Individual at Risley

Investigation into the circumstances surrounding the
death of a man
at HMP Risley in May 2007
Report by the Prisons and Probation Ombudsman for
England and Wales
November 2007
Final Report: November 2007
The man was 24 years old when he died at HMP Risley on 24 May 2007. The cause
of death was hanging.
One of my family liaison officers has contacted his partner and parents on my behalf
and I would like to add my condolences to hers. I hope that their questions are
answered in this report.
Two of my colleagues carried out the investigation. I would like to thank the
Governor of Risley and his staff for their positive approach to my investigation, and
particularly for the help of the liaison officer. I also asked for a review of the man’s
clinical care and am grateful to the clinical reviewer for his assistance.
The man was in prison because he had assaulted his partner. It was his second
time in custody, and suicide prevention monitoring and support measures had been
in place twice during his previous sentence. He was subject to a further period of
monitoring and support up to a fortnight before he died.
Unlike many of those whose deaths I investigate, this man was well supported by
prison staff, and all were aware that his relationship with his partner was central to
his wellbeing. There is no evidence that anything else distressed him. His wish to
attract her attention had led to him taking an overdose in April 2007. The
relationship ended on 21 May and some thought was given to whether the suicide
monitoring procedures should be re-opened. Given the circumstances, I have
personally found it difficult to understand why this precaution was not taken.
Investigations of two previous deaths at Risley made recommendations concerning
roll checks. It is disappointing to learn that the check before the man was found was
not carried out properly. He may well have hanged himself by then, and could have
been discovered an hour earlier than was actually the case.
I make four recommendations to the prison and health authorities that I hope will
further develop their joint approach to suicide prevention, and am pleased that they
have been largely accepted. I identify one example of good practice.
This anonymised version of the report has been prepared for publication on the PPO
website.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2007
Final Report: November 2007 2
Final Report: November 2007 3
CONTENTS
Summary 4
The Investigation Process 6
HMP Risley 8
Key Findings 14
Issues 45
Conclusion 52
Recommendations 53
Final Report: November 2007 4
SUMMARY
The man was 23 years old when he transferred to HMP Risley in January 2007. It
was his second prison sentence, both having been imposed for assaulting a member
of his family. On this second occasion he had seriously assaulted his partner, and
was serving over four years’ imprisonment.
He was consistently described to my investigators as an able, motivated, intelligent
and articulate young man, who liked to be in control of his life. These qualities, and
his willingness to disclose his troubles, led him to seek support from a wide range of
prison staff.
There were similarities between the man’s behaviour during his first and second
sentences, albeit for different reasons. In the first, he sought support regarding
financial difficulties. He made a serious attempt to harm himself and was twice
placed on suicide and self harm monitoring. In the second sentence, he was
preoccupied, to the point of obsession, with his relationship with his partner. He
appeared to share his feelings with everyone he came in contact with. The couple
had been reconciled whilst he was on bail and continued to have daily contact for the
first months of his sentence. The relationship dwindled and he began to complain
about her attitude towards him.
A sentence planning meeting took place on 19 April 2007, attended by the man’s
home probation officer. For the first time, he told her that his partner had children.
The probation officer correctly reported the information to the social services
department, so that they could assess whether there were any child protection
concerns.
Three days later, the man took an overdose of tablets prescribed to him for a chesty
cough. The Assessment, Care in Custody and Teamwork (ACCT) procedures were
opened to reduce his risk of self harm and suicide. He explained that he had taken
the tablets to seek attention from his partner. Although the relationship continued to
fade, one of the objectives of his ACCT plan was that he should have a supervised
family visit.
The ACCT objectives were achieved, though their scope was restricted as the full
range of professionals supporting the man were not party to them. The document
was closed on 8 May. Those responsible were satisfied with his statement that he
would give the relationship another seven days – until his birthday – and that, if it
was not progressing, he would be able to move on with the rest of his life.
There were delays before the family visit took place and before social services
visited the man’s partner and, by a tragic coincidence, both visits took place on
Monday 21 May. By all accounts the family visit went well, but during the social
worker’s visit later in the day, his partner said that she wanted to end the
relationship. The man was distraught, and made full use of his support network. All
the staff knew his situation and, although it was not a joint decision, no one thought
that re-opening ACCT was necessary.
Final Report: November 2007 5
During the night of Wednesday 23/Thursday 24 May, he packed his belongings,
obstructed the door panel, and apparently tied a ligature round his neck and
attached it to his upturned bed. The member of staff checking at 6.00am on 24 May
saw the obstruction, but took no action.
The man was discovered at the next check an hour later, by which time it was too
late for resuscitation to be attempted.
Final Report: November 2007 6
THE INVESTIGATION PROCESS
1. The investigation has been conducted by one of my assistant ombudsmen,
and an investigator. The investigation was opened on 25 May 2007, the day
after the man died. The investigator met the Governor and some of his staff,
together with representatives of the Independent Monitoring Board (IMB) and
Prison Officers’ Association (POA). She was briefed about events whilst the
man was in custody and the circumstances of his death. She received copies
of his prison records, and was given a tour of the prison, including the wing
where he lived.
2. Notices of the investigation were provided for distribution around the prison,
including to all the prisoners on his wing. The notices invited prisoners and
staff to contact the investigators if they wished to share any information. The
only response was from a man from another wing who had not known the
man.
3. Interviews were conducted during the following six weeks with two prisoners
from the wing, 17 prison and healthcare staff, and with his probation officer in
the community. The interviews were either tape recorded or notes taken, and
the record of each interview is annexed to this report. I also informed the
social worker involved with the man’s partner of my investigation, but have not
received a reply.
4. The investigation has been considerably assisted by the helpful cooperation of
Cheshire Police, who also interviewed many prisoners and staff and shared
their statements with my team. The interview with the probation officer was
carried out jointly by my investigators and the police.
5. I have also been assisted by the Warrington Primary Care Trust who
appointed a consultant public health expert to review the man’s clinical care
whilst he was in prison. The clinical reviewer sought advice from a mental
health specialist regarding aspects of the man’s treatment. The review is also
annexed to this report.
6. One of my family liaison officers contacted the man’s parents and partner to
ask whether they had questions for the investigators to consider. They
commented on the following matters:
• Whether he received the correct help for his problems in the community
and in the prison.
• The prison knew that the man got upset easily and had harmed himself
previously. He should have been put on a ‘suicide watch’ again.
• The prison would have known how he would have been affected by his
partner’s visit and should have provided additional support.
• What happened during the night of 23/ 24 May?
• Were the checks carried out correctly by staff?
• Why was the upturned mattress not seen blocking the door?
• What time did he die?
Final Report: November 2007 7
The man’s mother also questioned the way in which the social services
department dealt with the termination of his relationship with his partner.
Although the work of the department is outside the terms of my investigation, I
have been able to provide some information.
7. The man’s father expressed his appreciation to the prison for their support
following his son’s death, and especially for attending the funeral.
8. I have informed the Cheshire Coroner of my investigation and a copy of the
final report has been sent to assist his enquiries.
9. In the course of my investigation, information was brought to the investigators’
attention regarding the conduct of the early morning roll check on 24 May.
The information was immediately passed to the Governor who arranged his
own investigation. Subsequently, the member of staff responsible for the
check resigned from his duties. I understand that Cheshire Police have not as
yet decided whether the case should be referred to the Crown Prosecution
Service for consideration of further action.
Final Report: November 2007 8
HMP RISLEY
10. HMP Risley is a modern, purpose built prison which opened in 1964. It holds
1,085 men and is the largest training prison in the country. The man was held
in G wing, which has 180 cells, of which 12 are double. G wing prisoners are
expected to be drug free, and any who test positive for drugs are removed.
There are 35 staff based on F and G wings, some of whom are also
responsible for other duties in the rest of the prison.
11. Each prisoner has a personal officer who deals with any applications, such as
access to offending behaviour courses and employment. The personal officer
does not necessarily carry out other individual tasks such as reviewing cell
sharing risk assessments or carrying out ACCT duties. There had been a
policy at Risley for personal officer duties, but this had fallen into disuse and
was being reviewed at the time of this investigation. Prisoners also have an
offender supervisor within the prison whose role is to work with the offender
manager (the probation officer in the community).
Healthcare
12. Warrington Primary Care Trust (PCT) provides a 24 hour out-patient
healthcare service. Prisoners who require in-patient treatment are referred to
other prisons or to outside hospital. There are 22 full time equivalent PCT staff
and four from the Five Boroughs’ Mental Health Trust, plus outside specialists
such as dentists and opticians.
13. Prison staff are allocated radio call signs and Hotel 1 is allocated to the duty
healthcare nurse who responds to any emergencies. The prison does not use
code signs to distinguish between different types of emergencies, such as
code red and blue, which are commonly used in other jails.
14. Suicide and self harm awareness training is not routinely provided for
healthcare staff. The Head of Healthcare told my investigator that they are not
routinely notified of ACCT reviews and that the PCT is not represented at
Safer Custody meetings, although a mental health worker does attend.
15. The PCT employs mental health workers to provide primary mental health care
to prisoners with mild to moderate symptoms. Prisoners with more severe
problems are referred to registered mental nurses working for the Five
Boroughs’ Mental Health Trust. The man had a mental health worker who had
worked at Risley on three days a week for the past three years. She has
completed ACCT training. She described good information sharing within the
prison and said that mental health workers are aware of all prisoners on ACCT
and their review dates. She said that the arrangements for ACCT documents
to accompany the prisoner had improved, so she was able to read the record
and note that she had seen a particular prisoner.
Final Report: November 2007 9
Chaplaincy
16. The prison chapel is known as the All Saints Chapel and World Faith Centre.
The chaplains are employed by the Prison Service and work to a national
Code of Conduct which states that they are subject to the same conditions of
work and code of discipline as all other staff at Risley. There are six core
values and seven guiding principles. These include “the need to respect
confidences and maintain security”. The principles do not refer to the
chaplains’ responsibility to promote prisoners’ safety and welfare by sharing
information as necessary.
17. The chaplains receive ACCT training and are informed when every ACCT
document is opened. They ensure that each ACCT prisoner is visited every
day by one of the team.
Counselling Services
18. Prisoners can make use of the services of trained volunteer counsellors who
come in each week for pre-booked appointments. The arrangements for their
work are made by the volunteer co-ordinator. The counsellor who worked with
the man was a member of the British Association of Counsellors and
Psychotherapists. Her work is unpaid, but the prison pays her expenses,
professional insurance fee and her supervision expenses. She has been
trained in ACCT procedures.
19. The counsellor’s work is governed by a contract between the prison and
herself, dated 19 October 2006. Amongst other clauses, the contract sets out
the prisoner’s right to confidentiality and the counsellor’s responsibility to
override the right in specific circumstances. The counsellor is expected to
share information if there is evidence that failure to disclose might breach
prison security, or endanger the prisoner’s life or that of another, endanger the
well being of a child, seriously endanger the community or other vulnerable
people, or cause a serious threat to the counsellor. She said that she makes
prisoners aware of her obligation to pass on such information.
20. Although the contract expects counsellors to share information, there is no
equivalent statement about the prison’s responsibility to make counsellors
aware of information such as a prisoner’s risk of self harm or whether they are
receiving support from other agencies.
21. Counselling sessions are held in rooms located on the wings and so officers
would be aware that a prisoner was receiving support, whilst not knowing
confidential details. Each session generally lasts for an hour. The counsellor
does not keep a record of their content.
Prison Service Orders (PSOs)
22. Prison Service Orders are long term instructions from the Prison Service to
Governors, each with its own title and reference number. They are
Final Report: November 2007 10
supplemented by Prison Service Instructions (PSIs), and each Governor may
also issue Local Orders and Instructions.
Suicide and self harm monitoring
23. F2052SH was the suicide and self harm monitoring system in place during the
man’s first prison sentence. The arrangements were replaced by the
Assessment, Care in Custody and Teamwork system which was introduced in
PSO 2700 Assessment, Care in Custody and Teamwork (ACCT).
24. ACCT requires any member of staff who identifies concerns about a prisoner
at risk of suicide or self-harm to take action and record their actions. The
ACCT document should be available to all staff where the prisoner is located,
including workshops and visits. Within 24 hours of an ACCT being opened,
the prisoner is to be seen by an assessor and have a case review meeting.
The meeting draws up a care and management plan known as a care map. A
member of staff, usually the senior officer on duty at the time, is nominated to
be the case manager to oversee the management of the ACCT document and
attend case reviews.
25. As well as the care map, the document includes an assessment section which
covers eight specific areas, each requiring a comment. The section is
designed so that each area includes the action to be taken in response to the
assessment, with a judgement informed by information gathered earlier.
There is also an on-going record of significant events, conversations and
observations which is available to all staff on duty at the time.
26. ACCT reviews are held at intervals appropriate to the actions planned in each
prisoner’s care map. They are attended by the prisoner and the case manager,
together with other people responsible for specific actions.
27. Prisoners who are at risk of harming themselves may be offered access to a
Listener. Listeners are fellow prisoners who have been trained by the
Samaritans and provide confidential support.
28. In the 2007 calendar year to date (September), Risley had opened an average
of 16 ACCT documents each month, applying to an average of six prisoners.
In May 2007, 16 documents were opened, none of which was on G wing. On
the night that this man died, five were open and a sixth was opened during the
night. Five prisoners harmed themselves in May, one of whom was on G
wing. There were seven occasions in the month that the Samaritans
telephone was requested, none of which was on G wing.
Previous deaths at Risley
29. This is only the second death at Risley that my office has investigated since I
became responsible for investigating all deaths in custody in April 2004.
Although the circumstances of the first were entirely different, I made several
relevant recommendations concerning the prison’s response. I was pleased to
Final Report: November 2007 11
learn that my recommendations were implemented and the response to this
death was exemplary.
Roll checks
30. Roll checks are carried out to confirm that the number of prisoners on each
wing is correct. The standards for roll checks at Risley are set in the prison’s
Local Instruction Routine Roll Checks – Timing and Reconciliation 2.06, which
came into effect on 1 September 2004. An additional Instruction, 2.73,
expands the first. Day staff are required to carry out checks:
• before morning unlock at 7.45am
• after morning work at 9.30am
• lunchtime at 12.30pm
• after afternoon work at 2.30pm
• after tea at 5.15pm
• after lock up at 8.30pm.
Night staff are required to carry out checks:
• at the start of their duty (no time is specified)
• before the day staff start at 6.30am.
31. The instructions state that the purpose of the checks is to ensure that
prisoners are in the correct cell with the door locked shut, and that the bolt is in
the hole to secure the cell. Staff are also required to ensure that prisoners are
safe and well at each roll check.
32. Each cell door has an observation panel with a flap that can be opened from
outside. Prisoners are told at their induction that the panel must not be
obscured, and staff are instructed to remove any obstructions which they find.
In interviews for this investigation, it was apparent that it is custom and
practice for prisoners to place temporary obstructions over the panel when
they want some privacy.
33. Investigations conducted by the Prison Service itself into two deaths in custody
prior to April 2004 had made recommendations concerning roll checks. The
first was in February 2004 and the second a month later, and the prison’s
action plan included a Governor’s Order to “outline the responsibility of staff
carrying out roll checks … about staff’s ability to both see and hear the
prisoner”. It added that blocked observation panels should be cleared
immediately.
Night State
34. Night state describes when the prison is locked up for the night and staffing
levels are at a minimum. There is often just one night patrol officer per wing,
or on occasions, between two wings. Their role is to monitor the security of
the wing and prisoners. In respect of G wing on the night of 24 May 2007, one
Final Report: November 2007 12
officer support grade (OSG) was responsible for the wing. He carried a radio
and cell door key, which was in a sealed pouch secured to his belt.
35. The senior person on duty at night time is the night orderly officer (Oscar 1).
They are responsible for visiting wings to check on the welfare of the staff and
ensure they are carrying out their duties correctly. During night state it is not
usual to unlock a cell unless Oscar 1 deems it necessary and has sufficient
resources to deal with the situation.
36. Each duty begins with a handover from the evening staff, which is based on
the evening senior officer’s report in the observation book and includes the
names and numbers of any prisoners requiring additional observations
because they are on ACCT or are subject to Bullying Information Reports.
Night staff might be asked to make additional checks on prisoners because of
specific circumstances such as health problems.
Controlling Anger and Learning to Manage programme (CALM)
37. The CALM programme is one of many programmes designed to help prisoners
tackle the causes of their offending. CALM aims to help prisoners deal with
aggression and is run by the prison’s psychology department. There is a
waiting list for the programme but applications can be transferred from a
previous prison sentence.
Visits
38. Prisoners are entitled to send out visiting orders to their family and friends,
who telephone to book in on a specific date. Most visits take place in the visits
hall under the supervision of prison officers. Occasionally, for specific
reasons, family visits take place in a designated room off the hall, and may be
supervised by other members of staff such as chaplains.
Independent Monitoring Board (IMB)
39. The Prisons Act (1952) requires each prison to be monitored by a Board with
members from the local community who are appointed by the Secretary of
State. The Board has the right of access to every prisoner and every part of
the prison. Prisoners may apply to speak to an IMB member, but the man did
not do so and was not known to any of the members.
40. Each IMB produces an annual report and the one for the year prior to the
man’s death was published in June 2007. It comments on all aspects of
Risley, including the ACCT arrangements. Board members attempt to visit all
prisoners who are on ACCT, although they are not always successful. They
used to attend reviews held under the F2052SH process, but are not invited to
ACCT reviews. The IMB’s annual report says:
“At many ACCT reviews during the year only the prisoner and the wing SO are
present. Without being too judgemental it is in the interest of the SO to close
the file so as to reduce the resource required to support the prisoner. It is felt
Final Report: November 2007 13
that there should be a minimum of three people attending with the third
attendee coming from one of the other agencies in the prison. At present
healthcare do not attend if the prisoner is not on their case list.”
41. The IMB is represented at all Safer Custody meetings and is involved in all
discussions. Despite the Board’s misgivings about ACCT reviews, their
annual report confirms that they are content with the safer custody strategies
employed in the prison.
Her Majesty’s Chief Inspector of Prisons (HMCIP)
42. The most recent HMCIP inspection was unannounced and took place in
February 2006. Aspects of the report that are relevant to this investigation
include the finding that there were weaknesses in the prison’s work on suicide
and self harm prevention. Bi-monthly suicide and self harm committee
meetings took place but were not attended by the full range of multi
disciplinary staff, including healthcare, chaplaincy, work parties or education.
HMCIP recommended the appointment of a full time safer custody officer. The
prison has since revised its suicide and self harm strategy, and includes multi
disciplinary attendance at meetings.
Final Report: November 2007 14
KEY FINDINGS
43. In September 2006, the man assaulted his partner, was arrested and bailed to
appear in court in December 2006. He pleaded guilty to the offence and was
remanded for sentencing in January 2007. His probation officer was asked to
prepare a pre sentence report.
44. The probation officer interviewed the man twice about the offence, and was
aware that he had self harmed by attempting to cut himself immediately
afterwards. She described him as calm but remorseful, which was unlike his
feelings about his previous offence. She thought that he was living alone and
did not know that his partner had children.
45. She wrote in her report that the man recognised the seriousness of his
offence, but could not explain how it happened. He had taken steps to deal
with his aggressive feelings, but was waiting for the first appointment. Her
report recommended that he should serve at least three years’ imprisonment,
to allow sufficient time to address his offending behaviour and receive support
for his mental health problems. She said that he realised that a prison
sentence was likely and they discussed the impact it might have, including the
possibility of further self harm. The man told her that he was stable and not at
risk.
46. The probation officer sent the report to the court, together with the information
that the man was at risk of suicide and self harm. He pleaded guilty, and was
sentenced to four years three months’ imprisonment. The court duty probation
officer, interviewed him afterwards and recorded that he was upset about the
sentence. She saw that he had cuts on his arms, which were old wounds, and
he told her that he had made them three years previously. He said he had no
further thoughts of harming himself.
47. The man began his sentence at HMP Liverpool, where he went through the
standard reception and induction. He named his partner as his next of kin,
giving her address as his own. The officer completing the Cell Sharing Risk
Assessment (CSRA) assessed him as low risk for cell sharing, meaning that
there was no current evidence of risk and he was suitable for a shared cell.
The officer recorded that he was not on an open F2052SH and there was no
evidence of a previous document. The third part of the CSRA was completed
by a nurse who confirmed the assessment, and wrote that he had no problems
apart from drug abuse.
48. Four visiting orders were sent to the man’s partner whilst he was at Liverpool
and she visited on 22 January 2007.
49. The man transferred to Risley on 23 January, arriving at 11.55am, when he
repeated the reception and induction process. The officer completing parts 1
and 2 of the CSRA assessed him as low risk, but recorded that he preferred a
single cell. Prisoners are asked whether they have any concerns about
sharing a cell and whether they describe themselves as someone who gets
Final Report: November 2007 15
angry or frustrated quickly. The answer to both questions on the form was
negative.
50. The nurse who completed part 3 of the CSRA assessed him as medium risk
for cell sharing, meaning that there was no immediate risk but the situation
would need to be reviewed regularly. The form also shows that concerns were
raised in the self harm assessment because of “medical issues” and his
refusal to share a cell because of “anger management issues”. The nurse did
not consider that it was necessary to open an ACCT document, although it
was known that he had a history of mental health problems and had attempted
suicide the previous year. He was referred to the mental health team because
of his history of depression, panic attacks and suicide attempts during the
previous year.
51. The prison’s Public Protection Unit wrote to the probation officer the day that
he arrived, saying that the man was registered as a High Risk/ Dangerous
offender who was to be managed as level 1 in the local Multi Agency Public
Protection Arrangements (MAPPA). (MAPPA level 1 means that the offender
manager and her district manager would manage any public protection
issues.) The probation officer was offender manager in the community and an
officer was allocated as his offender supervisor within Risley. The letter also
said that victim enquiries were ongoing, but that the only issues related to self
harm and mental health and there were no child protection contact issues.
52. Also on the man’s first day at Risley, he renewed his contact with one of the
prison’s chaplains, who coincidentally was on duty in reception. The chaplain
was surprised to see him back in prison, and the man said he thought that he
had let the chaplain down by returning. He asked to come to the chaplaincy to
talk about his conviction and other issues. He was emotional and felt
remorseful and guilty about his offence, describing the relationship as volatile.
The chaplain said the man was sensitive, bright and eloquent. He wrote in the
chaplaincy contact sheet “will need to keep an eye on him”.
53. The chaplain wrote a statement to the Governor after the man’s death in which
he described him as a highly intelligent young man who was polite, well
mannered and meticulous in everything he undertook. The chaplain said the
man was a perfectionist. He felt that they had a “good, honest and open”
relationship, in which he seemed to be able to discuss personal matters. The
man also had considerable contact with other members of the chaplaincy
team.
54. New prisoners at Risley are located on C wing and the man remained there
until the end of February. He signed the C wing compact on 29 January,
agreeing that, amongst other rules, his observation panel must be kept clear at
all times. He completed his induction on 2 February, identifying worries about
his accommodation and a history of self harm in the resettlement record. The
End of Induction report asks the officer for an assessment of the prisoner’s
ability to cope, and the response was that there were no issues. The man’s
CSRA was reviewed the same day and he remained at medium risk.
Final Report: November 2007 16
55. The only entry in the man’s wing file whilst he was on C wing was on 30
January when his personal officer introduced himself. He applied for
enhanced status and was told that he must wait for three months. No other
issues were reported at the time and the form headed Initial Client
Assessment (Personal Officer To Use) was left blank.
56. Soon after the man was sentenced, he wrote to his probation officer to request
a copy of her completed assessment of him (known as OASys) as he thought
that the one at the prison did not contain the full details of his offence. He
believed that she had assessed him on the basis of his previous offence, but in
fact he had not seen all the information held at the prison. Her colleagues in
the victim support team were in contact with the man’s partner to ascertain
whether she wished any restrictions to be imposed when he was released. At
the time, she did not wish any conditions to be put in place.
57. On 28 January, the man applied for a second grant from the Prisoners’
Education Trust, the first having been awarded during his previous sentence
when he completed the Openings course with the Open University. On this
occasion, he hoped to complete his mathematics AS level. Three days later,
he successfully applied for a place on the Positive Parenting/ Higher Level
Learning course run by the prison’s education department. The course has 20
sessions, and the records show that he participated enthusiastically and
received good reports.
58. The man went to healthcare the same day, complaining of a chesty cough,
sore throat and coughing up blood. He was assessed by a nurse, who gave
throat pastilles and referred him to the doctor. Because the man was allergic
to paracetamol, he was prescribed a 28 day supply of Brufen (Ibruprofen)
tablets and advised to have plenty to drink and to keep warm.
59. Also in January, the man made another application to do the CALM course. It
was not linked to his first application (made during his previous sentence), as
all prisoners get a new number for each sentence and the applications were
not married up. This meant that he was expected to be re-assessed rather
than go straight on to the waiting list.
60. The chaplain saw the man during the first weeks of his sentence and thought
that he was happy and had settled down. No reference was made to the
financial problems that had beset him during his previous sentence, and the
focus was now on his relationship with his partner. The chaplain knew that he
received and sent daily letters to his partner, writing up to 12 or 13 pages at a
time. The chaplain was not concerned about his emotional or mental
wellbeing and felt that everything was going well for him. The man told him
that his partner recognised that his offence was a mistake and they had
resumed living together whilst he was on bail. His goal was to have a home
and a job, because then he would have achieved the same as his father had
done.
61. On 5 February, the man applied to use the gymnasium and was offered a
class two days later. He also attended the Emergency Life Support course.
Final Report: November 2007 17
His first appointment with the mental health team was on 8 February, but he
asked for it to be rearranged as he wanted to complete his gym induction.
62. A Public Protection Risk Management meeting was held on 9 February. This
is a paper exercise which determines any risk management issues and the
necessary actions to be taken by various parts of the prison. The form stated
that there was a high risk of violence and suicide and self harm. Alcohol was
identified as a particular problem. No child protection issues were identified.
The man’s offender supervisor was to refer him for domestic violence and
enhanced thinking skills courses and also for work on his alcohol misuse.
63. On 19 February, the man went to the chaplaincy to ask the staff to find out
when his partner had booked her next visit. After five or six weeks at Risley,
he had started to say to the chaplain that she had stopped writing to him and
was not keeping her promises to book visits. The chaplain thought the man
was frustrated that his partner was not paying him as much attention as she
had done initially.
64. The man used the prison’s complaints procedure for the first time on 22
February, complaining that five job applications had been rejected by security.
He referred to his educational qualifications and described himself as a “model
prisoner” who avoided trouble, drugs and bullying. The job applications are on
file, but are undated. They describe him as a “very quiet individual, keeps
himself to himself and has caused no control problems”. The response to the
complaint from the wing senior officer was that he had not been in the prison
long enough to be eligible, but he could appeal again to the Security
Department. The officer also wrote that he had been informed by the chaplain
that the man was “a trusted and good orderly the last time he was in Risley”.
65. Although the man applied for four visiting orders for his partner in February,
the only visit took place on 23 February. The chaplain commented that he
telephoned the man’s partner to ask why she had not arrived and then, with
her permission, allowed them to speak on the phone. The chaplain described
the man’s behaviour as volatile between the expected visits, and said that the
telephone conversations seemed to calm him. At the time the chaplain was
unaware that the partner was the victim of the man’s offence. The chaplain
thought that the telephone calls were appropriate because they had been
living together and because his partner agreed to accept each call.
66. The man was offered an alternative mental health appointment on 27
February, when he met his Mental Health Support Worker (MHSW), for the
first time. The MHSW routinely asks prisoners about their risk of self harm,
and the man denied that he had any current thought of harming himself. He
blamed his earlier attempts on the breakdown of previous relationships. The
MHSW felt that the relationship with his partner was “a protective factor”,
preventing him from harming himself. The MHSW described the man’s
appearance as well kept and said that he made good eye contact throughout
their meeting. He told her that he had good support from his partner.
Final Report: November 2007 18
67. The man told the MHSW that his sleeping pattern was changeable, depending
on his worries, and he was isolated and alone. He said that he experienced
the problems every day, and they were worse when there was little activity and
he was locked up. He thought that difficult experiences in his early childhood
were relevant, and said that every day he and his mother experienced his
father’s violence. His assessment of his difficulties on a scale of one to ten
was that they were scale three.
68. The MHSW learnt that the man was not working in the prison and wanted to
have a challenging, rather than a monotonous, job. He said that he had good
support from the chaplaincy, even though he did not have a religious faith.
The MHSW assessed that he was very willing to engage with her, was
motivated and able to concentrate, and had some insight into coping
strategies. They agreed to continue one to one meetings when they would
identify the goals for his contact with mental health services. In the long term,
he would undertake self help work on his behaviour. They aimed to reduce his
anxiety levels and improve his mood. He completed a goal planning sheet that
identified three goals and the steps necessary to achieve them, together with
any potential obstacles.
69. The man moved to G wing on 28 February, and was allocated cell 2-44 which
is a single cell. He signed the G wing compact indicating that he intended to
abide by the wing’s rules. Two days later he also signed the voluntary drug
testing compact. He was tested eight times and produced a negative result on
each occasion.
70. On 2 March, the man appealed about the outcome of his complaint about job
applications and was told that there was a three month waiting list for the jobs.
71. The second appointment with the MHSW was on 6 March. She recorded that
he wanted to increase his understanding of his feelings and the reasons for
low periods. He denied any thoughts of self harm and repeated that he had
good support from his partner, even though there were difficulties concerning
their trust and control of each other. The man told the MHSW that he found it
difficult to understand that his partner might go out whilst he was in prison.
The MHSW encouraged him to challenge any negative thoughts with more
positive and rational ones, writing them down before the weekend so that he
could use them when he felt particularly low.
72. One of the tools of the MHSW’s work is a book called “Overcoming
Depression” which she lent to the man. She said that he read the chapters
which he thought were relevant. She recorded that he displayed many
unhelpful thinking styles and she gave him information about dealing with
them. No other problems were reported and he said he had settled in well on
G wing. The MHSW thought that he might be better in the new wing because
it is smaller and the prisoners tend to be more mature.
73. The man saw the prison doctor on 11 March regarding a skin rash on his body.
The same day he made a third complaint, saying that when he arrived at
Risley he had referred himself for counselling. He wrote that he had applied
Final Report: November 2007 19
again every week but had not heard anything. He had “a number of issues
which he needed to resolve, concerning family and relationship problems and
anger”, and felt that he needed the sessions for his own well being. The
response was that there was no record of his applications, and he was seen
straightaway to make a new referral. The volunteer coordinator told the man
that he would be offered an appointment as quickly as possible, subject to
current waiting lists. She recorded that he seemed happy that his complaint
was being dealt with and thanked her for her intervention.
74. One of the man’s friends on the wing told my investigators that he knew him as
well as anyone there. He described the man as a private person, and said that
some prisoners did not interact with him. He would greet people, but was not
especially close. His friend said that he did not think the man had any
problems with prison life and was not bullied by other prisoners. At first the
man did not have a job, but his friend thought he gradually relaxed into prison
life, got a job and began going to the gym. The man’s friend knew about his
problems with his partner when she did not respond to letters and telephone
calls. He suggested that he was trying to control her from within the prison,
which the man conceded. His friend talked to him about life for families
outside.
75. On 17 March, the man used the complaints procedure again, this time in
respect of his application for the CALM programme. He explained that he had
been assessed during his previous sentence and was waiting for a place. He
wrote that, although he was currently seeking help from the mental health
team and had applied for counselling, “I feel I need urgent input from the
Psychology Department for my own well being. I have a history of anger,
depression and mental health problems and I am eager to address these
problems as soon as possible.” The response was that the treatment manager
was not in at the time and the complaint would be drawn to her attention.
76. The following day the man made another complaint, writing that his reception
parcel had not arrived and he had been told that it was not at the prison. He
was advised to ask his partner to ask the Post Office to investigate. He
complained again the next day, writing that he had not had the opportunity to
contribute to his OASys assessment. He said that it contained incorrect
information and he wanted to be involved in the assessment process. The
response was that the OASys was the responsibility of his probation officer
who would be reviewing it in the near future.
77. The medical record notes that the man did not attend his next appointment
with the MHSW on 19 March, and an alternative was arranged for eight days
later. In the meantime, on 26 March, he was given another 28 day supply of
Brufen tablets.
78. The man went to his third appointment with the MHSW on 27 March. He told
her that his mood was low and that it was worse in the evening when he was
alone. The MHSW recorded that he was finding it difficult to adjust to prison
life and was putting pressure on himself and his partner. He was able to
rationalise his negative thoughts whilst in the clinic, but said that he found it
Final Report: November 2007 20
more difficult when he was alone. He told the MHSW that he attended
parentcraft classes each morning, but was alone in the afternoon. He hoped
to get work in the kitchen, gardens or chaplaincy, and dismissed her
suggestion of the workshops.
79. The MHSW considered that the man was isolating himself on the wing and
they talked about how mixing with other people would benefit his mood. She
set goals to encourage him to be more sociable and advised him to ring his
cell bell if he felt low at the weekend. She also suggested that he refrain from
writing to his partner every day so that they would have more things to
discuss. Although his mood had deteriorated, the MHSW was not sufficiently
concerned that she felt she should report it to the wing. She arranged to
review him in two weeks or sooner if required.
80. The volunteer coordinator returned to see the man on 29 March and told him
that his first counselling appointment was offered for 5 April. She noted that
he appeared anxious to write the date down.
81. The chaplain continued to see the man every couple of days in the chapel
services and discussion groups, as well as when wing staff reported that he
was depressed and was asking for a one to one meeting. The chaplain tried
to encourage him to recognise that the relationship with his partner could not
succeed without the determination of both parties, and that it might be time to
put it behind him. The chaplain told my investigator that he began to be
concerned about the man’s frame of mind.
82. The man was seen in healthcare by a different nurse on 2 April, complaining of
depression and difficulty sleeping. He refused medication for depression and
was prescribed a sedative to relieve his insomnia.
83. The counsellor had her first session with the man on 5 April. She described
him as an open, intelligent and articulate young man, and they discussed his
family background and his general situation. He told her about his anger
problems and they spoke about his offences. In her statement to the police,
the counsellor said that she thought the man had assaulted his partner
because of his need to control the relationship. The counsellor thought that
remorse was the catalyst for his motivation to change his behaviour. Either at
this or a subsequent meeting, he told her that he had previously harmed
himself, but she did not think it was a current issue. The next counselling
session took place on 11 April.
84. The final parentcraft session was on 12 April. Each piece of work received the
teacher’s approval and the only record of a disagreement with one of the
man’s entries was at the penultimate session which covered children’s
behaviour. He wrote that, “if they still carry on with the behaviour a
punishment is enforced. Either time by themselves, loss of privileges or at last
resort a light slap.” The teacher underlined the final three words and
commented that “you shouldn’t need to slap”.
Final Report: November 2007 21
85. Although the man began the joinery course on 16 April, his attendance in the
first week was haphazard as he had appointments with healthcare, probation
and counselling. During the week some of the other prisoners asked the
instructor where “psycho” was. The instructor’s statement to the Governor
notes that it was common knowledge amongst prisoners that the man was
having problems with his partner.
86. One of the man’s friends in the class was at the time was on a different wing.
They got to know each other through work, and the friend described the man
as a nice guy. He said that he kept himself to himself, but thought that this
was because he did not follow a football team, and said that other prisoners
treated him well enough.
87. The third counselling session took place on 18 April.
88. A sentence planning meeting was held on 19 April, attended by the man, the
offender manager and offender supervisor. The full OASys document was
available and the man’s misunderstanding was clarified. The offender
manager had not seen him since before he was sentenced. She thought that
he appeared stable, happy and content about his relationship. Four objectives
for the next review period were agreed. He was to take part in the CALM
programme, seek housing advice, develop vocational skills, and maintain his
emotional stability through contact with the mental health team. The offender
manager said that he was always willing to work on his objectives and carry
out offending behaviour programmes.
89. In the course of the meeting, the man made the offender manager aware for
the first time that his partner had two children. He said that they had been to
visit him in prison and she told him that she would have to consider whether
there were any child protection issues. He provided details of the children’s
names and dates of birth for her records. The offender manager subsequently
checked with her colleagues in the victim support team, who had also been
unaware that children were involved, and then with her manager. They
recognised that there might be child protection concerns and so she
telephoned the local social services department, confirming the information by
letter on 27 April.
90. The man went to the chaplaincy at 2.00pm on 21 April to see whether his
partner had booked a visit for the following Monday. She was telephoned and
said that she had not managed to get through to the visits booking number.
The chaplain telephoned her again later, but got no reply. Later that
afternoon, the chaplain spoke to one of the wing senior officers (SO) about the
situation and recorded in the man’s chaplaincy contact record that the partner
was the victim of his offence. Another attempt was made to telephone her.
This too was unsuccessful.
First self harm – 22 April
91. The man did not go to the Sunday service in the chapel as he usually did. At
3.45pm, the chaplain was telephoned by a G wing officer and asked to see
Final Report: November 2007 22
him as his mood was “very low”. The chaplain said that he would be there in
half an hour after he packed up the equipment from the service.
92. At about the same time, the man told a wing officer that he had swallowed 94
Ibuprufen tablets. He was taken to healthcare to be examined and an ACCT
document was opened. The ACCT plan noted that the man should initially be
observed twice every hour, and should acknowledge the member of staff at
least twice. His medical record shows that the tablets were Brufen and that he
had taken them because of an argument with his partner. He told the nurse
that he had been experiencing paranoid ideas.
93. The chaplain reached the wing at about 4.10pm to be told that, in the interim,
the man had gone to healthcare as he had taken an overdose of tablets. The
chaplain was surprised by the information as he thought that the man was
strong, had a high intelligence, and was determined to get through any
difficulties. He went to see him straightaway and was told that the tablets were
either saved or from other prisoners, and that he had taken them because he
felt let down by his partner. The man wanted the chaplain to tell his partner
what he had done, and to explain that he had taken the overdose because of
her.
94. The man was transferred to Warrington General Hospital’s Accident and
Emergency Department for treatment. At his insistence, the chaplain went to
the hospital to see him at about 6.30pm. It was an unusual request, but the
chaplain felt it right to agree as the man was panicking about having taken the
tablets. His manner had changed by the time the chaplain arrived. The
chaplain wrote in his police statement that he was not convinced that the
tablets had actually been taken, as he thought that the man’s manner was
jovial. The chaplain asked him whether he actually had taken the tablets, and
he replied that the evidence was that his mouth was coated pink. The man
asked him again to contact his partner, but the chaplain felt it was
inappropriate. The nurse told the chaplain that she thought the man was fine,
and so the chaplain decided to leave the hospital.
95. The man returned to the prison at 11.00pm when the nurse he saw on 28
January was on duty and saw him in healthcare. She was aware that an
ACCT document had been opened. She checked the man and asked about
the overdose. He assured her that he had no more thoughts of harming
himself. She described his mood as miserable and low, and she thought that
he regretted his actions. He was escorted to G wing, vomiting on the way
back, which the nurse felt would be good for him.
96. The ACCT observations were carried out as required, but there was a delay
completing the immediate action plan. It should have been prepared when the
document was opened, but was overlooked until 9.30am the following morning
(23 April). The SO was the man’s ACCT case manager and prepared the
plan. Five immediate actions were identified including remaining in a single
cell, hourly observations with at least two conversations, access to the
Samaritans telephone and Listeners, and healthcare informed about
Final Report: November 2007 23
medication in his cell. The SO also arranged for an ACCT assessor to
interview the man prior to the first ACCT case review that afternoon.
97. The SO described the man as calm but embarrassed about his actions, and
she believed that he was being truthful when he said that he had no intention
of harming himself again. She said that he was completely open about why he
had overdosed and she felt he had no reason to lie about his future intentions.
98. The man saw the prison doctor during the day as a result of the overdose and
ACCT document. The doctor’s statement to the police refers to their
discussion of the man’s relationship with his partner. The man told the doctor
that they had been arguing and she was never at home to receive his calls.
He and the doctor spoke about his jealousy, insecurity and difficulty managing
his temper, and their origins in the violence during his childhood. The doctor
described the man as open and articulate during the conversation, and making
good eye contact. He did not appear depressed and presented in a stable and
appropriate manner. The doctor concluded that the overdose had been an
impulsive act that the man now regretted and had no intention of repeating.
99. The doctor reassured the man and advised him to make fewer telephone calls
to his partner. He arranged to follow up in two weeks, rather than the
customary one week, as he was not concerned and knew that he was also
being supported by a mental health nurse and counsellor.
100. The man did not go to the joinery class and the workshop instructor noted that
the wing had told him he was having problems. The instructor described the
man as a quiet and intelligent young man who had been a peer tutor during his
previous sentence and helped other prisoners with their courses. He was a
quick learner, who tried to complete tasks as quickly as possible to a good
standard.
101. Later in the day (23 April), the man went to the first ACCT review. This was
chaired by the SO and also attended by an ACCT assessor. The SO
explained that she decided who should attend the review, based on
information from the man who told her that he was in contact with the
chaplaincy. She did not have any other guidance about who should be invited.
The chaplain said that he was not aware that the review was taking place and
was not asked to attend.
102. Summarising the review, the SO wrote that it was obvious that the man had
had time to think about his actions and now felt embarrassed about what he
had tried to do. The trigger for his self harm was recorded as a change within
the relationship with his partner. Many of his anxieties were said to focus on
the relationship, and the chaplaincy was trying to arrange a family visit. The
SO believed that the visit would help him, and he said that he no longer
wanted to harm himself and agreed that it would be better if he talked things
through with staff. A care map was prepared that identified two issues
(relationship anxiety and childhood problems) and two actions (family visit and
appointment with psychiatrist) to be carried out by the chaplaincy and
Final Report: November 2007 24
healthcare. The SO said the man’s demeanour was consistent throughout the
day.
103. The ACCT observations were reduced to three observations and
conversations during the day and three at night. The man was to be reviewed
again on 1 and 8 May. The observations were carried out as required and
entries made in the ACCT records by a range of wing and other staff. The
quality was regularly checked by wing managers.
104. Also on 23 April, the chaplain spoke to the man who said that he wanted to
telephone his partner to find out why she had not come to visit him. The
chaplain wrote in the chaplaincy log that the man had admitted he had not
actually taken as many tablets as he had first said. He noted that they had a
good chat and he had told the man that he should not be deceitful as it could
lead to problems. The chaplain said that the man began to be very open with
him and they agreed that he should work out a strategy for his life inside and
after prison, with or without his partner. He said the man disclosed information
about his background that he felt needed more specialist help. The man
agreed that he needed psychiatric help and they decided that a request would
be passed to healthcare.
105. The volunteer co-ordinator heard about the man’s overdose and passed the
information on to the counsellor when she arrived at the prison on 24 April.
106. The workshop instructor knew of the overdose from the internal prison intranet.
He learnt of the ACCT document from the man, who asked to speak to him
after he arrived at the workshop. (The SO acknowledged that there should
have been an ACCT action point to notify the workshop that one had been
opened, but it was overlooked.) This was the first time the instructor had
known of an ACCT prisoner being on his course. The ACCT form was not
delivered to the workshop and so the instructor was unable to learn the man’s
history or record any observations.
107. The instructor spoke to the man in a separate room and the instructor thought
that he was distressed. The man wanted to continue working to take his mind
off his worries. The instructor knew that the man had talked to other prisoners
about his problems with his partner. He thought that the man was agitated
and described him having a fixed glare, and did not think he was concentrating
on what he was doing. The instructor observed that the man did not appear to
be concentrating sufficiently to work with joinery tools and so asked for him to
be returned to the wing. He said that the man agreed with the decision, saying
that it gave him the chance to sort out his problems. The instructor contacted
the wing to ask for more information, particularly concerning the man’s
suitability to work with tools. He said he was advised that he should decide as
he was in charge of the workshop.
108. The chaplain went to healthcare to refer the man for psychiatric assessment,
and was told to put it in writing. He prepared a memo, setting out the reasons
for his referral and took it back. He also contacted the man’s partner during
Final Report: November 2007 25
the day. She told him that she would be meeting social services to discuss her
children.
109. The chaplain recorded that he attended an ACCT review on 24 April, which
was his first involvement with the procedures in place for the man. He thought
that he was very depressed about his relationship and so the ACCT document
should remain open.
110. In the afternoon, the man went to the chaplaincy as he said he had some bad
news about access to his partner and her children. He spent about 45 minutes
with the chaplain. He was upset and they talked about dealing with his
problems. The man said he was not going to do anything to harm himself
again. When he calmed down and said he felt fine, the chaplain took him back
to G wing. The chaplain recorded in the chaplaincy log that the wing was
“alerted to keep an eye open for him”. He also noted that he was concerned
about his psychological state as there were possible mental health issues.
The chaplain wrote a referral to healthcare for a psychiatric assessment which
he delivered and discussed with one of the psychiatric nurses.
111. The man went to the chaplaincy again the next day (25 April), and talked to a
different member of the team, the co-ordinating chaplain. He noted that the
man was seen in the chapel as he was on ACCT and was okay.
112. The man’s fourth counselling session was booked for that day. He bumped
into the counsellor beforehand and asked if the session could take place at the
chaplaincy instead of the wing, and this was arranged. The counsellor knew
that the ACCT document was open, but it did not accompany the man to the
session and she did not make any entries in it. He talked about the overdose
and the ACCT document, saying that he had had a row with his partner and
had taken the tablets as a cry for help
113. The counsellor thought that the man enjoyed their sessions. He was always
ready and prepared when she arrived. She said the sessions were
increasingly dominated by discussion of his partner which he described as his
obsession. She tried to encourage him to think about other things in life, but
made little progress. The counsellor said the man did not seem to know where
he stood in relation to his partner. This did not fit with what he wanted, and he
found it difficult to cope with.
114. On 26 April, the man did not go to the joinery class in the morning but saw the
co-ordinating chaplain at the chaplaincy. The chaplaincy log confusingly notes
that his partner had booked a visit, but that she had not yet made the booking.
115. The man’s friend from the workshop moved to the same wing at the end of
April and they got to know each other better. At the time the man was on
ACCT and was away from work. His friend was trying to give up smoking and
offered him his tobacco. He said that the man was very grateful, as he had not
been getting any money from outside and had been borrowing tobacco. His
friend told the police that the man spoke to him about his relationship
difficulties, and that he had been placed on ACCT and removed from the
Final Report: November 2007 26
joinery class. The two men spent time together and his friend reassured the
man about his worries, all of which centred on threats to his relationship with
his partner. He said that other prisoners in the class used to tell the man that
his partner was not good enough for him.
116. The SO saw the man on the wing each time she was on duty, as well as at
ACCT reviews. She said that some days he was fine, but this depended on
his conversations with his partner.
117. The ACCT record includes an entry about the discussion between the
instructor and a wing officer who explained that the man could not be excluded
from the workshop simply because of ACCT, and that his mood should be
monitored each day. The man went to work in the afternoon when the
instructor observed that he was quiet, did not mix with the rest of the group,
but carried on with his work without any problems.
118. The man told the instructor the following day that he was concerned about his
partner and the instructor attempted to contact the chaplaincy on his behalf.
The man was upset as his partner had cancelled a visit, and asked to finish
work early that afternoon. The references to the possibility of a family visit
continue, interspersed with comments that he was quiet. His mood varied
from upset to happy, depending on whether the visit was to take place or not.
119. The man went to work on 27 April and again the instructor was concerned
about issuing tools to him. The man asked to speak to him, and said he was
distressed. The instructor again decided that he should not be at work. He
said that all the man talked about was his partner. (The ACCT document had
not accompanied the man to the workshop, and he was unable to record his
observations in it.)
120. The same day, the man went back to the chaplaincy and talked to the co-
ordinating chaplain again. A telephone call was made to the man’s partner,
and it was noted in the chaplaincy log that she said she had been unable to
arrange a visit.
121. On 28 April, the SO talked to the man and noted in the observation book that
he kept enquiring about the family visit, becoming upset because his partner
had not yet made the booking. The SO said that he mixed with other prisoners
and was not isolated, although he was not part of a specific group. As well as
talking to the man, the SO also observed his behaviour. He was not at all
nervous or secretive, which she took to mean he was not at risk of harming
himself.
122. The chaplain next saw the man on Sunday 29 April at chapel. He noticed a
change over the previous six days. He was no longer depressed but in an “an
upbeat mood”.
123. The fourth appointment with the MHSW was on 30 April. She was informed of
the overdose when she arrived at the prison and read the healthcare
observation book to find out what had happened. She knew that the ACCT
Final Report: November 2007 27
document was open and asked why he had taken the tablets. He described
the overdose as attention seeking rather than an act of self harm or an attempt
at suicide. He said that he wanted his partner to notice him. The MHSW did
not reassess the risk of suicide or self harm.
124. The MHSW recorded that the man was very insecure about the relationship as
he liked to be in control. His behaviour was described as impulsive when it
was not possible for him to take control. He denied any current thoughts of
self harm and was looking forward to his partner’s visit on Wednesday as there
were many issues that he wanted to discuss. The man told the MHSW that he
was also supported by the chaplaincy and his counsellor, and she thought that
they would also realise that his relationship with his partner was a protection
against self harm.
125. The man spoke to the MHSW about the goals set by his offender supervisor
and probation officer. He told her that he had recently begun the joinery
course and seemed to be enjoying it. The MHSW agreed to contact the CALM
tutor to enquire whether he needed to be reassessed and how long he would
have to wait for the programme to begin. She planned to review him again in
a week’s time. She explained to my investigator that the frequency of
appointments depended on her own availability as much as the prisoner’s
needs.
126. The workshop instructor discussed the man with the SO on 30 April as he was
concerned about his frame of mind whilst working with dangerous tools. In
interview, the instructor explained that he thought that the man was distracted
and was not concentrating and might accidentally harm himself. He was not
worried about him deliberately harming himself with one of the tools.
127. Another ACCT review was held on 1 May at 10.00am attended by the man,
the SO and the chaplain. The SO wrote that the man was still very anxious
and unsure about the relationship with his partner. He thought that his partner
was trying to distance herself from him, whilst talking as if everything remained
the same. The SO confirmed that the relationship was the sole source of his
distress and no other worries were ever reported. The man was said to be
confused and frustrated by waiting for her letters. He asked for a family visit to
sort things out. The chaplain was going to arrange the visit, which he thought
would help stabilise the man. The chaplain was also going to contact
healthcare to arrange a meeting with a psychiatrist.
128. The frequency of the night time observations was increased to two hourly, and
three observations continued during the day. The ACCT record makes
frequent reference to the man’s feelings about his partner. The SO told my
investigator that he did not say he had any thought of harming himself, and
she did not think that he was sufficiently upset to do so.
129. In the chaplain’s statement to the Governor, he referred to the ACCT review
and wrote that the man said he had taken the overdose because of difficulties
in his relationship with his partner. The chaplain thought that the man was
open and honest with him. The man told him that he thought his partner
Final Report: November 2007 28
behaved inappropriately, giving examples such as promising to book visits and
then making excuses.
130. The chaplain wrote in the chaplaincy log that he telephoned the man’s partner
after the review and the visit was arranged for 7 May at 9.15am. He explained
the procedures to her. The chaplain described the man as pleased, rather
than elated, by the prospect of the visit. He spoke about giving his partner
until his birthday (15 May) to decide whether their relationship should continue.
He said he would then stop trying to sort out the relationship and would move
on with the rest of his life.
131. The first of the man’s friends said that the man did not behave any differently
whilst the ACCT document was open and he was not worried about him. He
knew that he talked to staff, which he said was uncommon for prisoners.
132. At 9.00am on 2 May, the man was sent back to the wing from work. The
ACCT record notes that he said that the instructor did not want him to work
with tools. This was subsequently confirmed, and it was noted that the
instructor felt that he was a danger to himself as he was not concentrating on
using the joinery tools.
133. Later that morning, a third member of the chaplaincy team, noted that the man
was feeling better and had written to his partner. The third chaplain described
the man as “very controlling and reluctant to allow [her] to decide for herself
what she wants to do”.
134. The prison’s volunteer counsellors met that day and discussed when to report
suicide and self harm concerns. Afterwards, the co-ordinator and the
counsellor discussed the man’s situation. In interview for this investigation, the
counsellor said she thought that the man was happy with his experience of
counselling, but that he was “very focussed on his girlfriend and everything
appeared to be centred on her”. The man had his fifth counselling session that
day. The counsellor described him as a little brighter, and he told her about
the time he spent at the chaplaincy and the support he received there. She
said that he had told her that “it was a silly thing to do” to take an overdose,
and that he was unable to attend his joinery class whilst he was on ACCT.
135. The ACCT record states that the workshop instructor went to the wing on 3
May, but his own statement says that the conversation took place two days
earlier on 1 May. The instructor says he explained to the man that, because of
the risk from the tools, he should not return to work until he felt better. The SO
recorded that all parties agreed that he should have a week off work on full
pay. The SO said that the intention was for the man to miss work in order to
sort himself out.
136. Also on 3 May, the man was visited by the first member of the chaplaincy team
who noted in the log that he was “relatively ok, though still hoping to keep his
girlfriend, while learning to be realistic”.
Final Report: November 2007 29
137. The man’s friend who he met at the workshop told the police that he and the
man spoke together frequently and visited each other’s cells. He remembered
an occasion at the beginning of May when the man showed him the letters and
pictures of his partner and her children. He told his friend that his partner was
all that he had in the world.
138. The workshop instructor spoke to the SO about the man on Friday 4 May. The
SO told him that the man appeared much better, and that his partner was
coming to see him to sort out their problems.
139. On 5 May, a fourth member of the chaplaincy team saw the man and found
him calm but a little tense. He told her that he was fine but would be
telephoning his partner shortly and did not know what the outcome would be.
She recorded that they talked about the need to be philosophical about events
outside prison as he could not influence them, and wrote that the man needed
“a more positive coping strategy than just getting frustrated and anxious”.
140. The man went to chapel on Sunday 6 May and told the chaplain that his
partner had cancelled the visit planned for the following day. The chaplain
described him as disappointed, frustrated and angry, as he had been looking
forward to seeing her. He calmed down and the chaplain made several
attempts to contact his partner about the visit. The chaplain eventually spoke
to her, allowing the man to speak briefly. He said that they spoke amicably.
141. The man returned to work on 7 May, telling the instructor that he was okay.
He was allowed to remain. From then on, the instructor noted that the man
seemed fine and carried out his work to a good standard. He saw a big
improvement in his mood. The man told him that his partner was coming to
see him. The instructor observed that the chaplaincy had passed on the
information that the man’s partner had been booking and cancelling visits, and
this seemed to affect his moods.
142. The chaplain checked with the visits clerk, but a visit had not been booked.
He saw the man later in the day and found him to be more positive. He said
that he would be coming to the chaplaincy in the afternoon. Later that
evening, a wing officer noted that the man was in good spirits and could not
wait to come off ACCT.
143. The man’s CSRA was reviewed on 8 May by a wing officer who knew him from
working on the wing where she had carried out some of the ACCT
observations. She described him as a quiet person who only approached staff
with specific requests such as to go to the chaplaincy. She had formed the
impression that the man did not like dealing with female officers. She noticed
that he had been sad whilst he was on ACCT because of his relationship, and
said that the chaplain told her about the difficulties. The officer thought that all
the wing staff shared the knowledge about the importance of the relationship.
She had noticed that the man had recently seemed happier and had been
interacting more with other prisoners.
Final Report: November 2007 30
144. The officer explained that the CSRA review is a paper exercise which is not
carried out in conjunction with the prisoner or their personal officer. She said
that the assessment remains the same as previously unless further information
is supplied to alter the judgement. She had no additional information about the
man and so recorded that he remained medium risk and should be reviewed
every three months. Under the action required, the officer noted that the man
had “medical issues”, and easily became frustrated due to anger management
problems if sharing a cell. The review was not counter signed in the
appropriate section by the duty governor.
145. Another officer also knew the man from working on G wing. He said that he
was a quiet prisoner who would always be ready before he had to be locked
up and never drew attention to himself. He knew that the man was on ACCT,
and was aware of the difficulties in his relationship with his partner, but had not
provided any personal support.
146. The prison doctor’s follow up appointment took place on 8 May when the man
was still on ACCT. The doctor concluded that he would not plan further follow
up. His police statement indicates that the doctor felt the man was positive
and upbeat about his partner’s imminent visit. Although the man thought that
their relationship was improving, the doctor discussed alternative scenarios
and judged that he gave satisfactory replies.
147. The chaplain was invited to attend the ACCT review and went to the wing at
9.55am where the man met him and said that he wanted to come off ACCT.
The chaplain said that they would consider the facts at the review which was
to be attended by the man, the SO and the chaplain. The chaplain and the SO
spoke together first, and then the man was invited to join them. The report of
the review is timed at 4.00pm, although the chaplain said that it took place at
10.00am. It notes that the man was more “up beat” and his speech was
extremely positive. He was described as realising that he needed to move on
with his life even if this was without his current partner.
148. The chaplain felt the man was beginning to come to terms with his problems,
and wanted to get on with his sentence and return to work. The SO described
their efforts to gauge the man’s reaction to the possibility of the relationship
ending. She was confident that he was being open when he said that he
would have to move on with his life. She, the chaplain and the man agreed
that the document should be closed and the ACCT monitoring should cease.
A post closure review was planned.
149. The psychology department responded to a further complaint about the place
on the CALM course, telling the man that his application might have been
misfiled with that of another prisoner by the same name but would be dealt
with. As the programme was not due to start until July, the man was told that
he was not being disadvantaged in the meantime.
150. The man’s wing file for the same day records that he received a certificate
from the Social Life Skills department. The certificate is actually dated 18 May
Final Report: November 2007 31
and was awarded for participation in the Parentcraft and Reading Together
course.
151. On 9 May, the man was assessed in the mental health clinic by a Registered
Mental Nurse (RMN), following the referral from the chaplain. She was aware
of the man’s previous meetings with the MHSW and recorded that he had
various problems stemming from his childhood. He said he had no current
thoughts of harming himself and was to be given anger management booklets
and begin a “Thought Diary”. The RMN decided that regular meetings were
required and she would review him in two weeks.
152. The man had his sixth counselling session on 9 May. The counsellor thought
that his mood was brighter.
153. In between the ACCT document being closed and the post closure review, the
SO continued to see the man on the wing when she was on duty. She
described him as very happy as he thought that the relationship with his
partner had resumed and everything was okay. She confirmed that other wing
staff were also aware of his change of fortune and happy frame of mind.
154. The ACCT post closure review was recorded as taking place on 8 May at
9.00am with the man and the SO. However, in her statement to the police, the
SO confirmed that it was actually held on 14 May. She called the man to the
wing office and they spoke together. Because she had seen him frequently in
the meantime, the SO knew his frame of mind and the post closure review was
a formality. She and the chaplain had also discussed the man’s progress
several times.
155. The SO recorded that the man remained “up beat and positive during the
review”. He told her that he felt better after a visit from his partner as he had
been able to sort out his misunderstandings with her. He was described as
aware that he must not allow his relationship to take him so low that he felt like
harming himself. The man would remain in contact with the chaplaincy for
support, and said that he would tell staff if he felt low again.
156. Tuesday 15 May was the man’s 24th birthday. The chaplaincy log for the day
notes that his partner did not come for the visit as she did not have the bus
fare, and had re-booked for a later date. The chaplain described the man as a
little angry and told him that he should go to work as normal, in spite of his
disappointment, as he needed to keep himself occupied. The chaplain agreed
to make a final attempt to arrange the family visit, which was booked for 21
May.
157. The probation officer and her district manager held a high risk review of the
man’s case on 15 May. She was asked to repeat the OASys assessment to
coordinate with the new sentence plan. She was also asked to liaise with the
social worker again (as she had not received a response to her previous
communication) and ensure that the man’s partner had appropriate support as
the victim of his offence.
Final Report: November 2007 32
158. The following day, the volunteer co-ordinator and the man’s counsellor met
again. The counsellor was asked to pass a questionnaire on communication
to the man at the counselling session (his seventh) later in the day. The man
told his counsellor that he would complete the survey and return the form at
his next session on 23 May. The counsellor said that the man was very happy
as he had received a birthday card from his partner’s mother. He also told the
counsellor that his partner had visited him in the morning before the
counselling session.
159. The man’s friend thought that he seemed to improve in the week because he
was getting letters, visits and telephone calls from his partner. He knew that
the man was looking forward to a chaplaincy visit on 21 May. The SO said
that she continued to see the man frequently when she was on duty. She said
that he was not shy about speaking to staff and she was able to see that he
continued to be fine.
160. The man went to chapel on 20 May and the chaplain explained the
arrangements for the visit booked for the following day.
Monday 21 May
161. The man did not go to the joinery class in the morning because the family visit
was booked to take place between 9.15am and 11.00am. The chaplain, the
man and his partner were present throughout. Afterwards, the chaplain wrote
that he thought the visit went extremely well and that “the two partners seemed
very well reconciled”. He noted that the man told his partner he would not try
to control her. The man told the chaplain that, on a scale of one to ten, he was
on nine, and thanked him for organising the visit. The man’s friend also
noticed that he was happy after the visit, which he said had gone well.
162. The same day, the man used the complaints procedure once more. He
complained to the prison’s psychology department about his failure to get a
place on the CALM programme. He recounted his previous complaint,
clarified his previous prison number, and asked when a place would be
offered. In his complaint form, the man said that unlike most prisoners he was
keen and highly motivated. The reply confirmed that his original application
had been linked to the second. He just had to wait for the course to start and
did not need to be reassessed.
163. Also on 21 May, a child protection social worker visited the man’s partner
regarding the information from his probation officer. Although the social
worker has not provided any information for this investigation, a copy of her
police statement has been supplied. Initially, the man’s partner said that,
although the relationship had come to an end, she thought they might be
reconciled and so took her children to visit him. However, she went on to say
that she only visited because she was frightened of what the man would do to
himself and to her. She was adamant that she wanted to end the relationship
as she was frightened of him. She knew from the chaplain that he had taken
an overdose and said he had written threatening to harm himself again.
Final Report: November 2007 33
164. The social worker advised the man’s partner of possible future action by her
department if the relationship continued and it was necessary to safeguard the
children. She also made his partner aware that she would continue to liaise
with the probation officer.
165. An Officer Support Grade (OSG) was on night duty on G wing for the week
beginning Monday 21 May. He had been doing the job for 14 years and
regularly worked at night on G wing. The OSG had been trained in fire safety,
first aid and ACCT procedures. In interview, the OSG said that his duties did
not bring him into physical contact with prisoners. But he did get to know them
from carrying out roll checks and doing ACCT and other observations.
166. The OSG’s night time routine includes roll checks of all prisoners at the start of
the night and at 6.30am before going off duty. The OSG said he would look
through the observation panel into each cell to see the prisoner, but would not
wake them up. He said that, if an observation panel is obstructed, he is told to
get a response from the prisoner. When the checks are complete and the roll
known, the OSG records the figures and signs to confirm that the task was
complete. Throughout the night, the OSG said he would patrol the wing every
hour, using a pegging gun to confirm his route which goes past every cell.
167. The OSG confirmed that he knew the man from when his ACCT document
was open. He described him as a quiet prisoner who did not present any
problems and never rang his bell to ask for anything. They only had brief
conversations, even when the ACCT document was open.
Tuesday 22 May
168. The social worker spoke to the probation officer after her visit to the man’s
partner, and reported that she said he was controlling which made her
unhappy. She passed the information to the probation officer that the man had
attempted to take an overdose, and threatened to do so again. The social
worker then telephoned the man’s partner, and was told that she had already
sent a letter to end the relationship. The social worker contacted the probation
officer again to tell her about the letter and ask for any information about
further contact between the man and his partner.
169. The probation officer had been unaware of the self harm and so telephoned
the prison healthcare team for verification. She told the Deputy Head of
Healthcare that the man’s partner was likely to end the relationship and she
was concerned about his risk of self harm and suicide. The probation officer
said that the call was returned and her identity was confirmed, together with
details of the overdose the previous month.
170. The probation officer then telephoned the prison’s security department, and
was told that the staff were in a meeting. She also telephoned the man’s
offender supervisor. However, his telephone was on voicemail and she left a
message that she had rung. She did not explain the reason for her call as she
had already reported her concerns to healthcare. Finally, the probation officer
Final Report: November 2007 34
contacted the victim support team to ask for the man’s partner’s needs to be
reassessed as her situation had changed.
171. The chaplain received a telephone call from the man’s partner at about
1.30pm in which she said that she had had some bad news from social
services. She had been visited by a social worker the previous day and told to
break all contact with him. The conversation with the chaplain lasted about 15
minutes, and he described her as weeping and distraught about the news
which she asked him to pass to the man. The social worker had told her that
she had been told by probation that his mail and telephone calls would be
monitored. The man’s partner said that she was warned that, should she not
end the relationship, her children would be entered on the child protection
register and risked being taken into care. The chaplain wrote in his statement
that the man’s partner was upset during the conversation. She said that the
social worker considered that he was a danger to the children.
172. The chaplain discussed the information with the co-ordinating chaplain and
they decided to pass it to the man in person. The chaplain sent a message to
the wing to ask the man to go to the chaplaincy at 2.00pm. He went to the
chaplaincy as requested, and both chaplains spoke to him together. The
chaplain gave brief details of the morning’s telephone call from his partner and
allowed him to make a short telephone call to her. The chaplain wrote in his
statement to the Governor that the man and his partner were both upset. He
became angry, but then calmed down and told his partner that he loved her
and would be there for her when he was released from custody.
173. After the call, the man asked for a few minutes on his own for a cigarette.
Then the chaplain spoke to him again and the co-ordinating chaplain took him
to the chaplaincy lounge for a drink and cigarette. The co-ordinating chaplain
returned to check on his colleague, then went back to the man for another long
conversation.
174. The chaplain initially suggested that the man could try to work with social
services. However, he realised that the situation was more complicated as he
disclosed that he had been in breach of a bail condition when he lived with his
partner before coming back to prison. The co-ordinating chaplain wrote in his
statement to the Governor that the man was tearful, but his mood improved
and he spoke of moving on and making a fresh start. Eventually the man
calmed down, and at 4.00pm he asked to return to the wing.
175. The chaplain wrote that the man asked to return to the wing, saying that he
was okay and was sure that the relationship would continue. The chaplain
asked him if he felt he should be placed on ACCT. He wrote in his statement
that the man was emphatic that he should not go on ACCT and would speak to
the Senior Officer or the chaplaincy if he became more depressed. The
observation book records that the chaplain brought him back to the wing at
3.45pm, although his own statement records the time as 4.10pm. The
chaplain wrote in the observation book that the man was very upset but calm.
He added that he “did not feel that it is necessary to place [the man] on ACCT
but staff may wish to ‘keep an eye on him’ over the next day or so”. In
Final Report: November 2007 35
interview, he said that he did not expect staff to make extra checks on him, but
thought that they would speak to him in the course of their usual routine. His
assessment was that the man was “calm, collected, stable and able to
continue”, and that no extra monitoring was required as he had promised to
seek support from wing staff.
176. The man’s friend knew of the telephone call between the man and his partner.
He tried to cheer him up and said this was effective for a while.
177. The chaplain informed the SO of the man’s news. The SO recorded in his
wing file and the G wing observation book that the chaplain said that the man
was not to have any contact with his girlfriend. The chaplain told her that the
information came from the probation officer, but the SO was aware that
prohibition of contact must be on the authority of the Governor. The chaplain
told the SO he would complete a security information report (SIR), and she
telephoned the public protection unit to ask for advice. (In interview, the
chaplain confirmed that he had forgotten to complete the SIR.) The SO said
that they did not discuss re-opening the ACCT document. She felt that, as the
man had been with the chaplain, he would have a better understanding of his
frame of mind and would have said if he felt it was necessary to re-open
ACCT.
178. Later that evening, another wing officer escorted the man and three other
prisoners to the chaplaincy to attend a prisoners group. The officer overheard
the man tell the others about the possibility of the children going on the at risk
register. The officer thought that he was upset, but accepted and understood
the situation.
179. The man talked to the chaplain about how much he loved his partner and her
children. But if they had no future together, he said he would start again. The
chaplain thought he was in quite good spirits and again promised his support.
They spoke again about 15 minutes later when the chaplain said that he was
worried and wondered about opening an ACCT document. The man assured
him that he was fine and did not need to go on ACCT. They spoke about the
support that was available and the man shook the chaplain’s hand (which was
his custom), saying that he would see him on Sunday. The co-ordinating
chaplain also saw the man and noted that he seemed composed. As the man
left the chaplaincy at 7.30pm, the co-ordinating chaplain saw him give a
thumbs up sign and say thank you.
180. The man and his friend talked together during the evening. His friend knew
that the man was unhappy about social services’ comments about his
partner’s children. He said he reassured him that the children would not be
removed whilst he was in prison as they were not at risk. Whilst they were
talking together, the man’s friend noticed a plant in his cell and the man told
him how he liked to look after it.
181. As usual there was a duty governor on duty that evening and she carried out
the routine checks of the wings. She noted the previous comments in the
observation book and discussed them with the wing SO on duty that evening.
Final Report: November 2007 36
(The SO was not the one who had been involved with the man’s ACCT
reviews, but she did know him from her routine wing duties.) The duty
governor noted that ACCT was not considered necessary, but that staff would
observe the man over the evening duty and record their observations of his
actions. (There are no records of any observations in the observation book.)
182. The SO talked to the man at 7.30pm and recorded that he said he was alright,
but wanted to have the following day off work. She agreed to his request. In
interview, the SO described him as a quiet prisoner who was not afraid to
approach staff and discuss an issue. She had known him during his previous
sentence when she was aware of his financial difficulties. He would ask her to
check letters he had written and she commented that he was an articulate
letter writer. He mixed with other prisoners and was not isolated.
183. The officer who took the man to the chaplaincy earlier saw him again in the
evening and noticed that his eyes were red from crying. She knew that he had
talked to the SO and thought that she was dealing with any issues. The officer
gave a verbal handover to the OSG who was on duty again overnight. In
interview, she said she drew the OSG’s attention to the entries in the
observation book about the man and signed the book to that effect. She noted
that there were 189 prisoners, four of whom were on Bullying Incident Reports
(BIRs) but none on ACCT. She wrote that there were no other issues apart
from the man. The OSG confirmed the handover by signing the observation
book below the officer’s entry.
184. The OSG recalled being asked at the beginning of the week (but could not
specify the date) to look at the man every two hours or so, but said he was not
told the reason for the additional observations. In interview for this
investigation, the OSG said that he made the observations as requested but
did not record them. No incidents were recorded in the observation book
during the night and the OSG handed over in the morning.
Wednesday 23 May
185. The CALM tutor, replied to the man’s complaint on 23 May saying that she had
been able to trace the application made in his previous sentence and he did
not need to repeat it. He could go on to the waiting list for the next course
which was due to start at the end of July.
186. The workshop instructor wrote in his statement that he talked to a number of G
wing prisoners during the afternoon. They told him that they would be
surprised if the man came to work during the rest of the week as his partner
had jilted him.
187. The man had another appointment (his eighth) with the counsellor at 3.30pm,
and another wing officer unlocked his cell so that he could attend. The officer
did not notice that anything was the matter with him.
188. As the man walked towards the counsellor, she thought that he seemed
extremely distressed. She asked him what was the matter, to which he replied
Final Report: November 2007 37
that he “had good reason” as he had been told that he could no longer have
any contact with his partner and her children. He had a good family visit on
Monday, but his partner had told him that social services were coming to see
her as they had been contacted by the probation service. The man told the
counsellor that he had been told at the chaplaincy the previous day that his
partner’s children would be put on the At Risk register if she had further
contact with him. He said that her telephone number was being removed from
his approved list and they would have no more contact.
189. The man told the counsellor that he had been crying ever since he got the
news. He asked to terminate their session after half an hour. The counsellor
advised him that she was concerned about his state of mind and would speak
to wing staff. He composed himself and, as he made his next appointment, he
remembered the questionnaire and said he would return it then.
190. The counsellor immediately went to the wing where she spoke to the second
wing SO. The SO said that a letter had just arrived for the man which she
intended to take to him and would keep an eye on him during the evening.
(The counsellor thought that a letter had just been delivered to the man.) The
counsellor said that she raised the recent closure of the ACCT document with
the SO, wondering if it should be re-opened. She was advised that the man
would be seen.
191. The counsellor also left a message for the volunteer co-ordinator, asking her to
contact her as soon as possible. The counsellor subsequently reported to the
co-coordinator that the man had asked to end the session early, saying he
hoped she did not think he was rude in making the request.
192. The man and his friend talked again at about 4.30pm when the man went to
his cell during association. His friend thought that the man was upset as his
partner had written to end their relationship. The man left briefly, returning
with the plant his friend had noticed a few days earlier. He gave the plant to
his friend, saying that it had his partner’s name and he did not want it any
more as the relationship had finished.
193. The observation book states that the SO talked to the man towards the end of
the afternoon at 4.45pm. She had discussed him with the duty governor
beforehand. The man told the SO that he was alright, and that he had to
accept what had happened with his partner and move on. He asked to miss
work the following day because he was afraid that his concentration might slip.
The SO agreed and told him that his cell could stay unlocked whilst the
cleaners were carrying out their duties during working hours.
194. The man’s friend saw him in the exercise yard at the end of the evening before
they were locked in their cells for the night. The man approached his friend
and showed him the letter from his partner. His friend tried to reassure him
again, after which he thought the man was more positive and they chatted
about other matters. The officer who had previously completed the CSRA also
spoke to the man whilst he was in the yard and asked how he was. He told
her that he was fine and she did not think that he appeared to be upset.
Final Report: November 2007 38
195. The SO recorded that the man said he was not suicidal, but staff should be
aware and monitor him over the next few days. She said that she did not think
he was suicidal as he was laughing and joking. She wanted staff to look for
any change and, if necessary, place him back on ACCT.
196. Another officer was on duty. She remembered the SO saying that she was
going to talk to the man again in the morning. The officer carried out the
evening roll check at about 8.00pm. She told the police that she remembered
him standing at his sink, washing his hands, and did not notice anything
unusual about him or his cell. The officer said that she spoke to the man, who
replied, and continued the remainder of the check. The SO also spoke to the
man and he told her that he was alright. She did not think that he was upset
and so talked to him on the landing rather than in private. She asked him how
he felt and he told her that he had to accept what had happened and move on.
The SO felt that he was dealing with the relationship ending.
197. The observation book was checked again by both the orderly officer and the
duty governor who wrote that “night staff be aware of (the man)”. The same
OSG returned to duty that night and again signed to confirm that he had
received a handover briefing. In interview, the OSG said that he was not
briefed about any specific concerns and no prisoners were on ACCT.
198. The OSG carried out the evening roll check and began the pegging routine at
about 10.00pm. Loud music was coming from cell 2.52, a few doors away on
the same landing as the man’s (which was 2.44), and other prisoners were
complaining about the noise. The OSG told the prisoner to turn the noise
down, and said that racist comments and threats were made in response.
199. The prisoner rang his bell and kicked his door, but then quietened down until
11.30pm when he rang the bell at the same time as the SO arrived. The SO
spoke to the prisoner, who was again abusive and broke a bottle, threatening
to use the glass to cut his throat. The SO sought advice from the duty
governor, and two officers and a nurse were asked to come to the wing.
Eventually, the duty governor decided that the prisoner should be moved to
the segregation unit.
Thursday 24 May
200. The prisoner who had been making the disturbance was moved to the
segregation unit at about 4.00am. The OSG said that the prisoner was
bleeding and drunk when he left his cell, and the landing lights were off.
Afterwards, the OSG began the paperwork arising from his part in the matter.
He said that he began the morning roll check at about 5.45am, by which time it
was daylight and the wing was quiet. He was thinking about the outstanding
reports and that the night’s events had to be written in the observation book.
When he reached the prisoner’s cell, he noticed that there was blood and
broken glass on the landing floor leading in the direction away from the man’s
cell. The OSG said that he made a mental note that it would have to be
cleaned up, and continued with the roll check.
Final Report: November 2007 39
201. When the OSG reached the man’s cell, he opened the observation panel and
saw that it was obstructed. He said that he kicked the door, rather than
knocking, using his hand to open the panel. He said that he did not speak and
only made the noise from his kick which would have been equivalent to that of
a knock on the door. He said that the light at the time was dull and he did not
look through any other part of the door. He heard a response and continued
with the rest of the checks. The OSG was unsure what the response sounded
like, acknowledging that he was thinking about the rest of his duties but
confirmed that it sounded like speech rather than an inanimate sound. (The
prisoner in the cell next door to the man subsequently told the police that he
heard the night officer shout to him to uncover his flap and open the door.)
202. The OSG completed the check, handed over the records and made the entry
in the observation book. His shift finished and he left the prison after the day
staff arrived.
203. The officer who completed the CSRA came on duty again at 6.55am on 24
May. As she came through the gate, she was informed of an incident during
the night which had resulted in the prisoner being removed to the segregation
unit. She was told that there was blood and glass on the floor and she should
decide whether external cleaners were required. The officer reached the wing
about ten minutes later and the OSG gave her a handover, which she
described as normal except for the incident. No reference was made to the
man.
204. The officer began the morning cell checks at 7.05am, and said that the light
was bright. She checked each prisoner by opening their cell observation
panel, switching the light on and checking that they were alive and well. As
she approached cell G2-44 five minutes later, she could see through the gap
between the door and the frame that a barricade appeared to be in place. She
saw that the bed frame was standing upright against the door and then opened
the observation panel. The panel had been obstructed and she called out
twice, but got no response.
205. The officer used her radio to contact the control room and ask for assistance.
The call was passed to a Principal Officer (PO) who said that he would make
his way to the wing. He had come on duty that morning and was the orderly
officer (Oscar 1) in charge of the prison’s operations. (The PO is also Risley’s
suicide prevention co-ordinator.) The PO asked the officer to try to get a
mirror to slide between the door and the frame, thinking that the prisoner might
hit it which would help him know what he was dealing with.
206. The PO met the officer as he walked up the stairs to the landing at 7.20am.
He told her to telephone the gate office to send the next four staff on duty to
the wing whilst he removed the anti-barricade plate from the door. He did not
want her to use her radio from the landing as he did not want other prisoners
to be alerted. The PO also asked the officer to arrange a cell in the
segregation unit and ask healthcare to attend. He spoke through the door, but
did not get a reply. He then began to remove the bolts from the door, and
Final Report: November 2007 40
used his radio to repeat the request for more staff to attend. The mattress was
visible through the side of the door and nothing could be seen through the
observation panel.
207. Another officer was on duty on F wing at 7.15am when he received a
telephone call from the first officer to ask for assistance. The first officer told
him that the observation panel of cell G2-44 was covered and she believed
that there was a barricade behind the door. She said that she had failed to get
a response from the occupant and, as the other officer was a trained
negotiator, she thought he might be able to deal with the situation. (The
second officer is also a first aid instructor who holds an up to date first aid
qualification.) The second officer told his colleague to inform the control room
and ask the orderly officer to attend. He said that he would get someone to
relieve him on F wing and come as quickly as possible.
208. At approximately 7.25am, a third officer and the SO who had been on duty the
previous evening arrived at the prison. They were told that a prisoner had
barricaded himself in his cell on G wing. They went straight to the wing, where
they found the first officer and the PO, and advised that the man was not a
troublesome prisoner and he would not attack them. The third officer could not
see through the observation panel which was blocked. He is over six feet in
height, considerably taller than the PO, and was able to look through the crack
at the top of the door. He saw that the bed was upright and he attempted to
open the door. The door was barricaded and the officer pushed it so that it
opened about 12 inches. The third officer saw that the man was hanging from
the upturned bed. He told the PO that the man was hanging and that
immediate assistance was required.
209. Whilst the third officer was attempting to open the door, the PO had opened
the block on the door so that it could be reverse opened outwards on to the
landing. They went in together and saw the man hanging with his legs on
each side of his chair. The PO supported the man’s body whilst the officer
used his fish knife to remove the ligature and laid him on the floor. (The knife
is shaped like a fish and is designed to be inserted safely between the neck
and any ligature.) The officer said that the SO moved the chair away. The
man’s body was stiff and his hands and face were blue, with his tongue
protruding. The PO said it was immediately apparent that the man had died,
but he was not qualified to make a decision. He began to create enough
space for cardio pulmonary resuscitation (CPR) to begin.
210. The second officer was relieved on F wing at 7.25am and went straight to G
wing where he found the third officer outside the cell comforting the SO. The
third officer told him that the man was hanging from his upturned bed frame
and was dead. The third officer went inside the cell and saw a lot of blood on
the right hand side of the cell. He checked for signs of life but the body was
cold and in the early stages of rigor mortis. He saw the mark of the ligature
round the man’s neck, but there were no wounds there.
211. At 7.28 am, a nurse (who happened to be the one who treated the man after
he took the overdose) was in healthcare and was allocated as Hotel 1 (the
Final Report: November 2007 41
duty healthcare nurse). She received a call to attend G wing immediately.
The message did not give any information about the type of incident. She did
not know what equipment was required and took a basic first aid kit with her.
At the same time, one of her colleagues telephoned the control room and was
told that the incident concerned a prisoner’s barricade. The nurse did not think
it was as serious as she first thought. The Healthcare Manager telephoned
the wing to be told by the SO that there had been a death. The manager and
a second nurse followed the first nurse to the wing, taking the defibrillator with
them.
212. When the nurse reached the wing, she passed an officer who mentioned that it
was “too late”, and then saw the SO and the first officer, who she thought were
upset. The nurse arrived at the man’s cell. Two officers were outside and the
door was ajar. She was told that the prisoner had been found hanging and
had been cut down by staff. The nurse said that she needed to go inside the
cell and the second officer accompanied her. She saw the man lying on his
back with his head towards the window and noticed a deep and wide
indentation round his neck from the ligature. Her first impression was that
there were no signs of life. The nurse saw that his eyes and mouth were open
and his tongue was visible. The lower part of his face was discoloured and his
arms were raised slightly from the floor. She felt that his body was stiff and
cold.
213. As the nurse checked the man’s vital signs, she noticed fresh blood on his
right wrist which came from a wound there. She could not detect a pulse and
so checked his eyes but got no response. She concluded that the man had
died and made no attempt to administer cardio pulmonary resuscitation (CPR).
The nurse noticed that the cell had no personal belongings on display and a
couple of brown boxes were piled neatly by the sink. The officer asked her
where the blood had come from, and then noticed a knife made by inserting a
razor blade into the melted handle of the razor. He asked for an evidence bag
in which he placed the ligature and knife. They left the cell and the nurse said
that she checked the welfare of the officers and briefed her healthcare
colleagues who had arrived. They waited on the wing for the paramedics to
arrive.
214. The PO knew that the duty governor was not yet at the prison and so
delegated another SO to remain on the wing whilst he went to the
communications room to begin implementing the prison’s plan for dealing with
a death in custody. He and the communications staff continued working
through the plan until the duty governor’s arrival.
215. The ambulance was called at 7.30am and the chaplaincy at 7.40am. The duty
governor arrived at 7.45am and took over implementation of the plan for
dealing with a death in custody. The PO briefed the duty governor and was
then relieved of the Oscar 1 duties. The PO took over his suicide prevention
co-ordinator’s role and arranged for all the prisoners on ACCT to be reviewed.
216. The paramedics arrived at 7.50am and the second officer unlocked the cell so
that they could go inside. The nurse was present when their tests confirmed
Final Report: November 2007 42
that the man showed no signs of life. The paramedics left the cell which the
officer locked again. He waited outside until the SO who had been briefed and
a third SO began to keep a log of events. The nurse returned to the treatment
room. One of the chaplains attended and said the last rites, after which an SO
locked the cell again at 8.00am.
217. Other prisoners on the wing were checked at 8.12am and again throughout the
morning, with special attention to one who was on an open ACCT. One of the
prisoners said that support was offered after the man died, but little information
was passed on at the time. He thought that the other incident during the night
had led to a mood of uncertainty amongst prisoners. The man’s friend, who he
gave the plant to, said that his friends were not given any special treatment,
although a governor and member of the IMB were available to all the
prisoners. In interview, the friend suggested that the man might have
benefited from being moved to a shared cell and having someone to talk to
after his relationship came to an end.
218. The coroner’s office was notified at 8.15am. The chaplain was contacted at
home and notified of the man’s death.
219. A member of the IMB, arrived at the prison at 8.20am and then went to G wing
where he remained until 2.35pm. He was joined by another member and the
IMB chair, and together they observed staff attending to their duties. The IMB
members made themselves available for any staff and prisoners who wished
to speak to them.
220. The prison doctor was telephoned at about 8.30am before he arrived at the
prison, and told that the man had hanged himself. The doctor told the police
that he was shocked and described it as a tragic event. He thought that the
man was an impulsive person, and that this was an impulsive act.
221. The duty governor handed over to the Deputy Governor, and she in turn
handed over to the Governor when he arrived at 8.45am. At the same time,
prisoner’s pinphones were checked and cut off so that no information could be
passed on before the next of kin had been notified. Other than those with
visits or who were wing cleaners, prisoners were not unlocked as usual during
the morning, but remained in their cells where their meals were served to
them. The Governor commented that prisoners were very cooperative and no
cell bells were rung whilst they were locked up.
222. The cell was unlocked at 9.00am so that the doctor, who was accompanied by
the Head of Healthcare, could examine the man. The doctor checked for signs
of life and pronounced at 9.00am that the man had died. In his statement to
the police, the Head of Healthcare noted that the cell television had been
switched on. The SO sealed the door afterwards.
Final Report: November 2007 43
After the man’s death
223. A second contact was made with the coroner’s office at 9.00am, and
information provided that the police would take responsibility so that the
coroner’s officer would not attend. The police were informed, arriving at
9.40am to take charge of the cell and gather photographic and forensic
evidence.
224. The man was formally identified at 9.56am by the second officer, after which
the cell was searched. The ligature, a home made bladed weapon and some
letters were removed.
225. Another governor, who was a trained family liaison officer, and the prison’s
police liaison officer, were asked to contact the man’s family to tell them of his
death. Although the man had named his partner as his next of kin, knowing
about the relationship difficulties, they decided to go first to his father’s home.
The prison log records that they arrived at 11.05am, but got no reply and were
told by neighbours that he had been away for a few days. They decided to go
to the man’s partner and arrived at 11.30am. She handed over two unopened
letters to the governor, the first from the social services department and the
second from the man himself.
226. Efforts to locate the man’s father continued and a message was left at his
home asking him to contact the prison.
227. The staff care team was available to provide support for staff. Those staff
interviewed expressed their appreciation for that support, as well as that
received from their managers and the IMB.
228. During the morning, the man’s probation officer revised his OASys
assessment and made follow up telephone calls. She telephoned the prison at
11.40am and spoke to the offender supervisor. At this stage, neither of them
knew that the man had died. The probation officer reported that the man and
his partner had fallen out and she was going to end the relationship. The
probation officer told the offender supervisor that the letter might have already
been sent, and she was concerned about how the man might take the news.
The offender supervisor agreed to see the man and find out his reaction if he
had already received the letter. She also telephoned the security department
as she was concerned about the man’s letters and telephone calls from his
partner, and was asked to put her concerns in writing to the Governor. Shortly
afterwards, whilst still completing the OASys document, the probation officer’s
colleague telephoned to tell her of the man’s death.
229. After lunch was served to the prisoners, a notice was delivered to each cell to
inform them of the man’s death and offer support from the Listeners,
chaplaincy or staff. Prisoners were also told that there would be association
during the afternoon on the wing and they would not be required to work. The
duty governor described the atmosphere that afternoon as good and said that
prisoners were generally in good spirits.
Final Report: November 2007 44
230. As the police forensic examiner was delayed, the removal of the man’s body to
the Royal Liverpool Hospital could not take place until 1.10pm. The post
mortem confirmed that death was due to hanging with significant blood loss.
There was no suspicion of drugs and no letters were found. The man was fully
dressed when he was discovered. The words “do not revive” were written on
his chest. His right arm bore the words that he was sorry, together with his
nickname for his partner.
231. An inter faith prayer service was held in the chaplaincy at 3.00pm, attended by
15 prisoners. The man was also remembered at the services the following
Sunday, and the service sheets displayed his photograph in naval uniform.
Prayer cards, also mentioning him by name, were provided for prisoners’ use.
232. The police visited the man’s partner the following day and she handed over a
letter from him which had been franked by Risley on 23 May. The police
officer described the letter as blood stained.
Final Report: November 2007 45
ISSUES
Personal officer duties
233. Risley’s procedures for personal officers were prepared some years ago and
have fallen into disuse. They predate the introduction of offender
management and the close links now in place between offender supervisors in
the prison and offender managers in the community. It was apparent in this
investigation that the man’s personal officer had been allocated for a short
time and knew little about him. He was not expected to be responsible for
specific tasks, such as cell sharing risk reviews, nor take any special role in
implementing ACCT or have a general knowledge of the prisoner’s life in
custody.
234. I understand that the role of the personal officer is being reviewed, and so
make no formal recommendation. The Governor may wish to consider these
comments in the course of the review. As far as is practicable with shift
patterns and extra duties, I suggest that personal officers should carry out all
tasks for individual prisoners such as CSRA reviews and ACCT reviews. It
would also be helpful to clarify their links with offender supervisors.
Clinical care
Reception
235. The man went through the routine reception health screens at Liverpool and
Risley. As usual, they were largely derived from information provided by the
prisoner himself. As far as his eventual death in custody is concerned, there
are three relevant aspects to his reception at Risley. First, his history of self
harm was correctly identified but no details were provided regarding the
number of occasions or the methods used and it appears that previous records
were not retrieved. Secondly, a timely referral was made to the mental health
services and, although it was not classed as urgent, an initial appointment was
offered just over two weeks later. Thirdly, the healthcare nurse concurred with
the decision to allocate him to a single cell. His location was at his own
request because of what were referred to as anger management issues.
However, in spite of the man’s self harm history, there is no evidence of a risk
assessment taking place.
Medication
236. Soon after the man arrived at Risley, he caught a cough and cold and referred
himself to healthcare. The clinical reviewer has assessed that the advice and
treatment were appropriate, and Brufen tablets were prescribed because the
man was allergic to paracetamol. However, in spite of his known history of self
harm, he was given two prescriptions for a 28 day supply of the tablets without
any evidence of a risk assessment about his ability safely to hold the
medication in his own possession. Furthermore, there is no evidence of a risk
assessment being carried out after he took the overdose even though the
ACCT review listed it as an action point.
Final Report: November 2007 46
The Warrington Primary Care Trust and Five Boroughs’ Mental Health
Partnership should review the operation of the medication policy, in
respect of prisoners holding their own medication, and ensure that each
prisoner is risk assessed before medication is given to them and after
any incident of self harm.
Mental health
237. The clinical reviewer’s opinion is that the nature and severity of the man’s
mental health was correctly assessed and appropriate plans were made. On
the basis of the reviewer’s knowledge and the advice he received, he
endorses the assessment that he was suffering from mild depression,
accompanied by anxiety. He was not considered to need medication to
manage a mild illness, but instead needed support to improve his social and
problem solving skills.
238. As far as healthcare is concerned, the man was ably supported by the mental
health worker, and then appropriately referred to the doctor and mental health
nurse after he took the overdose. Their goal was to help him come to terms
with being in prison and manage his relationship with his partner. The
reviewer considers that the mental health worker’s contribution to achieving
these goals was comprehensive, but that they would have been enhanced by
more effective monitoring which included timescales being set and the
outcome reviewed.
239. I was pleased to find that the mental health team has a robust system for
following up prisoners who miss appointments. They are notified of the time
and date of their appointment in a private envelope, which is delivered by a
nurse directly to the prisoner or to be passed on by an officer. If any
appointment is missed, another is sent in the same way. In the event of a
second appointment being missed, and the prisoner being of particular
concern, the mental health worker would go to the wing to see them.
Alternatively, a telephone call would be made to the wing to follow them up.
This system worked in this man’s case. Each time he missed an appointment,
a follow up was booked.
Record keeping
240. On 22 May, the man’s probation officer learnt that he had attempted suicide in
April. She telephoned the Deputy Head of Healthcare who confirmed the
information. The clinical reviewer has interviewed the member of staff
concerned who has acknowledged that neither the fact, nor the contents, of
the telephone conversation were recorded. As it happens, staff throughout the
prison were already aware that the man was at risk, and so the omission was
not critical. I make no recommendation, although the Primary Care Trust may
wish to review the matter. Omissions such as this could be of critical
importance in other situations.
Final Report: November 2007 47
Response to hanging
241. Unlike many other prisons, Risley does not use a system to distinguish
between different types of healthcare emergencies. When the man was
discovered hanging, the nurse on call heard the radio alarm and had to make
a telephone call to ascertain what was required and the sort of equipment she
needed. Fortunately, the line was clear and she was told that she was
attending a barricaded cell. She did not regard the situation as life
threatening, and only took a first aid kit with her.
242. A second radio call was made for healthcare and, as it was during the day, the
nurse’s colleagues were on duty in healthcare. They too made a telephone
call. They were told that a prisoner was hanging and so gathered the
appropriate emergency equipment to take to the cell.
243. In the event, by the time the man was discovered, it was too late for any of the
interventions to be of any use. In other circumstances, it might make the
difference between life and death.
The Governor and Warrington Primary Care Trust should review the
arrangements for notifying healthcare of emergencies and consider
introducing codes to indicate the type of emergency.
244. The clinical reviewer had made a number of other recommendations to the
Primary Care Trust, which are not directly linked to the circumstances of the
man’s death. They include:
• improving record keeping
• provision of first aid kits on the wings
• benchmarking the performance of the mental health team
• assessing healthcare against Standards for Better Health.
These recommendations have been addressed in a separate letter to the
Primary Care Trust.
ACCT
Assessment of risk
245. Most staff, including those working in healthcare, consistently assessed the
man’s risk of self harm/ suicide (other than when he was on ACCT) as low.
The assessments were carried out by a range of professionals, including wing
staff, mental health workers, the prison doctor, general nurse and Accident
and Emergency staff.
246. Although the clinical reviewer thinks that the healthcare assessments were
appropriate, he comments that a prisoner’s risk should be assessed according
to their circumstances and situation. For example:
• Healthcare knew that the man was supported by wing staff and the
chaplaincy, but did not take their knowledge into account.
Final Report: November 2007 48
• The implications of his workplace were not considered. He was taking a
joinery course, working with potentially hazardous equipment and
needing to concentrate to remain safe.
• The man was not reassessed after he took the overdose.
• He remained in the same single cell, which was not a safer cell,
throughout.
ACCT reviews and action plans
247. After the man took an overdose of tablets about four weeks before his death,
the ACCT document was opened and reviewed in a timely manner in
accordance with ACCT guidance. However, those attending the reviews (the
wing senior officer and chaplain) were limited in their roles and their
knowledge of the other support provided for him. It would have been good
practice to involve other staff, such as the mental health worker, counsellor
and workshop instructor. Even if they were unable to attend, they could have
provided written comments.
248. The clinical reviewer recognises that healthcare staff did not have a central
role in the ACCT process in relation to observations, reviews or closure of the
documents. As the review states, it seems odd that, even when a prisoner is
known to mental health services, there is no express requirement to seek their
opinion. A prisoner’s mental health must surely be relevant to their risk of
suicide and self harm and it is difficult to understand why they are not routinely
involved. The contribution of their expert advice and knowledge of the
individual can only be of benefit in assessing the prisoner on ACCT.
249. The action plans prepared at each of the man’s ACCT reviews were largely
passive and, other than varying levels of observations, mainly included items
such as remain in a single cell, and have access to the Samaritans telephone
and Listeners. The only active suggestions were to organise a supervised
family visit and request a psychiatrist’s assessment.
250. This type of action plan might be appropriate in many situations, but in this
case, given the number of professionals involved, I cannot help feeling the
plan could have been more proactive. As the clinical reviewer has
commented, an observation regime is not an end in itself. It should be used to
safeguard the person whilst allowing time for therapeutic interventions to have
an effect. It is especially important for prisoners with a history of mental illness
who are on ACCT that there is a clear connection between the observation
regime on the wing and workshops, and the therapeutic regime provided by
the mental health worker, chaplain and counsellor. Not including these other
professionals in ACCT decision making was, in my view, a missed opportunity.
251. The decision to close the man’s ACCT document on 8 May was based on the
improvement in his mood at the beginning of the month and his statements
that he was giving the relationship until his birthday, seven days later, to see
whether it had a future. The SO and chaplain were both confident that his
resources were sufficient to enable him to overcome any difficulties. Although
other staff were not present when the ACCT was closed, no-one asked for it to
Final Report: November 2007 49
be reconsidered. (The mental health nurse told the clinical reviewer that she
believed that the man’s mood had genuinely improved as he was looking
forward to his partner’s visit.)
Information sharing throughout the prison
252. In many respects, information about this man was widely shared, but there
were significant oversights that should be addressed.
253. Although there is evidence of various professionals working well together on a
day to day basis, much of the information sharing relied on his own willingness
to disclose. For example, the counsellor’s contract requires her to report any
information about risk to prisoners, but there is no parallel expectation that the
prison will inform her of such matters. Fortunately, the man was willing to
disclose the support he received, and share the fact that an ACCT document
had been opened. Other prisoners might not be so open, which could mean
that a counsellor might inadvertently interfere with objectives agreed with other
parts of the prison.
254. Another gap concerns information sharing about ACCT documents. Although
mental health workers know when ACCTs are opened (although not when they
are closed), other healthcare staff are not always aware. The same applies to
staff from other disciplines. For example, the joinery instructor and offender
supervisor only knew that the man was on ACCT, and the counsellor only
knew of the mental health worker’s involvement, because the man himself
shared the information.
255. The workshop instructor’s statement to the Governor notes that, whilst the
ACCT document was open, the file did not consistently accompany the man to
the workshop. When the document did arrive, it was delivered late and
collected early, meaning that there was insufficient time for reading or
recording.
256. The clinical review says that very little information is exchanged between the
healthcare and psychology departments. When a patient with mental health
problems receives counselling from the prison, at the very least the mental
health service should be aware of the fact and of any relevant significant
issues which the counselling is seeking to address.
The Governor, Primary Care Trust and Five Boroughs’ Partnership
should work together to involve all practitioners in the implementation of
ACCT for prisoners who are known to them.
257. The clinical reviewer has commented that healthcare staff would welcome a
clear statement of their role in relation to ACCT, and the same applies to other
parts of the prison. In interview, both the Head of Healthcare and the prison’s
doctor acknowledged that they do not contribute to safer custody meetings,
something which is undoubtedly a source of frustration for the safer custody
manager. The active participation of healthcare in the safer custody strategy
would have benefits when it comes to the casework involved at an ACCT
Final Report: November 2007 50
review. Healthcare staff are not routinely nominated for ACCT training,
although I was pleased to note that the man’s mental health worker, workshop
instructor and counsellor had all been trained.
The Governor, Primary Care Trust and Five Boroughs Partnership should
ensure that all departments are actively involved in the prison’s suicide
prevention strategy.
Decision not to open ACCT on 22 May
258. The clinical reviewer carried out a helpful analysis of the research into suicides
in prison. He found seven characteristics typical of those who engage in
suicidal behaviour, of which two may have applied to this man. They were his
inability to make good interpersonal relationships (as evidenced by assaults on
his mother and partner) and his low self esteem (derived from his experience
of childhood abuse). The other factors (poor upbringing, social and economic
disadvantage, alcohol and drug addiction, poor educational attainment and
employment history, and weak problem solving ability and low motivational
drive) were less apparent. (Although in respect of alcohol, see paragraphs 11
and 68 above.)
259. The reviewer found that the man was in a minority in having good academic
qualifications and no history of social exclusion. However, his health status
was more typical in that nine out of ten prisoners have at least one mental
health disorder, including anxiety/ depressive disorders.
260. The key factor to the man’s risk of suicide and self harm was the relationship
with his partner. Whether they were party to the ACCT decision making or not,
all the staff involved shared his own opinion that the relationship was
fundamental and they were aware of his vulnerability. Likewise, all knew when
the relationship was at risk and when it came to an end. Almost all were
persuaded that the man was motivated to move forward with his life. Those,
like the counsellor, who thought that ACCT should be reopened were content
to leave the decision to wing staff.
261. I think it is telling that the man was described by all as someone who liked to
be in control of his life, and who did not cope easily when things did not go
according to plan. In that light, re-opening the ACCT when his major ambition
was circumvented would have been a sensible precaution.
262. A prisoner’s denial of thoughts of suicide or self harm should be only one
factor to be taken into account when deciding whether to open an ACCT
document. The prisoner’s words may not be conclusive and should be
supplemented by appropriate observations and vigilance. The man denied
any thought of harming himself, but everyone knew that the state of his
relationship was critical to his state of mind. That the end of the relationship
would have a catastrophic effect could, and possibly should, have been
foreseen.
Final Report: November 2007 51
263. I trust that implementation of my recommendation concerning the involvement
of all practitioners in the implementation of ACCT will help to address the
deficiencies highlighted here.
Roll check 24 May
264. The observation panel of the man’s cell was first found to be obstructed during
the morning roll check which was carried out by night staff. Although the
member of staff admitted that his mind was on other matters at the time, he
gave initial assurances that he had heard a response from within the cell.
Having heard what he described as a person making a response, the member
of staff took no further action regarding the obstruction. It was next seen at the
following check, about an hour and a half later, when the officer responded as
she was expected to. The outcome was the discovery of the man hanging
from his up turned bed.
265. It is not within the competence of this investigation to determine when the man
died and whether he could have been saved if he had been found at the first
check. However, I should say that I am entirely satisfied with the action taken
by the Governor when he realised what had happened. Within 24 hours of his
death, all staff had been reminded of the importance of carrying out proper
checks. When further information was passed on from the prisoner in the
neighbouring cell, the Governor commissioned his own investigation and
suspended the OSG, who has since resigned.
Final Report: November 2007 52
CONCLUSION
266. Unlike many of my investigations, the young man at the heart of this one was
very well known to staff of different disciplines within the prison, and was
supported by many of them. The man was preoccupied to the point of
obsession with his relationship with his partner, and openly discussed his
thoughts and feelings with his friends, as well as seeking support from staff.
All concerned recognised that the relationship determined his moods. It was
his explanation for the overdose and the reason the ACCT document was
closed. Judging by the words written on his body, it was also the reason why
he took his life.
267. There were some failings with the formal information sharing arrangements,
notably when the ACCT documents did not accompany him around the prison.
However, there were many other examples of good links, especially between
the chaplain and the wing staff who worked closely together whilst the ACCT
was open.
268. The ACCT arrangements would have benefited from including the opinions of
all who supported the man. Consulting the mental health worker, counsellor
and workshop instructor might not have changed the decision to close the
ACCT on 8 May. However, had those professionals attended ACCT reviews
and been consulted after his relationship broke down, it is possible, perhaps
probable, that the ACCT would have been reopened. My own view is that the
ending of the man’s relationship with his partner, coming as it did within weeks
of his suicide attempt, should have led to suicide and self harm monitoring and
support being restored.
Final Report: November 2007 53
RECOMMENDATIONS
The Governor and Primary Care Trust should:
1. Review the arrangements for notifying healthcare of emergencies and
consider introducing codes to indicate the type of emergency.
Since the publication of the draft report, I am pleased to learn that the
Governor and Primary Care Trust have accepted the recommendation
and are considering how to introduce emergency codes. The target date
for completion is January 2008.
The Governor, Primary Care Trust and Five Boroughs’ Mental Health
Partnership should:
2. Work together to involve all practitioners in the implementation of ACCT
for prisoners who are known to them.
This recommendation has been partially accepted, dependent upon
agreements between the agencies and the available resources. The
target date for completion is February 2008.
3. Ensure that all departments are actively involved in the prison’s suicide
prevention strategy.
The recommendation has been accepted and will be implemented by
February 2008.
The Primary Care Trust and Five Boroughs’ Mental Health Partnership
should:
4. Review the operation of the medication policy, in respect of prisoners
holding their own medication, and ensure that each prisoner is risk
assessed before medication is given to them and after any incident of self
harm.
The recommendation has also been accepted and will be implemented by
February 2008.
Good Practice
5. The chaplaincy is notified whenever an ACCT document is opened and
one of the chaplains visits each ACCT prisoner every day.
Final Report: November 2007 54