Individual at Manchester

Investigation into the circumstances surrounding the
death of a man at HMP Manchester
in January 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2008
This is the report of an investigation into the circumstances surrounding the death of
a man at HMP Manchester on 11 January 2008. Shortly before 5.00pm that day, a
man was found hanging in his cell in the Vulnerable Prisoners Unit. He was from
another country, spoke little English and was 29 years old.
I offer my sincere condolences to the man’s family and friends for their sad and
untimely loss.
The investigation was conducted by one of my colleagues. I also commissioned a
clinical review of the management of the man’s health needs while he was in custody
at Manchester.
I would also like to thank the Governor of Manchester and his staff for the help and
co-operation they offered during the course of the investigation. I pay particular
tribute to the investigation liaison officer who was exceptional.
In February, one of my family liaison officers telephoned the man’s uncle to arrange
a home visit to discuss the investigation. He said he did not wish to be visited at
home but confirmed that he did want to see my report. The man’s uncle raised a
number of concerns about the nature and cause of his nephew’s death. I trust these
are addressed in this report.
The investigation found that the care afforded to the man was appropriate. However,
I make four recommendations. The clinical review makes an additional eight which I
endorse.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2008
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CONTENTS
Summary
Investigation process
HM Prison Manchester
Key events
Issues
Recommendations
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SUMMARY
The man appeared at Magistrates’ Court on 12 October 2007, charged with a
serious offence against his wife. He vehemently denied this charge, claiming his
wife made the accusation because he would not buy her a house. The man was
refused bail as he was an illegal immigrant. He was taken to HMP Manchester,
arriving at about 5.30pm. This was his first time in prison. The man could speak
little English.
During the reception procedures, the man said he had no major concerns about his
health and did not have any mental health history. He said that, although he was in
prison, he did not feel suicidal. He was advised to apply for segregation because of
the nature of his alleged offences. He did so and was initially allocated a single cell
in the induction wing and kept apart from other prisoners. Three days later, the man
made superficial cuts to his wrist and leg. He claimed he did this because he was
frustrated at having to remain in his cell for long hours with little to do. He was taken
to the healthcare centre for assessment and a doctor decided to admit him as an
inpatient. Formal self-harm monitoring (Assessment, Care in Custody and
Teamwork - ACCT) procedures were also invoked. The man remained in the
healthcare centre until 26 October when he was considered to be well enough to
return to a wing. He was located in K Wing because the Vulnerable Prisoners Unit
(VPU) was full. He remained there until 30 October when he transferred to the VPU.
The self-harm monitoring procedures remained in force until 6 November when it
was thought the risk of further self-harm had diminished. Thereafter, he seemed to
settle into a pattern of hard work and befriended a small group of foreign national
prisoners who could speak his language. He shared his cell with another prisoner
who helped him fill in forms and to communicate with wing staff. Although he was
anxious about a number of matters such as the possibility of being deported, his
forthcoming trial, and his wife and daughters whom he dearly loved, the man gave
the impression that he was coping reasonably well. He gave no one, not even his
uncle whom he telephoned regularly, any indication that he was contemplating
suicide.
During the afternoon of 11 January 2008, the man apparently took his own life by
hanging while his cell mate was at an education class.
My report concludes that, although there was no evidence that the man underwent a
secondary health screen, and there were minor flaws in the ACCT procedures, the
medical and other care afforded to him at Manchester was appropriate. Although he
spoke little English, there is no evidence that he was unduly disadvantaged by any
language difficulties. I do not believe his death could reasonably have been
predicted or prevented. The prison promptly informed his family of his death. Staff
and prisoners were also offered appropriate support.
I make four recommendations in respect of ACCT, care plans and calling an
ambulance in an emergency situation. I endorse the eight further recommendations
made by the PCT relating to various clinical matters.
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INVESTIGATION PROCESS
The investigation was opened on 13 January 2008 by one of my Assistant
Ombudsmen. He met the Governor of Manchester to brief him on the nature and
scope of the investigation. On the same day, notices were issued to staff and to
prisoners inviting anyone with information or concerns about the man to contact my
investigator.
The investigation was carried out by one of my colleagues, who began his work at
the prison on 15 February. On that day, he met the Deputy Governor and
representatives of the local Independent Monitoring Board (IMB) and the Prison
Officers’ Association (POA). The meeting was also attended by the Clinical
Reviewer who had been commissioned by Manchester Primary Care Trust to
undertake a clinical review of the management of the man’s health needs. A Senior
Officer, who was the investigation liaison officer, also joined the meeting as did a
Detective Sergeant from the Greater Manchester Police. The PPO investigator
briefed those present on his terms of reference and methodology for the
investigation. Thirteen members of staff and three prisoners were interviewed
subsequently. Police witness statements were also made available to my
investigator.
In February 2008, one of my Family Liaison Officers, telephoned to introduce herself
to the uncle, in order to ascertain the extent to which he wished to be involved in the
investigation. The uncle confirmed that, while he did not wish to be visited, he
wanted to be kept abreast of developments during the course of the investigation
and to receive a copy of this report.
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HMP MANCHESTER
HMP Manchester, formerly known as Strangeways, is a Victorian local prison within
the Prison Service’s high security estate, situated not far from the city centre.
At the time of the investigation, the prison served Magistrates’ and Crown Courts in
the Greater Manchester area, and held up to 1,269 male adult prisoners, including a
number of category A (high security) prisoners. Its accommodation comprises two
Victorian radial buildings containing nine wings or units with a mix of single and
double cells, a segregation unit and a healthcare centre.
Healthcare at Manchester is commissioned by the Manchester Primary Care Trust.
The healthcare centre provides 24 hour nursing care and medical cover and has
beds for up to 38 prisoners.
HM Chief Inspector of Prisons, last inspected Manchester in May 2007. In the report
of that inspection, published the following October, Ms Owers recorded her view that:
“Despite population pressures, purposeful activity and resettlement
provision for Manchester’s wide range of challenging and needy
prisoners remained generally sound and staff-prisoner relationships
had improved since our last visit. Nevertheless, we note a number
of safety concerns, both for the prison and for the National Offender
Management Service, that need to be addressed as a matter of
urgency.”
Under the heading “Safety”, the Chief Inspector of Prisons went on to say:
“There had been a large number of deaths in custody over the past
three years and it was of concern that there had been some
recurrent recommendations arising from investigations by the
Prisons and Probation Ombudsman, particularly weaknesses in
record keeping. The safer custody manager had insufficient time
for her role.”
This investigation into the man’s death found evidence of minor flaws in record
keeping.
In their report on Manchester for the period 1 March 2006 to 28 February 2007, the
prison’s Independent Monitoring Board made the following general comment:
“During the year, HMP Manchester has continued to prove its
excellence. It has been awarded High Performance status and has
achieved the Investors in People award. The Board is proud on the
prison’s behalf of these achievements during what has been a
problematic, overcrowded year.”
The Board drew attention to their concern that about 90 per cent of inpatients in the
healthcare centre had mental health problems. They reported that 60 per cent of
prisoners on open ACCT forms were inpatients. They said there had been two
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deaths in custody in the healthcare centre during the reporting period but several
incidences when members of staff had successfully intervened. The Board
commented:
“It is thanks to their dedication and action above and beyond the
call of duty that more deaths have not occurred. There have been
many incidents of self-harm, some very serious. The staff do
everything they can to prevent prisoners harming themselves.
However, at times it is distressing for staff, as often a wound is
barely healed before a prisoner bleeds himself again, and the
process of treating him starts over.”
None of the recommendations I have made in previous investigations at Manchester
is relevant here.
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KEY EVENTS
Court appearance
The man appeared at Magistrates’ Court on 12 October 2007, charged with a
serious offence against his wife. He was refused bail due to the seriousness of the
offence. He was remanded in custody at Manchester prison. The man was from
outside the United Kingdom.
Reception at Manchester
The man arrived at Manchester at about 5.30pm. The Prisoner Escort Report (PER)
for the journey between the court and the prison carried no notations that he
presented any medical, security or other risks, including that of self-harm.
An officer saw the man on reception. Realising he could not speak English very well,
the officer used BIG WORD, a system by which a dedicated telephone number is
used to call an appropriate interpreter to translate between English and the mother
tongue of a foreign national prisoner. Both the prisoner and the member of staff
talking to him can hear the interpreter on separate telephone sets. The BIG WORD
facility used by discipline staff in reception has to be shared with the healthcare staff.
The man told the officer he was born on 5 July 1979 and was married with three
children. He told the officer where he was from and was unemployed. The officer
offered the man a free reception telephone call to his family. However, as he had no
telephone numbers on him, he could not make any calls. Neither could the officer
make any calls on his behalf. The officer told my investigator that all prisoners are
also offered a call to their legal adviser but, for the same reason, the man could not
use this facility.
Health screen
A nurse conducted a first reception health screen on the man the same day (12
October). The man once again gave his date of birth as 5 July 1979. He said he
had been living at an address in Greater Manchester prior to his arrest. He gave no
details of any doctor he had attended. No health information had been received at
Manchester from any outside source.
The man told the nurse he had been in custody before but gave no details as to
when, why or where. (The investigation found no evidence that he had been in
prison in the UK before.) He said he had not been homeless during the previous
year, and had not seen a doctor in that period. He was not taking any prescribed
medication. However, the man told the nurse he had experienced chest pains and
that he kept going to the toilet to pass water. He said he never used alcohol or
drugs. He added that he had never been referred to a psychiatrist for any reason,
and had never received any medication for mental health problems. The man told
the nurse he had never self-harmed and did not feel suicidal after being imprisoned.
The health screen form shows that the man asked to see a doctor and was referred.
However, the investigation found no evidence that he actually saw a doctor during
the reception process. He was considered fit for normal cell occupancy and work.
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There is a requirement that each new prisoner should undergo a secondary health
screen within a short time of arrival. The purpose of this screen is to enable medical
staff to assess prisoners’ specific health needs once they have settled. There is no
evidence that a secondary health screen was carried out for the man.
The author of the clinical review of the management of the man’ health needs, notes
that whereas the nurse, a Healthcare Assistant (HCA), knew that she was meant to
be supervised by a Registered Mental Health Nurse (RMN), the RMN could not
recall being asked about the man or to ensure that the man saw a doctor during the
reception process.
The clinical reviewer also points out that the form used by the nurse contains boxes
for staff to tick or cross when given answers by prisoners during the reception
interview. The clinical reviewer comments that questions answered by a single box
for ticks and crosses can be open to misinterpretation.
Cell sharing risk assessment
The officer and the RMN carried out a cell sharing risk assessment to assess the
man’s risk of harming others, before deciding whether he should be placed in a
single or a shared cell. This risk had to be balanced with the man’s risk of harming
himself. The assessment confirmed that the man had no previous convictions for
any violent offences. He told the officer he had never abused alcohol or drugs. He
also said he had no history of self-harm. The RMN indicated that there were no
health issues indicative of any risk of him harming others. She also recorded that
there were no concerns about any risk of the man harming himself. The man was
therefore assessed as suitable to share a cell.
Application for separation
As soon as the officer saw the nature of the man’s alleged offence, he advised him
that it might be in his best interests to apply to be located in the Vulnerable Prisoners
Unit for his own safety. This was authorised immediately by a senior manager.
Opening of ACCT (Assessment, Care in Custody and Teamwork) for minor
self-harm and admission to healthcare centre
On 15 October 2007, the man made a number of scratches to his wrist and leg using
a shaving razor issued or bought in the prison shop. An officer, who saw him in his
cell after he had done this, completed a form F213SH - a report of an injury to a
prisoner caused by self-harm. At interview, the officer confirmed that the man was in
a double cell in K Wing at the time. He thought that his cellmate might have pressed
the cell bell to draw the attention of staff to what the man had done. As far as the
officer could recall, he found the man lying unresponsive on his bed or on the floor of
his cell. The officer said he could see cuts to the man’s wrist and leg. He was
bleeding superficially from both injuries. The officer confirmed that prisoners were
permitted to keep razors in their possession unless on an Assessment, Care in
Custody and Teamwork (ACCT) form. (This is a document used to monitor those
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prisoners considered to be at risk of self-harm or suicide.) The officer thought the
man was feigning unconsciousness.
The officer summoned the unit manager, who was a Senior Officer, to the man’s cell.
At interview, the unit manger also recalled seeing the man lying on the floor, and that
other staff were in the cell with him. He too described the man as unresponsive and
thought he was feigning unconsciousness. The unit manager said:
“I told my colleagues we have to take the man to the healthcare
centre. As soon as I said that, he got up. He must have
understood what I said. When he stood up he looked ok. He
wasn’t bleeding very much. He must have cut himself using a razor
issued for shaving or a plastic knife. I don’t think there was much
intent. I don’t remember there being another prisoner in the cell
with him. I think I was the one who phoned the healthcare centre to
ask for help.”
The officer said he thought he knew the nurse who came to the cell and took the
man to the healthcare centre.
The nurse made the following entry in the man’s clinical record:
“Hotel 1 call out. Feigning unconsciousness. Refused to accept
treatment. Had a couple of scratches to wrists and left calf. Advised
to leave under supervision and I would attend later. Since then he
has wrecked his cell and has been brought across for assessment.”
The unit manager said he had no knowledge of the claim that the man damaged his
cell before he was taken to the healthcare centre.
The unit manager decided to open an ACCT monitoring form. Whenever an ACCT
form is opened, the Prison Service requires the following measures to be taken:
A concern and keep safe form should be opened immediately.
This form is used to help staff identify the main problems that caused the prisoner to
become at-risk. The unit manager opened a concern and keep safe form at 2.00pm
on 15 October. He completed only one of the boxes available on the form because,
he said, the man was taken straightaway to the healthcare centre for assessment. In
that box, the manager wrote:
“Discovered in K2-40 having cut his wrist and leg. Feigned
unconsciousness. When round, taken to HCC (healthcare centre).”
An immediate action plan must be drawn up.
The aim of the immediate action plan is to consider and record the most appropriate
environment and regime to support the person at-risk prior to the first ACCT case
review. An immediate action plan was drawn up for the man by a Senior Officer and
a Staff. A doctor saw the man and agreed to admit him to the healthcare centre as
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an inpatient. It was further agreed that the man should be placed on an intermittent
watch. This required staff to make four ‘conversational’ entries during the day and
four further entries during the night. The man’s ACCT record shows these entries
were duly made.
An assessment interview must be conducted with the at-risk prisoner within 24 hours
of the initial concern being raised.
This assessment helps staff to gain information that will be useful in formulating
ideas as to the severity of the risk of self-harm and how best to monitor and manage
the person concerned.
An officer carried out the assessment interview with the man. The officer wrote that
the man had entered the country illegally and had married in order to be permitted to
remain in the United Kingdom. He told the officer his wife was behaving badly
because he did not want to buy her a house.
The officer recorded that the man wanted to kill himself when he self-harmed. The
man told the officer he did not consider himself to be mentally ill but was low in mood
and tearful because he did not like being in prison. The man said he felt better when
he self-harmed “because of current problems”. The officer described the man as
very low and confused as to whether he wanted to die. The man felt he had nothing
to live for other than to prove his innocence.
At 7.00pm that day, the officer and the man agreed the following actions:
(cid:127) To place him in a cell with a prisoner who could speak his language.
(cid:127) To assist him to involve himself with wing activities.
(cid:127) To assist him to engage a solicitor.
(cid:127) To assist him to contact his friend via a solicitor.
(cid:127) To give him a telephone call.
The man was placed in a safer cell. This is a single cell designed and equipped in
such a way as to reduce the number of ligature points.
A first case review must also be conducted within 24 hours of the initial concern
being raised.
The man’s first case review was convened immediately after the oficer had drawn up
the immediate action plan. The panel comprised of a Senior Officer who was in the
chair, together with the officer and the man himself. The review took place in the
healthcare centre. The review was summarised as follows:
“Case review based on Big Word. Discussed involving the officer. The
following points need actioning tomorrow:
Try to locate with Bengali speaking prisoner.
Get friend’s phone number from solicitor.”
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The panel judged the man’s risk as being raised and set a further review date of 22
October. He was to be observed intermittently. This meant that staff was required
to observe him at least five times per hour and at irregular intervals.
A care and management plan (care map) should be drawn up.
The purpose of the care map is to identify actions that will disable any suicide plan;
link the at-risk prisoner to people who can provide support, build on any strengths or
interests the prisoner may have, and encourage alternatives to self-injury. The care
map in the ACCT form presented to my investigator was blank.
Further assessment by a doctor
The next day, a doctor saw the man and confirmed his admission as an inpatient in
healthcare. He wrote in his clinical record,
“Looks much better today. Still very difficult contact due to his very
poor English. No evidence of agitation. Normal behaviour. No
evidence of self-harm/suicidal risk at present. Stop intermittent
watch. Continue anti-ligature cell. Review tomorrow.”
On 17 October, the following entry was made in the man’s prison record by an
officer:
“.. Still very upset that his wife has accused him of this crime.
They were living together happily until two months ago. They have
4 month old baby. Also worried that not been able to phone anyone
yet. Asked staff who told me that forms are in progress.”
My investigator was told that, in order to be able to make telephone calls, a prisoner
has to open a PIN phone account. This account can only be opened after the
telephone numbers the prisoner wishes to use in prison have been checked for their
authenticity. The owners of each telephone number also have to be asked if they
are content for the prisoner to call them. Initially, the man had no numbers to be
registered. The process of opening a PIN phone account for him therefore took
longer than normal. My investigator was given a copy of the list of telephone calls he
made from Manchester. The list shows he started to make use of the telephone on
21 October.
Second ACCT review
The second ACCT case review took place at 9.30am on 23 October instead of 22
October as originally planned. On this occasion, the panel comprised of two officers
and a nurse. Also present was a staff nurse and a 2nd nurse as well as the man.
The review took place in the healthcare centre. It was summarised as follows:
“the man appeared quite calm at this review – smiling when spoken
to – states he is okay and doesn’t wish to hurt himself.”
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A fresh assessment of the man’s risk of further self-harm concluded that the risk had
reduced to ‘low’. A further case review was scheduled for 6 November.
On 23 October, a doctor made the following entry in the man’s clinical record:
“Normal behaviour in hospital wing. No evidence of mental illness
or self-harm tendencies. Sleeps well, appetite good. Emotionally
stable. Review on ward rounds of the consultant psychiatrist.”
Assessment by mental health in-reach group worker
On 24 October, a mental health group worker wrote in the man’s clinical record:
“Attended social/discussion group session HCC (Healthcare Centre).
Appeared nervous and anxious. In spite of his limitations to
communicate, he was able to ask questions and was attentive to
what was happening in session. Other members were keen to
encourage and support him.”
The next day, the mental health group worker added
“The man attended day care centre group session. Presented
anxious but pleasant in mood. Was able to interact and
communicate information about himself, with support from his peers
in the group, in spite of the language barrier.”
The investigation found that the healthcare centre did not have appropriate
nursing assessment documentation, and that the nursing care plan provided
was gained from the doctor’s interview with the man. The paper care plan
was not signed or dated because it had been printed from the electronic
copy.
ACCT case review prior to discharge from the healthcare centre
At 6.40pm on 26 October, a further ACCT case review was convened. The purpose
of this particular review was to assess the man’s risk before discharging him from the
healthcare centre. The panel comprised of a healthcare senior officer, an officer and
a nurse. The man was also present. So too was another prisoner who was used as
an interpreter. The review was summarised as follows:
“Explained to the man that he will be moving to K Wing. Explained
the support system open to him and process he will be going
through. He said he understood what was said.”
A follow up appointment was made for him to see a doctor a fortnight later. The
investigation found no evidence that this took place. A further ACCT case review
was to be held on 29 October. However, there is no evidence to show whether that
case review took place either.
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After having been discharged from the healthcare centre, the man was moved to K
Wing where he was allocated a shared cell. K Wing is essentially a remand wing,
but it also operates as an overspill unit for vulnerable prisoners when the Vulnerable
Prisoner Unit (VPU) is full. The man remained in K Wing until 30 October when a
vacancy in the VPU arose. Whilst in K Wing, he occupied a shared cell with another
prisoner who was to become his interpreter and friend in the unit.
Final ACCT case review
The man’s final ACCT case review was held at 3.45pm on 6 November. The panel
on this occasion comprised a senior officer, an officer, and a member of the from
Independent Monitoring Board. (I should say in passing that, while well-intentioned, I
do not believe that IMB members should be part of an ACCT review panel. This is
not a monitoring but a decision-making function, and hence inappropriate for an IMB.
I would be grateful if the Governor could share those comments with the chair of the
prison’s IMB who may in turn wish to consult with the IMB Secretariat or National
Council.)
The man also attended the review, as did his cellmate. The review was summarised
as follows:
“The man was bright to the review and was open. He has settled
onto E Wing (the VPU) very well. He has the support of a number of
prisoners and his family. The issues which caused this document to
be opened have now been resolved. It was agreed by all present
that the document be closed. He was reminded of all the support
networks available.”
The ACCT form was therefore closed.
My investigator scrutinised the entries made in the ACCT ongoing record for the
period 15 October to 6 November. These showed a clear and sustained
improvement in the man’s mental state.
ACCT post closure review
An ACCT post closure review was held at 6.30pm on 13 November by a Senior
Officer. The date mistakenly shown for the post closure case review was 6
November. The review was summarised as follows:
“The man has settled down on the wing. He has a number of
friends on the wing and he attends work. No more concerns at this
time and the form can remain closed.”
There is no evidence to show that any other member of staff or prisoner attended
this review.
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Appearance at court
On 31 December 2007, the man was taken to Crown Court. He was remanded in
custody at HMP Manchester once again, this time to await confirmation of a date for
his trial to begin. The Prisoner Escort Record (a form that accompanies each
prisoner on escort to provide a chronological record and to communicate risks a
prisoner might pose on escort or transfer) for the journey to the court carried the
notation that he was vulnerable because he had been located on the VPU.
However, it included no indication that the man was at risk of self-harm or suicide.
The man returned to the prison later that day. He was seen by a nurse who noted in
his medical record that there were no problems.
Events on 11 January 2008
The man was due to go to work on 11 January but complained of a stomach ache.
An officer allowed him to remain in his cell.
The man’s cellmate, said in a statement he gave to the Greater Manchester Police
that prisoners were locked in their cells during the morning of Friday 11 January
because of a staff funeral. He said he and the man were in the cell together from
7.45am until midday. Throughout that time the television was on. The cellmate said
he watched BBC News 24 from his bunk while the man remained on his prayer mat,
praying the whole time. The cell mate said the man was chanting and reciting from
the Qur’an. He thought the man’s behaviour that morning was no different to
anything he saw during the previous three weeks. The cellmate went on to say:
“About a week and a half prior, the man had started with a cold and
yesterday morning he was coughing. I was aware that the man
wasn’t feeling very well. I had told him to take some of my
paracetamol but he wouldn’t.
“At 12 midday, an officer unlocked our door where we were allowed
access to our lunch on the servery. Both the man and I were
fasting, through our own choice. I had started at New Year but the
man started on Thursday (10 January) for the Islamic New Year.
The man and I went to collect our food which was already prepared
on trays and went back to our cells where we left them until we
could eat at the close of our fasting. He placed his food in his
cupboard. I have no idea what it was. My food was a snack pack
and I placed it on the table. Shortly after the man left our cell and
went over to another prisoner’s cell (29) where he stayed for a
couple of minutes and returned with a book.
“The book was an Arabic prayer book. We were then locked in for
a further two hours. During that time, the man prayed and read his
prayer book. I prayed myself and then watched the TV prior to
2.00pm. The man told me he wasn’t feeling well and wasn’t up to
going to work that afternoon. I asked him if he wanted me to have a
word with an officer on his behalf. The man said yes. When the
door opened, it was another officer. I told him the man wasn’t well
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and if he would be excused. The officer said he would still have to
report to an officer downstairs.
“We both left the cell and I saw the man approach the officer
downstairs. I didn’t hear the conversation but he approached me
shortly after. He put his thumbs up in an ok motion, waved and
smiled. The man then climbed the stairs back towards our cell. I
didn’t see him again.
“At 4.20pm, I returned to my cell with an officer. He opened the
door but prior to doing so I opened the hatch and saw paper was
covering the glass. As the door opened, I went to put the light on
as it was in darkness when I saw via the outside lighting that the
man was hanging by the bars at the window. I was immediately
pushed to the side out of the way by the officer and only saw the
man for a few seconds. He was still and I knew he had died. I
couldn’t see what he was hung with or how he was hung. I was
shocked and just froze.
“I had no idea he had any intentions to taking his own life. He never
spoke to me about committing suicide and never communicated
any intentions of his actions at all. I feel very sorry and upset that
the man has taken his life.”
The officer told my investigator he was on duty in the VPU all day on 11 January. He
confirmed that all prisoners were kept locked up that morning because of a staff
funeral which he did not attend. The officer said he did not have any contact with the
man until about 11.45am when lunch was served. The officer remembered seeing
him come out of his cell to collect his meal. The man passed the point where the
officer was standing. The officer said he may have nodded to the man but he did not
have any conversation with him. He appeared to the officer to be “no different to any
other time”. The man gave him no impression that he was about to take his own life.
A few minutes later, he returned to his cell with his meal. The officer could not
remember whether the man’s cellmate was with him.
At about 2.00pm, another officer unlocked the man’s cell to enable him to go to work
and so that his cellmate could go to his education class. The man told him he was
not feeling well and wanted to stay in his cell. The officer advised the man to report
to the officer on the ground floor of the wing. The same officer was the officer who
had the authority to decide whether he could remain off work.
The officer was the movement’s officer at the time. The man and his cellmate
approached him together. The man told the officer he was not feeling well, having
been suffering from a heavy cold during the previous few days. As the officer knew
the man had a poor command of English, he asked his cellmate if there was a
problem. The cellmate told the officer that as far as he was aware, the man was fine
other than feeling the effects of the cold. The officer took the view that, as the man
was normally a good worker who regularly attended for overtime at weekends; he
could have the afternoon off. The officer told him this and advised him to seek the
advice of a nurse if he did not feel any better at tea time. The man returned to his
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cell and his cellmate went to his education class. He remained in his cell on his own
during the afternoon. At no stage did he press his cell call alarm.
Shortly after 4.00pm, work and education classes ceased for the prisoners in the
VPU. The prisoners therefore began to return to their landings. At about 4.20pm, an
officer began to unlock the prisoners in their cells. As he unlocked cell E4-V17 to
allow the cellmate to be locked up, the officer noticed “something against the bars at
the back of the cell”. As it was dark, he switched the cell light on and saw the man
hanging from the window bars. He shouted for assistance and took the man’s
weight. As he was doing so, two more officers entered the cell. One of the officers
helped the officer who unlocked the cell elevate the man’s body while the other
officer cut the ligature away from the window with her anti-ligature knife. Two
officers then lowered the man to the floor. One of the officers told my investigator he
noticed the man had fixed a table leg horizontally to his window bars which he had
used as a suspension point for the ligature made from a bedsheet. The officer did
not notice any other material used by the man in the construction of the ligature.
A senior officer, who had heard the call for assistance, pressed the alarm bell and
ran to the cell. As soon as she saw what had happened, she told a number of other
staff who had arrived to call for urgent medical assistance.
Once the man had been laid on the floor, one of the officers cut the ligature away
from his neck. Two officers then began to administer cardio pulmonary resuscitation
(CPR). Despite the fact that there was no response from him, they continued to
apply CPR until relieved by another officer and two nurses. One of the nurses said
that, as soon as she heard the call for assistance over the radio, she left reception
with principal officer (PO) and collected the emergency bag and the defibrillator from
the central rotunda en route to the VPU. On arrival at the cell, a nurse attached the
electrodes for the defibrillator to the man’s chest and asked her colleagues to stand
clear whilst it analysed the man’s cardiac rhythm. The defibrillator gave the
instruction “no shock advised – check for pulse”. No pulse could be found. CPR
was therefore continued. A nurse checked the man’s pupils and found they were
fixed and dilated.
In a statement read by my investigator, a governor said she was in her office on the
second landing in the prison’s rotunda when she heard the alarm. The governor said
she went to the cell and saw a number of staff attempting to resuscitate the man.
She explained in her statement who was undertaking which function. The governor
said that she borrowed a radio from a colleague and asked for urgent medical
assistance to be sent to the cell. The nurse and a PO arrived as a result of her call.
The governor said she asked the nurse if an ambulance was needed which the
nurse confirmed. The log of events shows that the prison’s control room was asked
to call an ambulance at 4.29pm; some eight minutes after the initial alarm had been
raised. The request was passed from the control room to the Ambulance Service
two minutes later. An ambulance arrived at the prison gate at 4.46pm and the
paramedic crew arrived at the cell at about 4.47pm. CPR was continued until the
arrival of a doctor at about the same time as the paramedics. The doctor said that,
by the time he arrived, “full protocol CPR including application of fully automated
defibrillator, ambu-bag with high flow oxygen O2 had been ongoing for more than 30
minutes by fully qualified staff, including nurses”. The doctor asked the paramedics
17
to “run a rhythm strip over half a minute approximately which showed definite
asystole”. (A rhythm strip is a means by which the heart beat can be measured and
shown on a graph. Asystole indicates no cardiac output.) The doctor examined the
man and found there were no carotid or femoral pulses, no heart or respiratory
sounds and no movements present. The doctor therefore confirmed the man’s death
at 5.00pm.
The investigation found that some staff either used no protective face masks or
inappropriate masks when applying CPR.
When the police examined the man’s cell they found a long piece of material they
thought he might have used to tether himself to prevent any chance of rescuing
himself once suspended. Only one of the members of staff interviewed by my
investigator - a nurse - remembered seeing this piece of material. The nurse said
she noticed that one end was tied to one of the man’s feet. However, she said she
did not think it was tied to anything at the other end.
Informing the next of kin
The Muslim chaplain telephoned the man’s brother in another country at about
6.45pm to break the news of his death. The brother asked the chaplain to pass on
the news to the man’s uncle in Oldham. The brother expressed his desire for the
man’s body to be returned to his own country for burial. At about 7.15pm, the
chaplain informed the man’s uncle and offered him his support. Arrangements were
made for the uncle to go to HMP Manchester to see the man’s cell and to talk to staff
about the circumstances of the man’s death.
The Governor paid for the man’s body to be repatriated to the man’s own country.
The man’s uncle said he was very grateful for the help given by the prison and felt
staff could not have done more. He also mentioned that the man’s family in his
country had been touched to receive a letter from the Governor. He was particularly
appreciative of the support given by the Imam.
18
Staff and prisoner care
Immediately after the man had been pronounced dead, the chaplain comforted two
of the man’s friends as they were very distressed. He arranged for one of them to
see a doctor.
The Governor issued a notice to prisoners and staff informing them of the man’s
death. Those prisoners who were subject to ACCT procedures were reviewed in
order to assess their reaction to the news. All those staff interviewed by my
investigator were full of praise for the level of care and support offered to them by
their managers and by the prison’s care team.
19
ISSUES
Here I examine:
(cid:127) Whether the man’s health needs were properly assessed and met.
(cid:127) Whether his risk of self-harm or suicide was properly assessed and managed.
(cid:127) Whether he was given appropriate support and facilities, given his status as a
foreign national prisoner.
(cid:127) Whether his death could have been predicted and, therefore, prevented.
(cid:127) Whether the emergency first aid was prompt and effective.
(cid:127) Whether appropriate courtesies were afforded to the man’s family in the
aftermath of his death.
I also address the concerns expressed by the man’s family.
Were the man’s health needs properly assessed and met?
As the man was from another country and spoke little English, not much was known
about his physical and mental health history when he arrived at HMP Manchester on
12 October 2007. There was no evidence that he had been in prison in this country
before.
The man underwent a full health screen as part of the reception procedures. The
assessment was undertaken using BIG WORD, a system using an interpreter over
the telephone. The author of the clinical review suggests that it would be better for
healthcare staff to have an office of their own in reception rather than having to share
the BIG WORD facility with discipline staff.
The man was able to confirm he had no major concerns about his physical health,
although he did disclose that he wanted to see a doctor about the frequency with
which he had recently been passing water. As far as his mental health was
concerned, the man said he had no psychiatric history and did not feel suicidal now
that he was in prison. The nurse who conducted the health screen referred the man
to a doctor. There is no evidence that an appointment took place. The man’s
presentation was such that, in the opinion of the healthcare assistant who
conducted the health screen, there were no grounds for believing he was at risk of
self-harm or suicide.
The clinical review found no evidence that the healthcare assistant who conducted
the health screen was properly supervised by a Registered General Nurse. The
clinical reviewer recommends that the Director of Healthcare at Manchester should
reinforce the need for trained staff to validate the actions of healthcare support
workers. The clinical reviewer also recommends that the Director should ensure
there is no breakdown in communications between the various staff involved in the
reception process.
The clinical reviewer points out that the form used for the reception screen contains
boxes for staff to tick or cross in relation to answers given by prisoners during the
interview. She suggests that answers recorded in this manner can be open to
misinterpretation and recommends that a more robust recording method should be
20
adopted. Having found evidence of poor record keeping in the man’s nursing care
plan, the Clinical Reviewer also recommends that changes to documentation should
be clearly signed and dated.
The investigation found no evidence to show that a secondary health screen was
conducted. The purpose of this screen is to assess a prisoner’s detailed needs once
he has settled into the prison. It should normally take place within two days of the
prisoner’s reception. I consider that this omission was not to the man’s detriment as
he was admitted to the healthcare centre only three days later where his health
needs were appropriately identified and met. Whilst I therefore make no formal
recommendations on this matter, healthcare staff should guard against similar
omissions in the future.
During the reception procedures, the man was advised that it would be in his best
interests to apply for segregation because of the nature of the offences for which he
had been charged. His segregation was immediately authorised and he was placed,
as a temporary measure, in a single cell in the induction wing and kept apart from
other prisoners. Three days later, the man inflicted minor cuts to his wrist and leg.
He was therefore admitted to the healthcare centre by a doctor, an associate
psychiatrist at Manchester. The man remained an inpatient until 26 October 2007
when it was decided he was well enough to return to a wing.
The clinical reviewer found evidence of a lack of nursing assessment for prisoners
admitted to the healthcare centre, and recommends that these should be developed
and implemented as soon as possible.
During his period in the healthcare centre, the man was monitored by the doctor and
one of his colleagues, also a psychiatrist. The man was also counselled by a mental
health group worker. The man was also subject to ACCT procedures. This served
to enhance the level of care he was given. However, the fact that a formal nursing
care plan was not drawn up for the man suggests a lack of diligence on the part of
the responsible staff. However, I am satisfied that this omission did not translate into
any lack of practical care or concern for him. It is nevertheless important for the
establishment to demonstrate the highest procedural and administrative standards,
not least to help guard against the risk that similar omissions might in future signal
lack of care.
I recommend that the Governor should, in conjunction with the Manchester
Primary Care Trust, ensure that nursing and medical staff are reminded of the
importance of drawing up a nursing care plan for every prisoner admitted to
the healthcare centre.
Notwithstanding these criticisms, I believe the general standard of healthcare given
to the man was appropriate.
Was the man’s risk of self-harm or suicide properly assessed and managed?
Could his death have been predicted and, therefore, prevented?
The man said he had no previous mental health problems when he entered prison
for the first time in October 2007. He told reception staff he did not feel suicidal.
21
There were no grounds for invoking self-harm monitoring procedures at that point.
However, as I have said above, ACCT procedures were put in place after the man
self-harmed three days later.
ACCT case reviews were convened on 23 October, 26 October and 6 November,
when, given the man’s improved state of mind, the ACCT document was in my view
appropriately closed.
However, the investigation found that no ACCT care map was compiled for the man.
I recommend that the Governor should remind his staff of the need to ensure
that a care map should be established for each and every prisoner made
subject to ACCT procedures and that the care map should be reviewed and
updated as long as the ACCT document remains in force.
My investigator noted that there was no evidence that a case review scheduled to
take place on 29 October was actually held. A post closure ACCT review took place
on 13 November. The member of staff who conducted that review in the man’s
presence felt confident that the form could remain closed. I am satisfied, given the
man’s presentation at the review, that the decision was justified. However, my
investigator noticed that the review was conducted by one member of staff on his
own. This is not good practice and Prison Service policy requires all ACCT reviews
to be attended by a multi-disciplinary team.
The Governor should remind his staff of the requirement for ACCT case
reviews, including post closure reviews, to comprise a multi-disciplinary team
so that a wide range of opinions can be brought to bear in the decision making
process.
That said, I should like to stress that the standard of care given to the man through
the ACCT process was in my view appropriate.
Between the time the ACCT form was closed on 6 November and the man’s death
two months later, he gave no outward signs of suicidal ideation. He seemed to settle
into a pattern of hard work in the workshop dedicated to vulnerable prisoners,
although some entries made in his prison record show that on one or two occasions
in December he failed to attend work without permission. It was about this time that
a number of prisoners were struck down by a virus that prevented many leaving their
cells. Although there is no mention in the man’s clinical record that he was included
in this number, there is every possibility that his absence from his place of work in
December was caused by the effects of the virus.
The man regularly telephoned his uncle. The uncle later told my family liaison officer
that at no stage did the man talk about committing suicide or give him the impression
that he would harm himself. The man called his uncle the day before he died.
Likewise on that occasion, he gave him no cause for concern.
The man’s cell mate told my investigator that the man prayed very frequently before
11 October and always cried after his prayers had ended. However, the cell mate
did not interpret the man’s behaviour as indicative of any risk of suicide. During the
22
morning of 11 October, the man appeared to his cell mate to be normal. When the
man, with the cell mate’s help, asked an officer for permission to remain off work
because he said he was unwell, neither the man’s cell mate nor the officer thought
that the man was behaving abnormally.
With the benefit of hindsight it seems likely that the man planned to stay off work so
that he could take his life undetected. From the evidence offered by the cell mate
and the staff who had contact with him in the last days of his life, I suspect the man’s
decision to take his life was carefully planned. He managed to put on a brave face to
his peers, staff and to his uncle while he was preparing to die. I believe his death
could not reasonably have been predicted or prevented.
Was the man given appropriate support and facilities given his status as a
foreign national prisoner?
The man was from another country but had spent some time in the United Kingdom
before his imprisonment in October 2007. His mother tongue was Bengali but he
could also speak Urdu. Those staff who had most contact with him thought he could
read English better than he could speak it. The investigation found that efforts were
made from the outset to help him cope with the language barrier. During the
reception procedures, BIG WORD was used. During the ACCT case reviews, it was
normal for another prisoner to attend who could speak English and Urdu or Bengali.
Translators were also used during the man’s time in the healthcare centre.
As soon as the man was transferred into the Vulnerable Prisoners Unit on 30
October 2007, he was placed in a cell with a cell mate who not only regularly
translated for him but also became a close friend. Entries made in the man’s record
show he made good use of the support that stemmed from his friendship with his cell
mate and at least two other foreign national prisoners in the wing.
The investigation found no evidence that the man was unduly isolated because of
the language barrier. However, it is possible that, as an illegal immigrant, the man
expected to be deported to his own country and this prospect frightened him. There
was, of course, little staff could do to reduce this anxiety other than to advise him to
seek legal advice. His record shows that support was given to him to contact his
solicitor. In addition, his uncle had also tried to help by engaging a solicitor and
encouraging the man to speak to her about his concerns.
Was the emergency first aid prompt and effective?
As soon as the officer saw the man hanging, he entered the cell and did everything
he could to save his life. He was accompanied by other discipline officers who were
followed quickly by healthcare staff. Between them, I believe staff made every effort
to resuscitate the man.
Appropriate emergency first aid equipment was taken to the cell without delay. All
the staff who tried to revive the man felt they were properly trained in first aid.
However, the investigation found that some staff had used either no protective face
masks or inappropriate masks when applying CPR. The clinical reviewer
23
recommends that appropriate face masks should be made available and that staff
should be trained in their use. I agree.
An ambulance was called at about 4.29pm, approximately eight minutes after the
man was found. A paramedic crew arrived at the cell about 18 minutes later.
Although the investigation found no evidence that the man’s chances of survival
were impaired by an apparent delay of eight minutes before an ambulance was
called, the hold-up seems too long. A similar delay in future could result in an
avoidable loss of life.
The local contingency plans for managing a life threatening emergency set out the
following requirement for the control room staff in relation to calling an ambulance:
“On receiving an urgent message regarding an injured or ill prisoner
contact Hotel 1 [the code for emergency healthcare assistance]
immediately and direct to the scene. On being informed of a
prisoner causing self-harm or other medical emergency requiring
emergency treatment at outside hospital request an ambulance to
attend prison and give as much detail as possible.”
The contingency plans also require the person who discovers a medical emergency
to request an ambulance but the instructions give no further detail.
The Governor should ensure that the contingency plans for managing a life
threatening situation make clear that an ambulance is called as soon as the
emergency is discovered. The Governor should bring this requirement to the
attention of all his staff.
Were appropriate courtesies afforded to the man’s family in the aftermath of
his death?
The man’s family were informed of his death promptly. At their request, the
Governor arranged for the man’s body to be repatriated to his own country and met
the costs in full. The man’s uncle was grateful for the help given him by prison staff
and said his relatives in his own country were touched by to receive a letter of
condolence form the Governor. I am satisfied that the Governor and his staff gave
kind and proper support to the man’s family. (I may also add that the way the prison
managed both staff and prisoner care in the aftermath of the man’s death was very
impressive.)
Concerns expressed by the man’s uncle
How was it possible for the man to have made a rope out of bedsheets in the
two hours he had available?
Materials such as bedsheets and shoe laces from which prisoners can fashion a
ligature are freely available in their cells. Such items are not normally withdrawn
from prisoners unless their risk of harming themselves is judged as being very high
and imminent. Although we are aware that the ligature was made from torn
24
bedsheets, it is not clear how the man did this or how long it took. The man was not
judged as being at risk of suicide at the time he took his life.
By what means did the man suspend himself from the window?
As noted, the ligature the man used was made from a bed sheet. This was attached
to a wooden table leg he had used as a cross bar he tied to the vertical window bars
covering his cell window. The cross bar was tied to the metal grill outside the
window so that it could not slip downwards under the man’s weight. The man then
used the cross bar as the ligature point. When the police examined the man’s cell,
they found another piece of material that the man seemed to have used to tie his feet
in such a position as to prevent him from rescuing himself. The only member of staff
interviewed during my investigation who could remember seeing that piece of
material was a nurse. She noticed that the material was tied to the man’s right foot
but she could not see where it was fixed at the other end.
Would it have been possible for the man to save himself?
It is not possible to determine whether the man could have saved himself. However,
given that it can take as little as 30 seconds for someone who is hanging to lose
consciousness, it is highly unlikely.
Was the man sharing a cell with a life sentenced prisoner who had murdered
his family?
It would be inappropriate to disclose details of the offences committed by the man’s
cell mate or of the sentence he was serving.
Why were there no marks on the man’s neck?
It is possible that the thickness of the material the man used as a ligature was such
as to leave no marks. However, this is not a question I can answer with any
authority. It is a point the man’s uncle may wish to put to the Coroner.
25
RECOMMENDATIONS
ACCT procedures
1. The Governor should remind his staff of the need to ensure that a care map
should be established for each and every prisoner made subject to ACCT
procedures and that the care map should be reviewed and updated as long as the
ACCT document remains in force.
2. The Governor should remind his staff of the requirement for ACCT case reviews,
including post closure reviews, to comprise a multi-disciplinary team so that a wide
range of opinions can be brought to bear in the decision making process.
Nursing care plans
3. The Governor should, in conjunction with the Manchester Primary Care Trust,
ensure that nursing and medical staff are reminded of the importance of drawing up
a nursing care plan for every prisoner admitted to the healthcare centre as an
inpatient.
Calling an ambulance
4. The Governor should ensure that the contingency plans for managing a life
threatening situation make clear that an ambulance is called as soon as the
emergency is discovered. The Governor should bring this requirement to the
attention of all his staff.
The following further recommendations have been made by the PCT:
5. The first screening process was carried out by a healthcare assistant but there is
no evidence this was overseen by a registered nurse nor that the man was seen by a
doctor. This was a period of transition from a paper system to an electronic one
which may have caused some confusion, but systems must be in place to document
clearly what happened during the process.
6. The paper first screening document has answers to questions that required a tick
or a cross. This method can lead to confusion if the form is not completed clearly.
Questions answered by a single box for ticks and crosses can be open to
misinterpretation and should be replaced by a more robust method.
7. All changes to documentation should be clearly made, signed and dated.
8. The Director of Healthcare must reinforce the need for trained staff to validate the
actions of the healthcare support workers. She must ensure there is no breakdown
in essential communications between all staff involved in the reception process.
9. It would be better for the healthcare staff to have an office of their own rather than
having to share with discipline staff for the use of BIG WORD, particularly when it is
considered how busy this area can be for both discipline and healthcare staff.
26
10. Nursing assessments should be developed and put in place as soon as possible.
Without these assessments robust person centred care plans cannot be developed.
11. On the man’s discharge from inpatient care, a follow-up review should been
arranged. The nurse in charge of the discharge process must be responsible for
checking all appropriate appointments are made and the prisoner is aware of
discharge details.
12. The discipline staff are usually the first people on the scene of a health
emergency whether this be an acute health episode or a self-inflicted incident and
most feel they should start CPR. It was noted during the interviews that some
discipline staff are either using no protective equipment or inappropriate protective
equipment. They should be provided with recommended face masks and given
appropriate training in their use.
At consultation stage, the Prison Service accepted all recommendations.
27