Individual at Leicester

Investigation into the circumstances surrounding the
death of a man at HMP Leicester
in August 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2009
This is the report of an investigation into the death of a man at HMP Leicester in
August 2007. He was found hanging in his cell. He had been in prison for less than
two months.
My colleagues and I offer sincere condolences to the man’s family and friends for
their sad loss. I must also apologise for the delay in issuing this report. This was
caused in part by a delay in receiving the clinical review.
The investigation has been undertaken by my colleague. I would like to thank the
Governor of HMP Leicester at the time of the investigation and his staff for their
participation. Particular thanks go to prison family liaison officer.
An appointed doctor undertook a review of the man’s clinical care on behalf of local
Primary Care Trust (PCT) and I also greatly appreciate his assistance.
The man had been identified by his personal officer as someone who was at risk of
committing suicide or self harm and had appropriately been placed on monitoring
and support procedures. Indeed, he illustrated a number of risk factors. He suffered
from paranoid schizophrenia and psychopathic personality disorder. He had a
history of depression, particularly following the death of his mother, and had
previously attempted to take his own life. He had been admitted to a psychiatric
hospital four years earlier. He drank to excess and took illegal drugs.
The investigation has highlighted a number of concerns about the man’s care and
my report includes eight recommendations, six of them derived from the clinical
review, and a number of other points for the Governor’s attention. I have also cited
two examples of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2009
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CONTENTS
Summary
The Investigation Process
HMP Leicester
Key Events
Events on 13 August 2007
Issues
Family concerns
Clinical care
ACCT
Recommendations
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SUMMARY
In June 2007, the man was detained at a Police Station, and charged with robbery.
He was assessed by a Forensic Medical Examiner, who noted that he suffered from
paranoid schizophrenia and psychopathic personality disorder and used
unprescribed methadone from time to time. The Forensic Medical Examiner
concluded that the man was mentally stable. He said he was taking medication to
treat his schizophrenia. He did not have any medication with him. The Forensic
Medical Examiner prescribed the relevant medication which was obtained the next
day. He told Forensic Medical Examiner that he had not deliberately self-harmed for
three years. He was judged fit to be detained. Nevertheless, half hourly
observations were arranged.
When the man arrived at HMP Leicester three days later on 25 June 2007, the initial
reception health screen noted that he had been in prison a year previously. He did
not have any concerns about his physical health. He said that he drank excessively
and that he had last taken alcohol three days previously. He also said that he had
used illegal drugs in the last month. He said that he suffered from schizophrenia and
that he had been in a psychiatric hospital in 2001. He told the nurse that he had
previously harmed himself both in prison and outside, but he did not wish to talk
about it. The man did not think he would harm himself as a result of being in prison.
The nurse offered to put him in contact with the chaplaincy, Listeners and
Samaritans for counselling as he was having trouble coming to terms with his
mother’s death in February 2007. (Listeners are prisoners who are trained by the
Samaritans to give confidential emotional support to fellow prisoners.) The nurse
referred him to the Mental Health In reach Team (MHIRT).
The man saw a doctor whose opinion was that he was fit for normal location and to
share a cell. He also recommended alcohol detoxification.
On the next day (26 June), the man had a secondary health screen by a doctor. The
record of that assessment contains information about his height, weight, blood
pressure and smoking.
On the same day, the man saw a detoxification nurse. He was showing signs of
alcohol withdrawal, and he was put on an alcohol detoxification programme. He did
not fully co-operate with the programme.
Two members of the MHIRT saw the man on 4 July 2007. They concluded that he
did not show any sign of mental illness and there was no role for them. They were to
see him again at the end of August to review his situation.
On 13 July, the man was placed on an Assessment, Care in Custody and Teamwork
(ACCT) form by his personal officer as she was concerned about his wellbeing.
(ACCT is the system used by HM Prison Service to monitor and support a person at
risk of suicide or self-harm.) He had his first ACCT review the next day and the next
review was scheduled for 30 July. (That review eventually took place on 5 August.)
On 31 July, the man’s personal officer was concerned about him and she noted in
his ACCT record that she had contacted the healthcare centre to ask for him to have
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another mental health assessment. His mental health was not reviewed and there is
no evidence that this message was ever received. On 5 August, the man said that
he wanted a different cellmate. He claimed that his cellmate was untidy and dirty
and he did not want to share the cell with him.
On 7 August, the man had a disagreement with his cellmate and asked to move
cells. His cellmate was moved out which left him in the cell on his own. Again, a
member of staff noted in his ACCT that he needed to be seen by a member of the
MHIRT. This never happened.
Sadly, the man was found hanging in his cell on the morning of 13 August 2007.
Attempts to resuscitate him were unsuccessful and he was taken to the local hospital
at 6.40am where he was pronounced dead.
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THE INVESTIGATION PROCESS
1. My investigator studied all relevant prison records relating to the man. These
included his main prison record, medical record and statements made by
prison staff.
2. A doctor was asked to carry out a review of the man’s clinical care and I am
grateful to him. My investigator also contacted Her Majesty’s Coroner to
inform him of the nature and scope of my investigation and to request a copy
of the post mortem report. Upon completion, this report will be sent to the
Coroner to assist in his enquiries into the man’s death.
3. One of my family liaison officers contacted the man’s partner who was his
nominated next-of-kin, and his father and step-mother. My family liaison
officer informed both parties about my investigation and offered them the
opportunity to ask any questions. They were also invited to raise any
concerns about the care he received whilst at Leicester for consideration as
part of my investigation. His partner told the family liaison officer that on her
last visit to him on 4 August 2007 he had told her that he had cut himself and
was not coping well in prison. He further revealed during a telephone call on
Sunday 12 August that he had cut his leg and was struggling in prison. His
partner asked if the investigation could identify what he had used to cut
himself and why he did not receive a further mental health assessment at this
time. She also asked why he had been allowed to have bed sheets when he
was being monitored as a risk of self harm or suicide. These points are
addressed under paragraphs 33 - 44 of my report.
4. My family liaison officer and my investigator also visited the man’s father and
step-mother at their daughter’s home. They were concerned as to why his
medication for schizophrenia had been discontinued whilst he was in prison.
They asked why the prison had not found an alternative method of
administering the medication, such as dispensing it in liquid form or under
supervision. They asked whether his personal officer had been on duty
during the night when he died. They questioned whether the man’s difficulty
with sleeping had been related to the cessation of his medication. They
asked whether his solicitor had been in contact with him during the weeks
prior to his death. They were also unhappy with the contact from the prison
following his death. They were upset that the prison appeared to be treating
his partner preferentially as the man’s nominated next-of-kin. They were also
distressed to receive a letter of condolence from the Governor which was
incorrectly addressed to the man’s partner. Again, these issues are
addressed in paragraphs 33 - 44. I hope this report will help the man’s family
and partner better understand what happened in the time leading up to his
death.
5. My investigator discussed aspects of the man’s treatment with staff at
Leicester and with the clinical reviewer. (Notices were issued to staff and
prisoners telling them of the investigation and offering them the opportunity to
contribute). During the course of the investigation 16 members of staff were
interviewed by my investigator and the clinical reviewer. My investigator also
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spoke with the police in relation to their investigation and obtained all their
statements.
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HMP LEICESTER
6. HMP Leicester is a category B local prison situated in the centre of the city. It
is a Victorian establishment with an operational capacity of 385 prisoners.
The main residential unit is a large, four-storey building. Level 1 holds the
First Night Centre, Segregation Unit and Behaviour Improvement landing.
Level 2 contains a self-contained Detoxification landing and Vulnerable
Prisoner Unit. Levels 3 and 4 hold prisoners on basic, standard and
enhanced status under the Incentives and Earned Privileges Scheme.
7. The most recent report at the time of the man’s death, by HM Chief Inspector
of Prisons, was published in August 2006. It says:
“Of particular concern was the approach to suicide and self-harm, given
that the prison had experienced nine deaths in custody over the previous
28 months, seven of them apparently self-inflicted. The timescale for
implementing recommendations from the inquiries into these deaths was
unacceptably long, and the operation of the new assessment, care in
custody and teamwork (ACCT) process for supporting those at risk of self-
harm was not effectively managed.
“A re-inspection by the Adult Learning Inspectorate in 2005 had found that
standards in education and training had slipped - most areas of training
were weak or unsatisfactory. Challenges had been implemented by a new
head of learning and skills, but there was as yet no education manager.
Opportunities for purposeful activity were limited, there was no vocational
training at all and only 80 of the prison’s 330 men could access education.”
Leicester received a further inspection in June 2008 which shows some
improvement:
“A safer custody policy and monthly meeting provided strategic oversight
to suicide and self harm work, and relevant management information was
collected and analysed. There were delays in receiving Prisons and
Probation Ombudsman (PPO) draft reports from previous deaths in
custody but local action plans were in place. A full-time safer custody
coordinator was in post and the quality of assessment, care in custody and
teamwork ACCT) documents was good, although reviews were
insufficiently multidisciplinary. ACCT assessors met monthly, and family
liaison work was very good. Listeners were generally well supported but
access was limited during the patrol states.”
8. Since April 2004, when I started investigating all deaths in prison custody,
there have been 15 other deaths at Leicester. There has been one homicide,
11 apparently self-inflicted deaths and three from natural causes. Not all
reports have been issued. There are no common issues between the death
of the man who is the subject of this report and my previous investigations.
9. Every prison has an Independent Monitoring Board (IMB). IMB members are
independent and unpaid. They monitor day-to-day life and ensure that proper
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standards of care and decency are maintained. The IMB report for Leicester
for 2007-2008 says:
“In-Reach Team. The Leicester Partnership Trust provides the two
members of the In-Reach team permanently based at HMP Leicester.
Though located within the healthcare facility the team provides secondary
mental health help to prisoners within the prison. However, the IMB is
concerned that this is insufficient personnel for the high numbers of
prisoners requiring mental health support.
“Safer custody - 2007 was the first full year of the Safer Custody Group
and this will expand further in the next year with the appointment of a
Violence Reduction Co-ordinator. The Safer Custody Committee meets
monthly. The IMB occasionally attends, and receives the minutes of each
meeting.
“ACCT - During the year (2007-2008) 263 ACCT documents were opened
compared with 268 in 2006-2007. ACCT documents are checked both
weekly and monthly and the majority are rated as ‘acceptable’ and some
as ‘excellent’. Systems are in place to improve the overall rating. The
Board is now satisfied with the ACCT reviews which take place. Prisoners
to be reviewed are highlighted in the Daily Report. Other agencies and the
IMB are now better informed and attendance has consequently improved.
ACCT assessors - during the calendar year 2007, the number of trained
assessors fell from 18 to 12, though staff have continued to manage the
workload. More assessors are due to be trained.”
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KEY EVENTS
10. On 22 June 2007, the man was detained at a Police Station and charged with
robbery. He was seen by a Forensic Medical Examiner, at 9.45pm. The
Forensic Medical Examiner noted that the man suffered from paranoid
schizophrenia and psychopathic personality disorder and that he used
unprescribed methadone from time to time. The doctor concluded that the
man was not withdrawing from opiates and that he was mentally stable. The
man said he was taking Chlorpromazine 50mg three times a day and
Olanzapine 10mg at night (both medications are used to treat schizophrenia).
He did not have any medication with him. The Forensic Medical Examiner
prescribed Diazepam 5mg that night to help the man sleep. Chlorpromazine
and Olanzapine were prescribed and obtained the next day. He told the
Forensic Medical Examiner that he had not deliberately self-harmed for three
years. Half hourly observations were arranged for him. The Forensic Medical
Examiner assessed that the man represented a medium risk of harming
himself but was fit to be detained.
11. On 25 June, the man was transferred from police custody to HMP Leicester.
An officer completed a cell sharing risk assessment which was agreed by a
nurse. He was considered a medium risk of sharing a cell with others. (That
is, there was no immediate risk if he shared a cell, but the situation would
have to be reviewed regularly.) The officer noted by way of the tick boxes on
the form that the man had abused alcohol/drugs and was currently dependent
on drugs or alcohol. The man said he had previously been monitored on a
F2052SH in prison. (This was the system used by the Prison Service to
monitor and support a person at risk of suicide or self-harm before the
introduction of ACCT.) The nurse noted that the man had mental health
problems and said he would like to share a cell with another prisoner.
12. The nurse completed a first reception health screen. She recorded that the
man had been in HMP Wellingborough one year previously. He told her that
he had not seen a doctor within the last few months but that he was taking
Olanzapine 10mg daily and Largactil (another name for Chlorpromazine) at a
dose of 150mg three times a day. This was not what he had told the police
doctor. The nurse recorded that he did not mention any concerns about his
physical health but said he was a heavy drinker, drinking 15 bottles of whisky
a week. He had last taken alcohol three days previously. She noted that he
had used LSD, cocaine and ‘speed’ (amphetamines) in the last month.
13. The man told the nurse that he suffered from schizophrenia and that he had
been in hospital in 2001. At this point in the record of the interview, he told
the nurse that he was taking Olanzapine 10mg daily and Largactil 100mg a
day. The nurse recorded information from the man that he had previously
harmed himself both in and outside prison. His most recent episode of self-
harm had been two months previously but he did not wish to discuss the
issue. He told her that he did not feel he was likely to harm himself as a result
of being in prison.
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14. According to the nurse, the man had told the police that he had not self-
harmed for three years. He indicated that his mother had died in February
2007. The nurse offered to put him in contact with the chaplaincy, Listeners
and Samaritans who would support him. He said that he did not believe in
them. The nurse referred him to the Mental Health Inreach Team.
15. In interview, the nurse said she thought that a doctor had been present with
her during the reception health screen. She explained that in the majority of
cases a doctor would be with her when she conducted a first reception health
screen.
16. The doctor completed a medical fitness assessment for the man. He told my
investigator and the clinical reviewer during interview that he was unable to
remember whether he had been present at the man’s reception health screen
interview. He did not recall anything significant having emerged from it. He
noted in that assessment that the man suffered from paranoid schizophrenia
and took Olanzapine and Largactil. He considered that the man was fit for
normal location and to share a cell. He also recommended an alcohol
detoxification programme. The doctor passed him as fit for light duties and
non-contact sport only, but in interview could not recall why. He surmised that
it was probably because of the man’s general appearance and alcohol
problems. He was prescribed a once only dose of Olanzapine 10mg and
Chlorpromazine 50mg.
17. The next day (26 June 2007), the man had a resettlement interview with a
member of the Probation Department. He was also seen by a Counselling,
Assessment, Referral, Advice, and Throughcare (CARATs) worker, to be
assessed for their programme. (The CARATs programme provides non-
clinical treatment for prisoners who have substance misuse problems.
CARATs teams assess prisoners and provide on-going support and referral to
outside agencies.) The man told the CARAT’s worker that he would engage
with the CARATs team and she was to arrange an assessment. A secondary
health screen was undertaken (the signature is not legible). The record of
that assessment only contains routine information about his height, weight,
blood pressure and smoking. His medical record says that a telephone call
was made to his doctor that morning to confirm his medication. The doctor
said that the man had last been prescribed Olanzapine 10mg on 6 June, but
this was not a repeat prescription. He was prescribed two doses of
Chlorpromozine 50mg.
18. On the same day, the man saw a detoxification nurse. The detoxification
nurse noted in the medical record that he had been admitted to hospital in
2000/2001 with a self-reported diagnosis of paranoid schizophrenia. He said
he was taking 150mg Chlorpromazine and 10mg of Olanzapine, which was
presumably to be daily. The detoxification nurse recorded that he had a
history of self harm and had cut his arms when he was very young. The man
told the detoxification nurse that he was not sleeping well and had aches in
his stomach, legs and arms. He said that he had blurred vision and poor
focus, felt slightly nauseous and was a little low in mood. The detoxification
nurse also recorded that the man was showing signs of alcohol withdrawal as
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his hands had a tremor when they were outstretched. He said that he was
suffering from extreme night sweats and was hearing voices. He told the
detoxification nurse that he had been inhaling £80 worth of cocaine and taking
£100 - £120 worth of amphetamine tablets daily. He reported that he was
drinking one to two bottles of whisky every day and that he had taken
between eight and 12 LSD tablets over the previous weekend. He had taken
cocaine, amphetamines and alcohol most recently on 21 June. A reducing
course of Chlordiazepoxide was prescribed from 26 June to 4 July, but he did
not attend to collect the majority of his doses. (Chlordiazepoxide is used for
the short-term relief of symptoms of anxiety and management of anxiety
disorders and for treating symptoms of withdrawal from acute alcoholism.) As
part of the detoxification programme he should have had two reviews, on the
fourth and ninth days of the programme. Neither of these reviews was
completed.
19. The continuous clinical record contains a note written on 26 June by the
mental health inreach nurse that she received a referral from the initial
reception nurse. The mental health inreach nurse made a telephone call to
the prison service mental health liaison nurse in Northamptonshire. He said
that he knew the man and that he would telephone the team on Thursday
(presumably 28 June) “to inform of collateral history”.
20. On 28 June, the man had a chaplaincy induction interview and was introduced
to his personal officer.
21. On 4 July, the man saw three members of the MHIRT. The mental health
inreach nurse told the clinical reviewer that the team had a report from a
consultant psychiatrist, which said that the man had a personality disorder
and not a psychotic illness. The team concluded that there was no evidence
of mental illness and no role for the MHIRT. The man was to see the prison
service mental health liaison nurse again at the end of August. Following the
assessment the mental health inreach nurse wrote in the man’s medical
record that she would ask the doctor to prescribe Olanzapine and
Chlorpromazine to help him with his short temper and anger issues. There is
no evidence that the nurse discussed this with the doctor, nor that the doctor
read this entry.
22. The man’s prescription chart shows that he was prescribed Chlorpromozine
100mg to be taken three times a day. Olanzapine was not prescribed as it
was ascertained from his GP that it had been prescribed only for three weeks
not as a repeat prescription. Healthcare staff did not make further enquiries
whether the doctor had intended to review this medication.
23. The man’s medical record shows that he did not attend to collect his
medication (Chlorpromazine) on many occasions between 4 July and 13 July.
He was warned on 9 and 11 July for hiding his medication under his tongue.
His medication was cancelled but it is not clear when that happened. The
prescription entries stop on 13 July.
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24. The man’s education and APEX induction was completed on 10 July. (APEX
is a personalised study plan relevant to the individual’s strengths.)
25. On 13 July, an ACCT form was opened for the man by his personal officer at
3.15pm. The man had told her that he felt he could not cope any more and
that he had lost his mother from alcohol poisoning in February 2007. He
added that he had turned to alcohol himself after his mother’s death. He said
his girlfriend was his main support, but he was concerned that he had not
heard from her since he was taken into custody. An ACCT assessment
interview was completed by another officer at 4.35pm. Following the
interview, the officer who completed the ACCT assessment and a senior
officer (SO) completed an immediate action plan. The plan was for the man
to stay in a shared cell and be observed hourly. He was also to be given
telephone calls as requested and as practicable. The chaplain also agreed to
try and get in touch with his partner.
26. The next day the first ACCT case review was carried out by another senior
officer (SO). The man was considered to be a high risk of self harm. He
continued to be concerned about his partner not contacting him, and the
chaplain was still trying to contact his partner for him. His personal officer
spoke to the Alcoholics Anonymous co-ordinators. She also contacted the
chaplaincy about bereavement counselling and spoke to a chaplain. The
chaplain told the personal officer that she would put the man on her list to be
seen, but she would not be able to meet him that week and was on leave the
following week. The chaplain managed to speak to his partner at 8.45am.
His partner said she was fine, did not have any concerns about the man and
was in contact with him by letter. The personal officer passed this information
to the man at 2.10pm that day. His next ACCT case review was scheduled
for Monday 30 July.
27. Another officer noted on 27 July that the man seemed very down and
recommended that staff should monitor him regularly. On 30 July there is a
note in the ACCT form by the SO who conducted the first case review, “I
spoke to [the man] and agreed to leave the review until Wed pm [1 August
2007].” There are no reasons given for the review being delayed. The SO
told my investigator:
“I can’t remember why the review was delayed, it is quite a long time ago,
but if there is something that crops up I am not going to be able to sit down
and do the interview then we don’t just leave them, we actually go and
speak to them and say, ‘Look, is everything okay, you know, we do need
to speak but unfortunately something has cropped up, I haven’t got time to
do this, can we do it another time’ and if an individual says, ‘No I really
need to sit down and talk with you,’ then if they are in agreement and you
have actually told them, you will keep the ACCT document open so they
are still going to be observed by the staff. The only difference you would
have got if I had done a review at the time would be either increased
observations or reduced observations. Every time I spoke to [the man] he
was pretty much the same. He wouldn’t open up very much even though I
kept trying to get behind things, he would give little snippets but he
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wouldn’t open up very much. I suppose it is difficult to explain. When the
prison is very busy it is hard to take an individual out with everything
around them. We did have a chat to say that the interview wouldn’t be
taking place and I asked if he had any problems, would he like to sit down,
or was it okay if we saw him in a couple of days. He was in agreement
with that.”
28. The next day the personal officer left a message with the MHIRT to contact
the wing regarding completing an assessment. However, the man was not
seen again by the MHIRT. There is no note in the medical record that the
message from the personal officer was ever received by the MHIRT, and the
MHIRT notes could not be located for my investigator to examine.
29. On 1 August, a governor completed management checks on open ACCT
forms. On the man’s ACCT he wrote, ‘ACCT review due today.’ The review
was not completed.
30. The next day the governor again completed management checks on open
ACCT forms. He wrote on the man’s ACCT, ‘Review needs to be completed
today.’ Again, the review was not completed.
31. On 5 August, the man’s ACCT record shows that he asked for a different
cellmate. He complained that his cellmate was untidy and dirty. An officer
then completed the ACCT review originally scheduled for 30 July. This officer
noted that the man was to remain on the ACCT for a further two weeks and
the next review was scheduled for 15 August. The ACCT Caremap was
updated, ‘Art classes stopped so to look at other classes or work.
Observation, Classification and Allocation Unit [OCA] to look at transferring
him to Wellingborough when sentenced.’
32. It appears that the man had a dispute with his cellmate on 7 August. At
5.30pm he spoke to another officer. He told her that his cellmate had
threatened him with a plastic knife following a disagreement about the
cellmate’s poor standard of hygiene. A cell sharing risk minimisation plan
form was completed for him and the cellmate was moved out, leaving the man
in a cell on his own. The assessment said that he would be kept in a single
cell pending a full case review with healthcare staff. The specific need for a
mental healthcare assessment was identified by a wing manager whose name
is illegible. This plan was agreed by a principal officer (PO), who noted that
the man needed to be assessed by mental health staff at the earliest
opportunity. Despite this, no review took place and in fact there is no
evidence that the need for a review by healthcare staff, and particularly the
need for a mental health review, was ever passed on to healthcare staff.
33. The continuing ACCT record shows that the man was feeling much better
after his cellmate was removed and that this lasted until 12 August.
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EVENTS ON 13 AUGUST 2007
34. The personal officer was on night duty on 12 August 2007 and started her
shift at 8.45pm. According to the ACCT observation record, she checked the
man every half an hour between 9.30pm and 2.00am on 13 August (the
entries are signed and dated). The personal officer noted that the man was
awake. In interview, she told my investigator that she spoke to him but he
appeared reluctant to talk to her. The personal officer said he appeared very
withdrawn but that was not unusual as sometimes he would be open and talk
but other times he would not open up. Another officer checked the man at
2.30am, 3.30am and 4.00am and noted in the observation record that he was
still awake. (There are several timed entries in the observation record, at
regular half hourly intervals from 9.30pm to 6.30am. The entries between
4.30am and 6.30am are signed by the second officer. The entries between
4.30am and 6.30am were clearly completed and signed before they were
actually undertaken.) At 4.00am, the second officer noted in the man’s ACCT
record that he was pacing up and down in his cell. He told the second officer
that he was fine but that he had not slept well.
35. At 4.30am, the man was seen hanging in his cell by the second officer. She
shouted for assistance and her colleague arrived, followed by the personal
officer. Her colleague unlocked the cell and went inside followed by the
second officer and the personal officer.
36. The officer’s colleague supported the man and cut the ligature to release him.
The ligature was made from a torn sheet and tied to the window bars. The
night orderly officer arrived at 4.34am. The night orderly officer and the
officer’s colleague laid the man flat on the ground. The officer’s colleague
noticed blood on the ground but could not find any obvious wounds on the
man. (He later found that the man had cut his leg). The officer’s colleague
checked the man for a pulse. He was not breathing and there was no obvious
pulse. He checked that the man’s airway was cleared and told the night
orderly officer to start chest compressions. The personal officer left the cell to
get a First Aid kit (mask) from the office on the fourth floor. He returned
immediately with the equipment and the officer’s colleague was then handed
a mask and began mouth to mouth resuscitation.
37. At around the same time, the second officer left the cell to go to the
healthcare centre to escort the nurse to the wing. The personal officer then
went back to the office on the fourth floor to raise the alarm for healthcare
assistance and to ask the control room to call for an ambulance using the
telephone in the office. (This is the personal officer’s account given to my
investigator and when interviewed by the police. However, the incident scene
log completed by her contradicts this and records that the second officer went
to get the first aid kit from the office at 4.33am and the personal officer went to
alert healthcare and the control room at 4.34am.) The gatekeeper’s log
records that they received a request to call the ambulance at 4.38am. The
ambulance was called at 4.39 and arrived at the prison at approximately
4.47am. The crew were in the prison by 4.50am and at the cell around
4.52am.
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38. A nurse arrived at around 4.38am and brought an oxygen cylinder. She did
not bring a defibrillator with her. The officer’s colleague connected the ambu
bag to the oxygen and then connected it to the mask and turned the oxygen
on. (An ambu bag is a hand-held device used to provide ventilation to
somebody who is not breathing or who is breathing inadequately.)
39. The officer’s colleague continued resuscitation using the ambu bag and
oxygen for 20 minutes while the night orderly officer maintained chest
compressions. The nurse offered to assist with the resuscitation but the
officer’s colleague said he was content to continue. The night orderly officer
then left to collect ambulance staff from the gate. The officer’s colleague took
over with chest compressions assisted by a PO, who administered the
oxygen. The paramedics then took over and the man was taken to hospital
where he was pronounced dead at 6.40am.
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ISSUES
Family concerns
40. As noted earlier, one of my family liaison officers spoke with the man’s partner
and his father and step-mother. His partner said that he had told her that he
had cut himself while in prison. She asked if the investigation could identify
what he had been using to cut himself. In fact, I have found no evidence that
the prison was aware that he was cutting himself. When he was found
hanging he had a cut on his leg. However, there is no evidence that any
member of staff was previously aware of that. My investigation has been
unable to identify when or how the man sustained the cut.
41. The man’s partner also asked why he did not receive a further mental health
assessment at this time. As I have shown, the members of the MHIRT who
saw him on 4 July considered that he did not have any mental health illness.
42. The man’s partner also asked why he had been allowed to have bed sheets
when he was being monitored as a risk of self harm or suicide. The relevant
Prison Service Order (PSO) is PSO 2700 which deals with suicide and self-
harm prevention. A revised PSO 2700 was issued on 26 October 2007 but
the version of PSO 2700 in force at the time of his death was issued on 4
November 2002. Chapter 4 of the November 2002 document is devoted to
‘Managing Prisoners Identified At-Risk to Self’ and section 4.4 of the chapter
which deals with ‘Removal of items in possession,’ says:
“Personal items including shoelaces and belts must not be removed from
at-risk prisoners as a matter of course. The reasons for the decision to
remove or return items must be recorded in the prisoner’s F2052SH.”
(F2052SH was the set of procedures previously used by the Prison
Service to monitor and support prisoners thought to be at risk of suicide or
self-harm. By the time of the man’s death, F2052SH had been replaced
by ACCT).
43. Section 4.1.3 of the same chapter of the PSO deals with special
accommodation and refers expressly to the removal of bedding or clothing
from the cell of a prisoner who is at risk of suicide. Section 4.1.3 says:
“Prisoners identified as being at risk of suicide or self-harm must not be
placed in an unfurnished cell … unfurnished cells do not contain furniture,
fittings, bedding and clothing.”
44. Staff at Leicester would have been acting in defiance of the PSO if they had
removed the man’s bed sheets from his cell. Nor do I think it would have
constituted humane treatment. I am satisfied that permitting him to retain his
bedding was an appropriate decision and one which complied with the
relevant Prison Service instruction.
45. The man’s father and step-mother were concerned that his medication for
schizophrenia had been discontinued while he was in prison. They asked
17
why the prison had not found an alternative method of administering the
medication to ensure it was taken, such as dispensing in liquid form or under
supervision.
46. The man’s family also asked whether his personal officer had been on duty
during the night he died. I have reported that the personal officer was indeed
on duty when he died and this is detailed in paragraph 30 above.
47. The family questioned whether the man’s difficulty with sleeping had been
related to his medication being discontinued. However, it appears that he had
trouble sleeping generally and this cannot be directly related to his medication
being discontinued.
48. The man’s family asked whether his solicitor had been in contact with him
during the weeks prior to his death. I have found no evidence that his solicitor
had been in contact with him during the weeks prior to his death. The only
recorded visits were from his partner on 7 July and 4 August.
49. Finally, the family were also concerned about the contact from the prison
following the man’s death. The prison correctly notified the man’s partner of
his death as she had been named by him as next of kin. On her own
insistence she then notified his brother, who told his father and step-mother.
50. The man’s father and step-mother explained that the prison told them that all
arrangements had to be made through the man’s partner who was his
nominated next of kin. They said the prison refused to have any dealings with
them directly, and insisted that all contact was through his partner. They were
very upset that they were informed of the man’s death by his brother, who had
been contacted by the man’s partner. They were aware that his partner had
been insistent that she break the news to his brother herself. However, the
family felt strongly that the prison’s Family Liaison Officer should have
supported her better, perhaps advising her to arrange to meet his brother and
then accompanying her to help break the news to him.
51. The man’s father and step-mother confirmed that they were invited to visit
their son’s cell, but chose not to do so. They were also upset that they were
not given any choice with regard to collecting his belongings. They had not
wanted to return to the prison but were told that they had to collect his
belongings in person. They had a meeting with the Governor following the
man’s death. However, they felt that the meeting was primarily for his partner
and said they were told they could attend the meeting if they wanted.
52. Section 3.4 of the Prison Service guidance on Family Liaison (PSO 2710 -
Follow up to deaths in custody) is entitled ‘Who is the family?’ This is clear
that prisons should be prepared to deal with more than one section of a
family. It says:
“The family may be large, split geographically, at odds amongst
themselves. Many modern families are split by divorce or separation and
there may be several branches all with equal rights to information. The
18
Family Liaison Officer may be able to get the family to nominate a single
point of contact who undertakes to keep other family members up to date.
This may not always be possible, or may not work in practice, so the
Family Liaison Officer should be prepared to deal with different sections of
one family if necessary. The police sometimes deploy more than one
Family Liaison Officer to a family. This may be an answer in extreme
circumstances of family division.”
53. The man’s father and step-mother said they were very hurt by the condolence
letter they received from the prison which referred to the man as their partner,
not son. This is deeply regrettable. I understand that a letter of apology was
sent by the Prison Service Area Office.
54. I simply report the account given by the man’s family. Clearly his family found
contact with the prison frustrating, and felt the prison gave preferential
treatment to his partner. I agree the prison could have been more proactive in
their contact with the man’s father and step-mother as well as his partner.
Although I make no formal recommendation I would draw to the attention of
the Governor the guidance in PSO 2710 regarding contact with more than one
section of the family. The Governor will wish to consider whether local
contingency plans should be revised.
ACCT
55. The Prison Service has various strategies to assist prisoners at risk of suicide
or self harm. Prisoners can be monitored by an Assessment, Care in Custody
and Teamwork (ACCT) form. They can speak to a Listener or access
Samaritan support over the telephone.
56. The man was known to be depressed about the death of his mother earlier in
2007. He said that he had previously attempted suicide. He also suffered
from paranoid schizophrenia and a psychopathic personality. He was
assessed as being at high risk of harming himself and was placed on an
ACCT on 13 July 2007 following concerns from his personal officer.
57. There was a delay in the second ACCT review being held despite reminders
by managers that a review was required. Prison Service Order 2700 ‘Suicide
and self-harm prevention’ says:
“The second and subsequent case reviews usually take place under less
pressure of time than the first one. Therefore it is possible that a wider
range of staff and specialists may be able to attend. One of the attendees
must be the named Case Manager (and failing that, the Manager
responsible for the prisoner’s location), one a residential officer who works
in the area where the prisoner is located and the other an appropriate
member of non-discipline staff. The case review must also be attended by
the prisoner. The Assessor is not required to attend subsequent reviews.
Where referrals have been made to specialist staff or those staff are
already involved in the care of the prisoner, they must be invited to attend
the next case review. Where attendance is not possible, they must
19
provide input in writing or by telephone to that case review (and
subsequent reviews if requested). Wherever possible the Case Manager
should arrange subsequent reviews at a time that he or she can be
present, in order to provide some continuity of care for the prisoner.
Where the named Case Manager cannot attend, they must explain to the
prisoner who is to take their place at the review, and record that they have
done this. A case review must be held following a change to a more lethal
method of self-harm, for example from cutting to using ligatures. The case
review will consider if another assessment is required.”
58. The two ACCT reviews held for the man were not multi-disciplinary as
recommended in the PSO and did not result in continuity in his care. The
second review was conducted by a manager who had not met him previously.
The Governor should remind staff of the requirements of PSO 2700 in
relation to the management of prisoners being monitored on ACCT
forms and ensure that reviews are carried out in a timely manner by the
appropriate people.
59. Between 9.30pm on 12 August 2007 and 6.30am on 13 August there are
several signed entries in the observation record for the man as he was on an
ACCT. These entries are at regular half hour intervals and record that checks
have been made on the prisoner depending on the level of observation
required in each case. However, I am extremely concerned that the entries
between 4.30am and 6.30am must have been completed in advance. I am
pleased that the prison issued a memo in October 2007 reminding staff about
required observation for prisoners who are on an ACCT document. That
memo states:
“The observations should be tailored to the individuals’ needs. All
observations should be irregular and not predictable, for example:
Once hourly - one observation should be made during an hourly period.
This should be random and irregular.
Twice hourly - two observations per hour, again should not be on the hour
and every half hour eg 13.30, 14.00, 14.30. They should be irregular.”
In light of my findings in respect of the entries made in the man’s ACCT
form after 4.30am, the Governor should consider what other actions are
required to ensure the integrity of the ACCT process.
20
Clinical care
60. I thank the clinical reviewer for a very comprehensive report and highlight
below the recommendations which I accept.
61. The clinical reviewer finds that communication between discipline staff and
healthcare staff was lacking. On 4 July 2007, the man saw members of the
MHIRT. They concluded that there was no evidence of mental illness and no
role for the MHIRT in his care. He was scheduled to see a member of the
team again at the end of August. There were concerns raised by staff in the
man’s ACCT on 31 July and 7 August indicating that he should be seen again
by the MHIRT team. However, there is no evidence that this was followed up
or that the MHIRT team were even aware of these concerns.
The Governor and PCT should investigate whether the lack of
communication between healthcare and discipline staff is an ongoing
failure and if so how urgent action can be taken to improve
communication between them.
62. I am also most concerned that the MHIRT notes for the man could not be
located for my investigator to consider.
63. The clinical reviewer identifies some training needs for medical staff. Not all
clinical staff interviewed were aware of current first aid (resuscitation)
procedures. The nurse that completed the first reception health screen said
that her cardiopulmonary resuscitation training had taught her to undertake 15
compressions to two breaths. However, the clinical reviewer points out that
the current standard, established some 18 months before the nurse was
interviewed, is 30 compressions to two breaths. In addition, the nurse that
attended the scene said she had not been trained to use a defibrillator and
would not be confident using one. That was why she did not bring a
defibrillator with her to the man’s cell. I believe that all healthcare staff should
be up to date with current first aid (resuscitation) procedures. All staff should
also be trained and confident to use a defibrillator.
The PCT should ensure that all healthcare staff are up to date with
current first aid (resuscitation) procedures. The PCT should also ensure
that all staff are trained and confident to use a defibrillator.
64. The clinical reviewer also finds that communication between MHIRT staff and
primary care staff was poor. There are no clear written notes to explain why
the man’s medication was not prescribed at the earliest opportunity. His
prescription chart shows once only prescriptions for Olanzapine 10mg for the
afternoon of 25 June and Chlorpromazine 50mg for the afternoon of 25 June,
morning of 26 June and afternoon of 26 June. There was a recommendation
after the MHIRT assessment on 4 July that Chlorpromazine and Olanzapine
should be prescribed for him. There is then a prescription only for
Chlorpromazine 100mg three times a day starting on 4 July. There is no
indication why Olanzapine was not prescribed.
21
65. The record shows that the man did not collect his medication on most
occasions and that he was caught concealing medication under his tongue on
9 and 11 July. The prescription was cancelled but the date of cancellation is
not given. Entries on the prescription chart stop on 13 July. It appears from
the clinical reviewer’s review that the medication was not dispensed in an
alternative form due to cost.
66. The doctor confirmed in interview that the man’s prescription for Olanzapine
had not been continued after the first night because information had been
received from his doctor that this was not a repeat prescription. The doctor
also confirmed that the man’s prescription for Chlorpromazine had been
stopped on 13 July. He was unable to say who had authorised the medication
to be stopped. It appears that a locum doctor gave permission for his anti-
psychotic medication to be stopped because he was not taking it regularly
and, when he did collect it, was hiding it under his tongue. There is no record
of who authorised the cessation of medication and no effort was made to find
out why he was not taking it. An instruction dated 4 June 2007 was issued to
healthcare staff to ensure that if prisoners refuse to take their medication they
are aware of their duty to investigate the reason why and record any action
taken. This instruction predates his admission to Leicester.
The PCT should undertake an audit to establish whether this instruction
relating to the recording of reasons when prisoners do not take
medication is being followed by healthcare staff.
The PCT should review the mechanisms for communication between
healthcare staff to ensure that there is a sound system in place.
The PCT should remind staff of the need to complete medical notes
appropriately and in accordance with the guidelines of the professional
bodies for doctors and nurses with regard to the expected standards of
records and record keeping.
67. The clinical reviewer has considered whether the medication could have been
given in an alternative form. The clinical reviewer asked the doctor whether
he might have considered prescribing Chlorpromazine to the man in liquid
form to make it harder for him to hide, but the doctor said that liquid
Chlorpromazine was not available at HMP Leicester because it was too
expensive.
68. The clinical reviewer also finds that there are overlaps in the first reception
health screen process. In the majority of cases a nurse completes the first
reception health screen in the presence of a doctor. This procedure is
sometimes followed by a secondary health screen undertaken by a doctor.
Much of the information is therefore duplicated.
The PCT should ensure that there is a robust reception health screen
process avoiding duplication of effort between the initial reception
health screen and the secondary health screen.
22
69. It appears that it took approximately eight minutes to call an ambulance after
the man was found hanging at 4.30am. The gatekeeper’s log records that
they received a request to call the ambulance at 4.38am. They called the
ambulance at 4.39am. Leicester’s contingency plans for a death in custody
do not point out sufficiently clearly that an ambulance should be called as
necessary and as quickly as possible. The Governor will wish to address this
as a matter of urgency.
70. The personal officer should be commended for her interaction with and care
for the man. The officer’s colleague should also be commended for his action
in terms of performing and directing CPR procedures for the man.
23
RECOMMENDATIONS
1. The Governor should remind staff of the requirements of PSO 2700 in relation
to the management of prisoners being monitored on ACCT forms and ensure
that reviews are carried out in a timely manner by the appropriate people.
2. In light of my findings in respect of the entries made in the man’s ACCT form
after 4.30am, the Governor should consider what other actions are required to
ensure the integrity of the ACCT process.
3. The Governor and PCT should investigate whether the lack of communication
between healthcare staff and discipline staff is an ongoing failure and if so
how urgent action can be taken to improve communication between them.
4. The PCT should ensure that all healthcare staff are up to date with current
first aid (resuscitation) procedures. The PCT should also ensure that all staff
are trained and confident to use a defibrillator.
5. The PCT should undertake an audit to establish whether this instruction
relating to the recording of reasons when prisoners do not take medication is
being followed by healthcare staff.
6. The PCT should review the mechanisms for communication between
healthcare staff to ensure that there is a sound system in place.
7. The PCT should remind staff of the need to complete medical notes
appropriately and in accordance with the guidelines of the professional bodies
for doctors and nurses with regard to the expected standards of records and
record keeping.
8. The PCT should ensure that there is a robust reception health screen process
avoiding duplication of effort between the initial reception health screen and
the secondary health screen.
Good Practice
The personal officer should be commended for her interaction with and care for the
man. The officer’s colleague should also be commended for his action in terms of
performing and directing CPR procedures for the man
24
Comments on draft report:
Family comments:
The man’s partner told my investigator and family liaison officer that due to his illness
the man had two distinct personalities and had even named his other personality,
using his middle name. She was never sure which personality she was going to see
but over time she learnt to differentiate between them.
She also pointed out that the summary of the report says that he had drunk alcohol
within the last three days but he had been in police custody during that time.
This was the information the man gave to prison staff during his reception healthcare
screening.
In response to the information in the summary that the man used methadone, his
partner said that she had never known him to use methadone.
This was information the man gave to healthcare staff.
The man’s partner also said that it was not true that he had not self-harmed within
the past three years (paragraph 12 refers). She described two incidents when he had
self-harmed in her presence.
The information in paragraph 12 reflected the information the man had given to the
Forensic Medical Examiner when he was detained at the Police Station.
The man’s partner also said that she has since been told by a friend who was in
Leicester at the same time as the man that he may have been bullied by other
prisoners. She was also told that possibly he told the officer who found him in his
cell (the officer described as ‘the officer’s colleague’ in this report) about the bullying.
The violence reduction coordinators have checked the relevant prison records and
there was no record of bullying being an issue for the man. The personal officer said
that the man definitely did not raise any concerns about being bullied with her and
she felt that if he had any such concerns he would have spoken to her about it. The
officer’s colleague also said that the man had never raised any concerns about being
bullied with him.
The man’s father and step-mother questioned why MHIRT decided that he showed
no signs of mental illness and there was no role for them in his care after examining
him on 4 July.
This was a decision taken by MHIRT based on their assessment of the man at the
time.
They were also concerned to read about the differing accounts of events given by
the personal officer to my investigator and the police and as detailed in the incident
scene log, as highlighted in paragraph 39.
25
They were also concerned that a radio was not used by staff to summon help when
the man was found in his cell.
I raised my concern over the length of time it took to call an ambulance in paragraph
71 and made a recommendation about this.
Further, the man’s family have voiced their concerns that the nurse in charge did not
know how to use a defibrillator.
The doctor shared those concerns and this issue is addressed in paragraph 65 and I
have made a recommendation about this.
Finally the man’s family said that they felt that generally Leicester does not seem to
have a system of management checks on ACCT forms to assess their quality.
I have noted my concerns about the management of the ACCT form completed for
the man in paragraphs 57-61 and made 2 recommendations about this.
Prison Service comments:
The Prison Service has accepted all the recommendations apart form
recommendation 6 which has been partially accepted. Action plan is attached.
Also the report by HM Chief Inspector of Prisons mentioned on page 9 is not the
most recent report. The establishment received a further inspection from HMCIP in
June 2008 therefore this quote is not from the most recent report by HM Chief
Inspector of Prisons. An additional paragraph has been added on page 9 to reflect
the more recent inspection and reads:
“A safer custody policy and monthly meeting provided strategic oversight to suicide
and self harm work, and relevant management information was collected and
analysed. There were delays in receiving Prisons and Probation Ombudsman (PPO)
draft reports from previous deaths in custody but local action plans were in place. A
full-time safer custody coordinator was in post, and the quality of assessment, care
in custody and teamwork (ACCT) documents was good, although reviews were
insufficiently multidisciplinary. ACCT assessors met monthly, and family liaison work
was very good. Listeners were generally well supported but access was limited
during patrol states. No separate record was kept of the use of gated cells, and
prisoners in crisis were, on occasions, placed in strip conditions in these cells. A
weekly cell sharing risk assessment (CSRA) meeting facilitated detailed discussions
about those prisoners who were deemed medium or high risk.”
26
Pleaseseeattachedactionplan.
No Recommendation Accepted/ Response Targetdate Progress(tobe
Partially for updatedafter6
accepted/ completion months)
Not
accepted
1 TheGovernorshouldremindstaffofthe Accepted InformationrelatedtocurrentACCTreviewsandPost
requirementsofPSO2700inrelationto Closurereviewsisnowonthedailybriefingsheetwhich
themanagementofprisonersbeing isemailedtoallstaff,thisisalsodiscussedattheDaily
monitoredonACCTforms&ensure Operationalmeeting,chairedbytheGovernor.The
Actioned
thatreviewsarecarriedoutinatimely ACCTqualitymanagementchecklisthasalsobeen
mannerbytheappropriatepeople. amendedtoincludeamoredetailedassessmentof
reviews.
2 Inlightoffindingsoftheentriesmadein Accepted ArobustsystemwherebytheOrderlyOfficer,Safer
MrB’sACCTformafter4.30am,the CustodyCo-ordinatorandtheDutyGovernorcarryouta
Governorshouldconsiderwhatother
programmeofqualitychecksofallACCTdocuments.
actionsarerequiredtoensurethe
TheSaferCustodyCommitteeexaminesallrecently
integrityoftheACCTprocess. Actioned
closedACCTdocumentsasafurtherqualitycontrol
measure.
3 TheGovernor/PCTshouldinvestigate Accepted PCT/SERCOfeelthiswasanisolatedissueandisnot
whetherthelackofcommunication anongoingfailure.ClinicalGovernanceCommitteewill
betweenhealthcarestaffanddiscipline continuetoensurethatthereferralprocessforprisoners
staffisanongoingfailureandifsohow tothementalhealthteamsisbotheffectiveandtimely.
May09
urgentactioncanbetakentoimprove
communicationbetweenthem.
4 ThePCTshouldensurethatall Accepted BasicLifeSupportispartofhealthcarestaff’s
healthcarestaffareuptodatewith mandatorytraining,andisuptodateforthisfinancial
currentfirstaid(resuscitation)
year.SERCO(PrisonHealthcareProvider)needto
procedures. ThePCTshouldalso
ensurethateitherspecificdefibrillatortrainingor
ensurethatallstaffaretrainedand
AdvancedLifeSupportismademandatoryforall
confidenttouseadefibrillator. healthcarestaffandthatyearlyupdatesaremadepart August2009
ofanindividual’spersonaldevelopmentplan.The
PrimaryCareTrustwillensurecomplianceby
encompassingthisrequirementintotheHealthcare
ClinicalGovernanceActionPlan,andif
required/appropriate,anycontractualagreements.
5 ThePCTshouldundertakeanauditto Accepted (Jointaction)PrimaryCareTrustandHealthcare
establishwhetherthisinstruction Providertocreateanaudittoolandensureauditof
relatingtotherecordingofreasons DNA’siscarriedoutonallpatientswhoDNAoveran
whenprisonersdonottakemedication agreedperiodoftime.Thiswillhighlightthenumbersof
August2009
isbeingfollowedbyhealthcarestaff. DNA’sandascertainifinstructionsarebeingfollowed.
Subsequentactionplanswillbeputinplaceifanyareas
ofconcernbecomeapparent
6 ThePCTshouldreviewthe Partially WhilstthePrimaryCareTrustaretheCommissionerfor
mechanismsforcommunication accepted healthcareatHMPLeicester,SERCOarethecurrent
betweenhealthcarestafftoensurethat healthcareproviderandanyworkregardingSERCO
thereisasoundsysteminplace. staffcommunicationneedstobeledbySERCOand
August2009
overseenandmonitoredbythePrimaryCareTrust.
PCTtofacilitateameetingwiththehealthcaremanager
toascertainhowsystemscanbeputinplaceandwhat
supportisneededtoensurethesesystemsare
effective.
7 ThePCTshouldremindstaffofthe Accepted Clinicalrecordkeepingaudithasnowcommencedand
needtocompletemedicalnotes iscarriedoutmonthlybytheHealthcareManager.
appropriatelyandinaccordancewith Resultsarereviewedandactiontakenwhere
theguidelinesoftheprofessional necessary.
Actioned
bodiesfordoctorsandnurseswith
regardtotheexpectedstandardsof
recordsandrecordkeeping
28
8 ThePCTshouldensurethatthereisa Accepted ThePCTwilloverseethis,andwillensurethata
robustreceptionhealthscreenprocess protocolisinplacere:healthcarescreeningprocess
avoidingduplicationofeffortbetween andthatSERCOensureallstaffaremadeawareofthis
theinitialreceptionhealthscreenand process.
August2009
thesecondaryhealthscreen.
29