Individual at Liverpool

Report of the investigation into the death of
a male prisoner at HMP Liverpool in June 2005
Prisons and Probation Ombudsman for England and Wales
July 2006
This is the report of an investigation into the circumstances surrounding the death of a
male prisoner at HMP Liverpool in June 2005. The man was found hanging in his cell
in healthcare at approximately 4.15pm that day.
I offer my sincere sympathy and condolences to the family of the man who have
suffered the tragic loss of a loved one. Prisoners and staff at Liverpool who had met the
man also expressed their sympathies. The man was a very vulnerable man who had
been considered as at risk of suicide or self harm in each of the prisons in which he
served his sentence.
The man died six days after Liverpool adopted the ACCT (Assessment, Care in Custody
and Teamwork) approach to the care of those at risk of suicide and self harm. The
investigation reveals failures in that system at the time of the man’s death. This report
also focuses on the decision to locate the man alone in his cell. At the time I issued my
draft report a clinical review had yet to be received. This has now been received and
notes that the mental health services were not involved in or informed about the key
decision to move the man into a single cell. They have made a number of
recommendations that I urge the prison to consider.
The investigation was carried out on my behalf by Mr T Wright. I am grateful to the
Governor and all Liverpool staff for their willing cooperation.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2006
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Contents
Summary
The investigation process
HMP Liverpool
Events leading to and following the death
Clinical review
Issues considered during the investigation
Conclusions
Recommendations
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SUMMARY
This is the report of an investigation into the death on 11 June 2005 of a male prisoner.
The man died in the Healthcare Centre at HMP Liverpool where he was serving a prison
sentence.
The investigators reviewed the man’s records and spoke to a number of staff and
prisoners. The man had a long criminal history and had been to prison before. He had
been in prison custody on this occasion since 31 July 2002. The man had abused a
variety of substances and had mental health problems. He had a history of mental
instability and had self harmed in the past. He was considered to be a suicide risk, and
a suicide prevention document was opened for him at each of the prisons where he had
served his current sentence.
The man was received into Liverpool prison on 3 June 2004, and was being treated for
his medical problems, which included a pain in his head that would not go away. He
continued to experience mental health problems and received treatment for these.
On 13 May 2005, the man seriously self harmed and was sent to outside hospital for
treatment. While there, he told his visitors that he intended to kill himself in the not too
distant future.
On 10 June, the man became extremely agitated while in his shared accommodation.
He was given some medication to calm him, moved to a single cell, and was put on a
constant watch until his condition improved. Later that day, a doctor decided that the
man could be kept in a single cell if necessary. It is possible that this decision – which
may have been made without full knowledge of the circumstances and without
interviewing the man – was flawed. Healthcare staff decided that the man should
indeed remain in the single cell. No risk assessment was carried out, and the suicide
prevention arrangements under the ACCT process, including the previous ACCT
observation schedule, were not reviewed to see what additional support the man might
need in a single cell.
At approximately 4.15pm on 11 June 2005, the man was found hanging from the door to
the toilet area of his cell in the Healthcare Centre by an agency nurse. Other staff were
alerted and cardio pulmonary resuscitation (CPR) was started. Healthcare staff and a
paramedic team attended the man, but efforts to revive him were unsuccessful and he
was pronounced dead at 4.35 pm. I find that staff arrived as soon as possible and did
all they could to save the man’s life.
The prison subsequently provided support to prisoners and staff. The Governor and the
prison chaplain personally broke the sad news to the man’s family.
The report makes four recommendations. The clinical review identifies a number of
learning points and I urge the Primary Care Trust in partnership with the Prison to
consider these fully.
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THE INVESTIGATION PROCESS
1. The investigation was opened on 15 June 2005. My investigators met with the
deputy governor and other senior staff. They were later given a helpful and
comprehensive briefing on the events leading up to and after the man’s death.
Ombudsman’s notices were issued to staff and prisoners, identifying the scope of
the investigation and inviting anyone who wished to see the investigators to make
themself known. My investigators visited Liverpool on 22 and 23 June, and again
on 28, 29 and 30 June.
2. Staff and prisoners in key positions or locations were identified and were invited to
speak to the investigating team. All responded willingly. The local branch of the
Prison Officers’ Association was briefed on 15 June. The representatives were
helpful and offered constructive comment and advice. My investigators spoke with
the chair of the Independent Monitoring Board on several occasions and found his
advice and assistance to be very valuable.
3. The Coroner’s office was contacted and additional information was provided.
4. A Family Liaison Officer from my office in the company of one of the investigators
visited the man’s sisters. They were later joined by his brother-in-law. The family
raised a number of issues of concern which I hope are covered in this report.
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HMP LIVERPOOL
5. Liverpool prison, also called Walton, was built in 1855. The site covers 22 acres
and has a single capped security wall. It is a local establishment serving the
Merseyside and Wirral area. It accommodates category B convicted male adults
and unconvicted men held on remand. On 16 June 2005, HMP Liverpool held 1,371
men in custody. It has a certified normal accommodation figure of 1,186 and an
operational capacity (maximum crowded capacity) of 1,473.
6. Liverpool was last inspected by HM Chief Inspector of Prisons in September 2004.
The Chief Inspector found that, while there had been improvement since the
previous inspection, the prison was not thought to offer a safe environment for
prisoners. The Chief Inspector said that bullying and drugs were rife and that staff
needed to develop skills, and assume responsibilities, for managing prisoners who
were not locked in their cells for most of the time. Her report said that the
establishment’s suicide and self harm policy was clear and widely understood.
However, it was felt that the level of staff training in this area was low.
7. The F2052SH system for supporting suicidal and self harming prisoners was
replaced by ACCT (Assessment, Care in Custody and Teamwork) on 5 June 2005.
This was later than the planned date of 1 April. It is understood that one of the
reasons for this was to allow staff training to be brought to the required level. By the
start date, there were 431 staff trained to foundation level including 33 staff in the
Healthcare Centre. There were 68 case managers trained including nine in
Healthcare, and 42 assessors trained (six in Healthcare). The requirement was that
all staff and prisoners were to be aware that the change was to take place, be
familiar with ACCT and be aware of their role in the process. This first phase of
training prioritised first line staff, giving good cover to the residential areas of the
prison. Not all staff had been formally trained on 5 June, but subsequent training
added another 118 by 18 October, including clerical staff.
8. There had been two earlier deaths in Liverpool prison during 2005: that of a prisoner
who died of natural causes and a prisoner who was found hanging. In December
2004, there were two deaths, one from natural causes and one of a prisoner who
was found hanging. In the investigation of the apparently self inflicted death, it was
found that individual members of staff provided a high standard of care, support and
monitoring for the prisoner while he was in the residential wing.
9. It is understood that a number of changes have been made to ACCT arrangements
at Liverpool in the light of these deaths. They include the appointment of a second
full time suicide prevention co coordinator. A second family liaison officer has been
nominated. A suicide prevention action plan is being worked up for inclusion in the
prison’s Performance Improvement Plan.
10. The healthcare facilities at Liverpool prison are provided by North Liverpool Primary
Care Trust.
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KEY EVENTS
11. The man was received into Liverpool on 3 June 2004, having been in prison custody
since 31 July 2002. He began his sentence at HMP Altcourse, spending time at
HMP Wymott and HMP Acklington. The man was underweight and appeared to be
in poor physical health. It would seem that his transfer to Liverpool was prompted
by the need for him to be in an establishment with a full time healthcare facility.
12. Throughout his time in prison, the man had experienced depressive symptoms, and
had self harmed a number of times by cutting his arms. He had periods when he
heard disembodied voices, and at times exhibited symptoms of paranoia. He
seemed to crave the attention of others, and it appeared that cutting himself was a
way to enable him to achieve this goal. F2052SH documents were opened for him
at all the establishments at which he served his sentence.
13. The man complained of pains or a “blockage” in his head and neck that, despite
medical investigation, could not be attributed to any physical cause. He presented
with these pains nearly all the time, not only when he saw the doctor. The man told
prisoners and staff that he was suffering pain on a regular basis. He often reported
sick, and the main medication given to him was analgesia. The man told staff that
this was having no effect on his pain, and he complained that he needed something
stronger.
14. The man had visits from, and correspondence with, his sister who was guardian to
one of his children.
15. He arrived at Liverpool on an open F2052SH, and was located in a general
residential area of the prison. Despite what seemed to be a positive beginning, the
man began to appear fearful of other prisoners. He believed that he was in danger
of harm from them because of the nature of his offence, and after a short time he
became withdrawn in his dealings with others. He spent a lot of time in his cell and
was unwilling to communicate with prisoners or staff.
16. The man was seen by a psychiatrist and was considered to be in need of a place in
the healthcare centre. He was transferred there on 7 September 2004. Initially he
was put in shared cell accommodation, and while there he became more
communicative and sociable with other patients and staff. However, he continued to
complain about his head and neck pains and was treated with paracetamol.
17. On 9 November, the man made superficial cuts to his arms that he showed to staff.
He told them that he did not feel safe and felt that other prisoners were going to hurt
him. The man seems to have had a morbid fear of transfer to a residential area
where he thought he might be harmed by other prisoners. This is a recurring theme
in the contact records made by staff in their dealings with him.
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18. On 22 November, the man was informed that his brother had died in suspicious
circumstances. The man became very upset and was seen by a psychiatrist and
the prison chaplain. While he was distressed about events, he did not express any
thoughts of suicide or self harm to the chaplain.
19. Because of his reports of continued head pain, it was decided that the matter should
be investigated further. On 7 January 2005, the man was taken to a specialist
neurological centre where tests were conducted, none of which identified any
physical cause for his symptoms.
20. It is noted in the man’s F2052SH, that on 26 January he became argumentative and
threatened that he would “… string myself up …” if put on ordinary location.
According to the accounts of staff, this is but one example of frequent comments of
this nature that were made by the man (as he said things like this so often, they
were not all recorded). It is not clear what triggered them, but any suggestion that
he might go to a wing made him anxious. Another occasion was on 10 February
when he told staff that he felt suicidal. As at other times, it appears that he was
offered reassurance by staff that he could stay in healthcare and would be safe.
21. On 23 February, the man attended his brother’s funeral and consequently received
extra support from staff. Although the man spoke of hearing voices and having
thoughts of self harm, the month of March seems to have been a relatively settled
time for him. However, a little later his paranoid behaviour resumed. He was seen
by a psychiatrist on 6 May, who suggested that the man’s head and neck pains
might be psychosomatic.
22. The man sent a letter to his sister on 4 April, in which he described the pain he was
experiencing. On 13 May, the man cut his arms again, but this time so seriously
that his life was threatened through loss of blood. A prison form, F213SH, was
raised (this is a form on which injuries to prisoners are recorded). As he usually did
after these acts, the man went to a member of staff and showed them what he had
done. He received immediate attention to stem the bleeding, and treatment at
outside hospital was arranged. While he was there he expressed suicidal thoughts
to members of his family who came to visit him. It is understood that he said that he
intended to kill himself in the not too distant future and before he was released from
prison.
23. On his return to the prison, the man was seen by a clinical psychologist to whom he
expressed the wish to commit suicide by hanging at an unknown point in the future.
He was still very preoccupied by the pain he described as a “blockage” that he was
experiencing in his head, ears and neck.
24. The man had not seen his daughter for some time. The reason for this was that the
prison had erroneously attributed child protection concerns and prevented any visits.
Attempts had been made earlier in the year by the community mental health team
and his daughter’s family support worker to arrange a visit to the prison and the
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error emerged. It was said that the man’s reaction to the prospect of seeing her
again appeared mixed. While apparently happy and excited at first, it seemed
subsequently to worry him and affect his mood in a negative way. It was suggested
that the man was concerned about his daughter seeing him in the poor physical
condition that he was in. It was proposed that the visit take place in early June. In
the event, the arrangements for the visit did not go smoothly and, unfortunately, an
attempt to arrange a special visit failed due to the non availability of a member of
social services staff to accompany the child to the prison.
25. On 6 June, a nurse was given a noose by another patient who said that it belonged
to the man. This was not thought to be significant, as the discovery of nooses was
not an unusual occurrence. The man seemed to the nurse to be in reasonable
spirits.
26. At approximately 6.00am on 10 June, the man was in his three bed room in the
healthcare centre with two other prisoners. He was seen to be in a highly agitated
state. He was repeatedly running and then banging his head against his locker.
Staff restrained him and he was placed in the association room with members of
staff. He had to be physically held in a chair to prevent him from banging his head.
When the doctor arrived, the man was given medication which seemed to calm him.
27. Later he was moved to cell M2-4, where he remained with members of staff. At
approximately 12.00pm, he was moved to a single cell, M1-3, with a member of staff
who stayed with him on constant watch until it was thought that the man had
improved. The available documentation does not indicate how long the constant
watch remained in place or who undertook the observation.
28. That afternoon, the deputy in-patient manager telephoned the doctor to ask him to
come and review the man to see if it was possible for him to be placed in a single
cell if required. The deputy in-patient manager told my investigator that staff had
concerns about the effect on other patients of seeing, or having to deal with, the
man in an agitated state. In effect, they wanted to know whether keeping the man in
a single cell was an option. At around 3.30pm, the doctor arrived and authorised
single cell accommodation “… if needed”. Subsequently the healthcare staff made
a team decision that the man should remain in a single cell.
29. The doctor says that the deputy in-patient manager asked him to assess the man
with a view to moving him out of the emergency cell. He saw the man in the cell,
but recalls that the man was sleeping so he did not speak to him. In coming to the
decision that the man could be placed in single cell accommodation if needed, the
doctor says he relied primarily on the advice of the deputy in-patient manager, as he
was not the man’s regular doctor. He was aware that the man had been on an open
ACCT and that the ACCT might still be open. He was also aware that the man had
cut his arms badly on 13 May, and of his threats to kill himself on 16 May and 19
May. He had seen the man only three times in all. The doctor says the man
presented a varying risk from hour to hour and day to day, and he had to trust the
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staff’s judgement, because he was not part of the man’s day to day care. In effect,
by saying that the man could be placed in a single cell, he was saying that
healthcare staff needed to make a judgement of the risks to the man and other
patients.
30. There was no review that day of the man’s ACCT document, including a review of
the care map. Accordingly, there appears to have been no formal review of the
overall care that the man needed in the light of his behaviour that day and his new
location. There is no evidence that any consideration was given to whether the level
of ACCT observations should be increased, and these remained at six times in 24
hours.
31. The man stayed in the cell for the rest of the day and that night. It was an
apparently uneventful period. According to the ACCT document, he was observed
twice by night staff.
32. He was seen by the chaplain the next morning, 11 June, at 9.25am. The chaplain
recorded that the man said his head hurt but that he would get over it.
33. The agency nurse coaxed the man to the morning exercise period, and it was
reported in the ACCT that he was quiet and lying on his bed over the lunch period.
As he did not feel up to going to collect it, his lunch had been taken to him. Thinking
the man could do with some fresh air, the agency nurse tried to persuade him to
attend exercise that afternoon, but he would not go. At approximately 3.30pm, the
in-patient manager, spoke to the man. She found him to be anxious and
complaining about his head pains. As these were the usual things that he spoke
about, she found nothing to alert her to any additional problems.
34. At approximately 3.50pm, the agency nurse locked the door to the man’s cell while
he went to prepare for the serving of the tea meal. At approximately 4.15pm, he
returned and looked through the man’s door observation hatch. He saw the man
hanging by his neck from the open door to the cell toilet area. After shouting for
assistance, he entered the cell and took the man’s body weight. Three staff
attended with resuscitation equipment. A further member of staff joined them after
informing the control centre of the emergency by using his radio. Cardio pulmonary
resuscitation was begun immediately.
35. A defibrillator was attached to the man and it registered a flat line. At 4.18pm, an
ambulance was called and paramedics were at the prison by 4.25pm and attending
the man very soon afterwards. Sadly, despite the attempts to revive him, the man’s
death was pronounced at 4.35pm.
36. My investigators spoke to prisoners who knew the man and were told that
healthcare staff offered emotional support to them following the tragedy. Staff who
were interviewed said that they knew of the staff care team and the help that they
were able to offer. It is not known what the rate of uptake was.
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37. The news of the man’s death was broken in person by the Governor and the prison
chaplain, who called on one of the man’s sister and his named next of kin. They
then went with her to another sister’s house. They afterwards visited her father.
One sister said that, as a result, she had felt rushed by events and had not had the
opportunity to take the news in herself.
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ISSUES
Clinical review
38. A clinical review, to be completed by 15 August 2005, was requested from North
Liverpool Primary Care Trust on 14 June 2005.
39. Mersey Care NHS Trust completed a clinical review of their service involvement with
the man. They summarised their findings as follow:
‘The man was a very distressed individual detained in the Prison Service. The risk
of him completing suicide was very high based on historical, dynamic and future risk
factors. The request for Psychological Services was to determine whether he would
benefit from a psychological approach and whether his symptoms were functional.
The Mersey Forensic Psychology Service saw the man within an appropriate
timescale and was in the process of completing a report at the time of his death.
Brief notes were made in the man’s inmate medical record as is custom and
practice and the bulk of information and recommendations were to be
communicated in a report following the final session. Psychological Services and
the CMHT were not involved in or informed about a key decision (moving cell) which
increased the man’s risk of suicide. There are a number of recommendations which
may improve the clarity of Psychological Service’s involvement in the future’.
40. The clinical review has identified a number of learning opportunities, which I urge
the Primary Care Trust and Prison to consider and action accordingly.
The Primary Care Trust and Governor should consider the findings of the
clinical review and draw up an action plan to address the identified learning
points.
Decision to place the man in single cell accommodation
41. The man had mental health problems and self harmed by cutting. In the period prior
to his death, the man had seriously self harmed and had spoken on a number of
occasions about killing himself and using a ligature. According to his latest cell
sharing risk assessment, he was not thought to be a danger to other prisoners.
However, he had become very agitated early on 10 June in his three person cell
which would have been distressing to those around him.
42. During the afternoon of 10 June, the doctor had a request from the deputy in-patient
manager, for his opinion whether the man could be placed in single cell
accommodation. The doctor authorised a single cell if it was thought necessary by
staff. The doctor has said that he was not the man’s regular in-patient doctor and, in
coming to the view that he did, he had to trust the judgement of healthcare staff. He
did not speak to the man at the time he decided he could be placed in a single cell.
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43. The decision to put the man into cell M1-3 alone - once the doctor had said this
could be done if required - was described by the deputy in-patient’s manager to
have been a team decision taken to reduce distress to other patients on the grounds
that the man’s behaviour might upset them. The man was not known to be violent
to others, but it is not hard to see how conduct such as he demonstrated on 10 June
could cause distress to someone who was locked in the same cell. However, there
is no documentary evidence that any risk assessment process was undertaken to
weigh up the risk the man actually posed to himself as well as to others.
44. The clinical review has identified that the community mental health team had no
involvement in or were informed about this key decision to move the man into a
single cell, despite their involvement in his care whilst at Liverpool.
45. By the afternoon of 10 June, the man’s circumstances had changed considerably.
He had said on a number of occasions during the preceding weeks that he would kill
himself, he had seriously self harmed, and a noose that was said to belong to him
was handed to staff on 6 June. Most importantly, he had become dangerously
agitated on the morning of 10 June, and had been moved to a single cell and put on
constant watch. Yet there is no evidence of any formal review of the suicide
prevention arrangements. There was no documented alteration to the man’s ACCT
observation schedule of six times daily. Given the background, this might
reasonably have been expected to have been changed to more frequent intervals,
or even a constant watch, with additional support provided to him by staff. In the
event, the man was observed only twice during the night of 10 June.
The Governor should review the placing of prisoners on an open ACCT in
single cell accommodation, and publish clear instructions on the limited
circumstances when this is appropriate.
Management of the suicide prevention procedures
46. The man was the subject of F2052SH and ACCT procedures. His last review was
dated 28 May 2005, when it was noted that he was experiencing fleeting thoughts of
self harm, but there was no mention of the very serious episode of cutting of 13
May. This is not to say that the matter was ignored. An F213SH had been raised
and filed, and there was a care plan review on 18 May, where there were a number
of quality entries describing the man’s condition and care. As he was resident in
healthcare, the core document for his care was the medical record, and it is often
the case that staff turn to this when wanting to update themselves or to contribute to
the record.
47. The ACCT that was opened for the man on 5 June was a continuation of the suicide
prevention care given to him on the F2052SH. An initial assessment interview was
conducted and recorded on 5 June, with an ACCT care map produced. The man
was put on weekly review and was to be encouraged to participate more in the life
of the wing. The case manager identified the need for the man to find alternatives to
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his self harming behaviour with the help of staff. The man often cut himself and
then showed the resulting wounds to staff, and it was this aspect of his behaviour
that seems to have been the main concern when his care was considered. Despite
the man having said on a number of occasions that he would kill himself (even
mentioning hanging), staff who looked after him were shocked when he was found
on 11 June. It would seem that they did not consider him to be someone who would
genuinely wish to kill himself, but rather a prolific self harmer who craved attention.
48. On 6 June, a noose was handed to a member of staff and she was told that it
belonged to the man. The nurse in question assessed the situation as giving no
cause for concern as the man himself appeared to be in a reasonable mood, and
the making and finding of nooses were regular events in Healthcare. During the
course of the investigation, it transpired that this indeed appeared to be a regular
occurrence involving some patients. It would appear that some patients would
exhibit evidence to staff of threatened self harm behaviour to gain their attention.
Nonetheless, all finds of ligatures must be taken seriously.
The Governor should issue clear guidelines on what to do when a ligature is
found.
49. The ACCT manual requires that a case review takes place within 24 hours of
opening a new document. This was not done in the man’s case. The concerns
about the man’s self harming behaviour had in fact been raised long before.
Perhaps the ACCT transition guidelines could have been clearer on this, but given
that the man had had a review within the previous fortnight, this was a reasonable
interpretation of the requirements. In any event, it would not have been possible for
every newly opened ACCT in the prison to have been reviewed in one day.
50. Not all staff in healthcare had ACCT training at the time of the investigation and this
should be addressed. For example, the agency nurse was not aware that the
ACCT is to be used by all staff to note their concerns. If he had comments or
concerns with a prisoner on an ACCT, he said he would speak to a more senior
member of staff. This is clearly less than ideal as important information may not be
recorded. The best person to report on these matters is the member of staff who
has the face to face contact, and who writes up the record as soon as possible after
the event.
The Governor and PCT should ensure that all staff, permanent and agency,
and particularly those in Healthcare, are trained in suicide and self-harm
awareness and the use of the ACCT documentation. This training should
make sure that staff are aware that potential self harming behaviour is
dangerous, whatever the motivation behind it.
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The man’s daughter
51. It is much to be regretted that the man’s daughter, was unable to visit him. I
understand that the man’s visits were stopped on child protection grounds, because
his records had become confused with another prisoner. The family believe that this
mix up created anxiety for the man and may have affected his mental health. I
support their views that denial of access to families can be distressing and may well
have played a part in the deterioration in the man’s mental health.
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CONCLUSIONS
52. The man was someone who clearly needed a lot of staff attention. I note that he
often cut himself and showed staff his wounds. This was seen as his pattern of self
harming behaviour, and may have caused staff to underestimate the level of risk
that the man presented.
53. He was located in a single cell at the time of his death. The process that led to his
being alone is a cause of concern. The authorisation was given by the doctor
without interviewing the man. It then appears that the actual decision to place the
man in a single cell was made by the healthcare team in the light of the doctor’s
authorisation. I note this was done without any risk assessment process, and
without any formal review of the care that the man required in the light of his new
circumstances. The support the man needed was not reassessed, and his ACCT
care plan and level of observations remained unchanged.
54. The clinical review has identified that the risk of the man contemplating suicide
whilst in prison was high, based on the historical, dynamic and future risk indicators.
The man was seen by the Community Mental Health Team and yet when it came to
the decision to move him into a single cell they were not consulted with.
55. Staff in healthcare do not seem to take the existence of ligatures as seriously as
they should. The Governor and the Primary Care Trust should review these matters
and produce clear guidelines on what to do when a ligature is found. The discovery
of a ligature should be recorded so that management and staff are aware of the
extent of the problem.
56. When the man was discovered in his cell, staff responded promptly, and I believe
that all reasonable steps were taken to save his life.
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RECOMMENDATIONS
The Governor should review the placing of prisoners on an open ACCT in single
cell accommodation, and publish clear instructions on the limited circumstances
when this is appropriate.
The Governor should issue clear guidelines on what to do when a ligature is
found.
The Governor and PCT should ensure that all staff, permanent and agency, and
particularly those in Healthcare, are trained in suicide and self-harm awareness
and the use of the ACCT documentation. This training should make sure that
staff are aware that potential self harming behaviour is dangerous, whatever the
motivation behind it.
The Primary Care Trust and Governor should consider the findings of the clinical
review and draw up an action plan to address the identified learning points.
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