Burn, Leona

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Ms Leona Burn,
a prisoner at HMP/YOI
Downview, on 3 March 2017
A report by the Prisons and Probation Ombudsman

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© Crown copyright, 2024
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Ms Burn was found hanging in her room at HMP Downview on 2 March 2017. She was
taken to hospital but died on 3 March. She was 34 years old. I offer my condolences to Ms
Burn’s family and friends.
Ms Burn was being managed under suicide and self-harm procedures, known as ACCT,
on the day she hanged herself. Although she had appropriately been assessed as posing
a high risk to herself, the investigation found a number of weaknesses in the way
Downview responded to this risk. I am particularly concerned that although Ms Burn’s
anxiety about her medication was one of her key risk factors, no one from healthcare
participated in the ACCT process and the GP who saw Ms Burn to review her medication
on the day she hanged her did not even know she was being managed under ACCT.
I am also very concerned that, although Ms Burn was assessed as a high risk to herself,
three staff took no action when they saw her with a possible ligature in her room on the
morning of 2 March 2017.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Kimberley Bingham
Acting Prisons and Probation Ombudsman February 2023

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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 14

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Summary
Events
1. On 19 July 2016, Ms Leona Burn was sentenced to 140 days imprisonment for theft
and breach of a supervision order. She was taken to HMP Eastwood Park.
2. Ms Burn had a long history of substance abuse. She had been prescribed
clonazepam medication for epilepsy and back pain in the community, and this was
continued in prison. She was allocated a single room as she was assessed as a
high risk of harm to others.
3. In August 2016, she was placed on the basic regime for fighting, which meant that
her television was removed. She said she would kill herself if her television was not
returned and was managed under suicide and self-harm procedures, known as
ACCT.
4. In October, Ms Burn received an additional sentence of 14 months. She was
transferred to HMP Downview on 22 November.
5. On 27 November, Ms Burn was placed on the basic regime for 28 days because of
poor behaviour. This meant her television was automatically removed.
6. In January 2017, the GP practice began slowly reducing Ms Burn’s clonazepam as
there was no evidence that she had a formal diagnosis of epilepsy. Ms Burn was
very unhappy about this.
7. On 25 February, Ms Burn was placed on the basic regime for 28 days after fighting
with another prisoner. She said she would not be able to sleep at night without a
television and that this would exacerbate her epilepsy. She said she would hang
herself because she could not cope with fits. Staff started ACCT procedures. Ms
Burn was assessed as being at high risk of suicide and she was observed twice an
hour. She was allowed to have a television at night to help her sleep, to be returned
during the day.
8. On 28 February, Ms Burn complained to an officer that her back pain was making
her feel suicidal, and said she had obtained some prescription medication illicitly
from another prisoner.
9. On the morning of 2 March, Ms Burn refused to return her television, as agreed. At
9.50am, she refused to return to her room after seeing a GP and was escorted back
by several officers. Ms Burn told the officers to wait and see what would happen
next. She wrapped herself in a curtain so staff could not see her. Staff had an
informal discussion and decided that Ms Burn would no longer be allowed her
television over night as she was not following the rules. They noticed that Ms Burn
had a length of fabric hanging in her room but did not ask her to hand it to them.
10. An officer checked Ms Burn at 12.20pm and saw her sitting on her bed. At 12.46pm,
another officer looked into Ms Burn’s room and saw her hanging from a ligature
attached to electrical pipes fixed to the wall. The officer radioed an emergency
medical code for assistance. Staff began CPR, paramedics arrived and detected
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signs of life. Ms Burn was taken to hospital at 1.55pm by ambulance but died on 3
March at 8.15pm.
Findings
Risk assessment and management of ACCT
11. The identification and management of prisoners at risk of suicide and/or self-harm is
everyone’s responsibility. We are concerned that healthcare staff did not consider
opening ACCT procedures on two occasions in early 2017.
12. Although the ACCT assessment on 25 February 2017 was commendably thorough,
we are concerned that there was no healthcare input into the subsequent ACCT
review. We consider this was a significant omission as Ms Burn’s concern about her
medication was a key risk factor for her.
13. Although Ms Burn’s level of risk was appropriately assessed as high on 25
February, we are concerned that there was too long a gap – a week - before the
next scheduled case review and that this did not adequately reflect Ms Burn’s level
of risk.
14. We consider that Ms Burn’s behaviour on 2 March should have prompted an ACCT
case review.
15. We are concerned that, although it had previously been agreed that Ms Burn could
have a television overnight to help her sleep, staff decided informally to remove the
television on 2 March, outside the ACCT process and without considering how this
might affect her risk.
16. We are very concerned that, although Ms Burn was on an ACCT, assessed as a
high risk to herself, and locked in her room in a distressed state, three staff took no
action when they saw her with a possible ligature in her room on the morning of 2
March.
Clinical Care
17. We are concerned that the nurse who conducted Ms Burn’s initial health screen at
Downview did so without reading information about her risk of suicide or self- harm.
18. Ms Burn had good access to primary care nurses and appropriate access to a GP
when required and was readily able to access the substance misuse team, which
kept comprehensive notes and shared information with other staff. The
management of her substance misuse was in keeping with recommended
guidelines on maintaining a stable rather than a reducing dose of methadone.
19. The clinical reviewer concluded that, although some of Ms Burn’s clinical care was
of a very high standard, the lack of healthcare input into the ACCT procedures
meant that her care was not equivalent to that which she could have expected to
receive in the community.
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Recommendations
• The Head of Healthcare should remind all healthcare staff, including GPs, they
have a responsibility to open ACCT procedures if they consider a prisoner is at
risk of suicide or self-harm.
• The Governor and Head of Healthcare should ensure that the ACCT document
accompanies prisoners when they move around the prison, including to
healthcare appointments.
• The Governor and the Head of Healthcare should sure that staff manage
prisoners at risk of suicide and self-harm in line with national guidelines,
including in particular that:
• Mental health staff attend or contribute to all ACCT reviews for
prisoners in their care and are fully involved in decisions about their
level of risk.
• A member of healthcare staff should attend all case reviews and
subsequent reviews where relevant.
• Case reviews assess the risk of suicide or self-harm based on all
available information and known risk factors and set a level of
observations which reflects that risk.
• Staff review risk and consider whether to hold a case review whenever
an event occurs which indicates an increase in risk.
• The Governor should consider initiating an investigation into the actions of SO A
and Officers B and C in relation to the piece of fabric they saw in Ms Burn’s
room on 2 March 2017, with a view to considering whether disciplinary action is
appropriate.
• The Governor should share this report with Officer A, SO B, a senior manager
and CM A and arrange for a senior manager to discuss it with them to ensure
they are aware of the Ombudsman’s findings.
• The Governor and Head of Healthcare should ensure that nurses conducting
reception health screenings always have access to the PER and have time to
read it.
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The Investigation Process
20. The investigator issued notices to staff and prisoners at HMP Downview informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
21. The investigator visited Downview on 9 March 2017. She obtained copies of Ms
Burn’s prison and medical records.
22. NHS England commissioned a clinical reviewer to review Ms Burn’s clinical care at
the prison. The investigator and clinical reviewer conducted seven joint interviews.
23. The investigator interviewed 18 members of staff and two prisoners at Downview
between May and June 2017. She then provided feedback to the then Governor
that three members of staff were aware of a ligature in Ms Burn’s room on 2 March
2017 but did not take steps to remove it and could not explain their actions
satisfactorily.
24. We suspended our investigation in July 2017 at the request of Surrey police, who
conducted a criminal investigation. The Crown Prosecution Service decided there
was sufficient evidence to charge three prison officers with gross negligence
manslaughter. A trial took place in July and August 2019. The officers were found
not guilty.
25. We informed HM Coroner for Surrey of our investigation. The coroner gave us the
results of the post-mortem examination. We have sent the coroner a copy of this
report.
26. We contacted Ms Burn’s family to explain the investigation and to ask if they had
any matters they wanted the investigation to consider. Ms Burn’s mother asked why
she was in a single room and why she was not watched more closely when
Downview knew she was at risk of suicide. We have addressed these questions in
this report.
27. We shared our initial report with HM Prison and Probation Service (HMPPS). They
did not identify any factual inaccuracies. We amended the wording of one
recommendation.
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Background Information
HMP Downview
28. HMP Downview was opened in 1993 as a low security prison for adult men. In 2001
it became a prison for sentenced adult women until October 2013 when it closed.
After extensive refurbishment, Downview re-opened in May 2016 as a women’s
prison. It currently holds up to 359 women, almost all in single rooms. The first night
and induction unit, A wing, where Ms Burn was located, can accommodate up to 44
prisoners.
HM Inspectorate of Prisons
29. The most recent inspection of HMP Downview was in August 2017. Inspectors
reported that levels of self-harm were low. Many women spoke positively of the
support they had received from staff in times of crisis. Most were able to identify a
member of staff they could speak with if they had a problem and told inspectors that
staff knew about issues and concerns that affected them.
Independent Monitoring Board
30. Each prison in England and Wales has an Independent Monitoring Board (IMB) of
unpaid volunteers from the local community who help ensure that prisoners are
treated fairly and decently. In its most recent annual report for the year to April
2018, the IMB reported that the standard of healthcare was consistently very good,
wing staff knew the women in their care and made particular note of women they
considered to be more vulnerable.
Previous deaths at HMP Downview
31. Ms Burn’s was the first self-inflicted death at Downview since 2013. Since Ms
Burns’ death, there have been two self-inflicted deaths (in April and August 2018).
In one of these deaths, we found that the woman had been on basic IEP.
Assessment, Care in Custody and Teamwork
32. Assessment, Care in Custody and Teamwork (ACCT) is the care planning system
the Prison Service uses for supporting and monitoring prisoners assessed as at risk
of suicide and self-harm. The purpose of the ACCT process is to try to determine
the level of risk posed, the steps that might be taken to reduce this and the extent to
which staff need to monitor and supervise the prisoner.
33. After an initial assessment of the prisoner’s main concerns, levels of supervision
and interactions are set according to the perceived risk of harm. Checks should be
made at irregular intervals to prevent the prisoner anticipating when they will occur.
Part of the ACCT process involves assessing immediate needs and drawing up a
caremap (a plan of care, support and intervention) to identify the prisoner’s most
urgent issues and how they will be met. There should be regular multi-disciplinary
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case reviews involving the prisoner. Guidance on ACCT procedures is set out in
Prison Service Instruction (PSI) 64/2011.
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Key Events
34. On 19 July 2016, Ms Leona Burn was sentenced to 140 days imprisonment for theft
and breach of a supervision order. She was taken to HMP Eastwood Park. It was
not her first time in custody.
HMP Eastwood Park
35. Ms Burn was assessed on reception by a healthcare assistant as having a
longstanding history of substance misuse, including heroin addiction, back pain,
nerve damage to her hand, and epilepsy (although the latter was not formally
diagnosed). She also had a history of self-harm and was recorded to have self-
harmed with a ligature in 2006. Ms Burn said she did not have plans or thoughts of
self-harm. Her Cell Sharing Risk Assessment (CSRA) level found she posed a high
risk of harm to other prisoners, and she was, therefore, allocated a single room.
She also had a history of assaults on staff and racist comments.
36. A urine test was positive for opiates, and she was referred to the substance misuse
service. A substance misuse clinician arranged for her to have detoxification
treatment. She completed the detoxification course on 26 July.
37. In August, Ms Burn was reduced from standard to basic under the Incentives and
Earned Privileges (IEP) scheme following a fight with another prisoner. This meant
that she would be on a restricted regime and lose access to some facilities,
including a television in her room. (The IEP scheme aims to encourage and reward
responsible behaviour. There are three levels: basic, standard and enhanced.) The
following day, Ms Burn told an officer that she would kill herself if her television was
not returned. ACCT procedures were opened. Ms Burn’s risk of harm to self was
assessed as low.
38. A few days later, Ms Burn had a disciplinary hearing in relation to the fight with the
other prisoner and was given seven days cellular confinement in the segregation
unit. The ACCT case manager met with Ms Burn and decided to close the ACCT
document. He did not record his reasons. At the end of August, a prison manager
decided to allow Ms Burn to have a television at night because she appeared to be
struggling.
39. On 20 October, Ms Burn received a 14 month sentence for further offences. She
was due to be released on 15 May 2017.
HMP Downview
40. On 22 November 2016, Ms Burn was transferred to HMP Downview. As part of the
Person Escort (PER) that accompanies a prisoner when they move from one
location to another, a ‘suicide/self-harm warning form’ was completed for Ms Burn.
It highlighted that Ms Burn had a history of self-harm in the community and that she
had stated she was concealing razor blades and “would cut up any officer in her
way”. As a result, it was decided that Ms Burn would be handcuffed for the journey
and her shoelaces were removed to prevent any potential self-harm.
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41. When Ms Burn arrived at Downview, a nurse carried out an initial health screen.
She recorded that Ms Burn had epilepsy and back pain and a history of drug
misuse, including the use of intravenous heroin, amphetamines and
benzodiazepines (sedatives), and was prescribed methadone (a heroin substitute)
and clonazepam (a benzodiazepine). She also recorded, incorrectly, that there were
no concerns about self-harm or suicidal intent and that Ms Burn had not tried to
harm herself in prison or in the community.
42. On the same day, Ms Burn was seen by another nurse from the substance misuse
team, who re-prescribed her methadone.
43. Ms Burn told a chaplaincy worker that she was not happy about being at Downview
and was worried about her epilepsy medication (clonazepam).
44. On 27 November, an officer, placed Ms Burn on a disciplinary charge after seeing
another prisoner hand her a white powdery substance. Custodial Manager (CM) A
chaired an IEP review and Ms Burn, and the other prisoner were both given 28 days
on the basic regime.
45. On 30 November, Ms Burn was seen by a worker from the substance misuse team.
He recorded that, as Ms Burn was due to be released in less than 26 weeks, she
should be maintained on a maintenance dose of methadone. He also recorded that
Ms Burn told him she was prescribed clonazepam for epilepsy and that she became
“defensive” when he asked questions about this.
46. On 15 December, a prison GP reviewed Ms Burn’s records in response to a request
to renew her prescription for clonazepam. He noted that she had not attended
appointments with a neurologist to confirm a diagnosis of epilepsy and he queried
whether she was on clonazepam for epilepsy or whether she was benzodiazepine-
dependant. He asked that she be booked in for a GP review and queried whether
her clonazepam should be slowly reduced. (Clonazepam is not a usual first or
second line treatment for epilepsy. Like other benzodiazepines it is widely misused
as a drug of addiction as it has a calming and hypnotic effect. The British National
Formulary says that benzodiazepines should not be prescribed for long periods and
should be discontinued as soon as feasible. However, sudden withdrawal may
cause side effects, including insomnia, and benzodiazepine withdrawal should,
therefore, be carried out at a rate that is tolerable for the patient and may take
several months or more for long-term users.)
47. On 18 December, a SO (Supervising Officer) chaired an IEP review. Ms Burn said
that she felt aggrieved because she had learnt that the prisoner who had passed
her the substance was no longer on basic. Ms Burn said she had appealed but the
custodial manager had not given her an answer. She swore at the SO.
48. On 21 December, a prison manager told Ms Burn that if her behaviour remained
acceptable, she could have a television and association from 24 to 28 December.
49. A prison GP booked four appointments for Ms Burn to discuss her medication, but
Ms Burn did not attend any of them. He arranged for a very slow reduction in
clonazepam from 16 January 2017.
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50. On 19 January, Ms Burn complained to a nurse that her dose of clonazepam had
been reduced. The nurse told her to discuss her concerns directly with a GP. Ms
Burn saw a GP on 20 January. He recorded that Ms Burn was “very anxious and
suicidal due to her worries about her medication, etc”. He told her that proof would
be needed from her community GP to continue prescribing her the medication. He
asked the healthcare administrator to write to Ms Burn’s GP requesting confirmation
of her diagnosis and current medication.
51. On 26 January, Ms Burn told a nurse that she was unhappy with the clonazepam
reduction and had not been aware of it before. The nurse said that the GP had
discussed it with her at their last consultation. She recorded that an officer told her
that Ms Burn was unhappy with her medication and that she said that the GP was
due to see Ms Burn again on 3 February.
52. The GP saw Ms Burn again on 3 February. Ms Burn said she felt her clonazepam
was being reduced too quickly, and the GP agreed to slow down the reduction. The
GP also prescribed her co-codamol (a painkiller) for her back pain. She recorded
that Ms Burn was happy with this.
53. On 9 February, a prison GP reviewed Ms Burn’s records and noted that the
clonazepam may have been reduced more quickly than intended. He corrected the
error and asked another GP to review the dosages the next day.
54. On the same day, Ms Burn met with a worker from the substance misuse team. Ms
Burn appeared stressed and said that the reduction of clonazepam was the source
of her stress and anxiety. She said she was not sleeping and was afraid she might
have an unwitnessed seizure. She also said she would revert to injecting heroin
again when she was released in order to self-medicate as she was not being
prescribed the correct medication. She became tearful and said she felt under
pressure to be ‘clean’ for her children and that she “did not want to leave them
without a mother”. The worker made a note in the staff observation book so that
officers would be aware. She planned to see Ms Burn again on 16 March.
55. On 17 February, Ms Burn saw a nurse. She said the co-codamol was not working
for her back pain and asked to be prescribed pregabalin, which she said previously
helped with her anxiety as well. (Pregabalin is used to treat nerve pain, epilepsy
and anxiety, but is also widely misused and traded in prison.) The nurse advised
Ms Burn to continue using her current medication and told her she would be placed
on the waiting list to see the GP about her medication.
56. On 22 February, Ms Burn saw a prison manager and they discussed her plans for
her release in May. Ms Burn felt she would be vulnerable to using drugs again in
the community and said she was likely to return to her partner, who was an illicit
drug user.
57. On 23 February, a prison GP reviewed Ms Burn’s records and identified that the
planned reduction in clonazepam had not happened. He advised a step down that
day and again in two weeks.
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Events of 25 February 2017
58. At 9.30am, on 25 February, Ms Burn was involved in a fight with a prisoner from
another wing while collecting her methadone. SO A chaired an IEP review with Ms
Burn and Officer A present, and decided that Ms Burn should be placed on the
basic regime for 28 days. Her television was therefore removed from her room. Ms
Burn was very unhappy with the outcome and argued that staff should have
prevented the fight because they knew there had been issues between her and the
other prisoner before.
59. At 11.00am, Ms Burn told Officer A that she would not be able to sleep at night
without a television and would have fits. She said she would hang herself because
she would not be able to cope with the fits. The officer started ACCT procedures
and the level of observations was set at twice an hour.
At 2.30pm Ms Burn had an ACCT assessment interview with SO B. She said that
the incident with the other prisoner and being placed on basic had contributed to
how she was feeling, though she had been feeling low for about three days and had
not been sleeping well. She said that she was feeling overwhelmed because she
did not have any external support, was still grieving for her father, had nowhere to
live on release, had suffered domestic violence from her partner, and was not
allowed contact with her three children who were all in care because of her drug
use. Ms Burn said that she did not want to be alive, had nothing to live for and if she
had the opportunity, she would hang herself. She said she would not be able to
cope without a television and was ‘adamant’ that she would hang herself. The
frequency of observations was set at twice an hour, and it was decided that Ms
Burn would see a GP to discuss her sleep problems, be referred for grief
counselling and would continue to receive support from the substance misuse team.
60. A case review took place immediately after the assessment. No healthcare staff
were invited to take part. No one from the mental health team was able to attend
because they only worked on weekdays and the ACCT review took place on a
Saturday. Ms Burn’s risk to herself was assessed as high. The duty governor
allowed Ms Burn to have a television at night but it had to be returned to the staff
office in the morning. It was recorded that Ms Burn was “a little less stressed out” as
a result. The next ACCT review was set for 3 March, with a request for a member of
the substance misuse team to attend. The frequency of observations remained at
twice an hour with the additional component of three conversations a day.
61. On 28 February, Nurse A from the mental health in-reach team visited Ms Burn on
A wing at the request of the visiting psychiatrist. She told the investigator that she
had not met Ms Burn before this. She said Ms Burn was very angry, distressed and
not willing to talk about her mental health. She complained she was experiencing
intense back pain and said she would “not go behind her door” (that is, would not
allow staff to lock her in her room) unless a GP prescribed her pregabalin and
clonazepam. She expressed thoughts of self-harm and said she “would act on
them” if she did not get her medication reinstated by a GP. She complained of
severe pain in her neck and back. She expressed anxiety but refused to elaborate.
She only wanted to talk about her medication. The nurse noted that Ms Burn was
not psychotic (that is, she was not out of touch with reality). She spoke to Nurse B
from the primary care team and arranged for her to see Ms Burn later that day.
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62. Nurse A told the investigator that she did not believe Ms Burn to be at immediate
risk to herself and she did not, therefore, request an urgent ACCT case review. She
did however inform Officer B that Ms Burn was distressed and would not settle. She
planned to return to see Ms Burn for a mental health assessment on 2 March when
she was next on duty.
63. Also on 28 February, Officer B recorded that Ms Burn had told her that she had
traded some tobacco with another prisoner for some pregabalin, and that she said
she could not go behind her door because the pain made her suicidal. The officer
submitted an intelligence report and made a note in the wing observation book.
64. Nurse B saw Ms Burn and told her to take co-codamol for her back pain and also
gave her ibuprofen (an anti-inflammatory). She referred Ms Burn for a pain-relief
review with a GP. Ms Burn threatened to kill herself that night so as not to
experience the pain she was having. She noted that Ms Burn had not complained of
any pain when she had seen her earlier in the day and that she was not limping
when she walked.
65. Nurse B concluded that Ms Burn was already on an ACCT, which meant she would
be checked twice per hour. She told the investigator that she did not add any notes
in the ACCT as she was happy with this level of observations.
66. On 1 March, Ms Burn said she was not feeling any better despite taking the
medication. A nurse recorded that Ms Burn had no suicidal thoughts and booked a
GP appointment for the next day.
Events of 2 March
67. On the morning of 2 March, Ms Burn refused to hand in her television as agreed.
68. At 9.46am she had an appointment with a prison GP. He wrote in her clinical record
that she was “very rude” and moaned about the clonazepam reduction and her back
pain. He offered to prescribe her naproxen, a prescription only anti-inflammatory
drug, but Ms Burn said it did not work. He advised her that she needed to try it. He
refused to prescribe her pregabalin. He told the investigator that he did not know
that Ms Burn was being managed under ACCT procedures.
69. Ms Burn returned to A wing at 9.50am in an angry mood and sat in the association
area even though she should have been locked in her room because she was still
on the basic level of the IEP scheme. She shouted at the officers that she would not
be locked in her room and remained sitting on the sofa. Staff used ‘minimal force’ to
get her up off the sofa and escorted her to her room. She said to the officers,
“Watch what I do behind my door”, and went in.
70. Officer C looked into Ms Burn’s room shortly afterwards but could not see her. Ms
Burn had wrapped herself in the privacy curtain and would not answer when Officer
C and Officer B knocked on her door. Officer C radioed for staff assistance. Ms
Burn shouted that she was alright and wanted to be left alone.
71. A senior manager, CM A, SO A, Officer C and Officer B then held an informal
discussion of Ms Burn’s behaviour that morning in the staff office and concluded
that the rules for prisoners subject to the basic level of the IEP scheme needed to
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be clearer. They did not consider increasing the frequency of ACCT observations
for Ms Burn and decided she would no longer be allowed her television overnight
because she was not complying with the rules. In the meantime, Nurse A arrived on
A wing to see Ms Burn but, after seeing the managers in the staff office, she
decided she would return in the afternoon.
72. At 11.15am, Officer C wrote in Ms Burn’s ACCT document “noose has been
removed from ceiling”. She told the investigator that she had seen a piece of
bedsheet hanging from above where Ms Burn’s television would have been. She
could not explain why she had used the term ‘noose’. She could not say whether
there was a loop at the end and thought it might have been where the fabric was
hanging that made her associate it with that word. She did not ask Ms Burn what it
was and when she checked on her again, the fabric had been removed. She did not
ask Ms Burn where it was.
73. Officer B told the investigator she saw a piece of green material hanging along the
vertical pipes alongside the wall in Ms Burn’s room. She did not recall mentioning it
to Officer C, although Officer C said that Officer B told her about it. She said she did
not ask Ms Burn what it was or why it was there. Officer B told SO A.
74. SO A told the investigator that after the officers mentioned the fabric, he spoke to
Ms Burn through the hatch in her door for about five minutes. He said she had a
piece of bedding in her hand. She was pulling it with her hands, and he interpreted
it as a kind of ‘stress reliever’. He did not speak to Ms Burn about the fabric and did
not feel that the frequency of observations needed to be increased.
75. A prisoner told the investigator that Ms Burn told her that she had tied two sheets
together and would hang herself to get out of the prison one way or another.
76. Ms Burn was last seen alive at 12.20pm by Officer B, who said she saw her sitting
on her bed. Officer D was patrolling A wing at lunchtime. She opened Ms Burn’s
door flap at 12:46pm and saw her hanging from a ligature made from a green sheet.
She radioed an emergency medical code blue, and an ambulance was called.
Officer A went into the room with Officer D, cut the ligature from the pipe and from
Ms Burn’s neck and checked for a pulse. Another officer began CPR. A physical
education instructor took over chest compressions from the officer until paramedics
arrived. A defibrillator was used but no shock was advised. At 1.22pm, a pulse was
found.
77. Ms Burn was taken to hospital but did not regain consciousness. At 8.15pm on 3
March, it was confirmed that Ms Burn had died.
Contact with Ms Burn’s family
78. Ms Burns and her family members lived in Wales. A chaplain from the prison’s
chaplaincy team telephoned Ms Burn’s mother to inform her that her daughter was
in hospital. Ms Burn’s mother, stepfather, sister and partner drove to the hospital
and met with the chaplain and the prison’s family liaison officer. Arrangements were
made for Ms Burn’s children, who were in care, to see her.
79. The prison contributed to the cost of Ms Burn’s funeral, in line with national policy.
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Support for prisoners and staff
80. After Ms Burn’s death, the Governor debriefed the staff involved in the emergency
to ensure they had the opportunity to discuss any issues arising and to offer
support. The staff care team also offered support.
81. The prison posted notices informing other prisoners of Ms Burn’s death and offering
support. Staff reviewed all prisoners assessed as at risk of suicide and self-harm in
case they had been adversely affected by Ms Burn’s death. A memorial service was
held, and Ms Burn’s friends gave several cards to her family members when they
visited.
Post-mortem report
82. The post-mortem examination gave Ms Burn’s cause of death as hypoxic brain
injury (damage to the brain due to lack of oxygen).
Events after Ms Burn’s death
83. In November 2018, SO A and Officers B and C were charged with gross negligence
manslaughter for failing to remove the ‘noose’. A trial took place in July/August
2019 and the officers were found not guilty.
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Findings
Assessment of risk
84. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), gives guidance to staff on how to
identify, manage and support prisoners who are at risk of harm to themselves or
others. It sets out the procedures (known as ACCT) that must be followed whenever
staff assess that a prisoner is at risk of suicide or self-harm and requires all staff
who have contact with prisoners to be aware of the risk factors and triggers that
might increase the risk of suicide and self-harm and take appropriate action. Any
prisoner identified as being at risk of suicide or self-harm must be managed under
ACCT procedures.
85. The PSI says that “the identification and management of prisoners at risk of suicide
and/or self-harm is everyone’s responsibility” and that “any member of staff who
receives information, including that from family members or external agencies, or
observes behaviour which may indicate a risk of suicide/self-harm must open an
ACCT”.
86. We are concerned that healthcare staff did not consider opening ACCT procedures
on two occasions in early 2017: on 20 January when a prison GP recorded that Ms
Burn was “very anxious and suicidal” about the reduction in her clonazepam
medication, and on 9 February when the worker from the substance misuse team
recorded that Ms Burn was stressed about her medication and spoke about not
wanting to leave her children without a mother. We recommend:
The Head of Healthcare should remind all healthcare staff, including GPs,
they have a responsibility to open ACCT procedures if they consider a
prisoner is at risk of suicide or self-harm.
87. We are satisfied that Officer A appropriately opened ACCT procedures when Ms
Burn was placed on the basic regime on 25 February and talked about hanging
herself if her television was not returned.
88. The subsequent ACCT assessment carried out by SO B was commendably
thorough and identified that Ms Burn had a significant number of risk factors: she
was on the basic regime which meant she would spend more time locked in her
room, a known risk factor for prisoners generally; she lacked family support, had
suffered domestic abuse from her partner, was upset at not being allowed to
contact her children and felt isolated; she had nowhere to live when she was
released; she was upset about the reduction in her medication; she was
complaining of significant pain and said she was not sleeping; and she said her
mood was low and that she did not want to be alive and would hang herself if she
had the opportunity. We consider that the SO appropriately assessed Ms Burn as a
high risk to herself and that it was good practice to agree that she could have a
television at night to help her sleep.
89. However, we are concerned that, although PSI 64/2011 says that healthcare staff
should attend the first ACCT review, no healthcare staff were present at Ms Burn’s
initial case review on 25 February, and there is no evidence they had been invited.
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Healthcare input was particularly relevant for Ms Burn because her concern about
her medication was one of her key risk factors. Without a healthcare input it was not
possible to develop a comprehensive caremap.
90. The case manager recorded that they would invite substance misuse staff to the
next review which was scheduled for 3 March. Given that Ms Burn was assessed as
high risk, with multiple risk factors, we consider that the gap of six days between the
initial review and the scheduled second review was much too long. We are
concerned that those present at the review did not identify that there were few, if
any, protective factors that would prevent Ms Burn carrying out her stated intention
of killing herself. In our Learning Lessons Bulletin, Self-inflicted deaths among
female prisoners, published in March 2017, and we found that staff may under-
estimate the risk of vulnerable women who present as very distressed and express
thoughts of self-harm. We consider in this case that staff at the first case review did
not take Ms Burn’s risk to herself as seriously as they should have done.
91. On 28 February, Ms Burn was angry and distressed about her medication and
complained of increased back pain. This had been identified as one of her key risk
factors on 25 February. It was still unresolved, and she said her back pain was
making her suicidal. She also said she had taken illicit prescription medication. The
next scheduled case review was still three days away and we consider that there
should have been a fresh case review to reassess Ms Burn’s risk.
92. PSI 64/2011 says that the ACCT Plan must travel to and from any location the
prisoner moves to, to ensure that the receiving member of staff is informed of the
prisoner’s risk status and is able to input to the ACCT Plan On-Going Record. We
are therefore concerned that GP who saw Ms Burn on 2 March to review her
medication said he did not know she was on an ACCT. This is particularly
concerning as the medication issue was one of Ms Burn’s key risk factors. We
recommend:
The Governor and Head of Healthcare should ensure that the ACCT document
accompanies prisoners when they move around the prison, including to
healthcare appointments.
93. After seeing the GP, Ms Burn returned to the wing in an angry mood because she
still did not consider that her medication issue had been resolved. Staff had to use
‘minimal force’ to return her to her room and she was clearly distressed when she
was locked in. Officer C appropriately called for assistance because Ms Burn had
hidden herself in her room. However, given the degree of Ms Burn’s distress, we
consider that this was another missed opportunity to hold an ACCT case review and
consider whether Ms Burn’s risk to herself had increased and whether the level of
observations should be increased.
94. Instead, staff held an informal discussion and decided that Ms Burn would no longer
be allowed to have a television overnight as she was not following the rules. We
have identified in previous PPO publications the importance of prison staff
considering the risks associated with withdrawing privileges when prisoners are
being monitored on the ACCT process. We are concerned that the decision not to
allow Ms Burn to have the television overnight was taken outside the ACCT
procedures and without consideration of the impact it might have on Ms Burn’s risk
to herself.
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95. As the overnight television had been explicitly agreed as a measure to reduce Ms
Burn’s risk, we consider that this was an error of judgement, particularly by the two
most senior staff involved: a senior manager and CM A. Ms Burn was left in her
room in a distressed state with two key risk factors unresolved: she did not consider
her medication was effective and she had lost the overnight television she
considered essential to enable her to sleep at night. These risk factors should have
been at the forefront of staff’s thinking, but instead they appear to have focussed on
taking punitive action in response to Ms Burn’s behaviour.
96. It is unfortunate that Nurse A arrived on A wing to conduct a mental health
assessment, not knowing that the managers were discussing Ms Burn. Her input to
a formal ACCT review would have been an asset.
The ‘noose’’
97. We are very concerned that, despite knowing that Ms Burn was on an ACCT and
had been assessed as posing a high risk to herself, and was now alone in her room
in a distressed state, Officers B and C did not attempt to remove the piece of fabric
they saw hanging in Ms Burn’s room, and that SO A did not take any action when
the officers told him about the fabric and he saw Ms Burn pulling a piece of sheet.
98. We are concerned that none of the staff asked her about it, tried to remove it or
asked her where it was when they noticed it had disappeared. Given the
circumstances and Ms Burn’s state of mind at the time, we consider that the
presence of the fabric – which staff described at the time as a ’noose’ and a
’ligature’ - should certainly have prompted an ACCT review and consideration of
whether Ms Burn should be subject to constant watch.
99. We make the following recommendations:
The Governor and the Head of Healthcare should sure that staff manage
prisoners at risk of suicide and self-harm in line with national guidelines,
including in particular that:
• Mental health staff attend or contribute to all ACCT reviews for
prisoners in their care and are fully involved in decisions about their
level of risk.
• A member of healthcare staff should attend all first case reviews
and subsequent reviews where relevant.
• Case reviews assess the risk of suicide or self-harm based on all
available information and known risk factors and set a level of
observations which reflects that risk.
• Staff review risk and consider whether to hold a case review
whenever an event occurs which indicates an increase in risk.
• The Governor should consider initiating an investigation into the actions
of SO A and Officers B and Officer C in relation to the piece of fabric they
saw in Ms Burn’s room on 2 March 2017, with a view to considering
whether disciplinary action is appropriate.
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The Governor should share this report with Officer A, SO B, the senior
manager and CM A and arrange for a senior manager to discuss it with them
to ensure they are aware of the Ombudsman’s findings.
Clinical care
100. The clinical reviewer concluded that, although some of Ms Burn’s clinical care was
of a very high standard, the lack of healthcare input into the ACCT case review
meant that her care was not equivalent to what might have been expected in the
community.
Primary care
101. The clinical reviewer noted that Ms Burn had good access to primary care nurses
and had appropriate access to a GP when required. However, she did identify some
concerns.
102. We share the clinical reviewer’s concern that the nurse who carried out the primary
health screen when Ms Burn arrived at Downview, incorrectly noted that she had no
history of self-harm. This was contrary to the transfer information. In interview the
nurse said that she only records what the prisoner tells her at an initial health
screen and that she did not have time to check or read previous records, including
the PER and any suicide/self-harm warning forms. This could have serious
consequences and is not acceptable. We recommend:
The Governor and Head of Healthcare should ensure that nurses conducting
reception health screenings always have access to the PER and have time to
read it.
103. Although Ms Burn often denied any mental health concerns when asked directly,
she did appear to be suffering from anxiety. The clinical reviewer thought that Ms
Burn may have benefited from a holistic assessment of her mood by her GP team,
although she noted that it was not certain that Ms Burn would have engaged with
them.
104. The clinical reviewer noted that the GPs involved in Ms Burn’s care wanted to
review her prescription of clonazepam for epilepsy. They tried to engage with her
but when she did not attend the arranged appointments, a GP decided to proceed
as planned and began a slow reduction of clonazepam in line with British Formulary
guidelines.
105. This was not unreasonable as there was no evidence that Ms Burn had been
diagnosed with epilepsy and clonazepam is an addictive drug which is abused and
traded illicitly in prisons. However, it appears that the reduction in her medication
caused Ms Burn great distress and the clinical reviewer queried the value of
attempting the reduction in Ms Burn’s short time at HMP Downview
Substance misuse
106. The clinical reviewer concluded that the management of Ms Burn’s substance
misuse was in keeping with the recommended guidelines. She was placed on a
stable dose of methadone, rather than a reducing dose, as she was due to be
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released within 6 months of arriving at Downview. The clinical reviewer commented
that the assessments, support and note keeping of two members of staff were
exemplary, and that Ms Burn stated that she felt supported by a particular member.
Inquest
107. No inquest was held in relation to Ms Burn’s death.
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