Individual at Woodhill

Investigation into the circumstances surrounding
the death of a man
at HMP Woodhill in August 2005
Prisons and Probation Ombudsman for England and Wales
May 2006
This is the report of an investigation into the death of a man. The man was found
hanging in his cell in the Healthcare Centre in HMP Woodhill on 1 August 2005. He
was 33 years old when he died. He came from a close knit family, and leaves a wife
and two children. He had been in prison for just two weeks, and was known to be at
risk of suicide. The loss of a loved one is always distressing, but especially so in
these tragic circumstances. I offer the man’s family my most sincere condolences
for their loss.
The assistant Ombudsman, and an Investigator, undertook the investigation, a key
part of which was to make sure that the man’s family had an opportunity to raise any
concerns about his death. My colleagues were able to meet with the family, and I
very much appreciate their willingness to discuss the man’s death so soon after their
bereavement. I do not underestimate how difficult this must have been for them.
I would also like to thank the Governor of Woodhill and his staff, for their assistance
in the investigation.
The Milton Keynes Primary Care Trust undertook a review of the man’s medical
care. Unfortunately, the outcome of this review was not available at the time my
draft report was published, but it has been incorporated into this final version.
There were also difficulties in interviewing two locum medical staff. It may be that
the Coroner will want to consider calling a representative from the Primary Care
Trust to the inquest to explain the position on these interviews, and to call the two
locum medical staff.
My report includes a significant number of recommendations. I hope these will go
some way towards preventing a tragedy such as the death of the man from
happening again.
This investigation has revealed significant failings in the care that Woodhill offered to
the man. As I say on page.5, I have concluded that there is a possibility his death
could have been avoided.
STEPHEN SHAW CBE
PRISONS AND PROBATION OMBUDSMAN May 2006
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CONTENTS
Summary
The investigation
Woodhill prison
Background to the prison
Previous deaths
Assessment, Care in Custody and Teamwork (ACCT) process
Woodhill’s suicide prevention procedures
Woodhill’s contingency plans
Events leading up to the man’s death
Offences and sentencing
The man’s time at Woodhill
Events on 1 August – the move from House Unit 1 to the Healthcare Centre
Events on 1 August – Healthcare Centre
Views of other prisoners who knew the man
Post Mortem
Clinical Review
Consideration of some of the issues surrounding the clinical care that the man
received
Were duty room staff aware that the man had been brought to healthcare?
Was the duty room adequately staffed?
Were staff aware of the arrangements for admitting prisoners to healthcare?
Conclusions
Recommendations
ANNEXES
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Summary
1. The man was 33 years old when he died on 1 August 2005. He had been in
Woodhill for just two weeks, but he was not new to prison life having served a
number of previous sentences. On 18 July, he had received a 15 month
sentence for possessing stolen property and dangerous driving.
2. The man had by then been diagnosed with severe to moderate clinical
depression, for which he was receiving 150mg daily of the anti-depressant
Venlafaxine, and regular home visits from the Community Mental Health
Team. At court, the man was identified as a possible suicide risk, and a
suicide warning form was raised. The man’s probation service officer also
wrote a note that day to the prison explaining the anti-depressant medication
he was taking, and enclosing some other documents about the man’s
medical history. The clerk to the court also enclosed the psychiatric reports
about the man, and identified the package as containing medical reports for
the urgent attention of the Governor.
3. The man arrived at Woodhill at just after 4pm. It seems likely that the
documents marked for the Governor’s attention were sent to the discipline
office and were then put in the internal mail to healthcare, where they arrived
on 20 July. As a result, the nurse and the doctor who saw the man on the
evening of 18 July did not have access to them. The nurse opened an ACCT
suicide warning form, and at 9pm the man was admitted to the Healthcare
Centre and placed in a single cell.
4. Because the man was admitted straight into healthcare, he missed out on
some of the prison’s standard induction arrangements. On 19 July, he was
seen by the Mental Health Inreach Team (MHIRT). A review of the ACCT
arrangements to support the man should also have been carried out on 19
July, but did not take place until 21 July. Also on 21 July, a prison doctor
prescribed the man 75mg of Venlafaxine daily for his depression. On 25
July, the man was again assessed by the MHIRT, on the mistaken
understanding that this had not already been done.
5. On 26 July, the man’s ACCT was reviewed, and he was discharged from
healthcare and moved to a shared cell on House Unit 1A. His ACCT
caremap was not updated to say how he would be looked after on the
residential wing.
6. Also on 26 July, the prison received a letter from his stepfather. This said
that the family had visited the man on 24 July, and were concerned about his
physical and mental condition and that he was not getting the medication he
had been prescribed. The man’s stepfather asked for a watch to be kept on
him. The letter was treated as routine correspondence, with a reply due by 5
August. Its contents were not considered before the man’s death.
7. On 22 July, the man’s family sent him a postal order, letter and some
photographs. On 29 July, as the man had not received this, he asked staff
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about it. He asked again on 30 July, 31 July and 1 August. The package
was located and returned to his wife after his death.
8. On a family visit on 31 July, the man had found out that his father was ill. On
the morning of 1 August, he talked to a chaplain about this.
9. At about 1.45pm on 1 August, the man told staff that he wanted to hang
himself. Healthcare staff decided that he should be readmitted to healthcare,
but there was no proper clinical assessment of his condition to inform this
decision and no review of his ACCT document. The man was reluctant to be
moved, but eventually agreed. At about 4.30pm, he was put alone in a
double cell, with bunk beds, in healthcare. There was no clinical assessment
of his condition when he arrived in healthcare, and no admissions process
was followed. He was seen by a chaplain at 5.12pm, and observed three
times that evening by the officer on the wing. He was found hanging from the
bed at about 8.15pm. Staff were unable to revive him, and he was
pronounced dead at about 8.30pm.
10. I conclude that there is a possibility that the man’s death could have been
avoided. I make a number of recommendations about what the prison should
do to prevent such a tragedy from recurring.
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The investigation
11. The assistant Ombudsman, and one of my investigators, carried out the
investigation into the man’s death. Notices were issued to staff and prisoners
telling them of the investigation and its terms of reference and offering them
the opportunity to participate. In the event, only one prisoner came forward
of his own accord, although almost all staff, and all prisoners, willingly co-
operated in the investigation.
12. The deputy Ombudsman, first visited Woodhill on 5 August 2005 to open the
investigation and obtain the paperwork. The assistant Ombudsman and the
investigator then visited the prison on 12 August to start the detailed work on
the investigation. They saw the Healthcare Centre, the residential wing
where the man stayed for a while, and the cell where he died. They met the
governing governor, the deputy governor, various members of staff, and
representatives from the Prison Officers’ Association and the Independent
Monitoring Board. They reviewed all the documentation they had been given,
asked for much more, and interviewed a number of staff and prisoners.
13. The second governor and subsequently another governor ably acted as
liaison officers for the investigation. They were open and honest about what
might have gone wrong in the time leading up to the man’s death, receptive
to feedback during the course of the investigation (as was the governing
Governor), eager to take steps to make procedural improvements, and did all
that they could to facilitate the task of my investigators. I am sure that their
positive approach to the investigation helped to ensure the co-operation of
staff within the prison in what, for some, was a difficult, painful and worrying
process, during which their actions were put under close scrutiny.
14. One of my Family Liaison Officers made contact with the man’s wife. The
family liaison officer and assistant Ombudsman visited the family on 24
August and met the man’s wife, her mother and the man’s stepfather. The
family’s solicitor was also present at the meeting. I am grateful to the family
for contributing to the investigation at what must have been the most difficult
and devastating time, as they came to terms with the death of a much loved
husband, son and father. The family raised a number of concerns about the
way The man was dealt with by the prison. I believe that all these issues are
covered in this report. The family liaison officer kept in touch with the man’s
wife during the course of the investigation.
15. My investigators also liaised with the Coroner’s office and the police during
the course of the investigation. Once the police had decided that there were
no suspicious circumstances surrounding the man’s death (which was not
until 20 October), they allowed my investigators access to the police
documentation. My investigators also eventually obtained a variety of
documentation from the Coroner’s Office, although there were long delays in
receiving this. For example, they telephoned the Coroner’s Office on 15
August, but were not able to speak to the Coroner’s Officer until 14
September, and documents vital to the investigation did not start to arrive
until 29 September and beyond.
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16. The assistant Ombudsman also spoke to the probation service officer who
had been supervising the man prior to his imprisonment, and had spent some
time with him after he was sentenced, but before he arrived in Woodhill.
17. Since April 2004, Milton Keynes Primary Care Trust (PCT) has been
responsible for the clinical care provided to prisoners in Woodhill. The PCT
is required, under National Health Service procedures, to carry out its own
review of the clinical aspects of the man’s care while in prison. The assistant
Ombudsman wrote to the Chief Executive of the PCT on 3 August to ensure
that the PCT investigation and my own investigation dovetailed as far as
possible. Unfortunately, it was not until 1 September that the PCT told my
investigators that a clinical reviewer had been appointed to conduct the
review. By that time, my investigators had interviewed most of the clinical
staff. Had the reviewer been appointed earlier, it would almost certainly have
been beneficial for the interviews to be conducted jointly. However, the
assistant Ombudsman liaised closely with the clinical reviewer during the
course of the investigation, including meeting with her to brief her on the key
clinical questions which my investigators considered needed to be answered.
One joint interview was conducted towards the end of the investigation with
one of the three medical officers who dealt with the man while in prison. The
Head of Clinical Governance at the PCT, was also present at this interview.
Of the other two doctors, I understand that the second of the locum staff
failed to attend the interview with The Head of Clinical Governance at the
PCT, the Clinical reviewer and the assistant Ombudsman, and the doctor that
worked on C wing healthcare was reluctant to attend an interview and he no
longer works at the prison. I understand that the PCT is continuing to try and
arrange for these interviews to take place.
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Woodhill prison
Background to the prison
18. Woodhill was opened in 1992 and was the last prison to be built with public
money. There is spacious residential accommodation, broken down into five
house units. There are large grassed areas between each house unit and
other buildings used for healthcare, administration, and the like. The prison
is located on the outskirts of Milton Keynes. It serves four Crown Courts and
magistrates’ courts within the Milton Keynes, Buckinghamshire, Bedfordshire
and Northamptonshire areas. The maximum operational capacity of the
prison is 762.
19. In her 2002 report, Ms Anne Owers, Her Majesty’s Chief Inspector of Prisons
(HMCIP), wrote that Woodhill is an extremely complex prison. “As a core
local, it holds all categories of prisoner from high risk category A prisoners
awaiting trial or sentence, to remanded young prisoners and fine defaulters.
In addition, it is one of only two prisons with Close Supervision Centres
designed to hold the most dangerous prisoners in the prison system.”
20. The residential wing – House Unit 1 – where the man was located for a few
days, is bright and airy. In contrast, C wing in healthcare, where the man
was placed when he arrived in the prison and where he died, is a rather dark
and dismal place. Healthcare cells in Woodhill do not have in cell electricity,
so it is not possible for prisoners to have a television. There is a television
room, but prisoners can only use this when they are out on association. Cells
do have access to radio, but reception is poor, and the programme is
controlled centrally, so prisoners cannot tune in to the station of their choice.
Prisoners are, however, allowed to smoke in the cells.
21. There is some evidence of an impoverished regime operating in healthcare.
Although the core day is intended to be the same in healthcare as in other
parts of the prison, staff told my investigators that lack of staff, and the variety
of regimes that could apply in healthcare (for vulnerable prisoners, young
prisoners and so on) could mean prisoners spending a lot of time behind
locked doors. They spoke of a time when prisoners on healthcare were given
their evening meal by passing the food through the observation hatch. There
is no evening association, and prisoners are locked up from about 4.30pm
onwards. One member of healthcare staff told my investigators that there
was a view amongst some officers that the regime needed to be harsh to
make it easier to encourage prisoners back to the residential wings.
22. There was also some evidence of a reluctance to provide support beyond a
certain level to prisoners on an open ACCT (a suicide watch procedure) on
the residential wings. My investigators were told that there was a view that
prisoners should be moved to healthcare if the level of observations required
was more than three per shift, because of the staffing resources that were
required on the residential wings to achieve this. A member of healthcare
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staff told the investigation team that a higher staff prisoner ratio in healthcare
meant that it was easier there to manage a higher level of observations. But
the consequence is that there may be prisoners in healthcare who have no
clinical need to be there, and for whom better care could actually be provided
on the residential wings.
23. Concerns about both the quality of the regime in healthcare and over reliance
of supporting potentially suicidal prisoners in healthcare were identified in the
2002 HMCIP report.
24. Newly arrived prisoners at Woodhill are normally located on House Unit 5.
On their first night, prisoners receive an individual induction briefing, lasting
20 to 30 minutes, from a member of staff. They are given a smoker’s pack (if
appropriate), and offered a three minute telephone call. The next day, they
are given a more detailed group introduction to the workings of the prison,
and about resettlement arrangements. There is subsequently a day of
introduction to education in the prison, and a further day dedicated to the use
of the gymnasium.
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Previous deaths
25. Between April 2004 and August 2005, there have been six other deaths at
Woodhill. Three of these were apparently self inflicted. In April 2004, a
prisoner who should have been identified as at risk of suicide or self harm,
but was not, took an overdose of medication which had been prescribed to
him to alleviate back pain. In June 2004, a prisoner who had been charged
with two counts of murder tied a ligature around his neck and made very
deep cuts to his neck with razor blades. He was found in his cell in the
Segregation Unit by the prison chaplain. There were no signs of life, no
pulse and significant blood loss, and an appropriate decision was made that
attempts to revive him would be futile.
26. The circumstances of each of these two deaths were quite different from the
man’s death. However, there are two specific recommendations arising from
the April 2004 investigation, the implementation of which my investigators
have checked during the course of the investigation into the man’s death.
These are set out below.
- I recommended that all staff involved in carrying out the First Reception
Health Screen interview should receive additional suicide refresher
training. A nurse carried out the man’s First Reception Health Screen.
She has been trained to a high level, as an assessor under the ACCT
procedure, in suicide awareness and prevention.
- I recommended that all staff trained in first aid were additionally trained
in the use of the defibrillator. The nurse first on scene arrived in the
man’s cell with the defibrillator when he was found hanging. She has
completed immediate life support training, which covers the use of the
defibrillator.
27. The third apparently self inflicted death occurred on the morning of 20 July
2005. This prisoner had arrived in Woodhill the previous day. My report of
this investigation is not yet finalised, but again the circumstances appear to
be quite different from those of the man. The prisoner was found in his cell
on a residential wing with a ligature around his neck. Strenuous and skilled
efforts were made to save him, but to no avail. Nonetheless, there are a
number of recommendations relevant to the man’s death. Specifically, I
expect to recommend:
- The introduction of a coding system at Woodhill so that staff, and
especially medical staff, can respond appropriately to a medical
emergency.
- A review of reception processes, with a view to minimising waiting
times for prisoners.
- A review of existing arrangements for ensuring that sufficient members
of staff retain their First Aid training qualification.
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28. The two other deaths in Woodhill since April 2004 were apparently from
natural causes. My report into the first of these, which occurred in February
2005, contains a number of criticisms of the healthcare the prisoner received
and made a number of recommendations which included:
- That healthcare professionals be reminded of the importance of
obtaining medical records from the prisoner’s General Practitioner
(GP).
- That healthcare professionals were reminded of the importance of
legible, accurate and through documentation, particularly in relation to
record keeping.
29. My investigation into the second death, in March 2005, concluded that the
prisoner received timely and appropriate medical care, and made no
recommendations.
30. I shall return to some of these recommendations from my previous reports in
my conclusions to this report.
Assessment, Care in Custody and Teamwork (ACCT) process
31. Since January 2004, Woodhill has used the Prison Service’s new ACCT
process for caring for suicidal or self harming prisoners. Prison Service
Instruction 18/2005 sets out what needs to be in place to run an effective
ACCT system, while Prison Service Order 2700 sets out arrangements more
generally for supporting suicidal or self harming prisoners.
32. The starting point is that all staff are responsible for the prevention of suicide
or self harm. Therefore, all staff in contact with prisoners are required to
have training at least to ACCT foundation level (a three hour course), and
there should be arrangements in place to ensure the training of all new staff.
In Woodhill, as part of the implementation process, 246 staff received basic
ACCT training, with a further 77 trained during 2005. In August 2005, there
were 334 officers in post.
33. Any member of staff who is concerned that a prisoner is at risk should open
an ACCT plan, stating the reasons for their concern. The Unit Manager or
Night Orderly Officer is then responsible for drawing up an immediate action
plan to support the prisoner. Within 24 hours of the concern being raised, a
trained ACCT assessor must conduct an assessment interview with the
prisoner. A case review is then held, ideally immediately after the
assessment interview. The Unit Manager must chair the first review, and
appoint a Case Manager (who must be a minimum grade of Senior Officer or
Nurse Grade F). The case review team must draw up a care and
management plan which sets out how the prisoner will be supported. Further
case reviews are then held as required.
34. In November 2005, Woodhill had 30 staff trained as ACCT assessors.
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35. The role of the Case Manager includes organising and chairing case reviews,
and ensuring care maps are actioned and updated. All Case Managers are
required to have attended the one day ACCT Case Manager training course.
During 2005, the prison trained 24 staff as Case Managers. It is not able to
say how many staff were trained during the ACCT implementation process.
In August 2005, there were 69 Senior Officers and 18 Principal Officers in
post.
36. Before a prisoner is returned from healthcare to ordinary location, there must
be a pre-discharge case review. The case review team must, amongst other
things, review the level of risk and update the care map, and arrange a
follow-up healthcare appointment.
37. When a prisoner moves units the receiving Unit Manager must appoint a
Case Manager.
Woodhill’s suicide prevention procedures
38. The suicide prevention policy in operation at Woodhill at the time of the man’s
death is dated May 2004. An updated version dated July 2005 is available in
draft. The points set out below relate to the May 2004 policy.
39. The policy says that a full time Safer Custody Co-ordinator (SCC) will co-
ordinate suicide prevention across the prison. This was taken over by a
senior officer in February 2005. The senior officer has some other duties as
well as being SCC.
40. Woodhill’s Safer Custody Committee is chaired by the Deputy Governor. The
prison says it meets monthly to consider strategic issues. A Suicide
Prevention and Anti-Bullying Sub-Committee also meets monthly, with a
focus on the day to day management of individual prisoners at risk.
41. The suicide prevention policy says that at risk prisoners in normal
accommodation should routinely be allocated to shared accommodation,
unless the prisoner represents a risk to others or their behaviour is too
disturbing. If they are placed in a single cell, the reason should be recorded
in the ACCT document.
42. The policy says that, following a deterioration in a prisoner’s state of well
being, the decision may be taken to place the prisoner in healthcare. This
can only be done following consultation with healthcare staff. The level of
supervision required must be established and specified on the case review
form, including whether the prisoner is at acute risk and therefore requires
constant observation, or whether the prisoner requires intermittent
supervision (where the prisoner is checked at least five times an hour). Staff
are required not just to observe the prisoner, but to interact with him.
43. Constant and intermittent observation can only be authorised by a doctor or
nurse, in consultation with the duty governor, or the duty governor, in
consultation with a doctor or nurse. The decision to locate the prisoner in
12
healthcare will be based on the assessment made by the assessor and in
consultation with the doctor or nurse and/or duty governor. (This is not in line
with Prison Service national healthcare standards, which state that admission
to healthcare is ‘at the sole discretion of the clinical head of healthcare (or
doctor/health care worker, deputised by him/her) and is based on clinical
needs, recorded in the patient’s clinical record.’)
44. A case review must be held prior to a prisoner being discharged from
healthcare following an in-patient stay. Staff from the unit to which the
prisoner is discharged must attend a pre-discharge case review to ensure the
care plan is amended to help the prisoner adjust to life on a normal
residential unit.
45. The suicide prevention policy also sets out emergency procedures for action
following self harm. It says that staff may enter a single cell alone in order to
preserve life. The safety of staff and the prison is also paramount, and must
be taken into account when deciding to enter a cell.
Woodhill’s contingency plans
46. Woodhill’s most recent contingency plans for handling a death in custody
expired in May 2005 and were reissued in July 2005.
47. The plans require that the person first on the scene should raise the alarm by
radio, telephone or alarm bell. A log keeper should be delegated and a note
kept of all staff and prisoners who were in the vicinity of the body. A note
should be made of the time each action is taken.
48. During the day and evening, the control room should tell healthcare staff
(radio call sign Hotel 1) to attend the scene. During the night, the plans do
not require a call to Hotel 1. The tasks of Hotel 1 during the day and evening
include collecting the emergency equipment required for the incident,
reporting to the scene and assessing the situation, asking the control room to
call for an ambulance if required, summoning the medical officer and
providing medical assistance to the prisoner. There are no actions set out for
Hotel 1 in the night state.
49. The control room is also required to:
- Call an ambulance when asked to do so.
- Tell the orderly officer, who is in charge of the day to day running of the
prison (radio call sign Oscar 1). The orderly officer should attend the
scene. At night it is the job of the orderly officer to request an
ambulance.
- Tell the duty governor (radio call sign Victor 2) of the situation.
- During the night state, tell the duty doctor.
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50. Once a doctor has certified death, the cell should be sealed until directed
otherwise by the police, the Coroner or the Coroner’s Officer.
51. During the day and evening, it is the responsibility of the orderly officer, in
consultation with the death in custody liaison manager, to arrange for a case
review for all prisoners on an open ACCT to identify what extra support or
vigilance is needed. The plans say that, day or night, it is also the
responsibility of the duty governor to ensure that all ACCT forms are
reviewed.
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Events leading up to the man’s death
Offences and sentencing
52. In January 2005, The man stole a mini digger, valued at £17,000, from a
building site. He put it in a van and drove off. He was pursued by the police
who tried to stop him. The van eventually overturned on the hard shoulder of
the motorway, and the man ran off but was quickly caught. On 9 May, he
pleaded guilty to possession of stolen property and dangerous driving. The
case was adjourned for pre-sentence reports.
53. In early June, the man went to see his GP complaining of depression. His
GP arranged for him to be seen that day by a consultant psychiatrist, and
various other appointments followed. The man said that he was suicidal, had
not been going out and thought other people were watching him. He was
diagnosed with clinical depression of severe to moderate intensity, and
provided with medication and support in the form of regular home visits from
the Community Mental Health Team.
54. On 5 July, the man’s health was reviewed by a doctor at a Community Mental
Health Centre. The man was still feeling suicidal. The doctor decided that
his medication should be increased – to 150mg of Venlafaxine – and the
home visits were to continue. The man was to be reviewed in the out patient
clinic in four weeks’ time. An arrangement was also made for the man to
have a CT scan of his brain, to rule out any boxing injury as the cause of his
depression.
55. On 18 July, the man returned to court for sentencing. The pre sentence
report said that the man was in contact with his GP about his mental health
and it was important that this continued. It said that the man was at high risk
of self harm or suicide, and asked that this information be passed to the
prison if he was given a custodial sentence. However, the probation officer’s
view was that a prison sentence would do little to address the man’s
offending behaviour and would be highly likely to have a negative effect on
him and his family. She did not consider him to pose a serious threat to the
public, and she thought that, in light of the man’s view that he would not be
able to cope while in custody, and his current mental health and suicidal
thoughts, a prison sentence was not suitable. She recommended that he be
given a Community Rehabilitation Order to address his offending behaviour
and provide support for changes in his lifestyle. He could be required to
undertake tuition to develop his literacy and numeracy skills, and increase the
chances of obtaining employment, while being the subject of an electronic
curfew order requiring him to be at home between 7.00pm and 7.00am each
day.
56. In the event, the court sentenced the man to 15 months in prison.
57. During the time leading up to 18 July, the man had been supervised by a
probation service officer. She was worried about the effect on the man of a
prison sentence, and made sure that the details of the man’s medical history
15
were available to the judge before sentencing. After the man was sentenced
but before he was taken to Woodhill, she spent some time in the cells with
him. She wrote a hand written note to the prison that afternoon expressing
her concerns. She said that the man was currently prescribed 150mg of
Venlafaxine daily for clinical depression, and had not brought any medication
with him. She asked that the information on the man’s mental health be
found. She also said that the man was terrified about being in Woodhill as he
believed that two men whom he said had assaulted him were in the prison.
She said that she thought the man should be kept in healthcare, and that he
had told her that he did not think he would make it through his sentence. She
put this note and the relevant papers, including the pre-sentence report and a
prescription confirming the man’s medication, in an envelope addressed to
healthcare, and handed it to the prison escort. She says the court clerk told
her he would also send the prison all the psychiatric reports about the man.
58. The man’s barrister recommended that the man be put on a suicide watch,
and a suicide/self harm warning form was duly opened at the court. It was
also noted on the form that the man said he had concerns about other
prisoners at Woodhill and feared for his safety.
The man’s time at Woodhill
18 July
59. The man arrived at Woodhill at 4.18pm, and was received in reception at
5.07pm. When a prisoner arrives, the paperwork that accompanies him is
taken to the front desk and dealt with by the Senior Officer on duty. The
evidence suggests that the clerk to the court did put the man’s medical
records together, including those from the man’s probation service officer,
and send them to the prison, as a handwritten note on the order of
imprisonment says:
“Urgent * P[re]S[entence]R[eport] attached plus medical reports for the
urgent attention of the Governor.”
60. A senior officer was on duty on the reception desk on 18 July.
Understandably, he cannot recall the man, or what happened to his records
from the court. He says that if an envelope addressed to healthcare arrived
with a prisoner’s documents, he would put it in the tray for the healthcare
officer on reception. If the documents were addressed to the Governor, he
would put them in a drawer for the discipline office where they would be
delivered the next day.
61. Certainly, the documents sent by the court and the probation service officer -
which included correspondence from the Community Mental Health Centre to
the man’s GP setting out the outcome of the review of the man’s case on 5
July, and a copy of a prescription of that date for the anti depressant
Venlafaxine at a strength of 150mg - were not available to medical staff who
saw the man on 18 July. By 20 July, the man’s handwritten note had arrived
in the healthcare wing office by internal mail and the medical documents
16
were, at an unknown subsequent date, linked to the man’s medical records.
The most likely explanation is that the documents marked for the urgent
attention of the Governor (which will have included those from the man’s
probation service officer) were sent to the discipline office and from there on
to healthcare in the internal mail.
62. At reception, prison staff completed various documents about the man. The
man’s core record gives his address as that of his wife. There is also a note
that he could not read or write. A cell sharing risk assessment concluded that
the man was a medium risk of harm to others. There is a note on the form
that says that the man was very worried about another prisoner, that his
barrister had said he should be put on the ACCT procedures, and that he had
been talking of a hunger strike.
63. The ACCT assessor carried out the first reception health screen. She says
that, if she had had the medical information from the court about the man,
she would have ticked the box on the form saying she had received
information from an outside source. The box on the form is blank. The
section of the form for details of the man’s GP has question marks in it. The
man told the ACCT assessor that he saw a psychiatrist regularly for severe
depression, and that he had an outstanding appointment at the Community
Mental Health Centre on 22 July. He explained that he had daily visits from a
care worker, and was taking medication for his mental health, although the
section of the form for details of the medication is blank. He said he had
previously tried to harm himself both inside and outside prison - the most
recent occasion being two years ago when he had taken an overdose - and
that he felt like harming himself now that he was coming into prison. He said
he had been treated on 16 July at the local accident and emergency
department for injury to his ribs, and that he wanted to see a doctor. The
man’s answers to the ACCT assessor’s questions meant that he was
required to be referred to the Mental Health Inreach Team (MHIRT) and to a
doctor. The ACCT assessor noted that the man was very nervous. The first
reception health screen was completed by 6.35pm.
64. At 6.45pm, The ACCT assessor opened an ACCT form. She said that the
man had attempted an overdose in the past and ‘could do something now
although he doesn’t want to’. She noted that he was extremely low in mood,
suffered from severe depression, and was vulnerable due to mental health
problems. The ACCT assessor, a nurse and healthcare officer agreed an
immediate ACCT action plan to support the man. (Neither the nurse or
healthcare officer have had formal training in the ACCT process.) They
decided that he should be admitted to the Healthcare Centre, spoken to or
observed twice an hour day and night, and given Listener access as required.
(Listeners are prisoners trained by the Samaritans.) The form says ‘Will
require telephone call’ which was to be the responsibility of the wing staff.
The man was also to be referred to the MHIRT. A note was made that the
next case review, due within 24 hours, should take place on 19 July.
65. There is a section on the inside cover of the ACCT form that asks for details
of the triggers or warning signs to prompt an immediate review, and the
17
person or department to be called. The instructions say that this should be
considered as part of each case review. This part of the man’s form says,
‘Has problems with another prisoner who he is sure is in the prison. If he
finds out that he is this may cause problems for him.’ There is no indication
of who should be called if an immediate review is required.
66. The man also saw the prison doctor that evening. The prison doctor noted
the problem of depression, two previous suicide attempts, and that the man
was being treated at the Community Mental Health Centre. The man said he
currently had thoughts of self harm, but would not do anything because of the
children. He said that he was taking three tablets, an anti-depressant, a
sleeping tablet and one other. The doctor said that the man should be
admitted to healthcare for observation, an ACCT form should be opened, and
there should be a discussion with his GP the next day about his medication.
Meanwhile, the doctor prescribed a sleeping draught (Sominex) for a period
of four nights. The man’s treatment chart shows that this medication was
administered nightly from 18 to 21 July.
67. The prison doctor said at interview that it was normally the MHIRT or the
doctor who were responsible for getting the GP records, but sometimes the
task could fall between the two. He would have expected the healthcare
wing doctor, to make sure the records were obtained the next day.
68. At 9pm, the man was admitted to the Healthcare Centre, wing C, and put
alone in cell 1-21A. He was said to be tearful and anxious due to family
concerns. There is a note that the escorting officer tried to ring his family, on
the authorisation of the duty governor, but that there was no answer. At
10pm, the man was given a Samaritans’ telephone while staff made a further
unsuccessful attempt to contact his family. By 11pm, the man was asleep.
He was checked regularly throughout the night.
19 July
69. The next day, the man seemed more settled, and staff invited him into the
office for a brief 15 minute induction to the prison. A prison officer
telephoned the man’s wife on his behalf, and arrangements were made for
the man to make a telephone call himself the next day, 20 July. To do this, a
PIN number had to be obtained from reception. (A new generic PIN number
is created each day which staff can use to give new prisoners their first night
telephone call.) The man was also asked to provide details of the telephone
numbers he wanted to be able to ring in due course from his own personal
PIN number. The man gave the numbers of his wife, mother and father.
70. There is a note in the wing observation book about the man’s smoker’s pack.
It says that the pack was issued to another prisoner who claimed to be the
man. The other prisoner refused to hand over the tobacco after the mistake
was identified, and he was placed on a disciplinary charge. The note does
not make it clear whether or not the man was issued with a new pack.
18
71. That afternoon, just before 3 o’clock, the man was seen by the healthcare
wing doctor. The man said that he had been taking anti-depressants under
the direction of a psychiatrist, and he wanted to take the same medication.
The doctor referred the man to the MHIRT. There is no record of any
conversation with the man’s GP.
72. An officer from the MHIRT saw the man just after the doctor. The officer from
the MHIRT noted that the man was tearful and distressed, and had a long
history of anxiety and depression, together with a family history of suicide. It
was not clear what medication the man was taking, and the officer from the
MHIRT was to contact the man’s GP and obtain his past history. The officer
from the MHIRT suspected that the man would not meet the criteria of the
MHIRT - that the prisoner has acute, or severe and enduring, mental health
problems - although each case is considered on its merits. He noted that the
man had suicidal thoughts but no intent to carry them out. He did not think
the man was currently at risk of suicide. The officer asked the MHIRT
secretary to request the man’s past medical history. He told my investigators
that, when he interviewed the man, the information from the court about the
man’s medical history was not with the records.
73. At about 7.30pm, the man asked to see a Listener to whom he spoke for
some time. Later that evening he was again given the Samaritans’ phone.
20 July
74. On the morning of 20 July, another prisoner died. That should have
prompted a review of all prisoners on an open ACCT. The man’s ACCT was
not reviewed.
75. During 20 July, the man asked about arrangements to phone his family. He
was told that staff were trying to sort out a PIN number for him. He is
reported to have been rather tearful, and said that it was his wife’s birthday.
He was able to make the telephone call at 1.45pm. His wife confirms that the
man did indeed ring her on her birthday.
76. At 3.20pm that day the man’s probation service officer, telephoned the
prison. The probation service officer says she rang to see how the man was,
and she was told that he was in healthcare. She asked the person to whom
she spoke to send the man her best wishes. One of the prison staff who
works on C wing in healthcare, says that the probation service officer’s hand
written note arrived on the wing in the internal mail and she brought it to a
nurse on the wing’s attention. The nurse on the wing made a note in the
man’s medical record that the probation service officer had telephoned, and
copied into the medical record the text of the probation service officer’s note.
This included the information that the man was being prescribed 150mg of
Venlafaxine daily.
77. A note was also made in the wing observation book and the man’s history
sheet that the prisoners of whom the man was scared were the two men that
assaulted him.
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78. At about 4.20pm, the prison officer from C wing healthcare noted that the
man was seen by the healthcare C wing doctor. There is an unsigned note in
the medical record at 4.30pm that says: ‘Note the above [ie the record of the
conversation with the probation service officer]. Called away.’ It has not
been possible to interview healthcare C wing doctor to find out the meaning
of this note, and what action he proposed to take. A note in the C wing
observations book says that, due to a death in the prison, healthcare C wing
doctor did not arrive until 4.20pm and then got called away to the segregation
unit at 4.30pm. The note continues, ‘Yet another day when C wing’s sick
parade wasn’t done.’
79. Later that day, the prison officer from C wing healthcare noted that the man’s
ACCT assessment was two days overdue, and that they had been asking for
it to be done since the morning.
21 July
80. An officer is a trained ACCT assessor. He carried out the ACCT assessment
with the man the following day, 21 July, at 9.45am. The man said that he had
been diagnosed with depression since 1999, and had lost three relatives, two
of whom took their own lives, and his son who had been still born. He said
that having a prison sentence had intensified his anxiety and depression. In
addition, there had been problems with people making threats against him,
and these individuals were now at Woodhill. He said that his last self harm
attempt was two years ago when he had taken an overdose. Although he felt
much better than when he first arrived at Woodhill, he still felt low most of the
day. He said he was unable to sleep even with the help of sleeping tablets,
and was not eating much. The ACCT assessor officer noted that the man
was very tearful during the interview when talking about his family, but that he
said he did not want to die and had not planned a suicide attempt. He had a
good relationship with his wife and two children, who would be visiting, and
good support from other family members and friends. The ACCT assessor
officer noted that the things that might help the man were proper medication
to help him sleep, and the possibility of him helping the cleaner.
81. The assessment was followed, at 10am, by an ACCT case review. The
prison officer from C wing healthcare (who has been trained in ACCT to
foundation level), the ACCT assessor officer, and the man were present. The
man said that although he thought about it, and felt very low, he had no
intention of killing himself as he had too much to live for and needed to
support his family. The review team concluded that the man remained a
‘raised’ risk, and that he should be observed three times each session (that
is, each morning, afternoon and evening shift), and five times at night.
82. An ACCT caremap was also agreed. This identified the following issues and
action:
- Highly depressed. To deal with this, the man had been referred to the
MHIRT on 19 July. There is no note about the outcome of this referral.
20
- Suicidal thoughts. To deal with this, the man was to ask for access to
Listeners, Samaritans, Chaplaincy and wing staff when he needed it.
- Unable to relax. To help the man with this, he was to use the therapy
unit. The ACCT assessor officer was to refer him to the Occupational
Therapist.
- Physical problems – deafness and sore ribs. To help resolve this, the
man was to see the doctor, and The ACCT assessor officer was to
place him on sick parade.
83. No action was agreed with regard to the question of the medication the man
was taking to help him sleep, or helping with the cleaning.
84. The man saw the healthcare C wing doctor again at 11.35 that morning.
There is a note in the medical record that the man wanted to go back on
Venlafaxine, as set out in the letter from the psychiatrist, and that Sominex
was not helping him to sleep. The man also mentioned the problems with his
ears and his ribs. The doctor prescribed 75mg of Venlafaxine daily, and
eardrops. He noted in the medical record that the man was due to be seen
by a psychiatrist, and was fit for ordinary location. It has not been possible to
interview the healthcare C wing doctor to find out why he prescribed 75mg of
Venlafaxine, when the medical record suggested he had been getting 150mg,
and whether any other medical information was now available. Nor has it
been possible to ask him about the reference to the psychiatrist (there is no
other evidence to suggest that the man was to be seen by a psychiatrist). It
was agreed that the man would remain in healthcare until after the weekend.
The man’s treatment chart shows that he was issued with 75mg of
Venlafaxine on the afternoon of 21 July, and every subsequent morning up to
and including 27 July.
85. Also on 21 July, and as agreed in the officer from MHIRT’s assessment of 19
July, the MHIRT asked the Hertsmere Community Mental Health Team for
psychiatric information about the man. No request was made of the man’s
GP.
86. The man’s personal PIN telephone number was set up on 21 July, allowing
him to make telephone calls if he had the money to do so. He came to the
prison with no money at all, and was given 50 pence a day ‘unemployed pay’
by the prison, together with an advance of £2.50. Thus on 21 July he had
£3.50 in his account. He spent £2.00 on 21 July, and again on 26 July. The
man’s wife says that on 22 July she sent him a letter and postal order for £20
so that he could buy things while in prison, but this never reached him.
22 – 24 July
87. During the night of 21 to 22 July, the man threw his chair around his cell
because he could not sleep. The prison officer from C wing healthcare told
him this was not acceptable behaviour. However, there were no other
reported problems with the man, either later that day or on 23 July.
21
88. On 22 July, while the Occupational Therapist from the MHIRT, was on the
wing, the man asked if he could speak to her. The occupational therapist
said that she did not know about his care, but that she was happy to talk.
The man was concerned about a conversation he said he had had with the
healthcare C wing doctor suggesting that he had alcohol or drugs problems,
which he strongly denied. The occupational therapist says that the man was
shaking when he spoke to her. He told the occupational therapist that he had
a diagnosis of depression, and that he had not had a MHIRT assessment.
The occupational therapist arranged for an assessment to be done on 25
July. Meanwhile, she advised staff that, as the man seemed agitated, he
should stay in healthcare until the assessment was complete.
89. The prison officer from C wing healthcare made a note in the man’s history
sheet dated 23 July, saying that he had been interviewed by the MHIRT and
he was to remain on healthcare. As 23 July was a Saturday when the
MHIRT do not work, it seems likely that the entry should have been dated 22
July.
90. On 23 July, the healthcare officer drew up a nursing care plan for the man.
He identified the main issue as depression, which was to be overcome by a
positive response to his prescribed medication. The man was to be
assessed while in healthcare and to remain on ACCT. Staff were to interact
with him to determine his mood.
91. Also on 23 July, another prisoner moved into the man’s cell. Both the man
and his new cell mate confirmed to staff that they were happy with this.
92. On Sunday 24 July, the man saw a second prison doctor who prescribed
Ibuprofen for the pain in the man’s ribs.
93. Later that day, the man had a visit from his wife, mother and son. Before the
visit, the man told prison staff that he was looking forward to the visit, and
that he had no concerns about it. The man told his family that he had not
received the postal order they had sent him, and that he was reduced to
smoking tea leaves or begging dog-ends off other prisoners.
25 July
94. On Monday morning, 25 July, the man said he wanted to be relocated onto a
normal wing. He was told that this was not possible until he had been
assessed by the MHIRT.
95. The occupational therapist undertook the MHIRT assessment that afternoon.
She did not know that the officer from MHIRT had already conducted an
assessment. However, she later saw the man’s name in a referral book,
realised he had already been assessed, but was not able to find the record of
the assessment.
96. The occupational therapist says that she spent about two hours with the man
that day, and he was much happier than he had been the previous week.
22
Although the man did not strictly meet the criteria for help from the MHIRT,
she thought that he needed support. She invited him to attend various
Occupational Therapy groups, including art therapy, relaxation, leisure and
cookery. The first session - of art therapy - was to be Thursday 28 July, and
he was to attend three sessions the following week. She arranged to see the
man on Friday 5 August for a one to one session. In her assessment, she
said that she thought the man was at high risk of self harm. She planned to
obtain further information about him from his GP. She suggested he might
need a CT scan to rule out the risk of physical problems, and noted that a
psychiatric appointment would be made if necessary. She considered that
one of the triggers that might increase the man’s risk was not receiving his
medication. As part of the risk plan, she said that the man’s medication
should be reviewed, as required, by the doctor or psychiatrist. She told my
investigators that the man was not able to say what medication he was
taking, and could only describe the size and colour of the tablets. She said
that if the man had been worried about his medication, she would have put
this in her notes, but her recollection was that the man’s main concern was
his family.
97. Although the occupational therapist’s note in the man’s medical record says
that the man was to be reviewed by the MHIRT on 27 July, she says this was
not the correct date. The intention was to see the man weekly, and this is
what she wrote on the assessment form. She also intended to see him on
Thursday 28 July at the art therapy class.
98. At the time of the assessment, the occupational therapist did not have the
information that had been requested from the Community Mental Health
Team. This arrived by recorded delivery later that week. Nor did she have
access to the medical documents that had arrived in the prison with the man,
but not been linked to his medical records.
99. The man also told the occupational therapist about the other prisoners that
he thought might be a threat to him. She passed this information on to a
Senior Officer.
26 July – healthcare
100. On the night of 25 to 26 July, wing staff noted that the man was awake until
after 2am talking to his cell mate. At 10am on 26 July, there was a review of
the man’s ACCT case with a view to discharging him from healthcare. The
review was conducted by a senior nurse, the ACCT case manager, the prison
officer from C wing healthcare and the man. The man was considered to be
settled in mood and behaviour, with no evidence of ideas of self harm or
suicide. The man said he was well enough and confident enough to be
moved to a normal wing. The level of risk was now identified as low. It was
subsequently decided that the case was to be reviewed on 2 August. There
is an indication on the ACCT form that the caremap was updated, but the
only caremap completed was the one dated 21 July. The senior nurse says
that additions would only be made to the caremap if there were specific
things that needed to be done. No-one from the residential wing where the
23
man was to be located attended the review, as the prison’s procedures
require. Nor was anyone from the wing identified as the new ACCT case
manager. There is a note that a follow-up healthcare appointment was to be
made by the treatments nurse on the wing, but no evidence that this was
done.
26 July to 1 August - the man’s time on a residential wing
101. At 10.45am on 26 July, the man arrived at House Unit 1A. He was given an
outline about the way the unit worked and an explanation of the ACCT
arrangements. The man said he was more positive about the future and
would approach staff if he had any problems. Later that day he asked for a
transfer application. A member of staff offered to write it for him but he said
he had a friend to do it.
102. By 8.30pm, the man appeared less positive. A member of staff asked him if
he was alright, and the man said he wanted to be but simulated hanging
himself. Wing staff told the Assistant Orderly Officer about this.
103. Also on 26 July, prison staff looked into the man’s concerns about risks from
fellow prisoners. Security staff spoke to the man, and confirmed that there
was a prisoner of the name given by the man on another wing. A note was
made on the man’s history sheet to say that he must not come into contact
with this prisoner. A note was also to be made in the wing observation book,
but this was not done.
104. That same day, the prison had received a letter from the man’s stepfather,
written the previous day. Attached to the letter was an appointment for the
man’s CT brain scan on 15 August. The letter said:
“I am the man’s stepfather and am sending on this hospital appointment
regarding a CT scan at hospital. His wife and mother visited him
yesterday, Sunday 24th @ 3.10, and are very concerned about his
physical & mental condition. He is not receiving the medication
prescribed by his doctors & the judge at his trial, he is very depressed, not
sleeping & we fear for his wellbeing. His solicitor has been advised and
will no doubt be enquiring.
“Please keep a watch on him & help him as there is so much going on
that he is worried about that he says he can’t cope with it.”
105. The prison secretariat passed the letter to healthcare for a reply by 5 August.
The Head of Healthcare says she received the letter on 27 July and looked at
the deadline for a reply. She was due to go on holiday the next day. As the
deadline for a response was some time after her return from holiday, and she
had other correspondence where the deadlines were approaching, she did
not deal with the man’s step father letter that day. She told my investigators
she thought it unlikely that she read the letter, and that she only checked the
deadline. She returned to work on 1 August but, because of pressure of
other work, she did not look at the man’s step father’s letter until the following
24
day. She told my investigators that there was no mechanism within the
prison for identifying urgent correspondence.
106. The ACCT document suggests that the man gave prison staff no cause for
concern on either 27 or 28 July. The man was due to be at the art therapy
class on 28 July but he did not attend. The occupational therapist made a
note that she would chase him up about this the following week.
107. Also on 28 July, the man’s treatment chart shows that he was not given his
Venlafaxine. There is no note in the medical records to explain why the
medication was not administered and it seems likely that this was an error.
108. During the evening of 28 July, the man made a telephone call to his family to
whom he spoke for over six minutes. During the conversation he told his wife
that the money he had been expecting still had not come. She said she still
had the post office slip, and that she would go back and check with the post
office. She asked the man if he was getting his medication. He said no, and
that the staff kept ‘fobbing him off’. He said he had been given one dose of
75mg of the anti-depressant, and that had been two days ago.
109. The next day, 29 July, the man told wing staff that he was waiting for a letter
with some photographs and a postal order. The officer on the wing asked
healthcare to check if they had received it. Later that day, the man enquired
again, and was told that healthcare had been asked to check and that he
should chase this up the next day. He did so the next morning, 30 July, and
the officer on the wing said he would look into it. The man asked again that
afternoon. By 5pm, the man appears to have lost his patience as he talked
about smashing up his cell and going to the segregation unit. Staff calmed
him down, but later that evening he said he was still waiting for his letter to be
sent over from healthcare. Wing staff once again said that he should raise
this the next day, 31 July.
110. On the morning of 31 July, the man refused his Venlafaxine and said he was
going back to bed. The man’s mother visited in the afternoon and told him
that his father was ill.
111. That evening, there is a note that the man was once again asking for his
post, and was again told the matter would be looked into in the morning.
Later on, there is a note that he was talking to his cell mate, and that they
really seemed to get on well.
Events on 1 August – the move from House Unit 1 to the Healthcare Centre
112. On the morning of 1 August, the man asked a prison officer about his letter,
photos and postal order for £20. She checked his account and confirmed
that the postal order had not been credited. She telephoned healthcare, who
could not see the postal order in their cash book. The man also asked the
prison officer about his smoker’s pack, which he said he had not received.
She told him she would ring House Unit 5 to find out what had happened to it.
The prison officer later went back to the man to tell him she was waiting for a
25
call back from House Unit 5, and that she would try the other healthcare wing
(A wing) about his letter.
113. At about 11am, the man spoke to staff about his father being in hospital.
Someone from the chaplaincy team came over to speak to him, after which
he seemed happier. But at lunchtime, although he ate some food, the man
was reported to be very low and asked to speak again to the prison officer.
At about 1.45pm, he approached her on the stairs and told her that he
wanted to hang himself. She sought advice from a more experienced
member of staff. The more experienced officer telephoned the healthcare
officer, who was in charge of the duty room in healthcare that afternoon. The
healthcare officer said that she should check with the nurse, who was the
nurse regularly assigned to distribute treatments to prisoners on House Unit
1. However, the House Unit 1 nurse could not be found, and so the more
experienced officer again telephoned the healthcare officer and then went
back to speak to the man. She found him in a low mood and again asking to
speak to the prison officer. The more experienced officer telephoned the
healthcare officer for a third time, saying that the man was low and speaking
of hanging himself. She said that she thought he needed to be assessed by
healthcare. The healthcare officer again advised speaking to the House Unit
1 nurse who was on his way back to the Unit.
114. The more experienced officer then went to seek the advice of the principal
officer, taking the man’s ACCT document with her. She says that the
principal officer said that she needed to get the advice of healthcare, and if
necessary to move the man to healthcare where he might be put on a
constant watch. She waited about ten minutes, but the House Unit 1 nurse
had still not arrived on the Unit so she telephoned the healthcare officer a
fourth time. She says she explained that she had spoken to the principal
officer, that the man was threatening to hang himself, and that he might have
to be moved to healthcare and put on a constant watch. The House Unit 1
nurse then arrived on the Unit.
115. Up to 1 August, The House Unit 1 nurse’s involvement with the man had
been to administer his medication on the wing. (The man’s treatment chart
shows that the House Unit 1 nurse administered the man’s medication from
29 July to 1 August.) The House Unit 1 nurse told my investigators that the
man had said his medication should be at a higher dose, and he agreed to
speak to a doctor to sort this out. He checked the man’s medical notes and
there was some indication that the man was right. He says he also received
a call on 1 August from staff on House Unit 1 expressing concern about the
man. The House Unit 1 nurse says he was in healthcare at the time, so he
went to see the prison doctor with the medical notes. The prison doctor
agreed to increase the dose of Venlafaxine to 150mg daily. The House Unit
1 nurse says he also explained to the prison doctor that the man was
currently distressed, and they agreed that it might be best to readmit the man
to healthcare on the grounds that it was better to be safe than sorry. I note
that, according to the House Unit 1 nurse’s account, the decision to admit the
man was taken by the prison doctor and the House Unit 1 nurse without
seeing the man, and without access to his ACCT document.
26
116. In contrast, the prison doctor says that the House Unit 1 nurse only
approached him about the man’s medication. On the basis of seeing the
man’s prescription for Venlafaxine before he came into prison, the prison
doctor agreed to increase the dose. He thought this conversation took place
at about lunchtime. He is adamant that there was no discussion at all about
anything other than the Venlafaxine. He says that the House Unit 1 nurse
told him nothing about any concerns about the man’s mental health or his
threats to kill himself. Had he known this information, he says he would have
asked the duty room to arrange for the man to be brought over for a
consultation with him.
117. The House Unit 1 nurse says he took the new medication chart to pharmacy
because he wanted to make sure that the new dose of Venlafaxine was
available when the man was readmitted to healthcare. The prison’s records
show that the 150mg Venlafaxine tablets were dispensed at 3.19pm on 1
August.
118. The House Unit 1 nurse says he also went to the duty room and said the man
should be admitted, asking if a bed was available. He told my investigators
that it was the responsibility of staff in the duty room and those in charge of
healthcare to decide where the man should be located. He said he and the
prison doctor in deciding that the man should be admitted to healthcare, did
not make an assessment of the sort of cell into which the man should be
placed or of whether or not he needed to be on constant watch.
119. The healthcare officer confirms that the House Unit 1 nurse spoke to him
about admitting the man to healthcare. He says he told the House Unit 1
nurse that, if he was concerned about the man and thought he should be
admitted, then healthcare would admit him.
120. The House Unit 1 nurse then went to House Unit 1, where he spoke to the
man who was standing outside his cell door. The prison officer and a second
prison officer were also present. The House Unit 1 nurse says the man
seemed alright, but it was difficult to tell and staff were concerned about him.
He thought the man needed to be observed more closely and his condition
reassessed. He had access to the man’s ACCT document on House Unit 1,
but he did not read it, and did not consider it was his responsibility to
reassess the man’s care. The House Unit 1 nurse has not received any
formal training in the ACCT process.
121. The House Unit 1 nurse says that he told the person in charge of the duty
room that the man was on his way over. He could not recall who was in
charge that afternoon (in fact, it was the healthcare officer) or whether he
telephoned or went over to the duty room to say that the man was arriving.
Once the man was escorted to healthcare, the House Unit 1 nurse says his
involvement ceased. In effect, he says his task was only to make the
decision (according to his account, jointly with the prison doctor) that the man
should be admitted to healthcare. He says it was the responsibility of staff in
healthcare to interview and assess the man when he arrived. He says he
27
would have expected the duty room to tell the ward staff that the man had
arrived, and for the ward staff to do the assessment and arrange for the man
to be seen by a doctor if necessary.
122. The House Unit 1 nurse made no note of his discussions with the prison
doctor, his assessment of the man, or of the decisions he made that
afternoon, either in the man’s medical records or in his ACCT document. Nor
did the prison doctor make any note of his decision to increase the man’s
medication, other than on the man’s treatment chart, or the reasons for it.
123. The more experienced officer says that the House Unit 1 nurse told her that
he had contacted healthcare and there was a double cell available on C wing.
The more experienced officer told the man that he was being admitted to C
wing, but he said that he did not want to go. She tried to explain that it was
the best place for him, and that he might be put on constant watch, but the
man remained reluctant and eventually walked off and went back to his cell.
The House Unit 1 nurse and the two prison officers also spoke to the man.
The prison officer had a long conversation with him, when he talked about the
problems with his medication and his missing letter and about going on
hunger strike. The prison officer said he could speak directly about these
issues to healthcare. She says that the man seemed very down and
confused about what he wanted, and she told him he would probably only
need to be in healthcare for two or three nights for assessment. By the end
of their conversation, he seemed more settled and agreed to go to
healthcare.
124. The two prison officers took the man to healthcare. They say he seemed in
better spirits on the walk over. When they arrived at C wing in healthcare,
they passed his ACCT form over to a third prison officer. The prison officer
says she fully explained the situation, and the second prison officer confirms
this.
125. The notes in the ACCT document written by the prison officer for 1 August
say:
“13.45 Whilst I was on my way to commence main moves the man
approached me to say he is feeling very low and he has a lot of
things on his mind he said he does not mind going to the block
then he stated he would hang himself. Told him I would speak
to him when I get back off moves he said thanks miss.”
“16.00 Spoke to the man who was refusing to go to Healthcare saying
he would rather go to the block told him it was for his best
interest to go so he could be assessed by Healthcare. Said he
would go but he would go on hunger and liquid strike. He also
kept saying he would not be back.”
126. The prison officer on C wing healthcare and the third prison officer were both
on duty on C wing in healthcare that afternoon. During the course of the
afternoon, The prison officer on C wing healthcare says the healthcare officer
28
in the duty room told them that the man might be arriving, and thus they had
been expecting him although they were not entirely sure he was coming. At
about 4.30pm, the third prison officer received the man in healthcare and
placed him in cell 20, the only vacant cell on the wing. This was a double
cell, with bunk beds, but the man was placed there alone. The hand-over
from staff from House Unit 1 took place in the C wing office. The third prison
officer dealt with the hand-over, and the prison officer on C wing healthcare
was present in the office. The third prison officer says the House Unit 1 staff
told him that the man had said he would kill himself, so he rubbed him down
and took his shoelaces from him as a standard precaution. The third prison
officer’s shift was due to finish at 5pm, and he left the wing at about 4.50pm.
The prison officer on C wing healthcare remained on the wing alone, as she
was on duty that evening.
127. The prison officer on C wing healthcare says she understood the concerns
about the man were that he was going on a hunger strike, and that she was
not aware that he was threatening to hang himself. She accepts that that
information is in the ACCT document, and that she did not read this
sufficiently thoroughly. In relation to the cell in which the man was placed,
she says she told the duty room that cell 20 was the only one available.
128. All the discipline officers who dealt with the man that day have received
ACCT training to at least foundation level.
129. When the man arrived on the wing, the prison officer on C wing healthcare
says she put him on the roll, and telephoned the duty room to say that he had
arrived. She believes she spoke to the healthcare officer, who expressed
surprise that the man had come over as he thought the problem had been
resolved.
130. The healthcare officer does not recall being told that the man had arrived on
the wing. He went off duty at 5.45pm, and he said at interview that he
thought he had gone home by the time the man was brought over. When my
investigator pointed out that the man had arrived before 5pm, the healthcare
officer said that he was not aware of that.
131. The duty room log shows that at 4.57pm the roll was correct. This means
that the count of the prisoners from the wings matched the roll board in the
duty room. This entry is initialled by the healthcare officer.
132. Healthcare staff made no arrangements for the man to be formally admitted
into healthcare, or for any assessment to be made of his mental health, what
accommodation was safe for him, and what care he needed. The prison
officer on C wing healthcare on House Unit 1 did not see it as his job to
arrange this. The healthcare officer in the duty room told my investigators
that, once the man had been placed in the cell in healthcare, he should have
been seen by a doctor and a decision made about changing the frequency
with which was observed. He said he did not know how that would be
arranged or who was responsible for organising it, and had no idea why it
had not been done. He said there might be a procedure for admission to
29
healthcare, but he was not familiar with it. The healthcare nurse was the
nurse responsible for A and C wing on healthcare that afternoon. He says he
could have been on either wing at about the time the man was brought over.
He would have conducted an assessment of the man and drawn up a care
plan, but no one told him the man had arrived or passed him the man’s
medical records to enable him to do this. He said the discipline staff on C
wing should have told him the man had been brought over, by telephoning
him on A wing if necessary. The healthcare nurse went off duty at 5pm. He
told my investigators that he was not aware of any standard arrangements for
admitting prisoners from a residential wing to healthcare.
133. An agency nurse appears on the daily staffing rota as taking over
responsibility for the duty room from the healthcare officer from 5.45pm to
6.30pm. However, the healthcare officer recalled handing over to a different
second agency nurse. The second agency nurse is shown on the rota as
assisting in the duty room. The agency nurse confirmed to my investigators
that, although she was down on the rota, she did not in fact cover the duty
room as the healthcare manager was around, and the agency nurse was
needed for treatments.
134. The healthcare officer says that he told the second agency nurse during the
handover that there was a problem with two prisoners from the main prison,
and that the doctor had gone to assess one of them. He says he told the
second agency nurse that he had spoken to the House Unit 1 nurse and told
him that, if he was concerned about the other prisoner (who was in fact the
man), that prisoner should come over to healthcare.
135. The second agency nurse says she arrived in the duty room some time after
5pm. She says she did not take charge of the duty room because the
healthcare manager was there, and it was the healthcare manager’s
responsibility to take charge. The second agency nurse says that she was
just assisting. The healthcare manager told my investigators that she did not
take over the duty room, but that from about 5.45pm she based herself in the
back of the duty room for support.
136. The second agency nurse says that, when she arrived, the healthcare officer
was in the duty room. She says she did not get a handover, although she
would have expected to have done so. At the time, she says the duty room
was in turmoil with lots of phone calls and prisoners being moved about,
although this was not unusual. The second agency nurse says she does not
recall anything about the man being admitted into healthcare. If he was
admitted at about 4.30pm, she would not have been in the duty room at that
time. She says no one mentioned him to her when she came on duty. The
healthcare manager also says that she was not aware that the man had been
admitted to healthcare.
137. The nurse that was first on scene arrived at about 6.30pm to take over
responsibility for the duty room. The second agency nurse says the nurse
first on scene was given a handover, although she was not sure whether she
did this herself or whether the healthcare manager did it. The second agency
30
nurse says she remained on duty, assisting the nurse that was first on scene,
until about 8pm.
138. The nurse that was first on scene confirms that she was given a handover by
the second agency nurse. She says she was told (but she was not sure
whether by the second agency nurse or the healthcare manager) that the
man had been brought over that afternoon because there were concerns
about him, that he was on an open ACCT, and that he was to be in
healthcare for observations overnight. She told my investigators that any
assessment of the man should have been done before she came on duty.
Events on 1 August – Healthcare Centre
139. Once the man had been placed in the cell in healthcare, he would have
remained locked up for the whole evening apart from contact over the
evening meal. When the meal was served, he would have been unlocked,
allowed to chose his meal from the door of his cell, and then been locked up
again to eat it.
140. At 5.12pm, a chaplain spoke to the man through the cell hatch and said they
had been unable to find out in which hospital his father was a patient. They
were to try and contact his mother. The chaplain noted that the man seemed
in good spirits. He went to the wing office and about five minutes later saw
the man again. To his surprise, the man’s mood had changed dramatically.
He made a note in the ACCT document that the man was now tearful and
said he wanted to transfer to a mental hospital.
141. At 6pm, the prison officer from C wing healthcare noted that the man did not
eat his supper. He told her about his father being in hospital, and that he
could not cope in House Unit 1A. At 7.30pm, the officer from C wing
healthcare noted that the man said he was alright, and did not want any
water. At 8pm she looked through the hatch and saw him lying on the bed.
He said that he was okay. These three observations were the ones the
officer from C wing healthcare was required to make under the ACCT
document (which specified three observations per session). The officer from
C wing healthcare said in her statement after the man’s death that the man
had stood at his door for most of the evening, smiling and talking every time
she passed. The officer from C wing healthcare told my investigators that
she recalled talking to the man about some photographs and money that
were supposed to have been sent to him. She looked on the computer and
found there was a parcel for him in reception. She told the man she would try
and get it for him the next day.
142. At about 8.15pm, a nurse started doing his rounds. He started at cell 13 and
worked his way round to cell 20. He looked through the hatch of cell 20 and
saw the man hanging from the bed. He knocked on the cell door to try and
attract the man’s attention, and then went to the main office which was a few
feet away to alert the officer from C wing healthcare. The nurse doing the
rounds and the officer from C wing healthcare returned to the cell, and the
officer from C wing healthcare radioed the control room with an urgent
31
message to say that someone was hanging. In her written statement, the
officer from C wing healthcare said that she was not allowed to enter the cell
alone and that the policy on this was very strict. She told my investigators
that she did not want to enter the cell alone. She said she would not have felt
safe to do so as the man could have been faking a hanging. She went to the
office to get scissors. She heard the control room radio an urgent message,
but not contact the radio call sign ‘Hotel 1’. The nurse that was first on scene
in the duty room was Hotel 1, and so the officer from C wing healthcare rang
her directly. The control room log has no record of a call to ‘Hotel 1’.
143. An officer from A wing was handing over to a third agency nurse on
healthcare’s A wing when she heard the urgent message about a hanging on
C wing. She and the third agency nurse went immediately to C wing (the
nurse doing the rounds says that help arrived in about one minute) and tried
to open the cell door, although the man’s feet at first wedged the door. After
a few seconds, she managed to get the door open. The officer from A wing,
the officer from C wing healthcare and the third agency nurse entered the
cell. The officer from C wing healthcare cut the ligature, while the officer from
A wing supported the body. The officer from A wing and the third agency
nurse checked for a pulse. The officer from A wing then started chest
compressions, while the third agency nurse started mouth to mouth
resuscitation. This life saving procedure is known as CPR.
144. The nurse first on scene then arrived at the cell. She did not bring any
equipment, on the grounds that she wanted first to check what was
happening. She then went to fetch the oxygen, which was in the treatment
room on C wing, and the defibrillator, which was in the main treatment room
downstairs from C wing with the rest of the emergency equipment. (A
defibrillator is a machine which can administer an electric shock intended to
restore heart rhythm.) The second of the locum staff then entered the cell,
although it is not clear exactly when this was. The nurse that was doing the
rounds says CPR was carried out for five to ten minutes before the doctor
arrived. The second of the locum staff checked for a pulse, while CPR
continued. After the nurse first on scene returned with the defibrillator, they
attached it to the man but the machine told them not to shock him. The nurse
first on scene then took over chest compressions from the A wing officer, who
went to C wing to fetch the ambubag which contains oxygen and equipment
to administer it. The second of the locum staff then asked for a canula and
adrenaline. The officer from A wing went back downstairs to the main
treatment room to get the emergency bag which contains this, and returned
to C wing with a nurse. Throughout this time, the nurse first on scene and
the third agency nurse continued CPR.
145. On instruction from the second of the locum staff, the nurse first on scene
and the third agency nurse then stopped CPR, and at about 8.31pm the
doctor pronounced the man to be dead. The second of the locum staff
appears to have made no record of the actions he took or of the death. He
failed to attend the interview that had been arranged, and so it has not been
possible to put this to him or to obtain his account of the actions he took that
evening.
32
146. Meanwhile, an orderly officer received the urgent message at about 8.15pm.
He arrived at healthcare and found staff trying to revive the man. At 8.18pm,
he asked that an ambulance be called, and this was done at 8.19pm. The
ambulance arrived at the healthcare centre at 8.29pm. The nurse from the
rounds says that by the time the ambulance arrived the doctor had
pronounced death. At 8.36pm, the orderly officer told the control room that
the man had died. The police were told at 8.37pm, and the ambulance left
the prison at 8.39pm.
147. There is no contemporaneous log, and so no timings, of who arrived and left
the man’s cell from the time he was found until the cell was secured.
148. The man’s cell was secured at 8.51pm. The police arrived at 9.09pm.
Governor and a second governor arrived on the unit at 9.44pm, and talked to
the night staff and the police. The police scenes of crimes officer arrived at
10.27pm and examined the cell. The Coroner’s Officer arrived at 11.05pm.
Shortly after this, the undertakers arrived and took away the man’s body.
149. The second governor and the healthcare manager made sure that all the
cases of all the prisoners in healthcare on an open ACCT were reviewed that
night.
150. The Governor had the responsibility for contacting the man’s family. He
arranged for a chaplain to accompany him, and asked the police to check the
next of kin details. Once this was done, the governor and chaplain visited the
house with the police, but it turned out to be the man’s wife’s sister’s house.
They were directed to a neighbouring house, where the man’s wife, their
children, and the man’s mother in law were found. They broke the news at
about 2am on 2 August. The man’s son was so distraught on learning of his
father’s death that he punched the wall and damaged his arm. The police
officers were invited in and helped administer first aid. The man’s son was
later taken to hospital.
151. Arrangements were also made for the police to break the news to the man’s
mother and stepfather, who were due at work at 3am. The Governor and
chaplain subsequently checked that this had been done. They were told that
The man’s mother would tell his father. The Governor and chaplain remained
with the family until about 5am.
152. Later that day, notices were put up in the prison telling staff and prisoners of
the man’s death. That afternoon, the second governor spoke to all the
prisoners on C wing to check how they had been affected by the man’s
death.
153. At 8pm that evening, a critical debrief was held for night staff involved in
finding the man and trying to save him. Those staff who spoke to my
investigators said that the prison had offered them support, and those who
had taken advantage of it had found it helpful.
33
154. The second governor was appointed the prison family liaison officer. She got
in touch with the family, and also wrote to them to confirm her role and to
offer any assistance. She also offered, on behalf of the prison, to pay the
family’s funeral expenses.
155. After the man’s death, the prison located the letter, photographs and postal
order about which the man had been enquiring, and returned them to his
wife. The second governor told my investigators that the letter had been
found in reception. She said it was marked as having been sent to House
Unit 1, and then on to healthcare, and finally back to reception. The man’s
wife arranged for the correspondence to be buried with him.
156. When the police searched the man’s cell, they found a brief suicide note, in
which the man sent his love to his wife and children and said sorry.
157. The man’s wife has raised concerns about the man’s clothes, which she says
were incinerated by the prison. However, after the cell was sealed the
responsibility for what happened to the man lay with the police and the
Coroner. I believe that the man’s clothes may unfortunately have been
incinerated after he was taken to the mortuary, but there is no evidence that
this was a matter in which the prison was in any way involved.
Views of other prisoners who knew the man
158. On 22 July, another prisoner who was a close friend of the man, moved from
healthcare wing A to wing C. While they were on the wing together (which
was from 22 July to 26 July), he says the man told him that he was not
getting the medication that he needed. When the man asked staff about this,
they refused to help. He particularly heard the man asking a doctor for
medication, and saying that he needed something to help him sleep.
159. The man’s friend says that while the man was in healthcare he was given a
letter confirming that he would be released on a ‘tag’ on 10 or 11 November.
He was very happy about this, as it meant that he would see his wife and
children again before too long.
160. The man’s cell mate on House Unit 1 says he and the man got on well,
although the man was depressed and talked of taking his own life. The
man’s cell mate read out to the man the papers about his release in
November, and pointed out that he only had 12 weeks to serve in prison. He
did his best to look after the man, and made it clear that he would do what he
could to stop him from committing suicide. He says that the man did not
have any problems on the wing, and that staff treated him well. The man did
not mention to him problems with his medication or his post.
Post Mortem
161. The post mortem was not available to my investigator at the time that this
report was issued in draft.
34
162. A toxicology report shows that there was no Venlaflaxine in the man’s blood
at the time of his death. The toxicologist notes that, when taking
Venlaflaxine, it may be several weeks before an anti-depressant effect is
observed. If it is taken on an irregular basis, the therapeutic benefits may not
be fully achieved. The toxicology report does not say how long Venlaflaxine
might be expected to remain in the body. The clinical review points out that
the man could have suffered some side effects from reduced and missing
doses of Venlaflaxine, but that there is no evidence that he complained of
these effects. The review also notes that there is no evidence to suggest that
a decrease in dosage is linked to increased risk of suicidal ideas.
163. The toxicology report notes that no other drugs or alcohol, apart from the
possible presence of a low concentration of cannabinoids, were detected.
Clinical review
164. The clinical review was not available at the time my report was issued in
draft. It makes a number of recommendations, which the Governor and the
PCT will no doubt want to work together to consider from a clinical
perspective:
- There are several systems of recording information – in particular in
relation to medical notes and ACCT – and notes system should be
streamlined.
- The PCT policy on record keeping should be followed.
- There are gaps in the reception admission notes and subsequent
assessments, and the policy on admission assessment to prison
should be reviewed or developed.
- The policy on admission to healthcare should be reviewed or
developed.
- There is a need for a clearer definition of the roles and responsibilities
of clinical and medical staff.
- There should be a policy for how to deal with non attendance at
Occupational Therapy groups, which should be outlined in the care
plan.
- A protocol is required for the procedure to be followed when prisoners
refuse prescribed medication.
- Visiting protocols should be reviewed to include some structures for
support when prisoners receive bad or distressing news.
- Clear roles and responsibilities should be determined for the Duty
Room, outlining the level of skill or qualification required to undertake
the role of the duty officer and the support mechanisms in place.
- Ligature knives should be placed in strategic places to ensure a rapid
response.
- A protocol should be developed on resuscitation procedures.
- Attempts should be made to ensure that all staff have up to date basic
or intermediate life support training dependent on their qualification.
- A protocol should be developed on Serious Untoward Incidents.
35
Consideration of the some of the issues surrounding the clinical care that
the man received
165. It is clear from this investigation that the prison failed to arrange for the man
to be fully assessed and properly admitted into healthcare on 1 August when
he was brought over from House Unit 1. My investigators therefore looked in
some detail as to what happened that day in healthcare, and how this might
have come about. The intention was not to try and identify individuals to
blame, but to see if there were fundamental failings in the system that lead to
the tragedy of the man’s death.
166. There are two wings in healthcare, A wing, on the ground floor, where more
seriously ill prisoners are generally located, and C wing on the first floor.
There is a duty room on the ground floor.
167. Staffing cover in healthcare is split into four shifts. There is a morning shift
(up to lunchtime), an afternoon shift (up to about 5pm), an evening shift (up to
about 8pm) and a night shift. The staffing rota for 1 August shows that, for
the discipline staff, two prison offers were covering the afternoon shift for C
wing, and two other officers were covering the same shift for A wing. One
officer then continued to cover C wing for the evening shift, and another
officer continued to cover A wing.
168. There were 16 healthcare staff on duty that day (excluding managers) to
cover all the shifts. Ten of these were agency nurses. Three permanent staff
were off sick, and three were on annual leave.
169. As well as nurses, Woodhill employs Healthcare Officers who are not
registered nurses but who have some clinical qualification. Prison Service
Standing Order 13 (Health Care) outlines the general role of the Health Care
Officer:
- Carrying out basic nursing care and such specialist nursing care as is
within their competence.
- Observing patients in their charge and alerting a Medical Officer to any
matters relating to the health or treatment of a patient which are
considered to warrant medical attention.
- Keeping accurate records of medication administered and other
significant nursing duties undertaken.
Were duty room staff aware that the man had been brought to healthcare?
170. The officer from C wing is certain that she told the duty room that the man
had arrived on C wing. She believes she spoke to the healthcare manager,
and that he expressed surprise that the man had come over. The healthcare
officer does not recall being told that the man had arrived before he went off
duty at 5.45pm. However, at 4.57pm the duty room log shows that the
healthcare manager signed to confirm that the count of prisoners on the wing
matched the roll board in the duty room. Accordingly, it seems likely that at
that time he was aware that the man was on the wing, even if he did not
36
attach any significance to this information, or know what he needed to do with
it.
171. There is some lack of clarity about the duty room handover arrangements
during the course of that evening. The healthcare officer says he handed
over to the second agency nurse and told her that, if House Unit 1 nurse was
concerned about the man, the man should be admitted to healthcare. The
second agency nurse says she did not receive a handover, and did not know
anything about the man. The duty room log, which should be updated before
a handover, does not have a record of the man being one of the prisoners on
an open ACCT.
172. The second agency nurse is not sure whether she or the healthcare manager
formally handed over to the nurse that was first on scene, but this nurse
confirms it was the second agency nurse who did the handover. The nurse
that was first on scene said she knew – although she was not sure whether
from the second agency nurse or the healthcare manager – that the man had
been brought over, was on an open ACCT, and was in healthcare for
observations for the night. She assumed that any assessment that the man
required would have been done before she came on duty at 6.30pm.
173. In my view, there is little doubt that the duty room knew that the man had
been brought over to C wing. I think it likely that this information was
conveyed to the healthcare officer before the 5pm roll check.
Was the duty room adequately staffed?
174. The Healthcare Centre has a document that sets out the tasks of the duty
room. This says that the person in charge of the duty room is the first point of
call for all Healthcare Centre enquiries, and that the person in charge must
act accordingly. Specific activities include, amongst other things:
- Making sure that the duty room roll board is accurate and up to date at
all times, so figures for available spaces are always at hand.
- Having an up to date knowledge of the client group on healthcare to
ensure safe transition of any moves that take place.
- When locating new admissions to the Healthcare Centre, making sure
that wing staff are adequately briefed on any information about that
prisoner.
- Ensuring that each prisoner is as safely located as resources will allow,
but being prepared to make moves within the healthcare wings as
necessary to maximise safety. This must be done in conjunction with
wing staff, the Senior Management Team and the Duty Governor.
175. The paper says that the person in charge of the duty room should be flexible
in their approach to duties and be prepared to carry out any reasonable
requests. If unsure, the person in charge should consult a senior manager.
176. The senior nurse for inpatient care in healthcare, is also one of the
Healthcare Centre managers. He has worked in the prison for several years
37
and became a ‘G’ grade nurse in January 2005. He told my investigators
that the role of the person in charge of the duty room was basically to
manage healthcare – dealing with queries about medication, assessing
whether prisoners are fit for transfer or for work and so on. He said it is a
very busy post, the first point of contact, and in effect the hub of the
Healthcare Centre. So, for example, if wing staff were not sure about a
prisoner with regard to self harm, the duty room would be the first point of
contact. Other staff to whom my investigators spoke confirmed that the duty
room ‘drives’ healthcare. The duty room was said to be a communication
point, involving asking questions so that the right people can be updated with
the right information.
177. On 1 August, the senior nurse covered the duty room for the morning shift.
The healthcare officer was in charge of the duty room that afternoon, assisted
by a Healthcare Assistant. The second agency nurse arrived in the duty
room some time after 5pm, and the healthcare officer left at 5.45pm. The
healthcare manager says that she based herself in the back room at about
5.45pm so that she was available for support. The nurse first on scene took
charge of the duty room at about 6.30pm.
178. The senior nurse said at interview that he had been seriously concerned
about the staffing levels on healthcare that day, as too many people had
been allowed leave, or were off for other reasons. In particular, the
healthcare officer was not sufficiently qualified or experienced to be in charge
of the duty room. His view was that the healthcare officer had neither the
experience of managing the duty room nor any experience of clinical
assessment. He said it was not so much a matter of grade as a matter of
experience. He raised this with the healthcare manager at about midday on
1 August. He said that, when he was explaining the problem, the healthcare
manager came in and said that he was not sufficiently experienced, prepared
or confident to cover the duty room. He said the healthcare manager told the
healthcare officer that all he needed to do was be in the duty room, and she
would make any management decisions. Thus, the healthcare officer’s role
in the duty room was to answer telephone calls, enquiries and so on.
179. The senior nurse told my investigators that he himself had been at work the
previous Friday afternoon, throughout the weekend, and on the Monday
morning. Normally, he would have stayed to cover the shortfall in the duty
room that afternoon. But he had already worked all weekend, and the
previous weekend, to cover a shortfall, and he was not prepared to do so
again.
180. The healthcare officer has worked at the prison for about eight years as a
discipline officer, and for the last five years on healthcare. He has an NVQ
level 3 healthcare qualification, which he obtained in the last 12 months,
having started to work towards it about six months after he started in
healthcare. He said at interview that he was supposed to be a hospital officer
(this is the old term for a Healthcare Officer), but he had not yet got his
certificate and was not being paid the extra money. He said he was covering
the duty room that afternoon against his will, having told the healthcare
38
manager earlier that he was not paid enough to be in charge of the duty room
and he did not want to be there. He said the phone never stopped ringing,
and he was under immense pressure for which he was not appropriately
paid. He did have the assistance of the healthcare assistant, but she was in
and out, was not up to the task, and he had not found her of any help at all.
He said he had essentially been left on his own to cope. He had previously
assisted in the duty room from time to time, but not very often, and had never
before been in sole charge. He said he normally worked on the wings and
administered treatments.
181. The healthcare manager said at interview that the healthcare officer was an
experienced healthcare officer, and although he did not normally work in the
duty room, he had done so previously. He had raised some concerns with
her about covering the duty room, but it was mainly about being on his own.
He also said he did not feel able to make managerial decisions. The
healthcare manager arranged for someone to assist him, and said that she
would be available to help with any managerial or clinical issues. She said
that at no point that afternoon did the healthcare officer tell her he was not
coping, although she had invited him to call her as she was around all
afternoon. She says she checked several times, and the healthcare officer
said he was busy but did not have any problems.
182. The senior nurse also said that the second agency nurse had never before
been in charge of the duty room. The second agency nurse is a Registered
Mental Nurse, and has worked as an agency nurse in Woodhill for about five
years. The second agency nurse said at interview that she did not consider
that she took charge of the duty room, but was simply assisting, since the
healthcare manager was there. The healthcare manager told my
investigators she did not consider herself in charge of the duty room, as she
was just available for support.
183. I conclude that there can be little doubt that the duty room was not
adequately covered on the afternoon and early evening of 1 August, by staff
of sufficient experience, confidence or competence to undertake the task.
The senior nurse had raised concerns earlier that day. The healthcare officer
had explicitly expressed his lack of confidence. And there was lack of clarity
as to who was in charge once the healthcare officer left and before the nurse
first on scene arrived. The problem was, it seems, not so much a matter of
grade as of familiarity with the task, although there was clearly also an
underlying dispute about pay. The list of duty room tasks is not
comprehensive, and my investigators have not been able to obtain any clear
description of the tasks that an healthcare officer in general is normally
expected to perform, or the tasks that the healthcare officer in particular was
assessed as competent to perform. In light of the healthcare officer’s limited
previous experience, the lack of clarity about the task, and the lack of written
procedures of which staff were aware (which I consider below), my view is
that the healthcare officer was not competent, or given the necessary tools,
to be in charge of the duty room that afternoon. It cannot be right that he was
left in charge of such a vital function without, at the very least, close and
active supervision of his performance, and clear instructions about the task.
39
184. In coming to this view, I have also considered the Nursing and Midwifery
Council’s Code of Professional Conduct. This requires a registered nurse,
midwife or health visitor to be personally accountable for their practice. This
means that they are answerable for their actions and omissions, regardless
of advice or directions from another professional. I am told that fully qualified
and paid Healthcare Officers, although not registered nurses, are normally
required by the Prison Service to be bound by the Code. My investigators
have not been able to gain sight of healthcare officer’s employment
documentation which might clarify whether or not he was signed up to the
Code. If he is bound by the Code, then he must take some responsibility for
taking charge of the duty room despite his own view of his ability to undertake
the task. But either way, it cannot be right that he was allowed by two senior
managers – albeit one under protest – to undertake a task that a signatory to
the Code would have been duty bound to refuse.
Were staff aware of arrangements for admitting prisoners to healthcare?
185. The house unit 1 nurse is a Registered Mental Nurse, and has worked at
Woodhill on an agency basis for over five years. He saw his task as only to
make the decision that the man should be admitted to healthcare. He did not
think it was his responsibility to undertake any further assessment of the
man, or decide on the type of cell in which the man should be located. He
thought it was the responsibility of the duty room to tell ward staff that the
man had arrived, and for the ward staff to assess the man and arrange for
him to see a doctor if necessary. The house unit 1 nurse did not think it was
his task to make sure that happened.
186. The healthcare nurse was the nurse responsible for covering both A wing and
C wing on the morning and afternoon of 1 August. The healthcare nurse is a
Registered Mental Nurse, and has worked at Woodhill on and off since 2003.
He told my investigators he thought the discipline staff should have told him
that the man had been brought over. Had they done so, the healthcare nurse
would then have assessed him. He was not aware of any standard
arrangements or procedures for admitting prisoners from a residential wing to
healthcare.
187. The healthcare officer was in charge of the duty room when the man was
brought over to healthcare. He thought that when the man arrived he should
have seen a doctor, who would make a decision about the level of
observations required. He did not know who was responsible for arranging
this. If there was a procedure for admission to healthcare, he was not aware
of it.
188. The head of healthcare told my investigators that a doctor should have
assessed the man, either on the wing or in healthcare, unless it was out of
hours in which case the most senior clinician in healthcare should have
conducted the assessment. She said this was usually co-ordinated by the
duty room, and it was the duty room’s responsibility to make sure the doctor
knew the prisoner had arrived. She would have expected the nurse referring
40
the prisoner to healthcare (in this case the house unit 1 nurse) to have a
conversation with the receiving doctor or other clinician about the admission
and the prisoner’s future care. She said that discipline staff should also have
told the nurse on the hospital wing, or the duty room, or some other clinician,
that the prisoner had arrived. She said it would be a joint decision between
discipline staff and healthcare staff as to which cell was suitable for the
prisoner. She would have expected house unit 1 nurse to tell the duty room
about the prisoner’s problems, and for the duty room to see what space there
was. It was the responsibility of the duty room to co-ordinate spaces, and to
move prisoners around if necessary to obtain a suitable vacant cell. On this
occasion, she thought that the cell in which The man was placed was the
only one available, and all the constant watch cells were full.
189. The head of healthcare accepted that, if the duty room expected a prisoner
and it seemed he had not arrived, she would anticipate the person in charge
of the duty room to check what had happened to him. She said that they had
identified the lack of adequate written procedures as a problem, and were
taking steps to put that right.
190. Towards the end of the investigation, on 16 November 2005, the prison sent
my investigator the prison’s policy for admission to healthcare that had been
agreed in September 2004. This says that when the prisoner arrives, they
should be shown to their new accommodation by a member of healthcare
staff. As soon as practicable, a duty doctor should review the prisoner and a
plan of care established. It says that healthcare staff will determine the
location of the prisoner within healthcare. None of the healthcare staff
interviewed in the course of the investigation mentioned this document.
191. I conclude that there was a general lack of understanding about the
healthcare admission arrangements when the man was brought over. I am
not convinced by arguments put forward by some staff that the confusion
arose, in part, because of the large number of agency nurses being used by
the prison. None of the agency nurses interviewed or spoken to during the
course of this investigation was by any means new to Woodhill. But in any
event, if there is a large number of transient staff, that is even more reason to
have clear, simple, practical written procedures, of which agency staff are
aware, and which they can be expected to follow.
192. My investigators were told by various healthcare staff that there were other
events on the day of the man’s death which may have caused things to go
awry. In particular, the man was brought over to healthcare at about the time
of the changeover from afternoon to evening shift. It had been a busy
afternoon, and another prisoner had also been identified as potentially
suicidal. A doctor had been called over to the wing to assess him that
afternoon, and he was subsequently admitted to healthcare later that
evening. There was no bed available for him in healthcare, and he had to be
put in a holding cell while prisoners were moved around to make space for
him. While I appreciate that this will have put extra strain on staff, and none
of the people my investigators spoke to was using this as an excuse, it is
41
disappointing that healthcare arrangements were insufficiently robust to cope
with both predictable and unpredictable crises.
Conclusions
193. The man was on an open ACCT document when, on 1 August, he said that
he intended to hang himself. Staff on the residential wing where the man
was located took his concerns seriously, and asked for some clinical input
into how the man should be dealt with. Healthcare staff decided that he
should be admitted into the Healthcare Centre. As a consequence, the man
was moved from the relative comfort of the residential wing, and the care of
his cellmate, and put alone in a cell in healthcare. This cell contained an
easy ligature point, was without a television or access to any company, and
was in far less pleasant surroundings. Yet there was no change in the level
of observations that had been agreed for the man some days before on his
ACCT review, and no proper clinical assessment of his condition or the care
that he might now need. A few hours later he was dead. How did this
tragedy come about?
194. My view is that a number of things went wrong. First, when the man was on
the residential wing and said that he wanted to commit suicide, there should
have been a proper ACCT case review, involving house unit nurse 1, wing
staff, the case manager and the man. A comprehensive assessment should
have been made of the man’s state of mind, and the best course of action to
support him (including the best location) should have been made. Instead,
there was no nominated case manager on the wing to take charge of the
case, no real assessment of any kind was made, and there is no evidence
that any other options were properly considered apart from an admission to
healthcare.
195. I recommend that the Governor reminds staff to ensure that, when a
prisoner who is on an open ACCT clearly deteriorates, there is an
urgent ACCT case review to decide on the best course of action, and
that this is properly documented in the ACCT record.
196. I also recommend that the Governor ensures that, when a prisoner on
an open ACCT moves location, a new, properly trained case manager
from the new location is always appointed, and that there is a process
for monitoring this to make sure it is done.
197. The second thing to go wrong that day was that cover in the duty room that
afternoon and early evening was inadequate, and so no-one made proper
arrangements for the man to be admitted. Third, the formal arrangements for
admission to healthcare, and the role to be played by different members of
staff, were not properly documented, and staff were not clear what they were.
Fourth, I do not believe that the house unit 1 nurse’s assessment of the man
on the residential wing was adequate. He simply decided that the man
needed closer observation (but did not feel that it was his task to specify what
this meant) and to be reassessed. He did not make a single note of his
decisions, or the reasons for them, in either the man’s medical records or his
42
ACCT document. Thus, even if there had been a proper admissions process,
clinical or medical staff reassessing the man would have had very little
information about why he had been admitted. A clearer briefing to the person
in charge of the duty room might, despite the lack of procedures, have
brought The man higher up the priority list for hard pressed staff in and
around the duty room that evening.
198. Although it is impossible to be sure what might have happened had things not
gone wrong, there is at least a possibility that the man’s death could have
been avoided. I therefore urge the Governor and the PCT to take urgent
steps to ensure that duty room staff are up to the task, that there are proper
handover arrangements when the shifts change, that proper admissions
procedures are in place and understood by staff, and the nurses on the
residential wings fully understand the extent of their clinical responsibilities
when deciding that a prisoner should be admitted to healthcare.
199. I recommend that the Governor and the PCT work together to ensure:
- That the role and responsibilities of the person in charge of the
duty room are clear, and that staff put in this position are
competent to undertake the task.
- That handovers always take place when shifts change, and that all
staff know it is their individual responsibility that they both give
and receive handovers, irrespective of their position in the
management structure.
- That proper procedures are in place for admission to healthcare,
and that all staff are aware of them and understand them.
- That nurses on residential wings fully understand the extent of
their clinical responsibilities when deciding that a prisoner should
be admitted to healthcare.
- That staff are once again reminded of the vital need to keep
proper records of clinical decisions, and to update both medical
records and ACCT records appropriately. The Governor and the
PCT may want to consider disciplinary action for those that still
fail to do so.
- That the clinical audit process reflects compliance with healthcare
policies and procedures.
200. I am also concerned that there may be a lack of clarity regarding the role of a
Healthcare Officer, the duties they are expected to undertake, and the
specific competencies of individual members of staff.
201. I recommend that the Governor and the PCT jointly review the role of a
Healthcare Officer and other healthcare staff, and the duties they are
expected to undertake according to grade. They should ensure that
roles are clearly defined, and that there is an adequate system in place
to measure the competency of individual members of staff against the
agreed standard.
43
202. There is some evidence that a low level industrial dispute may underlie some
of the questions about who can and should take charge of the duty room. I
do not know the details of this, but it seems to me it is something that needs
to be resolved urgently: for the benefit of a better run Healthcare Centre and
a better service to vulnerable and unwell prisoners.
203. I recommend that the Governor and the PCT investigate the question of
who is paid as a Healthcare Officer, and ensure that the duties and
responsibilities of all healthcare staff are clearly laid out according to
grade.
204. I do not know whether the healthcare officer was bound by the Nursing and
Midwifery Council’s Code of Conduct, and therefore whether he was in
breach of it.
205. I recommend that the Governor and the PCT conduct a local
investigation to establish whether the healthcare officer was bound by,
and in breach of, the Nursing and Midwifery Council’s Code of Conduct,
as a result of his actions on 1 August 2005 in agreeing, albeit under
pressure, to take charge of the duty room. I also recommend that
consideration is given, if appropriate, to whether healthcare managers
knowingly allowed the healthcare officer to breach the Code.
206. Although the shortcomings set out above were by far the most serious, my
investigation has suggested a number of other areas where I take the view
that the prison did less than it should to care for the man.
Separation of court correspondence from the man’s medical records
207. It is clear that staff at court did their very best to ensure that information about
the man’s medical history and his medication reached the prison. There is
little doubt that the information arrived. But because it was marked for the
urgent attention of the Governor, it seems likely that it ended up in the
internal mail, and actually took longer to find its way to medical staff than if it
had simply been marked for the attention of healthcare. As a consequence,
when the man arrived at Woodhill, he did not get the medication he had been
receiving before he was sent to prison. This need not have happened if the
records had been kept together.
208. Even when part of the correspondence – in particular the note from the
probation service officer – was linked up to the man’s medical record, it
seems that other documents were not. Certainly, they had not been linked
up at the time of the man’s second MHIRT assessment.
209. I recommend that the Governor reviews arrangements to ensure that, if
correspondence is marked for his urgent attention, it does in fact reach
its destination urgently.
210. I recommend that the Governor and the PCT work together to ensure
that the administration of medical records is up to the task, and that
44
documents that arrive at a later date are linked up promptly, and an
assessment made of the action that needs to be taken in the light of
their contents.
Induction process
211. If the man had not needed to be placed in healthcare when he arrived in
prison, he would have received a full induction programme with all the
benefits that that would bring. He would in addition have been assured of
receiving his smoker’s pack, and a first night telephone call home. Instead, it
was two days before he was able to speak to his wife, and there is some
doubt about whether he ever received his smoker’s pack. The lack of proper
induction arrangements for prisoners who arrive in healthcare means, in
effect, that some of the most vulnerable prisoners are likely to receive he
least support when they arrive in prison.
212. I recommend that the Governor reviews the arrangements for induction
of prisoners placed in the Healthcare Centre, to ensure that they have
the benefit of the same facilities as prisoners placed straight onto a
residential wing.
Reception process
213. My investigation into the death of another prisoner, in July 2005, has
identified lengthy delays in reception as likely to increase the stress of
imprisonment for newly arrived prisoners. The man, too, spent a
considerable amount of time waiting around on his first evening in prison. He
arrived at 4.18pm, was received on reception at 5.07pm, had his first
reception health screen completed by 6.35pm, saw a doctor, and was finally
admitted to healthcare at 9pm. Such long delays are likely to have
exacerbated the man’s sense of despair.
214. I recommend that the Governor reviews reception processes with a
view to minimising waiting times for new prisoners.
Regime in healthcare
215. Evidence from this investigation suggests that the physical surroundings and
the daily regime for prisoners in the Healthcare Centre are far inferior to
those provided on the residential wings. In addition, it may be that Woodhill
is too ready to move prisoners at risk of suicide or self harm to healthcare,
rather than support them on a residential wing.
216. I recommend that the Governor considers whether action can be taken
to improve the environment and regime in healthcare, and whether
more could be done to support suicidal or self harming prisoners on the
wing, if there is no clinical need for them to be located in healthcare.
ACCT arrangements
45
217. I have a number of concerns about the way Woodhill administered the man’s
ACCT document. The ACCT document was correctly opened on 18 July,
although there was no information given as to who should be called if an
immediate review was required. There should have been a proper
assessment and case review of the man’s ACCT within 24 hours. Nothing
was done on 19 July. On the morning of 20 July, another prisoner died. This
of itself should have prompted an urgent review of all open ACCT
documents, to make sure that vulnerable prisoners were protected. But it
was not until the morning of 21 July that the man’s case was reviewed.
218. When the man was moved from healthcare to a residential wing on 26 July, a
full case review was carried out. However, no-one from the residential wing
where the man was to be located attended the review, no new case manager
was appointed, and the caremap was not updated to take account of what
support the man needed on the residential wing. In fact, only one caremap
was ever completed, and that was the one on 21 July. Nor is there evidence
that a follow-up healthcare appointment was made, as procedures require.
219. I am also concerned that, although prisoners on an open ACCT located on
residential wings should normally be located in shared cells, unless there is a
documented reason not to do so, there is no similar requirement for prisoners
placed in healthcare. I recommend that this be reviewed.
220. Finally, this investigation has identified some evidence that, although a large
number of staff have received ACCT training, key healthcare staff dealing
with the man had no ACCT training – in particular the healthcare officer, a
nurse and the house unit 1 nurse. I also believe that it is important that the
Safer Custody Co-ordinator is allowed to focus on his task full time.
221. I recommend that the Governor ensures that:
- The first ACCT assessment is always done within 24 hours, and
that arrangements are in place to make sure that all open ACCT
cases are reviewed urgently in the event of another prisoner’s
death.
- A member of staff from the residential wing attends the case
review when a prisoner is discharged from healthcare.
- Caremaps are regularly reviewed and updated.
- Follow up healthcare appointments are always made when a
prisoner is discharged from healthcare.
- The arrangements for placing prisoners on an open ACCT alone
in a cell in healthcare are reviewed, particularly those cells with
bunk beds which provide an all too easy ligature point.
- All healthcare staff are trained in ACCT to at least foundation
level.
- The Safer Custody Co-ordinator is allowed to focus full time on
his task.
Dealing with the man’s stepfather’s correspondence
46
222. Woodhill received a letter from the man’s stepfather on 26 July, saying how
worried his family were about his wellbeing and about the fact that he was not
getting the medication he had previously been prescribed. It is a matter of
great concern that that letter was dealt with as routine correspondence, and
that there is no mechanism within the prison for identifying and acting on
letters that raise urgent issues. I understand that Woodhill has now taken
some steps to identify urgent correspondence when it is received in the
prison. My view is that there must also be an onus on the unit receiving the
letter to make their own assessment of urgency, and not simply to rely on a
decision by staff in a central secretariat.
223. I recommend that the Governor takes steps to ensure that urgent
correspondence is identified either on receipt by the prison, or by the
receiving unit, and is dealt with appropriately.
Correspondence sent to the man by his family
224. On 22 July, the man’s wife sent him a letter, photographs and a postal order.
It seems that this package travelled around the prison, and the man certainly
never received it. A package from home is likely to be of great comfort to a
vulnerable and potentially suicidal prisoner. The man was understandably
very agitated and distressed about its failure to arrive. It is of some surprise
that, when the man raised the problem several times over, it was not a simple
matter for staff to resolve. It seems that it was not until 1 August that staff
established that the package was in reception. Sadly, it is possible that the
man could have been given it the next day.
225. I recommend that the Governor reviews arrangements for receiving
correspondence for prisoners, to make sure it is properly tracked, gets
promptly to the prisoner, and that staff understand how to locate
anything that may go astray.
Obtaining information from the man’s GP
226. Although it was identified when the man arrived at Woodhill that there needed
to be a discussion with his GP about his medication the following day, this did
not happen. The prison doctor thought it was either the responsibility of the
doctor or the MHIRT team to make sure this happened, but that there was
some scope for confusion as to who was responsible. In my report following
the death from natural causes of a prisoner at Woodhill in February 2005, I
also pointed out the importance of obtaining a prisoner’s medical records
from his GP.
227. I recommend that the Governor and the PCT work together to ensure
that healthcare professionals obtain information from a prisoner’s GP
(or indeed any other relevant healthcare providers), and that there is no
room for doubt as to whose responsibility this is.
Ensuring prisoners receive their medication
47
228. There was one day when the man did not receive his medication. It seems
likely that this was an error. This investigation has not looked at how this
might have come about, but the prison will no doubt want to find out and
make sure that such an error cannot recur.
229. I recommend that the Governor and the PCT work together to check
that the arrangements for administering medication to prisoners are
adequate, and that the error in the man’s case will not recur.
Operation of contingency plans
230. The prison’s contingency plans in the night state do not make reference to
the function of the staff member in healthcare holding radio call sign ‘Hotel 1’.
That may be why, when the prison officer from C wing healthcare sent the
emergency radio message, she did not hear a call for Hotel 1. Luckily, she
was sufficiently quick thinking to make the call herself.
231. The contingency plans required a log keeper to be appointed and a note kept
of all staff who entered or left the cell. There were enough staff around
shortly after the man’s cell was entered to allow this to happen, but it was not
done. It is difficult now to be sure of the times that staff arrived at the cell to
try and save the man’s life.
232. I think the Governor may also want to remind staff that they can enter a cell
alone in order to preserve life, if they think it is safe to do so.
233. I recommend that the Governor ensures that the contingency plans are
updated, and that the role of Hotel 1 in the night state is clarified and
communicated to staff.
234. I recommend that the Governor ensures that staff are reminded to
delegate a log keeper, if one is available, as soon as possible after an
emergency is declared.
235. The Governor should remind staff that they can enter a cell alone in
order to preserve life, if they think it is safe to do so.
The efforts to save the man’s life
236. The evidence suggests that staff acted promptly and professionally to try and
save the man’s life. I recommend that the Governor makes sure that all staff
involved are aware of my finding on this matter.
237. I do, however, have some concerns that the nurse first on scene did not bring
emergency equipment with her to the cell, and that there were in fact three
journeys from the cell to obtain all that was needed. It may be that this was
caused by some initial lack of clarity about the nature of the emergency.
48
238. I recommend that the Governor and the PCT work together to ensure
that staff always bring all appropriate emergency equipment with them
to an emergency.
239. I also repeat my recommendation, made following the July 2005 death,
that the Governor considers the introduction of a coding system so that
staff can respond appropriately to a medical emergency.
240. I recommend that the Governor draws the attention of staff involved to
my view that, once the man was discovered, staff worked promptly and
professionally to try to save his life.
Training in first aid and use of emergency equipment
241. The prison has not been able to confirm whether or not the discipline officers
involved in saving the man’s life were trained in first aid.
242. I recommend that the Governor checks that staff involved in saving the
man’s life had adequate training, and if not, that he reviews training
arrangements to make sure that trained staff are always available in an
emergency.
Clinical care
243. The lack of a timely clinical review, and the fact that it has not been possible
to interview two of the doctors involved in the man’s care, means that I have
not been able to answer additional questions about the clinical care the man
received. I do not know why the healthcare C wing doctor apparently did not
speak to the man’s GP and did not prescribe the man medication of the same
dosage as he was getting in the community, and whether he got other
appropriate medication such as sleeping tablets. Nor can I say what effect
any failure to prescribe the correct medication may have had on the man.
Similarly, I do not know what action the second locum doctor took after the
man was discovered hanging in his cell, and what record he made, if any, of
the man’s death.
244. Now that there is a clinical review, the Governor and the PCT will not doubt
want to work together in considering these issues, and anything else not
already covered in my investigation.
Care of staff and prisoners
245. The evidence suggests that the prison took good care of staff and prisoners
after the man’s death, and took all appropriate steps to make sure that
everyone was appropriately supported.
49
Liaison with the family
246. I can appreciate how angry the man’s family will be with the prison about the
man’s death. Nonetheless, I take the view that the prison has taken all
reasonable steps to liaise with the family, both in breaking the bad news and
in subsequent interactions. I believe that the prison has handled matters
carefully and sensitively.
50
Recommendations
1. I recommend that the Governor reminds staff to ensure that, when a
prisoner who is on an open ACCT clearly deteriorates, there is an urgent
ACCT case review to decide on the best course of action, and that this is
properly documented in the ACCT record.
2. I also recommend that the Governor ensures that, when a prisoner on an
open ACCT moves location, a new, properly trained case manager from
the new location is always appointed, and that there is a process for
monitoring this to make sure it is done.
3. I recommend that the Governor and the PCT work together to ensure:
- That the role and responsibilities of the person in charge of the duty
room are clear, and that staff put in this position are competent to
undertake the task.
- That handovers always take place when shifts change, and that all staff
know it is their individual responsibility that they both give and receive
handovers, irrespective of their position in the management structure.
- That proper procedures are in place for admission to healthcare, and
that all staff are aware of them and understand them.
- That nurses on residential wings fully understand the extent of their
clinical responsibilities when deciding that a prisoner should be
admitted to healthcare.
- That staff are once again reminded of the vital need to keep proper
records of clinical decisions, and to update both medical records and
ACCT records appropriately. The Governor and the PCT may want to
consider disciplinary action for those that still fail to do so.
- That the clinical audit process reflects compliance with healthcare
policies and procedures.
4. I recommend that the Governor and the PCT jointly review the role of a
Healthcare Officer and other healthcare staff, and the duties they are
expected to undertake according to grade. They should ensure that
roles are clearly defined, and that there is an adequate system in place to
measure the competency of individual members of staff against the
agreed standard.
5. I recommend that the Governor and the PCT investigate the question of
who is paid as a Healthcare Officer, and ensure that the duties and
responsibilities of all healthcare staff are clearly laid out according to
grade.
6. I recommend that the Governor and the PCT conduct a local
investigation to establish whether the healthcare officer was bound by,
and in breach of, the Nursing and Midwifery Council’s Code of Conduct,
as a result of his actions on 1 August 2005 in agreeing, albeit under
pressure, to take charge of the duty room. I also recommend that
51
consideration is given, if appropriate, to whether healthcare managers
knowingly allowed the healthcare officer to breach the Code.
7. I recommend that the Governor reviews arrangements to ensure that, if
correspondence is marked for his urgent attention, it does in fact get to
its destination urgently.
8. I recommend that the Governor and the PCT work together to ensure that
the administration of medical records is up to the task, and that
documents that arrive at a later date are linked up promptly, and an
assessment made of the action that needs to be taken in the light of their
contents.
9. I recommend that the Governor reviews the arrangements for induction
of prisoners placed in the Healthcare Centre, to ensure that they have the
benefit of the same facilities as prisoners placed straight onto a
residential wing.
10. I recommend that the Governor reviews reception processes with a view
to minimising waiting times for new prisoners.
11. I recommend that the Governor considers whether action can be taken to
improve the environment and regime in healthcare, and whether more
could be done to support suicidal or self harming prisoners on the wing,
if there is no clinical need for them to be located in healthcare.
12. I recommend that the Governor ensures that:
- The first ACCT assessment is always done within 24 hours, and that
arrangements are in place to make sure that all open ACCT cases are
reviewed urgently in the event of another prisoner’s death.
- A member of staff from the residential wing attends the case review
when a prisoner is discharged from healthcare.
- Caremaps are regularly reviewed and updated.
- Follow up healthcare appointments are always made when a prisoner is
discharged from healthcare.
- The arrangements for placing prisoners on an open ACCT alone in a cell
in healthcare are reviewed, particularly those cells with bunk beds which
provide an all to easy ligature point.
- All healthcare staff are trained in ACCT to at least foundation level.
- The Safer Custody Co-ordinator is allowed to focus full time on his task.
13. I recommend that the Governor takes steps to ensure that urgent
correspondence is identified either on receipt by the prison, or by the
receiving unit, and is dealt with appropriately.
14. I recommend that the Governor reviews arrangements for receiving
correspondence for prisoners, to make sure it is properly tracked, gets
promptly to the prisoner, and that staff understand how to locate
anything that may go astray.
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15. I recommend that the Governor and the PCT work together to ensure that
healthcare professionals obtain information from a prisoner’s GP (or
indeed any other relevant healthcare providers), and that there is no
room for doubt as to whose responsibility this is.
16. I recommend that the Governor and the PCT work together to check that
the arrangements for administering medication to prisoners are
adequate, and that the error in the man’s case will not recur.
17. I recommend that the Governor ensures that the contingency plans are
updated, and that the role of Hotel 1 in the night state is clarified and
communicated to staff.
18. I recommend that the Governor ensures that staff are reminded to
delegate a log keeper, if one is available, as soon as possible after an
emergency is declared.
19. The Governor should remind staff that they can enter a cell alone in
order to preserve life, if they think it is safe to do so.
20. I recommend that the Governor and the PCT work together to ensure that
staff always bring all appropriate emergency equipment with them to an
emergency.
21. I also repeat my recommendation, made following the July 2005 death,
that the Governor considers the introduction of a coding system so that
staff can respond appropriately to a medical emergency.
22. I recommend that the Governor draws the attention of staff involved to
my view that, once the man was discovered, staff worked promptly and
professionally to try to save his life.
23. I recommend that the Governor checks that staff involved in saving the
man’s life had adequate training, and if not, that he reviews training
arrangements to make sure that trained staff are always available in an
emergency.
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