Individual at High Down

Investigation into the circumstances surrounding the death of a prisoner
in July 2004 while in the custody of HMP Highdown
Report by the Prisons and Probation Ombudsman for England and
Wales
December 2005
This is the report of an investigation into the death of a male prisoner in July
2004 in St Helier Hospital, Carshalton. The man had been found hanging in
his room in the Healthcare centre at HMP Highdown on the morning of 2 July.
He had been remanded into Highdown on the evening of 28 June.
I would like first of all to add my condolences to the man's family to those
already expressed by the investigation team. My family liaison officer has
been in contact with them as well. They were most gracious and helpful
during what must still be a very difficult time, and I hope this investigation
report will answer some of their questions. I know they have been particularly
concerned that the man was not on a formal suicide watch and about
difficulties in arranging visits to Highdown. I regret that, for reasons beyond
my control, this report has been so long in the making.
I commissioned two officers to the investigation, the senior investigating
officer was a deputy governor within the Prison Service and he was assisted
by an investigating officer from my office. I asked the investigators to look at
the circumstances surrounding the man’s death, to gather and analyse the
evidence, conduct interviews and audit policies and procedures and to make
known their findings and recommendations. I had myself visited Highdown in
the immediate aftermath of the man’s death. My contemporaneous note
suggests that on the day he was received, Highdown had received 50
prisoners. The man was the very last to be booked in.
The work of the investigation was considerably assisted by the goodwill of the
then Governor and I am most grateful to her. I also appreciate efforts of the
East Elmbridge and Mid Surrey Primary Care Trust who were commissioned
to prepare a clinical review of the healthcare received by the man whilst he
was at the prison. The actions of the doctor who attended to the man, who is
a locum at Highdown, have been referred to the General Medical Council.
It is increasingly appreciated that prisoners are at enhanced risk of self-harm
whilst detoxifying from illicit drugs. The sad story related in this report
illustrates that withdrawal from alcohol can be no less dangerous. My report
contains ten recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman
December 2005
Summary
Following an incident at the home of his estranged wife, the man was charged
with criminal damage and taken to Crawley Magistrates’ Court. He was
placed in the custody of Premier Custody Services and interviewed by a
Community Psychiatric Nurse (CPN). The CPN was sufficiently concerned
about the man’s mental health that a court form warning of the risk of suicide
or self harm was opened. He had a long-standing history of misusing alcohol
and was experiencing withdrawal symptoms. He was remanded in custody
and taken to HMP Highdown.
The court warning form raised sufficient concerns about the man’s state of
mind that the Prison Service’s equivalent procedure, the F2052SH, should
have been opened as a priority when he arrived at reception. This was not
done, as there appears to have been an unwritten rule at reception that only
healthcare staff could open the F2052SH form.
Relevant records were not available for healthcare staff in reception before
they carried out their interview with the man. Important information, including
the court’s self-harm warning form, was left in a tray for collection by
healthcare staff, but was only noticed after he had been interviewed and gone
to the healthcare centre. He not only had a very recent history of self-harm
but had on numerous occasions raised these concerns.
Because of the physical symptoms of alcohol detoxification, and his heart
condition, the man was located in the healthcare centre and placed in a gated
cell, to allow a greater level of observation. However, he was removed that
cell because he was climbing the gate and there was a risk of injury. The
decision to relocate the man may have been appropriate, but should have
been accompanied by a minimum of four observations by staff each hour until
the medical officer was able to review him.
The man remained in the healthcare centre and it seems that the
detoxification symptoms lessened and he began to sleep well. There were
concerns about his fluid levels, which were to be monitored, but 24 hours
elapsed before the instruction was implemented. He was assessed by the
locum prison doctor and by the prison’s psychiatrist and was prescribed
medication to relieve his symptoms. However, after four days as an in-
patient, at 10:12am on 2 July, he was found hanging from a ligature in his cell.
It is clear that the staff who responded were extremely committed to reviving
the man but were working in difficult conditions. His bed was fixed to the floor
and the space between it and the wall was restricted. A period of time passed
before the ligature could be cut down, as staff had to go to another part of the
centre to get the cut down box. The electrical supply to the healthcare centre
was also inadequate in that there were no sockets in the cells or corridors. An
extension lead had to be located before electrical equipment could be used.
Finally, there appears to have been some friction between staff at the prison
and those in the outside hospital where the man was taken, and several hours
passed before the prison was informed of his death.
Conduct of the investigation
The investigation was led by a deputy Governor of the Prison Service, who
was appointed under the transitional arrangements between the Prisons and
Probation Ombudsman and the Prison Service. He was assisted by an
investigator from the Ombudsman’s office. The Governor of Highdown made
the prison and healthcare records available to the investigation team.
Notices of the investigation were issued to staff and prisoners to inform them
of the investigation.
Prison and healthcare staff were interviewed by the investigators. A clinical
review was commissioned from the Primary Care Trust.
On my own visit to Highdown, I met a member of the Independent Monitoring
Board, the chair of the local branch of the Prison Officers’ Association, the
Head of the prison’s Care Team, and the Suicide Prevention Co-ordinator. I
also drew upon the IMB’s Annual Report for important background
information. I have found especially valuable the IMB’s comments on the
number of prisoners arriving at Highdown with “drug and alcohol problems”,
on the demands on reception staff, first night arrangements, and the
difficulties visitors face in baking telephone bookings.
A family liaison officer was appointed and she was in contact with the family
and the investigation team. At an early stage of the investigation, I also spoke
with the man’s parents.
HMP Highdown
Highdown is a local prison, for category B status prisoners, which was
completed in May 1992. It has four house blocks with a mixture of single,
double and treble occupancy cells, a segregation unit, and healthcare centre,
with 29 in patient beds.
The most recent report from HM Chief Inspector of Prisons, dated February
2004, said that there had been improvements in some important areas;
suicide and self-harm procedures, healthcare and resettlement particularly
showed progress. The suicide and self -harm procedures were identified as
good practice, but there were other deficits to be addressed - including
support in the early days of custody, with reception, first night and
detoxification all requiring improvement.
In general, the Inspectorate considered that Highdown appeared to be
orderly, relationships between prisoners and staff were cordial, and many
prisoners stated that most staff would help them if they had problems. The
Inspectorate noted that there had been improvements in the provision of
healthcare.
Key Findings
28 June 2004
The man was held in police custody from Saturday 26 June until Monday 28
June when he was taken to Crawley Magistrates’ Court. Whilst at court, he
was regularly monitored by staff. He had a legal visit for about 20 minutes
and was offered lunch and a hot drink and lunch, but refused.
Later in the afternoon, at 4:12pm he was interviewed by a community
psychiatric nurse, (CPN), for just over 30 minutes. The nurse noted that the
man had a severe alcohol problem, and was drinking between one and two
bottles of spirits per day. He believed that the man was suffering from an
alcohol-induced psychosis. The man was convinced that other prisoners and
the custody officers wanted to kill him. He told the nurse that he could hear
people talking and plotting about him although no voices were audible to
anyone else. The nurse also noted that the man had a pronounced tremor.
At about 5:15pm, the man was taken before the magistrates. He was refused
bail and committed for sentence at Lewes Crown Court on a date to be fixed.
He was remanded in custody and later taken to Highdown prison.
Whilst at court, the Senior Custody Officer (SCO) opened a suicide/self-harm
warning form, stating that the man demonstrated “really bizarre behaviour,
stated in court he poured petrol over himself”. In interview, the SCO said that
he remembered having enough concern about the man that he opened the
self-harm warning form. He stated that he would have opened a F2052SH
except that those forms were no longer in use at the court.
The man arrived at Highdown prison at 7:05pm and an officer on the desk
began the reception processes. The officer spent a good deal of time with the
man. He had read the self-harm warning form from the court and completed a
cell sharing risk assessment where he stated that the man felt suicidal. He
followed the routine in reception and left the record in a yellow box for
healthcare staff to collect. The man then continued through the reception
process and was searched and his property recorded.
A reception officer interviewed the man as part of the first night process. He
completed the prison’s induction booklet, recording that the man admitted to a
drink problem and said that he had harmed himself about five years earlier.
The reception officer had no other information to support these statements
and did not have all the available paperwork, such as F2052SH forms, the
warrant, Prisoner Escort Record (PER) forms or core record before he
commenced the interview.
Neither the desk officer nor the reception officer commenced F2052SH
procedures and there appeared to be an unwritten rule amongst staff that only
healthcare staff can open them. This is contrary to the prison’s Suicide
Prevention document, which states that all members of staff have clear
responsibilities and any member of staff can raise an F2052SH form. It goes
on to state that there is no discretion, and if a member of staff believes a
prisoner to be at risk, if threats to self-harm have been made or an actual
incident has taken place, then the F2052SH must be opened. The document
specifically refers to reception and first night in prison staff who are required to
talk to the prisoner and escort to ascertain whether the risk is current or
historical, and must be prepared to initiate the F2052SH procedures
themselves if necessary.
Reception officers had not had received up to date training in suicide and self-
harm procedures and were confused about who should complete the
F2052SH form. They also needed training to complete the cell sharing risk
assessments correctly. The form completed for the man has been ticked to
show that there was an open F2052SH as the officer had incorrectly assumed
that the court warning form was its equivalent.
A Healthcare nurse completed the first reception health screen and then saw
the man. During the interview, the nurse noted that he suffered from
depression and had covered himself in petrol on 26 June. In the nurse’s
opinion, the man's behaviour was “bizarre and agitated” and he was referred
to the doctor because of his physical health and at his own request.
The prison medical officer on duty that evening interviewed the man, and
remembered that he referred to photographs of his children. The doctor
recalled having a sensible conversation with him despite the problems
resulting from alcohol detoxification. The doctor has a good deal of
experience as a prison medical officer. In interview with the investigators, he
was unable to say whether he saw the self-harm warning form or not, but did
state that if he had seen it he would normally have signed it.
The man was placed in the healthcare centre and located in a gated cell to
enable increased observation. His first contact was with an officer on duty in
healthcare, who was designated to carry out night duty but was not a
permanent member of the healthcare staff.
This officer told the investigators that the man arrived in the healthcare at
about 8:50pm. She had been told that he was withdrawing from alcohol.
During the rest of the night he could not sleep, and she remembered making
him about ten cups of coffee and having long conversations with him. She
remembered him being polite, and asking her to call him by his first name. He
spoke about his two daughters and told her about setting fire to the car. He
also spoke about a photograph of him and his two daughters which he was
concerned about and asked the officer for her opinion. She said that she was
not there to judge him and said that if he was concerned he should speak to
his solicitor.
29 June 2004
The following morning, a nurse on duty in healthcare noted that the man had
settled well into the regime of the unit but that he said that people wanted to
kill him. She attributed this to alcohol induced psychosis.
Later in the morning, the prison’s psychiatrist interviewed the man. They
spoke at some length regarding the offence, his children and how remorseful
he was. The psychiatrist noted that the man had a happy childhood and a
good education. He also said that he and his wife had been separated for
about seven months, but had previously been together for about ten years.
He told the doctor about his heart condition and said he had a check up about
12 months ago, but kept missing his hospital appointments.
The psychiatrist noted that the man felt sad and discouraged about the future,
he felt he had failed and felt guilty and disappointed in himself. Again he
mentioned photographs of his children. She also recorded that he was
experiencing alcoholic hallucinosis - visual and auditory hallucinations -
saying that people were chatting outside and calling him a paedophile. It was
noted that the man should be observed every 15 minutes. The psychiatrist
has stated that she was not concerned about his mental state and that the
man was placed on this level of observations because of his physical
condition. Although she placed the man on a 15 minute watch, there are no
records to support this or to communicate to other professionals caring for the
man.
Later that day, the man was assessed by a locum Doctor, who noted his heart
condition and the detoxification regime. He recorded that the man should
increase his fluid intake and that he would refer him to a cardiac clinic
because of his heart condition.
During the evening and night, the man continued to have visual and auditory
hallucinations. He thought that his cell was flooded; he tried to unlock the
gate and stated that he could hear his wife speaking on the telephone. He
attempted to break the sink in the cell.
The officer in healthcare from the previous evening was on duty again that
night and spoke to the man. She said that she was not concerned about him
deliberately harming himself during the night, but was concerned because he
was climbing on the bars of the gated cell and was concerned that he might
fall and hurt himself. His hallucinations became worse during the night and
the officer stated that he did not really speak to her but spoke more to himself.
The night orderly officer was called and the man was moved to a room with a
solid door and the officer said that he fell asleep within ten minutes of moving
cells, which she felt was what he needed. Before the officer was about to
leave the centre, she asked the man if he was all right and he thanked her
and replied that he did not feel bad and had slept better than before.
30 June 2004
It was noted in the man’s medical record that he continued to have visual and
auditory hallucinations and he was seen by the medical officer in the morning
and prescribed five milligrams of diazepam. He was still dehydrated and it
was decided that there should be an hourly record of his fluid intake, which
was recorded on his inmate medical record. Healthcare staff said that the
man had been out of his cell during the day, and had visited the association
room where there was a television and reading materials.
It appears that the man went to sleep at about 11:30pm that night. In
interview with the investigators, the officer, in healthcare, did not remember
any further conversations with him that night as she believed that he was
asleep. She said that she was not instructed to carry out any form of regular
observations on him.
There appear to be two separate handover arrangements for night staff in the
healthcare centre, one for healthcare staff and another for officers. This
arrangement might mean that vital information was not passed on. There
should be one general handover, with medical in confidence matters being
dealt with separately.
1 July 2004
The man was woken by the nursing staff in the morning so that he could be
seen again by the psychiatrist. The doctor noted that the man had breakfast
but was still not drinking enough fluids. She said that he smiled during the
interview and even cracked a joke. She encouraged his intake of fluids and
increased the prescription of diazepam to ten milligrams.
At about 11:40am, healthcare staff saw the man again. The fluid and diet
chart was commenced, a day after it was initially requested.
Later that morning or during the early afternoon, the man’s mother telephoned
(a fact of which he was informed). He gave his consent to his mother being
contacted. New prisoners who are located in the healthcare centre should be
assessed to identify whether they need help with arrangements such as
completing PIN phone applications and visiting orders. The man was
described as experiencing visual and auditory hallucinations, being confused
and with bizarre behaviour. It is likely that assistance to expedite phone and
visits contact would have been helpful to him.
At about 2:50pm, it was noted that there was a gradual improvement in the
man’s condition. He was moved to room number one, had a bath, ate his
meals, took his medication and associated with the other patients. The
medical record indicates that the man slept well that night.
2 July 2004
The prison was on a full lockdown (all prisoners locked in their cells) following
allegations about a breach of security. Searches were being carried out at
various locations around the prison and staff were instructed that prisoners
must remain in their cells.
The man was due to participate in the prison induction programme that
morning, as was customary for prisoners in the healthcare centre. The
induction would have informed him of all aspects of the prison routine
including making telephone calls, visits, letters and making purchases at the
canteen, and the role of the Listeners (prisoners trained by the Samaritans).
The first entry in his medical record for the day was at 10:12am. It read, “Saw
inmate hanging – CPR started and ambulance ordered.”
Two Staff nurse’s entered the cell and state that they cut the ligature,
administered oxygen and a healthcare officer took over cardio pulmonary
resuscitation (CPR). In interviews, staff said that the man was in a confined
space between a bed fixed to the floor and the wall and that it was difficult for
them to work on him.
About three minutes later, at approximately 10:15am, the prison doctor
received a call on code 1 alert to go to the inpatients area of the healthcare
centre. She made her way from her office on the first floor to the ground floor
and was unaware at the time exactly what the emergency was. She said that
she did not hurry in response as she thought that the locum doctor was
already in that part of the centre. However, on her arrival she found that the
locum doctor was not present and so she took control. She checked for signs
of a pulse and respiration, but found neither. In interview, she remembered
three staff already working on the man and that a nurse got the defibrillator
out on the bed. An ambulance was called at 10:20am.
The electrical system in the healthcare centre is out of date as there is no
supply in the cells or corridors. The staff who attended to the man had to find
an extension lead in order to use emergency medical equipment.
The defibrillator was an automatic external defibrillator, which advises the
user of the course of action to be taken. The reading was that a shock should
not be given and so the prison doctor decided that she needed to get venous
access. Because the man was in a very tight location, she decided to move
him to the other side of the bed and so they slid him under the bed. Once he
was repositioned they continued to administer oxygen. The defibrillator was
still attached and it then read “Keep clear”. The prison doctor managed to
administer drugs to him and after about ten or fifteen minutes, his pulse
returned and so the cardiac massage was discontinued but respirations
carried on. At 10:45am the paramedics arrived and took over attending to the
man.
The gate book records that the ambulance arrived at 10:35am and left for St
Helier Hospital shortly afterwards at 11:04 hours. Both an air and road
ambulance arrived at the prison. The air ambulance was kept waiting for 15
minutes for permission to land and it appears that prison staff were unclear
about giving permission and also where it should land. The man remained in
the care of the hospital intensive care unit until 7 July when he passed away
at about 7:00pm. Initially, he was restrained but the restraints were later
removed.
Bed watch officers were present at his bedside, but at the request of his wife
and parents, they withdrew to another room. The prison liaison officer,
considered that prison staff must remain to give support when necessary but
they were told to keep a low profile, and did so as far as possible.
No consideration was given to granting early release from custody, despite
the wishes of the man’s parents and wife who were concerned about the
presence of prison staff in the hospital.
Although prison staff remained at the hospital they were not informed of the
man’s death until 4:50am on 8 July, some nine hours after it took place.
Letters of condolence were sent to the family but very unfortunately the letter
sent to the man’s wife referred to the loss of her son. Although two separate
letters were written, a clerical error meant that duplicate letters were sent.
Errors of this kind can happen in the best organised office, but it hardly needs
stating that the Prison Service must take extra care over letters to bereaved
relatives.
Other issues considered by the investigators
There is some confusion about the locum doctor and the timing of the
incident. He has said that he entered the cell at the same time as the two
Staff nurses, but they do not mention this in their statements. He also said
that he was working on the man for twenty to twenty five minutes before the
prison doctor arrived. The locum Dr was only mentioned as present on one
statement, although he himself said that he cut the ligature, which the two
Staff nurses say that they did themselves. The locum Dr states that he went
into the cell at the same time as the nurses, but their statements do not
support this. The locum doctor states that he worked on the man for 20 to 25
minutes before the prison doctor arrived, but this is not consistent with other
reports of the timings of the incident. I am aware of investigations by Surrey
Police into these matters.
Further discrepancies arose during the interview with the locum doctor for this
investigation. He had prepared a written statement, which he read to the
tape, and this included the following discrepancies: On page four of his
statement he stated that “doctor said because there is no space around here
to put that trolley we will push that bed and pull the patient out”. However, in
the same paragraph he stated “Now this is after 20 to 25 minutes have
passed at this time, at this moment I requested staff to send for doctor …..
because doctor … is upstairs doing sick parade”
He stated that he was working on the man for 20 to 25 minutes before the
prison doctor arrived, but also that he was not in the room at the time the
prison doctor arrived because he was in the office making sure the ambulance
was allowed in.
During a routine visit by the investigator to Highdown it was mentioned that
two nurses, nurses, who worked for a nursing agency, had made statements
about the locum doctor’s actions on 2 July. These nurses had been working
elsewhere in the healthcare centre when the man harmed himself. Neither
the investigator nor the prison liaison officer had previously been aware of
these statements and copies were obtained. The statements raised sufficient
concern for the matter to be referred to Surrey Police, who after investigation
referred the matter to the Crown Prosecution Service (CPS). The CPS
concluded that there was insufficient evidence to pursue criminal proceedings
against the locum doctor. The case was referred by the PPO to the General
Medical Council (GMC) for their consideration.
The Fitness to Practice Panel of the GMC considered the locum doctor’s case
in January 2009. In February 2009, the Panel found that his fitness to
practice was impaired and determined that his name should be erased from
the Medical Register. Although he subsequently appealed, the appeal was
then withdrawn and the locum doctor’s name was erased from 4 November
2009.
Conclusions
It is apparent that the man experienced symptoms of withdrawal following a
protracted period of alcohol abuse. At the time of the alleged offence against
his wife and her property, he had drunk a substantial amount of alcohol.
Together with the medication he was taking, this must have contributed to
what is described by his family as behaviour that was out of character. It was
his first offence of any kind and he was described as a kind and thoughtful
man with a strong and caring relationship with his family. There is no
evidence to suggest that he had been responsible for inappropriate behaviour
with his children, or that his life was in danger. It would appear that at the
time of making the remarks he was withdrawing from alcohol and suffering
auditory and visual hallucinations.
The Community Psychiatric nurse interviewed the man at court and confirmed
the extent of his alcohol problem and the effects of the early stages of
detoxification. Auditory and visual hallucinations had already begun whilst he
was there. Court staff recognised the risk and appropriately completed a self-
harm warning form, which highlighted that he had poured petrol over himself
after setting fire to his wife’s car.
The court’s suicide warning procedures should have been succeeded by the
prison’s own self-harm procedures, F2052SH, which should have been
opened at reception at Highdown. There were several missed opportunities
throughout his stay at Highdown when a F2052SH should have been opened
and the prison’s protocol was not followed. Subsequently, the man was
moved from a gated cell, without either a medical officer’s review of the
decision or regular recorded checks on his condition. This added to the risks
that were already present.
The man was located in healthcare for five days, in the course of which there
were deficiencies in the care and treatment of his detoxification symptoms.
He was dehydrated and there were delays in monitoring his fluid intake.
After he was discovered hanging, staff responded well despite the constraints
of space and the absence of electrical sockets. The healthcare staff should
be praised for their valiant efforts to revive the man. The prison doctor took
charge of the incident and through the strenuous efforts of her and the team
his breathing and circulation were restored.
Recommendations
Once a suicide self-harm warning form has been completed at court, the First
night in prison officer, the senior officer in reception and doctor should review
the information and consider whether to open the prison’s suicide and self
harm procedures.
Reception staff should be reminded that all staff are responsible for opening
these procedures if a prisoner indicates that he will harm himself. They
should be trained appropriately in suicide and self harm awareness.
All prisoners placed in a gated cell must be checked regularly and, if they are
moved during patrol state, the medical officer should review the situation at
the earliest opportunity. Prisoners removed from gated cells without the
medical officer’s authorisation should be placed on a frequent watch.
All staff in the healthcare centre should take part in a general handover report,
and a separate handover for nursing staff should only refer to medical in
confidence matters.
Newly received prisoners who are located in the Healthcare department
should be allowed a reception phone call, should be helped to complete a Pin
Phone application and an application for a visiting order. They should also
have access to a television and radio.
Rooms in the healthcare centre should be appropriately equipped. They
should have electricity sockets and fixed beds should be positioned to allow
ready access by staff.
The Governor should consider issuing fish knives to all staff as an immediate
aid to cutting ligatures.
The prison’s contingency plans should be revised to include the arrangements
for an air ambulance.
The Governor should remind senior colleagues of the need to give timely
consideration to the release on temporary licence for prisoners who are
critically or terminally ill in hospital.
A memorandum of understanding should be drafted between Highdown and
the local hospitals, which should include a protocol for staff on bed watches
and for hospital staff to identify their respective roles and responsibilities.