Individual at Pentonville

Investigation into the circumstances
surrounding the death a man
at HMP Pentonville on 19 June 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2008
This is a report into the circumstances of the death of a man at HMP Pentonville on
19 June 2007. Prison staff discovered the man hanging from the window bars of his
cell, behind furniture he had moved to shield himself from view. Despite staff
attempts at cardio pulmonary resuscitation and the attendance of paramedics, he
was pronounced dead shortly after 6.25am. At his death, he was 25 years old.
I offer my sincere sympathy and condolences to the man’s family and friends for their
loss.
The investigation was carried out on my behalf by my colleague. A clinical review of
the man’s healthcare at HMP Pentonville was conducted by Islington Primary Care
Trust. I am grateful for their comprehensive review.
I would also like to thank the Governor of Pentonville and his staff for their co-
operation and assistance with this investigation. Particular thanks go to the Deputy
Head of Prisoner Care, for his help throughout the investigation process as liaison
officer.
The man had been at HMP Pentonville for seven months. In May 2007, he received
four life sentences with a recommendation that he serve a minimum of ten years.
The nature of the offences he had carried out, his inability to understand why he had
committed them and their incompatibility with his faith, and the implications of the life
sentences, all appeared to weigh very heavily on him. A month before being
sentenced he had told a psychiatrist that he expected a life sentence, adding “this is
what I deserve but it does make me feel what is the point of carrying on.” Two
months after being sentenced, on a night when his cellmate unexpectedly did not
return from court, the man appears to have taken his own life.
I make eight recommendations, primarily covering healthcare procedures. I also
highlight three examples of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman September 2008
2
CONTENTS
Summary 4
The investigation process 5
HMP Pentonville 6
Key findings 7
Issues 14
Recommendations 18
Annexes
1. Documents considered during the investigation
2. Clinical review
3. Transcripts and notes of interviews
3
SUMMARY
The man was born on 18 February 1982. He died on the morning of 19 June 2007
at the age of 25 years in HMP Pentonville.
Between 2000 and 2006, the man had served three terms of imprisonment, each
time re-offending shortly after release. On 8 December 2006, he was charged with
several serious offences and remanded into custody at Pentonville.
On 28 February 2007, the man moved to the Vulnerable Prisoners’ Unit on D1
landing. The reason for this move is not documented in his prison records.
However, a cellmate said that he thought it was to do with an incident that had
occurred while the man was still in the community. On four or five occasions when
he was on D1, the man spoke to a Listener. He told both the psychiatrist and
probation officer who prepared reports for the court that he could not explain why he
had committed his offences. He also said that he wanted to take courses to
understand his behaviour.
On 18 April, when staff learned that the man had received sad news from home, they
arranged for him to talk to the prison Imam. The Imam organised a telephone call so
that the man could talk to his partner in an office rather than having to use a
telephone on the landing.
The man was sentenced to four terms of life imprisonment on 23 April 2007 with a
recommendation that he serve a minimum of ten years before being eligible for
release on licence. When he returned to Pentonville, the doctor in reception opened
an ACCT plan to give the man the additional support he needed. The man spent
some time talking to the Imam and then appeared to become brighter in mood. The
ACCT was closed at the first case review meeting which took place on 25 April.
On his return from being sentenced, staff had moved one of the man’s friends into
his cell. The two men were cellmates until the man’s death and they sometimes
spent all night talking. On 18 June 2007, the cellmate went to court and,
unexpectedly, did not return that evening.
When staff carried out the roll check at 5.30am the following morning, they could not
see the man in his cell as there was a line of furniture in the middle of the room.
They went into the cell and found the man hanging from the window bars behind the
furniture. Staff and paramedics attempted to resuscitate him, but sadly they were
unsuccessful.
A governor and family liaison officer visited the man’s family to break the news and
offer them help. They continued to support the family through the funeral and
beyond.
My report includes eight recommendations and draws attention to three examples of
good practice.
4
THE INVESTIGATION PROCESS
1. The man died on Tuesday 19 June 2007. My investigator opened the
investigation two days later when she visited the prison. She met the deputy
governor and with representatives of the Independent Monitoring Board and
the Prison Officers’ Association. She saw the man’s cell in D wing and
walked around the Vulnerable Prisoners’ Unit. She was given copies of the
man’s prison records.
2. The investigator and clinical reviewer separately interviewed staff and
prisoners who had been involved with the man during his time at Pentonville.
My investigator also spoke by telephone to his probation officer.
3. One of my family liaison officers spoke to the man’s mother and his partner to
ask if the family had any concerns that they wanted to be included in the
investigation. My investigator and family liaison officer visited the man’s
sisters and mother, at which time the family raised a number of issues. I hope
that this report goes some way to answering their concerns.
4. .
5
HMP PENTONVILLE
5. HMP Pentonville is a category B local prison, principally serving the eastern
and north eastern parts of Greater London. It holds unconvicted,
unsentenced and sentenced adult males and has an operational capacity of
1,152 prisoners. Opened in 1842, the four original cellblocks remain in use
but have been refurbished. There are now seven residential wings and a new
healthcare unit.
6. Pentonville remains one of the busiest and most overcrowded prisons in
England and Wales. It receives a high number of prisoners directly from the
local courts, and staff have constantly to manage population pressures.
Reception staff process anything from 60 to 100 prisoners per day.
7. A Samaritans supported Listener scheme is in place for prisoners who are in
distress or crisis and need to talk in confidence. Listeners are prisoners who
have volunteered for the role and have been trained by the Samaritans.
Healthcare
8. Pentonville’s healthcare centre is a purpose built facility, separate to the main
prison. Opened in 2005, the centre offers 32 in-patient beds and a primary
care clinic designed to mirror a community GP practice. During an inspection
in 2006, HM Chief Inspector of Prisons, Ms Anne Owers, found that medical
staff were still undertaking unnecessary tasks, and not all GPs had received
adequate induction to prepare them for working in a prison setting.
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KEY FINDINGS
9. On 6 December 2006, the man was arrested and charged with several
serious offences. At a very early stage in the process he confessed to the
investigating officers and asked them to pass on his apologies to his victim.
On 8 December 2006, at Waltham Forest Magistrates’ Court, he was
remanded in custody to HMP Pentonville.
10. All new prisoners go through the reception process and then move to the first
night centre for a two day induction. A duty member of the healthcare staff
assessed the man as fit for ordinary location and did not refer him to the
doctor. An induction officer interviewed the man and then completed the Cell
Sharing Risk Assessment (CSRA) and the first night interview and checklist.
He recorded that the man would prefer to share a cell with another Muslim
prisoner if possible. When he asked the man how he felt about being in
prison, the man replied, “angry”. However, when asked whether he had ever
thought about or actually harmed himself, the man said that he had not. The
induction officer also recorded that, when the man was asked what he did
when he felt depressed, he said that he prayed. The induction officer then
explained the support that was available from wing staff, the Samaritans and
Listeners.
11. The man did not attend his second reception screening scheduled for 10
December. The nurse noted in his medical record that he refused to get out
of bed and would not talk to her. When induction finished, the man moved to
a cell on the level four landing on A wing where he remained for almost three
months.
12. During his induction period, the man met the Imam. The man regularly
attended Friday prayers at the mosque. He joined the study circle and often
asked questions. He also helped the Imam with administrative tasks on the
landings and they often discussed religious issues. The man also took
educational courses; indeed, he had taken Key Stage 2 Maths and English
exams the week before he died and had planned to take advantage of further
educational opportunities in prison. After his death his family found out that
he had been awarded an “A”.
13. On 28 February 2007, the man moved to cell D1-33 on the Vulnerable
Prisoners’ Unit. The reason for his transfer is not recorded on any of the
documents provided by the prison. The unit accommodates men who feel
that, for a variety of reasons, they would not be safe on a normal wing. The
man’s probation officer told my investigator that the man had mentioned to her
that he was having problems on A wing. One of the man’s cellmates told my
investigator that he thought the man moved to the Vulnerable Prisoners’ Unit
because he was having trouble related to events that had happened before he
came into Pentonville.
14. The man settled into life on the landing. Staff and prisoners who spoke to my
investigator described him as a mature young man who was polite and
dignified. He was very quiet and reserved but made one or two friends with
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15. On 12 March 2007, the man was convicted of a number of serious offences at
Snaresbrook Crown Court. The court asked for a pre-sentence report and a
psychiatric report to be prepared. On 22 March and 12 April a consultant
forensic psychiatrist assessed the man. He concluded that he had a mild
depressive disorder as a result of being in prison, and arranged a follow-up
appointment for 10 May.
16. On 18 April, the man received word that his partner had miscarried a baby.
He told an officer on the wing who referred him to the Imam. The Imam spent
some time talking to the man. He also arranged for the man to use an office
telephone to speak to his partner. According to his fellow prisoner, the man
was “devastated” by the news and felt very frustrated at being apart from his
partner at such a sad and difficult time. He withdrew into himself even further.
17. Five days later, the man was sentenced to four terms of life imprisonment and
ordered to serve a minimum of ten years before being considered for release
on licence. The man’s cellmate told my investigator that he and the man had
discussed possible sentences before the court appearance. According to the
man, the judge was known as “harsh” and he knew it might be a stiff
sentence.
18. When the man returned to prison after sentencing, he went through the
normal reception process. The prison doctor examined the man in reception
at 7.30pm. The man told the doctor that he felt tired and “low” but made good
eye contact and denied having any thoughts of suicide. The prison doctor
assessed the man as being at moderate risk of self-harm and opened an
ACCT plan. (An ACCT document describes the problems facing a prisoner at
risk of harming himself and implements a plan to give support through a
period of crisis.) The prison doctor also referred the man to the mental health
team. He asked for him to be assessed within a week but this did not happen.
The prison doctor also prescribed sleeping pills for three days.
19. Staff discussed admitting the man to the healthcare centre but decided to
keep him on D1 and provide support there. The ACCT case manager
instructed staff to check on the man each hour, day and night. A fellow
prisoner, a man whom the man had known in the community, was moved into
the man’s cell and the two men spent all night talking. The man’s new cell
mate was a Listener but he told my investigator that he and the man always
spoke as friends - he did not act as a Listener for the man. The man told his
cellmate that he did not think he needed to be on an ACCT and that the staff
were making an unnecessary fuss. He also said that he was probably going
to appeal against his sentence. However, for most of the night the two men
chatted about the past rather than the present or future.
20. The following morning (April 24), an officer carried out an ACCT assessment
interview with the man. The ACCT assessor told my interviewer that he
8
21. The man was not willing to talk about his feelings or problems and gave fairly
brief answers to questions. The ACCT assessor asked him several times if
he wanted to die, to which he replied that he did not. The man said that he
was in regular contact with his family by telephone and letter. He told the
ACCT assessor that there was nothing the officers could do for him and that,
although he knew Listeners and the Samaritans’ telephone were available, he
was “not interested”. The ACCT assessor was concerned at how withdrawn
the man was, so he passed on his concerns to the senior officer on duty on
D1 as soon as he left the man’s cell. I should add that it would have been
helpful if the ACCT assessor had also made an entry in the ongoing record
section of the ACCT plan for staff on later shifts to read.
22. The man slept for most of the remainder of the day. By 4.30pm he was up
and he helped serve the evening meal. An officer noted that, although he was
less talkative than normal, he did chat as he was working. The officer also
wrote that the man seemed a lot better than he had been during the earlier
part of the day. That night, he watched television until after 4.00am.
However, he got up the next morning in time to take part in association at
9.30am.
23. At 10.30am on April 25, the Imam visited the man in his cell and they spoke
for approximately two hours. The Imam told my investigator that around the
time the man was convicted he had stopped attending the mosque. On this
occasion they talked about the sentence and how to cope with it. The Imam
said that the man was very quiet and calm. He was worried that the man
might harm himself but the man said, “Of course not. Of course not. Of
course not.” The Imam continued to talk to the man when he saw him on the
landing and always invited him to attend the mosque again or to visit privately.
The man always politely refused.
24. Once an ACCT plan is opened a case review should be held within 24 hours.
The man’s review took place almost two days later and appears to have taken
10 minutes. The meeting was chaired by a senior officer, with the man and a
prison officer also present. The man told the officers that he was fine and had
no urge to harm himself. He said that he was in regular contact with his family
and they were giving him a lot of support. He had also spoken to the Imam.
He said that he understood why staff had opened the ACCT plan, but that
everybody was fussing over him and asking if he was okay. The prison officer
said that the man was by nature a quiet person and kept himself to himself.
Those present all agreed that the ACCT plan should be closed. A post-
closure review was not held.
25. On 6 May, an officer from the wing had a long chat with the man about his
relationship with his partner and the impact of his lengthy sentence on her.
The man was assessed by the consultant forensic psychiatrist on 16 May for
9
26. The next entry in the man’s record was made on 25 May. An officer noted
that the man was mixing well with the other men on the wing. According to
the man’s cell mate, about this time the man helped staff cut down a prisoner
who had tried to hang himself on the landing. The man’s cell mate reported
that this had affected the man, who talked about what he had seen. When my
investigator asked for details of this attempted hanging, staff reported that a
prison officer had discovered a prisoner hanging on 23 May. The officer said
that he and his colleagues had dealt with the situation and the man had not
been involved. From the man’s cell mate’s recollection of his conversation
with the man, it would seem likely that, even if he had not been involved, he
had observed what had happened.
27. On 9 June, staff found a mobile telephone in the cell that the man and the
other prisoner shared. Both men were put on disciplinary report. When staff
examined the phone they found a text message from a woman in which she
had ended her relationship with an unnamed man. The man’s cell mate told
my investigator that the man had nothing to do with the phone and the text
message on it had not been for him. The disciplinary charge against the man
was subsequently dropped.
28. On the morning of 18 June, the man’s cell mate went to court for the first day
of his trial. At lunchtime the man did not collect his meal, so an officer went to
his cell and asked him if he was alright. The man replied that everything was
fine and it was just that he was not hungry. The man’s cell mate told my
investigator that the man sometimes missed meals. When the man collected
his food at teatime, the officer who had spoken to him earlier asked him if he
was hungry after missing lunch and he said that he was.
29. The man then went to a second prisoner’s cell and asked to borrow some
coffee. The second prisoner told my investigator that at the time the man was
wearing traditional clothes, which he did when going to the mosque and
sometimes when “he was feeling religious”. They talked briefly and laughed
until the prison officer called on the man to return to his cell. The second
prisoner said that the man seemed happy, not upset about anything. As the
man went into his cell he gave the prison officer a wry smile at being the last
person to go into their cell. The prison officer said that he would see the man
in the morning to which the man replied, “Fine.”
30. Under normal circumstances, a prisoner who is on trial will return to prison
and his own cell each evening. However, the man’s cell mate’s trial did not
begin on 18 June as expected and Pentonville was subject to a ‘lock-down’
which meant that they could not accept any prisoners from court. The
prisoner’s cell mate therefore spent the night in a cell at the court. This left
the man alone in his cell.
Tuesday 19 June
10
31. During the night of 18/19 June, an Officer Support Grade (OSG) and a prison
officer on D wing were on duty. D wing is a large unit with five landings
holding almost 400 prisoners. For the evening and morning roll checks, the
OSG and D wing officer agreed which landings each of them would check.
The OSG was responsible for counting the men on D1, so he made a list of
each cell and the number of men occupying it. The officers did the evening
check shortly after they came on duty at 8.45pm. During the night they
patrolled the landings, answered cell bells and checked on the men on open
ACCT plans.
32. At approximately 5.30am on 19 June, The OSG began his morning roll check
on D1. He worked his way along the left hand side of the landing and then
crossed to the right side. When he checked D1-33 he could not see anyone
in the cell although his list showed there should be a prisoner inside. The
OSG shouted to try to get the occupant to show himself but nothing
happened. He explained to my investigator that sometimes prisoners cannot
be seen as they hide during roll counts as a game, or they might be slouched
on the toilet.
33. The OSG raised the alarm and colleagues came to assist him. There are
slight variations in their descriptions of who carried out which actions. (I
believe that the differences are the result of all the focus being on trying to
save the man rather than on which colleague was assisting at any given
moment.) From the accounts provided by staff, I have concluded that what
happened was as follows.
34. The OSG could hear the D wing officer and the night orderly officer, in the
office at the top of the stairs to D1. He went to them and said that he could
not see the prisoner in cell D1-33. They went to the cell to check, whilst the
OSG went to the wing office to check the name of the man in the cell.
35. The night orderly officer looked through the observation hatch and could not
see anyone, so he called for assistance over the radio. The assistant night
orderly officer responded to the call. The night orderly officer opened the cell
door and went in with the D wing officer, the assistant night orderly officer
following closely behind. The night orderly officer saw that the bed was empty
and the two lockers which should have been against the right hand wall were
almost in the middle of the room. He could not see the wall at the back of the
cell. As he moved into the cell and past the furniture, he saw the man sitting
on the floor with a strip of bed sheet round his neck and attached to the
window bars. He immediately radioed for Level 1 (serious emergency)
medical assistance (this call was timed at 5.40am). The night orderly officer
and assistant night orderly officer lifted the man up and used D wing officer’s
anti-ligature knife to cut the sheet and remove it from the man’s neck. The
officers laid the man on the floor and the D wing officer moved the furniture
out of the way to make more room in the cell. The assistant night orderly
officer felt for a pulse but did not find one.
36. When the night duty nurse who is responsible for responding to emergencies
heard the call for Level 1 assistance, she collected the bag with resuscitation
11
37. When the night duty nurse arrived at the cell, she felt for a pulse but could not
find one. She asked the night orderly officer to call an ambulance. She noted
that the man was very cold, stiff and clammy, and so began CPR with the
assistant night orderly officer assisting her. With some difficulty (because the
man’s jaw was clenched) she put an airway into his throat to help get oxygen
into his lungs. Then she administered oxygen and the assistant night orderly
officer carried out chest compressions. When the man did not respond to the
CPR, the night duty nurse attached the defibrillator. The machine carried out
its checks and instructed the staff not to shock the man. As it did so, three
paramedics arrived and took over the man’s treatment. They continued the
resuscitation attempt from 5.56am until 6.23am when they decided that
nothing further could be done.
38. The duty care team member was available for the staff who had found and
attempted to resuscitate the man. At 7.15am, the Governor chaired a hot
debrief meeting, and half an hour later he held a full staff meeting. All open
ACCT plans were reviewed by an assessor. The Listeners were briefed and
support put in place for them. The senior officer in reception assessed the
ACCTs of prisoners who were going to court that morning and, where the
prisoner had already left the prison, he informed court staff that the ACCT
must be reviewed. At 8.56am, the senior prison doctor, confirmed the death.
When the man’s cell mate returned from court later that day, a governor met
him in reception. He took the man’s cell mate into a private room where he
broke the news of the man’s death and offered him support.
39. When the man had first arrived at Pentonville, he had nominated his sister as
his next-of-kin. The Safer Custody manager, the prison family Liaison Officer,
and a principal officer visited the man’s sister home to break the news.
Before they left, the prison family liaison officer gave the family a booklet
produced by the prison containing useful information that had his contact
details on the front cover. The governing governor later spoke to the family by
telephone and gave them his mobile phone number.
40. The following day, the prison family liaison officer visited again along with the
Imam. The Imam offered to help in any way he could and the family asked
him to arrange a Muslim funeral. The prison family liaison officer also visited
the man’s partner and provided information and support to her.
41. The funeral was held on Saturday 23 June and was attended by two prison
family liaison officers. The prison contributed financially to the funeral and
helped with transport throughout the week as arrangements were made.
42. On 27 August, a rock concert was held in Pentonville’s chapel to raise
awareness of the issue of suicide among young men. The role of Listeners in
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13
ISSUES
The man’s reflections on his crime and the consequences of his sentence
43. After his arrest, the man admitted his guilt almost immediately and pleaded
guilty to the majority of charges against him. He could offer no explanation for
his actions, and over several months he told a number of people that he could
not understand his behaviour. He was aware of the seriousness of the
offences and did not seek to minimise his guilt. He told his probation officer
that he was ashamed of and sorry for what he had done.
44. The man said to the psychiatrist who assessed him, “I deserve to go to jail. I
deserve a lot worse than jail.” He told his probation officer, “I’d have been
executed under Islamic law.” He told both his probation officer and the
psychiatrist that he wanted to understand his behaviour and was eager to
have counselling and do courses to get to the root of his actions. The man’s
probation officer discussed various options with him, including one long and
particularly demanding intervention. The man was open to doing even the
most demanding offending behaviour courses.
45. The man’s probation officer told my investigator that the man was aware of
how his offences conflicted with his faith. When the probation officer met the
man to prepare the pre-sentence report, he told her that he had lost his faith.
(He had never said this to the Imam.) The Imam told my investigator that the
man had borrowed a book on Islamic law from him. He regarded this as a
very unusual request as Islamic law is usually studied only by scholars.
However, the man had clearly read the book, judging from how well thumbed
it was when it was returned to the Imam after the man’s death. Among the
papers found in the man’s cell afterwards was an envelope. On it a single
word had been written over and over again - “repentance”.
46. After the man was sentenced, he appeared to be coping. The man’s cell
mate said that the man appeared ”laid back” about his sentence. However,
on one occasion when he commented on how well he was taking it, the man
replied, “Yes. You would think,” rather than saying, “Yes. I suppose,” as he
had done before. In retrospect, the man’s cell mate felt that perhaps the man
was not as comfortable with the sentence as he had appeared.
47. On 6 May 2007, an officer on the wing had a long chat with the man about his
relationship with his partner and the impact of his lengthy sentence on her.
The officer told my investigator that the man was considering how hard it
would be for his partner to cope with him being in prison for such a long time.
Another prisoner on D1 landing, told my interviewer that the man had
remarked that by the time he was released his one-year old son would be a
grown man.
Access to Listeners
48. When the man arrived at Pentonville he was told that Listeners were
available, as was the telephone to talk to the Samaritans. After he was
14
The man’s move to the Vulnerable Prisoners’ Unit (VPU)
49. The man moved from A wing to the Vulnerable Prisoners’ Unit on D wing on
28 February 2007. Information from the man’s probation officer and cellmate
suggest that the man was being ‘hassled’ in relation to events that had
occurred outside of prison. However, there is no documentation in the man’s
records to confirm or exclude this. There is no written request from the man
asking to move for his own safety nor is there an entry in his wing history
sheet to explain why he moved. The lack of information is unhelpful. It
should not happen that a prisoner is located in a unit for vulnerable prisoners
without his records containing a written explanation for the move.
The Governor should remind staff that, when a prisoner is moved to the
VPU, the reason is entered in his records.
50. The man found it difficult living in the VPU. He told his probation officer that
he did not want to be there as it meant getting ‘flak’ from other prisoners.
Once a prisoner has been in a VPU, it can be very difficult to return to a cell
on the main wings. Prisoners on normal location may stigmatise those in the
VPU and this attitude can make it hard to move a prisoner out of the unit.
According to the second prisoner, the man never went out during exercise
periods although he did go to the gym. When my investigator visited D1
landing she was shown the exercise yard used by the men on the unit. It is
overlooked by two accommodation blocks housing prisoners on normal
location.
The man’s desire to work
51. During his time on D1 landing, the man asked on a number of occasions to be
assigned work. The officer on the wing offered him work making up tea packs
(for the prisoners to use in their cells in the morning), but the man said that he
wanted something more interesting. The officer sometimes asked the man to
help out on the hotplate, serving food to the other prisoners when he did not
have enough workers. However, he could not make the position permanent
until the security department had cleared the man for work. My investigator
could find no evidence that staff had requested clearance for the man, and
staff could not explain why it had not been done.
15
The Governor should review the procedures for clearing prisoners for
work to ensure that applications are recorded and processed in a timely
manner.
ACCT
52. When the man returned to Pentonville after being sentenced to life
imprisonment, the prison doctor assessed his risk of self-harm as medium.
He opened an ACCT plan and, as noted earlier, a fellow prisoner who was
also the man’s friend was moved into the man’s cell. The following morning
the ACCT assessor spoke to the man and was so concerned about him that
he spoke to the senior officer on duty. However, there is no sign of these
concerns being documented in either the ACCT plan or the wing observation
book. It appears, therefore, that the information was not readily available to
the staff in the case review meeting who decided to close the ACCT the
following day.
53. PSO 2700 ‘Suicide Prevention and Self-Harm Management’ stipulates that
after an ACCT plan is closed, a post closure interview must be held within
seven days. This did not happen in the man’s case. The senior officer who
chaired the review that closed the ACCT plan, told my investigator that she
was not aware of this requirement. The procedure on D wing is for staff to
‘keep an eye on’ a prisoner after he comes off an ACCT plan and, if
necessary, make an entry in his history sheet.
The Governor should ensure that all prisoners on ACCT plans have at
least one post closure interview, as required by PSO 2700.
54. My investigator judged that the entries made in the ACCT recording staff
interaction with the man were of good quality, as were the management
checks. The policy at Pentonville is that, in addition to a management check
during the day, all ACCTs are also checked each night by the night orderly
officer or his assistant. They assess whether each document has been fully
completed and note any omissions or problems. They write a report on their
findings which is then passed to a governor for action. This is good practice.
Health
55. A clinical review was carried out investigating the clinical care that the man
received during his time in Pentonville. She concludes that his care was
appropriate and timely. However, she also identifies a number of procedures
that could be changed to optimise the delivery of care:
The Head of Healthcare should set up a recall system for patients who
miss the second part of their reception health screening assessment.
The Head of Healthcare should set up systems to ensure a referral to the
mental health team is acted upon.
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The Head of Healthcare should review nurse staffing levels in the main
prison at night with a view to improving staff working conditions and
reducing professional isolation and improving patient safety.
The Governor and Head of Healthcare should set up procedures to
enable staff from the healthcare centre to assist the staff in the main
prison during an emergency situation at night.
Nationally a protocol should be developed whereby healthcare staff
should have ready access to patients’ medical records held in other
prisons.
Family liaison
57. After the man’s death, the deputy head of prisoner care, the prison family
liaison officer and principal officer visited the family to give them the news.
They answered the family’s questions and explained the support that was
available. Before they left, they gave the family a booklet that clearly
explained what would happen and giving contact details of organisations that
provide support for bereaved families. On the front cover of the booklet are
contact details for the prison family liaison officer and another member of staff
for occasions when the family liaison officer is not available. As noted above,
the governing governor also gave the family his mobile phone number. I
commend the use of the family liaison booklet as good practice as it gives the
family a great deal of helpful information in a very accessible way.
58. The following day (20 June), the prison family liaison officer returned with the
Imam to discuss the funeral. The family asked the Imam to arrange and
officiate at a Muslim funeral for the man. He did so and was sensitive to the
fact that the family do not follow Islam. He arranged for the women to be
present at the graveside, which is not usual at Muslim funerals. The Imam’s
actions, and those of the Governor and family liaison officer, were examples
of good practice and should be commended.
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RECOMMENDATIONS
The Governor should remind staff that, when a prisoner is moved to the
VPU, the reason is entered in his records.
The Governor should review the procedures for clearing prisoners for work
to ensure that applications are recorded and processed in a timely manner.
The Governor should ensure that all prisoners on ACCT plans have at least
one post closure interview as required by PSO 2700.
The Head of Healthcare should set up a recall system for patients who miss
the second part of their reception health screening assessment
The Head of Healthcare should set up systems to ensure a referral to the
mental health team is acted upon.
The Head of Healthcare should review nurse staffing levels in the main
prison at night with a view to improving staff working conditions and
reducing professional isolation and improving patient safety.
The Governor and Head of Healthcare should set up procedures to enable
staff from the healthcare centre to assist the staff in the main prison during
an emergency situation at night.
Nationally a protocol should be developed whereby healthcare staff should
have ready access to patients’ medical records held in other prisons.
Good practice
The policy at Pentonville is that, in addition to a management check during
the day, all ACCTs are also checked each night by the night orderly officer
or his assistant. They assess whether each document has been fully
completed and note any omissions or problems. They write a report on
their findings which is then passed to a governor for action. This is good
practice.
I commend the use of the family liaison booklet as good practice as it gives
the family a great deal of helpful information in a very accessible way.
The Imam’s actions, and those of the Governor and family liaison officer,
were examples of good practice and should be commended.
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