Individual at New Hall

The circumstances surrounding the death of
a woman from HMP/YOI New Hall, at a hospital
On 12 October 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2006
This is the report of an investigation into the circumstances surrounding the
death of a woman at a hospital on 12 October 2004. At the time of her death, the
woman was serving a five month prison sentence at HM Prison and YOI New
Hall, near Wakefield, West Yorkshire. A post mortem examination carried out on
13 October 2004 concluded that her death was caused by hanging.
The investigation was carried out on my behalf by my colleague. I also
commissioned an independent clinical review of the management of the woman’s
health needs while she was at New Hall. This was conducted by a
representative of the Wakefield West Primary Care Trust (PCT). I am grateful to
the PCT for the thorough and comprehensive report he has written.
My thanks also go to the Governor and staff at New Hall for their help and co-
operation during the investigation.
This was one of a number of deaths I have investigated at New Hall. As the
report shows, a considerable number of the women at New Hall are either
mentally ill, or have a history of drug abuse or, in some cases, a history of self-
harm. It is no coincidence that those who have died at New Hall in recent years
fit into at least one of those categories. Although I am critical of some crucial
aspects of the management of this woman during her time at New Hall, I am
nevertheless impressed by the commitment of the Governor and her staff to the
challenging task of managing the needs of a difficult and vulnerable prisoner
population.
At consultation stage, the Prison Service partially accepted one of my
recommendations and fully accepted the remainder. The Service felt it was
heartening that in the midst of this sad case, and despite the criticisms raised, I
had recognised the difficulties caused by the imprisonment of so many mentally
ill and vulnerable women and girls and the commitment of the Governor and her
staff in catering for their needs. The Prison Service’s plan of action to implement
my recommendations is shown at the end of my report.
I hope that implementation of the recommendations I have made will help to
reduce the risk of further tragedies at New Hall and elsewhere in the Prison
Service.
Stephen Shaw CBE February 2006
Prisons and Probation Ombudsman
2
Contents
Part One. 1. Summary
2. Investigation methodology
3. The deceased woman
4. HM Prison and YOI New Hall
5. Events during the woman’s first period at New Hall:
9 June -16 July 2004
6. Events during the woman’s second period at New Hall:
16 August-11 October 2004
7. Events on and after 11 October 2004
8. Consideration of issues arising from the investigation
9. Recommendations
Annex A. Prison Service plan of action for implementation of
recommendations
3
1. Summary
In 2004, the woman spent two periods at New Hall. The first began in June of
that year, when she was remanded by Bradford Magistrates’ Court on a charge
of criminal damage. The woman was released from custody by the same court in
on 15 July. The second period began on 16 August, when she was again
remanded by Bradford Magistrates’ Court, this time for assault. This period
ended with her death on 12 October. Throughout both periods, the woman was
located in the Healthcare Centre.
During her first period at New Hall, a F2052SH (self-harm monitoring form) was
raised. The document was opened on 12 June and closed on the last day of the
month. Subsequently, the document was lost.
On 13 August 2004, the woman was arrested in Bradford for assaulting two
Police Officers and a Detention Officer. On 16 August, she appeared before
magistrates for those offences and was remanded in custody at New Hall. The
court custody staff assessed her as being at risk of self-harm. They passed this
information on to the Group 4 escort who took her to New Hall that day. In turn,
the escort staff passed it on to reception staff in the prison.
During the reception procedures, the woman presented as elated and confused.
She was assessed as being in need of urgent referral to a psychiatrist and was
immediately admitted to the healthcare centre. The reception staff were not
aware that, only six weeks earlier, the woman had been the subject of self-harm
monitoring procedures at New Hall.
On 17 September, the woman returned to court and was sentenced to five
months imprisonment. On her return to New Hall that day, she was again
located in the healthcare centre. Thereafter, she experienced frequent mood
swings and demonstrated abusive behaviour. She also expressed suicidal
thoughts on a number of occasions. Although a nursing care plan was
established and followed throughout her time at New Hall, no consideration was
given to making her subject to formal self-harm monitoring procedures.
At about 1pm on 11 October 2004, the woman was found hanging from the door
of her ward toilet by a member of the healthcare staff. The only other prisoner
allocated to that ward with her had gone to court earlier that day.
Resuscitation attempts by New Hall staff and, later, by paramedics were
sufficient to restore a weak pulse. The woman was therefore transferred to
hospital at about 2pm. She survived the night but died at 4.20pm the next day.
I draw attention to the fact that, although the woman’s medical care, diagnosis
and treatment during her first period at New Hall in June and July 2004, were
appropriate, there were some flaws in the way she was managed in the
4
healthcare centre during her second stay there between August and October
2004. I draw particular attention to the fact that she was not made subject to
formal self-harm monitoring procedures during that second period at New Hall.
I also express my concern that so many vulnerable and mentally ill adult and
young women are sent to prison where, all too often, their individual needs
cannot be met. This is not a matter over which the Prison Service has any
control. However, I will send a copy of this report to the Local Criminal Justice
Board and the Office for Criminal Justice Reform.
I praise the efforts of healthcare staff at New Hall, and of the paramedics, who
attended to the woman after she had been found hanging. They did so in very
harrowing circumstances.
I make a number of recommendations about suicide prevention policy and
practice at New Hall, as well as about a wide range of clinical governance issues
that arose during the investigation.
I stress that none of the criticisms contained herein should take away from the
commendable efforts made by the Governor and staff at New Hall, including
those who work in the healthcare centre, in their management of a difficult and
vulnerable prisoner population. The good practice found during the investigation,
including the comprehensive care plan drawn up for the woman, testifies to those
efforts.
5
2. Investigation methodology
The investigation was opened on 26 October 2004, when my investigator met
with the Governor, and representatives of the Independent Monitoring Board and
the local branch of the Prison Officers’ Association respectively. On the same
day, written notices were issued to staff and to prisoners explaining the nature
and scope of the investigation and encouraging anyone who wished to submit
information about the woman’s death to make themselves known to my
investigator.
An independent clinical review of the management of the woman’s health needs
was conducted by a representative of the Wakefield West Primary Care Trust.
A wide range of healthcare and other staff were interviewed. My investigator
talked to a number of prisoners about the ethos of the prison and spoke to a
close friend of the woman and to one of her cousins. My investigator also met
with two representatives of the local branch of the Prison Officers’ Association.
He discussed their concerns relating to the high number of self-harm incidents
with which staff at New Hall had to contend on a daily basis.
My investigator interviewed the woman’s son at Wetherby Young Offender
Institution.
During the course of the investigation, my investigator and one of my Family
Liaison Officers met with the woman’s mother. They explained to her the nature
and scope of the investigation. She raised a number of concerns that she
wanted the investigation to address. These have been addressed in the report.
6
3. The deceased woman
The woman was born in 1967. Her mother remembers her as a happy and
boisterous child. The woman grew up in Halifax and settled with a man of 18
who was extremely violent towards her. She had a history of self-harm during
her adulthood. The woman also had difficulties maintaining a stable life style and
relationships. Indeed, her circumstances were often described as “chaotic” and
problematic. She was diagnosed as having an emotionally unstable borderline
personality disorder and had been in contact with mental health services for a
considerable period. On occasions she was a psychiatric inpatient.
The woman left her first partner when she was 24. She married again at the age
of 30. She met her second husband in Halifax and together they moved to
Scarborough. They had a happy relationship but, tragically, her husband died
seven years later in October 2003. The woman had eight children: three boys
and two girls by her first husband, and one boy and two girls by her second
husband.
The woman never gained long term employment. From June 2003, she had
found herself before the courts for various charges of harassment, assault and
criminal damage. Her offences were mainly alcohol related. Prior to her
imprisonment in August 2004, she had been living in sheltered accommodation.
In prison, the woman’s behaviour was often unpredictable and violent, but she
was nevertheless regarded by many as cheerful and amusing. She died three
days before the first anniversary of her husband’s death.
7
4. HM Prison and YOI New Hall
Located near Wakefield in West Yorkshire, New Hall is a multi-purpose
establishment that operates as a local and a training prison for adult and young
women as well as for juveniles. The establishment can hold up to 426 prisoners.
At the time of the investigation, healthcare at New Hall was provided by the
Prison Service. The healthcare centre provides 24 hour nursing and medical
cover and has inpatient facilities for up to 19 prisoners.
In November 2003, Her Majesty’s Chief Inspector of Prisons inspected New Hall.
The report of that inspection was published in April 2004. It referred to the
vulnerability and needs of many of the prisoners. The Chief Inspector
commented on the high number of F2052SH forms open at the time of the
inspection and on the fact that all the inpatients in the healthcare centre at that
time were mentally ill.
Little had changed by the time the investigation into the death of the woman
began in October 2004. My investigator was told that staff at New Hall were
used to managing a very high number of self harm incidents every month. The
following table shows the number of self-harm incidents that occurred at the
establishment around the time the woman was there for the second time in 2004.
Type of self-harm August 2004 September 2004 October 2004
Lacerations 31 61 62
Ligatures 15 35 31
Overdose,burns etc 8 9 18
Comments 10 prisoners 13 prisoners 18 prisoners
account for 39 account for 94 account for 93
incidents incidents incidents
The Chief Inspector also wrote that there had been four self-inflicted deaths at
New Hall in 2002 and 2003. In her introductory remarks, she said,
“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 levels of self-harm linked to abuse, including
substance misuse. 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
8
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.”
Between April and October 2004, three women, including this woman, died at
New Hall. Each of them apparently took her own life. Two of them, including this
woman, had long histories of self-harm prior to imprisonment.
9
5. Events during the woman’s first period at New Hall:
9 June-16 July 2004
On 9 June 2004, the woman appeared at Bradford Magistrates’ Court on a
charge of criminal damage and was remanded in custody at New Hall. She was
to reappear at court the next day.
The Prisoner Escort Report (PER) completed at court by Group 4 staff that day
recorded that the woman was at risk of self-harm or suicide. A Court Custody
Officer completed a self harm warning form in which she recorded that the
woman had admitted self-harming during the preceding six months and that she
currently seemed depressed. The Court Custody Officer recommended that the
woman should be subject to intermittent observations during her journey to
prison. The woman was escorted to New Hall after her court appearance and
arrived at about 6.30pm.
The nurse on duty in reception at New Hall completed a proforma recording the
details of the woman’s first reception health screen. The nurse recorded that,
prior to her admission to prison, the woman had been living at an address in
Halifax and that she had been in custody at New Hall in 2003. A reference was
also made to the suicide/self-harm warning raised by Group 4 staff on the PER.
The woman admitted to the nurse that she had set fire to herself two weeks
earlier, and that she had recently been discharged from a Psychiatric Hospital in
Bradford. The nurse decided that the woman should be referred to a doctor for
mental health screening and that she should be admitted to the healthcare
centre.
A cell sharing risk assessment form was also completed on 9 June by another
member of the reception staff who recorded that the woman’s behaviour was
unpredictable and who judged that her risk of assaulting other prisoners was
high. It was therefore decided that the woman should be placed in single
accommodation. This same member of staff also noted in the woman’s file that
she was prone to aggressive and violent behaviour and that she was currently
not feeling suicidal. No F2052SH was opened.
On 10 June, a Staff Nurse followed up the note made on the woman’s reception
health screen proforma by asking for her to be seen either by a member of the
mental health in-reach team, or by one of the prison doctors. The woman was
seen by the mental health in-reach team on 16 June. Later on 10 June, the
woman swore and spat at an officer as she was being escorted to reception on
her way to court. When she arrived in reception, the woman became abusive to
staff there too. Later that day and on the next day, she appeared at Bradford
Magistrates’ Court. She was further remanded in custody on both occasions.
Her next court appearance was scheduled for 18 June. The PER completed for
her journeys to and from court at this time noted a continuing risk of self-harm.
No F2052SH was opened.
10
On 12 June, the woman underwent a mental health examination. A number of
illegible entries relating to this examination were recorded in her prison medical
record. The examination resulted in her referral to the mental health team.
On the same day, an entry was made in the woman’s medical record showing
that a F2052SH had been opened. The circumstances that led to the decision to
open the F2052SH were not recorded. When my investigator asked to see the
document, he was told that it could not be found. My investigator therefore
talked to a number of staff who were involved in the woman’s management at
that time, but none could remember why the F2052SH had been raised, or the
circumstances surrounding the decision to close it on 30 June. However, the
medical record shows that at 3pm on 12 June, the woman was seen walking
around her room in the healthcare centre responding to auditory hallucinations.
A similar entry was made on 14 June.
On 15 June, the woman was seen by a psychiatrist. During the consultation, the
woman explained that she felt anxious and in emotional pain all the time. She
asked the doctor to give her an injection so that she could “go to sleep for ever
and put an end to it all”.
On the same day, the woman was seen by a locum consultant psychiatrist who
wrote in the medical record,
“Woman’s hypomanic/mixed affective state
- needs anti-psychotic and sedative in short term to lower mood
elevation, agitation and get some sleep.
- ideally would be on mood stabiliser and would benefit from MHA
assessment if released.
Continue with controlled unlock and 2052 at present.
Prescription: chlorpromazine 25mg BD and 100mg nocte
Amoxyllin 250g tds for teeth until seen
Ideally urine/drug screen.’’
On 16 June, a number of entries were made in the woman’s medical record that
show that her case was being considered by a member of the mental health in-
reach team in conjunction with a doctor. It was also recorded that a urine sample
taken from the woman had produced negative results, that she was showing a
heightened response to hallucinations and that she was alluding to further
thoughts of self-harm.
On 17 June, a representative of the mental health in reach team was due to see
the woman but he found her in a very agitated and uncooperative mood. The
representative therefore tried to speak to her through her cell door in the
healthcare centre. She was so aggressive that he found it impossible to engage
with her. The woman remained agitated and aggressive for the rest of that day.
She slept badly that night and her fitness to return to court the following day was
11
questioned. However, she was more settled when she took breakfast on 18
June and appeared at court as scheduled. She was remanded in custody for a
further week.
On 19 June, the woman superficially grazed her knuckles on the furniture in her
cell. Her injuries were so slight that no treatment was deemed necessary, but a
self-harm injury form (F213SH) was appropriately raised by staff. Entries made
in the form drew attention to the fact that a F2052SH was already open. Further
entries made in the medical record show that she remained in an agitated state
for much of that day and for the following three days. She would go to sleep
relatively early in the evening and would wake up in the middle of the night. Her
medication was therefore adjusted in an attempt to stabilise her sleep pattern.
On 22 June, the following entry was made in the woman’s medical record:
“Cell entered after no response on checking. Ligature removed,
colour good and conscious. Refused to talk. F213 completed.’’
Beneath that entry appears an illegible signature against the words “wrong
entry”. No explanation for that entry was given to my investigator, other than it
probably alluded to an incident involving another prisoner. As the F2052SH
appertaining to that period was lost, my investigator was unable to confirm
whether the remark did in fact refer to the woman.
On 25 June, the woman reappeared in court and was remanded in custody for a
further week. On the same day, an entry was made in the medical record
showing that a care plan review was to take place. No details of that review were
recorded. The next day, she became abusive towards staff and she was placed
on report for throwing a table at her cell door. The woman attended an
adjudication (a disciplinary hearing) for this offence on 28 June and was given
seven days forfeiture of her television as punishment.
On 29 June, the woman was seen again by a psychiatrist who recorded that her
presentation over the previous two weeks was suggestive of hypermania. The
psychiatrist decided to increase the woman’s prescription of chlorpromazine (an
anti-psychotic drug prescribed for the treatment of disorganised and psychotic
thinking and to treat false perceptions) to 25mg twice daily and a further 150mg
at 6pm each day. The psychiatrist noted that this dosage could be reduced
during the day if the woman became drowsy.
On 30 June, an entry was made in the medical record by a Staff Nurse showing
that a F2052SH case review had taken place, and that a decision had been
made to close the document. As there are no other entries in the medical record
relating to the case review and the F2052SH has been lost, it is not possible to
ascertain the rationale behind this decision.
12
On 2 July, the woman returned to court and was remanded to reappear a week
later. The escort record for her journey to and from court on this occasion noted
that the F2052SH had been closed.
The medical record shows that on 4 July, the woman kept shouting at staff at
lunchtime, but that she returned to her room of her own accord. The next day,
she left her education class abruptly and asked to be allowed to stay in her room.
The psychiatrist saw her again on 6 July and noted that she was much improved.
He commented that she was due in court the following Friday and that if she was
returned to the community, another psychiatrist would need to be told.
There is no available documentary evidence to show that the other psychiatrist
was informed of the woman’s discharge from prison or of her behaviour, mental
state and clinical management whilst at New Hall.
Between 6 and 15 July, the woman continued to display episodes of
unpredictable behaviour. On 16 July, she appeared again before Bradford
magistrates and was given a conditional discharge from court.
13
6. Events during the woman’s second period at New Hall:
16 August -11 October 2004
The woman’s second period at New Hall in 2004 began only a month later on 16
August, when she was again remanded in custody by Bradford Magistrates’
Court.
Events in police custody
The woman had this time been arrested at 2:20pm on 13 August, for assaulting
two police officers and a detention officer in Bradford. She was seen in the
police cells at 2:45am on 14 August by a police doctor who noted that she had
been sniffing glue earlier that day, but that she was fit to be detained. The doctor
recommended that she should be referred for mental health assessment. The
woman was detained in police custody until her appearance before Bradford
Magistrates’ Court on 16 August. At that hearing she was remanded in custody
to reappear at court on 23 August.
During the period of her detention in police cells, it was noted that the woman
bore scars on her arms that were the result of recent self-harm incidents. The
information was noted on the PER completed by Group 4 staff (later to become
Global Solutions Ltd) when they escorted her to New Hall later that day. No
evidence was available to show exactly when the self-harm incidents took place.
However, a Prison Custody Officer raised a self-harm warning form on which she
recorded that the woman had tried to slash her arms whilst in police custody.
Reception at New Hall
Upon her arrival at New Hall during the evening of 16 August, the woman
underwent a first reception health screen, completed by a Staff Nurse who wrote
on page 1 of the health screen proforma, “F2052 warning.” During the screening
process, the woman told the nurse that she had been at New Hall in July and that
she had seen a doctor because of her mental health problems. The woman also
told the nurse that she had recently sustained bruising on her legs and scratches
on her arms. Guidance notes on the proforma completed by the nurse indicate
that if a prisoner reveals evidence of injuries, the details should be recorded on a
F213 (report of an injury to a prisoner). This was not done.
The woman admitted that she had recently suffered from manic depression and
that she had been a psychiatric inpatient a week earlier. She also admitted that
she had tried to harm herself in prison and in the community but denied
scratching her arms. The woman told the nurse that she did not feel suicidal and
that she would not harm herself as she felt safe at New Hall. She also told the
nurse that she wanted to see a doctor. She was admitted to the healthcare
centre primarily for mental health assessment. The nurse did not consider
opening a F2052SH. There is no documentary evidence to indicate that any
14
attempt was made to obtain her medical records from the psychiatric hospital at
which she had been an inpatient.
A cell-sharing risk assessment was completed on the same day. As the woman
was judged as presenting a risk of harm to others, it was decided that she should
be allocated single accommodation. She became violent during the reception
process and punched a hole in the reception desk counter. She was later placed
in a single room in the healthcare centre. No details of the woman’s previous
period of custody at New Hall were available during the reception process. The
fact that she had been the subject of self-harm monitoring procedures at New
Hall between 12 and 30 June 2004 was therefore overlooked. At Section 2 of the
cell-share risk assessment form, it was recorded that there was no evidence that
the woman had previously been the subject of a F2052SH.
The nurse wrote in the woman’s medical record that she appeared “quite
confused and elated in mood’’. The nurse also recorded that the woman was to
be admitted to the healthcare centre for urgent referral to a psychiatrist. This
was organised through the Care Plan Approach (CPA) co-ordinator in the mental
health in-reach team. He referred the woman to a visiting psychiatrist.
On 17 August, the woman appeared at a reception board taken by a Prison
Officer. The interview had to be terminated because of the woman’s bizarre
behaviour. She continually spoke to other prisoners in the vicinity while the
officer was trying to interview her, and kept telling the officer that her (the
woman’s) family was in danger. The checklist partially completed by the officer
did, however, include a reference to the woman’s self-harm history and to
information included in her core record that told of her attempts to harm herself
during and since childhood.
Consultation with the prison doctor
The woman was also seen by the prison doctor on the same day. The doctor
wrote in the medical record that the woman was very agitated, argumentative
and abrupt. As a result, the doctor terminated the interview and examination. At
11:05 am, CPA co-ordinator wrote in the medical record that he had “spoken to
Probation who would like to organise a full psychiatric via the court’’. The CPA
co-ordinator wanted to plan a clinical appointment as soon as possible.
Between 17 and 22 August, a number of entries were made in the medical
record showing that the woman was suffering from mood swings, hallucinations
and paranoid ideation. She was prescribed chlorpromazine 150mg by night and
25mg twice daily.
15
Care plan
On 18 August, a personal care plan was opened. This identified four problems
in respect of the woman together with a number of interventions designed to
help her deal with them.
The first problem was recorded as mental health-psychosis. The interventions
listed against this problem were:
• observe for signs of delusional ideas, especially paranoia focussed upon
individual figures.
• observe for signs of auditory hallucinations, ie talking to self when alone.
• observe interaction with peers.
• refer to mental-health or doctor.
The second problem was the woman’s aggression. The interventions listed for
this were:
• to maintain a firm and consistent approach.
• to ignore undesirable behaviour.
The third problem related to the question of the woman’s medication. The
interventions were:
• to offer and maintain medication.
• to observe for EPS (extra-pyramidal side effects) and report same to MO.
• to offer sun-block when outdoors.
The fourth problem was the woman’s need for a vaccination programme. She
was to be given hepatitis B vaccinations on 10 September, 16 September and 14
October.
First care plan evaluation
The care plan set out a programme of weekly evaluations, the first of which took
place on 21 August. On this occasion, the woman was described as
hallucinatory, less aggressive and more manageable. She was to continue to
take chlorpromazine.
Further appearances at court
On 23 August, the woman reappeared before magistrates and was remanded for
a further day. The escort record completed for her journey to and from court
indicated no risk of self-harm.
16
On 24 August, the woman was further remanded for three days. On 27 August,
she was remanded to reappear for sentencing on 17 September.
Second care plan evaluation
On 28 August, the second weekly care plan evaluation took place. The following
note was recorded:
“Mental state more settled, encapsulated reasonably well when
associating. Loses it when locked in. Responds to internal stimuli.
Less aggressive tendencies. Uncomfortable with change.”
Fluctuations in mental state
On 31 August, the woman lost her temper in an education class and kicked a
teacher on the shin. The adjudication for this offence did not proceed as she
was judged by the doctor to be unfit for both the hearing and any punishment
that the Governor could give her.
On 2 September, the woman was again seen by a doctor. He found her very
agitated. She told him that she was hearing voices that were talking about
demons. The woman was clearly very upset and told the doctor that she did not
want to live. The doctor did not consider opening a F2052SH. Neither did he or
anyone else review the appropriateness of the woman’s allocation to single
accommodation or the frequency of observation she required. My investigator
was told that all patients in the healthcare centre were routinely and
automatically observed every 30 minutes irrespective of their medical status.
However, the doctor did decide to increase the dosage of chlorpromazine from
25mg to 50mg twice daily.
Third care plan evaluation
On 4 September, the third care plan evaluation took place. The following record
was made:
“Mental state remains more stable. Able to encapsulate when associating,
becomes distressed when locked in. 1/9/04 altercation with (another
prisoner) - placed on report. Less aggressive tones overall noted.”
Consultation with in-reach
On 7 September, the woman was seen by a representative of the mental health
in-reach team to discuss her care plan. They talked about the woman’s social,
criminal and psychiatric background along with her current circumstances.
During the interview, the woman said that on release from prison she wanted to
move to a different area. The representative told her that he would liaise with
17
Shelter about finding her appropriate accommodation. He concluded his entry in
the medical record with the comments:
“Plan,
1. clinic
2. letter to doctor
3. liaise Probation
4. court 17/9/04’’
The representative wrote to a psychiatrist in Bradford on 13 September as
planned. In his letter, he asked the psychiatrist to visit the woman to plan her
ongoing and post-discharge care.
Fourth care plan evaluation
The fourth weekly care plan evaluation took place on 12 September. The
following record was made:
“Mood appears slightly flat ? would benefit from mood stabilizer.
Psychosis appears to be well encapsulated when on association
but responds when alone. No aggression noted. Status elevated
to enhanced (ie privilege level)”
Appearance in court for sentencing
On 14 September, the woman was allocated to a four-bed ward in the healthcare
centre where she remained until 22 September. The records do not make clear
how many other patients shared this ward with her during that brief period, or
whether the decision to allow her to move into shared accommodation was
based on a new cell sharing risk assessment.
On 14 September, the woman was distressed about the impending court
appearance at which she knew she was due to be sentenced. She did not take
her evening meal. The representative from the mental health in-reach team
wrote in her medical record that he discussed this matter with a psychiatrist who
agreed to review her case. However, the woman refused an interview with the
psychiatrist after telling him that she did not want to see any more doctors
because they did not help her. She said to him, “If you really want to help me,
get me a rope.’’ The psychiatrist did not consider opening a F2052SH.
On 15 September, the woman’s mood deteriorated. She declined to attend the
afternoon education period.
On 17 September, the woman appeared in court for sentencing. The escort
record suggested that there was no known risk of self-harm. For this court
18
appearance, the woman’s Probation Officer had prepared a pre-sentence report
in which she commented that, in her opinion, the woman presented a significant
risk of self-harm if sentenced to imprisonment. In the event, she was sentenced
to five months imprisonment. The report was sent to New Hall after the court
appearance and was delivered to the Sentence Planning Unit where prisoners’
sentence plans are normally drawn up. As the woman was serving less than a
year, it was not necessary for staff to complete a sentence plan for her. As a
result, the comments made in the pre-sentence report did not trigger any fresh
assessment of her risk of self-harm. However, as is pointed out in the Clinical
Review, the CPA Co-ordinator was aware of the concerns expressed in the pre-
sentence report and was able to a take account of this information and arranged
medical follow up and assessment.
Upon her return to New Hall that day, the woman was located once again in the
healthcare centre. No formal health screen took place following her change of
status to that of a sentenced prisoner. However, the next day she attended a
further reception board in the healthcare centre. A doctor commented in the
medical record that she was low in mood and had a change of circumstances.
Fifth care plan evaluation
The next evaluation took place on 19 September. The following entry was made
in the plan:
“Mood continues to appear flat and is reluctant to engage with
visiting psychiatrists. Is concerned she has nowhere to live. Result
from court - 5 month sentence.”
Psychiatric review
The medical record shows that a psychiatrist saw the woman again on 21
September, four days after she was sentenced. He included the following
comments in his entry:
“Sentenced on Friday 17/09 – 5 months. Will only serve 6 more
weeks. Homeless at the moment. Was living in hostel
accommodation. Feel terrible. Lost interest in activities. Don’t
want to do education, don’t want to talk to people. Want to curl up
and sleep and never wake up. Thought of hanging self - nowhere
to do it - I’ve looked …
… Can’t see a future – feel doomed, nothing good - feel like I’m bad.
ruminating all the time, past events. October 15th year since husband died
... Tearful often …
19
Feel worthless/useless ... I’ve failed. Unhappy all my life
Slashed my face when I was 17yrs old …’’
The psychiatrist changed the woman’s medication to 150 mg chlorpromazine at
10pm to improve her sleep. He also advised that she should be encouraged to
attend education classes, to use distraction activities, and to engage with staff
and counselling. He agreed to review her case after two weeks. He did not
open a F2052SH. At interview, he said to my investigator, “Clearly I haven’t
documented that I suggested that a F2052SH would be opened but I was under
the impression that a F2052SH was in operation.”
Release planning
On 22 September, the CPA co-ordinator saw the woman again, this time to keep
her informed of what was happening about her post-release accommodation. He
reassured her that he was in touch with Shelter and that he was trying to find her
a new GP.
Change of cell
On the same day, the woman was relocated to a five - bed room in the
healthcare centre. Her cellmate was a mentally ill woman. There is no record of
any cell sharing risk assessment having been completed.
Induction employment
On 24 September, it was decided that the woman should be given an opportunity
to engage in some form of employment in the prison. She was therefore to
commence an employment induction programme during the week commencing
27 September.
On 30 September, the woman returned from the induction workshop in distress.
My investigator was told that she found it difficult to remain in the company of
relatively large numbers of prisoners in an open area such as a workshop, and
that this may have contributed to her distress. It was agreed that she should
attend for work during the mornings only, until she felt better.
Further mental health deterioration
On 1 October, the woman declined to attend her education class. During the
day, her mood deteriorated. She complained that she was frustrated with her
cellmate. Staff responded swiftly and sympathetically by allowing her to relocate
to the four-bed ward in the healthcare centre which she shared with only one
other prisoner.
20
On 5 October, the woman was very emotional. Her mood was described by a
nursing assistant as “quite low”. The nursing assistant talked to her and
reassured her.
Sixth and last care plan evaluation
The only other record of a care plan evaluation presented to my investigator
related to that which took place on 10 October, three weeks after the previous
evaluation. The following entry was made in the plan:
“Her MH [mental health] continues to improve although presently
does appear worried regards prospect of t/ex [short for time expired
or release from prison] and no accommodation. ? depressive
element. Continue involvement with CPA.”
21
7. Events on and after 11 October 2004
At 8.30am on 11 October, the woman should have been given her medication of
chlorpromazine, but this was not administered. My investigator was unable to
establish the reason for this. The woman went straight to work but, at about
11am, she returned early because she experienced what staff described as a
panic attack. She told a nurse that she was worried about her accommodation
on release and whether she would be able to cope on her own. She was also
anxious about seeing her Probation Officer later that day. The nurse reassured
her and suggested to her that it would be inappropriate for her to return to work.
The nurse made a note to that effect in the medical record. The woman did not
go back to work. Instead, she remained in her ward in the healthcare centre.
The other prisoner who shared the ward with her had gone to court earlier that
day.
At midday, the woman took lunch and was then locked into the ward. The
healthcare staff then took their lunch break in the nearby rest room.
The staff office has a large window, abutted onto one side of the ward, giving
staff clear visual contact with those women located in the five-bed ward. There is
also a toilet recess area in the ward. In order to prevent prisoners in the ward
seeing confidential documents used by the healthcare staff in the office, the
blinds over the window were drawn. The staff were therefore unable to observe
the woman’s activities in the ward.
At about 1pm, as part of her routine checks of prisoners, a Staff Nurse looked
through the observation panel of the door that led into the ward. She saw the
woman hanging from the toilet door which was partly opened. The nurse called
for assistance. Four nurses who were in the rest room responded immediately.
One was asked to fetch the emergency equipment. Two others took the
woman’s weight while another cut the ligature. At this stage there were no
obvious signs of life. The woman was placed on the floor so that
cardiopulmonary resuscitation (CPR) could commence. One of the nurses
applied oxygen while another gave chest compressions. Both members of staff
noted that the woman was not breathing and had no pulse. At about 1.05pm, an
ambulance was called.
After about three minutes, a nurse telephoned the prison doctor who, at the time,
was taking his lunch break in the mess just outside the prison, and asked him to
attend. The nurse also fetched a resuscitation bag, emergency drugs and a
pulse oximetry machine. Meanwhile further attempts were made by two other
nurses to revive the woman.
At 1.21pm an ambulance operational supervisor arrived at the prison gate,
followed by a full paramedic team at 1.24pm.
22
At about the same time, the prison doctor arrived to attend to the woman. He
examined her and, although her breathing had not been established and her
pupils were fixed, he detected a slight pulse. Resuscitation techniques therefore
continued.
At about 1:35pm, the paramedics applied a defibrillator and gave further oxygen.
At 1:51pm, the woman was transferred to a nearby hospital. The ambulance
arrived at the hospital at 2:08pm.
The establishment’s contingency plan log shows that at 3:15pm the Prison
Service Press Office was informed of what had happened up to that point.
At 3:55pm, the woman was admitted to the Intensive Care Unit and placed on a
ventilator. At 4pm a member of the prison chaplaincy team visited her.
At 6pm, one of the senior managers at New Hall telephoned the woman’s mother
to let her know what had happened to her daughter. Arrangements were made
for a taxi to take her to see her daughter at the hospital. The cost of the taxi was
to be met by the establishment. At about 8:15pm, the senior manager met the
woman’s mother at the hospital and talked to her at length about the events that
had taken place earlier that day. As the senior manager retired shortly after the
woman’s death, it has not been possible to clarify why there was such a delay in
contacting the mother.
At 11:15pm, the woman’s mother decided to stay in the hospital overnight. A
short while later, other family members arrived at the hospital to see the woman.
All of them remained at the hospital overnight. The woman’s condition remained
unchanged that night.
12 October
The records show that at about 9:25am on 12 October, the woman’s mother was
awaiting advice from a doctor as to whether her daughter’s ventilator could be
switched off to allow her to breathe unaided. At 11:10am, it was confirmed that
the ventilator had been switched off, and the woman was breathing unaided.
The records show that, if the woman’s condition deteriorated, she would be re-
ventilated, but only for 24 hours.
Just after midday, a decision was made to withdraw the prison escorting staff.
The woman was effectively on temporary release from custody. Members of the
woman’s family remained at her bedside.
During the morning, the woman’s son, who at the time was also in prison locally,
was escorted to the hospital to see his mother. He was escorted in handcuffs.
Other members of the woman’s family arrived at the hospital during the course of
the morning. Both the Chaplain and the senior manager spent some time with
23
them. The record of communications between representatives of New Hall and
the family indicate that the mother did not want her daughter to be revived if
further difficulties arose. At 4:10pm, the woman passed away. The
establishment’s contingency plan log does not show if or when the Prison
Service Press Office was informed of her death.
Support for the woman’s family after her death
The next day, the Governor of New Hall spoke to the woman’s mother on the
telephone to express her condolences and to offer support, including financial
support for the funeral arrangements. During the conversation, the mother
expressed her concern that there had been a media announcement of her
daughter’s death in spite of the fact that she had asked that there should be no
publicity and that she had not been able to inform other close members of her
family beforehand. She was also concerned that her grandson had appeared in
the hospital handcuffed.
Between 13 and 26 October, the Chaplaincy team at New Hall kept in touch with
the woman’s mother to ensure that she felt supported following her daughter’s
death and in preparing for the funeral. She was reassured that the full funeral
costs would be paid for by the prison. The mother was offered the opportunity to
visit the prison, but she declined. She also requested that no prison staff should
attend the funeral. This request was honoured, but the Governor arranged for a
bouquet of flowers to be sent from the establishment to the undertakers.
The woman’s funeral took place on 27 October 2004.
24
8. Consideration of issues arising from the investigation
The following issues arose during the investigation:
• the absence of suicide prevention measures applied to the woman.
• the general level of care given to her.
• concerns expressed by the woman’s family:
- the nature of the medication prescribed for her
- the level of observations made on her
- the manner in which the news of her death was handled
- the escorting of her son to visit her in hospital in handcuffs
• the failure to administer the woman’s medication on 11 October
• issues raised by the Prison Officers’ Association.
The absence of suicide prevention measures applied to the woman
Loss of F2052SH 12-30 June 2004
The woman was made subject to self-harm monitoring procedures between 12
and 30 June during her first period in custody at New Hall in 2004. The
F2052SH that was used during that period was subsequently lost. It should have
been stored with her core and medical records following her release from
custody on 30 June 2004. It is an important document that should have been
available to staff when she returned to New Hall in August.
As a consequence of the loss of the F2052SH, my investigator was unable to
ascertain what specific circumstances led to the decision to place the woman on
self-harm monitoring procedures on 12 June. Neither was he able to judge how
well the woman was managed during the three-week period that the document
was open, nor to judge the appropriateness of the decision to close it.
The Governor should ensure that adequate arrangements are in place for
the safe storage of documents both whilst they are in use and after they
have been closed.
Absence of self-harm monitoring procedures: August to October 2004
I am concerned that at no stage during the woman’s second period of custody at
New Hall in 2004, was she made subject to formal self-harm monitoring
procedures.
The suicide prevention policy document in place at New Hall at the time of the
investigation lists a number of self-harm risk indicators, including the following:
- history of self harm
- pessimism about the future
25
- impending release.
These indicators were evident in the woman’s case: she had set fire to herself
prior to her imprisonment and had tried to slash her wrists whilst in police
custody. She was worried about where she was going to live once released from
prison and how she was going to cope in the community.
A pre-sentence report, prepared by her Probation Officer at the time of her court
appearance in September 2004, stressed that the woman would present a
significant risk of self-harm if imprisoned.
A few days after her court appearance, the woman told a psychiatrist that she
wanted to “curl up and sleep and never wake up”. She also said that she had
thought of hanging herself but that there was nowhere to do it because she had
looked. The psychiatrist thought that the woman was already on a F2052SH.
I believe that more careful consideration could have been given to the
assessment of the woman’s risk of self-harm and of the need to make her subject
to formal self-harm monitoring procedures. The nursing care plan drawn up for
her was comprehensive, but lacked any reference to the management of her risk.
The Governor and PCT jointly should review the extent to which the
establishment’s suicide prevention policy is appropriately applied by
healthcare staff, particularly in respect of those prisoners who, like the
woman, manifest symptoms suggestive of their being at risk of self-harm
or suicide.
The general level of care given to the woman
The Clinical Review assesses the management of the woman’s health needs
while she was in custody at New Hall on both occasions in 2004. In respect of
her first period of custody, the report concludes that her medical care, diagnosis,
treatment and review were thorough and appropriate.
However, the author of the Clinical Review draws attention to a number of flaws
in the management of the woman’s health needs during her second period of
custody. He makes a number of recommendations about:
- clinical governance, management and accountability.
- training in risk assessment and documentation.
- aspects of FACE (a tool by which the risk to self and others can be assessed)
and Care Plan Approach (CPA) documentation.
- clinical supervision.
- the physical environment of the healthcare centre, including the capacity of
staff to observe patients and the ligature points available in the centre.
- the need for visible leadership within the healthcare team.
26
- the administration of prescribed medication.
- the system for the restricted unlocking of prisoners.
I agree with the author’s findings and support the recommendations he has
made. These have been integrated with my own recommendations at the end of
my report.
Concerns expressed by the woman’s family
The woman’s mother asked my investigator to examine the following points:
- what medication was prescribed for her daughter and was her medication
changed at any time?
- why was she not observed more closely?
- why was her death announced by the media before her mother could inform
other close members of her family and when she had asked that there should
be no publicity?
- why was it necessary for her daughter’s son to be brought to his mother’s
bedside and to the funeral in handcuffs? Was the decision to do so based on
a risk assessment?
What medication was prescribed for the woman and was that medication
changed at any time?
Very shortly after her admission to New Hall in August 2004, the woman was
assessed as suffering from mood swings, hallucinations and paranoid ideation.
She was therefore prescribed chlorpromazine, an anti-psychotic drug for the
treatment of disorganised and psychotic thinking. This prescription was
maintained throughout her stay at New Hall, but the dosage was adjusted from
time to time according to the signs and symptoms that she presented. The
author of the Clinical Review raises no criticism about the prescription of
chlorpromazine or about the dosage.
However, the investigation found that the woman did not receive her medication
at about 8:30am on 11 October. At paragraph 6.3 of the Clinical Review, the
author comments as follows:
“I asked a consultant forensic psychiatrist, to provide an independent
medical opinion as to the difference the failure to administer
chlorpromazine on the morning of the woman’s death would have made.
He agreed that the absence of the drug on this occasion would have had
nothing more than a marginal effect on her mood in the time-scale
involved. However, there are clear duty of care issues that need to be
considered. Additionally, had this been a different drug being
administered, the effect on the individual could have been far more
significant.”
27
The following further comments are made in the concluding section of the
paragraph:
“The woman was in a hospital setting, she was receiving prescribed
medication and this medication was a key element of her treatment at
the time. The failure to administer the medication was not followed up
by any action, e.g. the workplace was not alerted and colleagues there
were not asked to monitor her/report any undue effect, there was no
discussion with senior colleagues or medical staff nor any other action
taken.
There are no systems or management checks in place for ensuring
medication has been administered appropriately before a patient
leaves the centre.
This situation therefore is most unsatisfactory and requires measures
to be put in place which place more vigilance on the administration
and monitoring of medications.
It is recommended that as a minimum:
1. There is a more robust unit medication policy in place that clearly
stipulates the arrangements for the administration of medicines by
registered nurses (as per South West Yorkshire NHS Mental Health
Trust policy).
2. There is a regular audit cycle established, administered by the local
Drugs & Therapeutic Committee, specifically focused on the efficacy
of the administration of medicines within the Health Care Centre.”
I endorse these recommendations.
Why was the woman not observed more closely?
My investigator was told that patients in the healthcare centre are routinely
observed by staff every 30 minutes, but that staff are not required to record
details of these observations unless the patient is subject to F2052SH
procedures. I have already made the comment that more careful consideration
could have been given to the assessment of the woman’s risk of self-harm and of
the need to make her subject to formal self-harm monitoring procedures. Had
she been subject to those procedures, the approach to her observation might
have been more structured and more responsive to her mental state.
The Clinical Review also comments on this matter. At paragraph 6.4 of the
review, the author comments as follows:
28
“In this particular case, the observation arrangements did not directly
fail. The woman was not on a F2052SH ... and therefore the service
requirement was for her to be monitored only on a 30 minute basis.
However, the arrangements for the management and oversight of
someone who was not on a F2052SH appear weak: there is no
procedural system in place to regulate this activity and there are
physical problems in the actual observation process currently which
need to be resolved.”
The physical problems to which the author refers relate to the presence and use
of blinds against the window which forms part of the partition between the ward in
which the woman was found hanging and the adjoining staff office. The blind
was in the closed position at the time the woman was discovered, thereby
preventing effective observation into the ward by staff. My investigator was told
that blinds were used to prevent prisoners looking at confidential papers in use in
the office.
In his review, the author comments,
“This particular issue poses a need to strike a balance between
confidentiality of records/documentation, access to observation and
patient dignity (the female prisoners are fully visible through the
glass window). Historically, the window has not been regarded as
having a primary function in terms of observation but in the light of
this incident a review and decision on the matter would be advised.”
I agree.
The Clinical Review goes on to make the following recommendations about the
physical arrangements for observing prisoners within the healthcare centre and
about observation policy in general:
“1. The Health Care Centre should review the physical
arrangements for observation within the unit, in particular the
use of the dividing glass window.
An observation/supervision policy be established (and audited)
that stipulates:
o the level of observation
o how observations are to be carried out
o recording and reporting arrangements
o monitoring and management arrangements
(South West Yorkshire NHS Mental Health Trust have recently
introduced a Supervision Policy which may be of
assistance).”
29
Included with these recommendations is a further suggestion, linked to the
physical problems to which the Clinical Review refers, that there should be a
“ligature review” to consider the proliferation of ligature points available in the
healthcare centre and ways in which these can be reduced. The author
recommends that this should be undertaken in partnership with the Safer
Custody Group (now part of the National Offender Management Service).
At the time of the investigation, the establishment’s suicide prevention policy set
out the procedures to be followed, including observation procedures, for
prisoners for whom a F2052SH is considered necessary. However, the policy
did not legislate for those prisoners, who, like the woman, find themselves in the
‘grey’ area in the Healthcare Centre: i.e. subject to a nursing care plan but not
subject to formal self-harm monitoring procedures.
It is within this context that I endorse the author’s recommendations.
Why was the woman’s death announced by the media before her mother could
inform other close members of the family and after requesting that there should
be no publicity?
My investigator was unable to ascertain the precise chronology of the events
concerning the handling of information in the woman’s case.
The establishment’s contingency plan log shows that at 3.15pm on 11 October,
the Prison Service Press Office was informed of the events regarding the woman
up to that point. There is no record of when the Press Office was informed of her
death. However, my investigator was told by the Press Office that the
establishment reported the death during the evening of 12 October. It is most
likely that, given the presence of some of the family members at the woman’s
bedside prior to, and at the point of, her death, an understandable assumption
was made by New Hall staff that the next of kin were fully aware of the
developing situation and that informing the Prison Service Press Office of the
woman’s prognosis at 3:15pm on 11 October was appropriate. It is unfortunate
that the log does not show when the Press Office was informed of the woman’s
actual death.
I understand the concerns expressed by the woman’s mother on this point, but in
the circumstances it would be unfair to criticise the establishment beyond this
recommendation:
The Governor should make sure that clear instructions are set out for the
handling of information to families and the Prison Service Press Office in
the event of the admission of a prisoner to hospital and after a prisoner’s
death. The Governor should also ensure that an accurate record is kept of
any communication made to the Press Office about such matters.
30
Why was it necessary for the woman’s son to be brought to her bedside and to
the funeral in handcuffs? Was the decision to do so based on a risk
assessment?
At the time of the discovery of the woman hanging at New Hall on 11 October
2004, her son was in prison at HMYOI Wetherby. Arrangements were made
between New Hall and Wetherby for the son to be taken to see his mother in
hospital. When he arrived he was in handcuffs.
My investigator interviewed the son and the manager at Wetherby responsible for
security. The son confirmed that he resented having to remain in handcuffs
during his visit with his mother, but was grateful for being allowed to see her.
The manager confirmed that a risk assessment had been completed at Wetherby
before permission was given by the Governor for the son to be taken to see his
mother. My investigator was shown the paperwork relating to the risk
assessment. He was not shown any paperwork relating to the risk assessment
undertaken for the funeral escort.
As much as I understand the concerns expressed by the woman’s mother, I am
satisfied that the decision to escort her grandson in handcuffs was based on a
full assessment of the security risk he presented and that the decision that he
should remain in handcuffs was justified.
Concerns expressed by the Prison Officers’ Association (POA)
The local branch of the POA raised the following matters with my investigator:
- They felt that, following the closure of mental institutions, many people who
would formerly have been sent to them were instead sent to prison. The
Prison Service’s healthcare resources were, therefore, having to cope with a
disproportionate number of mentally ill prisoners. The attention that had to be
afforded to such prisoners had the effect of reducing the amount of time staff
could spend with others. The POA considered that at New Hall the
Healthcare Centre was so full of mentally ill prisoners that it had effectively
become a no-go area for prisoners with other types of illness, or for prisoners
who simply needed a period of respite.
- The POA believed that there were so many prisoners subject to F2052SH
monitoring procedures at any given time that staff could not offer the level of
care each individual required. The level of observation required in each case
was too high for staff to be able to cater properly for individual needs. The
greater the number of F2052SH checks that had to be completed, the poorer
the quality each check became.
31
- They suggested that prisoners were frequently at the highest risk of self-harm
at weekends when staffing levels were at their lowest and when there was
often a reduction in the regime.
- Finally, the POA said that prisoners should be able to spend more time out of
their cells, not least because they could then be more easily observed.
My investigator asked the Governor to comment on the POA’s concerns.
• The Governor did not wish to comment on the claim made by the POA
that, following closure of mental institutions, many people who would
formerly have been sent to them were instead sent to prison.
• The Governor agreed that the inpatient unit at New Hall does, in the main,
cater for mentally ill women. However, she pointed out that the unit also
caters for women who have acute physical illness, if they cannot be cared
for on normal location. The Governor disagreed with the assertion that the
inpatient unit had become a ‘no go’ area for those women requiring
admission for acute physical conditions. The Governor stressed that the
inpatient unit criteria for clinical admission did not include admission for
women who need a period of respite. However, managers had co-
operated to facilitate that type of service as and when it was required, and
when it could be accommodated.
• The Governor pointed out that, during October 2004, there were 78
F2052SH documents opened. Seventy F2052SH documents were also
closed. There was a total of 111 reported incidents of self harm during
October 2004. The year to date (31 October, 2004) figure of self-harm
incidents indicated some 873 acts of self harm at HMP/YOI New Hall.
During the same period for 2003, there were 1,181 recorded incidents of
self-harm. The Governor noted that this showed a reduction of some 308
incidents of self-harm from the previous year.
• The Governor had some difficulty in commenting on the POA’s assertion
that the level of observations required in each case was too high for staff
to be able to cater properly for individuals needs, as these observation
levels were set by a multi disciplinary team of staff who had gathered to
assess/manage individual case reviews of those prisoners who were
deemed to be at risk at the time. The Governor pointed out that this was
in line with the Local Suicide & Self Harm Prevention Policy Document, as
the establishment promoted a “holistic” whole prison approach to the
management of those prisoners identified as being at risk of suicide and
self-harm.
• The Governor stressed that she was aware of the fact that the number of
prisoners subject to F2052SH monitoring at the time of the woman’s death
32
was slightly higher than the figure recorded the previous month. However,
she stressed that, although there were 111 acts of self-harm reported in
October 2004, only a small number of prisoners were responsible for a
high proportion of these incidents.
• In response to the POA’s assertion that prisoners were frequently at the
highest risk of self-harm at weekends, when staffing levels were at their
lowest, or when there was a reduction in the regime, the Governor
reported that 62 per cent of the incidents that occurred in October 2004
happened during weekdays and only 38 per cent occurred at weekends.
The times during which the incidents occurred were:
8am – 12 noon, 16 incidents (14.5%)
12 noon – 8pm, 65 incidents (58.5%)
8pm – 8am, 30 incidents (27%)
The Governor also provided similar statistics for incidents that took place
in the healthcare centre in the same month. Fourteen incidents of self-
harm were recorded for the month, involving only four prisoners. Of these
14 incidents, nine took place between Monday and Friday. The remainder
took place at weekends.
• In response to the POA’s concern about the length of time prisoners were
able to spend out of their cells, the Governor presented statistics showing
out of cell activity hours for the Healthcare Centre for the whole of 2004.
These showed that the yearly out of cell activity time was 7.91 hours of
purposeful activity per prisoner per day. The monthly figure recorded for
eleven of the twelve months was eight hours per prisoner per day. This
was against the prison’s Key Performance Target of ten hours. The
Governor felt that the hours achieved in the Healthcare Centre were
realistic, given the difficulties presented by a difficult and challenging client
group.
During the course of the investigation, my investigator was impressed by the
personal commitment shown by the Governor to the enormously challenging task
of catering for the individual and collective needs of those in her charge. My
investigator was no less impressed by the sincerity and determination shown by
the staff at New Hall in facing up to their responsibilities for the care of prisoners.
The representations made to the investigation by the Prison Officers’ Association
are, I believe, an expression of the genuine concern felt generally at New Hall
about the difficulties imposed on the institution by the imprisonment of so many
mentally ill and vulnerable young and adult women. The statistical information
presented to my investigator in respect of the number of self-harm incidents and
the number of F2052SH documents opened and closed at New Hall around the
33
time the woman died are testimony to the very serious problems faced on a daily
basis by the Governor and her staff.
Her Majesty’s Chief Inspector of Prisons has drawn attention to these problems
in her reports on women’s prisons, including New Hall. In my description of the
establishment earlier, I have referred to the report of an inspection of New Hall by
the Chief Inspector in November 2003 in which she commented that the prison
was holding women and girls who should not be there. I echo her words. The
woman was, in my view, typical of those damaged and vulnerable women whose
needs cannot be met in prison.
34
9. Recommendations
(These recommendations are derived both from the Ombudsman’s report
and the Clinical Review.)
1. Suicide prevention
• The Governor should ensure that adequate arrangements are in place for
the safe storage of self-harm forms both whilst they are in use and after
they have been closed.
• The Governor and PCT jointly should review the extent to which the
establishment’s suicide prevention policy is appropriately applied by
healthcare staff, particularly in respect of those prisoners who, like the
woman, manifest symptoms suggestive of their being at risk of self-harm
or suicide.
• The Governor should ensure that a clear policy is put in place in the
Healthcare Centre for the monitoring of inpatients, especially in respect of
those who are considered to be at risk of self-harm or suicide. The policy
should stipulate:
o the level of observation
o how observations are to be carried out
o recording and reporting arrangements
o monitoring and management arrangements, including audit (South
West Yorkshire NHS Mental Health Trust have recently introduced
a Supervision Policy which may be of assistance.)
• The Governor should review the physical arrangements for observation of
inpatients in the Healthcare Centre, especially where the window dividing
ward H2.01 and the staff office is concerned.
• The Governor should carry out a review of the current ligature points in
the Healthcare Centre.
2. Information to next of kin
• The Governor should make sure that clear instructions are set out for the
timely handling of information to families and the Prison Service Press
Office in the event of the admission of a prisoner to hospital and after a
prisoner’s death. The Governor should also ensure that an accurate
record is kept of any communication made to the Press Office about such
matters.
35
3 . Clinical governance
In conjunction with the Wakefield West Primary Care Trust, the Governor should:
• urgently review and agree clinical governance management and
accountability arrangements.
• review the arrangements for risk assessment and risk management to
ensure a co-ordinated process that brings together all risk assessment
activity.
• establish a prioritised training and development plan for relevant nursing
staff that includes risk assessment, management of deliberate self-harm
and suicide, and documentation standards.
• review the arrangements for the operation of the integrated FACE/CPA
documentation process to ensure that appropriate summarised
background and other relevant information is included within this
assessment process.
• review the arrangements for clinical supervision and ensure that systems
are put in place to help staff maintain and develop their standards of
professional knowledge and competence (consistent with Nursing &
Midwifery Council Code of Professional Conduct requirements).
• implement the recommendations from the “In Patients Risk Management
Profile 2003” and the report by Dr Louisa Snow: “Overview of Suicide and
Self Harm Prevention at HMP New Hall, 2004”.
• undertake a NHS Patient Environment Team Assessment (PEAT)
specifically for the inpatient facility in the healthcare centre, in respect of
its physical care environment, with the aim of providing an appropriate
therapeutic milieu for patient care (e.g. standards of decoration, furniture,
fitments).
• ensure that there is visible leadership within the Healthcare Centre in
support of staff and to promote and maintain standards (the siting of a
nurse manager’s office within the unit may assist in this process).
• ensure that a clear medication policy is put in place in the Healthcare
Centre that stipulates the arrangements for the administration of
medicines by registered nurses (as per South West Yorkshire NHS Mental
Health Trust policy).
36
• ensure that a regular audit cycle is established, administered by the local
Drugs & Therapeutic Committee and specifically focused on the efficacy of
the administration of medicines within the healthcare centre.
• ensure that the present “restricted unlock” system that operates within the
healthcare centre is made subject to a procedural process.
37
Annex A
PRISON SERVICE PLAN OF ACTION FOR IMPLEMENTATION OF
RECOMMENDATIONS
Accepted
/Partially Target date
No Recommendation accepted/ Response for
Not completion
accepted
The Governor should
Since the Implementation of
ensure that adequate
ACCT at New Hall (March 05),
arrangements are in place 28th February
all closed ACCT Documents are
for the safe storage of self- 2006
1 Accept returned to the Safer Custody
harm forms both whilst they
Office to be filed securely. Local
are in use and after they
Notice to staff to be issued to
have been closed.
remind staff of this process.
The Governor and PCT The Current Policy dated April
jointly should review the 2005 has recently been
extent to which the reviewed and the first draft is
establishment’s suicide due to go out to consultation to
prevention policy is the Suicide Prevention
appropriately applied by Committee, members of SMT,
healthcare staff, particularly POA and Y&H Area Safer
31st March
in respect of those Custody Advisor by 28th Feb
2006
2 prisoners who, like the Accept 2006. The Suicide Prevention
woman, manifest symptoms Policy & Procedures document
suggestive of their being at was reviewed as a result of a
risk of self-harm or suicide. previous PPO recommendation.
Once this has been accepted, it
can be discussed with PCT, and
review the extent to which it is
applied by Healthcare staff at
New Hall
The Governor should
ensure that a clear policy is The Current Suicide Prevention 31st March
put in place in the Policy Document identifies the 2006
Healthcare Centre for the minimum number of entries that
monitoring of inpatients, are required within an open
especially in respect of ACCT Document on a daily
those who are considered basis. These must be qualitative
to be at risk of self-harm or entries, which demonstrate
suicide. The policy should interaction (a conversation) has
3 stipulate: taken place with the prisoner
Accept
subject to ACCT procedures.
• the level of The level of observation a
observation prisoner is on will be considered
• how observations on an individual basis, and will
are to be carried be set by a local Case
out Management Review.
• recording and reporting
arrangements A new Inpatient Policy will be 30th April
monitoring and formulated in partnership with 2006
38
management South West Yorkshire Mental
arrangements, Health Trust which will cover all
including audit areas identified within the
(South West Yorkshire NHS Clinical Review.
Mental Health Trust have
recently introduced a
Supervision Policy which
may be of assistance.)
The Governor should Y&H Area Safer Custody 31st March
review the physical Advisor has agreed to look at 2006
arrangements for this recommendation in relation
observation of inpatients in to the observation of In patients
the Healthcare Centre, as part of his visit to review
especially where the ligature points within the
window dividing ward H2.01 Healthcare Centre at HMP/YOI
and the staff office is New Hall (As per
concerned. Recommendation 5) and include
in his report to the Head of Safer
4 Accept
Custody. The long-term plan for
the 5 bed ward area is that it will
become a day care facility. This
is due to be implemented in
January 2007. In the short term
levels of observations for this
facility will be covered in the
revised in patient policy
document as per
recommendation 3.
The Governor should carry 31st March
out a review of the current 2006
5 ligature points in the Accept As per Recommendation 4
Healthcare Centre.
The Governor should make HMP/YOI New Hall has trained
sure that clear instructions and appointed two Family
are set out for the timely Liaison Officers. Part of their
handling of information to role is to deal with the timely
families and the Prison handling of information to
Service Press Office in the families. Death In Custody
event of the admission of a Contingency Plans highlight the
prisoner to hospital and need to record the time we
30th April
after a prisoner’s death. contact the press office in
2006
6 The Governor should also Accept relation to any Death In Custody.
ensure that an accurate HMP/YOI New Hall to formalise
record is kept of any a local Protocol which identifies
communication made to the a formal risk assessment
Press Office about such procedure and strategy for
matters. working with bereaved families.
Consideration will be given to
allowing the Family Liaison
Officer to attend the Media
Liaison Officers Course.
In conjunction with the
Wakefield West Primary Carry out a review of the current
7 Accept
Care Trust, the Governor Clinical Governance August 2006
should: Management & Accountability
39
urgently review and agree arrangements in line with the
clinical governance findings contained within the
management and Clinical Review as part of this
accountability PPO Report. A project team will
arrangements. be established to develop joint
Clinical Governance
arrangements across the 3
service providers.
FACE Risk Assessment, Cell
Sharing Risk Assessment, Completed
reception screening and finally
ACCT Document where
appropriate are all completed for
Review the arrangements
prisoners who are admitted to
for risk assessment and risk
the In patient Unit. This
management to ensure a
8 Accept information will be shared on a
co-ordinated process that
need to know basis with other
brings together all risk
disciplines with the patients
assessment activity.
consent. All three documents will
be discussed at the weekly
multi-disciplinary ward round.
The Inpatient manager will be
responsible for the process.
Establish a prioritised Clinical Training and a Training
training and development Plan will be formulated for the
plan for relevant nursing Mental Health team, which will
staff that includes risk include Risk Assessment and
9 Accept
assessment, management Management of Self Harm, in August 2006
of deliberate self-harm and partnership with South West
suicide, and documentation Yorkshire Mental Health Trust.
standards.
Review the arrangements FACE & CPA is now in place
for the operation of the within the In-patient facility.
integrated FACE/CPA Every prisoner admitted as an in
documentation process to patient has a FACE document
ensure that appropriate completed and placed within the
10 Accept Completed
summarised background CPA folder on the P Drive to
and other relevant allow all Healthcare staff access.
information is included
within this assessment
process.
Review the arrangements
for clinical supervision and
ensure that systems are put
Carryout a Full Review of the
in place to help staff
current Clinical Supervision
maintain and develop their
Procedures in operation at New
standards of professional
11 Accept Hall and make recommendations
knowledge and
in line with the findings of the August 2006
competence (consistent
Clinical Review as part of this
with Nursing & Midwifery
PPO Report.
Council Code of
Professional Conduct
requirements).
Implement the Most if not all of the 30th
Partially
12 recommendations from the recommendations made by Dr December
accept
“In Patients Risk Louisa Snow in her report 2006
40
Management Profile 2003” “Overview of Suicide and Self
and the report by Dr Louisa Harm Prevention at HMP New
Snow: “Overview of Suicide Hall 2004” have been
and Self Harm Prevention implemented. These
at HMP New Hall, 2004”. recommendations shall be
reviewed in consultation with Dr
Louisa Snow.
A full review of current service
provision will take place, which
will systematically look at Risk
Management, Workforce Issues
and Service Delivery, which will
supersede the Risk
Management Profile 2003
document.
Undertake a NHS Patient
Environment Team PEAT Assessment completed in
Assessment (PEAT) September 2005, and Action
specifically for the inpatient Plan completed as part of this
facility in the healthcare assessment. All of the By End of
centre, in respect of its recommendations from PEAT Feb 2006
13 physical care environment; Accept Assessment have now been
with the aim of providing an completed with the exception of
appropriate therapeutic a civilian cleaner and pictures for
milieu for patient care (e.g. the walls of the In Patient Unit.
standards of decoration,
furniture and fitments).
The Operational Capacity of the By 30th April
In Patient Unit has been reduced 2006
from 19 to a 10 Bed Facility.
This allows for the conversion of
one cell into an In Patient Unit
Managers office once funding
has been secured. Bid for
Ensure that there is visible funding for conversion to be
leadership within the completed and submitted. The
healthcare centre in support interim measure has a SHCO as
of staff and to promote and inpatient manager, who has
14 Accept
maintain standards (the completed the first year of his
siting of a nurse manager’s RMN, supported by Head of
office within the unit may Healthcare who is RMN, and
assist in this process). Mental health Project manager
SWYMHT will appoint a band 6
mental health lead who will
based on inpatients, and line
managed by a band 7 who will
have overall responsibility for
clinical leadership.
Ensure that a clear Medication Policy will be 30th April
medication policy is put in formulated in partnership with 2006
place in the healthcare South West Yorkshire Mental
15 Accept
centre that stipulates the Health Trust
arrangements for the
administration of medicines
41
by registered nurses (as
per South West Yorkshire
NHS Mental Health Trust
policy).
Ensure that a regular audit This will be reviewed by the 30th April
cycle is established, Medicines Management 2006
administered by the local Committee and any appropriate
Drugs & Therapeutic action taken
16 Committee and specifically Accept
focused on the efficacy of
the administration of
medicines within the
healthcare centre.
Ensure that the present A full review of the Restricted
“restricted unlock” system Unlock system in operation Completed
that operates within the within the Inpatient Unit, has
healthcare centre is made been carried out and a written
17 subject to a procedural Accept Policy and Procedures
process. document for the Use of
Restricted Unlock status within
the In patient Unit has been
produced and implemented.
42
43