Anderson, Craig

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Craig Anderson,
a prisoner at Isle of Man Prison,
on 25 November 2022
A report by the 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
© Crown copyright, 2024
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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 does not have any jurisdiction in the Isle of Man but was invited by the CEO of
the Department of Home Affairs to conduct this investigation. PPO investigations are
undertaken to assist prisons in ensuring the standard of care received by those within
remit is appropriate. Our recommendations should be focused, evidenced and viable. This
is especially the case if there is evidence of systemic failure.
Mr Craig Anderson was found dead in his cell at Isle of Man Prison on 25 November 2022,
the day after he was sentenced. He had suffocated himself by placing a plastic bag over
his head. He was 28 years old. I offer my condolences to Mr Anderson’s family and
friends. A man died in the same way in March 2020, and there has been another similar
death since.
We found that staff at Isle of Man Prison had not been trained in how to effectively use
suicide and self-harm prevention measures, known as Folder 5. A recent inspection by HM
Inspectorate of Prisons identified poor understanding of risks and how to manage them,
and our investigation found similar issues.
The clinical reviewer found that mental health services at Isle of Man Prison were
inadequate, unsafe, and not equivalent to what is available in the wider community.
When Mr Anderson was discovered, he had been dead for some time. We have identified
a number of factors that should be addressed to improve the management and response
during a medical emergency.
Our investigation identified other issues fundamental to the care of prisoners. The
Department of Home Affairs and Department of Health and Social Care need to support
the Governor and Manx Care to improve staffing levels, governance, oversight, and the
management of risk. Clear protocols should be developed and guidance to support staff in
undertaking their duties to improve safety.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman January 2024
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 6
Key Events ....................................................................................................................... 9
Findings ......................................................................................................................... 20
Summary
Events
1. On 26 July 2022, Mr Craig Anderson was remanded to Isle of Man Prison,
charged with wounding, handling stolen goods and breach of a suspended
supervision order. On 24 November, Mr Anderson appeared in court and was
sentenced to five years imprisonment. He had been to prison before.
2. Mr Anderson had a long history of substance misuse and mental health issues.
He had a history of self-harm and around a month before he was remanded, Mr
Anderson spent four days in an inpatient mental health unit, following a suicide
attempt by hanging.
3. Mr Anderson was supported by the prison’s suicide and self-harm prevention
measures (known as Folder 5) on three separate occasions during his remand.
The last time was between 16 and 18 November, after staff identified he was
anxious and stressed about his impending sentencing hearing.
4. On 24 November, Mr Anderson appeared in court. During the hearing he became
distressed and later punched the cell door injuring his hand. When he returned to
the prison, staff were proactive in providing support, but nobody considered re-
opening the Folder 5. Staff increased observations over the lunch period, but no
other special monitoring was in place over night.
5. On 25 November at 7.33am, during the early morning routine check, an officer
found Mr Anderson unresponsive on the floor of his cell, with a plastic bag over
his head. The officer radioed for assistance and prison and healthcare staff
responded. Resuscitation attempts were unsuccessful, and paramedics declared
Mr Anderson’s death at 7.55am.
Findings
6. We found that Isle of Man Prison had not made sufficient changes or responded
to the learning from the death of a prisoner in March 2020. There are many
similarities between that death and Mr Anderson’s. We found that the learning
from the internal prison investigation and subsequent Coroner’s inquest did not
lead to sufficient change in how the prison manages prisoners’ risk of suicide or
self-harm.
7. We found, as did HMIP, the management of prisoners at risk of suicide or self-
harm was inadequate. Too much emphasis was placed on staff/prisoner
relationships and prior knowledge of the person. The decision to start Folder 5
procedures in the lead up to Mr Anderson’s sentencing date was appropriate, but
there were weaknesses in the management of the process. Staff closed Folder 5
procedures prematurely on 18 November and did not consider that his
sentencing date had been postponed until 24 November. After his sentence, staff
missed several opportunities to reopen the Folder 5. They placed too great an
emphasis on his assurances that he did not have any thoughts of suicide or self-
harm when assessing his risk.
Prisons and Probation Ombudsman 1
8. We found that prison, court and healthcare staff at Isle of Man Prison were not
certain what information should be included on the Person Escort Record (PER).
Mr Anderson’s last PER for his sentencing appearance did not include crucial
information about his history or risk.
9. When Mr Anderson returned to prison after sentencing, staff were proactive in
providing support. Although staff showed a high degree of concern for him,
nobody considered re-opening the Folder 5. We found that there was no formal
process or expectation that all prisoners were seen after a court appearance to
reassess their risk of suicide or self-harm.
10. The clinical reviewer found that the mental health provision at Isle of Man was
inadequate, unsafe and the care Mr Anderson received was not equivalent to
that which he could have expected to receive in the community. Despite Mr
Anderson’s significant mental health history, previous suicide attempts,
significant self-harm and numerous requests to see the mental health team, he
was never referred and assessed. We found there was confusion and a lack of
understanding about the referral process.
11. We identified unsafe practices regarding the issuing of medication, a lack of
clinical governance and quality oversight dedicated to prison healthcare.
12. Isle of Man Prison does not have a specific emergency response policy. When
Mr Anderson was discovered, staff responded quickly but an ambulance was not
immediately called.
13. Staff attempted to resuscitate Mr Anderson when he was clearly dead. Isle of
Man Prison and Manx Care did not have an updated policy guiding staff on when
resuscitation was not appropriate.
14. Mr Anderson’s body was not placed back into his cell after he was declared dead
and he was instead left on the prison landing for several hours.
15. Mr Andersons family were informed of his death by the police and not told in
person by prison staff as they should have been.
16. Some staff felt they had not been supported adequately by the prison following
Mr Anderson’s death.
17. Given the learning identified in this investigation, we consider that the
Department of Home Affairs should immediately commission an investigation into
all non-natural deaths at the prison. This will ensure a timely and objective
investigation is completed to identify any learning, providing clear
recommendations on any necessary change.
Recommendations
• The Governor, Manx Care and the Regional Manager for Bidvest Noonan should
ensure staff understand the purpose of and their responsibilities when completing a
PER and introduce a robust quality assurance process to monitor accurate and
appropriate information sharing.
2 Prisons and Probation Ombudsman
• The Governor and Manx Care should establish a process to ensure that prisoners
returning from a court appearance (in person or by videolink) are assessed for their risk
of suicide and self-harm.
• The Department of Health and Social Care and Manx Care should review the current
provision of mental health services at Isle of Man Prison and provide a dedicated
mental health service, which is sufficiently resourced to meet the needs of the
population.
• Manx Care should undertake a systemic population health needs assessment across
Isle of Man Prison to determine the prevalence of mental health conditions and need.
• The Department of Health and Social Care should ensure the practice of transcribing
and unsafe medication practices at Isle of Man Prison have stopped.
• Manx Care should ensure there is a dedicated lead pharmacy provision at Isle of Man
Prison and there is a prescriber available every day, even if that is for remote
prescribing.
• Manx Care should implement electronic medication administration records.
• Manx Care should ensure that patients who come in with complex and high-risk
medication (as per the RCGP guidance) have a medication review when they arrive at
the prison.
• Manx Care should have a dedicated clinical governance lead responsible for prison
healthcare at Isle of Man Prison to ensure practice is compliant and underpinned by
national guidance, legislation and evidence-based practice.
• The Governor should introduce a clear protocol to staff for effectively communicating a
medical emergency.
• The Governor and Manx Care should ensure that there is clear joint guidance and
training for all staff, about the circumstances in which resuscitation is inappropriate in
accordance with European Resuscitation Council Guidelines.
• The Governor should consider establishing a protocol with the Isle of Man
Constabulary to ensure that following a death in custody the deceased’s body is moved
back into their cell for dignity, if there is no suspicion of a crime.
• The Governor should ensure that the prison complies with its own policy for contacting
the family of a deceased prisoner and that they have adequately trained family liaison
officers.
• The Governor and Manx Care should ensure that all relevant staff, irrespective of
status, position, or experience, are able to attend a debrief following a death in custody
and that they receive appropriate aftercare support.
• The Department of Home Affairs should consider immediately commissioning an
independent investigation in the event of any future non-natural deaths at Isle of Man
Prison.
Prisons and Probation Ombudsman 3
The Investigation Process
18. The Isle of Man Department of Home Affairs asked the PPO to conduct an
independent investigation into the circumstances surrounding the deaths of two
prisoners, Mr Anderson’s death in November 2022 and another man in February
2023, who had died in similar circumstances. There had been a third similar
death in March 2020, but this was not investigated as the inquest had already
concluded (the Coroner provided details of the inquest findings). The PPO were
formally commissioned to investigate on 17 April 2023.
19. The investigator issued notices to staff and prisoners at Isle of Man Prison
informing them of the investigation and asking anyone with relevant information
to contact her. No one responded.
20. The investigator visited Isle of Man Prison on 2 May 2023. She obtained copies
of relevant extracts from Mr Anderson’s prison and medical records. She visited
the wing where he lived, reception, healthcare and met with senior managers.
21. The PPO commissioned an independent clinical reviewer to review Mr
Anderson’s clinical care at the prison. The investigator and clinical reviewer
interviewed 22 members of staff and two prisoners in June 2023. They
interviewed the Governor and General Manager for Integrated Mental Health
Services on 6 July.
22. The investigator and clinical reviewer met with the prison Governor and
separately with Manx Care in July, to provide feedback on the investigation and
share the emerging findings.
23. We informed The High Bailiff, Her Worship Coroner for Isle of Man of the
investigation. The Coroner gave us the results of the post-mortem examination.
We have sent the Coroner a copy of this report.
24. The investigator contacted Mr Anderson’s mother to explain the investigation and
to ask if she had any matters she wanted us to consider. Mr Anderson’s mother
asked the following:
• Did Mr Anderson have a full mental health assessment while at the prison?
• What support was provided after an incident of self-harm in September
2022?
• What happened after Mr Anderson appeared in court on 24 November 2022;
what information was relayed to the prison and what support was provided?
• What action was taken after Mr Anderson’s friend contacted the prison on
the evening of 24 November, to share her concerns about his welfare?
• Do prison staff have any mental health training?
• How was a letter sent from Mr Anderson’s partner given to him when it
appears that it did not go through the correct internal post process?
• Why did nobody from the prison contact Mr Anderson’s mother and why did
the prison not send a condolence letter?
4 Prisons and Probation Ombudsman
25. Mr Anderson’s mother received a copy of the initial report. She did not highlight
any factual inaccuracies.
26. Isle of Man Prison received a copy of the report. They identified some factual
inaccuracies, and the report has been amended.
27. Manx Care also received a copy of the report. They identified a number of factual
inaccuracies within the PPO and Clinical Review reports. We have made some
amendments to the reports as a result. Other points raised were not factually
inaccurate and our findings were based on the information provided to us from
documentation and interviews. Manx Care did not provide an action plan for the
recommendations specific to healthcare at Isle of Man Prison but provided a
copy of their Offender Healthcare Improvement Plan.
28. We note that the Prison Healthcare Team has been placed in ‘special measures’
by the Executive Director of Nursing. This is an internal governance mechanism
designed to ensure any incident or issue that is identified as extremely
challenging and / or high risk is afforded a level of attention, resource, and
leadership in order to facilitate positive change. He commenced special
measures meetings on 15 December 2023, and these will continue on a weekly
basis until such time Manx Care can be assured that adequate progress has
been made against Manx Care’s Offender Healthcare Improvement Plan.
Prisons and Probation Ombudsman 5
Background Information
Isle of Man Prison
29. Isle of Man Prison is in the Jurby parish of the Isle of Man. The prison is operated
by the Isle of Man Prison and Probation Service (part of the Department of Home
Affairs) and is the only functioning prison on the island, holding up to 138
prisoners. All prisoners at Isle of Man Prison are located in single cells equipped
with a toilet and washing facilities. The design of these cells means there no
ligature points. There are two wings that accommodate remand and convicted
prisoners, as well as wings s for female prisoners, and vulnerable prisoners.
There is also a segregation unit.
30. Manx Care (equivalent to the NHS in England) have provided healthcare at the
prison since April 2021. Prior to that, services were provided by the Department
of Health and Social Care (Isle of Man). Healthcare is provided between 7.30am
and 5.30pm Monday and Friday and until 8.30pm Tuesday, Wednesday, and
Thursday; and at weekends between 8.30am and 5.30pm. There is no inpatient
facility. A GP attends twice a week and a psychiatrist once a week.
HM Inspectorate of Prisons (HMIP)
31. The most recent inspection of Isle of Man Prison was in March 2023. Inspectors
reported that the quality of staff/prisoner relationships was a strength. Prisoners
were treated with respect and lived in decent conditions. However, governance
and oversight of many critically important areas of accountability were weak.
32. Inspectors found the management of prisoners at risk of suicide and self-harm
was inadequate. Interventions or responses were often disproportionate, risk
averse and too often lacked sufficient focus on care for individuals or their well-
being. There was poor understanding of risks and how to manage them,
including those associated with the management of prisoners in their early days
and those at risk of suicide or self-harm (similar findings were found in the
previous HMIP inspection in 2011). Inspectors found the monthly safer custody
meetings were unstructured.
33. After a suicide in March 2020, the prison formulated an action plan, but
inspectors considered some of the actions to be unnecessarily risk averse.
Prisoners with a history of self-harm were monitored irrespective of risk. Folder
5s (suicide and self-harm prevention measures) focused on monitoring rather
than promotion of wellbeing and did not address why prisoners felt like self-
harming. Some lacked care plans and multi-disciplinary input and case
management was inconsistent. Observations were recorded on the prisoners
record rather than the Folder 5 and there was no system to monitor these
prisoners when they left the wing or travelled outside of the prison, for example to
hospital or court.
34. Inspectors found 98% of prisoners had a named Custody Support Officer (CSO)
who met with them regularly. Most prisoners said their CSO took an interest in
their wellbeing. There was good access to Samaritans, but there was no
Listeners Scheme (prisoners trained by Samaritans to support their peers).
6 Prisons and Probation Ombudsman
35. The Care Quality Commission (CQC) carried out an inspection with HMIP.
Clinical governance of health services in some areas was weak. They identified
substantial staff shortages in 2022, and gaps in management, nursing and other
professions had impaired delivery of healthcare services by Manx Care. The
professional oversight and management of medicines and pharmacy services
was inadequate.
36. Inspectors noted that there had been recent organisational restructuring at the
prison, funding cuts and the retirement of experienced leaders resulting in a
leaner senior management team. 40% of officers had less than two years’
experience. These changes had been unsettling and almost three-quarters of
staff said morale was low. Inspectors said that senior officers were not visible on
the wings, but that the Governor was committed to change.
Independent Monitoring Board
37. 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 March 2022, the IMB
expressed their concern that Isle of Man Prison was the only facility on the island
for those prisoners with significant mental health issues, which was neither safe
nor suitable. They reported that prison staff worked tirelessly to monitor and care
for prisoners with mental health needs but were not trained to do so. They
described the situation as ‘an accident waiting to happen’. The IMB
acknowledged progress had been made with mental health pathways, although
they were not yet in place, and urged the Minister and Government Departments
to support and fund this provision within the prison.
38. The IMB noted that attendance at the monthly safer custody meeting was lower
than desired and attributed this to low staffing levels. They found overnight
concerns monitoring had increased, possibly due to staff being more aware and
observant and noted this to be a quick and effective safety net to flag individuals’
risk which is used as an early intervention prior to starting Folder 5 procedures.
Previous deaths at Isle of Man Prison
39. Mr Anderson was the second prisoner to die at Isle of Man Prison since March
2020. The previous death was self-inflicted and there has been one self-inflicted
death since. All three deaths had similarities, not least the method of suicide. We
have identified issues with the management of suicide and self-harm prevention
measures, mental health provision, early days in custody and the emergency
response.
Folder 5 – suicide and self-harm prevention measures
40. Folder 5 is the Isle of Man Prison’s system to support prisoners at risk of suicide
or self-harm. The purpose of a Folder 5 is to try to determine the level of risk,
how to reduce the risk and how best to monitor and support the
prisoner. Guidance on Folder 5 procedures is set out in the Self-harm and
Suicide Prevention Policy and Procedures dated 5 May 2022.
Prisons and Probation Ombudsman 7
41. After an initial assessment of the prisoner’s main concerns, levels of supervision
and interactions are set according to the perceived risk of harm. Checks should
be irregular to prevent the prisoner anticipating when they will occur. There
should be regular, multidisciplinary review meetings involving the prisoner every
48 hours As part of the process, a caremap (a plan of care, support, and
intervention) is completed. The Folder 5 should not be closed until all the
supportive actions have been completed and the risk is assessed to have
reduced. Observations are recorded separately on the prisoner’s electronic
prison record.
Incentives and Earned Privileges Scheme (IEP)
42. Isle of Man Prison has an incentives and earned privileges (IEP) scheme which
aims to encourage and reward responsible behaviour, encourage sentenced
prisoners to engage in activities designed to reduce the risk of re-offending and
to help create a disciplined and safer environment for prisoners and staff. Under
the scheme, prisoners can earn additional privileges such as extra visits, more
time out of cell and the ability to earn more money in prison jobs. There are three
levels, basic, standard, and enhanced.
Assessment, Care in Custody and Teamwork
43. Assessment, Care in Custody and Teamwork (ACCT) is the care planning
system HM Prison Service uses to support prisoners at risk of suicide or self-
harm. The purpose of the ACCT is to try to determine the level of risk posed, the
steps that staff might take to reduce this and the extent to which staff need to
monitor and supervise the prisoner. Checks should be made at irregular intervals
to prevent the prisoner anticipating when they will occur.
44. Part of the ACCT process involves assessing immediate needs and drawing up
support actions to identify the prisoner’s most urgent issues and how they will be
met. Staff should hold regular multidisciplinary reviews and should not close the
ACCT plan until all support actions are completed. Guidance on ACCT
procedures is set out in Prison Service Instruction (PSI) 64/2011 on safer
custody.
8 Prisons and Probation Ombudsman
Key Events
Background
45. On 26 July 2022, Mr Craig Anderson appeared in court charged with wounding,
handling stolen goods and breach of a suspended sentence supervision order.
He was remanded in custody and taken to Isle of Man Prison. Mr Anderson had
been to prison before.
46. Mr Anderson had a long history of substance misuse and drug induced
psychosis. He was also diagnosed with a range of mental health conditions
including depression, anxiety, and emotionally unstable personality disorder. Mr
Anderson also had a history of self-harm and attempted suicide. In June 2022,
he was admitted to Manannan Court, after he had attempted to hang himself.
(Manannan Court is not a designated secure mental health unit but is an acute
admission unit. The building is designed in accordance with the specification for
acute inpatient mental health facilities.) He was discharged four days later back
into the community.
47. Mr Anderson was prescribed antipsychotic medication (quetiapine), an
antidepressant (diazepam), anti-anxiety medication (pregabalin) and an asthma
inhaler (salbutamol). In September 2022, after he had been remanded, Mr
Anderson was diagnosed with hepatitis C (an infectious disease affecting the
liver, often acquired through intravenous drug use).
Arrival at Isle of Man Prison
48. When Mr Anderson arrived at Isle of Man Prison, prison staff started Folder 5
procedures due to his history of self-harm. Mr Anderson was observed every half
hour in the first 24 hours.
49. Healthcare staff assessed that Mr Anderson was not suitable to have his
medications in his possession, except for his inhaler, and needed to collect them
each day from the medications hatch. Mr Anderson’s medication for the first
three days were administered without a valid prescription because there was not
a dedicated prison prescriber available. (A GP remotely prescribed medications
on 29 July.)
50. On 27 July, Mr Anderson’s Folder 5 assessment was completed, and a review
held shortly afterwards. Mr Anderson told staff that he was impulsive when he
was upset or angry. He said that he felt low and worried about Social Services
involvement with his children but had no current thoughts of suicide or self-harm.
Four actions were identified on his caremap (a support plan to reduce risk): for
his medication to be fully issued; complete induction; add names and numbers to
phone list; and to be seen by the mental health team. Observations were
reduced to hourly.
51. The next day, an officer was assigned as Mr Anderson’s Custody Support Officer
(CSOs are a named point of contact to provide support to prisoners and help
solve any issues they may have). She noted in Mr Anderson’s prison record that
she knew him well from previous sentences, and that he did not raise any
specific issues.
Prisons and Probation Ombudsman 9
52. Between 29 July and 6 August there were four Folder 5 reviews. During these
reviews Mr Anderson continued to be concerned about his children and
difficulties with his ex-partner. He told staff that he was impulsive and if he were
to self-harm, it was likely to be a quick decision, but he had no current thoughts
of suicide or self-harm. During these reviews, Mr Anderson said that he wanted
to engage with the mental health team and the drug and alcohol team (DAT).
53. On 9 August, Mr Anderson appeared in court via videolink. Later, he attended his
Folder 5 review and told staff that he wanted to progress while in prison. The
Folder 5 was closed, without any mention of his earlier court appearance. A post-
closure review was scheduled for 16 August. Although he had completed his
induction, his medication had been sorted and telephone numbers had been
added to his PIN phone, he had still not been assessed by the mental health
team. The caremap was not updated at any of these subsequent reviews.
54. Over the next few days, Mr Anderson was noted to be settled and raised no
concerns. He regularly attended the gym and received very positive reports from
wing staff.
55. On 16 August, a post-closure review was completed. Mr Anderson was noted to
be in a better place mentally and was happy the Folder 5 was closed. He had still
not been assessed by the mental health team.
56. On 23 August, the CSO spoke with Mr Anderson following contact from Social
Services regarding his children. She noted that Mr Anderson appeared to be
managing the situation and his court case well. She recorded that Mr Anderson’s
behaviour on the wing was good, that he was working as a wing cleaner and
continued to attend the gym. Over the next few weeks Mr Anderson received
excellent reports regarding his standard of work. He spoke at length to staff
about his concerns regarding his court case and children, although no specific
issues were noted.
57. On 12 September, Mr Anderson appeared in court and was found guilty. Staff
recorded that he was very upset and would not speak to them. Mr Anderson also
received documentation from Social Services which upset him. A Senior Officer
(SO) in the Safer Custody Team spoke to Mr Anderson, and he became calmer.
She agreed to credit his account so he could use the telephone. Mr Anderson
said that he did not want to be placed on increased observations as he found it
irritating but agreed that she could check on him during her evening duty.
58. During the evening Mr Anderson pressed his emergency cell bell but did not
answer when the SO used the intercom to speak to him. She went to his cell with
another officer and when she opened the door found Mr Anderson had self-
harmed by cutting his cheek, neck, and ankle. All sharp objects were removed
from his cell and Folder 5 procedures were started. Observations were set at
every 15 minutes overnight and half hourly during the day until he could be fully
assessed. The Folder 5 healthcare assessment was never completed.
59. At around 8.50pm, the SO and a colleague escorted Mr Anderson to outside
hospital for his wounds to be assessed. Mr Anderson said he regretted his
actions, that it was impulsive because he was disappointed about the news he
received from Social Services regarding his children. They waited at the hospital
for three hours. At around 11.50pm, Mr Anderson started to become agitated that
he had not been examined as the A&E department appeared quiet. The SO was
10 Prisons and Probation Ombudsman
told that it was unlikely he would be seen in the next hour and despite trying to
persuade Mr Anderson to remain at the hospital, he decided he wanted to return
to the prison. When they arrived back at the prison around 12.50am, his wounds
were cleaned, and the SO applied steri-strips and a clean dressing to his neck
wound.
60. On 13 September, Mr Anderson was seen by the prison doctor and later
escorted to outside hospital to have his wounds assessed and treated. He was
observed every half hour on his return to the prison.
61. On 14 September, the SO completed the Folder 5 assessment. She noted that
Mr Anderson was frustrated that he had been found guilty and was also upset at
receiving paperwork from Social Services regarding his children. Mr Anderson
told her that he was stressed and regretted his self-harm but that he could be
impulsive and self-harmed to manage his frustration. He said he was not suicidal.
After the assessment she chaired the first Folder 5 review (this should have been
completed within 24 hours of the Folder 5 being opened). Observations were
reduced to hourly. Mr Anderson was noted to be frustrated at being observed so
frequently. Two issues were identified for the caremap: for mental health to
address Mr Anderson’s issues; and for Mr Anderson to inform staff if he received
any news from Social Services.
62. The next day, Mr Anderson smashed his stereo in frustration and observations
were increased overnight to every half hour.
63. On 16 September, Mr Anderson received more bad news from Social Services.
Staff allowed him to remain unlocked. Mr Anderson’s in-cell phone was not
working (there was an issue across the prison) and he was offered the use of the
wing office phone, which he accepted. The SO spent time with Mr Anderson and
a request was made by an officer for another prisoner to sit with him over lunch.
The officer recorded in Mr Anderson’s prison record that this request was denied
by the Deputy Governor because of security issues. (The Deputy Governor said
it was the Governor that made this decision, but the Governor did not recall this).
Mr Anderson accepted the decision. During a Folder 5 review it was recorded
that Mr Anderson was concerned about his mental health and the referral was
being chased by a nurse (who was employed as a bank nurse before taking up
her role as Lead Nurse on 8 November).
64. On 17 September, another Folder 5 review took place. Mr Anderson’s mood had
improved, he had spoken to his child on the telephone, and he had been
exercising in the gym with his friend. Observations were reduced to hourly during
the day and every two hours during the night. Over the next few days, Mr
Anderson appeared settled and compliant on the wing, associating with his
friends. No concerns were recorded.
65. On 20 September, Mr Anderson appeared in court. At 10.07am, after he had
returned to the prison, a GP at Isle of Man Prison saw Mr Anderson and recorded
that he was ‘down for MH [mental health] review following self-harm last week, in
court, doing much better’. We were unable to establish why Mr Anderson was
seen by a GP and not the mental health team. There is no evidence a full
assessment of his mental health was completed.
66. Mr Anderson was initially annoyed that his lunch had not been saved, but he
quickly settled and was provided with an alternative lunch. He received a letter
Prisons and Probation Ombudsman 11
from Social Services and was upset so asked to speak to the SO. Mr Anderson
asked if he could have peer support (support from another prisoner) during the
evening but was told this was not possible. The reason this was declined is not
recorded. Mr Anderson gave his Social Services documentation to the SO,
saying that he realised keeping the papers in his cell could be a trigger. His cell
was searched for any objects that he could use to harm himself; we do not know
if this included removing plastic bags. Folder 5 observations were increased to
every half hour. Although Mr Anderson said he was unhappy at the increased
observations, he accepted this was to ensure his safety and was not a
punishment.
67. Mr Anderson’s Folder 5 was reviewed on 21 and 23 September. He was noted to
be mentally in a better place and coping better with his situation, although he
remained concerned about his children and the impact of his court appearance
and sentence. Mr Anderson had still not had a mental health assessment.
68. On 28 September, a nurse met with Mr Anderson to inform him tests showed he
may have hepatitis C. She recorded that Mr Anderson had taken the news ‘okay’
but wanted to return to his cell. She explained that Mr Anderson needed to have
more tests to confirm the diagnosis, but that treatment was available. Later, Mr
Anderson asked to speak to healthcare as he had some questions having read
the leaflets given to him earlier on his condition. She went to his cell to provide
further advice and information. She asked staff to observe Mr Anderson more
frequently overnight. No concerns were noted.
69. On 29 September, the SO chaired the Folder 5 review attended by a nurse and
Mr Anderson. The review noted that Mr Anderson had been more settled and
while still processing the issues with Social Services, appeared to be managing
well. It was agreed to close the Folder 5 and a post-closure review was
scheduled for 6 October. The caremap was not updated and there is no evidence
that the action for the mental health team to assess Mr Anderson had been
completed.
70. During the post closure period, Mr Anderson had one difficult morning when he
appeared down after a telephone call to his ex-partner about their children, but
he spoke openly to staff. He continued to work to a high standard, attend the
gym, associate with his peers and received positive reports. Mr Anderson applied
to become an enhanced prisoner, but this was declined until there was a longer
period of sustained positive behaviour.
71. On 6 October, a nurse informed Mr Anderson that his hepatitis tests were
positive. She noted he was disappointed but accepted the diagnosis and was told
that an appointment had been made for him to speak to a specialist. (This
appointment took place on 10 October).
72. Later, a SO completed Mr Anderson’s Folder 5 post-closure review. He noted
that Mr Anderson appeared settled and was managing his issues well and
continued to receive support from prison and healthcare staff. Over the next few
weeks, Mr Anderson worked to a good standard and was settled on the wing.
73. On 14 October, Mr Anderson appeared in court, and he was told that he would
be sentenced on 18 November. When he returned from court, a nurse spoke to
Mr Anderson. He spoke about his anxieties around sentencing and the impact on
his children and told her that he felt less anxious having shared his feelings. She
12 Prisons and Probation Ombudsman
requested he was offered peer support over the lunch period but was told this
was not possible. The reasons for her request being declined are not recorded.
74. Mr Anderson’s deputy CSO also went to see Mr Anderson to check on him after
his court appearance. Mr Anderson told him that he was expecting to receive
around four years imprisonment and that he knew what triggered him so spoke to
staff or sat with another prisoner to manage his emotions. The CSO noted that
Mr Anderson had made real progress during his time on remand and if his
behaviour continued, he would likely receive his enhanced status.
75. On 26 October, the DAT Keyworker (a Criminal Justice Specialist), met with Mr
Anderson. She recorded he had completed work in respect of his drug misuse,
and he recognised the link to his mental health. Mr Anderson was able to identify
strategies that he could put in place to manage or avoid problems. Mr Anderson
told her that his mental health was not being addressed and that he wanted help
to manage his anger and emotions, and it was not just about medication. She
told him that she would arrange Dialectal Behaviour Therapy to support Mr
Anderson’s drug recovery work (DBT is used to develop skills to cope with stress
and to regulate emotions). This did not start before Mr Anderson died.
76. On 28 October, the CSO met with Mr Anderson. She recorded that his behaviour
and engagement were good and that she had no concerns. She noted that Mr
Anderson had secured a job with the gardening team and that he intended to
reapply for his enhanced status, which she supported. Mr Anderson applied for
his enhanced status after their meeting. On the application he wrote that he had
been asking to speak to the mental health team since he arrived at the prison
and, had he met with them, may have been able to manage his difficult emotions
better and achieved his enhanced status sooner.
77. On 30 October, Mr Anderson dropped two bags of rubbish from the upper
landing to the one below, which he refused to clean up. There are no other
details recorded.
78. On 31 October, Mr Anderson met with his advocate (legal representative). The
advocate told prison staff that they should be vigilant, as Mr Anderson would be
in court the following week and that ‘his behaviour and mood may be all over the
place’.
79. On 2 November, a SO told Mr Anderson that he had not been successful in his
application for enhanced status due to his behaviour a few days earlier. The SO
recorded in Mr Anderson’s prison record that he responded by saying ‘I might as
well go back to behaving the way I used to which includes cutting myself’. Later,
Mr Anderson asked to speak to the SO. He apologised for how he reacted to the
news about his enhanced status. Mr Anderson said he did not want his hard work
on improving his behaviour to go to waste and said that boredom played a part.
Mr Anderson also disclosed that his impending court hearing and dealing with his
children’s custody case was playing on his mind.
80. On 3 November, the deputy CSO recorded in Mr Anderson’s prison record that
he had pressed his cell bell and asked staff to remove his razor. Mr Anderson
said he had received documents from Social Services regarding his children and
recognised he may be triggered and wanted to keep himself safe. The CSO put
Mr Anderson on overnight concerns (additional monitoring throughout the night
before assessing if the prisoner requires ongoing support). There is no evidence
Prisons and Probation Ombudsman 13
staff considered starting Folder 5 procedures. No concerns were recorded
overnight, and Mr Anderson appeared to sleep well.
81. Over the next week, Mr Anderson attended the gym and his job in the gardens,
receiving positive reports. On 11 November, the CSO made an entry in his prison
record that his behaviour had been good, and, if it continued, he would be able to
apply for his enhanced status. Mr Anderson told her that there was some
confusion about his sentencing date, but that he was managing.
82. On 15 November, during lunch, Mr Anderson asked to speak to two SOs about
how he was feeling. He spoke about his history of self-harm, that he had recently
been ‘crying out for help with his mental health’ and that he did not always
manage situations well. Mr Anderson told them that his job with the gardens
team had a positive effect on his mental health. One SO recorded that Mr
Anderson explained that he was expecting to receive a parole sentence (over
four years) and that he had seen a nurse earlier and was hoping to work with
healthcare to break the cycle of the previous few years.
83. During the evening Mr Anderson pressed his emergency cell bell. The CSO
responded and found him with his head in his hands, upset that he had written a
letter which he said there was no point in sending it as he had missed the post.
Mr Anderson said he was ‘sound’ and just wanted to be left alone. She asked
him if he felt like self-harming. Mr Anderson said he did not, but that he had
nothing in his cell which he could hurt himself with. She spoke to a SO, and Mr
Anderson was placed on overnight concerns. No concerns were recorded, and
Mr Anderson appeared to sleep well.
16 November
84. On 16 November, Mr Anderson appeared very agitated. An officer recorded that
he was unsettled due to his impending sentencing hearing and that he would not
engage with staff. The officer recorded that Mr Anderson asked to speak to a SO
about a transfer out of the prison and said ‘yous either keep me here and I’ll
murder someone or get me shipped, the choice is on you’. Mr Anderson said he
was going to start causing trouble and fighting. The officer noted this was a
concerning shift in attitude and told Mr Anderson that the SO would see him later
that morning. Mr Anderson went to the library and was more settled when he
returned to the wing.
85. The SO spoke with Mr Anderson for over an hour. She recorded that Mr
Anderson accepted that he could be surly and difficult at times when he was
struggling but had also shown that, at times, he was able to manage his
emotions. Mr Anderson said he had been rude to an officer and wanted to
apologise.
86. Mr Anderson spoke of his personal issues, including his children and impending
sentence and that he thought a transfer may be beneficial. The SO explained
that a transfer to a prison elsewhere in the UK was very unlikely. Mr Anderson
also spoke about his frustration at being locked in his cell more now he was part
of the gardens team than when he was a wing cleaner (this information was
passed to senior management for awareness about time out of cell). Mr
Anderson said that he enjoyed attending the gym and working in the garden as it
felt less like prison but was concerned that he would be removed from the
gardens team once he was sentenced.
14 Prisons and Probation Ombudsman
87. The SO started Folder 5 procedures at 1.00pm, due to Mr Anderson’s impending
sentence on 18 November and how this was affecting his mood. In the entry on
Mr Anderson’s prison record she noted that once he had been sentenced the
period of ‘limbo’ would end. The SO completed the immediate action plan which
included that Mr Anderson should continue working, but as he was assessed as
low risk, peer support was not necessary. Observations were set to every four
hours. The SO completed the Folder 5 assessment and noted Mr Anderson was
having trouble sleeping, was low in mood, thinking negatively and upset that he
only spoke to his children once a month. The SO recorded that Mr Anderson was
focussed on the future and wanted an opportunity to rehabilitate himself.
88. The SO identified four actions for Mr Anderson’s caremap: to stay active through
work and education (in cell education packs were requested); keep safe and not
to self-harm; progress on rehabilitation (apply for enhanced status when
appropriate); and apologise to the officer (Mr Anderson apologised a short time
after the Folder 5 was opened). As the day progressed Mr Anderson appeared
calmer and slept throughout the night.
89. On 17 November, Mr Anderson attended the gym, spoke with staff, and had
lunch with his friends on the wing. No issues were recorded. The escort
contractor for court contacted the prison to inform them that Mr Anderson’s
sentencing date had been moved from 18 to 24 November. He was told to
contact his advocate for advice. Mr Anderson had a visit with a friend in the
afternoon. No further issues were recorded, and he was described as settled on
the wing and in a good mood.
90. On 18 November at 3.00pm, a nurse completed a Folder 5 healthcare
assessment. He wrote that Mr Anderson was ‘in a good place’ and despite some
concerns ‘happy he is not at risk’. A SO chaired the Folder 5 review, attended by
a nurse and Mr Anderson. (The SO incorrectly noted on the Folder 5 review that
another nurse attended). The SO recorded that Mr Anderson did not think he
needed to be on a Folder 5 and mentally felt ‘fine’ but that a transfer would
benefit his rehabilitation. The review recorded that all actions had been
completed, although three remained outstanding. The only action completed was
that Mr Anderson had apologised to an officer for being rude. There was no
record that the rescheduled sentencing date on 24 November was considered,
despite this being the reason for initiating supportive measures. The Folder 5
was closed, and a post-closure review was scheduled for 25 November.
91. Mr Anderson continued to be monitored during the post-closure period. His mood
was described as ‘up and down’. On 20 November, the CSO met with him, and
she recorded that his impending sentencing date was playing on his mind and
that he did not know what to expect but would accept his sentence. Mr Anderson
said he enjoyed working in the gardens, but also attended the gym and helped
with cleaning on the wing to keep himself occupied.
92. On 21 and 22 November, Mr Anderson was reported to be in a settled mood and
had worked well.
93. On 23 November at 10.17am, a nurse noted in Mr Anderson’s record that he had
a telephone consultation with a hepatitis C specialist nurse. The nurse noted that
Mr Anderson needed further blood tests and the specialist nurse indicated that
treatment in Liverpool would be considered, to start as soon as possible. Mr
Anderson understood and had no questions.
Prisons and Probation Ombudsman 15
94. At 3.10pm, an officer made an entry in Mr Anderson’s prison record and
described him as ‘very highly strung’. When he asked if he was concerned about
sentencing the next day, Mr Anderson responded by saying he ‘wasn’t arsed’.
The officer tried to encourage him to open up about his feelings, but Mr Anderson
said he was ‘just thinking about everything’, before changing the subject and
speaking about some CDs that he wanted. The officer made another entry a few
hours later, where he described Mr Anderson as more relaxed and that he was
socialising with other men on the wing.
95. The person escort record (PER - a document that accompanies all prisoners
when they move between police stations, courts and prisons which sets out the
risks they pose) was completed by a SO ahead of Mr Anderson’s court
appearance the next day. There was no information on this form regarding Mr
Anderson’s history of self-harm or that he was in Folder 5 post-closure. The lead
nurse completed the medical section of the form. There was no information noted
about Mr Anderson’s mental health and she recorded that there were no known
risks.
24 November
96. On 24 November, around 6.30am, Mr Anderson was woken to attend court, and
he requested a shower. Before he left for court Mr Anderson asked to speak to a
SO, and she went to see him. He said that he was concerned about how he
would manage if he was not sentenced, as he wanted to know his situation. Mr
Anderson said that he was hoping that a longer sentence than he had served
before would give him the opportunity to break the cycle of offending and work
with DAT. Mr Anderson gave her his razor, saying that if he was not sentenced,
he wanted to safeguard himself. Mr Anderson asked if she could arrange for him
to have peer support when he returned from court.
97. At 8.00am, Mr Anderson was searched and taken to court by Bidvest Noonan
staff. When he arrived, a senior custody officer met with Mr Anderson before he
appeared in court. She described him as chatty and that he appeared his ‘normal
self’ (it is not clear exactly how well she knew him). Mr Anderson appeared in
court and was sentenced to a total of five years imprisonment. During the hearing
it was reported that he had an outburst in court, but there is no specific
information recorded on the PER.
98. When he returned to the court cells he punched the door several times, injuring
his knuckle. The senior custody officer saw Mr Anderson was crying and he told
her that he was upset at the prospect of phoning his children to explain his
sentence. She said that he appeared to calm down and that punching the door
seemed to be an act of frustration. At 11.10am, she documented on the PER that
she cleaned the wound on Mr Anderson’s hand, applied a plaster and advised
him to put a cold dressing on his hand when he returned to prison. At around
12.00pm, Mr Anderson arrived back at the prison from court.
99. A SO had been made aware that Mr Anderson had punched the door at court
and went to see him as he arrived back in reception. She told him that she had
arranged peer support and Mr Anderson said he had calmed down. He told her
he had been sentenced to longer than he had expected but was okay. They
walked back to the wing together and she told Mr Anderson she was placing him
on observations over the lunch period. No concerns were recorded.
16 Prisons and Probation Ombudsman
100. At around 1.45pm, a nurse and an officer went to see Mr Anderson. He told them
he was frustrated and upset at the length of his sentence but had no other
thoughts of self-harm. They did not consider that his risk of suicide or self-harm
had increased. The nurse examined Mr Anderson’s hand and, although it was
swollen, he could move his fingers. He declined pain relief. Mr Anderson asked
for his medication early as he wanted to settle for the evening. He took this in
front of staff, except his antipsychotic medication which he took with him to take
later.
101. A SO saw him after he met with healthcare and noted that he appeared settled
and was in a good mood. Mr Anderson had been given some CDs from his
property, but the wrong disc was in one and he asked her to sort this out. She
agreed but explained that it may not be until the following day, which Mr
Anderson accepted. He told her that he wanted to have a resettlement meeting
and wanted to focus on setting his sentence targets.
102. Later that afternoon, the CSO went to see Mr Anderson. He told her that he was
fine with his sentence but would struggle not seeing his children regularly over
the next few years. They discussed how his behaviour would determine if he
reached his enhanced status as he would have extra visits and family days. Mr
Anderson said that he wanted to have a custody plan in place as soon as
possible to make the best of his sentence.
103. Around 5.00pm, CCTV shows Mr Anderson associated with his peers on the
wing. He had a bandage on his left hand. Mr Anderson spoke to an officer for a
short time, who then locked him in his cell at 5.16pm.
104. At around 6.25pm, the prison received a call from one of Mr Anderson’s friends
who said she was concerned having received an email from him the previous
week. She said that he had cut himself but had not yet been seen by the mental
health team or psychiatrist. A SO spoke to Mr Anderson’s friend, who said she
had just spoken to him on the phone and that he appeared in a good mood, but
she was concerned that in a few days’ time he may be affected when the length
of his sentence ‘sinks in’. The SO reassured her that staff had spoken to him at
length when he returned from court and that Mr Anderson would be seen by the
mental health team. The SO said that Mr Anderson’s friend did not share any
immediate concerns and he did not consider reopening the Folder 5 or placing
him on overnight concerns because he knew that Mr Anderson got frustrated with
being observed frequently.
105. At 9.06pm, an officer responded when Mr Anderson pressed his emergency cell
bell. He asked the officer why the telephone was no longer working, and the
officer explained that the phone system was down across the prison. Mr
Anderson appeared to accept this, and no concerns were noted. Because Mr
Anderson was not on any additional monitoring, he was not checked again
throughout the night.
106. The prisoner who lived in the cell next door to Mr Anderson said that they spoke
during the evening and Mr Anderson had said he was not bothered about his
sentence. He said that the conversation was no different to any other night and
there was no obvious sign that Mr Anderson was in crisis. He said when he woke
during the night he could hear Mr Anderson’s television but thought he had
possibly taken a sleeping tablet and just fallen asleep without switching it off.
Prisons and Probation Ombudsman 17
107. Between 15 November and 24 November, Mr Anderson made 138 calls to his
family and friends; not all calls were answered. The investigator listened to the
calls in the week before he died. At times Mr Anderson was jovial, but at others
sounded down. He told his family and friends that he was struggling with his
mental health and had waited over four months to be seen by the mental health
team and was only referred to the psychiatrist after he had self-harmed.
108. On 24 November, Mr Anderson made 26 calls, again not all were answered. He
spoke to six different friends, his mother and partner. He said that he had been
sentenced and that the information on the news made him look bad. Mr
Anderson spoke about getting off the island and wanted to rehabilitate himself.
The last conversation he had was at 6.19pm with his mother, which lasted for
around five minutes. Although at times he sounded a little down, there was
nothing in these calls that suggested he was in crisis. Mr Anderson spoke to his
ex-partner five times the day he was sentenced. These were not recorded as the
prison had incorrectly marked her number as though she was an advocate
(despite being listed as his partner). Mr Anderson tried to call her again twice
after he spoke to his mother, but they were not answered. (All prisoners’
telephone calls, except those that are legally privileged, are recorded, and prison
staff listen to a random sample.)
25 November
109. CCTV shows that around 7.31am, an officer started the early morning routine
check of all prisoners on the unit. She arrived at Mr Anderson’s cell two minutes
later. She looked through the observation panel in the door and could not see Mr
Anderson in bed. She checked to see if he was using the toilet, put the night light
on and saw him on the floor. She said Mr Anderson looked as though he had
slumped off his bed with his head was between his legs. She tried to get a
response from Mr Anderson by shouting his name and kicking the door. She
used her radio to request the operational manager attend the wing and made a
further urgent request for healthcare to attend.
110. The officer entered the cell at 7.35am, when she saw her colleagues responding
to her urgent request. She did not enter sooner, as there had been recent
incidents of prisoners pretending to be dead or trying to jump out at staff to scare
them, so she made a dynamic risk assessment not to enter until other colleagues
were present for her own safety. When staff entered the cell, they found Mr
Anderson with a white plastic bag over his head, tied with headphones. The
officer said that when she touched him, Mr Anderson was cold. Staff removed the
plastic bag and moved Mr Anderson to the landing where there was more space
to start cardio-pulmonary resuscitation (CPR). Two nurses quickly responded,
and officers shouted for them to bring the emergency medical equipment. They
attached a defibrillator to Mr Anderson which indicated he had no shockable
heart rhythm. One nurse was unable to insert an airway, as Mr Anderson’s jaw
was clamped shut due to rigor mortis.
111. Isle of Man Ambulance Service records show that an ambulance was requested
at 7.38am. Paramedics arrived at the scene at 7.49am. Mr Anderson’s death was
declared at 7.55am.
112. Staff covered Mr Anderson’s body with a sheet and placed screens around him
to preserve his dignity. A nurse sat holding Mr Anderson’s hand until around
18 Prisons and Probation Ombudsman
9.25am, before returning to her duties. Mr Anderson’s body remained in situ on
the landing. Police attended the scene at around 9.53am, and Mr Anderson’s
body was removed at 1.12pm.
113. Mr Anderson did not leave a suicide letter. After his death Mr Anderson’s mother
provided the investigator with a letter from his ex-partner, the contents of which
are likely to have upset Mr Anderson. We do not know when Mr Anderson
received this letter or if it had any impact on his decision to take his own life.
Contact with Mr Anderson’s family
114. Isle of Man Constabulary broke the news of Mr Anderson’s death to his family.
The police told prison managers that the family did not want anything to do with
them and so they did not attempt to make any further contact. The family did not
receive a condolence letter and there was no offer of assistance towards funeral
costs. Mr Anderson’s funeral was held on 21 December 2022.
Support for prisoners and staff
115. After Mr Anderson’s death, there was not a collective debrief for all staff involved
in the emergency response as there should have been. Senior managers did
speak to people individually, but not everyone felt supported. The staff care team
and prison psychologists also offered support.
116. The prison posted notices informing other prisoners of Mr Anderson’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 Anderson’s death.
The prison does not have a Listeners Scheme (prisoners trained by Samaritans
to support other prisoners), but Samaritans attended the prison and offered
support. A memorial service was held on 22 December 2022.
Post-mortem report
117. The post-mortem report concluded that Mr Anderson’s death was due to plastic
bag suffocation and ligature compression of the neck. Toxicology results showed
only his prescribed medication and did not find any illicit substances.
Prisons and Probation Ombudsman 19
Findings
Management of Mr Anderson’s risk of suicide and self-harm
118. Isle of Man Prison’s suicide and self-harm prevention measures are known as
Folder 5. This process is set out in the prison’s Self-harm and Suicide Prevention
Policy and Procedures dated 5 May 2022. This process is, in part, reflective of
the ACCT procedures adopted in England and Wales. The documentation is
similar to a previous version of ACCT plans, but the recording of daily
observations and contacts are made separate to the document in the prisoners’
electronic record.
119. In their recent inspection of Isle of Man Prison, HMIP found that the management
of prisoners at risk of suicide and self-harm was inadequate. We also found the
approach to the prevention and management of suicide and self-harm relied
heavily upon good staff/prisoner relationships, and previous knowledge of the
individual, rather than there being an evidenced based, objective assessment of
the risks and triggers. Staff had not been sufficiently trained and the process for
supporting prisoners at increased risk relied on monitoring rather than addressing
the needs of the prisoner to reduce that risk. This was evident in how Mr
Anderson was managed in the week leading up to and on his return from court,
when he was sentenced.
Folder 5 procedures
120. Prison staff started Folder 5 measures on three separate occasions during Mr
Anderson’s most recent time in custody (26 July to 9 August, due to history of
self-harm;12 to 29 September, after he made significant cuts to himself and 16 to
18 November, when he became stressed about his upcoming sentencing
hearing).
121. There was some good practice. Staff spent time with Mr Anderson to understand
his issues and frustrations, they were proactive in providing support and showed
compassion and understanding. There were frequent and detailed entries on his
prison record. However, we found too much emphasis was placed on staff’s
previous knowledge of Mr Anderson, rather than assessing and understanding
other factors that impacted on his risk. Staff did not consider asking Mr Anderson
if he wanted his family involved in the Folder 5 process as an additional source of
support.
Folder 5 - 16 to 18 November
122. Mr Anderson had received excellent reports for his work and engagement on the
wing and he was hoping to gain his enhanced status. Yet in the week or so
before he was due for sentencing (originally scheduled for 18 November), he
struggled controlling his emotions. Mr Anderson had previously spoken freely
about his impulsiveness and how this sometimes led him to self-harm. The
decision to start Folder 5 procedures was appropriate to provide him with
additional support leading up to his court appearance. However, when his
sentence date was rescheduled to 24 November, the upcoming court date was
not considered as an ongoing trigger. Nor, it seems, was his ongoing anxiety
20 Prisons and Probation Ombudsman
about Social Services’ involvement with his children, or the possibility that his
recent diagnosis of hepatitis C might also cause him to worry.
123. The decision to close the Folder 5 on 18 November was poorly judged, and
apparently based on Mr Anderson’s statement that he had no thoughts of suicide
or self-harm, rather than an objective consideration of the ongoing stressors in
his life.
124. Isle of Man Prison did not have an effective staff suicide and self-harm
awareness training programme. Staff who completed and managed Mr
Anderson’s Folder 5s had not been trained to complete the Folder 5 assessment
and nobody had been trained as case manager. Most staff had either never had
any specific Folder 5 training, or not received recent refresher training or ever,
except for observing a colleague. The policy requirement that reviews were held
every 48 hours, regardless of risk and need, meant that it was difficult to ensure
consistency in who chaired or attended the reviews.
125. Caremaps, used to record the specific issues that led to the opening of a Folder
5 and what actions would be completed to reduce the risk, were ineffective and
not reviewed. A good caremap identifies specific, realistic, achievable actions
which are linked to and should address the prisoner’s individual risks. One of the
actions on Mr Anderson’s caremap was that he should ‘keep himself safe and not
self-harm’, with little further detail of how that would be achieved. Several risk
factors were unresolved, including ongoing mental health problems that had not
been assessed, despite having been flagged as an issue when he first arrived at
the prison. A full mental health assessment would have assisted staff to make a
more informed decision about Mr Anderson’s risk. (The provision of mental
health support is covered in more detail in a separate section.) Drawing up an
effective caremap requires training, and in the circumstances, we are not
surprised that staff struggled with this aspect of Mr Anderson’s Folder 5.
126. Isle of Man Prison had been reviewing the Folder 5 process for some time and
had intended introducing a bespoke Custody Care Plan. However, during the
PPO investigation, the Head of Isle of Man Prison and Probation Services and
prison Governor decided the prison would adopt the newest version of the ACCT
process used in England and Wales, which was already well established. The
implementation of ACCT is set out in a comprehensive Prison Service Instruction
(PSI) 64/2011 Management of prisoners at risk of harm to self, to others and
from others (Safer Custody).
127. On 10 July, HMPPS Safety Team visited Isle of Man Prison for four days to
deliver ACCT training. During this training week, 79% of prison officers were
trained and 100% of healthcare, education, and Bidvest Noonan staff. In addition,
seven staff were trained as ACCT assessors and five as case coordinators. Four
staff have also been identified to complete the train the trainer course for ACCT
assessors, to ensure ACCT training can be delivered to those not able to attend
the initial training, or new starters. Any officer promoted to SO will be trained as a
case co-ordinator.
128. The decision to implement ACCT is a positive step forward. The ACCT process
will replace the Folder 5 from 1 October 2023. Given that Isle of Man Prison has
already made the decision to adopt the latest version of ACCT and introduced a
Prisons and Probation Ombudsman 21
comprehensive training strategy, we do not make a separate recommendation.
HMIP are due to return to Isle of Man Prison in April 2024, and will review how
the new system has been implemented.
Court appearance
129. Before he left for court on 24 November, Mr Anderson had asked for peer
support to be arranged for him on his return and handed over his razor. This
should have alerted staff to him feeling anxious and concerned for his safety.
130. Mr Anderson travelled to court with a PER form that was inaccurate and did not
have any detail about his mental health, previous incidents of suicide attempts
and self-harm or the fact he was in Folder 5 post-closure. We found that all staff
responsible for completing the PER were unsure what information should be
recorded. This meant that Bidvest Noonan escort contractors, and court staff,
were unaware of his risks. Mr Anderson was distressed in the courtroom dock,
but no specific details were recorded on the PER. When he was taken to the cell
after sentencing, he punched the door injuring his hand, yet nobody at the court
considered starting a Folder 5. The Regional Manager for Bidvest Noonan said
that it had been rare for court staff to initiate a Folder 5, but in more recent times
they had started the Folder 5 process very regularly. He said awareness of the
process had been poor and staff had not been provided with sufficient training on
when or how to complete them, despite several requests to the prison.
131. In March 2020, a prisoner took his own life the day after he had been remanded
into custody. The inquest found that vital information about his risk of suicide and
self-harm noted on the PER had not been considered when he arrived at Isle of
Man Prison. In response, the prison changed their process and emailed the PER
to all managers to ensure information was considered when assessing risk.
Although this change meant staff had the PER, there was no process to audit the
quality and accuracy of information or if staff understood how to assess the risks.
132. We found that despite the changes made after the previous death, crucial
information was missing from Mr Anderson’s PER which indicates that current
processes are not sufficient. We make the following recommendations:
The Governor, Manx Care and the Regional Manager for Bidvest Noonan
should ensure staff understand the purpose of and their responsibilities
when completing a PER and introduce a robust quality assurance process
to monitor accurate and appropriate information sharing.
Return to the prison after sentencing
133. When Mr Anderson returned from court, staff were proactive in checking on his
welfare and offering support, including safer custody, the healthcare manager
and his CSO. Observations were put in place over the lunch period, but staff
appear to have been overly accepting of Mr Anderson’s assurances that he did
not have any thoughts of suicide or self-harm and they did not consider re-
opening the Folder 5.
134. Although a prisoner’s presentation can reveal something of their level of risk, it is,
at best, only a reflection of their state of mind at the time that staff assess their
22 Prisons and Probation Ombudsman
risk (and it may not even be that) and should be considered as one piece of
evidence. It is critical that all risk factors are considered to ensure that a
prisoner’s level of risk is judged holistically. While we cannot know if continued
monitoring on Folder 5 in the days before sentencing or re-opening the Folder 5
on the day of sentencing would have prevented Mr Anderson from taking his life,
it would have provided an additional level of monitoring and support.
135. Isle of Man Prison has no separate policy or guidance for Early Days in Custody.
In England and Wales PSI 07/2015, Early days in custody, states that there must
be arrangements in place to assess prisoners whose status or demeanour may
have changed after a court appearance whether in person or via video link.
Further, Prison Service Order (PSO) 3050, Continuity of healthcare for prisoners,
says that events such as attending court or sentencing at court, are factors that
might have a significant impact on the health of a prisoner. When prisoners pass
through reception on their return from court, prisons are required to have
protocols in place for screening them to identify any potential suicide and self-
harm issues. Prison and healthcare staff at Isle of Man Prison said there was no
routine assessment of prisoners following an appearance in court. We consider
that Isle of Man Prison would benefit from adopting a similar approach to that in
English and Welsh prisons and make the following recommendation:
The Governor and Manx Care should establish a process to ensure that
prisoners returning from a court appearance (in person or by videolink) are
assessed for their risk of suicide and self-harm.
Availability of plastic bags
136. In response to the death of a prisoner in March 2020, the prison removed plastic
bags from reception and the induction unit. Following Mr Anderson’s death, they
stopped using plastic bags to deliver prisoners’ canteen. Since the death of
another prisoner in February 2023, all plastic bags used on the wings have been
removed, except for those used in the bins situated on the wing landing which
were swapped on a one for one basis. We do not know why all three men had
used this method, but it was suggested by most people interviewed, including
other prisoners, that this was the chosen method simply because it had been
effective previously. Not including the deaths at Isle of Man Prison, between
January 2020 and October 2023, the PPO has been notified of and began
investigations into 297 self-inflicted deaths in the prison estate in England and
Wales. Six of these (or 2%) were classified as suffocation using a plastic bag.
137. The ongoing availability and use of plastic bags at the prison was questioned by
the bereaved families. The cells in Isle of Man Prison had few, if any, ligature
points and we know that if a person is intent on taking their own life they will find
a way. We consider that a blanket approach to the management of suicide and
self-harm risk is not helpful and should be based on individual circumstances and
factors. If a prisoner is identified as at risk of suicide or self-harm then the
removal of plastic bags should be considered as part of the management plan.
Prisons and Probation Ombudsman 23
Clinical care
138. While there cannot be a direct comparison, the objective of the clinical review is
to establish if Mr Anderson received equivalent care to that he would have
expected to receive in the community. To provide a meaningful conclusion on
equivalence of care, the clinical reviewer focused on whether there was
equivalence of access to healthcare within the prison compared to the Isle of
Man community (given Manx Care provide both services) and compared with
healthcare provision delivered within prisons in England and Wales.
139. The clinical reviewer produced two reports. An overview of healthcare services
provided by Manx Care, and one specifically reviewing Mr Anderson’s care.
These reports should be read in conjunction with the findings in this report. The
clinical reviewer has made a number of recommendations which we have not
included in our report but should be actioned by the Department of Health and
Social Care and Manx Care.
Mental health
140. We found that the mental health services provided within Isle of Man Prison were
inadequate, unsafe, and not equivalent to what is available in the wider
community and in other comparable prisons in England and Wales. Issues
identified following the inquest into the previous death in March 2020, had not
been sufficiently addressed.
141. Mr Anderson had been known to mental health services since he was 11 years
old. Throughout his time at Isle of Man Prison, he asked to be referred to the
mental health team and was told that he had been. The referral process at the
time of this investigation was by way of an electronic form, completed by
healthcare staff, and emailed directly to the Integrated Mental Health Service
(IMHS). However, we found no evidence that Mr Anderson had been referred,
despite medical records suggesting he had. It is understood that Mr Anderson
was ‘open’ to the mental health team already when he arrived at the prison (so
no referral was necessary), but no one alerted them that Mr Anderson was in
custody or asked them to see him during his time there. Healthcare staff, prison
staff and prisoners told us that accessing mental health services within the prison
was difficult and waiting lists excessive. However, the General Manager of the
Integrated Mental Health Service said that referrals from the prison were low and
that there were no waiting lists.
142. The General Manager confirmed that the IMHS did not receive a referral for Mr
Anderson. We were unable to establish why a referral was not made or why his
mental health was never fully assessed. During the investigation, healthcare staff
told us that prisoners can either be under the care of the mental health team or
DAT, but not both. The General Manager confirmed that, if it was clinically
appropriate, a prisoner can be under the care of both services. A forensic
psychologist works at the prison, but we were told they only work with sentenced
prisoners. Referrals/allocations open to the IMHS should be checked on RiO (the
electronic mental health record) on reception, but this check was not carried out
for when Mr Anderson arrived at Isle of Man Prison.
24 Prisons and Probation Ombudsman
143. The clinical reviewer concluded that the confusion over Mr Anderson’s referral to
the mental health team reflected poor understanding of the process, poor
communication between services and poor integrated working. We make the
following recommendations:
The Department of Health and Social Care and Manx Care should review
the current provision of mental health services at Isle of Man Prison and
provide a dedicated mental health service, which is sufficiently resourced
to meet the needs of the population.
Manx Care should undertake a systemic population health needs
assessment across Isle of Man Prison to determine the prevalence of
mental health conditions and need.
Medication
144. Mr Anderson had been prescribed psychotropic medication for his mental health
before entering prison. However, when he arrived at Isle of Man Prison the
clinical reviewer found that the reasons for this medication were not fully
ascertained or understood. He was never seen for a face-to-face review of his
medication while in prison.
145. Between 26 and 29 July, Mr Anderson was given his medication without a
prescription, via a transcribed medication record (copying of previously
prescribed medications) created by prison nurses. We were told that nurses felt
they had to transcribe in the prisoners’ best interests, so they did not go without
their medication. This is not lawful prescribing and against the Nursing and
Midwifery Council prescribing code (NMC - professional standards of practice).
We found no evidence the medications prescribed to Mr Anderson had any
adverse impact on him. However, the governance around medication, in
particular medications that are deemed a high risk in prison settings, was poor.
Manx Care do not use The Royal College of General Practitioners (RCGP) 2019
guidance for ‘safer prescribing in prisons’. There should have been better
governance around prescribing highly sedative medication in response to Mr
Anderson’s increasing risk of suicide and self-harm. Further, he had his
quetiapine medication in his possession, which posed a potential risk of
overdose, a method he had previously used. We make the following
recommendations:
The Department of Health and Social Care should ensure the practice of
transcribing and unsafe medication practices at Isle of Man Prison have
stopped.
Manx Care should ensure there is a dedicated lead pharmacy provision at
Isle of Man Prison and there is a prescriber available every day, even if that
is for remote prescribing.
Manx Care should implement electronic medication administration records.
Manx Care should ensure that patients who come in with complex and
high-risk medication (as per the RCGP guidance) have a medication review
when they arrive at the prison.
Prisons and Probation Ombudsman 25
Physical health
146. The clinical reviewer concluded the physical healthcare Mr Anderson received
was good. He had an annual asthma review, which was stable, in line with NICE
guidelines (National Institute for Health and Care Excellence). Mr Anderson was
diagnosed with hepatitis C while at Isle of Man Prison. Staff provided him with
support and information and the management of his condition was in line with
NICE guidelines.
Governance of healthcare services
147. We found healthcare staff morale was low. Staff felt frustrated by the lack of
response from senior managers when issues were raised and how long
processes took to change. We were provided with the Manx Care governance
structure and there appeared to be a lack of clinical governance and quality
oversight dedicated to prison healthcare. The approach to making changes
around clinical governance and healthcare policy seemed to be largely reactive
after an event, rather than it being a proactive approach with a drive for
continuous evaluation and improvement. We found there were evident layers of
complicated bureaucracy when it came to clinical governance and making
changes to the healthcare system. We were not assured that there were clear
lines of responsibility within the governance and executive structure.
148. There was evidence of good clinical practice by individual members of healthcare
staff who worked on goodwill and dedication. However, we found that the
importance of promoting staff wellbeing and resilience was not given the priority it
deserves, with an overall lack of support, supervision, and training. Healthcare
staff said that there were no regular team meetings and that they did not have
clinical supervision. We were told that this issue related to recruitment
challenges, staff turnover, sickness, and several senior management changes.
Throughout our investigation the healthcare manager was required to help on an
operational level due to staffing issues, impacting on her managerial and
strategic responsibilities. We found there was not enough resilience within the
healthcare system at the prison. We make the following recommendation:
Manx Care should have a dedicated clinical governance lead responsible
for prison healthcare at Isle of Man Prison to ensure practice is compliant
and underpinned by national guidance, legislation and evidence-based
practice.
Emergency response
Communicating the emergency
149. Isle of Man Prison does not have a clearly understood policy on communicating a
medical emergency. (During the consultation process, Manx Care said that a
medical emergency response procedure was introduced by prison healthcare in
2014 in conjunction with the then Governor. Changes in prison and healthcare
leadership have led to a ‘loss of organisational memory’ which resulted in this
procedure not being recalled by staff during the investigation). When Mr
Anderson was discovered, an ‘urgent’ message was radioed. Some staff thought
this was for a medical emergency, some staff said this was for any significant
26 Prisons and Probation Ombudsman
incident and other staff did not know what an ‘urgent’ call signified. Staff did
respond quickly, including healthcare staff, but it was only once Mr Anderson had
been assessed that an ambulance was requested, a delay of around five
minutes. In this instance, the delay did not make any difference to the outcome,
as Mr Anderson was already dead.
150. PSI 03/2013, Medical Emergency Response Codes, which is used within
English, Welsh and Scottish prisons, sets out the actions staff should take in a
medical emergency. Two distinct codes are used; code blue if a person is
unresponsive or not breathing, and code red if there is significant blood loss or
burns. It contains mandatory instructions for Governors to have a protocol on
efficiently communicating the nature of a medical emergency, ensuring staff take
the relevant equipment to the incident and that there are no delays in calling an
ambulance. It says that if a medical emergency code is called over the radio, an
ambulance must be called immediately.
151. We found that staff did not have any clear guidance on effectively communicating
when there is a potentially life-threatening medical emergency. We recommend
the following:
The Governor should introduce a clear protocol to staff for effectively
communicating a medical emergency.
Resuscitation
152. In September 2016, Professor Sir Bruce Keogh, National Medical Director at
NHS England wrote to Heads of Healthcare for prisons and Immigration Removal
Centres in England and Wales introducing new guidance to support staff on
when not to perform cardiopulmonary resuscitation. This guidance was designed
to address the issue of inappropriate resuscitation following a sudden death in a
prison and was taken from the European Resuscitation Council Guidelines 2015
which state, “Resuscitation is inappropriate and should not be provided when
there is clear evidence that it will be futile”. We were told that the Manx Care
Governance Team were not aware of this guidance, despite it being published in
2016.
153. The officer told the investigator that she believed Mr Anderson was already dead
when she discovered him. A nurse said she observed that Mr Anderson showed
signs of rigor mortis, which occurs some hours after death. When paramedics
arrived, they also recorded there were obvious signs of death, and that rigor
mortis was present. We understand the commendable wish to attempt and
continue resuscitation until death has been formally recognised, but staff should
understand that they are not required to carry out CPR in these circumstances.
Trying to resuscitate someone who is clearly dead is distressing for staff and
undignified for the deceased.
154. Isle of Man Prison does not have a policy or guidance on when it is not
appropriate to start CPR. We were told by all those we interviewed that they were
required to commence CPR until a doctor or paramedic declared death, which
was reflected in guidance from 2015 which stated that staff should continue CPR
‘irrespective of the length of time they (the prisoner) was thought to have been
lifeless’. We were unable to establish what informed this guidance and it was
Prisons and Probation Ombudsman 27
suggested it was based on personal, moral, and ethical views of those involved
in writing the policy, although it was ratified by the Policies and Procedures
Committee of the Department of Health and Social Care.
155. Manx Care had identified the need for guidance on when it is not appropriate to
commence CPR after the previous death, which was again highlighted after Mr
Anderson’s death. There has been another death since, when staff felt the need
to commence CPR when it was not appropriate to do so. During her interview in
June 2023, the Care Quality and Safety Coordinator for Manx Care said that new
guidance was in the process of being agreed. Given this was three years since
the first of the three self-inflicted deaths, seven months after Mr Anderson’s
death, and there had been a similar incident in February 2023, we do not
understand why this guidance was not given greater priority. Had the guidance
been published sooner, the trauma staff experienced would have been reduced,
and the indignity for the deceased would have been avoided.
156. After Mr Anderson’s death there was a review of the prison healthcare
department’s response to the care needs of Mr Anderson by the Care Quality
and Safety Coordinator, which concerningly highlighted that the prolonged CPR
given to him was good practice.
157. Manx Care responded to feedback during the PPO investigation about the need
to expedite and publish revised guidance. The new guidance was agreed in June
2023, and reflects that in effect in England and Wales. However, it is directed to
Manx Care staff only and is not joint guidance for both healthcare and prison
staff. We make the following recommendation:
The Governor and Manx Care should ensure that there is clear joint
guidance and training for all staff, about the circumstances in which
resuscitation is inappropriate in accordance with European Resuscitation
Council Guidelines.
Events after Mr Anderson was declared dead
158. The Death in Custody Policy dated 19 April 2018 (subsequently reviewed on 1
December 2022 by the Deputy Governor) states that following a death the body
must be moved in accordance with the protocols previously agreed with the
police and Coroner. We requested a copy of this protocol, but it was not
provided.
159. After paramedics declared that Mr Anderson had died, his body was covered with
a sheet and screens placed around him. Prisoners remained behind their doors
and food was delivered to them by staff. Mr Anderson’s body was left lying on the
landing for around five hours before it was collected by a private ambulance. All
staff interviewed said that they believed his cell and the area on the landing was
a ‘crime scene’ and they could not move Mr Anderson’s body until the police had
given their authority. Isle of Man Prison do not have any specific death in custody
contingency plans, so were guided by the police who advised them to leave Mr
Anderson’s body on the landing.
160. The investigator contacted the Acting Detective Chief Inspector for Major and
Specialist Investigations and Intelligence Departments from the Isle of Man
Constabulary, to ask if there was guidance or policy on returning the deceased to
28 Prisons and Probation Ombudsman
their cell. She explained that the police would always request that, as far as
reasonably possible, a body is left in situ to prevent any further disturbance of
forensic evidence (although there was no shared understanding of what specific
evidence this referred to) in a suspicious case and to rule out any third-party
involvement. She said this was standard practice in any sudden death, but the
context of a prison death had not been specifically considered.
161. We consider it was inappropriate and distressing that Mr Anderson was not
moved back into his cell. There was no suspicion a crime had been committed.
Staff had already entered Mr Anderson’s cell when he was discovered and
moved him to the landing, so it would not have made any significant difference if
his body had been sensitively placed back into the cell. Prison managers
reflected that they were very conscious of the time it had taken to remove Mr
Anderson’s body, which was also the case in the previous death in March 2020
and the subsequent death in February 2023, but had not specifically had any
discussion with the Isle of Man Constabulary regarding a protocol following a
death in custody. We make the following recommendation:
The Governor should consider establishing a protocol with the Isle of Man
Constabulary to ensure that following a death in custody the deceased’s
body is moved back into their cell for dignity, if there is no suspicion of a
crime.
162. Both nurses did not want to leave Mr Anderson, and both stayed with him after
he was declared dead. One nurse had to return to her duties, so the other nurse
sat with Mr Anderson for around two hours because she did not want to leave
him alone where he was. When she did leave him, she also returned to her
healthcare duties. This event was hugely distressing for all staff involved in the
emergency response. Both nurses showed a high degree of compassion, went
beyond what could be reasonably expected and should be commended for their
level of care.
Informing Mr Anderson’s family
163. The Death in Custody Policy states that it is essential following a death that
prison staff work openly with bereaved families, that the prison must inform the
next of kin and any other person reasonably expected to be informed and that it
was good practice to appoint a dedicated family liaison officer (FLO).
164. Isle of Man Constabulary broke the news of Mr Anderson’s death to his family
before the prison had an opportunity to do so. The visiting prison chaplain is a
trained FLO at Isle of Man Prison and had undertaken his training at HMPPS
training centre. Although the Governor said he knew the chaplain was a trained
FLO, the Deputy Governor did not. He said he believed the decision for the
police to inform Mr Anderson’s family was made because there was not a trained
FLO at the prison.
165. Because the police told the prison that Mr Anderson’s family wanted no further
contact from the prison, they did not attempt to do so. Isle of Man Prison did not
consider contributing towards the cost of Mr Anderson’s funeral (in England and
Wales the prison contributes up to £3,000 towards funeral costs) and did not
send the family a condolence letter.
Prisons and Probation Ombudsman 29
166. The Governor explained that the Acting Detective Chief Inspector was against
the prison making contact, given the family’s feelings, and that the police had
appointed a FLO. He said he did not want to antagonise the family by contacting
them, against the advice from the police, but accepted that further efforts could
have been made and a condolence letter should have been sent.
167. We found that contact with Mr Anderson’s family should have been more
considered and the prison did not follow its own Death in Custody Policy.
Although the chaplain is a trained FLO, the prison must have enough trained
prison staff to undertake this vital role. We make the following recommendation:
The Governor should ensure that the prison complies with its own policy
for contacting the family of a deceased prisoner and that they have
adequately trained family liaison officers.
Staff support
168. Giving staff the opportunity to collectively discuss an incident and reflect on all
aspects of how it was managed is fundamental to providing the prison with
feedback on any issues that need to be addressed. It also provides those directly
involved with an opportunity to process events. This is also stipulated in the
prison’s Death in Custody Policy.
169. Although staff involved in the emergency response were spoken to individually
after Mr Anderson’s death by the operational manager, there was not a collective
debrief as there should have been. The staff care team and the TRiM manager
(trauma risk management for staff) contacted staff and support was offered by a
prison psychologist.
170. Many staff involved in the emergency response said that support after Mr
Anderson’s death could have been better and they did not feel sufficiently
supported. Both nurses had to return to medication duties, despite senior Manx
Care staff being in the prison. Neither Isle of Man Prison nor Manx Care have
specific death in custody contingency plans, which meant they were being
reactive on the day in a situation that was not common. While we accept that the
prison does not have many deaths, there should have been a proactive response
after the previous death in March 2020 and contingencies reviewed and agreed
so senior staff understood the expectations. We make the following
recommendation:
The Governor and Manx Care should ensure that all relevant staff,
irrespective of status, position, or experience, are able to attend a debrief
following a death in custody and that they receive appropriate aftercare
support.
Isle of Man Prison response to deaths in custody
171. There was no independent investigation into the circumstances surrounding the
death in March 2020. We understand that the prison conducted an internal
investigation and they responded to the findings at the conclusion of the inquest.
Changes were made to practice and processes at Isle of Man Prison; plastic
bags were removed from reception and the induction wing, anyone with a history
30 Prisons and Probation Ombudsman
of suicide or self-harm was placed on a Folder 5 when they arrived at the prison
and PER forms were sent to all managers. However, we found that these
changes did not result in improved management of those at risk of suicide or self-
harm.
172. The PPO was commissioned to complete an investigation into the two most
recent deaths, following the HMIP Inspection that took place between 27
February and 10 March 2023 (a prisoner died in similar circumstances in
February 2023). There are many similarities in all three self-inflicted deaths.
Although some of the learning in this report had already been identified by the
prison and Manx Care, the healthcare providers, this has not resulted in the
change we would have expected to see. We therefore recommend:
The Department of Home Affairs should consider immediately
commissioning an independent investigation in the event of any future
non-natural deaths at Isle of Man Prison.
Governor to Note
Safer Custody Meeting
173. Isle of Man Prison holds a monthly Safer Custody Meeting (SCM). The Self-harm
and Suicide Prevention Policy and Procedures document, dated 5 May 2022,
sets out who is required to attend, including the Deputy Governor, who is chair,
the Safer Custody Principal Officer and Healthcare Manager. The objectives of
the meeting include the monitoring, delivery and quality of the Folder 5
procedures. We found, as did HMIP, that governance and oversight of this
critically important area was poor.
174. The investigator requested copies of SCM minutes between June 2022 and June
2023. There were no minutes for July or December 2022. The Deputy Governor
said that the meetings may have been rescheduled for staff to attend and that
they were not cancelled but ‘postponed… so one meeting is counted as two,
effectively’. Of the ten meetings that did take place between these dates, the
healthcare manager only attended three meetings (10 January, 9 February, and
20 June 2023). The current manager only took up post a few weeks before Mr
Anderson’s death and there was no agreed protocol for someone else from Manx
Care to attend. The Principal Officer from Safer Custody also attended just three
meetings (8 September, 9 February and 20 June 2023). There was no specific
mention in these meetings of Mr Anderson’s death.
175. While we understand that there is a daily briefing and staff exchange information
about those prisoners where there are concerns, the SCM should be a priority for
the prison. We found that the information recorded lacked meaning. The
meetings were only monthly, and attendance was inconsistent.
176. During the investigation we raised our concerns with the Governor. Since 24
June 2023, the prison has now introduced a weekly Review of Complex Cases
(RoCC) meeting, the aim and objective of which is set out in the new Complex
Case Strategy. All staff have been informed and advised how to make a referral.
Attendance by the senior leadership team is mandatory, as well as
representatives from across the prison. The RoCC aims to ensure that risk
Prisons and Probation Ombudsman 31
information is accurately recorded, and relevant information is shared with all
prison and probation staff, as well as external agencies to ensure the safety and
well-being of prisoners. Given the prison has already taken action to address this
issue, we do not make a separate recommendation.
Prison record
177. Isle of Man Prison uses PIMS (Prisoner Information Management System) an
electronic record where all contacts and events are recorded. We found that
entries in Mr Anderson’s record were frequent and detailed. However, each time
a prisoner comes into custody, a new record is created for them. This means that
information recorded on earlier sentences is not so easily accessible, resulting in
potentially key information about risk being overlooked. The Governor will wish to
consider this.
Listeners Scheme
178. Isle of Man Prison does not have a Listeners scheme. (Listeners are prisoners
who have been specially trained by Samaritans to provide support to their peers.)
The first Listener scheme was introduced in an English prison in 1991 and
Listener schemes operate in almost every prison in the UK. The Deputy
Governor said the prison would be keen to introduce Listeners at Isle of Man
Prison, but Samaritans on the island were reluctant to deliver training. While we
understand the population is very small and many prisoners would not be serving
sufficiently long sentences to justify training, this should be further explored.
Body Worn Video Cameras
179. Body Worn Video Cameras (BWVC) are not currently used in Isle of Man Prison.
BWVC’s are an important source of evidence for investigations and wider
learning for prisons following an incident. HMPPS staff are required to wear
BWVCs, and the relevant policy requires prison staff to activate them during any
reportable incident, including medical emergencies. The Department of Home
Affairs will wish to consider this.
Healthcare to Note
Medical records
180. We found the clinical records system at Isle of Man Prison (and across the
island) was disjointed, cumbersome and not fit for purpose. The prison, hospital,
mental health team, and GP surgeries all have separate recording systems that
do not link up. This means that information either has to be duplicated across
systems, or more concerningly, significant information about care and clinical
need is not shared. We were told that various reviews of the medical record
sys