Individual at New Hall

The Investigation into the Death in Custody
of a woman
at HMP and YOI New Hall
in April 2004
Report by the
Prisons and Probation Ombudsman
for England and Wales
July 2005
This is the report of an investigation into the death of a woman who died at HMP
New Hall on 18 April 2004. I commissioned the Deputy Governor at HMP Everthorpe
as the lead investigator of this enquiry. He was assisted by a Residential Governor at
HMP Full Sutton. Liaison was provided by an investigator from my office. He led the
investigation from October 2004 until its conclusion.
I offer my sincere condolences to the woman’s family and friends and to the staff and
prisoners at HMP and YOI New Hall following her tragic death.
Despite this being a distressing and difficult time for all those who knew her, or who
assisted in the events surrounding her death, the enquiry team received consistent
support and cooperation during its work for which I am very grateful.
I would also like to extend my gratitude to the Wakefield West Primary Care Trust
and the South West Yorkshire Mental Health NHS Trust for the investigations they
have undertaken.
I thank West Yorkshire Police for their assistance during the course of this
investigation.
Lengthy sentencing remarks were made by the Learned Judge at Leeds Crown
Court on 8 August 2003 when he sentenced the woman to life imprisonment. In his
remarks he said:
‘’There is no doubt whatsoever in my mind that you are suffering from a personality
disorder with a well-established history of impulsivity, aggression, failure to tolerate
frustration and numerous episodes of attempt at deliberate self-harm … Your
condition is untreatable, the prognosis is poor and you are not currently motivated to
learn or change.’’
In later remarks the judge said:
‘’I am also satisfied that your mental instability is of a kind that has not been
amenable to any particular treatment. Nonetheless you and your mental state will
require and receive constant supervision and assessment and monitoring.’’
It is very difficult to imagine that a solitary cell in the Segregation Unit of one of her
Majesty’s Prisons was an appropriate location for a vulnerable and mentally unstable
young woman who required constant supervision, assessment and monitoring. I fully
accept that management at New Hall had already tried all the available alternatives.
I am deeply troubled by the impossibly difficult role that the Prison Service is being
obliged to undertake in such circumstances.
This version of my report, published on my website, has been amended to remove
the name of the deceased and the names of staff and prisoners who were involved
in my investigation.
Stephen Shaw CBE July 2005
Prisons and Probation Ombudsman
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CONTENTS
Page
SUMMARY 3
BACKGROUND 4
INVESTIGATION PROCESS 7
THE INCIDENT AND EVENTS LEADING UP TO THE WOMAN'S
DEATH 9
18 APRIL 2004 13
POST-INCIDENT RESPONSE 18
ISSUES RAISED BY THE WOMAN'S PARENTS 19
LEVEL OF COMPLIANCE WITH AUTHORISED PROCEDURES 21
REVIEW OF DEATHS IN CUSTODY AT
HMP AND YOI NEW HALL 2002 TO PRESENT 24
FINDINGS 25
CONCLUSIONS 28
RECOMMENDATIONS 30
GOOD PRACTICE 32
GLOSSARY OF TERMS 33
2
SUMMARY
1. The woman was born in June 1971 in Shipley, West Yorkshire.
2. For a significant part of her life she had received care and support from
mental health services. Pre-sentence reports prepared for her court
appearance indicated that historically she had not responded to treatment by
psychiatric services. She did however present a risk to both the public and to
herself.
3. She was received into custody on 20 November 2002 on a charge of arson.
A sentence of life imprisonment was passed for this offence on 8 August
2003.
4. Following sentence she was transferred from HMP and YOI New Hall firstly
to HMP Durham, then to HMP and YOI Bullwood Hall, returning to New Hall
on 29 March 2004.
5. Following reception she was allocated to a room in New Hall's Healthcare
Centre. She remained there until 5 April 2004 when she was moved to the
Segregation Unit.
6. She presented as a difficult person to manage. There is a history of
impulsivity, aggressive outbursts, a failure to tolerate frustration and
numerous episodes of deliberate self-harm. There were also a number of
offences against Prison Rules. It is for these reasons that she was moved to
the Segregation Unit.
7. On 18 April 2004 she was observed by staff on a number of occasions.
During the evening a note believed to have been passed out of her room
was discovered by a member of staff. Concerned by the note, staff entered
her room to check that she was alright. She was, and staff left. Twenty-eight
minutes later the officer on duty in the Segregation Unit opened the
observation hatch of her cell and immediately saw that she had a ligature
around her neck.
8. The officer sought assistance, both prison and nursing staff attended and,
following an emergency call to the ambulance service, paramedics also
attended. Tragically, and despite the best efforts of all concerned, she was
pronounced dead by the paramedics at 19:45.
9. The cell was sealed and investigations into her sad death commenced.
3
BACKGROUND
10. HMP and YOI New Hall assumed its current role in 1987 as a female closed
prison that services the courts. The certified normal accommodation is 327,
with an operational capacity of 385.
11. When the establishment was audited against Prison Service Standards
between 27 January and 14 February 2003 compliance with Suicide
Prevention Self-Harm Reduction Standards was rated as Good; with an
overall rating awarded to the establishment of Good.
12. Her Majesty’s Chief Inspector of Prisons (HMCIP) carried out an announced
inspection of New Hall between 10 and 14 November 2003. The report was
published on 28 April 2004. The prison is currently compiling its response to
recommendations made by the Chief Inspector.
13. In her report HMCIP states in the introduction:
"New Hall, like other women’s prisons we have recently inspected, is holding
women and girls who should not be there. They include those who are
seriously mentally ill, as well as some women and girls with high levels of
self-harm, linked to abuse, including substance abuse. Staff at New Hall
were doing their best to provide a stable and safe environment, but were
unable to do more than contain the level of need of some very damaged
individuals. Prison was likely to increase their vulnerability and mental
disorder, in some cases with tragic consequences, and caring for them
meant there was too little time to provide positive interventions for the less
damaged women and girls. There is an urgent need to provide alternative,
therapeutic environments where appropriate treatment and support can be
offered".
14. The woman was born on 7 June 1971 and was aged 32 at the time of her
death. She was born in Shipley, West Yorkshire. She stated on reception
interview that she wished her father to be recorded as the next of kin.
15. She was first received into custody on 20 November 2002 from Huddersfield
Magistrates' Court on a charge of arson. She returned to Huddersfield
Magistrates' Court on 5 December 2002 where the case was transferred to
Bradford Crown Court.
16. On 24 March 2003 she was transferred from HMP and YOI New Hall to the
New Haven Unit at St Luke’s Hospital, Huddersfield for psychiatric
assessment. She returned to New Hall on 21 May 2003.
17. On 8 August 2003 at Leeds Crown Court she was sentenced to Life
Imprisonment (Discretionary); a tariff of 18 months was set by the trial judge.
On 19 August 2003 she was transferred to HMP Durham, a first stage Lifer
Centre.
18. Durham transferred her to HMP and YOI Bullwood Hall on 29 January 2004.
Bullwood Hall is near Southend-on-Sea in Essex.
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19. On 29 March 2004 she was transferred from Bullwood Hall to New Hall
where she was allocated a room in the Healthcare Centre.
20. She remained in the Healthcare Centre until 5 April 2004 when she was
moved to the Segregation Unit following an adjudication and placement on
Prison Rule 45 for the purposes of Good Order Or Discipline (GOOD).
GOOD reviews were conducted and she remained in the Segregation Unit
up to the time of her death on 18 April 2004.
21. There are no dedicated cells in the Segregation Unit, nor elsewhere in the
prison for adult women, that meet the specification set by the Safer Custody
Group for ‘Safer Cells’.
22. She had appeared before the courts on five occasions prior to this sentence,
beginning in 1996. All cases, except one conviction for arson in 1998, were
disposed of by means of non-custodial sentences. A sentence of 16 weeks
imprisonment was imposed on 27 August 1998 for the offence of arson.
23. She was made subject to the procedures for those thought to be at risk of
suicide or self-harm on 20 November 2002. She remained subject to those
procedures until her transfer to the New Haven Unit at St Luke’s Hospital,
Huddersfield on 24 March 2003.
24. On return to New Hall on 21 May 2003 she was again made subject to those
procedures and remained on them until 2 August 2003.
25. On 13 August 2003 she was again made subject to these procedures. A
form F2052SH, which documents case reviews, action plans and records
interactions and interventions for those subject to these procedures, was
opened. This document remained open until the time of her death.
26. Pre-sentence reports from Mental Health professionals concerning her were
dated as follows:
• 24 January 2003
• 4 March 2003
• 4 April 2003
• 27 April 2003
• 23 June 2003
Having been made subject to Section 38 of the Mental Health Act she was
resident at New Haven Unit, St Luke’s Hospital, Huddersfield between 24
March and 21 May 2003
27. There are a considerable number of entries in both the history sheet
(F2052A and B) and form F2052SH (Suicide and Self-Harm at Risk form)
describing her challenging behaviour in custody.
5
28. On 18 April 2004 she was found in a room in the Segregation Unit with a
ligature around her neck. Medical assistance was summoned (nursing staff
and paramedics), but sadly she was declared dead by the paramedics who
attended.
6
INVESTIGATION PROCESS
29. The investigation drew upon both written documentation and interviews with
key witnesses and other interested parties. Members of the enquiry team
interviewed Prison Staff. Staff were given the opportunity to have a work
colleague or a trade union representative accompany them on interview, and
a member of the local staff care team was available for staff at the end of
each interview.
30. An investigator from my office visited the woman’s parents soon after her
death. The investigator made a note of the issues that they wished to bring
to the attention of the investigation team. In January 2005 her father raised
two further questions (about time in Segregation Units and anti-ligature
bedding) which are dealt with at a later section of this report.
31. To ensure the accuracy of the team’s recollection of the interviews, all
interviews, with the consent of the staff involved, were taped using PACE
recorders.
32. Documentation pertaining to the woman’s custodial history was examined in
detail, this included:
• Main Prison Record
• History Sheets
• F2052SH
• Life Sentence Plan
• Segregation Documentation
• Inmate Medical Records (Clinical Review by Primary Care Trust
(PCT) and Local Mental Health Trust).
33. In addition, the documentation relating directly to her death was examined to
ascertain the level of compliance with local and national procedures, as set
down to deal with such tragic circumstances.
34. Further documentation relating to the establishment's policy on managing
those thought to be at risk of self-harm and suicide was examined to
establish its adequacy and the degree to which it was implemented within
the establishment.
35. The enquiry team have had the opportunity to speak with the Police
Investigation Team and are grateful for their cooperation and report.
36. Arrangements for a clinical review of her case were made. This review was
carried out to cover two separate areas – mental health and physical health.
We are grateful to the local PCT for their report on the management of her
physical health. We are also grateful to South West Yorkshire Mental Health
7
NHS Trust for their comprehensive report concerning the provision of mental
healthcare to her both prior to and during her period in custody.
37. A notice to both staff and prisoners was issued by the investigation team,
extending an invitation to submit any relevant evidence concerning her
death. The investigation team is grateful for the contribution made by the
Chairman of the Prison Officers' Association in his presentation of the views
of his branch.
The woman’s father made a number of comments after seeing the report in
draft. A factual error about her birthplace has been corrected. He felt that
the issue of alleged bullying by two other prisoners in the Segregation Unit
had not been explored sufficiently. If she was being subjected to verbal
bullying by other prisoners, there was nowhere she could go in the
Segregation Unit to escape from it. Staff could go home at the end of their
shift but she could not.
8
THE INCIDENT AND EVENTS LEADING UP TO THE WOMAN’S DEATH
38. The woman was first received into custody at HMP and YOI New Hall on 20
November 2002 from Huddersfield Magistrates' Court on a charge of arson.
39. On 24 January 2003 a report was prepared by the firm of Solicitors in
relation to her court appearance for the offence of arson. In this report the
doctor comments that she had a long history of contact with psychiatric
services and had been admitted on a number of occasions as an in-patient
at St Luke’s Hospital.
40. The report goes on to say she had attracted a diagnosis of emotionally
unstable personality disorder, borderline type. There were recurrent attempts
of self-harm, immaturity, poor judgement, lack of self-control and low
tolerance to frustration associated with assaultative behaviour.
41. In the opinion and recommendation section the report states: "In the
woman’s case this disorder is associated with an abnormally aggressive or
seriously irresponsible conduct amounting to a diagnosis of psychopathic
disorder within the meaning of the Mental Health Act 1983. The pervasive
drive towards self-destructive behaviour, and the tendency to act impulsively
have resulted in a pattern of risk taking behaviour, as a result of which her
safety and that of others has been put at risk".
42. The final sentence at point three states: "The general psychiatric services
acquainted with the woman’s care have expressed the view that there is little
else that they can offer in terms of in-patient treatment that can alleviate or
prevent deterioration in her condition".
43. On 4 February 2003 she was seen by a Professor of Psychiatry who made a
declaration that, in his opinion, she was suffering from mental illness and
mental impairment within the meaning of the Mental Health Act 1983. The
report also stated that: "the patient has produced seriously irresponsible and
dangerous conduct warranting treatment of her mental impairment and
mental illness in secure conditions. A Section 37 may be in order later".
44. A psychiatric report was completed by the Professor on 4 April 2003. In that
report he states: "It is known that the woman suffers from borderline, or
emotionally unstable personality disorder, and this diagnostic entity contains
within it a degree of mood swings and depressive behaviour. It is possible
that she also suffers a bipolar affective disorder in its own right, which would
make the contribution of mood disorder much greater than that normally
found in the personality disorder alone".
45. The report continues: "In either case, she has already shown severe
challenging behaviour within the unit. This type of behaviour does not fit in
well with our more normal practice of rehabilitation psychiatry within a
forensic group of patients. While we are prepared to manage this is in the
initial stages, if it proved to be troublesome in the long run it is entirely
counter productive, and militates against the successful use of rehabilitation
strategies".
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46. On 27 April 2003 a psychology report was completed by a Clinical
Psychologist.
47. A further psychiatric report was prepared dated 23 June 2003 for the
woman’s court appearance. Under the section headed Opinion 1. Diagnosis,
the report states: "She suffers from personality disorder, namely emotionally
unstable (borderline) type. There is a well-established history of impulsivity,
aggressive outbursts, failing to tolerate frustration and numerous episodes of
deliberate self-harm". The report adds: "in my opinion her personality is
damaged and severe enough to be diagnosed as psychopathic disorder.
Historically, she has failed to respond in any meaningful or consistent
manner to treatment/intervention with local psychiatric services. Treatment in
secure care has yielded no positive outcome. More recently, while in the
New Haven Unit, she again presented as disinterested, amotivated and
hostile. There is no evidence to suggest that she is treatable".
48. The report continues: "The defendant is not mentally impaired. Formal
assessment of her level of intellectual functioning reveals an IQ in the below
average but not learning disability range. At interview it is clear she has a
good grasp of language but is (more likely) an unwilling historian rather than
a disabled one".
49. In addition the report states: "She does not suffer from serious mental illness
such as severe depression, manic depressive psychosis or schizophrenia".
50. The Prognosis section of the psychiatric report states: "the defendant’s
prognosis is poor. She is now 31 years old with a well-established and
lengthy history of maladaptive behaviours including aggression and self-
harm. There is no evidence to suggest her condition (psychopathic disorder)
had either been alleviated or is there evidence of a halt in its deterioration
following treatment".
51. Under the heading of Risk the report states: "the risk of further future serious
acts occurring should be understood as most likely occurring in specific
context. The defendant does not tolerate frustration, does not comply with
advice given and is often unwilling to delay her need for gratification. Such
traits have been present for many years and in situations where these issues
are relevant it is then most likely she would perpetrate acts of serious
violence to members of the general public or by self-harming".
52. Finally, the report goes on to state: "she does not suffer from a form of
mental disorder by which she could be detained in hospital".
53. The woman was sentenced to Life Imprisonment (Discretionary), with a tariff
of 18 months set by the trial judge on 8 August 2003. When passing
sentence the Learned Judge made reference to her mental state and made
comment that this would require and receive constant supervision,
assessment and monitoring.
54. The Department of Health has provided funding for Mental Health Services
via PCTs to prison establishments. New Hall received during the period
10
2003/2004 a figure of £70,000 for mental health services. This is being
increased to £139,000 for the period 2004/2005.
55. This enquiry has been unable to establish how the Department of Health
funding was allocated to establishments; for example, another female prison
in the North West was allocated £140,000 in 2003/2004. This provision is
twice that allocated to HMP and YOI New Hall, even though these two
prisons (allowing for some differences) perform a broadly similar role.
56. It has been evidenced that Mental Health In-Reach collaboratives are being
formed in order to assist the development of mental health services within
prison establishments.
57. On 19 August 2003 the woman was transferred from New Hall to the first
stage lifer centre at Durham. There then followed a transfer from Durham to
Bullwood Hall on 29 January 2004, and a further transfer from Bullwood Hall
to New Hall on 29 March 2004.
58. She was correctly made subject to procedures for those thought to be at risk
of Self-Harm or Suicide between 20 November 2002 and 24 March 2003,
between 21 May 2003 and 2 August 2003 and finally from 13 August 2003
up until the day of her sad death.
59. She presented as a difficult person to manage.
60. It is noted from records that she frequently accessed the Prisoner Listener
Scheme. The frequency of use would indicate she found comfort and
support from this service.
61. On 4 April 2004 an entry is made in the Form F2052B (Record of Events)
which states that she was intimidating other prisoners by banging and
shouting abuse constantly. A further entry states she was placed on report
for damaging her cell. Two further entries were made on 4 April, one records
her becoming an increasing management problem, refusing to return to her
room and, eventually, following location in her room, further banging on her
door, disturbing other patients. As a result of this behaviour she was
reviewed under the Incentives and Earned Privileges Scheme and placed on
the Basic regime level. The final entry for that day records that she continued
to shout abuse at other prisoners and attempted to hit a member of the
Healthcare staff.
62. She was moved to the Segregation Unit on 5 April 2004 to face charges laid
under Prison Rules. Following adjudication, during which she attempted to
assault the adjudicating Governor, it was agreed that she should be placed
on Rule 45 GOOD because of her poor behaviour at adjudication and in the
Prison Healthcare Centre.
63. The behaviour of other prisoners located within the Segregation Unit towards
her became a concern to staff. It is noted that on 13 April 2004 those
concerns resulted in a Bullying Incident Report Form being raised by an
Officer. This identified that it was suspected that another prisoner was
11
bullying her. The form makes comment that the other prisoner was spending
time mimicking and teasing her and this was not the first reported incident of
this kind of intimidation. The prisoner was warned as to her behaviour and
placed on Stage 1 of Anti-Bullying Procedures. The report form used,
although not the one within the establishment policy dated October 2003, did
contain all relevant information.
64. Stage One of Anti-Bullying Procedures is a warning issued following
investigation where suspected bullying has been confirmed. The bully is told
of the consequences of further or similar acts and her behaviour is more
closely monitored.
65. On 16 April 2004 two entries were made in F2052SH after ligatures were
discovered. The first entry was made at 09:55 and states:
"Three Officers removed a ligature from her neck; had a chat with her and
left her in better spirits".
66. At 10:45 one of the Officers made a second entry in F2052SH:
"Hiding underneath bed with ligature around her neck which was removed".
67. The next entry in F2052SH was also made by the same Officer and states at
10:50: "Given a phone call to her mother – is now in good spirits".
68. Two F2052SH case reviews were conducted at New Hall after she was
transferred from Bullwood Hall on 29 March. The purpose of a case review is
to share information on how a prisoner is coping and to reach team
decisions on what further action needs to be taken to address underlying
needs. The first review was on 30 March and the review coordinator, the
Healthcare Senior Officer wrote that: ‘’ She interacted well with the review.
She is happy to be here and is as settled here as she is anywhere. She likes
the staff and the regime. She can have her obs. (observations) reduced to
twice an hour.‘’ The second review was on 6 April and the coordinator on this
occasion also recommended that her observations be reduced to “two per
hour throughout”. At the end of her time at Bullwood Hall the woman had
been on intermittent observation which required more frequent observation
at irregular intervals throughout each hour. Scrutiny of her F2052SH reveals
that after the two New Hall review meetings observations were maintained at
the necessary level of two per hour until the time of her death.
12
18 APRIL 2004
69. The woman appeared to be asleep until about 05:10 on 18 April 2004 when
she awoke and was given a light for her cigarette. She was spoken to on a
number of occasions and replied on each occasion that she was OK. There
follow a number of entries within the F2052SH, the salient points are:
• 09:00 the entry reads: "still kicking door and threatening staff, no
evidence of self-harm"
• 10:40 She is visited by one of the establishment’s Governor grades
• 11:40 She is: "eating lunch, no problems"
• 14:15 "Banging door, shouting abuse, no evidence of self-harm"
• 16:45 "Given tea, no distress noted"
• 17:45 states: "Reading Harry Potter, no distress"
• 18:15 "Asked to see a nurse’; 18:45 ‘Given medication"
• 19:15 entry in F2052SH "given water"
• 19:20 Final entry in F2052SH "Ligature found, phoned for
assistance".
70. A CCTV system operated on a continuous record basis within the
Segregation Unit (the Police seized the tape recording for 18 April). A
summary of events listed by the Police is as follows (the time noted on the
CCTV was one hour behind real time, real time is used in the list below):
• 17:41 an Officer seen checking the woman in her cell, and again at
18:12
• 18:31 The same Officer opened cell and the woman goes to the staff
office
• 18:33 She is returned to her room by the officer who closes the room
door
• 18.37 a further check is made on her
• 18:53 Two Officers check her and one recovers a piece of paper
from the floor outside the room. Both Officers enter the cell where
they remain for one to two minutes, leave, close the door and one
returns to the office with the paper. The note reads as follows:
"I meant to do it as I have 32 years of complete misery. Anyone who
finds this note must understand it is not an accident".
• 19:21 She is checked by an Officer
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• 19:23 The same Officer is joined by two further members of staff. All
three enter the cell
• The police summary of events does not mention the fact that all
three members of staff left the cell before the arrival of healthcare
staff.
The investigation team have studied the CCTV tape, which clearly
shows this to be the case, and it is confirmed in the interviews given
by the three staff named in the preceding paragraph.
A slowed-down version of the tape was supplied by West Yorkshire
Police on 1 December 2004. A further version of the tape, with
precise timings, was supplied by West Yorkshire Police on 7 January
2005. This shows the three staff entering her cell at 19:23:49, then
emerging from the cell at 19:24:41, closing the door behind them. A
man, the Senior Officer, walks away from the cell. Two officers stand
outside the cell, then at 19:25:25, approximately 44 seconds later,
they re-enter the cell. Shortly afterwards they are joined by
healthcare staff.
The 7 January 2005 version of the tape shows that the first
contingent of healthcare staff arrived at her cell at 19:26:57
• 19:25 (police timing) Hospital staff attend
• 19:27 (police timing) Resuscitation/first aid kit brought
• 19:32 (police timing) Additional equipment brought
• 19:44 (police timing) Paramedics arrive and leave at 20:00
• 20:01 (police timing) The cell is locked and sealed, remaining so until
the Police arrive at 21:38.
71. A female Officer was the member of staff detailed to work in the Segregation
Unit on the evening of 18 April 2004.
72. During interview the Officer recalled from memory the events of that evening.
She stated her concerns at finding a note passed out by the woman and
thought, given her history, it would be likely that she may have a ligature
around her neck. Having entered the cell with another Officer to investigate
the note, she awoke the woman, had a brief chat and ascertained that she
was not in possession of a ligature. The second Officer was present in the
unit to assist in providing hot water to the prisoners that evening.
73. On checking the woman in her room 28 minutes later, at 19:21, one of the
Officers observed that she was on the floor behind the door. She asked her if
she wanted to talk, attempted to gain her attention and tried to get her to
stand up. The Officer believed that she was playing games. In an attempt to
make her believe she had returned to the office, the Officer opened and
14
closed the laundry room door. On returning to the woman’s room the Officer
noted that she had still not moved. At this point the Officer became more
concerned.
74. The Officer opened the hatch in the bottom of the door and looked in. She
saw the woman was on the floor with a ligature tied around her neck. The
ligature was not attached to any other object. According to the Senior Officer
it was made from a piece of green bedsheet. The officer rose to her feet,
returned to the unit office, and summoned assistance.
75. The Officer spoke to the Senior Officer on F wing and requested assistance
in order to enter the woman’s room. The Officer also requested, via a
telephone call to the communications room, assistance from healthcare staff.
76. The control room log for 18 April 2004 makes no reference to an internal
emergency call being made. Instructions contained in the establishment's
contingency plan for life threatening medical emergency and Operational
Order 29/2003 state that the member of staff should raise the alarm by UHF
radio, direct line or the internal emergency telephone number. The Officer
acknowledged that she knew and understood these instructions but did not
consider that there was an immediate risk to life and chose not to use them.
During interview the Officer confirmed that she was in possession of a UHF
radio.
77. During interview with the Principal Officer (the senior manager on duty in the
establishment that evening) it was established that he first became aware
that something in the prison was wrong on hearing a general commotion in
the Residential 1 corridor. He was then informed that something was
happening in the Segregation Unit and he should attend there.
78. On arrival he observed a Nurse and an Officer performing cardio pulmonary
resuscitation (CPR) on the woman. His next action was to make
preparations for a hospital escort and prepare to action the Contingency
Plans.
79. When asked about procedures on discovering a potential medical
emergency the Principal Officer stated: "standard procedure as far as I am
concerned is there should have been a blue call put across the radio
(operational order 29/2003, annex 27), which is a request for medical
assistance for somebody having trouble breathing, etc., or strangulation, or
ligature and then I should have been informed immediately of the situation".
80. Asked if he carried a radio the Principal Officer replied: "I carry a radio, it
wasn’t put across the radio at all".
81. Asked if he enquired as to why, he replied no, in effect he was dealing with
the incident. When asked what he would have expected to happen differently
had a blue call been made, the Principal Officer pointed out that
communication would have been faster and medical assistance response
time may have been shorter.
15
82. Following the calls for assistance a Senior Officer and a male Officer from F
wing arrived a few minutes later. Together with the female Officer who was
working in the segregation unit that evening, they entered the woman’s
room. The female Officer took out her ligature knife and cut the ligature from
the woman. The Senior Officer asked if she was breathing and if she was
OK. The female Officer felt for a pulse and stated to the Senior Officer that
she could feel the woman’s pulse and had felt her breathing. The female
Officer further added that it was not unusual for the woman not to respond
once ligatures had been cut off.
83. The Senior Officer recalled during his interview that whilst performing duties
as night orderly officer he had previous experience of being called to
incidents involving the woman where she had tied ligatures to her neck.
84. During interview the Senior Officer was asked if, on finding the woman in
room 10, he had any concerns that her situation was life-threatening. He
replied: "At that time no". He went on to say: "I thought that her colour looked
relatively normal. I knew healthcare staff had been called and were on their
way. I felt that, at that stage the situation was in the process of being dealt
with and it’d be appropriate for me to return to my wing".
85. At this time all three members of staff left the room expecting the woman to
make a full recovery. Staff stated to the enquiry team that, on occasions, she
would behave in a way designed to imply her condition was more serious
than it actually was. As recently as 16 April an Officer had written in
F2052SH that staff entered the woman’s room in mid morning. She was
hiding under her bed and they removed a ligature which was around her
neck. In interview a Nurse said that she had previous experience of the
woman using ligatures but the nurse said they were not serious or life-
threatening. On these previous occasions when the Nurse attended, the
woman took off the ligature when the nurse asked her to and the nurse
described one such occasion.
‘’She was still conscious, walking around. She had it round her neck and she
undid it and recovered immediately.’’
The male Officer from F wing said he could recollect the woman ‘’tying a
ligature and not moving on purpose.’’
The female Officer was asked by the senior investigator why the woman
used to use ligatures. The Officer replied that she enjoyed contact with staff.
‘’I think that she felt better when we were there and I think that was a way for
her to get an immediate response from staff
Question: ‘’So this ligature making and use of ligatures, do you think that
she always intended to seriously harm herself?
Female Officer: ‘’No, I don’t.’’
16
86. The Senior Officer returned to his wing. The two Officers remained awaiting
the arrival of nursing staff.
87. After a few moments the two Officers re-entered the room. They were
concerned that she was not recovering as they expected.
88. At 19:25 nursing staff arrived. A Staff Nurse entered the room and saw the
woman laid on her back with her head towards the door and her feet towards
the window. The Staff Nurse described her colour as quite poor. The Staff
Nurse felt for a pulse, looked at the woman’s eyes and then asked for
medical equipment. She then commenced mouth-to-mouth resuscitation,
assisted by one of the Officers who carried out cardiac compressions.
89. A Nurse explained that there was "no urgency" about the phone call received
in the Healthcare Centre requesting assistance in the Segregation Unit. She
was carrying the Hotel One nurse emergency radio at the time but there was
no Code Blue call on her radio to indicate that a patient was having life
threatening breathing difficulties. She and the Staff Nurse walked to the
Segregation Unit. The Staff Nurse quickly assessed the gravity of the
situation once they reached the Unit and the nurse then had to run back to
the Healthcare Centre to fetch the necessary emergency equipment
(defibrillator, oxygen, airways).
90. At 19:30, according to the control room occurrence sheet, a request for an
ambulance was made via New Hall’s control room. The occurrence sheet
states that the request came from Kilo 1. Documentation from the
ambulance service times the call to them at 19:28. The Staff Nurse was
joined in the Segregation Unit by the Nurse (who had run back from the
Healthcare Centre with the emergency bag containing oxygen and defib
rillation equipment), a second Nurse and the Sister. Staff continued attempts
at resuscitation until the arrival of the paramedics. They reached the prison
at 19:42 and the woman’s cell at 19:44. Despite the best efforts of staff at
resuscitation, the paramedics pronounced life extinct at 19:45.
91. The Head of Healthcare submitted a memorandum raising concerns
regarding the procedure for summoning an ambulance. These concerns are
based on the need to provide medical information to the ambulance service
and the possibility of delay created by all communication going via the prison
communications room.
92. All staff, together with the paramedics, left the room which was then sealed
pending the arrival of the police.
17
POST-INCIDENT RESPONSE
93. The paramedics who attended pronounced the woman dead at 19:45 as
recorded in the control room incident occurrence sheet. The establishment’s
contingency plans for a death in custody were activated. The cell was locked
and sealed awaiting the arrival of police officers. At 21:10 police and scenes
of crime officers attended New Hall and began their investigation into the
death of the woman. The death was notified to those persons and
organisations listed within the contingency plans.
94. The Duty Governor attended the establishment, received a handover from
the duty Principal Officer, and informed the Governor in charge of the
establishment. The Duty Governor arranged for a hot debrief of the staff
involved. During this debrief the police and the coroner’s officers arrived at
the establishment. A member of the Independent Monitoring Board and the
Care Team were also present at the hot debrief. Staff interviewed confirmed
that they were made aware of arrangements for their ongoing support and
care following this tragic death. Following discussions between the Duty
Governor and the Assistant Chaplain it was decided not to inform prisoners
that night but a notice was placed at the gate informing on-coming staff of
the woman’s death.
95. The death in custody initial action checklist was completed. This form
indicates that Police informed the woman’s father at 00:10 on 19 April of his
daughter’s death. The Prison Assistant Chaplain made further contact with
the family at 9:45 on 19 April. On Tuesday 20 April 2004 the prison’s family
liaison officer, together with the Chaplain and Assistant Chaplain, visited the
family of the woman. The family were given brief details of the events
surrounding the her death and informed of the subsequent Police and
Prisons and Probation Ombudsman’s office investigations. The family
requested to visit the establishment and arrangements were made for this to
take place on Friday 23 April.
96. My investigator met with the woman’s parents on 26 April 2004. Issues
raised by them at this time were referred to the investigation team for
consideration in the investigation. At the family’s request the Prison Chaplain
at New Hall conducted the funeral service for the woman. A Critical Incident
Debrief was held on 4 June 2004.
97. New Hall received by fax on 10 June 2004 a copy of a report sent by a
specialist registrar in forensic psychiatry to the doctor at HMP and YOI
Bullwood Hall regarding an interview with the woman which took place on 15
April 2004. In that report the specialist registrar stated another doctor’s pre-
sentence report prepared in June 2003 had concluded that the woman did
not suffer from a treatable mental disorder and could not, therefore, be
detained in hospital under the Mental Health Act. The specialist registrar
concluded there was nothing to suggest this position had changed and did
not feel it appropriate for the woman to be transferred to hospital.
18
ISSUES RAISED BY THE WOMAN’S PARENTS
How much time in Segregation Units?
98. The woman’s father expressed to my investigator his very strong belief that
she should not have been sent to prison due to the range and complexity of
her mental health needs.
99. In January 2005 he asked for two further matters to be investigated. He
asked how much of her sentence she had spent in Segregation Units and he
asked if she should not have been issued with an anti-suicide blanket.
100. I am grateful to the Safer Custody Governor at New Hall for his assistance
with her father’s first question. The information from Bullwood Hall is that she
spent 36 of her 59 nights there between 29 January and 29 March in the
Segregation Unit. The e-mail from the Head of Operations at Bullwood Hall
sets out the circumstances of the woman’s residence in the Segregation Unit
during that period.
101. She was then held in the Segregation Unit at New Hall from 5 April until her
death on 18 April. This was for reasons of GOOD.
102. In a second e-mail the Safer Custody Governor reported that she was also
held in the Segregation Unit at New Hall for a total of 16 days in June, July
and August 2003. Reasons for these locations included waiting for
adjudication, cellular confinement as an adjudication punishment and
GOOD.
103. Information about the time she spent in the Segregation Unit at Durham is
not readily available.
Reduced- Risk Bedding
104. The woman’s father asked if she should not have been issued with anti-
suicide bedding (her father’s term) because she was on F2052 SH. PSO
2700 is the Prison Service’s Order on Suicide and Self Harm Prevention
105. Chapter 4.1.3.1 of the Order states that ‘’Prisoners identified as being at
risk of suicide or self-harm must not be placed in an unfurnished cell. ….. In
the context of caring for prisoners identified as being at risk of suicide/self-
injury, strip cell and strip conditions refer to bare unfurnished cells which do
not contain furniture, fittings, bedding and clothing.’’
106. Chapter 4.4 of the same Order is entitled Removal of Items in Possession
and states:
‘’Personal items including shoelaces and belts must not be removed from
at-risk prisoners as a matter of course. The reasons for the decision to
remove or return items must be recorded in the prisoner’s F2052SH.’’
19
The decision by staff at New Hall not to remove her normal clothing and
bedding was in compliance with both the letter and the spirit of PSO 2700. It
was also a reasonable decision in the light of information recorded at the 30
March case review on her return to New Hall from Bullwood Hall:
‘’ She is happy to be here and is as settled here as she is anywhere.’’
107. I asked the Prison Service’s Safer Custody Group (SCG) if there are any
initiatives to introduce bedding that is more suicide-proof. I am most grateful
to the Built Environment Manager at SCG for responding to my query. He
informed me that a Safer Bed Linen trial is running from November 2004
until May 2005 in three separate prisons. The objective of the trial is to
assess bedding items in terms of Health and Safety, suicide prevention and
some other factors. 98 knitted sheets, 50 pillow slips and 18 blankets are
being tested in the three sites with the aim of providing bedding items that
are more difficult to tear than standard issue items.
20
LEVEL OF COMPLIANCE WITH AUTHORISED PROCEDURES
Overall assessment
108. Our overall assessment of compliance with procedures appears in the
Conclusions section of our report. We conclude that Segregation and Anti-
bullying procedures were in line with Prison Service Orders. New Hall’s
Suicide and Self-Harm Policy requires minor adjustments.
Procedures for those thought to be at risk of self-harm and suicide
109. Case Reviews recorded in the F2052SH were undertaken in accordance
with the relevant Prison Service Order and entries made in the Daily
Supervision and Support Record demonstrated appropriate interaction
between staff and the woman.
110. New Hall had in place a Suicide and Self-Harm Prevention Policy document
and procedures dated October 2003.
111. Minutes of the Suicide Prevention Team meetings were kept. It was not clear
from these minutes if the Anti-Bullying coordinator was a member of this
team, nor if the Area Suicide Prevention Coordinator received copies of the
minutes.
112. On visiting the Segregation Unit it was noticed that the Samaritans telephone
number was not displayed by the telephone in that area as required. This
was checked by the establishment’s Suicide Prevention Coordinator, agreed
to be accurate and immediately rectified.
113. The establishment’s Suicide and Self-Harm Prevention Policy lists a number
of risk factors in the consideration of suicidal ideation, however failure to take
medication and mood swings as identified in the Prison Service Order were
not listed in the establishment’s policy.
114. In at least one situation of ligature making by the woman, a F213SH could
not be found to record this event. The Prison Service Order specifies that:
"all instances of self-harm must be recorded on an incident report form, an
F213SH must also be completed". The order clarifies that this does include
ligature making.
115. The Prison Service Order highlights the need to ascertain if the prisoner is
being bullied. It was not clear within the establishment policy if prisoners
were being routinely asked if they were being bullied or intimidated when an
F2052SH was opened in order for the Anti-Bullying Coordinator to be
informed.
116. Following the decision for the woman to remain in the Segregation Unit the
Record of Case Review appropriately shows a member of Healthcare in
attendance as required by Prison Service Order No 1700. A Segregation
Safety Algorithm was also completed
21
117. There was no reference in the establishment’s policy for a doctor or nurse to
be consulted prior to unfavourable news being disclosed to any prisoner, this
applies to those subject to at risk procedures who are located in the
Healthcare Centre or under constant or intermittent supervision.
118. Operational Order 20/01 identifies internal systems are in place to facilitate
good communication between the different locations of prisoners who are at
risk, this also includes description of how prisoners subject to these
measures are moved around the establishment.
119. Operational Order 08/04 reference F2052SH Quality Checks states that unit
managers will carry these out at least once a month. In addition, the Suicide
Prevention Coordinator will carry out random quality checks at least once per
quarter. Prison Service Order 2700 Annexe B Quality Control states that a
residential manager or Duty Governor must audit the quality of F2052SH
entries at least twice per week, draw deficiencies to the attention of line
managers, monitor the response, and record that they have made these
checks.
120. Entries made in the Daily Supervision and Support Record have often been
signed as stated in the policy and Operational Order 20/01. However, the
Prison Service Order and the forms themselves state that the name should
be printed, not signed.
121. Operational Order 50/02 is in place to set out the review procedure and the
appropriate grade of the chair of the review board as specified in the Prison
Service Order.
122. No evidence could be found as to whether emergency response kits were
being checked monthly as required by the Prison Service Order. It was also
noted that the Segregation Unit did not have an emergency response kit.
123. No evidence was provided that all open F2052SHs were reviewed within the
specified period following the woman’s death.
124. Operational Order 09/04 does outline the requirement for notifying outside
agencies when a prisoner subject to these procedures is discharged.
125. Operational Order 16/03 outlines the review system that is in place to ensure
a case review is carried out prior to a prisoner being transferred.
126. The woman’s form F2052SH specifies a requirement for half-hourly checks.
The record shows that these were carried out as required, with the last entry
being made at 19:20.
Segregation Procedures (PSO 1700)
127. The Initial Authority for Segregation dated 5 April 2004 was appropriately
made. A Segregation Safety Algorithm dated 5 April 2004 was also
completed.
22
128. The requirement to conduct a Segregation Review was correctly undertaken
on 7 April 2004 by a multi-disciplinary team which consisted of a Governor
grade, prison officer, nurse and member of the Independent Monitoring
Board; this occurred within the specified 72-hour period. At this review a
further period of 14 days segregation under Rule 45 was approved.
Anti-bullying Procedures (PSO 1702)
129. The establishment operated an Anti-Bullying Policy in line with Prison
Service Order 1702 and this policy was activated in the case of suspected
bullying of the woman by another prisoner.
Contingency Plans
130. The establishment had in place contingency plans adequate for the purpose.
131. Following the declaration of death the cell was sealed pending the arrival of
the police. A hot debrief was conducted by the Duty Governor for staff
involved in the incident.
132. Procedures following a Death in Custody, as set out in Prison Service Order
2710, were also followed. The incident was reported as required, support for
staff and prisoners was in place, and follow-up support for the family was
made. The establishment continues to prepare for the inquest.
Other Procedures
133. The control room log for 18 April 2004 makes no reference to an emergency
call being made. Instructions contained in the establishment’s contingency
plan and Operational Order 29/03 state: "raise the alarm by UHF radio, direct
line or the internal emergency telephone number". An Officer acknowledged
that she knew and understood these instructions but did not consider that
there was an immediate risk to life and chose not to use them. The adverse
consequences of this decision by the Officer are set out in the Conclusions
section of this report.
23
REVIEW OF DEATHS IN CUSTODY AT HMP AND YOI NEW HALL 2002
TO PRESENT
134. The investigation team reviewed previous deaths in custody at New Hall
from 2002 to the present time, and compiled a matrix.
135. During this period there have been six deaths in custody prior to the
woman’s sad death. The youngest was aged 19, the eldest being 41. The
average age for the group was 26 years.
136. Of the seven deaths it is noted that six occurred during or directly before the
weekend. One death occurred on Friday afternoon, one death occurred late
on Friday evening. There were a further two that occurred on a Saturday and
two on a Sunday. Only one of seven deaths did not occur on or directly
before a weekend, this was death by natural causes.
137. Of the seven deaths one was by natural causes, of the other six a ligature
was used on each occasion.
138. Four women had current F2052SH forms open on them.
139. It can be noted that three women were known to have mental health issues
on reception. These women also had a history of self-harming whilst in
custody.
140. The previous six women who died were known to have issues relating to
drugs and/or alcohol before and during custody.
24
FINDINGS
141. We found that the woman had a long history of mental health problems. As a
result she demonstrated aspects of behaviour which were demanding,
destructive and could present as a serious risk of harm to herself and others.
142. Medical reports prepared on her indicated that she was failing to respond to
treatment. As a result it was determined that she was not suitable for
detention in hospital under the Mental Health Act (1983).
143. New Hall, at the time of her death, was in receipt of £70,000 from the
Department of Health for the provision of Mental Health In-Reach services.
The investigation team has not been able to clarify the basis upon which this
funding was made and why a disparity in budget can be seen across
establishments of a seemingly similar nature. Growth funding has been
provided for the year 2004/2005 in the amount of £69,000. Given the size of
population within New Hall, and the number of women and girls within the
establishment in need of these services, the enquiry has not been able to
establish whether this funding is adequate.
144. Her transfer from one prison to another clearly had an impact on the ability of
healthcare services to maintain the supervision, assessment and monitoring
required, as stated by the trial judge when sentencing her.
145. Throughout her period in custody she presented as a difficult person to
manage. She regularly resorted to acts of damage, self-harm and assaults
on others. The frequency of these types of incidents minimised the options
available within prison establishments suitable for her safe accommodation.
146. The Listener Service, which operates in prison establishments, was used
regularly by her.
147. At New Hall in the part of the prison that holds adult prisoners there are no
cells built to the Safer Cell specification, as defined by Safer Custody Group.
148. She was subject to procedures for those thought to be at risk of self-harm or
suicide when she was moved from the Healthcare Centre to the Segregation
Unit. A move of this nature is permitted within the conditions specified in
Prison Service Orders. Given the circumstances, and with no other suitable
option available, this was the only reasonable decision available to the
establishment.
149. It is clear from staff who have been directly involved in the woman’s care that
her behaviour influenced and, on occasions, conditioned the response by
staff. Paragraph 84 includes a number of examples of previous occasions
when she had been found with ligatures around her neck in situations which
were not perceived as life-threatening.
150. At 18:.53 a note was found on the floor outside her room in the Segregation
Unit which could be interpreted as meaning that she intended to take some
serious form of action. The note was placed in the F2052SH and she was
25
checked because of staff’s concerns that she might have a ligature, this was
found not to be the case. The interview with the Officer on duty in the
Segregation Unit established that this was a thorough check. The Officer
was concerned that she ‘’would have a ligature on’’ so she drew her ligature
knife and went into the woman’s cell with another Officer. She had a blanket
over her head so the staff removed the blanket but there was no ligature.
The staff had a brief chat with her and she said that she was fine. The
Officer agreed with the lead investigator in interview that her worries were
then diminished.
151. At 19:21, some 28 minutes after the discovery of the note, she was checked
in her room and at this time she was found to have a ligature around her
neck. The Officer stated to the enquiry that she did not believe, at the time,
that the situation was life threatening.
152. Neither the radio nor telephone emergency procedures were utilised at this
time.
153. Officers stated to the investigation team that they found her to be breathing
and to have a pulse when they entered her cell. In possession of this
information staff believed she would recover, as she had done on previous
occasions, and so left the cell. However, recovery was not complete. There
was no movement and no dialogue with her; medical staff had not yet
arrived. This was an apparent failure in the staff’s duty of care to her and we
recommend that the Prison Service’s Yorkshire and Humberside Area
Manager considers setting up an investigation to decide whether disciplinary
action should be taken.
154. When the Senior Officer left the Segregation Unit. the two Officers remained
outside the closed door of the woman’s cell for 44 seconds. One of the
Officers was watching through the cell hatch and when she saw that the
woman had not moved she and the other Officer went back into the cell.
They felt for a pulse and checked whether she was breathing.
155. When the Staff Nurse arrived on the scene she and one of the Officers
administered CPR to the woman. The Staff Nurse did mouth to mouth and
the Officer did chest compressions.
156. The Officer maintained compressions for approximately two minutes then he
was relieved by a Nurse once she had collected the defibrillation equipment.
Further equipment to monitor the oxygen in the woman’s system was
brought subsequently by another Nurse.
157. Despite the best efforts of the Officer and four nursing staff, she did not
recover and was declared dead by the paramedics when they arrived.
158. There are discrepancies between the timings recorded in F2052SH and
those evidenced by the CCTV system. We believe that the CCTV timings
were accurate, though they were one hour behind "real time".
26
159. The investigation found no serious failings in the local Suicide and Self-Harm
Prevention Policy document; however, there were some minor
omissions/errors found.
160. The investigation found no serious failings in the Segregation procedures.
161. The enquiry evidenced a policy and its use regarding suspected bullying by
prisoners.
162. The enquiry team found that emergency response kits were not regularly
checked as required and also that there was no emergency response kit
located in the Segregation Unit.
163. There is a concern, raised by the Head of Healthcare, that the current
procedure for the summoning of an ambulance may cause some minor
delay.
164. The investigation found that the post-incident response was both appropriate
and effective.
165. As a result of the comparison of previous deaths in custody at HMP and YOI
New Hall over a short period it is noted that, where a history of mental health
problems was identified, there was also a history of self-harm.
166. A comprehensive Root Cause Analysis investigation has been carried out by
the Senior Project Manager and the Assistant Director of Workforce
Development of South West Yorkshire Mental Health NHS Trust. We are
enormously grateful for the months of effort they have devoted to this project
and we also acknowledge the contribution of the Director of Clinical Risk at
the Mental Health Trust.
167. Chapter 6 of the Root Cause Analysis identifies Learning Points in seven
separate categories and Chapter 7 of the document makes
recommendations relating to Placements, Care Planning and Management,
Training, Emergency Procedures and Service Developments to meet the
needs of Women Prisoners.
27
CONCLUSIONS
168. New Hall is doing its best to provide a stable and safe environment for
women who clearly presented as difficult, vulnerable and a danger to
themselves and others.
169. The investigation team highlights the opinion of Her Majesty’s Chief
Inspector of Prisons that: "New Hall is holding women and girls who should
not be there. They include those who are seriously mentally ill, as well as
some women and girls with high levels of self-harm, linked to abuse".
170. The team acknowledges the major demands on staff at New Hall who have
to deal on a day-to-day basis with women who are self-harming, sometimes
on multiple occasions. The very first paragraph of HMCIP's April 2004 report
states: "The vulnerability and need of many of its prisoners was evident: an
average of 75 suicide watch forms were opened each month; there had been
124 incidents of self-harm in the month before the inspection; all in-patients
in the Healthcare Centre were severely mentally ill".
171. Current accommodation options within establishments holding female
prisoners are limited. Those who present in a highly disruptive way are either
confined to Healthcare or Segregation Units. No other alternatives are
currently available.
172. Funding has been allocated to provide Mental Health In-Reach services.
These services, even when combined with primary care, do not provide 24-
hour, seven day a week cover. Therefore the question remains over the
ability of the Prison Service to deliver appropriate interventions. HMCIP has
highlighted the need to provide alternative, therapeutic environments where
appropriate treatment and support can be offered. It is not clear on what
basis the funding for Mental Health In-Reach provision has been provided to
establishments.
173. Given that a ligature had been identified as being used in recent deaths, it is
of concern that the establishment has not been provided with cells to the
Safer Cell specification.
174. It is clear from the number of entries made in records that the woman
regularly sought the services of Prisoner Listeners. The enquiry concludes,
therefore, that she saw great value in being able to access Prisoner
Listeners.
175. Her frequent transfers between establishments following her sentence had
an impact upon the continuity of care provided by medical services. This
issue is explored in detail in the Care Planning and Management sections of
the Root Cause Analysis review conducted by South West Yorkshire Mental
Health Trust.
176. Evidence provided to the investigation team by staff involved with the care of
the woman demonstrated that exposure to her behaviour over a period of
time structured their response to this incident.
28
177. There are no instructions as to the actions required on the discovery of such
a significant note as that found by an Officer at 18:53.
178. The decision by the Officer not to use the emergency response procedures,
as set out in Operational Order 29/03, was based on the fact that the order
refers to there being a significant threat to life. We are concerned that, given
the serious nature of the note passed out by the woman, and the discovery
of the ligature just 28 minutes later, this was not deemed a significant threat
to life.
179. Potentially vital time was lost because the urgency of the situation was not
communicated to nursing staff (using Code Blue for an emergency related to
breathing difficulties). The first nursing staff on the scene did not bring
emergency equipment with them and one of the Nurses had to run back to
the Healthcare Centre to obtain the necessary equipment.
180. The woman was inappropriately left alone by the Senior Officer and two
Officers before the arrival of medical assistance. The three members of staff
left her cell at 19:24:41 and the two Officers did not re-enter it until 19:25:25
181. An ambulance arrived at the prison within 14 minutes of being summoned.
Even if the ambulance had been called slightly more quickly, it seems
unlikely that the eventual outcome would have been different because New
Hall’s own nurses reached the woman’s cell at 19:26:57. The paramedics
arrived at the cell at 19:44.
182. Requests by the ambulance service for detailed patient information are
currently routed via the establishment’s communications room, this is of
concern to the Head of Healthcare
183. The survey of seven deaths in custody immediately prior to and including
that of the woman, indicated that where there was a history of mental health
problems there was also a history of self-harm therefore a greater risk that
death may occur through self-inflicted injury.
184. New Hall liaised fully with the woman’s family following her death.
185. New Hall's Suicide and Self-Harm Prevention Policy has no serious
omissions but requires minor adjustments. The Segregation Procedures
were in line with Prison Service Orders. The Anti-Bullying procedures were
in line with Prison Service Orders
186. Inadequate checks were made of emergency response kits and staff raised
the issue with the investigation team regarding the lack of equipment in the
Segregation Unit.
29
RECOMMENDATIONS
National
1. The Prison Service's Yorkshire and Humberside Area Manager is invited
to set up an investigation to decide whether disciplinary action should be
taken against any members of staff. The issues to be examined by such an
investigation are:
(i) an Officer’s apparent failure to use emergency response procedures;
(ii) the decision made by the Senior Officer and the two Officers to leave
the woman’s cell at 19:24 on 18 April 2004 before she was known to
have recovered from placing a ligature around her neck and before
Healthcare staff arrived in the cell.
2. Consideration should be given to the provision of alternative therapeutic
environments where appropriate treatment and support can be offered to
those in need.
3. The provision and resourcing of mental health services within prison
establishments should be reviewed to ensure adequate care, support and
interventions can be provided throughout the day and night.
4. There should be cells to the Safer Cell specification provided within the
establishment.
5. Staff should not leave alone any prisoner who is failing to respond to
them or who is suffering from any injury other than that of a minor nature
prior to the arrival of healthcare staff.
6. Consideration should always be given to the impact upon the continuity of
care of an individual prior to any transfer.
.
Local
1. The wide-ranging recommendations made at the conclusion of South
West Yorkshire Mental Health NHS Trust's investigation are drawn to the
attention of the Governor, Area Manager and Head of the Women’s Team. A
multi-disciplinary group should be invited to respond to the report and
develop an implementation plan.
2. No instructions have been identified which provide guidance to staff at
New Hall as to what actions are required on the discovery of potential
suicide notes. Consideration should be given to providing such instruction.
3. Where there is evidence of injury, other than of a minor nature,
emergency response procedures (such as the use of "urgent message" or
30
the internal emergency telephone lines) should always be used. Therefore a
review of the current contingency plan at New Hall should be undertaken.
4. Consideration should be given to providing refresher training for staff in
order to assist them in resisting the most damaging aspects of being
conditioned by prisoners.
5. New Hall should review its Suicide and Self-Harm Prevention Policy given
the minor omissions identified in this report. This would also afford the
opportunity to incorporate the relevant operational orders into the policy.
6. There should be a review to ensure a sufficient supply of emergency
response equipment in appropriate areas. There should be regular checks of
the equipment and records of checks should be maintained.
7. The contingency arrangements for the summoning of an ambulance
should be reviewed to take account of the additional medical information
which is often now requested by the ambulance service
31
GOOD PRACTICE
The work of Samaritans and Prisoner Listeners within establishments was
clearly of great benefit. Their work should be recognised and their use
encouraged.
32
GLOSSARY OF TERMS
F2050 Main core record
F2052A History sheet/general observations
F2000 IMR Inmate Medical Record
F2052SH Self-Harm at Risk form
Care Plan Nursing care plan as in NHS
YOI Young Offenders Institution
HMP Her Majesty’s Prison
Off Prison Officer
ASO Acting Senior Officer
SO Senior Prison Officer
PO Principal Prison Officer
Gov Governor Grade
OSG Operational Support Grade (Auxiliary)
Listener Prison Samaritan
Nicking A disciplinary charge
Observation A general compilation of staff observations of
Book prisoners in a particular area
PER Prisoner Escort Record – Documentation confirming
that a prisoner has been handed over, e.g. from the
Prison Service to Group 4 for court appearance, etc.
Hot Debrief A debriefing of staff immediately following an incident
IEPS Incentives and Earned Privileges Scheme of which
there are three levels:
• Enhanced
• Standard
• Basic – this means the individual is in receipt of
all statutory entitlements, but privileges are
limited.
33