Individual at Buckley Hall

The death of a prisoner at HMP Buckley Hall
on 1 June 2004
A report by the Prisons and Probation Ombudsman
for England and Wales
April 2005
This is the report of an investigation into the death of a woman who died on Tuesday 1
June 2004, at 5.07 pm in the local infirmary. The woman had been a prisoner at
Buckley Hall prison and that day, at 4.00 pm, had been found in her single cell with a
plastic bag over her head, which was secured by shoelaces around her neck. This
report sets out my findings.
I offer my sincere condolences to her family. Despite coping with her mental health
problems, they remained loyal, loving and supportive. I have great respect for the
dignity they have shown.
I also offer my sympathies to the management and staff at Buckley Hall. They work
under difficult circumstances with large numbers of vulnerable women. The number of
deaths that have been prevented thanks to the care and diligence of prison staff can
never be truly quantified. When a death occurs, it has a profound effect on staff and
they often feel personally responsible.
I am grateful to the Governor of Buckley Hall, for the help and hospitality received
during the investigation. Every assistance was been made available to my
investigators and all staff co-operated fully and readily with the enquiry.
An investigator from my office led the investigation and was ably assisted by two Prison
Service Governors. I would also like to thank the Prison Service, for seconding to me
two Governors to assist with the enquiry. Their knowledge, commitment and hard work
have been of immense value in the investigation.
I am also grateful to Rochdale PCT for their help in conducting a comprehensive clinical
review.
The woman had long-term mental health problems, exacerbated while in prison by her
non-compliance with medication. This investigation has also revealed that the
medication she did take was not always supplied at the correct time.
What part this played in her death can only be speculated upon. Likewise her transfer
from Eastwood Park to Buckley Hall, a transfer that took the woman far from home and
from local support networks.
The woman had been the subject of F2052SH procedures on four occasions. A
decision to close the form is criticised in this report, although probably made little
difference in practice.
I have also noted that the woman had attempted to harm herself using a plastic bag on
two previous occasions (25 September 2003) and (9 March 2004), and spoken about
this method of self-harm in a mental health interview on 12 May 2004.
2
This is a relatively unusual method of taking one’s own life, although I understand it is
more common amongst older prisoners and amongst women. I do not believe that a
ban on plastic bags is feasible or would achieve anything in terms of the overall rate of
self-inflicted death in prisons. However, any pattern involving an individual prisoner
should obviously be taken into account in devising a care plan relevant to their specific
needs.
This report has been anonymised for publication on the website of the Prisons and
Probation Ombudsman.
STEPHEN SHAW CBE
PRISONS AND PROBATION OMBUDSMAN APRIL 2005
3
Contents
Contents..............................................................................................................4
Summary.............................................................................................................5
Glossary Of Terms..............................................................................................7
Background.........................................................................................................9
Establishment and Female Estate Background...............................................9
Investigation Process........................................................................................11
The Incident And Events Leading Up To The Death.........................................13
Post Incident Response ....................................................................................20
Level Of Compliance With Authorised Procedures............................................22
Management of Prisoners at Risk of Self-Injury or Suicide...........................22
Compliance with Contingency Plans.............................................................22
Findings.............................................................................................................24
Conclusions.......................................................................................................27
Recommendations ............................................................................................29
Good Practice....................................................................................................30
Recommendations Re: Staff Performance........................................................31
4
Summary
The woman was 40 years of age at the time of her death on 1 June 2004. She
had a troubled life, which in her adult years included recurrent episodes of
mental ill health and deliberate self-harm. Despite good support from both her
family and community psychiatric services, she had difficulties in managing
emotional and social stress, and over time she was involved in a number of
impulsive incidents that caused risk to herself and others. On 18 September
2003, she set fire to the sofa in her flat. The woman was remanded into custody
at HMP Eastwood Park and subsequently sentenced to 3½ years imprisonment
at Crown Court on 26 March 2004. This was despite the recommendations from
a consultant psychiatrist and the local probation service that she should be
assessed as an in-patient in an RSH.
Whilst at HMP Eastwood Park her mental state fluctuated, and she was involved
in at least four episodes that included threats of, or acts of, self-harm. This
resulted in three periods when she was the subject of F2052SH supervision
(suicide prevention procedures). The last of these concluded on 15 April 2004.
Throughout this time, her mental health was not considered to be such as to
require any transfer into the NHS. I consider Eastwood Park provided an
appropriate and effective level of general support and care, including specific
F2052SH supervision, throughout her stay at that establishment.
The woman was transferred to HMP Buckley Hall on 11 May 2004. The woman
herself seems likely to have seen this move in a negative light, as it took her
even further away from her family and other potential local support
arrangements.
On 12 May at Buckley Hall, the woman was again monitored through the
F2052SH procedures after she had indicated that she would harm herself at
some stage using a plastic bag. Over the course of the next fortnight or so her
mood remained variable, although there was no further indication of any act of
or intention to self-harm.
On 27 May, a case review concluded that the F2052SH was no longer required.
The view was taken that her circumstances appeared to be stabilising. This
review did not take into account her decision to stop taking her medication. This
points more generally to systemic deficiencies in the way in which Healthcare
and uniformed staff at Buckley Hall share, document, and take account of all
available information relating to individual prisoners at case reviews and during
the associated care planning stage of the F2052SH process.
I consider that her F2052SH form should have remained open. However, it is
unlikely that this would have resulted in any different practical supervision
arrangements over the course of the next days through to her death. Her mood
over the Bank Holiday weekend of 29-31 May appears to have been generally
positive. The woman reported physical complaints, but no other apparent
problems, when she spoke to a variety of staff over the course of 1 June. She
received appropriate support and management.
5
The woman appears to have last been seen alive at 2.30 pm on 1 June, when
she spoke with another prisoner and indicated she had no problems. She was
discovered at 4.00 pm in her cell with a plastic bag over her head. The bag was
secured by shoelaces tied around her neck. All appropriate attempts were
made to save and resuscitate her. Sadly, she was pronounced dead at 5.07
pm.
Contingency plans were activated appropriately, with support being offered to
both staff and prisoners immediately after the incident and in the longer term.
Communication with her family following her death was not well managed. They
were told of the death by the local police on the evening of 1 June, but were
unable to contact the prison that night to gain further information. A
misunderstanding with the prison the next morning meant that the family
discovered further details of her death from a newspaper report. This caused
them great distress.
There are deficiencies in the prison’s notification arrangements with bereaved
families, and with telephone access. This should be remedied as a matter of
urgency.
The investigation identified more sensible arrangements for the location of
emergency response equipment. Changes have since been made to bring
these into effect. However, I do not consider that the arrangements that were in
place at the time in any way contributed to her death.
The report includes nine recommendations and identifies four areas of good practice.
Additionally those made by the clinical review are endorsed.
6
Glossary Of Terms
Term used Explanation/Definition
Adjudication Prison disciplinary hearing
Basic regime Restricted privileges such as association, visits and
pay. Applied to prisoners who consistently fail to
follow prison rules
CPR Resuscitation, usually kiss of life and chest
compression
Comms Communications (as in Communications room)
Duty Governor The Governor grade who for a fixed period, usually
24 hours, is “in charge” of operations whether
physically in the prison or not
Escort The staff responsible for moving prisoners from one
place to another
Enhanced regime Prisoners who conform to regulations and who
receive additional privileges, e.g., additional visits
F200IMR A prisoner’s medical record
F2050 A prisoner’s main core record
F2052A History sheet for general observations
F2052SH Documentation for recording the monitoring, care
and support of prisoners identified as being at
increased risk of suicide/self-injury
F2052SH Open Prisoner is actively monitored under F2052SH
procedures
F2052SH Closed Prisoner was being monitored under F2052SH
procedures but, following a case conference, not now
considered to be at heightened risk
F2169 Medical reception assessment
Gov Governor grade
HCO Healthcare officer
HCSO Healthcare Senior Officer
Healthcare centre The prison’s hospital wing and treatment centre
HMP Her Majesty’s Prison
Hot Debrief A debriefing of staff as soon as possible after an
incident
Hourly watch Prisoner identified at risk of suicide/self-injury is
observed at hourly intervals
NOO Night Orderly Officer - the member of staff “in-
charge” of prison at night
Observation book/log General compilation of staff observations of prisoners
Officer Prison Officer
Operational Manager A Senior Prison Service Manager with responsibility
for the operation of the Women’s Prison Estate
Orderly Officer/Oscar 1 The uniformed Prison Officer (usually a PO or SO),
initially managing incidents within the prison
Oscar 2 Orderly Officer’s Assistant
Ordinary Location The main prison wings
7
OSG Operational Support Grade
Personal Officer An Officer assigned to take close interest in a group
of prisoners
PO Principal Prison Officer
SO Senior Prison Officer
Safe cell A cell designed to make the act of suicide/self-harm
as difficult as possible by, for example, minimising
the number of ligature points
Self-harm/injury Self inflicted harm or injury
Standard regime Relates to the Incentives and Earned Privileges
Process. A prisoner on a ‘standard regime’ is
receiving the standard level of privileges
Unfurnished cell A cell devoid of loose furniture
YOI Young Offenders’ Institution
8
Background
Establishment and Female Estate Background
In March 2002, Buckley Hall was re-rolled from an adult male to a closed female
training prison, in response to wider national population pressures affecting the overall
female prison estate.
Buckley Hall’s Certified Normal Accommodation and Operational Capacity figures are
ordinarily 350 and 385 respectively, although recently its capacity has been some 60 or
so places below these levels, as a result of refurbishment work on one of its six
residential units. Since the re-role the establishment’s prisoner population has been
drawn widely from across the country, and has also included significant numbers of
foreign national prisoners.
The establishment has had a good history in the support and management of prisoners
who have been vulnerable to self-harm and suicidal behaviour. Only one death by
suicide has been recorded, and this was of a male prisoner in 1997. The woman’s
death was therefore a special shock to both staff and prisoners at Buckley Hall, as the
establishment had taken pride in its efforts in this area. Most of the prisoners who were
interviewed in relation to the woman spoke well of the care and support which staff are
ready to offer women with regard to individual problems.
The establishment maintains an open and active regime, and, whilst some reference
was made to occasional relationship problems in some areas amongst individual
prisoner groups, the majority of prisoners who were interviewed compared their
experiences at Buckley Hall favourably with those at other locations. The
establishment was often characterised as being ‘stricter’ than other settings, although
this was seen as a positive feature, and relations and interactions between staff and
prisoners were also for the most part commented upon favourably.
In common with many other female and male training prisons, Buckley Hall has no in-
patient Healthcare accommodation. A full and wide range of primary care clinics and
services are available to prisoners through dedicated National Health Service general
nursing and mental health teams, who provide 24 hour primary care cover with the
support of sessional GP cover and other on call GP provision.
The wider female prison estate currently comprises 18 establishments. Seven of these
establishments perform a local prison role, including HMP Eastwood Park, whose
primary function is to hold women whilst on remand or until proceedings in court have
been completed. The other 11 establishments are training prisons, three of which are
open establishments, with Buckley Hall and seven other establishments together
comprising the remaining closed female training prison estate.
The geographical spread of these establishments provides a poor match in certain
areas of the country to facilitate individual prisoners’ closeness to home. This is
particularly true with regard to the West of England and Wales, and, as a local prison,
HMP Eastwood Park draws the greater number of its prisoners from South Wales,
Pembrokeshire, Cornwall, North Devon, Dorset, Wiltshire and Avon. There is also no
9
female training prison of any kind in the West of England. Eastwood Park attempts to
fulfil such a Resettlement function for women from these areas, who are serving short
sentences and who are assessed as needing to remain in closed conditions. When
possible, it will accommodate women in similar circumstances for the final three months
of longer sentences, after the bulk of their sentence has been served elsewhere in the
female training estate. If wider population pressures dictate, it is not unusual for
Eastwood Park to temporarily accommodate out-of-area remand and trial prisoners,
should other female local prisons not have the immediate capacity to do so in their own
right.
In the face of this overall picture, Eastwood Park is considered to fulfil its varying roles
to best effect. It was the woman’s misfortune that, once sentenced, she would have
been assessed as being unable to remain in this establishment, despite its relative
proximity to her home and family. HMP Buckley Hall in Greater Manchester and HMP
Foston Hall in Derbyshire were then the primary closed female training prison allocation
routes for prisoners in her circumstances, destinations which would equally apply to
women whose homes might be as far away as Pembrokeshire or Penzance.
10
Investigation Process
The investigation team made an initial visit to the prison. This initial visit was
very much for familiarisation with the establishment and for immediate fact-
finding. Notices to Staff and Prisoners providing outline details of the
Investigation were also drafted and issued, and informal meetings took place
with the establishment’s Governor and Deputy Governor.
On 14 June, the investigator visited the woman’s family at their home, when he
met with her mother, stepfather, two sons, brother and one of her two sisters.
This visit gave an opportunity to explain how the investigation might proceed
and to establish liaison arrangements with her family. They were able to raise a
range of concerns and issues, at the same time as they provided a useful and
significant amount of background information about the woman both prior to and
after her reception into custody.
Another member of the investigation team subsequently visited the woman’s
mother and step-father, with her elder son also in attendance on 5 July. An
update was then given of the progress of the investigation, with the family again
providing further helpful details to clarify a number of issues and to improve the
general understanding of her history. Further telephone contact with her family
was also maintained both prior to and after this visit.
The investigation team met collectively for the first time at HMP Buckley Hall on
17 June. The team then took possession of the wide range of available
documentation relating to the woman, and also took steps to commission other
information that was not at that point to hand. Agreement was also reached as
to the identities of those staff, prisoners and others whom the team might wish to
formally interview as part of their inquiries, and related arrangements were made
to give appropriate notifications to the various parties concerned.
The Senior Investigating Officer also met formally and individually with the
establishment’s Governor; the Chair of its Independent Monitoring Board, its
Acting Compliance Monitor and two members of its local Prison Officers’
Association Committee, to explain how it was expected that the investigation
might proceed. All concerned were co-operative and helpful in their responses,
something which characterised all of the exchanges in which the investigation
team were involved both within and beyond the establishment, as their inquiries
and full range of interviews took place across the remainder of June and the first
half of July.
The Prisons and Probation Ombudsman asked the Rochdale Primary Care
Trust to conduct a Clinical Review of the woman’s medical care throughout her
time in custody. Liaison was maintained with representatives of the Trust.
Information and provisional thinking was freely exchanged between these two
groupings, with this resulting, in some instances, in shared interviews with
individual members of the establishment’s Healthcare staff. Similar liaison was
maintained once each side’s respective inquiries and interviews had been
11
completed, in order to develop a common perspective on shared issues and
documentation.
In addition to their inquiries at HMP Buckley Hall, the Prison Service
Investigation Team also visited the woman’s previous establishment, HMP
Eastwood Park, to interview its Deputy Governor and its Safer Prisons Co-
ordinator, in order to gain a better understanding of her time at that
establishment and the circumstances surrounding her transfer to Buckley Hall.
An interview was undertaken with the woman’s Community Psychiatric Nurse
(CPN), whose contact with the woman dated back to the early 1990s. The
National Probation Service were helpful in providing documents relating to her
appearance for sentencing at Crown Court, several of which were of particular
use with regard to her general background and her overall circumstances during
the early part of 2004.
12
The Incident And Events Leading Up To The Death
The woman was first remanded into custody at HMP Eastwood Park on 19
September 2003, after she had appeared before the Magistrates Court on a
charge of arson with intent to endanger life. Earlier that day, she had been
assessed by a doctor in the local Accident and Emergency Ward. She
displayed no psychotic symptoms or any other sign of active mental illness,
appeared alert and well-orientated and, whilst describing previous suicidal
thoughts, also indicated no current active intention to self-harm.
On reception at HMP Eastwood Park, the woman’s mental health history and
current medication arrangements were appropriately noted. She was then
assessed using the Prison Service Cell Sharing Risk Assessment Tool (CSRA).
This is a mandatory procedure designed to assess an individual’s risk to others
and is used as the basis for allocating a prisoner to either single cell or other
shared accommodation. She appears to have been correctly assessed as high
risk for any form of cell sharing, given her earlier history of violence towards
other patients in psychiatric institutions.
On 25 September 2003, after the woman had previously been assessed as fit to
attend the next day’s remand court appearance, she rang her cell bell and was
found by staff with a cellophane bag over her head which was tied with a very
loose ligature. The woman then remained in her existing location and became
the subject of F2052SH procedures, the Prison Service’s supervision, support
and management arrangements for prisoners who are considered to be at risk of
suicidal or self-harm behaviour.
The woman remained the subject of continuing F2052SH supervision, with
reports being received on 10 October that she had been asking other prisoners
to help her to kill herself. On 5 November, the woman made superficial cuts to
her wrist, and following a subsequent fuller assessment on 7 November, when
she was found to be very confused, verbally aggressive and agitated, she was
located in the Healthcare Centre. It was also noted that she had previously
failed to have her depot injection on 26 October. This was then administered
and her subsequent mood monitored. the woman then appears to have
stabilised, and on 18 November her F2052SH form was closed, although she
continued to be held in the Healthcare Centre as this was considered the most
appropriate current location for her supervision and support.
On 1 January 2004, deterioration was noted in her mental health over the
course of the previous 24 hours, as she appeared unsettled and agitated and
was expressing some bizarre statements and paranoid ideas. The view was
then taken that her existing medication should be maintained, with continued
monitoring of her associated mood. On 8 January, the doctor again saw her for
assessment relating to his psychiatric report for the court. It was his view that
her mental health did not warrant any transfer to hospital at that time, and that
continued liaison should instead be maintained with her care staff at HMP
Eastwood Park.
13
On 17 January, the woman was again made the subject of F2052SH procedures
after she had been found having tied a ligature to a table leg, and was
constantly tearful and generally low in mood. the woman once more appears to
have stabilised after this episode, and her F2052SH form was closed on 3
February. She continued to be located in the Healthcare Centre.
On 9 March the woman was once more made the subject of F2052SH
procedures after night staff during their routine rounds discovered her with a
plastic bag over her head with an accompanying ligature. She then indicated
concerns about her forthcoming Crown Court appearance for sentencing and
about the welfare of her sons.
The woman was sentenced to 3½ years imprisonment at Crown Court on 26
March. Both the doctor’s report and her Probation Service Pre-Sentence Report
had recommended that a further adjournment be made to allow a fuller
psychiatric assessment in a regional secure unit, and both the woman and her
family appear to have been surprised and disappointed that this option was not
adopted.
The sentencing Judge indicated that, given the circumstances of the offence, his
main concern had to be the safety of others and that it was clear to him that at
that time he could not take the risk of her release. He added that, for the same
reason, he did not feel able to consider the suspended sentence option, which
her legal representatives appear to have instead canvassed at the hearing, also
stating that he did not consider that such an option could be justified under the
relevant accompanying legislation.
On her return to Eastwood Park, the woman was again initially located in the
Healthcare Centre and continued to be the subject of F2052SH supervision, but
she then moved to A Wing cell 1-18 on 30 March for standard sentenced
prisoner induction arrangements. She was further relocated to E Wing cell 1-04
on 2 April. At the time of her move to A Wing, the woman threatened that she
would involve herself in a joint suicide pact with a fellow prisoner, although this
was interpreted as an attempt by both parties to manipulate their location in the
Healthcare Centre. The woman otherwise appeared to be generally stable at
this time, and indicated that her current medication regime appeared to be
effective. Her F2052SH form was accordingly closed on 15 April.
On 10 May, the woman was given notification that, together with five other
similarly sentenced prisoners, she would be transferred to Buckley Hall on the
following day. These arrangements had been directed by the Prison Service’s
Population Management Unit as part of a wider co-ordinated set of moves to
best utilise prisoner accommodation at both Eastwood Park and other
establishments in the female estate. The woman was disappointed at this news,
and she indicated to staff that she was expecting a visit from her mother and her
sons, in the company of her CPN, later in the week, together with a subsequent
psychiatric review. She asked if her move might be delayed in these
circumstances, but no alternative arrangements were then made. The woman
advised her mother of this development in a telephone call later in the day,
14
when, whilst still indicating her disappointment, she concluded on a more
positive note that this move might give her the opportunity for a new start and
better prison employment.
The woman was then received at Buckley Hall on the afternoon of 11 May,
together with the five other prisoners from Eastwood Park. As sentenced
prisoners, all were familiar with prison reception procedures and were taken
through the processes relating to prisoners who have been transferred from
other establishments. Her identity and property were checked and she would
have been given some immediate information about her new establishment. The
reception building at Buckley Hall is purpose built, well lit and decorated.
Information about the support available for prisoners and the Prison Listeners
Scheme is displayed on notice boards in the Reception area.
A reception officer then also identified the woman as a high risk on the cell
sharing risk assessment, whilst the CPN identified her as a medium risk. A
manager’s assessment is required to confirm the CSRA and, in her case, Acting
Manager F, reviewed the recommendations and concluded that the woman
should be located in single cell accommodation.
As part of Buckley Hall’s Reception process, a member of the Mental Health
Team interviews all newly received prisoners. This practice is not a mandatory
requirement of the Prison Service, but is regarded as good practice in assessing
the vulnerability of prisoners who have been newly received into prison custody.
A CPN saw the woman on the following day, 12 May. During this interview the
woman stated that she would harm herself at some stage and that she would
use a plastic bag. She also stated to the CPN that she would ‘not be coming
back from this’. On hearing this statement, the CPN made the decision to open
an F2052SH at risk form and to initiate associated monitoring procedures from
12:45 that same day. At this stage the woman did not offer any more detailed
account of her vulnerability, and no subsequent statement was made to staff.
Following completion of the reception process, the woman was located on the D
Wing Induction Unit in cell 1-17. This unit provides newly received prisoners
with accommodation during a structured induction programme, which is
delivered over a two-week period and includes educational assessments,
allocation of work placements and opportunity for familiarisation with
establishment rules and procedures.
Whilst on the Induction Unit the woman was allocated a Personal Officer, a
standard procedure for all prisoners. The primary purpose of the Personal
Officer Scheme is to provide prisoners with a named contact in order to discuss
issues and assist prisoners in adapting to life in prison. The woman did not
express any specific concerns to her Personal Officer. She did not disclose an
increased vulnerability. It would appear that, during her stay on D Wing, the
woman seemed to give the general impression to staff and prisoners that she
was settling into life at her new establishment. The woman also specifically told
her Personal Officer that she was happy at Buckley Hall.
15
The woman was described by her Personal Officer as a very pleasant and polite
individual. She complied fully with the Induction programme but did not seek out
the company of others. Her presentation to staff was described as reasonably
consistent, and her demeanour during this period did not cause staff a
heightening level of concern. However, her Personal Officer also stated during
interview that she was aware that the woman was a rather fragile person and
that she spent a lot of time on her own. Her fellow prisoners described her
variously as a loner, a quiet individual, and someone who chose to spend a lot
of time alone.
The woman remained on an open F2052SH throughout her period on D Wing.
Her Personal Officer stated that she did receive additional support during this
period although the woman appeared to be preoccupied with concerns about
her physical health. On a number of occasions, the woman stated to staff and
other prisoners that she experienced difficulty in relation to physical pain as a
result of multiple injuries which she had sustained in 1993. Some of her
concerns focussed on her ability to undertake the work to which she had been
allocated. She stated that she wished to speak to Healthcare staff in order to
gain a doctor’s exemption from work. Her Personal Officer also stated during
interview that the woman sometimes had difficulty using a knife and fork.
On 14 May, her medical records also note that she was referred for consultation
with a Consultant Forensic Psychiatrist. On 17 May, the woman stated to
Healthcare staff that she was stressed and not sleeping. On 19 May, she
attended Healthcare to report that she was sick and to complain of back, leg and
arm pain. She stated that she had arthritis and was given a sick note,
exempting her from the requirement to participate in regime activities for the rest
of that day.
The woman refused food on six separate occasions, 12 May, 21 May (twice), 22
May, 24 May and on 25 May, the day on which she was moved to E Wing.
There is no documentary evidence that this information was used as part of the
F2052SH review or that the woman was spoken to about the reasons why she
was not eating all her meals. However, it appears from her medical records that
she felt her medication caused her to put on weight and that she sometimes
limited herself to one meal a day. At other times, the woman was observed by
fellow prisoners as having a good appetite and eating well.
On 17 May, the woman was seen by the wing SO and a CPN for the 72hr
Review of her F2052SH at Care Plan. She stated that she continued to have
thoughts of self-injury but that she was attempting to think positively and
attempting not to act out those thoughts. The outcome of the review was to
maintain the F2052SH monitoring procedures.
The woman complied fully with the D Wing Induction programme, and she was
allocated to work in Workshop 3 on 24 May. Workshop 3 is a packing workshop
where prisoners are involved in a range of activities related to re-packaging
curtains and other smaller items. She was also allocated accommodation on E
wing, and moved there from D Wing on 25 May at 10.30 am to cell 1-09 where
16
she remained until her death on 1 June. The woman remained on her F2052SH
at risk form.
During this period, a number of entries were made in her medical records which
suggest that she was struggling with the range of duties in Workshop 3, and that
she stated that she was experiencing pain as a result of her previously
sustained injuries. It should be noted, however, that her initial task in Workshop
3, the folding of curtains, was changed to work involving cotton wool balls. This
was because she had found the initial work too complicated, rather than too
physically onerous. With hindsight, her complaints relating to her physical
health were probably not particularly the product of the demands of this work,
but rather more indicative of her overall response to her immediate
circumstances and her feelings about her situation in general.
On 27 May, the woman was seen by another wing SO and a CPN to review her
F2052SH arrangements. The woman stated during this review that she was not
taking the medication prescribed to her for her mental health conditions,
although this was not recorded in the F2052SH. She stated that the medication
had many side effects and that she needed time without the medication. the
woman was asked if she had any thought of self-injury or any hallucinations, and
she stated that she did not. It appears that the woman presented throughout
feeling better and that her mood was apparently stabilising.
The outcome of the review was to close the F2052SH at risk form and to place
the woman on an extra support card. The use of extra support cards is not a
mandatory requirement of the Prison Service F2052SH at risk procedures. The
cards are used as part of Buckley Hall’s additional support to those who may no
longer require monitoring as part of the F2052SH procedures but who may
continue to need informal staff support in relation to specific issues. It is not
clear that her medical records were accessed as part of this review, or that her
refusal to take prescribed medication was explored in depth during this
assessment, which is therefore now considered to have been at least partially
deficient. Given the fact that the woman remained the subject of extra support
card arrangements, her level of supervision would not have differed greatly than
if her F2052SH had remained open, although it is still considered that this
decision to close the F2052SH at that time was not soundly based. This
appears to highlight a potentially systemic weakness in the way that Healthcare
and Residential staff shared, or documented, information relating to her.
Over the course of the Bank Holiday weekend of 29-31 May, the woman
appears to have interacted quite naturally with other prisoners and staff on E
Wing. With the help of another prisoner her hair was braided, and her overall
mood is reported to have been generally positive. Although a series of letters to
her parents reflecting this apparent upswing are undated, these would also
appear to have been written during this period.
On the morning of 1 June, it appears that the woman was unlocked at 7:30 as
part of the normal E Wing routine. During this period prisoners eat breakfast
17
and have an opportunity to take exercise in the open air. Those attending work
then leave the unit to attend workshops at approximately 8:30.
The woman was seen at approximately 8:45 by a landing officer, when she
asked if she could remain in her room that morning. She stated that she did not
feel well and that she wished to make contact with Healthcare in order to resolve
her concerns about attending work in Workshop 3. The woman stated that she
was registered disabled and that it was her understanding that disabled people
are excused from the requirement to attend for work. She also restated her
concerns about her physical health in relation to pain management, but gave no
further indication of any other problems.
The officer responded to her concerns by allowing her to rest in her room that
morning and stated that she would contact Healthcare and make enquiries in an
attempt to clarify the position on prisoners’ exemption from work. the woman
then remained in her room all morning. We have no report as to whether or not
the woman ate her lunchtime meal. However, no records of any refusal to take
a meal were made in the appropriate wing register. Given its postmark and
receipt later in the week, it seems possible that during this morning period the
woman may have written an undated letter and posted this to her CPN in the
community, in which she indicated the intention to take her life. None of this
was reflected in her exchanges with the staff or other prisoners who came into
contact with her during the course of that day.
Shortly after 13:00 and the lunchtime roll check, the woman appears to have
had separate conversations with officers, during which she restated her request
to remain in her room that afternoon, and to not attend activity in Workshop 3.
The woman repeated that she was registered as a disabled person and she
wished to be excused work as she experienced difficulty as a result of her
physical infirmity. At no time during these conversations did the woman state
that she was feeling low in mood or that she had any suicidal intentions. the
woman was allowed to rest in her room, and assured that enquiries would again
be made with Healthcare about her possible exemption from the requirement to
attend work.
At approximately 13:15, the woman was called to attend the wing interview
office for an interview with the CPN. This interview formed part of the ongoing
support for prisoners with mental health problems and was not a response to
heightened concerns about her medical condition. The interview was not
connected to any formal follow-up procedures for those recently removed from
the F2052SH monitoring arrangements. The woman had not herself requested
to see the Community Psychiatric Team.
The woman was not accompanied by any wing staff during this appointment.
During the 30-minute interview, the woman presented a positive outlook and did
not state at any time that she had suicidal intentions. No specific concerns were
raised with the CPN.
18
At the conclusion of the appointment, it appears that the woman made her way
back to her cell. There are no reported sightings of the woman during this
period. However, it is common practice for those attending such interviews to
make their way back to their accommodation using their personal issue courtesy
key. The wing cleaner and fellow prisoner stated during interview that she
subsequently observed the woman standing at her cell door and that the door
was unlocked at about 14:30.
After this last exchange there were no further reported sightings of the woman
and there were no recorded call bells from cell E1-09.
19
Post Incident Response
At approximately 15:55, two of the landing officers became aware that an iron,
available for prisoners to use on E wing, was missing, and they began searching
for this item moving from cell to cell in turn.
Approximately five minutes later, one of them unlocked cell 1-09. During
interview, he stated that he entered the room and observed the woman lying on
the bed, facing the wall. He began a visual search of the room. He stated that
he was not aware of anything immediately unusual and thought that the woman
was asleep on her side. He expected that the noise he created in the room
would awaken her. When this was not the case, he spoke out loud to explain
his presence. It was at this stage that he became concerned about the lack of
response from her. He then went across to the bed, standing directly over her.
The officer then became aware that the woman was not asleep and was lying on
her side with a plastic bag over her head. The bag was secured by shoelaces
tied around her neck. He immediately called for assistance from the other
landing officer, who was next door at this point searching for the iron, turned the
woman onto her back and removed the plastic bag and shoelaces, which were
securing the bag around her head.
The officer finding her raised the alarm using the radio urgent message
procedure. The message was called over the radio net as a Code Blue. This
Code is used to identify that there is a medical emergency requiring
resuscitation or that a prisoner is experiencing breathing difficulty. The officers
were not clear that the urgent message procedure had been received by the
Radio Control Room, as a number of difficulties had been previously
experienced by staff using the radio net that day. Without clear
acknowledgement that the urgent message had been received, the officer that
responded therefore left the cell to phone in the message at 16:06, using the
telephone in the E wing office.
At this point two other officers were despatched to ensure that all other prisoners
on E Wing were locked into their rooms. The wing SO attended the cell and
ensured that the Radio Control Room was informed that paramedical assistance
and an ambulance should be called to the prison to attend to her. At the same
time, Healthcare staff had been informed of the Code Blue medical emergency
on E Wing and two nurses made their way from the Healthcare Building, taking
with them oxygen and emergency equipment.
On arrival, the nurses took over care of the woman and continued resuscitation.
An initial assessment of her medical conditioned confirms that the situation was
very serious and that her condition appeared to be life threatening. One of the
nurses’s stated during interview that the woman did not appear to be breathing
and that they could not find a pulse. The other nurse requested the defibrillator
be brought from Healthcare and the officer finding her was despatched to collect
it. The Healthcare Manager and a third nurse also attended the scene and took
20
part in operating the defibrillator and monitoring the woman for any indication of
breathing.
Paramedics and an ambulance attended the prison at 16:20. Both were given
access to the prison without delay. On their arrival at E Wing, staff ensured that
access to her cell was unimpeded. Healthcare staff handed over her care to the
emergency paramedics, who then determined that the woman should be
transferred to the Infirmary as her condition appeared to be critical. The
ambulance departed the prison without delay at 16:40.
At 17:07, prison staff were informed that the woman had unfortunately been
pronounced dead at the Infirmary.
At approximately 17:15, the Police, Duty Independent Monitoring Board
member, and the Chaplain, were also informed of this outcome. The Deputy
Governor then conducted an immediate post incident debrief and ensured that
the Care Team were informed and available to provide support and guidance to
staff and prisoners. Prisoners were informed of her death in small groups and
permission for a longer period of association was granted in order to provide the
opportunity for peer support.
The police local to her family informed them of her death later that evening. The
establishment telephone numbers were given to her family by the police
together with limited information. Despite her family’s continuing efforts to get
through to the establishment by telephone, it was not until the morning of 2
June, that they were finally able to speak to Deputy Governor.
The telephone conversation appears to have taken place on the basis of a
misapprehension on Deputy Governor’s part. She believed that the family was
already fully aware of the circumstances of her death, and, on that basis, such
details were not provided. In fact, the family only knew that the woman had
died, by apparently taking her own life, but not how this happened. This was
regrettable, with matters then being further compounded by the family only
discovering this information when reading a report in a national newspaper,
whose source would appear to have been a Headquarters press briefing. This
aspect of the whole affair can only have added to the general distress
experienced by her family.
Further communication with the family was well handled.
21
Level Of Compliance With Authorised Procedures
The applicable areas where compliance has been assessed are:
(cid:1) Management of prisoners at risk of self-injury or suicide
(cid:1) Compliance with contingency plans
Management of Prisoners at Risk of Self-Injury or Suicide
The Investigation team recognised a significant establishment commitment to
Safer Custody and support for prisoners in particular. Staff at Buckley Hall
appear to be conscientious in their approach to the care of prisoners at risk and
compassionate in their response when concerns are raised about individual
wellbeing.
The establishment has a Suicide Prevention Co-ordinator (SPC). The SPC also
has responsibility for a residential Unit at Buckley Hall. However, it was clear to
the Investigation Team that the SPC exhibits high levels of personal
commitment to Suicide Prevention and to compliance with Prison Service
Procedures and Standards of care for those at risk.
The quality of entries made in the woman’s F2052SH documentation was
variable and lacking detail outlining meaningful interactions. It would have been
particularly beneficial had her F2052SH accompanied her to her place of work
and entries made to provide residential staff with more information about her
demeanour and attitude in the Workshop.
Her F2052SH was due for a mandatory 72hr review on 15 May. This did not
take place until 17 May, at this point the 72hr review was some 40 hours
overdue. It is mandatory for all 72hr reviews to take place within the specified
timescale.
Compliance with Contingency Plans
Compliance with the establishment’s Death In Custody Contingency Plan was good on
the whole. It would appear that staff were clear about their responsibilities and fulfilled
tasks with diligence and sensitivity.
Incident Management at the Scene was good and appeared to be well led by
those managers involved. A log of events was taken at the Scene and care was
taken to ensure that the impact on the regime was limited to provide an
appropriate level of care for all other prisoners.
It seemed to the Investigation Team that Section 4.7 of the establishment’s
Death In Custody Contingency Plan was not completed. This Section provides
a comprehensive log of information related to the death of a prisoner at Buckley
Hall.
22
Whilst the Investigation Team did not conclude that the issues relating to the
radio net significantly affected the establishment’s response, it is clear that a
fully functioning communications system is vital to the implementation of any
Contingency Plan Response.
23
Findings
The woman had a troubled history, childhood and from her early adult years she
had repeated episodes of mental ill health. Despite the support of her family
and community psychiatric services, she had periods of difficulty in coping, and
was sometimes a risk to herself and others.
Whilst at Eastwood Park, her mental health was at times variable. She was
involved in at least four episodes which included threats of, or acts of, self-harm,
which resulted in three periods when she was the subject of F2052SH
supervision, the last of these concluding on 15 April 2004. Throughout this time,
however, her mental health was at no time considered to be such as to require
any transfer into the psychiatric system. Against this background, Eastwood
Park is seen as having provided an appropriate and effective level of support
and care for the woman over the course of her time there.
In particular, Eastwood Park is considered to have made a correct Cell Sharing
Risk Assessment with regard to her, given her earlier history of violence towards
other patients in psychiatric institutions and the nature of her immediate offence.
Her location in normal residential prisoner accommodation during the final
weeks of her stay at Eastwood Park is also regarded as having been
appropriate, given the apparent relative stability of her circumstances once she
had been sentenced.
The overall current configuration of the female prison estate, and the related
absence of any female training prison of any kind for the West of England, then
resulted in the woman being allocated and transferred to Buckley Hall, an
establishment a considerable distance from her family and other local support
networks.
Buckley Hall currently draws its prisoner population across the country, including
women prisoners with such a sentence length as her from the West of England.
It has a regime that offers prisoners opportunities to gain educational and
employment skills in order to better equip themselves for their return to the
community. The establishment also appears to be well-regarded by the greater
part of its prisoner population, with more or less all of the women interviewed in
the present inquiries commenting favourably about the care and support which
staff were ready to offer women with regard to any individual problems. Her own
move there would seem likely to have prompted significant anxieties for herself,
however, given its unfamiliarity and distance from her family.
The arrangements relating to her reception and induction at Buckley Hall look to
have been managed correctly and with sensitivity. She was sensibly made the
subject of F2052SH procedures, whilst appropriate community psychiatric nurse
support was deployed which was then maintained on an ongoing basis. This
included exchanges with psychiatric services in the community to better inform
their future local engagement with her. The confirmation of the previous Cell
Sharing Risk Assessment relating to the woman also appears to have been
soundly based. At the end of her fortnight’s induction period on D Wing, the
24
woman remained the subject of F2052SH arrangements. Her exchanges with
both staff and prisoners at this point suggest that she was gradually adapting to
her new environment. Her transfer to E Wing and her allocation to activity in
Workshop 3 appear to have been appropriate in these circumstances. Whilst
the woman may still have had issues relating to pain management, the particular
work in which she was engaged was in no respect physically demanding.
On 27 May, a formal review was undertaken, with the woman in attendance, of
her F2052SH arrangements. She appeared to those present to have
successfully managed both her immediate move to E Wing and her introduction
to Workshop 3, and no additional reports had been received from either the
woman herself or any other party of any further intention to, or act of, self-harm.
With this information, it was concluded that she might be more appropriately
managed by the closure of her F2052SH, but still being the subject of the
establishment’s local extra support card arrangements. It was at the same time
also noted that the woman was not currently taking her prescribed medication.
This refusal of medication is not considered to have been given proper weight in
the wider assessment of her overall situation. Whilst there was no means of
compelling the woman to take her medication, she had a previous history of a
reduced tolerance to stress when not complying with her medication regime.
Despite her own presentation, and the other ostensibly more positive aspects of
her immediate situation, it would therefore seem preferable to have maintained
F2052SH supervision until any issues relating to her medication had been fully
resolved, and for her to have returned to full compliance with such
arrangements. Whilst subsequent developments suggest that the continuation
of existing F2052SH arrangements may ultimately not have had an impact on
the outcome of events, this decision to end such supervision is still considered
to have been ill-founded, and not to have paid sufficient heed to her previous
medical history.
Her mood throughout her time at Buckley Hall would look to have swung up and
down, although this would seem to have been more apparent privately and in
her own communications with her family. Her characteristic presentation to staff
was generally more positive than this, with issues relating to physical pain being
the only specifically reported problems after her statement on 12 May to the
CPN that she would harm herself at some stage. On the Bank Holiday weekend
of 29-31 May, the woman had various exchanges with other prisoners, staff and
her family, which each indicated that she was rather more settled than she had
been at that earlier point.
Against this background, there was nothing in her exchanges with both staff and
prisoners on 1 June to suggest any basic change in her apparent outlook, other
than her report of physical pain that prevented her from attending work. It is
possible that during the course of the morning the woman wrote to CPN in the
community to indicate that she intended to take her life. However, the woman
shared none of this with the staff and prisoners with whom she spoke over the
course of the lunchtime and early afternoon period.
25
After her last reported interaction with a fellow prisoner at 14:30, there looks to
have been no further contact with her until the landing officer entered her cell at
roughly 16:00, as part of the search for the missing iron.
The establishment then activated its internal Contingency Plans appropriately,
and offered good support to both staff and prisoners immediately after the
incident.
Communication with her family was initially not managed well. Incorrect
assumptions were made about the information that had been passed on by the
police. Her parents were unable to make telephone contact with the
establishment for a period of almost 12 hours following the first notification of her
death. Contact finally took place and full details of what had happened were,
inadvertently, not provided. The family’s distress was then further compounded
after they learned of the fuller picture from a report in a national newspaper.
Later exchanges between the establishment and her family were managed well,
but this earlier and important phase was, regrettably, clearly mishandled.
An inquest was held into the woman’s death in December 2009 at Heywood,
Lancashire. The jury unanimously returned a verdict that “[the woman] took her
own life whilst she was suffering from an enduring mental health condition”.
26
Conclusions
There was an awareness of the woman’s vulnerability at both establishments,
even if the woman may not have enjoyed in either setting the closer and longer
established relationships that were associated with her life in the community.
This lack of familiarity, and her failure to sometimes present herself and her
concerns directly or accurately to those involved with her care, would look to
have made it difficult to assess her true mood on a day-to-day basis. On the
Bank Holiday weekend which immediately preceded the day of her death, there
would seem to have been reasonably consistent indications in her exchanges
with other prisoners and staff at Buckley Hall, and with her own family, of at least
an apparent stability.
The only factor which in any way stands against this judgement would look to be
an underestimation, or lack of effective awareness, of her decision to at least
temporarily stop taking her medication, something which, on other occasions in
her past, had often been a precursor to problems. The decision to close her
previous F2052SH form on 27 May is seen as being ill founded in this light.
Had greater weight been given to this medication issue, it seems unlikely that
any significant change would have been made to her immediate supervision.
The options for her care in any prison setting might at any time cover a spectrum
from constant observation, in a highly controlled environment, through to the
general support arrangements for somebody who was known to have some
vulnerability that were in place at the time of her death. But it seems reasonable
to suggest that it would have only been the former option that might have led to
any different outcome in her case. The extended use of such arrangements for
any prisoner effectively removes from the individual concerned any sense of
control or normality, and then excludes them from any of the wider opportunities
of a prison’s regime. Taking every factor into account, it is hard to see that this
would have really been an appropriate or the preferable option under which the
woman might have served her sentence.
From this perspective the efforts of both Eastwood Park and Buckley Hall to
manage her care are seen as having been appropriate.
The current overall population management arrangements and limited allocation
options that apply in the female prison estate, and which resulted in her
allocation and transfer to Buckley Hall (and some considerable distance from
her family and other local support systems) are at the same time seen as an
aggravating factor in her underlying circumstances and prospects. From her
point of view, it seems likely that she will have seen her move to Buckley Hall in
a negative light, as it took her even further away from her family and other local
support arrangements.
With the exception of the decision to close her F2052SH form on 27 May, both
Eastwood Park and Buckley Hall are considered to have otherwise managed her
appropriately under the general provisions relating to F2052SH arrangements.
On the basis of this last specific instance, however, consideration needs to be
27
given to the extent that Healthcare and uniformed staff at Buckley Hall are fully
and effectively sharing, documenting and taking account of all available
information relating to individual prisoners at each review and associated
decision-making stage of the F2052SH process.
Although her F2052SH form may have been wrongly closed on this last
occasion, E Wing staff at Buckley Hall still offered the woman appropriate
contact and support, and in response to any specific issues which she raised,
over the course of both the Bank Holiday weekend and on the day of her death.
Following the discovery of the woman in her cell on 1 June, proper and
concerted attempts were made to resuscitate her.
Contingency plans were appropriately activated, and good support was provided
locally to both staff and prisoners in both the immediate and longer-term
aftermath of the tragedy.
Communication with her family following her death was regrettably not well
managed. Mistaken assumptions were made about what information had been
made known to them, and this would point to deficiencies in procedures for
notification arrangement with bereaved families. Over the course of the night
following her death, her family – despite consistent efforts – were also unable to
get through to the establishment by telephone, and improved procedures are
clearly required in this area.
28
Recommendations
1. The practice of holding F2052SH reviews without prior access to all relevant
prisoner information should be discontinued.
2. Case reviews should be multi-disciplinary with the attendance of health care
professionals with appropriate knowledge of the prisoner.
3. The establishment Suicide Prevention Leader should ensure attendance of
multi-disciplinary staff at F2052SH reviews, and that a greater emphasis be
placed on all appropriate departments contributing to the Suicide Prevention
procedures.
4. Buckley Hall’s radio communication system should be audited and a full
maintenance check should be completed in order to satisfy the establishment
requirement in providing an effective incident response.
5. The Investigation Team found that there was a lack of clarity about the
medical emergency response codes and this placed additional stress upon
those providing the response and in dealing with the situation. Clear written
guidance should be issued to all members of staff and necessary training be
initiated for all staff at Buckley Hall.
6. The Healthcare Manager should prepare recommendations on the
appropriate location of emergency response equipment at Buckley Hall.
7. Post death in custody protocols should be reviewed to incorporate a clearer
emphasis on the provision of information and support for bereaved families,
including an identified point of contact.
8. Arrangements for communication after such tragedies should be immediately
reviewed and a dedicated phone line and number be enabled. These
arrangements should be made known to bereaved families when first contact
is made.
9. Buckley Hall should investigate the possibility of utilising training to enhance
their support for bereaved families, through attendance on the Family Liaison
Course.
29
Good Practice
1. The Buckley Hall Care Team appear to have acted in an exemplary manner
throughout the post-incident period following her death. Their actions would
look to have made a significant contribution towards reducing the stress and
anxiety amongst those staff and prisoners who were most affected by these
sad events. Support was offered to those concerned with sensitivity and
compassion, together with a great deal of practical guidance and information.
This particular area of activity impressed the Investigation Team as a clear
area of excellent practice.
2. The establishment’s general response to its prisoner population following the
death of the woman is also considered to be worthy of commendation. The
arrangements for a local memorial service - which was attended by some
250 members of the Buckley Hall prisoner and staff community - seems to
have been universally well-received by those prisoners with whom we spoke.
This collective opportunity to remember the woman would also look to have
been accompanied by other individual examples of support and opportunities
for personal grieving.
30
Recommendations Re: Staff Performance
1. The efforts of the officers and their interactions with the woman on the day of
her death should be recognised as having been appropriate, in the light of
the information that was available to them about her immediate
circumstances. All three of these Officers responded to the woman with
diligence and support to her presenting needs, and made what seemed at
the time to be the right arrangements for the woman to stay off work, and for
her to be referred to Healthcare for further assessment of her reported
physical problems.
2. The emergency response of nurses should also be commended. Both acted
in a thoroughly professional and appropriate manner throughout the incident,
with both themselves and all other Healthcare staff who attended also trying
to serve her interests with care and compassion.
31