Individual at Shrewsbury

Investigation into the circumstances surrounding
the death of a man
at HMP Shrewsbury in June 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2009
This is the report of an investigation into the death of a man who was discovered
hanging in his cell at HMP Shrewsbury in June 2008. He had been in custody for
just over three months and it was his first time in prison. The man was 47 years old
when he died.
I extend my personal condolences to the family and friends of the man for their loss.
I would also like to thank the family for their assistance with my investigation and I
hope that I have addressed their concerns. I regret that my report is delayed and
apologise for any additional distress this may have caused.
The investigation was undertaken by two investigators from my office.
An independent review of the man’s medical care whilst in prison was commissioned
by the local Primary Care Trust. I am grateful to the Joint Commissioner for Prison
Healthcare and Substance Misuse for leading the panel review. Thanks are also
due to the Governor of Shrewsbury and his staff for their help and cooperation
throughout this investigation.
Given the inevitable constraints of a prison environment, I do not believe that staff at
Shrewsbury could have prevented the man’s death. However, while it seems the
man derived considerable benefit from the psychotherapeutic counselling he
received, I believe more could have been done to put in place supportive measures
for his mental health problems. I endorse the recommendations of the clinical review
and am pleased to note that many of these are reflected in the recent Service
Review for Shropshire PCT, carried out by the West Midlands Care Services
Improvement Partnership (the CSIP report).
In 2006, my office investigated another death at HMP Shrewsbury in which the
clinical review recommended a review of the mental health referral process.
Although the CSIP report will assist to address the problem, I am disappointed that
no formal action plan was developed in response to my previous recommendation
which I repeat here.
I make three further recommendations in respect of the suicide and self-harm
management procedures and the personal officer scheme, two of which echo those
made by Her Majesty’s Chief Inspector of Prisons in her report of an inspection
carried out in June 2006.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2009
2
CONTENTS
Summary 4
The Investigation Process 7
HMP Shrewsbury 8
Key Findings 9
Issues 24
Recommendations 35
3
SUMMARY
The man was born in June 1960. He was 47 years old when he died in June 2008 in
his cell at HMP Shrewsbury. It was his first time in prison.
Following an attempted overdose on 27 February 2008, the man had been arrested
for an assault against a family member. After a brief return to hospital, he was
remanded into custody at Shrewsbury on 1 March. He was assessed by prison
healthcare staff and placed on a constant watch due to his high risk of suicide. His
reception health screen concluded that he should have a mental health assessment
and an appointment with the doctor. My investigators found no evidence that either
took place. The man said he had suffered from depression for the last couple of
years, but had never before tried to harm himself. He was initially deemed
unsuitable to hold his own medication, which was administered to him at set times.
At a multidisciplinary Assessment Care in Custody and Teamwork (ACCT) review on
2 March, a registered mental health nurse concluded that the man was not actively
suicidal and reduced his level of watch to intermittent. (The ACCT document is used
to assess, observe and support prisoners who are at risk. It highlights the problems
and possible trigger points of a prisoner at risk of self harm, and delivers a
multidisciplinary plan to give support and help through a period of crisis.) Although
no formal mental health assessment was carried out, the man was found to have no
mental illness and was referred for counselling with a psychotherapist.
In March, the man appeared at Magistrates Court and was seen by a community
psychiatric nurse who thought that he was at high risk of suicide. In her
comprehensive assessment, she recommended an increased level of observation
and mental health in-reach contact. The self-harm warning form she sent to the
prison was not found on the man’s clinical record and there was no evidence of any
action as a result.
A week later, on 10 March, the weekly joint meeting between in-reach and primary
care mental health confirmed that the man was unsuitable for in-reach support and
he was referred back to the primary care team. However, no primary care
interventions were put in place, save for the counselling, and no formal mental health
assessment was carried out.
The man was a religious man who received regular chaplaincy support throughout
his time in prison. He also had regular visits from his family. The man was
remorseful about his offence from the start and remained depressed about its
seriousness, and its effect on those close to him, throughout his time in prison.
The man was regularly monitored under the ACCT process, and the level of
observations was reduced. Although he continued to be low in mood at times, his
demeanour improved and the ACCT procedures were closed on 7 April. They were
re-opened briefly later that month after a letter from the man to his wife was read by
security staff at the prison.
4
On 10 April, a month after the referral, the man attended his first counselling session
with a counsellor. He benefited from the sessions and slowly started to work through
his problems. Citalopram was prescribed, under supervision, to manage his
depression although it is unclear whether or not he saw a doctor. On 20 April, a
doctor signed off a repeat prescription without sight of his medical records, and his
medication was given to him in possession.
The man continued to see the counsellor each week and she encouraged him to
write a personal log to externalise his feelings. By mid May, the man had become
very anxious and propanolol was prescribed to manage his symptoms. Due to her
concerns, the counsellor invited a mental health nurse to join three of her sessions
with the man in an attempt to secure primary care support. None of these
interactions was recorded or planned actions written down as a result.
On 19 May, the man pleaded guilty to his offence.
The man was said to find it difficult to communicate with male authority figures. On
26 May, he refused a mental health assessment with a male nurse, and asked to see
the female nurse. No further assessment was scheduled. He did not show his
emotions to staff and prisoners on the wing where he was seen as a quiet man,
although popular with other prisoners.
By 3 June, the man had been prescribed his 70th day of medication in possession
but without a review taking place. The counsellor noticed the next day that the man
was calmer, although he kept pushing his eye which was a symptom of anxiety. She
concluded that he was distressed but did not think that he was suicidal. Over the
next few days the man made regular telephone calls to his wife and sister, at times
appearing emotional and overwrought.
On the morning of 8 June, the man attended chapel and was described as buoyant
and happy. Later that afternoon, he made what was to be his last telephone call to a
friend. He then settled down for the night to watch a film with his cellmate, before
going to sleep. At about 1.30am the following morning, the man’s cellmate found
him hanging from a ligature attached to the window. Officers and medical staff
quickly attended and gave cardio-pulmonary resuscitation until the paramedics
arrived. Sadly, the man’s life could not be saved and his death was pronounced at
2.11am.
My investigators found a stark contrast between the distress which the man wrote
about in his log and the way that he presented on the wing. With the benefit of
hindsight, it is clear from the log (the contents of which he did not show to the
counsellor) that he became very confused and distressed. However, he gave wing
staff no reason to believe he was about to take his own life.
Although the man was regularly reviewed under the ACCT regime and appropriate
decisions about risk were made, my investigators found flaws in the management of
the ACCT processes. Amongst them were a lack of continuity in case management
and a lack of staff and multidisciplinary input into case reviews.
5
I endorse the findings of the clinical review in this report. There was a lack of
primary mental healthcare provision, unclear referral processes and a dilution of
mental health nursing services due to a shortage of staff. Information and
communication with prisoners was unrecorded, and well documented treatment
plans were absent.
6
THE INVESTIGATION PROCESS
1. The investigation was opened at Shrewsbury on 12 June 2008 when my
investigator visited the prison. My investigator met the Governor and other staff
and was briefed on the circumstances surrounding the man’s death. My
investigator took away the man’s core record and all other relevant
documentation for examination. Notices were distributed around the prison
notifying staff and prisoners of the investigation and inviting anyone with
information about the man’s death to contact the investigation team.
2. My investigator and another of my investigators returned to the prison in late
July to interview staff and prisoners. An independent review of the man’s
medical care whilst in prison was commissioned by the local Primary Care
Trust. The clinical reviewer, Joint Commissioner for Prison Healthcare and
Substance Misuse, led the panel review and carried out joint interviews with my
investigators.
3. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of my investigation and to request a copy of the post mortem report.
Upon completion, this report will be sent to the Coroner to assist his enquiries
into the man’s death.
4. One of my family liaison officers contacted both the man’s wife and his sister.
She gave them the opportunity to discuss the purpose of the investigation and
raise any concerns or questions they wished to be addressed. The man’s
family raised a number of concerns:
 Did the man make any other attempts to take his own life whilst in
prison custody?
 What medication was the man prescribed in prison and what were the
likely side effects?
 Did the man hold his medication in-possession?
 What was used as a ligature?
 Did the man receive any mental health assessment?
 Why was the man not on suicide watch, given a previous attempt to
take his own life?
I have done my best to address these issues within my report. I hope that the
report helps the man’s family better understand the events leading to his death.
The man’s sister asked why he had been permitted to contact his wife on their home
telephone, given that the victim of his offence also lived there. His sister expressed
concern about the emotional and psychological impact that the man’s contact with
home would have had upon him. The nature of his offence meant that the man’s
communications were restricted, including reading his mail and monitoring and
recording telephone conversations. The man also signed a compact agreeing that
he would not make contact with the victim. I judge that the prison’s monitoring
appears to have been appropriate in this case.
7
HMP SHREWSBURY
5. HMP Shrewsbury is a category B local prison housing adult male prisoners,
unconvicted and convicted, mainly from the courts in Shrewsbury, mid-Wales
and Stoke on Trent. The prison has an operational capacity of up to 340
prisoners.
6. The cells are divided between A and C wing. C wing, where the man lived
during his time at Shrewsbury, is the smaller wing and normally holds around
22 vulnerable prisoners. It is a self-contained wing with direct access to the
workshops, kitchen and classrooms. A wing has two gated, constant watch
cells. The cells have the normal door and an additional barred door which
allows staff to observe a prisoner unhindered. The man was held in one of
these cells during his first few days in the prison.
7. Healthcare is provided by the local Primary Care Trust. The primary care
centre is staffed by a multi-disciplinary team under the management of a
general practitioner and a healthcare manager. It has no in-patient facilities but
does have nursing staff on duty at night giving 24 hour healthcare cover.
8. In June 2006, Her Majesty’s Chief Inspector of Prisons carried out a full
announced inspection of the prison. She reported that suicide and self-harm
prevention was managed under the remit of a safer custody principal officer.
Some innovative ideas to promote awareness and care had been developed.
The quality of ACCT documents was good, showing good levels of interaction
with prisoners and insight into individual cases. However Her Majesty’s Chief
Inspector of Prisons found a lack of consistency in case managers, which
meant that continuity of care was not guaranteed. I refer to this issue in my
report and, along with repeating Her Majesty’s Chief Inspector of Prisons’
recommendation with regard to the lack of consistency in case managers
attending ACCT reviews, I also repeat her recommendation with respect to the
implementation of the personal officer scheme at the prison.
9. The Independent Monitoring Board’s (IMB’s) report for the year ending 20 April
2008 states that, “Healthcare within the prison is continually striving to improve”
and that improvement and change remains the theme within the primary care
centre at the prison. With regard to issues of safer custody, the IMB reports:
“ACCT procedures at the prison are of a high quality with excellent
communication between staff and those at risk from self harm. There
are 24 ACCT assessors and every manager is trained as a case
manager to carry out daily review with multi-disciplinary team
departments.”
I regret to report that my own findings appear to be at odds with those of the
IMB.
10. Since my office took over responsibility for investigating deaths in prisons in
April 2004, there have been five deaths at Shrewsbury prior to that of the man.
All of those deaths were apparently self-inflicted.
8
KEY FINDINGS
Events leading up to the man’s death
11. The man took an overdose of tablets on 27 February 2008. He was arrested by
police in the early hours of 28 February and taken to hospital. During his stay
he seems to have considered suicide a second time by climbing onto
scaffolding outside his window, but changed his mind. On 29 February, he was
assessed by the police medical officer as fit for custody. His medical form
noted his hospital treatment and that he felt depressed and suicidal.
12. In March, the man was taken to Magistrates Court and charged with assault
against a female member of his family. His prisoner escort risk record, (used to
communicate information between police, court and prison staff) indicated that
he was a very high suicide risk. The man was therefore placed under constant
supervision.
13. At 10.48am, the man transferred to HMP Shrewsbury on remand on an open
Assessment, Care in Custody and Treatment (ACCT) document, which is used
to monitor and support prisoners judged to be at risk of self-harm or suicide. It
was the man’s first time in prison. Shortly afterwards at 11.05 am, the senior
officer in charge of reception, read on the suicide and self harm warning that
the man had taken an overdose and intended to kill himself as he had nothing
to live for any more. The form noted that he was very depressed due to the
seriousness of his offence.
14. An ACCT document was opened by a prison officer at 11.20 am. The officer
and senior officer and a registered mental health nurse (RMN), carried out the
routine Cell Sharing Risk Assessment. The RMN advised that the man should
be placed on a constant watch, and so the senior officer concluded that he
should be placed in a single cell until the constant watch ended, when he could
share a cell.
15. The officer also completed a First Night Care and Induction interview which
dealt with the practical issues of being received into prison. The officer
recorded the interview in the First Night Care and Induction booklet and again
noted the man’s low mood and thoughts of killing himself.
16. At 12.30pm, the RMN carried out a First Reception Health Screen in line with
routine practice in prisons. The man told the nurse that he had no physical
health problems, but mentioned his recent stay in hospital due to the overdose.
When asked about his mental health, the man said he had never received
psychiatric care but had suffered depression and been prescribed anti-
depressants, although he had not taken the medication. He described being
unhappy for the last couple of years but said that he had never before tried to
harm himself. The man told the RMN that he would consider harming himself
again, wished that he had died from the overdose, and still wanted to die as he
felt there was no way forward. The nurse noted that he was upset and talking
about different ways he could end his life. She recorded that the planned
9
17. The RMN later completed the mental health referral form, giving the reason as
the man’s overdose and noting a diagnosis of anxiety and depression. (The
clinical review established that this was not a referral to the in-reach secondary
mental health service, but to the mental health clinics run by the primary care
mental health team.) The nurse made a note of the health screen in the man’s
medical record, although without detailing any of the planned actions. There is
no record of the doctor’s appointment. The man’s medical records from his
community general practitioner were not requested as they should have been.
18. At 12.45pm, the senior officer completed an Immediate Action Plan as part of
the ACCT process. The man was present. The senior officer explained the cell
arrangements and the constant watch. The man was also given access to the
telephone and offered support from the Samaritans.
19. A second RMN was on duty on A wing where she was giving out medication to
prisoners. She noticed that the risk assessment for having medication in his
own possession had not been completed and went to reception to interview the
man. On the basis of the open ACCT and his recent overdose, she concluded
that his medication should be taken under supervision. She wrote this
information on the prescription chart in the man’s medical record in order to
alert other staff.
20. The man was placed in a gated single cell on A wing under the constant watch
of an officer. An ACCT assessment interview was carried out at 4.30pm with a
second officer. The man was still depressed, and distressed about his family
and how they would cope. However, he said that he would not kill himself.
After reassuring the man, the second officer thought that his mental state might
change and so they agreed that he would remain on constant watch.
21. At 10.30pm, 11 hours after being placed on the constant ACCT watch, the man
went to his first ACCT case review. An acting senior officer led the review. No
one else was present but she and the man. The acting senior officer spoke to
the man at length. He was very tearful, low in mood and extremely worried
about his family. He said that he felt he had no one to talk to, and the acting
senior officer suggested the support of the prison counsellor, the Listeners
(prisoners trained by the Samaritans to provide support and a listening ear, but
not counselling), Samaritans and the chaplaincy.
22. In line with the normal practice, the man was seen during his first 24 hours in
prison by the Church of England chaplain and offered pastoral support. In
interview, the prison chaplain described the man as extremely distressed and
concerned about his offence and his family. Throughout the man’s time at
Shrewsbury, he received regular support from the chaplaincy. Prisoners can
access the service 24 hours a day, although the man never asked for help out
of hours.
10
23. On 2 March, the man’s second ACCT case review was carried out by the acting
senior officer and on this occasion a third prison officer and the second RMN
were also present. (The nurse was there in line with the prison’s policy that
reviews of prisoners on a constant watch should be attended by an RMN.
Healthcare staff did not attend subsequent reviews.)
24. The man was quite tearful but composed and willing to talk about his feelings.
He spoke of his marriage and family relationships. He admitted to fleeting
thoughts of self-harm, but said that he had no plans to harm himself as his
preferred method (of overdose) was unavailable to him. He was glad to be in
prison where he could get the support he needed and was happy to be referred
to the prison counsellor. Although the man was tearful, the second RMN did
not believe him to be actively suicidal as he was positive and looking to the
future. The level of observation was therefore reduced from constant to
intermittent (five times per hour). No formal plan of action was recorded in the
man’s clinical record regarding ongoing primary care mental health provision,
and no primary care mental health assessment was carried out. The second
RMN concluded that the man did not fulfil the criteria for in-reach mental health,
and that his problems were of a psychological nature rather than linked to
mental illness.
25. The second RMN summarised the case review in the man’s clinical record.
She referred the man to a counsellor at Axis Counselling (commissioned by the
PCT to provide a counselling service in the prison), although without retaining a
copy of the referral on his medical record. The referral said that the man had
no mental health issues.
26. At 12.30pm the same day, the man saw a prison chaplain who described him
as talkative, tearful but stable. A fourth prison officer noted on his ACCT
observations that the man was calmer and more settled and it appeared that he
had found prisoners to talk to on the wing. They talked about his court
appearance the following day, after which he hoped to return to Shrewsbury
and obtain help to address his problems.
27. In March, the man appeared at Magistrates Court and was remanded at
Shrewsbury until 10 March. He was seen at court by the Community
Psychiatric Nurse of the court’s mentally disordered offenders team. She
completed a full assessment, noting that the man presented in a very anxious,
nervy, tearful manner, and considered that his risk of suicide was high. (The
comprehensive assessment was sent to the prison but was not found in the
medical record.) As a result, she completed a Possible Risk of Self Harm or
Suicide Form, advising the need for an increased observation level and mental
health in-reach contact, and sent it to the prison. (The clinical review found that
there was no mention of the referral having been received in the man’s medical
record, nor evidence of any planned action as a result of the risks highlighted.)
28. The man returned to the prison at 4.00pm, and was seen in reception by the
reception nurse. She commented on his Return from Court document that he
was “fine”, and recorded no change in status. (This contact was not
documented in his medical record either.)
11
29. Later that evening, at 6.30pm, the man took part in a further ACCT case review
with a second senior officer and fifth prison officer. The man was very tearful
and wanted to talk about his case and his children. He said he did not have
much to live for, although the second senior officer noted that he appeared a
little more settled by the end of the meeting. The level of observations
remained intermittent, five times an hour, and another case review was planned
for the next day (although it did not in fact take place). The man returned to his
cell and his ACCT record showed that he was feeling quiet, a little emotional
but a lot more settled than when he first came to prison.
30. A referral made by a Healthcare Nurse (primary care) for the man to be
assessed by the in-reach team was received the same day by South
Staffordshire and Shropshire Foundation Trust, the secondary mental health
service provider at the prison. (A copy of the referral was not held on the man’s
medical record.) The reason for the referral was the man’s “high suicide risk”,
and he was allocated to a third RMN.
31. On the afternoon of the next day, 4 March, the man saw the second prison
chaplain. They both came from where the man lived and the second prison
chaplain felt that this helped establish some trust between them. He said that
the man was very quiet at first, although he spoke openly about his situation.
He felt under some pressure and was in quite a low mood.
32. On 5 March, the counsellor received the man’s referral for counselling and his
name was added to the lengthy waiting list for the counselling service. The
second prison chaplain visited the man twice during the day, noting that he was
still emotional. The man received two letters from his family, which pleased
him.
33. The next day (6 March), the man was moved out of the gated cell into a shared
cell on A wing where he appeared to get on well with his cellmate. He received
another chaplaincy visit in which he admitted thoughts about dying, but said he
would not do anything in prison. His sister visited in the afternoon, which he
found supportive. (The man received visits from his family regularly throughout
his time in prison.) The second RMN noted that he was viewing the future
more positively and was remorseful about his offence. He found comfort in his
religion and hoped to attend church services regularly. The second RMN
recommended that the ACCT observations be reduced to hourly, due to the
man’s improved frame of mind.
34. On the morning of 7 March, the man attended a further ACCT case review. On
this occasion only the third senior officer was present. The review concluded
that, although still very low, the man had improved dramatically since his
reception and was coming to terms with his situation. The observations were
reduced to hourly and the man was relocated to C wing, the vulnerable
prisoners unit. The records suggest that he seemed happy there, settled in well
and socialised with the other prisoners.
12
35. A prison officer was assigned as the man’s personal officer and he introduced
himself, noting no problems on his wing history sheet. (The personal officer did
not remain the man’s personal officer throughout his time on C wing as
personal officers are allocated certain cells and so his personal officer changed
whenever the man moved cells.) The personal officer carried out the man’s
introductory interview and completed the Personal Officer Compact. (The
Compact records basic information about the prisoner, their attendance at
induction boards regarding support and welfare, and agreements about
expected behaviour. It reviews progress for the Incentives and Earned
Privileges scheme which is intended to encourage and reward good behaviour
by allowing access to privileges such as in-cell television, wearing of own
clothes and more time out of cell.) The man’s Compact is completed on the
first page of basic information and the section regarding IEP reviews, but the
remainder was left blank. A chaplain who visited the man noted that he was
much happier and found it helpful that his new cellmate also had a religious
faith.
36. The weekly meeting between the primary care mental health services and the
in-reach team took place on 10 March and discussed potential referrals, issues
of concern, and feedback on the in-reach allocation meeting. The third RMN
discussed the man’s referral with the second RMN and, on the basis of the in-
reach referral criteria, the nurse felt that it was an inappropriate referral. (He
had not been in contact with mental health services in the community, he had
not been on anti-psychotic medication and he had never been compulsorily
admitted to hospital.) The second RMN considered that initially the man should
be managed within primary care, and she agreed with the third RMN that the
initial plan would be to refer him to counselling. He would then be monitored
and treated in primary care and referred back if he deteriorated. The third
RMNnoted their decision in the man’s clinical record. (In fact, no primary care
interventions were put in place except for the counselling which began a month
later, and no formal primary care assessment was carried out or recorded in the
man’s medical record.)
37. At 9.40am, the man appeared at court via video link and no causes for concern
were noted on his ACCT record. He received a visit later that afternoon, after
which he saw the chaplain who noted that he was reasonably settled but had
some major decisions to make.
38. The weekly in-reach allocation meeting took place on 13 March and the third
RMN informed the team of the decision to hand the man’s case back to primary
care.
39. Later that morning, at 9.30am, the fourth senior officer carried out an ACCT
review with the man. No other staff were present. The man appeared very low
in mood, very tearful and upset. He spoke of concerns about his son. The
review noted his constant thoughts of suicide and, as a consequence, he was
advised to ask for counselling or make contact with the in-reach team. The
hourly observations remained in place. (There is no evidence that the senior
officer’s suggestions of a mental health referral were followed up by either the
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40. The man spoke at length later to the chaplain about his family relationships, but
stated he had no intentions of harming himself. He was considering asking for
a special visit with his wife with a chaplain present. He was quite emotional but
left the meeting more positively and still appeared to be in good spirits the next
day.
41. The man’s IEP review on 15 March noted that he was quiet on the wing but
appeared to have settled well. He mixed to a point with other prisoners, but
generally stayed in his cell.
42. On 18 March, in line with the standard healthcare practice when a patient is
transferred back to primary care, the third RMN wrote to primary care
confirming this. (The letter was not found on the man’s medical record, and
was only held on the in-reach team’s own records which are kept outside the
prison.) The man continued to receive ongoing chaplaincy support. His
general demeanour seemed settled over the next few days and he was said to
be in good spirits after a visit on 19 March.
43. The next ACCT case review took place on 20 March, with only the man and the
fifth prison officer present. The very brief review noted that he was still tearful
and unsettled, his thought process was poor and he had had little contact with
his wife. He remained on hourly observations.
44. On 25 March, the man had a further ACCT case review, attended solely by the
man and the acting senior officer as his Case Manager. The acting senior
officer spoke to the man at length and he told her he was feeling much better,
although he was a little nervous about a visit planned for the next day. She
noted that he was awaiting an appointment for counselling. She agreed with
the man that the ACCT should remain open, because he was still very nervous,
although the observations were reduced to three times daily.
45. The man received a visit from his wife the following day. A wing officer noted
that he looked a little glassy eyed, but the man said that it was her first visit and
was feeling emotional. A chaplain visiting him the next morning noted that he
was feeling quite talkative and positive about the visit.
46. On 29 March, the sixth prison officer spoke to the man who told him that
sometimes he felt he wanted to harm himself but he tried to get over it. The
next day the chaplain saw him and he was in good spirits. The man appeared
very concerned about issues relating to his son over the next few days, but was
reasonably settled on the wing. His ACCT case review on 1 April with the fifth
senior officer and seventh prison officer reflected those concerns, and so the
observations were kept at the same level.
47. The man received some good news about his son on 2 April and the second
prison chaplain, said this lifted his spirits. Notes in his ACCT document show
that he felt he could now concentrate on his own problems. However, that
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48. Over the next few days the man was noted as being both positive and generally
improving, although struggling at times. On 4 April, the chaplain talked to the
man and thought that his outlook was very encouraging. He noted that the man
had made good progress and was sorting through his issues. The chaplain felt
the man was gaining in confidence and could resolve his own problems.
49. The fourth senior officer and an eighth prison officer held an ACCT case review
on 7 April. They concluded that the man appeared fine, talkative, and that his
attitude was positive. Issues which had been worrying him had been resolved,
counselling had been arranged, and he was seeing the chaplaincy regularly.
The man’s ACCT was therefore closed and a post closure interview was
planned for 17 April.
50. On 10 April, over a month after his referral, the prison counsellor saw the man
for around 15 minutes for an initial counselling assessment. (The counsellor is
a qualified psychotherapist. She works with prisoners who are suffering from
depression and deals with issues such as relationships, anger and
bereavement.) The counsellor documented all her sessions with the man in his
Axis Clinical Record and his prison medical record. The man presented as an
anxious person and it was clear to her that he wanted to talk, but he was afraid
to open up. He was described by the counsellor as very vulnerable and the
work with him would need to be carried out slowly.
51. After the meeting with the counsellor, the prison doctor prescribed 20
milligrams of citalopram per day to be given under medical supervision for 56
days. (Citalopram is used to treat depression, is well tolerated and has few
side effects.) It is unclear from the records whether the man was seen in
person by the doctor or whether he was medically assessed.
52. Two days later, on 12 April, the personal officer reviewed the man’s IEP record.
He wrote that the man’s ACCT had been closed and that he appeared to have
settled down well. He gave staff no cause for concern about self-harm and the
officer recorded that he was “quite confident the worst is over”. The post
closure ACCT review took place as scheduled on 17 April and no further
problems were recorded. On 19 April, the man’s IEP review shows that he was
coping very well following his ACCT closure and was regarded as a ‘model
prisoner’.
53. On 20 April, the prison’s security department read a letter from the man to his
wife. It contained various comments that staff thought indicated possible
suicidal ideas. Given the man’s self-harm history, the ACCT was re-opened the
next day (21 April). In the case review, led solely by the fourth senior officer,
the man was described as being low in mood, tearful but with no current
thoughts of self-harm. Hourly ACCT observations were resumed. A chaplain
saw him later that day and recorded that, although there was a lot on his mind,
the man was reasonably settled.
15
54. Although there is no entry in his medical record save on the prescription chart,
on 21 April a second prison doctor signed a repeat prescription for 20
milligrams of citalopram to be issued “in possession” to the man initially for 28
days. The chart shows two repeats of the prescription to be given and
reviewed in two months time.
55. In interview it was established that a nurse had asked the second prison doctor
to issue the repeat prescription, but that the doctor did not see the man in
person to review or assess him. EMIS (a computerised healthcare record
system operating in many prisons) does not operate at Shrewsbury, and the
doctor did not have sight of the man’s medical record or the medication protocol
concluding that he should not be given his medication in his own possession.
(Although the instruction about in possession medication was written on part of
the prescription chart, the doctor only saw what was written on the repeat page
prescription page.)
56. The man’s ACCT record shows that on 22 April he seemed fairly relaxed and
was clearly benefitting from the friendship of his cellmate. In a conversation
with the chaplain on 23 April, the man discussed how his letter to his wife had
been misinterpreted. He said that he had not meant to give an indication that
he was thinking about suicide, although he could see why the ACCT had been
re-opened. There appear to be no further concerns about the man on his
ACCT records from this time.
57. The man had his first full counselling session with the counsellor on 24 April.
She noted that, although on an open ACCT again, he appeared to be steadier
and was not so tearful. She confirmed that he had no suicidal thoughts and,
“… he had a busy mind – all over the place …” and needed to talk. The
counsellor asked the man to keep a daily log of his feelings to externalise them,
rather than suppress them. The man used this private log in his counselling
sessions as a basis for their discussions. He would read out sections, although
he did not give the log to the counsellor to read herself.
58. During an ACCT case review with the acting senior officer on 25 April, the man
discussed the misinterpretation of the letter with his wife and said that
everything was fine. The acting senior officer said in interview that the man
made good eye contact, was bubbly, laughed and made jokes. He discussed
the counselling and how it was helping him. He felt that he was moving forward
and was positive. He had no thoughts of self-harm or suicide and the acting
senior officer decided that the ACCT should be closed. The man’s IEP review
on 27 April shows that he continued to be positive on the wing. On 30 April, the
man’s log (read after his death) indicates that he received a letter which had
made him very tearful, with feelings of guilt and remorse, and that he had a
very restless night.
59. On 1 May, the man had his second session with the counsellor. She knew that
his ACCT was closed, and he was able to open up a bit more with her. The
next day (2 May), the man wrote in his log that he had been given a new
cellmate and he was worried about others finding out the details of his offence.
16
60. In her session with the man on 8 May, the counsellor spent a significant period
on coming to terms with his offence and noted that his memories had come
flooding back. She commented on his low self-esteem and vulnerabilities and
helped him to work through issues with family boundaries. The man also
recalled the session in his log, saying how safe he felt in that environment. He
had woken that morning in a terrible state and had been comforted by his
cellmate who had offered to contact the Samaritans. The following day (9
May), the man’s log indicates that he felt very panicky and guilty about his past.
He said that he had tried to watch television but went off to bed wishing that he
had died.
61. On 10 May, the man’s personal officer recommended him for a position of trust.
Two days afterwards, on 12 May, the second prison officer carried out the
ACCT post closure review, concluding that the man felt safe in prison, had
adapted to prison life and was receiving counselling. He had no thoughts of
suicide and just wanted to be sentenced so that he could put the past behind
him.
62. The man disclosed in his session with the counsellor on 14 May that he was
feeling anxious and shaky. Due to her concerns, the counsellor invited the
reception nurse (RMN) into the meeting to discuss the possibility of further
medication to help manage his anxiety. The reception nurse agreed to
organise this and the man’s prescription chart shows that the second prison
doctor prescribed 40 milligrams of propanolol (commonly prescribed for anxiety
type symptoms) three times a day, to be administered by the nurses. There is
no evidence to show that the doctor saw the man in person.
63. On 16 May, the man wrote in his log:
“…Spoke to a third prison chaplain about how I was having thoughts of
killing myself when I get out as I would panic about being on my own
again.”
The man said he hated himself and wrote, “I just knew I’ll do it when I get out.
I’m afraid of the future, not now.” The man’s IEP review noted that he was
quiet and respectful and there were no issues. On 17 May, the man’s log
indicates that he was extremely worried about court and appearing in front of a
male judge, and also about facing the future.
In response to the draft report the man’s wife asked my investigator if he had
spoken with the third prison chaplain about the entry written by the man on 16
May. My investigator had not directly done so and as a consequence spoke
17
64. The man appeared by video link at court on 19 May. He was convicted after
pleading guilty to the charges against him. His log shows that he was very
distressed by the court experience. He had not slept well, and could only think
about killing himself. However, he told his barrister that he liked being in prison
and, if let out, would kill himself. Afterwards he asked to return to his cell with
the door open (as he felt safer from himself that way) and to see a chaplain.
In response to the draft report the man’s wife said that during his appearance at
court, on the video link, the man appeared distressed and was showing
extreme signs of anxiety. The man’s wife expressed concern that this was not
recorded in his prison record.
65. On 21 May, as a consequence of the man’s distress during his session with the
counsellor, she again invited the reception nurse to join them. The counsellor
did not think that the man was responding appropriately to his medication and
she agreed with the nurse to ask the doctor to increase the anti-depressant
dosage. It was decided that the reception nurse would arrange for the man to
be seen in the primary care mental health clinic. The counsellor noted in the
Axis clinical record that an agreement had been made for the reception nurse,
“to support the man in between the counselling sessions, and that the reception
nurse would keep an eye on him where possible”.
66. Following the session, the dose was increased to 60 milligrams daily and a
further repeat prescription was given to him in possession for 14 days. Again
the man was not seen in person by the doctor. The plan to refer the man to the
clinic was not documented in his clinical record. In interview, the reception
nurse confirmed that she had arranged for the man to be seen at the next
available clinic on 26 May and had put this in the clinic diary. However, this
was not recorded on the man’s medical record and the clinic diary could not be
produced.
67. The man’s own log recalled that he “was falling apart and crying a lot” in the
session on 21 May. He discussed how his actions hurt everybody, he truly
hated himself, saying “the chapel says God forgives me but I can’t forgive
myself. I wish I had a gun.” On 23 May, the man wrote about planning a
suicide or farewell letter:
“I’m cracking up. It isn’t a coward’s way out I’m after … I just can’t face
the future … I just want out … I know I’m going to do it. I don’t know
when, it’ll just happen.”
18
He wrote on 25 May of his continual worry about sharing out visit cards to his
family. He described how he pretended to be asleep when others approached
his cell as he did not want to talk to them. He wrote, “I’m not going to have a
future, my past will be wiped out and in the present I worry about them both.”
On 25 May, the man’s IEP review recorded another positive week without any
problems.
68. In interview, the reception nurse clarified that she had intended to see the man
over the weekend of 24 and 25 May as planned, but due to an incident on the
wing her contact with him had been brief. She explained to the man that she
could not see him at length but would arrange for him to be seen the following
week. (None of these interactions was recorded in the man’s medical record.)
69. The Healthcare Nurse went to see the man for a mental health assessment on
26 May. The nurse noted in the medical record that the man declined the
meeting, saying that he would prefer to see the counsellor. The man’s log,
however, indicates that he apologised and asked instead to wait to see the
reception nurse, a female nurse, when she was next free. The man wrote in his
log that he had seen the reception nurse after dinner. He had explained what
had happened and hoped she did not think he was being awkward. She said
she understood and would see him as soon as possible.
70. When the man saw the counsellor on 29 May, they talked further about his
family and marriage and his low self-esteem. That afternoon, the personal
officer allowed the man to use the prison telephone as he urgently wanted to
make a call. The personal officer did not know the reason for the man’s
urgency but recorded their interaction in his wing history sheet. In his log, the
man discussed how he felt he had let everyone down and needed to resolve
unfinished issues before he could move on.
71. On 30 May, the man’s writing in his log appears stronger and more positive, but
he still had many worries about how his actions affected others. His IEP review
noted a good week with no problems. On 1 June, the man received a visit from
his sister and friend and wrote that he felt happy afterwards. The next day, 2
June, the man tried to call his home a number of times. At 3.30pm, officers
carried out a routine search of the man’s cell and a ninth prison officer agreed
not to look at his log. In the afternoon and evening, the man had a difficult
conversation with his wife that upset him. He appeared to be concerned about
the length of his forthcoming sentence, but the calls were mainly related to
personal issues.
72. The man was prescribed a further 28 days of citalopram on 3 June. This was
the 70th day of medication being prescribed in possession without a face-to-
face review. In what was to be his last log entry, written later that day, the man
described his head “arguing” with him. He was worried about his visit the
following day with his wife, but thought that the counselling session would help
him. He spoke of his cellmate moving to a different prison and that it would be
strange not having him around. At 6.44pm that evening, the man called his
sister. Again, he discussed his concerns about his sentence. He said he had
experienced blackouts and was forgetting lots of things.
19
73. The man gave his log to the counsellor for safekeeping on 4 June. The
counsellor noted that the man felt calmer that week, but noticed that he became
distressed during discussions and was pushing his eye. He said that he
pushed his eye in order to feel the pain, which meant that he could concentrate.
He was anxious about his wife’s visit later that day, and the counsellor agreed
to see him briefly afterwards. She concluded that he was distressed but did not
think that he had any suicidal thoughts. She again brought the reception nurse
into the session although the clinical review does not suggest that any action
was taken by primary care staff as a result.
74. On 5 June, the counsellor saw the man as scheduled and he told her that the
visit had gone well. He said he felt stronger and had asked for some money to
be sent in the following week. This was the last time the counsellor saw the
man. In interview, she said that she did not think that he had any suicidal
thoughts and she noticed that he was brighter and seemed to be lifted by his
wife’s visit.
75. The man’s last IEP entry of 6 June read, “Another good week. No problems
whatsoever to staff. Polite and respectful.” That evening he had an emotional
conversation with his wife in which he said he was not feeling alright. She was
concerned about him, but he gave no impression of any suicidal ideation and
she did not report any worries.
76. Later that evening the man rang his wife and apologised for their earlier
conversation. He said that he would call her one last time to check she was
okay and then never ring her again. He said that she would receive another
letter, probably on the Monday, (9 June), setting out everything he wanted her
to do for him. The man called his sister and discussed plans he was making for
his finances. He referred to making a fresh start financially when he came out
of prison. The man seemed confused and overwrought at times and his sister
tried to calm him down. The man seemed concerned again about the length of
his expected sentence.
Events surrounding the man’s death
77. On Sunday 8 June, the man attended a chapel service led by the prison
chaplain. In interview the prison chaplain said that the man was buoyant and
seemed happy to be there. He had coffee and biscuits afterwards, chatted with
the prison chaplain and gave him no concerns. He ate his lunch as usual and
played pool with his cellmate and other prisoners between 2.00 and 4.00pm
whilst they were on association.
78. During a conversation with his wife that afternoon, the man described two sides
of his personality. One was the adult the man and the other was a little boy.
He said that he could not sort his head out and was struggling with the concept
of another six months of psychotherapy. He appeared concerned about his
sentence and spoke of “going to pieces” in his probation meeting. He said that
he had made his head bleed by scratching it and had been pulling at his eye
20
79. Later that afternoon the man called a male friend. it was the last telephone call
he made. He spoke of arguing with himself all the time and how his tablets
clouded everything. He discussed his sentence, which he felt was going to be
very long, but said that his solicitor had given no advice as yet. The man ended
the conversation by saying that he would be in touch soon. They laughed
about cold beers and the weather in Spain.
80. After he collected his tea, the man’s cell was locked up as usual for the night.
The man’s cellmate said in interview that the man got on with his customary
routine, including constant letter writing, and was his normal chirpy self.
81. A tenth prison officer came on duty on C wing at about 8.15pm and checked
that all the prisoners were in their cells. At around 11.00pm, the man and his
cellmate settled down to watch a film. The man got up to make a cup of tea for
them at about 11.15pm and they had a cigarette. The cellmate fell asleep soon
afterwards.
82. The cellmate woke in the night to go to the toilet and tripped on a chair in the
middle of the floor. He then saw the man hanging from the window. The
cellmate jumped up immediately, rang the cell bell just before 1.30am and
started shouting for help. On hearing the bell, the tenth prison officer
immediately went to the cell. He saw the man hanging by a ligature from the
window mesh at the back of the cell he asked the cellmate to support his weight
until he got assistance to unlock the door.
83. At around 1.30am, the tenth prison officer radioed for immediate assistance on
C wing. He did not specify a Code Blue (an emergency call that signifies to
staff an incident such as a hanging or one involving obstruction of the airways
has occurred) because he did not want to alert other prisoners and cause a
panic. The tenth prison officer immediately ran to the office close to the cell,
and telephoned A wing.
84. Three other prison officers’ were on duty on A wing. The night orderly officer in
charge of the wings that night, had been on A wing making his routine checks
and was in the office when the alarm was raised. The radios take a few
moments to activate after the button is pressed, but the tenth prison officer
started talking immediately so the officers only heard “C wing” without the call
for immediate assistance. They knew something was wrong because it is
unusual for the radios to be used at that time of the night and so they began to
make their way to C wing. Seconds later, the night orderly officer answered the
tenth prison officer’s call telling him there was a Code Blue on C wing and
someone in cell 1/04 was hanging. The night orderly officer then radioed a
Code Blue to staff for assistance. C wing was only a few yards away so the
eleventh and twelfth prison officers were able to run there quickly with the night
orderly officer unlocking the doors on the way. The eleventh prison officer
brought his first aid bag.
21
85. The night duty nurse initially heard the muffled call for assistance on C wing
and then heard the call for healthcare to attend C wing for a Code Blue
emergency. He therefore brought his Code Blue bag containing emergency
first line drugs, a defibrillator and an oxygen cylinder, and ran down to C wing.
The doors had already been opened so the path was clear as he ran down the
stairs at around 1.33am.
86. By the time the night orderly officer opened the door to C wing, the tenth prison
officer had already broken the seal on his key pouch and placed it in the cell
door in preparation for opening the cell door. He then went into the cell,
followed by the eleventh prison officer who helped the cellmate take the man’s
weight whilst the tenth prison officer used his anti-ligature knife to cut the man
down. The ligature (a shoelace) was too tight around the man’s neck to cut off.
He was blue in the face and the eleventh prison officer thought the man looked
as though he was already dead. Having released the man the two officers
carried him out of the cell and laid him on the floor of the landing to give
themselves more room to carry out cardio pulmonary resuscitation (CPR). The
eleventh prison officer then cut off the ligature with scissors from his first aid
bag. The tenth prison officer immediately began mouth-to-mouth resuscitation.
87. The night duty nurse, who arrived as the man was being laid on the floor,
checked for signs of life but could not find a pulse. The night duty nurse asked
the officers to cut the man’s shirt to expose his chest so that he could use the
defibrillator, which instructed them to continue CPR (30 compressions to his
chest and two ventilations to his mouth). The tenth prison officer continued with
mouth-to-mouth resuscitation whilst the night duty nurse carried out chest
compressions. The defibrillator did not advise staff to shock during the process
and so they continued CPR. The night orderly officer and the twelfth prison
officer ensured that an ambulance had been called. The eleventh prison officer
went back into the cell to comfort the cellmate who was inconsolable. Having
been relieved by the twelfth prison officer, the eleventh prison officer then went
to help the night orderly officer ensure that the ambulance staff could enter the
prison quickly.
88. The tenth prison officer and the night duty nurse continued CPR for about 20
minutes until paramedics arrived at around 1.50am and took over. The
paramedics declared that the man had died at 2.11am.
Dealing with the aftermath of the man’s death
89. At 2.15am, the night orderly officer contacted the duty governor to ask him to
attend. Police officers arrived two minutes later at 2.17am. The night duty
nurse asked for the man’s body to be returned to a cell to give some privacy
and dignity. The police officers wanted to preserve the cell for investigation and
for the man’s body to be placed in another cell. The eleventh prison officer
arranged for the two prisoners (who were already awake) from the adjacent cell
to be relocated to A wing, so that the man could be placed in their cell. At
2.45am, the duty Governor attended the prison and asked the prison chaplain
to attend to support staff and prisoners together with the care team. The prison
22
90. The night duty nurse saw the cellmate in the wing office afterwards to reassure
him, and contacted the emergency doctor to prescribe some medication to calm
him. At 3.50am, the cellmate was taken across to a cell on A wing where he
remained for the night and was offered a Listener and access to the chaplain.
Staff made statements and a hot de-brief (a meeting at which the events
surrounding the discovery of the man were discussed by staff) was held at
around 8.00am.
91. Later that morning, at 9.10am, the duty governor and the prison chaplain visited
the man’s wife at her home. The man’s wife was woken up as she had worked
a night shift the previous night. The duty governor and the prison chaplain had
not wanted to disturb her at work with the news and waited to visit in person the
following morning. They told the man’s family of his death and offered comfort
and support as they were obviously distressed. The prison chaplain gave the
man’s wife his telephone number and encouraged her to make contact if she
needed to. The man’s wife agreed to inform the man’s sister, his parents and
son of his death. Both the duty governor and the prison chaplain made contact
again with the family following this visit and the man’s wife and sister were
given the opportunity to visit the prison. They saw the chapel, where they lit
candles, and the man’s cell, where they prayed.
92. The duty governor and the prison chaplain attended the man’s funeral on
behalf of staff and the man’s friends on C wing. The second prison chaplain
held a small service at the prison on the same day for prisoners and staff who
wanted to attend. Prisoners arranged a collection for the man and raised £70.
93. The police found a number of letters in the man’s cell. They were addressed to
the Governor, Coroner, the man’s wife, his sister and friends, and stated his
intention to end his life. He also left a handwritten will. The post mortem report
concluded that the cause of death was hanging.
23
ISSUES
Clinical Review Findings and Recommendations
94. The local Primary Care Trust Clinical Review Panel carried out a review of the
man’s care and treatment whilst in prison. Their findings and recommendations
are summarised below and the review itself is annexed to this report.
Mental health provision
95. The clinical review found that:
“The paper based primary care mental health service records and
referral systems in operation at times failed to provide a clear audit of
where referrals had been made, how soon they would be dealt with, or
a clear process for assessing risk.”
96. This was evident in the absence of copy documentation held on the man’s
medical record in relation to the initial in-reach referral by the healthcare nurse
and the letter of referral back to primary care from the third RMN on 18 March.
Although the third RMN noted the outcome of the discussions in the clinical
record, no records were kept by primary care colleagues or further actions
planned for an assessment by primary care. It is unclear from the papers what
process was used for assessing the man’s risk and there was a clear delay in
the assessment taking place.
97. In interview the Service Manager for the prison in-reach team, confirmed that
the usual process for referral to in-reach mental health services would be via an
assessment by the primary care team. In the man’s case, he was referred
direct to in-reach by the healthcare nurse due to his high suicide risk. As a
result no primary care mental health assessment was carried out at this stage.
The second RMN confirmed in interview that, at the man’s ACCT case review
on 2 March, she concluded that this was an inappropriate referral for the in-
reach team according to the criteria they follow. However, her decision was not
documented. The decision was confirmed during discussions at the joint
meeting on 10 March, when the third and second RMN agreed that the man
would be monitored and treated in primary care. Although I am satisfied that
their conclusion was appropriate, the decision-making processes were unclear
and not well documented. Staff are largely reliant on colleagues to discuss
outcomes.
98. The clinical review found that:
“… there was no primary care mental health assessment undertaken
with the man, although this was indicated as a requirement from the
First Night Reception Screening … and that there was ”some confusion
over who the man should be assessed by and a clear delay in the
primary care mental health nurses responding to the original referral for
him to be seen. There was a lack of clarity around the need for an
assessment of the man to take place by the primary care mental health
24
service, despite a number of attempts made by the counsellor to
ensure the man was seen by them.”
99. Once the man had been referred back to primary care, there were no further
planned actions made or documented, save for the counselling to which he had
already been referred. Although the RMN had completed a referral for primary
care mental health assessment on 1 March, there is no evidence that the man
attended. In interview, the second RMN explained the referral process for a
primary care mental health assessment. The referral forms are kept in a folder
and, when a clinic is detailed, they are prioritised in order of urgency and an
assessment is carried out. Due to the shortage of staff (three mental health
nurses working in generic roles), the clinics do not run very regularly. A
caseload is not generated, and so the clinics are run on a sessional basis.
However, if someone is identified as needing follow up they will be reviewed.
My investigators were unable to confirm why the man’s case was not prioritised
for assessment. His mental health assessment was not followed up until 26
May, after the counsellor’s intervention. She told my investigators that she was
concerned that he needed more support.
100. A number of events should have prompted a mental health assessment,
including the self-harm warning form sent from the Magistrates Court to the
prison by Community Psychiatric Nurse on 3 March. However, there was no
mention of it having been received, nor any planned actions leading from it. On
13 March, in an ACCT case review, the fourth senior officer advised that the
man should have contact with the in-reach team. There is no evidence to
suggest that this was followed up.
101. On 26 May, the healthcare nurse recorded in the medical record that the man
had declined an assessment, preferring to continue with counselling. This
account conflicts with the man’s own log that indicates that he was reluctant to
see a male nurse and asked for the reception nurse. In interview, the reception
nurse (who had handed over the assessment to the healthcare nurse to carry
out) confirmed that she was aware of the man’s preference, but did not realise
that a male nurse would be on duty. She confirmed that she discovered this
afterwards, but accepted the healthcare nurse’s explanation that the man felt
quite happy with the counselling service and did not feel he would benefit from
mental health services. Without being able to interview the healthcare nurse,
who has since left the service, the clinical review panel were unable to
determine whether the man had declined or not.
102. In 2006 my office carried out an investigation into another death at Shrewsbury.
In that case the clinical review recommended a review of the referral process
and development of a protocol to manage urgent and non-urgent referrals from
primary care to in-reach. My earlier investigation found that there were delays
in assessment following referral, because of a lack of guidance or standards in
relation to the timeframe for processing referrals not marked as urgent.
103. I am pleased to note from the Service Manager’s interview that there are now
clear guidelines and criteria in place based on the NICE (National Institute for
Clinical Excellence) guidance which are well communicated to primary care
25
104. The clinical review found that
“There was a lack of recording detailing when the man was planned to
be seen. The clinical review team appreciate that some
communications with patients will be ad hoc and in between other
tasks. Nonetheless where a presentation had taken place between the
man and the mental health nurse that related to his care and planned
actions, the content of these discussions and the outcomes had not
been documented.”
105. On 1 March, the planned actions from the first reception health screen,
including a referral to the doctor and a mental health assessment, were not
recorded in the medical record. There is no evidence that the man saw a
doctor. On 14 May, the reception nurse agreed to arrange medication for the
man’s anxiety at the counsellor’s request. The reception nurse made no note
of this intervention in the medical record. On 21 May, the counsellor asked the
reception nurse to join the counselling session. She agreed to support and
keep an eye on the man and arrange an appointment for a mental health clinic.
Again the outcomes were not documented.
106. In interview, the reception nurse confirmed that she had seen the man and told
him she would pop in and have a discussion with him over the weekend. Due
to an incident on the wing on 24 May, she was unable to do this but briefly saw
him to explain. The reception nurse said she did not record any of her
interactions with the man because there was nothing to report. Although the
reception nurse said she arranged a mental health clinic for 26 May and put this
in the clinic diary, this cannot be confirmed. She said she thought there was
already a mental health referral in place. On 4 June, the counsellor asked the
reception nurse to join the session. Once more there was no record made of
actions taken by primary care as a result.
107. The clinical review has:
“… noted the absence of numerous important items of paperwork, such
as the referral made from the community psychiatric nurse of the
Mentally Disordered Offenders Team and the correspondence sent
from the third RMN from the In-reach service.”
In the Service Manager’s interview, the panel learnt that the in-reach service
considered the community psychiatric nurse to be a highly skilled and valued
professional. Had they been aware of her assessment, in-reach would have
taken her views very seriously.
108. The panel found, “… that the only intervention that the man was offered
alongside prescribed medication was counselling through Axis”. For over a
26
109. Through interviews, the panel learnt that primary care provision at the prison
was very limited. There were no group sessions or cognitive behavioural
interventions in place at the time of the man’s death. Mental health nurses
have a generic role that dilutes the quality of mental health care in primary care.
As such, fewer clinics are run with nurses dedicating the majority of their time to
clinical work. The second prison doctor raised concerns over the lack of
regular review at primary care level for people with anxiety or depression.
Assessments are not always followed up or reviewed with appropriate
treatment. This is very difficult in the prison population due to the high levels of
patients with those issues, in comparison with the community. Following her
full announced inspection of Shrewsbury in June 2006, HM Chief Inspector of
Prisons recommended that:
“A wider range of mental health primary care therapies including
options for group work should be available for prisoners with mild to
moderate mental health problems.”
110. The clinical review found:
“The role of the Axis counselling service was clearly significant in
providing much needed support to the man … However there is
evidence of a high demand for this service with the therapist managing
this demand and deciding who should be seen without
consultation with the healthcare service.”
111. Axis (the counsellor’s company) is commissioned by the PCT to provide
counselling services in primary care at the prison. The counsellor confirmed
that the average waiting time for her service was a month. She had expedited
the man’s appointment due to his suicidal thoughts. Decisions about taking
patients are based on need and judged by the counsellor, without liaison with
primary care colleagues and with minimal formal information sharing. The
Service Manager commented that, with hindsight, considering the man’s
suicidal ideation and previous attempts, some interaction between the
counsellor, primary care and in-reach would have been helpful. Although the
man clearly benefited from the counselling, it was quite separate from primary
care provision in the prison. I therefore consider that the man’s progress could
not have been properly followed up in the absence of further interventions or
communication and review between healthcare and the counsellor.
112. Although I consider that these issues had little bearing on the man’s eventual
death, I believe that better processes for referral, assessment and record
keeping, and increased primary care mental health provision, could have
improved the man’s quality of life. I therefore endorse the following
recommendations of the clinical review:
27
The Primary Care Mental Health Service should be a dedicated specialist
team who exclusively work in a mental health role at this primary level,
who complement existing secondary care provision. They should offer a
wide range of mental health primary care therapies for prisoners with mild
to moderate mental health problems including options for group work.
The formal risk assessment process carried out by the primary care
mental health nurses needs to be reviewed and improved and should be
based on best practice. The review should ensure there is a clear
framework for the risk assessment to be completed to include timescales.
This document should inform the need to carry out a full mental health
assessment and the outcomes of the risk assessment should be
documented in the continuous clinical record.
Following on from the primary care mental health service carrying out the
mental health assessment, for those who are deemed as requiring
intervention there should be a clear treatment plan formulated. This
should include the lead primary care mental health nurse, the frequency
of contact and the level of support offered. The treatment plans for
patients should reflect national clinical guidance, such as that provided
by NICE, National Service Frameworks and should be subject to clinical
audit as part of the clinical governance arrangements.
The primary mental health nurses need to be skilled in providing mental
health triage/rapid assessment, more detailed assessments and brief
interventions. Skills in cognitive behavioural therapy, brief solution focus
therapy, medication management and education, dual diagnosis … and
group work are crucial.
There should be an emphasis on regular team meetings between primary
and secondary mental health services to include the Axis counselling
service. This meeting should be used to discuss new referrals and
challenging cases with managers from identified services ensuring there
are effective communication protocols for those members of the team
who cannot attend and that the services are effective and integrated.
Medication and assessment
113. The clinical review found that, “the primary healthcare service does not
routinely request the medical notes of patients that may provide valuable
information about a patient’s medical history”.
114. The clinical review also found:
“… that the man was prescribed citalopram for a period of seventy
days without an initial medical assessment or subsequent review
taking place which would involve him being seen by the doctor”, and
that “the lack of a computerised patient record and case management
system posed difficulties in flagging up the need for medication
reviews”.
28
115. The clinical review note that each of the three times the man’s dose of
citalopram was repeated or increased, it was initiated by the nurse who
approached the doctor. This was also the case with the propanolol. In
interview, the reception nurse confirmed she was not a nurse prescriber. The
second prison doctor told my investigators that he has flagged up the issue of
repeat prescriptions of psychotropic medicines. He said that there is a lack of
manpower and information systems to facilitate reliable repeat prescribing and
review. The doctors are reliant on manual records and the pressure of clinics
means that reviews may not happen.
116. The clinical review panel found that the second prison doctor had not seen the
man or his medical records before prescribing him citalopram “in possession”,
against the advice of the medication protocol signed by the second RMN. The
electronic medical information system (EMIS) does not operate in Shrewsbury
and the doctor could not see the man’s records alongside the prescription
charts and protocol. In interview, the second prison doctor said that EMIS
would enable these documents to be linked. Although the second prison doctor
could not remember the exact details of the repeat prescription, he said he
would usually make a brief visual scan of the chart to see if the patient is on an
ACCT so that he would know not to give in possession drugs. The doctor said
that normally an ACCT patient would be barred from having medication in
possession for 28 days. He was shown the second RMN’s note on the chart
during the interview, but said he would only have been presented with the
repeats page at the time. The second prison doctor thought it would have been
a nurse’s decision to make an assessment of the man at this stage and allow
medication in possession. The nurse would then have asked the doctor to
prescribe it on that basis. I consider it would have been very helpful to have
documented these decisions in the clinical record.
117. The clinical review panel said it, “… believed that the medication prescribed to
the man was appropriate and given in the standard doses”. However, the lack
of review and absence of records is disappointing. Therefore, I endorse the
following recommendations from the clinical review:
The information systems should be addressed with immediacy to enable
the easy access of relevant health information and postal
correspondence.
There needs to be better use of the current resources and the nurse
relationship with the GP to review the psychotropic medication
prescribed within the recommended intervals. The Primary Care Trust
provider arm should review the current practice of prison doctors
prescribing medication without directly assessing the prisoner.
The process for initiating, reviewing and recording the decision to give in
possession medication should be examined to ensure a clear decision
making process.
29
There should be a formal process for all patient records and prescription
charts to be audited in terms of legibility, whether they have been signed,
and their accuracy and in particular whether they are able to be
comprehended by other practitioners.
Further clinical review findings and recommendations
118. The clinical review found that, in the absence of a more specialist assessment
of his mental state and the self-harm risk, it was difficult to estimate the man’s
risk of suicide. The panel was of the opinion that all reasonable attempts to
resuscitate the man were made. The panel also recommended:
A robust system of clinical supervision and line management is required
to support clinical activity for all nursing staff in the prison healthcare
team that is based around the specific needs of the client group.
There is a need for ongoing training for the primary healthcare staff which
takes into account the specialist training needs for the services they
provide.
The need for a clear service specification for the primary mental health
service that should be informed by the health needs assessment. This is
echoed in the recommendations made by Care Standards Improvement
Partnership in their review of HMP Shrewsbury Prison Healthcare.
The Axis counselling service should not continue to form part of a
subcontracting arrangement held by the primary healthcare service but
should have clear commissioning arrangements managed by the Prison
Healthcare Commissioner which should include the level of service, joint
working arrangements and managing the demands placed on the service.
119. In addressing these recommendations, the clinical review panel advised that
the recommendations of the clinical reviews undertaken at Shrewsbury in 2006
be re-examined. I am pleased to learn that many of these recommendations
are reflected in the recent Service Review for Shropshire PCT, carried out by
the West Midlands Care Services Improvement Partnership, and are in the
process of being implemented.
120. In particular, I note the development of a dedicated mental health team
delivering a range of interventions and carrying a caseload in its own right. The
assessment documentation and referral criteria are being reviewed. Training is
to be improved to incorporate a wider range of primary care level interventions
such as cognitive behavioural therapy.
I am also pleased to note the strengthening of links between primary and
secondary mental health services to maximise joint working and information
sharing. I am also encouraged by the attempts to ensure that reviews of
medication for those patients on anti-depressants or other psychotropic
30
Suicide and self-harm management
121. Despite the man’s high suicide risk when he arrived in prison, his demeanour
and mood appear to have improved over time. I am satisfied that the ACCT
was appropriately closed on 7 April, just prior to his counselling. He was
regularly reviewed and his ACCT was re-opened, cautiously and correctly,
following a letter to his wife on 21 April. Staff again ensured the man was
reviewed before closing the ACCT the second time.
122. The man was a quiet man who kept his problems close to his heart and it was
therefore difficult for staff to get a true picture of his feelings. He found solace
in his work and in prayer, and received support from the chaplaincy and his
cellmates. It was apparent that the man found it difficult to relate to male
authority figures. This may have prevented his inner emotions being observed
by prisoners or a predominantly male staff.
123. The counsellor said she was confident about the process for opening up an
ACCT, but did not think it necessary after 25 April. She said she certainly
would have done so if she had felt the man was at risk. The counsellor
requested primary care nurse support and help with medication from 14 May,
when she felt that the man’s mood was not lifting. About two weeks before he
died, she thought the man was feeling more relaxed and getting better. On 4
June, she was aware he was still distressed, but in her opinion he had no
suicidal ideation. On her last meeting with the man on 5 June, he was a lot
brighter and seemed lifted by his wife’s visit. The counsellor was not aware of
the content of his log or his suicidal thoughts. I consider that her judgement
was appropriate, based on her knowledge and observations.
124. In interview personal officer said that the man was always very quiet. He was
liked by the majority of prisoners and respected. Although the man was quite
traumatised on arrival in the prison, the personal officer did not observe a
significant change in his mood over time and described him as being pretty
constant. He gave no further indications of suicidal intent to prompt the
opening of an ACCT. The prison chaplain felt that there was a marked positive
change in the man over time as he became more confident dealing with people.
He saw the man at chapel on the Sunday before he died and said he behaved
normally, chatting and showing no outward signs whatsoever that would have
given him cause to open an ACCT.
125. The man’s previous cellmate, who knew him from outside prison, provided
emotional support and friendship. The previous cellmate said that the man was
low in mood on 2 June and had seen the chaplain. When the previous cellmate
was transferred to another prison on 3 June, he felt this might have been a
trigger to the man’s death. Although it is clear that the man valued this
friendship greatly, it is not apparent from his log that the previous cellmate’s
transfer caused him particular upset. The previous cellmate said that the man
never talked to him of harming himself. He was stressed, but his death came
31
126. To staff and other prisoners, the man appeared low in mood at times but
otherwise well. His counselling appeared to be providing him with support, but
was also making emotional demands that he had to deal with. By mid May
however, the man’s log provide an insight into his real feelings which were in
stark contrast to those emotions displayed externally. With the benefit of
hindsight, it is easy for the reader to see that the man was in distress,
particularly from the middle of May. However, he gave nothing away to staff
and showed no particular outward signs. I therefore conclude that the man’s
suicide could not reasonably have been predicted or prevented.
ACCT information sharing
127. At the heart of the ACCT process is the notion that suicide and self-harm
management is the responsibility of all staff in contact with the prisoner at risk.
This implies information sharing between healthcare and discipline staff.
Although healthcare staff owe a duty of confidentiality to patients, ACCT policy
makes it clear when it is appropriate to share information with non healthcare
staff. The ACCT document itself also asks the prisoner to agree to confidential
health information being shared in the interests of preventing suicide or self-
harm. Prison Service Order (PSO) 2700 (paragraph 1.11.2) states that
healthcare managers must ensure that healthcare staff are aware of the
importance of sharing information with staff from other disciplines, and that they
do share such information.
128. My investigators found little evidence of information sharing or liaison, despite
the fact that the man was on the primary care caseload. Despite the self-harm
warning form completed by the community psychiatric nurse and received on 3
March, no record made its way from primary care to the ACCT. The man’s
personal officer was unaware of the counselling he was receiving. Although the
ACCT records state that healthcare were informed of the ACCT being re-
opened on 21 April, nothing was recorded in the medical record. Despite her
considerable contact with the man, the counsellor was not formally involved in
the closure of his ACCT. It would have been helpful if the counsellor had had
greater liaison with the healthcare staff, who could in turn have shared risk
pertinent information with wing staff working with the man daily. Since he was
not receiving any mental health nursing support, no observations of his mental
state of mind could be made. The reception nurse appeared not to have been
aware of the man’s ACCT. If she had been she could have alerted staff to the
fact she was keeping an “eye out for him”.
129. Although I consider that this would probably not have changed the outcome in
the man’s case, and I make no formal recommendation, I encourage the
Governor and Healthcare Manager to remind healthcare staff of the importance
of sharing risk pertinent information with discipline staff.
32
ACCT procedures
130. Although the content of most of the man’s ACCT case reviews was adequate,
there was a lack of continuity of care. PSO 2700 (paragraph 19 Annex 8G)
states that, wherever possible, the case manager appointed to lead the case
reviews should arrange subsequent reviews at a time that they can be present.
This is to provide continuity of care for the prisoner. However, for most of the
man’s case reviews, a different case manager attended. This undermined the
level of understanding of his needs. My investigators established that there
was no individual allocation of managers for reviews, and no expectation for
them to attend subsequent reviews, as managers were allocated on a day to
day basis. HM Chief Inspector of Prison’s 2006 report recommended:
The case manager allocated to a prisoner at risk should remain the same
for the duration of the ACCT document so that the prisoner at risk
receives consistent support from familiar staff.
131. I support and repeat this recommendation.
132. PSO 2700 (paragraphs 13 and 17 Annex 8G) says that a Unit Manager should
chair the first case review, appointing a case manager who should also
consider other staff who could positively contribute. In subsequent reviews, it
should be possible for a wider range of staff and specialists to attend. One of
the attendees must be the allocated case manager, one a residential officer
and one an appropriate member of non-discipline staff. However, only four out
of eleven case reviews were carried out with more than one person present
other than the man. Only one of those was multi-disciplinary and included
healthcare staff. The second RMN confirmed that healthcare staff are not
normally invited to further reviews. Both ACCTs were closed by people who
had not recently reviewed the man’s case, the second by one person alone.
There was no evidence of consultation with staff who had been in contact with
the man recently. (When a prisoner is on constant watch, the case review
should be chaired by the duty governor or head of healthcare and a mental
health nurse should be present.)
133. Case managers should be trained to the appropriate level. The Acting Senior
Officer, although confident with the ACCT process, was trained only to
foundation level when she took charge of the first case review. Where a
prisoner is on constant watch, as in the man’s case, PSO 2700 (paragraph 9
Annex 8Y) states that the first case review must take place as soon as is
practicable and certainly within four hours of the ACCT being opened. The
man’s first review was eleven hours after the ACCT form was opened.
134. A care and support plan or caremap should be drawn up, implemented and
monitored. PSO 2700 (paragraph 31 Annex 8G) syas that the case manager
should review and update the caremap after each case review. PSO 2700
(paragraph 50 Annex 8G) states that the ACCT can only be closed once all
caremap actions have been completed and the review team judges it safe to do
so. Whilst I do not disagree with the judgement to close the ACCT on 25 April,
the care map was not sufficiently comprehensive, and was updated only once
33
135. While my investigators found that staff were confident in ACCT procedures, that
reviews were well timed and regular, and that the content of the ACCT was on
the whole well considered, I am concerned by the gaps and flaws described
above.
I recommend that the Governor ensures that staff follow the ACCT
procedures in accordance with PSO 2700 and local policy supporting it.
Personal Officer Scheme
136. PSO 2700 says that personal officer schemes can contribute to the care of at
risk prisoners and help reduce self-harm. The Chief Inspectors 2006 report
concluded that prisoners had assigned personal officers but they were not
easily identifiable and prisoners would approach whichever member of staff
was on duty. There was more emphasis on the personal officer scheme
encouraging good order and discipline, than on supporting the requirements of
the offender management model and prisoner welfare.
137. My investigators found that little progress has been made since the Chief
Inspector’s report. The Personal Officer Compact was only partially completed
on 7 March. The sections geared towards prisoner welfare were left blank.
This suggests that, as the Chief Inspector found, the emphasis is still geared
towards good behaviour. The Compact is completed by whichever officer is on
duty at the time, not necessarily the assigned personal officer. My investigators
undertook a random review of the Compacts and found that many were
incomplete, and that officers relied on the weekly IEP reviews in the Compact
to record reflective entries normally contained in the wing history sheets. There
was a lack of easily identifiable and consistent support. Personal officers were
allocated cells rather than individuals, so they changed on a cell move. This
happened in the man’s case.
138. Although my investigators observed some improvements in the personal officer
scheme, such as the allocation of officers to prisoners, rather than cells, I am
not convinced that the scheme has yet been successfully implemented. I
therefore repeat the recommendation in HM Chief Inspector’s 2006 report:
There should be focused management attention to ensure implementation
of the personal officer scheme and staff should have appropriate training
and support.
34
RECOMMENDATIONS
Healthcare
1. The commissioned Primary Care Mental Health Service should be a
dedicated specialist team who exclusively work in a mental health role at this
primary level, who compliment existing secondary care provision. They
should offer a wide range of mental health primary care therapies for
prisoners with mild to moderate mental health problems including options for
group work.
Partially accepted – An RMN will undertake mental health assessments and
have an on going case load of clients. However, their role will also include
medication rounds and working night duty. They also commented that
workforce planning for training in Short focused therapies have been
submitted for consideration.
2. The formal risk assessment process carried out by the primary care mental
health nurses needs to be reviewed and improved and should be based on
best practice. The review should ensure there is a clear framework for the
risk assessment to be completed to include timescales. This document
should inform the need to carry out a full mental health assessment and the
outcomes of the risk assessment should be documented in the continuous
clinical record.
Accepted – A formal assessment and referral documentation has been
developed which includes timescales for assessments to be carried out. This
will form part of the prisoners on going clinical records.
3. Following on from the primary care mental health service carrying out the
mental health assessment, for those who are deemed as requiring
intervention there should be a clear treatment plan formulated. This should
include the lead primary care mental health nurse, the frequency of contact
and the level of support offered. The treatment plans for patients should
reflect national clinical guidance, such as that provided by NICE, National
Service Frameworks and should be subject to clinical audit as part of the
clinical governance arrangements.
Accepted – Treatment plans will form part of the new mental health referral
pathway. They said that the prison health service will have a lead mental
health nurse who will ensure monitoring and audit of mental health referrals
and progress to care pathways.
4. The primary mental health nurses need to be skilled in providing mental
health triage/rapid assessment, more detailed assessments and brief
interventions. Skills in cognitive behavioural therapy, brief solution focus
therapy, medication management and education, dual diagnosis … and group
work are crucial.
Accepted – A triage assessment document is used at first reception which
35
5. There should be an emphasis on regular team meetings between primary and
secondary mental health services to include the Axis counselling service.
This meeting should be used to discuss new referrals and challenging cases
with managers from identified services ensuring there are effective
communication protocols for those members of the team who cannot attend
and that the services are effective and integrated.
Accepted – Regular meetings to discuss mental health referrals are already
being undertaken. The care pathway is integrated within the new referral
process. Work is being undertaken between primary and secondary mental
health on the development of pathway protocols. AXIS counselling will form
part of these multidisciplinary meetings.
6. The information systems should be addressed with immediacy to enable the
easy access of relevant health information and postal correspondence.
Accepted – The scoping of the introduction and implementation to be part of
the first wave of System One IT has been undertaken and we have now been
informed that this will not be available until 2010. To look at secure funding
for staff training and the implementation of existing EMIS system from own
budget.
7. There needs to be better use of the current resources and the nurse
relationship with the GP to review the psychotropic medication prescribed
within the recommended intervals. The primary care trust provider arm
should review the current practice of prison doctors prescribing medication
without directly assessing the prisoner.
Accepted – The Prison Service said that an RMN in post whose primary role
is to work with the GP in reviewing prisoners who are taking psychotropic
medication which is in line with the NICE guidelines.
8. The process for initiating, reviewing and recording the decision to give in
possession medication should be examined to ensure a clear decision making
process.
Accepted – The process of assessing prisoners for in possession medication
and documentation has been reviewed and documentation ratified at the Drug
and Therapeutic committee.
9. There should be a formal process for all patient records and prescription
charts to be audited in terms of legibility, whether they have been signed, and
their accuracy and in particular whether they are able to be comprehended by
other practitioners.
36
10. A robust system of clinical supervision and line management is required to
support clinical activity for all nursing staff in the prison healthcare team that is
based around the specific needs of the client group.
Accepted – Clinical supervision is available to all staff. The healthcare
provider manager will ensure that all staff have dedicated time to undertake
clinical supervision. Bi yearly audit on staff supervision will be undertaken by
clinical nurse manager.
11. There is a need for ongoing training for the primary healthcare staff which
takes in to account the specialist training needs for the services they provide.
Accepted – To scope clinical areas of speciality and source specialist
training/education and development and link to KSF review for PHC staff to
attend.
12. The need for a clear service specification for the primary mental health
service that should be informed by the health needs assessment. This is
echoed in the recommendations made by Care Standards Improvement
Partnership in their review of HMP Shrewsbury Prison Healthcare.
Accepted – The Health Needs Assessment is completed and is being signed
off by the Prison Health Partnership Board. A separate service level
agreement will be drafted for primary mental health services.
13. The Axis counselling service should not continue to form part of a
subcontracting arrangement held by the primary healthcare service but should
have clear commissioning arrangements managed by the Prison Healthcare
Commissioner which should include the level of service, joint working
arrangements and managing the demands placed on the service.
Accepted – A service level agreement has been drafted and is out for
comment. Performance measures are to be agreed and incorporated into a
service specification and reported quarterly to the commissioner.
Other recommendations
14. The case manager allocated to a prisoner at risk should remain the same for
the duration of the ACCT document so that the prisoner at risk receives
consistent support from familiar staff.
Accepted in principle – The case manager will, where predictable, diary all
future meetings, this will ensure that the continuity of the case management of
37
15. I recommend that the Governor ensures that staff follow the ACCT process in
accordance with PSO 2700 and local policy supporting it.
Accepted – All staff who work with prisoners should receive ACCT refresher
training. All new employees who will be working with prisoners will need to
complete an ACCT training course.
16. There should be focused management attention to ensure implementation of
the personal officer scheme and staff should have appropriate training and
support.
Accepted – The personal officer scheme will be prioritised by the Residential
PO. They will make sure that an updated scheme is implemented and
monitored. Staff will have support and training via wing meetings chaired by
the Residential Governor. New policy will need to be re-written when Prison
NOMIS is introduced.
38