of hearing something about his parole review. The in-
patient manager noted that the man’s reports had not been supportive of
early release, in which case he would be in prison until September. He said
that the man expressed no thoughts of self harm at this time and it was
agreed with other reviewers that the F2052SH be closed. When
interviewed, the in-patient manager confirmed that the man was fine on the
day his F2052SH was finally closed. He recalled telling the man that staying
in healthcare in isolation was not helpful, and that he really needed to move
on and try to become more involved.
58. The man was transferred from the healthcare unit to E wing on 29 April. A
Healthcare Centre Patient Discharge Summary (a form used to provide a
brief history of a prisoner’s care in healthcare to discipline staff on normal
location) was completed by the in-patient manager. The form indicated that
the man was no longer on an open F2052SH, and that he had been
admitted to healthcare four weeks earlier as a consequence of self injury. It
said that the man had not been a management problem and was keen to
undertake education.
59. On 30 April, the man’s wing sheets recorded that an application for
vulnerable prisoner status was approved due to the nature of his offence
and fears for his safety. On 3 May, the man submitted his appeal to the
Parole Board. The man said that the reports were negative towards him. In
addition to arguing for his release, he said that he was at risk of suicide as
he could not deal with being in prison.
60. The mental health nurse saw the man on E wing on 5 May. She wrote that
he was still awaiting the Parole Board’s decision, but did not believe it would
be positive as his probation officer wanted him to attend an alcohol
treatment programme in prison. The mental health nurse also noted that the
man had not been collected to attend the psychiatrists clinic on 3 May.
61. On 6 May, the control room received a telephone call from the man’s
grandmother. A note in his wing history sheets recorded that she had called
over her concern that her grandson had not contacted her recently. A
message was passed to the man for him to phone her. The man called his
grandmother’s number later that day and spoke with her for almost four
minutes. The records also noted that he had last called his grandmother’s
number on 4 May.
16
62. The man was seen by his psychiatrist, on 10 May. In a letter the psychiatrist
dictated to the healthcare doctor on 10 May (typed on 12 May), she reported
that the man had rarely been going out to exercise due to feelings of
anxiety. She said that he had had no recent panic attacks, but had no
confidence and remained anxious that he would be assaulted if others found
out about his offence. The psychiatrist wrote, in her letter to the healthcare
doctor:
“There was a note in his IMR saying that he had been trading
Diazepam. I informed him of this and told him that we would be
stopping his Diazepam. He denied that he had been trading Diazepam
and said that his panic attacks had only ceased because of the
Diazepam. He had little confidence in his other medication and was as
usual adamant to change to his anti-psychotic drugs.”
The psychiatrist recalled that there had been an entry in the man’s inmate
medical record which said “trading diazepam on the wings, please review”.
After seeing him on 10 May, the psychiatrist discontinued the man’s
prescription for diazepam, continued his prescription of risperidone and
venlafaxine and asked the mental health nurse to contact local services in
order to set up a psychiatric assessment in preparation for the man’s
release.
63. Although not mentioned in her letter to the healthcare doctor, the
psychiatrist also recorded on the man’s medical notes that he said he would
kill himself if not given diazepam.
64. During interview, the psychiatrist confirmed that on 3 May the man should
have attended a clinic with her but had not been brought to healthcare from
the wings. The psychiatrist said she had been told that the man was trading
diazepam. She said:
“There was a Post-it note stuck on his IMR, on the outside of it, that
was brought to my attention by the in-reach psychiatric nurse who had
been seeing him and I think the wing officers had put it on his notes
and passed it on to her, so it was shown to me and it was shown for a
second time on the 10 May. After his death when I saw the copied
notes, I saw no copy of the Post-it note.”
65. When interviewed by my investigator, the mental health nurse confirmed
that she brought to the attention of the psychiatrist the note indicating that
the man was trading his diazepam. She said that the information “came in
the form of a handwritten note on a piece of paper from the treatment room”.
The mental health nurse believed the note originated from the treatment
room on E wing but could not remember if a particular nurse’s name was
written on it. The nurse said she recalled the man had been unhappy and
adamantly denied he had been trading his diazepam.
66. The healthcare in-patient manager had had a lot of contact with the man
whilst he was located in healthcare. During his interview, he said he
17
believed the man would not have been the type of prisoner to have dealt in
drugs. He said that the man was too keen on making sure he got the drugs
himself, as opposed to passing them on to others. My investigators found
no evidence to suggest that the man was trading his Diazepam whilst he
was at Lincoln.
67. During her last assessment of the man on 10 May, the psychiatrist noted on
his records that he had said he would kill himself if he was not given
diazepam, and that he was fixated on having his medication changed.
When questioned about this, the psychiatrist said:
“When he [the man] was told about the Post-it note he started to say
immediately that, that’s probably the only thing that had helped him
here and again talking about how everybody else had let him down,
nothing else had been done for him, and he was saying that if it was
withdrawn he was going to kill himself despite the fact that we had
agreed to it being for short term use only and his panic attacks had
been much less prominent.”
The psychiatrist said, “I hadn’t seen it as a kind of serious intent to kill
himself because we went on to talk about plans for the future.” She went on
to say she, “had been clear beforehand that I was going to stop [the man’s
diazepam]. The Post-it note just reinforced the idea that we needed to
keep clear boundaries with him.” The psychiatrist said that having been
told of the man’s threat to kill himself she examined his mental state,
asking him questions about his mood, thoughts and plans for the future.
She said that the man was optimistic about the future and that their
discussion,
“…led me to believe that he had appropriate future orientation and was
not planning to kill himself at that time. I gained the impression that his
comments were impulsive and made in order to try to elicit the
response he wished i.e., to continue diazepam.”
68. When asked if there was any witness to the man’s threat of suicide the
psychiatrist said that he had made his threat in front of the mental health
nurse. She said that even though the man had recently been taken off an
ACCT “There was no evidence to indicate that his risk was more elevated
than usual at the time of threat…” The psychiatrist took the decision that an
ACCT was not necessary. She said that she discussed the man’s case with
the mental health nurse after he had terminated the interview and they had
agreed that his threats of suicide did not carry significant intent and as such
no further action was taken.
69. During her interview with my investigators the mental health nurse said that
she could not recall being in the room when the man made the threats to kill
himself if he was taken off diazepam. However, in later correspondence she
said:
“I was present for some, but not all, of the time that the man was in
18
consultation with the Doctor, [the psychiatrist] on Wednesday 10th May
2006, as I was also assisting another Doctor who was carrying out a
simultaneous clinic. I was not aware that the man had made any threat
of suicide.”
The mental health nurse added that it was only after the man had taken his
life that she was made aware that he had made a verbal threat of suicide.
70. That evening, the man made a telephone call to his grandmother, speaking
with her for approximately seven and a half minutes. Their conversation
was predominantly of a domestic nature, talking about parcels being sent in
to the prison and forthcoming visits. There was no indication that the man
was either feeling low or considering suicide.
71. The man’s cell mate told the police that the man appeared to be a loner and
had few friends in the prison. He said he got to know the man a little better
over a period of a week, during meal times and association. The other
prisoner said that the man did not talk of self harming and, although he
believed the man was not bullied on the wing, other prisoners would take
the “mick” out of him. On the morning of 11 May, the other prisoner moved
into the man’s cell on E wing, having had problems with a previous cell
mate. The man’s new cell mate told police that the man talked about his
“nana” and seemed to look forward to getting out of prison. That night, the
man and his cell mate went to bed at about 9.30pm. The cell mate told
police that the man awoke in the early hours before going back to sleep.
They both awoke at around 7.45am on 12 May.
Events of 12 May 2006
72. The man’s cell mate reported to police that he and the man cleaned their
cell on the morning of Friday 12 May, before being locked up and watching
the television together. He said the man appeared to be fairly calm, but at
one point started fiddling with a disposable razor saying that he had had
enough. The cell mate told police that he told the man not to be so stupid
and threw the disposable razor out of the window. The cell mate did not tell
officers about this incident at the time.
73. At about 10.30am, the man met with his CARAT worker. When interviewed
by my investigators, the man’s CARAT worker confirmed that they
discussed a number of issues with regard to his parole and offending, and
his problems with alcohol. She said that the man had given her no
indication that morning as to what he was going to do. She said that, if he
had, she would have opened an ACCT on him immediately.
74. A number of officers and staff at Lincoln described the man as being quiet.
The CARAT worker described him as being like “a naïve little boy” who
appeared lost. An officer on E wing recalled that the man “was a very quiet,
withdrawn young man, [who] didn’t mix well”. Another officer said the man
was, “Very quiet, keeping himself to himself, it was very difficult to engage in
conversation with him, however as time went on, the longer period he was in
19
Lincoln the easier it was and the more he would talk to you and ask for
things himself.”
75. The man’s cell mate told police that, when the man returned to his cell, he
had asked the cell mate to write a letter for him. The cell mate said he had
agreed to write the letter that afternoon. The cell mate also said that the
man had just received a letter from his grandmother containing a £50.00
postal order and picture of his nephew. He said the man placed the picture
in his drawer and screwed up the letter, unread.
76. The man had his dinner along with his cell mate at about 11.30am. Both of
them then remained in their cell, the man smoking on the bottom bunk. At
about 1.30pm, the cell mate was unlocked by an officer. The man’s cell
mate said that he left to attend the gym, telling the man that he would meet
him straight afterwards in the exercise yard. The officer then asked the man
if he wished to go on exercise, but the man declined. During interview, the
officer said that “this was nothing out of the ordinary from what I can
recollect he didn’t normally go on exercise or anything like that”.
77. The man’s cell mate told police that on returning from the gym he went
straight to the exercise yard. He remained there for about 20 minutes
before returning to the wing at about 3.00pm, reaching his cell about 10
minutes later. On returning to the cell, the cell mate said that he looked
through the spy hole and saw the man hanging by a ligature from the bunk
bed inside. The cell mate raised the alarm immediately.
78. My investigators established that a senior officer was talking to another
officer when they heard the man’s cell mate shout “he’s hanging, he’s
hanging”. They immediately attended the cell and saw that the man was
hanging by a ligature from the top bunk, facing the door. The senior officer
called a code 1 on the radio and entered the cell. He then took the man’s
weight along with another officer. Another officer also entered the cell at
about the same time and cut the ligature with an anti-ligature knife known as
a ‘Fish Knife’. (Fish knives are shaped like a fish, and contain a concealed
blade in the mouth section which is designed to allow the user to get
underneath the ligature. The action of pushing the knife forward cuts the
ligature away from the body. At the time, only a small number of officers on
the wing carried fish knives. I understand that all officers now carry them.)
79. The man was laid on the floor. Although he believed that the man had
already died, the senior officer commenced mouth to mouth resuscitation
and Cardio Pulmonary Resuscitation (CPR) without any protective
equipment until nursing staff arrived. The two other officers withdrew from
the cell upon the arrival of the first member of nursing staff to attend.
Approximately two minutes later, other members of healthcare staff arrived
with equipment including a defibrillator and oxygen. After applying a face
mask, the nurses continued mouth to mouth resuscitation and chest
compressions. The defibrillator was attached and shock administered. The
incident log records that an ambulance was called at 3.21pm, and was
20
contacted again at 3.27pm with further information.
80. The paramedics arrived at Lincoln at 3.29pm, and were escorted to the
man’s cell arriving at 3.33pm. The paramedics continued CPR on the man
with the assistance of nursing staff. Other nurses attended some minutes
later with additional oxygen and at 3.45pm, on establishing that more
oxygen was required, a nurse went to fetch it. The paramedics and nursing
staff continued with CPR for about an hour. At 4.16pm, the ambulance left
E wing and left the main gate of the prison at 4.20pm. Staff and paramedics
continued to work on the man during the short journey across the road to
Lincoln County Hospital. Shortly after arriving at the hospital, the man was
pronounced dead at 4.30pm.
81. For the duration of the emergency, comprehensive logs and notes were kept
by HMP Lincoln. A hot-debrief took place at 4.50pm, attended by a number
of staff. (Medical staff who had responded did not attend as they had to
continue treatments on the healthcare unit and wings.) Following the man’s
death, a review of all prisoners on open ACCTs was completed and staff
were offered the facilities of the welfare team at the prison.
82. The family liaison officer at Lincoln became aware of what had happened at
about 4.00pm. During interview, she told my investigator that because the
man had not left any details of his next of kin it took some time to establish
who should be contacted. The family liaison officer explained that the visits
book revealed the man had been due to receive a visit on Sunday 14 May
from two people. These people had differing names from the man but lived
in his home area, although no relationship had been identified. It was later
established that these people were in fact the man’s mother and brother.
The family liaison officer noted in the prison Family Liaison Log that, due to
the difficulties in contacting a family liaison officer from a local
establishment, the Coroner’s Office asked the police to visit the home of the
man’s brother.
83. Police visited the home of the man’s brother, but he was not in. They put a
card through the letterbox asking him to contact them. The following day,
the details of the man’s grandfather were found by the prison and he was
contacted at about 3.10pm on the Saturday afternoon. The man’s mother
contacted Lincoln prison at about 4.45pm. The man’s family went ahead
with their planned visit to Lincoln on Sunday and were met by the Governor.
The family visited the man’s cell and were given his property. After a
discussion with the man’s family, it was decided that the Prison Service
would not attend his funeral although a floral tribute was sent and the prison
paid the funeral expenses.
Clinical Review and Post Mortem Report
84. The clinical reviewer looked in detail at the level of healthcare the man
received during his time in prison. In particular, the review considers the
man’s time at Lincoln.
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85. In his review, the clinical reviewer says that staff should be commended for
their efforts to resuscitate the man. The clinical reviewer was satisfied that
all equipment was in working order and staff were appropriately trained. He
also reports that immediate life support training was in the process of being
undertaken by all relevant staff. He concludes that it was “…very unlikely
that resuscitation could have been successful in this case.”
86. The clinical reviewer confirms that the man was assessed for his mental
health needs on numerous occasions, and was seen by a specialist registrar
in psychiatry on three occasions, including an assessment two days before
his death. The clinical reviewer concludes that the man had been
“assessed very thoroughly and at frequent intervals. Staff communicated
their findings with each other. It is hard to see how a more complete
assessment could have been made.” The clinical reviewer confirms that the
man had been diagnosed some years previously as having a personality
disorder, and that this was the diagnosis that the man had been given whilst
at Lincoln. He says that, although treatment at Lincoln had been planned
for the man, he had received little treatment for the condition by the time of
his death. However, the clinical reviewer does “not feel that more intensive
treatment of his condition would have altered the outcome of events.”
87. With regard to the man’s medication, the clinical reviewer notes that he had
a history of wishing to change his medication and that he regularly
requested diazepam. The clinical reviewer finds that on more than one
occasion the man threatened to kill himself if it was not prescribed:
“The specialist registrar in psychiatry explained to us that his
behaviour is common in patients with personality disorder. There were
good reasons for not changing his medication as he requested: she
had negotiated a care plan with him at their previous meeting, and that
it would be harmful to renege on this; his condition appeared to be
improving, and thus his care could have been compromised if he had
reverted to less effective treatments; she did not believe that this threat
was a serious indication of intent to kill himself.”
88. In his clinical review the clinical reviewer explained that the man had been
“on and off” diazepam for some time prior to his death. He said that the
drug was used for the short term relief, 2 to 4 weeks, of anxiety that is
severe, disabling or subjecting an individual to unacceptable distress. The
clinical reviewer added that: “Diazepam is indicated for short-term use only.
Medical practitioners are discouraged from prescribing this drug.” The
clinical reviewer thought it unlikely that the refusal to prescribe diazepam on
10 May, contributed to the man’s death.
89. The Post Mortem examination reported that the man’s death was as a
consequence of suspension by ligature around the neck.
22
ISSUES
Reception
90. The man arrived at Lincoln on an open ACCT document. The senior officer
in reception, who carried out the man’s initial interview, was unable to recall
whether or not he had sight of the ACCT or PER (which also indicated that
the man was on an open ACCT) when he completed the CSRA form. The
fact that the man was on an open ACCT was also missed by all other
members of staff working in reception and on the first night induction centre.
91. The reception senior officer pointed out that, when a number of prisoners
were being processed at the same time, it would often not be possible to
have all the relevant documents together on the desk due to the limited
space available. During their visit to Lincoln, my investigators confirmed
this, and discovered that the lack of space means that initial interviews are
conducted within hearing of other prisoners, and in an open passageway.
92. After being processed by reception staff, the man was seen by a nurse from
healthcare. The nurse could not remember having sight of the ACCT
document or PER form during her health assessment of the man. Although
she recorded that the man had some mental health problems, she
concluded that there were no concerns at present. As a consequence of not
having sight of the ACCT and PER forms, the nurse missed the fact that the
man was considered to be at considerable risk of self harm.
93. What happened at his reception interview may have had little bearing on the
man’s death. Nevertheless, I believe that reception arrangements merit
consideration, as did the Chief Inspector of Prisons in her most recent report
on Lincoln in September 2005. The report mentioned the conditions in the
reception area, in particular that Cell Sharing Risk Assessments (CSRAs)
were completed at the desk in the main reception area. The Chief Inspector
found this made it less likely that a prisoner would disclose anxieties or ask
for help. The Chief Inspector recommended that CSRAs should be
completed in private.
I recommend that the Area Manager in conjunction with the Governor
reviews the facilities offered by the reception centre at Lincoln.
Adequate accommodation should be provided so that all interviews
with prisoners are carried out in private, with space to process
documentation fully. All interviews should be completed out of the
hearing of other prisoners.
I recommend that the Governor reminds all reception and healthcare
staff of the importance of establishing whether or not a prisoner is on
an open ACCT when entering the prison.
I recommend that nursing staff should have full access to all prison
records held on a prisoner, including PER forms, during the initial
health screen interview and assessment.
23
F2052SH and ACCT processes
94. I understand that Lincoln was one of the last prisons to transfer from
monitoring prisoners at risk of self harm by use of the F2052SH to the new
ACCT system. The man’s F2052SH was closed days before the ACCT
system came on line at Lincoln on 2 May 2006.
95. Two F2052SHs were opened by members of nursing and discipline staff at
Lincoln. The first was as a consequence of one nurse’s concerns about the
man’s thoughts of self harm. The second was opened by a senior officer in
response to the man’s self harm on 29 March 2006. Both were completed
to a good standard. Nevertheless, a small number of improvements could
have been made to the way that the man’s F2052SHs were handled,
including having a member of discipline staff present during his reviews, and
greater consistency in the make up of review boards.
96. Whilst at Lincoln, my investigators took the opportunity of reviewing some
current ACCTs opened on prisoners at risk. I am pleased to report that
these were generally completed to a good standard. Although a number of
minor issues were reported to the safer custody manager, my investigators
considered these to be teething problems whilst staff became used to the
requirements of the new processes.
97. However, it became apparent during the investigation that a number of staff,
including nurses, had not been fully trained in the use of ACCT.
I recommend that the Governor ensures that all staff are fully trained
in the ACCT process.
Report that the man was dealing in diazepam
98. During interview, the mental health nurse said she brought the psychiatrist’s
attention to a note suggesting the man had been trading in diazepam. The
psychiatrist described the note as a Post-it stuck on the outside of the man’s
IMR, and said that after his death it had disappeared from his records. Of
all the staff interviewed, only the psychiatrist and the mental health nurse
could recall the note. Both said they did not write it, although the mental
health nurse believed it had originated from the treatment room on E wing.
My investigators have been unable to establish who wrote this note, and
what happened to it after the man’s death. They have also found no
evidence to suggest that the man was trading his prescription drugs at the
prison.
99. It is clear in the psychiatrist’s letter to the healthcare doctor on 10 May, that
the Diazepam was withdrawn as a consequence of her belief that the man
was trading his drugs. The psychiatrist confirmed this in her written
statement.
24
100. The psychiatrist said that the prescription of Diazepam was only going to be
as a short-term measure anyway and that the man had agreed to the
arrangement. She told my investigators that the note reinforced the idea
that clear boundaries needed to be kept with the man. However, the
psychiatrist did not write in either the clinical record or in the letter to the
healthcare doctor that her agreement with the man was that the prescription
of Diazepam would be a short term measure only.
101. I am concerned that such important and sensitive information was simply
recorded on a Post-it note, with no name or further explanation as to the
source of the information. If the information was significant, it should have
been recorded properly on the man’s prison record, either by the submission
of a Security Information Report (SIR) or by comprehensive notes being
made in his prison record.
102. Although I make no formal recommendation, I would ask the Governor to
remind staff of the need to record all sensitive and relevant information
appropriately.
The Man’s Threat of Suicide
103. During his consultation with the psychiatrist on 10 May, the man threatened
to take his life if his prescription of diazepam was withdrawn. This was well
documented by the psychiatrist on the man’s medical notes. The
psychiatrist says that she fully considered along with the mental health
nurse the man’s threat. She concluded that the risk “did not carry
significant intent to warrant further action at that time.” The psychiatrist
believes that she discussed the man’s threat of suicide with the mental
health nurse, for her part the nurse does not recall having this conversation
with the psychiatrist. However, despite this discrepancy I am satisfied that
the psychiatrist gave full consideration to the man’s threat of suicide.
Hot-Debrief
104. My investigation has established that not all staff were able to attend the
hot-debrief. In particular, healthcare staff were unable to attend. Nor were
some of the nurses asked to produce incident statements, even though they
attended to the man in his cell.
I recommend that the Governor ensures that all those involved in
responding to a self inflicted death are invited to attend the hot-
debrief and any follow up de-briefs. All those involved in a response
should be asked to provide written statements.
Notification of the man’s death to his family
105. Although a prisoner record was completed for the man during the reception
process at Lincoln, his next of kin details were not recorded. I appreciate
that it is not always possible to obtain and record such details but, in the
man’s case, a number of problems occurred as a consequence of their
25
absence.
I recommend that the Governor reminds staff of the need to ensure
that every effort is made in obtaining prisoners’ next of kin details,
either from prisoners or from their records.
106. Once next of kin details were established, a number of difficulties occurred
when staff at Lincoln attempted to inform the man’s family of his death. I am
satisfied that these were beyond the staff’s control and I believe that the
prison could not have acted differently in the circumstances.
Clinical Review
107. In his clinical review, the clinical reviewer highlights the attempts that were
made to revive the man and says that all staff should be commended for
their efforts. I concur with this. I would also draw attention to the fact that
the senior officer administered mouth to mouth resuscitation and CPR to the
man without protection and with no concern for his own safety.
I recommend that the Governor commends all staff involved in the
resuscitation attempt. In particular, the senior officer should be
commended for his actions in attempting to save the man’s life without
consideration for his own safety.
I recommend that the Governor reminds staff of the benefits of
carrying face protectors which provide adequate protection during
CPR.
26
RECOMMENDATIONS
I recommend that the Area Manager in conjunction with the Governor
reviews the facilities offered by the reception centre at Lincoln.
Adequate accommodation should be provided so that all interviews with
prisoners are carried out in private, with space to process
documentation fully. All interviews should be completed out of the
hearing of other prisoners.
I recommend that the Governor reminds all reception and healthcare
staff of the importance of establishing whether or not a prisoner is on an
open ACCT when entering the prison.
I recommend that nursing staff should have full access to all prison
records held on a prisoner, including PER forms, during the initial health
screen interview and assessment.
I recommend that the Governor ensures that all staff are fully trained in
the ACCT process.
I recommend that the Governor ensures that all those involved in
responding to a self inflicted death are invited to attend the hot-debrief
and any follow up de-briefs. All those involved in a response should be
asked to provide written statements.
I recommend that the Governor reminds staff of the need to ensure that
every effort is made in obtaining prisoners’ next of kin details, either
from prisoners or from their records.
I recommend that the Governor commends all staff involved in the
resuscitation attempt. In particular, the senior officer should be
commended for his actions in attempting to save the man’s life without
consideration for his own safety.
I recommend that the Governor reminds staff of the benefits of carrying
face protectors which provide adequate protection during CPR.
27