Individual at Norwich

Investigation into the death of a man
on 19 January 2006, whilst a prisoner at HMP Norwich
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2006
This is the report of an investigation into the death of a man who was discovered
hanging in his cell on 19 January 2006, and died later at a local hospital. He had
been in the custody of HMP Norwich since 4 August 2005. He was 50 years of
age.
The investigation was undertaken by two of the investigators from my office. A
clinical review of the healthcare provided to the man was commissioned by Norwich
Primary Care Trust. I am grateful to for the report.
I would also like to express my thanks to the Governor of HMP Norwich, and his
staff for their help and active co-operation throughout this investigation. Not for the
first time, I have been struck by the personal commitment of the Governor in the
aftermath of a tragedy in his prison.
Given the inevitable constraints of a prison environment, I do not believe there was
more that staff at Norwich could have done to prevent the death of this man. He
had at times been closely monitored whilst in prison custody, as there was concern
that he might harm himself. In addition, measures were put in place to try to
support him through his mental health problems. Unfortunately, these did not in the
end prove sufficient to prevent his death.
I make three recommendations and the clinical review has identified a further five
that I endorse.
Stephen Shaw CBE
Prisons and Probation Ombudsman October 2006
CONTENTS
Summary
Investigation methodology
The subject of this report
HMP Norwich
Clinical Review
Events prior to the man’s death
Events surrounding the man’s death
Findings and conclusions
Recommendations
Summary
1. the man who is the subject of this report was arrested in August 2005, after
setting fire to the stairs in his house, apparently whilst trying to commit
suicide. He had tried to end his own life on ten previous occasions. He was
remanded into custody at HMP Norwich on 4 August and immediately placed
on a self-harm watch (F2052SH). (The F2052SH is a form used to record
the details of individuals who are considered to be at risk of self-harm, their
support plans and day to day observations.)
2. The man’s mood was unpredictable and could lower dramatically for no
apparent reason. For example, on 12 August at 4.30pm he was sleeping in
his cell. At 5.05 pm, he was found with a shoelace tied tightly around his
neck. Ten minutes later, he said that he was feeling fine.
3. He was placed on a F2052SH twice whilst at Norwich - once on arrival, and
again on 26 October 2005 after telling staff that he had thoughts of putting a
noose around his neck to make a vein stand out and then cutting it.
4. The man was taken off his self-harm watch on 23 November and moved into
a single cell on A wing the following day. On 9 December, he appeared at
Norwich Crown Court and was sentenced to 18 months imprisonment for his
arson offence.
5. On 15 December, he refused his early release date of 21 December, writing
back that he did not wish to be released on licence and was therefore
looking at 1 February 2007 as his date of release.
6. During January, he complained of, and was treated for, pain in his left
shoulder and neck. The prison doctor saw the man on the day he died, but
neither the doctor nor the nurse who walked him back to A wing detected
any signs of him being in crisis.
7. At 7.20 pm on 19 January, an officer answered a cell call bell. The man said
that his electricity had gone off. The officer told him that the switch had
‘tripped’ due to everyone returning from association and switching on their
televisions and kettles. The power was turned back on and the man
appeared fine.
8. About ten minutes later, a wing officer went to check on the man and found
him hanging from the window bars of his cell. He was cut down and officers
began to try and resuscitate him. Paramedics arrived and he was
transferred to the local hospital where he was pronounced dead at 8.32 pm.
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Investigation methodology
9. The investigation was opened at HMP Norwich on 24 January 2006. The
Governor and his staff produced the man’s core record and a large number
of other documents for examination. Notices were distributed around the
prison notifying staff and prisoners of the investigation.
10. A number of prison staff were formally interviewed.
11. Her Majesty’s Coroner was contacted to inform him of the nature and scope
of my investigation and to request a copy of the Post Mortem report. Upon
completion, this report will be sent to the Coroner to assist in his enquiries
into the man’s death.
12. One of my Family Liaison Officers (FLO) made contact with the man’s close
friends and family. Whilst they had concerns that his mental health problems
were not sufficiently addressed by the criminal justice system, they did not
wish to have a meeting with either my FLO or my investigators at that time.
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The subject of this report
13. The man was born in 1955. He lived alone and had suffered from
depression for a number of years for which he was receiving medication.
14. He was arrested in August 2005 and subsequently remanded into custody at
HMP Norwich. He had set fire to the stairs of his own house in an apparent
suicide attempt. He had made ten previous attempts to take his own life.
15. This was not his first experience of prison, although he had not offended for
over 20 years.
16. He was a man who preferred to be alone, as he found it difficult when there
were other people around. His friends said that his mood could change very
quickly and he would get depressed over seemingly trivial things.
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HMP Norwich
17. HMP Norwich prison holds convicted and remand prisoners, including adults
and young offenders. It is designated as a local prison and serves the courts
of East Anglia. The Certified Normal Accommodation is 591, and the prison
has an operational capacity (total crowded capacity) of 823. The current
Governor was appointed In December 2004.
18. A car park and road divide the prison. The majority of the population is
accommodated in the main prison complex. The other part of the prison
accommodates young offenders and the Healthcare Centre, which also
includes an elderly prisoner unit. The Healthcare Centre has out patient
facilities, as well as in-patient beds for prisoners with physical health
problems and severe and enduring mental health needs.
19. In March 2005, Her Majesty’s Chief Inspector of Prisons carried out a full
announced inspection of the prison. In her introduction, the Chief Inspector,
said that there were unacceptable deficits in safety and key
recommendations from seven recent deaths in custody had not been
implemented. She also identified that the management of prisoners who
were at risk of self-harm was poor. Additionally, she said that major
functions within the prison were inadequate and had been poorly managed.
Support plans for prisoners at risk were poor, access to the Samaritans
restricted, and prisoners’ cell alarm bells regularly muted. However, the
report also said that, since the appointment of the new Governor,
performance improvement was under way.
20. Since my office took over responsibility for investigating deaths in prisons in
April 2004, there have been eight deaths at Norwich prior to that of this man.
Six of those deaths were apparently self-inflicted.
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Clinical Review
21. A clinical review of the medical care that the man received whilst at Norwich
was carried out by the Norfolk Primary Care Trust.
22. In the report the author highlights similar areas to those reported by my
investigators. I have reproduced sections of her report below:
“The man was diagnosed with depression 3 years ago. He has a poor
self image and demonstrates social phobic behaviours. He was
referred to a Mental Health Hospital by his GP approximately 3 years
ago and he was receiving support from a Community Psychiatric
Nurse until approximately 2 years ago. The treatment for his
depression seemed adequate and doctors had reassessed this
medication on a number of occasions. Following his initial health care
assessment he was referred to the Mental Health In-reach team and
was also seen by a psychiatrist. It appears that he was well
supervised and cared for and that every opportunity to help him was
taken, e.g. ensuring he has a single cell as requested. The man was
receiving medication for his depression. He had had eleven previous
attempts at suicide since his teens, ranging from drinking mercury to
attempts at hanging. He remained on an active F2052SH for most of
his time at the prison. This is a reflection that the staff took his
comments and state of mind seriously.
“The man has a history of alcohol abuse especially binge drinking and
a previous dependency upon Heroin and Crack Cocaine. He
complained of generalised pains in his body including shoulders, back
and hand areas for which he received pain relief as and when
necessary. There was no specific reason identified for these pains.
“The issue of drug administration to prisoners and the fact that it took
two days before anyone questioned why the man had not collected his
medication or food suggests that these practices should be examined
and redesigned where appropriate.
“The resuscitation appears to have taken place as per guidance and
staff behaved professionally. Paramedic support was summoned as
soon as possible and during the wait every attempt was made by both
Discipline and Health staff to save the man’s life.
“As a general point the quality of record keeping could be improved.
This would include the dating of entries and the clarity of handwriting.”
23. The clinical review has identified five areas for learning, which are listed in
full in the recommendations section of this report. Commendably, I note that
steps have already been taken to address these and their implementation will
be monitored by the Clinical Governance structure.
5
Events prior to the man’s death
24. Following his arrest for arson in August 2005, the man appeared at West
Norfolk Magistrates’ Court and was remanded to HMP Norwich.
25. A detailed assessment report was provided by the Criminal Justice Mental
Health Team at the magistrates’ court. It ended by saying that, in the opinion
of the author, the man was a high risk of suicide due to the impulsive nature
of his previous attempts but that he was of low intent. It was felt appropriate
that he continued to be dealt with through the Criminal Justice System.
26. The Prisoner Escort Risk form (PER) noted the man’s risk of self harm,
stating the number of previous suicide attempts and that he suffered from
depression. During the reception process at HMP Norwich, the man told the
nurse that he had last been in prison 30 years ago. He said that he was
prescribed venlaflaxine for his depression and that he was a binge drinker.
He said that he felt stressed but not unduly so, but was concerned that he
might harm himself. He also stated during his cell sharing risk assessment
that he did not wish to share a cell as he felt like killing people when they
invaded his space.
27. The man was referred for a mental health assessment and an F2052SH was
opened. (The F2052SH was a Prison Service system used at the time in
Norwich to list observations of prisoners suspected of having thoughts of
suicide or self-harm, and to record details of any support plans put into place
during their period in crisis. The F2052SH has now been replaced at
Norwich and at an increasing number of other prisons by ACCT
(Assessment Care in Custody and Teamwork).)
28. He was placed into the healthcare unit for observation and assessment.
During the next few days, the man said that he was feeling ‘ok’ but finding it
difficult to settle into prison life. He also expressed concern about moving
into the main prison. On several occasions, he refused to come out of his
cell for association, not wishing to mix with the other prisoners.
29. On 12 August, the man was checked at 4.30 pm when he was asleep in his
cell. When he was next checked at 5.05 pm, he had a shoe lace twisted
tightly around his neck using a plastic knife as a tourniquet. He was blue in
the face and the ligature had to be cut off with a safety knife. Ten minutes
later, he said that he was feeling fine now but that he had been very
depressed earlier. He was put onto an irregular 15 minute watch.
30. The man’s case was reviewed again on 14 August. He said that he self-
harmed to cope. He spoke of going into a ‘pit’ and when in that ‘pit’ he self-
harmed. He also said that he never knew when he would go into the ‘pit’ -
being fine one minute and suicidal the next. He said that he was feeling
happy at the present and had no complaints about the way he was being
looked after, although he was worried about going to court.
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31. The man was encouraged to talk to staff rather than self-harm when in the
‘pit’. He remained in healthcare.
32. The man was seen by the prison doctor on 17 August. He said that he had
his court appearance in two weeks and needed something to calm him down
or he would not go. The doctor agreed that he would benefit from
medication at that time, but told the man that he should not demand
medication or make threats not to go to court if he did not get it.
33. At his next F2052SH review on 19 August, the man said that he had been
withdrawn since being seen by the doctor. He felt that he had been spoken
to aggressively by the doctor, which had led him to withdraw and decline his
food. He said that it was his intention to be too unwell to attend court. But at
the same time, he stated that he was no more at risk than previously. I note
that there is no record of him declining food in his F2052SH.
34. The man was seen by a forensic psychiatrist on 23 August. The psychiatrist
concluded that, despite his denial of any thoughts of suicide or self-harm, it
seemed suitable for him to remain on the F2052SH while he was facing the
uncertainty of court appearances.
35. When his case was reviewed on 27 August, he told staff that he still felt
suicidal several times a day, even describing the methods he had thought
about. The review team decided to keep the F2052SH open. The same
day, it was noticed that the man had two superficial two-inch cuts to his right
wrist. He claimed to have done them early that morning. No treatment was
required. He did not mention having made these cuts during his review and
there is no record of the incident in the F2052SH booklet.
36. By 3 September, the man said that he felt more stable in his mood and had
not been having any thoughts of self-harm or suicide. He said that he would
like to be more occupied and it was decided to give him a trial as a cleaner.
The review team, with the man’s approval, decided to close the F2052SH
booklet. He began helping the cleaners over that weekend and there is a
note in his main record, dated 11 October, that he had been an excellent
cleaner. An entry was made in his medical record on 23 September, noting
that he looked relaxed and conversed well. He said that he felt safe from
himself at that time.
37. On 30 September, the man complained of pain and swelling in his right
hand, and of an aching pain in his right shoulder and forearm. He was
prescribed diclofenac, an anti-inflamatory drug, and told to attend work at his
own discretion. On 5 October, the man was pronounced fit for work. Two
days later, he was seen by the doctor who noted that the pain in the man’s
arm had settled, and that, while he was still not sleeping well, generally his
mood had improved. He was still anxious about going to court.
38. On 26 October at 6.30 pm, the man spoke to staff in the B wing office and
said that since he had left healthcare in early September he had not been
coping well. He said that he did not like being surrounded by too many
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people. He added that he had thoughts of putting a noose around his neck
to make a vein stand out and then cutting it. He promised that he would not
do anything at present, but also said that he had not been taking his
medication for a couple of days. The man was moved to a single cell on C
wing and another F2052SH was opened.
39. He was seen the following morning, 27 October, in the healthcare treatment
room when it was noted that he was feeling very down and had not collected
his medication. He was offered the opportunity to return to healthcare, but
the man said that he would try to cope on the wing.
40. The man was the subject of a F2052SH review at 4 pm that day, when he
said that he was very emotional but would ring his cell bell if he felt like self-
harming. A support plan was set up for him. This was for him to take his
medication, to collect his food (staff would try and unlock him last), and to
find him employment (he had moved to C wing from B wing where he had
been a cleaner). He was also offered the support of a Listener. (The
Listeners are prisoners who volunteer to be trained by the Samaritans. They
then offer a similar service within the prison as the Samaritans outside.)
There is no record of the man ever actually having spoken to a Listener.
41. That afternoon, the man was seen in healthcare at the request of the wing
staff. He said that he was feeling low and had not been taking his
medication and had not eaten. The importance of eating regularly and taking
his medication was explained to him.
42. His mood continued to drop over the next few days. At his F2052SH review
on 8 November, he stated his intention to take his own life several times. His
support plan was for him to have an urgent mental health review, to see the
doctor the following morning, for him to be given a sedative for his court
appearance and for hourly observations at night.
43. A few hours later, the man had cleared up his cell – apparently so that it
would not have to be done after he had committed suicide. The
observations were increased to every 10 minutes, until he was transferred
back into healthcare. He was agreeable to that. It was not possible to
accommodate him in healthcare that night as all of the beds were occupied.
It was therefore decided to place the man under a constant watch until the
following day, when further endeavours would be made to admit him into
healthcare. He watched television and then slept with the bed covers over
him for the rest of the night.
44. At 7.45 am the following day, 9 November, the man told the observing
officer, “You missed it”. When the officer checked, he saw that there was
dried blood on his sheets and superficial cuts on his wrists. A nurse was
called and his injuries were cleaned with saline, but he declined any
dressing. The man seems to have spent his day talking about how he would
kill himself either in prison or on the outside if he got released.
8
45. He took part in another review, during which he expressed very similar
suicidal thoughts. He was kept on a constant watch with his agreement and,
after the review, transferred back to healthcare. He was due at court the
following day and was very anxious about it.
46. On 10 November, the man was convicted of arson with sentencing
postponed until 9 December. He had another F2052SH review on his return
to the prison. He was feeling very depressed and reluctant to talk. After
some encouragement, he said that he had constant thoughts of self-harm
and was finding it difficult to cope with his depression. He felt safer in the
healthcare unit and being in a single cell. His support plan was to encourage
him to comply with his prescription medication, to receive support from the
chaplaincy, to remain on constant watch and to be encouraged to read and
watch television.
47. I note from the F2052SH that, during the night of the 11 November, the
officer on night duty in healthcare was asked to keep a constant watch on
two at risk prisoners.
48. The man was taken off his constant watch with his agreement on 12
November. A minimum of four irregular observations an hour replaced the
constant observation. That was reduced to three per hour on the following
day, and to frequent irregular checks by 16 November.
49. Whilst it would seem that his mood was improving, there were still a number
of entries in the F2052SH regarding his refusal of food. On one occasion, it
was noted that he had not taken his food for 48 hours.
50. The man was seen in healthcare on 17 November by two doctors who
conducted a forensic psychiatric review. He claimed that he was no longer
feeling suicidal, but he had a longstanding wish not to be alive. He again
expressed his concern about a forthcoming court appearance.
51. On 19 November, the man told staff that he was not eating meals and had
not eaten for 48 hours, saying that he just did not feel like eating at that time.
He was encouraged to take fluids and a note to that effect was put on his
F2052SH. Later that day, he told staff that he was feeling better and
planned to have his tea meal. He took his meal, but did not eat it. By 5.10
pm he felt much better and was given some bread to make a sandwich
which he ate.
52. The following morning, the man told staff that he was feeling much better.
He told staff that he was a community carer outside of prison and that he
also had some knowledge of epilepsy. The man was very motivated when a
member of staff asked him to consider writing a self-help guide for prisoners
who have epilepsy.
53. Over the next few days, his mood went up and down. On 22 November, he
did not speak to staff, apologising the following day. That day (23
November), he told staff at 8.05 am that he was so frustrated at the
9
possibility of going into dormitory accommodation that he had broken his
glasses and thrown them out of the window.
54. At 3 pm that day, the man took part in another F2052SH review. He told the
review team that ‘he would not do anything silly’. He wished to be on his
own and specifically asked to return to the main prison. He was adamant
that he no longer needed to be on a F2052SH. The general feeling of the
review team was that it could be closed, but that he needed to be in a single
cell.
55. The same day, the man was seen by the prison doctor who also
recommended that he be allocated a single cell. He was moved to A wing
the following day.
56. On 28 November, the man told a wing officer that he had not been taking his
meals, just saying that he did not want to. He was seen by healthcare staff
on A wing the next day. He said that he felt okay in his mood, but that his
appetite was intermittent. He was not mixing with the other prisoners and felt
anxious at times. The man said the anti-depressants were helping and that
he did not have any thoughts of suicide.
57. On 3 December, The same wing officer wrote in the A wing Staff
Observation book that the man was ‘now a fully paid up member of the 4’s
landing’. The officer meant that, in his opinion, the man had settled into life
on the wing and was interacting with staff and other prisoners. The same
day, he put in a healthcare application stating that his right hand was painful
and becoming immobile due to swelling. The application was received on 4
December and the man was seen by the nurse on 6 December. At that time
his wrist was not inflamed, but he was given some aspirin to take when
needed.
58. The man was seen by a nurse on 8 December and declared fit to attend
court the following day.
59. On 9 December 2005, he attended Norwich Crown Court and was sentenced
to 18 months imprisonment for his arson offence. Later that day, he
submitted a further healthcare application, requesting reading glasses after
his were broken in healthcare. His application was received on 13
December and the man was put onto the optician’s list.
60. On 15 December, the man was informed that his release dates had been
calculated. His earliest date of release on home detention curfew was 21
December. He wrote back saying that he did not wish to be released on
licence and was therefore looking at 1 February 2007, his sentence expiry
date, as his date of release.
61. An entry in the A wing Staff Observation book on 24 December stated that
the man was quiet and generally polite to staff. He was now employed in the
print shop which he seemed to be enjoying.
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62. He submitted another healthcare application on Christmas Day complaining
of not being able to sleep. He added that, as a result, he had stopped going
for his medication and food. On 27 December, he was given a sleep leaflet.
63. Another application was submitted on 2 January 2006, as the man had been
unable to sleep for more than two or three hours a night for almost 14 days.
He also had an ear infection due to a head cold. He was seen by the doctor
on 6 January and given 50mg of phenergan at night for seven days to help
with his sleep, and a course of erythromycin, an antibiotic, for a chronic
infection of his left ear.
64. Later that day, the man spoke with a member of the wing staff about the sale
of his house. He was given advice for which he said he was grateful. He
was also corresponding with his friends who were helping with the sale.
65. The man was seen in the healthcare treatment room on 14 January, when
he complained of pain below his shoulder blade. Lanosil ointment was
rubbed in to good effect and he was given some aspirin. He was advised to
keep mobile.
66. He submitted a further application on 16 January, which he marked as
urgent, saying that he had pain in his left shoulder blade and poor movement
in his arm, neck and back. His name was put on the list to see the doctor on
20 January.
67. The man reported sick from work on 17 January, complaining of pain in his
shoulder. The wing staff contacted healthcare on 18 January, stating that he
had not been attending work, had not collected his medication for two days
and may not have been going to the servery for his meals. The wing officer
spoke at length with the man on the wing. The man said that, although he
had not had lunch, he would have tea and continue to collect and eat his
meals. He also said that he would attend his doctor’s appointment on 20
January. The officer later told the investigating police officers that he did not
get any indication that anything was wrong, or that the man was upset about
anything apart from the pain in his shoulder.
68. The man was seen on 19 January, by a prison doctor and prescribed some
‘Deep Heat’ cream and 400mg ibuprofen tablets to ease the pain in his
shoulder. Neither the doctor nor the nurse - who walked the man back to A
wing - detected any signs of him being in crisis and likely to self-harm.
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Events surrounding the man’s death
69. About 6 pm on 19 January, the man spoke with the wing officer on A wing.
He confirmed that he had seen the doctor and been given some painkillers.
They had a brief conversation and then the man got himself a cup of tea and
went to his cell to watch television. At about 7.20 pm, he rang his cell bell
and the officer asked one of his colleagues to respond. The officer went to
the cell and the man asked him if someone had turned his electricity off. The
officer checked the trip switch which is outside of the cell. He assured him
that it had just tripped, probably because association was coming to an end
and the other prisoners were switching on their kettles and televisions, thus
overloading the system.
70. The officer left to continue with his duties. During his interview the officer
said that the man appeared to be alright when he left him.
71. At 7.30 pm, the staff called for association to end and for the prisoners to
return to their cells. The wing officer went up to the 4’s landing to begin
locking the cell doors. When he got to the man’s door he saw that it was
shut, which he said in interview was not unusual. If the cell bolt is not shot
the prisoners can shut their doors themselves. The wing officer entered the
cell to check on the man and found him hanging from the metal window bars
at the rear of the cell, facing the window. He had used a bed sheet as a
ligature and there was an overturned chair just below him.
72. The officer turned around immediately and, when he could not see his
colleague on the 4’s landing, called over the rail to another officer who was
on the 3’s landing below. The first officer supported the man and cut the
sheet ligature with his safety knife. He lowered him to the floor and began
cardio pulmonary resuscitation (CPR). He was joined by the other officer
who called for further assistance on his radio stating that there was a ‘code
blue’. (That code is used to quickly communicate that there is an emergency
medical situation involving a person being unconscious, having breathing
difficulties, a ligature involved or something similar.) Two nurses arrived at
the cell a few minutes later. An ambulance had already been called. The
Senior Officer (SO) also arrived and assisted with the CPR.
73. The nurses found no signs of life when they examined the man. They put an
oxygen mask on him, and CPR was continued until the Rapid Response
paramedic arrived at 7.41 pm and the ambulance crew at 7.45 pm. The
crew took over attempts to resuscitate the man, including shocking him with
a defibrillator. After a few minutes, the paramedics believed that his
condition had slightly improved and arrangements were made for him to be
transferred to an outside hospital.
74. The man left the prison at 8.14 pm and was taken to the local hospital.
Unfortunately, he was pronounced dead at 8.32 pm, shortly after he arrived
at the hospital.
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75. The staff who were involved took part in a hot debrief which gave them the
opportunity to talk through the events. They were also offered the support of
the prison care team and welfare services. The prison’s contingency plans
for a death in custody were implemented, which included informing the
police.
76. The man had not listed any next of kin when he arrived at Norwich. In an
effort to trace any family he could have had, staff looked through documents
in his cell. The Governor was able to trace some of the man’s friends
through letters. He drove out to see them that night. They confirmed that
the man had been estranged from his family for some considerable time and
had not wanted contact with them.
77. I commend the actions of the Governor.
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Findings and conclusions
78. From the outset, it was obvious that the man would be a challenging prisoner
for Norwich to assist and care for. Not because he was disruptive or violent,
but because of his history of suicide attempts and his apparent determination
to end his life. I believe that the staff at Norwich did their best within the
inevitable limitations of a prison regime. It may be that his mental health
problems were not so severe as to justify compulsory treatment in a secure
psychiatric hospital, but it may also be doubted that prison was the right
location for someone with the man’s problems.
79. There were several periods during his time in custody at Norwich when the
man stopped eating and/or collecting his medication. On at least one
occasion, the fact that he had not been taking his medication or eating his
food was only brought to notice by the man himself, suggesting that the
issuing and record keeping procedures in these areas were less than
vigorous. Those procedures should be examined and any deficiencies
addressed.
The Governor should review existing arrangements for monitoring the
nourishment of vulnerable prisoners and consider if improvements are
necessary.
80. One particular area of concern is that, on the night of 11 November 2005, the
officer tasked with keeping a constant watch in healthcare wrote in his
F2052SH that he was responsible for two prisoners who required a constant
watch. I do not believe that situation to be in the best interests of either the
two prisoners in crisis or the officer. Sufficient staff should always be
deployed to carry out these duties, as it is not possible for a single officer to
give sufficient constant attention to more than one prisoner.
The Governor should ensure that staffing levels for prisoners requiring a
constant watch for reasons of self-harm are at least one to one.
81. The man was moved onto A wing on 24 November 2005, where he stayed
until his death. During interviews with staff conducted as part of this
investigation, my investigator, found that the wing officers were not aware of
the man’s self-harm history or the fact that he had twice been on F2052SH
booklets during his time at Norwich. I believe it is crucial for staff having day
to day interaction with prisoners to have sufficient information about those
prisoners, particularly if they have a history of self-harm. My investigators
and I were pleased to learn that, after the man’s death, steps had already
been taken to inform staff of past self-harm issues. An orange coloured card
has been introduced as part of the ACCT documentation. This is placed in
the general wing file to flag to staff that a prisoner has recently been taken
off an ACCT. I commend this practice and believe that the Prison Service
should consider implementing it throughout all establishments.
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Consideration should be given to implementing as national policy the use
of a coloured card to notify staff that a prisoner has recently been taken
off of an ACCT.
82. The man broke his glasses in frustration on 23 November 2005 and threw
them out of his cell window. He told staff of his actions that morning. He
was still on an F2052SH at the time and the conversation was duly noted in
the document. Despite that, it was not until 9 December, when the man
asked for a replacement set, that any action was taken. It was unfortunate
that, even though a F2052SH review took place a short while after the man
had told staff about his glasses, nothing was done to obtain a replacement.
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Recommendations
Policy
(cid:190) Consideration should be given to implementing as national policy the use
of a coloured card to notify staff that a prisoner has recently been taken
off of an ACCT.
Local
(cid:190) The Governor should review existing arrangements for monitoring the
nourishment of vulnerable prisoners and consider if improvements are
necessary.
(cid:190) The Governor should ensure that staffing levels for prisoners requiring a
constant watch for reasons of self-harm are at least one to one.
Health
The clinical review has identified a further five recommendations to be
addressed jointly by the prison and Primary Care Trust and their implementation
monitored by the Healthcare Governance structure:
(cid:190) Systems of communication should be put in place to ensure that wing
staff and other relevant people e.g. doctors are made aware of previous
self harm attempts so that they can observe, assess and record
prisoners’ behaviours and state of mind more effectively.
(cid:190) Healthcare staff receive training on record keeping and or be reminded of
their professional responsibilities.
(cid:190) A record keeping audit should be completed and the learning
implemented.
(cid:190) Mechanisms are in place to alert staff to prisoners failing to pick up
medication, especially if this medication is related to keeping the
individual mentally stable
(cid:190) A critical incident review by the staff involved in the decision to stop the
F2052SH might aid decision making in the future.
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