Individual at Doncaster

Investigation into the circumstances surrounding the
death of a man
at HMP Doncaster in July 2006
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2009
Draft Report: XXX XXXX: Date:
This is a report into the circumstances of the death by hanging of a remand prisoner
at HMP Doncaster, on 3 July 2006. He was 26 years old.
The man was found suspended in his single cell in the Segregation Unit and was
subject to suicide and self-harm monitoring. He was detoxing from heroin.
At various times after his arrest, the man had told police officers, prison healthcare
staff and prison custody officers that he had harmed himself in the past or was
considering doing so. At Doncaster, staff did not act on the information. Three
hours before his death, they opened a suicide and self-harm plan after he had
spoken to a Buddy. Two hours later, the man gave staff a letter addressed to his
partner that contained an explicit statement that he was going to commit suicide that
evening. A prison custody officer read the letter but took no action except to
continue his checks. At 10.00pm, he discovered the man and raised the alarm.
After a delay of several minutes, staff entered the cell and attempted resuscitation.
There was a further delay in getting the ambulance into the prison. Finally, the
paramedics attended and took the man to hospital where a doctor confirmed his
death. I must also offer my sincere sympathy and condolences to the man’s family
and friends for their loss.
I apologise for the length of time it has taken to produce this report. After the man
died, the South Yorkshire Police opened an investigation into the circumstances. I
postponed my investigation until their enquiries were complete.
The investigation was carried out on my behalf by one of my colleagues. A clinical
review of the man’s healthcare at Doncaster was undertaken on behalf of Doncaster
Primary Care Trust. I am grateful for the review, which I received on 13 February
2009. I would also like to thank the Director of Doncaster and his staff for their co-
operation and assistance with this investigation.
The man spent only four days in Doncaster. However, in that short time, staff in
different units made decisions that had a serious and negative impact on the care
that he received. Several decisions might not of themselves have had such serious
consequences, but cumulatively they meant that staff did not support the man as
their duty required. I am alarmed and saddened by much that happened to the man
and trust that my report will ensure a radical examination of Doncaster’s policies,
procedures and training.
I make 13 recommendations, primarily covering record keeping, self-harm measures
and staff training in these procedures and incident response.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2009
2
CONTENTS
Summary 4
The investigation process 5
HMP Doncaster 7
Key findings 8
Issues 15
Recommendations 23
3
SUMMARY
The man was born on 22 April 1980 and died at the age of 26 on 3 July 2006 in his
segregation unit cell in HMP Doncaster. On Friday 30 June 2006, he was arrested
and appeared in court where he was remanded in custody. During his time in police
and court custody, the man was on self-harm monitoring procedures. That
information was passed on to staff at Doncaster before his arrival.
In Reception at Doncaster, several staff spoke to the man and a nurse and a nursing
assistant assessed his health. The man told them that he was a heroin user and he
was put on a detox programme. He also said that he had taken an overdose of anti-
depressants the previous year. The senior nurse read the self-harm warning form
that the escort contractor had opened for the man but judged that he was “fine”. As
she did not consider that he was at risk of self-harm, she neither opened an ACCT
plan nor referred him for a mental health assessment. (The ACCT document
describes the problems facing a prisoner at risk of harming himself and implements a
plan to give him the additional support he needs to help during a period of crisis.)
The man spent the next two days on the Detox Unit, where he initially asked to move
cells to share with his half-brother. At lunchtime on Monday 3 July, he was told it
was not possible and he then assaulted a prison custody officer. Staff restrained him
and took him to the Segregation Unit. He had a visit from his partner that afternoon
and asked to see a Buddy afterwards. The man spoke of his problems and told the
Buddy that he was thinking of killing himself.
The Buddy reported this to staff and an ACCT plan was immediately opened. The
duty manager spoke briefly to the man and she then set the frequency with which
staff had to check him. After she left the unit, the man asked for and was given
writing paper and envelopes. At 9.15pm, he passed a letter to a member of staff. It
was addressed to his partner and talked about his intention to take his own life that
night and set out the arrangements for his funeral. The officer read the letter, sealed
the envelope and put it in the post tray. He increased the frequency of his checks on
the man but took no other action.
At 9.56pm, the officer saw the man slumped on the floor with a ligature attached to
the taps of the sink. He called for assistance, and then he and the nursing assistant
who was watching another prisoner stood outside the cell. The two emergency
response nurses arrived and joined them. After five minutes, the duty manager
arrived and unlocked the cell. The nurses assessed the man and then asked for an
ambulance to be called. They began cardio pulmonary resuscitation.
The ambulance arrived very quickly at the prison gate. However, staff could not
unlock an internal gate and, after a delay of seven minutes, the paramedics went to
the cell on foot. Eventually, they managed to move the ambulance through the
prison to the Segregation Unit and carry the man into it. They took him to Doncaster
Royal Infirmary where a hospital doctor certified his death.
My report identifies a number of serious shortcomings on the part of prison staff and
I make 13 recommendations.
4
THE INVESTIGATION PROCESS
1. The man died on 3 July 2006. My investigator opened the investigation four
days later when she visited the prison. She met the Director, a trade union
representative and a member of the Independent Monitoring Board. She saw
the man’s cells on C wing and the Segregation Unit and was given copies of his
prison records. She also met the man’s half-brother in one of the wings and
explained the scope and purpose of my investigation. She asked the Director
to display notices to staff and prisoners about my investigation.
2. The investigator returned to Doncaster on 8 July to meet with a team of
detectives from South Yorkshire Police who had begun an inquiry into the care
the man who died had received. The officer leading the inquiry asked that my
investigation be suspended until their investigation, and any subsequent court
proceedings, had been concluded. In return, the police agreed to share the
information they gathered, including the witness statements.
3. One of my family liaison officers (FLOs) and the investigator met separately
with the man’s partner, and his mother and father and grandparents, to explain
the reasons for my investigation being suspended. They offered to meet again
once the investigation was resumed.
4. The police investigation was closed in 2008 and the case papers were
delivered to my office in May that year. The FLO and investigator met with the
man’s father, mother and grandmother again and explained how my
investigation would be conducted. The family raised various issues, including
self-harm procedures, the failure to act on the man’s letter, the delay in opening
the cell, the delay in the paramedics arriving at the cell, and managers’ contact
with the family after the man’s death.
5
HMP DONCASTER
5. HMP Doncaster opened in 1994. It is a purpose-built category B male prison,
privately managed under contract by Serco Home Affairs. The prison is made
up of three houseblocks, each with four wings and has a maximum capacity of
1,145 prisoners. Its principal function is to serve the local courts and the
majority of its population are sentenced prisoners.
6. The report of the prison’s Independent Monitoring Board that covered the
period October 2006 to September 2007 highlighted no concerns relevant to
the man’s time in the prison.
7. The most recent inspection by HM Chief Inspector of Prisons, Dame Anne
Owers, was an unannounced full follow-up inspection carried out from 11 – 15
February 2008. The report expressed concern over some ACCT procedures
and described health services as “poorly managed”.
8. Between 2004 (when my office became responsible for investigating all deaths
in prisons) and the man’s death in 2006, there had been one other self-inflicted
death at Doncaster. The circumstances have some similarities to the man’s
death. Both men were on an open ACCT/2052SH. In my earlier report, I
discussed, “… the tendency of staff to base their decisions about the man’s
management on individual events rather than on the totality of his behaviour.”
6
KEY FINDINGS
30 June to 2 July
9. On 29 June 2006, the man was arrested and taken to Doncaster Police Station.
Whilst in custody, he told officers that he suffered from depression and had
recently tried to harm himself. The custody sergeant placed him on constant
supervision. A drugs test showed that he had taken heroin and he later told the
police doctor that he had taken it earlier that day. After being charged, he was
released on bail.
10. The following day, he was again arrested and charged with driving offences.
The custody sergeant placed him on constant supervision and highlighted self-
harm and drugs issues on the prisoner escort record (PER). (The PER is a
form that that accompanies each prisoner between court and prison. It
provides information about both the prisoner’s needs and the risk he poses to
others.) The man then appeared at Doncaster Magistrates Court and was
remanded into custody until 4 July.
11. Whilst at court, the GSL custody staff placed the man on frequent observations
and put him in a cell with another prisoner. They also contacted the reception
clerk at HMP Doncaster and informed him that the man was showing signs of
suicidal feelings. The clerk then put “SH”, indicating self-harm, against the
man’s name on the reception booking-in sheet. The GSL court staff completed
a suicide and self-harm warning form and again telephoned the reception clerk
to pass on this information. The suicide and self-harm warning form was
included in the paperwork that went with the man to Doncaster. The form is
bright orange to alert prison staff to the prisoner’s needs. It included the
erroneous information that the man had tried to hang himself whilst in police
custody.
12. During the afternoon, the unit manager who was the reception clerk’s manager
and the nurse working in reception that day came into the clerk’s office and
asked about the new prisoners who would be arriving later. The clerk said he
told them that the man was on his way and highlighted the information from
GSL staff about the possibility of self-harm. In interview, the clerk recalled
showing them the daily reception sheet and the letters “SH” next to the man’s
name.
13. When the man arrived at Doncaster, he went through the reception process. A
prison custody officer checked his identity and the warrant remanding him in
custody and completed the first section of the Cell Sharing Risk Assessment
form. The man told the officer that he would prefer a single cell when one
became available as a cell mate had assaulted him during a previous prison
sentence.
14. The duty staff nurse in reception, a registered general nurse, interviewed the
man and completed the First Reception Health Screen form. A duty healthcare
assistant was also present and she completed the Secondary Health Screen
form during the interview. She noted that the man appeared to be under the
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influence of alcohol or drugs, although he said he was fit and well. She
referred him to the doctor. She also wrote, “No concerns have been raised with
regard to the prisoner’s mental health.”
15. The reception nurse said when interviewed that the man “was pleasant, very
open” and made good eye contact with her. He spoke about his girlfriend and
child. His answers to her questions were relevant and he said nothing to make
her think he was suicidal. When she reached the section of the form that asks
whether the prisoner has thoughts of self-harm, she recalled the man saying,
“Oh no, no. I don’t do things like that. I won’t do things like that.” She read the
warning form from GSL staff and asked the man about the attempted hanging.
He denied it, saying, “They must be mixing me with someone else.”
16. However, when the nurse asked whether he had ever attempted suicide in the
past, the man said he had taken an overdose of anti-depressants a year earlier.
The First Reception Health Screen form instructs staff that, when a prisoner
answers “yes” to that question, they should refer him for a mental health
assessment. The nurse failed to do so. In her interview, she said that she did
not do so because her assessment was that “there was no problem with him”.
For the same reason, she did not admit the man to the Healthcare Centre or
open an ACCT plan.
17. When the nurse asked the man about his use of drugs and alcohol he said that
he was withdrawing from drugs. The nurse said at interview that she opened a
detox watch log. Once the log is opened, staff check the prisoner every 30
minutes and enter the time and their signature in the log. However, after the
man’s death, prison managers could not produce the log and it was unavailable
for both the police and my investigation.
18. From Reception, the man went to Wing 1C, which then housed the Detox Unit.
A prison custody officer (PCO) recalled at interview that the man arrived at
about 8.00pm along with another new prisoner, the man who had shared a
police cell with the man who died. He put them both in cell 1-31 on the upper
level. The member of staff who brought them from Reception gave the PCO
the main records file and the detox sheet for the man who died. The following
morning, healthcare staff assessed him and prescribed medication for a
standard seven-day opiate detox. The prescription charts in the man’s medical
records show that he received the first set of medications during the morning.
19. The wing PCO told police that, over the next two days, he checked the man
regularly and made entries in the detox log. However, this cannot be verified
as the log could not be produced. He said that he talked a lot to the man,
whose major concern was the possibility of receiving a long sentence at court.
The man said that if that happened, he would miss his family. The PCO said
that, although the man “sounded worried”, he did not say or do anything that
indicated that he was considering harming himself.
20. On Saturday afternoon, 1 July, the man’s girlfriend visited him. She later told
police that the visit had not gone well. the man told her that he had not yet
received any medication for detoxifying (although he had) and was in pain.
8
She felt he was suffering from withdrawal symptoms. The man ended the visit
early, telling her that he did not want her to see him “in that state”. However,
she also said that, “Although clearly he was not well and off colour, he wasn’t
depressed and certainly not in the frame of mind of harming himself.”
21. The man’s cellmate gave a statement to the police after the man’s death in
which he said that he knew the man quite well before meeting him in prison.
He said that he and the man “got on fine” and laughed and joked together. He
said that the man spoke about problems with his girlfriend and facing a long
prison sentence, but not about harming himself or committing suicide.
Although the two men got on well, the man wanted to share a cell with his
brother. On Sunday 2 July 2006, they told officers they had “fallen out” in the
hope that staff would then allow the man to move to his brother’s cell. Before
going off duty, The wing PCO completed his handover report which included
the man’s request to move cells. The PCO told the police, “I think we forgot to
mention that he wanted to be moved in with his brother.”
Monday 3 July
22. The following day, a different PCO moved the man’s cellmate to the cell next
door and moved another prisoner into the man’s cell. At some point during the
morning, the man asked to speak to a Buddy. (Buddies are prisoners who
have been given training in listening to and helping other prisoners with their
problems.) A Buddy went to the man’s cell and the man asked for help in
writing a letter. The Buddy told him that he did not have time then, but that he
would return later and help him. The man appeared cheerful and did not say
why he wanted to write a letter.
23. After lunch, the man told the PCO that he “wasn’t happy with his new cellmate”
and wanted to be moved in with his “cousin” (he had previously talked about
wanting to move in with his brother). The PCO told him that this was not
possible as “the logistics and workload made it not possible.” The PCO said at
interview that the man then “started shouting and swearing at me”. He told him
that he was putting him on a disciplinary report and then locked him in his cell.
(When prison staff think a prisoner has broken a prison rule, they may put him
“on report”. The prisoner must be told within 48 hours what offence he is
accused of having committed. A disciplinary hearing, also called an
adjudication, is then held. If the charge is proved, the adjudicator imposes a
penalty.)
24. The PCO opened the cell door a short while later to allow the man’s cellmate to
enter. The man came to the door and stood very close to the PCO. He was
again verbally abusive and said he wanted to “knock out” the PCO. The PCO
told the man to move back into the cell but he did not. Instead, he pushed the
door with some force, causing it to rebound off the PCO’s hand and fingers.
The man still refused to move back into the cell, and the PCO and several other
officers then used control and restraint methods to restrain him on the floor.
25. The Detox Unit manager arrived and handcuffed the man. Shortly afterwards,
the man became calm and staff helped him to sit on a chair. Once the two duty
9
nurses arrived, they accompanied the manager and an officer as they walked
the man to the Segregation Unit. One of the nurses later told the police that the
man laughed and joked with staff on the way to the Segregation Unit. She said
that he did not mention feeling suicidal but seemed “in good spirits”.
26. In the Segregation Unit, staff removed the handcuffs and searched the man.
All prisoners in the unit wear prison clothing, so the man put on prison tracksuit
trousers, a tee-shirt and slippers. The nurses examined him and, although he
complained of soreness in his leg, wrist and face, they did not see any injuries.
One nurse described him as appearing “fit and healthy”. The Segregation Unit
manager spoke to the man who said that he was concerned about his property
which was still on the wing. He said that he was due to appear in court the next
day, and did not expect to return to prison, so needed all his property together.
The man then used the telephone but there is no information about who he
called.
27. Later that afternoon, the man had a two-hour visit from his partner and their
young son. His partner told prison staff after the man’s death that she had
taken their son with her as he had specifically asked her to bring him.
According to his partner, he was, “his usual self” and they laughed and joked
together. They arranged that she would attend court the following day. They
also spoke about arrangements for the next time she visited. The visit ended at
3.38pm and a PCO escorted the man back to the Segregation Unit. The man
told him that he was facing a long sentence. Approximately an hour later, when
a Segregation Unit PCO checked on the man, he asked to speak to a Buddy.
The PCO passed the request to the unit manager, who arranged for a Buddy to
come from another unit.
28. At 5.15pm, the man asked to speak privately to the nurse who had arrived in
the unit to give the prisoners their medications. After the staff nurse gave him
his medications, he told her that he was feeling depressed and was ashamed
of being back in prison. He said that he had previously taken an overdose and
that he felt “low and lonely” in the Segregation Unit. He also said that his
girlfriend had ended their relationship and then he cried as he spoke about his
son. He said he was expecting to be sentenced to five years imprisonment.
During the conversation, the nurse stood in the open doorway of the man’s cell
and the PCO stood nearby, but out of earshot.
29. When the nurse left the cell, she told the PCO of her conversation with the man
and passed on his request to see a Buddy. The PCO spoke to his colleagues
who said that a Buddy had been arranged. The Buddy eventually arrived in the
Segregation Unit at 7.07pm. He asked the man how he was feeling. The man
said, “I don’t want to be here. Life isn’t worth living any more. I want to kill
myself.” He told the Buddy that he had just split up with his girlfriend as she did
not want to be by herself when he was in prison. (This was not actually the
case.) He also told the Buddy that he had been assaulted by his cell mate
during a previous prison sentence. The two men spoke for about 30 minutes
and the Buddy tried to reassure him. The man then said, “You’re alright to go
now. I’m sound.” The Buddy wished him luck at court and left.
10
30. The PCO and the night duty PCO were waiting outside the cell and the Buddy
said to them, “I’d advise you to keep an eye on him. He’s talking about killing
himself.” He then spoke further about his conversation with the man. (Buddies
should normally respect the confidentiality of their conversation but not where
there is a risk to life.)
ACCT monitoring
31. As the Buddy spoke, the PCO opened a blank ACCT booklet and began to
complete the Concern and Keep Safe Form. He noted that the man “had
thoughts of killing himself. Nothing to live for.” He also ticked the box that
indicated that the man’s mood was very low. He signed the form, put the time
as 7.45pm and then left the unit to complete his shift in another unit.
Meanwhile, the night PCO telephoned the duty director and reported the
opening of the ACCT.
32. The PCO went into the man’s cell and asked him what was wrong. The man
replied that he was in court the next day when he could be sentenced to five
years imprisonment. He said, “I’ve just had enough, basically.” At interview,
the PCO said that the man did not appear upset as he said this.
33. At 8.38pm, the manager who had taken over as duty director, came to the
Segregation Unit to interview the man and complete the Immediate Action Plan
of the ACCT. This section must be completed by a unit manager and lists all
the ways staff should help the prisoner on the ACCT. The manager spoke to
the man through the observation hatch in the cell door, and the CCTV timer
shows the conversation lasted two minutes. She said in interview that she
recognised the man from his previous times in Doncaster, and he recognised
her.
34. The man told her that his solicitor had said he could be facing five years
imprisonment and, if that was the case, his girlfriend would not wait for him. He
said that he was upset about that. He then asked about his property as he
needed it to be available when he went to court the next day. The manager
went to the office and arranged for his property to be ready the following day.
Twenty five minutes later, she returned briefly to the man’s cell and opened the
door. While she spoke to the man about his property, the PCO lit a cigarette
for him.
35. At interview, the manager said that the man’s main concern was his property,
which she had resolved. She said, “He was highly delighted that I’d done that.”
She did not see any indications that he would harm himself, describing him as
“chatty” and “in high spirits”. At 8.20pm, she completed the form and put the
man on 30 minute observations. As all prisoners in the Segregation Unit are
observed every half hour, this meant that the frequency with which staff
observed the man was not increased. In interview, the PCO recalled the
manager saying to him that the man “was not going to harm himself.”
36. At night, in common with all other prisons, Doncaster operates with a reduced
staff. During night patrol state, only Oscar 1 carries a full set of keys to unlock
11
all gates and cells. Wing staff and nurses do not have access to keys allowing
them free access around the prison and have to be escorted. However, prison
custody officers are each issued with a cell key in a sealed pouch for use in
emergencies. The staff instructions are that during the night state, a cell may
only be unlocked by a single member of staff where there is, or appears to be,
immediate danger to life.
37. After the manager left, the man asked the PCO for writing paper and
envelopes, which he then gave him. At 9.15pm, the man passed the PCO a
letter that was addressed to his girlfriend. In it, the man wrote very clearly of
his intention to commit suicide that night and gave detailed instructions about
his burial. The PCO read the letter, sealed it in the envelope and put it in the
tray for out-going mail. He began checking the man more frequently but took
no additional action.
38. The man in the neighbouring cell later told police that, at about 9.30pm, the
man called to him asking if he had any tobacco, to which he replied that he did
not. A few minutes later the man said to him, “I’m in court tomorrow.” When
the other prisoner asked him how long a sentence was he expecting, the man
replied “life”. This ended the conversation. About ten minutes later, the other
prisoner heard a metallic banging noise from the man’s cell that he thought
sounded like taps being pushed down. He said in interview, “Very shortly after,
I heard a spluttering cough coming from the man’s cell. I presumed that it was
the man and that he might have got his cigarettes after all.”
39. When the PCO checked the man at 9.56pm, he saw him lying slumped against
the sink with some sort of cloth attached to the taps. The sink was to the right
of the door and on the same wall. The man’s back was to the sink and he was
facing into the cell so the PCO could not see his face or neck. The PCO used
his radio to call for assistance. He did not enter the cell immediately but asked
a nurse on the unit for advice.
40. A nursing assistant was in the Segregation Unit that night to keep another
prisoner under constant observation. She told the police that she advised the
PCO not to enter the man’s cell until other staff arrived as he was on “a three-
man unlock”. In spite of seeing something clearly amiss and having opened
the man’s cell earlier in the evening without three members of staff being
present, the PCO and the nursing assistant waited outside the cell. The PCO
repeated his call at 9.59pm.
41. Two nurses responded as the emergency healthcare response team. All four
staff then waited outside the cell. The night orderly officer arrived at 10.00pm,
along with another PCO. The night orderly officer unlocked the door and staff
entered the cell. A nurse saw a ligature round the man’s neck, attached to the
taps of the sink, and asked for it to be cut. The PCO did so with his anti-
ligature knife and the nurses laid the man on the floor, with his head towards
the door. The man did not appear to be breathing, he had no pulse and his
pupils were fixed and dilated. The nurses began to administer cardiopulmonary
resuscitation (CPR). The night orderly officer went to the unit office and
12
telephoned the communications room to ask for an ambulance. The control
room log timed the request at 10.00pm.
42. The ambulance arrived at the main gate five minutes later and was escorted
into the prison by a waiting PCO. Once through the main entrance the
ambulance and paramedics were delayed for approximately seven minutes
while the PCO struggled unsuccessfully to open an internal gate. Rather than
wait any longer, the paramedics decided to go to the cell on foot and they
carried their equipment and a stretcher into the building. The PCO guided
them through the prison. When they reached the stairwell leading to the first
floor of the Segregation Unit, they found that the space was too narrow to let
them carry the stretcher up the stairs. They left the stretcher at the foot of the
stairs and went to the man’s cell on the upper landing.
43. The paramedics took over CPR from the nurses and attached a defibrillator to
the man. (A defibrillator is a machine that treats victims of sudden cardiac
arrest by delivering a shock to the heart.) The machine showed that the man
had no pulse, so they gave him pure oxygen and continued CPR. The female
paramedic asked a nurse to take over from her and she then returned to the
ambulance, collecting the stretcher on the way.
44. The officer who accompanied her then told her to drive to a different gate,
which she did. However, in her statement to police, she said that it was
“several minutes” before this gate was opened for her to drive through. She
parked at the end of the wing and, carrying the stretcher, re-entered the
Segregation Unit through the door in the end wall. They put the man on the
stretcher and moved him to the ambulance through the outside door. The
ambulance left the prison at 10.54pm. During the journey to Doncaster Royal
Infirmary, the male paramedic continued CPR. Sadly, on arrival, a hospital
doctor examined the man in the ambulance and pronounced him dead at
11.02pm.
45. The prison chaplain, the duty director and a uniformed prison custody officer
went to see the man’s partner at her home at 2.00am and broke the news.
They arranged for her mother and step-father to come and support her and
also for one of the man’s cousins to come to the house. Later that morning,
staff visited the other members of the man’s family. The man’s father visited
the prison to break the news to the man’s half-brother. Staff then opened an
ACCT plan for him. The following day, the family, in two groups, visited the
prison and met the Deputy Director. During the meetings the family raised a
number of issues and questions about the man’s time at Doncaster and the
circumstances surrounding his death.
13
ISSUES
Cell Sharing Risk Assessment form (CSRA)
46. When a new prisoner arrives in prison, one of the first forms to be completed is
the CSRA. The form is used to assess the potential risk the prisoner would
present to a cell mate. In Reception, an officer completes the first section and
the duty nurse the second. The induction officer completes the final part, very
often on the wing. Section 1 contains a list of documents that may accompany
a prisoner into custody.
47. The man arrived at Doncaster with a self-harm warning form from GSL, the
escort contractors. In Section 1 of the Cell Sharing Risk Assessment, the third
document on the list is F2052SH (sic) (open/closed) and tick boxes for yes or
no. This has been ticked as “No” which is technically correct as the warning
form is not an ACCT plan. However, this important document conveys crucial
information about a prisoner’s potential risk of self-harm and, in my view,
should feature on the CSRA.
The Prison Service should add the self-harming warning form to the list
of documents in Section 1 of the CSRA the next time the form is revised.
Health
48. The clinical reviewer raises several issues in his report. (The full review is at
Annex 1.) He begins the areas of concern section of his report with his findings
on documentation and standard of record keeping. He concludes that, “The
overall standard of documentation appears to be below adequate levels.” He
adds:
“The documentation made available does not demonstrate that a safe,
effective nursing process was followed in the provision of nursing care
for this gentleman. In particular they do not provide clear evidence of
the care planned and the decisions made.”
49. The reviewer makes eight recommendations altogether, which I endorse. They
cover record keeping, reception screening, ACCT procedures and the delay in
entering the man’s cell.
The Director and Head of Healthcare should ensure that all staff are
trained in and kept updated with the standards that are required in
relation to record keeping and that the standards have an audit plan in
place.
The Head of Healthcare should review the care planning process and
documentation to ensure that all patients receive a full assessment with
adequately documented plan of care to meet all their needs.
14
First Reception Health Screen
50. When the man arrived at Doncaster, his papers included a form warning that he
was at risk of harming himself. The reception staff nurse read it and
questioned the man about the information it contained. He said the information
was inaccurate and denied having any thoughts of self-harm. The nurse
decided that his answers and general behaviour did not warrant opening an
ACCT plan or admitting him to the healthcare centre. She did not change her
opinion even when the man told her that he was detoxing from heroin. When
asked at interview whether a prisoner who is detoxing is at an increased risk of
self-harm, she said that, in her experience:
“If they’re coming off drugs the main problem is physical … I’ve not
seen a detoxer before who told me they are depressed because they
are coming off drugs. They’ve just told me ‘Oh I’m ill, Miss. I feel so
ill’”.
51. The ACCT training that all staff receive highlights very clearly that the process
of detoxing is one of the factors that can heighten the risk of prisoners harming
themselves. (I will return to ACCT training later in this report.) However, the
nurse focused on the fact that the man made good eye contact with her and
told her that he had no current thoughts of self-harm. She told the police,
“He answered questions relevantly and I didn’t identify anything that
suggested he was suicidal.”
52. The nurse focussed on the man’s manner as he spoke to her and relied on this,
rather than the other information she had. As a result, in spite of having the
GSL self-harm warning form, and knowing that the man was detoxing, and that
a year earlier he had taken an overdose of anti-depressants, she decided that
he was not at risk of harming himself.
53. Although the man denied any current thoughts of self-harm, he did tell the
nurse that he had taken an overdose a year earlier. A positive answer to this
question requires a mental health referral. This is not optional or at the nurse’s
discretion. The nurse should have referred the man for a mental health
assessment but chose not to. In her statement to police she indicated that,
despite the instruction on the form, her understanding was that she only
needed to make a referral if she thought it was necessary. As already noted,
because her view was that the man was fine at the time, she thought she did
not need to refer him to the mental health team.
54. The clinical reviewer has considered the way in which the reception nurses
assessed the man. He concludes that, “Documentation surrounding this
decision is not clear and does not meet the NMC [Nursing and Midwifery
Council] standards on documentation.”
55. When the police asked the nurse if she had any concerns about the man, she
said she had not. She described seeing him afterwards in the Reception
15
waiting area. He was watching a football match on television and was
cheering. She took this as another indication that he was “fine”. I am aware
that, had she made the mental health referral, it would in all probability not have
led to an assessment before his death as the following two days were the
weekend. However, it is essential that the referral process is followed to
prevent other prisoners being put at risk through not receiving a mental health
assessment.
The Director and Head of Healthcare must ensure that all staff make the
referrals required by the First Reception Health Screen.
56. The reception nurse is a registered general nurse whose area of competence is
physical ailments. As such, she appeared to concentrate on the physical
presentation that the man gave. She discounted factors that might have
indicated that he was at an increased risk of harming himself. I am aware that
an increasing number of prison healthcare managers now assign registered
mental nurses to reception duties. This ensures that the nurse who sees new
prisoners has the expertise to assess their mental health needs fully. I
commend this as a way forward for reception screening at Doncaster.
The Head of Healthcare should consider assigning reception duties
primarily to registered mental nurses.
Detox watch log
57. When a prisoner goes to the Detox Unit, a record is kept of the times at which
staff observe him. The policy at Doncaster is for these observations to be
made every 30 minutes. After the man’s death, staff were unable to produce
his detox log and it has never been discovered. The reception nurse was clear
that she opened a detox log during the health screen after the man told her he
was “rattling”, that is, suffering withdrawal symptoms. The Detox Wing PCO
said that he made entries in the log after checking on the man.
58. However, assuming there was indeed a log, it had been lost by the time the
man’s prison records were collected after his death. This would tend to
indicate that filing procedures on the Detox Wing are not sufficiently robust.
The Director should ensure that detox watch logs are stored in a way that
guarantees their safekeeping.
Segregation Observation Log
59. Staff in the Segregation Unit must observe all prisoners every 30 minutes.
They note the time and their initials in a log for each prisoner. The log for the
man shows the night duty PCO’s signature against times beginning at 7.45pm
and every 30 minutes thereafter until 12.15am. The PCO appears to have
completed the log in its entirety at a single point in his shift. Given that the log
has entries for times after he discovered the man hanging, it is likely that he
completed the log near the beginning of his shift.
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60. The falsification of such documents renders them meaningless and is
unprofessional. It is also disturbing that the PCO appeared confident that his
actions would not be picked up by management checks.
The Director must ensure that his staff are fully aware of the necessity of
recording observations at the time of making them and that management
checks ensure compliance.
61. In the event, the PCO’s actual checks were better than those recorded in the
log. They were also better than required for the ACCT plan, as they were both
more frequent and irregular. Irregular observations, especially for prisoners on
ACCT documents, are good practice. They mean that prisoners cannot be
sure when the next check will take place. They cannot, therefore, plan any
action such as self-harm knowing that a certain time will elapse before being
discovered. The CCTV footage shows that the PCO made frequent and
irregular checks on the man. In the hour before the man’s death, he checked
him four times, rather than twice as required.
ACCT
62. Staff understanding of why and how ACCT documents should be opened and
completed is an area that needs to be thoroughly addressed. During the man’s
time at Doncaster, staff showed a worrying lack of rigour in assessing and
meeting his needs. Although I discuss the actions of named members of staff
below, I consider that the training of all staff ought to be considered.
The Reception nurse
63. The duty nurse in Reception did not open an ACCT for the man as, according
to her assessment, “there was no problem with him.” She seemed unaware of
the fact, highlighted during ACCT training, that detoxing can heighten the risk of
a prisoner harming himself. Her focus was on how the man appeared to her
then and there.
64. She also thought that because she had opened a detox watch log for him, he
would be observed every 30 minutes. She assumed that, if an ACCT had been
opened, the man would have been observed twice an hour – the same as for a
detox log. However, there is an important difference between checks for a
detox log and the interactions required by an ACCT plan.
The day shift PCO in the Segregation Unit
65. After the Buddy told Segregation Unit staff of his conversation, the PCO
immediately opened an ACCT plan. According to the Buddy, this PCO took a
blank booklet and, as he spoke began to complete it. His timely and
appropriate actions are in sharp contrast to those of his colleagues who took
over the ACCT plan.
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The night shift PCO in the Segregation Unit
66. As noted above, the night PCO’s checks on the man were better than the
manager stipulated. (Paradoxically, his falsification of the document
understated the actual observations he conducted.) However, his actions after
he read the man’s letter were totally inadequate. The information in the letter
should have alerted him to the fact that the man’s state of mind had
deteriorated. The man’s intention to take his life that night was stated clearly
and he gave detailed instructions about his funeral. The PCO should have
notified the night orderly officer of the letter immediately so that the man could
be given a higher level of support. The night orderly officer could have
increased the level of observations or had the man admitted to the in-patient
unit in the Healthcare Centre. The PCO’s failure to inform her meant that the
opportunity to increase the support for the man was missed.
67. When the police investigation ended, Serco took disciplinary action against the
night PCO and dismissed him. It is therefore unnecessary for me to make a
recommendation about his actions.
The day shift unit manager
68. The manager completed the unit manager’s sections of the ACCT plan. She
told the police that the only information she had about the man was that he had
assaulted an officer that morning, and that there was no information about him
being “down or depressed”. However, according to the reception clerk, the
manager knew that the man had been identified as being in danger of harming
himself even before he had arrived at Doncaster. The manager must also
surely have known that the day shift PCO had opened the ACCT after a Buddy
told him that the man had said that he wanted to kill himself. Finally, her entry
in the On-going Record section of the ACCT plan contained the information
that:
“He is at court tomorrow, expecting 5 years. Says his girlfriend has
dumped him as she won’t wait 5 years for him.”
In other words, the manager must have known that the man had other matters
on his mind (in addition to worrying about having his property at court the
following day). Having made arrangements for his possessions to be available
the next day, she appears to have regarded his problems as solved.
69. The manager told the police that when she spoke to the man he was “chatty”
and “in high spirits”. As with the Reception nurse, the manager focussed less
on what he said, than how he said it. ACCT training emphasises that the first
few days in prison are a time when some prisoners can be especially at risk of
self-harm. Additionally, the man was undergoing detox and was in the
Segregation Unit, both factors that can heighten risk.
70. However, the manager decided to set the frequency of observations as “Two
obs per hour not more than 30 minutes apart.” This requirement forces staff to
18
make the checks exactly 30 minutes apart and thus turns irregular checks into
regular observations. As explained above, irregular observations are far
preferable which is why ACCT procedures insist on them. It is worrying that a
manager made such a decision, particularly a manager who was responsible
for training staff in ACCT procedures.
71. There are two further issues with the manager’s instructions. As all prisoners in
the Segregation Unit are checked twice an hour, the man was not allocated
additional support as far as observations were concerned. The manager also
stated, “3 x quality entries in the wing history file per day.” When a prisoner
has an open ACCT plan, the entries should be made in the ACCT document,
not the wing file. Once an ACCT plan has been opened, it goes with the
prisoner as he moves around the prison. The information needs to be
contained in one place rather than in several documents.
72. The actions and inactions of the Reception nurse, the unit manager and the
night PCO all illustrate areas of ACCT training that need to be addressed. I am
very concerned that three members of staff, with different roles and grades in
the prison, displayed such shortcomings in their performance. This suggests
that this is less an individual problem and more of an institutional one. The
clinical reviewer shares my concern and makes recommendations about ACCT
training and processes.
The Director should review the effectiveness of ACCT training to rectify
any deficiencies and ensure that there is on-going monitoring.
The Director must ensure that staff know where to obtain support and
guidance when they have concerns or are unsure of what action to take in
relation to ACCT plans.
Delays after the discovery of the man
73. When the night PCO saw the man with a ligature round his neck, he raised the
alarm but did not enter the cell. The instructions for staff in this situation are
very clear and the PCO should have known what to do. Director’s Rule 18.2
“Cut down procedures” states:
“Where possible, a minimum of two PCOs will enter the cell … If only
one PCO is available, he or she must not waste time and must
endeavour to cut the noose while giving some support to the body.”
Because the PCO found the man during the night patrol state, Director’s Rule
10-14 “Night operating procedures” applied. It states:
“Procedure for unlocking a cell – Houseblock 1,2,3 and Segregation
Unit during night duty. In a life or death situation (ie, a prisoner
hanging) you will need to enter the cell/ward immediately, but before
doing so, transmit the radio message: ‘Prisoner hanging in cell
(number). I am now entering. Immediate help required.’”
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74. The PCO should have made the call on his radio, then opened the cell with his
emergency key and gone inside. However, he stayed outside and asked the
nearby nursing assistant for advice. Even after the two emergency response
nurses arrived, the PCO did not enter the cell. There was therefore a delay of
five minutes before the man was cut down and CPR began.
75. The PCO had received first aid training, including resuscitation techniques, in
August 2005. He should have been able to begin CPR if he had entered the
cell immediately. The clinical reviewer concludes that:
“From the evidence reviewed, it is not possible to comment on whether
or not this delay made any significant difference to the man or not.”
Nevertheless, such a delay could be critical in similar circumstances in the
future.
The Director should ensure that all staff are aware of their duty on
discovering a prisoner who has self-harmed, particularly during night
patrol state.
76. The ambulance arrived at the main gate of the prison five minutes after the
request was made. An escort was waiting and the vehicle moved quickly into
the prison. However, the escort spent seven minutes trying to unlock an
internal gate before the paramedics decided to go to the cell on foot. The route
the escort took through the prison meant that the stretcher could not be taken
onto the landing. Finally, when the ambulance was directed to another gate, it
took several minutes for the escort to open it.
77. It is unclear what caused the problem with the internal gates. The officer who
struggled to open the first one was told (over his radio) that the double lock was
not on. However, staff had great difficulty in opening the gates and this
delayed the paramedics. The route through the buildings led to a further delay
as they tried unsuccessfully to take the stretcher up the stairwell. Again, it is
not possible to say whether these delays made a significant difference to the
man.
The Director should review the contingency plans for moving an
ambulance through the prison as quickly as possible and ensure that all
staff are aware of the quickest routes when escorting paramedics.
Family liaison
78. Doncaster is privately run by Serco and the company’s logo includes the strap
line, “Bringing service to life”. When the Director wrote to the family after the
man’s death, the letter was printed on headed notepaper. I am afraid the
worthy aspiration of the strap line was in such sharp contrast to the
condolences being offered that it caused the family additional distress. It would
be more sensitive for letters to bereaved families to be headed by a logo
without the strap line or for the logo to be omitted altogether. I also commend
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the example of a Governor of another prison, whose condolences were offered
in a hand written, blank card.
The Director should ensure that, when writing to bereaved families, the
letter does not include the company strap line.
79. Senior managers at the prison offered to help the family with funeral expenses.
However, the payment was not made until very late in the day and only after
the man’s grandmother had twice telephoned the finance section. Prison
Service Order (PSO) 2710 “Follow-up to a death in custody” advises prison
staff to support the family by liaising directly with the funeral directors.
The Director should ensure that the instructions in PSO 2700 are fully
complied with in respect of financial assistance.
Conclusion
80. When the man arrived at Doncaster, it was his sixth time there since 2000 and
my investigator discovered that many of the staff said they “knew” him. This
appears to have contributed to a general air of complacency in how staff
reacted to him. Several members of staff discounted information about the
man’s past and current risk of self-harm. Their focus was on how he appeared
to them as he spoke to them. Staff inaction at key points during the four days
the man spent in the prison significantly increased his risk.
81. I urge the Director and his senior management team to improve policies,
procedures and training to tackle such complacency and ensure that their duty
of care to all prisoners is delivered to the highest standard. Having had the
mournful duty of issuing reports on many hundreds of self-inflicted deaths in
prison, I have to say that this is amongst the most alarming.
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RECOMMENDATIONS
1. The Prison Service should consider adding PEC’s self-harming warning form to
the list of documents in Section 1 of the CSRA the next time the form is revised.
The Prison Service responded:
“It is important to note that the CSRA process is focused on assessing potential
risk to a cell mate when in a shared cell and not on assessing self harm risk. The
Cell Sharing Risk Assessment (CSRA) process (and the accompanying form) are
currently being revised as part of a review of NOMS’ violence reduction strategy
and the relevance of a reference to the self-harming warning form will be
examined as part of the review.”
Recommendation 2 – 13 have all been accepted.
2. The Director and Head of Healthcare should ensure that all staff are trained in
and kept updated with the standards that are required in relation to record
keeping and that the standards have an audit plan in place.
3. The Head of Healthcare should review the care planning process and
documentation to ensure that all patients receive a full assessment with
adequately documented plan of care to meet all their needs.
4. The Director and Head of Healthcare must ensure that all staff make the referrals
required by the First Reception Health Screen.
5. The Head of Healthcare should consider assigning reception duties primarily to
registered mental nurses.
6. The Director should ensure that detox watch logs are stored in a way that
guarantees their safekeeping.
7. The Director must ensure that his staff are fully aware of the necessity of
recording observations at the time of making them and that management checks
ensure compliance.
8. The Director should review the effectiveness of ACCT training to rectify any
deficiencies and ensure that there is on-going monitoring.
9. The Director must ensure that staff know where to obtain support and guidance
when they have concerns or are unsure of what action to take in relation to ACCT
plans.
10. The Director should ensure that all staff are aware of their duty on discovering a
prisoner who has self-harmed, particularly during night patrol state.
11. The Director should review the contingency plans for moving an ambulance
through the prison as quickly as possible and ensure that all staff are aware of
the quickest routes when escorting paramedics.
22
12. The Director should ensure that, when writing to bereaved families, the letter
does not include the company strap line.
13. The Director should ensure that the instructions in PSO 2700 are fully complied
with in respect of financial assistance.
23
ANNEXES
1. Documents considered during the investigation
24