Individual at Swinfen Hall

Investigation into the circumstances surrounding the
death of a man at HMP & YOI Swinfen Hall
in June 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2010
This is the report of the investigation into the circumstances surrounding the death of
a man. He was found hanging in his cell at HMYOI Swinfen Hall in June 2009 and
was pronounced dead by paramedics shortly afterwards. He was 20 years old.
I would like to offer my personal condolences to the man’s family, friends and
everyone affected by his death.
One of the Ombudsman’s investigators undertook the investigation. In addition, the
local Primary Care Trust (PCT) asked a clinical reviewer to undertake a review of the
man’s clinical care, and I am grateful for her contribution to the investigation. I would
also like to thank the Governor of Swinfen Hall and his staff for their participation in
the investigation.
The man was remanded into custody to HMP Altcourse in May 2008 and sentenced
to 30 months imprisonment in September. He spent time at six prisons, including
Altcourse due to his behaviour, before moving to Swinfen Hall in April 2009.
In June, the man was moved to the segregation unit after being abusive to a member
of staff. He did not express any concerns about this to healthcare staff who visited
him on the unit. Another prisoner in the unit at the same time as the man said that
he had spoken to him over the weekend. He appeared to be alright and did not
mention feeling suicidal or low. The evening before his death, he told him that he
needed to think of a plan to get himself out of the segregation unit.
On a morning in June, the man was seen at 8.47am when he was unlocked from his
cell and went for a shower. Staff said that he appeared in a good mood and they
had no cause for concern. After having a shower, he was seen by a nurse at
10.00am during her routine review of prisoners in the unit.
At approximately 11.05am while the Governor was visiting prisoners on the unit, the
man was discovered hanging from the window bars in his cell. Staff immediately
intervened and cut the ligature. Both discipline and medical staff, as well as
paramedics, attempted to resuscitate him for over 30 minutes, but sadly, at 11.37am
he was pronounced dead.
The report makes ten recommendations. They relate mainly to information handling
and sharing within the prison and adherence to ACCT procedures. Others relate to
how calls are made to the emergency services, the emergency coding system and
clarity of medical documentation. Two of the recommendations are relevant to other
prisons that the man had been at and these will be shared with those Governors. I
was disappointed to learn of the defacement of official documents from an earlier
prison and, although I have made no formal recommendation, the Governor will no
doubt wish to ensure that this practice is not widespread.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Deputy Prisons and Probation Ombudsman February 2010
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CONTENTS
Summary
The investigation process
HMYOI Swinfen Hall
Key findings
Issues
Conclusion
Recommendations/Prison response
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SUMMARY
The man arrived at HMYOI Swinfen Hall in April 2009. He had initially entered
custody in May 2008 at HMYOI Altcourse as a remand prisoner and, over the next
12 months, he moved between various prisons before going to Swinfen Hall. The
reason for him moving on such a regular basis was his continued disruptive
behaviour.
His behaviour while in custody is well documented. He was regularly placed on
report (this is when a prisoner offends against prison rules) and spent frequent
periods in segregation units. While located in the segregation unit at HMYOI Stoke
Heath in March 2009, three weeks prior to his transfer to Swinfen Hall, he was
discovered by a nurse in his cell with a noose around his neck. The noose was not
attached to anything and, at the request of the nurse, he took it off and handed it to
her. He was subsequently placed on Assessment, Care, Custody and Teamwork
(ACCT) monitoring. As part of this process, an assessment was conducted during
which he said he had only put the noose on as he knew that the nurse was coming
and hoped that it would lead to a move out of the segregation unit. He went on to
say that, he had no thoughts of harming himself or taking his life. Despite his
insistence that he had no suicidal thoughts, the ACCT document remained open for
approximately three weeks and was closed three days before his transfer to Swinfen
Hall.
When the man arrived at Swinfen Hall a nurse asked him if he had previously
harmed himself, and he told her that he had once “jokingly made a noose”. The
closed ACCT document that had been sent with him was not made available to
either the nursing or the induction staff who later dealt with him.
The man appeared to settle in well at Swinfen Hall but his continued disruptive
behaviour resulted in him being placed on report very soon after his arrival. Staff
who dealt with him regularly described him as a “cheeky chap” who would always try
and push the boundaries. He was frustrated by not having a job when he arrived at
Swinfen Hall and would spend most of his time in his cell on the wing. When he
finally found employment, it was on the industrial cleaning course where he excelled
as a student. His behaviour on the course was in complete contrast to that which he
continued to display on the wing. His tutor described him as having huge artistic
talent and was an example to other prisoners on the course.
Unfortunately, the man got into trouble again in June and was once again moved to
the segregation unit. It is documented that he was not happy about this and staff on
the unit regularly talked to him about his behaviour. He was keen to return to his
wing and, on a weekend in June, he asked for his adjourned adjudication to be
heard. He was informed by both unit staff and the duty governor that if he behaved
and began adhering to the rules his adjudication would be heard over the weekend.
Although he initially followed this advice, he again became confrontational, resulting
in the adjudication not taking place.
On an evening in June, the man spoke with a fellow prisoner who was in the cell next
door. The prisoner said that the man spoke about not wanting to be in the
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segregation unit and that he need a “master plan” to get moved. It is not clear what
the man meant by this statement.
On a Monday in June the man was unlocked from his cell as usual by staff, provided
with hot water, and later given access to the shower. Despite his behaviour over the
weekend, he appeared happy and talked politely to staff. He was due to go to the
adjudication hearing later that morning.
At around 11.00am, the Governor went to the segregation unit to collect paperwork
and agreed to see all the prisoners on the unit. He reached cell 5, which was
occupied by the man, at approximately 11.05am. As the officer opened the cell door,
he immediately saw him suspended by a ligature at the back of the cell and called
his colleague for assistance. The ligature was cut and on doing so his body fell
forward and his head is reported to have struck the toilet. Staff placed him on the
floor and immediately started cardio pulmonary resuscitation (CPR).
One of the officers called for medical assistance and nursing staff quickly took over
the resuscitation attempts. Emergency paramedics arrived at the prison a short
while later and treatment continued for a further 15 to 20 minutes but sadly, at
11.37am they pronounced the man dead.
I conclude that there are no clear indications as to why the man chose to take his
own life. He was a young man who made no secret of the plans he was making for
his future and had the support of a loving partner and family. I have made seven
recommendations as a result of this investigation and the clinical review.
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THE INVESTIGATION PROCESS
1. The investigator telephoned the Governor in June to ask for the man’s prison
records and to arrange to visit the prison.
2. Notices were issued in June informing both staff and prisoners of the
investigation. They invited anyone who had information about the man’s death
to contact the investigator. No responses were received.
3. The investigator initially visited the prison in July where he met members of the
senior management team and representatives from both the Independent
Monitoring Board (IMB) and Prison Officers’ Association (POA). He also
viewed the cell in the segregation unit where the man was located and his cell
on the residential wing. The investigator spoke with a prisoner who knew the
man while he was in the segregation unit and who asked to speak with the
investigator again when he returned to interview staff. While at Swinfen Hall
the investigator was given all the documents relating to the man including his
medical records.
4. The local Primary Care Trust (PCT) was asked to commission a review of the
clinical care that the man had received whilst in custody. A clinical reviewer
undertook this review and her report is attached as an annex.
5. The investigator contacted the local police who had attended the prison
following the man’s death to inform them of the investigation and to arrange for
any relevant information to be shared. The police were satisfied that there
were no unusual circumstances but statements from staff would be sought.
The investigator contacted the police again in September to ask for copies of
photographs taken after his death in order to clarify points raised by his family.
I am grateful to Staffordshire Constabulary for sharing information.
6. A solicitor, who had been appointed to represent the man’s family, contacted
one of the Ombudsman’s Family Liaison Officers (FLOs) in July. The FLO
followed up the telephone call with a letter explaining the purpose of the
investigation and offering the opportunity for the family to meet her and the
investigator to discuss any concerns.
7. The investigator visited Swinfen Hall again in August where, over the course of
two days, he interviewed 14 members of staff and one prisoner who had either
known the man or been directly involved with assisting on the day of his death.
Copies of the transcripts of these interviews are attached as annexes to the
report.
8. The investigator and FLO visited the man’s family at their home in Liverpool in
September. Sixteen members of the man’s family, including his mother and his
partner attended the meeting. The family’s solicitor was also present. All
members of the family raised concerns or asked for clarification about his time
in custody. His mother also provided a list of 57 points on which the family
sought clarification. The investigator explained that he would attempt to
address them during the course of his investigation but it might not be possible
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to answer those that fall outside the remit of the Ombudsman’s office. The
family also provided a brief background about the man for which I am grateful
and I have used extracts in my report.
9. The investigator also contacted HM Coroner to inform him of the nature and
scope of the investigation. At the investigator’s request, the Coroner sent a
copy of the post mortem report, followed by a toxicology report. The toxicology
report indicated that there were no illicit drugs in the man’s system. The
findings of the post mortem suggested that his death was the result of “a reflex
vasovagal action referable to neck pressure causing his heart to cease
beating.” The pathologist goes on to say in his report that “this is the most
common mode of demise in hanging deaths”.
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HMYOI SWINFEN HALL
10. HMYOI Swinfen Hall has been a long-term closed young offenders’ institution
(YOI) since 1988. Prior to this, it had served as both a youth custody centre
and before that as a borstal. In addition to holding young offenders aged 18 to
21, the prison also operates as an integrated young adult prison for those who
are aged 21 to 25. Within the prison estate, Swinfen Hall is considered to be a
high performing prison.
11. The prison has the operational capacity to hold 624 prisoners (240 young
adults and 384 young offenders). It is made up of nine residential units housing
different types of prisoners, such as reception/induction, offending behaviour
programmes and life sentence/imprisonment for public protection (IPP)
prisoners. (IPP prisoners have no automatic right to release at the end of their
sentence.) The prison population is made up of prisoners from wide
geographical areas who are allocated to Swinfen Hall for varying reasons.
12. HM Chief Inspector of Prisons carried out a full inspection of Swinfen Hall in
September 2005. During the inspection she said that Swinfen Hall’s previous
description as a centre of excellence was being tested by an expansion plan
that would double the prison’s population. She was concerned that it was going
ahead without the provision of purposeful activity for the increased numbers.
13. A follow up inspection in April 2008 was carried out and in her report she said:
”… On our last visit, while commending much of what we found, we
were concerned that insufficient purposeful activity had been put in
place to meet its growth. On our return, for this short unannounced
follow-up inspection, we were pleased to find Swinfen Hall remained a
safe, respectful place, focused on resettlement, and that much
progress had been made in provision of purposeful activity …”
14. She also said in her report of suicide prevention and segregation:
”… Suicide prevention arrangements were good, but more needed to
be done to deal effectively with bullies. Nevertheless, drugs were not a
significant problem and vulnerable prisoners were safely managed on
normal location. Segregation staff worked well with some difficult
prisoners, although paperwork was poor and use of special cells and
strip clothing needed tightening up …”
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15. The Independent Monitoring Board (IMB) at Swinfen Hall published their most
recent annual report on the prison in April 2008. The Prisons Act 1952 requires
every prison to be monitored by an independent board appointed by the
Secretary of State from members of the community in which the prison is
situated. The IMB concluded:
“… Whilst finding it necessary to raise several points for attention, the
board is of the opinion that Swinfen Hall continues to maintain a very
good standard, providing a safe, respectful and structured environment
in which all prisoners in its care are encouraged to address their
offending behavioural needs. The prison has continued to deliver
strongly against its KPT (Key Performance Target) measures and has
been recognised with the High Performing Status award making it the
best performing prison in the West Midlands and in its comparative
group. In addition, it has gained the coveted Investors In People award
…”
16. The Ombudsman was given responsibility for investigating all deaths in prison
custody in 2004. Since then, this is the first self-inflicted death at Swinfen Hall
and there has been only one previous death from natural causes.
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KEY FINDINGS
HMP/YOI Altcourse
17. The man appeared at court in May 2008. He was remanded into custody and
taken to HMYOI Altcourse the same day. It was not his first period in custody
and he had been at Altcourse during a previous sentence in 2007. He was 19
years old when he entered custody on this occasion.
18. Shortly before being remanded into custody, he had been involved in a road
traffic accident and, as a result, had undergone an operation on his leg. He
discharged himself from hospital against the advice of doctors the day after the
operation. When he arrived at Altcourse, he was seen by a nurse who
completed a health screening. He told the nurse about his recent operation but
said that he had no concerns about his physical health. He said that he was
supposed to have stayed in hospital for two months but said that he had no
outstanding appointments. The nurse recorded that he had no history of
harming himself either in custody or in the community. He told the nurse that
he had used recreational drugs for the last four years, and had smoked ‘weed’
within the last month.
19. The following day, the man was assessed by one of the prison doctors who
recorded that, despite admitting to using recreational drugs, there were no drug
or alcohol issues. The doctor also referred to the operation on his leg and
recorded that he had stitches in his right thigh.
20. The man reported sick in May, complaining of pain in his right knee. He was
assessed by a nurse who recorded that he was now using crutches and had
been advised not to bear weight. He was also told that he would be seen by
the doctor the following day. A doctor, who saw him the next day, referred him
for physiotherapy and also arranged for his stitches to be removed.
21. During his first week at Altcourse, the man was given a number of warnings
due to poor behaviour. In May, he was given a manager’s warning and was
advised that any further warnings might result in him being downgraded on the
Incentives and Earned Privileges (IEP) scheme. (All prisons operate the IEP
scheme, which has three levels, enhanced, standard and basic. Each of the
levels offers the prisoner various privileges such as time out of cell, number of
social visits and amount of money available to spend, with enhanced offering
the most and basic the least. All prisoners are initially placed on the standard
regime but undertaking offending behaviour courses and adhering to the
regime, they can progress to enhanced. However, those who continuously fail
to comply with the regime or break prison rules can be downgraded to basic.)
22. In June, the man was found in possession of a mobile telephone, a banned
item in all prisons, and he obstructed staff from entering his cell by wedging his
crutches against the door. As a result, he was placed on report for both
offences. (When a prisoner is placed on report, they will be seen by a governor
and adjudication will take place. The prisoner will be given the opportunity to
explain his version of events in response to any charges and can ask for legal
10
advice. Once all the evidence has been heard, the governor will decide
whether the prisoner is guilty or not. If found guilty, the governor can give a
number of punishments such as loss of privileges, cellular confinement or a
suspended award depending on the seriousness of the charge. If it is a serious
offence, the adjudication can also be referred to an independent adjudicator.
They are serving judges who have the power to add time to a prisoner’s
sentence.)
23. The man’s disruptive pattern of behaviour continued at Altcourse, which
resulted in him being placed on report for fighting and other offences on
numerous occasions.
24. In June, a nurse examined the man as he had pain in his right leg after being
involved in a fight. The nurse told him that he should wait to see the doctor, but
he chose to return to his wing. The following day, he was advised to go to the
healthcare centre to see the doctor. He did attend but it is recorded that he
again left without being seen as he felt the doctor was not quick enough.
During that afternoon, he went to the healthcare wing and demanded to be sent
to outside hospital. Staff recorded that he had a hostile attitude and explained
that he would not be sent to hospital. He became aggressive and was told to
return to his wing.
25. In June, the man attended an adjudication hearing regarding the fight the
previous day and was told that his IEP status would be reduced. It is recorded
in his wing history file that he was not happy with this and became abusive
towards staff. The following day, he asked to see the doctor and told wing staff
that he had not been assessed following the fight. However, nursing staff had
noted in his medical record that this was not the case and that he had refused
to be assessed. He was added to the doctor’s list for that day.
26. When a doctor saw the man later that day, he recorded his previous medical
history relating to the car accident and the operation. The doctor arranged for
x-rays of the man’s leg and sent a referral letter to the orthopaedic department
at the hospital in June. He went to the healthcare centre regularly over the next
two weeks to monitor the injury to his leg. In July, during an appointment with
the prison doctor, the doctor recorded that the man felt his leg was getting
better, that he was able to walk unaided and had stopped using his crutches.
The doctor recorded that notes relating to the man’s operation at the hospital
had to be obtained.
27. Despite the man apparently saying that he no longer needed crutches, in July a
nurse recorded in his medical record that he had asked for a pair and that this
needed to be reviewed. The next day, he reported sick. He told another nurse
that his crutches had been taken away and he needed them to get around.
The nurse told him the matter would be referred to the doctor and gave him a
sick certificate excusing him from work for half a day until the issue had been
resolved.
28. A nurse asked the man’s residential unit about his mobility on the wing. Staff
noted in the medical record that, although he walked with a limp, he moved
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around unaided and appeared to have no trouble taking part in activities on the
wing. The outcome of the enquiries by nursing staff is not clear. Over the next
few weeks, he was seen again by both a doctor and physiotherapist and was
advised to continue with exercises to strengthen his leg. It is also recorded that
he did not attend for scheduled appointments with both the doctor and
physiotherapist during this time.
29. The man’s general behaviour continued to be disruptive and as a result, a
transfer was arranged. The reason given was to provide respite for staff and to
disrupt possible gang connections. He transferred to HMYOI Forest Bank in
August 2008.
HMYOI Forest Bank
30. When he arrived at Forest Bank, the man was seen by a member of the
healthcare team. He said that he had no physical or emotional problems and
declined to see the doctor. He was on the ‘basic’ IEP level and was placed on
the voluntary testing landing. (All prisoners on this landing are required to
remain drug free and to provide regular urine samples when asked to do so. A
compact is signed to this effect.) He moved to another wing after only a week,
as he was unable to provide a negative sample.
31. The man remained at Forest Bank for only a short time. In September, he went
to court and was sentenced to 30 months imprisonment. Following his court
hearing, he was taken to HMYOI Lancaster Farms where he had served
previous sentences. He was given a full induction at Lancaster Farms but only
remained there for six days before transferring to HMYOI Hindley in
September.
32. During the investigation, the investigator noticed that the photograph of the man
on the front of his wing history file had been defaced.
HMYOI Hindley
33. As with previous prisons, on his arrival at Hindley the man was seen by a
member of the healthcare team who completed a health screen. It is recorded
that he complained of a headache and was advised to go to the treatment room
in the afternoon to obtain some medication. The nurse noted that he was calm
and relaxed during the consultation and that he said he felt “alright”. After this
and the remainder of the reception process, he was allocated to A wing. His
IEP status appears to have been changed to ‘standard’ as the move to Hindley
was seen as a fresh start for him.
34. However, the man did not start well at Hindley. It was recorded in his wing
history file that the day after his arrival, he became abusive towards staff on a
number of occasions, which resulted in him losing three days association. An
entry in his wing history file in September reads:
“… Not a good start for the man on A wing receiving a minor report.
Looking back through his compacts, he has a lot of minor reports for
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being argumentative. He needs to learn to do as he is told first time or
risk being put on Basic …”
35. After completing his induction, the man was located onto D wing in September.
It was recorded that he appeared to be trying to “keep his head down” on D
wing but he continued to receive minor reports that resulted in him losing
periods of association.
36. In October, he was believed to have been passed drugs during a social visit.
As a result, the visit was terminated. He was removed from the visits area in
handcuffs and taken to the Care and Separation Unit (CSU). (The CSU is
another term used for a segregation unit. All prisoners located on a
segregation unit or CSU are required to be seen by a nurse and a safety
algorithm completed. The purpose of the safety algorithm is to ensure that the
prisoner has no injuries if they have been subject to restraint and that their
mental or physical well-being is not likely to be affected by being in the unit.) A
nurse assessed him on his arrival in the unit and recorded that there were no
injuries or concerns.
37. The man remained in the CSU and two days later attended an adjudication
hearing for possession of a controlled substance. Due to the serious nature of
the charge, the case was referred to an independent adjudicator. His
behaviour while on the unit was recorded as good and he was said to be polite
and respectful. However, he told the Governor, during a routine visit to
prisoners on the unit, that he was unhappy at being located there. Following
the adjudication hearing, staff decided that he should remain on the unit, as
they believed the item that he had received during the visit was still in his
possession. When the case was eventually heard by the independent
adjudicator, he was found guilty and 42 days were added to his sentence.
38. During an evening in October, the man and a fellow prisoner were allegedly
racially abusive towards another prisoner on the unit and they were placed on
report. However, at the adjudication the following day the charge was
dismissed. He returned to D wing later that week.
39. There were no further serious incidents involving the man while he was at
Hindley although he received three minor reports later in October and early
November. His poor behaviour finally resulted in him being transferred again in
November to HMYOI Brinsford.
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HMYOI Brinsford
40. The man’s prison documents indicate that on his arrival at Brinsford, he was
located into the Intervention and Support Unit (ISU), which is another term for a
segregation unit. He was assessed by a nurse who recorded that he
complained of mental, physical health and self-harm issues but he did not wish
to see a doctor. The following was also recorded in his wing history file:
“… Received from Hindley. Previous wing history files have a pattern
of poor behaviour resulting in minor reports. Has already complained
about his transfer and cleanliness of cells …”
41. The day after his arrival, the man told staff that he was not happy at being
transferred to Brinsford and he submitted an application for transfer. He said
that he would be unable to receive visits at Brinsford due to the distance his
family and friends would need to travel. During that day, he was given an
emergency telephone call from the wing office to inform his family of his move.
42. During December, the man’s frustration at not receiving visits and lack of
communication with his family continued. Staff allowed him to make a
telephone call from the wing office as he did not have any pin phone credit but
this appeared to do little to alleviate his frustration. (While in custody, prisoners
use telephones that require them to enter a pin number to access calls. They
are able to buy ‘pin credit’ each weekly if they have sufficient funds available.)
During the remainder of December and early January, staff recorded on several
occasions that he was abusive and had a poor attitude. Consequently he was
moved between various wings. In January 2009, he transferred to HMYOI
Stoke Heath.
HMYOI Stoke Heath
43. The man had served previous sentences at Stoke Heath and was familiar with
the regime. On his arrival, he raised no concerns with reception staff about his
transfer and a nurse assessed him. During the health screen, he told the nurse
about the injury to his leg and said that it meant he was allergic to wearing
jeans. When asked, he denied any thoughts of harming himself.
44. A member of wing staff held a resettlement interview with the man the day after
his arrival. During the interview, he said that he intended to return to live with
his girlfriend after release and that he had no other concerns.
45. During an appointment in January, a doctor recorded that the man was not
receiving any treatment or physiotherapy for the injury to his leg. A referral was
made for him to attend remedial gym classes and he was recorded as being
‘Labour Type Three’. (Prisoners are allocated work based on their labour type,
which ranges from one to three. One indicates that an individual can do all
types of work and three indicates that intense physical work should not be
allocated. The labour type is allocated by medical staff, usually after a
prisoner’s initial health screening and relates to their physical health
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capabilities. A prisoner’s labour type can be changed as necessary during their
sentence.)
46. A few days after his consultation with the doctor, the man raised with wing staff
the issue of not being able to wear jeans. He told them that the doctor had
excused him from wearing them. The wing staff contacted healthcare who said
that this was not the case, however an entry in his wing history file on the same
day records that he was excused wearing jeans. The investigator asked about
this and was told that, although wearing jeans was not detrimental to his health,
he had complained that they rubbed on his leg causing him discomfort. For this
reason, he was allowed to wear tracksuit trousers, which were looser and
irritated his leg less.
47. During the man’s first two weeks at Stoke Heath he was given an induction,
which he completed in January. During his induction period, his behaviour
raised little concern although he is recorded as having been verbally abusive to
staff on one occasion. After his induction, he was moved to F wing.
48. In January, the day after his arrival on the wing, the man was searched as staff
believed that he had a mobile telephone. No telephone was found during the
search but materials used to charge a telephone, including batteries, were
found and he was placed on report. At his adjudication the following day, he
asked for legal advice. The case was postponed for seven days and was later
referred to the independent adjudicator.
49. A nurse treated the man in healthcare in February. He said that he had a mole
on the top of his left arm, which would not stop bleeding, and an appointment
was made for him to see the doctor. When he saw him the following day, the
doctor explained that he could treat the mole by cauterising it as a minor
operation. (Cauterising burns the tissue to stop bleeding.)
50. The man continued to receive negative entries in his wing history file. In March,
he was found in possession of a substance that later tested positive for
cannabis and an adjudication hearing was held the next day. The adjudication
was postponed for seven days to allow him time to seek legal advice. During
March, he was involved in a fight with two other prisoners and was moved to
the segregation unit. A nurse assessed him following the fight and recorded
that he had no injuries and required no treatment.
51. The following day, the man reported having an asthma attack and was
assessed by a nurse who checked his medical history and confirmed that there
was no history of asthma. The nurse recorded that he looked well and had no
breathing difficulties. He told the nurse that he thought that he had a panic
attack due to being hot in his cell. The nurse also saw him later the same day
after he had knocked the mole on his arm and a dressing was applied.
52. An adjudication hearing took place in March about the fight that the man had
been involved in and he was found guilty. The penalty was 14 days loss of
earnings and canteen, 14 days loss of association and television and seven
days removal from the wing. His removal from the wing meant that he would
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remain in the segregation unit, as the two days that he had spent there pending
his adjudication counted towards the sentence.
53. Following the adjudication hearing, the man appealed against the decision.
The appeal form was forwarded to the Briefing and Casework Unit, which is
part of the National Offender Management Service (NOMs) who deal with such
appeals. They responded in May, upholding his appeal and indicating that the
charge should be “quashed” and any punishments be remitted on the grounds
that he had not had the opportunity to question the evidence or present a full
defence.
54. Despite being in segregation, the man’s behaviour did not improve. Staff
recorded that he had a negative attitude, was confrontational towards them and
was suspected of smoking cannabis. While in the segregation unit, a member
of the healthcare team visited him daily, (a requirement for all segregated
prisoners) and he was visited by the doctor every three days. He did not
express any concerns about his physical or mental health during these visits.
In addition to nursing staff, staff from F wing also visited him frequently and it is
recorded that during one of these visits he became argumentative and said that
he did not know why he was still there.
55. Over the next few days, staff recorded that the man spat at them as they
walked past his cell and passed tobacco to other prisoners out of his cell
window. In March, the Governor spoke to the man, who was due to return to
the wing that day. He asked the Governor about his next move and was told
that a decision was to be made later that day.
56. It was believed that the man still had a mobile telephone hidden on him and so
a metal detector was to be passed over him later that day to rule this out.
However, an entry in his wing history file later that day indicates that the
detector was not used and the Governor authorised staff to retain him in the
segregation unit for Good Order and Discipline (GOAD). (GOAD is a term used
when locating a prisoner in segregation without adjudication. For example, if it
is thought that their behaviour might lead to a disruption in the good order of the
prison. A governor is required to record the reasons for the prisoner’s
removal.) The reasons set out in his record were that he was being kept in the
segregation unit for the good order and discipline of the prison, pending a
security investigation into recent unrest on F wing. The documents also
indicated that he would remain segregated.
57. In March, a hearing was held by an independent adjudicator for the previously
recorded offence of having a mobile telephone charger and batteries in his cell.
The man was found guilty and 35 days were added to his sentence. He
appealed against this penalty, which was reviewed by a senior district judge.
The outcome of the adjudication was upheld and he was notified in April.
58. Two days later the man was placed on the ‘basic’ IEP regime after he refused
to hand over his training shoes to staff following exercise. Staff explained the
importance of him conforming to the rules. Despite this, it is recorded that he
continued to misuse his cell call bell and had to be removed from the exercise
16
yard after he was caught passing items to other prisoners. On his return to the
unit, the metal detector gave a repeat indication towards his lower back and
staff believed that he might still have a telephone.
59. The following day when the man’s cell was unlocked for exercise, he smashed
his flask in temper as he was still in bed. Throughout the morning, he shouted
abuse at staff as they walked past his cell and continued to misuse his cell call
bell. During the evening, an officer reported his behaviour to the orderly officer,
as he was constantly abusive and trying to get other prisoners on the unit to
make complaints against the staff. He continued to misuse the bell the next
day and, when spoken to by a member of staff, said “I will get a ship out soon
and will take you out of the game.” The officer recorded that he asked him
what he meant by this and he replied, “You will see”.
60. During an afternoon in March, the man asked to use the Samaritans telephone.
(The Samaritans telephone is a cordless telephone that is pre programmed with
the number of the local Samaritans and can be used by prisoners at any time if
they are feeling miserable.) He was allowed to use the telephone outside of his
cell where staff could observe him. He used the telephone for around 25
minutes and, when he finished, staff said that they heard a clicking noise.
When they checked the handset, they found that he had removed the security
seal and attempted to remove the batteries. He returned to his cell and staff
told him that he would not be allowed access to the telephone in future.
61. At around 7.00pm that evening, a nurse went to see the man in the segregation
unit. She recorded that he had a “noose” around his neck and told her that he
thought his mental health was deteriorating. He added that he did not know
why he was in the segregation unit or on “basic”. The documents supplied to
the investigator would suggest that it was unlikely that he did not know the
reasons.
62. The nurse asked the man to remove the noose. He did so but said he would
not hand it to staff until they provided him with tobacco and the Samaritans
telephone. It is not clear whether these requests were met but he handed it
over. An Assessment, Care, Custody and Teamwork (ACCT) document was
opened and he was placed on hourly observations. (ACCT is a process to
monitor any prisoner who is considered to be at risk of self-harm or suicide and
ensures that they are observed frequently and supported by staff. An
assessment carried out soon after the document is opened aims to identify the
individual’s immediate needs and concerns and a care plan is drawn up to
support them.) During the remainder of that evening, he continued to be
abusive and threatening towards the night staff, and misused his cell call bell to
demand tobacco.
63. In March, another nurse interviewed the man in the segregation unit about the
events of the previous evening to assess whether he needed any mental health
treatment. The nurse asked him if he had wanted to die. He replied that he
had waited until he knew that the nurse was on the unit before placing the
noose around his neck. During the conversation, he also said he would kill a
member of staff, before killing himself. The nurse recorded that he appeared
17
very angry about being in the segregation unit and that he said he did not want
to be there. The ACCT form requires a trigger or possible warning sign to be
recorded on the front cover. On his document, the trigger/warning sign was
recorded as “doesn’t want to be in segregation”.
64. The investigator wrote to both nurses in July asking if they would be able to
provide statements about their individual contacts with the man during his time
at Stoke Heath. One nurse telephoned the investigator and said that he did not
feel that he would be able to offer any more information than that already
recorded in the ACCT document or in the medical notes. No response was
received from the other nurse.
65. After the interview with the nurse, the man returned to his cell and was told that
he would be moving to another cell on the unit. Later that morning, he had
another adjudication hearing for being abusive to staff which again was
postponed for seven days to allow him time to seek legal advice. When it was
finally heard he was found guilty and received further loss of privileges for
another seven days.
66. An ACCT assessment was carried out in March by an assessor. She asked the
man about any recent acts of self-harm and recorded that he was agitated
when discussing how he felt. He said that he had previously made a noose two
nights before, but said that this had been silly, as he did not want to die then or
now. He went on to say that he felt he had a good life away from prison. When
asked about any current suicidal thoughts he said that he had none and no
longer wanted to be monitored under the ACCT procedures. He was asked
about his reasons for living and how he coped. He described a good and
positive relationship with his family and partner. He said that he had been
receiving regular visits before he moved to the segregation unit.
67. Following the assessment interview, the man attended an ACCT case review
that was also attended by two nurses. The case review records:
“… Mental health triage completed, no evidence of mental illness,
appears very angry about his current situation. The man clearly stated
he did not want to die. Stated that he would kill staff before himself.
Unhappy at being in segregation, said he has not got his tobacco.
Went on to say if he had his personal items and tobacco he would be
fine. Also said that he would like to speak to his family, as he has not
had a telephone call. £3 credit due to be added to account tomorrow
…”
68. Over the next two weeks, the man’s behaviour received mixed reports. Staff
who visited him from F wing recorded that, although he remained very
challenging, they felt that he was displaying a better attitude than on previous
days. However, other comments in his wing history file from segregation unit
staff record that he continued to be abusive towards both staff and other
prisoners and he had to be removed from the exercise yard on two separate
occasions after he was caught passing items to other prisoners.
18
69. In March, a nurse attended the segregation unit following a ‘code red’ call. (All
prisons use a coding system to notify medical staff of a medical emergency.
The codes used indicate the nature of the emergency i.e. red – bleeding, and
blue – breathing difficulties, which means they are able to respond with the
correct equipment.) When she arrived, she found that the man had knocked
the top of his mole, which was bleeding profusely. A dressing was applied and
no further treatment was required.
70. The man’s wing history file indicates that he had a particular difference of
opinion with an officer working night duties in the segregation unit. The officer
recorded in March that he was continuing to make threats to kill him and had
told other prisoners that he was going to squirt urine at him through his door.
The same evening the officer went to check on him as a part of the ACCT
monitoring and found that he had his observation panel covered. (The
observation panel is used to observe prisoners at night and to check on their
well-being without having to open the door. All prisoners are advised about the
need to not place anything over the panel to prevent staff from observing them.)
The officer went to the exercise yard to look through the cell window and could
see him standing behind his cell door, the man told him to “fuck off” when he
saw him but the officer was happy with this, as he knew he was all right.
71. The following day, the man is recorded as being disruptive throughout the
morning, kicking his cell door and threatening staff. During the morning, staff
asked a nurse to come to the segregation unit as he had been seen with blood
on his forehead.
72. A nurse assessed the man and recorded that the blood was from the mole on
his left upper arm and there was no injury to his head. He told the nurse that
he was waiting to have the mole removed by the doctor once his behaviour has
settled down and he no longer had to be unlocked by three officers. (It is not
clear when or why it had been considered necessary for him to be unlocked by
a minimum of three officers. It can be assumed that staff felt that his
unpredictable and at times threatening behaviour gave enough cause for
concern to warrant this. However, I have not found any documentary evidence
relating to this decision during the course of the investigation.) The nurse noted
that no other concerns were raised and he had no thoughts of suicide or self-
harm.
73. A case review of the man’s ACCT was held in March in which it was recorded
that:
“…the man communicated well with good eye contact. States he has
no self-harm thoughts, but states he hears voices or screams. There
are no negative entries until today when he put blood over his forehead
claiming that he had a cut. After cleaning it off and being examined by
healthcare staff there was no cut at all, apart from picking a spot on his
left arm. Due to these voices and boredom factor it is decided to keep
this ACCT document open …”
19
74. A further ACCT review was scheduled. Over the next two days, the man faced
two additional adjudications for damaging property. One was postponed for the
reporting officer and the other for the man to seek legal advice. Staff from F
wing visited him and recorded that he felt that he was being “stitched up”.
75. In March, it was recorded that the man was having a “better day”. However, he
still had to be brought in early from exercise after he was seen to be taking
something from a cell window. He was visited again that day by staff from F
wing and reiterated that he felt that he was being “stitched up” and being
treated unfairly.
76. The following day, the man was removed from the exercise yard again after he
was passed an item from a cell window. When staff from F wing visited him
later that day he apologised for picking the item up and said that he hoped he
would still have the opportunity for a shower and telephone call. (It would not
be normal practice for these aspects of the regime to be withdrawn before any
adjudication hearing.) In March, a meeting was held to discuss his behaviour.
It was decided that as there was a visible improvement in his behaviour there
was no longer any requirement for him to be unlocked by three staff.
77. The man’s behaviour continued to improve with only one negative entry in his
wing file for passing items on the exercise yard. However, a review of his IEP
level, decided that he should remain on ‘basic’ for the time being. Although
unhappy about this decision, it is recorded that he dealt with the news in a
“mature manner”. He had also been polite to staff and other prisoners and was
conforming to the regime.
78. However, it seems that the improvement was short lived and the following day
the man was once again confrontational towards staff. When staff from F wing
visited him, he said that he felt that all staff were “stitching him up” and the next
day he was said to have argued with his peers during exercise.
79. During a review of his segregation that day, the man was “argumentative” and
“unreasonable”. He walked out of the review and the governor chairing the
meeting recorded:
“…the man has a very short fuse if things are not going the way he
wants them to. I think that he has displayed a negative side to his
character on the review today. Staff to continue to encourage and
support him to maintain recent improvements in behaviour …”
80. A record of the ACCT review, carried out in conjunction with the segregation
review, was written by the Senior Officer (SO) and includes the following
extract:
“… This review was started as part of his Rule 49 review as well. Part
way through the man stormed off and left the meeting. I spoke with
him again afterwards and he said that he was not hearing voices
before and had no intention of self-harming. He said that his main
issue is being in segregation and I explained reasons for this and the
20
support available. He repeatedly said that he did not feel suicidal and
recent entries and staff interaction support this …”
81. Following the man’s discussion with the SO, the decision was taken to close
the ACCT document. A post closure interview was scheduled to take place on
7 April. (When an ACCT document is closed, a date should be set for a
member of staff to conduct a post closure interview with the prisoner. The
timing of the interview can vary depending on the needs of the individual and
there can be more than one follow up interview. The purpose of the interview is
to discuss how the person has been feeling since the end of the additional
monitoring and support how they are managing with problems and whether
they feel that they could cope with similar problems in the future.)
82. No further significant issues arose at Stoke Heath over the next few days and
the man was transferred to HMYOI Swinfen Hall in April 2009. The Prisoner
Escort Record (PER) form completed by staff at Stoke Heath prior to his
transfer indicated on the front that an ACCT document had recently been
closed. This is a requirement under the guidance published by the National
Offender Management Service.
HMYOI Swinfen Hall
83. On arrival at Swinfen Hall, the man was not immediately seen by a member of
the healthcare team. After the rest of the initial reception process was
completed, he was located onto B wing that serves as the induction wing. The
following day, a nurse assessed him on the wing as part of the reception
process. The nurse has been working at Swinfen Hall since December 2008
and previously worked at other prisons. The medical record indicates that she
had previously known him while working at Brinsford when she assessed him
before his transfer to Stoke Heath. However, when asked about this by the
investigator, the nurse could not specifically recall him and explained that she
would have seen a large number of prisoners since then.
84. During her assessment of the man, the nurse recorded the information about
his earlier leg operation and asked him about any previous drug use. He said
that he occasionally used cocaine and, before he went into prison, would use
cannabis daily. The nurse also asked whether he had ever been subject to
ACCT in the past and he replied that he had previously “jokingly made a
noose”.
85. The investigator asked the nurse whether she would have had access to the
closed ACCT document during the health screening process. She replied that
she would ask a prisoner about this during the screening process but it would
not be usual to have the document in front of her. She went on to say that she
would be aware if a prisoner was on an open ACCT but there was no way of
knowing if a document had been closed other than asking the prisoner. When
asked about the man’s appearance during the health-screening interview she
said that she could not recall the initial interview but agreed that if there had
been anything significant she would have recorded it and was likely to
remember him. The nurse did record in his medical record that:
21
“… mentally – states well and appears level, nil thoughts of self-harm
or suicide ...”
86. Later that morning following his health screening with the nurse, a Senior
Officer (SO) held a reception interview with the man. The SO has worked at
Swinfen Hall for ten years and been an SO for the last five. During this time, he
has worked as an SO in Safer Custody and on a residential unit, and is
currently the night manager. At the time of his interview with the man, the SO
had been temporarily promoted to Principal Officer (PO).
87. The investigator asked the SO about an entry he made in the man’s wing
history file referring to him being unsettled in previous prisons and also asked
how he had obtained this information. The SO recalled that the man had
mentioned his problems at Stoke Heath during the interview. The SO also said
that he had gained some information from his previous wing history files. He
added that he was quite calm, chatty and amiable and showed no signs that he
was unhappy about being transferred to Swinfen Hall.
88. The investigator told the SO about the circumstances of the man’s previous
ACCT document and asked whether he had been aware of this at the time.
The SO said that he could not recall being aware but, when he asked him
whether he had any history of self-harm or anything that he was concerned
about, he had replied “no”.
89. Given the SO’s previous experience of Safer Custody at Swinfen Hall, the
investigator asked whether he would expect an ACCT document that had been
closed as recently as the man’s to be available to staff conducting any initial or
induction interviews. The SO said that he would have expected the document
to be held with the rest of his records but could not recall seeing it. The SO
said that his impression of the man was that he was “quite a confident lad” who
had put himself across well and there were no concerns that he was vulnerable.
90. The man initially appeared to settle in well on B wing and continued the
induction process. In April, staff found him fighting with another prisoner in the
shower area during evening association. Both the man and the other prisoner
stopped when asked to do so. They were escorted back to their cells and
placed on report. The nurse was asked to see both prisoners following the fight
she recorded in the man’s medical record that he had red marks on his neck
but no treatment was necessary. During the adjudication that followed, the
charge was dismissed and no further action was taken.
91. The following day, a member of the prison chaplaincy team visited the man on
the wing as part of the induction process. The member of staff recorded that:
“… Good relationship with family, happy to be here, says he is
remorseful over his offence, no self-harm or bereavement issues,
expecting family visits and wants to attend chapel. No major
concerns …”
22
92. In April, during the evening duty, a strong mobile telephone signal was detected
by staff and indicated to the cell occupied by the man. (Prisons use a device
that will pick up the signal from a mobile telephone. The signal is often stronger
when the telephone is initially turned on or in use. Although it cannot pinpoint a
location, the strength of the signal can narrow the area down to a particular
group of cells.) An officer who was on duty that evening, recorded in the man’s
wing history file that when he attempted to look into his cell after the signal was
detected, he found the observation panel covered by toilet paper.
93. The officer has worked at Swinfen Hall for four years and throughout this time
has been assigned to B wing, the induction unit. The investigator asked the
officer about his first impressions of the man. He said that he was a “likeable
chap” who got on well with staff on the wing. He also asked how previous or
current ACCT information is obtained as part of the induction and whether
induction staff would have been made aware of the ACCT. The officer
explained that a prisoner would be seen initially in reception where any current
or previous ACCT information would be collated and passed to the induction
unit staff. It would also be drawn to the attention of staff, particularly the
prisoner’s personal officer. (There is no evidence that this process was
followed in relation to the man’s previous ACCT information.)
94. In relation to an evening in April, the officer said that when he saw the man’s
observation glass covered his initial thought was that he was doing something
that he should not be. He banged on the door and told him to remove the
obstruction. When challenged, the man said that he had been using the toilet.
The officer documented his concerns, informing the wing SO that it might be
advisable to search the man’s cell the following morning.
95. The officer and the wing SO went to search the man’s cell before the prisoners
were unlocked the next day. They told him that he was believed to have a
mobile telephone and so he would be escorted to the segregation unit and his
cell searched. The man was not angry, as can sometimes be the reaction from
prisoners and the officer said he seemed to accept it as a consequence of what
he had been doing. The officer said that during the cell search that followed a
number of items were found, including batteries and other things known to be
used by prisoners for charging mobile telephones. The man was placed on
report.
96. When the man arrived in the segregation unit, a nurse completed the safety
algorithm, assessed him and wrote in his medical record:
“… Patient has been moved to the segregation unit, believed to have a
mobile telephone in his possession. The PO asked to clarify where
prisoner has plates following road traffic accident seven months ago.
Saw the man and verbal consent given to relay any information found
in his medical record to the PO and segregation staff. Entry found in
patient’s summary dated 2/4/09 about the possibility of patient going for
x rays to locate possible metal work in his leg but was transferred
before this took place …”
23
97. Later that afternoon, a member of the healthcare team contacted the hospital to
ask for notes about the man’s operation. The hospital agreed to send the
discharge letter that he would have been given if he had not left against advice.
The nurse and a Governor went to the segregation unit at 3.10pm to speak with
the man again. The nurse recorded that he insisted he did not have a
telephone and that the detector had indicated due to the metalwork in his leg.
The nurse advised him of the information supplied earlier by the hospital. The
Governor also told him that the detector had signalled there was a telephone
and not because of metalwork in his leg.
98. The Governor has worked at Swinfen Hall since September 2006 and is
currently the Head of Offender Management. He explained to the investigator
that his first contact with the man was on the day of his arrival at Swinfen Hall.
He remembered him because he did not meet the criteria for placement at the
prison, as he was not serving a long enough sentence. He was one of three
prisoners who arrived there from Stoke Heath. The Governor was in reception
that day to make sure everything was all right when they arrived but did not
speak to him directly at this time.
99. The Governor recalled the man telling him that the detector had gone off due to
the pins in his leg, and that nursing staff were contacting the hospital for further
information. The governor said that when he was confronted with the
information from the hospital, he confessed to having a telephone but said that
he had broken it up and flushed it down the toilet. The man had asked whether
disposal of the telephone would mean that he would not face adjudication and
the Governor advised him that one would still take place. It was held the
following day and adjourned to be heard by the independent adjudicator.
100. The man returned to B wing following the adjudication and continued his
induction programme. The officer who was his personal officer while he was
located on B wing and was interviewed by the investigator. The officer has
worked on B wing for the last four years. She told the investigator that she
would have a conversation with the man whenever she was on duty. He was
always asking to move to C wing, as he knew people there from Liverpool. She
said that he came across as a confident and jovial young man who would have
a laugh with you. In all her dealings with him, she had never considered him
vulnerable.
101. In April, after completing his induction, the man moved to C wing. The following
day, his adjudication was heard in the segregation unit by the independent
adjudicator. He was found guilty of being in possession of an unauthorised
article and had 28 days added to his sentence. (He subsequently appealed
against the decision but was unsuccessful, and was informed that 28 days was
the correct punishment.)
102. The man was not employed immediately when he arrived onto C wing which
appeared to be quite frustrating for him. Another officer was allocated as his
personal officer and introduced himself to him. The officer has been an officer
at Swinfen Hall for the last three years and worked solely on C wing. When
interviewed by the investigator, the officer was asked about what the man had
24
done to try to gain employment. He said that he had settled in well to C wing
and, when he introduced himself, he had already applied to do a Learn Direct
and a gym course. He offered to follow both applications up for him. The
officer said that it was not possible to give a timescale for how long a prisoner
might wait to be employed as it depended on spaces being available which was
a big problem. The officer had a period of leave at the start of May and, during
his absence, another officer was the man’s personal officer.
103. This officer has worked as an officer at Swinfen Hall for six years. The
investigator asked her about an entry that she made in the man’s wing history
file in May, in which she described his as “a drain on resources”. The officer
said that he was a prisoner who would “always be shouting at you through his
door no matter what you were doing”. She said that this was not done in a
“nasty or aggressive way but it was draining”, as you would have to go and see
what he wanted. She said that she felt that this was just part of his character
and that he appeared to be unable to let you walk past his cell without shouting
a question.
104. The investigator asked the officer whether she had ever considered the man to
be vulnerable. She replied that she regarded him to be “the opposite”. She
described him as a likeable and very strong willed person. She said that there
were times when he could become a little aggressive if things were not going
his way, but she said that he was manageable and staff could reason with him.
105. When the personal officer returned from leave in May, the man was still without
a job, and he told him that he would try to find out what was happening. Being
without any activity continued to be the main frustration for the man and he
complained to staff about always being on “bang up”. Staff told him that they
were unable to keep him out of his cell, but that he was due to begin an
industrial cleaning course.
106. Over the next week, the man was given warnings about his behaviour. During
a review of his IEP status in May, the SO recorded in his wing history file:
“… Not the best reporting period. Several negative comments but now
in work so improvement should follow. To remain on ‘standard’
regime …”
107. Despite being on the course, the man continued to receive negative comments
about his behaviour on the wing over the next few weeks. The personal officer
recorded that he would constantly enquire about his prospects for release on
Home Detention Curfew (HDC). (HDC allows prisoners serving between three
months and under four years early release from prison to serve a maximum of
90 days in the community wearing an electronic tag, which must not be
removed, and while subject to a curfew.) The officer told the investigator that
he had completed the application for him to be considered for HDC. The man
gave him letters and other documents to support his chance of being granted
early release, which the officer took to the Offender Management Unit (OMU)
who dealt with HDC requests. The officer said that the man had spoken about
setting up a landscape gardening business when he was released and had
25
applied for a grant from the Prince’s Trust. He had put together a portfolio of
his plans for the business, which the officer had read and considered to be
“impressive”.
108. The officer recorded that during one of their conversations, the man had said
that if he failed to be granted HDC he would “have nothing to lose”. The
investigator asked the officer what he thought he meant by this. The officer
said that whenever the man said anything negative he would always have a
grin on his face. He said that he was due to be released in October regardless
of whether he was released early and he took his comments to mean that he
did not really care, as he would soon be released anyway.
109. A review of the man’s cell sharing risk assessment took place in June. He had
been considered a ‘medium’ risk when he arrived at Swinfen Hall but following
a review of his risk, this was raised to ‘high’ due to his behaviour. (All prisoners
are subject to a cell sharing risk assessment on reception into custody. They
are asked a number of questions relating to previous periods of custody, any
violent or racially motivated behaviour or concerns that they may have with
sharing a cell. The form provides staff with guidance on the suitability of an
individual to share a cell with other prisoners. A rating is given ranging from
high to low.)
110. Unfortunately, the man was informed in June that his application for HDC had
been refused. He submitted a complaint the same day in which he asked to
speak with the Governor about the decision. The Governor, a residential
governor, replied:
“… The main reason for being refused your HDC is that your home
probation officer did not support the application and your current
offence was committed while you were under probation supervision.
You have also been assessed as having a high risk of reconviction.
The decision was made after reading your letters so your views have
been taken into account, the decision will not be changed. If you need
to apply for a transfer, please complete an application form …”
111. The man was involved in a fight with another prisoner on the same day. At
adjudication in June, he was found guilty and the penalty was seven days loss
of association and earnings. Due to his continued poor pattern of behaviour, on
22 June he was reduced to ‘basic’ on the IEP scheme.
112. The man’s behaviour on the wing was in complete contrast to that on the
industrial cleaning course, which he had been attending since 25 May. His
tutor in the class wrote a number of positive comments in his wing history file:
“…the man earned 10 positive entries over the first two weeks of the
course earning a positive comment. He earned a further 10 positive
entries to earn a positive comment, completing his Cleaning Operatives
Proficiency Certificate (COPC) Level 1, will be called back for NVQ
Level 2 later in the year …”
26
113. The tutor told the investigator that the man’s behaviour during the course was
“impeccable”. She said that he had spoken to her about his plans for the future
and, in particular, the gardening business that he planned to start on his
release. To encourage prisoners on her course to work hard she gave a ‘Man
of the day’ award to the person who worked the hardest. The man won this
award on more than one occasion and also earned a ‘Man of the course’
award. After the students had completed the five-week course the tutor
arranged for them to clean the new education department on 22 June. They
were able to put the skills that they had learnt into practice. She was so
impressed with him that she wrote the following in his wing history file:
“…The man was fantastic this morning cleaning C room in new
education putting the rest of the group to shame showing how to put
skills learned on his COPC Level 1 into practice. I was really proud of
him. He also does not enter into immature behaviour usually started by
other prisoners who were throwing paper at each other this morning
and he did not retaliate. Well done …”
114. The man appealed against the decision to place him on basic. He considered
that the positive comments that he had earned had not been taken into account
when the decision was made. In June, before his appeal was heard, he was
verbally abusive to a female officer and placed on report. As a result, the
appeal was rejected and he was informed that he would remain on basic with a
review in July. During the remainder of that day, he continued to display
negative behaviour.
115. In June, the man’s hearing for abuse to the female officer was postponed for
seven days to allow him to consult his solicitor. Due to his perceived disruptive
behaviour on the wing, it was decided he should remain in the segregation unit
until the adjudication resumed.
116. A nurse completed a safety algorithm which indicated that there was no clinical
reason to advise against segregation. The man was not happy with being kept
in the unit and was demanding throughout the day, pressing his cell call bell
and asking for items to be collected from the wing. During the evening, he
asked an officer if he could speak with a Listener. The officer has worked at
Swinfen Hall for around five years and has worked in the segregation unit for
the last two and a half years. He told the man that as he was a high risk in
terms of sharing a cell it was not possible for him to have a Listener, but he
could provide the Samaritans telephone.
117. The officer gave the man the Samaritan’s telephone but after a short while, the
man told him that he could not get a signal. When the officer checked the
telephone, he found that the man had tampered with the settings and been
trying to dial another number. The officer recorded that the man told him that
he had just wanted to “mess about” and that he had “no thoughts of self-harm”.
118. The investigator asked the officer if he had any concerns about the man when
he had asked for the telephone. The officer said that his demeanour was
27
positive; he was laughing and said that he just wanted to mess around with the
telephone.
119. During the later part of the evening, the man continued to be disruptive by
constantly pressing his cell call bell and demanding items to be passed to him.
The SO, who had interviewed him when he first arrived at Swinfen Hall, was on
duty as the night manager. He went to the segregation unit to speak with him
after receiving a call from the officer on duty about his behaviour.
120. The SO told the investigator that he recalled the particular night as he had dealt
with two cell fires in other areas of the prison. He said that he had received a
call from the officer in the segregation unit who informed him that the man was
pressing his bell constantly and making demands. When he asked him why he
was down there, he explained about his adjudication earlier that day. He told
the SO that he wanted some “burn” (tobacco). The SO reminded him that he
could not be given anything and that while he was on segregation, he was only
entitled to three cigarettes a day. The man explained that, because he had
only come onto the unit that day, he had not had his allowance. He said his
tobacco was still in his cell on the wing and asked the SO to fetch it. The SO
Sherwin reiterated that he could not pass him anything.
121. The conversation about the tobacco went on for sometime and the man asked
again for the Samaritans telephone. During the discussion, he said that he did
not really want the telephone and asked again about his tobacco. After
explaining again that he was not allowed to pass anything the SO told him that
if he promised to stop being disruptive, he would collect his tobacco the
following morning. The following morning he went to the man’s cell and
collected his tobacco as promised. He took it to the segregation unit at around
7.30am before going off duty. He knocked on his door to tell him that he had
left it in the office and he replied “cheers boss”. (The SO was on duty again the
following night but had no further contact with him.)
122. During a morning in June, the man reported no problems to the nurse during
her daily visit to the prisoners in the segregation unit. An officer from ‘C’ wing
also visited and brought him cigarette lighter and a packet of cigarette papers.
The man told him that he was alright and was going to try to behave in future.
123. Later that day, the man had a shower and went onto the exercise yard. He had
decided that he no longer wished to speak to his solicitor and was keen for his
adjudication to take place. The investigator spoke to the officer, a segregation
unit officer, during the investigation. The officer has worked at Swinfen Hall for
five years and has been a segregation officer for approximately four years. He
said that he felt that the man was “just a prisoner that played up, one of many
prisoners that play up to try and get the system to work for him”. He said that
this is common and that the man was trying to get out of the unit, as he did not
want to be there.
124. The man told the officer that he no longer wanted legal representation. He
wanted his adjudication to go ahead so that he could take the punishment and
get back to the wing. The officer told the investigator that unfortunately, by the
28
time the man said this, adjudications had finished for that day. The officer was
aware that the man had written to the adjudicating governor asking for his
charge to be heard. He was present when the Governor told him:
”I cannot do it today as adjudications are finished. On the proviso
that you behave yourself, follow the rules and regulations in the
segregation unit then we will put your adjudication on for Sunday.”
125. The officer said that the man followed these instructions for a couple of hours.
He then began to misuse his cell bell again asking staff about his adjudication
and saying, “right, can I have my adjudication now, I have kept my head down
for a couple of hours”. Staff reminded him what he had been told by the
Governor. He continued to be “demanding” and was advised of what was
expected of him and the rewards on offer if he conformed to the regime.
126. The man was told that if he stopped shouting and “being abusive” towards staff
then the adjudication would take place as the governor had instructed. The
investigator asked the officer what he meant by “being abusive” and how he
would describe the man’s behaviour. He described him as:
“… aggressive, juvenile in his attitude. He would ask a question and if
he did not get the answer that he wanted he would try to become
intimidating, pulling himself upright and squaring his shoulders, his
voice and manner would change and he would become quite
aggressive in his tone bordering on shouting at times.”
127. One Sunday in June, the nurse saw prisoners in the segregation unit and
recorded that the man had no concerns. He also told a member of the
chaplaincy team that he was alright and had no concerns. During the day, he
continued to ask about his adjudication. He was told by an officer that he
should stop pressing his cell bell and asking when the governor would be
arriving or it would not take place. The officer recorded that he became
threatening towards staff again.
128. The man continued to be abusive. He was unlocked from his cell to use the
telephone during the afternoon and spoke with his mother and grandfather.
The investigator listened to a recording of the call. His grandfather was
disappointed that he had once again been segregated. He informed him that
he needed to start behaving or he would not get out as expected in October.
Prisoners in the segregation unit are allocated a set time to use the telephone
so that they can all have the opportunity to use it. When he had been on the
telephone for his allocated time the officer asked him to end his call. He initially
refused but then complied with the request. He then complained to another
officer that he felt that staff were “stitching him up” and was told that he had
been given the same as all other prisoners on the unit.
129. The Governor went to the segregation unit later that afternoon and asked the
staff whether they felt that the man had complied with the instructions he had
been given the previous day. Staff told the governor about his continued
abusive behaviour. They decided that his adjudication would not be heard but
29
he would be given the opportunity to have it on the Monday if he started to
comply with what had been asked of him. The officer and Governor told the
man the decision. The officer said that he seemed to accept the reasons and
fully understood that the hearing could take place the following day.
130. However, towards the end of the afternoon, the man again pressed his cell bell
and asked for his adjudication to be held that day. When he was told that it
could not, he became abusive. He is reported to have said that he had a
telephone and making serious threats against the Governor and the officer.
The officer placed him on report. He is reported to have been quiet for the
remainder of the afternoon and evening.
131. While in the segregation unit, the man spoke to other prisoners, including a
prisoner who was in the cell next door to him. The investigator spoke with him
during the investigation. He first met the man when he was located in the
segregation unit in June. The prisoner said that the man appeared fine and
would always join in any banter that was going on. He explained that both he
and the man would shout to other prisoners on the unit. When asked how he
felt the man got on with staff on the unit, he told the investigator that he felt at
times the man’s relationship with them was “mixed” and he could be a ”bit of a
pain”. However, he also said that it seemed that staff would get into arguments
with him, which served to antagonise him. The prisoner said that the man
would press his cell call bell quite often and continuously ask for tobacco.
132. The investigator asked the prisoner about the Sunday and whether he could
recall anything significant about the man. The prisoner said that during the
afternoon the man had threatened an officer for which he had been placed on
report. Following this, the man had told him that he only had a few months left
and would be happy to serve it in the segregation unit. The prisoner said that
he and the man discussed various things that evening. He recalled him saying
that he needed a “master plan” to get himself moved out of the segregation
unit, but did not say what he intended to do.
Events in June
133. On the morning of a day in June, three officers arrived for duty in the
segregation unit at 7.30am. The first officer told the investigator that he made a
cup of tea and then checked events from the previous evening. The officer said
that due to the man’s attitude towards him the previous day, it was decided that
the other two officers would deal with him as much as possible. Once they had
discussed what needed to be done that day the first officer and his colleagues
began the morning routine.
134. Prisoners in the segregation unit are provided with a breakfast pack the
previous evening that contains cereal, a carton of milk and possibly a bread roll
and sachet of jam. When staff begin the morning routine they go to each cell,
offer hot water, and provide each prisoner with their allocated three cigarettes.
Prisoners are also asked whether they would like a shower and exercise during
the morning. Prisoners on report will also be given their adjudication paperwork
30
at this time. Once this is complete, the staff begin unlocking in turn those
prisoners requiring a shower and/or exercise.
135. The second officer went into the man’s cell to give him some hot water. The
officer has worked at Swinfen Hall for six years and been a segregation unit
officer for nine months. In his police statement, he said that he noticed a length
of torn bed sheet tied to his bed and asked him what it was for. He told him
that he was using it for “exercise” purposes. The officer told him that he could
not have it and removed it from the cell, discarding it in a pile of rubbish in the
corridor. In his statement the officer said that he “did not think much to this and
it did not cause me concern“.
136. When interviewed by the investigator some time after making the police
statement, the officer did not mention these facts despite being asked to clarify
his interaction with the man that morning. The investigator wrote to the officer
and asked him to provide a statement giving details of this particular interaction
with the man. In the subsequent statement provided, the officer said that he
had noticed the torn bed sheet tied to the man’s bed but after removing it had
not been concerned as he said, “prisoners use bedding all the time”.
137. The first officer told the investigator that the man had asked to have a shower
and, as the other staff told him that he had been behaving, he escorted him to
the shower room. It is recorded in the unit diary that this was around 8.47am.
The officer had a conversation with him on the short walk to the shower room
and thought he appeared quite happy.
138. The second officer went to see the man after he had returned from the shower
to give him his adjudication paperwork. In his statement to the police following
his death, the officer said that he had issued him with the documents relating to
the threats he had made towards the first officer the previous day, and had read
the charge aloud to him. He said that he made no reply to the charge.
139. The second officer also said in his police statement that he took the man some
tobacco between 9.00am and 9.30am. He appeared to be fine and normal and
was not upset or angry. The officer said that he just kept asking when he would
get his exercise and about his adjudication.
140. At 9.00am, the nurse went to the segregation unit to see all the prisoners. The
nurse recorded that the man told her that he felt “anxious and depressed”. The
investigator asked the nurse whether she had been concerned by what he had
said. Despite what he said she did not feel there was any difference in the way
that he spoke to her that morning to any other time. The nurse said that he
always came across as “quite assertive” and “upbeat”. He had never appeared
to her as someone who was withdrawn and he did not seem to be withdrawn
that day. She told him that he would have the opportunity to speak to the
doctor who would be visiting later that morning.
141. The Governor, who was going to be the adjudicating governor that day, arrived
in the segregation unit at around 10.20am and discussed with the unit staff the
number of adjudications. The adjudications began at 10.30am. A number of
31
prisoners in the segregation unit were due to have adjudications and others
needed to be collected from the residential wings. The third officer was
responsible for collecting and returning prisoners to the wings. The first officer
was the adjudication liaison officer, which required him to ensure the governor
had the correct documents during the adjudication.
142. The Governor of Swinfen Hall went to the segregation unit that morning in order
to collect some documents. He told the investigator that he was completing
paperwork in his office on the Monday morning and needed some information
about an ongoing adjudication. He was aware that adjudications would still be
taking place so staff would be busy and therefore decided to collect it himself.
143. When the Governor arrived at the unit, no staff were visible and he assumed
that they were all involved in adjudications. He went to the unit office and
signed the diary to say that he had been there when, the second officer came
in. The officer told the Governor that there was a break in the adjudications as
they were waiting for some prisoners to be returned to the wings and others to
be brought down. The officer asked the Governor if he would like to do the
“rounds” which involves speaking briefly to all the prisoners located on the unit.
The Governor agreed to do so while he was there and amended the entry that
he had just made in the diary to read, “All seen”, although he had not yet visited
each prisoner.
144. The Governor said that the officer explained why each prisoner was held on the
unit and their progress. He recalled the officer telling him about the man’s
behaviour which had also been mentioned during the morning briefing meeting.
After the officer briefed him about each prisoner, they went out into the corridor
to visit the prisoners, starting at cell number one. As the nurse was
interviewing the prisoner in that cell, they moved immediately to number two
and the first officer joined them.
145. As they were leaving cell number four at approximately 11.05am, the prisoner
asked the second officer a question and he stepped back to answer him. The
Governor and other officer continued to cell five, which was occupied by the
man. As the first officer began to open the door, he turned to the Governor and
said, “watch yourself with this one gov” which the Governor understood to
mean a warning about the man’s behaviour. The officer opened the
observation panel. The Governor saw that it was covered with paper and
thought to himself that he would need to challenge the man about this.
146. The officer said that, as he opened the man’s door, he saw him hanging at the
back of the cell from the window grill. He shouted to the second officer but
could not recall exactly what he said. The officer went into the cell and took
hold of the man by what he thought was his t-shirt and tracksuit bottoms to lift
him up while he cut the ligature with his anti-ligature knife. (All staff who have
direct contact with prisoners are issued with an anti-ligature knife. The knife
has a tamper proof blade and is designed for cutting ligatures quickly and
safely.)
32
147. Although the officer thought that he had a secure hold of the man, as he cut the
ligature it quickly became apparent that he only held his t-shirt and he slumped
forward striking his head on the toilet. The second officer had gone into the cell
behind the first officer and between them they lifted the man and laid him on the
floor of the cell. The second officer had already called a ‘code blue’ via his
radio to request medical assistance. (There are two codes in use at Swinfen
Hall. Blue and Red, code blue indicates a prisoner who has either stopped
breathing or has breathing difficulties. Red is used when a prisoner is
bleeding.)
148. The man was not breathing and the first officer could not find a pulse. The
officers began to administer cardio pulmonary resuscitation (CPR). The
Governor, who was still at the door, told the investigator that, as he was not
needed to help with the CPR, he left the cell to see whether assistance was
arriving. He saw the nurse, who had been on the unit, running towards him and
she went into the cell.
149. Another Governor who had been conducting the adjudications arrived at the
cell and asked whether an ambulance had been called. The first Governor then
went to the office and telephoned the control room to tell them that an
ambulance was required. The control room staff telephoned back to find out
whether the person was conscious or unconscious. (The relevance of this
question is to assist the emergency services in sending appropriate
assistance.)
150. On hearing the ‘code blue’, the nurse immediately made her way to cell five and
saw the Governor standing outside. When she went into the cell, both officers
were administering CPR. After assessing the situation, she ran back to the
treatment room in the unit to collect an oxygen cylinder and other emergency
equipment. By this time, other staff who had heard the radio calls began to
arrive on the unit.
151. A Senior Officer (SO) was working in the programmes department situated
close to the segregation unit when he heard the ‘code blue’ and immediately
made his way there. He was directed to the man’s cell and saw both officers
and the nurse administering CPR. The second Governor asked the SO to take
over the chest compressions from the second officer, as he was becoming
tired. This officer and the SO then continued to take it in turns to give chest
compressions until the third officer, who had returned to the unit on hearing the
‘code blue’, was asked to take over from the second officer.
152. The Healthcare Manager also went to the unit and took with her a portable
defibrillator. (Defibrillators deliver a brief electric shock to the heart, which
enables the heart's natural pacemaker to regain control and establish a normal
heart rhythm. The defibrillator is an electronic device with electrocardiogram
leads and paddles. During defibrillation, the paddles are placed on the patient's
chest, staff stand back, and the electric shock is delivered.) She said that
when she arrived the nurse was giving the man oxygen and she took over. She
placed an airway into his mouth and gave some breaths before placing the
defibrillator pads onto his chest. She said that she checked for signs of life
33
throughout. The defibrillator did not shock him and she explained that this
indicated there was no shockable rhythm, so CPR was continued. This was
carried out in two-minute cycles and the defibrillator continued to indicate that
there was no heart rhythm. She said that she had been administering
treatment for around ten minutes before paramedics arrived.
153. The ‘first response’ paramedics arrived in the segregation unit at 11.13am, ten
minutes after the ‘code blue’ call had been made. An ambulance and further
paramedic staff followed at 11.25am. The Healthcare Manager said that the
paramedic staff took over the first aid. They continued to attempt resuscitation
for a further 15-20 minutes. At 11.37am, paramedic staff stopped resuscitation
attempts and pronounced the man dead.
Following the man’s death
154. Swinfen Hall contacted HMP Liverpool following the man’s death, at 12.25pm
and made a request for someone from Liverpool to be sent to inform his next of
kin. It is usual practice for the prison where the death has occurred to break
the news but when the next of kin live some distance away it is not unusual for
other prisons to be asked to assist. Governors at Liverpool were happy to
assist and contacted Swinfen Hall at 3.55pm to say that the family had been
informed. A Governor at Swinfen Hall telephoned the man’s mother at 4.40pm
and expressed his condolences. He also informed the family that he had
appointed a liaison officer to assist the family.
155. Other prisoners who were considered to be at risk of self-harm at Swinfen Hall
at the time of the man’s death were all reviewed as part of the ACCT
procedures. Also, staff and prisoners working and located in the segregation
were offered support from the staff care team and chaplaincy.
34
ISSUES
ACCT post closure interview
156. The ACCT procedures require a post closure Interview to be conducted with a
prisoner within seven days of the document being closed. This remains a
requirement even when a prisoner is transferred within the seven day period,
as happened to the man. HMYOI Stoke Heath as required indicated on the
Prisoner Escort Record (PER) that an ACCT had been closed in the last seven
days. However, when he arrived at Swinfen Hall this information was not acted
on or passed to the relevant department. (The PER is a form that accompanies
staff escorting prisoners on journeys to and from the prison. It provides a
chronological record of the events on the journey eg meals served, times
journey started etc. It also serves as a communication tool about risks a
prisoner poses on escort or transfer.)
157. During the investigation, the investigator asked about the procedures in place
at Swinfen Hall to ensure that post closure interviews take place. He was given
a copy of the prison’s Safer Custody Policy that sets out the requirements
under PSO2700:
”… When receiving a prisoner in the post-closure phase of ACCT (i.e.
the ACCT Plan has been closed, but the final post-closure review has
not been signed off) the receiving Unit Manager must nominate a Case
Manager (or undertake the role themselves) to oversee the continuing
closure process.
“The closure must be recorded in the F2052A (history sheet).”
“The closed ACCT Plan remains on the wing until completion of the
post closure interview(s). Once it is confirmed there are to be no further
post closure interviews the closed ACCT Plan must be stored safely in
the F2050 core record …”
158. In spite of this policy, it is clear that no systems were in place at Swinfen Hall to
ensure that these instructions are carried out and the man did not have a post
closure interview.
The Governor should ensure that a system is in place at Swinfen Hall to
identify prisoners who require post closure ACCT interviews and a record
of the completed interview should be made in the individual’s wing
history files. This should include prisoners transferring into the prison.
159. As part of the clinical review, the clinical reviewer commented that while at
Stoke Heath, the man was reviewed daily by a member of the healthcare team
while in segregation. However, a consultant forensic psychiatrist assisting with
the review has said that when he was placed on the ACCT a referral to the
prisons mental health in reach team (MHIT) would have been appropriate. As a
result she makes the following recommendation. This recommendation is
relevant to HMYOI Stoke Heath and will be shared with the Governor.
35
Consideration should be given to systems in place for referral to the
prisons in reach mental health team.
160. The clinical review panel comment that the man’s reception screening records
indicate that he had raised no issues with regards to his mental health or self-
harm. However, he had requested to speak to a Mental Health Nurse while at
HMYOI Altcourse in 2007, as he felt low and depressed. Following this a
referral was made but he failed to attend two subsequent appointments. The
clinical review panel indicate in the clinical reviewer’s report that it is good
clinical practice to outreach on the prison wing or to ascertain the reasons
behind the non attendance. It is the opinion of the panel that the man’s non
attendance at appointments contributed to the eventual outcome in any
significant way. The clinical reviewer makes the following recommendation.
This recommendation is relevant to HMYOI Altcourse and will be shared with
the Governor.
Consideration should be given to systems in place for the reporting and
follow up of prisoners that fail to attend appointments.
Sharing information between departments
161. On reception and during the induction process both nursing and discipline staff
spoke to the man but none of them had access to the closed ACCT document
that should have been stored with his wing history file, as per the guidance
previously mentioned. The information gained about his previous ACCT history
was only obtained by questioning him and was not recorded anywhere that
would inform other staff who would deal with him later.
162. The man’s previous ACCT had been opened because he placed a ligature
around his neck while in the segregation unit at Stoke Heath. Although he
indicated that he did not intend to take his own life at that time, this information
should nevertheless have been recorded when he arrived at Swinfen Hall.
163. During the investigation, the investigator asked staff working in the segregation
unit whether they would have dealt with the man differently if they had known
that he had tied a ligature around his neck only a few weeks earlier. The staff
were not aware of the incident. They pointed out that knowing this would not
have necessarily have led to another ACCT being opened, but it would have
indicated that he might need to be watched more closely for changes in his
behaviour.
164. If this information had been recorded in the man’s wing history file when he
arrived at Swinfen Hall, it would have enabled staff to make themselves aware
of his previous history. The importance of sharing information between the
different departments should not be underestimated.
The Governor should remind staff of the importance of recording
information in a prisoner’s wing history file.
36
The Governor should ensure that when prisoners are transferred into
Swinfen Hall their previous wing history files are kept with those
subsequently opened so that information can be shared.
The Governor should instruct residential wing staff to pass on all relevant
information from the wing history file to segregation unit staff when a
prisoner moves to the unit.
Ligature points
165. During the initial visit to Swinfen Hall, the investigator was shown the cell that
the man occupied in the segregation unit. He was concerned that the ligature
point used by the man was an obvious one that could potentially result in
further self-harm attempts. He brought these concerns to the attention of the
Governor who assured him that immediate action would be taken to address
this problem. I am aware that changes to the fabric of the segregation unit is a
matter of funding which has been sought by him. The Governor has provided
assurances that all prisoners will be suitably assessed before being located in
the cells highlighted by the investigator. I make no further recommendation in
relation to this.
Requesting emergency assistance
166. Although there is no suggestion that the prison failed to call an ambulance,
there does appear to have been some confusion amongst staff about the
process for doing so.
167. When the man was found, officers immediately began to administer CPR and
healthcare staff brought equipment quickly. When the Governor asked the
control room to call an ambulance for a ‘code blue’, this should have been
sufficient for one to be immediately called. However, the control room staff
telephoned back to enquire whether the patient was conscious or unconscious.
I feel that this is information that is required by the emergency service
switchboard and should have been available to the control room staff at the
outset to ensure that there was no chance of a delay.
168. The clinical reviewer has also highlighted this confusion in her report. I make
the following recommendations, the first of which takes account of the views
expressed by her.
The Governor should produce guidance for control room staff to clearly
explain the process to be followed when an ambulance is requested and
specify who is responsible for ensuring that this is done.
The Governor should also issue a Notice to Staff reminding them of the
medical emergency coding system and providing a clear definition for
each of the codes.
37
Emergency first aid
169. The staff that discovered the man and the nurse that initially attended were
quick to begin performing CPR and giving mouth to mouth, and administering
oxygen as soon as it was available. The clinical review panel highlight a need
for staff to have access to pocket masks in order to assist them in emergency
situations. The clinical reviewer makes the following recommendation.
It is recommended that healthcare staff are provided with pocket masks
for use in this type of situation.
Medical records
170. During the review of the man’s medical records, the clinical reviewer found that
a large number of abbreviations were used. While easily understood by those
writing them, they proved less so for any other person attempting to gain
information. As a result of these findings, she makes the following
recommendation.
The Head of Healthcare should ensure that the use of abbreviations on
medical records is avoided unless a locally agreed list of abbreviations is
in place.
Defacement of documents
171. The investigator noticed that the photograph of the man on the front of his wing
history file had been defaced. It is not known who did this but regardless of who
was responsible, this is an official document and this act was inappropriate and
very unprofessional.
38
CONCLUSION
172. The man had been in prison on and off for a number of years and was aware of
the rules and regulations. He spent time in several prisons during his most
recent sentence, being transferred from the majority because of his reluctance
to abide by the rules and regimes.
173. It has been clear throughout the investigation that, despite the man’s battles
with authority, he also had a very likeable side and was referred to by staff as a
”cheeky chap” who enjoyed a laugh. The character that he portrayed while on
his wing or in the segregation unit was in complete contrast to the young man
who took an active part in his cleaning course. His tutor described him as
having qualities that she admired, that he always wanted to be the best and
had huge artistic talent. He had expectations of starting his own business and
was apparently looking forward to his release when he died.
174. The investigation has uncovered no clear reason why a young man who had
the support of his family and partner and expectations for his future would
choose to take his own life. Indeed, the man’s explanation that he had “been
silly as he did not want to die then or now” when he was found with a noose
around his neck on an earlier occasion suggests that he may well not have
intended his actions in June to result in his death.
175. The investigation concludes that in relation to the way in which the man was
dealt with while in custody was appropriate. The clinical review also indicates
that the clinical practice at Swinfen Hall and medical staff interaction with him
was appropriate.
39
RECOMMENDATIONS
1. The Governor should ensure that a system is in place at Swinfen Hall to
identify prisoners who require post closure interviews and a record of
completed interviews should be made in individual’s wing history files. This
should include prisoners transferring into the prison.
The Prison accepted this recommendation and gave the following
response:
When an ACCT Plan is closed and a Post Closure Interviews date is set, the
Case Manager will:
(cid:1) E-mail’s the establishments SPC advising of the ACCT closure and the
date of the Post Closure Interview.
(cid:1) Record this date in their S/O Handover diary as well as on the Prisoners’
Prison NOMIS Wing File.
In addition The SPC will:
(cid:1) Place the date of the Interview onto his/her Outlook Calendar and
forward this via the “Invite Attendees” Email service to the Prisoners
Wing Managers.
(cid:1) This will place the Interview onto the Wing Manager’s outlook calendars.
Once a Post Closure Interview has been conducted the Case manager will:
(cid:1) Record details of the interview on the Prisoners’ Prison NOMIS Wing
File.
If further Interviews are required, set a new date as per the above
procedure
2. Consideration should be given to systems in place for referral to the prisons in
reach mental health team. (This is relevant to HMYOI Stoke Heath)
A response to this recommendation is still awaited from HMYOI Stoke
Heath.
3. Consideration should be given to systems in place for the reporting and follow
up of prisoners that fail to attend appointments. (This is relevant to HMYOI
Altcourse)
The prison accepted this recommendation and gave the following
response:
The healthcare manager will implement a system to ensure those offenders
who fail to keep mental health appointments are routinely followed up
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4. The Governor should remind staff as to the importance of recording
information in a prisoner’s wing history file.
The prison accepted this recommendation and gave the following
response:
(cid:127) Prison NOMIS has now been introduced at Swinfen Hall. This is an IT
system that staff use to record prisoner information in their individual
computer Wing history files. All staff have access to these files.
(cid:127) Hard copy Wing history files are currently retained (where applicable) on
the Prisoner’s wing.
(cid:127) Information to Staff (ITS) reminder to be issued.
5. The Governor should ensure that when prisoners are transferred into Swinfen
Hall their previous wing history files are kept with those subsequently opened
so that information contained within them can be shared.
The prison accepted this recommendation and gave the following
response:
(cid:127) Prison NOMIS has now been introduced at Swinfen Hall. This is an IT
system that staff use to record prisoner information in their individual
computer Wing history files. All staff have access to these files.
(cid:127) Hard copy Wing history files are currently retained (where applicable) on
the Prisoner’s wing.
6. The Governor should instruct residential wing staff to pass on all relevant
information from the wing history file to segregation unit staff when a prisoner
moves to the unit.
The prison accepted this recommendation and gave the following
response:
(cid:127) Prison NOMIS has now been introduced at Swinfen Hall. This is an IT
system that staff use to record prisoner information in their individual
computer Wing history files. All staff have access to these files.
(cid:127) Hard copy Wing history files are currently retained (where applicable) on
the Prisoner’s wing.
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7. The Governor should produce guidance for control room staff to clearly
explain the process to be followed when an ambulance is requested and
specify who is responsible for ensuring that this is done.
The prison accepted this recommendation and gave the following
response:
(cid:127) A Control Room protocol for code red and blue has been produced and the
Local Security System (LSS) has been updated with the following;
(cid:127) LSI 5.31 Code red and code blue definitions
(cid:127) LSI 5.35 Oscar 1 response to code red/blue
(cid:127) LSI 5.34 Control room - response to urgent message code red/blue.
The LSS is available to all staff on the Intranet
8. The Governor should also issue a Notice to Staff reminding them of the
medical emergency coding system and providing a clear definition for each of
the codes.
The prison accepted this recommendation and gave the following
response:
Information to Staff (ITS) to be issued regarding the emergency coding system
definitions as per the LSS in Recommendation 7.
9. It is recommended that healthcare staff are provided with pocket masks for
use in this type of situation.
The prison accepted this recommendation and gave the following
response:
Currently working with the Resuscitation officer of the PCT to overhaul
emergency equipment. This includes issuing each nurse with a pouch to
connect to their belt containing a pocket mask and gloves. Each nurse here at
Swinfen does have a face shield that was issued this year.
10. The Head of Healthcare should ensure that the use of abbreviations on
medical records is avoided unless a locally agreed list of abbreviations is in
place.
The prison accepted this recommendation and gave the following
response:
The record keeping review team recommend that abbreviations are not used.
It is acceptable to write longhand with abbreviation in brackets afterwards if
the entry contains the expression repeatedly but the abbreviation only counts
for that entry.
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