Charnley, Bradley

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Bradley
Charnley, a prisoner at HMP
Risley, on 13 August 2020
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
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to
any cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Bradley Charnley was found hanged in his cell at HMP Risley on 13 August 2020. He
was 23 years old. I offer my condolences to Mr Charnley’s family and friends.
Mr Charnley had a history of mental health problems, substance misuse and self-harm.
However, although Mr Charnley had risk factors for suicide and self-harm, there was little
to indicate to prison staff that he was at imminent risk of suicide.
I am, however, concerned that Mr Charnley did not have a planned mental health
assessment in the weeks before he died, and there is no evidence that his mental health
was monitored in that time. This was a missed opportunity to review Mr Charnley’s mental
health and wellbeing fully before he died. I have also recommended a more collaborative
approach between the substance misuse team and the mental health team.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister CB
Prisons and Probation Ombudsman May 2021
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 10
Summary
Events
1. Mr Bradley Charnley had a history of mental health problems, substance misuse
and self-harm, and had been in prison several times since the age of 16.
2. He was transferred to HMP Risley on 28 June 2019. He was referred to the
substance misuse and mental health teams when he arrived.
3. On 16 June 2020, following a deterioration in his mental health, a nurse started a
full assessment of Mr Charnley’s mental health, but was unable to complete a
comprehensive assessment due to time restraints imposed as a result of the
COVID-19 pandemic. Although she scheduled a follow-up appointment for four to
six weeks’ time, it never took place and he was not monitored or reviewed in the
meantime.
4. On 13 August at around 5.08am, while conducting his morning roll check, the night
patrol officer found Mr Charnley hanging in his cell and immediately radioed a
medical emergency ‘code blue’, indicating a life-threatening situation. The night
patrol officer waited for assistance from his manager who arrived within seconds,
closely followed by two officers and a nurse. They entered the cell and found signs
of rigor mortis, so did not attempt to resuscitate Mr Charnley. At 5.34am,
paramedics confirmed Mr Charnley had died.
Findings
Management of risk of suicide and self-harm
5. We consider that Mr Charnley gave prison staff no reason to consider that he was
at imminent risk of self-harm and suicide in the days and weeks prior to his death.
We conclude that his death was not foreseeable.
Mental health assessment and follow-up
6. However, we agree with the clinical reviewer that Mr Charnley’s mental health was
not fully assessed following a referral in May 2020. Mental health staff did not
monitor or assess him again over the next four to six weeks, as planned. We
consider that the failure to follow-up the interrupted mental health assessment was
a missed opportunity to review Mr Charnley and put in place appropriate support
before he died.
7. For this reason, the clinical reviewer concluded that the mental health care Mr
Charnley received at Risley was not equivalent to that which he could have
expected to receive in the community.
8. We were told that mental health services were restricted at the time at Risley
because of the COVID-19 pandemic.
Substance misuse
9. Despite Mr Charnley’s long history of substance misuse, post-mortem toxicology
tests found no traces or drugs or alcohol in his system when he died.
Prisons and Probation Ombudsman 1
10. The clinical reviewer found that Mr Charnley’s mental health and substance misuse
issues were significantly interlinked. We share her concern that although Mr
Charnley clearly had both mental health and substance misuse needs, there was
little joined up working from the two respective teams. We have recommended a
more collaborative approach between the two teams.
Emergency response
11. The control room officer waited five to six minutes before calling an ambulance after
receiving the code blue call. As a result, he failed to meet the requirements set out
in Prison Service Instruction (PSI) 03/2013, which state that an ambulance should
be called immediately after an emergency code. Although it would not have saved
Mr Charnley’s life, we consider that such a delay could be crucial in future
emergencies.
12. We have no other concerns regarding the emergency response, which was prompt,
professional and appropriate.
Key working
13. We commend Mr Charnley’s key worker who saw Mr Charnley regularly and
developed a meaningful relationship with him.
Recommendations
• The Head of Healthcare should:
• work with the Mental Health Lead to ensure there is a robust system for timely
mental health referrals and assessments; and
• ensure that mental health appointments are appropriately recorded on
SystmOne.
• The Head of Healthcare and Substance Misuse Team Manager should ensure that
they work collaboratively to improve joint working and joint care planning for patients
with both substance misuse and mental health issues.
• The Governor should ensure that all staff are made aware of and understand PSI
03/2013, as well as local instructions, and their responsibilities during medical
emergencies, including:
• immediately calling an ambulance when a medical emergency code is called;
and
• promptly providing information about a prisoner’s condition to the control room
so that they have this information when requesting an ambulance.
• The Governor should share this report with the keyworker, so he is aware of the
Ombudsman’s findings.
2 Prisons and Probation Ombudsman
The Investigation Process
14. The investigator issued notices to staff and prisoners at HMP Risley informing them
of the investigation and asking anyone with relevant information to contact him. No
one responded.
15. The investigator obtained copies of relevant extracts from Mr Charnley’s prison and
medical records.
16. The investigator interviewed nine members of staff at Risley. The interviews were
completed by video link and telephone due to the restrictions imposed as a result of
the COVID-19 pandemic.
17. NHS England commissioned a clinical reviewer to review Mr Charnley’s clinical care
at the prison. The majority of the interviews were conducted jointly by the clinical
reviewer and the investigator.
18. We informed HM Coroner for Cheshire of the investigation and have sent the
coroner a copy of this report.
19. We contacted Mr Charnley’s family to explain the investigation and to ask if they
had any issues that they wanted the investigation to consider. We have not
received any questions from the family, and they have not requested a copy of this
report.
20. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS identified some factual inaccuracies, which we have addressed in this
report.
21. The initial report was also shared with NHS England. NHS England identified one
factual inaccuracy, which we have addressed in this report.
Prisons and Probation Ombudsman 3
Background Information
HMP Risley
22. HMP Risley is a medium security training prison which holds over 1,000 convicted
men. Manchester Mental Health NHS Foundation Trust provides healthcare
services in the prison. Greater Manchester West Mental Health Foundation Trust
provide mental health services. Substance misuse services are provided by
Change, Grow, Live (CGL). There is 24-hour healthcare cover.
HM Inspectorate of Prisons
23. The most recent full inspection of HMP Risley was in June 2016. Inspectors
reported that support for prisoners at risk of suicide and self-harm was adequate,
but the quality of ACCT documentation varied. Inspectors found the mental health
team was enthusiastic and well-led. A weekly meeting identified men needing
immediate attention and those needing a routine mental health assessment were
usually seen within two weeks.
24. HMIP also carried out a scrutiny visit to Risley in November 2020 on the conditions
and treatment of prisoners during the COVID-19 pandemic. They found that the
amount of violence and self-harm had reduced at the start of the restrictions. There
had been a subsequent rise in the number of incidents, but this remained below
pre-pandemic levels. This was in the context of improved prison safety and
reducing trends in both violence and self-harm in the year up to the pandemic.
Safety meetings had continued throughout the pandemic and managerial oversight
of this area was good. Inspectors found evidence of a good level of support for
prisoners at risk of suicide or self-harm, supported by the ACCT case management
process. They saw staff engaging well with prisoners. Most prisoners (79%) said
that staff treated them with respect. Key work had been well embedded in the
prison before the pandemic, and weekly checks on the well-being of more
vulnerable prisoners and those near to release had continued during the COVID-19
period.
Independent Monitoring Board
25. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 31 March 2018, the IMB
reported that 53% of prisoners on A-E Wings did not feel safe. (Mr Charnley lived
on A Wing.) The number of prisoners on ACCT suicide monitoring procedures at
Risley had decreased.
Previous deaths at HMP [Prison]
26. Mr Charnley was the fourth prisoner to take his own life at Risley since August
2018. There were no notable similarities in the first two cases to the death of Mr
Charnley. The third case is still being investigated by the Ombudsman.
4 Prisons and Probation Ombudsman
Assessment, Care in Custody and Teamwork
27. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner. 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.
28. As part of the process, a caremap (plan of care, support and intervention) is put in
place. The ACCT plan should not be closed until all the actions of the caremap
have been completed. All decisions made as part of the ACCT process and any
relevant observations about the prisoner should be written in the ACCT booklet,
which accompanies the prisoner as they move around the prison. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011.
Prisons and Probation Ombudsman 5
Key Events
Background
29. Mr Bradley Charnley first served a custodial sentence in 2013, when he was 16
years old. He served several sentences over the next seven years. He had a long
history of mental health problems, substance misuse and self-harm, and a complex
custodial history. Mr Charnley’s medical records contain frequent references to his
substance misuse (psychoactive substances (PS), cannabis, amphetamine,
cocaine and ecstasy). He was assessed as at risk of suicide or self-harm several
times and monitored under HMPPS suicide prevention measures, known as ACCT.
He reported auditory and visual hallucinations to the mental health team, which he
said lessened when he reduced his PS use.
30. On 20 February 2018, Mr Charnley was released from prison on licence. After
committing further offences, he was recalled to prison and taken to HMP Preston on
15 March. During the course of his offences, Mr Charnley self-harmed by stabbing
himself in the neck with a knife. When he arrived at Preston, he was assessed as
at risk of suicide or self-harm and was subject to ACCT monitoring.
31. On 26 October 2018, Mr Charnley was sentenced to 44 months’ imprisonment for
affray and threats to kill.
32. Mr Charnley was transferred to HMP Lancaster Farms on 19 November 2018. Mr
Charnley failed to attend several mental health appointments during his time at
Lancaster Farms and his behaviour became increasingly chaotic. Staff segregated
him following his suspected involvement in a serious assault on a prisoner on 21
June 2019. (Mr Charnley was later interviewed by police as part of a related
manslaughter investigation, but no charges were brought against him.) From 24
June, staff monitored Mr Charnley under ACCT procedures (starting with a short
period of constant supervision) after he tried to stab himself with a television aerial,
repeatedly headbutted a window and his cell wall, and threw himself off his bed.
HMP Risley
33. Although he was still subject to ACCT monitoring, Mr Charnley was transferred to
HMP Risley on 28 June 2019 and located on D Wing. The reception nurse referred
him to both the substance misuse and mental health teams for assessment.
34. Staff at Risley assessed that Mr Charnley was no longer at risk of suicide or self-
harm and closed the ACCT on 1 July. They recorded that Mr Charnley seemed
better and his behaviour was good, although they incorrectly noted that he had no
history of self-harm.
35. On 3 July, the mental health team discussed Mr Charnley’s referral. In the light of
the ACCT review, they decided that there was no evidence that Mr Charnley had
any mental health issues and discharged him from their caseload. They recorded
that he would still get support from the substance misuse team (CGL).
36. On 10 July, Mr Charnley told a substance misuse team worker that he did not think
he needed support because he was ‘in a good place’.
6 Prisons and Probation Ombudsman
37. Mr Charnley was subject to five Challenge, Support and Intervention Plans (CSIPs)
while at Risley. (CSIP is a multi-disciplinary approach which focuses on those who
pose a raised risk of being violent and works to change their behaviour. It is
centred on the needs of the individual, providing them with support to improve and
manage their behaviour.) Mr Charnley’s keyworker said in interview that he thought
it was possible that Mr Charnley was involved in illicit activity on D Wing and
recalled that he was often involved in fights.
2020
38. On 6 May 2020, Mr Charnley told an officer that he was struggling with his mental
health and wanted to engage with the mental health team. The officer submitted a
paper referral for Mr Charnley the same day, but the mental health team did not
note it on SystmOne until 18 May. Staff discussed Mr Charnley’s referral at the
next mental health team meeting on 20 May and scheduled a mental health triage
assessment for 5 June.
39. On 2 June, a nurse examined Mr Charnley after he was found under the influence
of PS. The nurse reported that Mr Charnley was alert and responsive, was of good
colour and had no apparent injuries.
40. On 5 June, a mental health nurse carried out a mental health triage assessment, as
planned. Mr Charnley described feeling “all over the place” and appeared
uncomfortable and distressed. He said that his mental health had deteriorated after
abstaining from illicit substances for two months. He reported that he had self-
medicated and used illicitly obtained quetiapine (an anti-psychotic medication which
he had been prescribed in the past). He described intrusive and racing thoughts,
which were “too disgusting” to discuss, and said he had been exercising to help
manage his mental state. After discussion at the next mental health team meeting,
the nurse added Mr Charnley to her caseload and referred him for a full mental
health assessment.
41. The same day, a substance misuse worker visited Mr Charnley and offered him
advice following his use of PS three days earlier. Mr Charnley told her that he did
not require support as he was engaging with the mental health team.
42. On 16 June, the mental health nurse saw Mr Charnley for a full mental health
assessment but was unable to complete a comprehensive assessment due to time
restraints imposed as a result of the COVID-19 pandemic. Mr Charnley again
described having “disgusting” and intrusive thoughts, which he would swear at and
try to bat away with his hand. Mr Charnley pulled unusual facial expressions during
the assessment and appeared preoccupied. He said that he had been abstaining
from drugs but had slipped up as he started using PS again to relieve his
symptoms. He felt he would benefit from being treated with quetiapine. She told
him that this could be considered if he stopped his illicit drug use.
43. The mental health nurse recorded that she did not feel that Mr Charnley was at risk
of suicide or self-harm as he expressed thoughts about his future and was making
plans for when he was released from prison. In interview, she said Mr Charnley
seemed quite bright and engaged during the assessment and that she “didn’t have
any inkling at all that he had any intention on taking his life”. She felt that a further
period of monitoring (which she described in interview as “watch and wait”) would
Prisons and Probation Ombudsman 7
help gain a better understanding of the relationship between Mr Charnley’s PS
misuse and the symptoms he experienced.
44. The mental health nurse scheduled a follow-up assessment in her personal diary for
four to six weeks’ time. She made no corresponding entry in Mr Charnley’s medical
record. She told the investigator that she did not have time to carry out the follow-
up assessment as planned due to the COVID-19 pandemic. She said that only
urgent mental health cases (defined as prisoners who were acutely unwell and may
need to be transferred to a secure hospital under the Mental Health Act) were being
referred to the psychiatrist due to limited resources during the pandemic. She
assessed that Mr Charnley’s mental health needs were not urgent.
45. The keyworker met Mr Charnley after his mental health assessment on 16 June.
He noted that Mr Charnley’s mental health had deteriorated over the last few
months. On 9 July, he noted that Mr Charnley’s mental health had been affected by
the prison lockdown in response to the COVID-19 pandemic, but that he was in
good spirits and said he was seeing the mental health team who were helping him.
46. Following an assault on another prisoner on 13 July, staff moved Mr Charnley from
D Wing to A Wing and managed him under a CSIP for the final time. The CSIP was
closed three days later and no further action was taken. Mr Charnley said he was
happy to have a fresh start on a new wing. The keyworker recorded that he had
heard that Mr Charnley had been paid to assault the other prisoner.
47. On 11 August, the keyworker met Mr Charnley for the last time before he died. He
noted, “Bradley still chilling on A Wing and enjoying his new environment. He has
already made new friends and contacts on his new wing and is keeping out of
trouble”. He said in interview that Mr Charnley seemed “exactly the same as he
always was” during their final meeting. He said Mr Charnley was always laughing
and joking whenever they met. He described Mr Charnley as a “happy character”,
and said he had no suspicions in the days and weeks leading up to his death that
he would self-harm.
12 August
48. At 4.18pm on Wednesday 12 August, Mr Charnley left his single cell and walked to
the servery to collect his evening meal. Mr Charnley returned to his cell at around
4.20pm and an officer secured the door.
49. At 5.02pm, an officer checked Mr Charnley through his cell observation panel
during his early evening roll check. He raised no concerns. An Operational
Support Grade Officer (OSG) checked Mr Charnley in the same way at 9.08pm for
the evening roll check. He raised no concerns.
8 Prisons and Probation Ombudsman
13 August
50. At 5.08am on Thursday 13 August, during a morning roll check, the OSG saw Mr
Charnley hanging in his cell. He immediately radioed a medical emergency ‘code
blue’, indicating a life-threatening situation. The Custodial Manager (CM) arrived
within seconds, closely followed by two officers and a nurse. According to the
Ambulance Service’s call record, the control room officer called an ambulance at
5.13am.
51. When the officers went into the cell, they found Mr Charnley hanging from the top of
his toilet privacy screen by a ligature made from a piece of curtain. An officer said
in his statement that he believed Mr Charnley’s feet were either not touching the
floor or only touching very slightly, and that the screen and ligature were taking his
weight.
52. An officer cut the ligature and, with assistance from a colleague, laid Mr Charnley’s
body on the cell floor. He noticed a piece of broken razor blade on a unit in the cell.
(This appears to have been used to cut the curtain to make the ligature.)
53. The nurse noted signs of rigor mortis, meaning Mr Charnley had been dead for
some time, so staff did not attempt cardio-pulmonary resuscitation (CPR). At
5.34am, paramedics confirmed that Mr Charnley had died.
54. After Mr Charnley’s death, the prisoner in the cell next door to Mr Charnley told an
officer that Mr Charnley might have been in debt to other prisoners on the wing, as
he had asked to borrow £5 to “pay a debt off”. Another prisoner also mentioned
that Mr Charnley owed £20 to a prisoner on the wing.
Contact with Mr Charnley’s family
55. Mr Charnley had nominated his mother as his next of kin. The Governing Governor
could not reach her on the telephone that morning. She called Mr Charnley’s father
at 7.15am on 13 August and broke the news of Mr Charnley’s death to him. Risley
maintained contact with Mr Charnley’s family and, in line with national instructions,
contributed to the costs of the funeral.
Support for prisoners and staff
56. The duty governor held one to one debriefs with prison staff involved in the
emergency response. All staff and prisoners were offered the support of the
prison’s care team.
57. The prison posted notices informing other prisoners of Mr Charnley’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 Charnley’s death.
Post-mortem report
58. A post-mortem examination identified Mr Charnley’s cause of death as hanging.
Post-mortem toxicology tests found no traces of drugs or alcohol. However, the
toxicologist commented that because of the variable nature of PS, the possibility
that Mr Charnley used PS prior to his death cannot be entirely excluded.
Prisons and Probation Ombudsman 9
Findings
Management of risk of suicide and self-harm
59. Prison Service Instruction (PSI) 64/2011, which governs ACCT suicide and self-
harm prevention procedures, requires all staff who have contact with prisoners to be
aware of the risk factors and triggers that might increase the risk of suicide and self-
harm and take appropriate action. Any prisoner identified as at risk of suicide or
self-harm must be managed under ACCT procedures.
60. We have considered whether staff at Risley should have recognised Mr Charnley
was at risk in the weeks and months leading up to his death and begun ACCT
procedures to support him.
61. Mr Charnley had some risk factors. As set out in this report, he had a history of
mental health issues and self-harm and used illicit substances. His keyworker said
he had been affected by the restricted regime caused by COVID-19 and was
concerned that Mr Charnley’s mental health was deteriorating (although he was
reassured by Mr Charnley that he was receiving help from the mental health team).
62. Despite Mr Charnley’s troubled history, he had not self-harmed since June 2019,
prior to his transfer to Risley, and in the months leading up to his death he did not
present or express any thoughts of suicide or self-harm during his contact with
prison staff. At interview, officers told us of their shock and surprise at Mr
Charnley’s death. Both the officer who conducted Mr Charnley’s final CSIP and his
keyworker, with whom he had a close relationship, knew Mr Charnley well and
thought he seemed his normal self. We cannot say that staff could have identified
him as at imminent risk of suicide or self-harm before he died. We consider that Mr
Charnley’s death was not foreseeable.
Mental Health Assessment and Follow-Up
63. The clinical reviewer noted that Mr Charnley’s substance misuse impacted
significantly on his mental health and resulted in an increase in psychotic
symptoms, including auditory and visual hallucinations, which in turn contributed to
his risk of suicide or self-harm.
64. The clinical reviewer was concerned about what she described as “an unacceptable
time lapse” between Mr Charnley’s mental health referral made on 6 May and its
consideration at the mental health team meeting on 20 May.
65. Mr Charnley’s eventual mental health assessment on 16 June 2020 was interrupted
and the nurse did not review him in four to six weeks as she had planned.
66. The mental health nurse said that Mr Charnley was making plans for the future and
did not appear to be at risk when she saw him on 16 June. We note that making
plans for the future is not a reliable guide to a prisoner’s risk of suicide. As we have
said repeatedly, it is important that staff take into account the prisoner’s risk factors
and do not rely solely on what he says or how he presents. In this case, in order to
assess Mr Charnley’s risk to himself, the nurse should have taken into account his
previous history of self-harm, his admitted use of PS, and his psychotic symptoms,
and should have considered whether these symptoms might be exacerbated by his
10 Prisons and Probation Ombudsman
PS use and/or by the fact that he was spending long periods locked in his cell
because of the COVID restrictions.
67. It is not possible to say whether the failure to follow-up the interrupted mental health
assessment impacted on Mr Charnley’s death, but we are concerned that it was a
missed opportunity to review Mr Charnley and put measures in place to support him
before he died.
68. The mental health nurse told the investigator that she used a personal diary to
record when Mr Charnley’s follow-up appointment would be and did not record it on
SystmOne (the electronic medical record). We agree with the clinical reviewer that
this is not good clinical practice.
69. The clinical reviewer concluded that Mr Charnley’s mental health care at Risley was
not equivalent to that which would have been received in the wider community.
Although we appreciate the difficulty of maintaining services during the COVID-19
pandemic, we make the following recommendations:
The Head of Healthcare should:
• work with the Mental Health Lead to ensure there is a robust system
for timely mental health referrals and assessments; and
• ensure that appointments are appropriately recorded on SystmOne.
Substance misuse
70. Mr Charnley had an extensive history of substance misuse and had admitted using
PS in June 2020. Despite this, toxicology tests found no traces or drugs or alcohol
in his system when he died.
71. The clinical reviewer concluded that Mr Charnley’s mental health and substance
misuse issues appear to have been significantly interlinked. She noted that when
Mr Charnley was at HMP Haverigg, there was a very consistent and collaborative
approach to managing this. However, this approach was not continued when Mr
Charnley was transferred to HMP Lancaster Farms and later to Risley.
72. The clinical reviewer concluded that although Mr Charnley clearly had both mental
health and substance misuse needs, there was little joined up working from the two
respective teams at Risley. We agree with the clinical reviewer that a more
collaborative approach needs to be adopted going forward. We make the following
recommendation:
The Head of Healthcare and Substance Misuse Team Manager should ensure
that they work collaboratively to improve joint working and joint care
planning for patients with both substance misuse and mental health issues.
Emergency response
73. Prison Service Instruction (PSI) 03/2013 requires Governors to have a medical
emergency response code protocol, which instructs staff how to communicate the
nature of a medical emergency using agreed emergency codes and ensure that the
Prisons and Probation Ombudsman 11
control room calls an ambulance immediately as soon as an emergency code is
called.
74. The OSG radioed a code blue medical emergency promptly when he found Mr
Charnley hanging.
75. The control room officer recorded in his handwritten log that he received the code
blue call from the OSG at 5.07am (the CCTV footage shows it as being 5.08am
exactly). Although the control room officer recorded that he called an ambulance at
5.11am, the Ambulance Service call record (which is exact) says it was 5.13am. It
would not have saved Mr Charnley’s life if the ambulance had been called earlier as
he had been dead some time when he was found. However, we are concerned that
there appears to have been a five to six-minute delay from receiving the code blue
to calling an ambulance. This could make a critical difference in other medical
emergencies.
76. At interview, the control room officer said he waited to obtain the prisoner’s name,
approximate age, exact location and other information before calling an ambulance,
and described this approach as “good practice”. We consider that the prison should
have a local emergency protocol which requires staff to quickly relay information
required for the ambulance, including whether the patient is conscious and
breathing.
77. We recommend:
The Governor should ensure that all staff are made aware of and understand
PSI 03/2013, as well as local instructions, and their responsibilities during
medical emergencies, including:
• immediately calling an ambulance when a medical emergency code is
called; and
• promptly providing information about a prisoner’s condition to the
control room so that they have this information when requesting an
ambulance.
78. In other respects, the emergency response by the staff who found Mr Charnley and
responded to the code blue was prompt, professional and appropriate. We share
the clinical reviewer’s view that staff in the emergency response acted appropriately
and with professionalism in what must have been challenging circumstances.
Key working
79. The key worker scheme is a key part of HMPPS’s response to self-inflicted deaths,
self-harm and violence in prisons. It is intended to improve safety by building better
relationships between staff and prisoners and helping prisoners settle into life in
prison. All prisoners in the male closed estate must be allocated a key worker
whose responsibility is to engage, motivate and support them through the custodial
period. Governors in the male closed estate must ensure that time is made
available for an average of 45 minutes per prisoner per week for delivery of the key
worker role, which includes individual time with each prisoner.
80. The keyworker for Mr Charnley met him very regularly and made detailed notes of
their conversations in Mr Charnley’s electronic record. It is clear that the officer had
12 Prisons and Probation Ombudsman
developed a good working relationship with Mr Charnley, and we commend him for
that. We recommend:
The Governor should share this report with the keyworker, so he is aware of
the Ombudsman’s findings.
Inquest
81. The inquest into Mr Charnley’s death concluded on 19 May 2023. Mr Charnley’s
death was caused by hanging.
Prisons and Probation Ombudsman 13
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