Individual at Woodhill

Investigation into the circumstances surrounding the
death of a man at HMP Woodhill
in April 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
November 2009
This is the report of the investigation into the apparently self-inflicted death of a man
at HMP Woodhill in April 2009. He was found hanging from the bunk beds in his cell
at 12.00pm during a routine check. He was 50 years old.
I offer my sincere condolences to his friends and family, and all those touched by his
loss.
The investigation was carried out by one of the Ombudsman’s investigators. The
local Primary Care Trust (PCT) commissioned a clinical reviewer to undertake a
review of the clinical care the man received at Woodhill. I am grateful for her
thorough and timely review. I would also like to thank the then Governor of Woodhill
and his staff for their co-operation. Particular thanks go to the senior officer who was
the establishment’s investigation liaison officer and offered excellent assistance.
The man was apparently not someone who shared his thoughts and feelings readily,
and he tended to keep his own company. He had been in prison before (including at
Woodhill) and on this occasion had been on remand for three months. He was
charged with a number of offences and knew he might face a lengthy sentence.
That said, he gave staff no cause for concern and consequently was not being
monitored under the prison’s suicide and self harm procedures.
I judge that there was little that staff at Woodhill could have done to prevent the
man’s death. An unfortunate combination of circumstances including a lock down
search of the prison (meaning all prisoners remained locked in their cells for the
majority of the day) and the transfer of his cellmate first thing that morning may have
made his actions easier. Generally, I am pleased to note the professionalism of staff
at the prison, although I make five recommendations, four concerning healthcare and
one the prison’s emergency response procedures.
This version of my report, published on the website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in the
investigation.
Jane Webb
Deputy Ombudsman November 2009
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CONTENTS
Summary
The investigation process
HMP Woodhill
Key events
Issues
Conclusion
Recommendations
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SUMMARY
The man arrived at HMP Woodhill in December 2008, having been remanded from
court charged with a number of robberies. He had a history of injecting drugs but
chose not to tell healthcare staff about this on his arrival. He said he had been in
prison (including at Woodhill) before and had no concerns, other than that he needed
reading glasses. The nurse assessing him concluded that the man had no physical
or mental health problems and referred him to the optician.
Shortly after his arrival, the man made an undated written application for a doctor’s
appointment. He wrote that he had brought drugs into the prison with him, had used
them all and had left himself “in trouble”. An appointment was made for 9 January.
The man apparently made no other mention of having used drugs at Woodhill, or
needing any medical intervention as a result. The doctor, who had not seen the
application form, recorded that the man had no health concerns and no further action
was taken.
After his induction, the man moved to a double cell on House Unit 3A, sharing with
another prisoner whom he knew from the community. He was allocated two
personal officers, and told one that he had no history or current thoughts of suicide
or self harm. Staff apparently had no concerns about the man, although they noted
that he spent a lot of time in his cell.
The man referred himself to the prison substance use support service and had an
appointment with a member of the team on 16 January. He explained his history of
drug use and agreed to work with the service during his time in prison. He also
asked for support on release. The man gave the drugs worker no other cause to be
concerned for his welfare.
Between January and March 2009, the role of House Unit 3A was changing and, as
a result, the man’s cellmate was to be moved to another unit. In late January, the
cellmate told a member of staff that he was worried about the man. It has not been
possible to discover the exact nature of his concerns, but the man reassured staff
that he was fine.
The man began working full time in the prison kitchens in early February. Staff
described him as quiet but hard working and he became one of 12 prisoners trusted
with greater responsibility. In March, the man spoke to another prisoner working in
the kitchen and said he might like to talk to him in his capacity as a Listener (a
prisoner trained to offer confidential support to other prisoners). As it was not
convenient to talk while they were working, the prisoner advised the man to find him,
or another trained Listener, when back on the unit. The man did not go on to speak
to a Listener during his time at Woodhill.
On 3 March, the man began sharing a cell with another prisoner whom he also knew
from the community. The man said he knew he might be facing a long sentence and
that the thought was “doing his head in”. He told his cellmate that he had previously
tried to harm himself in the community, but gave no indication that he had any
current thought of doing so. The cellmate said that the man used Subutex (a heroin
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substitute) regularly while at Woodhill. He did not think the man was in debt to or
being bullied by any other prisoners.
The man resigned from his kitchen job on 31 March. Kitchen staff asked an officer
on House Unit 3A to find out why, and the man told him that he would be “leaving
soon”. His demeanour gave staff no reason to worry.
One day early in April, the prison underwent a lock down search, following
information that prisoners were planning an escape. As a result, all prisoners were
to remain locked in their cells until the entire prison had been searched. Staff said
that prisoners received notice of the search the previous evening, but those on
House Unit 3A said they did not receive any notification.
First thing that morning, the man’s cellmate was told that he was being transferred to
another prison. A senior officer collected him from the cell at 9.15am and described
the man as seeming fine. The cellmate thought that, in hindsight, the man had been
upset by his departure. Neither the man’s cellmate nor the officer who saw him that
morning had any concerns.
At about 12.00 noon, staff arrived at the man’s cell to deliver his lunch. They found
him hanging from the top of the bunk beds, suspended by a thickly twisted bedsheet.
The officers removed the ligature and tried to resuscitate him, quickly joined by a
number of healthcare staff. He was taken to hospital by ambulance, but efforts to
resuscitate him were unsuccessful and hospital staff pronounced that he had died.
After his death, another prisoner said that the man had talked of harming himself
about three days before his death. It appears that the prisoner did not tell staff of his
concerns.
I make five recommendations as a result of this investigation. Four concern
healthcare policies and procedures and one concerns the emergency radio protocol.
I am satisfied, however, that the man’s death was neither foreseeable nor, for that
reason, preventable.
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THE INVESTIGATION PROCESS
1. The Ombudsman’s office was informed of the death of the man in April 2009.
The investigation was allocated to an investigator later that day. One of the
Ombudsman’s investigators visited HMP Woodhill on 7 April to open the
investigation and met some staff who knew the man and a member of the
Independent Monitoring Board (IMB).
2. The investigator issued notices inviting staff and prisoners to contact her with any
information they felt might be relevant to the investigation. There was no
response to the notices. The investigator carried out interviews with staff and
prisoners at Woodhill between May and June 2009. A prisoner who had shared a
cell with the man at Woodhill but had since been transferred to HMP
Wellingborough was also interviewed. Additionally, the investigator made
telephone contact with the man’s criminal defence solicitor.
3. Milton Keynes PCT appointed a clinical reviewer to undertake a review of the
clinical care the man received at Woodhill. The clinical reviewer and the
investigator conducted a number of joint interviews with members of healthcare
staff.
4. The investigator was provided with relevant documentation covering the man’s
time at Woodhill, including a copy of his prison records, his medical record and
the staff incident reports written after his death.
5. HM Coroner for Buckinghamshire was informed of the nature and scope of the
investigation, and provided the investigator with copies of statements gathered by
the police. A copy of this report will be sent to him to assist with his inquiries.
6. One of the Ombudsman’s family liaison officers contacted members of the man’s
family to invite them to be involved in the investigation process. They did not
raise any particular concerns or questions about the care the man received at
Woodhill. However, I hope this report will provide them with a picture of his time
there and of the events in April.
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HMP WOODHILL
7. HMP Woodhill is a local prison which can hold 819 adult male prisoners, on
remand, convicted or sentenced. The prison serves a number of functions. In
the late 1990’s, Woodhill joined the High Security Estate and now also holds
category A prisoners.
8. Each prison in England and Wales is subject to performance monitoring by the
National Offender Management Service (NOMS). NOMS produces quarterly
performance ratings, compiled using an agreed framework. Woodhill’s
performance has been rated as “good” (the second best rating available) for the
past three quarters.
9. The prison last underwent a full announced inspection in September 2007. The
Chief Inspector praised the new management team, and new Director of High
Security, for focusing appropriately on:
“… the prison’s principal role, as a local prison, holding short-sentenced and
low risk adults and young men – without losing sight of the security and
control needed to safely contain its high risk population.”
10. Improvements were noted in all four key areas inspected: safety, respect,
purposeful activity and resettlement. However, “serious deficits” were also
highlighted. The lack of available activity places for the population meant that
only 30 percent of the population were engaged in work or education. The
provision of healthcare was also of “considerable concern”, with mental
healthcare “limited and ineffective”.
11. The inspection noted that safety had improved, and that both violence reduction
and safer custody work were “much more effective” than at the time of the last
inspection.
12. Prisons in England and Wales are also subject to monitoring by an Independent
Monitoring Board (IMB), made up of volunteers from the local community.
Members of the IMB have access to every part of the prison and each prisoner
there. They produce an annual report, the latest available for Woodhill covering
the period June 2007 to May 2008.
13. The IMB noted the challenges of balancing the security demands of the prison’s
high security role with the needs of the majority of the prison’s non-category A
population. They also noted the pressures of overcrowding, staff shortages and
recruitment difficulties. However, better links with local community agencies and
with the Primary Care Trust were noted. The Board also recognised
improvements in the daily regime and purposeful activities on offer.
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KEY EVENTS
14. In December 2008, the man appeared at Northampton Magistrates’ Court,
charged with a number of robberies. His case was to be heard at the Crown
Court and, in the meantime, he was remanded into the custody of Woodhill. He
arrived at the prison at 4.00pm. The Prisoner Escort Record (PER) that
accompanied him from court to the prison noted that the man had substance use
problems. (One function of the PER is to highlight the risks the individual might
pose to themselves or others.)
15. Once the man was processed through reception, he moved to the First Night
Centre, where most prisoners spend their first night at the prison. The man
underwent the first reception healthscreen with a nurse there. (The healthscreen
is designed to identify any immediate physical or mental health problems
requiring referral to the doctor or other specialist service.) The nurse had not
read any other health related information about the man before conducting the
assessment. The man told the nurse he had not seen a doctor recently, was not
prescribed any medication and had no recent physical injuries. He said he had
no concerns about his physical health, but needed glasses. The nurse noted that
the man had been at Woodhill before.
16. The nurse, who has worked at Woodhill for 15 years, was interviewed as part of
this investigation. He could not specifically remember assessing the man in
reception. He explained that it is quite common to assess prisoners on their
arrival without having seen any other health information about them. However,
he said he would always see the PER as he had to complete one section of it.
The nurse said that the man did not have his glasses with him, and so he would
have referred to him to the optician. This referral is not recorded on the
healthscreen, but he explained that he would have completed a referral form
which would have been processed by an administrator. (The clinical reviewer
confirmed that the man saw the optician on 16 March and received prescription
reading glasses on 26 March.)
17. The man said that he had no history of mental health problems and had never
tried to harm himself. The nurse asked whether he had any concerns about
being in prison, and he replied that he did not. In interview, the nurse explained
that the healthscreen was essentially a checklist. If the prisoner highlighted any
areas of concern, the nurse would probe for further information. The nurse said
he was quite experienced at assessing body language and identifying prisoners
who were hesitant in their answers, and would take the time to draw them into
conversation. The man told the nurse that he did not drink alcohol, and had not
used drugs in the past month, although his PER recorded that he had substance
use issues. The nurse told my investigator that where the PER and the prisoner
provided conflicting information, he would normally ask the prisoner about the
information on the PER. He said, however, that ultimately he would take the word
of the prisoner. The nurse did not record on the healthscreen whether he and the
man discussed the conflicting information on the PER. He said that prisoners are
not routinely drug tested on arrival, unless they said they used drugs.
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18. After completing the first reception healthscreen, the nurse carried out the
secondary healthscreen. (This is designed to gather more detailed information
about the prisoner’s medical history. It must be completed within seven days of
the prisoner’s arrival, but not usually on the same day as the first reception
healthscreen.) He recorded that the man had no outstanding hospital
appointments, hereditary health conditions or concerns. The man told the nurse
that he was a smoker, but did not want to stop. He and the nurse signed both
healthscreens. The nurse decided that the man did not need to be referred to the
doctor or to any of the other specialist services available.
19. The nurse also completed the healthcare section of the Cell Sharing Risk
Assessment, which assesses whether the prisoner is suitable for sharing a cell.
The assessment also provides another opportunity to consider whether there is
evidence the prisoner may be a risk to himself. The nurse recorded that there
was no indication that the man might harm himself. He noted that there were “no
problems” and assessed the man as a low risk to other prisoners, and therefore
suitable for sharing a cell. An officer completed the remainder of the form. She
noted that she had seen both the PER and the warrant accompanying the man
into prison. The man told the officer that he had no substance misuse problems,
did not get angry easily and had been at Woodhill before. The officer also judged
the man to be a low risk to other prisoners and suitable for sharing a cell.
20. A second officer met the man that evening, and completed the first night
“passport”. The second officer was interviewed as part of the investigation. He
explained that the passport provides an opportunity to assess the prisoner and to
consider “what we need to be thinking about for this person, what actions we
need to put in to keep the person perhaps safe from themselves or from other
people”. He noted that the man had been given information about what to expect
from his first days in custody and offered a telephone call. The officer wrote that
the man did not know the telephone numbers of any friends or family and so had
not made any calls. He confirmed that he gave the man information about
Listeners and the Samaritans, and that use of his cell bell was explained.
(Listeners are prisoners trained and supported by the Samaritans to offer a 24
hours a day, confidential listening service to other prisoners. The cell bell, one of
which is installed in every cell, can be used to alert staff attention, and is intended
for emergency use.) The officer also completed the housing needs assessment
and recorded that the man had no fixed accommodation prior to coming to prison.
The man said he would be living with his father on his release. Following their
meeting, the officer made an entry in the man’s wing history sheet, writing that he
“doesn’t have any thoughts of self harm or more”.
21. In interview, the second officer said that, had he had any concerns about the
man, he would have placed him on an Assessment, Care in Custody and
Teamwork (ACCT) document. (The ACCT system is in place across all prisons in
England and Wales and is designed to support and monitor those judged to be at
risk of suicide or self harm.) He also confirmed that had he concerns of any
nature about the man, he would have recorded them in his file.
22. It appears that within days of his arrival at Woodhill, the man applied for an
appointment with the prison doctor. The referral form is undated (and in fact, no
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space is provided to record the date) but the man wrote that he wanted to see a
doctor because he “came into prison Tuesday with gear (hidden somewhere) and
things, now done what I came with, now I’ve left myself bang in trouble”. (Gear is
a common street name for heroin.) The healthcare department could not confirm
whether an appointment was booked as a result. The man did, in fact, see the
prison doctor on 9 January. The doctor made an entry in the man’s medical
record, noting he was “no longer constipated. Has no complaints at the moment.”
The doctor was interviewed during the investigation and said that he could not
remember examining the man on 9 January, and had not seen him again. He
was shown the referral form the man had completed and said he had not seen it
before. He was unable to confirm whether his examination of the man was a
result of the referral form. There is no evidence to suggest that any substance
use issues were reconsidered in the light of his application.
23. On 14 January, the man moved to House Unit 3A after his induction period was
completed. This unit holds 82 prisoners in a mix of single and double cells.
When the man arrived it was the substance support wing, holding prisoners with
histories of substance use. However, its role was in the process of changing to
accommodate prisoners with jobs in the prison. Staff working there described it
as a generally calm unit with a good atmosphere and few problems. Both staff
and prisoners described relationships between them as positive, and most staff
thought that prisoners would approach them if they had any problems. The man
was placed in a double cell with another prisoner whom he already knew. (Some
staff described the two men as cousins whilst others thought the prisoner was the
man’s father-in-law.)
24. The man was assigned two personal officers. (The personal officer scheme is
intended to provide prisoners with a named point of contact who they can
approach with any questions or concerns. At Woodhill, personal officers should
make entries in their prisoners’ files at least every two weeks.) One of the man’s
personal officers made an entry in the man’s file on his arrival, noting that the
man had completed an application for a job in the prison. The personal officer
also filled in the Personal Officer Interview Sheet, recording that the man had
never tried to harm himself in the past. The man said he had no issues or
concerns and did not need to complete any courses while in prison. He signed
the Voluntary Drugs Testing Compact, agreeing to remain drug free while on the
unit and undergo drugs tests whenever he was required to do so.
25. Two days later, on 16 January 2009 a CARATs worker saw the man after he
referred himself to the service. (The Counselling, Assessment, Referral, Advice
and Throughcare service is established in all prisons in England and Wales. It
offers non-clinical interventions to prisoners with substance use issues, including
group and one to one sessions. CARATs can also refer prisoners to community
agencies on their release.) The referral form the man completed is not dated, but
he wrote that wanted to see CARATs for “personal [reasons] to do with drug
problems”.
26. The CARATs worker recorded that the man had been an intravenous
amphetamine user before coming into prison. He told her he had started using
drugs four years ago and, prior to coming to prison, was using them every day.
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The man said his former partner had been a heroin user, and that he had
committed offences so she could buy drugs. He said that his partner had left him
since he had been remanded into custody. The man said he had never sought
treatment for his drug use in the past, but now wanted to work with CARATs and
have support in the community on his release. The CARATs worker recorded
that she sent a copy of the man’s assessment to his community Drug Intervention
Programme and that she had begun to devise a care plan for him.
27. The investigator spoke to the CARATs worker as part of this investigation. She
said that she met the man once during his time at Woodhill, spending about half
an hour with him. He caused her no concern during their meeting. Although he
mentioned that his partner had ended the relationship, he did not seem upset but
said he felt “used” by her. The CARATs worker said that, had she had any
concerns about him, she would have opened an ACCT, as she had been trained
to do. The man did not tell her that he had brought drugs into the prison with him.
28. The man’s second personal officer recorded that he talked to the man on 29
January about the amount of time he spent in his cell. He wrote that the man said
he did not know anyone on the unit, and “just wants to get on with his sentence”.
The man told the officer that he wrote to his family. The second personal officer
concluded that the man “seems ok”. Three days later, the first personal officer
made an entry in the man’s file following a conversation with his cellmate. The
entry is not easy to understand but appears to outline the cellmate’s concerns
about the man. The first personal officer wrote:
“Informed by his cellmate he shows concern on when he transfers he would
not be able to cope. Having spoken to the cellmate he states all is well. Shall
monitor this issue, staff are aware. When I asked the man how he is feeling
on the wing and if there was anything I could help him with, he stated is “ok”.
Have asked him to put in some app[lications] for ed[ucation]/work to keep
himself busy. Shall chat with him again next week.”
29. The investigator attempted to interview both the first personal officer and the
cellmate but was unable to. The first personal officer has been on sick leave
since the investigation began and efforts to contact him were unsuccessful. The
cellmate was asked if he would be willing to speak to the investigator, but did not
wish to do so.
30. Staff told the investigator that the role of the unit was due to change in March.
The cellmate was to transfer to another wing as he was not in employment, but
the man was to stay on House Unit 3A, as he had applied for full time work. It is
possible that the cellmate thought the man would not be able to cope if they were
not sharing a cell.
31. The first personal officer received confirmation on 2 February that the man had
been given a job in the prison kitchen and he began working there the following
day. The first personal officer wrote that, as a result of his job, the man had
gained confidence. The officer noted that the man was receiving support from his
cellmate.
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32. On 17 February, the man made an application to see a probation officer in the
prison, due to “personal circumstances”. The man was told that, as an
unsentenced prisoner, he was not allocated a prison probation officer. He was
given the name of a member of staff who dealt with prisoners seeking bail. He
was also invited to provide more information about the nature of his application,
so that staff could decide what action to take. The man did not do so, and made
no further applications.
33. A solicitor from the firm of solicitors representing the man in his criminal matters
visited Woodhill on 2 March. The investigator spoke to the solicitor by telephone.
He said that, as a former police officer in the Northampton area, he had known
the man for a number of years and thought they enjoyed a good relationship. He
had been unable to advise the man of the sentence he might receive if found
guilty of his offences, but told him it was likely to be lengthy. The solicitor visited
the man several times at Woodhill, and said that on one occasion, the man said
he wanted to “sort everything out because he had had enough”. The solicitor
took this to mean that the man wanted to change aspects of his life and stop
using drugs, and did not want to return to prison again. He told the investigator
he never had any concerns that the man might be thinking of harming himself.
He explained that, had he any concerns, he would have informed prison staff
immediately. The solicitor said he had been very shocked to learn that the man
had died.
34. Two further officers became the man’s personal officers when he moved to cell
1:20 on the ground floor of House Unit 3A on 4 March. The man was now
sharing a cell with another cellmate whom he had known for some time outside
prison. The second cellmate was transferred to HMP Wellingborough on 1 April,
and was interviewed there by the investigator. He said that he and the man were
both amphetamine users, who had met through mutual friends. He described the
man as quiet and generally “keeping himself to himself”. He said the man would
not normally share his thoughts or feelings with other people. The second
cellmate told the investigator that the man and his girlfriend had split up since he
came to prison and he had seemed upset about this. He said the man had been
in prison before, but was “hating it” this time. As he had been charged with a
number of serious offences, the man thought he might be facing an Indeterminate
Public Protection (IPP) sentence. (IPP sentences apply to those who are
convicted of certain serious violent or sexual offences and are deemed to pose a
“significant risk of serious harm in the future”. The sentencing court must set a
minimum period of imprisonment required, but the individual will only be released
after that point if they can show the Parole Board that they have reduced the risk
to the public.) He told the second cellmate that he would not be able to handle a
long sentence.
35. The man appeared at Northampton Crown Court in March. He was convicted of
two offences and was to face trial for nine more. He was remanded into custody
to appear at the Crown Court once the trial date had been fixed. The third
personal officer made an entry in the man’s wing file on 27 March, recording that
no concerns or issues had been raised.
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36. On 31 March, the man resigned from his kitchen job. The investigator spoke to
one of the chefs responsible for managing prisoners working in the kitchen. She
said that the man had worked well and was helpful, always doing what was asked
of him and “keeping his head down”. The chef said the man became a “Super
12” prisoner, the term given to the 12 most trusted prisoners working in the
kitchen. She had no reason to be concerned about him, and had never noticed
any changes in his mood. She described him as quiet, and said he did not talk to
others in the kitchen very much. None of the other kitchen workers had reported
any worries about him.
37. The chef showed the investigator the kitchen observation book (where staff
record information every day) and the entry made on 31 March. The entry
records that kitchen staff telephoned House Unit 3A that morning to ask why the
man had not come to work. An officer on the unit went to speak to the man and,
having done so, said that he had resigned because he would be “leaving soon”.
When the member of kitchen staff asked what this meant, they were told the man
might be referring to an upcoming court appearance. The investigator also spoke
to the officer who, unfortunately, could not remember the conversation he had
with the man. He said, however, that had the man caused him any concern, he
would have talked to other staff, and made a note in the file and the unit
observation book. The chef said that all those working in the kitchen were very
shocked to learn that the man had died. She confirmed that, since his death, no
one had mentioned having any concerns about him.
38. The investigator spoke to a Listener who worked with the man in the kitchen.
The Listener said he did not know the man well as they only worked together for a
short time. He said that one day (he could not remember exactly when, but it
would have been some time in March) whilst working together, the man had said
he might like to talk to him in his capacity as a Listener. The Listener said that, as
they were working in the kitchen, it was not appropriate to talk in detail then, but
he had told the man to find him when they were back on unit 3A (where the
Listener also lived). The man gave no indication of why he might want to speak
to a Listener. He did not come to see him, and shortly after, the Listener was
transferred to another unit. He explained that prisoners are generally not able to
ask to see a particular Listener, but if the man had asked, he would have been
able to speak to any Listener available in the prison. In March 2009, there were
several Listeners living on House Unit 3A, and the Listener explained that they all
wore green t-shirts so that they could be easily identified. He was fairly confident
that prisoners at Woodhill were aware of, and knew how to access, Listeners.
The day the man died
39. A lock down search of Woodhill was planned for a day in April, following
information that prisoners might be planning an escape attempt. This meant that
over the course of the day every cell in each unit would be searched in detail.
Prisoners remained locked in their cells until the entire prison had been searched.
Staff told the investigator that all prisoners received a notice of the search under
their cell doors first thing that day. However, several prisoners living on unit 3A
on that day were interviewed and said that they had not received any information
13
about the search. Staff were deployed across the prison so that no one searched
the unit where they were normally based.
40. A senior officer (SO), one of the unit 3A managers, was tasked with patrolling the
unit while staff searched other units. (Generally, when prisoners are locked in
their cells, fewer staff are on duty. This is often known as a ‘patrol state’.) At
about 8.20am, he went to cell 1:20 to tell the man’s cellmate, who was being
transferred to HMP Wellingborough that day, that he would return in an hour to
take him to reception. The SO said prisoners being transferred would normally
be informed the night before, to give them an opportunity to telephone family and
friends and pack their belongings. The cellmate told the investigator that he had
received no warning before his transfer.
41. The SO returned to the cell at 9.15am. He said that the two prisoners wished
each other well as the cellmate left. He noticed nothing of concern in the man’s
demeanour, and thought that, had the cellmate had any concerns, he would have
discussed them on his way to reception.
42. The cellmate told the investigator that as he was about to leave the cell, the man
said “don’t go”. At the time, he had not thought anything of this, and had not been
concerned. However, he said the man had been feeling low, and had been
sleeping a lot. He described the man as “not his usual self” but thought this was
because he was worried about the sentence he might receive. The man had told
the cellmate that the thought of a long sentence was “doing his head in”. He said
he had tried to harm himself before in the community, but never mentioned
thinking of or wanting to harm himself while in prison. The cellmate said that the
man was taking Subutex (a heroin substitute) about twice a week at Woodhill,
(although he had not been a heroin user in the community) and using tobacco to
trade with other prisoners. As far as he knew, the man was not in debt to any
other prisoners, and was not being bullied or pressured.
43. At 11.40am, staff began to serve lunch on unit 3A. Because the prisoners were
still locked in their cells, they were served cold food at their cell doors, with staff
unlocking each cell in turn. About 20 members of staff were on the unit, helping
to serve lunch. A prison officer was one of those serving lunch to the cells on the
ground floor. He was interviewed and explained that staff had begun with cell
1:01, working round to end with the man’s cell 1:20, which is located in the far
corner of the unit.
44. The prison officer reached the man’s cell at about 12.00 noon, while other staff
were serving lunch to the prisoners in cells 1:18 and 1:19. A card is displayed
outside each cell, detailing the names of the prisoners in the cell. The officer saw
that cell 1:20 contained two prisoners (the cellmate’s name had not yet been
removed from the card). Before unlocking the cell, he looked through the
observation panel in the cell door. He saw the man hanging from the frame of the
top bunk bed, suspended by a bed sheet, facing the cell door. The officer opened
the cell, calling for staff to help as he did so. He went in and tried to support the
weight of the man’s body, putting his arms around his waist. No other staff had
arrived and so the officer called out again.
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45. A second officer heard his colleague’s call, went into the man’s cell and helped to
support the weight of his body. He told the investigator that the ligature around
the man’s neck was made from a thickly twisted bedsheet. All frontline staff at
Woodhill carry a ligature knife, which is specially designed to cut ligatures safely.
The second officer tried to cut the ligature using his knife but was unable to
because the material was so thick. Both officers recalled a number of other staff
arriving in the cell very quickly. A third officer also tried to cut the ligature but
could not. An SO who had arrived at the cell took the third officer’s ligature knife
and managed to cut through the material. The staff laid the man’s body on the
cell floor and the SO checked for a pulse and signs that he was breathing and
found neither. The SO described the man as looking “in a bad way”. Because
the cell was small and cramped, staff carried the man to the association area, a
large, spacious area directly outside the cell.
46. A fourth officer also responded to the call for staff. When she arrived at the cell,
she found four members of staff already there. She used her radio to call for
medical staff to attend a “medical emergency”. The officer told the control room
the nature and location of the emergency.
47. Staff began to attempt to resuscitate the man. The third officer told the
investigator that he always carries a resuscitation pack, containing a one way
valve for giving mouth to mouth resuscitation, alcohol wipes and latex gloves. He
said he had received first aid training when he joined the prison service five years
ago, but had done none since. However, he said he felt comfortable beginning
mouth to mouth resuscitation.
48. Two Healthcare Officers (HCO) were dispensing medications across the whole
prison that day, because of the lock down search. At 12.00 noon, they were
helping colleagues dispense medication on House Units 3A and B. One HCO
was carrying a radio, and both members of staff heard the emergency call for
staff to go to unit 3A. The other HCO was interviewed during the investigation
and said he responded to the call, quickly running to the unit. He had not heard
the exact wording of the radio call and so did not know what kind of emergency it
was. On entering the unit, he saw a number of staff gathered outside cell 1:20,
and made his way to them. He saw the man lying on the floor with staff about to
commence mouth to mouth resuscitation. The HCO confirmed that the man was
not breathing and began chest compressions.
49. Emergency medical equipment is kept in the central area separating unit 3A and
3B. The equipment includes a defibrillator (a machine which delivers electric
shocks and can help to restart the heart in some circumstances) and oxygen. A
nurse and the HCO who was carrying the radio collected the equipment and then
assisted the resuscitation efforts. The HCO who was first to arrive at the scene
told the investigator that they attached the defibrillator and followed the automatic
instructions. The defibrillator advised that no shock should be delivered and so
staff continued to administer cardio-pulmonary resuscitation (CPR). By this time,
several members of healthcare staff had arrived, and staff took turns to deliver
breaths and compressions.
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50. A prison doctor was completing paperwork in the healthcare centre when he
heard the medical emergency call over the radio. He collected his medical bag
and went quickly to House Unit 3A. The doctor was interviewed during the
investigation and explained that, on checking, the man had no blood pressure
reading, and his pupils were fixed and dilated. He could not find a pulse and
advised staff to continue with CPR. Every two minutes he re-checked the man for
a pulse. The doctor said that staff gave the man oxygen; he tried to administer
medication intravenously, but could not find a vein.
51. An ambulance arrived at the prison at 12.10pm and at unit 3A three minutes later.
The paramedics assessed the man and asked staff to continue CPR while they
treated him. They decided that the man should be taken to Milton Keynes
Hospital and he was placed in the ambulance. When a prisoner has to leave the
prison, a risk assessment should be carried out which assesses whether they
need to be restrained (in handcuffs) and how many officers need to go with them.
Because of the nature of the emergency, the man was not restrained. Two
officers were directed to escort the man to hospital in the ambulance. The
paramedics asked the nurse who had carried out the man’s first reception
healthscreen, and who had arrived to help with resuscitation efforts, to
accompany them in the ambulance, which left the prison at 12.40pm. During the
journey to hospital, one of the accompanying officers and the nurse continued to
administer CPR under instruction from one of the paramedics.
52. On arrival at the hospital, the man was assessed by doctors who pronounced at
12.51pm that he had died. The man was moved to a quiet room, and a member
of prison staff came to collect one of the officers and the nurse. The other officer
who had accompanied the man in the ambulance remained at the hospital with
the man until the coroner’s officer arrived.
53. After the man had been taken to hospital, staff found a length of plaited bedsheet
approximately eight feet long in his cell bin.
54. Later that day, another officer told the man’s former cellmate that he had died.
The prisoner said he had told unit staff that he had concerns about the man and
that he posed a risk to himself. The prisoner told the officer that he had found the
man with a ligature on one occasion, which he had thrown in the unit bin. He said
he had shown an officer the ligature before disposing of it. The prisoner could not
remember the names of any members of staff he had spoken to. Because the
prisoner did not wish to take part in the investigation, it has not been possible to
investigate this matter further.
55. Several days after the man’s death, a second Listener approached a principle
officer (PO), the unit 3A manager. The Listener told the PO that another prisoner
had talked to the man about three days before his death. This prisoner said the
man had told him he would kill himself. Unfortunately, the prisoner could not be
interviewed as he had already been released from the prison and had no
forwarding address. It would seem that he did not tell any staff what the man had
said.
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Contact with the man’s family
56. The duty governor asked two Family Liaison Officers to visit the man’s family to
inform them of his death. At 1.45pm, they and a governor went to the man’s
father’s home. The prison Family Liaison Officers remained in contact with the
man’s family over the following weeks. They attended the funeral and arranged
for members of the man’s family to visit the prison and House Unit 3A.
Support for other prisoners
57. On hearing the nature of the emergency radio call at 12.00 noon on the day the
man died, the senior officer in the prison control room instructed that staff carry
out a check on all prisoners on an ACCT document. The lock down search
continued in the afternoon.
58. Following the man’s death, the then Governor issued a notice informing
prisoners, which was placed under all cell doors. The second cellmate, who had
been transferred to HMP Wellingborough earlier that day, was also told that the
man had died. He said he was very upset when he heard and was placed on an
ACCT for five days so that he could be offered the necessary support. He told
the investigator that, in the days that followed, he received support from the
prison chaplain, the mental health team and staff on the wing where he was
located.
Support for staff
59. At 2.00pm, the Deputy Governor held a ‘hot debrief’. (This is a requirement of
Prison Service Order (PSO) 2710 Follow up to a death in custody. The PSO
directs all staff involved be invited to attend a meeting held immediately after the
death. The purpose of the hot debrief is to provide reassurance and information.)
As the man had been taken to hospital, staff did not know for certain at the time
that he had died. The Deputy Governor confirmed his death during the hot
debrief.
60. All staff interviewed as part of this investigation said they felt very well supported
by senior managers. Those who attended the hot debrief described it as helpful.
A member of the IMB also attended and said he had been impressed with how
sensitively the Deputy Governor handled the meeting.
61. Staff involved had all had contact with a member of the prison’s Care Team (of
whom they all spoke very highly) and were provided with ongoing support in the
days and weeks following the man’s death. Some staff said they were offered the
opportunity to leave work early on the day the man died.
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ISSUES IDENTIFIED DURING THE INVESTIGATION
Clinical care
62. The clinical reviewer concludes in her clinical review that the man’s mental and
physical health was appropriately assessed on his arrival at Woodhill and that he
gave no indications that he intended to harm himself. She notes, however, that
the secondary healthscreen was conducted on the same day as the first reception
healthscreen. A senior nurse at the prison told the clinical reviewer that this
should not happen. Prison Service Order (PSO) 0500, Reception, directs that the
secondary healthscreen must take place within seven days of the prisoner’s
arrival. The clinical reviewer suggests that staff receive clarification on the ideal
timing of the secondary healthscreen. The secondary healthscreen provides
healthcare staff with another opportunity to assess the general wellbeing of newly
arrived prisoners. I believe that for this reason, while the PSO is vague about the
most appropriate timing of the secondary healthscreen, it should not be
conducted on the day the prisoner arrives.
The Head of Healthcare should ensure that first and secondary
healthscreens are not conducted on the same day.
63. The man completed an application form to see the doctor, apparently within a few
days of his arrival. He said he had brought drugs into the prison, which he had
now taken and had “left himself in trouble”. The clinical reviewer was concerned
to find that the application form was undated, and in fact provides no space for
recording the date. She was not able to track what action was taken by
healthcare on receipt of the application. The man was examined by a prison
doctor on 9 January, but there is no record of the reason for the appointment, or
whether it was as a result of his application (although the clinical reviewer
concludes that this is the most likely reason.) Since January, a new system has
been introduced whereby prisoners wishing to make an appointment with the
doctor or other health service now do so by telephone. The clinical reviewer
makes the following recommendation:
The Head of Healthcare should ensure that the doctors’ appointment
system enables staff to accurately track each patient’s contact and
treatment.
64. The clinical reviewer highlights a general problem with healthcare record keeping
at Woodhill. She notes that it was not always possible to identify which members
of staff made entries in the medical record or what actions were taken. She
concludes that redesigning or updating some healthcare forms might help to
improve general record keeping, and I endorse her recommendation in that
respect. A number of other prisons now use an electronic healthcare system,
which has largely improved the standard of record keeping. The Head of
Healthcare might wish to pursue this option with the PCT; in the meantime the
standard of record keeping in healthcare should be improved.
The Head of Healthcare should ensure that all entries in medical records
meet the requirements of the Nursing and Midwifery Council guidance.
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Indications of the man’s vulnerability
65. On his arrival at Woodhill, the man was asked several times whether he had ever
harmed himself in the past, or whether he now had any thoughts of self harm or
suicide. The man told staff that he had no concerns and no thoughts of harming
himself.
66. During the course of the investigation, the investigator spoke to a number of
people who had contact with the man during his three months at the prison. No
one had any concerns about him. The second cellmate, who shared a cell with
the man in the weeks before his death and knew him from outside prison, said the
man told him he had harmed himself in the past. On the second cellmate’s
departure from Woodhill, the man said “don’t go”. At the time, he thought nothing
of this, but said that, in retrospect, perhaps he should have been concerned. The
solicitor, from the firm of solicitors representing the man in his criminal matters,
also knew him well. The man gave him no cause to worry.
67. After the man’s death his first cellmate and another prisoner said that the man
had talked of harming himself. The first cellmate said that he had found the man
with a ligature and had shown it to staff before disposing of it. Unfortunately,
neither the first cellmate nor the other prisoner could be interviewed. I am
satisfied that, had such indications of risk come to light, staff on unit 3A would
have taken the appropriate action. Staff were clear about their obligations under
the ACCT process and the unit managers were confident that any concerns
would have been recorded in his wing file and the unit observation book. I have
found no reason to doubt this.
The response to finding the man hanging
68. Staff interviews and incident reports written shortly after the man’s death indicate
that the staff responded quickly to finding him hanging. The officer who found the
man hanging entered the cell and supported the weight of the man’s body until
other staff arrived and helped to cut the ligature. Staff moved the man to the
association area outside his cell, which gave them space to assess his condition
and begin CPR. Although not all of the discipline staff present had up to date first
aid training, those who administered CPR said they felt comfortable and confident
to do so. I have made previous recommendations about first aid training for staff
at Woodhill and have been assured that a sufficient number of discipline staff
across the prison have received up to date training. The Governor will wish to
assure himself that this is still the case.
69. Healthcare staff who happened to be working on unit 3 were alerted to the
medical emergency and arrived at the man’s cell very quickly. One of the HCOs,
one of the first to arrive, described the staff response as “organised … and under
control”. Healthcare staff began to assist with CPR, while others fetched the
emergency medical equipment which was stored in the central area between
units 3A and B. The clinical reviewer found that within minutes of the medical
emergency radio call, 11 members of healthcare staff had arrived on unit 3A. I
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am pleased to echo her conclusion that the resuscitation attempts were made
effectively and efficiently.
70. The clinical reviewer highlights, however, that two members of healthcare staff
had not received Basic Life Support training within the last year, in line with the
NHS Milton Keynes local policy. She advises that this be addressed as a matter
of urgency. The Ombudsman made a similar recommendation in a recent report
and so I do not repeat it here. The Head of Healthcare will now wish to assure
themself that the appropriate action has been taken. One member of discipline
staff interviewed thought that discipline staff should receive training in the use of
the defibrillator because they are often the first to arrive at an incident. Again, a
similar recommendation was made in the recently issued report. The Prison
Service responded that all nursing staff had been trained to use a defibrillator and
can respond quickly to a medical emergency. However, as the defibrillators are
stored in the central area of each unit, the Governor and Head of Healthcare
might wish to re-consider training a spread of discipline staff too.
71. Each set of emergency medical equipment in the prison should be checked
weekly and a log book is provided to record the dates of such checks. The
investigator and clinical reviewer examined the log books on two units (including
unit 3) and found that weekly checks were not being carried out. On unit 3, the
equipment had usually been checked on a monthly basis and, at the time of the
investigator’s visit, had not been checked since the day after the man died (some
six weeks before). Although there is no suggestion that the emergency
equipment did not work on the day the man died, it is essential that it be checked
on a regular basis and in line with local policy.
The Head of Healthcare may wish to review the protocol for checking
emergency equipment and ensure it is implemented.
72. Interviews with discipline and healthcare staff highlighted some confusion about
the correct procedures for alerting staff to a medical emergency. The investigator
was told that the policy had recently changed. Healthcare staff interviewed were
following a policy dated April 2006, which used the term ‘Code Red’. In fact, the
correct procedure is to announce an ‘Urgent Message’. While I am satisfied that
this confusion had no impact on the response to finding the man, the Governor
will wish to address it nonetheless.
The Governor may wish to remind staff of the correct emergency radio
procedure.
73. The man was not pronounced dead until he arrived at Milton Keynes Hospital.
After he died, one of the officers who had accompanied him in the ambulance
remained with him until the coroner’s officer arrived. He told the investigator that
he had not wanted the man to be alone. I commend the officer for the sensitivity
and care he showed to the man at that time. I ask the Governor to formally pass
on my commendation to the officer.
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CONCLUSION
74. The man had been in prison a number of times before, and had been at Woodhill
previously. He had been charged with a number of serious offences and knew he
might be facing a lengthy sentence, which he told his cellmate he would struggle
to cope with. He was 50 years old and isolated from his family. He had a history
of drug use and there was suggestion that he had been taking drugs while at
Woodhill. Two other prisoners said that the man talked about harming himself,
but did not make staff aware of this. In fact, staff had no concerns about him and
so he was not being monitored under the suicide and self harm procedures.
While I make five recommendations, I judge that his death was not foreseeable or
preventable.
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RECOMMENDATIONS
For the Head of Healthcare:
1. The Head of Healthcare should ensure that first and secondary healthscreens are
not conducted on the same day.
The Prison Service has accepted this recommendation. Secondary
healthscreens are now carried out on the prisoner’s second day in the prison as
part of the New Prisoner process.
2. The Head of Healthcare should ensure that the doctors’ appointment system
enables staff to accurately track each patient’s contact and treatment.
This recommendation has been accepted. The telephone appointment system
is logged and auditable.
3. The Head of Healthcare should ensure that all entries in medical records meet
the requirements of the Nursing and Midwifery Council guidance.
This recommendation has been accepted. All nurses will be given the Nursing
and Midwifery Council guidelines and education regarding documentation
standards is ongoing.
4. The Head of Healthcare may wish to review the protocol for checking emergency
equipment and ensure it is implemented.
This recommendation has been accepted. A new Emergency Equipment
Checking Protocol has been implemented and emergency equipment has been
reviewed.
For the prison Governor:
5. The Governor may wish to remind staff of the correct emergency radio
procedure.
The Prison Service has accepted this recommendation. New instructions have
been issued to staff.
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