Individual at Norwich

INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING
THE DEATH OF A MAN AT HMP/YOI NORWICH
IN SEPTEMBER 2005
Report by the Prisons and Probation Ombudsman for England and Wales
July 2006
This is the report of an investigation into the death of a prisoner who died in his cell
on the Healthcare Centre at Norwich prison on 30 September 2005. He had been
found hanging. The man had been diagnosed as suffering from severe and enduring
mental illness at the time of his death.
I would like to offer my sincere condolences to his family and those affected by his
death.
The man was acutely mentally ill and a prolific self-harmer. Staff in Norwich cared
exceptionally well for him. However, his needs were too great for Norwich, or for any
prison, and he required treatment in a secure mental health setting.
Prison staff worked tirelessly to ensure that he was transferred to such a mental
health setting. However, there were significant obstacles to overcome. I believe the
National Health Service failed to acknowledge their responsibilities towards the man
who is the subject of this report. I am using this report to urge the Department of
Health to review the pathways of care and performance standards to ensure such
tragic circumstances do not recur.
The investigation was conducted on my behalf by two of my investigators. One of
the investigators and a family liaison officer from my office, met the solicitor
appointed by the man’s family to discuss the investigation and to enable him to share
the concerns the family had.
The Assistant Director of Quality and Organisational Development, Norwich Primary
Care Trust, conducted a comprehensive clinical review into the clinical care afforded
to the man during his time at Norwich. I am most grateful for her expert findings and
opinions. They have provided an invaluable insight into the problems faced by HMP
Norwich in caring for prisoners suffering severe mental illness.
I would also like to thank the Governor of Norwich and his staff for their cooperation
during the investigation. I am particularly grateful to the Principal Officer and another
officer who acted as the local liaison officers, and efficiently provided my
investigators with all they required to conduct the investigation. The improvements
Norwich has made in response to a series of deaths in custody have impressed me,
as has the Governor’s eagerness to learn from this exceptional tragedy.
Since April 2004, I have had the mournful duty of investigating around 200 self
inflicted deaths in prisons and elsewhere. I regard this report as one of the most
important I have prepared in that time.
STEPHEN SHAW CBE
PRISONS AND PROBATION OMBUDSMAN JULY 2006
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Contents
Summary
Investigation process
The man’s time at Norwich from 4 March 2004
Events from 29 September 2005
Contact with the man’s family
Findings and Conclusions
- Care afforded to the man
- F2052SH
- Items in cell
- Mental health placements
- Family concerns
- Emergency response
- Crisis management
Summary of recommendations
Good practice
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Summary
The was 40 years old when he died in the Healthcare Centre at Norwich prison on
30 September 2005. He had been found hanging.
The man had grown up in a travelling family and had two children himself. In the
years prior to his death, he and his family had suffered much family bereavement.
The man’s father, two brothers, sister and his brother in law had all died.
In his teenage years, he began to misuse alcohol and drugs and got into trouble with
the police.
Between 1989 and 1990, he was admitted to a psychiatric hospital on four
occasions.
In 1992, the man was sentenced to life imprisonment for violent offences. He was
transferred to a secure hospital in the early part of his sentence, but returned to
prison. Psychiatric reports prepared for his trial had diagnosed him as having severe
personality disorder, extensive paranoid delusions, depression and obsessive-
compulsive disorder.
During the course of his sentence, the man was twice transferred to open prisons,
but he failed to cope well and was returned to closed conditions.
The man was transferred to HMP Norwich on 5 March 2004, and spent most of his
time in the Healthcare Centre. He was supported by various mental health
professionals and with medication. In October 2004, he underwent a further
psychiatric review by a visiting psychiatrist. She noted: ‘At the present time, the
most pressing aspect of his mental disorder is obsessive-compulsive disorder and
associated depression with hopelessness and suicidal ideation. At the time of my
assessment these symptoms were incapacitating and in my opinion the man urgently
requires treatment’. It was felt that the man ‘would have no prospect of being able to
improve sufficiently to be able to progress further in his sentence without such
inpatient treatment.’ The man was at first accepted by an acute secure mental
health facility. Later they decided they could not cope with his self-harming
behaviour and told Norwich they could no longer take him.
The man’s health deteriorated. He became increasingly paranoid, and was a prolific
and extreme self-harmer. The man was subject to F2052SH procedures (a
document used to monitor and support those at risk of suicide and self harm) for
virtually all of his time at Norwich. The man’s self-harming behaviour led to black
eyes, lacerations to his face and wrists, and he would sometimes reopen these
wounds. He twice took an overdose of prescribed medication. He also swallowed
foreign objects which required removal at outside hospital.
Healthcare staff demonstrated great empathy with him. The Head of Healthcare and
Mental Health Lead were tireless in their attempts to have him transferred to a
secure mental health facility. They were operating in a system that worked against
them. It appeared as though prisoner-patients dropped to the bottom of a long
waiting list. Whilst in prison, their supervision was guaranteed, offering a degree of
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protection. In all other respects, the prison environment was completely unsuitable
for him.
The man was turned down for a by two secure hospital placements before his death.
He was due to be assessed by staff from Rampton special hospital.
At 00.50am on the 30 September 2005, staff performing checks of prisoners subject
to F2052SH procedures found the man hanging in his cell. They cut the ligature,
lowered him to the floor and attempted resuscitation. Efforts continued when the
ambulance arrived, but to no avail. The man was pronounced dead at 1.20am.
My report draws attention to problems concerning staff radios. I also make
recommendations relating to involving the family in a prisoner’s care when they are
subject to F2052SH procedures, to training in the use of the defibrillator, and to
staffing during the night-time patrol state. I commend the work of three members of
staff.
However, the most significant recommendations concern the relationship between
the Prison Service and the Health Service in respect of prisoner-patients with severe
mental health problems. There is a need for a fundamental review of the mental
health pathway to ensure that prisoners receive the most appropriate care and
treatment as quickly as possible.
During his time in HMP Norwich, staff showed great compassion and kindness to the
deceased who was struggling to cope with his debilitating illnesses. The fact
remains, however, that prison was not a suitable place for someone with his needs.
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Investigation process
I appointed two colleagues to conduct the investigation into the circumstances
surrounding the death of the man who is the subject of this report.
They made an initial visit to Norwich to collect documentation and meet the
Governor. They visited the cell where the man died. They met with members of the
Prison Officers' Association (POA) local branch committee and the Independent
Monitoring Board (IMB).
Notices were issued to both prisoners and staff, inviting anyone whom might have
information relating to the man’s death to make themselves known to the inquiry.
The investigation team then returned to Norwich to interview prisoners and staff.
Along with one of the investigators, one of the Ombudsman's family liaison officers
met the solicitor appointed by the man’s family. They explained the purpose of the
investigation and invited him to raise any concerns. The family’s main issue was that
they were unaware of how unwell the man was, and would have appreciated being
contacted about his state of mind.
A clinical review of his health care whilst in prison custody was undertaken by
Norwich Primary Care Trust.
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The man’s time at Norwich from March 2004
On 5 March 2004, the man arrived at Norwich from HMP Blundeston. He was initially
placed in the Segregation Unit at his own request where he told staff that he was
going on a “dirty protest” (a term used to describe when a prisoner deliberately soils
himself or his cell with excrement or urine). A few days later, he attempted self-harm
by swallowing an overdose of Amtriptyline that required treatment in an outside
hospital. He was then transferred to the Healthcare Centre, where he remained until
his death. In light of his mental condition and attempts at self-harm, he was placed
on an open F2052SH. This was only closed once. It was reopened the day after it
was closed as he had swallowed a television aerial.
Throughout his time in the Healthcare Centre, he was described as a paranoid man
who felt that fellow prisoners were talking and laughing about him behind his back.
The man spent a lot of time in his cell and did not associate with many prisoners.
However, he did build up a rapport with some members of staff and would seek
reassurances from them in respect of trying to secure a bed in a secure hospital.
The man was assessed by a visiting psychiatrist who prescribed an antidepressant
(Cipramil). The man was closely monitored and supported and underwent various
assessments from psychiatrists and mental health professionals. In October 2004, a
forensic psychiatrist undertook an assessment of him. The consultation report
describes ‘depressive and obsessive compulsive symptoms but nothing obviously
psychotic’. She noted a physical deterioration including weight loss that was obvious
from a previous prison photograph and written descriptions. She also stated that the
man felt ‘hopeless and feels that he cannot be helped’. The psychiatrist noted: ‘At
the present time, the most pressing aspect of his mental disorder is obsessive-
compulsive disorder and associated depression with hopelessness and suicidal
ideation. At the time of my assessment these symptoms were incapacitating and in
my opinion he urgently requires treatment’. It was felt that he ‘would have no
prospect of being able to improve sufficiently to be able to progress further in his
sentence without such inpatient treatment’. The psychiatrist referred him to Three
Bridges regional secure unit.
There was a long period of time (approximately six months) before Three Bridges
eventually decided that they would not accept him for a bed. The reason behind the
decision was his level of self-harming behaviour. Throughout this time, there is
evidence that healthcare staff tried on many occasions to contact Three Bridges to
determine the outcome for him and check that he was still being considered for a
bed.
During this time, his behaviour continued to deteriorate. He kept his cell in darkness,
hanging bed sheets and blankets from the window. When in the company of others,
he usually wore a towel over his head. He sought reassurance from staff that they
and prisoners were not talking about him. He was also paranoid about the food he
was given. He was concerned it was being poisoned, particularly if food had been
cut up. Healthcare staff contacted kitchen staff and arranged for him to be given
food that was whole, such as tomatoes and apples. They also gave him food in
sealed packets. This was often an arduous process, but the staff spent a great deal
of time building his trust.
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The man’s self-harming behaviour continued. He would sometimes beat himself up
causing injuries, and healthcare staff reported that he frequently had black eyes. In
February 2005, he took an overdose of paracetamol. There were also numerous
incidents of him cutting his face and wrists. The man often reopened wounds, and
on occasion he would make the wounds worse by inserting faeces. The man also
swallowed objects, such as toothbrushes, television and radio aerials, pens, and
sometimes razor blades.
On 30 May 2005, he told staff he had swallowed a television aerial that was
approximately 15cm in length and a razor blade. He made it clear that the reason he
kept swallowing items, was so that he would need abdominal surgery to remove
them. This would give him a wound with sutures that he could then pull open to self-
harm even further. The prison nurses and doctors monitored him and on 2 June he
was taken to the Norwich and Norfolk Hospital for the aerial to be removed.
However, he refused to have the procedure. The head of healthcare visited him and
outlined the seriousness of the consequences of refusing surgery. The man told her
that he was upset that Three Bridges had not accepted him. Throughout the
conversation, he had a towel over his head. With the manager’s gentle persuasion,
the man agreed to have the procedure, but later when she had left he refused again.
A doctor from the Norvic mental health unit visited him along with the healthcare
manager. The man once again agreed to have the procedure. Once they left the
hospital, he again refused. On 8 June, when he had finally agreed to proceed, the
healthcare manager visited him in hospital again and sat with him throughout the
procedure holding his hand. The hospital staff removed a 15cm aerial and a
toothbrush via his throat.
The man also smashed items in his cell. At times, he also attempted to assault other
prisoners on the rare occasions he left his cell. He said this was because he thought
they were talking about him. When this happened, he was restrained and taken
back to his cell even when he said he wanted to go to the segregation unit.
On 11 June, the man again swallowed aerials and was referred to the hospital for
their removal. He refused, but eventually agreed after intervention from the
healthcare manager. On 17 June, staff at the Norfolk and Norwich Hospital removed
a television aerial, two toothbrushes and a pen.
During this time, the healthcare manager and the head of the mental health team,
continued in their attempts to find him a mental health in-patient bed. They were in
contact with social services and Norwich PCT.
At the end of June, the man again swallowed objects including aerials and a razor
blade, and he was again transferred to hospital.
The healthcare manager visited him in hospital. She was later called to say that he
was being discharged without undergoing a procedure to remove the objects. It
appears that the hospital were unwilling to treat him for the same problem yet again,
although on this occasion he was not refusing treatment. The x rays clearly showed
that there were razor blades and three pieces of aerial lying transversely. The
healthcare manager was concerned that he was at significant risk of perforating his
stomach or bowel and suffering internal bleeding. The Healthcare Centre at Norwich
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does not have acute hospital facilities in the event of a significant bleed. The
hospital subsequently wrote a letter outlining their acceptance of responsibility for the
potential consequence of not operating on him. The healthcare manager instigated
a care plan informing staff how to deal with him in terms of observation. In the event
of any deterioration or stomach pain he was to return to hospital immediately. If
collapse or obvious bleeding occurred, a blue light ambulance was to be called.
Furthermore, if he needed to be restrained, it was not safe for him to be bent over.
An assessment was made by the healthcare manager in conjunction with the head of
the mental health team restricting the man’s access to objects, such as aerials, and
to ensure he was given only polystyrene in his cell.
On 1 July, Hertford Primary Care Trust agreed to fund a placement for the man. the
healthcare manager and the head of the mental health team kept up the pressure
and on 13 July an arrangement was made for the man to be assessed for a
placement at Redford Lodge. The man was anxious about the outcome of his
assessment.
The man was not accepted at Redford Lodge, and was visited by two officers from
Hertford PCT on 21 July. They assured him that they were looking for a placement
but that the process took time. The man said he felt hopeless and wanted to kill
himself.
On 26 July, the man cut his left wrist with a razor blade. The wound was cleaned
and steristripped. He was tearful and needed a great deal of reassurance from staff.
He later reopened the wound. He was found in his cell and had lost approximately
1.5 litres of blood. This was a potentially life threatening situation. An ambulance
was called urgently and he was taken to hospital.
The healthcare manager once again chased up his placement and heard he was to
be assessed by the Spinney Centre.
On 31 July, the man removed the stitches in his arm. He also threatened to harm
himself with objects in his cell but eventually handed them over to staff. Over the
next few days, he kept reopening the wound and expressing extremely paranoid
thoughts and behaviour.
On 10 August, the head of the mental health team wrote a somewhat desperately
worded letter to the Spinney Centre asking for their urgent assessment.
Throughout August, the man was extremely paranoid. On 16 August, he asked staff
to call his sister in law to check his family were okay. Staff did this and reassured
him. His sister in law said she would write to him and he seemed happy with this.
On the same day, he handed two razor blades to staff and admitted to swallowing six
toothbrushes. The man was seen by the doctor and monitored over the following
days.
On 17 August, the healthcare manager chased up his placement again and
requested acknowledgement of the head of the mental health team’s letter. In the
following days, the man thought his medication and food were being tampered with
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and became convinced that other prisoners were calling him names. Despite
reassurance, he harmed himself by giving himself two black eyes.
On 24 August, the man was assessed by the Spinney centre. In the following days,
his thoughts were pre-occupied by the assessment and he was anxious about what
would happen if he were to be turned down.
On 5 September, the head of the mental health team and the healthcare manager
and were informed that the man had been rejected by the Spinney Centre. As he
had reacted badly to previous rejections, they devised a care plan which included
increasing his observations to every 15 minutes. They broke the news to him
together to explain the rejection and to say that attempts would be made to find
another placement. The man appeared quite accepting of the decision. Entries in
his records in the following few days indicate that the man appears to have taken the
news relatively well.
During his time at Norwich, his F2052SH was regularly reviewed. In the review that
took place on 9 September, it was decided that the level of observations could be
reduced to hourly. In order to prevent him planning to self-harm around the
observation times, staff ensured that the checks were not at the same time each
hour. Further reviews were conducted on 17 and 25 September. Both concluded
that the man was still at a high risk of self-harm, and kept the support plan in place
including the hourly observations.
From this point until his death, the man seemed to have some good days, and some
bad days. On 22 September, the staff nurse noted that the man said he “feels like
the light has gone out at the end of the tunnel. Doesn’t think he will be accepted
anywhere.” However, there were times when he seemed quite positive. One
prisoner who helps run the library, reported that in the week before the man died he
appeared more upbeat. He said that: “The man came out of his cell a bit more; he
came to the library and even took the towel off his head. He seemed more at peace
with himself.” He reported that the man liked the company of the prisoner opposite.
This prisoner had come to the Healthcare Centre long after him and had been
accepted to a mental health unit.
Another prisoner said that the man did not mix with others so he had felt it a real
privilege that he had allowed him to cut his hair for him in his cell the week before his
death. The man had removed the towel and he saw this as a big step forward.
However, staff who knew him well said that he would have a few days where he was
more upbeat and would come out of his cell, but then have a few days when he was
low. There was no pattern to his behaviour. The head of healthcare said that in the
last week of the man’s life she would see him on a daily basis. The man was
anxious and she would try to reassure him. The head of healthcare did not really
notice a significant change in his behaviour. It was decided that the head of
healthcare or the head of the mental health team would meet him weekly to update
him on any progress in finding him a placement.
On the days leading up to the man’s death, the F2052SH shows that he often felt
physically and mentally unwell. He was in a low mood, hearing voices, exhibiting
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paranoid behaviour and crying. He was worried about what would happen to him
after being rejected by the Spinney centre.
On 27 September, a wing nurse spent a large amount of time talking to and
reassuring him. He was very distressed and claimed that ‘he would self-harm
although he did not want to’. He rang his buzzer at 2am and the nurse responded.
He said that ‘he had had enough and wanted to do a test run on hanging himself’.
She talked to him and eventually persuaded him to hand over some strips of sheets
that he had in his cell. Over the next two days, he was seeking regular reassurance
from staff. It is evident that staff spent a great deal of time with him trying to relieve
his anxiety. The wing nurse and the staff nurse in particular demonstrated a high
level of engagement with him and concern for him.
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Events from 29 September 2005
On 29 September, the man’s F2052SH shows that he declined to remove a bed
sheet he had hung up from the window. He was therefore sitting in darkness, but
appeared in quite a good mood.
The wing officer checked on him at 9.15pm and again at 10.30pm, and commented
that the man had been joking with him but seemed to experience mood swings. At
11.30pm, the wing nurse went to see him. The man was concerned that he was
going to be transferred to another prison. The wing nurse reassured him that this
was not the case. The man then asked her not to come to the hatch again, as he
wanted to be alone.
At 00.30am on 30 September, the wing officer started to conduct another set of
routine checks. The man’s cell was the last cell that needed to be checked, so he
arrived there at approximately 00.50am. There was some green sheet hung over the
observation hatch and the wing officer moved it to one side. He saw the man facing
out the window and thought he was hanging.
The wing officer proceeded to run down the stairs to L wing to alert the prison officer
and the two healthcare staff who were on duty, the wing nurse and the nursing
assistant. They were all on L wing whilst the nursing staff were carrying out their
night duties.
They all ran back up the stairs. The prison and the wing officers entered the man’s
cell, followed by the nursing staff, and confirmed he was hanging from the window
bars facing out of the window. He had used part of a bed sheet as a ligature. The
wing nurse sent the nursing assistant to fetch the resuscitation equipment, and the
wing nurse informed the communications room via her radio that they had someone
hanging. In her interview, the wing nurse said her mind went blank when she
radioed through and reported that there was a hanging rather than using the coding
system (code blue to indicate a prisoner was not breathing).
The prison officer supported the man while the wing officer cut him down using
ligature cutters. (The cutters are carried on their person as part of a standard issue
to night staff.) The nursing staff then proceeded with resuscitation. For a very short
time (whilst the nursing assistant returned with the resuscitation equipment), the
prison officer began chest compressions.
The wing officer left the room to contact the communications room by phone to
check they had received the information, an ambulance had been requested, and the
duty governor informed.
At 1.04am, the ambulance arrived and paramedics took over the resuscitation
process. Sadly, this was unsuccessful and the man was pronounced dead at
1.20am.
Norwich has comprehensive contingency plans in place to respond to a death in
custody. These were implemented and systematic recording of events took place.
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Contact with the man’s family
The duty governor arrived at the prison at approximately 1.40am. He accessed the
man’s records to identify the address of his next of kin.
The duty governor identified that the man’s next of kin lived in Hertfordshire. Good
practice was observed when he contacted the duty governor at HMP The Mount to
ask if they would visit the family to break the news. This was the closest prison to
the family’s home and would therefore be able to break the news quicker. The duty
governor at The Mount, agreed, and in conjunction with Hertfordshire Police he
informed the man’s nephew. The duty governor at HMP/YOI Norwich spoke to the
man’s sister the following day.
The Governor took the role of the family liaison officer. He arranged for the man’s
property to be returned, and offered financial assistance with the funeral. I am very
impressed that the Governor took on this responsibility himself.
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Findings and conclusions
Care afforded to the man who died
The man had a dual diagnosis of personality disorder and depressive mental health
problems. This led to a complicated pattern of self-harm. He was given a lot of time
and reassurance from staff who delivered individualised care. He was prescribed
medication by qualified psychiatrists and this was administered as prescribed.
The medical records are well kept, with comprehensive entries. These entries
demonstrated the high level of care, interaction and multi agency working afforded to
him.
Staff considered his individual needs and took steps to try to meet them. Good
examples are the attempts to provide him food that had not been cut, and not
automatically taking him to the segregation unit when he demonstrated violent
behaviour towards others.
Some individual members of the healthcare team showed exceptional dedication in
caring for him. I would like the wing nurse, the head of the mental health team and
the head of healthcare to be recognised for their work and commitment. It can be
clearly seen from the health records their compassion for the man. Although his
behaviour was very difficult at times, they dealt with him extremely sensitively. In
particular, the healthcare manager went beyond the call of duty, especially in relation
to his treatment in hospital outside the prison. This can be seen in the quality of
record keeping. The level of detailed documentation in the medical records is to be
commended. The head of the mental health team and the healthcare manager also
worked extremely hard to cut through the barriers preventing his placement in an
appropriate mental health setting.
I recommend that the Governor commends the wing nurse, the head of
healthcare and the head of the mental health team for their exceptional work
with and on behalf of the man who died.
F2052SH
It was entirely appropriate that the man was subject to F2052SH procedures for the
vast majority of his time in Norwich, as he remained at significant risk of self-
harming. The documentation shows a mixture of observation and quality entries,
demonstrating considerable interaction with him.
The man was subject to hourly observations. I believe this too was appropriate. The
man was a prolific self-harmer, but it had been over two months since an incident of
self-harm had endangered his life. However, my investigators noted that in the
afternoon there was often a gap two to three hours between checks. Comparisons
were made with other F2052SH documents on the Healthcare Centre, and this
seemed to be the case across the board. When my investigators asked the Head of
Healthcare if there could be any reasonable explanation for this, she acknowledged
the checks should have been made. Whilst I do not believe this affected his care, I
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urge the prison to address this matter and formally monitor the timing of interactions
and observations in the F2052SH as part of a local audit programme.
I recommend that the Governor reminds staff of their responsibility to conduct
checks on prisoners subject to suicide and self harm procedures and in
accordance with the individualised care plan. The timing and quality of these
entries should be regularly audited by managers.
Items in cell
There was one occasion when a risk assessment regarding what the man might or
might not have in his cell was carried out. However, one area of concern surrounds
the practice of giving prisoners like him, who are known to be prolific self-harmers,
access to blades. On more than one occasion he harmed himself using blades. It
seems reasonable, therefore, that access to blades should have been prohibited or
supervised. Whilst items should not routinely be withheld, and it is probable that he
would have used other implements to harm himself, few things are as potentially life
threatening as a blade. I suggest that consideration is given to issuing electric
razors to prolific self-harmers, particularly those located in the Healthcare Centre.
Mental health placement
The head of healthcare reported that, in the past year, 19 patients had been
transferred from HMP Norwich to secure mental health beds. She described the
process as “frustrating”. It involves the prison’s mental health staff identifying a
patient’s need for a secure mental health bed and then referring them to the
appropriate Mental Health Trust. The Mental Health Act Commission is then
engaged with a view to a visit by the relevant area psychiatrist, who will then assess
the patient. The head of healthcare said that in some instances it is difficult to get an
area psychiatrist to visit Norwich, however local assessments are relatively easy.
Once a patient has been assessed, the Mental Health Act Commission is notified.
There then is a period of waiting until a bed becomes available and the transfer can
take place. It is not unusual for a prisoner to wait for more than three months for a
bed. Furthermore, there does not seem to be a time limit on securing a bed, despite
the assessment determining that the patient has an immediate need for transfer to a
mental health setting.
The man was initially accepted by Three Bridges regional secure unit but was
subsequently ‘knocked back’. This was because the unit believed they could not
cope with his level of self-harm. Furthermore, there was no duty upon them to find
him another placement, as he was beyond their catchment area. Healthcare staff
told him this was the reason for their decision and he accepted this. It was the
opinion of many healthcare staff that mental health units only accept patients they
can easily treat and that high levels of deliberate self-harm are not felt conducive to
unit’s success. The head of healthcare recalled that the man understood that his
high levels of self-harm were undermining the efforts to get him a secure bed. He
was also acutely aware that there were some prisoners who had been assessed
after him and had managed to obtain a secure placement. This fuelled his paranoia.
They included a prisoner in the cell opposite him who was due to transfer to a secure
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unit on 30 September. The man would become extremely anxious about obtaining a
secure bed.
tHe head of healthcare told the investigators what benefits she thought the man
would have obtained from a placement in a specialist mental health unit. Whilst all of
his problems might not have been treatable, some of the symptoms could have
been. For example, he was extremely conscious of his eyes and took to wearing a
towel over his head to prevent him ‘glancing inappropriately’ at people. If this
obsessive behaviour could have been treated, this might have significantly improved
his quality of life and given him a sense of hope for the future. She believes that he
would have been receptive to treatment.
The man was due to have an assessment by Rampton special hospital in mid
October. The head of healthcare said he was anxious about this, believing that
Rampton was the end of the line for him. The man had been at Ashworth special
hospital some years before and believed there was stigma attached to those
transferred to Rampton.
The clinical reviewer found it was evident from the notes and professional opinions
that his mental health care needs could not be met within HMP Norwich. The
Healthcare staff tried on numerous occasions to have him transferred to a secure
hospital setting, but a range of factors prevented this occurring. These included
excessively long periods of time between referral and assessment, and from the
point of assessment to making a final decision. There was also an unacceptable
delay (six months) for Three Bridges to decide that the man could not be accepted.
The clinical reviewer examined this further and found that there appeared to be a
reluctance on the part of psychiatrists from outside of the area to travel to Norwich to
undertake an assessment. However, the local Norvic clinic seemed very
accommodating and often undertook assessments on prisoners at the request of the
Norwich Mental Health In-reach Team. However, this seems to be an informal
arrangement rather than a formal one and is made possible through the personal
networks of key staff.
There are also wider questions about moving prisoners like him, with significant
mental health problems, around the prison system. This must impair the ability to
treat mental health problems effectively and consistently. The impact on someone
as ill as this man of being moved from people who knew him well, and enduring the
stress of travel, would have been great.
The circumstances surrounding his death were tragic. He was desperate for help,
and prison staff were trying extremely hard to help him. But prison simply was not
the right place for him. Unfortunately, his death is symptomatic of a wider issue.
There are a significant number of seriously mentally ill prisoners within the prison
system, all of whom would greatly benefit from specialist care in a mental health unit.
I strongly endorse the following recommendations from the clinical reviewer:
I recommend that the Department of Health use this man’s case as the basis
for a fundamental mental health pathway review. This review should include
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relevant clinicians from both prison and health providers. This review will
enable the identification of the specific ‘bottlenecks’ and ‘hurdles’ that this
type of prisoner and the Prison Service face in managing those with severe
mental health and personality disorders. Actions should be taken to address
the bottlenecks and hurdles faced, ensuring that prisoners with mental health
needs get the most appropriate service at the time that they most need it.
I recommend that the Department of Health should formalise the target
response times of the Mental Health Trusts to include: time of referral to
assessment, point of assessment to acceptance, and acceptance to
admission.
This would reduce a great deal of anxiety and frustration for both the prisoner and
the healthcare staff concerned. These response times should be used as
performance targets to monitor the care afforded to those in prison with treatable
severe and enduring mental illness.
I recommend that the Department of Health should review and reduce the three
month (good practice) standard waiting time for obtaining a mental health bed,
and implement formalised time targets for the various stages of the referral
and assessment process. There is a need for clarification of the language
used i.e. there is a difference between accepting a prisoner for a bed and
saying you are finding a bed. This is can potentially be used as a stalling
method.
There appears to be some ambiguity and lack of clarity about the responsible
Primary Care Trust for prisoners identified with secondary and tertiary mental health
needs. The Department of Health is clear that, in the case of mental health this
responsibility rests with the Primary Care Trust where the prisoner resided at the
time of their arrest and not the local PCT responsible for the establishment.
I recommend that Primary Care Trusts are reminded of their responsibilities
towards prisoners identified with mental health needs, resident in their
catchment area at the time of their arrest, even if located in a prison outside
their geographical location.
Family concerns
The man’s family said through their solicitor that they were not aware of how unwell
he was, and did not know about his self-harming behaviour. The man did not share
this information in his telephone calls. There was one occasion when he asked staff
to contact his sister in law to ask how his children were. However, there is no
documented evidence that staff encouraged him to contact his family, or asked if
they could contact them on his behalf. The man’s family said they would have
arranged a visit had they known, and would have appreciated that opportunity.
Prison Service Order (PSO) 2700, 3.4 Follow-up actions, and care for prisoners who
have self-harmed states:
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3.4.3 After consultation with the prisoner, the nominated next of kin must be
notified, unless:
- There is a clinical reason not to, or;
- If aged 18 and over, the prisoner does not consent, or;
- The prisoner’s support plan indicates otherwise (e.g. in the case of a prisoner
who repetitively self-harms).
3.4.4 Where appropriate, after serious incidents of self-harm consideration should
be given to allowing the prisoner themselves the opportunity to notify the next
of kin by a phone call and/or an extra exceptional visit.
I recommend that the Governor should ensure that the local self-harm and
suicide awareness policy reflects PSO 2700 and encourages and supports the
informing of the prisoners next of kin.
The duty governor observed good practice by contacting the duty governor of the
prison closest to the family address to break the news of the man’s death. I
welcome the actions of governors from HMP Norwich and HMP the Mount in
ensuring that the man’s family were told in person by a representative of the Prison
Service. The Governor may wish to consider sending a copy of this report to the
governor at The Mount. (Unfortunately, some confusion around the spelling of the
address led to a delay in the man’s family being notified.)
Emergency response
When the wing officer attended the man’s cell, he believed it was a possible fatality.
He chose to run downstairs to alert the assistant night orderly officer and nurses
instead of using his radio. In the event, the alarm was raised promptly, and staff
were in the man’s cell in seconds.
The wing nurse instructed the healthcare assistant to collect the emergency bag.
She entered the cell with the officers, and then called the communications room via
her radio to alert them that there was a hanging on healthcare, and an ambulance
was required. Once resuscitation attempts had started, the wing officer left the cell
to phone the communications room, and although they had called an ambulance
they reported that the radio message was unclear.
The deputy governor reported that there had been problems with some radios, in
that their battery life and reception had been poor. There has been considerable
investment in this area. However, it still appears that staff do not have full
confidence in their radios.
Running down the stairs, not entering the cell and not contacting the
communications room immediately by radio could have created unnecessary delays
in treatment. Staff must have confidence that radios will transmit a clear message to
the communications room staff.
I recommend that the Governor arrange for a test of radio reception and
ensure batteries of all radios are checked regularly and rectify any problems.
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The wing nurse commenced Cardio Pulmonary Resuscitation (CPR) and was
assisted by the nursing assistant. When asked if they had a defibrillator, the wing
nurse replied “we do but they are somewhat temperamental and I am afraid the
majority of staff are not trained to use them”. The head of healthcare was asked
about the defribrillator and whether this was working. She said that the equipment
was in full working order and not temperamental. It has a self-testing device. In her
previous role in the NHS, she had worked in resuscitation. Although not used when
the man was discovered, the head of healthcare is adamant that use of the
defribrillator would not have affected the outcome.
There are two defribrillators at Norwich, one in the YOI and one in the main prison
although not all staff had been trained in its use. This has been highlighted by the
Healthcare Manager to the PCT and there will be training in the future.
I endorse the following recommendation from the clinical review:
I recommend that all relevant healthcare staff should undertake training in use
of the defibrillator machines.
Crisis Management
Norwich prison is on a split site divided by a car park and a road. One section of the
prison accommodates young offenders in the YOI and houses the Healthcare
Centre, including an elderly prisoner unit. The remainder of the population is
accommodated in the main prison complex.
At night, the night orderly officer and assistant night orderly officer are in charge of
the prison. Individual officers carry a cell key in a sealed pouch which they can open
in cases of emergency. But the orderly officers are the only people with access to
keys around the prison, and only they can order the opening of the gate for an
ambulance to enter.
The night orderly officer was in charge of the main prison. The prison officer/
assistant night orderly officer, was in charge of the section of the prison holding
young offenders and the Healthcare Centre. The prison officer left the man’s cell
whilst CPR was underway to facilitate the arrival of the ambulance. He went to the
young offender part of the prison and obtained the keys from a safe. He also
collected an officer from the YOI. He then went to the gate and explained the
situation. The prison officer gave the key to another officer instructing him to open
the main gate for the ambulance, and ensure all gates between the main gate and
Healthcare Centre were open to allow immediate access. The prison officer then
returned to the man’s cell where CPR was still underway.
In the meantime, the night orderly officer left the main prison and made his way to
the Healthcare Centre and took control of the situation.
The main part of HMP Norwich holds approximately 750 prisoners. In this part of the
prison, there are wings which hold prisoners on remand and those who are
sentenced. There is a first night centre and a detoxifcation unit. The other part of
the prison holds approximately 230 prisoners, including young offenders aged 18-21,
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the Healthcare Centre with in-patients, and the elderly prisoner unit. It appears to
me that a great deal is expected of one senior officer, as night orderly officer, and
one officer as his assistant based on the other part of the prison. I do not believe
that the care that the man received, or the speed in which it was delivered, was
affected in any way. However, I can envisage a situation arising where the officer in
charge has to leave the scene, potentially resulting in more serious consequences.
I recommend that the Governor considers re-profiling the management needs
of Norwich at night state.
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Recommendations
Clinical
I recommend that the Governor reminds staff of their responsibility to conduct checks
on prisoners subject to suicide and self-harm procedures and in accordance with the
individualised care plan. The timing and quality of these entries should be regularly
audited by managers.
I recommend that the Department of Health use this man’s case as the basis for a
fundamental mental health pathway review. This review should include relevant
clinicians from both prison and health providers. This review will enable to
identification of the specific ‘bottlenecks’ and ‘hurdles’ that this type of prisoner and
the Prison Service face in managing those with severe mental health and personality
disorders. Actions should be taken to address the bottlenecks and hurdles faced,
ensuring that prisoners with mental health needs get the most appropriate service at
the time that they most need it.
I recommend that the Department of Health should formalise the target response
times of the Mental Health Trusts to include: time of referral to assessment, point of
assessment to acceptance, and acceptance to admission.
I recommend that the Department of Health should review and reduce the three
month (good practice) standard waiting time for obtaining a mental health bed, and
implement formalised time targets for the various stages of the referral and
assessment process. There is a need for clarification of the language used i.e. there
is a difference between accepting a prisoner for a bed and saying you are finding a
bed. This is can potentially be used as a stalling method.
I recommend that Primary Care Trusts are reminded of their responsibilities towards
prisoners identified with mental health needs, resident in their catchment area at the
time of their arrest, even if located in a prison outside their geographical location.
Local
I recommend that the Governor ensures that the local self-harm and suicide
awareness policy reflects PSO 2700 and encourages and supports the informing of
the prisoners’ next of kin.
I recommend that the Governor arranges for a test of radio reception and ensures
batteries of all radios are checked regularly and rectifies any problems.
I recommend that all relevant healthcare staff should undertake training in use of the
defibrillator machines.
I recommend that the Governor considers re-profiling the management needs of
Norwich at night state.
All recommendations have been accepted by the Prison Service and the Department
of Health.
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Good Practice
I recommend that the Governor commends the wing nurse, the head of healthcare
and the head of the mental health team and for their exceptional work with the man
who died.
I am very impressed that the Governor took on the role of family liaison officer
himself
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