Doherty, James

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr James Doherty,
a prisoner at HMP Wormwood
Scrubs, on 18 November 2021
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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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.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr James Doherty died of asphyxia (suffocation caused by insufficient oxygen in the body)
after he was found hanged in his cell at HMP Wormwood Scrubs on 18 November 2021.
He was 25 years old. I offer my condolences to his family and friends.
Mr Doherty reported being threatened by prisoners on several occasions in the weeks
leading to his death and spent most of his time alone in his cell. Although I am satisfied
that there were no indications that Mr Doherty was at imminent risk of suicide or self-harm
and that staff could not have reasonably foreseen his actions, I am concerned that they
missed multiple opportunities to escalate their concerns, to explore fully the underlying
reason for his behaviour and to arrange a wing move. I am also concerned that despite
numerous requests, the prison did not provide the investigator with a document that would
have been significant in understanding as fully as possible Mr Doherty’s isolation in his cell
and any potential consideration that staff gave to moving him to another wing.
Mr Doherty had a history of mental health difficulties and healthcare staff generally
responded in a timely and appropriate way. However, we found that they failed to arrange
two GP reviews and escalate his self-reported multiple NHS identities.
I am concerned that when Mr Doherty was found hanged, staff did not immediately
consider entering his cell. This caused an unnecessary delay in Mr Doherty receiving
emergency medical treatment.
I am also concerned that the prison did not allocate Mr Doherty a keyworker or notify his
next of kin of his death, in line with national policy.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister CB
Prisons and Probation Ombudsman August 2022
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 10
Summary
Events
1. On 9 August 2021, Mr James Doherty was remanded to HMP Wormwood Scrubs,
charged with several offences, including harassment and criminal damage. (He
was subsequently sentenced to 16 months in prison).
2. At reception, Mr Doherty told a prison GP who reviewed him that he had been
admitted to a mental health hospital in the past and attempted suicide in 2020. The
GP referred him to the mental health team and prescribed several medications,
including an antidepressant.
3. Over the next 4 weeks, a prison GP reviewed Mr Doherty on two occasions but had
difficulty obtaining his medical history which Mr Doherty said was due to him having
multiple NHS identity numbers. A mental health nurse conducted an initial
assessment and concluded that he did not display any psychotic symptoms.
4. On 13 October, a consultant psychiatrist attended an in-reach team meeting and
recorded that the plan was to discharge Mr Doherty to primary care. Later that day,
Mr Doherty asked an officer if he could move wing as he felt under threat from other
prisoners. However, there no evidence that staff took any action.
5. On 30 October, Mr Doherty told an officer that he had received death threats. On
31 October, another officer conducted a welfare check, recorded that Mr Doherty
felt under threat from prisoners and that he informed a supervising officer (SO).
However, there is no evidence that staff considered a wing move.
6. On 14 November, a prison manager saw Mr Doherty’s name on a whiteboard in an
office under the heading ‘do not unlock’. She checked his case notes, found that he
was under threat from other prisoners and asked a supervising officer (SO) to do a
welfare check. The SO subsequently enquired about a wing move but it did not
take place.
7. At 5.23am on 18 November, an Operational Support Grade (OSG) found Mr
Doherty hanging from a ligature and radioed a medical emergency code blue. An
OSG and an officer arrived at 5.24am but remained outside the cell. At 5.25am, an
officer arrived, and unlocked the cell. Officers removed the ligature but did not start
cardiopulmonary resuscitation (CPR). At 5.29am, healthcare staff arrived and
confirmed that it was inappropriate to start CPR as Mr Doherty had died.
Findings
8. Mr Doherty had several risk factors but gave no indication to staff that he was at
imminent risk of suicide and self-harm. While we are satisfied that staff could not
reasonably have predicted his actions, we are concerned that they missed multiple
opportunities to address his self-isolation and to arrange a wing move.
9. The prison was unable to provide the PPO with a copy of a wing observation book,
which would have helped to clarify what action staff took to address Mr Doherty’
self-isolation and to facilitate a wing move.
Prisons and Probation Ombudsman 1
10. Staff did not immediately enter the cell when they found Mr Doherty hanging, and
this caused a delay of two minutes. While we are satisfied that this did not affect
the outcome for Mr Doherty, in other emergencies, it could be critical.
11. We are concerned that the prison did not allocate Mr Doherty a keyworker and that
staff had very little meaningful contact with him.
12. We are also concerned that the prison did not inform Mr Doherty’s next of kin of his
death in line with Prison Service instructions.
13. The clinical reviewer considered that the care that Mr Doherty received at HMP
Wormwood Scrubs was equivalent to that which he could have expected to receive
in the community. However, there were some failings: Healthcare staff failed to
arrange two GP reviews and to escalate his self-reported multiple NHS identities.
Recommendations
• The Governor should ensure that all operational staff:
• consider a CSIP referral when there is evidence to indicate that a prisoner may
be at risk of violence; and
• refer self-isolating prisoners to the safer custody department for discussion at
the weekly safety intervention meeting, in line with local policy.
• The Governor should review the process for sharing safety information to ensure
that all prisoners identified as a risk of harm to themselves or from others are
brought to the attention of the safer custody team.
• The Governor should ensure that:
• operational staff promptly consider a cell move when a credible risk to a
prisoner’s safety has been identified and record the reason if it is not considered
appropriate; and
• all evidence relevant to a death in custody is retained and that evidence is made
available to the PPO, in line with PSI 58/2010.
• The Governor should ensure that the keyworker scheme provides meaningful and
ongoing support to all prisoners in line with national policy.
• The Governor should ensure that all prison staff are made aware of and understand
their responsibilities during medical emergencies, including that staff enter cells as
quickly as possible in life-threatening situations.
• The Governor should ensure that Prison Service staff conduct an evidence-based
risk assessment when deciding whether to visit a prisoner’s next of kin.
• The Head of Healthcare should ensure that healthcare staff:
• are aware of their responsibilities for escalating concerns about prisoners who
refuse to collect their prescribed medication; and
2 Prisons and Probation Ombudsman
• promptly report a disclosure of multiple NHS identities using formal reporting
mechanisms.
• The Governor and Head of Healthcare should ensure that a copy of this report is
shared with the staff named in this report and that a senior manager discusses the
Ombudsman’s findings with them.
Prisons and Probation Ombudsman 3
The Investigation Process
14. The investigator issued notices to staff and prisoners at HMP Wormwood Scrubs
informing them of the investigation and asking anyone with relevant information to
contact him. No one responded.
15. The investigator obtained copies of relevant extracts from Mr Doherty’s prison and
medical records.
16. The investigator interviewed eleven members of staff at Wormwood Scrubs
remotely using Microsoft Teams between 20 January and 1 February 2022.
17. NHS England commissioned a clinical reviewer to review Mr Doherty’s clinical care
at the prison. The investigator and clinical reviewer jointly interviewed healthcare
staff and eight members of prison staff.
18. We informed HM Coroner for London West of the investigation who gave us the
results of the post-mortem examination. We have sent the coroner a copy of this
report.
19. The Ombudsman’s family liaison officer contacted Mr Doherty’s family to explain the
investigation and to ask if they had any matters they wanted us to consider. His
family wanted to know if he was being bullied by officers. We have addressed this
concern in this report.
20. Mr Doherty’s family received a copy of the initial report. They did not raise any
further issues or comment on the factual accuracy of the report.
21. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies and their action plan is annexed to this
report.
4 Prisons and Probation Ombudsman
Background Information
HMP Wormwood Scrubs
22. HMP Wormwood Scrubs is a local prison in West London holding almost 1,300 men
on remand from West London courts or those serving short sentences or coming to
the end of long sentences. Practice Plus Group provides physical health services,
and Barnet, Enfield and Haringey Mental Health Trust provides mental health
services.
HM Inspectorate of Prisons
23. The most recent inspection of HMP Wormwood Scrubs was in June 2021.
Inspectors found that the prison was safer than it had been in the past but that the
reduction in violence was at least partly due to most prisoners being locked in their
cells for 23 hours a day. Challenge, support and intervention plans (CSIPs) were
not used to full effect and only 11 plans had been started within 12 months. They
also found that although leaders had been working to improve the quality and range
of keywork, much more needed to be done to make sure that every prisoner had
meaningful access to keywork.
24. Inspectors found that levels of self-harm had reduced substantially. They noted that
the prison held regular safety meetings and a safety action plan included learning
from Prisons and Probation Ombudsman (PPO) investigations. However, they
found that not all PPO recommendations had been implemented effectively.
Independent Monitoring Board
25. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to May 2021, the IMB reported that
the CSIP process was re-launched following a period of suspension during the
COVID-19 pandemic and that a weekly multidisciplinary safety meeting took place
to discuss the most challenging and vulnerable prisoners. The board found that
there had been a reduction in violence and attributed this to the limited time that
prisoners spent mixing with each other.
Previous deaths at HMP Wormwood Scrubs
26. Mr Doherty was the eighth prisoner to die at Wormwood Scrubs since November
2019, and the fifth to take his own life. There has been one self-inflicted and two
natural cause deaths since then. There were no similarities with the circumstances
of the previous deaths.
Prisons and Probation Ombudsman 5
Key Events
27. On 9 August 2021, Mr James Doherty was remanded to HMP Wormwood Scrubs
charged with several offences, including harassment and criminal damage. He had
been in prison before and although mental health staff reviewed him several times,
they did not give him a formal diagnosis of mental illness.
28. When he arrived, a nurse conducted an initial health screen. She noted that he had
a history of anxiety but strongly denied thoughts of suicide or self-harm. At 9.24pm,
A prison GP reviewed Mr Doherty who told him that he had previously been
admitted to hospital for paranoia and had been managed under suicide and self-
harm prevention procedures, known as ACCT, at HMP Bedford in July. He also
said that he had found a cellmate hanging in 2020, tried to hang himself the same
year and wanted to re-start antidepressants. The prison GP referred him to the
mental health team and prescribed several medications, including citalopram (an
antidepressant).
29. At 12.37pm on 10 August, a mental health nurse, triaged Mr Doherty’s mental
health referral and recommended an in-reach mental health assessment. At
1.08pm, a nurse conducted a secondary health screen and noted that Mr Doherty
had reported a history of anxiety, depression, paranoia and hearing voices. She
also noted that he had not reported any substance misuse problems or thoughts of
suicide or self-harm. At 2.33pm, a pharmacy technician checked Mr Doherty’s
prescribed medications and recorded that he did not have a summary care record
(SCR, an electronic record of important information created from community GP
records).
30. On 23 August, a prison GP reviewed Mr Doherty. He told her that he had stopped
taking citalopram after one week as it did not help him. He said that he found it
difficult to sleep, felt anxious and heard voices telling him off but not to self-harm.
He said that he had found mirtazapine (an antidepressant) helpful in the past but
the prison GP found no SCR to confirm this. Mr Doherty told her that he had more
than one NHS number and that this had caused problems in the past. The prison
GP changed his antidepressant to mirtazapine and booked a follow-up review.
However, there is no record that she reported the possibility of multiple NHS
identities to the appropriate governance team.
31. At 11.35am on 2 September, a prison GP reviewed Mr Doherty through his cell door
because he did not want to attend her clinic as he did not want to wait outside the
consultation room with other prisoners. She recorded that although he felt that
mirtazapine had helped and did not report any thoughts of suicide or self-harm, he
continued to feel anxiety and have difficulty sleeping. She increased his
mirtazapine dose, recorded that he was still waiting for an in-reach mental health
assessment and that she had booked an appointment to review him in three weeks.
However, there is no record that this took place.
32. At 4.37pm, an officer recorded that Mr Doherty had been given an Incentives and
Earned Privileges (IEP) warning for fighting with a prisoner on B Wing. (IEP is a
scheme which encourages and rewards responsible behaviour.) He noted that Mr
Doherty told him that they were “just play fighting” and “having a laugh”.
6 Prisons and Probation Ombudsman
33. On 6 September, prison staff moved Mr Doherty to a cell on D Wing. Location
records show that the reason given was ‘general move’.
34. On 9 September, a Community Psychiatric Nurse (CPN) conducted a mental health
assessment. He recorded that Mr Doherty said that he had anxiety and paranoia
and that he had been admitted to a mental health unit in 2020. He noted that Mr
Doherty said he had attempted suicide by hanging in the past but did not report any
current thoughts of suicide or self-harm. The CPN concluded that Mr Doherty did
not show any psychotic symptoms but appeared to display drug-seeking behaviour
as he kept asking for medication to relax. He noted that his case would be
discussed at the in-reach team meeting.
35. On 15 September, the CPN chaired the in-reach team’s new referrals meeting and
reported that Mr Doherty’s presentation was not indicative of severe mental illness.
Attendees decided to obtain his discharge summary from the mental health unit
before making an allocation decision.
36. On 17 September, a pharmacy technician asked Mr Doherty why he had not been
collecting his medication. He told her that he was mostly sleeping in the evening
and was therefore unable to get to the medication hatch. However, he said that he
would attend in future.
37. On 30 September, Mr Doherty was sentenced to 16 months in prison. At 12.49pm,
an officer spoke to Mr Doherty about his sentence and recorded that Mr Doherty
had expected a shorter sentence but had no issue with it. At 3.33pm, a CPN
recorded that he had reviewed Mr Doherty who had not reported any thoughts of
suicide or self-harm.
38. On 13 October, a consultant psychiatrist attended an in-reach team meeting and
recorded that staff were still waiting for a discharge summary from the mental health
unit. However, she noted that a CPN had contacted them and they had confirmed
that Mr Doherty had not been diagnosed with a severe mental illness. She added
that the plan was to discharge him to primary care.
39. Later that day, an officer made an electronic case note (NOMIS) entry and
submitted an intelligence report stating that Mr Doherty had asked to move to
another wing as he felt under threat from other prisoners. However, there is no
evidence that staff took any further action.
40. On 30 October, an officer recorded on NOMIS that Mr Doherty had told him that
someone had slipped a death threat under his cell door. He said he that he gave
the note to an officer, whose name he could not remember, and the officer said that
he would deal with it. The officer submitted an intelligence report stating that he
would put a note in the wing observation book and added Mr Doherty’s name to the
threat board in the wing office. However, there is no record that staff considered a
challenge support intervention plan (CSIP) referral. (CSIP is a national case
management model for managing those who are violent or pose a heightened risk
of being violent. It can also be used to support victims or potential victims of
violence.)
41. On 31 October, an officer recorded that he conducted a welfare check to find out
why Mr Doherty did not want to leave his cell for exercise and to mix with other
Prisons and Probation Ombudsman 7
prisoners. He said that he felt unsafe on the wing, that some people were after him
and that he would like to be moved. The officer recorded that he had escalated this
to the duty senior officer but there is no evidence that staff took any further action,
such as referring Mr Doherty to the weekly safety intervention meeting (SIM, a
multidisciplinary risk management meeting, chaired by a member of the prison’s
senior management team to provide additional support and guidance to staff).
42. The Head of Safety told the investigator that on 14 November, she went into the D
Wing office during her rounds as duty manager and noticed a board with Mr
Doherty’s name on it under the heading ‘Do not unlock’. She subsequently looked
at NOMIS, found several entries about Mr Doherty about which she and the safety
department had not been aware and asked a Supervising Officer (SO) to conduct a
welfare check.
43. A short while later, the SO made a NOMIS entry under the name. He told us that
he had just returned from annual leave and could not remember his login details, so
he used a colleague’s login details to avoid a delay. He recorded that Mr Doherty
said that he was fearful for his life on D Wing and that prisoners had threatened to
“get him” when he “gets out”. He subsequently updated the Head of Safety and
suggested that he should ask to move to A wing. She agreed. He noted that he
‘opened up communication with A Wing’ but was unable formally to ask the wing
SO for a move. The Head of Safety told us that she also informed a Custodial
Manager (CM) that Mr Doherty required a move but he remained on D Wing.
Events from 17 to 18 November
44. At 9.24pm on 17 November, an OSG looked through Mr Doherty’s cell door
observation panel to conduct roll check. In his prison statement, The OSG said that
he saw Mr Doherty standing in the cell and that that he did not have any concerns
about him.
45. At 5.23am on 18 November, another OSG looked through the cell door observation
panel to conduct a roll count. She saw him hanging from a ligature made from a
bedsheet, attached to a light fitting. She radioed a medical emergency code blue
(indicating that a prisoner is unconscious or has breathing difficulties). At 5.24am,
an OSG and an officer arrived. They looked through the observation panel but did
not enter the cell.
46. At 5.25am, an officer arrived and looked through the observation panel. About 20
seconds later, he entered the cell with another officer. He took Mr Doherty’s weight
while she cut the ligature and they laid him on the bed. He checked Mr Doherty’s
vital signs but did not start cardiopulmonary resuscitation (CPR) as he was cold to
touch and did not have a pulse. At 5.29am, two nurses arrived, conducted an
assessment and found that rigor mortis was present. They concluded that it was
inappropriate to start CPR as it was clear that Mr Doherty had died.
47. At 5.29am, an ambulance arrived at the prison and at 5.32am, paramedics arrived
at Mr Doherty’s cell. At 5.33am, a paramedic pronounced that Mr Doherty had died.
48. Mr Doherty left eight notes in his cell, six for his family and two for prison staff. In
the first letter to staff, he appeared to talk about events leading to his offence. In
the second letter, he said that a prison officer asked him if there was anything in his
8 Prisons and Probation Ombudsman
cell and he said, “I got two guns, a criminal record and a load of problems. I think
you’re going to need a bigger box”.
Contact with Mr Doherty’s family
49. A short while later, the Governor telephoned Mr Doherty’s brother, his named next
of kin, to break the news of Mr Doherty’s death. At 6.30pm, the prison’s appointed
family liaison officer (FLO), a safety hub manager phoned Mr Doherty’s brother and
offered support.
50. At 2.15pm on 19 November, Mr Doherty’s sister contacted the FLO and said that
she was taking over as the next of kin as his brother was finding it upsetting. The
FLO explained the role of a prison family liaison officer and arranged for her to visit
the prison and to collect Mr Doherty’s belongings.
51. The FLO provided ongoing support to Mr Doherty’s family until his funeral, which
took place on 1 December. The prison contributed towards its cost, in line with
national policy.
Support for prisoners and staff
52. After Mr Doherty’s death, a prison manger debriefed the staff involved in the
emergency response to ensure that they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
53. The prison posted notices informing other prisoners of Mr Doherty’s death, and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Doherty’s death.
Post-mortem report
54. The post-mortem report established that the cause of Mr Doherty’s death was
asphyxia caused by hanging/strangulation. No illicit substances were identified in
routine post-mortem toxicology tests.
Prisons and Probation Ombudsman 9
Findings
Assessment of risk
55. Prison Service Instruction (PSI) 64/2011 on safer custody requires all staff who
have contact with prisoners to be aware of the risk factors and triggers that might
increase prisoners’ risk of suicide and self-harm, and to take appropriate action.
Any prisoner identified as at risk of suicide and self-harm must be managed under
ACCT procedures.
56. Mr Doherty was not subject to ACCT monitoring at Wormwood Scrubs. Prison
records show that he did not have any difficulties with staff, which includes any
bullying, and never reported any thoughts of suicide or self-harm. While we are
satisfied that staff could not reasonably have predicted that Mr Doherty intended to
take his life based on his presentation and the information available to them, we
consider that they missed several opportunities to explore the underlying cause of
his isolating behaviour, which may have led to formal monitoring and extra support.
57. Mr Doherty first reported feeling under threat from other prisoners on 13 October
but there is no record that staff considered a CSIP referral. A SO told us that it was
difficult to get a prisoner on a CSIP as safer custody did not always reach the same
conclusion as the referring wing staff. The Head of Safety said that the prison had
only been using CSIP to support violent offenders at the time of Mr Doherty’s death,
but they planned to start using CSIP to support victims as part of the national CSIP
re-launch that was taking place at the time of interview (February 2022). She also
said that custodial mangers (CMs) for each wing would be leading on CSIP. While
we are encouraged to hear that the prison plans to address the issue, we are
concerned that HMIP found CSIP to be inadequate during their inspection in June
2021 and that five months later, there appeared to be little improvement.
58. The prisons safety policy (2021) states that self-isolating prisoners should be
referred to the SIM. Despite self-isolating for several weeks, staff did not make a
SIM referral for Mr Doherty. The Head of Safety told us that she would expect
officers to discuss any concerns about a prisoner during daily briefings and, if
required, refer them to the safer custody team for discussion at the SIM. We are
concerned that staff did not notify safer custody in line with local policy, which
meant that they missed a number of opportunities to discuss Mr Doherty in a multi-
disciplinary setting and to devise a plan to monitor and support him.
59. Prison staff submitted two intelligence reports highlighting the risk posed to Mr
Doherty by other prisoners. The Head of Safety told us that security analysts
normally send safety intelligence to the safer custody team for them to follow-up but
there was no evidence that they shared Mr Doherty’s information. This meant that
the safer custody team was not aware of him until Ms Perham checked his NOMIS
record on 14 November. We therefore consider that staff missed a further two
opportunities to review Mr Doherty and to refer him to the SIM.
60. We make the following recommendations:
10 Prisons and Probation Ombudsman
The Governor should ensure that all operational staff::
• consider a CSIP referral when there is evidence to indicate that a prisoner
may be at risk of violence; and
• refer self-isolating prisoners to the safer custody department for
discussion at the weekly safety intervention meeting, in line with the local
safety policy
The Governor should review the process for sharing safety information to
ensure that all prisoners identified as a risk of harm to themselves or from
others are brought to the attention of the safer custody team.
Re-location to A wing
61. Although we are satisfied that a SO promptly saw Mr Doherty for a welfare check on
14 November and enquired about a wing move, we are concerned that staff did not
move him, or record the reason for not moving him. The Head of Safety told us that
her instruction to a SO and a CM was to move Mr Doherty at the earliest
opportunity, which she expected would be the following day, as it was a Sunday
and the prison was operating at around maximum capacity. The CM said that A
Wing was at capacity daily and that Mr Doherty was not subject to ACCT
monitoring. He added that the wing observation book, which staff read during
briefings, was updated to indicate that Mr Doherty required a move. We are,
however, concerned that the prison was unable to send us a copy of the
observation book.
62. PSI 58/2010, The Prisons and Probation Ombudsman (PPO), states that as a basic
principle, the PPO must have unfettered access to documents during their
investigation. The prison told us that a CM searched for the observation book on
multiple occasions but was unable to find it. This meant that we were unable to
confirm the information given to us by an officer and the CM. Observation book
records frequently provide crucial evidence for investigations, and we would expect
the prison to ensure that these are easy to obtain after a death in custody to enable
appropriate scrutiny and accountability.
63. We cannot know whether the outcome would have been different if Mr Doherty
moved wings but the immediate threat is likely to have been reduced. We make the
following recommendation:
The Governor should ensure that:
• operational staff promptly consider a cell move when a credible risk to a
prisoner’s safety has been identified and record the reason if it is not
considered appropriate; and
• all evidence relevant to a death in custody is retained and that evidence is
made available to the PPO, in line with PSI 58/2010.
Key worker support
64. The Prison Service’s Manage the Custodial Sentence Policy Framework 2018
states that all prisoners within the male closed estate must be allocated to a prison
officer who will have a keyworker role. It also says that Governors must ensure that
Prisons and Probation Ombudsman 11
time is made available for an average of 45 minutes per prisoner per week for the
delivery of keywork, which should include time with each prisoner.
65. During the three months between being remanded to prison and taking his own life,
prison staff do not appear to have had many meaningful conversations with Mr
Doherty. He did not have an allocated keyworker and the contact he had with staff
was brief. The prison told us that the keywork scheme was suspended nationally in
March 2020 as a result of the COVID 19 Pandemic and that in the with the Prison
service’s exceptional delivery model, keywork was only being delivered to
vulnerable prisoners or those assessed at risk of suicide or self-harm. We consider
that Mr Doherty’s self-isolation and reported threats from other prisoners made him
vulnerable and that he should have had a keyworker. The lack of regular contact
meant that it would have been more difficult for staff to pick up on signs that his
mood might be deteriorating as a result of his circumstances and to help facilitate a
wing move. We make the following recommendation:
The Governor should ensure that the keyworker scheme provides meaningful
and ongoing support to all prisoners in line with national policy.
Emergency response
66. Prison Service Instruction (PSI) 03/2013 on medical response codes requires
prisons to have a two-code medical emergency response system. Wormwood
Scrubs’ local policy instructs staff to use a medical code blue to indicate an
emergency when a prisoner is unconscious, or having breathing difficulties, and a
code red when a prisoner is bleeding. Calling an emergency medical code should
automatically trigger the control room to call an ambulance, and for a member of
healthcare staff to attend.
67. PSI 24/2011 on the management and security of nights states that staff have a duty
of care to prisoners, to themselves, and to other staff, and that the preservation of
life must take precedence over usual arrangements for opening cells. It says that
where there is or appears to be an immediate danger to life, a single member of
staff can enter the cell alone, after performing a rapid dynamic risk assessment.
68. An OSG responded quickly when she found Mr Doherty hanging in his cell. She
used an appropriate emergency medical code and control room staff called an
ambulance immediately, in line with prison service instructions. At interview, an
OSG told the investigator that she was unable to unlock the cell as she was
shadowing and did not have a key pouch. (At night, OSGs carry a cell key in a
secure pouch for use in emergencies.) A CM told us that OSGs shadowing nights
are expected to learn how to conduct roll checks and to feel confident doing them
alone. He said that the OSG was on her seventh night of shadowing and that
another OSG, who was experienced, was on the wing. We are satisfied that the
OSG acted appropriately.
69. An OSG and an officer responded promptly to the code blue but waited outside Mr
Doherty’s cell for another officer to arrive. The officer told us that she did not enter
the cell as she had been trained not to enter cells on her own at night. As two
OSGs were present, we consider that staff should have entered the cell. Although
we appreciate the distress of seeing a prisoner in such circumstances and that staff
12 Prisons and Probation Ombudsman
must have regard for their own safety, we are concerned that they did not enter Mr
Doherty’s cell earlier given the risk to life.
70. While we accept that the delay entering the cell is unlikely to have affected the
outcome for Mr Doherty, in future cases, it could be critical. We therefore make the
following recommendation:
The Governor should ensure that all prison staff are made aware of and
understand their responsibilities during medical emergencies, including that
staff enter cells as quickly as possible in life-threatening situations and where
it is safe to do so.
71. Two nurses took six minutes to arrive at Mr Doherty’s cell. A nurse told us that they
were in the healthcare unit when they received the code blue and went to the office
to collect the medical emergency bags. He said that they began making their way
to the cell but that their progress was slowed by multiple locked gates. We are
satisfied that their actions were appropriate.
72. The clinical reviewer was satisfied that the decision not to start CPR was
appropriate as it was evident that Mr Doherty had died.
Contact with Mr Doherty’s family
73. Prison Rule 22 requires that the Governor should inform families at once when a
prisoner dies. PSI 64/2011 requires that wherever possible, the family liaison
officer and another member of staff visit the next of kin or nominated person to
break the news of the death. It notes that time is of the essence to try to ensure
that the family does not find out about the death from another source. If the next of
kin lives a long distance away, consideration must be given to asking a family
liaison officer from the nearest prison for help.
74. We are concerned that Mr Doherty’s brother was notified of his death by phone and
that there is no evidence that this decision was based on a risk assessment. Ms
Harrison told the investigator that staff did not conduct a home visit as his family
were from the travelling community and that staff did not always visit in person.
While we appreciate that it will not always be appropriate to conduct a home visit
and that staff safety is a priority, an evidence-based risk assessment must underpin
the decision. We make the following recommendation:
The Governor should ensure that Prison Service staff conduct an evidence-
based risk assessment when deciding to visit a prisoner’s next of kin.
Clinical care
75. The clinical reviewer concluded that t the clinical care that Mr Doherty received at
Wormwood Scrubs was equivalent to that which he could have expected in the
community. Mental health staff completed appropriate assessments, obtained
information from community health services and frequently asked him about his
emotional wellbeing. She did, however, identify some areas for improvement.
76. The clinical reviewer considered that healthcare staff failed to arrange a follow-up
review with a prison GP and missed a further opportunity to arrange a GP review
when Mr Doherty stopped collecting his medication. She also considered that
Prisons and Probation Ombudsman 13
healthcare staff did not escalate the potential concern about Mr Doherty having
multiple NHS identities in line with local policy.
77. While we cannot be certain whether additional GP reviews and the amalgamation of
Mr Doherty’s NHS records would have changed the outcome for Mr Doherty, in
other circumstances, it could be critical. We therefore make the following
recommendation:
The Head of Healthcare should ensure that healthcare staff:
• are aware of their responsibilities for escalating concerns about prisoners
who fail to take their prescribed medication; and
• promptly report a disclosure of multiple NHS identities using formal
reporting mechanisms.
Learning lessons
78. We have identified a number of concerns in this report. We consider it is important
that staff learn from our findings. We recommend that:
The Governor and Head of Healthcare should ensure that a copy of this report
is shared with the staff named in this report and that a senior manager
discusses the Ombudsman’s findings with them.
Inquest
79. At the inquest, which took place on 18 March 2024, the Coroner concluded that Mr
Doherty died of suicide.
14 Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk