Individual at Doncaster

The circumstances surrounding the death of a man
at HMP/YOI Doncaster in September 2005
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2007
This is the report of an investigation into the death of a young man who was
found hanging in his cell at HMP/YOI Doncaster shortly after 5am on 20
September 2005. He was just 18 years old. His tender age should be borne
in mind throughout the pages that follow. Just two days before he died, he
was calling out for his “Mummy”.
The investigation was conducted by two colleagues. I also commissioned an
independent clinical review of the management of the man’s health needs
while he was at Doncaster. This was conducted by a representative of the
Doncaster Central Primary Care Trust. I am most grateful to the PCT for their
work.
My thanks also go to the Director and staff at Doncaster for their help and co-
operation during the investigation.
During his short time in custody, the man’s behaviour and mood declined
dramatically. Aside from the impact of imprisonment itself, I have identified no
other reasons to explain why this occurred. He apparently ended his own life
in the prison’s healthcare centre, subject to a two-man unlock, and in a grilled
cell to which a sheet of opaque Perspex had been fixed - making it difficult for
him to see out or for staff to see in.
The man had made a series of attempts at self-harm in the week before his
death. The attempt he made on 16 September was the fourth in as many
days. No doubt the Coroner’s inquest will wish to consider if his death could
have been prevented had more robust measures been taken following the
self-harm. In the meantime, I hope that the recommendations made in this
report will assist all prisons – public and private alike – to avoid similar
tragedies in the future.
Stephen Shaw CBE June 2007
Prisons and Probation Ombudsman
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Contents: Page
Summary 4
Investigation process 7
HMP/YOI Doncaster 10
Events prior to the night of 19/20 September 11
Events during the night of 19/20 September 27
Issues 29
Recommendations 42
3
SUMMARY
The man was remanded in custody to HMP/YOI Doncaster on 25 August
2005 to await further court appearances. He was 18 years old at the time and
had not been in prison before.
During the reception procedures carried out upon his arrival, it was noted that
the man had no concerns about his physical health, had never tried to harm
himself and the experience of being imprisoned did not make him feel
suicidal. He was assessed as being fit to go to work in the prison, and to be
allocated to a houseblock. A cell sharing risk assessment concluded that he
presented a low risk of harming others. He was therefore allocated to shared
accommodation.
The man spent his first 17 days at Doncaster in a number of different double
cells, first in C wing and later in A Wing, where he could complete his
induction programme. During that period he got on reasonably well with other
prisoners, but had some difficulty in his relationships with staff. Between 2
and 9 September, he was given repeated warnings about his conduct. On 10
September, he assaulted a fellow prisoner and was moved to another unit to
await a disciplinary hearing. The next day, he assaulted an officer. The man
claimed that his behaviour had been caused by his concern that other
prisoners were planning to beat him up because they thought he had AIDS.
He also claimed that ropes had been found under his bed that were going to
be used by officers to hang him. After assaulting the officer, he was forcibly
restrained and then escorted to the healthcare centre primarily to be checked
for injuries. On his way to the centre, he told his escort that he wanted to end
his life. Upon his arrival at the healthcare centre, he was seen by a nurse
who decided to open a F2052SH (self-harm monitoring document) and to
admit him to the centre for observation.
Thereafter, the man remained in two different cells on the upper floor of the
healthcare centre. For most of the time, he could only be unlocked if at least
two members of staff were present, such was his volatile behaviour. He
remained subject to self-harm monitoring procedures until the day he died.
Frequent F2052SH case reviews were held, but the man was not present at
any of them. A nursing care plan was also opened and maintained for him,
but this was used more as a log of events than as a proactive, forward-looking
management tool.
At approximately 5pm on 13 September, the man made a ligature from his
bedding in cell 2.27, placed one end around his neck and wedged the other
end in the door frame. At the time, he was subject to a 30 minute watch.
Fortunately, this act of self-harm was discovered immediately. He was moved
to cell 2.28, a cell variously described by staff as “anti-ligature”, “ligature free”,
and “safer cell”. The man remained on a 30 minute watch. At approximately
5:30pm, he made a ligature from his t-shirt and suspended himself from the
door in his new cell. As a result, he sustained red marks on his neck. He was
kept in the same cell after this self-harm attempt because it was deemed to be
the safest cell available, but was placed on a 15 minute watch. Despite the
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fact that he had twice attempted to self-harm within the space of 30 minutes,
and despite the fact that he had successfully suspended himself from the
frame of his cell door, no action was taken to prevent him from making a
further self-harm attempt beyond continuing to observe him every 15 minutes.
On 14 September, the man tried to cut his arms. His injuries were slight and
did not required suturing. Once again, he was kept in the same cell and
remained on a 15 minute watch. On this occasion, a nurse attempted to
contact his family but was unsuccessful.
On 15 September, a psychiatrist conducted an interview with the man through
his cell door after being advised that he presented a risk of assault. As the
cell door was fitted with a dark blue Perspex sheet that, over time, had
become heavily scratched, the psychiatrist found it difficult to see or hear.
The psychiatrist felt that he could not exclude the possibility of underlying
mental illness. He recommended that the man should continue with a course
of chlorpromazine prescribed earlier and agreed to keep him under review.
On 16 September, the man was discovered to have made another ligature
from his t-shirt in cell 2.28. At the point of discovery, he had not placed the
ligature around his neck. He remained in cell 2.28 and was again kept on the
same level of observations.
Throughout the weekend of 17/18 September, staff continued to observe the
man every 15 minutes. He continually displayed paranoid and noncompliant
behaviour but did not repeat his earlier self-harm attempts.
At 11.15am on 19 September, the man was seen by the clinical manager at
Doncaster who noted that he had become extremely agitated. As a
consequence, the option of administering oral doses of haloperidol and
lorazepam were considered by the psychiatrist and the medical officer. It was
decided that if the man was not compliant, an intra-muscular injection of these
drugs could be given. However, as the clinical manager was not sure what
oral dosage had been taken by him, she decided not to administer an
injection.
The member of staff who was on duty on the upper floor of the healthcare
centre during the night of 19/20 September noticed that the man had calmed
down. He was observed every 15 minutes throughout the night. He was
seen sleeping on his bed until about 3 am. At that time, the night patrol
noticed that the man was asleep against the door of his cell, wrapped in his
quilt. At about 5am, the night patrol saw that his head had dropped forward
and that his lips looked odd. On closer examination, he saw a ligature
wedged into the door frame. After failing to obtain a response from him, the
night patrol raised the alarm. He and the other staff who arrived at the cell
attempted to resuscitate the man. However, all attempts to revive him failed.
He was pronounced dead at 5:41am by paramedics.
The investigation found that genuine efforts were made to provide with the
mental health care he needed. However, his nursing care plan tended to be
5
somewhat reactive and referrals to the mental health in-reach team were
informal. I express concern about some aspects of the suicide prevention
measures used to monitor and review the man’s risk, and about the tendency
of staff to base their decisions about his management on individual events
rather than on the totality of his behaviour. I am critical of the fact that, at the
time of the investigation, F2052SH case reviews did not make provision for
the attendance of the prisoner under review. I am also critical of the fact that
a Perspex sheet fitted to the door of the man’s cell impaired the ability of
healthcare and specialist staff to see and hear and to communicate with him.
I say that the self-harm attempts made on 13 September and 16 September
should have sent clear signals to staff that the cell in which he was located
was not as safe as was thought, and that these factors should have prompted
more robust measures to prevent him from making further attempts on his life.
I make eight recommendations about these and related issues. Nine further
recommendations are made in the clinical review.
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INVESTIGATION PROCESS
The investigation was opened on 22 September, when my investigators met
with the Director, chair of the Independent Monitoring Board and a
representative of the Public Service Union at Doncaster. They were briefed
on the nature and scope of the investigation. On the same day, notices were
issued to staff and to prisoners announcing the investigation and inviting
those with information about the man’s death to make themselves known to
the investigation team.
My investigators interviewed six specialist staff, eleven Prison Custody
Officers, three Unit Managers, three prisoners and the Suicide Prevention Co-
ordinator at Doncaster. They also had informal discussions with three
prisoners who got to know the man in prison.
On 9 November, my investigator and one of my Family Liaison Officers met
with members of the man’s family in their solicitor’s office. They explained
how the investigation was proceeding and gave them an opportunity to raise
any concerns about the care given to the man while he was at HMP/YOI
Doncaster. His family expressed a number of concerns, all of which are
addressed in this report.
7
HMP/YOI DONCASTER
Doncaster is a large, privately-managed local prison and young offender
institution run by Serco Home Affairs. Although the prison is certificated to
accommodate 771 prisoners, its operational capacity (maximum crowded
capacity) is for 1,120 male young offenders and adult prisoners. The
accommodation consists of three houseblocks, each of which contain four
units or wings holding 90 prisoners.
Healthcare at Doncaster is directly provided by Serco. The healthcare centre
offers 24 hour nursing and medical cover, and has inpatient facilities for up to
29 prisoners on the upper floor of the building. However, as so many of its
occupants require to be accommodated in unshared cells, the average
number of inpatients does not normally exceed 18. The inpatient floor is
staffed predominantly by Prison Custody Officers who receive special training
in the care of those prisoners admitted as inpatients, but who are not nurses.
The middle floor is designated as an outpatients department. This is where
the nursing staff are normally based. It is from this floor that they are
deployed to respond to incidents anywhere in the prison that require nursing
or medical attention. Nursing staff also deploy to the upper floor when
necessary as part of their ordinary care for inpatients. The lower floor of the
building is no longer part of the healthcare centre.
The most recent inspection of Doncaster by Her Majesty’s Chief Inspector of
Prisons took place in April 2003. The report of that inspection contained a
number of recommendations, none of which I consider to be relevant to this
investigation.
On 21 April 2004, another prisoner died at Doncaster after taking an overdose
of heroin. The findings and recommendations contained in my report of the
investigation into that death do not apply here.
8
EVENTS PRIOR TO THE NIGHT OF 19/20 SEPTEMBER
Arrest and imprisonment
The man was arrested in February 2005 on suspicion of possessing a class A
drug. He had run away from the police and dropped a package that was later
recovered and sent away for analysis. In the meantime, he was bailed to his
aunt’s address and told to report to the police station at a later date. He failed
to attend on the due date and was then arrested and subsequently remanded
in custody by magistrates on 25 August to await further court appearances.
He was taken to Doncaster prison. He had never been in prison before.
25 August
Reception health screen
On arrival at Doncaster at about 7pm that day, the man underwent a reception
health screen. During this procedure, he said that he was on remand until 2
September and that this was his first time in prison. He said that he had been
charged with supplying a class A drug. He had recently seen a doctor for a
minor ailment, but had no outstanding appointments. He reported that he had
no concerns about his physical health and that he had never received
treatment from a psychiatrist. He said that he drank alcohol occasionally and
smoked cannabis daily. He said that he had never tried to harm himself and
that he did not feel like harming despite being in prison. He felt no need to
see a doctor.
During a secondary health screen completed by a nursing assistant, it was
noted that the man exhibited no abnormal behaviour, that he did not appear to
be under the influence of alcohol or drugs, and that there were no concerns
about his mental health. A Staff Nurse who completed the primary health
screen felt that it was not necessary to refer the man to a doctor. He was
assessed as being fit for work, did not need to be admitted to the healthcare
centre and was not in need of detoxification.
Custody assessment
An initial custody assessment was also completed as part of the reception
procedures. The man said that he did not need any help in respect of
substance misuse. He also said that he was unemployed and in full time
education. He reiterated that he was due back in court on 2 September. He
was expecting to receive visits while in custody.
Cell sharing risk assessment and allocation to houseblock
As is routine, the man was also subject to a cell sharing risk assessment. He
was assessed as presenting a low risk of harming others and could therefore
be allocated, if necessary, to a shared cell. In line with normal practice for
newly received prisoners, he was initially allocated to the induction unit in
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Houseblock 3. However, upon his arrival in the unit, it was discovered that
there were no vacancies. The man was therefore accommodated in
Houseblock 1 on a temporary basis, and was initially allocated to a double cell
on the first floor of C Wing. The records show that he remained in this cell for
only one minute from 7.46pm. My investigators were told that the reason for
the rapid change of cell was probably the fact that staff did not want him to
share a cell with the occupant, who was a drug addict under detoxification.
He was therefore moved to another double cell on the same floor of C wing,
where he remained until 7:11pm the next day. He was then moved to A Wing
in Houseblock 1 where he occupied a double cell until 2:03pm on 8
September. During this initial period, he got on reasonably well with other
prisoners. However, he had difficulty relating to staff.
Behaviour warnings
On 2 September, the man received a warning for his conduct after saying that
one of the Prison Custody Officers (PCOs) working in C Wing was ‘talking
shit’. He was told that he should demonstrate more respect for staff. That
day, he was taken to Leeds Magistrates’ Court where he was again remanded
in custody, this time until 30 September. During the evening, he was late
returning to his cell for the evening lock up period.
During the morning of 4 September, the man received a formal warning after
again being disrespectful towards staff and taking too long to return to his cell
at lock up. Later that day, he was also warned for smoking on the landing at
the tea time lock up.
During the night of 7 September, the man used insulting language to a
member of the night staff. The following morning, the Unit Manager spoke to
him about his rudeness.
On 8 September, the man was relocated to Houseblock 3D so that his
induction programme could be initiated. This was some two weeks after he
had arrived. He was placed in cell 3D2.49, where he remained until 10.17am
on 10 September.
During the night of 9/10 September, the man repeatedly kicked his cell door
and swore at the night duty officer. The next day, he was given another
formal warning about his behaviour.
10 September: Assault on a fellow prisoner
At approximately 7:30am on 10 September, another prisoner who was located
in a neighbouring cell, complained to a Prison Custody Officer (PCO) that the
man had assaulted him. The man was confronted with this information by the
PCO and admitted that the assault had taken place. The PCO therefore
placed him on a disciplinary report. He was then relocated to Houseblock 2 to
await his adjudication. My investigators were told that prisoners who are
placed on report are sometimes moved to this unit and placed on a basic
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regime whilst awaiting the adjudication (disciplinary hearing) rather than being
formally segregated.
11 September
Admission to the healthcare centre and initiation of self-harm
monitoring procedures
At approximately 1pm on 11 September, the man (who at the time was
occupying a shared cell) started shouting and kicking at his cell door. A PCO
heard the noise and approached his cell. As the PCO opened the cell door,
the man lunged at him and pushed him in the chest. Two PCO’s restrained
him and led him to another cell to allow him to settle down. At interview, one
of the PCO’s told my investigators that the man had earlier asked to move to
another cell because he “was having problems with his cellmate and because
other people on the wing thought he had AIDS.” The PCO said that the man
believed his cellmate “was going to beat him up” because of this. The PCO
explained that, once the man had calmed down, he took him to the healthcare
centre so that he could be seen by a nurse in case he had sustained any
injuries as a result of being restrained. The PCO said that when he arrived at
the centre he said to a nurse, “I’ve brought him down to be checked for
injuries that might have been caused by restraint but he’s been talking about
ending it all.”
The nurse decided to admit the man to the healthcare centre and made the
following entry in his medical record at 3:15pm that day:
“HCA: The man was brought to the HCC (healthcare centre)
following being C&R (controlled and restrained). He stated
that some hanging ropes were found under his bed and that
prison staff were going to use it to hang him. Before they do
that he will do it himself. He felt paranoid that the whole
wing were talking about him being HIV positive when he
stated that he is not. F2052SH (self-harm monitoring
document) opened, on a L3:30.(level 3 observation - every
30 minutes). Admitted upper healthcare for adjudication.
[The nurse later clarified that he meant to use the word
“assessment” instead of “adjudication”.] Above action
sanctioned by myself.”
The nurse also completed a Form F213 (report of an injury
sustained by a prisoner). On the form he wrote that no treatment
was required. At interview, the nurse confirmed that the man had
sustained no injuries.
My investigators were unable to establish whether the man’s reference to the
discovery of hanging ropes was real or imagined. At interview, neither of the
PCO’s made any reference to such a discovery. The nurse told my
investigators that he questioned the man about these claims and formed the
opinion that they were not true.
11
12 September
Examination by doctor
On 12 September, a prison doctor saw the man at 9:15am. The doctor wrote
in his F2052SH,
“Currently very paranoid. Thinks that everybody is plotting
against him. Agitated. Watch raised due to threat of SH (self
harm). Ref for Psych opinion.”
The doctor wrote in the man’s medical record,
“Complains of paranoid ideation and agitated. PMH (past
medical history) seen by psych as a child. On examination -
definite paranoid ideation. Refer psych for opinion.”
Opening of nursing care plan
A nursing care plan, or inpatient clinical pathway of care, was opened
for the man upon his admission to the healthcare centre. The
document was indexed as follows:
1. First admission assessment
2. First 24 hour core care plan
3. 48 hour assessment
4. Individual multi-disciplinary care plan
5. Care plan evaluation sheet
5. Communication sheet
6. Discharge procedure and summary
First admission assessment
The information recorded on the proforma used for the first admission
assessment included a brief analysis of the risk the man presented in
a number of areas such as violence, arson, self-harm, substance
misuse, depression, psychotic illness and sleeping problems. The
findings emanating from that risk assessment were summarised as
follows:
“Stated PMH (past medical history) seen by psychiatrist as a
child. S/B (seen by) Dr 12/9/05. Refer psychiatrist for
assessment.”
First 24 hour core care plan
This listed 12 targets that were to be achieved that day, of which nine
were initialled as having been met.
12
48 hour assessment
The copy of the care plan presented to my investigators did not
include any information relating to a 48 hour assessment.
Individual multi-disciplinary care plan
This noted that there were two main areas of concern: self-harm
ideation and mental health. The plan recorded that the man’s care
treatment aimed to prevent self-harm and to promote his mental
health wellbeing. The plan included the following interventions:
(cid:127) monitor 30 minute observations
(cid:127) report on mood
(cid:127) allow to voice anxieties
(cid:127) reassurance to be given /offered
(cid:127) refer for RMN assessment
(cid:127) refer to psychiatrist
(cid:127) give prescribed medication and monitor effect
Care plan evaluation sheets / communication sheets
The copy of the nursing care plan presented to my investigators
contained a number of evaluation sheets and communication sheets
that, together, were used to record daily occurrences during the time
was in the healthcare centre.
Adjudication
Later on 12 September, the man was taken to the segregation unit from the
healthcare centre to face an adjudication (disciplinary hearing) for assaulting a
PCO on 10 September and another PCO on 11 September. The records
show that the man was considered by the doctor to be fit to undergo the
adjudications but unfit to undergo cellular confinement if imposed. The man
pleaded guilty to both charges. He explained to the adjudicator that he had
assaulted one of the PCO’s because he, the PCO, had shouted out of his cell
window that he was HIV positive. He also explained that he had pushed past
the other PCO so that he could get out of his cell because he feared for his
life and because he had heard that he was going to be hanged that night.
The adjudicator decided to adjourn each hearing so that a report on the man’s
medical condition could be acquired. In the event, no medical report was
forthcoming before the man died. The adjudication was therefore never
completed.
First High Risk Assessment Team case review
On the same day, an initial self-harm case review was convened by the High
Risk Assessment Team (HRAT). My investigators were told by the
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establishment’s Suicide Prevention Co-ordinator (SPC) that she was
responsible for ensuring that the cases of any prisoner subject to self-harm
monitoring procedures were regularly reviewed by the HRAT and that she
chaired all such reviews. The SPC explained that she made sure that staff
throughout the prison were aware of the names of every prisoner who was on
a F2052SH (self-harm monitoring document). She also explained that the
practice at Doncaster was that, prior to each case (or HRAT) review, an
appropriate member of staff interviewed the prisoner and submitted a report of
that interview, with recommendations, for consideration. The SPC said the
policy at Doncaster was that a minimum of three staff should attend each
HRAT case review. The panel normally comprised a nurse, the appropriate
residential manager and herself. If necessary, the SPC discussed the review
report with the author, if that person was unable to attend as a panel member.
The SPC told my investigators that, at Doncaster, prisoners did not attend
their own reviews. She said that it was her experience that prisoners felt
intimidated by the process.
In keeping with this policy, the man was not present at his first case review on
12 September, or indeed at any of the other reviews convened to consider his
case. The review was summarised as follows:
“F2052SH opened on 11/9/05 on 2C as he said that Officers
on the wing were plotting to hang him. Before they do he will
do it himself. He presented as paranoid and on edge. He
thinks Officers are after him. Admit to Health Care. He is
feeling insecure and anxious. He said self-harm was an
option.
MO (Medical Officer): Currently very paranoid. He thinks
everybody is plotting against him. Very agitated. Refer for
psychiatric opinion. Not much interaction due to him being
on 53/4 (a prison rule under which prisoners can be
segregated whilst awaiting a disciplinary hearing). No self-
harm voiced. He appeared to sleep.
SPC findings: The man is on remand until 30/9/05. He
states he fears for his safety after overhearing staff threaten
to hang him and make it look like suicide. He states he has
no thoughts of self-harm or suicide but is clearly agitated and
feels paranoid. He is quite clear and rational in his own
beliefs. He states food at lunchtime was contaminated with
mucus and hair. He states that other prisoners are
spreading rumours he is HIV to the extent he believes his
friends in his home town have been telephoned and told. He
states he has no history of drug use other than cannabis.
He genuinely believes he will die if he is sent back to the
Houseblock.
Medical record: Nothing of relevance.
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HRAT: The man has been referred to the psychiatrist and
will be seen on Thursday. His adjudication was remanded
for medical reports. He will remain on Health Care until
reviewed by the psychiatrist. He says he is not suicidal but
HRAT agreed to continue the F2052SH for a further period
of observation.”
The panel decided that the man was to remain on a 30 minute watch.
Although the man later seemed to be more settled in the healthcare centre, he
was described as a little confused. He told a member of staff that he thought
he was in danger on the upper floor of the healthcare centre. He was
reassured, but continued to display paranoid behaviour that night. He
believed that, if he went to sleep, staff would try to hang him. He thought he
could hear people talking about him and his problems.
13 September: self-harm attempts
On two separate occasions on 13 September, the man made a ligature in his
cell. The first occasion was at 5:05pm, when staff discovered that he had
made a ligature from his bedding. He had placed one end around his neck
and had attached the other end to the heating pipes in his cell (2.27 on the
upper floor of the healthcare centre). The Form F213SH completed
afterwards noted that, on this occasion, he had sustained no injuries. As a
result of this self-harm attempt, the man was moved to cell 2.28 which was
designated as an “anti-ligature” cell.
At about 5:30pm, the man made another ligature, this time from his t-shirt. He
had placed one end around his neck and had wedged the other between the
cell door and the door frame. He was found in a sitting position immediately
behind his door. A PCO noted on the F213SH that there were red marks on
the man’s neck. A nurse made the following entry in his medical record:
“Seen after attempted hanging. States he did this before the
officers do it to him. Also stating that he feels guilty because
he neglected his younger brother who, he feels, he should
be taking care of. States his mother’s voice is telling him to
kill himself as he is not worth it. Talked about being
abandoned by his parents and being brought up in care.
Had drawn a number of pictures and written phrases in his
book. Watch raised to level two -15 minutes.”
My investigators were unable to trace the book mentioned above.
However, the man wrote a letter to his brother that day, expressing
his love for him and wishing him a happy birthday.
The same nurse also made a similar entry in the F2052SH. Besides
increasing the frequency of observations, staff removed the ligature and all his
clothing other than his underpants.
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Throughout the night of 13/14 September, the man continued to shout and
bang the furniture in his cell. He told a member of the night staff that he knew
that person was going to hang him that night and would not listen to any
reasoning. The man threatened to slit the officer’s throat as soon as he had
a chance to do so. His behaviour was such that other prisoners became
agitated.
14 September: Second HRAT case review, assault on staff and further
self-harm attempt
At 8:10am on 14 September, the man’s case was again reviewed by the High
Risk Assessment Team. The man was not present at the review. The form
used to record the panel’s deliberations contains a box which purports to
show the members of staff present at the review. On this occasion one of
those listed was the nurse who made the entry in the man’s medical record.
However, at interview, the nurse said that she had never attended a case
review. My investigators were later told that the list shown on the form was
indicative of who was eligible to attend rather than a statement of who was
actually present.
The review was summarised as follows:
“Last review: 12/9/05
The man seems a bit more settled. He seems to think he is
in danger on Health Care. He was reassured. He says
Officers are going to try to hang him.
13/9/05 – found in cell with a ligature round his neck made
from a bed sheet and was holding it. No injuries evident.
He was found to have made a ligature from a t-shirt.
F2052SH raised to level 2. Red marks were noted, no other
injuries evident. He said he attempted hanging before
Officers could do it. He also stated he wanted to die. He is
upset his parents abandoned him and he has let his brother
down who is now in care. He flooded his cell and was not
listening to reason. He was constantly banging and shouting
all night and verbally abusive to staff and other prisoners.
He asked for a chat and tried to force his way past staff. He
had to be restrained twice. He is constantly shouting and
very incoherent and paranoid.
MO (Medical Officer): Still very paranoid, not seen
Psychiatrist yet, seeing him tomorrow, medication
prescribed.
Another member of staff wrote: I did not speak to the man
personally as staff felt it would aggravate him further.
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Information was obtained from Officers. The man is
currently feeling paranoid believing staff are going to get
him. He refuses to talk to them until other prisoners are
around. He also has issues regarding debts outstanding on
the wing. He spends the majority of his time banging in his
cell. He has a history of self-harm though denies any future
self-harm intent. He is due to see the Psychiatrist tomorrow
to determine any issues underlying his behaviour.
(My investigator was unable to discover what role the author played
at Doncaster.)
HRAT: The man was fine when he attended Middle Health
Care earlier today. The MO has prescribed medication but
given his current volatility it may not be possible to
administer it. In-reach are very concerned about him. HRAT
agreed to continue F2052SH at Level 2.”
Later that morning, the man was seen by a doctor who wrote in the medical
record:
“still very paranoid, not seen by psych yet.”
The doctor decided to prescribe chlorpromazine 50mg twice daily.
Chlorpromazine is an anti-psychotic drug normally prescribed to reduce
aggression and to suppress abnormal behaviour. It can have a tranquilising
effect on the patient.
A Staff Nurse who had last seen the man during the reception procedures
carried out on 25 August, was now so concerned about him that she
attempted to contact his next of kin. At interview, she said that the man she
now saw in the healthcare centre was very different from the man she had
seen in reception. The nurse made the following entry in his medical record:
“Registered with CPA (Care Pathway Approach) in Leeds.
They have his name, date of birth, and address, but no
referral details on file. GP’s contacted via health authority-
nothing on file. NOK (next of kin) ... (sister) - no number for
that address on file. Girlfriend ... mobile number not
recognised. No persons for that name and address with
BT.”
At approximately 10:30am that day, the man rang his cell bell and asked a
PCO if he could speak to him. As the PCO unlocked the cell door, the man
tried to force his way out of the cell. The PCO struggled with him in order to
prevent him from leaving the cell. As he did so, the PCO’s keys snapped
away from his key chain but remained in the door lock. Another PCO arrived
at the scene and called a response team. A nurse also arrived and secured
the PCO’s keys to her key chain. A number of other staff responded and
used force to bring the man under control. He was initially placed on the floor
17
outside his cell. The Operations Manager supervised the incident. Knowing
that the man’s mental health was being monitored, the Operations Manager
decided that he should be kept in the same observation cell. He therefore
ordered the staff to reduce the level of restraint they were applying to the man
so that he could be placed back in the cell. As they did so, he kicked and
attempted to bite one of the PCOs. Restraint was therefore reapplied. The
man was then relocated into the cell. As staff withdrew from the cell, he
grabbed the edge of the cell door preventing it from being closed. Further
restraint was therefore applied to him inside the cell. This time, staff were
able to close the cell door. The man was not injured, although the F213
completed after the incident shows that he sustained red marks on his torso
caused by being wrestled to the ground.
In the healthcare centre daily handover log for 14 September, a PCO made
the following entry:
“After opening the man’s cell door, he tried to push past me.
He snapped my keys and had to be C&R’d (restrained). On
putting him in his cell, he kicked off again and had to be
C&R’d again. He is now a 2-man unlock.”
My investigators were told that the term “2-man unlock” refers to the minimum
number of staff who should be present in order safely to unlock a prisoner
known to be volatile or prone to assaulting staff or other prisoners. At
Doncaster, approval for this measure must be sought from an Assistant
Director. Whilst my investigators could find no written evidence that such
approval was given in the man’s case, it is clear that, in view of his behaviour,
it was a necessary and appropriate precaution.
At 11am, a note was made in the man’s F2052SH that he was constantly
shouting that staff and other prisoners were trying to kill him. He was
described as very incoherent and paranoid.
At about 3pm, the man tried to cut his arms with a plastic knife. No F213SH
was presented to my investigators in relation to this incident. However, a
nurse recorded in his F2052SH that his injuries were cleaned and dressed,
and that he then settled. The nurse recorded in the F2052SH that he was to
be observed at “level 3 - 30” (every 30 minutes) and then replaced that entry
with “level 2 -15” (every 15 minutes). In the medical record, the nurse wrote
that the man was to be observed at “level 3-30”. It was clear to my
investigators that the inconsistencies in the entries made in each document
were a record keeping error on the nurse’s part and that the level of
observation she meant to record in both documents was level two rather than
level three. However, inaccuracies such as this could lead to confusion and
potential omissions.
Wherever they are located at Doncaster, prisoners are provided with plastic
knives, forks and spoons with which to eat their meals. It was one such
implement that the man used to cut himself.
18
At 3:25pm, the man was described as paranoid and unpredictable. An entry
made in his F2052SH at 6:30pm shows that he was still banging and shouting
and that he remained abusive. His behaviour remained thus throughout the
following night.
15 September: Consultation with psychiatrist and third HRAT
case review
At 5:15am on 15 September, an entry was made in the man’s F2052SH to
record that he had been shouting and then sleeping intermittently throughout
the night. However, he had not voiced any intentions to self-harm.
Later that morning, the man was seen by a psychiatrist. Because of his
volatile behaviour, the psychiatrist thought it unwise to enter his cell to
interview the man. He therefore remained outside the cell door while he
talked to him. The cell door took the form of a metal grille gate onto which a
dark blue Perspex sheet was fitted. At interview, the psychiatrist explained to
my investigators that his normal practice was to interview prisoners in a
separate room. He said that, if the healthcare staff had any concerns about
the safety of staff, they would advise that the prisoner should be seen in his
cell and interviewed through the hatch in the door or, as in this man’s case,
through the Perspex sheet. The psychiatrist said he had been advised that
the man’s behaviour was unpredictable and that his (the psychiatrist’s) safety
could not be guaranteed. The psychiatrist found it difficult to see clearly
through the darkened Perspex, even when the two of them were only inches
apart. Despite the difficulties, he proceeded with the interview. The following
is a paraphrased version of the entry made in the man’s medical record by
the psychiatrist:
“I examined him on 15/09/05 through the cell door. It was
difficult to actually see him because of the Perspex. He
stood in his underpants and his mattress was located
immediately behind the cell door. He was able to converse
with ease but somewhat demanding. He asked for a
cigarette and toast, which was duly supplied. He said that
when he arrived at HMP Doncaster he was aware others in
the wing were spreading a rumour he was HIV positive. He
then stage managed a suicide attempt in order to be placed
elsewhere. He acknowledges he rushed at a prison custody
officer, injuring the latter. He denies any prior history of
contact with psychiatric services. He asked for my
identification and was easily assured when this was
produced. He appeared somewhat guarded and probably
suspicious. He was not obviously hallucinating and certainly
not thought disordered.
At this time I would not exclude the possibility of underlying
mental illness but I am not certain this is indeed the cause of
his presentation. At the time of my interview with him on
19
15/09/05 he was fit for adjudication. He will continue in
receipt of Chlopromazine and we will monitor his progress.”
On the same day, the High Risk Assessment Team reviewed the man’s case.
The man was not present. The review was summarised as follows:
“Last review: 14/9/05.
The man cut his arm with a plastic knife. The injuries were
cleaned and dressed. He will not listen to reason and
presents as paranoid and unpredictable. He has been very
abusive, banging and shouting. He takes meals behind his
door. He was shouting through the night and slept on and
off. He voiced no self-harm. He was seen by the
Psychiatrist through his door.
Psychiatric review: Unable to make a proper assessment at
this time. Fit for adjudication.
SPC findings: The man is very unpredictable at the moment.
He is quite rational in his beliefs then becomes volatile and
aggressive. He states his self-harm yesterday was a game
of attention seeking. He is adamant he is not suicidal. He
wants his medication one minute and then is questioning
what the reason is for it the next. He wants to speak to the
Psychiatrist and explain he does not need to be in the Health
Care or on a watch. He was shouting to the prisoner in the
next cell then talking in a rational manner to myself.
HRAT: The nurse reported that the man has been a lot
more settled than yesterday but he is still unpredictable.
HRAT agreed to continue the F2052SH at Level 2.”
16 September: further self-harm attempt
At about 9:45am on Friday 16 September, whilst carrying out his observations
of the man, a PCO discovered that he had made a ligature from his t-shirt.
The man had pushed one end of the ligature through the door frame but,
when discovered, had not placed the other end around his neck. He was in
cell 2.28 at the time. This cell was classified as an anti-ligature cell.
The PCO made the following entry in the man’s F2052SH:
“Found during checks to be making a noose out of his tee
shirt. Ligature pushed through gate but not attached to his
neck. Says he wants to kill himself rather than die a painful
death - says that people are going to stab him. Asked me to
give him tablets to help him die. Advised he will only be
given what he is prescribed.”
20
A similar entry was made in the man’s medical record. The signature of the
nurse who made the entry is illegible. At interview, a nurse suggested that it
was probably made by her nursing colleague who attended the cell with her.
The nurse could not remember who that was. She examined the man in his
cell immediately after the noose was discovered, and made the following entry
in the F2052SH. It read as follows:
“Seen on upper healthcare after making a noose. Says he
wants some tablets so that he can die. Unable to see further
than this ideation. L2-15.”
Similar entries were made in the man’s medical record. At
interview, the nurse was asked whether, in view of the man’s
manifestations of suicidal expressions, she had considered placing
him on a constant watch. The nurse told my investigators that she
was not unduly concerned about the man at the time. She thought
that her decision not to place him on a constant watch may have
been influenced by the fact that, although he had fashioned a
ligature from his t-shirt, he had not placed it around his neck.
At 1pm that day, an entry was made in the man’s F2050A (record of events)
showing that he had spent the morning shouting and banging on his cell door
as well as “asking for his mum”.
Weekend 17/18 September
Regular observations were made on the man throughout the weekend. The
observation log used at Doncaster merely requires staff to place their initials
against the times at which they make each observation, and to place a tick on
the form if the prisoner is asleep, or a cross if the prisoner is awake. No
qualitative entries were therefore made on the form used to record the
observations made on the man. These were reserved for the continuous
record in his F2052SH.
During the night of 16/17 September, the man’s behaviour continued in the
same vein. At 4:57am on Saturday 17 September, the following entry was
made in his F2052SH:
“Shouting and banging most of the night. Very disruptive to
UHCC (upper healthcare centre) harmony. No self-harm
voiced. Shouting for Mummy and Dad. Also shouts that
they are going to kill him. Also whistling and banging pipes,
cups and heating pipes.”
Further entries made in his F2052SH on Sunday 18 September show that the
man behaved in a similar fashion throughout the day. One particular entry
made at 6pm that day stressed that he needed “to be watched carefully when
taking his meds - twice today he tried to palm his tablets.” On the same day,
an entry made in his medical record refers to “six days of unrelenting
outbursts at the cell door”. It was decided that the man should be given one
21
10mg dose of diazepam to test its effect. Diazepam is normally prescribed for
short term use in cases of anxiety or insomnia. The man was also to be
referred to the Mental Health In-reach Team (MHIT). The clinical review
attached to this report comments that no formal referral was made.
19 September: Seen by psychologist prior to next HRAT case review
On Monday 19 September, the man was seen by a psychologist who
completed a report for consideration at his next F2052SH case review. The
psychologist wrote:
“At time of interview it wasn’t possible to open the man’s cell
due to his two-man unlock status. He was quite agitated and
it seems has been over the weekend. He told me the police
were coming to take him away in a helicopter. He then
continued to shout”
The psychologist made a similar entry in the man’s F2052SH at 9:15am.
Oral/intramuscular medication
At 11.15am, the following entry was made in the man’s medical record by the
Clinical Manager:
“Seen by in-reach - extremely agitated - doctor contacted -
liaised with psychiatrist to have oral Haloperidol 10mg and
Diazepam 5mg 6-8 hrly. If not compliant, to have
Lorazepam 2mg IM (intra muscularly) with Haloperidol
10mgs IM. If condition deteriorates psychiatrist will arrange
a consultation before Thursday.”
At interview, the doctor explained this matter as follows:
“... on 19 September, I did speak to the psychiatrist because,
having seen the man and seeing how he was, I felt that he
needed a further urgent review by the psychiatrist. His
condition had deteriorated from when I’d seen him on the
15th. In the interim period, what I suggested was that we had
an interim review by a psychiatrist again for any possible
further intervention he may have felt was appropriate. I also
gave instructions to the nurses that he should given some
diazepam until the lorazepam arrived. Both drugs are of the
same class of medication. They didn’t have any oral
lorazepam at the time in the prison pharmacy, so the
substitute drug, which is diazepam, was to be given to try
and calm him down until the psychiatric assessment could
take place. I left instructions to get hold of the psychiatrist
and see if he could come in as soon as possible to see this
chap. After I had left the prison, I actually rang the
psychiatrist from my mobile and explained that this chap was
22
quite agitated and his mental state had deteriorated more
than when I had seen him on the 14th. So it was worse than
that and probably worse than the 15th when the psychiatrist
had seen him. I asked if he could offer some advice. The
psychiatrist gave me further instructions as to what he
should be given. He said that he couldn’t actually attend
himself at that time. However, if he didn’t settle with the
medication that he suggested, then arrangements would
have been made to get either himself or one of his team to
attend to reassess the prisoner.”
During his interview, the psychiatrist was reminded of the entry that had been
made in the man’s medical record at 11.15am on 19 September. The
psychiatrist was asked if had been given any of those drugs (lorazepam and
haloperidol) orally. He said that he did not know and that he had not seen any
medication card or the man’s medical record.
My investigators examined the prescription charts contained within the man’s
medical record. These show that an entry was made in the ‘once only
prescription’ section on 19 September for haloperidol 10mg and lorazepam
2mg. An entry made against these drugs in the ‘directions’ section shows that
each drug was to be given intra-muscularly. However, neither entry was
signed by a doctor and no entry was made in the section of the chart marked
‘given by’. Beneath the entries that had been made is the comment, “(verbal
message doctor.) Agree with psychiatrist.” These entries appear to support
the suggestion that no intra-muscular administration of either lorazepam or
haloperidol was given to the man.
The Clinical Manager told my investigators that she spent nearly two hours
that day talking to the man and trying to persuade him to take his medication.
She was sufficiently concerned about him to telephone the doctor for advice.
The Clinical Manager said that the doctor told her to try to give the man some
haloperidol as well as diazepam orally. She explained that haloperidol is an
anti-psychotic drug that has a calming effect on a patient. The Clinical
Manager explained that any medication prescribed for the man had to be
pushed under his cell door because of the risk of assault. It was therefore
difficult to determine what medication he had taken. The Clinical Manager
said that in view of this uncertainty, she did not proceed with an intra-
muscular injection.
The Clinical Manager told my investigators that, although the man was not
rational at the time, she did not think he was suicidal. She said that, for most
of the time she spent with him, there was very little interaction with him. She
recalled that he did settle down during the afternoon, but was aware that he
often did. It is not clear whether the man settled down because he had taken
the oral medication offered to him.
Another entry, timed at 12:15pm, was made in the medical record above the
earlier entry, described above. It reads as follows:
23
“Referral accepted by in-reach. Unable to interview at this
time due to 2 man unlock and volatile presentation.”
This entry was made by a member of the in-reach team. At 2:55pm, the
following entry was made in the F2052SH:
“Quite disruptive - appears to have taken medication on the
instructions of the doctor. Under in reach team. For urgent
psychiatric review. HRAT: remain L2-15.”
The final entry made in the man’s F2052SH was made at 6pm on
19 September. It read:
“Banging and shouting most of the morning. This afternoon
a little quieter.”
The final entry made in his medical record was:
“HRAT review. Remain L2.15.”
The man’s final HRAT was summarised as follows:
“The man has been very disruptive, shouting and banging.
This behaviour has continued all weekend. 16th September
2005: Made another noose with tee shirt.
HCA1 (Healthcare Assessment 1) - issues over safety,
mental health issues
HCA2 (Healthcare Assessment 2) - made a noose, cannot
make sense of problems, mental health issues, to remain on
a L2 15 minute watch.
The man has been shouting and banging and asking for his
mum, palming medication and is currently on a 2-man
unlock.
Psychologist’s findings: At the time of interview it was not
possible to open the man’s cell due to his two-man unlock
status. He was quite agitated and it seems has been over
the weekend. He told me the police were coming to take
him away in a helicopter, he then continued to shout.
HRAT: Agreed remain on L2 15 minute watch.”
The case review summary bore the SPC’s signature and was dated 28
September 2005. My investigators were told that this short delay was due
only to the fact that the person upon whom she relied to type the review
summary was on leave at the time.
24
EVENTS DURING THE NIGHT OF 19/20 SEPTEMBER
During the night 19/20 September, a Prison Custody Officer was on duty in
the healthcare centre as a night patrol. At interview, he told my investigators
that he was aware of the fact that the man was forever banging and shouting
in his cell and that his behaviour disrupted the smooth running of the
healthcare centre. However, at about 7:50pm on 19 September, when the
PCO began his night duty, he noticed that the man was asleep. At the PCO’s
hand-over briefing, he was told that the man had received some medication.
The PCO thought this was the reason why he was asleep.
The PCO’s shift commenced at 8pm and finished at 6am the next day. He
was alone on the upper floor of the healthcare centre, but knew that nursing
staff were available throughout the night on the floor below.
The PCO was aware of the fact that the man was to be observed every 15
minutes. When he began his shift, he saw that the man was asleep on his
bed. However, the PCO told my investigators that in the early hours of 20
September, possibly at about 3am, he noticed that the man was asleep by his
door. The PCO did not witness the man moving from his bed to the door.
According to the PCO, the man was in the habit of placing himself by the door
so that he could shout through it or sleep there.
The PCO made a record of the observations he made of the man on a form
entitled “Suicide Watch Log and Notes”. The form shows that he observed
the man at 15 minute intervals throughout the night. The recorded timings of
each observation fell precisely at 15 minute intervals, suggesting that the man
might have been able to predict exactly when the PCO was due to visit his
cell. However, the PCO assured my investigators that his routine involved the
observation of a number of prisoners, including the man, and making entries
on the proforma at the end of each patrol. The PCO stressed that no prisoner
would have known precisely when the next observation was to be made and
that his actual observations were not made precisely every 15 minutes.
The PCO said that he saw nothing unusual until about 5am when he noticed
that the man was asleep on the floor of his cell, leaning against the door in a
sitting position and wrapped in his quilt. The PCO noticed that the man’s
head had dropped forward and that his lips looked really weird”. The PCO
said that the man’s lip was “sticking out and looked unusual”. The PCO
shone his torch into the cell to get a better view. He then saw a ligature
wedged between the door and the frame. He told my investigators that he
was not sure whether the ligature was in place earlier in the night.
The PCO wanted to be sure that the man was not “setting a decoy” as he
knew that he had recently injured two members of staff and, as a result, was
on a “two-man unlock” (the procedure whereby two members of staff must be
present before unlocking a prisoner known to be volatile). The PCO therefore
25
tried to push the knot to force a reaction from the man. However, the ligature
would not move. At that point, the PCO raised the alarm by calling for
assistance from the first-response team over the radio. He then broke the
seal on his emergency pack of keys and unlocked the man’s cell door. As he
pushed the door open, the ligature fell from the door frame, causing the man
to fall to the floor. The PCO moved in to the cell and cut the ligature away
from the man’s neck. He could find no pulse, nor any signs that the man was
breathing. At this point, he laid the man flat so that he could commence
cardiopulmonary resuscitation (CPR).
At about 5:05am, a nurse and a PCO arrived at the man’s cell. They both
helped to administer CPR. At about the same time, the Night Orderly Officer,
who was at the gate when the call for assistance was sent, made her way to
the healthcare centre and on arrival began to supervise the staff involved and
co-ordinate their activities. She gave instructions to a PCO to ask the
Communications Officer to call for an ambulance.
The log shows that the ambulance was called at 5:05am and that it arrived at
the prison about 15 minutes later. Three PCO’s escorted the paramedic crew
to the healthcare centre. When the crew arrived at the man’s cell, they took
over CPR from the staff.
It is clear that prolonged attempts were made to revive the man. Sadly, they
were unsuccessful. He was pronounced dead by the paramedics at 5:41am.
No suicide note was found.
After police officers had completed their examination of the cell, the man’s
body was removed from the prison at approximately 11am.
An Assistant Director and the chaplain from Doncaster informed the man’s
sister of his death at 5pm that day at her home.
The man’s funeral took place in October 2005. Two members of the
Doncaster chaplaincy team attended. The prison contributed £1,000 towards
the funeral costs.
26
ISSUES
Here I address the concerns expressed by the man’s family. I also examine
the quality of mental health care afforded to the man and the effectiveness of
the suicide prevention measures taken to assess and manage his risk.
(cid:127) Why did the man change so radically between 25 Aug and 11 Sept?
During the initial health screen carried out as part of the reception procedures
on the day the man first arrived at Doncaster, he told staff that he had no
concerns about his physical health and that he had never received any
treatment from a psychiatrist. He said that he had never tried to harm himself
and that he did not feel like doing so now that he was in prison. He felt no
need to see a doctor. The nursing assistant who completed a secondary
health screen noted that the man exhibited no abnormal behaviour, that he
did not appear to be under the influence of any alcohol or drugs and that there
were no concerns about his mental health. The man was assessed as being
fit for work. He did not need to be admitted to the healthcare centre and was
not in need of detoxification. He was therefore allocated to a houseblock
where he was to share a cell. However, it was immediately discovered that
the prisoner with whom he was to share a cell was a drug user under
detoxification. The man was therefore moved to another cell in the same
wing. The next day, he was moved to yet another cell, this time in A Wing,
where he remained for two weeks. Although he got on reasonably well with
other prisoners during this period, he had difficulty relating to staff. As a
result, he was given several warnings about his disrespectful attitude and
poor conduct.
On 8 September, the man was moved to another houseblock so that his
induction programme could commence. During the night of 9/10 September,
he repeatedly kicked his cell door and swore at the night duty officer. The
next day, he assaulted a fellow prisoner. On 11 September, the man started
shouting and kicking at his cell door. He then assaulted one of the officers
who came to his door and claimed that his cellmate was going to beat him up
because he had heard that he had AIDS. The man had to be forcefully
restrained and was taken to the healthcare centre. On the way to the centre,
he said to staff that he “wanted to end it all”. He also said that ropes had
been found under his bed and that staff were going to use them to hang him.
was seen by a nurse.
The nurse told my investigators that as soon as the man arrived in the
healthcare centre, he “singled him out” to talk to him. The nurse therefore
thought that if he gave the man his attention “things might get better”. The
man repeated to the nurse his claim that ropes had been found under his bed.
The nurse told my investigators that he did not believe this was true. He said
that he told the man he would help and protect him and that he did not think
that there were any ropes. The nurse thought that the man was ill and knew
27
that if he were to return to the wing his health would be adversely affected.
The nurse therefore decided to admit him and to open a F2052SH.
The next day, the man was seen by a doctor who diagnosed him as suffering
from paranoia and decided to refer him for psychiatric assessment.
The dramatic change in the man over a period of a little over two weeks is
impossible to explain. It is possible that he quickly became frightened by
being locked up for the first time in a prison cell with people he did not know
and that this was the basis of his paranoia. It is also possible that he had
access to mood altering drugs on his wing: the toxicology report showed
evidence of “earlier use of cannabis”. But there is no evidence to confirm that
he did take drugs after his arrival at Doncaster or to show this may have
contributed to the deterioration in his mental state.
(cid:127) How was the man able to hang himself given the layout of the cell? How
did he connect the ligature in the door?
The man died in a cell on the upper floor of the healthcare centre. The cell
was designed in such a way as to minimise the risk of the occupant harming
himself by any means. It contained a bed that was totally boxed in and affixed
to the floor without any springs or sharp edges. The bed could not, therefore
be moved. There were no points on or around the bed from which a ligature
could be fixed. The bedding provided comprised a mattress, pillow and quilt.
Affixed to the wall were a toilet and a sink. All fittings lacked ligature points or
any items that could be removed or used for self-harm purposes.
The cell door took the form of a metal grille-gate rather than a solid door. By
this means, observation into the cell could be maximised. However, to
prevent the bars on the door from being used as ligature points, a sheet of
Perspex, a few millimetres thick, was fitted to the inner surface. The Perspex
was dark blue and heavily scratched. Around the perimeter of the sheet was
a tiny gap between it and the door frame. However, at the bottom of the door
the gap was sufficiently large to enable items to be pushed along the floor and
into the cell. The investigation found that not only did the presence of the
Perspex sheet impede observation into the cell, it also impeded
communication.
To the casual observer, the possibility that a ligature could be attached to the
door frame seemed remote. At the top and sides of the door the gap between
the Perspex and the frame was no more than two or three millimetres.
However, the man succeeded in placing the ligature he had made from his
quilt in the gap that was available and placing the other end around his neck.
When he was discovered, he was in a sitting position with his body weight
against the door. It appeared that he had, in that position, possibly pulled
down on the ligature and asphyxiated himself.
(cid:127) Why was the man provided with bedding and clothing with which he could
kill himself?
The investigation found that the only bedding in the man’s cell at the time of
his death was a mattress and a quilt. When he was discovered hanging, he
28
was dressed only in his underpants. The ligature he used was fashioned from
a piece of material he had torn from his quilt cover. I am satisfied that the
materials that were available to him at this time drew an appropriate balance
between reducing his risk of self-harm and depriving him of basic comfort.
However, I have the following comments to make about certain aspects of the
management of his attempts at self-harm earlier in September. On 13
September, he made a ligature from his t-shirt and used it to try to hang
himself in his cell. This was a serious attempt by the man to harm himself: the
tautness of the ligature left red marks on his neck. At the time, he was being
observed every 30 minutes. As a result of this development, the frequency of
observations was increased to level two - every 15 minutes. This seems to be
an appropriate reaction by the healthcare staff. However, the investigation
found no evidence to show whether the man’s t-shirt was removed.
On 16 September, the man made another ligature, again fashioned from a t-
shirt. On this occasion, although he had pushed the ligature through the cell
door, he did not place it around his neck. This time, the t-shirt was removed.
Although I have concerns that this may not have been done on the first
occasion, I am satisfied that sufficient account was taken of the man’s risk of
carrying out yet another similar self-harm attempt by removing his t-shirt on
this second occasion.
(cid:127) Why was the man not on a constant watch given his previous attempts at
self-harm?
The following table shows the cell locations and level of observations decided
upon after each of the man’s self-harm attempts at Doncaster:
Date Details of self-harm Cell Observations at Decisions made
time of self-harm
13 Sept 5pm Made a ligature from his HCC Level 3: every 30 Moved to cell 2.28
bedding. Wedged one end 2.27 minutes
in the door and placed the No change in
other around his neck. observations
13 Sept 5:30pm Made a ligature from his t- HCC Level 3: every 30 Observations
shirt. Wedged one end in 2.28 minutes changed to level 2:
the door and the other every 15 minutes.
around his neck. Red marks No change in cell
left on his neck. location
14 Sept 3pm Tried to cut his arms with a HCC Level 2: every 15 No change in
plastic knife. 2.28 minutes observations.
No change in cell
location
16 September Made a ligature from his t- HCC Level 2:every 15 No change in
9:45am shirt. Wedged one end in 2.28 minutes observations.
the door but did not place it No change in cell
around his neck. location
Each decision made in respect of the frequency of observations to be applied
to the man was made by a nurse. After each of his self-harm attempts, the
High Risk Assessment Team convened to review his case.
29
The panel that met on 14 September, following the man’s two self-harm
attempts the previous day, agreed that, in line with the decision made by a
nurse, the man should continue to be observed every 15 minutes. The
member of staff who submitted a report to the case review admitted that he
did not interview him prior to the review because he thought by doing so he
might aggravate him. However, information offered to the review by staff
suggested that the man was concerned that he was in debt on the wings, and
that he was feeling paranoid. It was reported that he spent most of his time
banging and shouting in his cell and that he was due to see a psychiatrist the
following day to determine whether there were any issues underlying his
behaviour. It was noted that he had a history of self-harm, but that he said he
denied any future self-harm intent. The HRAT concluded that he should
continue to be observed every 15 minutes.
The man’s second attempt at self-harm on 13 September resulted in red
marks on his neck, such was the tautness of the ligature. At the time, he was
being observed every 30 minutes and was in cell 2.28. It is fortunate that he
was found early enough to prevent him from inflicting more serious harm. The
options available to staff for preventing a further attempt at self-harm were
limited. There was no better cell available, but the frequency of observations
could have been increased either to level two (every 15 minutes) or to a
constant watch. I believe that, in view of the nature of the information
available, the decision to increase the frequency of observations to level two,
rather than to a constant watch, was justified. However, as I will argue later, I
am concerned that insufficient account was taken of the fact that the man had
placed a ligature in the door frame and had suspended himself from that
ligature point in a cell regarded as the safest cell in the healthcare centre.
After the man’s next self-harm attempt on 14 September when he tried to cut
his arms with a plastic knife, the HRAT agreed, once again, that the frequency
of observations to be applied to the man should continue at 15 minute
intervals. The case review summary took account of a report from a nurse
that the man was more settled than he was the day before, but was still
unpredictable. The summary also mentioned that he had said that his self-
harm attempt of the previous day was an attention seeking game and that he
was not feeling suicidal. The man had been seen by the psychiatrist earlier
that day. The case summary referred to the fact that the psychiatrist felt
unable to make a proper assessment at that time. With the benefit of
hindsight, one might feel that a different judgement should have been made
as to the risk of suicide the man presented on 15 September. However, given
the information and evidence available, I believe the decision that he should
continue to be observed every 15 minutes was justified.
The self-harm attempt the man made on 16 September was his fourth attempt
at self-harm in as many days. The review of his case following this episode
did not take place until Monday 19 September. The record shows that his
review was chaired by the Suicide Prevention Co-ordinator and attended by a
nurse and the Clinical Manager. The review summary noted that over the
weekend, the man had been banging and shouting in his cell, “asking for his
mum”, and “palming medication”. The summary also referred to the fact that
30
the psychologist who wanted to assess him prior to the review was unable to
do so in the cell a the man was still on a “2 man unlock”. Nevertheless, the
psychologist submitted to the panel his view that the man had remained “quite
agitated” over the weekend and referred to a comment made by him that “the
police were coming to take him away in a helicopter”.
The cumulative effect of yet another episode of self-harm was mitigated by
the fact that, when discovered, the man had not placed the ligature around his
neck. However, the option of increasing the frequency of observations to a
constant watch was available.
My investigators interviewed a nurse who saw the man that day after the
ligature had been found. The nurse was asked whether she considered
placing the man on a constant watch. She said that, at the time, she was not
unduly concerned about him. The nurse thought that she might have been
influenced by the fact that the man had not placed the ligature around his
neck.
When seen in isolation from the man’s earlier self-harm attempts, this
particular episode may not have justified a decision to place him on a constant
watch. However, I am concerned that a number of other factors do not
appear to have been taken into consideration by staff in judging how best to
manage the man’s propensity for self-harm:
- He was being held in a cell that was described to my investigators
variously as an anti-ligature or ligature-free, or reduced-risk cell. At
5.30pm on 13 September, he sustained red marks on his neck after
trying to hang himself. As a result, the frequency of observations was
increased to a 15 minute watch. But that event clearly demonstrated
that it was possible for a prisoner to hang himself in the cell. The
Perspex sheet fitted to the interior aspect of the cell door actively
inhibited visibility into the cell. It also made it difficult to communicate
with the occupant. Such difficulties were brought into sharp relief by
the psychiatrist’s description of his interview with the man from the
corridor on 15 September. The man had already demonstrated on 13
September how quickly he could, unobserved, place a ligature in the
door frame of the cell. Thus, not only did it inhibit monitoring of the
man, but it must also have had a debilitating effect on him. At a time
when his mental state was unstable, his sense of isolation was
probably increased by an inability to see or hear properly any person
who spoke to him.
- The self-harm attempt on 16 September was the fourth such event in
as many days. It is clear that the healthcare staff and the High Risk
Assessment Team considered the man’s current presenting behaviour
after each self-harm attempt. It is less clear whether they took into
account the totality or the pattern of his behaviour over a period of time.
- Cell 2.28 is located farthest from the office on the upper floor of the
healthcare centre in which staff are situated. Thus, the only time its
31
occupant is likely to be observed is when a planned observation is
made. There is a case for considering whether the cell should be sited
nearer the staff office or if closed circuit television equipment should
be installed in the cell itself.
I believe that the options available for the better management of the man’s
self-harm should have included the replacement of the dark blue sheet of
Perspex in cell 2.28 with a totally transparent sheet that left no gap between it
and the door frame. The healthcare staff or the High Risk Assessment Team
should have considered inviting the man to attend his case reviews. They
should also have agreed a proactive and strategic approach to his
management rather than reacting each time he self-harmed. They should
have considered the totality of his behaviour rather than dealing with each
self-harm attempt in isoIation.
I must be careful not to intrude into matters that have yet to be considered by
a Coroner’s jury. However, I believe that, on 16 September, there was a case
for placing the man on a constant watch. This option could have been
initiated in conjunction with either the removal or the replacement of the
Perspex sheet. The Coroner’s jury may wish to consider if the man’s death
could have been prevented had these actions been taken, and had the overall
pattern of his behaviour been examined that day.
The Director should, as a matter of urgency:
- Either: arrange for the removal of the Perspex sheet fitted to the
inside of the door in cell 2.28 in the healthcare centre so
that the cell can only be used as a gated cell,
or: arrange for the replacement of the dark blue Perspex with
a totally transparent sheet that leaves no gap between it
and the door frame.
(These options should be discussed with Safer Custody Group in
NOMS Headquarters.)
- Review local suicide prevention policy to ensure that prisoners
considered to present a risk of suicide or self-harm attend their
own case reviews as a norm unless there are exceptional reasons
for not doing so. Any such reasons should be fully documented.
- Issue clear guidance as to what criteria should be used in judging
whether an at risk prisoner should be placed on a constant watch.
- Consider the merits of re-siting the staff office on the upper floor
of the healthcare centre so that it is nearer the cells that hold
prisoners in need of frequent observation.
32
- In conjunction with Safer Custody Group in NOMS Headquarters,
consider the merits of installing closed circuit television
equipment in cell 2:28 on the upper floor of the healthcare centre.
(cid:127) Did the man store drugs so that he could overdose?
On 16 September, a nurse recorded that the man had asked for tablets so
that he could die. He was told that he would only be given medication that
had been prescribed.
The nurse concerned explained that no medication was kept in the
possession of inpatients. Rather, it was administered from the drug trolley
under supervision. She told my investigators that, even so, it was not
possible to prevent a prisoner storing drugs so that he could overdose. The
nurse said that it was possible for a prisoner to swallow tablets and later to
regurgitate them.
The investigation found no corroborative evidence that the man was storing
drugs with the intention of overdosing. The toxicology report submitted to the
Coroner commented as follows:
“The results reflect earlier use of Cannabis. They do not
suggest intoxification with cannabis at the time of death. The
concentration of Diazepam is low and would be unlikely to
reflect regular therapeutic range dosage. Procyclidine (traces
of which were present) is occasionally abused. It is also often
co-prescribed with oral or injected neuroleptic or anti-psychotic
drugs. These drugs may not be detected on routine
screening. Further directed analyses may be possible if the
deceased was prescribed anti-psychotic medication.”
Neither the toxicology report nor my investigation into the man’s death
uncovered evidence that he took an overdose of any drugs, whether
prescribed or not.
(cid:127) Was the man’s mental health properly assessed and managed?
Upon the man’s admission to the healthcare centre on 12 September, a
nursing care plan was opened. The plan was based on an assessment of his
current mental state and on his psychiatric history.
The interventions planned for him listed a number of objectives designed to
prevent his self-harm and to promote his mental health wellbeing, including
recommendations for his referral to a registered mental nurse and to a
psychiatrist.
The entries made in the daily review communication sheets that form an
integral part of the nursing care plan logged frequent descriptions of the
events that occurred while the man was an inpatient.
33
In the clinical review, the author makes the following comments about the
quality of the mental health care afforded to the man in general, and
specifically about the quality of the nursing care plan:
Page 6
“Whilst there is evidence of an initial plan of care there is no evidence
of subsequent amendments or reviews to his plan of care. The man’s
progress is documented as indicated in the IMR, weekly care plan
evaluation sheet and daily review communication sheet, but this
represents a diary rather than any systematic review and reappraisal of
his plan of care in light of subsequent problems and events.”
Page 9
“It is clear from the documentary evidence that his progress and care
were well documented. However, it is difficult to determine from the
care plan whether an holistic plan of care had been determined as it
focussed principally on the physical dangers associated with his
attempts at self-harm. Other physical and mental health issues do not
appear to have been explored from the point of view of treatment and
so underlines what seems to have been a reactive strategy.”
Page 10
“The man’s pathway of care is described in the various documents
presented. However, the main purpose of these documents would
appear to detail progress rather than determine a cause. There is
evidence of care planning. However, this seems to be rather limited in
its scope in terms of any holistic approach …
“… From interviews with members of the Mental Health In-reach Team,
it would appear that efforts were made to determine what, if any,
previous mental health problems the man had suffered. However, this
had little success and provided little information. Referral to the Mental
Health In-reach Team would appear to have been informal as they
stated that they became aware of him simply because of his disruptive
behaviour due to the proximity of their office and the upper health care
unit and they could hear him and so intervened informally.”
Page 11
“… Evidence is provided that the regime of treatment had been
reviewed and amended. However, there is no evidence of any other
form of therapy or treatment. Intervention seemed principally to be
reactive.”
At interview, my investigators asked the prison doctor what forms of treatment
had been considered for the man other than medication. The doctor said:
34
“There isn’t any other formal prescription of treatment. If his
mental condition was deteriorating to such an extent that he
needed to have more intervention, he would have been
sectioned under one of the Mental Health Acts. And that is an
option that we would take, and have taken before. He would
then be removed from the prison and taken to another facility
where he could be treated. Under the Mental Health Act you
can instigate treatment as necessary but we cannot do that in
prison. We do it in conjunction with the psychiatrist but we are
guided by the consultant psychiatrist’s assessment of the
patient. They have the experience and the knowledge for that,
but I cannot do it on my own.”
The doctor could not clearly recall whether he discussed this option with the
psychiatrist. However, the doctor told my investigators that he and the
psychiatrist were considering the use of acuphase. The doctor explained as
follows:
“Acuphase is a drug that is administered intra-muscularly for
people who are extremely disturbed or agitated. We have a
protocol for administering that. We just can’t say that the
doctor says give him acuphase. We have to have a formal
assessment by a psychiatrist and then mental health nurses
need to assess him as well and make a decision. We video
tape the whole procedure to prove that we have actually done
that. The other possibility would have been sectioning him
and removing him from the prison. Yes, on reflection I may
have discussed that with the psychiatrist and that’s why he
said to me, ‘Give him the medication (lorazepam and
haloperidol). See what happens to him and we will reassess
him again.’ And part of the reassessment would have been
these options.”
During his interview with my investigators, the psychiatrist said that,
after assessing the man on 15 September, he thought there might be
“some suggestion of underlying mental illness”, but he was not sure.
The psychiatrist gave no indication that he had considered the option
of transferring him to a psychiatric unit, but it is clear from the
treatment he recommended after seeing the man that he was
prepared to review his case again if necessary.
In his clinical review of the management of the man’s health needs,
the author of the clinical review comments:
“Evidence is provided that the regime of treatment had been
reviewed and amended. However, there is no evidence of any other
form of therapy or treatment. Intervention seemed principally to be
reactive.”
35
The clinical review includes a specific recommendation that care
planning at Doncaster should be reviewed to emphasise the
importance of a holistic approach.
(cid:127) How could the psychiatrist carry out an effective assessment of
the man on 15 September through the door of his cell?
The psychiatrist told my investigators that it was his normal practice to
interview prisoners in a room in the healthcare centre. The only
circumstances in which he would not do this were if he was advised by prison
staff that there were safety issues. In such circumstances, he would talk to a
prisoner with the cell door open or through the hatch in the door, or, as was
the case with this man, through the Perspex. On 15 September, the
psychiatrist was advised that it was unsafe for him to interview the man with
the cell door open. This was because he had earlier rushed past an officer as
he opened the cell door, with the result that the officer was injured. The
psychiatrist therefore remained outside the cell and talked to him through the
Perspex. He told him the man that he could not see him properly. The man
therefore came to the door and stood against the Perspex. An officer stood
nearby, out of earshot. The cell next to the man was occupied by another
prisoner. At interview, the psychiatrist said he felt that the confidentiality of his
interview with the man was not impaired by his proximity to the other prisoner
or to the officer. However, he recalled that both the Perspex and the cell
lighting made it difficult for him to see. He said, “The assessment
circumstances were far from ideal in the sense that it was not face to face, it
was through Perspex.”
Nevertheless, the psychiatrist completed his assessment of the man and was
able to reach a conclusion that he should continue with chlorpromazine and
that his progress should be monitored.
It is much to the psychiatrist’s credit that he continued to conduct an interview
with the man in such adverse circumstances. That said, and however much I
recognise the need to protect staff from volatile and unpredictable prisoners,
and the limited resources available at Doncaster for private consultations, it
was entirely inappropriate for the psychiatrist to have to interview the man in
such circumstances. He could hardly see the man, let alone speak to him.
There was no guarantee of privacy. Whatever difficulties the psychiatrist
experienced, it is not hard to imagine the limitations placed on the man or
himself during the interview.
The Director should take urgent steps to provide appropriate facilities
and resources that allow specialists to see patients in conditions of both
safety and appropriate privacy.
(cid:127) Why was the man’s family not informed that he had been admitted to the
healthcare centre and that he had tried to self-harm?
36
The Prison Service has issued guidance to staff about the involvement of
relatives and friends in ACCT Reviews. At page 11 of the ACCT form, the
following general guidance is given:
“Ideas to help diffuse a crisis and address problems:
Has suicide plan: Disable the plan
Practical problem triggering pain: Neutralise pain/help solve problem
Mental health or withdrawal problems: Refer to health worker
Alone: Link to social support (e.g. family, friend, Listener, staff)
Feels low: Help get more active, involve in regime
Pattern of self injury: Distraction, comfort, alternatives
Known factors that indicate higher risk: Note these in trigger boxes and
monitor for these occurring.”
At page 12 of the ACCT document, the following specific advice is given in
relation to the conduct of effective reviews:
“Consider asking the individual if he/she wishes a
friend/relative/Listener to attend the Case Review. If so, you
must ensure that the individual (if an adult) has signed a
consent form for the relative/friend/Listener to attend. For the
under 18, it is good practice to involve the Child Protection Co-
ordinator and YOT worker, and if appropriate, the
parents/carer.“
The man was admitted to the healthcare centre on 11 September. Three
days later, a nurse became so concerned about him that she felt it necessary
to contact his next of kin. On 14 September, she wrote in his medical record
the passage I quoted earlier:
“Registered with CPA (Care Pathway Approach) in Leeds.
They have his name, date of birth, and address, but no
referral details on file. GP’s contacted via health authority-
nothing on file. NOK (next of kin) ... (sister) - no number for
that address on file. Girlfriend ... mobile number not
recognised. No persons for that name and address with BT.
At interview, the nurse said to my investigators,
“I remember trying to contact his family, his sister and his
girlfriend. I attempted to contact his GP for information and we
came across a brick wall all the way. The phone numbers that
he had given us for his sister and his girlfriend were
unobtainable. I can say that because I made both calls. I also
then checked with BT to make sure that I had written the
number correctly. I gave them names and addresses and
there was nobody listed for either addresses he’d given us. I
37
can’t remember if he gave me his GP’s address but I
contacted the health authority at his home address to see
which GP he was registered with. I contacted that GP’s
surgery and they had nothing.”
The nurse explained that, at the time, she was trying to establish if the man’s
current behaviour was typical of his normal presentation. She said:
“If perhaps the day that he came into prison he’d had half an
hour of lucidity, I would have been fortunate enough to sit
opposite him and to establish whether his presentation was
normally so bizarre or whether his bizarre behaviour was due
to his incarceration.”
The nurse emphasised that the only person to whom she spoke was the GP’s
receptionist and so she did not disclose any information about the man. She
said that, had she been able to speak to a family member, she would not
have discussed such issues over the phone. Rather, she would have asked
the family to come in to the prison to talk about his disposition face to face.
The man’s sister and aunt told my investigators that they were aware that
attempts had been made to contact them but that none was successful.
However, they suggested that someone could have contacted them via his
aunt’s address to which he had been bailed, or with the help of his solicitor or
the police.
I sympathise with the family on this point. It is clear that the nurse did think of
contacting them and that she made a genuine effort to do so. If there was
reason to contact the family by 14 September, there were certainly good
grounds for doing so thereafter, given the deterioration in the man’s
demeanour. There was no evidence that any further attempts were made to
communicate with, or to involve, the family after 14 September. The
investigation could not find any evidence to show that the man gave his
consent for staff to contact his family. However, it is acknowledged that the
nurse’s efforts were in his best interests.
The Director should develop a policy for communication with, and
involvement of, prisoners’ next of kin, using evidence based best
practice.
The healthcare provider and Director should review the learning
identified in the clinical review and develop an action plan to address
the points raised.
(cid:127) The Post Mortem report says that there were scratches on the man’s chest
and describes these as evidence of self-harm.
My investigators took advice on this point from the author of the clinical
review. The author expressed the view that the marks found on the man’s
chest were likely to have been caused by the intervention of the paramedic
38
crew in using specialist equipment to attempt to revive him. There is no
evidence that the marks were the result of any self-harm attempts by the man.
(cid:127) Why did it take so long to break the news of the man’s death to the family?
The man’s sister told my investigators that, at about 10.30am on 20
September, a man she did not know knocked on her door and told her that
“something had happened to her brother.” She said that she went to her
aunt’s house and that her aunt then telephoned the prison twice. On the first
occasion, her aunt was not certain what the person on the other end of the
phone was talking about. She therefore phoned again at about 2:30pm and
spoke to a woman whose name she did not know. On this occasion, she said
her aunt was told that her brother had died and that the chaplain would be
visiting her at about 5pm. She said the chaplain and someone else arrived at
4pm.
My investigators spoke to the Director of HMP/YOI Doncaster and interviewed
the chaplain about this point. The Director explained that he rang the
telephone number listed in the man’s prison record for use in an emergency in
order to break the news of his death. The number was that of his girlfriend.
However, there was no answer. As there was no other contact telephone
number listed, the Director next rang the man’s Probation Officer who offered
an alternative number. At the same time, a prisoner rang the man’s uncle to
tell him about the man’s death. The uncle rang the prison to find out more
details and was put through to the Director. As the Director did not know the
uncle, and as he was not listed as the man’s next of kin, he was initially
reluctant to give any further details. However, in view of the risk that other
prisoners might do so, the Director decided to confirm the man’s death to the
uncle there and then.
At interview, the Chaplain told my investigators that, shortly before the man’s
death, an agreement had been reached with the local police that before any
family was visited by officials from the prison, a risk assessment had to be
carried out because, occasionally, such visits had caused difficulties in the
community. The Chaplain explained that the completion of a risk assessment
gave the police the opportunity to consider the most appropriate way to
manage family visits.
When the West Yorkshire Police were contacted, they explained that there
was a tall ships race taking place that day, attracting a huge number of
spectators. The police therefore advised that, in view of the heavy traffic in
the area, they were better placed to break the news of the man’s death to his
relatives. However, my investigators could find no evidence that the police
actually informed his family of his death.
At about 5pm that day, one of the Assistant Directors at Doncaster
accompanied the Chaplain to the home of the man’s family to break the news
39
personally. When they arrived, they discovered that the family had already
been informed by a prisoner.
I recognise that the man’s relatives must have been very distressed by the
manner in which they came to learn of the news officially so long after he had
died. However, it is clear that the Director and his staff made reasonable
attempts to contact the family as quickly as possible. Their attempts were
frustrated by a telephone call made by a prisoner to the man’s uncle and by
other circumstances beyond their control.
40
RECOMMENDATIONS
I make the following recommendations:
The Director should, as a matter of urgency :
1. Either: arrange for the removal of the Perspex sheet fitted to the
inside of the door in cell 2.28 in the healthcare centre so
that the cell can only be used as a gated cell,
or: arrange for the replacement of the dark blue Perspex with
a totally transparent sheet that leaves no gap between it
and the door frame.
(These options should be discussed with Safer Custody Group in
NOMS Headquarters.)
The Prison Service accepted this recommendation and said:
“New specially designed doors have been fitted to cells 2.27 and 2.28 which
incorporate safety glass. The identified reduced risk cells are not gated and
the transparent panels leave no gap between the safety door and the frame.
These would be the only healthcare cells used for constant observation.”
2. Consider the merits of re-siting the staff office on the upper floor
of the healthcare centre so that it is nearer the cells that hold
prisoners who are considered to be most in need of frequent
observation.
The Prison Service did not accept this recommendation, and said:
“There are procedures in place to monitor prisoners, e.g. continuous
observation for those considered to be at a high level of risk. It would not be
reasonable to expect that an officer should remain located in an office at all
times for this purpose, and in fact officers would be encouraged to move
about the unit.”
3. In conjunction with Safer Custody Group in NOMS Headquarters,
consider the merits of installing closed circuit television
equipment in cell 2-28 on the upper floor of the healthcare centre.
The Prison Service partially accepted this recommendation and said:
“HMP/YOI Doncaster would not wish to rely on a person observing a TV on
UHCC. However, we would undertake a continuous observation if someone
was considered to be at a high risk. Where this occurs, there would be staff
member outside the cell. As an additional resource, this might be useful.
However, we would not wish it to detract from one to one interaction and
observation with the patient/prisoner.”
41
4. Review local suicide prevention policy to ensure that prisoners
considered to present a risk of suicide or self-harm attend their
own case reviews as a norm unless there are exceptional reasons
for not doing so. Any such reasons should be fully documented.
The Prison Service accepted this recommendation and said,
“The current ACCT process ensures that prisoners are present at their own
case reviews. If this is not possible, a record of this would be made in the
appropriate documents. This process is overseen by the dedicated Suicide
Prevention Co-ordinator.”
5. Issue clear guidance as to what criteria should be used in judging
whether an at risk prisoner should be placed on a constant watch.
The Prison Service accepted this recommendation and said:
“Clear guidance is given in Director’s Rule 18.1, within the ACCT paperwork
and via suicide prevention training.”
6. Take urgent steps to provide appropriate facilities and resources
that allow specialists to see patients in conditions of both safety
and appropriate privacy.
The Prison Service accepted this recommendation and said:
“An interview room is available on UHCC and on the middle healthcare
location.”
7. Develop a policy for communication with, and involvement of,
prisoners’ next of kin, using evidence based best practice.
The Prison Service accepted this recommendation and said:
“The revised Prison Service Order 2700 lays greater emphasis on the
involvement of families in the ACCT process. This will be published in Spring
2007. The Suicide Prevention Co-ordinator intends to lead a discussion
around communication with next of kin and a local policy will be devised.”
8. The healthcare provider and Director should review the learning
identified in the clinical review and develop an action plan to
address the points raised.
The Prison Service accepted this recommendation and said:
“Immediate actions were taken following the death of this man, i.e. change of
doors.”
42
The recommendations made in the clinical review are:
1. Although no criticism is inferred in this case, the importance of
vigilance during reception screening needs to be emphasised
ensuring the process does not become mechanistic. This needs
to be communicated to staff and staff training for reception
screening reviewed.
The Prison Service accepted this recommendation and said:
“The reception process has been reviewed and changed in line with Prison
Service guidelines for first night reception screening. HMP/YOI Doncaster
have also developed their own secondary screening process and staff have
undertaken training.”
2. The processes which ensure effective communication between
Prison Custody Officers and Nursing staff in the Healthcare
Centre working on the Upper Health Care need to be reviewed.
Effective liaison needs to be ensured so that staff feel adequately
supported. It would be preferable that one common record is
used between Prison Custody Officers and Nursing Staff ensuring
continuity and a shared understanding of the patient’s care and
progress.
The Prison Service accepted this recommendation and said:
“The Healthcare Manager is currently in discussion with PCT with a view to
developing integrated notes into which the officers and other identified
persons may contribute. A dedicated nurse is also identified on a daily basis
and alongside the Healthcare Manager and Senior Nurse/s would be the link
between Officers and nurses. Officers also attend case reviews for ACCT on
a regular basis and provide a valuable contribution.”
3. Where patients are thought to have significant mental health
problems, referral to NHS Mental Health services should be
routinely considered and any discussion and decision
documented. Referral process should be reviewed and any
changes cascaded ensuring staff fully understand when this
should be considered and the mechanism to do so. Problems
encountered in terms of referral and/or appropriateness of
services available should be raised with the commissioning PCT.
The Prison Service accepted this recommendation and said:
“Referrals are made to a contracted Forensic Consultant Psychiatrist.
Following assessment if referrals are required to NHS Mental Health Services
they would be initiated at this point. There is also a referral process in place
for secondary mental health issues via the mental health in-reach team.”
43
4. Care planning needs to be reviewed emphasising the importance
of a holistic approach, strengthening the review process clearly
providing a rationale for action. It should demonstrate the
therapeutic role of care/intervention rather than a purely
monitoring function as is supported by the Nursing and Midwifery
Council Guidelines for Record Keeping (2005).
The Prison Service accepted this recommendation and said:
“Currently all healthcare patients are subject to an individual care planning
process. The implementation of integrated notes will enhance this process.”
5. Accurate record keeping is essential. The prison should ensure
that all prisoner/patient records meet established record keeping
guidelines (Nursing and Midwifery Council Council (2005),
Guidelines for Record Keeping, Department of Health, 2006, NHS
Code of Practice Records Management ). Each entry should be
signed and authors should print their name to facilitate
identification. The prison should consider routinely undertaking a
record-keeping audit to ensure record keeping standards are
maintained.
The Prison Service accepted this recommendation and said:
“A record keeping audit has been undertaken and this will advise for future
training issues. This will be undertaken bi-annually. Ongoing individual
refresher training is being undertaken.”
6. The process for deciding the level of watch for patients at risk of
self harm needs to be reviewed and any changes clearly cascaded
and understood by all staff. The mechanism needs to be
transparent and documented.
The Prison Service accepted this recommendation and said:
“Director’s Rule 18.1 clearly states how to document and cascade information
in line with ACCT procedures.”
7. The HRAT team needs to ensure the active involvement of the
patient in review. This may include attendance by the patient, or
patient’s advocate. The role, purpose and outcome of the review
needs to be communicated to patients so that they understand
this.
This Prison Service accepted this recommendation and said:
“The ACCT process is multi-disciplined and the patient is invited to the review
if he is deemed fit to do so.”
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8. As a matter of urgency the ‘safer custody cell’ needs to be
reviewed:
(cid:127) Potential ligature points identified and removed/minimised.
(cid:127) Perspex cover needs to be replaced with clear rather than
tinted Perspex, this needs to be assessed and renewed as
necessary when significantly scratched/damaged.
(cid:127) In order to ensure effective observation it is recommended
a closed circuit TV camera should be considered, securely
positioned in the cell ensuring continuous monitoring. It
should be emphasised to staff the need for actual physical
monitoring and this should include interaction with the
patient when appropriate to determine mood, behaviour and
response to treatment.
The Prison Service accepted the first two of these three recommendations
and partly accepted the third. The Service’s response the first two
recommendations was as follows:
“The cells were reviewed and urgent attention was paid to the revision of
cells.”
The Service’s response to the third recommendation was the same as for
recommendation three above.
9. Following significant events such as this it is recommended that
the prison consider facilitating Significant Event Analysis for
staff, in an open, blame free environment they can discuss
underlying issues, tease out learning points both positive and
negative and support each other. This should be in addition to
any routine debriefing following such an event.
The Prison Service accepted this recommendation and said:
“A process for significant event analysis is now being undertaken in
conjunction with our PCT colleagues. Routine de-briefing is undertaken as a
matter of course following any significant event and there is also a process for
referral and support by the staff care team.
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