Individual at Lowdham Grange

The circumstances surrounding the death of a man
On 27 March 2005 at HMP Lowdham Grange
Prisons and Probation Ombudsman for England and Wales
October 2005
Contents
Summary 4
The man 5
HMP Lowdham Grange 6
Conduct of the investigation 7
Key findings 8
Recommendations 18
Annexes 19
2
The man was aged 45 when he died, apparently at his own hand, on 27
March 2005 in his cell at HMP Lowdham Grange. This is a report into the
circumstances surrounding his death. The loss of any family member is
distressing, but especially so whilst they are in custody and I offer my sincere
condolences to his family and friends.
The investigation was carried out by a member of my office. I would like to
thank the Director of Lowdham Grange for making the necessary facilities
available to my investigator. I am aware that since carrying out the
investigation, the Director has left the prison and a new Director appointed.
The new Director, following discussions with my investigator, has resolved
some of the outstanding issues for the man’s family, which had not been
addressed previously. I am grateful for his personal pro-active approach to
the findings of my report and dealing with matters with sensitivity. I am
particularly grateful for the help and support of the prison’s Liaison Officer.
In the course of the investigation, I asked for a clinical review of the care and
treatment received by the man to be carried out. I am much indebted to
Newark and Sherwood Primary Care Trust (PCT) for its generous offer to
undertake the review, as this was outside its own contractual obligations with
Lowdham Grange. The offer of assistance demonstrates the strong links that
have been developed between Lowdham Grange and the local PCT.
My report makes a number of recommendations for the prison. Looking at
what happened both before he died, and in the immediate aftermath of his
death, there are several areas where improvements are required. However, I
have been pleased to commend three examples of good practice as well.
That said, it is evident that he was experiencing serious difficulties in his
relationship with his partner, something that was well known to staff and
prisoners and which had previously resulted in his being monitored under the
F2052SH (suicide and self-harm) procedure. It is regrettable that prison staff
took the decision not to re-open the F2052SH, despite his distress following a
succession of telephone calls little more than 24 hours before his death.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2005
3
Summary
1. At 11:45pm on Saturday 26 March, a Prison Custody Officer (PCO) began
a routine check of the cells on F wing in HMP Lowdham Grange. The
check required him to view the prisoners through the cell door observation
flap and confirm that the prisoners were in their cells.
2. When he arrived at cell F5, he noticed that the man was sitting on the
floor, with his back against the end of the bed, and his legs inside the toilet
area. The officer spoke to him, but did not receive a response. He
therefore summoned assistance from another PCO, who was also on duty
on the wing. This PCO attempted to obtain a response from the man by
banging on the door and calling out his name. As the two officers could
not communicate with him, one PCO left the cell area and summoned
assistance by telephone from the Night Duty Manager.
3. The Night Duty Manager attended the cell along with two further PCOs.
He unlocked the cell door and saw that the man was suspended at the
neck by a ligature. The ligature had been passed over the top of the toilet
door and tied around a toilet brush, which was then anchored against the
door and wall. The Night Duty Manager used an anti-ligature knife to cut
and remove the ligature from around the neck and then laid the man on
the floor in order to carry out cardio-pulmonary resuscitation (CPR). One
of the PCOs began to give mouth to mouth resuscitation and continued
until the nurse arrived.
4. A duty nurse received a radio call to attend F wing. When she arrived, she
saw one of the PCOs performing mouth to mouth resuscitation. She
checked for signs of life, but found that the man was not breathing and did
not have a pulse. His pupils were fixed and dilated, his skin cold and
cyanosed around the mouth. She began chest compressions and the
PCO continued mouth to mouth resuscitation. They continued CPR until
the paramedics arrived at 00:20am and took over the man’s medical care.
5. The paramedics performed a heart trace. This gave no indication of a
heartbeat, and they decided to stop any further attempt at resuscitation.
6. The man was taken to the Queens Medical Centre, Nottingham and
pronounced dead at 05.54am by the Prison Medical Officer.
7. My report reveals both some good practice on the part of Lowdham
Grange, as well as areas of practice where improvements are required.
4
The man
8. He was born on 1 January 1960 in Ireland and was aged 45 when he died
at Lowdham Grange.
9. The man was 14 years of age when he received his first conviction and
aged 44 when he received his current sentence. In total, he had 42
previous convictions recorded against him, seven of which were for violent
offences, and had received 14 custodial sentences. On 24 July 2003, he
was sentenced to six years imprisonment at Sheffield Crown Court for
burglary offences.
10. He was from a travelling community, based in the Sheffield area. He and
his previous partner had three children, but the relationship had broken
down. He was in a new relationship and was engaged to be married and
had two children with his new partner. His new partner said that she had
encouraged him to see his children
5
HMP Lowdham Grange
11. The prison opened in February 1998 and is a privately managed
establishment, operated by Premier Custodial Group Ltd, part of Serco
Group plc. The prison stands on the site of the former Lowdham Grange
Borstal.
12. The prison has a largely industrial based regime, but has seen an
expansion of its education service over the period of time that it has been
opened. It offers a variety of vocational training, domestic and kitchen
work, gymnasium, gardening and offending behaviour programmes.
13. The prison offers single cell accommodation in two houseblocks, each
comprising four wings. Nursing staff are directly employed by the prison.
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Conduct of the Investigation
14. The investigation opened on1 April at Lowdham Grange. My investigator
met with the Director and his management team and received a briefing
about the circumstances surrounding the man’s death. He then visited the
cell where the man had been found.
15. A number of prison documents were made available by the Director, which
the investigator read. The prison records and reports identified which
members of staff the investigator would need to interview.
16. Several PCOs, managers and support staff were interviewed and in the
majority of cases the interviews were carried out using recording
equipment. Three prisoners, who had been transferred to various
establishments, were also interviewed. These latter interviews were not
recorded on tape.
17. A clinical review was commissioned to review the care and treatment
received by the man during his time in custody.
7
Key findings
18. On 24 July 2003, the man was sentenced by Sheffield Crown Court to six
years imprisonment. He was charged with seven offences, and found
guilty of six of the charges against him.
19. Since February 2003, when he was on remand, five F2052SH documents
had been opened. The F2052SH system is the Prison Service’s
procedure, also in use at Lowdham Grange, for monitoring those prisoners
who are deemed at risk of suicide or self-harm. The monitoring system
allows any member of staff who has concerns regarding an individual
prisoner to open an F2052SH form. The unit manager and a member of
the healthcare team assess the information and then make a decision
regarding the level of observation that should take place. The prison has
three levels of observation:
• Level one: Irregular watch and observed at least every two minutes.
The prisoner is located in the Segregation Unit and observed by a
nurse or a PCO. Whenever this occurs every effort is made to transfer
the prisoner to a prison with an in-patient healthcare facility as soon as
possible.
• Level two: 15-minute watch, at irregular intervals, with the prisoner kept
on normal location, and observed by a PCO.
• Level three: 30-minute watch, at irregular intervals, with the prisoner
kept on normal location, and observed by a PCO.
20. Prison staff are required to make entries into the F2052SH record and
note the time, date, and print their name, along with any significant
observations that they may have. The prison carries out specific training
to all staff regarding suicide and self-harm, which includes the completion
of the F2052SH record. The High Risk Assessment Team (HRAT)
reviews the F2052SH, and makes a decision regarding the level of
observation required and/or whether to close the file. The HRAT meeting
is chaired by the Suicide Prevention Coordinator. The team consists of an
assessor, healthcare representative, unit manager, chaplain, the prisoner
and any other interested party.
21. The man’s most recent form was opened on 19 February 2005 (not 2002
as indicated on the front page of the form), and was closed on 14 March.
Throughout the times that he was being monitored, the level of monitoring
fluctuated between level one and level three. The documents show that
the support offered to him was appropriate.
22. My investigator found that a number of entries in the F2052SH relating to
the man did not show the name of the person making the entry and were
not signed and dated. Additionally, a number of gaps were found between
individual entries.
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The Director should remind all staff of the need to accurately record their
name, signature and date, when making an entry in an F2052SH and not
to leave gaps between individual entries.
23. On 9 March 2005, the man was interviewed by the Criminal Justice Liaison
Community Psychiatric Nurse (CPN), North Nottinghamshire Community
Forensic Service and another CPN. The health assessment was
requested following a referral made by the prison’s Psychology
Department, due to the man’s persistent low mood, exacerbated by
problematic social issue outside prison, and recent laceration of his wrists.
On 10 March, the Criminal Justice Liaison CPN wrote a report to the
Prison Medical Officer, Lowdham Grange Healthcare Centre, regarding
the interview. She noted that there remains the risk of impulsive acts of
self-harm/suicide as the relationship difficulties continue, which seems
likely at this time. Unfortunately, due to annual leave, the letter was not
read by the Prison Medical Officer, until after the man’s death. I
understand that the letter was also sent to the Clinical Manager, Senior
Psychologist and Consultant Psychiatrist, and they concluded that, as the
letter did not contain any action points and was for information only, that
they were aware of, they took no further action with the contents. My
investigator asked if the prison had any formal arrangements in place to
allow external agencies to pass important information into the
establishment and was informed that they did not.
The Director should seek to develop protocols with external agencies,
which would allow essential information to be passed to the prison.
24. The relationship problems that the man had with his partner were well
known to wing staff, as he would openly display how upset he was and
discuss his feelings with them. On 25 February, he cut his wrists, which
was thought to be a direct result of his relationship problems. As a result,
he was placed on F2052SH level one monitoring.
25. On 25 March, he expected to receive a visit from his partner but she did
not arrive. He made six telephone calls to her during the afternoon. Staff
on the wing described them as angry exchanges, and they could see that
he was visibly upset at the end of the calls. The transcripts of the calls
confirm that he made six phone calls to his partner, throughout which he
pleads with her not to end the relationship, and she insists it is over.
During the calls, he indicated to her that he was going to end his life. By
the end of the sixth call, it was evident that the relationship difficulties had
not been reconciled.
26. Another PCO had previously assisted the man with reading and writing
and had come to know him well. He was fully aware of his domestic
problems and of the telephone calls that day. Due to the level of his
concern for the man, he spoke to the Unit Manager who responded quickly
and made arrangements for the man to be seen the same day by a
member of the healthcare team and a prison counsellor.
9
27. The Unit Manager also knew the man well and had previously been a
member of his HRAT meetings. He was aware of the reasons why the
man had been placed on F2052SH monitoring, as well as knowing about
his self-harm history.
28. The investigator asked the Unit Manager if either he or the PCO had
opened an F2052SH following the telephone calls. He confirmed that they
had not, but had considered it and thought that it was not necessary on
this occasion. The man was known to threaten to harm himself and did so
when his relationship with his partner was in difficulties. On earlier
occasions the suicide and self-harm monitoring arrangements were put in
place, and it is difficult to understand why it was not done on this occasion.
29. The prison counseller holds the European Diploma in Therapeutic
Counselling 2000. She had seen the man on a number of occasions to
discuss his suicidal and self-harm thoughts and had been a member of the
HRAT meetings involving him. She was aware of the difficulties he was
experiencing with his relationship. She knew that whenever problems
arose in his relationship, he was at high risk of self-harm. In February
2005, following a difficult period in the relationship, he had informed the
counseller that he intended to harm himself, which he later carried out by
cutting his wrists.
30. Following the telephone call from the Unit Manager on 25 March, the
prison counseller interviewed the man and he informed her that his partner
had told him on the telephone to cut up and hang himself. The counseller
said that when she saw him that day, he appeared upbeat and she did not
consider him to be at risk of self-harm.
31. Each wing has a Staff Observation Book. The book is available to any
member of staff to record and pass on information and observations to the
wing staff. My investigator examined the observation book entries and
identified an entry dated 23 March which said keep an eye on the man,
down again. The entry is signed but unidentifiable.
32. The investigator enquired why the information about the man’s distressing
telephone calls was not recorded, and why the interventions of healthcare
and the counsellor were also not recorded. The Unit Manager was unable
to explain why he had not made any entry. The PCO said that it was his
intention to make an entry in the observation book after the weekend and
said, to have written it earlier would mean that he was writing to himself.
The prison counseller said that she had not considered making an entry in
the book.
33. It was clear to my investigator that the wing observation books were not
being used correctly and to their full potential. He raised this with the
Director, who made immediate arrangements to remind all staff of the
need to use the observation books.
10
34. Premier Prisons’ own Investigation Officer informed my investigator that
the man’s partner had said she had telephoned the prison to inform them
that he was feeling suicidal. She could not recall the date, time or name of
the person that she had spoken to. She also informed my Family Liaison
Officer (FLO) of her attempt to warn the prison of his suicidal thoughts,
saying that she had telephoned, written and had spoken to prison staff
when she last visited the prison. It has not been possible to substantiate
her information, as there is no written record of the warnings being
received at the prison. The investigator enquired whether there was a
procedure to allow staff to record information from friends or relatives who
may be concerned about a prisoner, but there are no such arrangements.
The Director should introduce a system for staff to record information from
members of the public and pass on the information, as appropriate.
35. PCOs are required, as part of their normal duties, to work during the night.
They are responsible for making periodic checks throughout the night and
to confirm that the prisoners are secure. They also respond to any cell call
alarms, and carry out general administration duties. When officers initially
arrive on the wings to commence night duty, they accompany the evening
duty officers who lock prisoners into their cells for the night. The evening
duty officers carry out a full roll count by opening the cell doors to confirm
that the cell is occupied and that the prisoner is alive. When evening staff
have carried out their roll count, the night patrol officer physically checks
that the door is locked and secure. Evening duty staff confirm the wing roll
to the Duty Manager and, once the roll is accounted for, they are allowed
to leave the prison.
36. Each night patrol officer is issued with a radio and a cell key. The key is
carried at all times and kept in a leather pouch, which is sealed with a
plastic, numbered, security tag. The officer can break the security seal in
an emergency situation and, providing the officer believes it is safe to do
so, enter the cell. Additionally the officer can request assistance by using
the UHF radio urgent message procedure, or by dialling 222, which is the
emergency telephone number and goes directly to the prison control room.
37. Night patrol officers are required to patrol the wing and are given specific
predetermined instructions regarding the route that they must take. At
strategic points around the wing there are a number of magnetic strips,
which the officer has to visit. Each officer is issued with a hand held
recording device, known as a Morse gun, which is placed against the
magnetic strip. The gun memory records the action and location of the
magnetic strip and, at the end of the officer’s duty, the memory is
downloaded into a computer, which allows the manager to check that the
specified patrol has been carried out.
38. At approximately 10:00pm, the night patrol officers are required to carry
out a full roll check of the prison and to report their roll to the Night
Manager. The roll check confirms that the prisoner is in his cell. The
Night Manager collates the prison roll and records the figures.
11
39. During the night, PCOs at Lowdham Grange are also required to carry out
at least three flap checks. Flap checks mean that the officer is required to
lift the cell door observation cover to check that the prisoner is present and
alive. This procedure is good practice, as it provides additional
observation of the prisoner during the night-time period. In the man’s case
the procedure meant that he was discovered earlier than would otherwise
have been the case.
The additional night time observation checks are good practice.
40. Each wing is monitored 24 hours per day by video camera, and the image
recorded onto videotape. The video equipment records the images at
three second intervals, and not as a continuous picture. The resulting
picture, when played back, produces an image that appears faster than
normal motion.
41. At 9:15pm on 26 March, a PCO commenced duty as a night patrol officer.
His duty that night was to patrol Houseblock Two, E and F wing. He
received a handover from the evening duty staff, but no information
specifically about the man. However, he did recall that he had been
informed that the man had had a bad call from his wife, but could not recall
what day this was. He confirmed that there were no entries in the wing
observation book to indicate that the man had upsetting telephone calls,
had been assisted by staff and the counsellor or that he was considered
as being in a vulnerable frame of mind.
42. At approximately 10:05pm the PCO carried out a full roll check of F wing
and confirmed to the Duty Manager that the roll was correct. He recalled
seeing the man alive, and that he was sitting at his table listening to his
radio.
43. The investigator asked to view the video recording for F wing in order to
confirm that the PCO had carried out his flap check and roll check.
Unfortunately, whilst the camera monitor located in the wing office was
showing an image, the video recorder was faulty and the images were not
recorded. The prison management was unaware of the failure of the
system until my investigator informed them of it.
The Director should ensure that all video monitoring equipment is regularly
checked and maintained in full working order.
44. Although the video recorder was not working correctly, the Morse Gun log
shows that the gun memory was activated by the magnetic monitoring
strips at the correct times.
45. At approximately 11:40pm, the officer commenced the flap check,
beginning at cell number one, and moving along in a clockwise direction.
About five minutes later, he looked into cell number five and saw that the
man was sitting on the floor, with his back against the foot of the bed and
12
his legs inside the toilet area. He attempted to obtain a response from
him, but was unable to do so. The Officer asked another PCO, who was in
the wing office, to assist him.
46. At approximately 11:46pm, both PCOs returned to the cell. One PCO
banged on the cell door to attract the man’s attention, but was also unable
to obtain a response. One PCO returned to the wing office and
telephoned the Night Duty Manager, who was on Houseblock One, and
requested his assistance.
47. The investigator asked the PCOs why they did not enter the cell, as they
both had a cell key. The officers said that they did not feel that it was safe
to enter the cell, but were aware that they could have done so.
Considering that two trained officers were present at the cell and clearly
unable to obtain a response from the man, it is difficult to understand why
they felt that they were unable to enter the cell. Additionally, the officers
were asked why they had not used the radio to alert the control room to
locate the night manager. The officers said that they did not wish to alert
other prisoners to what was happening and, as they knew where the Night
Duty Manager was, they decided to telephone him instead. The officers
were asked if they were aware of the urgent message procedure, and both
confirmed that they were. However, when asked by the investigator to
describe how they would transmit an urgent message, they did not give
the correct response.
48. Whilst the delays may not have had a detrimental effect on this occasion, it
could be the case that valuable time was lost by failing to use the radio
equipment provided and by not entering a cell promptly.
The Director should ensure that all staff required to carry a prison radio are
competent to transmit and respond to an urgent message.
49. The Night Duty Manager commenced duty at 6:45pm and received a
handover from the day Duty Manager. At 10:30pm, he carried out a
routine check of the prison. At 11:20pm, he was called to Houseblock One
to re-set the electric supply, as the power had failed in the wing. At
11:40pm, he received a telephone call from a PCO informing him that he
was unable to obtain a response from the man and asking him to attend
Houseblock Two. He responded immediately to the call, accompanied by
two PCOs who were on duty in Houseblock One.
50. When he arrived at the cell, he unlocked the door and saw a ligature
secured at the top of the toilet door by a toilet brush and around the man’s
neck. He was carrying an anti-ligature knife, which is specifically designed
to allow the user to get underneath the ligature and cut it. He explained
that he had difficulty placing the knifepoint under the ligature, as it was
extremely tight. He cut the ligature at a point away from the neck, which
then released the pressure on the noose and allowed him to lift the noose
from the neck. Once released from the ligature, he laid the man on the
floor in preparation for medical assistance to be given.
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51. A PCO checked for signs of life but was unable to obtain a pulse or any
sign of breathing. She immediately began mouth to mouth resuscitation
and CPR, together with a nurse, who had responded to a radio call from
the prison control room.
52. The nurse is normally based at HMP Doncaster and was working at
Lowdham Grange because the prison had insufficient nursing staff. It was
her first visit to the prison. At approximately 11:40pm, she received a
radio message asking her to attend Houseblock Two. A grab bag was
available, but she did not take it, as she had not been informed of the type
of incident, or that the request was for urgent medical assistance.
Additionally a defibrillator was available, but as she was unaware of the
nature of the medical request, it was not taken.
The Director should ensure that calls for medical assistance indicate the
nature of the assistance required, so that medical staff are in possession
of the appropriate equipment when requested to attend a patient.
Additionally, all medical staff should be reminded that they are to take the
“Grab Bag” to every request for medical assistance and consideration
given to including a defibrillator in the grab bag.
53. At approximately 11:50pm, the nurse arrived at the cell and saw the PCO
carrying out mouth to mouth resuscitation. In interview, she could not
recall if CPR had commenced. She checked for signs of life and, with the
PCO, continued with CPR until the arrival of the paramedics.
54. About 22 minutes later, the paramedic team arrived and began to check
for signs of life. The heart monitoring equipment was attached to the man
and gave a flat line reading. This indicated that he was dead, and so they
decided to stop any further attempts at resuscitation. The paramedics left
the cell area and went to the wing office to complete their report. The
nurse and the PCO decided to remain with the man, as they did not want
him to be alone. This was a simple act of decency and demonstrated a
high level of care.
The Director should commend both the nurse and PCO for their efforts to
resuscitate the man and for the level of care and decency shown to him
following his death.
55. Although the wing camera had not recorded the events at the cell, a video
recording was available from the wing entrance camera, which gave
accurate timings of staff entering and leaving the wing.
56. Following any death in custody, the area is sealed off pending the
attendance of the police. This is normal practice and is done to preserve
any evidence, as the area is a potential scene of crime. Once the
paramedic team left the wing, the Night Duty Manager locked the cell door
pending the arrival of the police. The video evidence shows that the police
arrived on the wing at 00:44am.
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57. At approximately 01:50am, the nurse returned to the Healthcare Centre to
make an entry in the Inmate Medical Record (IMR). As she was making
her entry in the IMR, she noticed that the record said that the man was on
an F2052SH, level three, 30-minute observation. The record was
incorrect, as the F2052SH was closed nearly two weeks earlier and this
was not transferred to the IMR.
58. Police Officers removed a number of items from the cell for examination,
including three cassette tapes, one of which contained a message from
the man to his family. My investigator understands from the police officer
dealing with the case that a copy of the tape has been passed to the
man’s partner. The cell was released back to the Director, as no criminal
investigation was taking place. The Director made arrangements for the
cell to be blessed and, following the man’s funeral, the cell was re-
decorated.
59. Prison emergency procedures allow for both main gates to be opened at
the same time, the procedure is known as “Gate Override”. Gate override
reduces the delay in allowing emergency vehicles into the prison. The
procedure requires the person operating the gate systems to be
specifically trained to carry out the task. My investigator examined the
emergency systems for 26 March. He found that the gate override system
had not been operated and that the PCO in charge of the gate during the
night was not trained to perform the override procedure. The short delay
in allowing access by the emergency services did not make any difference
in this case. However, the potential delay could have been vital in a
different situation.
The Director should ensure that all staff required to operate the gate
systems are competent to operate the override procedures in the event of
an emergency.
60. Following any serious incident in prison, the Director undertakes a series
of de-brief meetings to establish the events and circumstances. The first
de-brief is known as a hot de-brief and usually takes place before those
involved leave duty. This is to ensure that recollections of events are
recorded as accurately as possible. The second meeting is known as a
cold de-brief and allows all those involved to examine the incident
collectively, and to look at what was handled well and what areas could
have been improved upon.
61. The prison has a system in place that allows any member of staff to
receive individual counselling and advice from an independent
organisation. The facility is well publicised and confidential, so that the
Director cannot monitor staff access or attendance.
The confidential counselling arrangements are good practice.
15
62. My investigator discussed the incident de-briefs with a number of staff and
found that on the majority of staff felt supported. However, there was a
small number of staff who had not attended the cold de-brief, as they were
unaware of the meeting and consequently felt unsupported.
The Director should ensure that all staff involved in an incident are
informed of de-brief meetings.
63. Prior to beginning the investigation, notices were displayed which informed
staff and prisoners of the contact details for the investigator. There were
no replies from prison staff, but three replies from prisoners who had
known the man. They all described him as having relationship difficulties,
and said that they would offer him support. One prisoner facilitated a
three-way telephone between the man and his partner, as the man had no
credit left on his telephone account. Another prisoner described the
support received by the man from the prison staff as very good, whilst
another one said that he felt the care plan support was poor.
64. I try to involve the family of the person who has died in prison in the
investigation process, and take into consideration any concerns they may
have about the care and treatment of their relative. One of my FLOs
contacted the man’s partner and sister, to explain the investigation
procedure and enquire whether they had any concerns.
65. His partner’s main concern was that she said she informed the prison of
his suicidal thoughts but considered that nothing was done. I have
considered this issue earlier in the report.
66. His sister also raised issues about his property, which was passed to his
partner. They had also noticed bruises and cuts to his face and hands.
Finally, they said that assistance with the funeral expenses had not been
offered.
67. My investigator has established that prison records show that the man had
said that his next of kin was his partner, which was the reason the property
was returned to her. In relation to the marks on his body, the Post Mortem
Report notes a number of marks which are reported as being consistent
with attempts at resuscitation. Finally, the FLO contacted the prison’s
Director regarding a contribution towards the cost of the funeral and this
was subsequently paid.
The Director should review the prison’s contingency plans to ensure that
an offer of payment towards funeral costs is made promptly.
68. The man’s partner said that she had asked the Director for permission to
visit the cell where he died and speak to the prisoner in the adjacent cell.
She said that she was told to put her request in writing to the Director,
which she said she did. My investigator discussed the request with the
Director, who said that he did not offer the opportunity for the man’s
partner to visit the cell, as she had previously been aggressive towards
16
him. The Director also said he was aware of her request to view the cell
via my FLO, but again it had not been put in writing. The Director
explained that, following the man’s death, the cell was re-decorated and a
new prisoner had been allocated to the cell. He considered that allowing
the man’s partner to visit the cell would be inappropriate and that he would
not be allowing a visit to take place. However, I am pleased to be in a
position to add that the new Director has since reviewed the decisions
taken by his predecessor and agreed to allow the man’s family to visit the
cell where he died. He asked the man’s partner to telephone him to
arrange the visit, this was communicated to her and a date agreed for the
visit to take place.
The Director should ensure that the advice given in PSO 2710 “Follow up
to Death in Custody” is followed.
69. The clinical reviewer concluded in his report that the quality of Primary
Care delivered by the Healthcare team at the prison was of a high quality
and that it was consistent with the Clinical Guidelines on the management
of depression.
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Recommendations
1. The Director should remind all staff of the need to accurately record their
name, signature and date, when making an entry in an F2052SH and not
to leave gaps between individual entries.
2. The Director should seek to develop protocols with external agencies
which would allow essential information to be passed on.
3. The Director should introduce a system for staff to record information from
members of the public and pass on the information, as appropriate.
4. The Director should ensure that all video monitoring equipment is regularly
checked and maintained in full working order.
5. The Director should ensure that all staff required to carry a prison radio are
competent to transmit and respond to an urgent message.
6. The Director should ensure that calls for medical assistance indicate the
nature of the assistance required, so that medical staff are in possession
of the appropriate equipment when requested to attend a patient.
Additionally, all medical staff should be reminded that they are to take the
“Grab Bag” to every request for medical assistance and consideration
given to including a defibrillator in the grab bag.
7. The Director should ensure that calls for medical assistance indicate the
nature of the assistance required, so that medical staff are in possession
of the appropriate grab bag when they are requested to attend an incident.
8. The Director should ensure that all staff required to operate the gate
systems are competent to operate the override procedures in the event of
an emergency.
9. The Director should ensure that all staff involved in an incident are
informed of de-brief meetings.
10. The Director should review the prison’s contingency plans to ensure that
an offer of payment towards funeral costs is made promptly.
11. The Director should ensure that the advice given in PSO 2710 “Follow-up
to Death in Custody” is followed.
Good Practice
1. The additional night time observation checks are good practice.
2. The Director should commend both the nurse and PCO for their efforts to
resuscitate the man and for the level of care and decency shown to him
following his death.
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3. The confidential counselling arrangements are good practice.
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