Individual at Preston

Investigation into the circumstances surrounding the
death of a man at HMP Preston
in December 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
January 2007
This is the report of an investigation into the circumstances of the death of a man at
HMP Preston on 27 December 2005. He was found hanging in his cell at 5:25am,
but attempts to resuscitate him were sadly unsuccessful. The man had been in
Preston for about a month.
I extend my condolences to the man’s family and all those touched by his death.
The loss of a family member is always painful, especially so whilst they are in
custody. I would like to thank the family for their assistance with my investigation
and I hope that I have addressed their concerns in this report.
The investigation was led by two of my Assistant Ombudsmen. I would like to thank
the management and staff at HMP Preston for their assistance and co-operation.
Particular thanks go to the prison’s liaison manager, who helpfully arranged facilities
for my investigators.
An independent review of the man’s medical care in prison was commissioned from
Preston Primary Care Trust. I must also like to thank the North West Regional
Development Team, Prison Health, who carried out the review.
In addition to some ‘housekeeping’ points, I make seven recommendations in this
report. Perhaps the most important concerns information sharing between staff.
The clinical review has identified a further six learning opportunities that I urge the
prison/PCT partnership board to take forward. However, none of this should detract
from the good standards evident in the self-harm and suicide management
processes at Preston, and the response to the man’s death. I have drawn attention
to a number of examples of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2007
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CONTENTS
Foreword
Summary
The investigation process
HMP Preston
Key events
(cid:127) The man’s admission into HMP Preston
(cid:127) Events leading up to the man’s death
(cid:127) Events of 26 December
(cid:127) The prison’s response to finding the man
(cid:127) The prison’s response following the man’s death
Issues considered during the investigation
Recommendations and Good Practice
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SUMMARY
The man was born in 1977 in Glasgow. He was found hanging in his cell at HMP
Preston in the early hours of 27 December 2005. At the time of his death, he was
just 28 years old.
The man had a close relationship with his family although they had spent some
periods apart. They had last seen him in August 2005 and remained in contact until
the day before his arrest on 25 November 2005.
The man appeared before Magistrates’ Court on 26 November charged with sexual
offences. He was remanded into custody to Preston prison.
On arrival at Preston, the man was assessed by reception staff. The nurse on duty
was sufficiently concerned about the level of suicide and self-harm risk to open an
ACCT (Assessment, Care in Custody and Teamwork) document. (This is a regime
under which prisoners at risk of self-harm or suicide are managed.) The nurse
described the man’s depression and deep sense of remorse and referred him to the
doctor. The man also suffered from diabetes (for which he took insulin) and asthma.
As part of the man’s ACCT, a plan set out the appropriate supportive regime,
including his location in a double camera cell “until deemed no longer necessary”,
and regular observations by staff. He appeared “very low” at this point. At his case
review, he expressed a wish to write to his family to let them know he was in prison.
This moving letter illustrated the man’s feelings of remorse and intention to seek
help. He was also referred to the mental health in-reach team (MHIT) as a result of
the ACCT being opened.
The man was granted ‘poor coper status’ at his own request due to the nature of his
offence. He was allocated to F wing, a small vulnerable prisoners unit, where he
remained. During his time on F wing, he was given an appropriate induction. His
personal officer noted that, although he and other staff encouraged the man to spend
more time out of his cell, he was quite an introverted character and did not socialise
much. He was prescribed Fluoxetine for his depression by the doctor.
After his induction, the man’s demeanour and mood slowly improved. ACCT records
show that he was cheerful in mood and was starting to mix well with other prisoners.
On 3 December, the man’s ACCT was closed at a multi-disciplinary case review.
This acknowledged that he was still a little low, but he was aware of the avenues of
support available to him and had not attempted to self-harm since he arrived. His
risk was recorded as being “low”.
On 5 December, the man was reviewed by the mental health in reach team using
records duly obtained from a community mental health team and outside hospital.
Based on judgements made in these records that the man presented “no obvious
mental illness”, his lack of registered mental health illness status, the closure of his
ACCT and his regular involvement with the primary care team due to his insulin
dependency, he was referred to primary care with no need for a further mental health
assessment. His wellbeing and general presentation were to be monitored daily by
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primary care healthcare staff. If concerns arose, they were to refer him for a mental
health assessment.
Despite the man’s desire to seek help through counselling, his attempts were
frustrated by a lack of primary care level mental health provision, particularly short
term crisis counselling. The man appears never to have received any outreach
mental health support and accessed no counselling services, despite attempts made
by his doctor. However, the management of his self-harm and suicide risk on normal
location through the ACCT process had otherwise worked very well.
On 11 December, the man and his cellmate were moved out of the camera cell to
another cell on F wing to make room for a third prisoner who was on ACCT. On 16
December, the man’s ACCT closure review noted that he felt better, still had down
periods but no episodes of self-harm.
In the afternoon of 26 December, the man was involved in a dispute with another
prisoner over the use of the pool table on F wing. The man was reprimanded by an
officer and felt that he had been unfairly blamed. The man was upset and returned
to his cell. Following refusal of his insulin and tea meal that evening, a nurse and
two officers went to speak to the man to reassure him and try to dissuade him from
his refusal of medication. The man continued to refuse treatment and an ACCT was
subsequently opened by officers.
During this conversation, the man handed the nurse a note that she described in his
clinical record as a ‘suicide note’ but the man referred to as an ‘Advanced Medical
Directive’ (AMD) setting out his wishes. He said that “being of sound mind, body and
judgement”, should he go into a “diabetic coma or any medical problem including
suicide”, he did not wish any “medication, oxygen, blood transfusions, or any heroic
life saving measures. As I do not have any more reason to live.” The note was
addressed to medical staff.
Healthcare and discipline staff have differing recollections as to whether the note
was shown or summarised to discipline staff, and whether officers were aware of the
reference to suicide or only the issue of diabetic coma. My investigators found no
plans to do anything further with the AMD and that staff were unclear as to its
implications. Healthcare staff also had differing recollections of the information
handed over to night staff, and the various written records did not clarify this further.
However, I conclude that this did not affect the outcome. The man was placed
appropriately on regular half hourly observations, carried out through the night. He
appeared to be unsettled, although he did sleep at times. No discussions took place
about placing him a camera cell.
Just after 5:25am on 27 December, an officer found the man hanging from a bed
sheet tied to the window bars in his cell. Both healthcare and discipline staff
immediately lifted the man down and attempted CPR, but unfortunately attempts to
resuscitate him, including those by paramedics, were unsuccessful. The man was
pronounced dead at 5.45am. The post mortem report concluded the cause of death
to be asphyxia by hanging.
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The prison made arrangements for the police in Glasgow to contact the man’s family
as soon as possible to inform them of his death. The family were also contacted by
the prison family liaison officer who kept in touch. The man’s funeral was held on
Friday 6 January 2006.
Over the time the man was on the ACCT, his mood had steadily improved and he
was becoming much more sociable on the wing (although still low at times). He
expressed no wish to harm himself until after he had served his sentence and made
this clear to a number of staff. He had also not self-harmed since he had been in
prison.
Despite the overall good level of care the man received at Preston, my report makes
seven recommendations for improvements that could be made in relation to the
management of suicide risk. The most significant of these concern information
sharing between healthcare and discipline staff, and the treatment of advanced
medical directives. I make these recommendations recognising fully the support
needed by staff to make this work in practice. I also highlight some examples of
good practice.
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INVESTIGATION PROCESS
1. One of my assistant ombudsmen first visited HMP Preston on 3 January 2006.
She was given the initial papers that had been assembled about the man and
was briefed about the circumstances surrounding his death. She also met with
a member of the Independent Monitoring Board. A notice to staff and to
prisoners was issued by the prison, inviting anyone who might have information
relating to the man’s death to make themselves known. In the event no-one
came forward.
2. My two investigators, both assistant ombudsmen, went to Preston to
commence the investigation formally on 9 January. They toured the prison,
and met with the Governor and a representative of the Prison Officers’
Association. Preston Primary Care Trust was commissioned to undertake a
clinical review of the man’s health care whilst in custody. A clinical review was
carried out by the North West Regional Development Team, Prison Health.
3. My investigators returned to Preston on 24, 25 and 26 January to interview
further staff and prisoners. The operational manager was the deputy head of
residential, acted as the prison liaison officer and made all necessary
arrangements for interviews and ensured all papers were made available to my
investigators. All the interviews were taped and transcribed and are attached
as annexes.
4. One of my family liaison officers contacted the man’s family. They had already
asked some questions about the man’s time at Preston of the prison’s family
liaison officer on 28 December, and he communicated these to my
investigators. The family asked to see a copy of the draft report. My
investigator and family liaison officer went to visit the man’s parents and sister
at their home in Glasgow on 30 January to discuss their concerns and the
progress of the investigation so far. I have endeavoured to deal with all these
issues in my report or in correspondence with the family.
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HMP PRESTON
5. HMP Preston is a local prison in the centre of Preston in Lancashire. The
prison was first built in 1790 and became a local prison in 1990. It receives all
adult male prisoners from Crown Courts and Magistrates’ Courts serving
Lancashire and Cumbria.
6. The prison’s residential areas consist of six main houseblocks, one of which is
a small vulnerable prisoner unit, F wing, holding 33 prisoners. The cells in this
unit are all double cells. Four of the cells have overt CCTV cameras in them
(‘camera cells’). A Listener (a prisoner trained by the Samaritans) is the single
occupant of one of these cells. (The man lived in F wing throughout his time at
Preston.)
7. A First Night Centre is located on the top level of D wing. It accommodates
non-detoxing prisoners for the first three nights of their time in Preston,
although the man did not spend any time here. All of the cells on this landing
have overt CCTV cameras and observe prisoners at all times when they are in
their cells.
8. The healthcare unit has very recently been refurbished and is designated as an
area resource. It can take up to 30 in-patients, with 12 of the beds designated
as area resource beds. Nursing cover is provided 24 hours a day. There is a
full time GP who works Monday to Friday and another GP who provides out of
hours emergency cover.
9. In her report of an announced inspection in July 2004, Her Majesty’s Chief Inspector
of Prisons reported that good systems were in place to help prisoners at risk of
suicide and self-harm, although they were limited by not being part of a broader safer
custody approach to managing prisoners’ safety.
10. In December 2005, the certified normal accommodation at Preston was 418
and the operational capacity (maximum crowded capacity) was 620. On the
night of the man’s death, the prison roll was 562. Typically, there are 30
movements in and out of reception on each weekday.
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KEY EVENTS
The man’s admission to HMP Preston
11. At the man’s appearance before magistrates on 26 November, the hearing was
adjourned until 2 December. The man left with GSL escorting staff at 10.40am
and arrived at HMP Preston at 11:20am. His Prisoner Escort Record (PER)
included ticks for his ‘risk categories’ on medical condition, sex offence and
suicide risk. The further information box was completed as follows, “High risk.
Has tried to kill himself by overdosing on insulin three times in last week. He is
diabetic...”
12. A prison officer carried out the reception interview with the man and completed
form F2050 (the core prison record). Personal details such as the man’s date
of birth, nationality, height, weight, identifying scars or tattoos were all recorded.
The man gave the name, address and phone number of his mother as his next
of kin.
13. A second prison officer completed the cell sharing risk assessment. (This form
is intended to identify those prisoners who may be a risk to other prisoners if
they were to share a cell together.) The man was assessed as being low risk
on the basis of information he gave.
14. All the cells in Preston are shared cells. In the man’s case, since he was
deemed at risk of self-harm or suicide, it would anyway have been considered
safer practice to place him in a shared cell. However, the man said he had
concerns about sharing a cell and described himself as someone who got
angry and frustrated quickly. My investigators believe this may have been
linked to his desire to acquire “poor coper” status (a status given to vulnerable
prisoners who may not wish to be placed on a normal wing).
15. A Registered General Nurse, was on duty in reception that day. Her role was
to interview and assess all new receptions. She completed the Prison
Service/Department of Health form, First Reception Health Screen, on the man.
This asks a wide range of questions about health including any diagnosed
illnesses, alcohol and drug use, and mental health history including any
previous attempts of self-harm. The form is heavily reliant on the answers that
the prisoner gives.
16. The registered general nurse saw the man at approximately 12:00pm. She was
particularly concerned about him and said he was withdrawn, seemed full of
remorse for his offence and had said that he just wanted to end his life. She
had seen details of his attempted overdose of insulin on the PER and
suicide/self harm warning form completed by his escorting officer. He had his
insulin medication with him, so this could be immediately prescribed. She also
explained that he would have had a “Well Man” check up the next day. She
spent some time talking with the man, trying to reassure him and said that he
would be seen by a doctor.
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17. The form was placed on the man’s Clinical Record. The man said that he had
seen a doctor as an in-patient at a Hospital for depression and suicide
attempts. He was waiting for an endoscopy and to see a diabetic consultant.
He was receiving insulin for his diabetes and Salbutamol and Becotide inhalers
for his asthma. The man reported no substance misuse problems.
18. Under the ‘Mental Health’ section, the form asks whether the prisoner has ever
received treatment from a psychiatrist outside prison or stayed in a psychiatric
hospital and the man replied that he had. The man also said that he had no
care worker or psychiatric nurse in the community, although Preston’s Mental
Health In-Reach Team later found records of his contact with a community
mental health team in October and November 2005. The man said that he had
received medication for mental health problems, but gave no details. In relation
to self-harm, the man said that he had taken an overdose of insulin.
19. The form says that, if ‘Yes’ is recorded in answer to any of these questions, the
prisoner should be referred for a ‘mental health assessment’. However, there is
no corresponding tick under the ‘Planned Action’ section on page eight to
initiate such a referral. The form should have been ticked for completeness,
but the registered general nurse gave two reasons for not doing so, one of
which raises questions about the functionality of the reception screening form.
First, the registered general nurse confirmed that a mental health referral to
outreach nurses would have been automatic (the day after) for all prisoners put
on an ACCT (Assessment, Care in Custody and Teamwork) plan. (This is a
regime under which prisoners at risk of self-harm or suicide are managed and
one which the registered general nurse commenced for the man.) She knew,
therefore, that he would be seen even though she had not explicitly made such
a referral on the form.
20. Secondly, the form refers to referral for an actual mental health ‘assessment’
and the registered general nurse believed that the man’s mental health issues,
despite being problematic, did not amount to a mental health illness sufficient to
require him to have an assessment carried out. She said that MHIT only take
on clients who have actually been diagnosed with a mental health illness by a
psychiatrist: “They’re not automatically sent for a mental health referral
because they [MHIT] don’t class people who are suicidal as having been
diagnosed with a mental health problem, it’s something people can have
without being mentally ill.”
21. The registered general nurse opened an ACCT for the man in accordance with
the Healthcare Centre Responsibilities, set out in the local ‘Caring for the
Suicidal Strategy’. She had been trained in ACCT procedures. She completed
the ACCT Concern & Keep Safe form at 12:45pm. This sets out the immediate
concerns the initiator has about the person, recent events, and behaviour or
information that gives cause for concern. The registered general nurse referred
to the information she had obtained and recommended that the man should not
have any in-possession medication. She then passed this to the Unit Manager,
to help him decide on the immediate action to be taken. She made
corresponding entries in the man’s medical record and referred to his request
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for psychiatric help. The man should have received a further reception health
check within five days of arrival, but none was completed.
22. The registered general nurse kept the man behind to see a doctor because she
was concerned about him. She said she was concerned at his risk of suicide,
because he had so readily admitted his remorse for his offence which she felt
was very unusual at this stage. He saw the doctor at about 12:50pm and the
registered general nurse thought he might have been prescribed some night
sedation. He was assured he would see medical staff the next day. The man
saw medical staff regularly after being transferred to the wings because he
could not keep his medication himself. He was seen again by a doctor on 30
November.
23. The registered general nurse’s final task was to complete section three of the
Cell Sharing Risk Assessment form. Again she noted the relevant information
she had obtained. The registered general nurse saw the man on a number of
occasions after this on F wing, whilst doing medical treatments. She said his
mood seemed to ‘pick up’ over time, and he was getting on with the other
prisoners and compliant with his medication.
24. The prison’s liaison officer carried out a ‘poor copers risk assessment’ at the
man’s request, to see whether there were sufficient grounds for him to be given
poor coper status and therefore located in the Residential Support Unit (RSU or
F wing/vulnerable prisoners unit). The nature of his offence gave him priority
and, although the assessment was not finalised until a few days later, he
moved directly to F wing to cell F1-08 rather than going to the prison’s First
Night Centre.
25. In line with ACCT procedures, the unit manager, a prison officer (also on F
wing) and the safer custody officer (responsible for dealing with operational
policy and procedure in relation to ACCT in the prison) carried out an
Immediate Action Plan for the man, setting out the appropriate environment and
regime to support him. He was to be located in a double camera cell “until
deemed no longer necessary” and observed hourly during the daytime, with
three quality entries to be made on his records in the morning, afternoon and
evening. During the night and on patrol state (when prisoners are locked in
their cells), he was to be under half hourly observations. He was given access
to a Samaritans phone and to Listeners. (Listeners are prisoner volunteers
who are trained by the Samaritans in listening and befriending skills to support
other prisoners.) Later that day, the man was moved to cell F1-05, a camera
cell.
26. The safer custody officer, a trained ACCT assessor, then carried out an
assessment interview at 3.00pm to gather information about the risks the man
posed to himself. The record shows that the man had tentative suicidal
ideations, linked to the guilt he felt for his offence and appeared “very low”.
27. At 3.11pm, the unit manager and the safer custody officer carried out a case
review with the man to consider his needs and the type of care required. They
developed a caremap to show how that support would be delivered. The man
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said he felt “lightened” after talking to the safer custody officer and accepting
his offence. The man said that he was aware of the avenues of support
available to him on the unit. They made plans for the man to contact his family
by letter (finally sent on 29 November) to inform them he was in custody. This
was a very personal and moving letter in which he showed great remorse, and
demonstrated his intentions and desire to seek help. He wrote of his feelings
about the possibility of losing his family and said he was sorry for the harm he
had caused. A follow up case review was planned for 2 December. When the
man had been to prison for a previous offence, his family had made clear that if
it happened again they would find it difficult to come to terms with the situation.
When the man’s letter of 26 November arrived they found it moving and hard to
respond to, so were taking their time to respond. The man’s mother, also
received a birthday card from her son, apparently sent to her shortly after his
arrival in prison.
28. On the same day, the safer custody officer completed a mental health referral
form for the man as part of the ACCT process. Generally in every case where
an ACCT is opened, the prisoner is referred to the MHIT for a background
check or to obtain information on his mental health history. The referral form
identifies two “risk issues” for the man: “next court appearance” and “time of
sentence”. The man described his acceptance of responsibility for his offence
and that he needed help. He said that he had recently spent some time in a
community mental health unit and that approximately four weeks ago he had
spent a week in a psychiatric hospital. He also said that he had made at least
four suicide attempts in the last month.
29. The man had a first night interview with an officer, to introduce him to Preston’s
regime and take account of any concerns he may have had. His ACCT notes
that, on the evening of 26 November, the man was “lying on bed watching TV
as first night … quiet”, and later, “‘watching TV and chatting to cell mate, went
to bed around midnight and appears to have slept through the night.”
Events leading up to the man’s death
30. F wing is a small vulnerable prisoner unit that holds 33 prisoners. The man
was placed in a camera cell, F1-005, with a fellow prisoner. Although he did
not remain in this cell, the man continued to share with the other prisoner and
they seemed to get on well. There were five regular staff on F wing at the time
and the shortfall was backfilled by staff from another wing.
31. The induction process provides new prisoners with information about the prison
regime and support services available, including Listeners, bail information and
anti-bullying. The local Caring for the Suicidal Strategy also says that the Duty
Listeners rota will ensure that each new reception is introduced to a Listener
within 24 hours. In the last HMCIP inspection report in July 2004, it was
reported that access to Listeners was good and 79 per cent of respondents
said they could speak to a Listener at any time. My investigators could not tell
whether the man saw a Listener during his first night since this is not recorded.
My investigators interviewed the Listener on F wing. He said that the man had
never approached him to discuss his emotions and described the man as
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someone who kept himself to himself. He was “one of those who preferred to
deal with things themselves.” He also said he felt the man was an emotionally
unstable person and had been up and down in mood throughout his time at
Preston, spending time lying on his bed. However, as far as he knew he had
not discussed killing himself.
32. The Induction Checklist on the man’s core record is blank, save for two
references to a follow up assessment being done and a chaplaincy visit. The
file contains a Custody and Care Plan Assessment opened on 26 November
and carried out on 27 November. This identifies the prisoner’s immediate
needs such as suitability of location and being on an ACCT. In July 2004,
HMCIP had also reported that some prisoners were not receiving a full
induction and recommended that all prisoners should have access to the same
induction programme irrespective of their location.
33. The prison chaplain saw the man on 27 November and talked with him about
his concerns about his home and his offence. The man also spoke about his
recent attempted overdose. The chaplain said that whenever the man wanted
to see the chaplain he could put in a request and he would be seen within 24
hours. The man never attended the chapel whilst he was at Preston, although
he was offered the opportunity.
34. The man saw his personal officer at some point that day. His personal officer
said that he spoke to the man on a number of occasions, although never about
his offence or how he was feeling. He said the personal officer scheme was
not one where officers would have responsibility for particular individuals;
rather, they all covered for each other. However, he would have had daily
contact with the man whenever he was on shift. The last HMCIP report showed
that the personal officer scheme had only recently been introduced. At that
time there was little evidence it was having a positive effect on prisoners’
experience. Several prisoners reported that they would not necessarily discuss
their problems with their allocated officer, but would approach any member of
staff with whom they got on well.
35. The HMCIP Report made a recommendation that the required fortnightly
entries in wing history files by personal officers should be sufficiently detailed to
provide the reader with up to date information on the prisoner and his individual
circumstances. The man’s personal officer made two records on the man’s
wing history sheet during his time at Preston: one on 16 December and the
other on 19 December, saying that he did not seem to want to help himself. He
noted that on a previous ACCT he had said he felt a bit depressed and
lethargic. The man’s personal officer had tried to encourage the man to spend
more time out of his cell associating with others, but said the man was quite
introverted and did not socialise much.
36. On receiving the man’s referral on 28 November, the Senior Mental Health In-
Reach Nurse, wrote to community mental health unit to request details of the
man’s mental health history including a possible diagnosis. On 30 November,
the unit enclosed the information sheets received from a hospital referred to
earlier in this report.
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37. On 29 November, the man had an early second case review following an act of
self-harm elsewhere in the prison, in line with local policy. A senior officer and
an officer attended with the man and concluded that he had come to terms with
his crime and no longer had any desire to self harm or attempt suicide whilst in
prison. He wished to be punished for his crime “and face the consequences as
a mark of respect to his victim”. The man said that he would kill himself after
his sentence, upon release. They recorded his level of risk as remaining
“raised”.
38. On 30 November, a note on the man’s clinical record described him as
continuing to have suicidal thoughts, low moods and wanting help. The doctor
prescribed him with Fluoxetine. On 1 December, an officer recorded on the
man’s Custody and Care Plan Assessment follow up that he “wants
counselling”. On 2 December, the man was escorted to court for a hearing in
relation to his offence. The hearing was adjourned until 19 December to be
heard by video link. His ACCT case review was delayed until the following day.
The man’s behaviour was closely monitored and recorded on his ACCT
document and in police records.
39. Since his arrival in Preston, the man’s demeanour and mood had slowly
improved. The ACCT records show him starting to associate a lot more, having
cheerful moods and starting to mix well with other prisoners. On 3 December,
at a multi- disciplinary case review, a senior officer made the decision to close
the man’s ACCT. The chaplain, the man and his personal officer attended.
They acknowledged that the man was still a little low, however he was aware of
the avenues of support available to him and noted that he had not attempted to
self-harm since he arrived. His risk was this time recorded as being “low”. The
man’s personal officer said that they tried to encourage the man to mix more
with others on association. Prior to his death he appeared to be mixing more
than when he first came onto the wing.
40. Healthcare staff were informed and a note was made on the man’s medical
record. Four members of staff including a governor and a senior officer carried
out ACCT Quality Checks each day. The Safer Custody Team completed a
‘closed ACCT quality check report’, concluding that the ACCT was opened and
closed appropriately.
41. On Monday 5 December, the MHIT discussed the man’s case at a referral
meeting led by the MHIT Manager. The MHIT manager told my investigators
that the MHIT are a secondary level mental health care provider employed by
Lancashire Care Trust. The Trust provides mental health services for the
prison under a service level agreement commissioned by the PCT. Their
primary role is identifying, maintaining and treating prisoners with “severe and
enduring mental illness”. The team had been operational for just over a year
when my investigators spoke to the MHIT manager. They receive around 36
mental health referrals each month, of which they put forward about 12 cases
for a full “assessment”. However, since there are no formal primary care
mental health services at Preston (the MHIT manager described this as a
“missing layer”), the team have accepted responsibility for all mental health
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referrals “on an interim basis”, to act as a single point of initial access. In
practice, this means that cases that would not usually meet their criteria are
monitored against a number of care “pathways”. These are unique to Preston
and were set up by the team to mirror processes in the community. They
consist of various checks on a person’s mental health history, CPA
assessment, clinical records etc, to establish the level of service to which the
person should be referred.
42. Due to the team’s NHS status, they can more easily access confidential
medical information and gather communication than other parts of the prison,
and therefore their input is invaluable. They are often used purely as a tool to
gather relevant background mental health information. Based on this, the team
then decide whether the case should be taken onto their caseload and a full
assessment done. If not, prisoners are then “signposted” to other interventions
- such as GP, primary care, or a psychiatrist - which may be better equipped to
meet the prisoner’s needs.
43. In the man’s case, on the basis of (a) judgements about his mental health
history, in particular that he was discharged with “no obvious mental illness”
from hospital, (b) his lack of CPA registered status, (c) the closure of his ACCT
on 3 December, and (d) his daily involvement with the primary care department
due to his diabetes, the MHIT concluded there was no need for a further mental
health assessment and referred the man to primary care. The MHIT wrote to
the primary care manager, on 5 December to request that, as the man was an
insulin dependent diabetic coming into daily contact with primary care, his
wellbeing and general presentation should be monitored. If concerns arose he
should be referred for a mental health assessment. The letter also said that
information received by the MHIT indicated “more of a primary care level of
contact with mental health services”.
44. The MHIT manager confirmed that primary care level contact with mental
health services would involve seeing a GP perhaps once a week for anxiety or
depression, being on medication, and perhaps involvement of a primary care
mental health nurse. The MHIT manager also said, “there’s no talking therapy
as such at primary care level. It’s only once … more people become involved
that the case becomes more complex … i.e. psychologists, social workers,
psychiatrists that it goes up to an enhanced level.”
45. The man remained outside the MHIT caseload and would only have come into
contact with their services again if re-referred or via discussion at a multi-
disciplinary team meeting. This is a forum for staff to raise concerns of clinical
significance about particular prisoners at a minuted meeting. The MHIT
manager also said that staff discussed certain prisoners on an ad hoc basis,
just to get a more expert opinion, “sometimes people … feel … better or safer if
we’re involved.”. Preston MHIT has created a notification procedure to update
ACCT teams on referrals made. A feedback letter is placed on the prisoner’s
ACCT folder. The man’s is blank and undated, but The MHIT manager
explained that by this time the ACCT had been closed so there was no need for
notification.
15
46. On Wednesday 7 December, a nurse saw the man and recorded in his medical
record that he had refused his insulin. The readings of his blood sugar levels
gave her enough cause for concern to discuss the matter with a Sister who
advised her to administer insulin, to tell the man to eat a good lunch, and to re-
check in the afternoon. She also made a note to discuss this with the prison
doctor. The man would have received his medication from the nurses at a
hatch on the wing and administered the injection by himself watched by staff.
47. On 9 December, the prison doctor saw the man and reported that he had low
blood sugars. She said that his insulin had been increased before entry to
prison and made a note reducing the levels. The prison doctor confirmed that
the man had been self-medicating rather than self-harming on this occasion.
The prison doctor told my investigators that she had spent 25 minutes in
consultation with the man, which was unusual. She described him as being
deeply disturbed by what he had done. The prison doctor provided my
investigators with the greatest insight into the man’s feelings at that time.
Despite having initially denied his offence, he now admitted it and spoke of his
deep regrets about the harm he had caused to his victim and the family, and his
desire to seek treatment.
48. The prison doctor described the man as having been “at one stage been very
close to his family and unlike the majority of my patients who have had either
no childhood or very troubled childhoods, he wasn’t claiming that any of his
behaviour was in relation to his early life.” The prison doctor said she did not
consider that the man was “clinically depressed” at this time. Although he was
deeply upset, she did not think he was seriously suicidal. Had she done so,
she would have spoken to officers on the wings. She felt that since he was
sincere about wanting to complete his sentence, he would not have considered
suicide at that time. The man’s parents were upset that the man had re-
offended, but always knew that the closeness they previously had experienced,
would return in time.
49. The man requested counselling from the prison doctor. She said that the man
was aware that the sex offender treatment programme would provide support in
the medium to long term, once he had started his sentence at a new prison, but
he wanted short-term help to come to terms with himself and discuss his
offence. She said he could not move on any further without the right type of
help. The prison doctor explained to the man that there was no primary care
counselling available at Preston. The prison doctor recognised the distress this
caused the man and made a note to discuss the possibilities at the next multi-
disciplinary meeting. The prison doctor said that, although the chaplaincy
service offered counselling, there was a long waiting list, with priority given to
those who were seriously suicidal. On 11 December, the man and his cellmate
were asked to move out of the camera cell to F1-011 to make room for another
prisoner who was on an ACCT.
50. The prison doctor discussed the man’s request at the multi-disciplinary meeting
which concluded that the man should be referred to outreach care. His clinical
record shows an entry on 15 December, by one of the nurses, explaining that
outreach does not offer counselling, so the man was then referred to the
16
chaplaincy counselling. The prison doctor said that she did not see the man
again after this. Had she been aware that the referral had gone around in a
circle, she probably would have asked to see him again to see how he felt. The
prison doctor felt certain that the particular nurse who made the referral would
have explained the situation to him.
51. During the course of the investigation, my Assistant Ombudsmen spoke to the
chaplain who confirmed that he had received an application after 15 December,
requesting counselling for the man. He explained the difficulties in providing
counselling to prisoners from F wing: (a) the need to escort prisoners to the
service via reception; (b) a general perception by counsellors that such
intervention might not be helpful at this stage of the prisoners custody and may
interrupt treatment programmes in the next prison; (c) only one of the three
counsellors was actually trained in dealing with sex offenders and they felt they
did not have the necessary expertise for this specialist area; and (d) there are
long waiting lists for counselling. Therefore, it would not have been possible to
see the man until March/April 2006, by which time he would probably have
transferred to a different prison. These factors meant that there was little
provision of counselling for prisoners on F wing, the man found this upsetting.
52. The safer custody officer carried out the ACCT closure follow up review with the
man on 16 December. The man said that he felt better, but still had down
periods. He referred to having written to his parents, but he had not received a
reply. When asked whether there was anything in his life he felt positive about,
he said that he felt positive about the fact that he would get help. The man
appeared to be aware of the support available to him to help him cope should
he have further problems. A copy of the form was passed to healthcare and
put on the man’s medical record. No further entries are made until the day
before the man died. On 19 December, the adjourned court hearing was again
adjourned until 27 January 2006.
Events of 26 December
53. A prison officer came on duty on F wing at around 12:15pm. He is not a regular
member of F wing staff. At around 3:00pm, there was an argument over the
pool table in the association area between some prisoners, including the man
and another prisoner, over whose turn it was to play. The man’s cellmate said
that the other prisoner had tried to stop the men playing by tipping up the table.
An officer told them to list their turns on a piece of paper on the wall, but the
other prisoner ripped it off the wall. The man took the white ball off the table
and went down to the wing office.
54. An officer reprimanded the man for taking the ball as it could have been a
dangerous object and said that he should have come and spoken to staff
before doing so. He also tried to ascertain whose turn it was. Since this could
not be resolved, he withdrew all the balls from the table. The officer said that
voices were raised but this was nothing out of the ordinary. The two prisoners
my investigators interviewed said they felt that the reprimand had been quite
loud and done openly in front of other prisoners.
17
55. The man and his cellmate went back to his cell and was “sulking” over the
incident for the rest of the afternoon. The man had felt it was unfair to have
been reprimanded when he had not been the instigator and had not been given
the chance to explain himself. Unfounded allegations were made that the
man’s father had telephoned the prison on Boxing Day with a message to an
officer to pass on to the man that had upset him. My investigators found no
evidence to substantiate this. The man’s parents have expressed their
astonishment about these allegations and confirmed that he did not phone the
prison. The man’s cellmate said that the man had been “up and down” in mood
over the last month - and had discussed feeling depressed and suicidal - but
this had not been relayed to staff. The prisoner my investigators interviewed
was not the Listener on that night but the man would have been able to access
one had he asked.
56. At 4:00pm, the officer was the only officer on the wing as the prison was in
‘patrol state’. Patrol state occurs at times during the day, when there are
reduced staffing levels to ensure good order and discipline, as well as the
overall security of the establishment, the prisoners will remain locked in their
cells during these periods, but are promptly attended to in the event of an
emergency. At around this time, a registered general nurse came to administer
medication. She is an agency nurse, but has worked at Preston for two years.
She had never come across the man before that afternoon. She noticed that
he had not come for his insulin injection. The man’s cellmate said that he had
alerted her to this and asked the officer to go and collect him. When he did so,
the man refused and said he did not want to take his insulin. The registered
general nurse told the officer that he needed to have his treatment and that she
would like to talk to him. The officer again approached the man and asked him
to report to the nurse. The man reluctantly went down to the treatment room
and the nurse explained that he was at risk of a diabetic coma if he continued
to refuse treatment. Again he refused the medication and walked away. The
officer also warned him of the potential consequences of his behaviour and
asked him if he understood what he was doing. The man said he did.
57. Later, one of the officers told the registered general nurse that the man had
also refused his tea meal. The officer asked the nurse for her advice, and she
said that they could not force him to take his insulin but should keep a close
eye on him and check whether he ate or not. The officer said that both were
concerned about the man at that point, but were under the impression that he
would change his mind. The registered general nurse said that although his
behaviour could have serious implications in the long term, this was the first
incident of refusal so she was not unduly worried. She returned to the
healthcare centre and made a record of the incident in the Nurse in Charge
‘Handover of Significant Events’ (used to hand over to other healthcare staff) at
4:30pm. At 6:05pm, she also made a similar note in the man’s clinical record
and mentioned the pool table incident, as did the officer in the wing records.
58. The registered general nurse was still concerned about the man, so between
6:30 and 7:30pm she returned to the wing with the officer to speak to him. He
radioed the assist Orderly Officer to unlock the man’s cell. He was still refusing
medication, food, or drink. The three of them discussed the man’s actions with
18
him outside his cell door. They tried to persuade him to eat, drink and take his
medication and ensured he understood the consequences of his behaviour.
The prison doctor explained to my investigators separately that food refusal
together with the lack of insulin would actually have the effect of slowing the
deterioration down. The man’s blood sugar levels would rise, but more slowly.
The man said he just wanted to face the consequences and did not want any
help. They offered him support from the Listener, the chaplain, a friend, or use
of the Crisis Suite, and said that they could do something further the following
day. The man’s cellmate described the officers as having offered the man
“everything you can possibly think of” and said they had given him plenty of
support that night. The registered general nurse said that the man told her he
did not want to talk to anybody; he had just had enough of his life. At that time,
the registered general nurse said she did not think the situation was really
serious, since the man could not have slipped into a coma in just one day.
They were in effect buying time with him and would be able to refer him to the
appropriate person the following morning.
59. The assist Orderly Officer said that he spoke to the man on a personal level to
ascertain reasons for his actions and to give him reassurance. He is one of the
few officers trained in mental health problems. The man said he had felt
unfairly blamed and was being made out to be the bully. The assist Orderly
Officer tried to reassure him that no action had been taken against him and that
officers had not interpreted it that way. He also said the man was upset about
not having had any contact with his family and mentioned his previous
overdoses. The officer said that the pool table incident was mentioned, but the
man said it was not anything to do with that. His feelings had been building up
over a few weeks.
60. The assist Orderly Officer sought advice from two nurses who were on duty in
healthcare that evening, as to the length of time before any symptoms could
develop. He was advised that this would be at least 72 hours or maybe longer
before lethargy, and eventually unconsciousness, would set in. He was able to
inform the night staff and the man’s cellmate about this later so they could keep
an eye on the man. For his part, the man continued to ignore all requests to
comply with his medication and this prompted the assist Orderly Officer to ask
the officer to open an ACCT. The man said he understood what the ACCT
entailed. They continued to try to persuade the man to change his mind and
offer him support.
61. As part of the ACCT process, the assist Orderly Officer asked the man whether
he had anything in the cell that could be used to self-harm, or a note. The man
passed the registered general nurse a note he had written addressed ‘To
Medical Staff’. This note, described by the man as an ‘Advanced Medical
Directive’, said that “being of sound mind, body and judgement”, should he go
into a “diabetic coma or any medical problem including suicide”, he did not wish
any “medication, oxygen, blood transfusions, or any heroic life saving
measures. As I do not have any more reason to live.” The registered general
nurse said to the man that he sounded serious and he replied, “I am.”
19
62. Asked by my investigators what status she would have given this note, the
registered general nurse said it was legal and sounded very serious. That was
why she showed it to her colleague and put it in his notes. She was under the
impression that he knew what he was saying when he wrote the note and was
of sound mind. When asked whether she would have abided by the man’s
stated wishes in the directive, the registered general nurse said she was not
sure. The registered general nurse and her colleague agreed that they had
offered him all the help they could give at the time. The registered general
nurse told my investigators that the note did not mention anything about an
intention to hang himself, just about a diabetic coma and his wish for no
intervention. She said she was aware of his previous attempted overdoses,
although did not know how serious he was at this time.
63. The registered general nurse told my investigators that she had shown the note
to both wing officers and confirmed that they knew what he had written.
However, the officer said that he did not know of the contents of the letter as
the man had said it was private and for medical healthcare. The assist Orderly
Officer said he had never read the note. He had asked the registered general
nurse what it said, but she said she could not tell him as it was ‘in confidence’.
On pressing her again a little later, she told him that it said if he were to lapse
into coma or get ill he was not to have any medical intervention. The assist
Orderly Officer asked again if he could see the note just to clarify whether there
was anything else relevant, but again the registered general nurse did not show
him. The assist Orderly Officer said that bearing in mind he was only
concerned about a coma situation that could be as much as 72 hours away,
having asked all the questions he did not anticipate the man’s intentions to take
his life that night. The assist Orderly Officer had asked him if he had made any
plans and the man said no. His main focus was on the man falling into a coma,
not anything more deliberate or immediate: “I’d a clear picture in my mind that
the following day, if there was anything going on in his mind, that we could sort
it, a night’s sleep. He did not mention in any way that he was going to take his
life by other means. I’d absolutely no other considerations having spoken to
the man. He’d concealed his end very, very well.”
64. My investigators gave the assist Orderly Officer the opportunity to read the
directive during interview. Asked whether having read it on the day he might
have changed his opinion, he said it still did not lead him to believe that the
man was going to self harm in any other way than by insulin refusal, but it did
throw a slightly different slant on things. At the time though, he had to work
with the information he had in front of him: “Reading the letter [now], it is quite
plain something was going to happen, but like I say, I can only work on the
actions that I took at the time.”
65. An officer completed a self-harm/attempted suicide report and opened an
ACCT at 7.15pm. He said they were unsure at the time whether suicide was
intended, but the risk of self-harm via food refusal was sufficient reason to open
the ACCT. The officer referred to the letter to medical staff “stating his
intentions”. He also referred to this in the wing history sheet as a “letter for
healthcare staff regarding his actions”. There had been no discussion to move
20
the man to healthcare since this would not have been usual practice. ACCT
encourages the management of suicide/self harm risk on normal location.
66. The registered general nurse returned to healthcare and discussed the man
with her colleague. She told him that the man was refusing his insulin, food
and had given her a note stating he did not want medical intervention in the
event of any life threatening situations. She gave the note to her colleague. He
asked if wing staff were aware of the note and if an ACCT had been opened.
She said they were aware and, on calling the wing, she confirmed the ACCT
had been opened. She recorded these events in the man’s medical record at
7.30pm. She made a note to discuss with the GP, healthcare manager and
MHIT the next day. The registered general nurse said she intended this to be
in relation to further intervention, but not to deal with the directive specifically.
She referred to the opening of the ACCT and a “suicidal note” given to her. My
investigators found no further evidence of plans to deal formally with the
Advance Medical Directive.
67. At 8.00pm, the assist Orderly Officer completed the ‘Immediate Action Plan’ on
the ACCT and indicated that the man was to stay in his double cell and a
referral made to MHIT. He was to have access to the Samaritans phone, the
Listeners upon request, and to the Crisis Suite if necessary. The level of staff
observation was set at hourly checks during the day (with three quality
comments during this time) and half hourly observations at night (with an hourly
comment). The assist Orderly Officer made these decisions based on the fact
that the man got on well with his cellmate and, since the man’s cellmate took
sleeping tablets at night, he wanted staff to observe the man more frequently.
It was not because he thought the man was at any raised risk because of a
diabetic coma. Two prisoners mentioned in their evidence an officer joking that
if he had to return after his shift to complete forms due to the man’s behaviour
he would “kill him”. My investigators found no further evidence to support this.
68. The option of moving the man to a camera cell was not considered. On the
night of 26 December, two of the camera cells were occupied by prisoners on
an ACCT, but the remaining cell was occupied by two prisoners not at risk of
self harm or suicide. The assist Orderly Officer then completed a mental health
referral form noting that the man’s current problems were a “lack of contact with
family members due to custodial offences”. The reality is that there was in fact
only a two to three week gap in contact between the man and his family.
69. An officer came on duty for the night shift at 7:50pm. The night duty officer is
not a permanent officer on night shift or F wing, and he had never met the man
before. He was responsible for checking on all the prisoners and carrying out
observations on those on ACCT. He carried an anti-ligature knife and a cell
key in a sealed pouch in accordance with local policy. The night duty officer
was familiar with the local contingency plans for suicide that are available on
each wing. The assist Orderly Officer said he briefed the night duty officer fully
and introduced him to the man, making him aware of the level of support that
would be offered through the night. He also asked the man to sign the ACCT in
agreement. The officer informed him of the four open ACCTs.
21
70. At around the same time, the night orderly officer took over for night duty. He
had only been working at Preston for about six weeks and it was his first
experience of night duty. His responsibilities were to oversee the running of the
prison at night, make checks on staff and unlock cells if necessary. The assist
Orderly Officer returned to the centre of the prison to handover and informed
the night orderly officer about the ACCT being opened due to the man’s refusal
of insulin and the potential medical risks. The night orderly officer went over to
F wing during the night and spoke to the night duty officer, but there were no
concerns expressed over the man at that time. The night orderly officer recalls
26 December as a very quiet night.
71. At about 8:30pm, two night nurses who are permanent night duty staff, came on
duty. The registered general nurse left the prison before they arrived.
Handover between shifts in healthcare is done verbally and there are three
written records staff may check: the In Patient handover book, the Nurse in
Charge Significant Event Handover, and the Primary Care Observation Book.
The registered general nurse did not add anything to her earlier entry in the
Nurse in Charge Significant Event Handover about receiving the directive. The
In Patient handover book, signed by her colleague, referred to an ACCT being
opened but not to the medical directive. The Primary Care Observation Book
mentions neither.
72. The registered general nurse’s colleague gave a verbal handover to the two
night nurses that the man had refused insulin and food and that, if during the
night he changed his mind, they should ensure he got access to food and
prescribed medication. He also said he told them of the ACCT, but was unsure
whether he had mentioned the note. Neither of the nurses recalled being told
about the man’s food refusal, the ACCT or the note, although the first night
nurse had signed the handover sheet from the nurse stating “(the man) – RSU.
Refusing insulin and food. On ACCT.” There were no immediate concerns for
the man’s health at the time as he had only refused insulin that evening. The
first night nurse said they had seen the medical directive for the first time on
discovering it on the man’s clinical record whilst recording incident details the
following day.
73. At 9:00pm, the night duty officer began the night observation procedures
requiring him to look through a small window in the cell door to check the
prisoner. He first observed the man lying on his back in bed in his underwear.
He made himself known, but the man did not respond. The man’s cell mate
appeared to be asleep and the night duty officer did not speak to him that night.
At 10:00pm, he observed the man lying on the bottom bunk asleep.
Throughout the night he appeared to be in and out of bed and intermittently
asleep. When the man was awake, the night duty officer did not attempt to
make conversation so as not to wake other prisoners. However, at 2:00am
when the night duty officer observed the man on the toilet he made eye contact,
appearing annoyed that his privacy was being compromised. The night duty
officer said that the man’s cell was well illuminated all night as the television
was on. During the half hourly checks, the night duty officer did not notice
anything unusual about the man. The night duty officer recorded hourly
observations until 5.00am the next day when he observed the man standing up
22
in his cell with his back to the door. He had something in his hand, which with
hindsight he questioned might have been a ligature. He looked as if he was
about to use the toilet. The man did not turn around or acknowledge the night
duty officer.
The prison’s response to finding the man
74. Just after 5.25am on 27 December, the night duty officer was carrying out a half
hourly check on the man. At first, on looking into the man’s cell he thought he
was just standing at the back of the cell with his arms at his side. It was then
that he saw a ligature around his neck. He was hanging from the window bars
facing the door and was unconscious. Realising that his radio battery was flat,
the night duty officer had to run downstairs to the office to call a “Code one on F
wing on F2” to the communications room by telephone. (A code one signifies
to staff that there has been a hanging or attempted hanging, so that they are
aware of what to expect before arriving.) At 5.27am, this message was relayed
to all night staff, including the night orderly officer and medical staff. The night
duty officer then immediately ran back to the cell, broke the seal on his key
pouch, opened the door and entered the cell. He also broke the seal on the
anti-ligature ‘fish’ knife he was carrying and attempted to cut the man down.
Unfortunately, he could not do this on his own as the man had used a full bed
sheet. The night duty officer remembered that the man looked a normal colour
and, although he was quite cold on the top half of his body as the window was
open and it was cold outside, he was quite warm to the touch under his arms.
He was not breathing. Because the man’s cellmate had taken sleeping tablets
that night, he was still asleep and was woken up when other staff arrived.
75. An officer arrived at the cell first within about a minute, followed by a second
officer. A third officer then arrived followed by the night orderly officer shortly
after, but there was not enough room for all four officers to fit easily in the cell.
Within minute, the two night nurses arrived outside the cell carrying the green
emergency bag that the second night nurse had picked up from the C wing
treatment room on their way. This contained oxygen, airway equipment, a
blood sugar testing kit, an ambu-bag and mask. They did not consider bringing
the defibrillator with them (it was also kept in the treatment room). They just
wanted to get to F wing as soon as possible and assess the situation.
76. The man’s cellmate was moved to another cell, accompanied by an officer for
support. The three officers lifted the man up and the second officer lifted the
ligature over his head. They then moved him onto the landing where there was
more room so that medical staff could attempt resuscitation. The man was a
tall and well-built man and the cell was very small, so the officers had trouble
carrying him out. The first night nurse asked the night orderly officer to call for
an ambulance. He also contacted the duty governor. The ambulance was
called at 5.35am.
77. The second night nurse noted that the man was unconscious, not cyanosed
(abnormal blue discoloration of the skin and mucous membranes), but very
cold. Both nurses checked for signs of life but there were none. There was no
rise and fall of the chest and no pulse. They then commenced Cardio-
23
Pulmonary Resuscitation (CPR) with the first night nurse doing chest
compressions and the second night nurse giving ventilation via an ambu-bag (a
mask and airbag). The second night nurse had some difficulty inserting the
airway into the man’s throat. She found it hard to hold the man’s head up, so
the first night nurse held the mask in place whilst she held the airbag. Chest
compressions were continued by the second officer and then the night duty
officer until paramedics arrived. The third officer left to attend to other duties.
They could see the man’s chest rise and fall so they knew oxygen was reaching
his lungs, but there was still no response. The nurses told my investigators that
with hindsight, because the ambulance was on its way and because of the
man’s condition, there would not have been much point in using the
defibrillator. However, they did not think about it at the time. The CPR was
continued until the paramedics arrived eight minutes later at 5.43am.
78. As the night orderly officer is the only member of staff with a set of keys at
night, he went to the gate lodge and met the arriving paramedics. The outer
and inner gates were opened one at a time, in accordance with local protocol to
ensure maximum security for the prison. The night orderly officer said this
would have taken a matter of minutes. He took them straight to the emergency
exit to F wing, which is right opposite the ambulance gates. Fortunately, this
had been taken off the night locking system minutes before the man was found
by the assist orderly officer.
79. Two of the paramedics took over at this point. They hooked the man up to their
ECG monitor, took a heart trace and made several other assessments. They
found no activity so they decided that efforts to revive the man should cease.
They pronounced life extinct at 5.45am. The paramedic recorded that the
man’s outer extremities were cold, that there was evidence of pooling (where
the blood accumulates in one part of the body due to lack of circulation) and
that the man was in asystole. The paramedics covered the man’s body and put
him back in the cell. The first night nurse contacted a doctor who arrived about
half an hour later. At 6.55am, the doctor recorded in the medical record that
paramedics had confirmed the death, the man’s body was in the cell and there
was no need for further medical inspection. At around 6.15am, the cell was
sealed to await the arrival of the police.
80. The first night nurse then went to see the other prisoner who was very upset.
She made an entry in the clinical record and on the Primary Care Observation
Book. The second night nurse completed form F213SH to record details of
what had happened.
The prison’s response following the man’s death
81. The duty governor arrived soon after and ensured all staff had completed
statements. About half an hour later the acting Governor arrived and the night
orderly officer gave him a verbal handover of what he had set out in the central
observation log for the prison. All contingency plans for a death in custody
were put in place, including contacting the relevant authorities and supporting
staff.
24
82. The duty governor held a hot de-brief for staff involved at around 8.15am. He
thanked all of the staff and they discussed what had happened. A
representative from the Care Team attended and made subsequent contact
with all staff who had been involved. The night orderly officer was fairly new to
HMP Preston, recently promoted, and this was his first time on night shift. Both
The night duty officer and the night orderly officer returned to duty that night.
Although both nurses were offered Care Team support, they missed the hot de-
brief because they could not be released from their shift. A manager (not their
own) contacted them to see how they were coping, but this was not until the
following night shift.
83. Because the man’s family live in Glasgow, the acting Governor asked Glasgow
Police to break the news of the death to the man’s parents that morning. The
prison also tried to contact a chaplain in a nearby prison. The police went to
their house to inform them. Only the man’s mother was at home at the time.
The police offered to stay until her husband arrived, but the man’s mother said
it was not necessary. The police did not give clear details about exactly what
had happened and simply said it was a suicide. They gave the man’s mother a
card with a contact number for the acting Governor and advised her to ring the
prison.
84. The man’s father rang the prison at about 12:00 noon and spoke to an
operational manager and the prison family liaison officer. At this point, the
prison’s liaison manager had not been informed whether the police had made
contact with the family, or what details they had been told, so he was initially
unsure of what to tell the man over the telephone. Unbeknown to him, Glasgow
police had in the meantime called the acting governor and told him that the
family had been informed. When the man asked for the exact details of the
man’s death, the prison’s liaison manager said that he could not disclose all the
details before the post mortem, just that he had taken his own life. The liaison
manager told my investigators he felt the telephone was an impersonal medium
through which to convey the exact details of the death, and so he arranged to
meet the family in person the next day to deliver the news. Unfortunately, the
family were shocked to see details of the ‘hanging’ on Ceefax the next day
before this meeting took place. The press release also gave details of the
man’s alleged offence that the family found upsetting. The family said that,
despite this, the prison’s liaison manager had dealt with the situation
sensitively.
85. The acting Governor sent a letter of condolence to the family on 28 December
with a list of agencies that could offer support. The prison’s liaison manager
and the Roman Catholic Priest met the family and visited the man in the Chapel
of Rest. The Priest gave the family Preston’s ‘Death in Custody support
booklet for families’. The prison’s liaison manager returned some of the man’s
personal possessions to them. The prison offered to contribute towards the
cost of the funeral. The family were asked if they wanted to visit the prison, but
declined.
86. The man’s family also wanted to clear his son’s flat and so the prison’s liaison
manager made the necessary arrangements.
25
87. The post mortem report concluded the cause of death to be asphyxia by
hanging.
88. The man’s funeral was held on Friday 6 January 2006.
26
ISSUES CONSIDERED DURING THE INVESTIGATION
Mental Health
Referral process and decision to refer to primary level care
89. Overall, the man was dealt with well at reception and the decision to open the
ACCT was appropriate. The ‘mental health assessment’ box of the First
Reception Health Screen form should have been ticked for completeness, since
the man answered ‘yes’ to the questions that gave rise to a mental health
assessment referral. However, the registered general nurse’s comments give
rise to questions over the functionality of the form. She knew that the man’s
mental health problems did not amount to a mental health illness sufficient to
require an assessment. As the MHIT manager confirmed, such an illness
would be defined as being “severe and enduring”, such as paranoid
schizophrenia or bipolar disorder and would relate to a secondary level of
mental health care. She knew that the MHIT only took secondary level cases
onto their books and that they would have concluded an assessment was
unnecessary. She also said that, as part of the ACCT, the man would have
been seen by outreach mental health nurses.
90. In the event, the man was referred to the MHIT as part of the ACCT process.
Whilst I accept the registered general nurse’s reasons for leaving the form
blank, it should always indicate the planned action on the last page whether or
not someone is eventually referred by MHIT for an assessment.
I recommend that all Healthcare staff be reminded to fully complete
Reception Health Screening documents and refer prisoner patients to
appropriate specialist services.
91. The clinical review concludes that the decision to refer the man to primary level
mental health care was a sound one. However, the clinical review also finds
that a primary care service is not established both in terms of referral criteria
and its provision. It concludes that the whole process of mental health services
needs reviewing, including referral criteria to in-reach and primary care.
Further reception health checks
92. The clinical review finds that no secondary screen/well man assessment was
completed for the man within five days of reception as required. It concludes
that the practice of not requiring further screens for those prisoners moved to
the vulnerable prisoner unit is unacceptable and recommends a change in
practice.
Primary care level mental health provision
93. The standard of healthcare provided in prisons should be equivalent to that
which prisoners could expect to receive in the community. During the man’s
time at Preston, he requested ‘counselling’ on a number of occasions, most
27
pertinently reflected in the letter to his family. At his follow up ACCT review, the
man said that he felt positive about the fact he would get help.
94. In the man’s long discussion with the prison doctor, she gained great insight
into the man’s feelings and he asked for counselling. He was aware Preston
offered no primary care counselling, which distressed him as he wanted short-
term help to come to terms with himself and discuss his offence. The man’s
referral for support was thereafter somewhat circular as he was passed to
outreach for counselling, even though they did not offer this service, and then
back to the chaplaincy where it was clear for numerous reasons that this was
not the right type of support.
95. Despite this, the man was offered Listeners, the Samaritans and visits to the
chapel, none of which he accepted. Officers also tried to encourage him to
associate more on the wings and to take part in activities. The man was also
given anti-depressants to help his depression and low mood. However, there
appears to be a lack of primary care mental health provision, particularly short
term crisis counselling, in the absence of other possible counselling for sex
offenders at that stage of their custodial sentence. As far as my investigators
could tell from the records, the man never received any outreach mental health
support and accessed no counselling services. It appears that there was little if
no provision for support and advice for someone in his position.
96. The MHIT’s remit does not cover primary care, although provides a useful
signposting service. Due to pressure on resources and the volume of self-
harming prisoners, provision by the MHIT is not possible in primary care and
would be inappropriate.
97. The prison doctor said that the MHIT had a “very narrow remit, narrower than
you would find in a community mental health team in the wider community.”
She said that, although there were outreach mental health nurses from the
NHS, employed in the prison by the PCT, there was still no formal system to
provide a structured treatment programme similar to the community. She
highlighted that the ACCT process works well in these primary level cases.
However, she felt there was a gap, although she said that counselling would
not have prevented the chain of events that occurred. It is disappointing that
the man was unable to access this low level support despite several requests.
98. The clinical review considers whether the level of primary level mental health
care available at Preston was reasonable and comparable to that expected in
the community. It concludes that, although the man’s needs were generally
met, apart from the service provided by the chaplaincy, there was no access to
primary care counselling and this was not recorded anywhere as an imminent
need. It notes that a primary care service is not established in terms of
provision and questions the effectiveness of a service (MHIT) that refers to
another (primary care/counselling) knowing it may not be able to deliver that
service. It recommends a comprehensive review of the process and delivery of
mental health services at Preston, including the provision and quality of
interventions and unmet need. I endorse this recommendation.
28
99. I understand that, at the time of completing this report, the PCT, Lancashire
Care Trust and prison healthcare have already embarked on the first stages of
this review and the issues raised by the clinical review were discussed at a
Prison Partnership Board meeting on 26 June. I am pleased that this work has
been progressed so rapidly.
Information sharing between medical and discipline staff
100. The registered general nurse recalls discussing the man‘s Advance Medical
Directive, with an officer and the assist Orderly Officer. She also recalls
showing the note to them and referred to it as a “suicide note”. Neither officer
recalls being shown the note and each maintains that, although they knew
about the man’s intentions not to be resuscitated should he go into a diabetic
coma, they were not aware of the man’s reference to suicide or having “no
more reason to live”. According to the officers, they were dealing with a self-
harm issue and to some extent had not appreciated the immediacy of the risk.
101. The assist Orderly Officer considered that, had he seen the full note, he
probably would not have behaved differently. The night orderly officer told my
investigators that had he known about the note he might have had stronger
concerns and put the man on 15 minute observations. However, he doubted
whether this would have prevented the man from taking his life. The registered
general nurse’ colleague confirmed that, due to the nature of the contents of the
note, he would have shared them with anyone relevant. He knew that
discipline staff were aware of the contents, although he could not confirm they
had actually seen it.
102. National guidance on confidential health information sharing states that
disclosure should normally only take place with the consent of the individual
concerned. Disclosure without consent can be made in exceptional
circumstances if it is considered essential to protect the individual from the risk
of death or serious harm (HM Prison Service Information and Practice
Guidance on the Protection and Use of Confidential Health Information in
Prisons and Inter-Agency Information Sharing 1/2002).
103. The ACCT: Caring for People at Risk in Prison guidance sets out guidelines for
confidentiality and appropriate disclosure agreed by the Prison Service and the
Department of Health. The healthcare team is responsible for providing
relevant information about their patients to ACCT Assessors and Case
Managers as part of the assessment. The guidelines state:
(cid:127) There is a professional duty for all healthcare workers to receive patient
information and use it in a confidential and professional manner at all times.
(cid:127) All healthcare workers have a duty to pass on information that involves
issues of patient safety, vulnerability or immediate risk to self or others to
relevant staff, wherever possible, firstly ascertaining the person’s consent to
share this information. In situations where the individual’s safety is
compromised but they are unable or unwilling to give consent then health
professionals have a duty of care and the relevant information may be
disclosed.
29
(cid:127) Health or social information of a sensitive nature needs to be released in a
way that ensures that patient confidentiality is maintained but any issues
involving their safety or vulnerability are highlighted to the relevant staff.
(cid:127) Information that is received and identified by any staff as highlighting risk
including physical, medical or social risks involving the prisoner or
immediate others needs to be shared in a timely way with the relevant
people.
104. Preston has a clear local policy on confidential health information sharing,
particularly in relation to ACCT. It states that the care for prisoners at risk must
be multi-disciplinary. Healthcare managers should ensure that procedures are
in place to allow Unit Managers and members of Assessor teams to access
relevant, risk-pertinent information about prisoners for whom they are caring.
Risk-pertinent information is defined as “information relevant to understanding
the level of risk and also information about how to reduce that risk”. The policy
also highlights that the person at risk can consent to relevant health information
being shared with residential staff involved in their care by signing the ACCT
plan.
105. If discipline officers were only focussed on the risk of death by diabetic coma, I
conclude that it was reasonable for them to have waited until the following
morning before taking further action. I also conclude that they would not have
acted differently had they known the full details of the note. Indeed, officers
followed all the correct procedures to support the man in his distress.
Nevertheless, full disclosure of the note to the officers was both possible and
desirable, in order to allow staff to assess and fully understand the level of risk
and decide what support was needed to reduce it.
106. I consider that the note contained risk pertinent information that was relevant to
understanding the man’s safety, vulnerability and immediate risk. I consider
that the reference to suicide is relevant to assessing the level and immediacy of
that risk by wing staff. Staff involved had different recollections of the
information shared and therefore I cannot be conclusive about what took place.
While I do not consider that the full disclosure of the note, if it was not
disclosed, would have prevented the man’s death, I think this confusion
highlights the uncertainties staff feel in relation to sharing information between
different disciplines.
107. In any event, wing staff had obtained the necessary consent from the man by
asking him to sign page two of the ACCT. In order to ensure that the ACCT
process is effectively managed by both medical and discipline staff, Preston’s
local policy needs to be reinforced to reduce uncertainties around information
sharing. The clinical review also concludes that, although information was
shared, awareness training and education is needed on information sharing to
avoid the inevitable confusion over guidelines governed by a multitude of
legislation.
The Governor and Head of Healthcare should ensure that both healthcare
and discipline staff are made fully aware of and understand local policy
30
on confidential health information sharing, and remind all staff of the
importance of information sharing, particularly in relation to ACCT.
108. Generally, I note there was a good level of information sharing and
contemporaneous records made in the ACCT and the clinical record. There
are three records that facilitate the handover of information between medical
staff at Preston. Again there are differing accounts of the information handed
over verbally and the records show inconsistencies. I consider that at least the
first night nurse would have known about the ACCT and food refusal since she
signed the in-patient handover sheet. It is likely that neither of the nurses knew
about the note. The only reference was on the clinical record and staff are not
required to look at this on handover. A verbal handover should be sufficient so
long as the person handing over is fully apprised. The first night nurse said
that, had she been aware of the full circumstances, she would have made a
decision to transfer the man to healthcare that night to keep a closer eye on
him.
109. As I set out in this report, I do not consider that the man should have been
transferred to healthcare. However, I do consider that staff should be given as
thorough a handover as possible whether in writing or verbally between shifts.
The records of the circumstances were inconsistent and the directive should
have been communicated both verbally and noted in the records.
110. Whilst not a formal recommendation, healthcare staff should be alert to the
need to record information in healthcare records consistently and to provide a
thorough handover to staff on changing shifts
Treatment of the Advanced Medical Directive
111. Following refusal of his insulin medication and tea meal on the evening of 26
December 2005, the registered general nurse, the officer and the assist Orderly
Officer went to speak to the man to reassure him and to try and dissuade him
from his course of action. They pointed out the possible consequences of not
taking his insulin. The man continued to refuse his treatment and an ACCT
was subsequently opened by officers. During this conversation, the man
handed the registered general nurse a note, that she describes in the clinical
record as a “suicide note” but the man referred to as an ‘Advanced Medical
Directive’ setting out his wishes. It said:
“To Medical Staff
I (the man) being of sound mind, body and judgement give an
Advanced Medical Directive, that should I go into a diabetic coma
any other medical problem including suicide I do not wish any
medication, oxygen, blood transfusions, or any heroic life saving
measures. As I do not have any more reason to live. Thanks for
your co-operation. (signed by the man).”
112. The registered general nurse took this back to the healthcare centre and
showed it to her colleague. They discussed the matter, ensured that an ACCT
31
had been opened by officers, and her colleague put the note on the man’s
clinical record.
113. The Department of Health provides guidance on providing healthcare to people
in prison who have withdrawn consent to treatment in ‘Seeking Consent:
Working with People in Prison’ (DoH July 2002). The guidance states: “If your
work involves providing health care to people in prison, you need to make sure
you have your patient’s consent to do what you are doing, if they are able to
give it. Respect for people’s rights to determine what happens to their own
bodies is a fundamental part of good practice. It is also a legal requirement.
The fact that a patient is also a prisoner does not affect their right to determine
whether or not to accept treatment, where they have the mental capacity to
make such a decision.”
114. The guidance continues: “Before you provide treatment for a patient, you
should ensure that you have their consent to do so. For a patient’s consent to
be valid, the person must:
(cid:127) have the capacity (be “competent”) to take that particular decision
(cid:127) be acting voluntarily (not under duress)
(cid:127) be provided with enough information to enable them to make the decision.
“The law presumes that an adult has the capacity to take their own
healthcare decisions unless the opposite is proved. People with the
capacity to take a particular decision are entitled to refuse any
treatment being offered, even if this will clearly be detrimental to their
health. No competent adult (defined as a person aged 18 or over)
can be treated against their will.”
The guidance states that healthcare staff should assess the capacity of the
person to make the decision in question and the conclusions drawn should be
recorded in the prisoner’s clinical record.
115. The guidance goes on to consider ‘Advance Directives’ in which people can
express clear views as to how they would like to be treated if in future they
were to lose capacity:
“If a person makes an advance refusal of certain kinds of treatment,
then such a refusal is legally binding if, at the time of making the
decision, the individual was competent, they understood in broad
terms the implications of their decision, and the refusal is applicable
to their current situation.”
Decisions relating to determining capacity to withhold consent are a
matter for the responsible treating doctor (or nurse/healthcare officer
if an emergency arises and a doctor is unavailable) in consultation
with other members of healthcare. Nurses and healthcare staff
would be expected to take all action to preserve life while seeking
advice and attendance of a suitably qualified person.
32
116. Healthcare and discipline staff involved acted correctly in their approach not to
force the man to accept treatment without his consent. The man was acting
voluntarily when he wrote the note, and staff gave him sufficient information
about the potential consequences of his action to enable him to make that
decision. However, the next stage would have been to assess his competence
to make that decision and therefore the legal status of the advanced directive.
117. In the circumstances, the man was not at any risk of falling into a coma
immediately. Whilst I am satisfied that it was reasonable to have delayed any
action to be taken until the morning, there seem to have been no explicit
discussions amongst staff about whether the man had the relevant capacity to
withhold consent.
118. Although the registered general nurse assessed the man as being of sound
mind and recorded a plan to discuss this with the doctor, the healthcare
manager and MHIT the following day, she later told my investigators that she
meant this in relation to further interventions but not specifically to deal with the
directive. When asked whether she would have abided by the man’s stated
wishes, she said she was not sure. Asked by my investigators what status she
would have given the directive, she said “it was legal and sounded very
serious”.
119. The nurse also told my investigators that he had never come across a medical
directive before and felt he would benefit from further training in this matter. At
the end of his shift, he filed the directive on the man’s medical record. He did
not inform night staff about it and said he was unaware of any other staff
involvement. Two other nurses had since discussed this with the Healthcare
Manager and confirmed that, had they known about it, their response would not
have changed. Unless the document was witnessed by a doctor or solicitor
they would not have given it more formal recognition. The first night nurse said
she had never come across a directive before. Discipline staff did not discuss
its implications with my investigators, referring to it only as a note.
120. Overall, my investigators found that staff did not feel properly trained or
equipped in how to deal with the advanced medical directive. Preston does not
have a local policy on advanced directives. The clinical review recommends
the provision of awareness training and education regarding medical directives
for all staff and I am pleased that the PCT have already agreed to this. I fully
support this, particularly as staff have raised this as a training need.
The Governor and Head of Healthcare should develop a local policy
dealing with advanced medical directives based on national policy and
guidelines.
Transfer to the Healthcare Centre
121. Prison Service guidance says that healthcare staff are responsible for providing
appropriate care, where the person is at risk of self harm or high risk. This
does not mean that that person should be located in the healthcare centre. The
clinical review concludes that the decision not to transfer the man to the
33
healthcare centre was reasonable. However, it also makes a recommendation
that the healthcare service develop a pathway to provide an evidence base on
which clinicians can base their decision to refer or not. I support the conclusion
and recommendation.
34
Self-harm, suicide prevention and the use of CCTV camera cells
122. Prison Service Order 2700 sets out policy for identifying and managing
prisoners at risk of suicide or self-harm and the care and support of such
prisoners. It advocates an individualised, preventative and multi-disciplinary
approach. The local policy at Preston mirrors this approach and is linked to the
Violence Reduction Strategy dealing with bullying, indicating a holistic approach
to safer custody.
123. The local strategy is based on a multi-disciplinary team approach rather than a
purely medical model to support prisoners at risk, preferably on normal location
using shared accommodation. Preston has a full time suicide prevention co-
ordinator at senior officer level and an assistant officer dedicated to the ongoing
implementation and monitoring of ACCT. Nearly all staff had been trained in
ACCT procedures by December 2005. My investigators viewed the minutes of
the local Safer Establishments Committee meetings whose membership
reflects a multi-disciplinary approach.
124. The first ACCT for the man was opened on reception by a member of
healthcare staff in a timely and appropriate manner, based on clear judgements
about the man’s behaviour and what he told staff about his previous self-harm.
Possible mental health issues were identified and he was appropriately referred
for support. The Immediate Action Plan and assessment interview were carried
out in accordance with procedures and an appropriate level of case review
followed to assess the man’s state of mind. He was assessed after his court
appearance on 2 December and the ACCT was closed the next day in
consultation with him. Unfortunately, the ACCT closure was not noted on the
man’s wing history sheet. This is important information for staff on the wing to
be aware of. In accordance with local policy, the post closure follow up review
was held within 14 days.
125. Over time, the man’s mood steadily improved. Although still low at times, he
was associating more with other prisoners. He expressed no wish to harm
himself until after he had served his sentence and made this clear to a number
of staff. He had not self-harmed since he had been in prison. Preston has in
place a quality check document that helps staff monitor the consistency and
quality of the ACCT documents. This is checked and signed by a number of
staff (including a senior officer and the Governor) each day. The quality of
record keeping was of a good standard and the man was afforded the
appropriate level of care. The only observation I have is that, despite Preston’s
local policy and ACCT guidance on continuity of care, the man’s case reviews
were carried out by different people each time.
126. On the night the man died, there were 16 open ACCTs in the prison, five on F
wing. Levels of observations set were appropriate and the assist Orderly
Officer took appropriate considerations into account in making that decision.
The man was offered access to various avenues of support and was able to
discuss his concerns with both wing and healthcare staff. His immediate action
plan was timely and thorough and he was referred to the MHIT.
35
127. There are four overt camera cells on F wing. One of these cells is permanently
occupied by the Listener. On the night of 26 December, two of the other
camera cells were occupied by prisoners on an ACCT, but the remaining cell
was occupied by two prisoners not at risk of self harm or suicide. This means
that it would have been possible to move those prisoners in order to place the
man (with his cellmate) in a camera cell, after he had been placed on the ACCT
that night. However, I recognise that this might not have been practical at such
a late stage in the evening. Given that the assist Orderly Officer and the officer
knew that there was no risk of the man falling into a diabetic coma for the next
72 hours, it was reasonable to have waited until the next morning to make such
a decision. The assist Orderly Officer said that although a camera cell had not
been considered, it seemed appropriate for the man to remain in his double cell
with his cellmate with whom he got on well. He also said that the observations
were set half hourly with a view to increasing them to every quarter of an hour if
deemed necessary during the night.
128. My investigators found that there was some confusion amongst staff about
whether or not it was standard local policy to put prisoners on ACCTs in
camera cells. The night duty officer said that, by and large, when a camera cell
is available those prisoners on ACCTs go into them. But for some reason it
was not done that evening. He also told my investigators he felt that the man
should have been in a camera cell. The man’s personal officer said that the
prison tried to accommodate prisoners on ACCTs in camera cells, even if that
meant moving those not on an ACCT around. The Suicide Prevention Co-
ordinator felt that this was not standard policy as did the prison officer. The
assist Orderly Officer told my investigators that it was not normal practice, but
suggested that this might be something Preston could consider in the event of a
suicide risk or if someone was withdrawing from drugs. The first night nurse
said those on ACCT should be placed in camera cells if available. The night
orderly officer said that, although they should not replace observations,
prisoners on open ACCTs should be placed in camera cells, if available, as a
secondary check.
129. When the man was first placed on an ACCT, it was decided to place him in a
camera cell “until deemed no longer necessary”. This implies that his
behaviour made the use of such a cell a necessity. In addition, after the ACCT
had been closed, officers made a decision to move him out of the camera cell
to make room for someone else who was on an ACCT. Again this indicates the
routine use of such cells for prisoners at risk.
130. I accept there are some practical difficulties in ensuring every prisoner on an
ACCT is held in a camera cell. As the suicide prevention coordinator explained
to my investigators, on both A and B wings there are no camera cells, and there
may not be enough camera cells in which to house all those on ACCTs. I fully
accept this and recognise the inadequacy of a blanket policy without
consideration of the circumstances of each case. Other staff pointed out that
CCTV footage can be unclear, particularly at night, and that cameras are not
watched constantly when staff are on patrols. This is also highlighted in my last
report into a self-inflicted death at Preston in 2005. However, placing ACCT
prisoners in camera cells would provide a supplementary measure to safeguard
36
prisoners at risk, although it cannot replace other mechanisms such as
observations. Preston’s local ACCT guidance suggests that the benefits of
locating the prisoner in a cell that is easier to supervise by staff should be
considered.
The Governor should clarify to all staff whether or not it is standard local
policy for all prisoners on ACCT to be placed in camera cells if available,
and, if not, provide guidance on the circumstances in which this might be
appropriate.
Staff and medical response to the man on 27 December
131. Staff responded quickly and appropriately to the discovery of the man hanging.
Preston has a coded response system that enables staff to recognise the type
of incident and carry the appropriate equipment there. The clinical review
concludes that the code system is well established, rehearsed and utilised and
that the staff response was carried out in a timely way and to a high
professional standard.
132. On hearing emergency codes, medical staff take a green bag containing
oxygen, airways equipment, a blood sugar testing kit, an ambu-bag and mask
to the incident. There are two green bags available held in the healthcare wing,
and they are quick to retrieve in an emergency. The bag is often left outside on
the centre so it can be picked up on the way. Both nurses are required to
respond. The defibrillator machine is also kept in the treatment room near the
centre so it can also be easily accessed. All medical staff had been trained to
use it in October/November 2005.
133. Both nurses told my investigators that it is not usual practice automatically to
take the defibrillator to an incident. Nurses attend first, assess the situation and
if necessary send someone back to the centre to retrieve it. The second night
nurse was not certain if anyone other than healthcare staff had access to those
keys. There was also some confusion amongst the healthcare staff interviewed
over the correct use of the defibrillator. Although it would have made no
difference to the man’s medical care that day, the Head of Healthcare may wish
to consider whether the defibrillator should be taken to medical emergencies as
a matter of course.
The Head of Healthcare should consider making it local policy to take a
defibrillator to a Code One emergency as a matter of course.
134. At night, the gates between the healthcare centre and the wings are left open
for emergency access. When the ambulance arrived at the prison, the outer
and inner gates were opened one at a time, in accordance with the local
security policy. In some prisons in an emergency, the gates are opened
simultaneously, to avoid undue delay for the ambulance’s path. Although this
process only took a matter of minutes and had no effect on the outcome of this
case, I consider the double opening of gates in an emergency best practice.
Whilst not a formal recommendation, I would urge the Governor to consider
altering the protocol to allow double opening of the gates in an emergency.
37
135. When the night duty officer attempted to use his radio to call the Code One
emergency, he found his batteries were flat and had to run downstairs to the
office to call the communications room by telephone. Although this only
delayed the message being conveyed by a matter of seconds, I consider that
this was still an unnecessary delay. The night orderly officer told my
investigators that this is a common problem in the prison that batteries do not
charge up properly. Oscar Two who took the doubles off that night also ran out
of batteries for his radio. I encounter the problem of flat radio batteries all too
often in my investigations. The Governor will wish to consider if this is a
general problem at Preston and if action can be taken to remedy it.
Prison response following death/support for staff
136. Although nursing staff were offered Care Team support, they missed the de-
brief because they could not be released from the rest of their shift. PSO 2710
states that staff wishing to attend but unable to attend to do so should be
followed up as a group or individually. I consider that nursing staff involved
should have been released from duty to attend the de-brief. I do not consider
that they were followed up sufficiently by their line managers or other staff.
The Head of Healthcare should remind managers of the importance of
staff care and welfare in accordance with PSO 2710 and local policy,
particularly the importance of attending the staff de-brief following a
death in custody.
Notification of the death to the family
137. Overall the prison dealt sensitively with notification of the death to the family.
Although the prison did not inform them personally, this was reasonable in the
circumstances since the man’s family lived a long way from the prison and the
prison made appropriate arrangements for the police to do this. The family
were given a contact number for the prison’s family liaison contact. They saw
the prison’s Roman Catholic priest and were offered support and advice
throughout the early days after the man’s death. The prison’s liaison manager
kept in regular contact with the family. He liaised with the Coroner and the
man’s landlord in order to access his property.
138. In light of the advice in PSO 2710, published after the man’s death, one of my
Assistant Ombudsmen asked the prison to consider contributing a further sum
to the funeral costs. The Governor readily agreed in accordance with the new
guidelines.
139. The prison’s liaison manager told my investigators that when the man called
him he did not know whether the police had made contact with the family or the
details conveyed. It was an awkward conversation in which he established that
they knew of the man’s death, but he felt the telephone was an impersonal way
of conveying the exact details. He felt it better to talk to them in person the next
day. It was unfortunate that Ceefax published details of the man’s death and
offence before this meeting took place. It is standard practice for the prison or
38
the Prison Service’s National Operations Unit to issue a press notice including
details of the offence. This is not usually done until it is confirmed that the
family have been informed of the death. In this case, the family had been
informed but were not in possession of all the facts. Although I appreciate the
prison’s liaison manager’s sensitivity to the family finding these details
upsetting, the prison should have released them to the family as soon as
possible to avoid their finding out publicly.
Bullying and supervision on the wings
140. The man’s family raised concerns about the possibility of the man being bullied
on F wing. My investigators found that this was not substantiated by evidence.
The man was involved in a dispute over the pool table on 26 December
involving another prisoner. Both the man’s cellmate and the other prisoner
interviewed first described the prisoner’s behaviour as ‘bullying’, but both later
confirmed that the man was not the subject of persistent bullying. The other
prisoner said that the man had never discussed being bullied with him and the
man’s cellmate that he had not generally been bullied on the wing.
141. The man’s personal officer was unaware of any bullying against him and said
that F wing was a fairly open and small wing where officers were generally
aware of incidents. An officer said that the prison had a monitoring procedure
that would be put in place in the event of bullying which involved both the victim
or ‘target’ and the bully being closely monitored. The assist Orderly Officer
spoke with the man about the pool table incident and the man’s concerns were
focussed on being unfairly blamed and being made out to be a bully himself.
The assist Orderly Officer reassured him that no action had been taken against
him and that officers had not interpreted it in this way. The man did not
mention that he felt he was being bullied, just that he had been unfairly treated
by staff.
142. The most recent report by Her Majesty’s Chief Inspector of Prisons showed that
bullying was not being effectively tackled at Preston and made a
recommendation to ensure an effective anti-bullying scheme. Preston has
since developed a Violence Reduction Strategy under which tackling anti-social
behaviour procedures are governed. This is closely aligned with the Suicide
Prevention Strategy with relevant violence reduction information being
cascaded to safer custody meetings. Under the strategy, bullying is defined as
“conduct motivated by a desire to threaten, hurt, or frighten someone. It can be
physical, verbal, psychological, emotional, or economical and involves an
imbalance of power. It is usually repeated behaviour, unprovoked and intended
to cause fear or harm to the victim.”
143. Whilst there was clearly an altercation between the man and another prisoner
over the pool table that should not have been left unsupervised by staff, my
investigators found no evidence that this amounted to a systematic and
repeated pattern of behaviour that would constitute bullying. An officer
reprimanded the man about the pool ball and the man felt he had little chance
to defend himself. The officer appears to have raised his voice in the earshot of
other prisoners in the open part of the wing which might have upset the man.
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The only reference in the wing record describes an argument and pool balls
being removed from the table. It does not mention how or whether the other
prisoner was dealt with (I think he should have been reprimanded too). Neither
is the incident referred to on the man’s wing history sheet.
The Governor should remind all wing staff to keep all areas for
association properly supervised so that prisoners feel safe, and that all
incidents are dealt with accordingly and properly recorded.
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RECOMMENDATIONS AND GOOD PRACTICE
The following recommendations were made following the investigation and all have been
accepted by the Prison Service. The response from the Prison Service has been
included after the relevant recommendation.
1. All Healthcare staff should be reminded to fully complete Reception Health
Screening documents and refer prisoner patients to appropriate specialist
services.
A Staff Information Notice is to be issued by Head of Healthcare and a system of
management checks to be implemented to ensure compliance.
2. The Governor and Head of Healthcare should ensure that both healthcare
and discipline staff are made fully aware of and understand local policy on
confidential health information sharing and remind all staff of the
importance of information sharing, particularly in relation to ACCT.
Confidentiality and appropriate disclosure is covered in pages 21 & 22 of the
ACCT pocket guide for staff and it is a national requirement that all staff in contact
with prisoners/trainees are familiar with ACCT i.e. trained to at least ACCT
Foundation level.
Staff Information Notice to be issued which highlights the relevant section of the
local ACCT protocol.
3. The Governor and Head of Healthcare should develop a local policy dealing
with advanced medical directives based on national policy and guidelines.
Policy to be developed and published as part of the local Caring for the Suicidal
Policy.
4. The Governor should clarify to all staff whether or not it is standard local
policy for all prisoners on ACCT to be placed in camera cells if available,
and, if not, provide guidance on the circumstances in which this might be
appropriate.
Local Caring for the Suicidal Policy document to be amended to clarify the use of
camera cells.
5. The Head of Healthcare should consider making it local policy to take a
defibrillator to a Code 1 emergency as a matter of course.
Policy to be developed and notified to staff
6. The Head of Healthcare should remind managers of the importance of staff
care and welfare in accordance with PSO 2710 and in accordance with local
policy, particularly the importance of attending the staff de-brief following a
death in custody.
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Staff Information Notice to be issued, reminding all staff of the role of Staff Care
and Welfare services.
All managers to be reminded via e-mail of the importance of the Staff Care and
Welfare services.
7. The Governor should remind all wing staff to keep all areas for association
properly supervised so that prisoners feel safe, and that all incidents are
dealt with accordingly and properly recorded.
A Staff Information Notice to be published
Good Practice
8. I commend the night duty officer’s actions in entering the man’s cell on his
own without waiting for colleagues to arrive.
9. I commend the use of the feedback letter, updating ACCT teams on action
taken by MHIT following a referral, and placed on the prisoner’s ACCT
folder, as a good example of information sharing.
10. I commend as good practice the ‘Closed ACCT Quality Check Report’ used
and completed by the Safer Custody Team, to assess whether ACCTs have
been opened appropriately at reception and the correct support put in
place.
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Clinical Review Recommendations
The following learning has been identified by the clinical review. I endorse these
learning opportunities and am pleased to report that the PCT / Prison partnership
have accepted all the recommendations and drawn up an action plan to address
them.
1. A system needs to be established to ensure that prisoners moving from
reception to the vulnerable prisoner wing have a second screen within five
days of reception.
Nurses are checking the reception register to ensure that all well man
assessments are completed. This will also be added to the primary care task list
to ensure this is completed
2. That clarity is achieved for the Mental Health Service within HMP Preston in
terms of:
(cid:127) Provision, including quality of interventions
(cid:127) Roles and responsibilities
(cid:127) Referral criteria to in-reach and primary care
(cid:127) Unmet need.
This should be done by way of a comprehensive review with commissioner,
provider and prison involvement.
This was discussed at the Partnership Board meeting held in August 2006. The
Commissioners have agreed to facilitate a review of the Mental Health In reach
Services and ensure these dove tail with developing mental health provision. The
prison mental health development group is also working on a document that
describes the tiers of service and referral criteria for services provided and those
under development. The consideration of implementing an unmet needs system
as described in the Care Programme Approach will be considered as part of this
development
3. The prescription and administration record chart should be completed fully
and the ‘medication omission use codes’ used appropriately. A note of
refusal in the clinical record is useful. A frequent audit of these should be
undertaken by the Healthcare Manager (or designate) to ensure the
standard is maintained on no less than a six monthly basis.
Prescription cards are checked twice weekly to ensure compliance with
medication and accuracy of information as part of an ongoing system of audit.
A notice to staff will be reissued to ensure that they complete prescription cards
and record any refusals in line with policy.
4. That staff are re-educated and re-trained if necessary to the standards of
record keeping set out by their appropriate professional body. The
standard of record keeping should be audited by the Healthcare Manager or
designate to ensure maintenance of the standard and should be no less
than on a six monthly basis.
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Training to be sourced on record keeping and delivered to staff. This will reinforce
requirements of NMC also audit to take place on recordkeeping as part of
Healthcare Audit Calendar October 2006.
5. Healthcare and discipline staff to receive awareness training and education
regarding information sharing, use of existing guidelines/protocols and
advanced medical directives. The aim of which should be to enable
confident disclosure of information between professionals and clarity of the
legal processes needed to ensure directives are used appropriately, for the
prisoner, their families/carers and staff.
Relevant training to be sourced and a session to be delivered
6. That the partnership board review the [emergency response code] system
with the aim to ensure it remains ‘fit for purpose’ for the needs of prisoners
within HMP Preston and this should be done no less than annually.
To be placed on Agenda for Partnership Board meeting planned for October 2006.
Presentation will take place on current system and discussion to ensure it is ‘fit for
purpose.’
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