Individual at Shrewsbury

INVESTIGATION INTO THE CIRCUMSTANCES
SURROUNDING THE DEATH OF MAN AT
HMP SHREWSBURY IN AUGUST 2004
Report by the
Prisons and Probation Ombudsman
for England and Wales
October 2005
This is the report of an investigation into the circumstances of the death of a
man at HMP Shrewsbury in August 2004. I offer my sincere condolences to
his relatives and friends.
Tragically, the man was the second of three men to hang themselves in
HMP Shrewsbury during a sixteen day period. The first died on 19 August
and the third died on 1 September. Their deaths share a number of
common features – all died on A wing within a short period of arriving at
Shrewsbury, and all were drug users who were not assessed as being at
risk from suicide by the prison.
Shrewsbury is a small local prison and such a cluster of apparently self­
inflicted deaths was profoundly shocking for all concerned. I would like to
thank the acting Governor of Shrewsbury throughout the latter half of 2004,
and his staff for their help and support during this investigation. I am also
extremely grateful to colleagues in West Mercia police for their cooperation
and helpfulness at all stages of our investigation.
Three of my investigators examined events at Shrewsbury, each paying
particular attention to the death of one individual.
Shropshire County Primary Care Trust carried out a clinical review of the
three deaths, and I am greatly obliged for their advice on the clinical factors
in these cases. The Section Head, Substance Abuse, Prison Health at the
Department of Health, also provided invaluable commentary on the clinical
management of the three men’s drug misuse.
The findings of this report speak for themselves. I was very pleased to learn
that a new detoxification regime was introduced at Shrewsbury on 1
February 2005. I am also aware that a new Medical Officer has been
appointed and will take up the post shortly.
The report makes a number of recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman
July 2005
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Contents
Summary
Conduct of the investigation
HMP Shrewsbury
Her Majesty’s Chief Inspector of Prisons
Background information
Events prior to the man’s death
Issues considered during the investigation
Common issues emerging from the three deaths in August/
September
Recommendations
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SUMMARY
The man arrived at HMP Shrewsbury on the afternoon of Monday 30 August
2004. He had spent the two previous days in police custody during which
time he had been prescribed symptomatic relief for heroin withdrawal.
Although he gave a full medical history outlining a previous suicide attempt,
a diagnosed mental health problem (for which he may have been taking
medication), and withdrawal from heroin, a further mental health
assessment was not recommended as staff said he presented positively.
He was located on the induction wing and placed in a cell with one other
person. The doctor saw himlater that day and, in line with his practice, a
detoxification prescription was prepared to begin the following morning. The
man was not given any symptomatic relief for withdrawal.
During the evening, he spoke briefly with his cellmate and told him he was
suffering with stomach cramps. The following morning at 6.00 am, during
routine cell checks, he was found suspended by shoelaces.
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CONDUCT OF THE INVESTIGATION
The investigation team consisted of 3 investigators working for the Prisons
and Probation Ombudsman. They visited Shrewsbury on a number of
occasions in August and September 2004, when they were given access to
all the documentation held by the prison on the man who is the subject of
this report.
They met with members of the man’s family.
Taped interviews were held with prison staff and prisoners who had had
important contacts with any of the men who died. Notices to Staff and
Prisoners were issued inviting anyone with relevant information to make
contact with the investigation team. All staff were offered the opportunity of
being accompanied by a friend or trade union colleague whilst being
interviewed.
The investigation team maintained regular contact with the West Mercia
Constabulary investigation, led by Acting Detective Inspect and by the
Detective Constable. I am extremely grateful to our police colleagues for
their cooperation and helpfulness at all stages of the investigation.
My investigators wrote to Shropshire County PCT requesting a clinical
review of the three deaths. The review was led by the Trust’s
Commissioner for Substance Abuse. I am greatly obliged to himand his
colleagues for the quantity and quality of their professional advice on the
clinical factors in these three cases.
My investigators also wrote to the Section Head, Substance Misuse, Prison
Health at the Department of Health in London. I am very grateful to himfor
supplying expert written comments on the clinical management of the
substance misuse of the three men who died.
A prison doctor was Medical Officer at Shrewsbury from 1992 until 31
August 2004. My investigators made available to him copies of the
documents produced by the PCT and by the Section Head, Substance
Misuse, Prison Health at the Department of Health in London. In response,
the medical officer has written an eight page letter putting on record some
observations that he feels may be pertinent to the investigation.
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HMP SHREWSBURY
There has been a prison on the present site since 1793 but the main
prisoner accommodation in use dates from the 1870s. The site offers little
room for expansion or structural change.
Shrewsbury is a local prison for adult male prisoners. It houses unconvicted
and convicted men, mainly from the Magistrates’ and Crown Courts in the
Shrewsbury, Mid Wales and Stoke on Trent areas. In the 12 month period
prior to this investigation, the population had fluctuated between 290 and
350 prisoners. The certified normal accommodation of the prison is 182 but
the operational capacity (maximum permitted number of prisoners) at the
time of the three deaths was 350.
The cells at Shrewsbury are on A and C wings. A wing has a certified
normal accommodation of 160, with an operational capacity of 307. C wing
has a certified normal accommodation of 22, with an operational capacity of
43.
A wing cells are located on four Victorian galleried landings. The wing has
one anti­ligature cell and two constant observation cells. C wing is used for
vulnerable prisoners with special needs and it has one anti­ligature cell. A
wing’s role was both complex and wide­ranging. It accommodates a broad
mix of prisoners, both remanded and convicted. The wing holds prisoners
subject to every level of the Incentives and Earned Privileges Scheme,
those detoxifying from various substances, and prisoners requiring support
with matters such as mental health and learning difficulties. Newly admitted
prisoners are generally housed on the ground floor of A wing, which is
known as A1.
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HER MAJESTY’S CHIEF INSPECTOR OF PRISONS
The most recent full inspection at Shrewsbury by Her Majesty’s Chief
Inspector of Prisons took place in November 2001. The remarks in the
preface to her report are of considerable relevance to the present
investigation. The first paragraph of HMCIP’s preface observes strikingly:
“Shrewsbury Prison has no inbuilt advantages. It is one of the oldest, most
overcrowded and cramped local prisons in the country. It has to manage
the great majority of its 330 prisoners on one wing, with no impatient
healthcare, limited training space and no outdoor recreation facilities.”
However, in the second paragraph of her preface, HMCIP remarks:
“Yet it has among the best staff/prisoner relationship of any prison we have
inspected. From the Governor down, staff were visible and approachable.”
The issue of self­harm also appears on the same page of the report. The
HMCIP stated:
“One area that urgently needs addressing is the risk of self­harm in the early
days of imprisonment. This is very strongly linked to the absence of proper
detoxification facilities, which itself reflects inadequate medical cover. 60%
of those identified as at risk of self­harm were in the process of
detoxification. The prison’s only recent suicide was a recently admitted drug
user, and the majority of self­harm incidents had taken place in reception
and induction cells within the first few weeks in the prison. Listeners
(Samaritan/Trained Prisoners) and staff were in effect having to support
those with substance related needs. It is to the credit of the Governor and
management that they had identified this dangerous gap, and were seeking
advice from other local prisons in order to identify the risks and deal with
them more appropriately.”
In the section of her report dealing with Substance Use, HMCIP wrote at
Chapter 3.8.4:
“Apart from a recently written alcohol detoxification protocol, there were no
current detoxification protocols for substance users. We were told that the
normal practice was to prescribe up to three days of dihydrocodeine,
diazepam and zimophain. Staff and prisoners verified this. The general
opinion among them was that ‘the detox is crap’. We agreed that the
current detoxification practice was inadequate.”
At Chapter 3.2.4 of her report, HMCIP recorded:
“The most recent death in custody had been in August 2000. There had
been an inquest in April 2001. The Governor of another prison had carried
out an internal investigation and had reported that the prisoner belonged to
that group of drug users who appear to be at risk in the first week or so after
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reception. He commented that these were prisoners who were voluntarily
coming off drugs or unable to renew medication and also said that they
should merit special attention from the policy makers on suicide awareness
and self­harm.”
HM Chief Inspector then recommends. “The Prison Service should ensure
that the observations and recommendations of an investigation into a death
in custody at HMP Shrewsbury (2001) are addressed and reflected in policy
throughout the service.”
The Inspectorate made an unannounced inspection at Shrewsbury between
9­11 August 2004, the week before the first death. The inspection report
was published in December 2004. One of the central purposes of this
unannounced inspection was to check on progress made at Shrewsbury in
response to recommendations made by the Chief Inspector after her
previous visit in November 2001.
In the introduction to her 2004 report, HM Chief Inspector observed with
pleasure that Shrewsbury had retained the very good staff/prisoner
relationships and the commitment to continuous improvement which had
impressed her on the previous inspection. She remarked that the great
majority of her recommendations had been achieved and important areas of
the prison had significantly improved “even though Shrewsbury has the
dubious accolade of being the most overcrowded prison in an overcrowded
prison system”.
However, in the same introduction, HMCIP indicated that some weaknesses
needed attention and she highlighted the issue of detoxification as follows:
“In our last report, we expressed great concern about detoxification
procedures, and these remained defective, in spite of the fact that nearly
two­thirds of prisoners admitted to having injected heroin in the period
immediately before imprisonment. More analysis of patterns of suicide and
self­harm was needed, in a prison that had experienced three self­inflicted
deaths that year (and has since had three more).”
Section 2 of the HM Chief Inspector’s 2004 report is headed Progress Since
the Last Report. This section sets out recommendations made by the
Inspectorate in March 2004 and notes progress made in implementing these
recommendations. In relation to substance use, the first recommendation
made in March 2002 was that the medical officer should undertake training
in working with substance users, so that he might provide the services set
out in Prison Service Order 3550. The December 2004 report observes that
this recommendation was not achieved and that the GP in post at the time
of the unannounced inspection was due to leave at the end of that month.
HM Chief Inspector of Prisons accordingly made a further recommendation
as follows:
“The replacement medical officer should receive adequate training in
working with substance users to support and complement the work of the
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substance misuse nurses and the specialist medical officer from the
Psychiatric Hospital.”
The concluding paragraph in the Substance Use subsection of the 2004
new report reflects the recommendation made in March 2002 that a work
plan for developing a comprehensive detoxification programme for prisoners
should be developed in consultation with the area drugs strategy
coordinator and the clinical adviser to the Prison Service Drugs Strategy
Unit.
The 2004 report recorded:
“Two specialist substance misuse nurses had been recruited to work with
prisoners who needed detoxification from drugs. However, the large
percentage of prisoners whose main drugs use was heroin were not
prescribed any medication on the first night. Wing staff said that such
prisoners, especially those experiencing their first time in prison, were
therefore under additional stress through not knowing how to cope with the
initial withdrawal of drugs.”
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Events prior to the man’s death
The man was arrested at 1.10 pm on Saturday 28 August and taken to the
police station. Police Bail was not granted and, since it was Saturday, he
was held at the police station until the Monday when he appeared at the
Magistrates’ Court. Just after 10.00 pm on Saturday, he was seen by the
Forensic Medical Examiner (FME) because he said he was withdrawing
from heroin. The medical examiner notes that he was feeling depressed,
had ‘no suicidal ideation’ but that he had a history of self­harm. The record
indicates that the examiner advised 30 minute checks and custody records
show that these were adhered to for the duration of his time in the police
station. The doctor prescribed Nitrazepam and Dihydrocoedine (for
withdrawal symptoms), the last dose of which he was given at 8.00 am on
the morning of Monday 30 August.
The man’s Prisoner Escort Form (PER) indicated that he was regarded by
the police as a risk under the categories of medical condition, violence,
drugs/alcohol issues and suicide/self­harm. Further details were given as
‘past history self­harm, asthma, suffers mental health problems’. This
information would have been drawn from interviews he had with the police
as part of their risk assessment process and from his consultation with the
doctor. His property record indicates that he had a number of items
retained including his shoes and laces which appears to be routine rather
than because of specific concerns. The man was handed to the escort
services at 8.10 am on Monday. A copy of the medical form was attached
to his PER but not his medication form which would have listed the
medication he had been given.
As a result of the information on the PER form, staff from Reliance Custodial
Services deemed hima potential risk of suicide and self­harm and
consequently checked him every 15 minutes. Although unable to recollect
himin any detail, staff believe that nothing untoward happened whilst he
was in their care. They said that details would have been recorded on the
PER had this not been the case.
At court, the man was remanded into custody and his case was adjourned
for one week. His solicitor, who had represented himfor some time, told my
investigator that his demeanour gave him no cause for concern and that the
man spoke positively about the future.
At about 2.00 pm, soon after arriving at HMP Shrewsbury, he was seen by
the duty nurse for the purpose of completing a First Reception Health
Screen form. This is the primary means of assessing a new prisoner’s
health needs and whether or not they may represent a self­harm or suicide
risk. The nurse had in her possession the PER and the medical form
outlining his assessment at the police station. In response to questions in
the first part of the health screen, he gave details of his GP and told the
nurse that he was receiving prescribed medication of Largactil and Zispin
and medication for asthma. The man also told the nurse that he did not
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drink alcohol, but did use a gram of heroin intravenously per day. In
interview, the nurse stated that in her experience this was consistent with
being a heavy user of drugs.
Questions eight to ten of the health screen ask about mental health. The
author is required to make an assessment about whether to refer someone
for a more detailed assessment depending on the answers given. The man
described having undergone psychiatric treatment due to having a
breakdown in 2003 and suffering from ‘impulsive disorder syndrome’. He
went on to repeat details of the drugs prescribed for him and that he had
been taking them for 12 months. In response to being asked about self­
harming, he described having cut his wrists about 12 months previously. In
interview, the nurse describes her practice as always examining the
prisoner’s scars and, although nothing of this nature is recorded on the
form, she recalls that his injuries were not extensive. According to the
guidance given on the form a ‘yes’ answer to one or more of the questions
should trigger a referral for a mental health assessment. The nurse ticked
‘yes’ to all three questions. She did not, however, refer himfor a mental
health assessment.
Question 11 asks whether the prisoner feels like harming themselves and
the duty nurse has indicated that the man did not. Finally, the interviewer is
asked to comment on their impression of the prisoner and she has written
“states no problems. Feeling rough due to withdrawal”. At this point the
form requires the author to consider opening a F2052SH if the prisoner has
answered yes to either of the two questions about self­harm. The form does
not ask for any explanation of the author’s decision, but simply asks that it
be considered. In interview, the duty nurse was asked whether she had
considered opening a F2053SH. She explained that, in light of his self­harm
history, she had considered it. However, when he stated that he did not
have any problems and did not feel like harming himself, she did not feel the
need to open one.
The final part of the screen requires the author to outline the planned action
as a result of the assessment. The duty nurse indicated that the man would
be referred to the doctor for his physical health and substance abuse and
would be referred to drugs services. Contrary to the guidance given on the
form, she did not refer himfor a mental health assessment. In interview, the
duty nurse explained that this would not necessarily be a barrier to receiving
further help as referrals could be done verbally, or at a later stage, should
the nurse think the prisoner requires help. It seems, however, that the man
did not give the duty nurse any cause for concern during her assessment.
The nurse went on to complete the part of the cell sharing risk assessment
form where, again, she indicated that in her view there were no concerns
regarding self­harm. She also carried out the urine samples which were
positives for morphine, cannabis and benzodiazepines.
During the rest of the reception process, the man was seen by at least three
officers, two of whomspecifically asked him about self­harming. The first
officer was responsible for completing the core record details and one of the
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questions asks about self­harm and suicide. In interview, the first officer
said he was able to specifically recall asking himthe question because he
said the man “chuckled” when asked and said he felt fine. The officer had
no concerns about him.
The last member of staff who saw him was the first night officer. This officer
is required to complete some sections of the cell sharing risk assessment
form, and the prisoner profile form, and to begin to make the prisoner
familiar with aspects of life at Shrewsbury. The officer recalls the man
saying he was withdrawing and was tired, but he did not have any other
concerns about him. The officer took himand other prisoners onto the wing
where he was located by wing staff.
The man was located in cell A1 – 12 with another prisoner at about 4.00 pm.
Cell A1 – 12 was one of a small number of cells that had less natural light
than usual due to the temporary erection of tarpaulin covered scaffolding
placed a few feet outside the cell windows. Both men had come into prison
that day and first spoke to each other in the holding cell in reception. The
man’s cellmate recalled that he thought it was strange that the man did not
have any shoelaces in his shoes. Both men were withdrawing and were
allocated a cell with bunk beds. Upon entering the cell, the cellmate asked
the man if he could have the bottom bed which the man agreed. He recalls
them just having a general conversation and that the man complained a lot
about stomach cramps which his cellmate assumed were as a result of
withdrawing and not getting any medication.
The man was seen later that day by the medical officer. The doctor
conducted an examination of himon the wing and had sight of the First
Reception Health Screen. The doctor wrote up a standard detoxification
prescription chart, to begin the next day. He would have had sight of the
police medical form and therefore been aware that for two days the man
had been receiving symptomatic relief for drug withdrawal. It is impossible
to say what interpretation the doctor made of any of the other problems the
man presented with. He did not complete an entry in the IMR and the
medical form is incorrectly completed. He records, under the section
headed ‘physical description’, that the man used Largactil and Zispin but no
further details or assessment are given. He doctor’s writing is extremely
difficult to read.
The man’s cellmate recalls that he watched television until about 9.00 pm
and then went to sleep. At this time he believes that the man was lying on
his bed and still complaining about stomach cramps. Twice during the
night, the first time he thinks was about 1 am, he got up to go to the toilet
and saw the man at the window. At night, the cellmate does not wear his
glasses and describes his eyesight as very poor. He says that he asked the
man if he was ‘ok’ on both occasions, but did not get any response from
him. Not believing that there was anything suspicious, he returned to his
bunk and went back to sleep.
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Discovery of the man hanging
The man was discovered hanging at the window by the duty officer during
the 6.00 am roll check. Having called for help, the officer entered the cell
with the senior officer (SO) who was followed by a wing officer. The duty
officer used scissors from his anti­ligature bag to cut the man down from the
window wire meshing and, with the help of the SO, placed the man on the
floor. It became apparent immediately that the man had been dead for
some time and the officers did not attempt resuscitation. A wing nurse
arrived on the scene shortly after but did not commence any treatment. His
cellmate was removed from the cell by the wing officer and taken to the
intervention suite. A senior Listener (a prisoner trained by the Samaritans to
support other prisoners) was woken up to sit with the man’s cellmate at this
stage. The man was pronounced dead at 6.25 am by the doctor.
The man used shoelaces as a ligature but it remains unclear whose they
were, or where, they came from. His cellmate commented that he noticed
that he did not have laces in his shoes when he met him in reception.
However, it has not been possible to confirm this. Given that the prison did
not view himas a risk, there was no reason why he would not have been
given new laces. The man did not leave a suicide note.
Contact with the man’s next of kin
The man gave his ex­wife as his next of kin although it would appear that
they were estranged. The police made contact with her in the first instance
and the prison liaison officer contacted her a few days later. His ex­wife was
invited to come to the prison, which she decided to do, and was collected
from home by taxi which the prison arranged. The cell remained sealed and
she was able to visit the wing and met with the Governor.
The investigators met with the man’s ex­wife when she visited the prison
and subsequently have spoken with her on the telephone. It would appear
that, although divorced, she and the man had remained in contact until July
2004. She had no concerns about his treatment at that time.
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Issues considered during the investigation
First Reception Health Screen
According to the instructions given on the health screen the duty nurse
should have referred himfor a mental health assessment. The guidance
states ‘If “yes” recorded to Questions 8, 9 or 10 (outside prison) refer for
mental health assessment’. The man answered ‘yes’ to all three questions.
Although he presented well the combined features of a previous suicide
attempt, a diagnosed mental health problem for which he had been
prescribed medication and withdrawal from heroin should have prompted a
mental health referral.
Questions 10 and 11 ask about self­harm and suicide and the guidance
states ‘If “yes” recorded to Question 10 or 11 consider opening a F2052SH’.
The man gave a ‘yes’ response to question 10 and a ‘no’ to 11. The form
does not require the author to explain their rationale for not opening a
F2052SH. In interview, the duty nurse stated that she did not feel that the
man was at risk and consequently did not open a F2052SH.
The prison’s GP
When the man saw the doctor he completed a medical in confidence record.
However, the form is completed incorrectly and the writing is very difficult to
decipher. In addition, the doctor did not write an entry in the medical record
and it is impossible to know what assessment, if any, he made of the man’s
history and presenting problems.
Detoxification regime
The doctor prescribed a standard detoxification regime to begin the next day
and he was not given any symptomatic relief for that night. However, the
man apparently hung himself before the regime began. The
Dihydrocodeine detoxification programme that was used in Shrewsbury at
the time of the man’s death is not in line with national guidelines.
The man complained to his cellmate that he was experiencing stomach
cramps. According to the health screen, he told the duty nurse that he
‘feeling rough due to withdrawing’. Although there is no evidence that his
death was related to the withdrawal symptoms he was experiencing, the
heightened risk of suicide in those withdrawing from opiates is well
documented.
Clinical review
Shropshire Primary Care Trust undertook a clinical review of the man’s care
whilst in Shrewsbury. The review panel share the concern that the duty
nurse did not follow the guidance given regarding a mental health
assessment. They take the view that given that the man was withdrawing
13
from heroin, and known to have a history of mental health problems, a
F2052SH should have been opened until he had had a mental health
assessment. In addition, they felt that if a nurse does not open a F2052SH,
when there is evidence of past self­harm/suicidal intention, then the form
should record their reason for not doing so. They also comment on the
standard of record keeping by the doctor.
The panel state that any prisoner withdrawing from opiates should be
identified as at an increased risk of self­harm or suicide until they have been
more fully assessed. They recommend that symptomatic relief be routinely
available, especially in the time between reception and the start of any
detoxification. The detoxification regime at Shrewsbury at the time was not
supported by the panel and was not in line with national guidelines.
In addition, the Section Head for Substance Misuse at Prison Health
undertook a review of the clinical management of the man’s substance
misuse programme. He agreed with the recommendations made by the
panel and made further comments on the notes made by the prison doctor
and the detoxification regime.
Dark cells
The man and the other two men were in cells facing west on A1 and A2
landings. The amount of natural light in these cells was severely restricted
by the proximity of metal sheeting erected by contractors engaged in
rebuilding work on the site.
On 14 September 2004, the acting Governor told his manager that he had
consulted widely across the establishment following the recent deaths and
that one recurring theme deserved the Area Manager’s consideration. He
wrote that cells facing west on A1 and A2 landings looked directly towards
the fencing that had been erected around the demolished gymnasium site
and new education block extension. He said “The prisoners believe the lack
of light is oppressive and has contributed to the depression that led to all
three suicides. The fencing is less than a metre from the cells. Prisoners
located in the A1 cells cannot see anything but the fence, irrespective of
where they stand.”
The acting Governor suggested that cells A1­12 to A1­20 should be taken
out of commission, and that affected cells on A2 landing should only be
occupied by prisoners on the enhanced level of the Incentives and Earned
Privileges Scheme, as such prisoners are confined to their cells for shorter
periods of time. The Area Manager accepted the governor’s suggestion.
The cellmate
In interview, he spoke of receiving considerable attention in the immediate
aftermath of the man’s death. At that time, he felt he was coping with the
trauma. However, as time went by he spoke of his increasing distress. It
appears, however, that staff were not monitoring him to the same level as
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before and he spoke of one officer being very unsympathetic when he
asked for a Listener. His request to see a Listener was not followed up. It
is imperative that prisoners, and staff, are offered support over a number of
weeks rather than just days after being involved in a death.
15
COMMON ISSUES EMERGING FROM THE THREE DEATHS IN
AUGUST/SEPTEMBER 2004
There are some significant linkages between the three deaths in
August/September 2004. A striking feature is that each hanging incident
occurred so soon after reception at the prison. All three men were dead
within less than a week of their arrival at Shrewsbury. Two of the deaths
occurred within 24 hours of reception and one man died before he had
received his first meal at the prison.
All three deaths occurred in cells facing west on A1 and A2 landings. The
amount of natural light in these cells was severely restricted by the proximity
of metal sheeting erected by contractors engaged in rebuilding work on the
site. I commend the Governor for his prompt identification of this issue and I
note that the Area Manager agreed to take the cells out of the commission
in response to the Governor’s suggestion. It would not be surprising if
prisoners held for prolonged periods of time in such dark cells suffered
adverse psychological consequences. However, as indicated in the
previous paragraph, the three men who died spent only brief periods of time
in their respective cells. All of them had been held at Shrewsbury before.
Detoxification
The most important connection between the three men was that they all
used heroin in the community and all three were withdrawing as they
entered Shrewsbury. I have paid particularly close attention to the
detoxification arrangements that were in place at Shrewsbury in
August/September of last year. The advice I have received on this matter is
contained in the reviews conducted by Shropshire County PCT and by the
Section Head, Substance Misuse, Prison Health at the Department of
Health in London.
The Clinical Review Panel (CRP) appointed by Shropshire County PCT
commented as follows in its reviews of the deaths of all three men:
“The CRP believes that any individual withdrawing from opiates is at an
increased risk of self­harm or suicide, noting that individuals withdrawing
from opiates often experience symptoms of depression and can have rapid
and unpredictable mood swings.”
The CRP was told by the Healthcare Manager at HMP Shrewsbury, that at
the time of the three deaths:
“the prescribing of medication to relieve the symptoms of opiate withdrawal
between admission and the commencement of detoxification was not
available.”
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She also explained that prisoners did not start a detoxification programme
until the day after their arrival at the prison. In response, the CRP
recommended that:
The prescribing of medications for the symptomatic relief of the
effects of opiate withdrawal be made routinely available especially in
the period between reception and the commencement of detoxification
the next day.
The CRP also noted that the detoxification regime in place at HMP
Shrewsbury at the time of the three deaths in August/September 2004 did
not follow recognised clinical guidelines for the management of substance
misuse problems. The standardised Shrewsbury prison detoxification
programme consisted of the prescription of dihydrocodeine 90 mg twice a
day for three days, dihydrocodeine 60 mg twice a day for three days,
dihydrocodeine 30 mg twice a day for three days and Mirtazepine 15 mg at
night for nine days. The CRP accordingly recommended that:
A detoxification programme, which is in line with national guidelines,
should be introduced at HMP Shrewsbury as soon as possible.
The Section Head of the Department of Health reports that “dihydrocodeine
detoxification is not recommended by the Department of Health”. He refers
to guidelines issued by the Department of Health in 1999 in the document
Drug Misuse and Dependence – Guidelines on Clinical Management. The
guidelines state at Page 38 that codeine­based drugs, such as
dihydrocodeine, are not licensed for use for the treatment of drug
dependence and the same page of the document adds:
“The product licence for dihydrocodeine does not include the treatment of
opiate dependence and there is concern amongst practitioners about its
widespread use.”
He also observes that, contrary to Prison Service Order 3550, the
dihydrocodeine protocol at HMP Shrewsbury shows no evidence of the
involvement of the local NHS Substance Misuse Specialist.
He concurs with the Clinical Review Panel’s conclusion that prisoners
withdrawing from opiates without the assistance of medication are at a
heightened risk of suicide. He therefore recommends:
As part of a first­night reception, prisoners reporting a current
problem with opioid drugs should be given a brief assessment using
the Short Opioid Withdrawal Scale, or a similar measure. A moderate
score on this scale would occasion symptomatic prescribing and a
more acute problem should indicate medical examination on the first
night.
He further recommends:
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The PCT and the prison consider the establishment of a clinical
withdrawal management unit where drug­dependent prisoners would
stay for the first few days of custody until their symptoms stabilise.
Prison Service guidance on detoxification and related issues is set out in the
Prison Service Order entitled Clinical Services for Substance Misusers
issued in December 2000. The introduction to the Order states that it
requires all Governing Governors “to ensure that effective treatment of
substance misusers is delivered by evidence­based services which identify,
assess and treat substance misusers in line with Department of Health
guidelines (1999).”
The Order contains a checklist on the clinical management of opiate
misusers which requires the following mandatory action:
“Each prison will have a detoxification service for opiate misusers,
developed in conjunction with (a) local NHS consultant using evidence­
based guidelines in line with those of Department of Health (1999).”
Shrewsbury’s Drug Strategy document was most recently reviewed on 1
March 2004. Detoxification does not figure prominently in the document. A
number of treatment options are listed at pages 26 and 27 of the document,
with the commentary on detoxification stating:
“Detoxification is carried out in line with the agreed protocol and complies
with HCS8 [Prison Healthcare Standard 8]/NHS Guidelines in place.”
New, improved detoxification procedures began on 1 February 2005. I
accordingly recommend that the prison’s Drug Strategy document be
urgently revised if this has not already happened, and that
detoxification arrangements are given greater space and prominence
in the new document.
Clusters of three deaths
I contacted the Prison Service’s Safer Custody Group (SCG) seeking
information about clusters of apparently self­inflicted prison deaths in recent
years. I am grateful to the representative of SCG for his detailed response
to my investigator.
He has supplied a table showing all cases since 1978 where three self­
inflicted deaths have occurred in less than 30 days. This table shows the
Shrewsbury cluster as being the third worst in Prison Service records. At
HMP Manchester three deaths occurred within two days in 1982 and at
HMP Leicester three deaths occurred within 11 days in March/April 2000.
At HMP Gloucester, another relatively small local prison like Shrewsbury,
three deaths occurred within 18 days in February 2004. In his e­mail he
observes that: “only local prisons seem to experience significant clusters”
and that “the risk of having additional suicides does increase after an initial
death”.
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F2052SH Procedures at Shrewsbury
None of the three men who died between 19 August and 1 September 2004
were on an open F2052SH at the time of death, but the investigation team
examined suicide prevention procedures at Shrewsbury. My investigators
discussed these matters with the Senior Officer and Suicide Prevention
Coordinator (SPC). On the day of our discussion, six prisoners were on
open F2052SH. He told my investigators that they were mainly, but not
exclusively, located on A1 landing near the staff office. He indicated that
these documents were usually opened by Healthcare staff, but the prison
was not easily able to provide detailed information about reasons for
opening F2052SH’s or significant statistical trends. I understand that such
information is starting to be collected for Suicide Prevention Committee
Meetings and I recommend the support of this initiative. The SPC task
at Shrewsbury is not presently full­time and I strongly recommend to the
Governor and West Midlands Area Manager that consideration be
given urgently to the appointment of a full­time coordinator. Although
Shrewsbury is a small local prison, the case for a full­time post seems a
strong one in view of the number of recent apparently self­inflicted deaths,
the need for more refined information to be collected and presented to
management at the prison and the need to improve the quality and amount
of staff training on this crucial subject.
The Suicide Prevention Co­ordinator said he was eager for anti­ligature
knives to be issued to staff at Shrewsbury. The Senior Governor who
investigated the circumstances of the death at Shrewsbury in March
2004 made a recommendation that anti­ligature knives should be
issued to members of staff with appropriate training. I recommend
that this should now be implemented without delay.
The lead investigator audited F2052SH procedures on 23 September 2004
when five booklets were open. Two prisoners were on intermittent watch
and three were on hourly watch. With one exception, all the men on
F2052SH were in single cells. The explanation given was that it was not
considered appropriate for them to share a cell with another prisoner.
Regular reviews had taken place but no entries had been made on page 6
of the document by the Medical Officer. This was perhaps not completely
surprising because another doctor had taken over at short notice as locum
Medical Officer on 1 September 2004. I recommend, however, that any
new or locum Medical Officer at Shrewsbury receives training in
F2052SH procedures within a week of taking up post in view of the
importance of exchanging sufficient information between healthcare
staff and prison officers, especially when prisoners at risk are being
held on normal location.
On the day of the audit, it was noticeable that an officer had been detailed to
F2052SH duties but the entries over several days in all the booklets
examined suggested observation of the men at risk, rather than much
interaction with them. My investigators were informed by staff that it was
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rare for booklets to be opened on men located on the second and third
levels of A Wing and rarer still on the fourth (topmost level) of the wing. I
am aware that the staff at Shrewsbury have already been exhorted to write
more detailed entries in at­risk documents, but it may well be that further
training is required, backed up by regular and vigorous management checks
on this matter.
My investigators also observed that the prison did not have readily
accessible information about prisoners who had previously been subject to
Self­Harm at Risk Procedures. I was informed that such information
generally disappeared from the Local Inmate Data System (LIDS) computer
system 12 weeks after a man left the prison. Reference to previous
F2052SHs seemed a matter of chance, or due to the good memory of a
particular officer or nurse in Reception. The opening of an F2052SH does
not of itself ensure that a potentially suicidal prisoner will remain alive, but it
is critical that staff should be aware of recent periods when prisoners were
thought to be at risk.
The absence of “organisational memory” in respect of prisoners who have
previously been on F2052SH is disturbing and I draw this issue to the
attention of the National Offender Management System (NOMS) Safer
Custody Group. It is not desirable that the only source of information about
a prisoner’s recent history should be the prisoner himself, and I
recommend that the Governor of Shrewsbury attempts to devise a
more reliable and robust system for retaining information about
previous Forms 2052SH. The introduction of the integrated case
management system, NOMIS, will capture this information in the future.
Action taken at Shrewsbury following the three deaths
The Prison Service’s Director of Operations requested an urgent review
following the three deaths. This review was undertaken on 2 September
2004 by theWest Midlands Area Principal Psychologist, and by the
Outreach Support Coordinator for the Safer Custody Group. Their brief was
to review the recent incidents in order to identify any common issues that
could be acted upon immediately.
Their report, entitled Common Themes and Learning Points from Recent
Deaths in Custody at HMP Shrewsbury, was completed on 2 September
2004. They examined Reception, First Night Centre and induction
procedures at the prison. They also included a section on drug strategy and
detoxification, pointing out that the establishment did not have a dedicated
drug detoxification unit. They quoted a staff member who felt there was not
a proper system for drug detoxification.
They noted that other staff members “stated how the system at HMP
Shrewsbury is improving, but they constantly struggle due to lack of
resources”.
20
Their review made eight recommendations. On 14 September 2004, the
acting Deputy Governor at Shrewsbury, wrote to the principal psychologist
and to the outreach support coordinator to update them on some of the
recommendations they had highlighted.
In the First Night Centre section of their report, the principal psychologist
and the outreach support co­ordinator refer to the impression that A Wing is
poorly lit and dark with little natural light.
The acting Governor initiative in writing to his Area Manager about the cells
facing west on A1 and A2 landings mirrored concern expressed to my
investigators by a prisoner at Shrewsbury. He asked to see my investigation
team and said he had noticed that the people who were committing suicide
(his expression) were on the side of A Wing where all the windows had
been covered up by sheeting outside. The prisoner understood that all the
windows on one side of the wing were covered with corrugated sheeting
because “gym was supposed to be falling down, there’s been structural
damage or something, so they have had to knock the building down”.
The prisoner also said that the number of suicides at Shrewsbury could be
diminished if prisoners on induction spent more time out of their cell. He
agreed there was an induction programme for new receptions, but said that
prisoners spent the remainder of their time in their cells apart from
association periods on a Wednesday evening and a weekend morning or
afternoon.
21
RECOMMENDATIONS
CLINICAL
The Governor and Chief Executive of the PCT are invited to consider
establishing a disciplinary enquiry in view of the duty nurse’s apparent
failure to comply with the requirements at page 6 and 7 of the First
Reception Health Screen.
I endorse the recommendations made by the Clinical Review Panel
established by Shropshire County PCT. I attach particular weight to the
recommendations calling for the prescribing of medication for the
symptomatic relief of the effects of opiate withdrawal on the first night of
custody, and for the introduction of a detoxification programme at HMP
Shrewsbury in line with national guidelines.
I note that half of the 12 recommendations listed in the Action Plan resulting
from a clinical review of Deaths in Custody at HMP Shrewsbury have
already been accepted and achieved. I urge the Governor to ensure that
remaining actions are accomplished by the dates stipulated in the Action
Plan.
Consideration should be given to revising page 7 of F2169 so that the
author is required to explain their decision­making progress in relation to
opening a F2052SH.
SUBSTANCE MISUSE
I endorse the recommendations made by the substance misuse specialist
from the Department of Health. If they are accepted by the Area Manager
and PCT, then I recommend that an expanded Action Plan be drawn up as
soon as possible.
OPERATIONAL
A training needs analysis should be undertaken to include the training
needs identified in the course of this investigation and the clinical review.
Anti­ligature knives should be introduced to individual members of staff.
The Governor should meet with senior police and escort contract colleagues
with the aim of improving the quality of information recorded on Prisoner
Escort Record forms.
Consideration should be given to the appointment of a full­time Suicide
Prevention Coordinator.
Any new or locum Medical Officers at Shrewsbury should receive training in
F2052SH procedures within a week of taking up post.
A more reliable and robust system for retaining and retrieving information
about prisoners previously on F2052SH should be introduced.
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