Individual at New Hall

Report on the death of a woman at HMP and YOI
New Hall in February 2005
Report by the Prisons and Probation Ombudsman for England
and Wales
March 2006
This is the report of an investigation into the death of a woman at HMP New Hall on
2 February 2005. She was awaiting trial at Leeds Crown Court, and had been in
prison for nearly three months when she died. The purpose of the investigation
was to establish the circumstances and events surrounding her death, including the
quality of care provided by the Prison Service.
The investigation was undertaken by two investigators from my office. I
commissioned a clinical review from West Wakefield Primary Care Trust. I thank
West Yorkshire Police for their assistance to my investigators.
I would also like to express my thanks to the Governor of New Hall and her staff for
the help and active co-operation that my investigators received throughout the
investigation.
A key part of the investigation was to ensure that the woman’s parents and family
had the opportunity to raise any concerns they had about her death. My Family
Liaison Officer and investigation colleagues met the woman’s parents, and have
done their utmost to answer their questions. I offer my profound condolences to
them for their loss.
I took over responsibility for investigating deaths in prison custody in April 2004.
This is the fourth apparently self-inflicted death that I have investigated at New Hall
since then. The woman harmed herself on many occasions before her death. Her
background of self-harming behaviour and significant mental health issues is an
obvious link between her and some of the other investigations I have already
carried out. I refer in the report to some excellent practice at New Hall, including an
impressively detailed, speedy and caring response to her death. However, I also
highlight apparent major professional shortcomings in the immediate response
when she was first discovered hanging in her cell in the Healthcare Centre.
This version of my report, published on my website, has been amended to remove
the names of the woman who died, her family, my staff and any prison staff or
prisoners who were involved in my investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2006
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CONTENTS PAGE
Summary 3
Conduct of the investigation 5
Background 6
Previous offences and custodial history 9
Previous self harming behaviour in prison custody 10
Chronology of events at HMP New Hall, between November 12
2004 and 2 February 2005
Self harm issues prior to the woman’s death 15
The Head of Safer Custody 17
HMP New Hall 19
The last week of the woman’s life 21
Follow up by the prison after the death 28
The woman’s complaint, under confidential access, 29
on 10 January 2005
Times of telephone calls to and from the upper Healthcare Centre 31
The woman’s location in the Segregation Unit 32
Observation of the woman between 4:50pm and 6:15pm on 2 February 34
Conclusions 37
Recommendations 43
2
SUMMARY
1. The woman was born in 1978. She was 26 years old when she died in cell H2-
8 in the Healthcare Centre at New Hall on the evening of 2 February 2005.
She was well known at the prison, as she had served a number of previous
sentences there.
2. On this occasion, she was received at New Hall on 9 November 2004. She
had been remanded in custody charged with making threats to kill. She
remained continuously in custody at New Hall until her death. She made a
number of court appearances, and on 11 January was committed to Crown
Court for trial. Her next court appearance was due to take place on 9
February.
3. The woman was held in the Segregation Unit (CSU), at her own request under
Prison Rule 45, from the day of her arrival until 21 January. As soon as she
arrived at the prison, the suicide and self harming monitoring arrangements
involving the F2052SH form were initiated as she told the nurse who
interviewed her that she had attempted to kill herself outside prison.
4. The woman’s prison records show many incidents of self harm during her
previous sentences, and also during the last three months of her life at New
Hall. Her segregation and self harm at risk status were reviewed at
appropriate intervals. She was interviewed by a psychiatrist who worked at
New Hall on a sessional basis, and also by a psychiatrist instructed by her
defence solicitors.
5. For several weeks in December and January, there was concern that she was
not eating. On 21 January, a Nurse located her in the prison’s HCC for further
observations, noting that she had deteriorated after not eating for several days.
The woman told a chaplaincy volunteer, and regular visitor to her, that she
heard voices saying she was a “fat pig”, and so had stopped eating. The
woman said she believed that when she stopped eating, the voices diminished.
6. On 30 January, another Nurse found the woman lying on her bed with a
ligature around her neck. Staff entered her cell, and removed the ligature.
She was then transferred to cell H2-8 which had camera surveillance.
7. On the day of her death, the woman was seen by a large number of staff at
New Hall. She had lengthy sessions with the chaplaincy volunteer, and with
her probation officer. She asked the probation officer to talk to her solicitor
about the progress of the court case, and also to make contact with the
National Self Harm Association. The woman attended education classes, and
a case review of her F2052SH status took place at 2:30pm. Staff attending the
review were encouraged that she seemed to be settling well in the Healthcare
Centre, but decided she should continue to be observed at 30 minute intervals
and the F2052SH should remain open. The woman expressed an interest in
attending the gym.
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8. She was locked in her cell at 4:50pm, after sharing tea with other prisoners in
the in-patient unit. No recorded observations took place until 6:15pm, when
she was found hanging from a sink tap in the toilet area of her cell. A male
nurse was working in the upper healthcare that evening, and he was on the
scene almost instantly. When she was first discovered, there were three
members of staff (a nurse and two prison officers) on duty in the upper
healthcare centre. Telephone evidence indicates that the male nurse spoke to
a female nurse at 6:23pm. He asked her for advice about the action he should
take but, as he spoke calmly, the female nurse did not think the situation was
grave. She finished dispensing medication to prisoners on the ground floor of
the healthcare centre, and at approximately 6:30pm went upstairs to see if the
male nurse needed any help. No cardio pulmonary resuscitation (CPR) was
commenced before her arrival, no additional staff had been summoned and the
emergency bag had not been obtained from the Nurses’ Office. The female
nurse has 25 years professional experience, and her assessment was that the
woman had already died or was near death when she first saw her.
9. Telephone records show that a prison officer telephoned the prison’s Control
Room at 6:30pm to request that an ambulance be summoned. West Yorkshire
Ambulance records indicate they were called to the prison at 6:35pm. The
Control Room log records the call to the Ambulance Service as taking place at
6:36pm. Although New Hall is located some distance from the nearest town,
the paramedics arrived rapidly but pronounced the woman’s life extinct at 6:56
pm.
10. I have made recommendations in relation to the male nurse to the Wakefield
West Primary Care Trust and to the Prison Service’s Area Manager for
Yorkshire and Humberside. I recommend further investigation as to why he
did not sign the F2052SH between 4:50 and 6:15pm. I am also greatly
concerned by the long delay before any assistance, either internal or external,
was summoned. The evidence I have seen suggests that he did not
appreciate the gravity of the situation, and did not take all appropriate steps to
try to resuscitate the woman. I recommend further investigation by the
relevant authorities of his apparent failure to exercise his professional duty of
care to her.
11. The arrangements for breaking the news of the woman’s death to her mother
were prompt and effective.
12. The report concludes with 12 recommendations while drawing attention to the
very good practice demonstrated in the aftermath of the sad events
documented in this report.
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CONDUCT OF THE INVESTIGATION
13. This investigation was conducted by two investigators from my office. Their
first visit to New Hall was made on 4 February 2005, two days after the
woman’s death.
14. Notices were issued to staff and prisoners telling them of the investigation and
its terms of reference, and offering them the opportunity to participate.
15. My investigators examined the cell in the Healthcare Centre where the woman
died. They also visited the CSU where she was located on both this and
previous occasions at New Hall.
16. My investigators obtained a very large amount of documentation relating to the
woman’s last and previous periods of imprisonment. Interviews were
conducted with one prisoner and a wide range of staff who had significant
contacts with her, especially on the last day of her life.
17. One of my Family Liaison Officers arranged a meeting with the woman’s
mother. My investigation has attempted to answer the questions posed by the
mother and her friends at that meeting. The mother engaged a solicitor in
Leeds who has made contact with my investigators on a number of occasions.
The documents requested by the solicitor have been supplied, and further
questions posed by the solicitor on the mother’s behalf have been addressed.
18. I am very grateful for the assistance my investigators received from the
detective sergeant who led the investigation into the woman’s death for West
Yorkshire Police. My investigators have also had access to the reports written
following the apparently self-inflicted deaths of prisoners at New Hall in April,
July and October 2004.
19. An independent clinical review of the medical care the woman received whilst
in prison has been conducted by a reviewer appointed by Wakefield West
Primary Care Trust. The reviewer worked to terms of reference agreed with
my investigators.
20. My investigator discussed a number of current national policy issues with the
Deputy Head of the Women’s Team at Prison Service headquarters. I am also
very grateful to the Healthcare Consultant and Programme Director for the
Women’s Team and Juvenile Group, for supplying a background note on three
significant matters:
• A review commissioned by Home Office Minister Baroness Scotland which
will examine provision for women with complex needs in the criminal justice
system
• Criminogenic factors of women offenders
• Information about a range of projects being taken forward by the Women’s
Team
5
BACKGROUND
21. There is a great deal of documentary information about the woman contained
in her previous prison records. Another important source of information is the
pre-sentence report written by her probation officer in February 2001. The
report was written for a Magistrates' Court, and at the time the woman was
charged with offences of threats to kill, possession of an offensive weapon and
making nuisance telephone calls.
22. The woman was born in 1978 and suffered from a congenital deformity of the
hip, which resulted in a limp. Her condition affected her ability to walk and
stand for long periods, and she was still receiving treatment when the
probation officer wrote her report. The woman remembered being bullied at
school as a result of her limp.
23. At the age of 17, she left home in order to acquire some independence. She
lived in student accommodation and attended a nursery nursing course but did
not complete the course. At the time of the report, she was unable to work
because of problems with her mobility.
24. The woman told her probation officer that she drank 40 units of alcohol a week,
and also regularly used cannabis. In 1999, she received an Absolute
Discharge at a Magistrates' Court for possession of cannabis resin.
25. The report stated that she had a history of self-harm. In 1999, she was
transferred from hospital in London to hospital in her local area after sitting on
the parapet of Tower Bridge and talking to a security guard about the number
of people who committed suicide there.
26. In the Offence Analysis Section of the report, the probation officer explained
that the current alleged offences were directed at police officers, and were part
of an ongoing pattern of behaviour involving similar offences and incidents for
which the woman had previous convictions dating back to 1999. The woman
told her probation officer that she realised there was an obsessive-compulsive
nature in her behaviour towards the police in her local area.
27. In paragraph 26 of the pre-sentence report, the probation officer wrote that
over a lengthy period of time the woman had become obsessive in her
behaviour, which was mainly directed at the police. At times, her behaviour
could be interpreted as being of nuisance value, such as frequent silent phone
calls. However, the length of her obsession and the escalation of her
behaviour, together with the specific and serious threats to one officer, gave
her probation officer concerns about future risk.
28. In 2001, the woman was sentenced to four years imprisonment for two
separate threats to kill in January 2001, and for possession of an offensive
weapon (a knife) in a public place in late January 2001.
29. In February 2001 a specialist registrar in forensic psychiatry wrote a psychiatric
report for her court appearance. In the section of the report dealing with her
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previous psychiatric history, he said that the woman first presented to
psychiatric services in November 1996 when she was 18 years old. She was
admitted to hospital as an informal patient after a referral from a college
counsellor. She had complained of hearing voices for about four months prior
to her admission. She was not observed to display any hallucinations or other
symptoms of mental illness during the five day admission, and she was
discharged without any psychotropic medication.
30. In October 1997, the woman’s General Practitioner (GP) referred her again,
and she attended an outpatient clinic in October 1997. She again complained
of hearing voices, this being a female voice asking her to do "silly things". She
was referred again by her GP in July 1998 after experiencing low moods,
irritability, bouts of aggression and thoughts of taking an overdose. She failed
to attend two outpatient appointments and was subsequently discharged back
to the care of her GP.
31. The woman was readmitted to hospital in December 1998, after taking an
overdose of 32 paracetamol tablets. On assessment, she did not display any
symptoms of mental illness, but was admitted overnight as part of a crisis
intervention package. At her own request, she was discharged the following
day.
32. She was readmitted to a local hospital in May 1999 after spending the previous
evening in a psychiatric ward at a London Hospital. The specialist registrar
recorded that the woman’s friend had called the police, as she had spoken
about jumping off Tower Bridge. She spent five days in hospital, but was not
considered to be depressed or to have any suicidal ideas. She was eventually
discharged, after coming back drunk after an access visit.
33. There was a further two-day assessment in November 1999 after the woman
attended the same hospital with suicidal ideas. In October 2000, she was
referred by her GP, and went to the psychiatric outpatients clinic. At the time,
she admitted drinking approximately 50 units of alcohol per week and was
attending a local alcohol counselling service.
34. The woman was assessed by the Duty Psychiatric Senior House Officer in
December 2000, after two overdoses during the previous weeks. On both
occasions, the overdose was said to be impulsive and to occur after drinking
alcohol. During the interview, she threatened to kill a policeman, and said that
he had previously sexually assaulted her. It was thought that hospital
admission was not required, as she did not display any evidence of a
depressive or psychotic illness.
35. The specialist registrar visited the woman at New Hall in February 2001, in
order to write his court report. In the Opinion section at the conclusion of his
report, he wrote:
“[The woman] has had long standing contact with the psychiatric services
characterised by her self presentation at times of crisis, typically when
threatening to or having committed self-harm. During a number of inpatient
assessments she has not displayed any aversive symptoms of a major mental
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illness and has been consistently diagnosed as suffering from a personality
disorder.”
36. A Consultant Forensic Psychiatrist interviewed the woman in the Healthcare
Centre on 20 April. He had been asked to write a confidential psychiatric
report for the Crown Court. She told him that she had had enough of life, and
had tried to kill herself on eight occasions in the preceding 14 days. She said
that she refused food, lacerated herself and tied ligatures as a means of killing
herself. She particularly wished to be free of the stresses of prison life, and to
be free of flashbacks. Physically,she felt weak and tired, and her mood was
low all the time with little variation. She said all these symptoms had been
present for a long time, but were markedly worse since an alleged sexual
assault by a policeman in September 2000.
37. The Consultant Forensic Psychiatrist’s report referred to times in the woman's
life when her level of alcohol intake increased dramatically, and remained out
of control. She told the psychiatrist that she regularly used cannabis from the
age of 21, and continued to do so until being remanded into custody. His
conclusion was that she was not suffering from any significant form of mental
illness. In particular she was not suffering from a psychotic disorder or a
significant form of depression. His report said that:
“The most appropriate psychiatric diagnosis in this case is of personality
disorder of the emotionally unstable borderline type … Her personality
disorder, combined with her seriously irresponsible behaviour, would merit a
legal classification of psychopathic disorder. However, in my opinion, this
disorder is not amenable to compulsory treatment in hospital under the terms
of The Mental Health Act 1983. [The woman] also suffers from dependent
alcohol abuse which has no doubt exacerbated the abnormalities in her
personality and compounded her offending behaviour.”
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PREVIOUS OFFENCES AND CUSTODIAL HISTORY
38. Her first appearance in court was in June 1999, when she was convicted of
sending a letter or other article conveying an indecent or grossly offensive
message. On 17 December of the same year, she was sentenced to four
months imprisonment for a number of offences, including sending letters or
other articles conveying a threat. In March 2000, she was sentenced to 14
weeks imprisonment for using the public telecom system to send false phone
messages to cause annoyance, inconvenience or needless anxiety. Five
months later, she was sentenced to a further eight weeks imprisonment for
persistently using the public telecommunication system to cause annoyance,
inconvenience or needless anxiety. The sentence on 6 September 2001 of
four years imprisonment has already been described. In March 2003 and July
2004, she was sentenced to further short periods of imprisonment for common
assault and affray respectively.
39. The woman was well known at New Hall as she served all or some of each
sentence there. She also served parts of the four year sentence at HMP Low
Newton, HMP Durham and HMP Buckley Hall.
9
PREVIOUS SELF HARMING BEHAVIOUR IN PRISON CUSTODY
40. There are numerous instances when the woman engaged in self-harming
behaviour while she was in prison custody. During 2001, for example, Report
of Injury to Inmate forms (F213) were completed at regular intervals at both
New Hall and Low Newton. On 1 April, she was found with a ligature tied
securely around her neck. Later the same day, she was found with a further
ligature around her neck. On 2 April, a prison officer checked her in her room
in the CSU. The officer got no response and went into the room to find her
semi conscious with a ligature made from shoe laces tied tightly around her
neck. Her face was blue. The ligature was removed and a nurse was called
immediately.
41. On 30 June, the woman was found again in the CSU with a ligature around her
neck. When the ligature was removed, her throat was bruised and raw. Staff
recorded that her throat was swollen and her eyes were puffed. On 10 July,
she was found again in the CSU with a ligature around her neck. A similar
event occurred on 14 August. The ligature was quite tight and she had slight
bruising around her neck. The next day a ligature was again removed from her
neck.
42. On 17 August, an officer discovered that the woman had covered the
observation panel of the cell door, so that staff could not see into her cell. She
would not respond to staff, so they went into the cell and found another ligature
round her neck. The following evening, the same thing happened. The same
officer wrote that the woman had obstructed the panel, and did not respond to
staff. She had tied a ligature round her neck, and it was removed.
43. Four days later, the officer recorded that the woman had blocked the panel and
the officer could not obtain a response. She opened the hole for the fire hose,
and saw that the woman’s face was a reddish purple colour. Assistance was
quickly summoned, and a ligature was removed from her neck. The nurse
recorded that the woman had swelling to her eyes and reddening to her face,
but her pulse was regular and strong. The same officer had to respond in the
same way two nights later. She again opened the fire hose hole and saw that
the woman was a purple colour. The Night Orderly Officer (NOO) and nurse
were sent for. They responded very quickly and the ligature was removed. On
26 August, another officer again recorded that the woman's cell was entered
so that a ligature could be removed from her neck.
44. The woman was sentenced to four years imprisonment on 6 September, and
was transferred to Low Newton. Two days later on 8 September, there were
two reports of injuries. Just after midnight, an officer reported that she had cut
her left arm using a piece of glass from a watch face. The following evening, it
was discovered that she had cut the same arm with a piece of glass she had
secreted on her person. Her arm was cleaned and dressed and the glass was
removed.
45. During the four year sentence, the woman was seen by a number of
psychiatrists. On 12 September 2001, a Consultant Forensic Psychiatrist at
10
the hospital she had attended before, wrote to the Medical Officer at Low
Newton. He recorded that the woman was being constantly observed and
wanted to be "off them" - that is, off the constant observations. She accepted
that her past behaviour had caused concern. His letter continued:
“She is still determined to kill herself, saying that she had had enough of being
a prisoner and didn't care any more ... Essentially, she does not impress as
being mentally ill … She is definitely at serious suicidal risk, and will attempt
this if given any opportunity whatsoever. She must therefore continue on
twenty-four hour observations, and I suspect that these will be necessary for
the foreseeable future.”
46. On 29 November, the woman made a more serious suicide attempt. She was
found with a noose around her neck, cyanosed, not breathing and without a
pulse. (Cyanosis is a bluish-purple discoloration of the skin, usually resulting
from a deficiency of oxygen in the blood.) The Medical Record stated that
approximately five minutes went by before there was any spontaneous
breathing (gasping in first instance). She was taken to hospital, and returned
to the prison on 7 December. The psychiatrist who saw her on Christmas Eve,
was concerned that she might have sustained some degree of brain damage
following her suicide attempt.
47. On 23 August 2002, the same psychiatrist wrote to the Medical Officer at Low
Newton and said that the woman had refused food and been on hunger strike
for the previous four weeks. The letter continued:
“Although she is not eating any food, she is drinking fluids, milk etc. [The
woman] is also considered to be an ongoing suicide risk. She openly states
that she will kill herself if given the chance. I understand that her last
attempted suicide was five days ago, when she tied a ligature around her neck
whilst hiding herself under her bed sheets. She is on constant observation.”
48. His conclusion was that she was not presenting with any type or form of mental
illness, and he saw the primary diagnosis as borderline personality disorder
with a long history of deliberate self-harm.
49. A locum Consultant Forensic Psychiatrist assessed the woman at Buckley Hall
on 11 November 2002 and wrote to the Medical Officer. He said she told him
that she previously harmed herself as a mechanism for relieving tension rather
than with the intention to commit suicide. He recorded that:
“However, she said that the last episode made her extremely fearful on
account of her unconsciousness and narrow escape. She assured me that
she had no further intentions to self-harm provided that she remained in her
current location.”
50. The woman had been in the CSU at Buckley Hall for the previous four months.
The psychiatrist expressed concern that her suicidal behaviour had been
responded to by transferring her to the CSU, though he recognised the
difficulty of managing her at a prison which had no inpatient facilities.
11
CHRONOLOGY OF EVENTS AT NEW HALL BETWEEN 9 NOVEMBER 2004
AND 2 FEBRUARY 2005
51. The woman’s last period of imprisonment at New Hall began on 9 November
2004. She was remanded in custody, accused of making threats to kill. She
arrived at the prison late in the morning, and the First Reception Healthscreen
was conducted by the male nurse who was first on scene when she died. She
told the male nurse that she was last at the prison five months earlier, and that
she suffered from asthma. When he asked whether she had been treated for
any form of mental health problems, she replied that her GP had treated her
for depression in 2001. She said she had received medication for her nerves,
and that trazodone and chlorpromazine were prescribed in 2001. When asked
whether she had tried to harm herself, she replied that she had attempted to
kill herself by inhaling gas and added that she currently felt suicidal.
52. The male nurse referred her to the Medical Officer and to the Registered
Mental Nurse (RMN) Screening Clinic. He assessed her as fit for normal work
and location. He also decided to open a F2052SH (Self-harm at Risk Form)
immediately. This form can be opened by any member of staff who is
concerned about a prisoner. Its purpose is to ensure that as much help as
possible is given to a prisoner during a difficult period when she may either be
at risk of self-harm, or after a self-harm incident. The form was opened at
12:30pm, and the nurse recorded his concerns about the woman’s history of
self-harm and that her manner was agitated. He said that she was determined
to kill herself and presented as at significant risk of self harm. He noted that
she would be located in a single cell in the CSU. The first entry on the Daily
Supervision and Support Record Section of the F2052SH was at 1:00pm. It
states that, whilst being interviewed, the woman said she would kill herself,
that she had nothing to live for and was fed up with her way of life.
53. She was taken to the CSU just before 2:00pm, and just after 3:00pm, she told
an officer that she had taken 20 tablets. The prison’s Medical Officer (MO),
decided that she should be sent to the Accident and Emergency (A and E)
Department at a hospital in Wakefield. The MO wrote to the doctor in charge
at the hospital to inform him of the woman’s statement that she had taken 20
dihydrocodeine tablets at approximately 3:00pm. The woman was drowsy and
sleepy, but was able to communicate. The A and E Senior House Officer
assessed her and wrote to the MO. He said that she denied taking an
overdose, and that she had suicidal thoughts but “states not going to do it now.
Has a plan”. She returned to her cell in the CSU just after 9:00pm.
54. Between 9 November 2004 and 21 January 2005, the woman remained
continuously in the CSU. She then agreed to move to the prison’s Healthcare
Centre. During the last three months of her life, there were many incidents of
self-harm. These are discussed in greater detail later in this report.
55. The woman made a written request on 9 November 2004 to be located in the
CSU for her own protection. Prison Rule 45 authorises a prison governor to
segregate a prisoner, at his or her request. Reviews of her status were held at
regular intervals, as required by Prison Service Order 1700. The F2052SH
12
also remained open throughout the period at New Hall until her death, and
again regular reviews of the risk of self-harm were carried out.
56. The woman twice appeared before the Governor for alleged breaches of prison
rules. The first adjudication was when she refused to move to cell 2 in the
CSU on 2 December 2004 after being told to do so. At the adjudication on 4
December, the acting Deputy Governor punished her by ordering seven days
forfeiture of the privilege of canteen, but the punishment was suspended for
two months. On 31 January 2005, two days before her death, she appeared in
front of another governor and admitted calling an officer “a fat bastard”. On
this occasion, the punishment was a caution about her behaviour.
57. The first adjudication, when she refused to move to another cell, followed staff
concern about her welfare. At the time she was located in Cell 3 in the CSU,
but she had blocked the cell observation panel and restricted staff visibility into
the cell. A Use of Force form completed at the time states that she was
required to move to cell 2, which allowed better observation, as she was on the
F2052SH. The woman refused to walk to the new cell and, according to the
form, became aggressive and lunged towards staff. Approved Control and
Restraint Techniques were used by staff, in order to relocate her to the safer
cell. The entire relocation was witnessed by the Chairman of the prison’s
Independent Monitoring Board (IMB). (The IMB is an independent committee
of local citizens, appointed by the Home Secretary, whose role is to ensure
that prisoners are treated correctly and in accordance with the rules.)
58. During her time at New Hall, the woman had extensive dealings with the Head
of Safer Custody (HSC) at the prison. The HSC’s responsibilities include
oversight of the CSU, as well as the challenging task of dealing with self-harm
issues in an environment where self-harm is relatively commonplace. The
HSC met the woman frequently in relation to her Rule 45 reviews. She wrote
him a very important letter on 22 December 2004 in which she raised the
issues of:
i medication
ii psychiatric care
iii recreation, education and employment
iv room occupancy.
She also wrote a formal complaint about the HSC on 10 January 2005, but the
matter did not come to the attention of the Prison Service’s Yorkshire Area
Manager until after her death. The HSC also received a letter from the
woman’s solicitors on 19 January 2005, to which he responded on 25 January.
59. The woman did not receive many visitors, but she was in correspondence with
a young woman who had herself previously been a prisoner at New Hall. On
24 December 2004, the Governor of New Hall wrote a memorandum to the
Healthcare Manager at the prison, following up concerns expressed by this
woman. The woman had written to another governor at New Hall, saying that:
“I know you are not the Governor of the CSU (Segregation Unit) but I have got
worries about one of the prisoners on there. [The woman] wrote to me today
stating she had been tying ligatures and intends to hang herself if the voices
demand so.
13
I am really worried about her mental state and I am wondering if you could
influence Healthcare to get the psychiatrist to hurry up and see her before she
does resort to hanging herself.”
60. The Healthcare Manager noted in the woman’s Medical Record that she had
received the memo from the Governor. She noted that the woman had
actually been seen by the consultant forensic psychiatrist the previous day.
She recorded that the psychiatrist had decided to increase the woman’s
medication, and he himself wrote in the Medical Record on 23 December that
she was well known to him previously. He referred to the court report he had
prepared in May 2001.
61. The woman received good support from the Chaplaincy team at New Hall
during the last three months of her life. A particularly noteworthy contribution
was from a volunteer who visited the prison every Wednesday. The
chaplaincy volunteer acted as the woman’s champion, confidante and friend,
and it was clear to my investigator that the two women liked and respected
each other very much. In interview, the volunteer explained to my investigator
that she would collect the woman from her cell to take her to the chapel where
they had lengthy, private conversations in its peaceful and supportive
atmosphere.
62. Shortly before the woman’s death, the Chaplaincy had introduced a system of
short written contributions for inclusion in F2052SH of women at risk of self-
harm. The volunteer’s entry for 12 January 2005 states that she spent one
hour and 15 minutes with the woman. She observed:
“[The woman] was quite low in spirit today and is trying hard to be positive but
not succeeding. She believes that her only way forward is to obtain the
appropriate psychiatric care she needs.”
They spent another hour together on 26 January, after the woman had been
moved to the Healthcare Unit. She observed:
“[The woman] was much happier today – she is enjoying having daily
education and mixing with small numbers of women.”
14
SELF-HARM ISSUES PRIOR TO THE WOMAN’S DEATH
63. A significant number of self-harm incidents are recorded in the woman’s
F2052SH, Local Incident Report forms, and on Forms 213SH which are used
to record any act of self-harm or attempted suicide. On 14 November 2004,
staff entered her cell and removed a ligature from around her neck. Half an
hour later, it was noted that she had blocked the observation panel and staff
again had to enter the cell to remove the block. At 1:10pm on 17 November,
staff entered her cell and removed a ligature.
64. On 23 November at 11:50am, the chaplaincy volunteer wrote in the F2052SH
that the woman had told her that the voices in her head were making her self-
harm and she had to kill herself but she did not want to. She wanted the
voices to go away. At 8:30pm the same evening, she was discovered lying on
the floor with a ligature tied. She did not respond to staff, and so they entered
the cell and removed the ligature.
65. At 1:45pm on 16 December, staff entered the woman’s cell to remove a
ligature from her neck, and at 2:45pm on 29 December the same thing
happened.
66. 9 January 2005 was a particularly disturbed day for the woman. At 8:40am,
she showed an officer her right arm. She had made superficial burns with a
cigarette which were dressed by a nurse. At 10:25am, staff entered the cell to
offer her the opportunity to go to chapel. She jumped out of bed and lunged at
one officer, then attempted to grab another around her head, knocking the
officer’s glasses across the floor. A general alarm bell was sounded and staff
used approved control and restraint methods to restrain her. At 12:35pm, an
officer recorded that a ligature was removed. It was anchored to a sink tap
near the door, similar to the circumstances of her death the following month.
At 3:50pm, the same afternoon, the woman told the Chaplain that she would
hang herself. At 6:14pm she rang her cell bell and reported to staff that she
had burned her left forearm with a cigarette.
67. On 21 January, the woman was moved from the CSU to the Healthcare
Centre, then on 30 January at 2:25pm she was found with a ligature around
her neck. The local incident report form completed by a nurse states that she
was found lying on her bed with a ligature around her neck. Staff entered the
cell and the ligature was removed. At the time, she was in Cell H2-3.
68. The next entry in the F2052SH at 2:50pm states that the woman was moved to
a cell which had camera surveillance. The new cell was H2-8, where she
remained until the time of her death. Pictures were fed from the camera room
to a bank of television screens in the Nurses Office in the In-patient Area of the
Healthcare Centre. However, no members of staff were assigned to watch the
television screens and no tapes were retained by the prison. This meant that
the cameras had no memory, and staff could only see what was happening at
the moment that they looked at the screen.
69. At 10:45am on 1 February, a Chaplain recorded in the F2052SH:
15
“Had a chat with [the woman], she told me about her concerns of the ‘voices’
she is hearing and about how she feels about her weight. I advised her to
speak to the nursing staff. She did mention that she would hang herself as
staff couldn’t see her in the toilet.”
16
THE HEAD OF SAFER CUSTODY
70. As already indicated, the HSC was the prison’s most senior member of staff
whom the woman saw most regularly. She wrote a very clearly worded letter
to him on 22 December 2004, which he noted and signed on 29 December.
The first issue raised by her in her letter was her medication. She wrote that
the medication prescribed by the prison doctor was not the same as that
prescribed by her own psychiatrist. She felt that the dosage given by the
prison doctor was not helping her, so she refused to take it. She said she had
complained, but the doctor was not prepared to give her the dosage she was
receiving before she came into prison. She asked for her medication to be
reviewed.
71. There is indeed a record of a formal complaint by the woman, dated 12
November 2004, which relates to her medication. She complained that she
would like to be on the dosage of trazodone that she had received whilst in the
community. In response on 25 November, the MO wrote on the complaint
form that she had been sent to hospital because she took an overdose of
dyhydrocodeine. The MO wrote that, for safety purposes, the level of
trazodone was reduced. He added that she was dependent on trazodone, and
he thought that he would slowly reduce her dose.
72. In interview, the HSC said he had suggested that the woman write down her
concerns, because she sometimes found it difficult to express them during the
formal segregation review which could be attended by people whom she did
not know well. He said that he did not pass her document to healthcare
colleagues, but kept it on her CSU file “so that it could be discussed and
monitored at seg reviews”. Although the HSC referred to speaking to
healthcare staff about her medication and discussing it in reviews of her
segregation, there is no documented confirmation of this.
73. The second matter which the woman wrote to the HSC about was her
psychiatric care. She wrote of a commitment in the F2052SH review “three
weeks ago” that she would be put in regular contact with the RMN, but she
claimed she had still not seen one. She added that the psychiatrist from a unit
in Dewsbury had twice arranged to see her, but had cancelled both
appointments. The last sentence of this section reads as follows:
“I am hearing voices and am sure that this, linked with my depression can be
treated but if I never get to see anyone from this specialist area, how can I get
the help that I need?”
74. The HSC said in interview that he had enquired why the appointments had
been cancelled. He was not aware of any pending visits from a psychiatrist.
He said that he seemed to recall discussing the contents of the woman’s letter
at a segregation review after he had been given it. He said that he asked
healthcare staff at the reviews to ascertain whether the psychiatrist from
Dewsbury would attend to conduct a psychiatric assessment. Later in the
interview, the HSC calculated that the woman would have given him her letter
after the segregation review on 29 December which she did not attend in
17
person. Again there is no record that the woman’s comments about her
psychiatric care were duly considered at the next segregation review.
75. The third issue raised by the woman was her need for something to occupy her
time. She wrote that she had great difficulty mixing with other people, and told
the HSC that she would appreciate it if he could sort out some work for her to
do “without having to mix with other prisoners”. He explained in interview that
he had a long discussion with her about the difficulty of putting her on Prison
Rule 45A whilst permitting her to mix with prisoners in the workshops. The
woman was actually asking for some work that she could do inside her own
CSU cell, but the HSC replied that he was not aware at that time of any sort of
in-cell type of activity which she could undertake. He added that his strategy
was to arrange as much out of cell activity time as possible.
76. The woman’s last point was in relation to Room Occupancy, and she wrote
that she had asked to move to a room round the corner. At the time she was
in Cell S1-9, where she said she did not sleep because of hearing voices in her
own head. She wanted to get away from the constant disturbances through
the night from the other prisoners. She wrote that she knew the HSC wanted
to put her on normal location, but argued that if she could mix with others
successfully she would not be in the CSU now. He explained that she had
actually been in one of the five rooms in the rear section of the CSU, but had
been moved to one of the front cells so that it was easier for staff to observe
her. The HSC added that he regularly challenged the woman’s theory that she
was at threat from other prisoners, and he spoke of introducing her to normal
location in a gentle and staged way.
77. On 19 January 2005, the woman’s solicitor wrote to the HSC expressing
concern about her psychiatric condition, and reporting that she had written to
him consistently confirming that she was hearing voices. He also suggested
that she should not be removed from the CSU until a psychiatric opinion was
obtained, because of her significant concerns about removal. By the time the
HSC returned from annual leave, and replied to the letter on 25 January, the
woman had been moved to Healthcare. He explained that the move was for a
period of mental health assessment.
78. The Continuous Medical Records Section of the woman’s Medical record
contains a lengthy entry made by the staff nurse in Healthcare on 21 January.
She writes that the woman was seen on the CSU where she was refusing to
respond to wing staff. She had not eaten for several days, and was unable to
produce a urine sample when asked by the nurse. The staff nurse asked for
her to be moved to Healthcare for further observations as she had
deteriorated. The nurse left the woman and returned after ten minutes to find
that she had got dressed and was willing to relocate. She admitted that she
needed further observations and complained of dizziness.
18
HMP NEW HALL
79. HMP/YOI New Hall is a local and training prison for adult women, female
young adults and juveniles. It is located in the village of Flockton, midway
between Huddersfield and Wakefield. New Hall was originally used as a
satellite prison for HMP Wakefield. In 1961, its role was changed and it held
young adult males. In 1987, it was converted to a women’s prison. There are
367 certified normal accommodation places at the prison. The operational
capacity (the maximum number of prisoners who can be held) is 426. On the
morning of 2 February, 338 prisoners were in custody at the prison.
80. In November 2003, Her Majesty’s Chief Inspector of Prisons (HMCIP)
inspected New Hall and her report was published in April 2004. She referred
to the vulnerability and needs of many of the prisoners. She observed that an
average of 75 suicide watch forms were opened each month, that there had
been 124 incidents of self harm in the month before the inspection, and that all
the in-patients in the Healthcare Centre were severely mentally ill.
81. HMCIP reported that there had been four self-inflicted deaths at New Hall in
2002 and 2003. The introduction to the report states that:
“New Hall is holding women and girls who should not be there. They include
those who are seriously mentally ill, as well as some women and girls with high
levels of self harm, linked to abuse, including substance abuse. Staff at New
Hall were doing their best to provide a stable and safe environment, but were
unable to do more than contain the level of need of some very damaged
individuals. Prison was likely to increase their vulnerability and mental
disorder, in some cases with tragic consequences; and caring for them meant
that there was too little time to provide positive interventions for the less
damaged women and girls. There is an urgent need to provide alternative,
therapeutic environments where appropriate treatment and support can be
offered.”
82. HMCIP wrote in enthusiastic terms about the CSU, remarking that it was
bright, clean and well maintained. She and her colleagues saw CSU staff deal
professionally with some difficult women, and showing a great deal of care.
They found that the work in the CSU was of the highest standard and
represented very good practice. They observed efforts to return prisoners to
normal location wherever possible. They also noted that some prisoners, who
should probably not have been in prison, either had great difficulty surviving on
the wings or would be a danger to others. They considered that every effort
was made to provide a reasonable quality of life for the women in the CSU.
Their overall conclusion was that the CSU was a good facility which provided
excellent standards of care to some troubled women.
83. My present responsibilities for investigating the deaths of all prisoners in
England and Wales began on 1 April 2004. Between April and October 2004, I
investigated three apparently self-inflicted deaths at New Hall. These deaths
have not yet proceeded to inquest, but there are a number of apparent links
between the death of the woman and the three fatal incidents between April
and October 2004. Two of the three women who died in 2004 had lengthy
19
histories of self harm, and extensive contact with psychiatric services. The
prisoner who died in October 2004 was located in the in-patient section of
Healthcare, and was found hanging from a toilet door in a ward there.
20
THE LAST WEEK OF THE WOMAN’S LIFE
84. On Sunday 30 January 2005, the woman was placed on report by an officer for
allegedly using insulting words to him. The incident happened at
approximately 2:05pm. Just 20 minutes after using abusive and insulting
words to the officer, a nurse found the woman with a ligature tied around her
neck.
85. When the woman appeared the next day in front of a governor, she pleaded
guilty to swearing at the officer and said she had been in an angry mood. The
governor imposed a caution - the lightest possible punishment - for her breach
of Prison Rules.
86. The next event of significance was recorded in the woman’s F2052SH by a
Chaplain during the morning of Tuesday 1 February. When asked about her
record, the Chaplain said that she and the woman were chatting about their
respective weights and having a laugh about the Chaplain’s weight. The
Chaplain’s impression was that she seemed to be happy that she was no
longer in the CSU. In Healthcare, she had the opportunity to mix with other
women “and they were only a small number of women, so I think she felt ok
with that”. The Chaplain recalled that the woman’s mood did not change as
she went on to speak about hanging herself in the toilet. The Chaplain felt that
she was a lot happier than on many other occasions when she had seen her,
but she recorded the information in F2052SH and also spoke to a nurse in the
office. The Chaplain told the nurse of the woman’s opinion that she could not
be seen while she was in the toilet area of her cell. The nurse assured the
Chaplain that the woman could be seen and the Chaplain was reassured.
87. The F2052SH indicates that on Wednesday 2 February, the woman was in an
education class, under constant supervision, between 9:00am and 9:45am. In
interview, the course tutor for Healthcare Education described the woman as a
willing student, who was reticent at first in his classes, but within a few days
chatted and interacted quite well with other people. The tutor taught her during
the morning of 2 February, but his main recollection was of the F2052SH
review that he attended in the afternoon. His governing memory was that she
seemed comparatively upbeat and made a couple of little jokes about food.
The tutor said:
“During the morning education session and during this (afternoon review)
meeting, I had absolutely no reason to think that [the woman] was down, if
anything she was going the opposite way.”
88. The F2052SH then shows that the woman moved from the Education class to
the chapel at 9:45am. My investigators conducted a lengthy interview with the
Chaplaincy volunteer. She explained that she had been meeting the woman
on and off for a number of years at the request of one of the Chaplains. She
said that the woman found it difficult to make relationships with people. She
added, “I suspect it was quite a while before she felt she could trust me, but
she did trust me … whenever I saw [the woman] as we parted for the rest of
the week, we always had a hug, it was that sort of relationship.”
21
89. The meetings between the volunteer and the woman took place in the prison
chapel. The volunteer would collect the woman from her cell, usually in the
CSU, then return her at the end of their one to one meeting. The meetings
lasted on average about an hour. She said that she tried to give the woman a
bit of normality. She would start off their sessions by asking her what sort of
week she had had, what she had been watching on television and how she
was feeling.
90. She recalled that the woman’s mood at the beginning of their meeting on 2
February was “quite jolly really, she wasn’t down as I had seen her in the past,
she was smiling, she linked arms with me, we walked down to the chapel
together, she was quite jovial”. When asked to explain why the woman could
have been in a good mood that day, the volunteer replied that she told her
what she had been doing in Healthcare. She enjoyed taking part in education,
had something to do and was not just watching television. The volunteer
described the woman as quite a bright girl, and observed that she had more
education opportunities in Healthcare than had been the case in the CSU.
91. The second reason for the woman’s good spirits, according to the volunteer,
was that she was due to go to court the following week. She had talked about
the court appearance, and said she might be admitted to a unit near her family.
She had told the volunteer that, at long last, she might get some help from that
unit and was positive about the prospect.
92. The volunteer’s recollection was that her session with the woman that day
lasted approximately three quarters of an hour, and ended at 10:30am when
she escorted her to the Probation office. The volunteer said she was shocked
when she was told that the woman had hanged herself. She said that her
death was a shock as the woman had seemed happier, was looking ahead and
seemed more positive. She summed up the woman’s mood on the morning of
2 February as follows:
“I thought she was in good spirits, I mean I have seen [the woman] when she
has been down but she was bright and breezy and that is why it was such a
shock when I was told what had happened, I couldn’t understand it.”
93. The woman was escorted by the volunteer to see the probation officer. In
interview, the probation officer said that she had supervised the woman in the
community in 2000. At that time she was quite concerned about her, and
thought she appeared mentally unwell. She had spoken to the woman’s GP
who said that he would refer her to see a psychiatrist. The probation officer
first saw the woman at New Hall on 24 January 2005, shortly after she had
been transferred to Healthcare. She asked the woman why she had stopped
eating, and she replied that the voices in her head were telling her that she
was “a big fat slag”. On 1 February, the woman asked to see the probation
officer. She said she wanted to ring her solicitor to see how things were
coming along with her court case and about the possibility of admission to the
unit near her family.
94. The probation officer telephoned the woman’s solicitor whilst they were
together on 2 February. The solicitor said that a psychiatrist would be coming
22
to see the woman about admission to the unit, and it would be after her next
court appearance. The probation officer said that the woman was pleased with
the news. She would have liked the visit before the next court appearance, but
knew that these things did not happen quickly.
95. The probation officer also recollected that the woman brought a document with
her. She had been in contact with the National Self Harm Association
previously, and wanted to get back in touch so that she could have some more
support. While the woman was with her, the probation officer made several
telephone calls in an attempt to trace the organisation. Eventually, she left a
message on an answer phone at a self harm organisation. She said that the
woman was pleased because they had been very helpful to her in the past.
During the F2052SH review in the afternoon of 2 February, the probation
officer promised the woman that as soon as the self harm organisation
returned her message she would pass it on to her.
96. The F2052SH suggests that the woman returned to Healthcare at 11:15am,
though the probation officer’s recollection is that the woman spent a good hour
with her, after the session with the volunteer. At 12:30 pm, a nurse recorded in
the F2052SH:
‘Failed to respond to check, Orderly Officer informed and cell entered.
Breathing noted.’
97. In interview on 1 April 2005, the nurse who was asked for advice by the male
nurse when he found the woman, spoke about that incident. She said that she
heard the nurse who made the entry on the F2052SH tell another nurse that,
during the lunchtime period, they asked for assistance to go into the woman’s
room because she was not responding. She was lying in bed, with blankets
covering her head and body. When the nurse called her by name, she did not
respond. When the nurse had assistance from officers, she went into the room
and satisfied herself that all was well.
98. The woman’s F2052SH review took place at 2:30pm on 2 February. It was a
well-attended, multi-disciplinary review with three representatives from
Healthcare, including the male nurse, as well as the probation officer, the tutor
and the woman herself. The review was chaired by a Senior Healthcare
Officer (SHO). The purpose of the review was “to share information on how
the prisoner is coping and reach team decisions on what further action needs
to be taken to address underlying needs”.
99. The summary of the review stated that the woman had tied a ligature on 30
January. She said that she had started eating the previous Saturday and was
feeling much better. Even though she was doing well, the summary noted that
she was still not very stable and remained a self harm risk. It was decided that
she should remain in Healthcare on an open F2052SH with 30 minute
observations.
100. The support plan for the woman included making links with the gym which she
had said she would like to attend. She was to be encouraged to continue
23
eating an appropriate diet and to join purposeful activity. The support plan also
noted that she was to remain on 30 minute observations.
101. The last prisoner to have significant contact with the woman was located in the
cell next door in the upper Healthcare. The prisoner remembered being in a
relaxation class with the woman during the afternoon of 2 February, after which
they had tea with the other prisoners from the class. She said that the woman
seemed quite happy at tea time. The two women were giggling about things
that had happened in the class, and she thought that the woman seemed quite
happy and contented. My investigator asked the prisoner if anything happened
at tea time to upset the woman afterwards, and she replied “she didn’t get
upset about anything, she was alright”. The prisoner thought that she and the
woman were locked in their cells at about 5:00pm. This time corresponds with
the penultimate entry in the F2052SH made by the male nurse who states that
she was locked in her cell at 4:50pm.
102. On the evening of 2 February, the staff on duty on the upper in-patients landing
were the male nurse and two prison officers, one male and one female. The
normal routine was that the two prison officers arrived at 6:00pm, to be briefed
by the nurse on duty, before unlocking the women for association in the
Association room at the end of the landing. During this evening shift, there
were three other nurses on duty in various parts of the prison. The nurse who
worked closest to the male nurse was in the Nurses’ Office on the lower level
of Healthcare, dispensing medication to Residential One prisoners.
103. It has been difficult for my investigators to establish the precise time when
important events happened between 6:00 and 6:30pm. The three staff on duty
in in-patients and the nurse dispensing medication all wrote statements later
on the evening of 2 February. Some of the timings in their statements are
inconsistent with each other. There is further inconsistency between the
statements taken that day and what they told my investigators when they were
interviewed some weeks later.
104. On 2 February, the female officer wrote that she found the woman at 6:10pm,
and the male nurse wrote that he was called to the cell at approximately
6:10pm. The female officer was the first person to find the woman. She
initially looked through the observation hatch of her cell but could not see her.
She shouted her name and opened the door, thinking that she was using the
toilet or standing at the sink. She got no reply, and so she looked into the toilet
area in the corner of the cell where she saw the woman in a kneeling position.
There was a ligature, made from a piece of green towel, around her neck. It
was attached to the hot tap. The officer pulled out her safety knife and called
her male colleague into the cell.
105. The male officer cut the ligature away from the knot. In his statement, he
wrote that there was no response from the woman at this stage. The male
nurse instructed the officers to place the woman in the recovery position so
that he could observe her. The male nurse’s statement of 2 February indicated
that he could feel a light pulse, but that the woman did not respond to verbal or
painful stimuli.
24
106. In interview on 1 March, the male nurse recalled that the woman was slumped
against the sink area when he first saw her. The staff moved her out of the
toilet area because it was quite confined, and she was placed initially on the
floor of her cell. The male nurse tried to get the woman to respond by calling
her name and applying pressure to various points in her body. When that did
not appear to be effective, he said that he asked the female officer to remain
with her while he obtained oxygen from the pharmacy. The pharmacy is just a
few doors along the corridor from the woman’s cell.
107. The male nurse explained that he chose to move the woman from the cell floor
to her bed when he was administering the oxygen. He did so because he
thought he could detect a slight pulse and he felt the oxygen would be more
effective if she was at a height. Despite the fact that the woman did not
respond to verbal and painful stimuli, and he considered it necessary to
administer oxygen, no calls for assistance were made at this time to any other
parts of the prison. In interview, the male officer on duty said that he was
attempting to supervise the other women who were on association, while the
nurse and the female officer stayed in the cell with the woman. The cell door
was mainly shut, and he said he could not see inside from where he was
standing. He estimated that about five minutes passed before the male nurse
came out of the cell to collect the oxygen cylinder.
108. The male nurse said that, once he had collected the oxygen cylinder, he put
the mask on the woman and turned the oxygen on but it had no effect. He and
the other nurse both carried radios, but he left the woman for a few moments
to go to the Nurses’ Office across the corridor and telephone his colleague. He
said that he explained “what had happened, what we are trying to do and could
she, you know, give us some assistance”. The male nurse’s statement on 2
February indicates that he summoned his colleague at 6:15pm, then applied a
defibrillator machine to the woman at 6:16pm and commenced cardio
pulmonary resuscitation (CPR).
109. The male officer’s statement times the arrival of the second nurse at
approximately 6:16 or 6:17pm, and further states that she instructed him to
telephone for an ambulance at approximately 6:30pm. Apart from the male
nurse’s telephone call to his colleague, there is no evidence of assistance
being requested prior to 6:30pm by means of an alarm bell or radio message.
110. The second nurse’s statement on 2 February mentions the telephone call
received from the male nurse. She said that “he said inmate [the woman] had
been found in her cell with a ligature around her neck and was unresponsive. I
advised him to monitor her vital signs and check her pupils.”
111. In interview, the second nurse said that she received a phone call from the
male nurse requesting advice, not assistance. She did not detect any urgency
in his voice and so, after advising him, she continued to issue medication for a
further eight to ten minutes by her own estimate. After finishing dispensing
medication, she decided to ‘’nip upstairs to make sure everything was alright.’’
When she arrived, the male nurse was alone in the cell with the woman. Apart
25
from the two officers and the male nurse, there were no other staff in the in-
patient unit.
112. The two nurses collected emergency equipment, attached the defibrillator and
oxygen and began to administer CPR, which had not been attempted until
then. They said that the defibrillator did not advise them to administer an
electric shock to the woman, so they continued with CPR until the paramedics
arrived at approximately 6:50 pm by the second nurse’s timing.
113. During the interview conducted by my investigator and the clinical reviewer on
21 June 2005, the male nurse explained why there was no oxygen in the
woman’s cell by the time the second nurse arrived. After the woman did not
respond to painful stimuli he had obtained an oxygen cylinder from the
pharmacy directly across the corridor from the nurses’ office. He was asked for
how long he administered oxygen to the woman before reinforcements arrived.
He answered: ‘’At that point, when that (administering oxygen) still wasn’t
effective, then that was when I returned the oxygen and phoned for [the
second nurse].’’
114. There is no dispute that the emergency bag in the Nurses’ Office, containing a
defibrillator and other emergency equipment, was not obtained until the second
nurse arrived. CPR did not begin until she arrived at the cell.
115. The second nurse is very experienced. On the day of her interview, she had
been nursing for exactly 25 years, of which the last 13 had been at New Hall.
She had been trained in the use of the defibrillator, and had used it on two or
three occasions prior to 2 February 2005. The male nurse was not trained in
first aid but had done some resuscitation and defibrillator training at the end of
2004. He had not had an opportunity to use his training in earnest before 2
February 2005.
116. The second nurse explained that the automatic defibrillator machine tells staff
what to do. The machine did not instruct staff to administer an electric shock
to the woman, but did tell them to commence CPR. The male nurse carried
out chest compressions whilst she administered oxygen. In due course they
were joined by a Senior Officer (SO). Then the second nurse held the mask to
the woman’s face and the SO tried to force oxygen into her lungs by squeezing
the ambu bag.
117. The male officer’s statement written on 2 February suggests there was a time
delay of approximately 13 minutes between the second nurse’s arrival and her
instruction to him at approximately 6:30pm to telephone for an ambulance. At
his first interview on 1 April, his view was that the time gap was much shorter
than 13 minutes and seemed “about five minutes”. He was asked by my
investigator about the very precise times recorded in his statement on 2
February. The officer replied that the times he recorded were those agreed at
the de-brief meeting, held later in the evening. He appears to have relied on
the collective times agreed at the meeting, and indeed said in interview:
“I mean the times come from everybody, I accept that this is my statement
but at the time I agreed with the times.”
26
118. The second nurse was scathing about the de-brief meeting. She said:
“I think that things were written on a white board, times were written on a white
board in the association room and we were instructed this happened at this
time, this happened at this time and I saw it as this is assisting us in writing our
statement and I just went along with it, I was overwhelmed, there was probably
eighteen people in that room that weren’t directly involved in this case and it
was very overwhelming … I was expecting de-brief and we didn’t get one, we
got a memo writing session it was.”
119. The second nurse was insistent that the first thing she said when she arrived at
the woman’s cell was that an ambulance should be called straight away. In
her second interview, she said that it was her professional opinion that the
woman was already dead or near death when she arrived, and she provided a
considerable amount of technical information to explain why that was her
opinion.
120. The telephone evidence discussed later in this report leads me to conclude
that the second nurse did indeed issue instructions for an ambulance to be
summoned very soon after her arrival in the upper healthcare centre. The first
entry in the control room’s Incident Occurrence Sheet is at 6:36pm and the
event recorded is:
Request by [the male officer] via landline to phone for 999 ambulance at [the
second nurse’s] request.
121. The control room made a 999 telephone call to the ambulance service at
6:37pm, and the arrival of the ambulance in the prison is recorded at 6:52pm.
Staff from other parts of the prison arrived at Healthcare soon after the male
officer’s telephone call to the control room. The SO assisted the two nurses as
they gave the woman oxygen and chest compressions.
122. A witness statement signed by one of the ambulance technicians indicates
that, at 6.50pm on 2 February, he attended New Hall prison. He examined the
woman and diagnosed that life was extinct at 6:56pm.
27
FOLLOW UP BY THE PRISON AFTER THE WOMAN’S DEATH
123. After the woman’s death a letter to her mother was discovered in her cell. The
letter appears to suggest that she intended to take her own life. Parts of the
letter read as follows:
“The voices were becoming really bad and I didn’t feel I was getting any help
for them so I decided to get rid of them good and proper by hanging myself off
the taps like I said I would.
“At the end of the day I was in a camera’d room and they should have been
watching me constantly because I also told the Chaplain the other day what I
was going to do.”
124. Her letter also included a request for a particular song to be played at her
funeral.
125. At 8:30pm on the day of the woman’s death, one of the Chaplains and the
Governor went to the address given by the woman for her mother. There was
no response from inside the house so the Chaplain telephoned the mother on
a mobile phone number that the woman had also supplied. The Chaplain
broke the news of the woman’s death to her mother during that telephone call.
The mother told them that she was actually living a few miles away from the
address given by the woman. The Chaplain and Governor drove there and
spoke with the mother in person.
126. On the morning after the woman’s death, the Head of Safer Custody went
around the prison breaking the news in person to groups of prisoners. I
commend him for his actions which were admirable and an example of very
best practice.
127. Swift and sensitive arrangements were made to deliver the woman’s property
to her mother.
128. The woman’s funeral service took place two weeks after her death. At the
request of her mother, the prison Chaplain conducted the service. Her mother
was invited to visit the prison after the woman’s death and has done so. There
has been regular contact, both by telephone and in person, between the
mother, the HSC and the Chaplain. The cost of the funeral service was met by
the prison.
28
THE WOMAN’S COMPLAINT, UNDER CONFIDENTIAL ACCESS, ON 10
JANUARY 2005
129. Prisoners have a right to make formal written complaints under confidential
access to the governing Governor, Area Manager or Chairman of the IMB.
The woman wrote on the complaint form that she wanted to make a complaint
about the HSC. She said that her mental health had become worse, and she
was severely depressed and suicidal, not because she was in the CSU but
because of the HSC. She complained that he had put her in cell 2 for about
one and a half days, and that he had stopped her mail coming in and going out
of the prison.
130. Most regrettably, the HSC had no opportunity to respond to these allegations
before the woman’s death. When the woman made her complaint, the usual
Complaints Clerk was on leave and her colleagues attempted to deal with it on
her behalf. The complaint was sent in a sealed envelope to a senior Prison
Service manager at his office. The senior Prison Service manager had
previously had responsibility for all female prisons, but in April 2004
management responsibilities were changed and the area manager for
Yorkshire took over. The senior manager’s office returned the envelope to
New Hall, and it was not forwarded to the correct area manager until 1
February. The complaint was received at the correct office on 3 February, the
day after the woman's death.
131. The HSC was unaware of the complaint until 15 March when he was
interviewed by my investigator. I am entirely certain that the woman’s
complaint was wrongly directed because of an administrative error rather than
as a deliberate attempt to impede investigation of the issues raised. I am very
sorry indeed that the error resulted in considerable distress for the HSC. It is
clear to me that he invested a great deal of time and effort in doing the very
best for the woman that he could. Although he offered a vigorous rebuttal to
her allegations when interviewed by my investigator, he should have had the
opportunity to respond to them whilst she was alive.
I recommend that the Governor reminds the relevant staff of the correct
procedures and address to be used for confidential access complaints.
132. The woman’s solicitors wrote to the HSC on 19 January. They told him of her
concern that letters she had recently written had not been received by various
individuals. They asked him to enquire whether her post was being diverted or
delayed in any way. He replied on 25 January after checking with the prison’s
mail room. He assured the solicitors that there were no restrictions regarding
her mail, and that no letters had been stopped.
133. In response to the woman’s complaint to the manager that the HSC put her in
cell 2 in the CSU for about one and a half days, he recalled taking some action
some time in early January. He received a call on a Saturday evening that she
had blocked off her observation panel in the CSU and was not responding to
staff. Her door was barricaded and staff were unable to open it. The HSC
went himself to the CSU, and he could not get a response from her either. He
29
was concerned about her safety because he did not know whether she had a
ligature. He explained how staff opened the door outwards, and then re-
located her to cell 2 in the CSU. Cell 2 has a drop down flap in the door, which
enables staff to observe directly what is happening inside the cell. Other CSU
cells have glass panels and, if they are blocked, staff cannot see clearly into
the cell. The barricade took place on a Saturday evening and the HSC said
that his strategy was to ensure that staff were able to observe the woman
throughout the coming night. He added that the cells in the CSU are cleaned
to a very high standard, and are all clean and tidy before prisoners are located
there.
134. The HSC’s recollection that the woman was moved to Cell S1-2 on a Saturday
is confirmed by an entry in the Staff Observation Book maintained in the CSU.
The second entry for Saturday 8 January states that she “blocked obs panel
off, would not talk to anyone, cell was entered and [the woman] was relocated
to Cell S1-2. [the HSC’s] instructions.”
135. As indicated elsewhere in this report, Sunday 9 January was a very disturbed
day for the woman with self harm incidents taking place at 8:30am, 12:35pm
and 6:40pm. At 3:50pm that day, she told a Chaplain that she would hang
herself. At 10:25am, staff entered her cell after they could gain no response
from her. She jumped out of bed and lunged at one officer, before attempting
to grab a second officer around her head, knocking the officer’s glasses across
the floor.
136. The HSC was so concerned about her unpredictable and volatile behaviour
that day that he gave instructions for her to be unlocked by three staff rather
than the usual two. A further entry in the Staff Observation Book on 10
January notes that she was relocated in Cell S1-9 from Cell S1-2, and the
unlock level was reduced from three to two staff.
137. The woman wrote her formal complaint under confidential access on 10
January. It is reasonable to conclude that her reference to being located in
Cell S1-2 refers to the weekend she had just spent there.
30
TIMES OF TELEPHONE CALLS TO AND FROM THE UPPER HEALTHCARE
CENTRE
138. After the first round of interviews with the two nurses and two officers on duty
on the night the woman died, my investigators commissioned information
about telephone calls made to and from the upper Healthcare centre between
5:30pm and 6:45pm on 2 February. The information was requested because
of the conflicting timings in the statements and interviews of these four
members of staff.
139. The prison’s current telephone list indicates that extension 4395 is located in H
Wing (upstairs). This is the Nurses’ Office in the in-patient part of Healthcare.
A report was created on 26 April which shows that a number of telephone calls
were made to that extension between 5:35 and 6:13pm on 2 February. At
6:21:06, a brief telephone call was made from extension 4395 to extension
number 4277, which is the wing centre in the Residential One area. The next
call was at 6:30:41, made to extension 4230 which is the prison’s control room.
This call lasted 44 seconds and was from the male officer to request that an
ambulance be called.
140. My investigators were then informed that there is a second telephone,
extension 4294, in the Nurses’ Office of upper Healthcare. On 6 May, a report
was created showing phone calls to and from that extension between 5:30 and
6:45pm on 2 February. Between 5:30 and 6:20pm, there were no calls to or
from extension 4294. At 6:22:51 an attempt was made to call extension 4340,
which is the Nurses’ Office in the out-patient part of the Healthcare Centre, but
the call was not answered. At 6:23:37, another call was made to extension
4350 which is shown as Pharmacy in the current telephone list. The telephone
numbered 4350 is situated just beside the hatch in the downstairs Nurses’
Office, through which the second nurse dispensed medication to prisoners
from the Residential One area. On this occasion, the telephone was answered
and a conversation of 47 seconds duration took place. This is the telephone
call in which the male nurse asked the second nurse for advice about the
woman. The next recorded call did not take place until 6:38:39 and was a call
to extension 4294.
141. These telephone call records therefore show that the male nurse did not speak
to the second nurse for advice until 6:23:37. A further seven minutes passed
before the call to the control room, at 6:30:41, which asked for an ambulance
to be summoned. The delay of seven minutes is almost entirely consistent
with the second nurse’s estimate in interview that eight to ten minutes passed
between the male nurse’s call to her and her own arrival at the woman’s cell.
31
THE WOMAN’S LOCATION IN THE SEGREGATION UNIT
142. Information obtained from the woman’s previous prison records indicates that
she spent lengthy periods in segregation units prior to arriving at New Hall on 9
November 2004. The Chaplaincy volunteer knew her very well and shared
confidences with her. She told my investigators that the woman preferred to
be held in a CSU because she found it difficult to make relationships with other
people, especially when they were in large groups.
143. The woman was issued with a piece of statement paper at 12:35pm on the
afternoon of her arrival at the prison, and she wrote that she wished to be
located on the CSU for her own protection. A Segregation Safety Algorithm
was completed. This states that she was first placed in the CSU at 1:55pm. A
registered nurse or doctor is required to complete Parts A and B of the
Algorithm. In this case, a Registered General Nurse (RGN) completed Part A
of the form although Part B was left blank.
144. The second question in Part A enquires whether the prisoner has self harmed
during this period of custody or is on an open F2052SH. The RGN answered
yes to that question, but no to the following question which is: “Do you think the
prisoner’s mental health will deteriorate significantly if segregated?” At the end
of Part A the RGN has not recorded an opinion as to whether ‘’there are or are
not healthcare reasons to advise against segregation at this time.’’ I assume
the nurse was of the opinion that there were no healthcare reasons to advise
against segregation. All the boxes ticked in the first part of the algorithm lead to
a shaded conclusion at the bottom of the first page of NO HEALTHCARE
INTERVENTION AT THIS TIME. (capital letters in original form)
145. Part C of the form requires the Duty Governor to decide whether a prisoner is
to be segregated or not. There are two important points to be considered at
this stage by the Duty Governor. The first is that a prisoner on an open
F2052SH must only be located in the CSU in exceptional circumstances which
should be described on the form. An F2052SH had been opened on the
woman by the male nurse following information obtained during her First
Reception Health Screen. The HSC decided that the woman should be
segregated, but did not record any exceptional circumstances to justify his
decision. When the HSC talked about his decision with my investigators, he
said that the woman was well-known to prison staff from her previous periods
in custody. The HSC consulted staff about her request for segregation, and
was told that her time in custody was mainly in the CSU because she always
requested protection “and that was the norm for [the woman] when [she] came
into custody at New Hall”.
146. Prison Service Order 2700 on Suicide and Self Harm Prevention contains
advice on Segregation at Chapter 4.1.2 of the document. The PSO states:
“Prisoners who are at risk of suicide or self harm must not be routinely held in
the Segregation Unit under Rule 45 GOOD unless, exceptionally, they are
such a risk to themselves or others that no other suitable location is
appropriate. Such prisoners must only be placed in a Segregation Unit in
exceptional circumstances, or where all other options have been tried, but
32
considered inappropriate ... If the decision is taken to locate prisoners at risk of
self harm within the Segregation Unit this must be for as short a period of time
as possible, and the temporary nature of this must be reflected in the care
plans.”
147. There is no evidence that all other options were tried but considered
inappropriate on 9 November 2004. However, there seems to be no doubt that
the CSU was where the woman wanted to be located. Her written application
confirms that fact, and previous prison records state how difficult it was to
move her out of the CSU at New Hall, Buckley Hall or other prisons.
148. The decision to segregate her under Prison Rule 45 had to be reviewed within
72 hours, and this duly happened. The Segregation Review Board on 12
November was chaired by the HSC, and attended by the woman herself. A
nurse also attended, as did a member of the prison’s IMB. The form used by
the Review Board asks whether there are any specific concerns about the
mental health of the prisoner or the risk of self harm. The HSC recorded that
the woman had a history of self harm and overdose but noted that there were
no mental health issues.
149. Further reviews of her segregation took place on 17 November, 1 December,
15 December, 29 December and 12 January 2005. She herself attended
some of these reviews but refused to attend others. The review on 17
November noted there were no mental health issues but spoke of self harm
issues. On 1 December, the Specific Concerns section of the form noted that
she was awaiting psychiatric assessment, and on 15 December the same
section stated that she was to be assessed by a psychiatrist. The woman
attended all of that meeting, but refused to attend the next one on 29
December 2004. The Specific Concerns section of the document noted that
she was currently on an F2052SH, but there had been no self harm incidents
for a couple of weeks. There was a known eating disorder, which was
highlighted in the general notes about her behaviour at the Segregation
Reviews on both 15 December and 29 December 2004.
150. The woman wrote her letter to the HSC on 22 December, but the letter is not
referred to at either the review on 29 December or the next one on 12 January
2005.
151. The review form completed on 15 December noted that she was to be
assessed by a psychiatrist, and this did indeed happen immediately before
Christmas, but there was no further reference to psychiatric assessment in
subsequent reviews. At the review on 12 January, some thought was given to
transferring her to another prison if she continued not to engage with the
regime at New Hall. The next review was scheduled for 26 January 2005, but
prior to that date she was transferred to Healthcare.
33
OBSERVATION OF THE WOMAN BETWEEN 4:50PM AND 6:15PM ON 2
FEBRUARY 2005
152. In the Daily Supervision and Support Record section of the woman’s F2052SH,
the penultimate entry was made at 4:50pm by the male nurse. He recorded
that she was locked in her cell. There were no more entries until the last entry
at 6:15pm, also made by the male nurse. It states that she was found with
“ligature to neck”. The Case Review, which the male nurse had attended, was
held less than four hours earlier and had confirmed that the woman was to
remain on 30 minute observations.
153. My investigators asked the male nurse about observation of the woman
between 4:50pm and 6:15pm, and asked whether she had been observed
between those times. He replied:
“[The woman] was observed although we don’t necessarily record that in this
document, [she] will have been checked twice between the lock-in period and
just after 6:00pm when we unlocked her.”
154. When asked about his reply the male nurse added that there was a policy in
HCC at that time to the effect that:
“We didn’t actually have to record every half an hour, only if something
significant happened so if during those checks [the woman] was observed to
have been on the floor that would have been documented, if we observe [the
woman] and there were no areas for concern, then we wouldn’t necessarily
record anything, quite standard in the Healthcare department.”
He said the policy had been written down by a Senior Officer who was no
longer working at the prison.
155. The male nurse was asked who made checks on the woman between 4:50pm
and 6:15pm. He said he had made the checks himself, “and the reason I know
that is we had another lady who was on four entries an hour and the policy at
that point is if anybody was on more than two observations an hour it had to be
documented, so I had to check the other girl every fifteen minutes and that is
documented”. He said that the other prisoner was in a cell three doors down
from the woman. The last official check on the other prisoner was recorded at
6:00pm and, as it was conducted, the male nurse would have walked past the
woman’s cell and glanced in.
156. My investigator made contact with the former Senior Officer in the Healthcare
Centre. He is now the Healthcare Manager at HMP Moorland. He supplied a
memorandum (headed 2052SH observations) which includes the following:
“Most, if not all, prisoners located on the Healthcare Centre would have had
specified observation levels and I would expect staff to record their
observations in writing at those specified intervals of time. The only exception
to this would be if staff were constantly in the presence of a prisoner for longer
than the specified observation period and providing this was accurately
recorded it would be acceptable to make one entry to cover that period.”
157. At the time of the woman’s death, the prison’s policy on suicide prevention was
entitled Suicide and Self Harm Prevention Policy and Procedures. It was
34
issued in October 2003 and was due to be reviewed in October 2004. It was to
be replaced by a new policy but, at the time of her death, the local policy was
that set out in the October 2003 document. It states at paragraph 3 on page
12 that all prisoners subject to F2052SH procedures and in a single cell will be
observed at irregular intervals, as the support plan indicates. The policy then
adds in bold type that these observations must be recorded.
158. My investigators examined all the F2052SH documents that were open in the
Healthcare centre on 2 February, the day that the woman died. There were
three other women on open forms 2052SH in the upper Healthcare.
• Prisoner JR was locked in by the male nurse at 4:50pm, and then there
are three entries on her Support Record made by the male officer at
6:00pm, 6:30pm and 7:00pm. The entry at 6:00pm notes no sign of self
harm, but the figures in the Time column have been altered, and it is not
possible to see the original entry.
• Prisoner EC was also reviewed on 2 February, and it was decided that
she should be observed at 30 minute intervals in the camera room. In
this case, an entry made by the male nurse at 5:10pm indicates that the
prisoner was locked in after a cigarette. The next two entries on the
Support Record were made by the male officer at 6:00pm and 6:30pm.
They report no signs of self harm.
• During the morning of 2 February, prisoner JE smashed up her room
and broke her television. She was surrounded by broken glass and cut
her arms with the glass. A new F2052SH was opened by an SO, and it
was decided that there must be four observations per hour. JE is the
woman to whom the male nurse refers at paragraph 155 of this report.
Her cell was in the corner of the landing. He had to pass the woman’s
cell to reach JE’s cell. The Daily Supervision Record section of JE’s
F2052SH does show that the male nurse made 11 consecutive entries,
beginning at 3:45pm on 2 February. Entries were made every 15
minutes from then until 5:45pm. His final entry was made at 6:05pm,
with the following two entries, at 6:30pm and 6:45pm, made by the male
officer.
159. The investigators also examined tea time entries in the woman’s own
F2052SH for the days immediately prior to her death. She was in Healthcare
on an open F2052SH between 21 January and 2 February.
• On 21 January, she was observed half hourly at tea time.
• On 22 January, she was observed at 4:50pm, 5:23pm and 6:00pm by a
Nursing Auxiliary (NA).
• On 23 January, she was observed every half hour and this was again
the pattern on 24 January.
• On 25 January, recorded observations were made at 4:55, 5:30 and
6:10pm.
• On 26 January, the male nurse was on duty and the record shows that
she was locked in at 4:55pm and then the next entry was made at
6:20pm.
35
• On 27 January, she was observed every half hour.
• On 28 January, the male nurse was again on duty and there were no
half hourly observations.
• On 29 January, the NA was again on duty and she was observed every
half hour.
• On 30 January, another nurse was on duty and she was observed
every half hour.
• On 31 January, a further nurse was on duty and observed her at 4:55,
5:30 and 6:20pm.
• On 1 February, she was observed at 5 pm then not until 7:45pm. The
entry in the support record at 7:45pm was made by a prison officer.
160. Analysis of this information shows that the woman spent 13 tea times in
Healthcare between 21 January and 2 February. On ten of those thirteen
occasions, she was observed at half hourly or almost half hourly intervals over
the tea time period. On 26 and 28 January, when the male nurse was on duty,
there was no recorded observation of her during the tea time period. On 1
February, there was no recorded observation between 5:00pm and 7:45pm.
The male nurse’s understanding that observations need not be recorded thus
appears to be at variance with the practice of his colleagues, apart from the
member of staff on duty from tea time on 1 February. Since the woman’s
death this officer has retired and it was not possible to interview him.
36
CONCLUSIONS
161. The deceased was a young woman who had harmed herself on numerous
occasions prior to her death. She had most recently tied a ligature round her
neck on 30 January, just three days before her death. However, the
consensus of opinion about her around the time of her death was that there
were several reasons for optimism. The members of staff who attended the
final F2052SH review on the afternoon of 2 February felt very encouraged
about her. The move from the CSU to Healthcare seemed to be going well.
The SO who chaired the meeting thought that she was looking ahead to the
future. She had expressed an interest in going to the gym, was interacting on
Healthcare, attending education, eating again and there was the possibility of a
place for her at the unit near her family.
162. As well as talking to staff at the meeting, the woman also spent time that day
with education staff, with the prison’s Probation Officer and with the Chaplaincy
volunteer. She did not indicate to any of these people that she intended to
harm herself that evening. The poignant letter left by her for her mother
appears to suggest that she intended to take her own life, as she named a
song that she wanted played at her funeral. She refers to the voices in her
head becoming really bad and her decision to “get rid of them good and proper
by hanging myself off the taps like I said I would”. From the available
evidence, I am unable to conclude whether the woman made this decision just
a short time before her death, or whether she had formed the intention
previously.
163. One of the questions raised by the woman’s mother is whether she should
have been constantly watched, given her frequent attempts to harm herself
and hang herself. I conclude that half hourly observations were a reasonable
response to the perceived level of risk. Her risk of self harm was regularly
assessed, and the most recent Case Review took place just a few hours
before she died. It was attended by staff from a wide range of disciplines,
including education, Healthcare staff, and the prison probation officer, as well
as the woman herself. The summary of their discussion did not ignore the
ligature incident which had taken place three days earlier, but recognised a
number of positive factors, particularly her decision to start eating again during
the previous weekend.
164. I am unsure whether the woman was observed by the male nurse between
4:50pm and 6:15pm on 2 February or not. He assured my investigators that
he did observe her during that time, although he made no entries on F2052SH.
He explained that he was acting in accordance with instructions issued by an
SO. The SO’s memorandum about the subject states his expectation that staff
would record their observations in writing each time they were made. I am
aware that since the woman’s death the F2052SH system at New Hall and in
many other prisons has been replaced by Assessment, Care in Custody and
Teamwork (ACCT). ACCT encourages prison staff to make fewer entries in
the ongoing record, but to ensure that entries of significant events,
conversations and observations are of high quality. However the system in
operation at the time of the woman’s death was F2052SH, and the prison wide
37
policy issued in October 2003 stated in bold type that observations of prisoners
subject to F2052SH procedures when in a single cell must be recorded. I
make two recommendations in relation to this matter.
The Area Manager for Yorkshire and Humberside in conjunction with
Wakefield West PCT should consider setting up a disciplinary
investigation to establish whether [the male nurse] contravened
published observation policy.
New Hall’s published Suicide and Self harm Prevention Policy document
should clearly state the prison’s policy on recording observations of
prisoners at risk of self harm. The document should also indicate
whether the policy applies in all areas of the prison or not.
165. It is difficult to establish the time when the woman was first found hanging in
her cell in the Healthcare Centre, but I conclude that it was probably between
6:10 and 6:15pm. The male nurse’s entry in the F2052SH times the beginning
of the incident at 6:15pm. Information from staff about the time when the
second nurse first came to the in-patient area is contradictory. I attach
considerable importance to the telephone records for the two telephones in the
Nurses’ Office. The records establish that the male nurse did not seek advice
from the second nurse until 6:22:51pm at the very earliest. The records also
show that a telephone call from the male officer to the Control Room was not
made until 6:30:41 at the very earliest. The control room records may be
slightly inaccurate because they indicate a telephone call from the male officer
at 6:36pm, and a 999 call to the West Yorkshire Ambulance Service at 6:37pm,
whereas the Ambulance Service’s own record states that the first call from
New Hall was at 6:35:44.
166. The telephone records suggest that the male nurse did not appreciate the
gravity of the situation, and it appears that he did not know the most
appropriate steps to take to attempt resuscitation. The defibrillator was not
obtained until the second nurse arrived, CPR was not begun promptly and the
woman was placed on a soft rather than hard surface when he prepared to
administer oxygen. During my investigation I wrote to the Governor of New
Hall about these apparent shortcomings in the male nurse’s professional
competence.
In light of these findings relating to [the woman’s] care, I recommend that
the Area Manager and Wakefield West PCT should consider what action
is now required, whether by way of discipline or by providing urgent
further training for [the male nurse].
167. I make no criticism of the two prison officers on duty in the in-patient area at
the time. I accept that they believed that the best course of action in the
circumstances was to maintain the association period for the remaining women
in the area, whilst trying to provide the necessary support to the male nurse. I
recommend that the Governor reviews her contingency plans for responding to
major incidents in the Healthcare Centre. The working assumption of staff, as
well as documents such as the Suicide and Self harm Prevention Policy, is that
38
incidents of suicide and self harm are likely to occur outside Healthcare, and
Healthcare staff will proceed to other parts of the prison to support other
colleagues. The contingency plans should clearly state the actions to be taken
if such incidents take place in Healthcare itself.
168. I conclude that the second nurse behaved appropriately and injected the
necessary level of urgency when she arrived in the in-patient unit. I note her
professional opinion that the woman was already dead or near death when she
first got there.
169. The Chaplaincy volunteer was a shrewd and sympathetic friend to the woman
for an extended period of time. She said that the woman did not find it easy to
mix with people, and found large groups of people very difficult. She felt that
was why she asked to be located in the CSU most of the time that she was in
prison. The woman herself asked to be located in the CSU as soon as she
arrived at New Hall on 9 November, and her request was granted.
170. The Cell Sharing Risk Assessment (CSRA) completed on 9 November stated
there was a high level of risk that the woman might assault a cellmate if she
shared a cell. When asked by the Reception Officer, she said that she was
concerned about sharing a cell, and described herself as a person who quickly
got angry and frustrated. Because of the assessment that she posed a high
rate of risk of harm to others, the matter of her location was referred to both a
duty manager and duty governor. Both agreed that she should be located in a
single cell in the CSU.
171. That decision was made despite the recognition recorded on the CSRA that
the woman was extremely vulnerable and on an open F2052SH. PSO 2700
states that prisoners at risk of suicide or self harm must not routinely be held in
the CSU. They should only be held there in exceptional circumstances, or
where all other options have been tried, but considered inappropriate. I have
seen no evidence that an alternative to the CSU was sufficiently considered
when the woman arrived at the prison. Location of a prisoner on an open
F2052SH in the CSU is a matter of last resort.
I recommend that the Governor reminds senior colleagues that the
requirements of PSO 2700 must be fully complied with.
172. The woman’s Rule 45 status was regularly reviewed between November 2004
and January 2005. Part C of the Segregation Safety Algorithm was not fully
completed by the Governor on 9 November. The form requires the Governor
to record the exceptional circumstances which justify the location of a prisoner
on an open F2052SH in the CSU. The written explanation is not simply a
minor procedural matter, but is vital to the safety and well-being of prisoners.
I recommend that the Governor reminds senior colleagues that the
requirements at Part C of the Algorithm in relation to explanations for
decisions and a record of case conference discussions must be fully
observed.
39
173. At the woman’s first Segregation Review Board no mental health issues were
noted, but her history of self harm and overdose was recorded. I take the view
that a history of self harm should raise specific concerns about the prisoner’s
mental health being reviewed. The form asks for details of the support to be
taken.
I recommend that information about the support available should be
recorded at future boards for prisoners who have a history of self harm.
174. Later reviews recorded that the woman was to be assessed by a psychiatrist,
but subsequent forms did not indicate whether it happened.
I recommend that review boards improve continuity by following up and
recording whether recommendations from earlier boards have been
implemented.
175. On 22 December, the woman wrote to the HSC setting out four issues that
concerned her. Two issues were medical matters, and the others concerned
her daily life in the CSU. I have no doubt that the HSC did his utmost to
resolve the issues, but nevertheless the letter should also have been
distributed to Healthcare. The woman’s concerns about her medication and
psychiatric care should have been referred to clinical staff who were competent
to handle them. The Governor was telephoned about the woman’s mental
state on Christmas Eve, and wrote the same day to the Healthcare manager. I
consider that pattern should be emulated by her colleagues.
176. The woman’s mother has expressed concern about the length of time she
spent in the CSU before being transferred to Healthcare. The HSC said that
he felt he was acting in her best interests by trying to move her from the CSU
to a normal location. He was well aware that a prisoner’s mental health may
deteriorate if they continue to be located in the CSU for a long time. There is
very clear evidence that he was doing his best to move her from the CSU in
the letter of 19 January from the woman’s solicitor which states: “There is
presently concern being expressed by yourself as to why she is on segregation
and [her mother] has expressed significant concerns as to the prospect of
being removed from the Segregation wing.” Once the woman had been
admitted to the CSU on 9 November it was difficult to remove her, not least
because of her own attachment to the unit. The HSC was clearly making
appropriate efforts, and the woman herself was involved in the discussion.
177. The woman’s complaint about the HSC did not reach the correct area manager
until after her death. The three week delay is unacceptable, but I readily
conclude that the delay was due to an error, rather than a deliberate attempt to
block a prisoner’s complaint.
178. The prompt way in which news of the woman’s death was broken to her
mother was very good practice. The Governor and the Chaplain went in
person to see her mother. When they did not find her at her home, they
travelled further to speak to her in person. I commend the Governor for
undertaking the task in person and for her determination to speak to the
40
woman’s mother face to face. The way in which the HSC told small groups of
prisoners about the woman’s death was also most impressive. The Chaplain
conducted the woman’s funeral service a fortnight after her death. I know that
there has been regular support, both by visits and telephone calls, for the
mother from the Chaplain and the HSC. Financial support for funeral costs
was supplied promptly and sensitively by the prison.
179. I conclude that members of the Chaplaincy team at New Hall offered valued
support to the woman and her family. The Chaplain’s role in the days and
weeks after her death has already been discussed. I pay tribute here to the
admirable work over weeks, months and years by the Chaplaincy volunteer. I
am aware that she is part of a team of volunteers, but it is right to highlight the
enormous support she gave to the woman. She exemplifies the contribution
that can be made by voluntary workers in a prison setting. It is probable that
only a few friends and neighbours and the New Hall community know about
her voluntary work there. She was the only visitor the woman had, apart from
her mother. She acted as the woman’s champion, trusted friend, advisor and
confidante. The two women respected each other, and she had the woman’s
very best interests at heart. An example is that she persuaded the woman at
Christmas time to come to the Carol Service. She agreed to attend as the
volunteer arranged for them to sit together, and remain in the chapel until other
prisoners left.
I recommend that the Yorkshire Area Manager writes to [the volunteer] to
thank her for her voluntary contribution at New Hall over the years, and
particularly to draw attention to my comments and to express his
appreciation for her practical support and encouragement for [the
woman].
180. A second Chaplain was another member of the Chaplaincy team who had
valuable contact with the woman. On 9 January and 1 February, she told this
Chaplain that she intended to hang herself. On both occasions the Chaplain
took appropriate action, making a detailed entry in F2052SH and speaking with
relevant staff. On the second occasion, the woman claimed that she could
hang herself in the toilet of her cell without being seen by staff. The Chaplain
discussed her claim with a nurse, and was reassured that staff were able to
see the woman. New Hall is an environment where self harm is a regular
occurrence, but this Chaplain did not ignore the woman’s claim and responded
appropriately to it.
181. I have some misgivings about the hot de-brief conducted on the evening of 2
February. The male officer referred to a structured timescale being agreed at
the de-brief and the second nurse complained about the overwhelming number
of people who were present. She described it as a memo writing session, with
no opportunity for discussion of their feelings about the woman’s death. At the
time my investigators conducted a second round of interviews in late June, a
critical incident de-brief had still not taken place.
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I recommend that the Governor reviews and improves the de-briefs at the
prison. In particular, staff should write statements independently, and
should not be provided with “agreed” timings.
182. The woman’s mother asked through her solicitor whether her daughter, with
her severe psychiatric history and propensity for severe self harm, should ever
have been held in custody, rather than in hospital. I do not know what options
the court considered, but I share the view of HM Chief Inspector of Prisons as
expressed in her most recent report on New Hall. The Chief Inspector records
that New Hall, like other women’s prisons recently inspected, is holding women
and girls who should not be there. They include those who are seriously
mentally ill, as well as some women and girls with high levels of self harm.
Prison is likely to increase their vulnerability and mental disorder, in some
cases with tragic consequences.
183. Sentencing policy is not a matter directly within my remit. However, no reader
of this report can fail to be troubled by the level of distress that the woman
experienced and expressed.
I recommend that the circumstances of this case are drawn to the
attention of the Local Criminal Justice Board and to the Office for
Criminal Justice Reform.
184. The cameras currently in use in the in-patients area of the Healthcare Centre
are of limited value. There were insufficient staff to monitor and analyse the
images obtained. The cameras do not appear to film the whole area, including
the toilet in each cell. Page 9 of the clinical review addresses the issue of
situational strategies to remove the means of suicide. The existing cameras
create the impression of providing extra security, but it is difficult to measure
the actual value. It may well be that the provision of additional safer cells
would be preferable to inadequate camera coverage.
I recommend that the Governor reviews the use and value of the cameras
in the in-patient centre.
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RECOMMENDATIONS
Operational
1. I recommend that the Governor reminds the relevant staff of the correct
procedures and address to be used for confidential access complaints.
2. New Hall’s published Suicide and Self harm Prevention Policy should clearly
state the requirements for recording observations of prisoners who are at risk
of self harm. The document should also indicate whether the policy applies
in all areas of the prison or not.
3. I recommend that the Governor reminds senior colleagues that the
requirements of PSO 2700 must be fully complied with.
4. I recommend that the Governor reminds senior colleagues that the
requirements of Part C of the Algorithm in relation to explanations for
decisions and a record of case conferences must be fully observed.
5. I recommend that information about the support available should be
recorded at future boards for prisoners who have a history of self harm.
6. I recommend that review boards improve continuity by following up and
recording whether recommendations from earlier boards have been
implemented.
7 I recommend that the Yorkshire Area Manager writes to [the volunteer] to
thank her for her voluntary work at New Hall over the years, and particularly
to draw attention to my comments and to express his appreciation for her
practical support and encouragement for [the woman].
8. I recommend that the Governor reviews and improves the conduct of de-
briefs at the prison. In particular, staff should write statements independently
and should not be provided with “agreed” timings.
9. I recommend that the circumstances of this case are drawn to the attention
of the Local Criminal Justice Board and to the Office for Criminal Justice
Reform.
Healthcare
10. The Area Manager for Yorkshire and Humberside, in conjunction with
Wakefield West PCT, should consider setting up a disciplinary investigation
to establish whether [the male nurse] contravened published observation
policy.
11. In light of these findings relating to [the woman’s] care, I recommend that the
Area Manager and Wakefield West PCT should consider what action is now
required, whether by way of discipline or by providing urgent further training
for [the male nurse].
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12. I recommend that the Governor reviews the use and value of the cameras in
the in-patient centre.
Good Practice
In the sad circumstances following the woman’s death, I have been most impressed
by how the prison then responded. The prompt way in which news of her death
was broken to her mother was an example. The Governor and the Chaplain went
in person and, when they did not find her at home, they travelled further to speak to
her in person. I commend the Governor for undertaking the task in person and for
her determination to speak to the woman’s mother face to face. The way in which
the HSC told small groups of prisoners about the woman’s death was also most
impressive. The Chaplaincy team also emerge very well from this report. I would
be grateful if my comments could be drawn to the attention of all those concerned.
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