Individual at Brixton

Investigation into the circumstances surrounding the
death of a man
at HMP Brixton in May 2006
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2009
This is the report of an investigation into the circumstances of the death of a man at
HMP Brixton on 27 May 2006. The man was found hanging in a communal shower
room. It appears his date of birth may have been wrongly recorded by the Prison
Service. According to his father he was 31 years old when he died.
I extend my sincere condolences to the man’s family and friends for their loss.
The investigation was carried out by two of my colleagues. Lambeth Primary Care
Trust agreed to carry out a review of the man’s clinical care and treatment while at
Brixton. This report was not received at my office until September 2007, delaying the
issue of this report. However, I am most grateful to the clinical reviewer for the
extreme thoroughness of his review on which I have drawn extensively.
The Prison Health Unit of the Department of Health provided observations on the
man’s alcohol detoxification programme. I would also like to thank the Governor of
Brixton, and his staff for their help in this investigation.
The man was an Irish national who was remanded into Brixton on 20 April 2006
pending extradition proceedings connected to an offence that occurred in Dublin in
2005. The prison wing where the man was located contained a number of other Irish
prisoners and there were six with whom the man associated.
On 23 May 2006, the man was made subject to special monitoring when he made a
comment to a family support worker in the prison suggesting that he might be at risk
of self-harm or suicide. Other than indicating on reception to the prison that he had
self-harmed in the past, that was the only time that the man said anything to indicate
to staff that he might have been at risk. In contrast, the man spoke about suicide with
his companions and asked one of them to write a note for him as his will, giving
directions for his cremation. Staff were never made aware of this.
I conclude that there were a number of missed opportunities to gain information about
the man’s mental health history and risk that could have greatly improved the
management of his care at Brixton.
I have made four recommendations. One is about dealing with prisoners who
obscure cell door observation panels. Two are about access to and the security and
safety of the shower room on G-wing. The other recommendation is about the
appointment and support of family liaison officers. The clinical review makes a further
19 recommendations about the man’s healthcare and about suicide prevention
procedures that I fully endorse.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2009
2
CONTENTS
Summary 4
The Investigation Process 7
HMP Brixton 8
Key Events 9
After the man’s Death 17
Issues and Conclusions 20
Key Findings from Clinical Review 25
Recommendations 27
3
SUMMARY
The man was born in Dublin. His prison paperwork records his date of birth as 12
September 1973, but the man’s father has told my office that his son was in fact born
on 12 September 1974.
In 2005, the man was allegedly involved in an incident in Dublin that the Garda (the
Irish police force) dealt with as suspected murder. The man left Ireland and came to
England.
For some time, the man lived at a residential unit in east London. The residential unit
is part of the Spitalfields Crypt Trust that provides support and accommodation for
people with drug or alcohol problems (the man had been an alcoholic for a number of
years). In April 2006, the man’s whereabouts became known to the police. He was
arrested, charged with murder and taken into custody. On 20 April 2006, the man
was remanded into HMP Brixton pending proceedings for his extradition back to
Ireland.
During the reception health screening process on arrival at Brixton, the man was
asked about self-harm. He said that he had harmed himself in the past, but had no
present thoughts of self-harm. He repeated these answers when he was seen by an
officer for a cell sharing risk assessment. The man was also seen by a doctor that
day who prescribed him medication for opiate detoxification and for symptoms of
alcohol withdrawal. The doctor also prescribed medication for depression. The
doctor noted that the man was a schizophrenic (a view he based upon the man’s own
report of his community prescribed medication and his report of having been under
the care of a community mental health clinic). The doctor recorded that the man’s
mood was satisfactory. The man was referred to the mental health outreach team by
the doctor (a nurse made a similar referral the following day).
Once the reception process was completed, the man was allocated to a cell on G-
wing. At that time, G-wing was the first night centre as well as holding remand
prisoners and those going through a detoxification regime.
As might be expected of a London prison, Brixton holds prisoners of many different
nationalities. At the time that the man was on G-wing there were a number of other
Irish prisoners on the wing, with six of whom he became friends. These included the
man’s cell-mate and another prisoner who knew him from time they spent together at
Mountjoy prison in Ireland.
From 13 May 2006, the man began to miss out from collecting some of his prescribed
medication. After 16 May, he ceased to collect any of his medication. Records of this
were made in the man’s prescription charts but this information does not seem to
have been passed back to the healthcare unit.
The officers on G-wing consistently described the man as a happy and chatty person
who got on well both with staff and with other prisoners. They had no fears for the
4
man’s safety and so it came as a surprise to them when an F2052SH1 form was
opened for him on 23 May. Whilst healthcare staff were aware of the man’s recent
past history of self-harm, the wing staff were not.
The F2052SH form had been opened by a family support worker employed by a local
charity. She opened the form when the man told her that he was facing a life
sentence and said he would prefer that they had him dead rather than alive
(presumably referring to his extradition back to Ireland). A Senior Officer who knew
the man quite well spoke to him on the afternoon of 23 May as part of the suicide and
self-harm procedures, and again on the following day. The Senior Officer’s note of
their conversation on 24 May included that the man had said he had no intention of
harming himself. Even so, the Senior Officer decided to keep the F2052SH open and
it remained open until the man’s death. However, the evidence of all the officers was
that the man’s behaviour while the F2052SH form was open was no different to how it
had been previously.
The man had two visitors on 26 May. One visitor was a manager from the Spitalfields
Crypt Trust. The other was the man’s solicitor. Both thought that the man seemed
emotionally well.
On the morning of his death (27 May), the man was seen by a doctor for an F2052SH
review. The doctor was visiting G-wing as part of his general medical rounds when
he was asked to see the man. The doctor did not have the man’s medical records.
As the doctor is also a native of Dublin, he and the man spent time chatting about the
city and the doctor thought that this allowed them to establish a rapport. The man told
the doctor that he had been misunderstood by the charity worker who opened the
F2052SH form. He had not intended his remarks to her to have been taken literally.
The doctor was satisfied that the man was not at risk.
From around 11.30am, prisoners on G-wing were served lunch. One of the officers
spoke to the man at about 12.10pm. He asked the man if he had had his lunch and
the man said that he had. At the time the man was sitting on the landing having a
cigarette with one of his friends. The man then told his friend that he was going to
have a shower. (Each landing on G-wing has a communal shower room. There are
no doors fitted to these rooms so prisoners can access them at any time.)
Following lunch, prisoners were locked into their cells and counted. When the count
was made at around 12.30pm, officers realised that the man was missing. A search
was made and, when one of the officers went into the shower room, she saw the man
hanging from a ligature that had been tied to a pipe running across the ceiling. The
officer shouted for assistance and other officers entered the room. Staff cut the
ligature, placed the man on the floor and commenced cardio pulmonary resuscitation
(CPR). Healthcare staff, including a doctor, responded on being alerted that there
was a Code One2 incident. Despite their efforts to resuscitate the man, he was
pronounced dead by the doctor at 12.47pm.
1The F2052SH process was used at that time to monitor and support prisoners judged at risk of self-
harm. The F2052SH process has since been replaced by ACCT (Assessment, Care in Custody and
Teamwork).
2Code One indicates a possible life threatening incident.
5
Following the man’s death, a note was found in his pocket stating that he wanted his
body to be cremated and giving directions about the disposal of his ashes. The man
had difficulties with literacy so had asked another of the Irish prisoners to write the
note for him. It seems that the man spoke to the other Irish prisoners about suicide,
but they did not take his comments too seriously and did not report these
conversations to the officers.
This investigation has found that Brixton missed several potential opportunities to
obtain more insight into the man’s state of mind. The first was a letter from one of the
managers at the Spitalfields Crypt Trust. The letter referred to the man’s history of
self-harm and reported him as saying many times that, if he should ever return to
prison, he would commit suicide. A copy of this letter was contained in the records
that my investigator obtained from Brixton. However, none of the staff interviewed
during the investigation could recall seeing the letter.
Secondly, Brixton failed to obtain the man’s community medical records. They
included important information about his risk of self-harm or suicide. The man had
told Brixton that he did not have a GP, but he also reported that he was taking
prescribed medication.
Finally, despite the separate referrals by the reception doctor and a substance misuse
nurse to Brixton’s psychiatric outreach team, he was never reviewed by that team and
the two referral forms have never been traced.
This report makes 23 recommendations. Of these, 19 are healthcare related and
derive from the clinical review.
6
THE INVESTIGATION PROCESS
The investigation was opened on 7 June 2006. My colleagues visited Brixton and met
a number of prison staff including the Governor, the prison’s family liaison officer and
a representative from the Prison Officers’ Association. My investigators also met a
representative from the Independent Monitoring Board (IMB). My investigators
informed them of the nature and scope of the investigation. Notices were issued to
staff and prisoners notifying them of the investigation. Eighteen members of staff and
seven prisoners were interviewed.
Lambeth Primary Care Trust agreed to carry out a review of the man’s clinical care
and treatment while at Brixton. A member of staff from the Prison Health Unit of the
Department of Health provided observations on the man’s alcohol detoxification
programme.
One of my Family Liaison Officers contacted the man’s father to inform him of the
investigation. My family liaison officer, together with my investigator visited the man’s
father and one of his daughters, to take details of their concerns. The man’s sister
said that her brother had very visible scarring to his arms from self-inflicted cuts. She
thought that he should have been monitored more closely to try to prevent further acts
of self-harm. She also thought her brother should have been referred for a psychiatric
assessment.
The man was angry that there was open access to the shower room where his son
was able to hang himself out of view from prison officers3. The man thought that a
lockable door should be fitted to prevent unauthorised access to the shower room.
Apart from the fact that his son was able to use the shower room in order to take his
life, the man’s father pointed out that the room could be used by prisoners to carry out
assaults. However, even without a door, the man’s father thought that it should be
possible for staff to deploy themselves in such a way that would prevent prisoners
from going into the shower room at lock-up time.
Both the man’s father and sister said that they were upset at the way Brixton dealt
with them following the man’s death. Contacting the prison’s family liaison officer had
been difficult and there was a substantial delay in the man’s ashes being sent to
them. They then faced two further substantial delays before Brixton firstly reimbursed
them for the funeral director’s fees they had incurred and then only later reimbursing
them for the interment fees. The family were also upset that Brixton’s family liaison
officer initially told them that the man was found dead in his cell, rather than in the
shower block as they later learned was the case. Another matter that caused the
family great anguish was the apparent loss of the man’s belongings and the long
delay before this was confirmed.
3The annexes contain a plan of G-wing showing the shower room and its open access.
7
HMP BRIXTON
Brixton first opened in 1819. Its primary role is as a local prison holding remand and
trial prisoners committed to the local magistrates’ courts as well as the Inner London
and Southwark Crown Courts. Brixton also holds prisoners committed to Bow Street
Magistrates’ Court which is responsible for extraditions to Ireland.
Brixton has four main residential units. G-wing, where the man was located,
comprises four floors. It contains 151 cells of which 61 are double cells. Brixton has
recently gone through reconfiguration, but at the time the man was there G-wing was
the first night centre and induction unit. G-wing also held remand prisoners and those
going through detoxification.
The last inspection of Brixton by Ms Anne Owers, Her Majesty’s Chief Inspector of
Prisons was an unannounced inspection in February and March 2006. Ms Owers’s
report of her findings included:
‘The inspection found continuing improvement [since the previous inspection]
in some areas. Prisoners were out of their cells a great deal, for longer periods
than we have seen in most public sector local prisons …
‘Brixton suffers from a poor build environment and little had been done since
the last inspection to address this …
‘Delays in agreeing and providing the significant capital investment had
impacted badly on the morale of staff, and on the outcomes for prisoners …
‘In spite of the obvious enthusiasm of senior managers, the improvements that
have been put in place, and the commitment of many staff, Brixton was still not
performing sufficiently well against three of our four tests of a healthy prison –
respect, purposeful activity and resettlement … Managers have ensured that
Brixton has developed a sense of purpose and a positive vision of what can be
delivered. However, in order for that vision to be realised, it needs capital
resources from the centre …’
One of the concerns raised by the man’s father to my staff was the potential for
prisoner-on-prisoner assaults in the shower room. This matter was put to Brixton. In
response, Brixton confirmed that there had been five such assaults in the shower
rooms on G-wing during the previous two and a half years. The response went on to
indicate that Brixton accepted that lockable doors needed to be fitted to the shower
rooms. In the meantime, a notice to staff to check the shower areas periodically
would be issued.
8
KEY EVENTS
20 April to 25 May
On 20 April 2006, the man was remanded into Brixton from Bow Street Magistrates’
Court. He had been arrested that day in connection with a suspected murder in
Dublin in 2005. The man was an Irish national and Bow Street Magistrates’ Court
was the court responsible for dealing with his extradition proceedings.
When the man arrived in Brixton one of the documents that came with him was a
Prisoner Escort Record (PER) form. This is a form that is completed when one
agency, such as the police, pass a prisoner on to another agency such as the Prison
Service. The PER form highlights possible risk factors applying to that prisoner, for
instance the possibility that the prisoner might be violent, might have drug or alcohol
related problems or might be at risk of suicide or self-harm. The man’s PER form was
ticked by the police to show that his risk categories were judged to be: violence,
escape risk, suicide/self-harm, vulnerable.
Upon his reception into Brixton on 20 April, the man was seen by a reception nurse
for a first reception health screening (FRHS) interview (this is part of the standard
Prison Service reception process). Part of the FRHS procedure explores issues
relating to self-harm. The man reported that he had harmed himself in the past, both
in prison and outside. He said that the last occasion had been nine months
previously. The man was also asked whether he had any present thoughts of self-
harm and he said that he did not. During the health screening process, the man said
that he was not registered with a GP but also reported that he was receiving
prescribed medication (anti-psychotics and sleeping tablets). He said that he usually
drank two bottles of whisky and 15 cans of beer (although no note was made of the
period over which the man would consume these amounts). The man reported that
he used heroin on a weekly basis and cannabis daily. The reception nurse made a
separate entry in the man’s clinical record:
‘… Currently on anti-psychotics but says never been treated by psychiatrists.
Most recent [self-harm] 9 months ago – denies any current thoughts of [self-
harm/suicide]. Open and honest conversation. Good engagement. Good eye
contact. [Plan] –> [refer for] mental health [assessment] ...’
After seeing the reception nurse, the man was seen by one of the prison doctors (the
first doctor). The man reported that he had been diagnosed with schizophrenia. The
first doctor prescribed several drugs for the man including dihydrocodeine for opiate
detoxification as well as medication for depression and medication to help with the
effects of alcohol withdrawal. The first doctor noted that the man’s mood was
satisfactory. Even so, the first doctor referred the man to the psychiatric outreach
team. At interview, he said he made the referral in part because of the man’s
declared diagnosis of schizophrenia and the community prescribed drugs he was
taking. However, there was no other record that the man had schizophrenia and no
efforts were made to obtain his community clinical records.
On the same day, the man was seen for a cell sharing risk assessment by his landing
officer. The man said that he had no concerns about sharing a cell. He reported that
9
he had self-harmed in the past but said he was ‘fine now’. Once the reception
process was completed, the man was located into a shared cell on G-wing.
On 21 April, the man was seen by a nurse from Brixton’s Substance Misuse Team.
Among other things, the nurse recorded the man saying that he had past diagnoses
of schizophrenia and depression. As the nurse did not have the man’s clinical
records she relied entirely on what he told her. This caused her to record inaccurate
information. The nurse’s plan included referring the man to the psychiatric outreach
team. At interview, the nurse maintained that she made such a referral. She said
that she always does so for every prisoner with mental health problems. She said the
fact that the prison doctor had recorded making a referral the previous day would not
have prevented her from also making a referral.
The Senior Officer had worked at Brixton for four years. He was not a substantive
senior officer but had been promoted temporarily into that grade since the end of
2005 and had been working on G-wing for a year. He described the man as “a nice
chap”. He said that they chatted frequently and had a laugh. The Senior Officer said
that his first contact with the man was when he asked to move to a single cell. The
Senior Officer told the man that G-wing does not have a sufficient number of single
cells. The only way he could move to a single cell would be if he had a job in the
prison as staff tend to reserve the privilege of a single cell for those who are working.
The man said that in that case, he wanted a job. Thereafter, the man would ask
every day if he could have a job. No posts were available, but staff allowed the man
to give a hand to those prisoners with jobs.
After 16 May it appears that the man failed to collect any of his prescribed medication.
This was not followed up by healthcare staff.
A charity worker for Adfam, an agency that supports families of prisoners with drugs
or alcohol related problems, also supports prisoners during their induction into Brixton
and she met the man on 19 May. He approached her that day to ask her to contact a
manager he knew from a rehabilitation unit (the Spitalfields Crypt Trust). The man
wanted the unit manager to visit him at Brixton. The charity worker estimated that she
spent between 10 to 15 minutes with the man. She said that the man was quiet, but
he did not seem unduly troubled.
The next time that the charity worker met the man was on 23 May. She told him she
had contacted the manager from the rehabilitation unit who said that he was very
willing to visit. The charity worker told the investigators that the man did not seem to
take in what she was saying. She then left the man to see other prisoners. About
half an hour later, the man approached her and said that he was facing a life
sentence. He could not see he had a future and would rather that ‘they had him dead
than alive’. The charity worker was concerned by these comments so she asked the
man if he had ever self-harmed or made suicide attempts in the past. The man said
that he had, and showed her the scarring on his arms. As a result, the charity worker
opened an F2052SH form so that the man would be made subject to special support
and monitoring.
The F2052SH process required that prisoners were seen by the senior officer in
charge on the same day the form was opened and as soon as possible that day. On
10
23 May, the Senior Officer saw the man at 4.00pm. The Senior Officer told my
investigators that, from his previous contact with the man, it seemed out of character
for him to be made subject to F2052SH monitoring. His comment to the man was:
‘What’s this about mate?’ The man replied that he was just a little bit down because
he expected to be extradited back to Ireland and was worried about his court case.
He also said that he tended to have ups and downs due to his use of drugs over
many years. The Senior Officer said that the man was downplaying the issue of
suicide/self-harm as much as possible, and mentioned once more that he would like a
job and a single cell. The Senior Officer told the man that he would have to remain in
a double cell for the time being.
The Senior Officer did not note on the F2052SH form how frequently the man should
be observed. He explained to my investigators that prisoners deemed at high risk
and requiring frequent observations were managed in the healthcare unit. The Senior
Officer did not think that the man fell in that category. For prisoners not considered at
high risk there was a set protocol understood by all officers. This was that there
would be two contacts with the prisoner in the morning and two in the afternoon. At
night time, the prisoner would be observed every hour.
The Senior Officer reviewed the man again on 24 May. No member of healthcare
was involved in the review but the Senior Officer was accompanied by one of the wing
officers. The Senior Officer wrote the following summary of the review:
‘Stated that he is not a self-harmer and has no intention of suicide. Stated …
worried about his trial but this is not a reason why he would harm himself.
Attempted suicide, but this was fifteen years ago when he was young. He has
overcome his heroin addiction, now well integrated in G-wing with staff and
other prisoners. I personally have no further concerns [for] the man.’
The Senior Officer could have closed the F2052SH that day but he chose instead to
keep the form open. He said that his reason for keeping the form open was that,
even though he knew the man by sight, he did not feel he knew him well enough as a
person to close the form so soon after it had been opened. The Senior Officer went
on to say that he was shocked when the man later took his life. He said that it was
typical with prisoners at risk of self-harm to be withdrawn. But the man was not like
that, he was always laughing and joking. The Senior Officer said that all of the staff
were just as surprised as he was.
The first officer, who was responsible for dealing with jobs for prisoners on G-wing,
told the investigators that the wing holds 220 prisoners. He said most of them wanted
jobs, but there were only around 30 available. For a prisoner to be offered a job, his
behaviour must be reasonable and he must present no security risk. If these criteria
are met, the prisoner will go on a waiting list until a job becomes available. The man
had a reputation for being well behaved so he was placed on the waiting list. The first
officer said that the man would approach him most days to ask about a job, but took it
well each time he was told that there was nothing for him yet. The first officer said
that, in addition to that contact, he also saw the man out and about on the wing. The
man was quite a cheerful and outgoing person who would chat to the staff and to his
large group of friends. The first officer said that the man’s friends were other Irishmen
whom he knew from outside of prison.
11
The first officer said that it seemed strange to him when an F2052SH form was
opened for the man. He was still smiling and was his usual self even on the day the
form was opened. The first officer said that he asked the man if he was alright and he
replied that he was fine. Prisoners subject to F2052SH monitoring often tend to be
subdued and withdrawn. This was not the case with the man.
G-wing’s cleaning officer told the investigators that as well as dealing with the wing
cleaners she also deals with the prisoners working at the servery. As with the first
officer, the cleaning officer found that the man would approach her asking for a job.
The cleaning officer said that the man was always polite and respectful and seemed
quite a nice man to talk to. However, theirs was a fairly superficial relationship so she
did not feel that she properly got to know him as a person.
Another officer, the second officer, said that the man was a happy prisoner. He was a
polite man who never caused the staff any problems. He also seemed to get on well
with the majority of other prisoners. The second officer thought that the man was
coping well with prison life and he was surprised to find out that an F2052SH form
had been opened for him. The second officer said that he would try to monitor
prisoners on open F2052SH forms through the day. Throughout the time that the
man was subject to F2052SH monitoring he remained his usual self.
The third officer gave similar evidence about how the man seemed to be coping. He
described him as a happy-go-lucky type of person. The third officer said that on 23
May he was about half way through working a week of night shifts. He said he was
shocked to find out that an F2052SH had been opened earlier in the day for the man.
He asked the late shift staff for the reasons. The third officer said that, in line with his
usual practice, he went to speak with the man to check how he was. The third officer
said that the man’s mood was no different that night to how it usually was.
For much of the time through the night of 23 May and into 24 May, the observation
panel in the man’s cell door was obscured (it is not known whether it was the man or
his cell-mate who was responsible for doing this). This meant that the third officer
was unable to look into the cell to check on the man. The third officer explained to the
investigators that, while officers carry keys at night time, the keys are kept in a sealed
pouch. The seal should be broken only in the case of an obvious emergency, for
example a fire inside a cell. However, in the man’s case the third officer knocked on
his cell door at regular intervals through the night and obtained responses from him.
He made a record of these interactions in the man’s F2052SH form. The third officer
said that another option for dealing with the situation would have been to have
contacted one of the two Night Orderly Officers4 on duty to ask them to open the cell.
The third officer said that he would have contacted the Night Orderly Officer if the
man had not responded each time that he knocked on his door. However, given that
the man did respond, the third officer felt that he had dealt with the situation in an
appropriate manner.
Another officer gave similar evidence to other officers about the man being an
approachable person who was easy to speak to.
4The Night Orderly Officer is the officer in charge of the prison at night time.
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26 May – the day before the man’s death
On the morning of 26 May the manager from the Spitalfields Crypt Trust, visited the
man (the man had been living at one of the Trust’s residential units, for about nine or
ten months before his arrest). The visit lasted about 25 minutes. The man told the
manager about the circumstances surrounding the offence on which he was facing
extradition. When he heard the man’s explanation, the manager told him there
appeared to be grounds for mitigation and he advised him to speak to a solicitor.
The manager from the rehabilitation unit told my investigator that the man remained
in a good mood throughout the interview and he left thinking that the man was okay.
He said that he was very surprised when he learned that the man had taken his life.
That said, the manager also mentioned that the man always said that he “would
never go back to prison”. The manager felt that he had not previously realised or
understood the significance of these words.
The man’s solicitor visited him at about 4.00pm on 26 May. She told my investigator
that the man did not seem depressed that day. He knew that it would be at least a few
more weeks before his extradition to Ireland. The man said that the staff were treating
him well and, by the end of their meeting, he was eager to go, telling her that he had a
nice meal waiting for him.
One of the landing officers thought that the man seemed a bit upset after his legal visit
on 26 May. The landing officer believed that the man understood from the meeting
that he was facing extradition back to Ireland and was also facing a life sentence if
found guilty of murder. The landing officer said that, although the man seemed upset,
there was no indication that he might be considering self-harm.
A note in the man’s medical records shows that he missed an arranged appointment
on 26 May for a doctor’s review of his F2052SH. Nothing is recorded to suggest that
wing staff were contacted by healthcare to ask why the man had failed to turn up. Nor
is there anything to suggest that healthcare staff attempted to re-arrange the
appointment.
27 May – the day of the man’s death
On the morning of 27 May, a second prison doctor was doing his rounds on the wing
when the Senior Officer asked him to see the man for an F2052SH review (the Senior
Officer noticed that the man had missed seeing a doctor on 26 May for this review).
At interview, the second doctor said that was the first time he had met the man. As
fellow natives of Dublin, the two of them spent some time chatting about this
connection. The second doctor said that, when they spoke about the issue of self-
harm, the man insisted that he had been misunderstood. He said that when he met
the charity worker he had used the ‘throwaway’ line that he: “Would rather be dead
than be back in Dublin”. The man said that he had not meant for the comment to be
taken literally. The second doctor said that he spent some time (around 20 to 30
minutes) talking with the man. The man was laughing and joking and the second
doctor did not consider him to be at risk. The second doctor made an entry in the
man’s F2052SH form that the man was “well now”. He signed and dated the form
13
and entered the time as 10.10am. The second doctor confirmed that he saw the man
without sight of his medical records as they would have been locked away in the
healthcare centre.
This assessment took place in the wing treatment room. The Senior Officer was
present, as were two nurses who were carrying out their own duties. The second
doctor said that the room felt crowded and it made for a totally unsuitable environment
to try to explore a person’s suicide risk.
The Senior Officer had taken the man to see the second doctor that morning and he
confirmed that he stayed in the room. The Senior Officer recalled them talking about
Ireland and having a laugh and a joke. The Senior Officer also recalled the man
telling the second doctor that he was fine. Following this consultation, the man should
have been locked back into his cell. This is because at that time in the morning it is
the 2’s landing that is unlocked for association. The 3’s landing, where the man was
located, has its association in the afternoon. However, instead of locking the man in
his cell, the Senior Officer allowed him to stay out and to associate with the prisoners
from the 2’s landing. The Senior Officer said that the man was the sort of person who
could be trusted not to take advantage in such situations. As a result the man was
seen more frequently by staff that day. The Senior Officer added that his view is that
it would be better for prisoners to be out on association all day rather than being
locked in their cells.
The cleaning officer said that she saw the man on two occasions that morning. The
first time was at about 10.30am or just after. The man again asked the cleaning
officer whether she had a job for him. The second time the cleaning officer saw the
man was at about 11.00am when he greeted her as he was walking past. The
cleaning officer said that the man was smiling and seemed happy.
The second officer said that he last saw the man at about 12.10pm when he was
sitting on the landing with a friend having a cigarette. The second officer asked him if
he had had his lunch and the man nodded in reply. The second officer told my
investigator that the man gave him no cause for concern. The second officer
completed paperwork for the man’s F2052SH form writing: “Has been out of cell today
had a review and had dinner.” The second officer timed the entry at 12.30pm. That
was the time he completed the form, not the time that he saw the man.
Three prisoners recalled speaking to the man on 27 May. One said that the man was
his usual self. They exchanged hellos but that was all. Another said that the man told
them in the late morning that he was going to take a shower. He did not say that he
was going to harm himself. The third said that the man was smoking a lot that
morning and was acting strangely.
The man’s cell-mate said that he had lain in bed all morning on 27 May and did not
see the man at all that day.
The discovery of the man’s death
The evidence given by the officers indicates that lunchtime is a busy, even hectic,
time on G-wing. Lunch is served at about 11.30am and, once prisoners have
14
collected their lunch, they are supposed to return to their cells ahead of lock-up. In
practice, prisoners will take their food to their cells but will then start collecting other
things that they should have collected during the morning, such as tobacco.
Prisoners on the 3’s landing are the last to be locked up as that landing holds
prisoners going through detoxification (so they have to collect medication as well as
lunch). Once locked up, the prisoners are counted. The count should, in theory, be
completed in time to submit the figures by 12.30pm.
The first officer was working on the 2’s landing that day and the cleaning officer was
working on the 1’s landing. Both officers, together with another who was working on
the 4’s landing went to the 3’s landing to help once their own landings were locked.
By this time all of the cells on the 3’s landing had been locked but one prisoner, the
man subject to this investigation, was missing.
The cleaning officer told the investigators that she began helping to look for the man
by checking from cell to cell (in case he had decided to sit in with a friend in a different
cell). The cleaning officer said that at about 12.35pm she reached the end of one
side of the landing and went to check the shower room5. As she walked in she saw
the man hanging from a ligature tied to a large pipe running across the ceiling. The
cleaning officer said that she ran out of the shower room and shouted that there was
a Code One emergency. She said that the first officer and the officer from the 4’s
landing were nearby and they went straight into the shower room.
The first officer said that he ran into the shower room and put his arms around the
man’s waist to support his body-weight. His colleague cut the ligature and they
placed the man on the floor. The first officer checked for a pulse but found none. He
said that at this point the Senior Officer arrived and started mouth-to-mouth breathing
while the officer from the 4’s landing gave chest compressions (heart massage).
The Senior Officer confirmed that the man was already on the floor when he arrived.
He said that he and one of the officers attempted to resuscitate the man and
continued with their efforts until relieved by healthcare staff.
The man’s clinical records contain the following entry made by the second doctor:
“… staff found [the man] hanging in showers, commenced CPR (cardio-
pulmonary resuscitation), mouth-to-mouth … code 1 at 12:38, nursing staff on
scene by 12:40, I arrived 12:41, [patient] cyanosed (blue in colour) , pupils
dilated, CPR continued, intubated, defibrillator applied, pupils fixed dilated at
12:47, [patient] cyanosed, no cardiac response, pronounced [dead],
resuscitation discontinued.”
(There were some inconsistencies in staff’s evidence about the provision of CPR to
the man. This is covered in detail in the clinical review).
When the man’s clothing was searched, a note was found in his pocket stating that he
wished to be cremated and that he wanted his ashes to be spread over his mother’s
5This is a large, communal, shower room at the end of the landing. There is no door at the entrance
to the room but once inside a person cannot be observed from outside.
15
and brother’s graves. The man had asked one of the other prisoners to write this note
for him.
The duty member for the Independent Monitoring Board (IMB) was in Brixton that
afternoon. Her written report mentioned that she accompanied the Senior Officer
when he broke the news to the man’s cell-mate. She noted that the Senior Officer
offered the man’s cell mate the chance to see a Listener6. The Senior Officer
comforted the man’s cell mate and took him to the wing office for a cup of tea.
The IMB member also recorded that there was no-one from the prison care team
immediately available to support staff. Later that afternoon, Brixton’s Governor held
a hot debrief for the staff involved in the response when the man was found. The
main purpose of the hot debrief was for staff support. There was no subsequent
debrief to consider possible learning points from the man’s care and treatment.
6Listeners are prisoners trained by the Samaritans in offering emotional support to other prisoners.
16
AFTER THE MAN’S DEATH
Contact with the man’s family
When the man was admitted to Brixton he did not provide any details about his next-
of-kin. It is standard practice in the case of a death in prison custody for officers from
the local police force to attend the prison. In the man’s case, officers from the
Metropolitan Police attended. In order to help make contact with the man’s family, the
police contacted their extradition unit and obtained the name and address of the
man’s father. The police then contacted the Irish Garda (Ireland’s police force). An
officer from the Garda, who knew the man, visited the family home on the same day
to break the news to the man’s father.
Brixton’s suicide prevention co-ordinator, is also Brixton’s Family Liaison Officer
(FLO). On 28 May, the day following the man’s death, the FLO telephoned the man’s
father to give his condolences, to explain his role as prison FLO and to explain what
would happen next. One of the man’s sisters was in the house and the FLO also
spoke with her.
The prison FLO had several further telephone discussions with the man’s father and
his daughter. Amongst the matters they discussed were the arrangements for the
man’s cremation, the return of his ashes to Ireland and payment of the funeral
director’s fees. These were matters that the man’s father and his daughter raised
when they were visited on 4 August 2006 by my investigator and my Family Liaison
Officer. The man’s sister said that she had paid the funeral director’s fees herself and
had still not received reimbursement. She also mentioned that it had taken seven
weeks from the time of her brother’s death for his ashes to arrive. That had been a
difficult time for the family as they were waiting for the ashes in order to hold a
memorial service. My investigator contacted Brixton on 7 August about
reimbursement of the funeral director’s fees. Reimbursement was made later that
week. At a later stage, the solicitors acting for the family approached my office to say
that the man’s interment fees had not been paid nor had his belongings been returned
to the family. Brixton refunded the interment fees but the man’s belongings have not
been located.
Further information from prisoners
The investigators spoke with seven prisoners who knew the man. All of these
prisoners apart from one are Irish.
The one non-Irish prisoner told the investigators that he works at the servery on G-
wing and got to know the man through that contact. The prisoner said that among the
group of Irish lads, the man was the quiet one and the others gave him a bit of hassle.
The prisoner said that the staff also gave the man a hard time. The prisoner said that
there were a lot of cell searches and strip searches of prisoners happening on the
wing. The prisoner said that the man found strip searches particularly stressful.
The man’s cell mate was aware that the man was facing extradition because of a
murder charge and had said that he was going to take his life because of this. The
17
cell mate said that he told the man that he was being stupid. The cell mate said that
the Irish prisoners had spoken about the man after his death and agreed that he had
made up his mind about what he was going to do. The cell mate added that the
officers on the wing were good and were unaware that the man had said anything
about ending his life. The cell mate could not recall how often he and the man had
been strip-searched in the time they shared a cell. The cell mate said that it was the
security officers who carried out strip searches and the man had referred to them as
“scum-bags.”
Another prisoner said that throughout the time the man was in Brixton he periodically
spoke to fellow Irish prisoners about suicide. However, he said it so many times they
just did not believe him.
A prisoner who knew the man from the time they had been together in Mountjoy
prison in Ireland said that in talking about his anticipated trial for murder, the man had
said there were things about his case that he would not want to emerge. He did not
say what these issues were however. The man said that that he was thinking of
killing himself, but he was laughing and joking when he said it so the other prisoner
did not take him too seriously.
A further prisoner said that about a week or two before the man’s death he had been
a bit depressed because of his impending extradition and trial. However, there was
nothing to cause the prisoner to think that the man would take his life.
There was a further prisoner who said that the man spoke to him about suicide. This
was because he was unhappy with the thought of receiving a life sentence. However,
this prisoner felt that the man’s intentions were not immediate. He said that when the
man asked him to write the note about his wish to be cremated, he said nothing to
suggest that he was going to do anything to himself in the immediate future. When he
told the other Irish prisoners about the note he had written for the man, they all told
the man not to be so stupid. The prisoner added that the staff at Brixton were fine.
None of the prisoners told staff what the man had been saying before his death.
Afterwards, however, the prisoner told the cleaning officer about the note he had
written for the man. He told her that the man was expecting to be extradited, that he
was anticipating a life sentence, and that as he claimed to have no family, “there was
no point.”
Another prisoner knew that the man was worried about being extradited back to
Ireland but he said nothing about feeling suicidal. This prisoner said that the man got
on well with the other prisoners and he added that the officers at Brixton were fine in
the main.
The second officer told my investigators that after the man’s death a prisoner told him
that the man had remarked that the pipe in the shower room would be able to take his
weight. The prisoner said that he had thought nothing of this remark at the time.
18
The letter from Spitalfield’s Crypt Trust
One of the managers with Spitalfield’s Crypt Trust, wrote a letter on 12 April 2006
that he marked: ‘FOR THE URGENT ATTENTION OF THE ARRESTING OFFICER’.
The manager’s letter went on:
“We have information on file regarding [the man’s] mental and emotional
condition, which we strongly believe should be taken into account during [his]
detention.
“1. [He] has a history of ‘self harm’ and alcoholism.
“2. [He] has attempted suicide in the past.
“3. [He] has expressed on numerous occasions that should he ever
return to prison he would commit suicide.
“4. [He] takes medication to manage his diagnosed psychotic mental
condition.
“We would like to document that we feel [the man] would be at great risk of
committing suicide during his detention and would recommend that he is
considered “at risk” whilst in your care.”
A copy of this letter was included within the set of documents for the man provided to
my investigator. It is unclear where in the man’s records this letter had been
originally filed. None of the staff spoken to during the investigation could recall
seeing the letter while the man was in custody. Nor could Brixton explain how or
when the letter was received at the prison.
19
ISSUES AND CONCLUSIONS
Lack of psychiatric outreach assessment
The man’s records show that two separate referrals were made for him to be
assessed by the psychiatric outreach team. The first doctor made the initial referral
when he saw the man on 20 April, the day he arrived at Brixton. The man had told
the first doctor about a previous diagnosis of schizophrenia. The second referral to
the psychiatric outreach team was made on 21 April by the nurse from the substance
misuse team. The nurse made the referral when the man told her about past
diagnoses of schizophrenia and depression. The nurse said that, even though the
first doctor had made a referral to the outreach team the day before, she made a
separate referral to make sure the man would be seen.
Both the first doctor and the nurse from the substance misuse team insisted at
interview that they each made a referral. Despite this, the man was never seen by
the psychiatric outreach team. However, this was not noticed by anyone in
healthcare. Nor have the referral forms ever been located. This was a failure in
delivery of care and is a matter upon which the clinical reviewer has made a clinical
recommendation.
Other healthcare issues
Although the man said at reception that he was not registered with a GP, he also said
that he was taking prescribed anti-psychotic medication. This should have prompted
staff to question the man further about a potential community healthcare provider. I
would then have expected Brixton to obtain the community records. The clinical
reviewer has made a recommendation on this.
Upon arrival at Brixton, the man was prescribed a number of different medicines.
From 13 May, he began to miss out collecting some of his medication, and after 16
May he ceased collecting medication altogether. This was noted in the man’s
prescription charts by the nurses responsible for dispensing medication on the wing.
However, this information seems not to have been passed to the healthcare unit so
the man was not reviewed and not asked why he had ceased taking his medication.
This again is a matter upon which the clinical reviewer has made a clinical
recommendation.
My investigator asked the clinical reviewer whether the man’s depression and anxiety
levels would have been affected when he ceased taking his medication. The clinical
reviewer said that it would not be possible to predict the effects in an individual case.
I note that the man was prescribed dihydrocodeine (DF118) for opiate detoxification. I
have said in other investigation reports that DF118 is not licensed for this purpose.
Although DF118 was once widely used in prisons to assist with detoxification, I
welcome the much more frequent use these days, including at Brixton, of Subutex
and methadone.
20
F2052SH procedures
On 23 May, an F2052SH form was opened by a visiting family charity support worker.
She did so when the man said that he was facing a life sentence and could see no
future. The Senior Officer saw the man for a wing manager’s review. The Senior
Officer knew the man as a jovial person so was surprised that an F2052SH had been
opened for him. The man said that he was just a little bit down because of his court
case. The Senior Officer decided that the man was not at high risk and should be
managed on the wing. Brixton’s suicide prevention co-ordinator confirmed that the
majority of prisoners on an open F2052SH were managed on the wing. For these
prisoners he expected the F2052SH to contain three meaningful entries each day.
He also said that the number of entries in the form would not reflect the actual
frequency of observations made by the staff7.
I consider the Senior Officer’s decision to manage the man on the wing to have been
a reasonable one. However, he made his decision without consulting healthcare and
that was contrary to the F2052SH process. (The ACCT process that has now
replaced the F2052SH process provides for greater integration between discipline
and healthcare staff.)
Through the night of 23 May into 24 May the observation panel in the man’s cell door
was obscured. It is not known whether it was the man or his cell-mate who covered
the panel. Nor do we know why they did so, although it is a recurring practice by
prisoners in order to gain some privacy. The third officer was on duty on G-wing that
night and he recorded having regular conversations with the man during the night.
The third officer tried to persuade the man to remove the obstruction, but without
success. The third officer could have contacted the Night Orderly Officer to ask him
to unlock the man’s cell door. However, given that the man responded each time that
his cell door was knocked, the third officer did not consider it necessary to contact the
Night Orderly Officer. I am satisfied on this matter that the third officer’s judgement
and actions were reasonable. However, I also consider that the man should have
been spoken to the following day for an exploration of his actions of the previous
night. Although the obscuring of cell flaps is mainstream, it represents a self-evident
threat to safety and security. For this reason, it should always be challenged by staff.
I recommend that the Governor issue renewed guidance to staff about
challenging and dealing with prisoners who obscure their cell door observation
flaps.
The man’s clinical records show that he missed a GP appointment on 26 May for an
F2052SH review. Apart from making that entry, no further action seems to have been
taken by healthcare staff. As the man was on an open F2052SH, wing staff would
have to have escorted the man to the appointment. In my opinion, healthcare should
have contacted wing staff to ask them to bring the man for his review to be done that
day.
7The ACCT document requires an entry stating the required frequency of observations to be
observed on each prisoner on an open ACCT form.
21
On Saturday 27 May, the Senior Officer noticed from the man’s F2052SH that he had
not yet been reviewed by a doctor. When the second doctor came to the wing as part
of his morning rounds, the Senior Officer asked him to see the man. The second
doctor said that as fellow Dubliners they spent some time chatting about this
connection. The man insisted that he had been misunderstood when he made what
he claimed was a casual remark to the charity worker on 23 May. The second doctor
said that the man laughed and joked throughout the 20 to 30 minutes that they
remained together. The second doctor was satisfied that the man was not at risk.
The second doctor saw the man without his clinical records. These were locked away
in the healthcare unit. Of course, if the man had been seen by a doctor on Friday 26
May as was originally intended, he would have been seen in the healthcare unit and
his clinical records would have been with the doctor. If the doctor had had access to
the man’s clinical records, that might have helped in the assessment of his potential
risk. The doctor would also have noticed that the man had not been assessed by the
psychiatric outreach team despite the two referrals made for him.
The environment in which the F2052SH review took place, warrants comment. The
second doctor saw the man in the G-wing treatment room where the Senior Officer
and two nurses were also present. I agree with the second doctor that this was a
totally unsuitable environment in which to explore such a sensitive matter as a
person’s potential risk of suicide.
The letter from the Spitalfields Crypt Trust
The documents received at my office from Brixton about the man included a letter
from a manager at the Spitalfield’s Crypt Trust. The manager marked the letter for
the urgent attention of the arresting officer. The manager explained that the man had
a history of self-harm and had attempted suicide. He referred to the man having a
diagnosed psychotic mental condition for which he was receiving medication. The
letter went on to say that the man was felt to be at great risk of committing suicide
during his detention. This letter clearly contains very important information. However,
it has not proved possible to find out how and when it came to be received at Brixton
and no one spoken to during this investigation could recall seeing it.
The shower room and other issues connected to G-wing
The man’s father was concerned about the open access to the communal shower
room. The man occupied a shared cell and this limited his opportunities for harming
himself in his cell. What the man would have known, however, is that from just after
12 midday the shower room would probably be unoccupied while prisoners finished
their lunches and were getting ready for lock-up. During this time, staff would have
been very busy and once inside the shower room the man would be out of sight. This
was the opportunity that the man took. I share the man’s father’s concerns about this.
His father also pointed out that open access to the shower room allowed for the
possibility of unobserved prisoner on prisoner assaults. Five such assaults have
been recorded on G-wing during the last two and a half years. Brixton has
acknowledged that the solution to the problem is to fit lockable doors to restrict
access to the shower rooms.
22
I recommend that the Governor takes steps to reduce the number of assaults
and the potential for incidents of self-harm occurring in the shower rooms on
G-wing. Preferably, this would entail fitting lockable doors to restrict access.
If the installation of lockable doors is not considered feasible, I recommend, as
a minimum, that the overhead pipes in the shower room be boxed in to
eliminate this very obvious ligature point.
The pipe in the shower room to which the man tied the ligature is at ceiling height. In
order to secure the ligature the man might well have stood upon a chair that the
investigators observed when they went to the shower room on their first visit to
Brixton. My investigators asked why this chair was needed as the shower room has a
fixed bench for prisoners to leave their clothing while showering. My investigators
were told that the chair did not belong in the shower room. Instead, officers thought
that a prisoner must have brought the chair from one of the resource rooms on G-
wing. My investigators asked for the chair to be removed, but when they returned to
Brixton a week later the chair was still present. They asked again for the chair to be
removed. I am disappointed that this reminder was needed.
During one of the staff interview, the member of staff commented on how busy G-
wing was and how busy staff were kept. The investigators felt the same way when
they visited G-wing. I am pleased that Brixton has since reconfigured its wings to
balance more effectively the pressures and workload.
Other family issues
The man’s family were upset with Brixton’s family liaison arrangements. The family
complained about constant difficulty in contacting the Family Liaison Officer (FLO).
They felt that the family liaison system had broken down in their case and this added
to their deep distress. The family specifically complained that they waited many
weeks for the return of the man’s ashes and even longer before they received
reimbursement of the funeral director’s fees. There was then a further delay before
reimbursement of the man’s interment fees. It would also seem that the man’s
belongings have been mislaid. It took Brixton over 18 months to finally confirm that
the belongings could not be found and this considerable delay has understandably
compounded the family’s great upset for the loss of their loved one. The family had
particularly hoped for the return of a number of items of chain wear given to the man
by his mother by which they could have remembered him.
At the time of the man’s death, Brixton’s suicide prevention co-ordinator was also
Brixton’s only FLO. In the former role, the FLO was engaged heavily at the time
following the man’s death in delivering training to staff in ACCT (the process that has
replaced the F2052SH). Like the man’s father, my investigator also had recurring
difficulty in contacting the FLO. I understand that there are now two other trained
FLOs at Brixton. I welcome the fact that Brixton now has an FLO team. Family
liaison is an important task and those assigned to it must have had sufficient training
as well as having ample time and support from prison management to allow them to
perform effectively. Prison Service Order 2710 gives detailed advice and guidance
about this extremely important role.
23
I recommend that the Governor ensures that his prison adheres to the
principles set out in Prison Service Order 2710 relating to selection, training,
support and supervision of family liaison officers.
Searches of prisoners and their cells
My investigator was told that strip searches of prisoners combined with searches of
their cells occur routinely. The selection of a particular cell is usually a random
process. The exception is where the prison receives information that a prisoner
might be in possession of unauthorised articles. Brixton’s security department holds
no record of the man ever having been subject to such a search. I am not able,
therefore, to say anything definitive about this matter.
Recognition of the man’s risk of suicide/self-harm
As has been mentioned, this investigation has revealed a number of missed
opportunities to have better assessed the man’s potential risk of suicide. These
missed opportunities include the failure to obtain the man’s community clinical
records, the breakdown in his referral to the psychiatric outreach team and the
seeming failure by anyone at the prison to read the letter from the manager from the
Spitalfields Crypt Trust.
However, it is a matter of speculation what might have happened if the community
records had been obtained and if the psychiatric outreach team had assessed the
man. What we do know is that the man presented as a seemingly happy person who
let out very few signals to suggest he was in danger. He made a remark that led to
an F2052SH being opened, but almost immediately afterwards insisted to staff that
his words had been misinterpreted. The evidence from staff suggests that the man’s
behaviour was the same after the form was opened as it had been before.
We know that the man made various remarks to fellow prisoners and even asked one
of them to write what was, effectively, a last will and testament. However, none of the
prisoners reported these remarks to staff; indeed none of them thought that the man
was at immediate risk.
The man had two visitors on the day before his death. Both thought that the man
seemed well, including the manager from the rehabilitation unit who knew him from
his time at the Spitalfields Crypt Trust (this was not the same manager as the one that
wrote the letter). Even on the day of his death, the man was in good humour when
he saw the second doctor for a review of his F2052SH. The man then spent the rest
of the morning associating with other prisoners and he was last seen alive just
minutes before his death when smoking a cigarette with one of his friends who had no
suspicions of what the man was about to do.
Another of the prisoners said though the man was acting strangely that morning.
24
KEY FINDINGS FROM CLINICAL REVIEW
The full clinical review is appended at annex A. Listed below is a summary of the
clinical reviewer’s main findings:
(cid:127) There were inaccuracies in the man’s records about his past medical history,
his clinical diagnoses and present medication.
(cid:127) There was an inadequate system for obtaining clinical records from community
providers.
(cid:127) The man was referred twice to Brixton’s psychiatric outreach team but neither
referral reached its destination so no mental health assessment undertaken.
(cid:127) There was no system for the man to be reviewed by a clinician during the first
few weeks after his arrival at Brixton. Such a system would have identified that
the man had not had a mental health assessment.
(cid:127) There was no system to trigger a review when the man ceased taking his
medication.
(cid:127) There was no active involvement by a pharmacist in the management of the
man’s medication.
(cid:127) There were surprisingly few significant entries in the man’s medical records.
(cid:127) There was an inadequate system for managing appointments for prisoners
attending the GP clinic.
(cid:127) There was an inadequate system for follow-up of prisoners failing to attend the
medical review of their risk of self-harm.
(cid:127) The residential unit manager who saw the man for initial consideration of the
F2052SH form had had no training in mental health nor in assessing risk of
self-harm.
(cid:127) The GP’s review with the man of his self-harm risk was conducted in an
unsatisfactory environment and without reference to his medical records.
Although the GP carried out a thorough assessment, he failed to make an
adequate record on the F2052SH form.
(cid:127) A letter from the Spitalfields Crypt Trust with warnings about the man’s risk of
suicide was filed in his records with seemingly no attention paid to its contents.
(cid:127) Staff generally followed correct procedures when trying to resuscitate the man
but there were some deficiencies such as the ratio of rescue breaths to chest
compressions.
25
(cid:127) There was no significant event analysis to review the man’s care and treatment
following his death.
(cid:127) The managerial control of systems in healthcare was found to be poor.
(cid:127) The nurse should be commended for her quick response when the Code One
emergency was raised.
26
RECOMMENDATIONS
My report makes three recommendations and I endorse all 19 recommendations
made in the clinical review. The Prison Service has responded to the majority of the
recommendations and the responses are inserted in italics following each
recommendation. The Prison Service has not provided responses however to
recommendations one, three, four and eleven.
1. I recommend that the Governor issue renewed guidance to staff about
challenging and dealing with prisoners who obscure their cell door observation
flaps.
No response received from Prison Service.
2. The Governor should take steps to reduce the number of assaults and the
potential for incidents of self-harm occurring in the shower rooms on G-wing.
Preferably, this would entail fitting lockable doors to restrict access.
Response from Prison Service: recommendation partially accepted. The new
Violence reduction strategy has been published which will help to reduce assaults
and ensure that incidents are investigated. A survey of all recesses has been
commissioned to look at the feasibility of locking off these areas however the
showers are used during association periods and have limited supervision. Target
for completion: March 2008.
3. If the installation of lockable doors is not considered feasible, I recommend, as a
minimum, that the overhead pipes in the shower room be boxed in to eliminate
this very obvious ligature point.
No response received from Prison Service.
4. I recommend that the Governor ensures that his prison adheres to the principles
set out in Prison Service Order 2710 relating to selection, training, support and
supervision of family liaison officers.
No response received from Prison Service.
The clinical reviewer made 19 recommendations in his clinical review. Some of
these are for consideration at a local level. Others are for consideration at a national
level. The recommendations in full are contained in the annexed clinical review, but
they are summarised below:
5. There should be a system for recording the receipt and agreed action for all
documents and papers for prisoners.
Response from Prison Service: recommendation accepted. HMP Brixton does
attempt to acknowledge and record all records and information that arrives with the
prisoner at reception and a reminder will go out to staff regarding this. Action
completed.
27
Nationally PSO 0500 makes it mandatory for all establishments to have in operation
a local protocol to ensure that reception staff act on information received, and that
there is efficient transfer of information/documentation. Currently there is no mention
in this PSO of what to do with a letter, in the prisoners possession that alerts staff to
a risk of suicide. This will now be added to the table on information flows that
appears in PSO 0500.
6. When new prisoners are seen by the doctor on arrival in Brixton all relevant
documents (such as FME reports) should be present.
Response from Prison Service: recommendation accepted. This is now listed as an
action for nurses working within reception. There will be ongoing review of this to
further improve information available to doctors. Action completed.
7. Healthcare management at Brixton should consider the possibility of developing
the system of assessment for newly arrived prisoners to ensure more complete,
accurate and thorough early assessments. One such approach might be as
follows:
a. Limit the First Reception Health Screen (FRHS) to the identification of
immediate needs.
Response from Prison Service: recommendation accepted locally. On going
discussions with clinical leads within Brixton and the London wide offender
health team as any changes to the reception screen needs wider agreement.
Target for completion: end of January 2008.
b. The following morning make urgent contact with the prisoner’s GP and
obtain a brief, faxed, summary of past medical history and medication.
Response from Prison Service: recommendation accepted locally. Staff
information notice circulated to ensure that we attempt this. Action completed.
c. Later on during the day following admission, a fuller and more
comprehensive assessment of the prisoner to take place with the prison GP.
Response from Prison Service: recommendation partially accepted locally.
Discussions between healthcare and Deputy Governor have been ongoing.
Further discussion needed with the wider prison regime and managers. Target
for completion: February 2008.
d. A review date to be set, usually not longer than two weeks later for any
prisoner with health problems or on medication, when they could be reviewed
by a doctor in the light of fuller GP records. This review to include an agreed
decision for the date of the next clinical review by a doctor or nurse.
Response from Prison Service: recommendation accepted locally. This has
been a target for healthcare and will be further discussed with EMIS leads from
the PCT. Whilst this happens with some patients it is not yet an automatic
process. Target for completion: March 2008.
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8. A robust and effective system should be instituted to enable the medical records
of all new prisoners to be obtained from the most recent GP that the prisoner was
registered with.
Response from Prison Service: recommendation accepted locally. Discussions with
healthcare and the appropriate representatives from the local PCT have been agreed
to resolve this issue. Target for completion: April 2008.
9. A system should be instituted for healthcare staff to review newly arrived GP
records for all new prisoners. The system should include the identification of any
significant discrepancies between the history given by the prisoner on arrival and
the clinical details in the medical records.
Response from Prison Service: recommendation accepted locally. This is the
responsibility of the primary care manager and is subject to review of the
effectiveness of the current system. Action completed.
10. The system for reviewing the treatment and management of new prisoners by the
end of their second week in prison should include the involvement of a member
of the pharmacy team.
Response from Prison Service: recommendation partially accepted locally. This is to
be judged on a case by case basis. HMP Brixton is looking at good practice
guidance and measuring its application within a prison environment. Target for
completion: March 2008.
11. Systems must be in place at Brixton to ensure that the clinical records of a
prisoner are always easily available to any member of healthcare who sees and
assesses a prisoner.
No response received from Prison Service.
12. Consideration should be given to the development of an information-sharing
protocol to cover:
a. Sharing clinical information between primary care, mental health and
substance misuse teams;
Response from Prison Service: recommendation accepted locally. Written
protocols between healthcare staff now in place with regular review at multi
disciplinary meetings. Action completed.
b. Sharing clinical information between healthcare and discipline staff;
Response from Prison Service: recommendation accepted locally. This is being
discussed and will be written following draft and comments. Target for
completion: April 2008.
c, Standards and expectations of record-keeping;
Response from Prison Service: recommendation accepted locally. Currently in
draft and for sign off. Target for completion: February 2008.
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d. Records of healthcare review appointments; procedures for obtaining
consent to access prisoners’ own GP records and then obtaining those
records.
Response from Prison Service: recommendation accepted locally. Being
drafted. Target for completion: April 2008.
13. The system for arranging appointments for prisoners to be seen by the GP or
another clinician, including the arrangements for prisoners on self-harm review
procedures, should be urgently looked at and improved.
Response from Prison Service: recommendation accepted locally. This has been
reviewed on a regular basis and will continue to be so. Healthcare staff now a much
more integral part of the ACCT reviews and proactive in arranging appointments with
appropriate services. Action completed.
14. Formal assessments of the mental state or risk of self-harm and suicide of any
prisoner should only be carried out by a member of staff who has had adequate
training and experience to carry out such an assessment.
Response from Prison Service: recommendation accepted locally. Healthcare
ensure this for healthcare employees and are an active part of the training
programmes for ACCT assessors. Additional support and further training has been
given through external mental health organisations and this will increase. Action
completed.
15. Formal assessments of the mental state or risk of self-harm and suicide of any
prisoner must always include a minimum level of contact and discussion with
members of the healthcare team.
Response from Prison Service: recommendation accepted locally. A training
package has been agreed for wing based nurses and more integrated multi
disciplinary working in evidence. Wing nurses aware of those on open ACCT forms.
For review in May 2008.
16. Formal assessments of the mental state or risk of self-harm and suicide of any
prisoner should be undertaken in an appropriate environment.
Response from Prison Service: recommendation accepted locally. All attempts are
made to ensure assessments carried out in appropriate environments however
emergency assessments are at times needed although the environment is always a
consideration and as such is recorded. Action completed.
17. All clinical contacts between the healthcare team and a prisoner should be
documented appropriately in the clinical records.
Response from Prison Service: recommendation accepted locally. This is subject to
regular review. Action completed.
18. Documentation of self-harm and suicide risk assessments (now ACCT) should
always be completed as required on the form.
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Response from Prison Service: recommendation accepted locally. Nurses now
record in open ACCT documentation and not only clinical records. Action completed.
19. The training needs of all discipline staff should be reviewed, and must include up-
to-date training in cardiopulmonary resuscitation (CPR). Senior discipline staff
who may be required to make decisions in relation to suicide and self-harm risk,
must have regular and up-to-date training in suicide prevention and appropriate
mental health issues. Ideally there should be increased training in suicide
prevention for all discipline staff.
Response from Prison Service: recommendation accepted locally. This is being
tackled through the primary care mental health stream which has been awarded
funds via the Sainsbury Centre for Mental Health for this purpose. The programme
will begin in Feb 2008 at the earliest.
20. Healthcare management must institute effective systems to monitor and ensure
compliance with agreed processes and procedures.
Response from Prison Service: recommendation accepted locally. Being reviewed
through clinical governance. Monitoring is ongoing.
21. Healthcare management should institute a system to monitor the progress of
internal and external referrals such as to the Outreach Mental Health Team.
Response from Prison Service: recommendation accepted locally. In place and also
monitored by the London Offender Health Team. Action completed.
22. A process of significant event analysis (SEA) must be introduced for all major
incidents such as deaths or attempted resuscitation.
Response from Prison Service: recommendation accepted locally. Agreed between
the major stakeholders and to be further discussed for implementation. Target date
for completion: March 2008.
23. Consideration should be given to developing a process of identifying prisoners
who may be at particularly high risk of suicide as soon as they enter Brixton.
There should then be a system to offer these prisoners frequent contacts with
appropriately trained members of staff.
Response from Prison Service: recommendation accepted locally. Discussions are
on going and will be supported by the primary care mental health bid for training and
awareness. Target for completion: February 2008.
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