Individual at Whitemoor

INVESTIGATION INTO THE CIRCUMSTANCES
SURROUNDING THE DEATH OF MAN AT HMP WHITEMOOR
IN NOVEMBER 2006
Report by the Prisons and Probation Ombudsman for England and
Wales
September 2007
This is the report of an investigation into the circumstances of the death of a man on
19 November 2006 at HMP Whitemoor. He had been found in his cell, hanging from
his upturned bed. .
I would like to offer my sincere condolences to his family and those touched by his
death.
The investigation was undertaken by four of my investigators. Both they and I would
like to thank the Governor of Whitemoor, the prison’s appointed liaison officer for
their cooperation during the course of our inquiries.
The man was a resident in the Dangerous and Severe Personality Disorder (DSPD)
unit at Whitemoor. The unit is one of only two DSPDs within the Prison Service. It
has specialised staff who run a unique regime of group and individual support, as
well as courses to help improve prisoners’ medical conditions and challenge their
offending behaviour.
The man had been in the DSPD unit for approximately 18 months. In this time he
had been continuously assessed by a multi-disciplinary team of psychiatrists,
psychologists, nurses and discipline staff. He had been a prolific self-harmer, often
presenting with very challenging behaviour.
After several drug treatment regimes to help with his condition, he was given depixol.
He had an extreme reaction to this medication, and developed a growing fixation
with his medical problems. During the night of 18 to 19 November, he blocked the
observation hatch in his cell door, barricaded the door with his bed, and used a
ligature to hang himself. It appears that he had planned his death.
The treatment that the man received in Whitemoor was of a high standard. But I am
not certain that every member of staff performed all the checks that were required of
them on the night of his death. I make a total of four recommendations. Two of
these relate to improving procedures for responding to emergencies. However, I
should also say that I have been impressed by the speed with which the governor
addressed other matters brought to his attention during the course of the
investigation.
Following the inquest regarding this death, I have redacted the report to protect the
anonymity of the man and his family.
Stephen Shaw CBE
Prisons and Probation Ombudsman September 2007
CONTENTS
2
Summary 4
The Investigation process 6
HMP Whitemoor 7
Key events 9
- May to October 2006 10
- October to 17 November 2006 14
- 18 and 19 November 2006 15
Issues
- Clinical treatment 20
- ACCT 23
- Night of 18 to19 November 24
- Crisis management 25
- Beds 27
- The significance of birthdays 27
- Staff, communication and relationships 27
Recommendations 30
3
SUMMARY
The man who died began a ten year sentence for serious offences against his
partner in April 2003. After spending time in both Exeter and Albany prisons, he was
transferred for assessment to the Dangerous and Severe Personality Disorder
(DSPD) unit at HMP Whitemoor in May 2005.
He found it difficult to cope in prison. He was a prolific self-harmer, but there is no
indication that he had made any serious attempt on his life whilst in prison, prior to
his death on 19 November 2006. He was supported and managed through the
Assessment, Care in Custody and Teamwork (ACCT) processes for virtually all his
time in custody. Together with self-harming, he would frequently cause damage to
property and make threats to others (although he did not hurt anyone else in prison).
The assessment period concluded on 29 October 2005. The psychiatrists and
psychologists concluded that he met the criteria to be accepted for treatment in the
DSPD. He was given a definite diagnosis of borderline personality disorder and
obsessive-compulsive personality disorder.
His pattern of behaviour continued for some time. At times he appeared to be
improving and then he would regress. The level of attention and commitment from
staff was high. He was regularly reviewed by a multi-disciplinary team. Along with a
range of therapeutic interventions, he was treated with different medications. After
several months of trying different drug treatments, the lead psychiatrist decided, with
his agreement, to try some depot medication, depixol. (This medication acts by
blocking a variety of receptors in the brain, particularly dopamine receptors.) He was
given the first dose on 15 May 2006, and a second dose five days later. After this
injection, he rarely self-harmed or spoke of his offence and victim which had
previously been a preoccupation. However, his attention turned to the side effects of
the medication.
At first, he was restless and felt the need to move, but this eased over time.
However, he began to find daily tasks difficult. He spoke of “time lasting longer than
time”. He found movement difficult and complained of pains in various parts of his
body. He had to be encouraged to eat and wash. He remained under close
supervision and various medications were used in an attempt to allieviate these
problems. The lead psychiatrist also sought advice from a pharmacist as to possible
side effects. She also referred him to a neurologist who concluded that there was
nothing neurologically wrong.
In August and September 2006, the man self-harmed on three occasions and was
again subject to ACCT procedures. In October, he moved from red to green spur.
He was uncomfortable with the move as he had built up trusting relationships with a
number of staff on red spur. Other prisoners from red spur moved at the same time,
including one of his friends.
On 16 October, staff decided to close the ACCT. They continued to provide a high
level of support and a care plan was in place. The man had said that he wanted to
die. A number of prisoners and staff heard him say this on many occasions.
4
Many clinical staff said they had never seen a presentation of illness like his. They
had tried a number of therapies. The lead psychiatrist decided to refer him to a
psychiatric secure hospital to ask if they would admit him for a period of assessment.
She was hoping they would be able to provide views or further suggestions on how
to best care for him. The letter had not been sent by the time of his death.
The day before his death was his birthday. He had received a card from his brother,
and had a birthday lunch with his friend. Significantly, he gave a number of CDs to
his friend. He also telephoned his brother. During the conversation, he complained
of feeling physically and mentally unwell which he attributed to the depot medication.
That evening, he pressed his cell bell on three occasions. He asked for some
spellings from a staff member. It later became evident that he had used them in a
note found in his cell explaining his actions. He also asked for some toilet paper with
which he blocked the observation panel in his cell door. Finally, he asked the female
officer not to check on him again as he was about to strip wash.
When an officer conducted the early morning roll count, his observation panel was
blocked. The officer could not make visual contact with him and did not attempt
verbal contact. The officer said in interview that he thought he heard him moving.
My investigator informed the governor of this matter and he subsequently launched
an enquiry into the conduct of the officer. It is recommended that all staff are
reminded of their responsibilities in checking prisoners.
It seems that the man had planned his actions. He warned staff not to come to his
cell. He blocked the observation panel. He turned his bed upright, and moved it to
act as a barricade to the door as well as a ligature point. He also appears to have
taken several steps to ensure it would be difficult for him to breathe, or for staff to
resuscitate him.
On the morning of 19 November, after day staff had received no response during
their roll count, they found him hanging in his cell. There were clear signs of rigor
mortis. Whilst staff acted with the best of intentions, a number of issues became
evident during this investigation regarding the management of the emergency
situation. Staff were not equipped with ligature knives and had to run to the wing
office to get ligature scissors. They were unclear as to whose responsibility it was to
call an ambulance. The nurse commenced cardio pulmonary resuscitation despite
the presence of rigor mortis. Some of the contingency plans conflicted with others.
However, a family liaison officer was quickly appointed and, along with a governor,
visited the family to break the news.
My report concludes that, during his time at Whitemoor, the man received a high
level of care and support from experienced and skilled staff. However,the
investigation raised concerns about safer custody issues such as the checks on the
night of the man’s death, the lack of ligature knives and movable beds. The
governor has acted quickly to rectify the problems identified. The main finding of this
report is the need to review emergency procedures, including raising staff awareness
of their responsibilities in emergency situations.
5
THE INVESTIGATION PROCESS
1. I appointed one of my investigators to lead the investigation on my behalf.
She visited HMP Whitemoor where she met the governor. On her initial
visit, she was given a tour of the prison, including the cell where the man
had died. She met with members of the local committee of the Prison
Officers' Association (POA) and the Independent Monitoring Board (IMB).
2. Notices were issued to both prisoners and staff, inviting anyone who might
have relevant information relating to the man to make themselves known.
One prisoner came forward and was interviewed.
3. One of my family liaison officers contacted the man’s family. His family
had been concerned by the injections that he had received, and had raised
concerns with his probation officer. They also wondered whether hospital
might have been an appropriate place, given the side effects that he
suffered. The family also questioned why his bed was so easily moved.
These issues are considered later in this report.
4. The lead investigator returned to Whitemoor with fellow investigators and
the Secretary to the Forum for Preventing Deaths in Custody. The
investigation team interviewed prison staff and prisoners, both formally
and informally. The team examined the man’s prison record, medical
records and a series of prison documents. They also assessed the care
that he received against Prison Service standards, orders and policies. A
clinical review of his healthcare in custody was carried out by
Cambridgeshire and Peterborough Mental Health Partnership NHS Trust.
6
HMP WHITEMOOR
5. Whitemoor is a maximum security prison for category A and B male
prisoners. It is one of eight high security prisons. Whitemoor’s Dangerous
and Severe Personality Disorder (DSPD) unit opened in 1999. It is part of
the Government’s pilot DSPD programme, a joint initiative between the
Department of Health, Home Office and Prison Service. This initiative
aims to develop new mental health services for a small number of people
who may be dangerous as result of a severe personality disorder.
6. Whitemoor also has a Close Supervision Centre (CSC) which opened in
October 2004. The unit is a small therapeutic centre aiming to provide a
supportive, safe, structured and consistent environment.
Background to Dangerous and Severe Personality Disorder (DSPD) and the
DSPD units
7. There are currently four DSPD units: two in high security prisons
(Whitemoor and Frankland) and two in special hospitals (Broadmoor and
Rampton). Together, these units provide over 300 places. Over 200 of
them are currently occupied. The places are in high demand with over
600 referrals in an 18-month period. This is not surprising given that
current estimates indicate that some 2000-2500 people in custody meet
the DSPD criteria.1 By the end of November 2006, a total of 123 prisoners
had been assessed at Whitemoor’s DSPD unit and 75 were undergoing
treatment.2
The role of psychiatry
8. Within the DSPD unit, the role of psychiatry fits within an overarching
psychological model of treatment (in contrast to the predominately medical
model of most mental health service provision). The main focus of the
treatment model is facilitating change in the personality disorder (and the
associated risk), but the management of mental and physical health
problems is also important. One of the psychiatrists’ specific contributions
to treatment is in the form of prescribing and managing psychotropic
medication. Compliance with medication is monitored as far as possible
(recognising that disposal, hoarding or trading medication may be a
manifestation of personality disorder). Medication is not administered
without the consent of the prisoner.
Nursing interventions
9. Many prisoners will experience episodes of crisis throughout the phases of
their treatment. The nursing team plays an important role in attending to
1
Data provided by the DSPD Programme Unit.
2 Home Office website.
7
prisoners in distress. The nurse’s role is interwoven into the model of
treatment. Through interpersonal, psychological and behavioural nursing
techniques, they try to reduce prisoners’ physical and psychological
distress. Nurses play a key role in supporting prisoners through periods of
crisis, and the manner in which this is done is intended to enable prisoners
to see themselves in a more positive light.
The role of discipline staff
10. The model of treatment on the DSPD unit is at odds with the traditional
role of prison officers. It has been recognised that discipline staff working
on the unit have had to adapt to a style of working that focuses on the
treatment of individuals rather than on the management of them. A senior
officer (SO) told the investigation team that discipline staff on the unit tend
to fall into two distinct groups: those who consider themselves in the more
traditional landing officer role and those who identify more with their role
as group workers. All officers receive some mandatory training (such as a
three day course on personality disorder awareness), but the officers who
work with the groups also receive training in skills to equip them to lead
cognitive interpersonal groups. This training is delivered on an ongoing
weekly basis. Discipline staff tend to work exclusively on one unit within
the DSPD unit.
Occupational therapy
11. Aside from individual therapy and group work, prisoners in the DSPD unit
have access to education, gym, employment opportunities and training
workshops. Some prisoners have work outside the unit as there are few
employment opportunities within it. One of the unit’s senior officers told
the investigation team that there are plans for occupational therapy to be
available to prisoners in the evening.
8
KEY EVENTS
12. From the beginning of his sentence in 2002, the man found it difficult to
cope with prison life. He felt great remorse for his crime and was filled
with self-loathing. This led to habitual and serious self-harm which took a
number of forms including food refusal, cutting, swallowing and inserting
objects. At times, staff also found him quite difficult to deal with as he
would often make threats towards them and other prisoners.
13. The man moved to Albany in June 2003. He still found it difficult to cope
and was seen by mental health services. He was making attempts to
contact his victim and her family. He was also continuing to act
aggressively towards others and himself. His self-harm was alarmingly
regular.
14. In 2004, his mother died. He took this badly, and his pattern of behaviour
continued. Staff at Albany consulted the DSPD unit at Whitemoor as to
whether he would be an appropriate candidate for their programme. For
the majority of this time, he was subject to the F2052SH procedures (since
replaced by Assessment, Care in Custody and Teamwork – ACCT).
These are processes to support and supervise those judged at risk of self-
harm and/or suicide.
15. The man moved to the DSPD unit at Whitemoor in May 2005. He was
housed on red spur, the assessment unit. On arrival, he said he did not
want to take the medication for his heart condition. He said that he knew
the consequences of not taking medication, and he wanted to die although
he was not planning to take his own life. He was still subject to F2052SH
procedures. Within days of his arrival, the assessment of suitability for
treatment began.
16. On 5 June 2005, staff decided to close the F2052SH as he appeared to
have settled in and was much calmer. That afternoon, he self-harmed by
cutting his wrist. He was paranoid that staff had been laughing at him and
was aggressive. He also experienced chest pains and was given GTN
spray to alleviate them. The cut to his wrist was particularly deep and
clinical staff noted that, “The man seemed determined to kill himself.” The
F2052SH was re-opened and he was moved to the ’gated cell’. (This is a
cell with a gate door rather than a solid door, and allows staff to see clearly
in the cell at any time.) From then until the end of October 2005, he self-
harmed on at least 13 occasions. For the most part, he refused medical
help when he did so.
17. The man made threats to others on at least eleven occasions. He had
also smashed his cell, and started a dirty protest which had led to a
closure of the showers on red spur. Some prisoners felt that he was
developing an unhealthy interest in the female staff. His behaviour made
him unpopular with some prisoners, and he received threats from others.
Staff felt that he was trying to make himself disliked so another prisoner
would harm him. During this time, he had written and handed to staff
9
confessions to other crimes which later proved to be false. He also tried to
contact his victim’s family on several occasions. He was constantly
subject to the F2052SH procedures and intermittently spent time in the
gated cell.
18. A similar pattern of behaviour continued for some time. However, staff felt
that he was generally slowly improving and he self-harmed less often. In a
care plan drawn up on 1 May 2006, the general feeling was that there had
been a slow, sustained improvement in his behaviour. However, this was
interspersed with several regressive episodes. Staff considered the
possibility of introducing time-limited attention as he would talk at length to
them if allowed to do so.
May to October 2006
19. In the first two weeks of May, the man flooded his cell and made threats to
other prisoners and himself on four occasions. After discussion with him,
the lead psychiatrist decided to try depot medication of depixol. This acts
by blocking a variety of receptors in the brain, particularly dopamine
receptors. (Dopamine is involved in transmitting signals between brain
cells. When there is an excess of dopamine in the brain, it causes over-
stimulation of dopamine receptors.) The medication blocks these
receptors and stops them becoming over-stimulated, thereby helping to
control psychotic illness. Giving the depixol by injection releases the
medicine slowly over a period of two to four weeks. This is known as a
‘depot’ injection.
20. The lead psychiatrist described the depot injection given on 15 May as a
“test dose”. At this time it was felt that the man had a good response
without evident side effects. He was given a further 40mg dose five days
later. After this second dose, he only self-harmed once until August.
Similarly, with the exception of one incident where he smashed two cells
on 30 June, he did not behave aggressively again. However, a few days
after the second dose, he developed a marked feeling of inner
restlessness and urge to move. Staff and prisoners told my investigators
that he would just keep walking and moving constantly. This continued for
about four weeks before gradually subsiding.
21. Due to his response to the drug, he had no further injections but was
started on amisulpiride (100mg) a day – an antipsychotic drug. Within four
to five days, he had developed what the lead psychiatrist described as
“marked akathisia [a slowness in movement, small muscle movement] with
Parkinson facies [immobile, expressionless, mask-like], and very little
movement.”
22. The man remained under close supervision by both clinical and discipline
staff. The doctor gave him carbamazepine. This is a drug used to treat
disorders such as manic depression. The man was distressed at the
change in himself, and spoke a great deal about how he was feeling. He
10
did not feel the carbamazepine was helping. On 21 July, the lead
psychiatrist doubled his dose of carbamzepine and noted that he was also
on sleeping tablets. The nursing handover sheet notes that he seemed
“lost and distressed”.
23. On 26 July, the man attended a one to one session with his therapist who
noted that the depot medication had brought his behaviour under control,
but had resulted in severe side effects that had since gradually diminished.
Nevertheless, he remained convinced that they had not entirely gone. He
complained of continuing discomfort in his legs and worried about
permanent damage. The therapist felt that his response to the side effects
was typical of how he responded to most problems in his life, in that he
became obsessional, constantly ruminating and seeking reassurance.
The therapist further noted that the man had little concept of time and had
disruptive sleep, unable to think about anything other than his mental
state. Wing and clinical staff recorded that he had not been eating all his
meals and was having to be encouraged to care for himself.
24. On 28 July, the man approached the lead psychiatrist on the landing. The
doctor wrote in the clinical record that the man repeatedly expressed
distress about “time lasting longer than time”, his legs and a feeling of
restlessness. Following their conversation, the doctor contacted the
pharmacist at Helsdon Hospital, Norwich, to follow up a telephone request
made earlier in the week. The doctor gave an account of the man’s
medication, side effects and current symptoms. The pharmacist thought
the side effects to be a result of the depot injections which could take two
months to fully leave his system. The pharmacist felt the akathisia was
unlikely to be due to the amisulpiride, but agreed it was appropriate to
report the issue. He wondered whether the symptoms might be due to
depression. After this conversation, the doctor spoke to the man and told
him of the pharmacist’s views about the side effects and how long they
might last.
25. On 2 August, the lead psychiatrist wrote to a consultant neurologist at
Edith Cavell Hospital, Peterborough, to request a neurological
assessment. The letter says that, after a period of increasing instability on
the man’s part, the lead psychiatrist had prescribed a test dose of depixol
depot medication (20 mg IM on 15 May). It reports that he made a good
response without evident side effects, and was given a further 40mg some
five days later. A few days after the second dose he developed marked
akathisia. This continued for about four weeks before gradually subsiding.
26. The akathisia was the main reason for the lead psychiatrist’s letter.
Apparently, this is an unusual side effect for a low dose of an anti-
psychotic medicine, but is frequently a presenting symptom of idiopathic
Parkinson’s disease. The lead psychiatrist wondered if the reaction to the
medication was an indication of the development of the disease.
27. The lead psychiatrist wrote that as well as the continuing shuffling, the
man looked almost catatonic, needing active support and prompting to
11
care for himself (eating, drinking, washing etc). The amisulpiride was
stopped as soon as these symptoms became apparent. They gradually
disappeared over the next few days.
28. The second part of the letter explains that the man had also developed a
new set of symptoms, largely psychological – poor concentration, unable
to occupy himself and some heaviness/restlessness of his legs. He was
also repeatedly reflecting upon whatever was preoccupying him at the
time, e.g. his offence, guilt, and the side effects of his medication. The
lead psychiatrist explained that these symptoms had already been
discussed with an experienced psychiatric pharmacist who believed the
majority of the symptoms to be related to the depot medication.
29. The following day, he was prescribed quetiapine (25mg) for seven days.
This medication is an anti-psychotic drug.
30. On 4 August, the man harmed himself by cutting his neck. A nurse visited
him on the wing to clean and dress the wound. He told the nurse he was
unable to cope, and that he could not even concentrate to watch the
television or listen to music. An ACCT form was opened.
31. The man self-harmed again several days later using razor blades. He was
having a great deal of interaction with clinical and discipline staff. Clinical
staff spoke to him every day, as evidenced by daily notes in the nursing
handover sheet. At this time, they were noting when he ate, drank, and
managed to clean his cell.
32. The man’s personal officer told my investigators that he felt that the man’s
behaviour had been largely about self-punishment. He had built a trusting
relationship with him. He felt that the man was ashamed of his offences
and would sometimes take his anger out on property and the cell.
Although he sometimes threatened to, he never hurt anyone else in prison.
33. However, his personal officer said there was quite a change from August:
“The last six months prior to his death, he was a slightly changed
character, he was always saying it was his change in medication that
he went on to. He became very morose he was stating ’I don’t have
any family, I don’t have any friends’, he had lost his outside contacts
and we had to strive very hard to actually encourage him to write
whereas before he was always prepared to write to people ... The
letters were coming in but he was writing nothing out. I said ’ You’ve
got to keep your contacts’, and then he was stating ’well I haven’t got
anything’ … it was a difficult period for him I would say from about the
August through to his death.”
34. On 1 September, the team of psychiatrists reviewed his care. He again
complained that his body was not functioning as it should be, although his
memory was clear. The clinical record notes “repeated requests for help”.
The psychiatrists reassured him that they were awaiting an appointment
12
with a neurologist. They decided not to change the dosage of his
medication and to review it again in two weeks.
35. Early in the morning of 4 September, the man cut the right side of his neck
with a razor. He pressed his cell bell and told staff. Another ACCT was
opened. Later in the day, he underwent an ACCT assessment with the
assessment officer. The man told the officer that he believed his problems
were related to a reaction to the depot medication he had taken four
months previously. The man said the self-harm was not a suicide attempt
but a cry for help. He cut his neck and scratched his victim’s name into his
left forearm. The officer noted that the man had been unable to
concentrate and was constantly picking his ear, fingers and lips during the
assessment. He felt the man was incapable of engaging in rational
conversation. The man said that, although he did not want to harm himself
any more, he did feel like dying. The officer noted that the man had
previously said that he had no reason to live. The man said that he had
been seen by the neurologist and he was anxious about the result of the
consultation.
36. Following the ACCT assessment, a multi-disciplinary team (together with
the man) held a review of his ACCT document. During the review, the
man spoke in riddles, and said he felt hopeless. He kept speaking over
others and repeating himself. It is recorded that he wanted help from
others, but seemed to struggle to help himself. Many staff noted that he
could not seem to move on and was repetitive in his complaints.
37. On 7 September, the lead psychiatrist received a letter from the consultant
neurologist at Edith Cavell Hospital, regarding his consultation with the
man several days earlier. The neurologist found the man to be extremely
depressed and introspective. The assessment concluded that, although
he was demonstrating some slowness in movement and response, he was
not genuinely akathenetic in a Parkinsonian sense and there was no
rigidity. His reflexes were normal. The doctor attributed his neurological
state to his underlying psychological condition and the side effects of the
anti-psychotic medication. He did not feel that there was any real
evidence of alternative neurological pathology and, apart from avoiding
anti-psychotics as far as possible, he could not suggest anything else.
The consultant neurologist stressed that if the lead psychiatrist remained
concerned about the man, he would be happy to review him, but no
arrangements were made to do so at the time.
38. Staff held an ACCT review on 11 September. The man presented as
highly anxious and very low in mood. He said he could not perform daily
tasks such as washing. The review concluded that he was not suicidal but
was very low and needed ongoing support.
39. The next ACCT review was held a week later. The man was feeling the
same, adding that doctors did not know what was wrong with him. Officers
spent time with him, even sitting and listening to a CD with him. Some
staff reported that he was able to complete some tasks. The review had a
13
sense of exasperation about it. It was clear a range of support had been
offered to him, and it was felt he really needed to engage and show a level
of commitment. In the care map, they agreed that he was to see the
nurses and his therapist every day to discuss his emotional issues. The
man agreed to try to shower daily and keep himself and his cell clean. It
was also suggested that he should speak with a member of staff for five
minutes every day about a subject other than his health.
October to 17 November 2006
40. Over the next week, there seemed to be a slight improvement in the man’s
demeanour. He did manage to speak to staff about things other than his
health, and was spending time with his friend and fellow prisoner.
However, he seemed to think he had not made progress. At his next
ACCT case review on 2 October, he said he still felt hopeless. Staff noted
that he smiled and laughed twice during the review. This was a real
contrast to his normal demeanour and the session ended in good spirits.
41. The man failed to attend the group therapy sessions. Staff set him the
challenge of completing a daily tasks sheet. This consisted of things such
as washing himself, having a shave, cleaning his cell etc. The aim was to
attempt to help him get into some sort of daily routine. Staff commented
that he seemed more positive, although he maintained he was insane.
42. On 3 October, a probation officer visited him to check his welfare. This
was in response to concerns raised by his family after the man had told
them of problems he was experiencing following his injection. The man
began to deteriorate again. He complained that he was losing his hearing
and kept getting upset and crying. He was due to move to green spur.
(Ordinarily, prisoners only stay on red spur during their assessment). The
man had stayed on red spur longer, as staff wanted the group with whom
he had been assessed to move together and had to wait until there was
room on another spur.) The man was anxious about the move. He had
formed a trusting relationship with a number of staff primarily based on red
spur. They had spent a great deal of time with him and were used to
dealing with him.
43. The man continued to report a loss of hearing, together with bad eyesight,
and described himself as “a dead man walking”. He moved to green spur
around 12 October, as did his friend His friend told my investigators:
“He [the man] was always depressed but I think he became a bit more
depressed, you know and his appearance was at times you’d have to
tell him to go and get a shower and that and clean his cell and things
like that, you know, yes. But apart from that he was, generally he was
the same you know apart from complaining about how his legs and
arms were and he was always on about that.”
44. The man’s personal officer had daily contact with him on red spur. On
green spur, contact was very limited, although his personal officer did
14
make an effort to go to see him on several occasions. It is not clear
whether he was allocated another personal officer after his move.
45. Over the next few days, he complained that he could not move his arms or
legs properly, sometimes not attending to get food or medication. On 16
October, he attended another ACCT review. He talked at length about his
problems with the depot injection and his struggle to get up. He said that
he did not want to self-harm. He said he wanted to die, but he was not
physically able to kill himself. He maintained that no one understood him
or could help him. He admitted that the self-harm had been in part an
attempt to get more one to one attention. A decision was made to close
the ACCT.
46. The following day, the man was on the landing of green spur. He saw a
gate open that would enable him to get onto red spur and he ran towards
it. The man was restrained by staff and taken back.
47. On 8 November, the man started to write a letter to his victim’s mother.
He finished the letter the night before his death. Staff noticed that he was
not venturing out of his cell much despite encouragement, and was only
eating intermittently. On 10 November, an officer made a note in his wing
file that he would not come out of his cell and “appears to have given up”.
48. On 16 November, the lead psychiatrist wrote to the referrals manager at
the Butler Clinic, Langdon Hospital. He asked for the man to be assessed
with a view to transferring to the hospital for further treatment under
section 47/49 of the Mental Health Act. In the event that he could not be
admitted to the clinic, the lead psychiatrist requested an opinion on
treating his condition and the possibility of involvement in his resettlement
plans. However, this letter would not have reached the clinic before the
man’s death.
18 and 19 November 2006
49. Saturday 18 November was his 31st birthday. He telephoned two of his
brothers and had received a card from one of them. He did not talk to his
first brother for long. In the second call, he spoke for several minutes but
his phone credit then ran out. During this conversation, he said that he
had lost the hearing in his left ear as well as his sense of smell. He said:
“I can’t stop picking, I’m in agonies of pain, I can’t function, I can’t make
a bed - I can’t watch TV ... I’m dead you see, I died at 30 … You see
my mind’s gone … and there ain’t no way out. I’m never escaping me
own self.”
50. He went on to complain that he felt like his body was moving forward and
back, although he knew it was not:
“I wake up every morning at half past three … and I can’t function and I
want to function, and I genuinely can’t function. I’m in that bed in
15
agonies of pain, arms under the pillow, all from half past three in the
morning ‘til about 10 – 11 o’clock at night when I fall back to sleep
again when the brain shuts down. That’s my life … and then I’ve got to
function to clean the cell and I can’t.”
51. The man’s brother sympathised. He checked that he was able to wash,
offered encouragement and urged him to talk to staff. He asked what he
was going to do that day. The man replied:
“I’m only out now to play some CDs because I’ve got to escape my
own self … It tortures me, everything mentally tortures me. Everything
and everyone … Anyway I’ve only got 3p left, I’ve got to go. But thanks
for the card … Remember what I tell you I never went insane, I never
done this to myself. It’s total cruelty and inhumane what they’ve done
to me. And to leave me like this and to know there’s no cure and
there’s no way out.”
52. The man’s friend said he made him a special dinner and gave him some
chocolate for his birthday. The man showed him the birthday card he had
received from his brother. The friend recalled that several days before his
birthday the man had repeatedly said, “Can I trust you friend?” he thought
that by saying this the man was trying to tell him something, but knew that
he would tell staff if he thought the man was going to harm himself. The
man also gave several CDs to his friend and said “remember me”. The
friend said that he did not think this was unusual as he was often saying
odd things such as asking him to say a prayer for him. He had known him
for about 18 months, and he had often made comments that he was a
dead man walking. He had no suspicions that anything was different on
this occasion.
53. Another prisoner said that the man had been upset that afternoon and had
approached an officer. The prisoner alleged that the officer had said he
was too busy to talk. The prisoner said that later that afternoon he had
raised his concern about the man to the same officer. My investigator
interviewed the officer concerned. She also made enquiries of other staff
and prisoners as to staff attitude and response to him. The investigator
was satisfied that the man received a good level of care.
54. All prisoners on the DSPD were locked in their cells at approximately
4.30pm. The man’s cell was located in between two others. The
prisoners in both the adjacent cells were category A and therefore subject
to regular checks throughout the evening and night.
“… he was in darkness, we turn all the lights off so it’s complete
darkness and he said “hello, can you give me some spellings please?”
so I said yes. And there’s a little, what we call a night light outside, so I
put that on. He passed me the piece of paper out that he wanted me to
write spellings on. I took that and I still couldn’t see, the light wasn’t
that good, so I asked him to put the main light on in his cell … he was
16
fully dressed, his cell was in the same order as what it usually was, bed
was in the right place and everything because I did have a look. He
asked for three spellings … [they were] anxious, distressed and slip.
At that time I didn’t think that they were strange spellings but something
must have told my conscience because I asked him who he was writing
to and he actually said to his therapist. I asked him if he was okay, he
said yes fine, so I said okay, if you need anything put your cell bell on.”
55. A prisoner occupied the cell directly below the man’s cell. He remembered
hearing an officer talking to him about some spellings, and recalled the
officer telling him that if he needed anything he should use the cell bell to
contact her.
56. The final time he used his cell bell was at 10.43pm. When the prison
officer attended, he said he wanted to warn her that he was about to have
a strip wash so she should not come to check on him. The officer asked
again if he was okay, and he replied that he was fine.
57. The prisoner said that he heard banging noises coming from the cell
directly above him. He considered this to be unusual from him. He
believed he heard the man moving his bed. He could not be sure of the
time but believed it may have been around 11.00pm.
58. My investigators also asked to speak to the prisoners located in the cells
either side of him. One prisoner declined to be interviewed, but a second
prisoner told my investigators that he remembered the evening well. He
had been unwell on that particular evening and the pain had kept him
awake for most of the night. He recalled hearing the man moving his
furniture. He said he could not be sure of the exact time as he was
dozing, but he thought it was around 11.00pm or midnight.
59. Throughout the night, staff are required to perform ‘pegging checks’.
These are patrols in which the officers use an electronic wand to “peg” at
specific points. The pegging points are in different positions over the
landing. At the beginning of a night shift, an officer is given a list of the
points s/he must cover at certain times. This ensures that the officer is
patrolling the wing, at random intervals. It does not require staff to check
individual cells. Staff also have to check on those subject to ACCT
documentation, as well as make regular observations of category A
prisoners. On the night of 18 to 19 November, the patrols were shared
between the first and the second prison officers. A third prison officer,
was also on duty, assigned to the gated cell which was holding a prisoner
considered to be at a high risk of self-harm. Unless a prisoner is classed
as category A, or is subject to ACCT procedures, they would not be
checked between the evening roll count and the roll count the following
morning. In this man’s case, he was seen after the evening roll count
when staff responded to his cell bell.
60. In the morning, staff are required to perform a roll check. This involves
every officer checking every cell. They also have to make a visual or
17
verbal contact with every prisoner. The second prison officer signed to
say this check was performed at 5.25am.
61. The second prison officer told my investigators that he conducted the roll
check at the same time as ‘pegging’ over the course of an hour. He said
that he remembered checking the man’s cell sometime between 4.10 and
5.15am. He recalled that a prisoner was in the cell next door to the man’s
and he was awake at that time. He had checked that prisoner as both he
and the prisoner in the cell the other side of the man were category A. He
checked the man at the same time. My investigator asked if he saw him or
if something was obscuring the observation panel. He replied, “at that
time there was, but I was happy, I could hear him in his cell”. He said that
he did not try to get a verbal response as he could hear movement. The
prisoner next door also thought he heard movement from the man’s cell in
the early hours of the morning. The checks of category A prisoners are
recorded and those records show that the prisoner next door was checked
at 0.01am, 1.48am, 3.31am, 5.20am and 7.05am.
62. When the morning staff arrived, they began the morning roll count. A
fourth prison officer started to check green spur at approximately 7.20am.
He could not get a response from the man’s cell, and asked the second
prison officer to try and get the man to talk to him while he continued the
checks. The second officer went to the cell. The observation panel was
blocked by toilet paper. A fifth and sixth prison officers and then tried to
get a response from him.
63. Each cell has an inundation point. This is a small access point through
which a hose can be inserted in the event of a cell fire. The sixth officer
collected the key and looked through the inundation point, but the view
was obscured by the man’s mattress. He thought that the man might have
barricaded his cell. The prison was in patrol state. (This means that all
prisoners have to be in their cells, with the doors closed, unless there is an
emergency. Patrol state is due to either staff movement or reduced
staffing levels.) Staff asked permission to unlock his cell. There were
plenty of staff around, as night staff were still on duty. The orderly officer
therefore authorised the opening of the cell.
64. The sixth officer told my investigators that, through the crack at the edge of
the door, he could see that the bed had been moved. It took all his
strength to open the door. The fifth and sixth officer found the man
hanging from his upturned bed. The man had put toilet paper up his
nostrils, a plastic bag over his head and then hanged himself with a shoe
lace. The officers supported the man’s bodyweight and another officer
went to get the “suicide box” and ligature scissors. The third officer entered
the cell and helped take the man’s bodyweight. The sixth officer removed
the bag from the man’s face. One of the officers cut the ligature. They
placed him on the floor and tried to find a pulse. The officers told my
investigators they saw very clear signs of rigor mortis and were unable to
find any life signs. Nursing staff then arrived and attempted resuscitation.
18
65. The first nurse received a telephone call in the healthcare centre. She
was informed that there was somebody hanging on D wing. She,
accompanied by another nurse, collected the emergency bag and oxygen
and ran to D wing. In spite of the distance and heavy equipment, the first
nurse thought it only took them a few minutes. She told my investigators
that, as she was approaching the cell, she asked staff if the paramedics
had been called and was told that it would be done straight away. It is
unclear whether paramedics had been called prior to this. In any event,
there was no significant delay in their arrival.
66. The first nurse said that on arrival at the man’s cell, there were no signs of
life. He was cyanosed (a blue colouring of the skin), there was clear
evidence of rigor mortis and his pupils were fixed and dilated. The first
nurse’s understanding was that she should continue cardio pulmonary
resuscitation (CPR) until paramedics arrived.
67. There is a slight variation in some of the times given. The first nurse noted
that she was called at 7.35am. According to the communications room
log, the ambulance was called at approximately 7.42 and arrived at around
7.50am. They further attempted resuscitation, but paramedics
pronounced the man dead at 8.05am.
68. Contingency plans were activated. As part of this, the man’s next of kin
was identified and a family liaison officer appointed. The family liaison
officer, together with a governor, travelled a considerable distance in order
to break the news in person.
69. The man’s family was particularly grateful for the assistance of the family
liaison officer. They were especially grateful for her help with arranging
the funeral, and visiting them with the man’s belongings.
19
ISSUES
Clinical treatment
70. A clinical review was carried out by a multi-disciplinary panel of
professionals. (Some members of the panel had been involved in the
man’s care, others had not.) Many of the findings are outlined in this
section of my report. However, I urge the governor and head of healthcare
to consider all the issues raised in the full review.
71. Although young, the man had a history of cardiac problems and had
suffered a myocardial infarction (heart attack). He was inconsistent in
taking medication (this was mainly for his heart problems). He was also
prescribed anti-depressants and anti-psychotic drugs.
72. The clinical review concluded that:
“The man’s physical health care was monitored by the Primary Care
Service. Treatment for cardiac problems – evidence clearly indicates
that the man took his cardiac medication only intermittently. He had
regular BP [blood pressure] and other routine checks done. It is
possible this refusal of his medication was another method of self-
harming. He was offered an appointment with an external specialist
which he declined. He could not though be forced to take his
medication.”
73. I endorse the following recommendation from the clinical review:
Where a prisoner refuses to take his medication, external specialist
advice should be sought (where relevant) to advise on impact of the
refusal and any mitigating steps which can be taken to alleviate
negative effects.
74. Two sets of clinical records are kept for each prisoner, one set in the
DSPD and another in central healthcare. This clearly does not provide a
cohesive set of notes across healthcare professionals, particularly if
primary care staff are dealing with health concerns that are not psychiatric
problems. Although this was not a big issue in the care of this man, it is
possible that in some instances combined records would be more
beneficial.
75. The man was seen and assessed regularly by the lead psychiatrist, and by
psychologists, therapists, mental health nurses, and nurses. His issues
and presentation were discussed at every weekly multi disciplinary team
meeting. Staff had tried a number of different methods, including different
medication. In spite of this, the man was still erratic and demanding. He
harmed himself, and damaged property. He also exhibited sexually
disinhibited behaviour. In May, after a number of other options had been
tried, the lead psychiatrist decided on a trial dose of depot medication. In
interview with my investigators, The lead psychiatrist said:
20
“[The man] continued to self-harm and he was also repeatedly
destructive and he destroyed, smashed property and I think four
successive cells. There had been previous damage to property but it
had never been, there had never been a pattern of just one after
another and another. That had a huge impact on the wing because
every time that happens then the prisoners have to be locked away …
It had got so bad that he was moved to the Segregation Unit and
discussed with staff and we decided at that point that we would talk to
him about the possibility of his having an injection of depot medication,
not because we thought he was psychotic but because it is a
recognised approach to dealing with, managing severely disturbed
behaviour. I approached him about that … and talked to him about it
again and he agreed that he would try it.”
76. As noted earlier, at first there appeared to be no side effects. The initial
dose was very small and they waited five days before giving a second
dose. The lead psychiatrist explained that any side effects would normally
appear within five days.
77. Once he had the injection, his self-harm dramatically reduced and he
stopped talking about his index offence. However, he became distressed
about the side effects. Many staff and prisoners reported a clear change
in him after he took the medication. At first he seemed restless and felt
the need to keep moving. The clinical review says:
“Following this he developed akathisia which continued for
approximately ten weeks. He was given medication for these side
effects. From this time he no longer talked about his offences or his
victim and focused on his physical symptoms. VH [The lead
psychiatrist] felt the side effects were genuine and confirmed that such
side effects are not unknown though they usually reduce after two
weeks.
“The side effects persisted and the depixol injection was discontinued.
He was prescribed amisulpride. He continued to be restless and
deteriorated appearing at one time to be almost catatonic showing no
ability to self care. During this period he needed prompting to do
anything including eating and drinking. Gradually this behaviour
ceased, the amisulpride was discontinued and he was commenced on
carbamazepine and prozac. VH believed him to be highly sensitive to
the medication.
“Due to concerns about the side effects VH made a referral to a
consultant neurologist who after examining him detected neither
physical abnormality nor impairment of memory.
“Some staff were suspicious that he was exaggerating or putting on the
symptoms as they felt that when he was not being observed the
symptoms appeared to desist. VH emphasised that she did not believe
21
he was putting it on initially, although at times there did appear to be an
exaggeration of the symptoms.”
78. The man’s reaction was uncertainly unusual. The staff on the DSPD are
experienced and were confused by his presentation. The lead psychiatrist
explained to my investigators:
“None of us has ever come across anybody who has had as extreme a
reaction, as prolonged a reaction and this total and sustained change
in presentation. We concluded that his distress instead of being
expressed in all the self-harm was now being expressed in his somatic
symptoms and that’s the best explanation that we’ve been able to
come to and in retrospect I haven’t come up with a better explanation.
That in the community he used alcohol to cope with distress, when he
was first in prison he used a lot of self-harm and quite dramatic
behaviour and that then from the time in April and April onwards that it
was in these somatic symptoms.
“…[I thought in] maybe June, July you know this is a very unusual
presentation, how can we take it forward, should we get a second
opinion, a second psychiatric opinion, should I ask one of my
colleagues because there are other psychiatrists that come to the
prison? Actually it’s quite difficult, he could give a coherent account of
what’s happening but it’s actually the overall picture not just what you
get in a one-off interview that was actually really quite important in
making an assessment. So I thought it wasn’t clear that there was
going to be a great deal to be gained by getting a sort of hour’s
assessment done. So I had in mind at what point should we think
about referring him to hospital with the idea that it would have to be his
local Medium Secure Unit and Medium Secure Unit with an appropriate
level but knowing that he would not be at all a typical case for
admission to a Medium Secure Unit, but I thought well at least if they
were to come and assess him then they might have a different view
and in the longer term it would be likely that they would need to be
involved in his final care.”
79. The man was aware that consideration had been given to him attending a
psychiatric hospital. A nurse said that he seemed comfortable with the
idea of going to hospital. The nurse explained that, although the
environment would be different, the work that he would be involved in
would be the same. The lead psychiatrist had written a letter of referral
but it was not sent before the man died.
80. The man’s therapist told investigators that:
“He [the man] was always extreme but the ways that he was extreme
changed so he would be, could be extremely aggressive, could be
extremely passive, he could be extremely penitent but the ways he was
extreme changed and he presented in lots of different ways while he
was, certainly since I knew him. But what he would actually say and
22
the level of despair that he was actually feeling didn’t really change,
just the way that he dealt with it changed. Sometimes he would be
aggressive to others and sometimes he would be more aggressive
towards himself by attacking himself or starving himself and
sometimes, he was just totally passive. All he would do was smoke
and lie on the bed and you couldn’t move him, you just couldn’t actually
get him out of his cell. He presented in very extreme ways but in very
different ways but it was the severity of the presentation that was
consistent.”
81. Overall, the care given to him was well considered. Actions were taken to
address concerns as they were raised and he was constantly supported
and monitored by a multi-disciplinary team of nurses, psychologists, a
therapist and psychiatrist. (It is important to understand that the DSPD is
quite different from the normal prison environment, with a large number of
specialists and trained professionals on hand.)
ACCT
82. Whitemoor’s safer custody policy complies with Prison Service Order
2700, Suicide and self-harm prevention: “Personal items including
shoelaces and belts must not be removed from at-risk prisoners as a
matter of course. The reasons for the decision to remove or return items
must be recorded in the prisoner's ACCT.” I support this policy. However,
where a prisoner repeatedly uses razor blades to self-harm, consideration
should be given to allowing use only under supervision, or restricted in-
possession use.
83. The man’s ACCT was closed on 16 October. He attended with his
personal officer and the first nurse. The content of the review at first
appears alarming. The man said he did not want to self-harm. He wanted
to die, but was physically unable to kill himself. The SO, who chaired the
review, described the meeting to my investigators:
“He was very talkative. I mean I remember putting in that he is always
saying he wants to kill himself. One of the things, he had always said
that but then you would say ’do you mean that’ and he would say ’no I
don’t, I’m not capable of killing myself, I don’t want to.’ It was
something he has always said, it will probably appear on a lot of things
but when asked it was just an attention thing and asked bluntly was it
and he would say ’yes’, he had no intention at this time and in fact he
had even stopped self-harming.”
84. The SO said there was still a care plan in place to inform staff how best to
approach him and respond to his behaviour. As such, he would still be
monitored and have a high level of staff interaction. The SO also said that
he explained to the man that the ACCT could be re-opened at any time.
His personal officer felt that the ACCT had been a useful tool in managing
him, in that he knew someone would regularly come to talk to him even if
23
he was locked in his cell. The ACCT had been closed before, sometimes
with an interval of a few weeks before being re-opened.
85. His personal officer recalled that he had said that no one understood him,
and he felt paralysed. At the review, he had also said he was not going to
do anything “silly” or kill himself and that he wanted help with his
medication. Along with other staff, his personal officer told my
investigators that, although the man self-harmed, there had never been a
serious intention to kill himself. Wing and clinical staff spoke with him
daily. Indeed, a number of staff told my investigators of their detailed
interactions with him, attending him night and day. Prisoners confirmed
that staff had been attentive.
86. Even with hindsight, the personal officer thought the decision to close the
ACCT was reasonable. He said:
“I mean if you look at it you could think to yourself, well he is still
threatening to kill himself, but I think at the time his mood had
improved. He stated before that he wouldn’t have done anything, he
felt better, he was stating to staff that he couldn’t get his body moving
but he would be walking up and down the landing no problem
whatsoever and talking to some of the other inmates on the spur. At
the time I can remember them saying he seems to be a lot better within
himself, it’s taken time but he seemed to be better.”
87. My investigators asked staff whether they felt there was a possibility that
they had become fatigued with him, and accustomed to the things he had
been saying. The personal officer responded that it was important to
make decisions as a team as the man’s presentation could change. After
the closure of the ACCT, the man had a follow-up interview in which he
expressed no new concerns.
Night of 18 to 19 November
88. On the evening of 18 November, the man called a prison officer several
times. The first was to ask for toilet roll. The second time he asked the
prison officer for some spellings. These were ‘anxious’, ‘distressed’ and
‘slip’. The officer asked whom he was writing to, and if he was alright. He
replied he was okay and was writing to his therapist. A note addressed to
his therapist was found after the man’s death. In the note, the man
thanked him for his support but said he could no longer cope.
89. With the benefit of hindsight, we can understand the importance of the
three words the man asked to spell for him. However, he had written
letters on almost a daily basis. Indeed, he was encouraged to write about
his thoughts and feelings. Other staff felt it was not uncommon behaviour
for him. In fact, the sixth prison officer actually said he would have been
pleased to know that he asked for spellings as it would mean he was
writing again. Later that evening, at 10.43pm, the man again spoke to the
24
first prison officer, warning her not to check on him for a while as he was
about to strip wash.
90. The second prison officer was in charge of conducting the roll check of all
prisoners on green spur throughout the night of 18 -19 November. He told
my investigators that he conducted the roll check during the course of
about an hour, whilst also checking category A prisoners. He believed that
the time he checked the man’s cell was between 4.10 and 5.15am. His
cell was located between two category A prisoners and he checked them
at the same time. The times that the prisoners either side of him were
checked were logged by the officer and recorded in the category A check
log. The entries closest to the time the officer gave are: 3.31 and 3.35am,
then 5.20 and 5.23am.
91. The second prison officer told my investigators that the observation panel
in the man’s cell was blocked at this time. As a result, he could not make
visual contact. He said he did not attempt to get a verbal response from
him, but he was sure he had heard him moving.
92. When the man was found at approximately 7.30am, there were clear signs
of rigor mortis. This usually develops between four and ten hours after
death, although it is dependent on a range of factors including the ambient
temperature and body mass of the individual. However, it seems unlikely
that he could have been moving around his cell when the second prison
officer says he heard noises. It may be that the noises the officer heard
were actually coming from elsewhere.
93. In any event, the night orders are clear. When conducting a roll count, the
officer conducting the count must make visual or verbal contact with every
prisoner. During the investigation, my investigator raised this issue with
the governor of Whitemoor who subsequently launched an enquiry into the
second prison officer’s action on the night of 18/ 19 November. Whatever
the outcome of that investigation, I think the following recommendation
would be prudent:
The governor should remind all staff of the importance of making
visual or verbal contact with every prisoner when conducting a roll
count.
Crisis management
94. Whitemoor has clear instructions on staff entering cells during patrol state.
Staff made attempts to get a response from the man, and acted in
accordance with local policies in asking for permission to open the cell
door at that time of day.
95. When they entered the cell and found the man, two officers supported his
body whilst another officer ran to collect the anti-ligature scissors from a
box in the office. Prison Service Instruction (PSI) 32/2006 requires all
prisons to ensure that anti-ligature knives are carried by frontline staff. In
25
some cases, the carrying of knives can save crucial seconds. The PSI
came into effect on 20 November and Whitemoor had already stocked the
ligature knives in order to implement the instruction. In this case, it would
not have affected the outcome. However, in an investigation into a
subsequent death at Whitemoor, it came to light that there had been a
delay in the implementation of the instruction on anti-ligature knives. The
knives have since been issued.
96. The healthcare staff were aware they were running to a person found
hanging. They did not take the defibrillator machine with them but, given
the weight of the equipment they were already carrying, they could not
reasonably have been expected to carry one. However, in some cases,
the quick use of a defibrillator can save lives.
97. There was some confusion between the nurse and wing staff over who
should call for an ambulance. The head of healthcare was clear that any
one can call for an ambulance. However, in Whitemoor’s “Death in
custody, senior officer action sheet” it says: “On instruction from
healthcare staff, call an ambulance (via 999) and duty doctor.” Although
this did not lead to a delay in getting care for the man, other situations may
arise where this confusion could cause unnecessary delays.
98. When the man was found it was clear to all staff that rigor mortis had set
in. The first nurse commenced CPR until paramedics arrived. Whilst some
clinical staff feel they would like to try CPR in such instances, it can be
argued that this is both disrespectful to the deceased and very difficult for
staff.
99. PSO 2700 requires that, where there is clear evidence of rigor mortis,
resuscitation should not be attempted. Whitemoor’s healthcare policy
complies with this. However, again there are conflicting instructions to
staff. Whitemoor’s “Death in custody first on-scene action sheet” reads: “If
the prisoner is not breathing, attempt resuscitation unless rigor mortis of
the limbs has clearly set in (rigor mortis is a condition of extreme stiffness
affecting the arms and legs after death, making it virtually impossible to
bend the wrists, elbows or knees).” Conversely, the prison’s “Death in
custody, orderly officer preservation of evidence action sheet” says:
“Primary first aid will be given until such time as a doctor confirms death.”
All the issues relating to the action sheets, and emergency procedures
were conveyed to the governor at the time of the investigation.
The governor should carry out a review of emergency procedures,
with particular attention to ensuring that instructions and procedures
are consistent. The outcome should be conveyed to all staff to
remind them of their responsibilities when responding to
emergencies.
100. Furthermore, I concur with the clinical review, that:
26
There should be a review of the emergency response from clinicians,
in terms of the equipment available. Consideration should be given
to making defibrillators and emergency equipment available at
strategic places in Whitemoor. The review should include
appropriate training (including regular update training) for staff in
defibrillator use.
Beds
101. The man had turned his bed upright. He then used this both as a
barricade to his cell door, and a ligature point. This was discussed with
the governor at the time of the investigation. Work has begun securing the
beds to the floor, and anticipate that all beds will be been bolted to the
floor to prevent them being easily moved by the end of this year. In the
meantime, anyone deemed at risk, is located in a cell with a secured bed.
The significance of birthdays
102. Given that the man’s death occurred on either his birthday, or the day
after, my investigator asked the Prison Service’s Safer Custody Group if
there was any correlation between the date of someone dying and their
birthday. They told me that between 1978 and April 2007, there had been
six apparently self inflicted deaths in prisons on the individual’s birthday. A
review of cases where deaths had occurred several days before or after a
birthday was also conducted. The overall finding was that there is a slight
increased risk around a prisoner’s birthday. However, there are far more
significant risk factors. Moreover, there may be a number of significant
dates for an individual - anniversaries, the date a loved one died, their
sentence date, etc - many of which will be unknown to staff.
Staff, communication and relationships
Support for staff
103. Many of the non-discipline clinicians who work in the DSPD unit belong to
professional bodies and they are obliged to receive the appropriate level of
supervision designated by that body. In addition, as detailed in the D wing
protocol on individual therapy, all clinicians offering individual therapy
should receive clinical supervision from a qualified psychologist or
psychotherapist at least once every fortnight. The investigation team was
told that the current monthly external clinical support available to the unit’s
psychotherapists (of whom there are three) is to be withdrawn, although
clinical supervision is still provided by other clinicians on the unit. The
investigation team spoke to several members of non-discipline staff about
the levels of support they received. The majority spoke favourably of the
supportive nature of the unit.
104. The support and supervision service available to discipline staff on the
DSPD unit is still being developed. An SO explained that there is currently
an ad hoc system in place for getting clinical supervision, although staff do
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have access to external counsellors, known as “Care First”, for a support
session every four to six weeks. One of the governors also told the
investigation team that, during 2006, systems had been developed to
provide operational staff with clinical supervision and senior officers were
being trained to enable them to deliver this support. He said that, as the
unit’s manager, he personally felt that there was strong peer support on
the unit and that the clinicians were available if he needed their support.
Certainly, there was a great deal of support offered to both prisoners and
staff after the man’s death.
Relationships between staff
105. The Integrated Multi-disciplinary Treatment Model for the DSPD Unit, HMP
Whitemoor (March 2006), acknowledges the potential for conflict between
discipline and clinical aims of the unit. In the first three years of the unit’s
existence, the discipline staff were not aware of the details of the treatment
model. The unit focused exclusively on assessing prisoners as the
treatment component of the programme had not yet begun.
106. The introduction of ‘treatment’ proved to be problematic in terms of
discipline staff adapting to a treatment model. As mentioned earlier, the
uniform staff had a shared sense of a broader purpose, however there was
no clarity as to how this was to be achieved in the medium and longer
terms. There was awareness that the work of the DSPD unit would grow
increasingly clinical, but it was unclear how the discipline staff’s role would
adapt to accommodate this process.
107. Up to this point in the DSPD unit’s development, the discipline staff had
achieved significant success in reducing problematic behaviour with this
challenging prisoner group, by applying a management model to the care
of the prisoners. Running parallel to this process, the clinical team was
developing an increasingly treatment-orientated programme. The
Integrated Multi-disciplinary Treatment Model for the DSPD Unit HMP
Whitemoor (March 2006) says: “It should be of no surprise that tension
developed between both these models and the professional groups that
championed them. It is well established that while a management model
and a treatment model are not mutually exclusive, they do act in significant
tension to each other.”
108. Generally, my investigators found that the clinical and discipline staff
worked together well. This was particularly demonstrated in the care that
the man received. However, there were some tensions between discipline
staff involved in running the therapeutic group work and those that were
not. It was clear that some staff felt that they were not as involved in the
running of the unit, or as aware of individual needs of prisoners, if they
were not involved in group work. My investigators found that there was in
fact, a large amount of information sharing available.
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Communication and information flow
109. Information about prisoners was gathered by many members of staff
across each of the disciplines. In an environment where all the prisoners
have complex needs, the effective management and sharing of this
information is crucial.
110. Information about prisoners on the unit is recorded and shared in several
different ways. Integrated case notes are written for each prisoner with
entries made by discipline, clinical and psychology staff. These notes
document significant contact between the individual and others on the
wing, and are available to all staff on the unit. Clinical staff also record
information in the prisoner’s medical records. Notes and observations
about individuals may be entered in the relevant observation books on
each spur.
111. Three briefing sessions (one at the start of each shift) and three de-
briefing sessions (one at the end of each shift) are held everyday. This is
an opportunity for staff across all disciplines to share information about
individual prisoners, including any specific concerns.
112. In addition to these regular briefings throughout the day, each of the unit’s
spurs holds a weekly multi-disciplinary meeting. They are chaired by a
principal officer or senior officer and the minutes are available to staff
across all disciplines. At these meetings, staff explore a variety of issues,
including operational matters and whether any prisoners are in crisis or on
open ACCT forms. The meetings are also used to discuss prisoners with
urgent care needs and to develop strategies for how to manage them.
The man’s individual therapist, told the investigation team that the
deceased was frequently discussed at these meetings. My investigators
were told that some discipline staff were encouraged to attend. However,
it was clear from the minutes that they did not always take up the offer to
participate. Where possible, it is clearly right that representatives of wing
staff should attend, preferably on a rota basis, to encourage involvement
from a range of staff and to spread the learning. That said, on the whole,
my investigators judged that good systems of communication were in
place and were well used.
113. I conclude that the treatment that the man received at Whitemoor from the
multi-disciplinary team was of an extremely high standard. A large number
of individuals spent a great deal of time with him during his stay in the
DSPD unit.
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RECOMMENDATIONS
1. Where a prisoner refuses to take his medication, external specialist advice
should be sought (where relevant) to advise on impact of the refusal and any
mitigating steps which can be taken to alleviate negative effects.
2. The governor should remind all staff of the importance of making visual or
verbal contact with every prisoner when conducting a roll count.
3. The governor should carry out a review of emergency procedures, with
particular attention to ensuring that instructions and procedures are
consistent. The outcome should be conveyed to all staff to remind them of
their responsibilities when responding to emergencies.
4. There should be a review of the emergency response from clinicians, in terms
of the equipment available. Consideration should be given to making
defibrillators and emergency equipment available at strategic places in
Whitemoor. The review should include appropriate training (including regular
update training) for staff in defibrillator use.
The Prison Service has accepted all the recommendations.
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