Adams, Yasmin

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Ms Yasmin Adams,
a prisoner at HMP Foston Hall,
on 13 November 2016
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.
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 Yasmin Adams died on 13 November 2016 in hospital after she was found hanged in
her cell at HMP Foston Hall. She was 25 years old. I offer my condolences to Ms Adams’
family and friends.
Ms Adams had a history of suicide attempts, frequently self-harmed, had mental health
issues and substance misuse problems. She also often displayed challenging behaviour.
This made the task for staff managing her immensely difficult. I note that individual staff
worked hard to keep Ms Adams safe, but I am concerned about the lack of an integrated
and strategic approach to Ms Adams’ care at Foston Hall. Ms Adams’ case reviews were
not multidisciplinary and staff did not consider managing Ms Adams under enhanced case
management, which would have included more senior and specialist staff in her case
reviews. The investigation also found that healthcare services were fragmented, and in
particular, the substance misuse and mental health teams do not provide an integrated
service.
I am also concerned that there is no clear policy outlining the use of the D wing annex and
prisoners are informally located there for a range of reasons, including segregation and
cellular confinement without the associated safeguards. Finally, the investigation found
that while staff called healthcare when Ms Adams was found on 12 November, they did not
immediately call an emergency code.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Nigel Newcomen
Prisons and Probation Ombudsman August 2017
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 8
Findings ......................................................................................................................... 18
Summary
Events
1. On 29 August 2016, Ms Yasmin Adams was sent to HMP Foston Hall after being
sentenced to six months imprisonment for possession of a blade/point in a public
place. She had a history of suicide attempts, self-harm, mental health problems
and substance misuse.
2. A nurse in reception started suicide and self-harm prevention procedures (known as
ACCT) after Ms Adams told her that she wanted to kill herself. A few days later, a
GP prescribed an antidepressant for Ms Adams after checking her prescription in
the community. Ms Adams was supported by a substance misuse worker for her
alcohol misuse while at Foston Hall and was given information on harm reduction,
pre-release relapse and risk management, and provided with mindfulness and
relaxation techniques.
3. Ms Adams frequently self-harmed while in prison and made and used ligatures
made from a variety of materials, most often in the evening and when she was
locked in her cell. Ms Adams was managed under the ACCT process throughout
her time at Foston Hall and had 64 case reviews. Staff assessed Ms Adams’ risk
as raised for most of the time she was at Foston Hall, and she was observed three
to five times an hour. Ms Adams’ case reviews were not multi-disciplinary, and her
case managers did not consider involving her family in the ACCT process, or
managing her under the enhanced case review process.
4. On 11 September, a nurse referred Ms Adams to the mental health team after Ms
Adams told her she was hearing voices. A mental health nurse reviewed Ms
Adams at regular appointments and referred her for an assessment with a trainee
forensic psychiatrist, who prescribed antipsychotic medication and continued to
monitor her mental state. A consultant forensic psychiatrist assessed Ms Adams
and recommended that she be transferred to hospital under the Mental Health Act
on her release because of her risk of suicide in the community. Her ACCT case
managers and substance misuse worker were not aware that arrangements were
being made to transfer Ms Adams to hospital.
5. Staff disciplined Ms Adams after she displayed challenging behaviour, including
running away from staff, shouting and kicking her cell door and lighting fires in her
cell. She sometimes had privileges withdrawn, but her ACCT case managers
developed a behaviour management plan that allowed her access to a TV at night
and time out of her cell on days she was well behaved. She was disciplined with
cellular confinement for two periods while she was at Foston Hall and subject to this
punishment when she died. Staff did not record any exceptional circumstances
justifying the decision to segregate Ms Adams while she was being managed under
the ACCT process. On one occasion a mental health nurse provided conflicting
advice about segregating Ms Adams, but there was no explanation of how this
advice was taken into consideration as part of the decision to segregate.
6. On the morning of 12 November, staff removed several ligatures that Ms Adams
had tied around her neck. At 10.58am, a prison manager visited Ms Adams and
spoke to her about why she had ligatured, gave advice on activities she could use
to distract herself, and said he would come back and visit her that afternoon. At
Prisons and Probation Ombudsman 1
2.25pm, two officers checked on Ms Adams as part of ACCT procedures and saw
that she was taking a table and her TV into the bathroom. Ms Adams said she
would hang herself with the TV cord. The officers removed the TV and table from
Ms Adams’ cell and told a prison manager what had happened.
7. An officer checked on Ms Adams at 3.10pm and noted that she was standing at her
door. At 3.39pm, the officer returned to check on Ms Adams with the prison
manager. They could not see Ms Adams in her cell, so went into the bathroom to
check on her. The prison manager and the officer found Ms Adams hanging from
the shower rail from a ligature made from clothing.
8. The officer cut the ligature while the prison manager held Ms Adams. They lowered
her to the floor and called a code blue (indicating that a prisoner is unconscious or
has problems breathing). Another officer arrived and helped to move Ms Adams
into the middle of her cell and started cardiopulmonary resuscitation (CPR).
Healthcare staff arrived and continued CPR and gave Ms Adams oxygen. At
4.07pm, paramedics arrived and continued trying to resuscitate Ms Adams. They
found a faint pulse and at 4.37pm, Ms Adams was taken to hospital. Ms Adams
remained in hospital on life support, but on 13 November at 1.45pm, her life support
was turned off and she died.
Findings
9. The investigation found that Ms Adams was challenging to manage, but her care
was not sufficiently holistic. ACCT case reviews were not multidisciplinary and
enhanced case reviews were not considered for Ms Adams, despite her clear risk of
self-harm and suicide, mental health problems and challenging behaviour. Staff
also failed to consider involving Ms Adams’ family in the ACCT process.
10. The investigation found that the D wing annex was used for both safety and
punishment and there was no clear policy outlining its purpose and use and hence
many of the safeguards surrounding segregation and cellular confinement were not
applied. We consider that Ms Adams’ challenging behaviour, which was often
managed using the disciplinary process, had much to do with the distress of being
locked alone in her cell. The investigation identified that staff should consider the
risks of using punitive approaches to address manifestations of distress. The
investigation also found that when Ms Adams was placed into cellular confinement,
staff did not sufficiently consider healthcare reasons not to segregate, or document
whether there were exceptional circumstances which justified segregation, as
required under Prison Rules.
11. The investigation identified that there was no integrated working within healthcare,
and particularly between mental health and substance misuse services. Foston
Hall does not have a dual diagnosis policy and, while Ms Adams was receiving
support from both mental health and substance misuse services, there was no
information sharing between these services or evidence that an integrated service
was provided.
12. The investigation also found that while staff called for healthcare when they found
Ms Adams, there was a delay of three minutes in calling a code blue.
2 Prisons and Probation Ombudsman
Recommendations
• The Governor and Head of Healthcare should ensure that prison staff manage
prisoners at risk of suicide or self-harm in line with national guidelines, including:
• holding multi-disciplinary ACCT reviews involving all staff who can contribute to
the care of the prisoner at risk;
• using the enhanced case review process when appropriate; and
• involving the prisoner’s family in the ACCT process, when appropriate, and
record this in the ACCT plan.
• The Governor should ensure that staff consider the risks associated with using
punitive approaches to managing self-harm or manifestations of distress.
• The Governor should ensure that there is a clear policy outlining the purpose and
use of the D wing annex and that prisoners located there are subject to the
safeguards contained in PSO 1700 and PSI 64/2011 as appropriate.
• The Governor and Head of Healthcare should ensure that staff manage prisoners
held in segregation in line with national guidelines, including that:
• there are exceptional circumstances for segregating a prisoner who is identified
as at risk of suicide and self-harm, and that the reasons for segregating are
clearly documented in the ACCT plan, including other options that were
considered but discounted; and
• staff consider healthcare advice indicating cellular confinement is not appropriate
and document how they have taken this into account when deciding to segregate
a prisoner.
• The Governor and Head of Healthcare should ensure prisoners with dual diagnosis
receive appropriate integrated treatment.
• The Governor and Head of Healthcare should ensure that all prison and healthcare
staff are made aware of and understand PSI 03/2013 and their responsibilities
during medical emergencies as outlined in the local Medical Emergency Response
Code Protocol so that staff efficiently communicate the nature of a medical
emergency, and there is no delay in calling, directing or discharging ambulances.
Prisons and Probation Ombudsman 3
The Investigation Process
13. The investigator issued notices to staff and prisoners at HMP Foston Hall informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
14. The investigator visited Foston Hall on 23 November. She obtained copies of
relevant extracts from Ms Adams’ prison and medical records and interviewed one
prisoner.
15. NHS England commissioned an independent clinical reviewer to review Ms Adams’
clinical care at the prison.
16. The investigator and clinical reviewer interviewed 11 members of staff and four
prisoners at Foston Hall on 4 and 5 January and 7 February. The investigator
interviewed a further three members of staff and one former prisoner by phone.
17. We informed HM Coroner for Derby and South Derbyshire of the investigation who
gave us the results of the post-mortem examination. We have sent the coroner a
copy of this report.
18. One of the Ombudsman’s family liaison officers contacted Ms Adams’ mother to
explain the investigation and to ask if she had any matters they wanted the
investigation to consider. Ms Adams’ mother said that she would like to know why
the prison did not contact her after her daughter made serious attempts to self-
harm, why it took the police two to three hours to notify her that Ms Adams had
been taken to hospital and why it was the police and not the prison that notified her.
Ms Adams’ mother also wanted to know about the level and frequency her daughter
was being observed and whether prison staff considered constant observation. Ms
Adams’ mother received a copy of the initial report. She did not raise any further
issues, or comment on the factual accuracy of the report.
19. The initial report was shared with HM Prison and Probation Service (HMPPS) who
provided comments and this report has been amended accordingly.
4 Prisons and Probation Ombudsman
Background Information
HMP Foston Hall
20. HMP Foston Hall is a closed women’s prison serving courts in the Midlands. It
holds up to 344 prisoners, including unconvicted and unsentenced women, short
and long term young adult women under 21 years old and sentenced women,
including some serving life sentences. CARE UK provides primary healthcare
services. There are daily GP sessions from Monday to Friday, with out of hours
provision at other times. Three primary care nurses and a healthcare assistant are
on duty during the day, reducing to one nurse and a healthcare assistant from
8.00pm to 7.15am. CARE UK provides mental health provision.
HM Inspectorate of Prisons
21. The most recent inspection of HMP Foston Hall was in June 2016. Inspectors
reported that care for prisoners at risk of self-harm was generally sound and women
identified as a risk to themselves or others or those with complex needs were
identified and managed through an enhanced case review process. Inspectors
noted that custodial managers developed care plans for women with complex
needs. The number of women managed under the ACCT process was high and
case managers generally knew the women well and were caring and supportive.
Inspectors recommended that mental health service capacity reflect the particularly
needy population and include offering prompt access to talking therapies and group
work.
Independent Monitoring Board
22. 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 November 2016, the IMB
reported that prison managers prioritised safer custody and made efforts to improve
the effectiveness of the ACCT process. The IMB also highlighted the high number
of women on open ACCT documents, but reported a proactive approach to manage
those subject to ACCT, including good action plans to manage and reduce the risk
of self-harm.
Previous deaths at HMP Foston Hall
23. Ms Adams was the fifth of six women to die at Foston Hall since January 2015. Our
investigations into the deaths of two women in July 2015 and September 2015,
found that ACCT case reviews were not always multidisciplinary and, in the later
investigation, that prison staff underestimated the woman’s risk of suicide and self-
harm.
Prisons and Probation Ombudsman 5
Assessment, Care in Custody and Teamwork
24. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner.
25. After an initial assessment of the prisoner’s main concerns, levels of supervision
and interactions are set according to the perceived risk of harm. There should be
regular multi-disciplinary review meetings involving the prisoner. As part of the
process, a caremap (plan of care, support and intervention) is put in place. The
ACCT plan should not be closed until all the actions of the caremap have been
completed.
26. All decisions made as part of the ACCT process and any relevant observations
about the prisoner should be written in the ACCT booklet, which accompanies the
prisoner as they move around the prison. Guidance on ACCT procedures is set out
in Prison Service Instruction (PSI) 64/2011.
27. Enhanced case management should be considered under the ACCT process where
a prisoner’s behaviour is so challenging and disruptive that they need additional
case management so that their heightened or exceptional risk of harm to self,
others and/or from others is managed within the normal custodial regime. The
Enhanced Case Review Team will involve all relevant disciplines and include more
specialists and a higher level of operational management than a typical ACCT Case
Review Team.
Dual diagnosis
28. Prisoners with mental health problems and substance misuse issues are known as
having ‘dual diagnosis’. In January 2016, we published a Learning Lessons Bulletin
about the mental health of prisoners. This bulletin highlighted that difficulties in
coping with mental health problems can be made worse when a prisoner also has
to cope with battling drug or alcohol misuse. The bulletin recommended that mental
health and substance misuse services should work together to provide coordinated
care to prisoners, including the use of agreed dual diagnosis tools to assess
prisoner needs, and regular meetings to discuss and plan joint care.
Segregation and cellular confinement
29. Segregation units (sometimes known as care and separation units) are used to
keep some prisoners apart from others. This can be because they feel vulnerable
or under threat from other prisoners or if they behave in a way that prison staff think
would put people in danger or cause problems for the rest of the prison. They also
hold prisoners serving punishments of cellular confinement after disciplinary
hearings. Segregation is authorised by a prison operational manager who has to be
satisfied that the prisoner is fit for segregation after an assessment by a member of
healthcare staff.
30. Segregation unit regimes are restricted and prisoners are usually permitted to leave
their cells only to collect meals, make phone calls and have a daily period of
exercise in the open air. PSO 1700 says that normal cells within the segregation
6 Prisons and Probation Ombudsman
unit should be well lit and equipped to a similar standard to other locations within
the prison.
31. As segregation is an extreme and isolating form of custody, prisoners at risk of
suicide or self-harm should be placed there only as an exceptional measure on the
authority of a senior manager. Where possible, segregation should not be used for
prisoners at risk of self-harm and where a prisoner is on an open ACCT they must
only be located in segregation units in exceptional circumstances. The reasons
must be clearly documented in the ACCT plan and include other options that were
considered but discounted.
Prisons and Probation Ombudsman 7
Key Events
32. On 29 August 2016, Ms Yasmin Adams was transferred to HMP Foston Hall after
being sentenced to six months imprisonment for possession of a blade/point in a
public place. She had been released from Foston Hall a month earlier after serving
a sentence for similar offences.
33. Ms Adams had a history of substance misuse, suicide attempts and self-harm and
had been diagnosed with borderline personality disorder (a serious mental disorder
marked by a pattern of ongoing instability in moods, behaviour, self-image and
functioning) and attachment disorder (a temporary disorder caused by a stressful
event).
34. A nurse assessed Ms Adams in reception. Ms Adams said that she had started
taking 20mg of fluoxetine (an antidepressant) two or three days previously. Ms
Adams told the nurse that she wanted to kill herself, so he started suicide and self-
harm prevention procedures (known as ACCT).
35. On 30 August, a nurse assessed Ms Adams for her second reception screening.
Ms Adams said that she had started self-harming in the early hours of that morning
and still had thoughts of self-harm. There is no record that Ms Adams self-harmed
that day.
36. Later that morning, an officer assessed Ms Adams under the ACCT process. Ms
Adams told him that, after her grandmother died in April 2015, her life had ‘spiralled
out of control’ and she started self-harming and made several suicide attempts.
She said that she had never been in trouble before her grandmother’s death, and
that she would be better off with her. He noted the anniversary of Ms Adams’
grandmother’s death as a trigger in the ACCT document (a trigger is an event that
might increase the risk of suicide or self-harm). He noted that Ms Adams had a
boyfriend and a close relationship with her mother, her aunt, and one of her sisters.
37. After her assessment, the officer held the first ACCT case review with Ms Adams
and another officer. The officers spoke to Ms Adams about bereavement
counselling and chaplaincy agreed to provide her with support while she was at
Foston Hall and then refer her to services in the community when she was
released. They noted that Ms Adams was open to speaking to bereavement
counselling services. The officer noted that chaplaincy would provide bereavement
support as an action in the caremap (plan of care, support and intervention). The
review team assessed Ms Adams’ risk as raised and agreed that she would be
observed four times an hour with one conversation a day.
38. Four days later, after a nurse had contacted Ms Adam’s GP in the community to
check her medication, a prison GP prescribed fluoxetine for Ms Adams.
Substance misuse treatment
39. On 2 September, a substance misuse worker assessed Ms Adams. Ms Adams told
her that she smoked approximately £10 worth of cannabis a day and had drunk
alcohol daily for the past four weeks. She also said that she had overdosed on
paracetamol the day before she arrived at Foston Hall and she had a history of
ligaturing and self-harm. The worker said that she did not think that Ms Adams was
dependant on alcohol and did not observe any withdrawal symptoms.
8 Prisons and Probation Ombudsman
40. The substance misuse worker said that her main concern about Ms Adams was her
cannabis misuse because of the effect this could have on her psychological state
and mood. She continued to support for Ms Adams’ during her time at Foston Hall
by providing information on harm reduction, pre-release relapse and risk
management and provided mindfulness and relaxation techniques. She said that
she was worried about Ms Adams’ safety on release, so she referred her to a social
worker to provide support and advice about the services available to her in the
community.
Managing Ms Adams’ risk of suicide and self-harm
41. Ms Adams had attempted suicide several times in the community and was a prolific
self-harmer in prison, with at least 57 incidents recorded before she died where she
made ligatures that prison staff had to remove from her neck. There were a further
four incidents of self-harm recorded that did not involve ligatures, where Ms Adams
cut herself using metal from her lighter, a staple, and on one occasion she burned
her arm with a lit tampon.
42. Ms Adams ligatured most frequently in the evening and when she was locked in her
cell but she was also found with ligatures at other times of the day. She used a
variety of materials including socks, clothing, cleaning cloths, bed sheets and her
kettle cable. While the material was most often tied loosely around her neck, at
times it was tighter and more difficult to remove, leaving red marks on her neck.
Prison staff said Ms Adams did not lose consciousness when she tied ligatures and
she was never found suspended. Staff spoke to Ms Adams about the risks
associated with her behaviour on a number of occasions, but Ms Adams often
laughed or smirked after a ligature was removed. Healthcare staff examined Ms
Adams after each ligature and on all occasions found that she was breathing and
swallowing normally and that no treatment was required.
43. Ms Adams sometimes talked about suicide. When staff asked her about this, she
did not have a plan and would usually become more positive and talk about her
boyfriend and being released. Before ligaturing, staff said that Ms Adams would
often press her cell bell or put a note under her door telling staff to stay away
because she was going to kill herself. Staff said that Ms Adams did not really talk
about why she self-harmed, but sometimes said that voices told her to do it.
44. Ms Adams’ risk of self-harm was managed under ACCT procedures throughout the
time she was at Foston Hall and staff held 64 case reviews. Ms Adams’ ACCT
case managers said that she would sometimes participate in the case review and
be quite open and talkative, while at other times she would be quiet and it would be
difficult to get information from her. Nursing staff attended 10 ACCT case reviews
and mental health staff provided verbal input into two case reviews. There were
several case reviews where only one officer was present at the review. Actions
identified in the caremap included referring Ms Adams to substance misuse and
mental health services, engaging in activities within the prison, speaking to staff
about her feelings and staff checking why she was unable to call her mother. Staff
did not consider managing Ms Adams under the enhanced case management
process or involving Ms Adams’ family in the ACCT process.
45. Throughout the time staff managed Ms Adams under ACCT procedures, her
observations ranged between three and five an hour with either one or two
conversations each day. Staff assessed her level of risk as either high or raised,
Prisons and Probation Ombudsman 9
apart from a brief period where they assessed it as low on 30 October after it was
noted that she had been settled for a few days. Staff assessed Ms Adams’ risk as
raised at the time of her death.
46. Staff disciplined Ms Adams several times at Foston Hall for kicking her door,
refusing to return to her cell, running away from staff, or being in places where she
was not allowed to go. Ms Adams was punished by being put on basic IEP level,
where she remained for most of her time at Foston Hall (this scheme aims to
encourage and reward responsible behaviour. There are four levels: entry, basic,
standard and enhanced). Her punishments included limiting the amount she was
allowed to spend at the canteen, limiting the amount she could earn, and limiting
the amount of time she could spend in association.
47. Staff provided updates on Ms Adams at weekly multi-disciplinary Support and
Intervention meetings. An officer explained that prisoners who had been managed
under the ACCT process for more than four weeks were automatically referred to
this meeting, which provided an opportunity for staff to share information to help the
ACCT case manager to think of new ways of working with the prisoner.
48. On 19 October, minutes from the Support and Intervention meeting noted that two
officers had developed a ‘Care, Support and Behaviour Management Plan’ for Ms
Adams. One officer said that staff often used this type of plan with prisoners who
were being managed under the ACCT process but also had behavioural issues.
Under the behaviour management strategy, if Ms Adams was well-behaved during
the day, she could leave her cell to assist the wing cleaners and would be allowed
to use a TV in the evenings. Staff also provided her with distraction packs that
contained puzzles and colouring books which Ms Adams enjoyed using. Other
support mechanisms that staff provided for Ms Adams were noted in the plan,
including ongoing mental health services, bereavement support from chaplaincy,
and her use of the gym.
Mental health care
49. On 11 September, Ms Adams told a nurse that she had been hearing voices telling
her to kill herself and was struggling to cope. The nurse noted that Ms Adams
appeared distressed, covered her face and had been crying. She referred Ms
Adams to mental health because she said she was hearing voices and her
frequency of self-harm had increased. She returned to Ms Adams cell twice that
night after staff removed ligatures from Ms Adams’ neck. She noted that there were
no obvious marks on Ms Adams’ neck and that officers had removed items of
clothing from her cell.
50. On 19 September, a mental health nurse assessed Ms Adams. Ms Adams said
that she thought she would be better off dead or hurting herself in some way nearly
every day. The nurse assessed Ms Adams using screening tools for anxiety and
depression and noted that Ms Adams scored 21 on the Generalised Anxiety
Disorder Assessment (GAD) and 22 on the Patient Health Questionnaire (PHQ-9),
which indicated that she had severe anxiety and depression. She referred Ms
Adams to the psychiatrist for an assessment.
51. The next day, a trainee forensic psychiatrist assessed Ms Adams. Ms Adams told
him that she was struggling to cope with the loss of her grandmother and that her
mood was low and she had been crying. Ms Adams said she had been hearing
10 Prisons and Probation Ombudsman
voices constantly for three weeks, she struggled to sleep and the voices kept her
awake. She said the voices often told her to kill or harm herself, and shouted when
she would not listen to them. Ms Adams said that she had been cutting herself and
ligaturing because of the voices.
52. The trainee forensic psychiatrist noted that there were no other psychotic symptoms
and that Ms Adams had previously been diagnosed with borderline personality
disorder. Ms Adams said that she had been taking fluoxetine for four weeks but it
was not helping. He noted that Ms Adams had ongoing thoughts of suicide and
self-harm but did not have a plan to take her own life. He told investigators that he
did not feel he had enough information at the end of his assessment to make a
diagnosis, so he arranged to see Ms Adams for another appointment in two weeks
time. He noted that the primary mental health team would provide weekly support
to monitor her mood, mental state, and the effect of her medication.
53. On 23 September, a nurse noted that staff had discussed Ms Adams at a multi-
disciplinary meeting and that her team would arrange for a GP to review Ms Adams’
medication and the trainee forensic psychiatrist would reassess her. She also
noted that the mental health team would speak to wing officers about therapeutic
ways to support and manage Ms Adams’ mental health and provide weekly
distraction packs. She recorded that the mental health team would refer Ms Adams
for relaxation and art therapy groups, and they would consider referring her to
community mental health services, depending on how she was close to her time of
release.
54. Later that day, a GP reviewed Ms Adams’ antidepressant medication. Ms Adams
told her that she did not think she should be on antidepressants because she had
felt worse since she started taking them. The GP told Ms Adams to take her
fluoxetine on alternate days for 2 weeks and then stop. After the review, the GP
told a nurse that she was weaning Ms Adams off antidepressants over the next two
weeks, but would like her reviewed by the psychiatrist because she was presenting
as quite complex. She also wanted the psychiatrist to review Ms Adams’
medication because antidepressants had not worked in the past, and she was
hearing voices. The nurse noted that she would speak to the mental health team
and the trainee forensic psychiatrist about this.
55. On 4 October, the trainee forensic psychiatrist reviewed Ms Adams. Ms Adams told
him that she was doing ‘alright’, that she had tried to kill herself the other day by
tying a ligature, but that she got help from staff. Ms Adams said that she was
hearing the voices all the time and that they were telling her to kill herself but she
would not tell him the plan because the voices would ‘go mad’. She said that
nothing would stop them and they were ‘inside her head’. He prescribed 10mg of
olanzapine (an antipsychotic) and noted that she should continue to take the same
dose of fluoxetine (rather than reduce her dose as suggested by the GP). He noted
that he would review Ms Adams in four weeks and that she should continue with her
weekly mental health appointments.
56. On 25 October, a nurse reviewed Ms Adams and noted that she continued to
struggle with voices telling her to harm herself. Ms Adams said that this last
happened two days ago when she tried to hang herself with a sock. She said that
her work as a cleaner and the distractions packs helped her not to focus on her
negative thinking. She was taking her medication every day. The nurse noted that
she would assess Ms Adams again in two weeks.
Prisons and Probation Ombudsman 11
57. On 27 October, a consultant forensic psychiatrist assessed Ms Adams. He noted
that he could not make a formal diagnosis because Ms Adams did not engage in
the assessment, but that she appeared to have features of emotionally unstable
personality disorder, including a tendency to act unexpectedly, chronic feelings of
emptiness, and recurrent threats and acts of self-harm. He also noted that Ms
Adams appeared to meet the criteria for multisubstance misuse in the community.
He recommended that Ms Adams be detained under the Mental Health Act in an
inpatient unit specialising in personality disorders, when she was released from
prison. He noted that he had contacted Stoke Clinical Commissioning Group to
identify a bed for Ms Adams on release, and had also spoken to specialist
commissioners at NHS England about the possibility of obtaining a bed in a locked
rehabilitation centre. He reported that there was a risk of suicide for Ms Adams if
she was not detained when she was released from prison, and that her risks would
be managed in prison using the ACCT document, close supervision and supportive
care.
58. Ms Adams’ ACCT case managers told investigators that they did not know that the
psychiatrist had assessed Ms Adams and recommended that she be detained
under the Mental Health Act on her release. Ms Adams’ substance misuse worker
said that she often referred prisoners to mental health services but did not usually
hear back about her referrals and did not know about Ms Adams’ mental health
care while she was at Foston Hall. The trainee forensic psychiatrist told
investigators that he was not aware that Ms Adams was undergoing substance
misuse treatment in prison.
D Wing annex and cellular confinement
59. The D wing annex at Foston Hall consists of two, gated, observation cells. It is part
of the segregation unit and is separated from D wing by a locked door. Foston Hall
does not have a policy that outlines how the D wing annex should be used,
however, the Deputy Governor told investigators that it is used as a safer
environment for women in crisis who are at high risk of serious self-harm or suicide.
She said that another function of the annex is as a safer location for women whose
behaviour would normally mean they are segregated because of their risk to others,
but who are also vulnerable in terms of risk to themselves.
60. Ms Adams was located in the D wing annex at various times while she was at
Foston Hall. Sometimes Ms Adams was taken to the D wing annex when her risk of
self-harm increased so that she could be more closely observed. At other times Ms
Adams was relocated to the D wing annex after she was punished and given
cellular confinement, but could not be located in a cell on a normal wing because
she was a risk to herself or others (cellular confinement is where a prisoner is kept
on the wing, but is locked in their cell for most of the day and taken out to shower
and exercise separately from other prisoners on the wing).
61. Ms Adams did not like being alone in her cell and would often press her cell bell,
kick her door and shout when she was locked in her cell. She would also refuse to
go into her cell or run away from officers when it was time to be locked up. Staff
sometimes needed to return Ms Adams to her room using control and restraint
procedures. Each time restraints were used, healthcare staff examined Ms Adams.
As her behaviour did not improve, Ms Adams was disciplined using the adjudication
process. She was punished by placing her on cellular confinement, which was
served either in the D wing annex or in a normal cell on the wing.
12 Prisons and Probation Ombudsman
62. On 18 October, after Ms Adams lit small fires in her cell, she was moved to the D
wing annex overnight for safety reasons. On the morning of 29 October, Ms Adams
would not return to her room. Staff locked the wing and used restraint procedures
to take Ms Adams back to her cell. That afternoon, Ms Adams ran to the recycling
unit on the exercise yard and tried to get on top of some metal containers. Ms
Adams refused to get down and tried to run past an officer, so staff restrained her
and took her to the D Wing annex. They noted in Ms Adams’ prison record that her
clothing had been removed but was later returned, and that she had been given a
distraction pack. A nurse assessed Ms Adams and noted Ms Adams had a bruise
on her hand and told her to put it under cold water. The next day, staff held an
ACCT case review in the D wing annex and assessed Ms Adams’ risk as
unchanged (raised) and the frequency of observations remained at four an hour
with one conversation.
63. On 31 October, Ms Adams was punished for refusing to return to her room and
given seven days of cellular confinement, 14 days loss of association and 21 days
of reduced spending at the canteen. A nurse assessed Ms Adams for the prison
health screen and noted that there were no medical reasons preventing
segregation. Staff did not note the exceptional circumstances for segregating Ms
Adams on the prison health screen, or in her ACCT document, as required under
prison segregation rules. There is no record about any other options that were
considered to manage Ms Adams’ behaviour.
64. An officer and a nurse reviewed Ms Adams under the ACCT process and noted that
she was tearful and that she felt like ligaturing because she was in the D wing
annex. Later that evening, staff reviewed Ms Adams under the ACCT process
again after she tried to ligature using a sock. Ms Adams said that the voices had
told her to do this. For both ACCT case reviews, staff assessed her level of risk as
unchanged (raised) and continued to observe her four times an hour with two
conversations a day.
65. On 1 November, the trainee forensic psychiatrist assessed Ms Adams with a nurse.
Ms Adams told him that things had been ‘alright’, she was sleeping better, and that
she continued to hear voices but did not listen to them anymore. She said that she
had not had any suicidal thoughts since she moved to the D wing annex but had
attempted to harm herself on Sunday because of the voices. He noted that Ms
Adams seemed ambivalent about any active thoughts of suicide and said she had
no current plans to harm herself. He noted that although Ms Adams was hearing
voices during the review, she was able to ignore them and continue to focus and
her thoughts of suicide appeared to have stabilised over the past few days. He
recorded that there were to be no changes to Ms Adams’ medication and that she
came across as more settled and able to exert more control over the voices.
66. At 2.25pm, Ms Adams was moved from the D Wing annex to C wing. Two officers
reviewed Ms Adams’ risk under the ACCT process and noted that Ms Adams was
pleased to have moved back to the wing but she was not sure if she would self-
harm. Approximately 20 minutes later, Ms Adams started banging on her door.
Staff noted in her ACCT document that the banging continued until she spoke to
staff at 3.26pm. Later that afternoon, she threatened to climb out of the window and
began screaming and kicking the bathroom door which staff had locked so they
could observe her. Ms Adams threatened to hang herself in the bathroom, so staff
Prisons and Probation Ombudsman 13
moved her back to the D wing annex. Two officers held an ACCT case review with
Ms Adams. Her level of risk and frequency of observations remained unchanged.
67. On 3 November, a nurse reviewed Ms Adams in the D wing annex. She noted that
Ms Adams was calmer, had no thoughts of self-harm, and no self-harm had been
reported by officers in the past few days. She recorded that no other concerns had
been raised and that she had explored coping strategies with Ms Adams. She
noted that she would review Ms Adams in one week.
68. On 4 November, Ms Adams was moved back to C wing. A few hours later, Ms
Adams rang her cell bell because she had made some superficial cuts to her arm.
Staff took her to healthcare but there are no notes about any treatment in her
medical records. Later that evening, Ms Adams refused to move out of her
bathroom so staff could see her. Staff decided to move Ms Adams to a cell in the D
wing annex, but Ms Adams refused to move and staff moved her using force. An
officer reviewed Ms Adams under the ACCT process after she was moved, but
nobody else attended the review, including Ms Adams.
69. The next day, staff moved Ms Adams back to C wing and held an ACCT case
review, where an officer noted that she was keeping herself distracted with drawing
and colouring, and watched TV at night as part of her behaviour management plan.
He noted that Ms Adams had an IEP review and staff decided that she would
remain on basic level because of her refusal to move to a safer environment the
day before.
70. At 9.00am on 6 November, Ms Adams’ period of cellular confinement ended. On 6,
8, 9 and 10 November, Ms Adams self-harmed by tying ligatures and making
superficial scratches on her arm. On 8 November during her ACCT case review,
Ms Adams said that she was upset after her mother had not contacted her after she
wrote her a letter. She asked to have her PIN phone numbers checked so she
could call her mother. Staff did not consider involving Ms Adams’ mother in the
ACCT process.
71. At 8.40am on 10 November, Ms Adams refused to return to her cell so staff moved
her using control and restraint procedures. An officer told a prison manager about
what had happened and a nurse examined Ms Adams and noted that she had no
injuries.
72. At 8.50am, staff held an ACCT case review with Ms Adams where they assessed
her risk as high and she remained on four observations an hour with one daily
conversation. Ms Adams had a ligature removed by prison staff during the day and
at 5.30pm, staff held another ACCT case review where her risk was assessed as
raised and her observations remained unchanged. An officer asked Ms Adams why
she had ligatured and she shrugged her shoulders. There is no note in Ms Adams’
records explaining why staff decided to reduce Ms Adams’ assessed level of risk at
this case review.
73. At 7.00pm on 10 November, a nurse examined Ms Adams after she had tied a
ligature. Ms Adams told him about the voices she was hearing. She said that she
suffered from this illness as a child and thought she had ‘outlived the problem’ but
the voices had become constant of late and she did not know how to cope with it.
She said that she intended visiting her GP when she was released and talked about
her release date. She said that she felt reassured and did not have any further
14 Prisons and Probation Ombudsman
thoughts of suicide or self-harm. He noted that the mental health team would
review Ms Adams.
74. On 11 November, a healthcare assistant assessed Ms Adams after officers had
removed a ligature. She noted that there were red marks to the front of Ms Adams’
neck and that no treatment was required. An acting supervising officer held an
ACCT case review with another officer, and Ms Adams spoke to staff but hid her
face for the majority of the review. The officer noted that they reminded Ms Adams
about the support that was available and that she asked them for more distraction
work. The review team assessed her risk as raised.
75. At 2.25pm, staff disciplined Ms Adams for refusing to move back to her cell and
gave her five days cellular confinement. At 3.30pm, a nurse assessed Ms Adams
for the prison health screen. She noted in the segregation paperwork that there
were healthcare reasons not to segregate Ms Adams at the time, but also circled
‘no’ on a form asking if there were any clinical reasons not to segregate at this time.
There is no note in Ms Adams’ record explaining how this advice was considered
and staff did not record any exceptional circumstances for Ms Adams’ segregation
on the prison health screen, or in the ACCT document as required by prison
segregation rules.
76. At 3.45pm, an acting supervising officer and another officer held the second case
review that day. Ms Adams said she was not bothered about her punishment but
felt like self-harming. The officers encouraged her to focus on the positives and
noted that she understood this, and would listen to music and use her distraction
work. The review team assessed her risk as raised and her observations remained
at four an hour. This was Ms Adams’ last ACCT case review.
Events of 12 November
77. At 10.20am, an officer noted in the observation book that Ms Adams had hidden in
her bathroom with a ligature around her neck. He and another officer tried to
remove the ligature, but Ms Adams resisted and they had to hold her down to
remove it. At 10.29am, both officers checked Ms Adams as part of ACCT
procedures and found her in the bathroom with a ligature around her neck for the
second time that day. One officer said that Ms Adams struggled when they tried to
take the ligature off so they had to hold her arm to remove it.
78. At 10.58am, a prison manager asked Ms Adams why she had ligatured that
morning and she said that she was bored. He asked what they could do to help
and Ms Adams said she wanted her cell door left open. He said that he could not
do this because she was on cellular confinement, but she had her TV and colouring
books to distract her. He said that he would come back in the afternoon to speak to
her again and get her out of her cell for a bit and go to his office. Ms Adams said
that she would see him that afternoon and he left her cell.
79. At 11.15am, Ms Adams gave an officer a complaint form. Ms Adams wrote on the
complaint that an officer kept banging her head against the wall when removing her
ligature and she wanted something done about this.
80. At around 1.40pm, a prisoner came and spoke to Ms Adams through her cell door.
Ms Adams told her that she had nothing to live for and ‘nothing to come out to’. The
prisoner said that this was not an unusual conversation to have with Ms Adams and
Prisons and Probation Ombudsman 15
that she had spoken to her about this before. She told Ms Adams that she had
herself to live for and said that by the end of the conversation, she thought she had
convinced Ms Adams not to harm herself. She went to the gym around 2.30pm.
81. At 2.25pm, Ms Adams was sitting in her bathroom and would not come out, so two
officers went into Ms Adams’ cell. She told them they could not come in and took
her table into the bathroom, and then tried to take her TV into the bathroom. Officer
A said that she thought Ms Adams would use the table to barricade herself in her
cell and Ms Adams said that she would use the TV cord to hang herself. Staff
removed the table and TV from Ms Adams’ cell. She said that while not unusual,
this was new behaviour for Ms Adams so she told a manager about what had
happened. Approximately 20 minutes later, Officer B noted that he had checked Ms
Adams as part of the ACCT process and she was standing at her cell door and
appeared okay.
82. At 2.55pm, both officers went to check on Ms Adams but she did not respond and
they could not see her, so they went into her cell. Ms Adams was holding her
breath and her face was red. Both officers checked Ms Adams’ neck for a ligature,
but there was none. Ms Adams told the officers that she did not want them in her
cell.
83. At 3.10pm, Officer B checked Ms Adams and noted that she was standing at her
cell door. At 3.39pm, a manager went into Ms Adams’ cell to check on her with the
officer, but could not see her. He went to the bathroom, and when he opened the
door, he saw Ms Adams hanging from the shower rail with a ligature made from
clothing. Ms Adams had her back towards him and he noticed that her feet were
blue. He told the officer that Ms Adams was hanging and they needed to get her
down, and called for healthcare assistance over the radio but did not call a code
blue.
84. The manager held Ms Adams while the officer cut the ligature. He said Ms Adams
was cold and her body was very limp. He lowered Ms Adams to the floor and the
officer put her in the recovery position. The manager said that they needed to find
out if she was breathing and noticed that the ligature was loose but still around her
neck.
85. Officer A arrived at Ms Adams’ cell followed by an acting governor. Officer A asked
them if Ms Adams was breathing. They said they did not know. She removed the
ligature from Ms Adams’ neck, and then moved her into the centre of her cell and
started CPR. At 3.42pm, the governor called a code blue and asked for healthcare
and an ambulance. The control room log notes that an ambulance was called at
3.42pm, however, ambulance records note that they received a call from the prison
requesting an ambulance at 3.45pm.
86. At 3.43pm, nursing staff arrived at Ms Adams’ cell. They attached the defibrillator
machine which advised no shock. One nurse took over CPR from Officer A and the
other nurse managed Ms Adams’ airways and gave her oxygen. They took turns
and rotated performing CPR and managing Ms Adams’ airways. Officer B was
taken out of Ms Adams’ cell by another member of staff and was supported by the
Care Team.
87. At 4.07pm, paramedics arrived at Ms Adam’s cell. They continued attempts to
resuscitate Ms Adams and gave her two rounds of adrenaline. Paramedics were
16 Prisons and Probation Ombudsman
able to detect a faint pulse. At approximately 4.37pm, Ms Adams was taken to
hospital by ambulance.
88. At approximately 1.45pm on 13 November, Ms Adams died in hospital. Ms Adams’
family were with her when she died.
89. After Ms Adams’ death, two former prisoners who were at Foston Hall with Ms
Adams contacted Ms Adams’ mother and said that they were concerned about the
way Ms Adams was treated in prison. The investigator interviewed one of the
former prisoners who said that Ms Adams just needed someone to talk to and that
staff did not provide her with enough support. She said that after staff moved Ms
Adams to the D wing annex, she was ‘covered in bruises’ and that she often had
bruises on her wrists and elbows because staff moved her using force. The clinical
review noted that each incident of controlled movement was attended promptly by
the healthcare staff for assessment, and in most cases no treatment was required.
The post-mortem report noted there were no injuries to suggest that Ms Adams was
restrained or assaulted prior to her death.
Contact with Ms Adams’ family
90. After the paramedics left on 12 November, the deputy governor and family liaison
officer (FLO) contacted the police and asked them to tell Ms Adams’ family that she
had been taken to hospital. The FLO decided to ask the police to speak to Ms
Adams’ family rather than visit herself because she thought this would be quicker.
However, she said that the police took a little longer to notify Ms Adams’ family
because the address Ms Adams had provided to the prison was incorrect. At
9.45pm, she met Ms Adams’ mother at the hospital.
91. At around 1.45pm on 13 November, Ms Adams’ mother told the FLO, who was at
the hospital, that Ms Adams had died. The FLO offered condolences and support.
The prison contributed to the costs of Ms Adams’ funeral, in line with national
guidance.
Support for prisoners and staff
92. After Ms Adams’ death, the acting deputy governor debriefed the staff involved in
the emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
93. The prison posted notices informing other prisoners of Ms Adams’ 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 Ms Adams’ death.
Post-mortem report
94. The post-mortem report noted Ms Adams’ cause of death as hypoxic brain injury
after cardiac arrest due to hanging.
Prisons and Probation Ombudsman 17
Findings
95. Ms Adams was a very challenging person to manage and support. While she self-
harmed frequently, we are satisfied that staff recognised her risk of self-harm and
set an appropriate level of observations. Constant supervision would not have been
appropriate for Ms Adams as this should be used only at times of acute crisis and
for the shortest time possible. While Ms Adams’ pattern of self-harm fluctuated, it
occurred regularly and continued throughout the time she was at Foston Hall.
96. Staff warned Ms Adams many times that her chosen method of self-harm was
extremely dangerous, but she continued to ligature. Ms Adams spoke about
wanting to die but staff said that when they asked her questions about this, it did not
usually appear to be her intention and she would start talking about her plans for
the future. No one we spoke to thought she wanted to die. It does not appear that
the act of self-harm on 12 November that led to Ms Adams’ death was any different
from the numerous previous occasions when she had tied something around her
neck. There is no evidence that Ms Adams intended to kill herself on 12 November
and it seems that her death was the consequence of her very risky self-harming
behaviour.
97. We consider that, given the nature and frequency of Ms Adams’ self-harm, it would
have been extremely difficult for prison staff to have prevented her death. However,
the investigation identified some deficiencies in ACCT procedures, use of the D
wing annex, her segregation and cellular confinement, dual diagnosis and
emergency procedures, which we set out below.
ACCT procedures
98. Prison Service Instruction (PSI) 64/2011, which gives guidance on how to manage
suicide and self-harm procedures, requires ACCT case reviews to be
multidisciplinary where possible, involving staff from relevant departments and
services. Ms Adams had 64 case reviews between August and November 2016.
Few of these reviews were sufficiently multidisciplinary and several reviews had just
one other member of staff present, which is poor practice. Even when
multidisciplinary attendance is not possible, it is implicit that ACCT case reviews,
which are based on teamwork, involve more than one member of staff.
99. PSI 64/2011 recommends that prisoners at risk of suicide and self-harm are
managed under an enhanced case review process in a number of circumstances,
including prisoners whose behaviour is so challenging and disruptive that they need
additional case management so that their heightened or exceptional risk of harm to
self, others and/or from others is managed within the normal custodial regime.
Management by an enhanced review team is not mandatory, but it includes more
specialists and a higher level of operational management. While individual teams
were doing some good work to support Ms Adams, there was little evidence of
integrated working. Her ACCT cases managers did not know that the mental health
team were arranging for Ms Adams to be sectioned under the Mental Health Act on
her release, and the mental health and substance misuse teams did not provide an
integrated service as outlined in the prison’s dual diagnosis policy. With Ms Adams’
behaviour, mental health problems, and frequent ligaturing, it would have been
appropriate to consider an enhanced case review approach. A more high-level
18 Prisons and Probation Ombudsman
approach from an enhanced case review team might have resulted in more regular
attendance by mental health staff at reviews and a more coherent approach to
managing Ms Adams’ behaviour.
100. In March 2017, we published a Learning Lessons Bulletin about ‘Self-inflicted
deaths among Female Prisoners’, where we found a clear theme of poor joint
working between mental health and custodial staff, or weak integration of mental
health care into the prison. Poor joint working involved limited information sharing,
including limited input of mental health care professionals into ACCT reviews, or
insufficient information on the woman’s healthcare being incorporated into the
ACCT document. We recommended that prisons should use enhanced care
management to bring greater senior engagement, oversight, and responsibility for
keeping the most complex and challenging female prisoners safe.
101. PSI 64/2011 says that prisoners who pose a risk of harm to themselves must be
encouraged to communicate with their families, and that consideration must be
given to inviting the prisoner’s family to ACCT case reviews where this is thought to
be beneficial. Contact with family can provide an important source of support to a
prisoner in crisis and staff should facilitate this wherever possible and appropriate.
Ms Adams’ mother told investigators that she would have liked to have been
involved in her daughter’s care. In the week leading up to her death, Ms Adams
told staff that she was upset that she had not spoken to her mother. While staff
may have had reasons for deciding not to involve Ms Adams’ family in the ACCT
process, there was no evidence that her case managers considered inviting her
family to case reviews, or otherwise involving them in the process.
The Governor and Head of Healthcare should ensure that prison staff manage
prisoners at risk of suicide or self-harm in line with national guidelines,
including:
• holding multi-disciplinary ACCT reviews involving all staff who can
contribute to the care of a prisoner at risk;
• using the enhanced case review process when appropriate; and
• involving the prisoner’s family in the ACCT process when appropriate, and
record this in the ACCT plan.
D Wing annex
102. The D wing annex at Foston Hall is part of the segregation unit and used as a safer
environment for prisoners at risk of self-harm, or as a location for prisoners who
would be segregated but are vulnerable because of their risk to self. Earlier in her
sentence, Ms Adams was moved to the D wing annex because she required a safer
environment, but later she was moved there because she was under cellular
confinement and her behaviour meant she could not be located in a normal cell on
the wing. From 30 October until 6 November, and from 11 November until the time
of her death, Ms Adams was often moved between the D wing annex and cellular
confinement on C wing. While we recognise that Ms Adams’ self-harm reduced
while she was in the D wing annex, we are concerned that there is no clear policy
governing the use of this location.
Prisons and Probation Ombudsman 19
103. Some staff told investigators that the D wing annex was not seen as being part of
the segregation unit. However, when Ms Adams was located there, it was
sometimes noted in her ACCT document that she was in the segregation unit.
Foston Hall does not have a policy outlining the purpose of the D wing annex and
circumstances under which prisoners will be moved there for safety or punishment.
104. Prison Service Order (PSO) 1700 that details the procedures to follow when
segregating prisoners and prisoners who are located in the D wing annex under
cellular confinement are subject to the Prison Service Rules on segregation. PSI
64/2011 provides that gated cells must only be used when a prisoner requires
constant supervision in order to receive concentrated attention designed to reduce
their risk of suicide or fatal self-harm. Constant supervision can only be authorised
by the Daily Operational Manager or the Senior Clinical Manager after consultation
with each other and the decision documented in the ACCT Plan. If a prisoner is
located in the D wing annex because they need to be in an observation cell for
safety reasons, the safeguards for constant supervision in PSI 64/2011 must be
provided. Without a clear policy outlining the purpose and use of the D wing annex,
there is a risk that prisoners that are segregated in this location or moved for safety
reasons will not be subject to the safeguards and protections for prisoners provided
under PSO 1700 and PSI 64/2011. We make the following recommendation:
The Governor should ensure that there is a clear policy outlining the purpose
and use of the D wing annex and that prisoners located there are subject to
the safeguards contained in PSO 1700 and PSI 64/2011 as appropriate.
Use of punitive measures to manage Ms Adams’ behaviour
105. In our Learning Lessons Bulletin about self-inflicted deaths of female prisoners, we
identified that staff had inappropriately used punitive approaches, such as the
adjudication process and the IEP scheme, to try to address instances of self-harm
or manifestations of distress. Ms Adams ran away from staff when it was time for
her to be locked up, shouted and kicked her door, repeatedly pressed her cell bell
and lit fires in her cell. Staff often used control and restraint procedures to relocate
Ms Adams, and her behaviour was regularly addressed by placing and maintaining
her on the basic level of the IEP scheme and through adjudications which resulted
in her punishment and being placed in cellular confinement. This approach was not
effective in managing Ms Adams’ behaviour, which we consider was in part a
consequence of her distress at being alone in her cell. Their impact may, indeed,
have been counter-productive.
106. We acknowledge that Ms Adams’ behaviour was challenging to manage and that
staff tried to identify alternative approaches through considering her at the Support
and Interventions meeting. However, rather than using punitive measures to
manage Ms Adams’ behaviour, we consider that staff could and should have
explored alternatives that addressed the underlying causes of Ms Adams’ poor
behaviour. When Ms Adams was located in the D wing annex and had more
contact with staff, her behaviour improved and her level of self-harm reduced.
Similarly, prisoners said that Ms Adams calmed down when she had someone to
talk to. Involving her family and more senior staff and specialists through the
enhanced case review process would have provided a more holistic approach to
her management and may have identified ways of engaging Ms Adams and
20 Prisons and Probation Ombudsman
addressing the underlying causes of her behaviour and self-harm. We make the
following recommendation:
The Governor should ensure that staff consider the risks associated with
using punitive approaches to managing self-harm or manifestations of
distress.
107. As segregation is an extreme and isolating form of custody, prisoners at risk of
suicide or self-harm should be placed there only as an exceptional measure on the
authority of a senior manager. PSO 1700 and PSI 64/2011 both advise against the
use of segregation for prisoners at risk of self-harm where possible and require that
prisoners on open ACCTs must only be located in segregation units in exceptional
circumstances, and the reasons must be clearly documented in the ACCT plan and
include other options that were considered but discounted. There was no record of
the exceptional circumstances for segregating Ms Adams, or other options that
were considered to manage her behaviour.
108. PSO 1700 requires that a doctor or registered nurse must complete the Initial
Segregation Safety Screen for prisoners who may be given a period of cellular
confinement in order to advise the adjudicator if there are health factors that would
indicate that cellular confinement would be unsuitable or unsafe. The adjudicator
must take the doctor or nurses’ advice that cellular confinement is inappropriate into
account.
109. On 11 November, a nurse assessed Ms Adams and noted that there were
healthcare reasons not to segregate Ms Adams, but also circled ‘no’ on a form
asking if there were any clinical reasons not to segregate at this time. However, in
authorising Ms Adams’ cellular confinement, prison staff did not record exceptional
reasons to segregate her as a prisoner being managed under ACCT procedures,
that the nurse’s recommendation in deciding to segregate Ms Adams was taken into
account, or what other options had been considered. These reasons were also not
recorded in the ACCT document or on Ms Adams’ health screen, as Prison Service
instructions require. Ms Adams’ safety might have been given as an exceptional
reason to segregate her, but this was not noted as a reason in her prison record.
We make the following recommendations:
The Governor and Head of Healthcare should ensure that staff manage
prisoners held in segregation in line with national guidelines, including that:
• there are exceptional circumstances for segregating a prisoner who is
identified as at risk of suicide and self-harm, and that the reasons for
segregating are clearly documented in the ACCT plan, including other
options that were considered but discounted; and
• staff consider healthcare advice indicating cellular confinement is not
appropriate and document how they have taken this into account when
deciding to segregate a prisoner.
Dual diagnosis
110. The PPO published a learning lessons bulletin on ‘Prisoner Mental Health’ in
January 2016. In this bulletin we identified that difficulties in coping with mental
health problems can be made worse when a prisoner also has to cope with
Prisons and Probation Ombudsman 21
difficulties of battling substance dependence. We recommended that mental health
and substance misuse services should work together to provide a coordinated
approach to prisoner care which should involve the use of agreed dual diagnosis
tools to assess prisoner needs and regular meetings to discuss and plan joint care.
111. Foston Hall does not have a dual diagnosis policy. The trainee forensic psychiatrist
and a nurse told investigators that they were not aware of any support the
substance misuse team had provided to Ms Adams and a substance misuse worker
said that she had not been informed about the care being provided by the mental
health team. The nurse said that she would usually become aware that a prisoner
under her care is also receiving support from the substance misuse team if the
prisoner tells her or she referred them for services. The substance misuse worker
said that when she refers a prisoner to the mental health team, she is not always
told the outcome.
112. The clinical review report noted that there was no evidence of integrated working
with the wider healthcare team, in particularly the mental health team. The report
recommended that the healthcare team review how individual complex case
discussions are planned to promote an integrated approach to case management,
with particular reference to the joint working between mental health and substance
misuse.
113. Mental health and substance misuse services should work together to provide a
coordinated approach to prisoner care which should involve the use of agreed dual
diagnosis tools to assess prisoner needs and regular meetings to discuss and plan
join care. We make the following recommendation:
The Governor and Head of Healthcare should ensure prisoners with dual
diagnosis receive appropriate integrated treatment.
Emergency response
114. PSI 03/2013 on Medical Emergency Response Codes requires staff to use a code
blue or equivalent code in a medical emergency and for the control room to call an
ambulance immediately an emergency code is used. The PSI is clear that prisons
should not wait for healthcare staff or a duty manager to decide whether an
ambulance is needed and that an ambulance can be cancelled later if not needed.
115. There was a delay of three minutes in calling a code blue for Ms Adams. At
3.49pm, a manager called for healthcare when he found Ms Adams but did not call
a code blue. A governor called a code blue three minutes later when she arrived at
Ms Adams cell. There is a discrepancy between the control room log and
ambulance records about the time an ambulance was called. In an emergency,
even a short delay in calling an ambulance can have a significant impact on a
person’s chance of survival. We make the following recommendation.
The Governor and Head of Healthcare should ensure that all prison and
healthcare staff are made aware of and understand PSI 03/2013 and their
responsibilities during medical emergencies as outlined in the local Medical
Emergency Response Code Protocol so that staff efficiently communicate the
nature of a medical emergency, and there is no delay in calling, directing or
discharging ambulances.
22 Prisons and Probation Ombudsman
116. The inquest, held from 8 to 19 April 2024, concluded that Ms Adams died from
misadventure. The jury found that the following contributed to her death:
• The prison’s mental health team were not always invited to ACCT reviews, did
not attend any ACCT reviews, and only contributed to two (out of 64) by
telephone. This omission possibly contributed as the mental health team could
have given a fuller picture of Ms Adams’ current mental health state, which may
have informed the decision-making process.
• On 11 November 2016, Ms Adams was placed in cellular confinement in a cell
with a fixed shower rail. This probably contributed because the shower rail is a
prominent ligature point that she had used previously, and it was also out of
sight of prison officers.
• There should not have been a gap of 29 minutes in observations between
3.10pm and 3.39pm on 12 November. This omission possibly contributed
because it provided Ms Adams a greater opportunity to ligature and not be
discovered and not receive medical attention sooner.
Prisons and Probation Ombudsman 23
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