Individual at Liverpool

Investigation into the circumstances surrounding the
death of a man in August 2006 whilst in the custody of
HMP Liverpool
Report by the Prisons and Probation Ombudsman for
England and Wales
January 2008
This is the report of an investigation into the death of a man at HMP Liverpool. He
was found by his cellmate in the bathroom of their shared cell with a ligature around
his neck. Despite efforts to resuscitate him, he was pronounced dead shortly after
his arrival at the hospital. He was 22 years old.
I would like to extend my sincere condolences to his family and to all those touched
by his untimely death. The man’s family is understandably shattered by his loss. He
was a troubled young man who, five weeks earlier, had found himself in an adult
prison for the first time. He had been remanded in custody after being charged with
demanding car keys from drivers with the intention of crashing one of their cars so
that he could die.
The investigation has been undertaken on my behalf by two of my investigators. A
clinical review of the healthcare the man received whilst at Liverpool was also carried
out by the Head of Mental Health Integrated Commissioning at Liverpool Primary
Care Trust, with clinical advice from a Medical Director and General Practitioner. I
must apologise for the delay in producing this report.
From the time the man came into custody, he was identified as being at risk of self
harm. He was monitored under the Prison Service’s arrangements for caring for
prisoners at risk of self harm and suicide. However, it is arguable that the level of
risk that the man posed to himself was not recognised sufficiently.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2008
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CONTENTS
Summary
Investigation Process
HMP Liverpool
Key Events
Consideration
Recommendations
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SUMMARY
The man was arrested on 14 July 2006. He had been threatening drivers with
violence in an attempt to get their car keys so he could crash a car and kill himself.
He was remanded in custody to HMP Liverpool. Although he had spent short
periods in custody in the past, it was his first time in an adult prison.
On reception, the man was asked questions by a staff nurse as part of the standard
procedure. He responded that he had not tried to harm himself before and did not
feel suicidal. When the staff nurse spoke to him, he did not have details of
documentation that had arrived at the prison flagging up his risk of suicide.
Nevertheless, although he declined to see a doctor, the staff nurse insisted that he
do so after feeling that his presentation was not quite right. Having read the man’s
suicide/self harm warning form, and assessing him the doctor concluded that the
man did not warrant observation in the healthcare centre.
The day after the man’s arrival, his cellmate on B wing alerted his landing officer to
his concerns about the man’s state of mind after finding blood on his bed sheet. The
man told the officer that he was depressed but, paradoxically, was feeling better.
The officer decided to initiate an Assessment, Care in Custody and Teamwork
(ACCT) document for assessing, monitoring and supporting prisoners at risk of self
harm or suicide. The man was assessed by a trained assessor and attended a case
review. He told the staff there that his attempt to kill himself had been real but he
had changed his mind and now wanted to stay alive.
The man’s risk of self harm was raised to high and he was taken to the healthcare
centre. He was assigned a named nurse to go to for advice and support. He told
her of his poor body image and that he was conscious of his limp. On 20 July, he
was found in a bathroom stabbing himself in the chest with a ball point pen. He was
prescribed an anti-depressant but refused to take it. Later that day, he was the
victim of an unprovoked assault by another prisoner who threw boiling water on his
face and neck, resulting in hospital treatment. His named nurse commented that this
was the worst thing that could have happened to the man at that time as it reinforced
his low self esteem. Liverpool did not tell the man’s family of the assault.
After a week, the man left the healthcare centre at his request after his risk of self
harm was re-assessed as low. He was seen by a Prison Community Mental Health
Team Nurse-Practitioner and a Consultant Psychiatrist who concluded that the man
was suffering from mild depression and was not suicidal.
Although the man had started to attend education classes, he soon decided that he
did not want to go and wanted to be left alone. Staff described his demeanour as
withdrawn and quiet.
Whilst on a visit, the man told his mother that he had attempted suicide with a noose
but it had not worked. Following this, the man’s aunt telephoned Liverpool to alert
them to her fears about his safety. The mother had previously tried to contact the
prison with concerns for her son, and on one occasion had resorted to asking a
worker in the visits canteen to pass a message on.
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A case review was held on 18 August at which the man denied that the conversation
with his mother had taken place. He admitted that he had not been taking his
medication. His risk of self harm or suicide was assessed as low.
In the last week of August, staff were alerted to a crisis in the man’s cell by his
cellmate kicking the door repeatedly. They entered the cell and found the man
suspended from the window bars in the cell bathroom. Despite efforts to resuscitate
him, the man did not regain consciousness and died shortly after his arrival at the
local hospital.
I make several recommendations concerning the care of prisoners at risk of self
harm. I attach particular weight to the recommendations relating to the ACCT
process and the importance of balancing what a prisoner says about how he feels
against his actual behaviour.
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THE INVESTIGATION PROCESS
1. My investigators visited HMP Liverpool on several occasions and were given
access to all prison records relating to the man. These included his main
prison record, his medical records and statements from staff. However, initial
progress was delayed because my investigators were unable to obtain timely
responses from Liverpool’s liaison officer with regard to arrangements for staff
interviews. Unfortunately, this was not an isolated example and I am
disappointed that more than one of my investigators has encountered
difficulties in making effective contact with Liverpool.
2. My investigators interviewed staff and one prisoner, and met representatives
of the Independent Monitoring Board and Prison Officers’ Association to offer
them the opportunity to raise relevant issues. Contact was made with a
Sergeant of Merseyside police who confirmed that there was no third party
involvement in the man’s death.
3. The man’s family was offered, and accepted, the opportunity to contribute
towards the investigation process. One of my investigators and my Family
Liaison Officer visited the man’s mother to learn of concerns raised by his
family about his care whilst in Liverpool and how news of his death had been
handled.
4. The mother wondered whether the man could have been placed on a different
wing where he could have been observed more closely. She said she was
unclear as to what medication he had been prescribed, whether he had
actually been observed taking his medication and whether it had taken effect.
5. She expressed concern that a prisoner had been able to throw boiling water
over him and that she had not been notified when this assault happened. She
spoke of her difficulties in identifying appropriate staff to speak to about her
worries for her son’s well-being. She said she had resorted to asking a staff
member in the Visits Canteen if they would pass a message on to the main
prison on her behalf.
6. Referring to the day the man died, the mother wanted to know when his cell
had been checked by the officer unlocking for exercise, and why his cell toilet
had not been checked at that time given that the man was known to be at risk
of self harm. She questioned the frequency of checks made on prisoners at
risk and the reliability of the ACCT plan document. She said there was no
proof that entries were made when staff said they were.
7. Concerning the immediate aftermath of the man’s death, his mother wanted to
know why there was a two hour delay in the family being notified, and why
there was confusion over the hospital to which the man had been taken. She
had noted that her son had a number of scratches and marks on his body,
particularly on the top of his head and she wanted to know what had caused
them. She added that she had been given her son’s belongings but had not
received some photographs of his girlfriend.
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8. A clinical review was requested from Liverpool Primary Care Trust. I am
grateful to the clinical reviewers for undertaking this review in a timely
manner. As a result of the Community Mental Health notes being made
available after the clinical review had been completed, an addendum was
produced.
9. My investigators informed Her Majesty’s Coroner of the nature and scope of
the investigation. He has been provided with a copy of my report.
10. After seeing a draft version of this report, the man’s family mentioned the
name of a friend who had been at Liverpool at the same time as the man but
has since been released. He was contacted by one of my investigators and
was able to provide further helpful information.
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HMP LIVERPOOL
11. HMP Liverpool is a refurbished Victorian prison which serves the courts of the
Merseyside and Wirral areas. It holds up to 1,480 prisoners. The man’s
death was the third of four apparently self-inflicted deaths that occurred there
in 2006.
12. B wing has capacity for 161 prisoners. As well as prisoners new to Liverpool,
it holds unconvicted prisoners and is staffed during the day by a minimum of
12 officers and two senior officers.
13. All staff should receive basic training in suicide awareness and how to
implement the Prison Service’s procedures for caring for prisoners at risk of
suicide and self harm, Assessment, Care in Custody and Teamwork (ACCT).
At the time of the man’s death, the last published inspection report by Her
Majesty’s Chief Inspector of Prisons on Liverpool was in September 2004. It
noted that, although more staff needed to be trained in suicide awareness, all
staff the inspectors spoke to knew what action to take if they found a prisoner
in distress or who had self harmed. An unannounced inspection took place in
February 2007 and was published in June 2007. Liverpool’s comprehensive
and informative Suicide and Self Harm Prevention Policy includes a section
on the role of staff in remaining alert to signs and signals of distress in
prisoners.
14. Mersey Care NHS Trust is responsible for providing a Prison Community
Mental Health Team to provide continuity of care for prisoners in the
community and in prison. Liverpool operates a system using a weekly single
point of referral meeting to assess and review a prisoner’s mental health with
a view to selecting the most appropriate healthcare professional to meet their
needs.
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KEY EVENTS
15. The man had a history of car theft. When he was 17, he was badly injured in
a car accident after a stolen car he was driving crashed. As a result, he was
in a coma for three weeks. Although he regained consciousness, he was in
hospital for three months and suffered a stroke which partially disabled the
right side of his body so that he walked with a slight limp.
16. On 14 July 2006, the man had an argument with his girlfriend. According to
his mother’s statement to the police, he had drunk a quantity of alcohol and
appeared upset. He asked his mother for her car keys and said he wanted to
kill himself. When she refused to give them to him, he stormed out of the
house and was later arrested for threatening drivers with violence in an
attempt to get their car keys. He was charged with three counts of blackmail
and possession of an offensive weapon. His Prisoner Escort Record (PER)
which accompanied him from police custody to court indicated that there were
warnings from 2005 concerning drugs, concealing weapons and long standing
short term memory loss as a result of a head injury.
17. The man appeared at the Magistrates’ Court on 17July and was remanded in
custody. On the warrant committing him to stand trial at the Crown Court was
written, “suicide wish identified. Bench request prison to assess whether
appropriate to hold on a Hospital Wing.” The accompanying bail form gave
three reasons for refusing bail: that he was in custody for his own protection
or welfare due to suicide threats, previous offences and “evidence of self-
injury: attempted suicide”. The last of these was underlined.
18. The duty probation officer at the magistrates’ court (who was familiar with the
man having met him when she worked for a training and employment
organisation) faxed a suicide risk form concerning him to HMP Liverpool
probation office. This read, “Recent offence part of endeavour to take his own
life. Magistrates committed and remanded in custody on the understanding
that he would be in the Hospital Wing.” In the Inmate Concern Book, the duty
probation officer at Liverpool noted the concerns expressed by the court about
the man and sent copies of the fax to the doctor in Reception.
19. The man saw a Registered Mental Health Staff Nurse (RMN) on reception. In
response to the standard questions in the First Reception Health Screen form,
the man answered that he had been in custody before as a young prisoner,
had not tried to harm himself previously and did not feel suicidal. He declined
to see a doctor.
20. At interview with my investigators, the RMN said that he had interviewed him
without any prior knowledge of his history. This meant that he could only go
by what he was being told at the time. The RMN said he did not have any
documents about him at the time, and was certain that he had not seen the
suicide risk form that came from the court probation officer.
21. The RMN recalled meeting the man because “…he looked so young … he
was telling me that there was no problems, he was feeling okay but there was
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22. The RMN noted in the man’s medical record that he had seen a suicide/self-
harm warning from the police concerning him but, although he advised the
man to see the doctor, he declined saying that he felt better. My investigators
asked the RMN whether he had seen the suicide/self-harm warning form
before or after he had spoken to the man. He was not sure, as he had written
his notes some time after first meeting him, but thought he had seen the form
after conducting the initial health screen.
23. He said that something about the man had prompted him do two things he
would not do normally. He had noticed that the man was sitting in the
reception waiting room with other prisoners who were eating a meal but he
was not. The RMN gave him some food and, despite his having declined to
see the doctor, he grabbed hold of him just as he was about to leave
Reception for the main part of the prison and insisted that he see the doctor.
Asked why he did so, he could only describe it as intuition.
24. Despite the suicide/self-harm warning form, the man denied feeling suicidal or
distressed when he was seen by the prison doctor in Reception. The doctor
wrote in the man’s medical record that his demeanour and eye contact were
good and that he did not seem to be experiencing discomfort. He decided
that it was not necessary for him to be in the healthcare centre for observation
but, as a precaution, he told the man about the availability of Listeners
(prisoners trained by the Samaritans to listen to and support prisoners
experiencing distress). The doctor told one of my investigators that the man
kept saying he wanted to go to the gym and, despite the suicide warning
forms, his mood was good and he appeared to have some insight into his
problems. The doctor decided that the man did not need to be placed in the
healthcare centre at that time and that it appropriate for him to be placed on
an ordinary wing. However, he made a note in the medical record that the
wing should follow up with Listeners if necessary.
25. The man was taken to B wing, the designated wing for unconvicted prisoners,
and seen by the First Night Centre officer who is responsible for newly
received prisoners. He told the officer that he was expecting to be remanded
in custody and that he had no problems. The officer was not aware that the
man’s offence was linked to an attempt to end his life. The next day the man
attended induction for new prisoners. This included learning the routines of
the wing, suicide prevention and discovering more about Listeners and
Insiders (prisoners who are trained to answer queries about day-to-day life in
prison).
26. That evening, the man’s cellmate told the landing officer of his concerns about
the man’s well-being, saying that there was blood on his bed sheets. The
officer went to their shared cell and spoke to the man who told him that he
wanted to self-harm and was depressed. Paradoxically, the man also said
that he felt better. It was not established how he had harmed himself. The
landing officer told my investigators that, not only did his conversation with the
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27. After talking to the man, the landing officer decided to open an ACCT
(Assessment, Care in Custody and Teamwork) Plan, a document which can
be initiated by any member of staff to monitor and assess the care of
prisoners at risk of suicide or self-harm. In the ACCT Plan, the officer
described the man’s mood as low due to being in Liverpool for the first time.
28. The opening of the ACCT Plan triggers a process for staff to provide a
prisoner in distress with individual care. The landing officer discussed the
purpose of the ACCT plan with the man who said that wanted to stay in the
same cell with his current cellmate. An Immediate Action Plan was drawn up
by the wing senior officer (SO) at 7:10pm with the involvement of the man and
the landing officer. They agreed that the man would remain in a shared cell.
He would be seen for a full assessment within 24 hours, and he would be
seen by a doctor to explore his feelings of depression. The Listeners scheme
was explained to the man. It was written in the ACCT plan that he would
move to the crisis suite if his low mood worsened. The level of observation on
the man was set at one observation per staff shift period and three
observations during the night. There are three day shift periods.
29. On 19 July, the man was assessed in more depth by a wing officer, a trained
ACCT assessor. The man told the wing officer that he had suffered a stroke
when he was 17 and was feeling depressed because of the after-effects of
that. He said he had tried to hang himself with a torn bed sheet but could not
go through with it and now wanted to stay alive. A case review followed the
assessment. The man said that his attempt to kill himself had been real but
he had changed his mind and now wanted help. He said that, although he
had contact with both his family and his girlfriend, he hid his feelings and
problems from them. He wanted to be occupied and again talked about
attending the gym and perhaps education classes.
30. After assessing what the man had said, the duty SO, the wing officer and the
man discussed a plan of action known as the CAREMAP. The man’s
depression was identified as an issue so an urgent referral to the mental
health team was made. It was also decided that he should attend remedial
gym (gym sessions with exercises tailored to address specific physical
problems).
31. The man’s risk of self harm was raised to “high” with a plan to review his
situation on 26 July, in a week’s time. The duty SO written summary noted
that the man was very vague and she told my investigators that he was not
very forthcoming, did not really want to co-operate with the process, and that
he did not know what he wanted and found it hard to concentrate. When
asked why she had raised his risk, she said that the man “was not overly
defensive but just did not engage”. Her work experience and knowledge told
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32. Also on 19 July, another RMN working in the prison’s healthcare centre, went
to see the man on B wing as a result of the ACCT plan being opened on him.
A member of B wing staff had telephoned her to register their concern about
him. She told my investigators that she was very concerned when she saw
the risk alert form from the Magistrates’ Court in the man’s medical record
which stated that magistrates had an expectation that the man would be
admitted to the healthcare centre. She showed it to her manager who told her
to go and take the man immediately from B wing to the healthcare centre.
She spoke briefly to him and asked him to go with her, which he did, albeit
reluctantly.
33. The second RMN talked to the man for some time and he began to speak
about his offence. He said that he was not a “drinker” but had had a few
drinks to get up some courage before threatening someone for their car keys.
It had been his intention to take the car and crash it, thereby killing himself.
He mentioned the car accident he had been involved in when he was 17 and
his stroke. The second RMN said his body image was distorted and he saw
himself as very slight so he wanted to go to the gym to “be bigger”. She said
he was conscious of his limp. She had tried to assure him that he was not as
small as he feared nor were his disabilities as obvious as he felt they were.
The interview ended with the nurse reassuring the man that she was available
for him to talk to at any time. She explained that she would be his named
nurse and the person he should go to if he had any worries. Equally, she
would check regularly on him. The man remained in the healthcare centre. It
was noted in his ACCT Plan at 7:30pm that evening that he had attended
evening association (a period for recreation where prisoners can socialise) but
that he had “isolated himself from others”.
34. On 20 July, the healthcare officer (HCO) who is also a registered mental
health nurse was working in the healthcare centre. She told my investigators
that she saw the man go to the bathroom and a few minutes later (about
9:35am) she called through the door to check that he was okay as she knew
that he had problems with self harm. The man did not reply so the HCO went
into the bathroom but could not see him in the bathing area. She found him in
a toilet recess sitting on a chair stabbing himself in the chest with a ball point
pen. He continued to do this when she approached him, but eventually
stopped and handed her the pen after she asked him to several times. The
HCO called out to the senior nurse but, although they tried to get the man to
open up about his feelings, he remained unwilling. The HCO spoke to the
second RMN about the man’s actions and updated his clinical record and
ACCT Plan accordingly. The man then got ready for a visit he was due to
have with his mother. Whilst he was having his visit, the second RMN spoke
to the duty doctor about him and he agreed to write a prescription for the anti
depressant Zispin, also known under its generic name as Mirtazapine.
However, throughout his stay in the healthcare centre, the man refused to
take his medication as he felt he did not need it.
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35. When describing how the man had behaved during the incident, the HCO said
that he did not seem agitated or distressed. On the contrary, “he seemed
quite self possessed really.” He was not frenzied, there were no marks on his
body and he did not need medical treatment. She said it was clear to her that
he did not want their involvement in any way.
36. When the second RMN talked to the man about what had happened in the
bathroom, he said he had done it out of frustration rather than any real
attempt to harm himself. He said he was frustrated with being in the
healthcare centre. He did not want to be there as he felt there was a certain
stigma associated with it. The man told the nurse that he did not have a
suicide plan to cut himself, take an overdose or hang himself. He admitted
that the way he would have wanted to die was by stealing a car and crashing
it.
37. Later that day, the man collected his lunch from the servery and passed
another prisoner on the way. Without provocation, the second prisoner
shouted abuse at the man and threw hot water over him, scalding the man’s
face and neck. The man fell to the floor and was kicked by the prisoner, who
was then restrained by staff. The man’s burns were treated. He was said by
the second RMN to have been very angry and she spent some time calming
him down. The assailant was charged under the Prison Rules with assault.
38. The second RMN and two officers accompanied the man to a local hospital to
have his injuries assessed. He was prescribed painkillers and cream and
returned to Liverpool. The nurse felt that the assault was the worst thing that
could have happened to the man as it compounded his low self esteem
associated with his poor body image. She did not tell the man’s family that he
had been taken to hospital after an assault but believed that someone else
would have done so.
39. The next day the man’s mood was described in the ACCT plan as “sullen”.
The day after that (22 July), the man again refused his medication and
appeared generally unhappy. However, an entry in his clinical record by the
HCO said that he could be “distracted to laughter”. She explained to my
investigators that at times the man appeared very low in mood but, with some
engagement, one could strike up a conversation with him and have a shared
joke.
40. On 23 July, the second RMN referred the man to the Single Point Referral
(SPR) meeting to take place the next day, having previously done so on 19
July. This is a weekly meeting held by mental health agencies who visit and
work in the prison. It is composed of several mental health professionals with
different specialisms. During this meeting, all prisoners who are referred are
discussed, and a decision is made about the most appropriate professional to
see them. The man told the second RMN that he felt better and wanted to go
back to a prison wing.
41. On 24 July, the man again refused his anti-depressant and, after seeing the
GP, the prescription was stopped as he was not compliant. The SPR meeting
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42. On 25 July, the HCO recorded that the man was still asking to return to an
ordinary location and “was a little flat but interacted well”.
43. The staff nurse described the man as quite friendly and pleasant whilst in the
healthcare centre. She told my investigators that he chatted to her about
sport as she was involved in marathon running and he was interested in
getting fit. In her opinion, the man was a poor coper and appeared
vulnerable. She described him as quietly spoken, not loud or a user of coarse
language. She knew that he was not happy in the healthcare centre. The
man thought he might settle in better if he was on a wing where he wanted to
be.
44. On 26 July, the man and the second RMN discussed returning to an ordinary
wing. A review of the man’s progress was held, attended by three members of
staff (including RMN2) and the man. It was noted that the man had not
recently self harmed and had not expressed suicidal ideation. It was agreed
that he could return to B wing, but the second RMN reiterated that he should
ask a member of staff to call her if he wanted to see her at any time. The
man’s self harm risk was reviewed and assessed as low.
45. The RMN2 prepared and signed a healthcare centre discharge report on 26
July, a copy of which was placed in the man’s ACCT plan and his medical
record. It said that the man had not expressed self harm intent whilst in the
healthcare centre and that his return to B wing was at his request. The man
returned to B wing but remained on the ACCT plan. However, second RMN’s
name was not specifically mentioned in the man’s CAREMAP as the person
to contact.
46. On 27 July, it was noted in his ACCT plan that at education induction the man
was “extremely quiet and withdrawn but stating is feeling ok.” No written
observations were made in the man’s ACCT plan between 28-30 July.
47. On 1 August, the CPN contacted the man’s aunt, a mental health support
worker, to obtain some background information about the man before her
scheduled assessment with him. The CPN visits Liverpool weekly but is not
based at the prison. She agreed to keep the aunt abreast of the man’s
progress provided he was happy with this.
48. On 2 August, the man was seen by the CPN to conduct an initial mental
health assessment. At first the man seemed reluctant to talk, but he told her
that he was hearing voices and this was causing him some distress. The
CPN told my investigators that the “voices” the man spoke of were probably
thoughts in his head as he was quite low in mood. The man was unsure how
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49. A teacher wrote in the man’s ACCT plan on 3 August, “Very quiet. Has not
engaged at all with other members of the class. Has produced some limited
work. Very limited communication skills. Seems distant and withdrawn.” An
officer also wrote that day that the man did not answer when he was asked
how he was, and seemed distant as if his mind was on other things.
50. At his ACCT case review on 4 August, the man said he did not know how he
felt about anything and was not very talkative. It was noted that he seemed to
keep his thoughts and feelings to himself, which made it difficult to
communicate with him. It was decided to keep him on the ACCT plan for a
further two weeks. His level of self harm risk was reviewed and was kept as
“low”.
51. On 7 August, the man was seen by a Consultant Psychiatrist, for a more in-
depth consultation. His medical record note shows that he expected a
sentence of between three and five years. The man told the doctor that he
felt unhappy, had problems sleeping and was losing weight (half a stone since
he had been in prison). He attributed his lack of enjoyment in activities to his
physical weakness, and again spoke about wanting to go to the gym to build
up his strength and walk better. When asked about the future, he mentioned
seeing his girlfriend and the importance of seeing his family. He denied any
suicidal ideation. The man said that he had been prescribed Zispin two
weeks previously but did not take it and was not on any medication. An entry
in the man’s medical record of the psychiatrist’s meeting with him concluded,
“Not psychotic, mildly anxious, not suicidal, no aggressive intent.” The Prison
Community Mental Health Team notes show that the psychiatrist concluded
that the man was suffering from mild depression. He prescribed Mirtazapine,
an anti-depressant, and recommended that the CPN “review him in two weeks
with a view to refer him back to primary care if there are no further problems
identified.”
52. On 8 August, the CPN contacted the man’s aunt and mother to let them know
the outcome of the psychiatrist’s review. She wrote in her notes that she
offered them support up to his trial and advised them that, if there were any
problems, they should contact her. The CPN also referred the man to
remedial gym for exercise.
53. On the same day that the man saw the psychiatrist, the wing officer wrote in
his ACCT plan that the man had refused to go to Education and had seemed
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54. During the next few days, the man appeared to mix more with other prisoners.
However, on 17 August he was sent back to B wing from Education after
saying that he did not feel right mixing with other people, and that he did not
want to do Education, or have a job and just wanted to be alone. At
lunchtime, he asked an officer if he could see the doctor in the afternoon. She
wrote in his ACCT plan that he seemed very low.
55. The man saw a doctor, who is employed at Liverpool as a general
practitioner, on his return from a visit with his mother on 17 August. The man
had told a member of staff that he felt low and needed help. The doctor wrote
in the man’s ACCT plan that he did not communicate, was still very withdrawn
and should remain in a double cell at all times. He noted that there was still a
risk of self harm. He wrote a similar entry in the man’s medical record adding
that the man was currently taking Zispin, but that it had not taken effect and
that he should be closely observed.
56. The man’s mother told police that approximately a week before his death, the
man told her and his girlfriend during a visit that he had made a noose, put his
head in it and attempted suicide. It had not worked and his neck had been
sore for a couple of days afterwards. Immediately after she arrived home, the
mother contacted her sister who said she would pass the information on to the
prison. The mother said that, after a previous visit when the man had spoken
of wanting to be in heaven, she had eventually resorted to asking canteen
staff to let officers know of the man’s state of mind, having had difficulties
identifying and alerting appropriate prison staff.
57. On 18 August, CPN wrote in the man’s Prison Community Mental Health
Team notes that the mother had telephoned Liverpool after her son told her
he had contemplated a suicide attempt by hanging but had changed his mind
and had not told a member of staff about this. The CPN went to B wing and
spoke to a senior officer about the telephone call. She then took part in the
man’s ACCT review.
58. The CPN told my investigators that, during the ACCT plan review, the man
denied he had spoken to his mother about thoughts of suicide and said that
he no longer felt that way. He was challenged about not taking his medication
and agreed to start taking it. The CPN was concerned about his cell being on
the highest landing of B wing (the Fives) both in terms of the problems he had
with his mobility and with his being on an ACCT plan. The man agreed to be
moved to a lower landing. The man’s risk of self harm at the review meeting
was assessed as being “low.” His next ACCT review was arranged for 1
September. The CPN telephoned the man’s aunt after the ACCT review to let
her know the outcome and “that I had seen the man and he was fine.” She
told my investigators that her impression of him was that he had “a
problematic personality rather than a serious mental illness.”
16
59. My investigators asked the SO who had also attended the ACCT plan review
as the Case Manager, why the man’s risk of self harm had been assessed as
“low” given his mother’s telephone call saying he had made a ligature. The
SO said his understanding was that the man was taking his prescribed
medication, was feeling better and had no thoughts of self harm at that
moment, so did not warrant being raised to high risk. The SO added that he
thought the CPN asked the man about the ligature but did not recall the man’s
response. Whilst it was thought too soon to close the man’s ACCT plan,
nobody objected to the risk being assessed as low. Asked by my
investigators whether, in retrospect, the man did present a low risk, the SO
said, “probably not … after what he did I would have marked it at least raised.”
60. After the review, the man asked the SO if he could stay on the Fives for the
exercise and because he felt better there. He was told he would not be
moved but in fact, later that evening, he moved to cell B4-07 on the landing
below to share with prisoner A, whom he had known since he was a teenager.
61. A day later (19 August), the man told the duty officer at 12:40pm that he was
again happy to be in a cell with a prisoner he knew. At 3.20pm, however, the
man was taken to see duty nurse after an officer was concerned about his
state of mind. After talking to him, the nurse deduced that the man only
wanted to have a single cell. He was told this was not possible. He was also
reminded to take his medication regularly. The duty officer wrote in the man’s
ACCT plan that evening that the man looked “quite down and miserable” but
when asked how he was, he said he felt okay and was not thinking of self
harm.
62. Prisoner A said to one of my investigators that the man had used a mobile
telephone belonging to another prisoner to telephone his girlfriend. The
man’s girlfriend told him that the prisoner concerned had telephoned her
afterwards and they had chatted. The man had been very hurt that this had
occurred and was annoyed both with his girlfriend and the prisoner.
According to prisoner A, two or three days before his death, the man had
confronted the prisoner on the exercise yard about it. Asked by my
investigator whether it was possible the man was being bullied by that
prisoner, prisoner A replied that the mobile telephone owner was warned off
harassing the man by a more high-status prisoner and that had been the end
of the matter.
63. On 21 August, prisoner A was told by another prisoner that the man had run
along the landing when there were no staff present and rammed his head into
a wall. He lost consciousness temporarily. The man’s cellmate told my
investigator that he had mentioned this to an officer but could not remember
which one. The CPN saw the man on the same day. She described his
presentation as “fairly morose”. The Consultant Psychiatrist also saw the man.
He recommended increasing the dose of Mirtazapine to 30 mgs and would
review him in four weeks. The man told him he felt tired and could not
concentrate. He had headbutted a wall and felt low. He denied any suicidal
ideation. The psychiatrist assessed his risk of suicide as low.
17
64. On 22 August, the man was seen at 8.30am by his personal officer mixing
with other prisoners. (A Personal Officer is a prisoner’s first point of contact if
they have any queries or need information.) The officer told my investigators
that at Liverpool, personal officers are allocated prisoners on the basis of their
cell location. He did not know the man particularly well as the man had only
moved to his landing a few days before when he had not been on duty. At
9.30am, the man asked to speak to a Listener (a prisoner trained by the
Samaritans to support other prisoners experiencing anxiety and distress).
65. On 22 August, prisoner A appeared in court via videolink from Liverpool and
was successful in obtaining bail. He went back to the cell he shared with the
man to tell him he would be leaving and to pack his belongings. The man told
his friend he was happy for him but looked “gutted”.
66. Prisoner B moved into the man’s cell that day. Prisoner B told the police that
he chatted with the man and they played cards together. The man told him
that he heard other prisoners, not only on B wing but other wings, talking
about his girlfriend making pornographic videos and photographs. Prisoner B
thought he was “being paranoid” as he had not heard anyone saying these
things. He told my investigators that prisoners were shouting out of their
windows, but not saying anything that concerned the man. The man
complained to him of anxiety and said he had a knot in his stomach.
67. At 4.38pm, the man left a message on his parents’ answering machine:
”Alright Mum, I’m just phoning to say that I’m sorry and that yeah, no more
fucking. My girlfriend is fucking talking about me all the time to [inaudible] and
speaking to them all on the phone, telling them everything and saying that
she’s fucking cracked me up and I can’t handle it no more and whatever
happens next, I’m sorry I loved her. Ta ta.” At 7.00pm, the duty officer asked
the man how he was. The man replied that he was okay. The officer wrote in
the man’s ACCT that he was “morose and very monosyllabic”.
68. On 23 August, the man telephoned his parents at 8.06am. He told them of his
concerns about his girlfriend communicating with other prisoners and being
seen in pornographic videos that other prisoners were talking about. He was
also concerned that she had played a role in his father’s work van being
stolen. His parents asked him for evidence to support his allegations and
suggested that he must have been mistaken. The man asserted that his proof
was “all these fucking words in my head.”
69. Prisoner B later gave an account to the police of their activities that day. He
said that he and the man played cards in the morning but the man appeared
“quite miserable”. Told to cheer up, the man asked whether he could confide
in his cellmate and said again that his girlfriend was making pornographic
videos and photographs and was sending them to other prisoners so they
could laugh at him. He also felt that his girlfriend was involved in the
disappearance of his father’s van.
70. Two entries in the man’s ACCT plan by an officer that morning described him
as looking very nervous. He was last seen by an officer at 12.30pm after
18
71. In the afternoon, the second wing officer unlocked the man’s landing for
exercise. This meant going from cell to cell asking the occupants if they
wanted to go out on to the exercise yard. Although she normally worked on
the Fives landing, she was detailed to work on the Twos landing that day but
was assisting the Fours landing, where the man’s cell was, to unlock for
exercise. The officer knew the man as, a couple of days before, she had
arranged for a healthcare member of staff to see him because he seemed low
in mood and it was difficult to get any response from him. She was aware he
was on an ACCT.
72. After lunch, prisoner B lay in the top bunk, covered with a blanket and went to
sleep. He recalled a female officer unlocking his cell at about 2.30pm and
saying, “Are you coming out lad?” He did not hear the man respond and he
did not answer the officer either. She closed the cell door. Prisoner B tried to
go back to sleep but could not. He looked under his bunk to the bottom and
noticed that the man was not there. He remembered thinking that the man
might have gone out on exercise. When he opened the connecting door of
their cell washroom, however, he saw the man hanging from the window bars.
He described the man as looking very pale. Prisoner B told my investigators
that he kicked the cell door to attract the attention of the officers as he had
found in the past that it got a better response than pressing his cell bell.
73. The second wing officer told my investigators that, after unlocking the Fours
landing for exercise, she began to walk down the stairs at about 2.40pm. She
could not remember whether she actually saw him when she had previously
opened his cell to enquire about exercise. The officer told my investigators
that it was not uncommon to open a cell and find that the occupants were not
there because they might have a visit or be in Education. She would not
necessarily regard an empty cell as something untoward, even if one of the
usual occupants was on an ACCT plan. However, she said that officers
usually knew the prisoners on the landing where they normally worked.
74. The second wing officer heard loud banging on a cell door. She described it
as being louder than usual. Thinking she might have forgotten to unlock a
prisoner, she made her way to cell B4-07. As she approached it, the banging
got faster. She unlocked the door and saw the man’s cellmate who appeared
to be in shock and was unable to make himself understood. She went into the
washroom area and found the man. She lifted him up to support his weight
whilst the third wing officer, who was behind her, shouted for more staff
assistance. This arrived within seconds.
75. The third wing officer was also normally based on the Fives but had been
detailed that day to move newly remanded prisoners to the Fours and Fives.
He knew that the man was on an ACCT but had not had any specific contact
with him. Whilst updating the movements board on a lower landing, he heard
19
76. The prison officer heard the third wing officer shout for staff. He ran to the
man’s cell and saw the second and the third wing officers holding the man up
by his legs. The man was still hanging from a sheet which was attached to a
window. None of the officers present was carrying a ligature-cutting tool. The
prison officer climbed on to the heating pipes which run along the back wall of
the cell and washroom. Using a pair of nail scissors that one of the officers
gave him, he cut the ligature from the man’s neck. He told one of my
investigators that he found it difficult to cut the sheet with the nail scissors but
managed to do so. Along with the other officers, the prison officer placed the
man on the floor and began cardio-pulmonary resuscitation (CPR).
Healthcare staff arrived two minutes later in response to a Code Blue radio
message (a message meaning that a prisoner was not breathing).
77. At 2.41pm, the GP arrived at the man’s cell. He was closely followed by three
nurses and a healthcare manager. In his police statement, the GP said that
on his arrival he asked the officers to stop CPR whilst he made an
assessment. He described the man’s appearance as pale with no blood flow,
no pulse and not breathing. He then recommenced CPR with the wing nurse.
Another nurse took over CPR whilst the GP administered adrenaline and
monitored the man’s condition with the help of a defibrillator and other
interventions. No signs of life were detected.
78. The man’s medical record says that paramedics arrived after 22 minutes.
However, North West Ambulance Service told my investigators that they
received an emergency telephone call from Liverpool at 2.46pm. They arrived
at the prison at 2.52pm and reached the man at 2.55pm. He was taken to the
local hospital at 3.14pm by paramedics. Sadly, he could not be resuscitated
and was pronounced dead at 3.25pm.
79. Soon after the man was found, prisoner B, the man’s cellmate, was taken to
the Listeners care suite. He described his feelings of devastation, having
found the man suspended. Two Listeners stayed with him until the next day
to provide him with support.
80. At 2.52pm, Liverpool opened their Command Suite (this is used by senior
managers to co-ordinate information when serious incidents occur in the
prison). It was headed by the Deputy Governor, as he was the most senior
governor on duty, and attended by other participants including the chaplain
from the Staff Care and Welfare Team. Once the man’s death had been
confirmed, contingency plans were activated by the Deputy Governor, the last
action being confirmed at 4.30pm.
81. The Deputy Governor and chaplain left the prison at 4.40pm to tell the man’s
family of his death in person. They arrived at the family home in Southport at
about 5.30pm.
20
82. After the man’s death was confirmed, B wing post box, which is emptied daily,
was checked for outgoing mail. An undated letter from the man to his mother
was found. In it, he said he was “fine and I’m goin to try an stay that way.”
He expressed affection for his mother and said that he missed her. The man
spoke about hearing one prisoner shouting to another about his girlfriend. In
the letter, the man expressed his concerns about his girlfriend being involved
in the disappearance of his father’s van. He asked his mother to keep her
away from their home and told her not to show his girlfriend the letter. The
man wrote that he had wanted to write a nice, long letter but “now my head is
battered and I can’t think.”
83. A post mortem and toxicology analysis of blood and urine were carried out.
The toxicology report indicated that Mirtazapine, caffeine and a trace of
alcohol (which may have been due to consumption a considerable time before
his death or produced after death) were found in the man’s blood. The cause
of death was given as neck compression and hanging.
84. A clinical review of the healthcare the man received said that the man’s
background history should have been completed before 7 August 2006 if only
to inform those caring for him. It pointed out, “with regard to his anti-
depressant medication there appears to be some discrepancy between the
notes made in the clinical record and the recording on (sic) medication on the
drug sheets. It is difficult to be certain what the man had actually taken.” It
concluded that, “the level of care offered to the man is appropriate. There
was no evidence of enduring mental illness, but he did have mental health
issues. These were addressed with medication and psychological support in
a sensitive way. The man’s character appeared to be such that there was
nothing more that could have been done to help him.”
85. After considering the notes made by the Community Mental Health Team on
the man’s case, the doctor assisting the lead clinical reviewer produced an
addendum to the clinical review. This said that “Despite his denial of suicide
intent he remained on ACCT status and, therefore, under regular observation.
I am unaware of the frequency of these reviews, but in view of the
discrepancy between what he told his family and what he told prison staff, the
prison would be expected to err on the side of caution to cover this uncertain
level of risk. This is clearly a difficult judgement call …”
21
CONSIDERATION
86. The man had been at HMP Liverpool for just over five weeks. For all of that
time, he struggled to maintain the appearance of being able to cope in prison.
87. The man’s apparent desire to harm himself was noted on the magistrates’
court warrant, the suicide/ self harm warning form completed by court escort
staff, and on the risk form completed by the court probation officer, yet this
information was not seen by the RMN when he completed the man’s initial
health assessment. It is not clear why the documentation detailing his risk of
self harm was not available before the assessment. The man told the nurse
that he had not harmed himself before and did not feel suicidal, and he
declined to see a doctor. It is fortunate that the nurse’s intuition made him
insist, unusually, on the man seeing the doctor. The prison doctor assessed
the man and decided that he did not need to be in the healthcare centre for
observation. The suicide risk forms were filed in the man’s medical record.
The man was then seen on B wing by the First Night Officer, responsible for
new prisoners, who was not aware of the possible risks the man posed to
himself. It was only the next day, when his cellmate alerted an officer after
blood was found on the man’s bed sheet, that an ACCT document was
opened.
88. The man’s ACCT assessment and case review on 19 July are notable
because they crystallise the essence of the pressures within himself. He told
the assessor that he was feeling depressed because of the result of his
stroke. He revealed that he had tried to hang himself and that the attempt
had been real but he had changed his mind. He had decided that he could
not go through with it and now wanted to stay alive. He admitted that,
although he had contact with his girlfriend and family, he hid his problems
from them. The assessment reveals a level of honesty in his interaction with
staff and insight into his situation regarding the possibility of taking his own life
that, arguably, he did not make visible again so completely at any time whilst
at Liverpool. As a result of the assessment, the man’s risk of self harm was
correctly raised to high.
89. Following concerns expressed by B wing officers, the man was taken to the
healthcare centre for a week of observation after the second RMN saw the
suicide risk documentation in the man’s medical record and showed it to her
manager. The nurse became the man’s named nurse whilst he was in the
healthcare centre. As such, she was his first point of contact for any concerns
he might have. The man did not want to be there and talked to the nurse
about his frustrations.
90. Whilst in the healthcare centre, the man was badly scalded as a result of an
assault with boiling water by another prisoner. Although the second RMN
accompanied him to hospital, she did not tell the man’s mother of the assault
but was sure that another member of staff would have done so. However, this
did not occur and the mother only found out after seeing her son’s injuries
when she visited him at Liverpool. The man had already been identified by
Liverpool as a vulnerable young man with low self esteem who, at that time,
22
91. The man returned to B wing at his own request as he had not expressed
suicidal ideation and the episode with the ball point pen was not taken as
evidence of serious self harm. The second RMN told the man that he should
ask a member of staff to call her if he ever wanted to talk. I am heartened that
when B wing staff subsequently had concerns about the man’s state of mind,
he was able to see a doctor or a nurse without undue delay. However, whilst
the named nurse protocol seemed to work well within the healthcare centre, it
operated less well outside. It relied on the man specifically asking for the
second RMN but she was not mentioned by name in the ACCT plan
CAREMAP (except in the Healthcare Centre Discharge Report she had
prepared) nor in other documentation relating to the man - except for his
medical record which was not accessible to non-medical staff. Therefore,
when B wing staff had concerns about him on 19 August, he was seen by a
nurse who was not familiar with him. Perhaps not appreciating the
significance of his concerns, she missed the opportunity for more positive
intervention.
92. The lack of clarity as to the appropriate member of staff to contact existed not
only in the prison but was experienced by the man’s mother when trying to
communicate her fears about her son’s state of mind. The mother expressed
understandable frustration to my investigators about having to ask a visits
canteen worker if they would pass on her concerns about the man to staff in
the prison.
I recommend that the Governor devises an effective system for families
of prisoners at risk of suicide to have a specific point of contact if they
have concerns.
93. On 18 August, whilst on a visit with his mother, the man told her that he had
earlier made a noose and attempted suicide but it had not worked. He added
that he had not spoken to a member of staff about this. The man’s aunt
(although the Prison Community Mental Health Team notes say it was his
mother) contacted Liverpool to pass on this important information. Despite
her telephone call, at the review the man told the staff present that he had not
spoken to his mother about thoughts of suicide and he no longer felt that way.
Whilst he was challenged about his suicidal feelings, he was not challenged
about the contents of his aunt’s telephone call. It appears that his family’s
concern about his attempt to hang himself was not given adequate weight by
the members of the review, and his denial of their conversation was taken at
face value.
94. I accept that there are many prisoners who may express thoughts of self harm
who do not go on to take their own lives or, conversely, that there may be
prisoners who do not voice their intentions but then kill themselves to the
apparent surprise of those around them. What concerns me about the man’s
23
I recommend that the Governor reminds ACCT case reviewers to
balance carefully what a prisoner says about their feelings of suicide/
self harm during the review with evidence of their actual behaviour.
95. The man had admitted at his ACCT assessment on 19 July that he hid his
problems from his family. So the fact that the prison had been given such
troubling information from a family member should have sent alarm bells
ringing. I am concerned that at the review meeting on 18 August the man’s
risk of self harm was assessed as low. This was all the more surprising as in
the two weeks since his previous ACCT review his appearance had been
variously described in his ACCT plan as “low”, “withdrawn” and “distant”. This
is despite the man replying when asked how he was, that he was “ok”,
“alright” or “fine”. Moreover, the day before the 18 August review, an entry in
his ACCT plan said he had told the education department that he just wanted
to be left alone. He did not feel right mixing with people and then asked an
officer if he could see a doctor as he felt low and needed help. Throughout
his period on ACCT, the level of observation (one conversation per shift and
three observations at night) did not change. Given the significant content of
the man’s aunt’s telephone call on 18 August, his level of risk should have
been raised and increased staff observation put in place.
96. The second RMN told my investigators that she did not know the man had
made a noose. She said that, had she known, she would have acted on the
information and brought him back to the healthcare centre. The second RMN
was asked by my investigators why the frequency of the man’s observation
had not been increased, especially given the mounting evidence that he was
becoming very withdrawn. She replied that she was sure that the man would
not harm himself because they had built up a rapport so he could talk to her if
he needed to.
I recommend that the Governor puts in place a system to ensure that the
frequency of observation written on the front cover of an ACCT
document matches the level of risk that the individual prisoner poses.
97. It was good practice for the CPN to update the man’s family on the outcome
of the ACCT review. I have difficulty sharing her description of the man as
being “fine”, although I accept that this is the impression he was seeking to
convey to the members of the review.
98. During the man’s stay in the healthcare centre, he was prescribed
Mirtazapine, an anti-depressant. However, his medical record states that it
was discontinued after he refused to take it because he did not feel he
needed it. On 7 August, Mirtazapine was prescribed again. Although nursing
staff understood that he was refusing to take it, and had told staff at his last
ACCT review that he had not been taking it, the toxicology report after his
death indicates that Mirtazapine was found in his system.
24
99. The man’s family asked about the cause of the scratches seen on his body
after he died. The post mortem report lists a number of marks on the man’s
body. The Comments and Conclusions section of the post mortem report
mentions fading bruising in his right fourth and fifth fingers and adjacent
knuckle areas. It goes on “Whilst bruising could have a number of
explanations, this may have been caused by the deceased landing a punch.
The bruising appears to predate the day of death.”. . Concerning the
photographs that the man’s thought had not been returned, Liverpool’s Family
Liaison Officer provided my investigators with a cell clearance certificate
which listed the contents of the man’s cell as they were being packed. This
included a quantity of photographs. He assured my investigators that he had
taken all of the man’s belongings to the family home.
100. My investigators visited B wing on several occasions. They found it
difficult to readily identify ACCT prisoners from the wing board. ACCT plans
were kept in a different part of the office and no photographs of the prisoners
were displayed. My investigators mentioned their concerns to the then Head
of Safer Custody who indicated that Liverpool was exploring ways of making
ACCT information clearer and more accessible for staff. I understand that a
pilot scheme for identifying the correct occupants of cells by having more
informative cell cards has been developed.
101. The man’s mother has asked about the reliability of staff entries in the
ACCT document. The man’s ACCT booklet was generally completed to a
good standard and I have found no reason to question its veracity. It is true,
however, that his ACCT plan did not contain any written entries between 28
and 30 July. This was contrary to the specified frequency of observations
which should have taken place and been recorded.
I recommend that the Governor ensures that the on-going record within
an ACCT document is kept up to date.
102. On the afternoon he died, the second wing officer opened the man’s
cell for exercise. Although she knew the man by sight on B wing, she did not
in fact know that it was his cell and there was nothing to indicate that one of
the occupants was on an ACCT plan. She was not familiar with the Fours
landing as she usually worked on the Fives and did not recall seeing the man
when she unlocked his cell.
103. The man’s family has asked why the second wing officer did not check
the cell toilet. The man’s cellmate, prisoner B, said that a female officer had
unlocked the cell that afternoon and asked “Are you coming out, lad?” This
indicates that the officer may have seen only one prisoner in the cell and, as
the cell was occupied, there would not have been a need to check the toilet.
In any event, she was not aware that it was the man’s cell.
I recommend that the Governor puts in place a system to ensure that staff
are easily able to identify the cells and whereabouts of ACCT prisoners.
25
104. After finding the man, prisoner B attracted the attention of the staff by
turning on his cell bell and kicking his cell door. He told my investigators that
kicking the door was the best way to capture the attention of staff as they did
not always respond to cell bells. My investigators tested random cell bells on
B wing. They were unable to hear them ring in the main body of the wing and
answering appeared to depend on an officer seeing that a light was
illuminated on the indicator panel on the Twos. There is no electronic
registering system to record that a cell bell has been activated. (I make no
formal recommendation on this matter, but draw my investigators’
observations to the attention of the Governor.)
105. None of the staff who were first to reach the man was carrying a
ligature cutting tool (despite B wing being issued with three). They had to cut
the ligature with nail scissors which, fortunately, one of them was carrying.
Since the man’s death, Prison Service Instruction 32/2006 requires all
uniformed staff in closed prisons (such as Liverpool) to be issued with an anti-
ligature knife and carry it when on duty.
106. An entry by the GP in the man’s medical record read that paramedics
took 22 minutes to arrive. I believe this to have been mistaken. My
investigators contacted North West Ambulance Service who confirmed that
they received a telephone call from Liverpool at 2.46pm, arrived at the prison
at 2.52pm and reached the man at 2.55pm. The NHS standard deems eight
minutes as reasonable, so the arrival of the ambulance appears to have been
within accepted guidelines. I am a little troubled, however, that although the
Code Blue was transmitted over Liverpool’s radio communication system at
2.39pm, an ambulance was not called until 2.46pm. I have not been able to
determine the reason for the apparent delay. Nevertheless, I remind the
Governor that Prison Service policy, issued via a letter to Governing
Governors in March 2004, on the access of ambulance and paramedic
services, states:
“It is essential in clinical crises that prisoners should have rapid access to
emergency paramedical services … It is the responsibility of the Governing
Governor to ensure that a protocol exists at each prison to facilitate the
immediate access to both the prison and the individual prisoner when
emergency paramedic services are summoned. It is also essential that
internal procedures should not waste undue time in summoning emergency
assistance. It should not, for example, be a requirement in every case for a
member of the Health Care Team to attend the scene before Emergency
Services are called. However, a subsequent 999 call to the Ambulance
Service should be made to cancel the response if, after the original 999 call
has been made, a member of the Health Care Team arrives with the patient
and deems that an emergency ambulance is not required.”
This letter was followed up by a letter in September 2006 to all Governors
reiterating the requirement to have a protocol agreed with the local NHS
Ambulance Trust
26
I recommend that the Governor ensures that staff at all levels are aware
of the importance of calling an ambulance promptly.
107. The man’s mother asked why it took Liverpool over two hours to tell her
family of her son’s death. I have considered the time span that Liverpool took
to complete the necessary procedures when a prisoner has died. As the most
senior governor on duty when the man died, the Deputy Governor was in
charge of managing the aftermath of the man’s discovery. He remained in
this role until all the requirements of Liverpool’s contingency plan had been
fulfilled at 4.30pm. He left the prison at 4.40pm with the chaplain and arrived
at the family’s house shortly before 5.30pm. It was proper and fitting that the
Deputy Governor chose to deliver his distressing news to the family
personally rather than by telephone or by asking the police to do so. He
would have been able to provide first hand information to the family as to the
circumstances of the man’s discovery. I am sympathetic to the mother’s
concern that there was a delay. However, I am satisfied that care was taken
not to make news of the man’s death public until his family had been told and
that the delay in doing so was not excessive.
108. After the man had been found, his cellmate, who was naturally
distressed at what he had witnessed, was cared for in a sensitive and
supportive manner by staff and Listeners. This was very good practice.
27
RECOMMENDATIONS
In response to the draft version of this report, the Prison service accepted all the
Prison and Probation Ombudsman’s recommendations. Its response to each
recommendation is below:
I recommend that the Governor devises an effective system for families of
prisoners at risk of suicide to have a specific point of contact at Liverpool if
they have concerns.
Accepted – HMP Liverpool at present operates a Anti bullying hot line, for
concerned offenders and their families. This will now be extended to a point of
contact for offenders, family or friends who have concerns about the welfare
and safety of those in custody. This line is monitored daily and any issues will
be passed to managers for action within their area. Target date for completion
September 2007
I recommend that the Governor reminds ACCT case reviewers to balance
carefully what a prisoner says about their feelings of suicide/self harm during
the review with evidence of their actual behaviour.
Accepted- Case reviewers will be reminded on their training to make this
distinction. In addition, Safer Custody managers will periodically sit in on
ACCT reviews to ensure that reviewers are supported in their role and can
make appropriate distinctions between self harm feelings and evidence of
actual self harm behaviour.
I recommend that the Governor puts in place a system to ensure that the
frequency of observation written on the front cover of an ACCT document
matches the level of risk that the individual prisoner poses.
Accepted – HMP Liverpool operates a robust ACCT training program, in line
with national guidelines. This identifies how to complete the ACCT document.
However trainers will emphasise this point in refresher training which is
currently ongoing for all staff. All ACCT documents are monitored by Safer
Custody Senior Officers daily and any shortcomings identified with the case
manager.
I recommend that the Governor ensures that the on-going record within an
ACCT document is kept up to date.
Accepted – A robust system exists within HMP Liverpool to ensure that all
staff are fully trained in the completion of ACCT documents. However this
issue will be emphasised by trainers in the ongoing ACCT refresher training.
Safer Custody officers will also be vigilant to this issue during their
management checks.
I recommend that the Governor ensures that staff at all levels are aware of the
importance of calling an ambulance promptly.
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Accepted – The Governor will issue a notice to staff to make sure that staff are
aware of the procedure to request the attendance of an emergency ambulance
at the soonest possible time.
Good Practice
It was good practice for the CPN to update the man’s family on the outcome of
the last ACCT review.
Accepted – Liverpool Prison always endeavours to involve families to help
support and reduce the risk of self-harming.
After the man had been found, his cellmate, who was naturally distressed at
what he had witnessed, was cared for in a sensitive and supportive manner by
staff and Listeners.
Accepted – This is normal practise at HMP Liverpool for all offenders exposed
to distress.
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