Individual at New Hall

Investigation into the circumstances surrounding the death of a woman
on 29 July 2004 at HMP New Hall
Prisons and Probation Ombudsman for England and Wales
June 2005
FINAL REPORT
CONTENTS
Summary 4
The woman 5
HMP New Hall 6
Investigation Process 7
Findings 8
Recommendations 19
Annexes 22
2
The woman was aged 29 when she died on 29 July 2004 in her cell at HMP
New Hall. This is a report into the circumstances surrounding her death. The
loss of any family member is distressing, but especially so whilst they are in
custody and I offer my sincere condolences to her family and friends.
The investigation was carried out by a member of my office, and assisted by a
manager from HMP Northallerton. I would like to thank the Governor of New
Hall for making the necessary facilities available to my investigator. I also pay
thanks for the help and support of the Liaison Officer for his invaluable
assistance.
In the course of the investigation, I asked the Wakefield Primary Care Trust to
undertake a clinical review of the care and treatment received by the woman
from HMP New Hall, and one was commissioned. The Suicide Prevention
Consultant, of the HMPS Women’s Team, also undertook a snapshot of the
prison’s suicide and self-harm procedures and compliance with the relevant
Prison Service Order. The Nurse Consultant, Substance Misuse, again of the
HMPS Women’s Team, reviewed the prison’s compliance with Prison Service
Policy on detoxification. I am grateful for all three documents. They make a
number of recommendations in their reports, all of which I support.
My report makes recommendations for the Prison Service, for the Prison and
for Derbyshire Probation Service under five separate headings. One of the
recommendations is repeated from a previous death in custody investigation.
I am pleased to be able to make three good practice recommendations.
Overall I am satisfied that the care and treatment the woman received was
appropriate and compassionate. However, I do have concerns that self-harm
warnings were not dealt with appropriately.
Stephen Shaw CBE
Prisons and Probation Ombudsman for England and Wales
June 2005
3
Summary
1. The woman died on 29 July 2004 some 13 days after being remanded
into the custody of HMP New Hall, by South Derby Magistrates’ Court,
where she had been charged with theft. The court appearance was
adjourned until 6 August to allow for further enquiries to be made and
to determine the most suitable method of dealing with the case.
2. The clinical review carried out on behalf of the Wakefield PCT makes
no recommendations for the prison. It makes two observations under
the heading “Commentary and Recommendation”.
• It was obviously felt that the level of observation possible in the
detox unit was sufficient to ensure that any attempt at self-harm
would be detected. In consequence no F2052SH was opened,
despite the “gesture” which had occurred prior to admission.
• Had a F2052SH been opened, an enhanced level of supervision
may have helped prevent her death on the wing five days after
the end of detox.
3. The woman’s family have no questions regarding the care and
treatment she received whilst in prison and are content to leave the
investigation team to assess this on their behalf. Her family were
invited to meet with the Governor at the prison, which they did. They
described the prison as being supportive at the time of her death and
afterwards. The only question to which they would like an answer to is
why she decided to end her life. Unfortunately, this is a question to
which this report cannot provide an answer.
4. The investigation team found that the prison Chaplaincy Team was
viewed by prisoners as very supportive, accessible and caring. A
service for the woman was held at a church in Wales, attended by the
Governor, Deputy Governor and Chaplain. The Governor has very
kindly offered to assist her family with travelling costs in order that they
can attend the inquest. This is an excellent gesture.
5. At the time of her death, there had been a total of eight self-inflicted
deaths in New Hall since 1 January 2000. Since her death there have
been a further two self-inflicted deaths at the prison.
4
The woman
6. She was born on 31 March 1975 in Wales and aged 29 when she died.
She was one of a family of five girls and a boy. She was educated in
Wales and left school at the age of 15 years. It was soon after leaving
school that she began to offend, which resulted in a number of court
appearances and custodial sentences. The majority of her offending
history was drug related. She had one son, whom she adored, but had
not seen for some time. At the time of her death, her son was living
with his natural father.
7. On 16 July 2004, she was remanded into custody on theft charges. It
was whilst in the court cells pending her transfer to New Hall that she
made an attempt to self-harm by tying a ligature around her neck using
her shoe laces. There was no information to suggest that she had
made any attempt to self-harm previous to the court cell incident.
8. On her arrival at New Hall, she agreed to join the prison detoxification
programme. She was placed on a methadone reduction programme,
which she completed five days prior to her death.
9. As she had not been considered by the prison to be at risk of suicide,
she was not given the opportunity to sit down with a multi-disciplinary
suicide and self-harm team to discuss what had caused her to attempt
to harm herself in the court cells.
5
HMP New Hall
10.New Hall is located at Flockton on the outskirts of Wakefield and was
originally used as a satellite prison to HMP Wakefield. In 1961 the role
of the prison changed to holding male young offenders and in 1987 it
changed again to an all female establishment. It currently holds adult
women and young offenders who are either sentenced or remanded
into custody by the courts. The Certified Normal Accommodation
(CNA) is 367 with an Operational Capacity of 428. The population
breakdown at January 2005 was adults 74 per cent, young offenders
11.6 per cent and Juveniles 14.4 per cent.
11.The prison offers a variety of regime activities including offence related
courses. It has a well-established detoxification unit, offering support
and treatment to those who wish to engage with the programme.
12.In November 2003, the Chief Inspector of Prisons carried out an
inspection of the prison and summarised the visit saying:
• there is a need for active involvement by community agencies, such as
social services, drug treatment providers, employers and housing
agencies, to support the work done in the prison.
• like other women’s prisons, New Hall is holding women and girls who
are seriously mentally ill or with high levels of self harm, linked to
substance abuse. There is an urgent need to provide alternative
therapeutic environments where appropriate treatment and support
can be offered.
13.In February 2003, a full Standards and Security audit was carried out
by the Prison Service. The prison was given a “Good” rating for both
Security and Standards and rated at 84 per cent in both areas. The
latest Audit carried out in February 2005 assessed the security as 85
per cent, critical baseline standards as 83 per cent and standards audit
modules as 71 per cent. The self-audit for Suicide and Self-harm was
assessed as 90 per cent.
6
Investigation Process
14.The investigation team met with the Governor at the prison. T he
Governor briefed the team and made a number of documents relating
to the woman available. She appointed a manager to act as the teams
Liaison Officer. The team also met with a member of the Independent
Monitoring Board (IMB) and a member of the Prison Officers
Association, (POA), to brief them about the investigation.
15.The investigation team viewed the cell that the woman had occupied.
In order to familiarise themselves with the wing routines, they spoke to
staff employed on the wing.
16.The documents were examined and a list of staff and prisoners
identified whom the team would want to interview. The Liaison Officer
made the necessary arrangements for the interviews to take place.
17.The investigation team was given additional specialist support
regarding suicide prevention and substance misuse from members of
the Prison Service Women’s Team.
18.The investigation team received full co-operation from staff and
prisoners.
7
Findings
19.On 16 July 2004 the woman, who at the time was of no fixed abode
(NFA), was remanded into custody by the South Derbyshire
Magistrates’ Court on theft charges and allocated to HMP New Hall. A
Probation Officer was in court when she was remanded into custody.
Her role was to monitor court appearances which may require action by
the Probation Service. The Probation Officer made a statement to the
police and said that she had noticed the woman becoming depressed
when the court heard of her son being taken into care in Wales. The
Probation Officer was so concerned at the woman’s body language
that she suggested to her line manager that the woman should be
interviewed immediately. She stated that she had made this
suggestion in order to assess the woman for any thought of self-harm
and to alert the custody staff.
20.The Probation Officer’s line manager gave a statement to the police
and stated that he interviewed the woman following his Probation
Officer’s request. The woman had admitted to him that she had tried to
commit suicide in the court cells that day by tying her shoelaces around
her neck and that the cell custody officer had found her. She also said
on at least two occasions to him, “I’m going to do it”. He had made an
entry on the Probation Case Records and Management System
(CRAMS) that she was depressed and withdrawing from heroin. He
stated that she was suicidal and that she had removed her shoelaces
to tie around her neck. He also said that he had alerted Group 4
(escort company) and HMP New Hall to his concerns. He said that the
woman informed him that she had not wanted to be found and that she
was concerned at just having her son taken from her and feared she
would lose him.
21.The woman was located in the court cells awaiting transfer to prison.
The investigation team understand from the police officer dealing with
the incident that, due to the level of concern for her safety a 15-minute
monitoring watch was commenced by the court staff. This means that
she would have been observed at least every 15 minutes.
22.The Senior Probation Officer (SPO) completed the Post-Sentence
Interview (PSI) report and the Prison Service Suicide and Self-Harm
Warning form alerting the escort company and Prison Service to the
fact that she was suicidal. However, he did not make any specific entry
onto the warning forms that she was upset at her son being taken
away.
Concerns of suicidal or self-harm issues should clearly note the
specific information (if known) on the Self-Harm Warning Sheet.
23.The SPO also took the additional precaution of ringing the prison’s
Probation Office directly and informing them of what had occurred in
the cells.
8
The SPO should be commended for his efforts to alert the
establishment to his concerns.
24.The SPO telephoned New Hall Probation Office and spoke to the
Probation Administration Assistant. She made a brief note of her
conversation which indicates that he had informed her of the child
protection issues. She then transferred a summary of the message
onto the Head of Custody (HoC) by e mail.
25.Following a previous death in custody, it had been recommended and
accepted by the Governor that any information regarding concern of
self-harm being received from an outside source required the recipient
of the information to carry out specific tasks. The prison Suicide and
Self-Harm Policy was updated in October 2003 to reflect this. At page
six, paragraphs five and six, the policy says that the person receiving
the information should ensure: (a) the prisoner/trainee location is
identified, (b) the Orderly Officer is informed, (c) the relevant
Residential Manager is informed, (d) records action taken in telephone
log book or wing book. The investigation team could find no evidence
of this having taken place. Paragraph six of the policy instructs that a
review of the information should be made by the Orderly Officer in
consultation with other relevant staff and the individual and an
assessment made to open form F2052SH and if not then a record to
show why the form was not opened. This procedure was not carried
out either.
26.It is unclear why the Probation Administration Assistant did not follow
the instructions contained in the Local Suicide and Self-Harm Policy
and contact the Orderly Officer. However, the investigation team are
satisfied that she made every effort to ensure that relevant staff were
informed. In her statement, she said that following the phone call from
the SPO she took the information to Reception staff. The investigation
team was unable to establish whom the message was passed to and
none of the Reception staff interviewed recalled any conversation with
the Probation Administration Assistant regarding concerns about the
woman.
27.Unfortunately the HoC was not on duty at the time the Probation
Administration Assistant sent the e-mail to her. However the HoC
confirmed that she opened the e-mail the following day when she
returned to duty. She followed up the e-mail that day and was satisfied
that the woman had been assessed and that the need to open a
F2052SH was not required.
28.Once the Reception staff receive someone into custody they either
open a new prison record (F2050 Core Record) for a first time
reception or add information to an existing core record. The
information would also be entered on the Local Inmate Data System
(LIDS), which is a computer system holding the core information on an
9
individual prisoner. The prisoner is then searched before being
interviewed by the Reception screening nurse. The nurse will complete
a Cell Sharing Risk Assessment form, which is used to identify anyone
likely to harm others and notes any concerns.
29.The Core Record was completed. The woman was given prison
number JL8656.
30.In the woman’s case the risk assessment form shows at section three
that the warning from the Prison Escort Record (PER) and Suicide and
Self-Harm Warning sheet written by the SPO had been transferred to
the assessment form.
31.Additionally, the Reception Officer also noted the information from the
PER form and Self-Harm Warning sheet and made an entry on the
reception sheet, underlined in red, “warning”. It is a matter of concern
that, despite clear warnings from the Probation Staff at Court, the
policy was not followed by at least five members of staff who initially
dealt with the woman at New Hall.
The Governor should ensure that all staff adhere to the local
Suicide and Self-Harm Policy regarding information being
received from an external source. (Previous Recommendation)
32.The Orderly Officer will, as part of their duties, visit the Reception area
and sign the Reception book to show that they have attended. The
investigation team were not satisfied that the Orderly Officer would
ever be made aware of anyone arriving on a warning form, where a
decision had been taken not to open a F2052SH by the Reception
staff.
The Orderly Officer should examine the Reception register each
evening and satisfy himself/herself that all prisoners received that
day with a warning note have been assessed correctly with regard
to not opening a F2052SH.
33.The Reception Unit has a Senior Officer as the line manager. T he
manager appeared to be regularly taken away from the area to support
the establishment. The absence of the line manager leaves a void in a
vulnerable area in which officers are making decisions without clear
leadership.
The Governor should consider re-examining the staffing profiles
to ensure that a manager is on duty in the Reception department
at all times, when prisoners are likely to be received/discharged.
34.The Reception referral sheet identifies a number of action points, all of
which were dealt with by the Healthcare Department. The Reception
Urine Testing record indicates that the woman had tested positive for
10
benzodiazepine, cocaine and cannabis and had agreed to consent to
an Opiate Detoxification programme.
35.The investigation team examined the procedure for deciding how a
prisoner arriving at the prison and identified as being at risk would be
assessed to decide whether to open an F2052SH. Additionally, the
team asked what the procedures were for processing a prisoner
through Reception. Four Reception Officers were interviewed. The
answers given varied from “it’s the nurse that decides once she has
interviewed the prisoner”, “an individual can open the document” and “it
is a group decision following discussion”, with no clear definitive
answer being given. It is clear that some confusion exists within the
Reception group as to who has the responsibility.
The Governor should ensure that no single individual has the final
say regarding whether to open form F2052SH or not.
36.A nurse interviewed the woman on her initial reception into custody and
decided not to open an F2052SH. In her statement, the nurse
confirmed that she was aware of the warnings regarding the woman
and that she had read and understood the local policy regarding
information received from an outside source. She said that it does not
always happen due to the information being received from outside
sources being false. She went on to say if one was opened on every
girl who said they had been depressed in the past, then everyone
arriving would have a F2052SH opened. This view is a cause for
concern. She also said that all those on the “detox” unit were subject
to a 30-minute observation check by the wing staff. The investigation
team found that this only applied to the night-time lock up periods, not
during the day and applicable to the first 48 hours only. Observation
during the day was not so predictable.
37.The investigation team questioned the Reception staff about the
Suicide and Self-Harm Warning sheet and asked why it had not been
acted upon. A number of staff gave the impression that the escort
company over-used the warning notice, “just to cover their backs” and
assessed all prisoners as at risk. We could find no evidence to support
this and the Reception records examined clearly showed this not to be
the case.
The local suicide and self-harm policy should be republished as a
matter of urgency and a retraining programme developed to
ensure that all staff are aware of their responsibilities.
38.Prisoners arriving at Reception are processed in stages and are
interviewed by up to three different people, including the nurse.
However, the available prisoner information about the prisoner may not
be available to each officer/nurse when they conduct the interview.
Important information may be known to one person but not to the other
members of the team.
11
The Governor should remind Reception staff of the importance of
sharing information in order to make informed decisions.
39.Members of Wakefield West Primary Care Trust reviewed the
investigation draft report and suggested an additional recommendation
regarding the reception process, which I am happy to accept.
The reception process should be more effectively co-ordinated
across the multi disciplinary Healthcare team.
40.My investigator met with a Manager from the escort company at
Wakefield. The Manager explained that the F2052SH had been
withdrawn from the courts and escort agencies and replaced with the
Suicide and Self-Harm Warning form. However, it was his belief that
the form would be processed in the same way as the F2052SH and
that a multi-disciplinary suicide and self-harm team would review the
prisoner. He was not aware that the prison did not recognise the new
form in the same way as anyone arriving on an open F2052SH. An
open F2052SH is the term used by the Prison Service to refer to
anyone arriving at an establishment and being monitored under the
self-harm procedure.
41.The Suicide Prevention Consultant for the Women’s Team was
commissioned to carry out a “snapshot” of New Hall’s adherence to
Prison Service Order 2700 (PSO 2700) Suicide and Self-Harm
Prevention. She identified difficulties within New Hall of communicating
prisoners “at risk” and that the prison was not meeting all of the
mandatory requirements of Annex “A” of PSO2700. Her report makes a
number of recommendations for the prison. The investigation team
concurs with her recommendations.
The Governor should action the recommendations made by the
Suicide Prevention Consultant.
42.The Reception officers and nurse were asked about their knowledge of
the local suicide and self-harm policy and when they last received
training on the subject. It was clear from the answers given that
Reception staff had given little attention to it and that training was
viewed as optional.
The Reception staff should receive additional training on the local
suicide and self-harm policy. The training should be a mandatory
annual subject for Reception staff. Suicide and Self-Harm training
should be a mandatory requirement for all new officers
designated to work in the Reception area.
43.On 17 July, an officer interviewed the woman and completed the
Detoxification Wing Compact and the Detoxification Induction form. He
did not identify any concerns from the interview.
12
44.The woman was initially allocated to the Detoxification Unit on a nine
day methadone reducing programme. She remained there until 24 July
and then moved to E wing, where she shared a cell. On the morning of
29 July, her cellmate was discharged from the prison leaving her on
her own.
45. A member of the Prison Service’s Women’s Team reviewed the
prison’s compliance with PSO 3550 and concluded that the woman’s
withdrawal from drugs was adequately managed in accordance with
the agreed women’s protocols in place at the time of her reception.
Her report makes eight recommendations and notes that the
recommendations are made with a view to improving the care of this
very vulnerable, high-risk group of women in prison.
The Governor should action the recommendations made by the
Nurse Consultant.
46.A nurse interviewed the woman on her initial reception into New Hall
and noted a previous history of depression and arranged for her to be
interviewed by the psychiatric services. On 26 July, the Forensic
Nurse Consultant interviewed her. Using the Functional Analysis Core
Environment (FACE) Risk Assessment Form, he noted on page one a
self-harm attempt within the previous week. The identified risk of self-
harm was noted on two occasions under the heading of “History” which
rated her as “Low Apparent Risk”. As she had made a self-harm
attempt within the last month the indicator was incorrect and should
have been identified as current, as per the instructions.
The Governor should remind clinical staff of the importance of
ensuring that the FACE record is completed accurately.
47.Following the interview with the Forensic Nurse Consultant, she was
later interviewed by “the In Reach Team” consisting of the CPA Co-
ordinator, the Assistant Healthcare Manager and another Clinical
Manager (Unidentified). The In Reach Team is commissioned by the
West Yorkshire Mental Health Trust to work with patients with severe
and enduring mental illness. In his statement, the CPA Co-ordinator
said that the purpose of the meeting is to look at the needs and safety
of an individual. The current history was available to them and they
were aware of the self-strangulation attempt but did not at any stage
decide to open form F2052SH. The CPA Co-ordinator said that the
meeting does not have a recognised chair and the discussions are not
minuted. The woman was not considered as falling within the scope
of the team. She was though referred to a Clinical Nurse Specialist
(CNS) as identified on page 1 of the FACE document. She did not see
the CNS, as she died before an appointment could be obtained.
13
The FACE assessment meeting should have a recognised
chairperson, who is responsible for the agenda, terms of
reference and taking a record of the decisions made.
48.A member of the Probation Service met the woman on 27 July at New
Hall and informed her that her son would be returning to his father. Her
report contains an entry made on 28 July, which described the woman
as being low and tearful during the visit. The visit date has been
confirmed by the prison as 27 July and not 28. It also indicates that
this would be confirmed in writing. The final entry shows that a letter
had been typed and placed in the post. The police officer responsible
for the case confirmed that he found no evidence to show that the
woman or the prison ever received the letter. A copy of the letter has
been made available to the investigation team by the police and
informs her of the decision to allow her son to remain with his father. It
is a matter of concern that the Probation Service did not share with the
prison the nature of their visit and the observations about her distress.
The Governor should seek protocols with visiting agencies with
the aim of sharing information that is likely to cause distress to a
prisoner and to alert the prison to any observations of the
prisoner noted during a meeting
49.The Chaplain had arranged for her to be interviewed by Victory
Outreach UK, which is an organisation providing Christian homes for
young people in need and is based in Gwent, Wales. Her application,
written on 29 July, identifies that she wanted to change her life style
and live normally. During the morning of 29 July, she was interviewed
by a member of the Victory Outreach team and offered a place at a
home in Wales on her release. The prison Chaplain described her as
being pleased with this outcome.
50.During the day, she had attended the induction programme as planned
and spoken to a number of prisoners. Prisoners who knew her well all
described her as being normal, bright and bubbly and having no cause
of concern for her welfare. Two prisoners suggested that she was
being bullied on the wing, but the investigation team found no evidence
to support this.
51.At approximately 1:40 pm, she left the wing to attend a pre-arranged
group meeting in the Chapel. Instead of going to the group she went to
the Healthcare Centre and asked to see the dentist. She insisted that
the dentist should remove a tooth, as she was in considerable pain.
Toothache is masked by the use of heroin and users of the drug may
experience toothache when they stop using the drug. The dentist
agreed to her request and extracted one of her teeth. She then left the
dental suite and attended the Chapel, where she remained until the
evening meal time. The Chaplain confirmed that she had been with
her at approximately 4:10 pm and that she had shown no signs of self-
harm. On her return to the wing, the Senior Officer responsible for the
14
unit spoke to her and warned her about her conduct following the
incident earlier that afternoon in the Healthcare Centre. She
apologised to the manager for her behaviour. A nurse made an entry
on her wing history sheet about the inappropriate behaviour in the
dental suite.
52.Another prisoner, saw the woman at approximately 4:40 pm. The
woman had collected her breakfast pack and a cup of tea. Breakfast
packs are issued during the evening meal for prisoners to take for the
following morning. The woman had spoken to the prisoner and had
said that she was “going to get her head down”, as she was still in pain.
The wing was then locked up at 5:15 pm.
53. An Officer recalled locking her in her cell after she had collected a meal
from the wing servery at approximately 5:10 pm. He then carried out a
roll check. He confirmed that she was alive at that stage, as she was
eating her meal. He knew her and did not consider that she was at risk
when he locked her in her cell. She appeared happy that she had had
a tooth removed.
54.At approximately 5:15 pm the Senior Officer was informed by the
Officer who had locked the woman up that a television was missing
from one of the cells. She immediately took the decision to have each
cell searched at 6:00 pm when the evening staff would be back on
duty. In her statement, the Senior Officer confirmed that the search
began at just after 6:00 pm.
55. The Officer began searching the cells at sometime between 6:00 pm
and 6:10 pm. He commenced the search at cell E1 and moved
numerically along the wing.
56.At approximately 6:09 he arrived at cell E15 and looked into the room
via the observation panel, but was unable to see the woman. He
attempted to open the door and was unable to do so, as her body was
preventing the door being fully opened. He summoned assistance
from another Officer.
57.At 6:09 pm, an Officer, who had possession of the wing radio, sent out
a “Code Blue” message to the control room. “Code Blue” is the local
procedure for alerting medical staff that assistance is required involving
breathing difficulties so that they know which type of emergency
equipment that they need to transport to the incident. The Code Blue
message obtained the correct response from the medical team. New
Hall also uses a different message to alert the medical staff of blood
spillage incidents. This is good practice.
58. When the Officer entered the cell he saw that she was face down with
a ligature around her neck and suspended horizontally approximately
15 to 18 inches above the ground. Her left arm was through the lower
bunk bed head and her legs on the floor towards the cell door. He
15
used his “Fish Knife” to cut the ligature. However, she remained
suspended above the ground, as her arm was caught through the bed
head. Fish Knives are so called due to the shape of the design and are
designed to enable the user to get under the ligature and the action of
pushing the knife forward cuts the ligature.
59. At approximately 6:10 pm, the other Officer arrived at the cell and
along with first Officer lifted her from the bed head and then laid her on
the floor. At the same time, the Senior Officer arrived and began
checking for a pulse and was unable to find one. At the same time, the
Doctor, who was working in the adjacent wing, was notified of the
incident. Due to the very short distance involved, he and his team
were at the cell very quickly. The Nurse and two Staff Nurses assisted
him.
60.Both the Doctor and the Nurse made handwritten statements following
the incident. Additional statements were taken to clarify whether
Cardio Pulmonary Resuscitation (CPR) had commenced. The Doctor
confirmed that CPR was carried out for approximately 45 minutes,
although the Nurse was unable to recall if prison staff had begun the
procedure prior to his arrival. The investigation team are satisfied that
instructions to undertake CPR had been given by the Orderly Officer to
the officers at the scene. They did not have time to begin due to the
rapid response of the medical staff and it was the medical team who
commenced the CPR.
61.The Control Room Incident Occurrence Sheet shows that medical
assistance (Code Blue) was requested at 6:09 pm by an Officer. The
ambulance was requested at 6:10 pm and arrived at 6:25 pm. At 7:00
pm, the Orderly Officer (radio call sign Oscar 1) informed the control
room that a second ambulance had been requested, as the first one
had a puncture.
62.The second ambulance arrived at 7:06 pm and left at 7:24 pm with the
woman on board. The final log entry, which does not synchronise with
the log timings, shows that death was pronounced at 7:04 pm. In his
statement, the Principal Officer confirmed that she was put in the first
ambulance at 6:44 pm and the Paramedic pronounced life extinct at
19:04, which concurs with the incident sheet. She was then transferred
to the second ambulance at 7:10 pm and left the prison at 7:25 pm. As
she had been pronounced as dead at 7:04 pm when she was still
within the prison, the police would have preferred her body not to have
been removed from the prison until the Coroner’s Officer had given
his/her authority.
The Governor should develop a clear protocol with the Police and
Coroner for the removal of a body from the establishment and
insert the instructions into the contingency plans.
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63.Following the incident the Governor held a staff debrief meeting with
those staff directly involved. The report does not record any findings.
It does comment that paramedics are unable to pronounce anyone
dead at the scene and that this has to be carried out at the hospital.
This is contrary to the incident reports that the Paramedic pronounced
life extinct at the scene at 7:04 pm. My investigator discussed this with
the police officer dealing with the case and he confirmed that
paramedics do have the authority to pronounce life extinct.
The correct protocol for establishing life extinct and the removal
of a body needs to be clarified and inserted into the contingency
plans.
64.The prison is required to test its own contingency plans by way of a
“desk top exercise”. Desk top exercises are used to examine the local
contingency plans for dealing with a specific incident and aim to
replicate a real incident and identify any shortfalls in the procedures.
With the exception of “Hostage Incidents”, the Prison Service does not
specify a mandatory period for the testing of “Death in Custody”
contingency plans.
The Prison Service should consider making the testing of the
Death in Custody contingency plans a mandatory annual event.
65.The investigation team examined the most recent contingency plan
“Desk Top Exercise” report, for a death in custody, carried out in
January 2003. The test incident was for a night time event, when
minimum staff would be on duty to respond. The report did not identify
any failures with the plans, but noted that the Chaplain should be
contacted earlier. The plans had not been tested using a multi agency
approach. A multi-agency approach would identify any difficulties in
making contact with external support such as Police, Ambulance, and
Coroner Office.
The Governor should consider testing the plans using a multi-
agency approach.
66.In the woman’s case, the prison contingency plan incident log and the
Deputy Governor’s statement identify difficulties contacting the local
police and family. This was due to the telephone numbers on the local
contingency plans being incorrect. Had a multi-agency approach to
testing the contingency plans under “desk top conditions” been carried
out, the telephone numbers would have been identified as being
wrong.
The Governor should ensure that the contact numbers for the
police are updated.
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67. The Senior Officer completed a self-harm questionnaire following the
incident, which identifies the initial information. The Principal Officer
completed the local incident report form.
68. Two Officers accompanied the woman in the ambulance. Once it
became evident that she had died both officers asked if they could go
with her to the hospital, “out of politeness”. This was a simple gesture
of compassion, at a very difficult time.
The two Officers should be commended for the care and decency
shown to the woman.
69.The investigation team asked if the wing had a telephone available for
prisoners to use to speak directly to the Samaritans. The team were
directed to what an officer called the “cleaning cupboard”. The
telephone was inside a locked room and was indeed the cleaning
cupboard. The room did not have a chair and to access the phone
meant leaning across a scrubbing machine. The room was extremely
untidy, smelly with stale mops and cluttered. On the wall by the side of
the phone was a laminated notice “This call will be monitored”. This is
not acceptable.
The Governor should ensure that telephone calls to the
Samaritans are not monitored.
70.The matter was brought to the attention of the Deputy Governor who
made immediate arrangements for all the Samaritan phones to be
checked and any notices removed. The telephones are bright yellow
and located in places that would make it readily identifiable to other
prisoners that the person using the phone was feeling vulnerable
and/or suicidal. The investigation team understands that the yellow
telephones are being withdrawn and all areas will have a cordless
phone, which can be handed discreetly to a prisoner. I welcome this.
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RECOMMENDATIONS
NATIONAL
• The Prison Service should consider making the testing of the Death in
Custody contingency plans a mandatory annual event.
LOCAL
1. Reports
• The Governor should action the recommendations made by the Suicide
Prevention Consultant from the HMPS Women’s Team.
• The Governor should action the recommendations made by the Nurse
Consultant, Substance Misuse, HMPS Women’s Team.
2. Suicide and Self Harm
• The Governor should ensure that all staff adhere to the local Suicide and
Self-Harm Policy regarding information being received from an external
source. (Previous Recommendation)
• The Orderly Officer should examine the Reception register each evening
and satisfy himself/herself that all prisoners received that day with a
warning note have been assessed correctly with regard to not opening a
F2052SH.
• The Governor should ensure that no one person has the final say
regarding whether to open form F2052SH or not.
• The local suicide and self-harm policy should be republished as a matter
of urgency and a retraining programme developed to ensure that all staff
are aware of their responsibilities
• The Governor should remind Reception staff of the importance of sharing
information in order to make informed decisions.
• The reception process should be more effectively co-ordinated across the
multi-disciplinary healthcare team.
• The Reception staff should receive additional training on the local suicide
and self harm policy. The training should be a mandatory annual subject
for Reception staff. Suicide and self-harm training should be a mandatory
requirement for all new officers designated to work in the Reception area.
• The Governor should seek protocols with agencies with the aim of sharing
information that is likely to cause distress to a prisoner and to alert the
prison to any observations of the prisoner noted during a meeting.
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• The Governor should ensure that telephone calls to the Samaritans are
not monitored
3. Reception
• The Governor should consider re-examining the staffing profiles to ensure
that a manager is on duty in the Reception department at all times, when
prisoners are likely to be received/discharged.
4. Healthcare
• The Governor should remind clinical staff of the importance of ensuring
that the FACE record is completed accurately.
• The FACE assessment meeting should have a recognised chairperson,
who has responsibility for the agenda, terms of reference and taking
record of the decisions made.
5. Contingency Plans
• The Governor should develop a clear protocol with the Police and Coroner
for the removal of a body from the establishment and insert the
instructions into the contingency plans.
• The correct protocol for establishing life extinct and the removal of a body
needs to be clarified and inserted into the contingency plans.
• The Prison Service should consider making the testing of the Death in
Custody contingency plans a mandatory annual event.
• The Governor should consider testing the plans using a multi-agency
approach.
• The Governor should ensure that the contact numbers for the police are
updated
FOR DERBYSHIRE PROBATION SERVICE
• Concerns of suicidal or self-harm issues should clearly note the specific
information (If known) on the Self-Harm Warning Sheet.
GOOD PRACTICE
• The SPO should be commended for his efforts to alert the establishment
to his concerns.
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• The two Officers who escorted the woman in the ambulance should be
commended for the care and decency shown to her.
• The Prison Service should consider the use of “Code Blue” and “Code
Red” nationally
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