Individual at Forest Bank

Investigation into the circumstances surrounding the
death of a man at HMP Forest Bank
in July 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
October 2008
This is the report of an investigation into the death of a man who was found
hanging in his cell at HMP Forest Bank on 15 July 2007. He was 38 years of
age.
I would like to offer my own and my colleagues’ condolences to the man’s
family and friends. I hope that my report addresses all the concerns they may
have. I must also offer my apologies for the delay in its completion.
The investigation into the man’s death was carried out on my behalf by one of
my investigators. A clinical review was conducted by Salford Primary Care
Trust (PCT). I would like to thank the then Director of Forest Bank and his
staff for their co-operation and assistance.
The man had been in Forest Bank for a number of months and was an
enhanced prisoner with no warnings or adjudications against him. However,
two weeks after his arrival at the prison, the man had referred himself to the
mental health team. He was assessed and diagnosed as suffering from
depression. Although the man’s mental health appeared to improve, on the
afternoon of 14 July 2007 he received a telephone call from his partner ending
their relationship. Some time the following evening, the man appears to have
taken his own life.
This is the first apparently self inflicted death to have occurred at HMP Forest
Bank since my office began investigating all deaths in prison custody in April
2004. My investigation into the man’s death highlights a number of lessons
regarding healthcare issues and the staff response when an alarm is raised.
I have made nine recommendations and indicated a number of other issues
that the Director of Forest Bank will wish to address.
Stephen Shaw
Prisons and Probation Ombudsman October 2008
CONTENTS
Summary 4
The investigation process 6
HMP Forest Bank 9
Key findings 10
Issues 18
Recommendations 23
Annexes 24
SUMMARY
The man was transferred to Forest Bank from Ashton-Under-Lyne Police
Station on 30 March 2007. The man’s escort records said that he suffered
from mental health problems. On his arrival at Forest Bank, the man went
through the standard induction process. Although part of the reception
process involves a medical assessment, my investigation has found no
evidence to confirm that the man received one.
The man settled into prison life quickly and his records indicate that he had no
known problems. However, on 11 April 2007, the man approached a member
of the Mental Health In Reach Team (MHIRT) asking to be seen by someone.
A mental health assessment was conducted on 24 April. It was recorded in
his medical record that he was feeling low and depressed and was
experiencing suicidal thoughts. The man was prescribed anti-depressants.
After the man’s assessment, two members of the mental health team
discussed whether it would be necessary for him to be put on an Assessment,
Care in Custody and Teamwork (ACCT) document. (The ACCT is a
document used to assess, observe and support prisoners at risk of self harm.)
A decision was taken that, at that stage, the man would not be placed on an
ACCT but would be assessed for any increased risk of suicide.
Over the subsequent weeks, the man was assessed weekly by members of
the MHIRT. Although no significant change in his mood was noted, the man
told staff that he continued to feel low. He felt his medication was not working
and he was sleeping poorly. MHIRT staff told the man that his medication
would take time to work and that it would be reviewed in a couple of weeks.
On 24 May, the man was again seen by a member of the MHIRT. Once more
he reported symptoms of depression and disturbed sleep, but denied any
thoughts of self harm. The strength of the man’s medication was increased.
Entries on the man’s wing history sheets recorded that he was pleasant, polite
and quiet, and caused no problems on the wing. As a consequence of his
good behaviour, the man was given enhanced prisoner status on 1 July. An
officer who regularly had contact with the man said that he had a nice manner
and never seemed to complain about much.
The man was seen again by a member of the MHIRT on 6 July. It was
reported that, since the increase in dose of his medication, his mood had lifted
significantly and there had been an improvement in his energy and motivation
levels. In the weeks leading to his death, the man showed no signs of
depression and was optimistic about his future.
At around lunchtime on 13 July, the man and his sister discussed the
possibility of his son being brought into prison to see him. Soon after, the
man spoke to his partner who informed him that she would not allow the visit.
The man spoke with his sister again that evening, discussing possible
alternative arrangements for his son to visit.
On 14 July 2007 at 12.46pm, the man had a difficult telephone conversation
with his partner. She informed him that she would not allow him to see their
son and told the man that she no longer wished to see him, ending their
relationship. On finishing the call, the man was seen to smash the telephone
receiver.
The man was heard to slam his cell door on two separate occasions that
afternoon. On investigating, staff found the man sitting on his bed, upset and
angry. A prisoner who was sitting with the man said that he had received a
bad phone call. Before lock up that evening, the man apologised to staff for
his behaviour earlier in the afternoon.
At 3.28am the next morning (15 July 2007), the man was found hanging from
the door of his cell. On being alerted to the emergency, staff went to the
man’s cell. It was clear that the man had been dead for some time so cardio
pulmonary resuscitation was not attempted. The man was subsequently
pronounced dead by paramedics at 4.15am.
As a result of my investigation, I have made nine recommendations to the
Director of Forest Bank. In particular, I have asked him to review the prison’s
night procedures and advice to staff on when to enter a cell when a prisoner
has apparently self harmed. I have also asked him to consider changing the
emergency call signs used at Forest Bank in order to make them easier for
staff to understand.
I have made a number of recommendations relating to healthcare issues in
the prison. These include a recommendation that the Director ensures that all
prisoners entering Forest Bank receive the mandatory healthcare
assessment. I have also recommended a local review of issues surrounding
self harm risk and medical confidentiality. I have also been concerned that
staff may not be recording their interactions with prisoners as effectively as
they could, and that there is uncertainty as to the actions to be taken at night if
a prisoner is found in a medical emergency,
THE INVESTIGATION PROCESS
1. My investigator carried out the investigation into the man’s death. Notices
were issued to staff and prisoners at HMP Forest Bank informing them of
the investigation and inviting them to contact my investigator. My
investigator met the Director of Forest Bank and the chair of the
Independent Monitoring Board (IMB). He also made himself known to the
local union representative.
2. My investigator was shown the wing on which the man spent the last
months of his life. They reviewed the man’s prison and health records, in
addition to other documentation made available to them, and interviewed
a number of staff and prisoners.
3. An independent clinical review was undertaken on behalf of Salford PCT.
My investigator spoke with a Detective Inspector (DI) from Greater
Manchester Police who is acting on behalf of the Coroner. My
investigators have also been in contact with the Coroner’s office and a
copy of this report will be sent to the Coroner to assist with her enquiries.
4. The investigators had access to a copy of the CCTV footage from D wing.
Having reviewed the footage they established that the recorded timings
are approximately five minutes behind actual time. For the sake of clarity,
the CCTV timings quoted in this report have had an additional five minutes
added so that all timings correspond.
5. One of my family liaison officers, spoke with the man’s mother. The man’s
mother raised a number of issues. She said that the man was generally a
‘happy-go-lucky’ person and that his family were in shock with what had
happened. However, she recognised that something was wrong when the
man was in prison because of his weight loss and depression. She
believed that this was because the man’s girlfriend would not allow him to
see his son in prison and had refused to compromise.
6. The man’s mother told my family liaison officer of her concern that the
man might have obtained sleeping pills from another prisoner and that
these may not have mixed well with his anti-depressants. Although my
investigator was unable to establish whether or not this was the case, I
understand that there would have been no contra-indication to prescribing
sleeping tablets with anti-depressants.
7. The man’s mother explained that the police had broken the news of the
man’s death to her shortly before she and members of the family were
due to visit him in prison. She said that, although the police were kind,
they were unable to give her any specific information as to what had
happened.
8. The man’s mother talked positively about the help and support she and
her family had received from the prison. She said that the funeral
expenses had been met. The family visited Forest Bank and spent some
time in the man’s cell. The man’s mother confirmed that all of the man’s
belongings were returned to her, and she commented on the sensitive
way in which this had been done. The man’s mother said she was very
grateful for the efforts made by staff at Forest Bank.
HMP FOREST BANK
9. Forest Bank is a local prison in Greater Manchester and is managed and
operated by Kalyx, a private company. Built on the site of a former power
station, the prison opened in 2002. It has a population of over 1,000
remand, convicted and sentenced adult male prisoners and young
offenders. The prison serves all courts in the Greater Manchester area.
10. The establishment consists of six house blocks. Each block contains two
wings and there are two landings on each wing. D wing is an enhanced
wing with a capacity of approximately 175 prisoners.
11. Healthcare facilities at Forest Bank are provided by Kalyx. GP, pharmacy
and dentistry services are contracted out and are provided by local
practitioners. Services provided by the Mental Health In Reach Team are
commissioned from, and delivered by the Salford Primary Care Trust.
12. In August 2005, Forest Bank underwent an unannounced short follow up
inspection to that completed in 2002 by Her Majesty’s Chief Inspector of
Prisons, Ms Anne Owers. In 2002, Ms Owers had described Forest Bank
as a very good local prison. However, in 2005 she noted her
disappointment that progress had not been maintained, highlighting a
significant deterioration in safety.
13. The man had no contact with the prison’s Independent Monitoring Board
during his time at Forest Bank.
KEY FINDINGS
14. The man was received into custody at Forest Bank on 30 March 2007.
During his time at Forest Bank, the man appeared at court on a number of
occasions (the last being on 28 June). At the time of his death the man
was awaiting sentence.
15. Global Solutions Limited (GSL, now part of the company G4S) provide
escort services on behalf of Forest Bank. GSL staff noted in a Court
Application Form (used when the man transferred from Ashton-under-
Lyne police station to Forest Bank on 30 March 2007) that the man had a
‘mental condition’. This information appears to have been obtained from a
Prisoner Escort Record dated 29 March in which it said the man suffered
from mental health issues and had been treated for burns. (No other
escort forms make reference to the man’s mental health. It is not clear
how the man received his burns, although he had been remanded into
prison for arson.)
16. Upon his arrival at Forest Bank, the man was given a guided tour of his
wing, D2, and had an induction interview at which he was provided with
general information about prison life. The man gave his partner’s name
and contact details as his next of kin.
17. The man acknowledged on a Reception/Induction Checklist that a medical
examination would form part of the reception process. (My investigator
has found no evidence to suggest that an examination or first reception
health screen actually took place.) A cell sharing risk assessment was
completed by the reception officer concluding that the man would not be a
risk to other prisoners.
18. An entry on 8 April 2007 in the man’s wing history sheet said that he had
settled onto the wing and had no known problems. On 22 April, it was
recorded by wing staff that he had ‘no issues’. It was recorded in the
man’s medical record that on four occasions during early April he was
seen by healthcare staff to renew dressings for his burns.
19. On 11 April, the man approached a member of the Mental Health In
Reach Team (MHIRT) at the prison. He appeared distressed and asked if
he could be seen by a member of the team. (Members of the Mental
Health In Reach Team at Forest Bank are employed by Salford Primary
Care Trust (PCT). The team runs a system of open referrals. Prisoners
are able to make referrals themselves or can be referred by medical
officers or any other member of staff. The aim of the team is to see all
non-urgent referrals within 14 days and urgent referrals the same day.)
20. The man was seen by a mental health assessor on 24 April, fourteen days
after having referred himself. The assessor was on placement with the
MHIRT at Forest Bank. She later discussed her assessment with her
supervisor a Registered Mental Health Nurse (RMN) and Assessment,
Care in Custody and Teamwork (ACCT) trainer. (The ACCT is a
document used to assess, observe and support prisoners at risk of self
harm. It highlights the problems and possible trigger points of a prisoner
at risk of self harm, and delivers a multi-disciplinary plan to give prisoners
support and help through a period of crisis.) The registered mental health
nurse recorded in the man’s medical record that he had:
“… been feeling low and depressed for the past year currently
experiencing suicidal thoughts, in the evening. Has thought about
hanging himself, no immediate plans to act on thoughts. Discussed
presentation with G.P. prescribed Citalopram 10mg OD. Will review
twice a week, and assess mental state/current risk.”
The mental health assessor also noted the man’s history of suicide and
that he had made an attempt to hang himself in 1988. She recorded that,
should his risk of self harm increase, he should be placed on an ACCT
book.
21. My investigator asked the registered mental health nurse whether she had
considered opening an ACCT document when she became aware of the
man’s thoughts of suicide. The registered mental health nurse said that
she had discussed it at length with both the mental health assessor and
the man and the decision was taken that it would not be necessary. The
registered mental health nurse went on to say, “… our plan was to
continually assess the risk of suicide and if we felt it was to increase, then
we would place him on an ACCT document.”
22. The registered mental health nurse saw the man for a second time on 27
April. She wrote in his medical record that there was no improvement in
the man’s mental state, and that he had not been sleeping well due to
problems with his partner and not being able to see his son. The
registered mental health nurse explained to the man that it might be a
couple of weeks before he felt the effect of his medication.
23. On 3 May, the registered mental health nurse visited the man on the wing.
She noted no significant change in his mood. The man felt his anti-
depressant medication was having no effect. He denied any thoughts of
suicide but his lack of sleep continued to be a major problem. The
registered mental health nurse again told the man that his medication
would take a number of weeks to work.
24. In an entry on the man’s wing sheets dated 6 May 2007, an officer records
that the man was polite, compliant and had no known problems. On 10
May, The registered mental health nurse saw the man again. She said
that there was no improvement in his mental state and that he continued
to feel low and was not sleeping. The man said that his medication
continued to have no effect. The registered mental health nurse replied
that his medication would be reviewed in a couple of weeks.
25. The man’s wing history sheets say that on 20 May he continued to be
“polite and compliant”. During a review by the registered mental health
nurse on 24 May, the man reported symptoms of depression and
disturbed sleep. However, he denied any current thoughts of suicide or
self harm. The registered mental health nurse liaised with the prison GP
and organised an increase in strength of his anti-depressant (Citalopram)
to 20mg, with a review in two weeks time.
26. On 26 May, wing history sheets record the man as being “pleasant and
polite, no change.” An entry on 30 May recommending that the man be
given enhanced prisoner status said, “The man is quiet and compliant,
causes no known problems on HB D2 – has had no warnings or
adjudications since arrival – recommend enhanced status.” The man was
given enhanced prisoner status on 1 July.
27. The man was seen again by the registered mental health nurse on 6 July.
She wrote in his medical record, that since the increase in dose of his anti-
depressants, the man had reported that his mood had lifted significantly,
with an improvement in his energy and motivation levels. She said he
continued to deny any thoughts of self harm. However, she noted that the
man continued to suffer from poor sleep, saying that he often only got
three hours sleep a night and woke early in the morning. The registered
mental health nurse told my investigators that in the weeks leading to the
man’s death there was, “… no evidence of depression, he was bright, he’d
put weight on, he was going to the gym and he was reasonably optimistic
about his future.”
28. Prisoner Custody Officer (PCO) an officer who regularly worked on D
wing, said that the man:
“… had a nice manner, and never seemed to complain about much, if
he had a problem he would come and see you, he wouldn’t come
ranting and raving at you, he was quite respectful.”
In the weeks leading to the man’s death, the custody officer said that his
behaviour was consistent with his normal mood. Another officer who also
worked on D wing, said that he did not know the man well but confirmed
that he was quiet and compliant.
29. At 12.39pm on 13 July, the man had a telephone conversation with his
sister. They discussed the man’s mother visiting him in prison and
bringing his youngest son. The man asked his sister to contact his partner
in order to make arrangements for his son’s visit. Soon afterwards at
12.46pm, the man spoke with his partner. During their telephone
conversation she told him she would not allow their son to visit in prison.
30. That evening at 6.04pm, the man spoke with his sister once again. They
discussed possible travel arrangements for his son to visit him in prison.
31. The man spoke with his partner on Saturday 14 July at 12.46pm. During
their conversation she ended their relationship. She told the man that she
no longer wished to see him and that she would not allow him to see his
son. A prisoner knew the man and occupied cell 58, the cell next door
(The man was in cell 59). The prisoner told my investigators that he was
using the telephone next to the man at the time. He said that the man
repeatedly smashed the telephone receiver after speaking to his girlfriend.
32. Another prisoner, with whom the man had socialised, occupied the other
cell adjacent to the man (cell 60). The prisoner told police that around
2.00pm on 14 July he heard the man slam his cell door five or six times.
The prisoner said that he went to have a look and, on seeing the man’s
cell door closed, decided to leave him alone. At about 2.30pm the man
came out of his cell and stood on the landing, where he was joined by the
prisoner. The man informed the prisoner that his girlfriend had just told
him she was going out with another man that evening and this had “done
his head in”. The prisoner attempted to comfort the man as he looked
depressed and seemed upset.
33. At about 2.00pm the two custody officer’s were on D wing when they
heard a cell door slam on the first landing. The custody officer said
that on looking up he saw the man’s cell door swing back open, with
the man sitting in his cell. The officer went to investigate. He said the
man was:
“… sat in his cell with his mate from next door, and I could see he was
visibly upset and I said you know, ‘What’s going on like, what’s the
matter’ and the prisoner from next door said, ‘Oh he’s alright boss, he’s
had a bad phone call, I’ll sort it out, he will be okay.’ So with that I said
‘Alright then fine’ and I came away …”
34. The door to the man’s cell was again banged several times at around
3.00pm. The custody officer went upstairs to see what was wrong. The
custody officer told my investigators that the man was lying on his bed and
was obviously upset, angry and shaking. The prisoner from the cell next
door was sitting in the cell with the man. The prisoner told the officer that
the man had received a bad phone call. The custody officer decided to
give the man a “bit of space” because he had just received a bad phone
call.
35. The PCO said that, at about 3.30pm, the man came down to the wing
office and asked if he could speak to a member of staff from the
chaplaincy. The PCO said that he made the call and, as the man had
requested, left a message for a member of the chaplaincy to visit at their
earliest convenience. The PCO said that he could see that the man was
upset and again asked him if he wished to talk about anything. The man
did not want to.
36. During the afternoon the man asked the other prisoner to cut his hair.
However, he was unable to do so as no one was prepared to lend him
some hair clippers. The prisoner said that shortly before lock up at
5.00pm he told the man that he would see him in the morning, to which
the man had replied “yeah”. The prisoner did not speak with the man after
lock up, but the man gave no indication of his intention to harm himself.
The prisoner from the cell next door said that the man was “up and down”
in the weeks leading to his death. He said that the man thought he would
be reconciled with his girlfriend.
37. The custody officer spoke with the man again at about 4.20pm. He said
that, having been let out of his cell for dinner, the man did not collect his
meal but just filled his flask with hot water. As the man walked past he
said, “I’m sorry about before.” The custody officer told the man not to
worry and that he would see him in the morning. The man replied, “Ok
boss.”
38. My investigators asked the custody officer and the other officer if they had
considered entering details of the afternoon’s events in the man’s wing
history sheets. The custody officer said that he would have done so had
the man been on an open ACCT. But because the man’s actions were
out of character and appeared to be just about a bad phone call, he did
not consider that an entry needed to be made. Doing so would only make
the situation worse for the man as staff would harass him, asking if
everything was okay. The custody officer said he did not enter anything
as “… prisoners get bad phone calls all the time …” The custody officer
thought there was no need to take it any further.
39. Although the date is not confirmed, in a note addressed to his parents, the
man indicates that at 7.15pm he is “… going now as I have things to do.”
40. A prison officer told police that he arrived at the prison at about 8.00pm
and, after a pre-shift briefing, made his way to D wing, arriving at about
8.30pm. An entry in the Staff Observation Book indicates that the prison
officer arrived on the wing for his night duty at 8.00pm. At the time of the
man’s death, the prison officer had been in post approximately a year and
it was only his second shift of night duties.
41. Although the prison officer was unable to confirm if he looked into the
man’s cell at the start of his shift, he told police he carried out a check of
the whole wing:
“… one of the cells I checked was cell 59 on landing 4. The male in
this cell was watching T.V. lying on his back. There were no special
circumstances attached to the male in cell 59.”
42. At about 9.30pm the prisoner in the adjoining cell, heard a chair in the
man’s cell being scraped across the floor. He told police, “… I then heard
a small bang which I recognised as his door hitting the frame.” The
prisoner said that he thought no more of it. The prisoner told my
investigators that he did not hear the man’s television or any other noise
from the man’s cell that evening.
43. The last roll call of prisoners at Forest Bank on a Saturday is completed at
10.00pm. (A roll call is the process completed by staff at intervals
throughout the day. It involves counting the number of prisoners locked in
their cell, ensuring that all prisoners are accounted for.) The Staff
Observation Book for D wing records that the prison officer confirmed he
had counted a roll of 87 prisoners on D wing at 10.00pm. However, the
prison officer told my investigators that during the evening he realised that
his radio was tuned into the wrong channel and as such had not heard the
message asking for the evening roll call to be completed. The prison
officer said that he therefore phoned communications and asked if the
prison roll had in fact been called. The prison officer said that he panicked
when told that it had. Instead of counting and checking the prisoners as
required, he gave the figures recorded for the previous roll call that were
written on the office notice board. He did not complete the count of
prisoners himself. The prison officer said that this happened at
approximately 10.30pm. (According to the communications log the prison
roll was not actually called until 10.30pm and was confirmed at 10.50pm.)
44. At 00.53am the next morning (Sunday 15 July 2007), the prison officer
pegged at point 4 on landing 4 on D2. His next two pegging points were
both on House block D1. (Pegging is an electronic system used to record
an officer’s movements on a wing at night.) When the prison officer
returned to D2 landing at 3.17am to peg again at point 4, he noticed that
the man’s cell light was on. The prison officer told my investigators that
this was not unusual as some prisoners were awake at that time in the
morning. However, he decided to see what was happening. (When
asked if he had noticed the man’s cell light being on all night, the prison
officer said he had not.)
45. According to CCTV footage, the prison officer looked through the man’s
cell door at 3.28am. The prison officer said he saw the man hanging from
the door to his right and immediately called a code yellow two. (This is an
emergency code used by staff at the prison to summon assistance in
response to finding a prisoner with breathing difficulties.) The
communications log timed the code yellow at 3.29am. The prison officer
then returned to the vicinity of the wing office, on the landing below the
man’s cell, to await the arrival of support staff.
46. A Senior Prison Custody Officer (SPCO) was working under the code sign
Papa 1. (During the night one of Papa 1’s roles is to escort staff, such as
nurses, to the wings when required.) The Senior Prison Custody Officer
told police that he was with a second Senior Prison Custody Officer
(working under the code sign Oscar 2) in the central office when the
emergency ‘code yellow house block D2’ was called. The Senior Prison
Custody Officer told police that on their way to the wing he and the second
Senior Prison Custody Officer met with a third Senior Prison Custody
Officer (code sign Oscar 1). (Oscar 1, assisted by Oscar 2, is responsible
for the running of the prison during the night.) At this point the Senior
Prison Custody Officer changed direction in order to collect a Registered
Mental Nurse (RMN) and In-Patient Manager at Forest Bank. The
Registered Mental Nurse needed to be escorted from the healthcare
centre as nursing staff do not carry keys at night. On their way to the
wing, the nurse, who had not been first aid trained for several years,
asked the Senior Prison Custody Officer what had happened. The Senior
Prison Custody Officer told him that he did not know as there had been no
further updates on the radio. The nurse took an emergency bag with him.
This contained treatments for minor wounds, although it was not a
complete resuscitation kit. The prison defibrillator (a machine that
supplies a shock to the heart in an attempt to re-start it) was located in the
healthcare centre and was not taken.
47. The second and third Senior Prison Custody Officer’s were met by the
prison officer at the entrance to the wing at 3.30am. The three officers
went to the man’s cell. After looking through the observation hatch, they
returned downstairs to the area outside the wing office.
48. The nurse and the Senior Prison Custody Officer proceeded to house
block D2 where they were met by the three officers at 3.32am. The third
Senior Prison Custody Officer told them that a prisoner had hanged
himself and appeared to be dead. All three officers and the prison officer
then made their way to the man’s cell.
49. Using his cell key the third Senior Prison Custody Officer opened the door
to cell 59 at 3.33am, approximately five minutes after the prison officer
had first discovered the man hanging. The Senior Prison Custody Officer
could see over the third Senior Prison Custody Officer’s shoulder that the
man appeared to be hanging from the hinge of his cell door.1 His head
was slumped forward. Despite some difficulty in entering the cell, caused
by the fact that the man was blocking the door, the Senior Prison Custody
Officer went in followed by the prison officer. The prison officer assisted in
taking the man’s weight and the Senior Prison Custody Officer cut the
ligature from around his neck before he and the prison officer laid the man
on the floor. The prison officer told police that the man, “… appeared to
be lifeless, and was cold to touch.” The Senior Prison Custody Officer
said that the man was clearly dead. The prison officer, who was suffering
from shock, went and sat in the wing office.
50. The nurse then went into the cell. He told my investigators it was clear
that rigor mortis had set in. He checked for a pulse, but there was none
and he felt there was little point in attempting resuscitation. The nurse
requested that an ambulance be called and told his colleagues that a
1The man was housed in a normal cell on normal location and used the door pivot hinge as a
ligature point. There were three similar self inflicted deaths at HMP Dovegate in mid 2002
where the door pivot was used as a ligature point.
In response to these deaths the Prison Service’s Safer Custody Group and Custodial
Property developed an anti-ligature door strip for use on the pivot hinges of safer cells that
became available in late 2002. (A safer cell is a cell from which all obvious ligature points
have been removed.)
Guidance advising prisons of the anti-ligature door strip was first issued in April 2004 and was
updated in the Safer Cell Guide issued in March 2005. However, the cell in which the man
died was not a safer cell and the above standards would not have been applicable.
doctor would be required to confirm the man’s death. All staff present
then withdrew from the cell.
51. The third Senior Prison Custody Officer said that he asked the
communications room to call for an ambulance at approximately 3.30am.
(The emergency contingency plans for a death in custody record that an
ambulance was called at 3.29am and the communications room log that it
was called at 3.33am. I attach no significance to these minor
discrepancies in the timings.)
52. The Senior Prison Custody Officer and the third Senior Prison Custody
Officer collected ambulance staff from the gate and returned to D2 Block
with them at 4.10am. The man was pronounced dead by the paramedics
at approximately 4.15am.
53. Correspondence addressed to the man’s family and partner, expressing
his intention to take his own life, was found in his cell. In the letters the
man expressed his concern over the breakdown of his relationship.
54. In her incident statement, the second Senior Prison Custody Officer said
that she logged all details of events from outside the cell from 3.25am to
7.30am. A hot debrief for staff took place at 7.30am although not all staff
involved attended.
55. Later in the morning of 15 July Forest Bank’s family liaison officer, met
Deputy Director to discuss arrangements for notifying the man’s next of
kin. During their meeting they were informed that the man’s mother had
been told the news of her son’s death at 8.15am by Greater Manchester
Police. The family liaison officer contacted the man’s mother at 10.00am.
He introduced himself as a point of contact and offered the prison’s
condolences. The man’s family were subsequently offered the opportunity
to visit his cell and collect his personal belongings. The man’s family
visited Forest Bank the following Sunday. The family liaison officer
attended the man’s funeral. The man’s funeral expenses were met by the
prison.
56. The custody officer said that other prisoners on the wing were informed on
the man’s death that morning. He said that several of the prisoners saw
the wing Listener. Staff who had been involved in finding the man told my
investigators that they had been well supported by the care and welfare
team at the prison.
57. A forensic pathologist conducted a post mortem at Hope Hospital, Salford.
The forensic pathologist concluded that the man had died as a direct
consequence of hanging and that there were no other injuries to suggest
the involvement of any other person. At the time of writing, my
investigator had not received the toxicological report into the man’s death.
ISSUES
58. The In-Patient Manager at Forest Bank, told my investigators that all
prisoners have an initial health screen, completed by either a qualified
nurse or healthcare assistant, on their reception at Forest Bank.
59. The registered mental health nurse told my investigators:
“... initial health screen in reception covers all aspects of illnesses,
medications that they are on, general health, physical health and there
is a section on mental health such as ‘are you under mental health
services’, ‘have you ever been admitted to a psychiatric unit’ and it
does look into thoughts of suicide as well.”
The registered mental health nurse said that, before the introduction of
VISION, health screen records completed during the reception process
were not always present in the medical record. (VISION is the name of
the computerised system that now records the healthcare records of
prisoners.)
60. The man was asked to acknowledge on his Reception/Induction Checklist,
that a medical examination would take place. However, my investigators
have found no evidence to suggest that either an examination or first
reception health screen actually happened.
61. The clinical reviewer confirms that there was no evidence either in the
medical record or recorded electronically that the man was medically
examined when he arrived at Forest Bank. In his summary, the clinical
reviewer says that the extent of the man’s mental illness and alcohol
abuse was not fully realised until his mental health assessment on 24 April
2007.
The Director and Healthcare Manager must ensure that initial health
screens are carried out on all prisoners on admission.
62. The man himself asked to be seen by a member of the MHIRT on 11 April
and was seen by the mental health assessor 14 days later. During my
investigation it became clear that a comprehensive and thorough mental
health assessment had been completed by the mental health assessor
(overseen by the registered mental health nurse) and that the man was
subsequently reviewed on numerous occasions. The clinical reviewer
highlights the thorough mental health assessment as evidence of good
practice. He reported to my investigator that:
“The notes of the mental health assessment appear to have flagged
up ‘red markers’ for a suicide risk, but monitoring over the ensuing
months showed a lessening of this risk, associated with a general
improvement in his [The man’s] health and social activities.”
63. My investigators asked the registered mental health nurse if information
was shared between the MHIRT and discipline staff. The registered
mental health nurse said that she and her colleagues had to be careful
about sharing information as much of it was medical in confidence. The
registered mental health nurse confirmed that the man’s state of mind was
not discussed with any of the officers on his wing. The custody officer told
my investigators that he was unaware the man had been in contact with
the MHIRT. The custody officer was aware that the man was taking some
kind of medication but, due to patient confidentiality, was not aware of the
reason.
64. The clinical review concludes that whilst the man undoubtedly suffered
from depression and previous alcohol abuse, medication and monitoring
improved his condition over time. However, the clinical reviewer judges
that there was no communication between wing staff and the MHIRT as a
consequence of respecting medical confidentiality. Information sharing, in
particular between medical and discipline staff, is a recurring theme for my
office. Staff often cite medical confidentiality as a reason for not having
shared information that, had it been communicated properly, could have
assisted in keeping prisoners safe.
65. The clinical reviewer recommends that there should be a multi-disciplinary
approach to those prisoners at risk of suicide or self harm and that client
confidentiality should not prevent communication between MHIRT and
discipline staff. I concur with the clinical reviewer’s findings. It is a
misunderstanding of the concept of medical confidentiality to believe that it
prevents the sharing of information relevant to the safety of the patient or
others. I make the following recommendation:
The Director should ask the Mental Health in Reach Team to
complete a review into the issues surrounding prisoners’ risk of self
harm and medical confidentiality.
66. My investigator asked the custody officer and the other officer if they had
considered making an entry in the man’s wing history sheets regarding
their contact with the man and the fact he had received an upsetting
phone call. Both said that, had the man been on an ACCT, they would
have made entries on several different prison records. The custody officer
said that because:
“… it had been about a bad phone call I didn’t think it needed
entering because then staff would have been harassing him and
saying ‘Are you ok?’ and I thought it would maybe spiral the
situation or make him more upset.”
Other staff on the wing were unaware of the man’s behaviour because
those officers who witnessed it did not record what had happened. An
entry in the wing observation book would have been one way of
communicating the man’s actions.
The Director should remind staff of the importance of
communicating significant information about prisoners both verbally
and in written records.
67. When the prison officer discovered the man in the early hours of 15 July,
he called an emergency code yellow 2 to summon assistance for a
prisoner with breathing difficulties. During interviews with staff it became
apparent to my investigators that some staff were confused about the
exact meaning of the code yellow and the difference between yellow 1
and yellow 2.
68. The registered mental health nurse told my investigators about the
emergency code system in use at Forest Bank. He said that in most
cases staff just called a code yellow and, as a result, the codes were
sometimes misused. Although I appreciate that there are no mandatory
requirements to use any specific emergency code system, many prisons
use a simpler emergency call system such as red (for blood loss) and blue
(for breathing difficulties) codes. These inform staff of the nature of an
emergency in language that is easily understood. I therefore make the
following recommendation:
The Director should consider introducing a simplified and effective
system for summoning assistance in an emergency.
69. When he found the man hanging, the prison officer raised the alarm but
did not enter the man’s cell. He returned to the wing entrance on the
landing below to meet the two Senior Prison Custody Officers. All three
officers went to the man’s cell and, having observed the situation, returned
again to the area around the wing office. My investigators asked the
prison officer if there was any reason why he did not enter the cell
immediately on discovering the man. The prison officer said that he could
not be sure that the man was dead and that he could have been faking the
situation. The prison officer added that there were security considerations
because he was on his own. (It is not unknown for prisoners to set up
such a situation in order to ambush staff.) The prison officer followed the
instructions of the two SPCOs on their arrival.
70. The third Senior Prison Custody Officer was asked why he did not enter
the cell immediately, when both the second Senior Prison Custody Officer
and the prison officer were present. He said that he would have done so
had the man shown any signs of movement or breathing. The third Senior
Prison Custody Officer said that, because of the way the man looked, it
was obvious he had been dead for some time. When the first Senior
Prison Custody Officer was asked if he had been surprised that his
colleagues had not entered the cell earlier, he said that he was, but on
looking into the cell himself he understood why they had not.
71. It was apparent to my investigators from their interviews with staff that
some were unaware of the local procedures to be followed with regard to
entering a cell at night in response to a suspected death or similar
emergency.
72. My investigator reviewed the local night instructions for dealing with a
suspected death in custody. He established that the local instruction 2.87,
Nights – Death in Custody/Suspected Death in Custody, lacked clarity in
explaining to officers the procedures to be followed in the event of
discovering a suspected suicide or death during the night. In particular,
the instruction lacked guidance on when a cell should be entered and the
action to be taken upon discovering a prisoner in distress.
The Director should review Forest Bank’s instructions and
procedures relating to the discovery of a death or suspected death,
paying particular attention to the night instructions. Attention
should be focussed on when a cell may be unlocked and the staffing
level that is required to do so. The Director should also ensure that
all staff are aware of these instructions.
73. My investigators asked the registered mental health nurse what
emergency equipment he took with him when responding to the code
yellow. He said that he was only informed of the full nature of the incident
when he reached the cell. The emergency bag he had with him was not a
complete resuscitation kit, and only contained items for treating minor
wounds. The registered mental health nurse did not take the defibrillator,
which was located in healthcare. When asked if the defibrillator was
something he would automatically take to a code yellow, the registered
mental health nurse said, “No, because thankfully, touch wood, it’s very,
very few times that we need it, and if people need a defibrillator I would be
getting an ambulance in anyway.”
74. The clinical reviewer asked why the defibrillator did not form part of the
emergency pack. The registered mental health nurse said that it was
probably “not a good idea” and there was “seldom need to use it anyway.”
The nurse added that he was “mental health trained not a first aider”. He
believed some of the nurses had been trained to use the defibrillator “…
several years ago, but certainly not recently.”
75. The clinical review states there is no point having equipment in the
healthcare centre if staff have not received appropriate and updated
training on how to use it. I agree that Forest Bank should address this
clinical governance issue and provide appropriate training.
The Director and Healthcare Manager should satisfy themselves that
night duty staff, especially medical staff, have adequate first aid and
defibrillator training and are aware of their location in the prison.
The Director and Healthcare Manager should consider the optimum
number and location of defibrillators in the prison.
The Healthcare Manager should review the contents of the
emergency bag, ensuring that appropriate equipment is available.
76. The ambulance was not called until 3.33am after staff had entered the cell
cut the man down and checked for signs of life. The registered mental
health nurse conceded that he did not ask for an ambulance to be called
until staff had cut the man down. The registered mental health nurse
pointed out that any member of staff could call an ambulance if they
thought that one was needed.
77. The third Senior Prison Custody Officer told my investigator that he
awaited the registered mental health nurse’s instruction before calling for
an ambulance, as it was not something that he would do “off his own
back”. He said that an ambulance would not automatically be called after
a code yellow as the code could just relate to a superficial injury. The
third Senior Prison Custody Officer explained that any incident requiring
medical assistance was called a code yellow.
78. A letter to Governors from the Director of Prison Health in March 2004
advised that it was the responsibility of Governors to ensure a protocol
existed to facilitate immediate access to paramedic services. The letter
advises that:
“It is also essential that internal procedures should not waste undue
time in summoning emergency assistance. It should not; for
example, be a requirement in every case for a member of the
Health Care Team to attend the scene before Emergency Services
are called. However, a subsequent 999 call to the Ambulance
Service should be made to cancel the response if, after the original
999 call has been made, a member of the Health Care Team
arrives with the patient and deems that an emergency ambulance
response is not required.”
The Director and Healthcare Manager should ensure that a local
protocol is in place that provides clear advice about situations in
which the Ambulance Service should be called.
79. In their feedback to the Director, my investigators expressed concern
about the generally poor quality of entries in wing history sheets and other
records, many of them being formulaic. Although I make no formal
recommendation, the Director will wish to ensure that staff to engage in
constructive dialogue with prisoners and make full and accurate entries in
all prison records.
80. My investigators have also drawn to my attention the poor quality of post
incident reports/statements completed by staff who responded to the
man’s death. Again I make no formal recommendation but ask the
Director to remind staff of the importance of completing comprehensive
and accurate statements. All staff involved when a prisoner dies suddenly
should be invited to attend the hot debrief.
81. Although the Senior Prison Custody Officer was not first on scene, and he
was not responsible for managing the situation, I commend the immediate
and effective actions that he took once he reached the man’s cell.
RECOMMENDATIONS
Director
1 The Director should ask the Mental Health in Reach Team to complete
a review into the issues surrounding prisoners’ risk of self harm and
medical confidentiality.
Accepted – Local Safer Custody Team to discuss with in-reach team
and amend suicide prevention policy.
2 The Director should remind staff of the importance of communicating
significant information about prisoners both verbally and in written
records.
Accepted – Staff information notice to be published to remind staff of
importance of communicating any issues. All residential managers
now check 10% of all files monthly and Head of Regimes checks they
take place.
3 The Director should consider introducing a simplified and effective
system for summoning assistance in an emergency.
Accepted – Implementation of system of CODE RED for bleeding and
CODE BLUE for breathing issues to be discussed with SMT and
COMMS meeting.
4 The Director should review Forest Bank’s instructions and procedures
relating to the discovery of a death or suspected death, paying
particular attention to the night instructions. Attention should be
focussed on when a cell may be unlocked and the staffing level that is
required to do so. The Director should also ensure that all staff are
aware of these instructions.
Accepted – A full review of night procedures to be carried out also a
review in to the procedures for staff entering cells in night state. Any
changes to be published on the LSS and cascaded to staff via
information notices. Local Safer Custody Team to assist with
procedures when entering cell in night state due to self harm or suicide
attempt.
Director and Healthcare Manager
5 The Director and Healthcare Manager must ensure that initial health
screens are carried out on all prisoners on admission.
Accepted – All prisons entering Forest Bank complete initial health
screening whilst in reception and before locating on the induction wing.
6 The Director and Healthcare Manager should satisfy themselves
that night duty staff, especially medical staff, have adequate first aid
and defibrillator training and are aware of their location in the prison.
Accepted –
7 The Director and Healthcare Manager should consider the optimum
number and location of defibrillators in the prison.
Accepted – There are 3 defibrillators on site. They are located in the
reception, healthcare and in the central hub of the prison.
8 The Director and Healthcare Manager should ensure that a local
protocol is in place that provides clear advice about situations in
which the Ambulance Service should be called.
Accepted – A local protocol will be completed to provide clear advice
concerning when an ambulance can be called and by whom.
Healthcare Manager
9 The Healthcare Manager should review the contents of the emergency
bag, ensuring that appropriate equipment is available.
Accepted – A review of contents of emergency bag will be carried out
and finding reported on.