Individual at Norwich

Investigation into the circumstances surrounding the death of a prisoner at
HMP and YOI Norwich in August 2004
Report by the Prisons and Probation Ombudsman for England and Wales
March 2005
CONTENTS
Summary 5
Investigation Process 7
Events leading up to the man's death 10
The crisis management 11
Notifying the man's family 12
Staff Support following the man's death 13
Suicide Prevention at Norwich Prison 14
Findings 15
Conclusions 18
Recommendations 23
2
This is a report of the investigation into the death of a prisoner who was just 19 years
old when he died in HMP Norwich in August 2004.
I would like to offer my sincere condolences to the man's family and friends.
The investigation was conducted under the terms of the transitional arrangements
agreed between my office and the Prison Service, which came into effect on 1 April
2004. The bulk of the investigative work has been conducted on my behalf by a
governor from HMP Littlehey and a member of staff from HMP Blundeston. A clinical
review was conducted by Norwich Primary Care Trust. I am very grateful to all
members of the team for their work. A colleague from my office, liaised with the
investigating team.
The man's death was the first self­inflicted death at Norwich prison since the
Ombudsman was passed responsibility for the investigation of deaths in custody.
Sadly, another prisoner died in September 2004. The report into that death will
consider if the issues can be drawn together to see if any lessons can be drawn to
try to prevent similar tragedies in the future.
STEPHEN SHAW CBE
PRISONS AND PROBATION OMBUDSMAN
3
SUMMARY
The man who died was born in January 1985. He was 19 years old when he died.
He had previously served a period of custody in HMYOI Warren Hill, where he had
attempted suicide and self harmed. After a period of relative stability living with his
girlfriend and her parents, he was remanded into HMP & YOI Norwich on 26 July
2004. During the reception process the man had been identified as requiring a
detoxification programme from alcohol, which was successfully completed. He had
found this difficult, and following the detoxification programme was prescribed anti
depressants. He was well liked by his peers, and staff did not have any serious
concerns about the man who was described as generally cheerful. He suffered
mood swings and reported feeling anxious and being unable to sleep at times.
During his time at Norwich prison, the man attended education classes, and
underwent a Substance Awareness and Relapse Prevention course via Care
Assessment Referral Advice and Throughcare (CARATS).
In August, the man moved from a shared cell to a single cell after being on a waiting
list for such a move. He was seen to be cleaning the cell, making the best of a cell
that was in poor repair.
That evening he had been upset following a telephone conversation with his
girlfriend, a conversation that was cut short because he ran out of phone credit. It
was his perception that the relationship was over. An officer was concerned when
he saw the man upset and allowed him to use the office phone to try and contact his
girlfriend again. He was unable to contact her but spoke to a friend who the man
described as a "go between". Following the phone calls, the officer arranged for a
Listener (another prisoner trained by the Samaritans) to speak with the man.
The officer was not sufficiently concerned about the man to warrant opening a
F2052SH (a form used by the Prison Service to monitor and support prisoners
thought to be at risk of suicide or self­harm). He did, however record in the handover
book that the man had been upset and spoken with a Listener. Staff who came on
duty for the night were not aware of any concerns relating to the man, and did not
read the handover book.
In late August, the man was found hanging at 5:50am by an Officer Support Grade
(OSG) during the morning roll count. The OSG radioed for urgent assistance and
went to the office to get the ligature knife from the "self harm box". Staff arrived,
entered the cell and cut the ligature, made from torn bed sheets from around the
man's neck. Efforts to revive him proved fruitless and he was pronounced dead at
6:30am. It was the Doctor's opinion that he had been dead for some time.
The police were asked to inform the man's sister (his next of kin), of his death.
However, the police did not confirm they had informed her, and the first news his
sister received of her brother's death was in a telephone call from the governor of the
YOI.
4
He was a vulnerable young man. However, without previous knowledge of him,
there were no specific indications that he was at a high risk of harming himself during
his time at Norwich. Nevertheless, a number of lessons can be learnt from the man's
death to help prevent another tragedy in the future. This report contains 16
recommendations.
5
INVESTIGATION PROCESS
In April 2004, the Prison and Probation Ombudsman was passed the responsibility of
investigating all deaths in custody. Under transitional arrangements, two governor’s
of HMPS were appointed to conduct the investigation on the Ombudsman’s behalf
along with and investigator from the Ombudsman’s office.
The investigation team visited HMP & YOI Norwich, where they received a brief from
the in charge Governor, ahead of visiting the cell where the man died. They also
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.
Along with my investigator, one of the Ombudsman's family liaison officers visited the
man's girlfriend and her parents. The family liaison officer also had telephone
contact with the man's sisters and adoptive parents and offered to visit them. The
family liaison officer remained in touch with them.
We interviewed prison staff who were involved in attempts to save the man's life, and
prisoners who knew himincluding the Listener who spoke with the man the evening
prior to his death . We also interviewed and examined documentation from other
staff who were either associated with the wing or known to the man who died. There
were also prisoners from neighbouring cells and a Listener who were interviewed.
We examined the man’s prison record and a series of prison documents.
A clinical review of his health care whilst in prison custody was undertaken by
Norwich Primary Care Trust.
6
BACKGROUND
The man who died had previously spent time at Warren Hill Young Offenders
Institution (YOI). In the records of his time at Warren Hill, the man had spoken about
the problem he had with using drugs and alcohol. Pre sentence reports state that
these issues left him vulnerable to the influences of others when in a group.
During his time at Warren Hill he attempted suicide. He was twice placed on a
F2052SH form. This is a mechanism that is used by the Prison Service to monitor
and support prisoners who are at risk of suicide and/or self harm. The man had felt
particularly vulnerable after the break up of a relationship with his girlfriend at that
time. Norwich prison were not in receipt of the information contained in this record.
He was remanded to HMP & YOI Norwich on 26 July 2004 from Colchester
Magistrates Court. He was also attending court for a separate matter and had
attended a hearing in August at Harwich Magistrates Court.
When he arrived at Norwich prison he went through the reception and induction
procedures. He was open with staff about previously being subject to a F2052SH,
and about having a history of alcohol abuse.
The initial Cell Sharing Risk Assessment for the man was completed on 26 July.
Section 2.7 of the form asks if the prisoner is on an open F2052SH form, it is ticked
as ‘yes’. There is also a part on the form that allows you to mark where this
evidence was gained from, and it is marked ‘P’ for prisoner, indicating that the man
provided this information himself. There is one additional explanatory note, which
reads, ‘states may have been on an F2052SH previous’. Section 3 of the form is
completed by healthcare staff and asks for a conclusion on risk the man may pose to
himself or to others. The box “Insufficient evidence to give opinion” is marked. The
‘Low’ risk box was also marked (detailing no current indication / evidence of risk,
suitable for multi cell location.) Following this, the Assessment asks: ‘Following the
self harm assessment have any concerns been raised?’ This was ticked as ‘no’
In his healthcare reception screening, he disclosed he had not expected to be sent to
prison, and a friend had taken his own life some two years earlier. He also said he
drank eight units of alcohol a day. He later told the Doctor he drank up to 30 units of
alcohol per day and the Doctor prescribed him a twelve day chlordiasziporxide
detoxification programme.
The man was also referred to the CARAT'S team for an assessment. This took
place on 30 July. It was noted that, ‘The man was very upset when we met. He had
just been put on remand, which he was not expecting. He seems very distressed
and worried.’ On interview, the CARAT worker said the man had been ‘sobbing’ and
that he was very worried about his girlfriend having an accident on her moped. It
seems he may have believed that his girlfriend was expecting his baby. The CARAT
worker said she tried to contact his girlfriend on his behalf. She stated, that although
clearly upset, he did not appear to be at risk of harming himself at this time. This
was the last time she had had direct contact with him. He later attended a four day
Substance Awareness and Relapse Prevention course via CARATS, during which
7
he had spoken of his belief that he would soon be released. He did not display the
signs of distress the CARAT worker had previously witnessed.
In August, the man submitted an application to see healthcare staff. He stated
“Doctor prescribed me chlordiaziproxide for shakes, depression, lack of sleep. Don’t
seem to be working, waking up feeling worse than ever.” He was seen by a detox
nurse, the next day. The nurse noted in the man’s Inmate Medical Record (IMR),
that once the detoxification programme had been completed the Doctor might
prescribe zispin (an antidepressant). Indeed, the man was prescribed this once he
had completed his detoxification programme.
A few days later, the man did not collect his detoxification medication. That
afternoon, a nurse from the Mental Health In­reach team went to see the man but did
not speak with him as he was at education.
He seemed to settle into prison life and was popular with his peers. The man’s
personal officer, described himas a well­liked prisoner who mixed well and was
generally cheerful.
We spoke to a number of prisoners throughout the investigation. A cell mate had
shared a cell with the man until sometime in August. He said the man had been
anxious when he had not received a letter from his girlfriend for a few days, but when
one arrived he was fine. He was not expecting to be sentenced to a long period in
custody and was looking forward to getting out and making it up to his girlfriend. The
man rarely expressed concerns to other prisoners and seemed generally happy.
He had a substantial amount of personal mail in his cell. Most of it was letters and
cards from his girlfriend. The mail was not dated so we cannot follow the sequence.
All the letters contained messages of love for the man, and were looking forward to
his release. However, there was one letter where his girlfriend had been told some
things that had upset her and made her feel that the man kept letting her down.
Although a number of negative subjects were raised, the letter closed with her saying
she wanted to be with himand that she would love him forever.
8
EVENTS LEADING UP TO THE MAN'S DEATH
The man was located on F Wing in the Young Offender part of the prison. There are
three landings on the Wing, holding 169 young people. There were 30 prisoners on
F2 landing. The man was relocated from a double cell on F2 landing to a single cell
(F2­18) a few days before he died. The man’s personal officer explained that
prisoners who requested a single cell were put on a waiting list and allocated a
space when it arose. Staff said there had been no concerns evident about the man
moving into a single cell. An officer stated that he had recalled speaking to the man
in the afternoon about the good job he was making of cleaning his cell. He had no
concerns about his behaviour at the time. A wing mate, who lived in the cell
opposite, also reported seeing the man during the afternoon. He had been cleaning
his cell, and the wing mate did not see anything of concern in the man’s mood. It is
worth mentioning that, when investigators saw the man’s cell, it was in a poor
condition.
During evening association on the night before he died, the man telephoned his
girlfriend. The man’s cell mate said he saw the man after the phone call and he
seemed upset, but not in tears. His cell mate gave him a cigarette, turned round
briefly and he was gone. The man left association early and returned to the wing.
An officer said he saw the man crying at approximately 6.30pm.
We were able to listen to a tape of the telephone conversation between the man and
his girlfriend. He sounded anxious and asked several times if the relationship was
over. At no point during the conversation did she say the relationship was over.
They also discussed his sentence. She was worried he would get a significantly
longer sentence than he anticipated. She was clearly upset but agreed at the end of
the conversation that he could phone her again on Thursday and they would talk
more.
In his written statement, the officer said the man had told him he thought his
girlfriend was trying to finish with him and that his money had run out during his
phone call to her. The officer allowed the man to use the office phone to call her
back again. The first number he tried was to her mobile. This was switched off, so
the officer allowed himto try a second number, this time to a friend who the man
described as a ‘go­between’. He asked his friend to speak to his girlfriend and
assure her he was going to change when he got out of prison and that he would ring
her again Thursday evening when he got some more phone credit. The officer said
he appeared in a better frame of mind following the call.
The officer offered the man the services of a Listener (another prisoner trained by
the Samaritans) which he accepted. The Listener went into the man’s cell and
stayed with him for half an hour. After this, the officer asked the listener how the
man was and he replied that the man was okay. The officer said he then asked the
man if he was okay and he nodded. The officer could not recall anything positive or
negative about his body language at the time.
The listener said that he had heard the man talking out of his cell window later that
night, and passing tobacco.
9
THE CRISIS MANAGEMENT
At 5.50am the day the man died, an Officer Support Grade (OSG) performed the
landing roll check as usual. When he looked inside the man’s cell he saw him with a
ligature around his neck tied to the window bars. The OSG contacted the control
room and asked for urgent assistance to the man's cell.
Two officers responded from F1 office. As they were approaching F2 landing, one of
the officer’s saw the OSG run to the office and collect the “Self Harm box” which
included scissors in order to cut the ligature.
This officer opened the cell door and saw that the ligature was tied at the top of the
window and the man had one foot on a chair nearby. The ligature was made from a
torn bedsheet. The officer contacted the control room to request medical assistance
recording a ‘code 1’. There are three codes used at Norwich prison to call for urgent
assistance, code 1 is used when a prisoner is not breathing and is believed to be
dead. A Prison Service Nurse (PSN) stated she received this call at 5.55am.
The OSG cut the ligature from the man’s neck. They laid him onto the floor by his
bed and started CPR. A prisoner, who lived in the opposite cell, confirmed that he
had seen staff attempting to resuscitate the man on the floor and that they had
continued to try for "20 minutes".
The PSN arrived at 5.59am. She had come via the F Wing treatment room to pick
up the emergency response kit. The PSN asked the OSG to call an ambulance and
took over CPR from the officer.
There are different accounts of the exact time of arrival of the ambulance. These
vary from 6.06am to 6.13am. Once the paramedics arrived they continued CPR until
the doctor arrived at 6.28am, and pronounced the man's death at 6.30am.
Following the man's death the staff carried out all contingency plans. This included
switching off the pin phone system until his Next of Kin could be informed.
He left a suicide note. The content of the note shows that he felt his relationship with
his girlfriend had finished, but he made it very clear in the note that she was not to
blame for his decision. He was very upset during and after the phone call. However,
the content of his telephone conversation on the night of his death shows that
although the man's perception was that the relationship had ended, in fact, she had
left it open to him to engage in further dialogue later that week.
10
NOTIFYING THE MAN’S FAMILY
The prison asked the police to make the initial contact with the man’s sister and
break the news of her brother's death. The prison did not receive confirmation that
the police had contacted her, and she reported that she heard of her brother’s death
in a telephone call from the Governor.
The Chaplain, made further contact with the man’s sister by telephone. The
Chaplaincy department maintained all further contact with the family. The
Chaplaincy visited the family, as well as his girlfriend and her family. They also
conducted the man's funeral service. The man’s girlfriend and her family
commented on the level of support they had received from the Chaplaincy and were
grateful for this.
The man’s sister and her adoptive parents visited the prison. They were met by the
Deputy Governor and the Governor.
11
STAFF SUPPORT FOLLOWING THE MAN’S DEATH
All staff involved in finding and attempting to revive the man were asked to attend the
office of the Deputy Governor for a “hot debrief”. Staff were offered the services of
the Care Team and Staff Care and Welfare. The Governor then spoke to the staff
separately. The staff directly involved in the incident have since been offered and,
where requested, given support from the Care Team, Chaplaincy and other staff and
managers at the prison. Staff reported follow­up contact having been made by the
care team. Those interviewed felt they had been well supported.
The Samaritans had been in regular contact with the Listener and he had received
additional support from other agencies, including CARATS, and the Chaplaincy.
The manager of the YOI ensured staff spoke to all prisoners likely to be affected by
the man’s death as soon as possible. When the prisoners were on exercise at
9.00am, the chaplain led a prayer and a minute's silence. Following this, the
Samaritans attended the unit at 11.00am to offer support. The Listeners were
briefed and also offered support.
12
SUICIDE PREVENTION AT NORWICH PRISON
A monthly meeting is chaired by a Senior Manager and the Suicide Prevention Co­
ordinator and is attended by all functional areas within the prison.
The current policy document states that a F2052SH should be opened if staff have
any concerns.
The two previous audits for Suicide and Self Harm Prevention were carried out in
2003 and 2004. The result in June 2003 was an ‘Unacceptable’ 52% rating. The
follow up audit in July 2004 showed significant improvement to an ‘Acceptable’ 72%
rating.
The training department provided training records relating to Suicide and Self Harm
Prevention for staff involved in the incident. They held records on only three of the
staff involved. The three staff had undergone suicide prevention training, varying
from 15 months and over tens years prior to the man’s death.
The Independent Monitoring Board (IMB) draft Annual Report for the period January
2003 to February 2004 notes that ‘staff relationships remain good, particularly in the
YOI’. It further notes that, with regard to F2052SH procedures, while these had been
problematic, ‘there have been definite signs of improvement in the last 2 to 3
months’.
13
FINDINGS
· Previous records.
The man who died had previously spent time in HMYOI Warren Hill. The records of
his time in Warren Hill YOI were not requested by Norwich.
· Cell sharing risk assessment.
The cell sharing risk assessment was not completed correctly. There is no evidence
that the issues raised by the form concerning the man previously being subject to a
F2052SH were pursued any further.
· Healthcare issues
There is no evidence that his previous medical records from his local GP or previous
sentence were requested.
There were several examples in the medical paperwork where professionals did not
meet the recognised standards for record keeping. These include:
­ The first reception screening form was not signed and baseline observations
had not been completed.
­ On xx August, a nurse from the Mental Health In reach team went to visit the
man but he was at education. There is no record of the rationale behind the
visit or who referred him.
­ A Prescription was written for amoxycillin on x August but there is not
recording clinical indication to support this and no corresponding entry in the
continuous medical record.
­ A prescription was written for Zispin on xx August but again there is no
corresponding entry or explanation in the continuous medical record. The
only reference to depression was found on x August when he saw the detox
nurse. There is no evidence of a follow up assessment.
­ Many entries in the IMR are not dated, and do not have the name printed
against the signature.
The man was identified as requiring an alcohol detox on reception, and a twelve day
chlordiaziproxide regime was prescribed and commenced the following day. His
application to see healthcare on at the beginning of August clearly indicates that he
was not coping with the detox. He was seen and assessed by a nurse on the
following day and was advised that an anti depressant, Zispin might be prescribed
when the detox was completed. No other support, advice or follow up are
documented.
The nurse that went to see himdid not follow up seeing the man after the abortive
attempt. The reason for this is recorded in The Ledger of Contacts as being that the
man was being seen by a psychiatrist on 5 August. There is no evidence that he
was ever referred to or seen by a Psychiatrist whilst in prison. It would appear that
there was a misunderstanding due to another prisoner's psychiatric assessment
completed by the psychiatrist being misfiled in the man’s IMR.
· The use of the office phone for prisoner phone calls
There is no policy in place at Norwich prison for staff to follow to allow prisoners to
make phone calls from an office if they have a domestic issue.
14
· F2052SH and Handover procedures
The officer said in his written statement that the man had not indicated to him that he
would self harm and consequently, the officer did not believe it was necessary to
open an F2052SH. However, an entry was made by the officer about the man in the
Observation book that night. It read, ‘put in with a listener at 19.15 (been dumped by
girlfriend)’. The officer did not recall speaking to anyone else with regard to the man
on that evening.
Staff coming on duty stated they did not receive a handover detailing any concerns
regarding the man, nor did they recall reading the entry in the observation book
about himhaving spoken to a Listener.
The night staff coming on duty did not receive a handover from the day staff going off
duty, and did not read the wing occurrence book so were not aware of the Listener
talking to himduring the evening.
· The man’s cell
The man’s cell was in a poor state of repair. The walls had not been painted for
some time, and there was a space where a notice board was missing covered with
toothpaste marks. The door to the toilet and washing facilities was missing. The
toilet was stained inside and was missing half the seat. There was plaster missing
from around the doorframe. A similar situation was found in other cells inspected on
the landing.
Furthermore, the window bars in the man's cell presented a number of ligature
points.
· Notifying the man’s family
The man’s sister, was notified of her brother’s death by telephone, by the Governor.
She believed the police had visited the man’s sister in order to break the news.
· Crisis Management
Staff finding the man acted appropriately and with speed in removing the ligature and
laying him on the floor for CPR. The evidence clearly indicates that attempts to
resuscitate himcontinued until the Paramedics arrived.
Norwich prison's protocol for entering cells as a singleton night patrol if a prisoner is
believed to have attempted to take his own life says that “you can enter the cell
alone”. In this instance, the OSG decided to wait for assistance from other staff,
which took only a couple of minutes to arrive.
The OSG had to leave the cell to go and collect the "Self Harm box", containing the
ligature knife while he was waiting for other staff to arrive.
It is clear that local procedures were followed in respect of a death in custody. A
debrief took place and appropriate support was offered to staff and prisoners
affected.
15
· Staff training
Training records were found, and showed that suicide prevention training had been
undertaken by three members of staff involved in finding and attempting to
resuscitate him. The time lapse from the training and the man’s death varied from
15 months to over ten years.
16
CONCLUSIONS
It is not normal practice on entering a prison for records from a previous period of
custody to be requested. There were few indications that the man intended to take
his own life and it is unlikely that access to his previous custody records would have
altered what happened. However, once he divulged that he had been on a F2052SH
on a previous sentence, records of this might have provided useful insight. Whilst it
is unrealistic to expect that previous records are requested on every prisoner
entering prison, where elements of risk are uncovered it would be sensible to request
back records.
I recommend that, where evidence concerning risk of harm to a prisoner or
other prisoners is identified, any records from a previous period in custody are
requested.
The man had moved to a single cell the day prior to his death. It is clear from
evidence given by landing staff that there were no concerns as to his state of mind at
the time of the move. Indeed, he was portrayed in a positive light by staff and
prisoners witnessing him cleaning his cell. However, the Cell Sharing Risk
Assessment that had been completed when he was remanded to Norwich was not
completed properly or comprehensively. He said he had been on a F2052SH
previously. I would expect the member of healthcare staff to ask further questions
about this; perhaps why he was subject to the F2052SH or, if he had a single cell at
that time, for example. There is no evidence of any further investigation. It may
have been that the man came across as being content and assured healthcare staff
he was fine, leaving them to believe there were no concerns. The point is that, given
the fact that he said he had previously been on a F2052SH, staff completing the
assessment should demonstrate that this has been considered.
I recommend that staff involved in completing Cell Sharing Risk Assessments
are reminded of the importance of considering self harm issues when
completing the assessment.
There is no evidence that the man’s previous medical records from his local GP or
previous sentence were requested. These would have alerted healthcare staff to
previous self harm attempts. This, in turn, would have meant further support and
assessment could have been made available to the man. It is recognised that if this
was policy for all new receptions it would be a very significant undertaking. He did
not disclose any mental health issues on the reception healthcare screening.
Indeed, healthcare staff may never have been aware that he had a history of self
harm as there seemed to be poor communication on this subject. However,
obtaining medical records would be best practice.
There were several examples in the medical paperwork where professionals did not
meet the recognised standards for record keeping. Entries in the IMR were not
timed, and names not printed following a signature. What is of more concern is that
there was a lack of explanation surrounding decisions that were made. This was
particularly evident when a prescription was made; there was little or no
corresponding entry in the IMR as to the reason for the prescription. I therefore
endorse the recommendations made by the clinical reviewer.
17
I recommend that a record keeping audit should be carried out if one has not
been completed in the last six months.
I recommend that training should be provided for healthcare staff at all levels
regarding record keeping and their professional responsibilities.
I recommend that all prescriptions have a corresponding entry in the
continuous record made by the Prescriber that also gives the assessment
process and reasons for the prescription.
The man who died underwent a twelve day alcohol detoxification programme.
However, his application to see healthcare on at the beginning of August clearly
indicates that he was not coping with the detox. He was seen and assessed by a
nurse the next day and was advised that an anti depressant, Zispin, might be
prescribed when the detox was completed. No other support, advice or follow up are
documented, and it is not clear what, if any follow up occurred to see how he was
coping.
There was evidence that the CARATS team were also supporting himalthough no
information had been shared with healthcare at this time.
I recommend that a review of the alcohol detoxification programme is carried
out to explore and develop the inclusion of other support packages, advice
and follow up.
A nurse, from the Mental Health In­reach team went to see the man on early in
August but did not see him because he was in education. There is no
documentation as to how the referral was triggered, why or by whom. The nurse did
not follow up the man again, but I believe this was a misunderstanding due to
another prisoner's assessment being misplaced in his IMR.
There was no clear process to receive and direct Mental Health In­Reach referrals.
They could be informally received via Officers, Treatment Room Nurses or other staff
and there was no structured approach to recording this. The clinical review of the
man’s healthcare, found that systems were beginning to be developed to give clear
auditable pathways, improve patient care and reduce the risks.
I recommend that the new Mental Health Referral system and policy is
supported by management in its implementation and reviewed in six months.
The man was upset by the phone call he had with his girlfriend on the evening before
he died. This conversation had ended earlier than he would have liked because his
phone credit ran out. Realising he was clearly upset, an officer acted
compassionately by allowing himto use the office phone to try and contact his
girlfriend again. The officer was present in the room whilst the phone calls took
place but obviously could only hear one end of the conversation. Good practice in
other prisons has been for a senior officer to credit the pin phone system when
prisoners need urgent use of the phone. This ensures that the calls can be recorded
so situations of concern can be monitored. It also means that a senior officer has to
18
be consulted. This is useful for two reasons. First, one person on the wing is
keeping track of the reasons the calls are being allowed to avoid abuse of the
system. Secondly, a senior officer is consulted when a situation like the man’s
arises and a decision can be made by more than one person as to any action that
needs to be taken, such as opening a F2052SH.
I recommend that a system is established for senior staff to credit the PIN
phone system.
The current Suicide Prevention Policy at Norwich states that a F2052SH should be
opened if staff have any concerns. The officer did not open an F2052SH as a result
of his interaction with the man, although his use of the services of a Listener would
indicate that he was concerned about him. The officer told us that, although the man
had been distressed, he did not feel that the man was at risk of self­harm. The
officer had asked the man if he was alright once the Listener had left his cell, and he
had said he was ok. With the gift of hindsight this did not appear to be the case.
There is no evidence of any further interaction to gauge his state of mind.
I recommend that Norwich’s local instructions on Suicide Prevention be
revisited to ensure staff are clear on when an F2052SH should be opened.
The officer had written in the log book that the man had been upset and had spoken
with a Listener. The only person who receives a handover on issues arising from the
day is the assist Night Orderly Officer. Staff on duty on the night of his death had not
read the observation book entry regarding the man so were not aware of any
concerns about him. Day staff had not verbally handed over any concerns regarding
him. As the man had not been assessed as being at sufficient risk of self harm to
require an F2052SH, it is difficult to conclude that this knowledge would have altered
events. However, it is clear that even if the officer did not feel his level of concern
warranted opening a F2052SH, he was sufficiently concerned to allow him to make
calls on the office phone, request a Listener, and check the man was ok. Had staff
been aware of this, it might have increased their vigilance.
I recommend that instructions regarding handover of issues arising from the
day or night be reviewed.
The OSG had to leave the cell to collect the ligature knife from the "Self Harm box"
which was in the wing office while he was waiting for other staff to arrive. The policy
of entering a cell alone should be reinforced to make it clearer for officers when
making the judgement call, because seconds could save lives. On this occasion, it
seems that speedy intervention would not have saved the man who died.
I recommend that the paragraph in Norwich's Suicide Prevention Strategy
concerning entering cells alone is re­written to give more information to
patrols, in particular, that speed is of the essence when confronted by a
hanging prisoner.
It is good practice for singleton patrols to carry ligature cutters on their person as a
personal issue; having cutters located in the wing office wastes precious seconds.
19
I recommend that ligature cutters be carried as personal issue to singleton
patrols.
The condition of the man’s cell was unacceptable with fixtures and fittings broken
and/or in poor repair. The walls had not been painted for some time. A similar
situation was found in other cells inspected on the landing. Furthermore, the window
bars presented a number of ligature points.
I recommend the redecoration of F Wing cells at the earliest opportunity and
that inventories of cell fixtures, fittings and contents be checked on a regular
basis to ensure cells are maintained in a decent condition.
Staff at Norwich prison notified the police of the man’s death and requested that they
visit his sister to break the news. However, no confirmation was sought or received
from the police to confirm that they had visited her. Consequently the first she knew
about her brother’s death was when she was called by the Governor. It is
unacceptable that the man’s sister, however unwittingly, was notified of her brother's
death by telephone. She was on her own, and it left her deeply distressed.
Breaking the news of a self­inflicted death in custody is both sensitive and
demanding. The way in which it is carried out may well colour a bereaved family's
whole relationship with the Prison Service. The two main objectives should be to
break the news speedily and to do so in a way that emphasises the Prison Service's
accountability, sense of shared loss, and commitment to the family as members of
the public that the Service serves. I appreciate that speed and personal involvement
of the Prison Service may sometimes be in conflict.
If at all possible, the governor or other member of senior management in the prison
where the prisoner has died should personally break the news. Where this is not
possible, I do not think that the Prison Service should routinely rely on the police:
I recommend that, where it is not possible for the governor or a senior
manager from the prison where there has been a an apparently self­inflicted
death to break the news personally, a governor at the prison closest to where
the deceased’s next of kin lives should normally be asked to break the news of
the death on behalf of the Prison Service as a whole.
If, as a last resort, the police are needed to inform the family, the prison should seek
confirmation that the police have made the visit before they make further contact.
I recommend that if, as a last resort, the police are needed to inform the family,
the prison should seek confirmation that they have made the visit before they
making contact.
It should be noted that the support from the Chaplaincy was exemplary, and greatly
appreciated by the man’s girlfriend’s family.
It is clear from examination of training records that training in Suicide Prevention was
not regularly undertaken. However, staff responding to the incident had acted
appropriately.
20
I recommend Norwich prison should promote Suicide Awareness training
amongst all staff working with prisoners.
He was a vulnerable young man. He had been detoxing from alcohol, which can in
itself induce sleep deprivation and mood swings. Although, the man was described
as generally cheerful by staff and prisoners, it is possible that these mood swings left
him particularly depressed at times with an inability to think through issues clearly.
21
RECOMMENDATIONS
NATIONAL
I recommend that where evidence concerning risk of harm to a prisoner or other
prisoners is identified that any records from a previous period in custody are
requested.
I recommend that a system is established for senior staff to credit the PIN phone
system.
I recommend that a policy is adopted by the Prison Service whereby a Governor at
the prison closest to where the deceased’s next of kin lives breaks the news of the
death to the next of kin.
I recommend that if, as a last resort the police needed to inform the family, the prison
should seek confirmation that the police have made the visit before they make
further contact.
I recommend that ligature cutters be carried as personal issue to singleton patrols.
LOCAL
I recommend that staff involved in completing Cell Sharing Risk Assessments are
reminded of the importance of considering self harm issues when completing the
assessment.
I recommend that the paragraph in Norwich's Suicide Prevention Strategy
concerning entering cells alone is re­written to give more information to patrols, in
particular, that speed is of the essence when confronted by a hanging prisoner.
I recommend that a record keeping audit should be carried out if one has not been
completed in the last six months.
I recommend that training should be provided for healthcare staff at all levels around
record keeping and their professional responsibilities.
I recommend that all prescriptions must have a corresponding entry in the
continuous record made by the Prescriber that also gives the assessment process
and reasons for the prescription.
I recommend that a review of the alcohol detoxification programme is carried out to
explore and develop the inclusion of other support packages, advice and follow up.
I recommend that the new Mental Health Referral system and policy is supported by
management in its implementation and reviewed in six months.
I recommend that Norwich’s local instructions on Suicide Prevention be revisited to
ensure staff are clear on when an F2052SH should be opened.
22
I recommend that instructions regarding handover of issues arising from the day or
night be reviewed to ensure that this is effective.
I recommend the redecoration of F Wing cells at the earliest opportunity and that
inventories of cell fixtures, fittings and contents be checked on a regular basis to
ensure cells are maintained in a decent condition.
I recommend Norwich prison should promote Suicide Awareness training and all
staff working with prisoners.
23