Individual at Whitemoor

Investigation into the circumstances surrounding the
death of a man at HMP Whitemoor
In December 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2010
This is the report of an investigation into the death of a man in his cell at HMP
Whitemoor in December 2007. He was on the Fens Unit at HMP Whitemoor, one of
just four dangerous and severe personality disorder units (DSPDs) in the country.
He died as the result of an overdose of heroin probably taken during the afternoon
before his death whilst celebrating the forthcoming birthday of a fellow prisoner.
That prisoner also took an overdose, but he survived. The man was 42 years old.
I wish to offer my sincere sympathy and condolences to the man’s family and friends
for their loss.
This investigation was conducted by one of my investigators. I would like to thank
the Governor of Whitemoor and his staff for their help and co-operation during the
investigation. I also wish to thank a prisoner who agreed to be interviewed.
A clinical review of the care and treatment received by the man whilst he was at
Whitemoor was conducted by a panel convened by the Cambridgeshire and
Peterborough Foundation Trust I am grateful to the clinical reviewer and his team for
their work. I must apologise for the delay in issuing this report, but it was necessary
to await the final version of the clinical review which I received in November 2008.
Self-evidently, the apparently ready availability of substantial amounts of heroin on a
DSPD unit in a high security prison is of great concern. I also judge that, had staff
responded more appropriately to how the man presented, it is likely he would have
survived. I have made five recommendations as the result of this investigation and
endorse the eight recommendations in the clinical review.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Acting Prisons and Probation Ombudsman May 2010
2
CONTENTS
Summary
The Investigation Process
HMP Whitemoor
Key Findings
Issues
Recommendations
Clinical Review Recommendations
3
SUMMARY
The man was convicted of rape and robbery, and in 1997 was sentenced to life
imprisonment with a 15 year tariff. He was transferred to HMP Whitemoor in
December 2006.
He was a resident on the Dangerous and Severe Personality Disorder (DSPD) unit
at Whitemoor, one of two DSPDs within the Prison Service. It is a unit with
specialised staff running a regime of group and individual support, with courses to
help prisoners with their conditions and to challenge their behaviour.
After completing a 15 week assessment, the man commenced treatment on the unit.
His lead clinicians were a consultant clinical psychologist and a consultant forensic
psychiatrist. The psychiatrist diagnosed him as having bipolar affective disorder,
causing him to have severe mood swings, and endeavoured to stabilise his moods
with prescribed drugs.
The man had used various illegal drugs since the age of 18, including cannabis,
cocaine, ecstasy and possibly heroin. However, during his sessions on the DSPD
unit he made it clear that he was against the use of non-prescribed drugs.
Generally, during his time on the DSPD unit, it was thought by the staff and his
clinicians that the man was responding well to treatment and taking part in the
activities and group sessions.
He had a history of self-harm dating back to his time at HMP Brixton in 1996, with a
total of seven suicide attempts being recorded. The majority of the time he would
self-harm by cutting himself; whilst at Broadmoor Hospital in 1997 he cut off part of
the little finger on his left hand.
In February 2007, an ACCT document was opened after the man was found inside a
chest freezer in the wing kitchen. (ACCT stands for Assessment, Care in Custody
and Teamwork. This is the Prison Service system to support and monitor prisoners
at risk of suicide or self-harm.) He did not harm himself again and the ACCT was
closed two months later.
On 22 October 2007, a second ACCT document was opened when the man was
found trying to drive a screw into his forehead by banging his head against the wall.
His medication was adjusted and the ACCT was closed on 5 November.
When the man’s cell was opened on 7 November 2007, staff saw that he had injuries
to his hands. He said that he had been punching the cell wall up to 100 times during
the night. A third ACCT was opened. Initially, he refused to co-operate with the
ACCT procedure, refusing to attend the case reviews and saying that he did not feel
he needed to be on it.
The man was friendly with another prisoner. The prisoner’s birthday was
approaching, and on Saturday 9 December they and another prisoner cooked and
ate a lunchtime meal to celebrate. Afterwards, the prisoner and the man took some
heroin that they had obtained from another prisoner.
4
A short while later staff saw that the prisoner appeared to be intoxicated. He
became worse so medical staff and an ambulance was called. Staff saw that the
man was acting as if he too was intoxicated, but he did not seem as badly affected
as the prisoner. Twenty-three paper wraps of heroin were found in one of the
prisoner’s socks just before he was taken to hospital.
The man was taken back into his nearby cell for a search. Nothing was found on
him and his manner became loud and very aggressive when told his cell was to be
searched. The officers withdrew and the cell was not searched. The ACCT
observations were increased to four times an hour and he was left to sleep in his
cell.
Just after 6.00am the next day an officer checked on the man who had been snoring
loudly all night. He saw that some black/brown fluid was leaking from his mouth.
The officer called healthcare staff for advice and was told to encourage him to sit up.
The officer shouted through the cell door and the man got up but then collapsed to
the floor. The nurse and other staff were called as well as an ambulance with
paramedics, but their attempts at resuscitation were unsuccessful. He was
pronounced dead at 6.50am.
5
THE INVESTIGATION PROCESS
1. The investigation was opened by one of my senior investigators on 12
December 2007. The Governor and his staff produced the man’s core record
and a large number of other documents for examination. Notices were
displayed around the prison to inform both staff and prisoners of the
investigation.
2. My investigator formally interviewed a number of members of staff and a
prisoner regarding the man’s death. The transcripts of those interviews were
annexed to the draft report.
3. One of my family liaison officers contacted the man’s mother as his next of kin.
The family liaison officer explained the purpose of the investigation and
provided the man’s family with the opportunity to raise any issues or questions
they wanted explored or addressed. His mother asked to be sent a copy of the
draft report when it was complete. Having received and read the draft report,
the man’s mother did not wish to make any specific comments about the
Ombudsman’s findings. She did however comment that the recommendations
reflected her own concerns about the care her son received.
4. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of my investigation and to request a copy of the post mortem report.
The inquest into the man’s death took place in October 2009 when the Coroner
issued HMP Whitemoor with a rule 43 report letter. This set out matters of
concern to the Coroner and asked that the Governor of Whitemoor respond to
those concerns. The Governor of Whitemoor responded to the Coroner on 2
December 2009 and a copy of that response is attached as a new appendix
(labelled as F1) to this report. The outcome of the inquest was that the man
died as a result of non-dependent abuse of drugs.
5. Cambridgeshire and Peterborough Foundation Trust (previously called
Cambridgeshire and Peterborough Mental Health Trust) was asked to prepare
a clinical review of the care that the man received whilst at Whitemoor. A
clinical reviewer was appointed to chair a clinical review panel. The review was
also attached as an annex to the draft report.
6
HMP WHITEMOOR
6. Whitemoor is a maximum security prison for men in security categories A and
B, and is one of eight prisons within the Prison Service’s high security estate.
The prison includes a pilot assessment spur which examines the links between
a prisoner’s dangerousness and severe personality disorder. The unit has
developed in partnership with the Department of Health and Ministry of
Justice’s Mental Health Unit. In February 2002, this was complemented by the
opening of another spur which has a pilot regime for the management and
treatment of dangerous and severe personality disorder.
7. There are currently four DSPD units, two in high security prisons (Whitemoor
and Frankland) and two in special hospitals (Broadmoor and Rampton).
Together, these units provide over 300 places. They are in high demand, with
over 600 referrals received in an 18 month period.
8. The DSPD is situated on D wing at Whitemoor. The staff-prisoner ratio is
higher within the DSPD than the other wings, and is supplemented by a wide
ranging multi-disciplinary team. Prisoners have their own cells and the facility
to cook their own meals in kitchens on their respective landings. Additional
background on DSPD units is given in an annex to the draft report.
9. Within the DSPD unit, the role of psychiatry fits within an overarching
psychological model of treatment (in contrast to the predominantly medical
model of most mental health service provision). I understand that the main
focus of the treatment model is facilitating change in the personality disorder
(and the associated risk), but management of mental and physical health
problems is also important. One of the psychiatrists’ specific contributions to
treatment is prescribing and managing psychotropic medication.
10. The nursing team also play an important role on the unit, especially with
distressed prisoners. Not surprisingly, many prisoners experience episodes of
crisis throughout the phases of their treatment. The nurses’ role is interwoven
into the model of treatment. Through interpersonal, psychological and
behavioural nursing techniques, it is hoped to reduce a prisoner’s physical and
psychological distress.
11. The model of treatment on the DSPD unit builds substantially upon the
traditional role of prison officers. It has been recognised that discipline staff
working on the unit have had to adapt to a style of working that focuses on the
treatment, alongside the management, of individuals.
12. All the officers receive some mandatory training, including a three day course
on personality disorder awareness, but those officers who work with prisoners
in group sessions are trained in skills to equip them to co-facilitate cognitive
interpersonal groups. This training is delivered on an ongoing weekly basis.
Discipline staff tend to work exclusively on one part of the overall DSPD unit.
13. Aside from their individual therapy and group work, prisoners in the DSPD unit
have access to education, gym, employment opportunities and training
7
workshops. Some prisoners work outside the unit as there are few employment
opportunities within it.
14. Her Majesty’s Chief Inspector of Prisons writes in her April 2008 report of the
full unannounced follow-up inspection of HMP Whitemoor:
“The Fens unit was one of two prison sites providing assessment and
treatment of dangerous and severe personality disorder (DSPD) alongside
two special secure hospitals offering parallel treatment. DSPD prisoners
were allocated to either the Westgate unit in HMP Frankland, which worked
in tandem with Rampton in the north, or the Fens unit in Whitemoor, which
worked alongside Broadmoor in the south. The treatment was experimental,
although grounded in the empirical literature concerning what works
clinically with this group of offenders. Although each of the prisons and
special secure sites operated a different treatment model, all strove to use a
common set of assessment tools in order to measure the impact of
treatment, which was subject to a national evaluation…
“The DSPD programme on the Fens unit provided good staff training and
support, with a comprehensive daily briefing and well established
multidisciplinary work. A reflective learning environment had led to some
understanding about the risk of self harm in the context of DSPD treatment,
but this had not yet been incorporated into the safer custody strategy. There
was a crisis intervention suite to help DSPD prisoners. Relationships were
generally good but the dynamics on the assessment spur were not wholly
therapeutic.
“In common with the Westgate unit at HMP Frankland, levels of self-harm
among Fens unit prisoners were high compared with mainstream high
security prisoners, and three were on open Assessment, Care in Custody
and Teamwork (ACCT) documents at the time of the inspection. There had
also been three self-inflicted deaths of prisoners in the unit in the previous
18 months, underlining the potentially destabilising effect of DSPD
treatment. In our survey, 41% of Fens unit prisoners said that they currently
felt unsafe, compared with 33% of mainstream prisoners in Whitemoor. This
elevated proportion was duplicated in the Westgate unit, where 40% said
that they felt unsafe at the time of the survey.”
She recommended that, “The cluster of recent deaths should be examined to
establish any learning, particularly in relation to procedures on the Fens unit,
and the safer custody strategy adapted accordingly.” (I understand the prison
has taken all of the recommendations from my reports, alongside inquest
verdicts, and incorporated them into its death in custody rolling action plan.)
15. Each prison has an Independent Monitoring Board (IMB). IMB members are
independent and unpaid. They monitor the day-to-day life in their prison and
ensure that proper standards of care and decency are maintained. The IMB
produces an annual report on their prison. In the latest report for Whitemoor,
2007-2008, the chairperson wrote about the DSPD unit:
8
“On average this Unit holds sixty to sixty-five prisoners deemed to have
Dangerous and Severe Personality Disorders (DSPD). It is one of the four
High Secure Units for men, two of which are based in the Prison Service and
two in the National Health Service. They are ‘piloting’ this programme for
offenders with severe behavioural problems. All participants who undergo
the treatment are volunteers. Upon arrival, either from the wings in the
prison or from other establishments, the prisoners undergo several weeks of
assessment to ascertain if they are suitable to participate in the intervention
programme. The programme itself is lengthy and may take several years to
complete. The Unit itself is extremely well resourced, by both the Health
and the Prison Services. It also has the benefit of the services of some very
highly trained personnel and a staff/prisoner ratio that is the envy of the
other wings. In fact there appears to be some resentment towards the wing
from other parts of the prison for this very reason. Worryingly there is no
funding, at present, for a ‘step down’ programme in order to offer support to
those prisoners who complete the course. This appears something of an
anomaly if the agencies involved are truly committed to its success and to
resolving the problems of this group of prisoners.
“It will be many years before the effectiveness of the Unit is able to be
assessed. Its success or otherwise will only truly be known when some of
the offenders are released into the wider community at the end of their
sentence.
“Fifty-three prisoners are presently logged onto the referral database, forty-
five with Life sentences and eight with determinate sentences. There are
twelve Lifer cases requiring a full review; twenty-seven prisoners who have
been accepted for assessment are Life sentenced prisoners, ten of which
are non-compliant. Five prisoners accepted for assessment are determinate
sentenced prisoners and all are compliant. It is imperative that prisoners
accept the treatment offered in its entirety, otherwise it becomes a pointless
and costly exercise.
“The prisoners in the Unit often complain about lack of activity. However,
the course itself can be very demanding and intense and requires a great
deal of ‘soul searching’ by the participants. The truths that the prisoners
learn about themselves can make them very vulnerable and in need of
intensive support. ACCTs are more prevalent on this wing than other areas
of the prison.”
16. Since I was given the responsibility for investigating all deaths in prison custody
in April 2004, there have been seven deaths at Whitemoor prior to that of the
man. Four were apparently self-inflicted and three were from natural causes.
Two of the self-inflicted deaths were of DSPD prisoners, although the issues
raised in my investigation reports were not similar to those in this case.
9
KEY FINDINGS
17. The man committed offences of rape and robbery in March 1996. He was
sentenced to life imprisonment with a 15 year tariff in May 1997.
18. The man entered the prison system in April 1996 on remand after his arrest.
He was held at HMP Brixton before being transferred to Broadmoor Special
Hospital a year later. It was not his first time in custody, as he had previously
served prison sentences in the USA and the UK.
19. The man was held at Broadmoor until August 1997 when he transferred to
Whitemoor. In September 2004, he moved to HMP Full Sutton where he
remained until his transfer to the DSPD unit at Whitemoor on 7 December
2006. The unit has three sections or spurs. Red spur (where he was housed)
is the assessment spur while green and blue spurs are for treatment. The
DSPD unit is called the Fens Unit but is often referred to as D wing by staff at
Whitemoor. There is no CCTV coverage on the spurs.
20. Prior to his arrival at the DSPD, the man had attempted to commit suicide
seven times since 1996 and self-harmed on a number of occasions, mainly by
cutting himself. In April 1997, whilst at Broadmoor he cut off most of the little
finger of his left hand when he was told he would be returning to prison.
21. The man had been selected for the DSPD unit some years before when he was
at Whitemoor but had declined as he had not wanted to give up being a
Listener. (A Listener is a prisoner who has volunteered to be trained by the
Samaritans to provide a similar service to that organisation within the prison.)
22. A consultant forensic psychiatrist working on the unit was interviewed by my
investigator who asked her about how the DSPD unit operates. She said:
“Well its part of the government’s programme of managing men who are
considered to be dangerous, i.e. at high risk of serious re-offending by
reason of severe personality disorder. So this was the first of the four high
secure units to be set up. It’s been established here at Whitemoor on an
existing prison wing with some adaptation, mainly the conversion of what
were previous single cells into offices, interview rooms and other facilities for
the use of clinical staff. And all the clinical staff who are attached, either
employed to be at work on the DSPD Unit or who are seconded from an
NHS trust are based on that wing. It’s a residential programme, there’s a
process by which prisoners are referred, they would all be people who had
committed serious offences in the past and for whom there is … clear
evidence of personality disorder. They come into the programme, they
undergo a residential assessment that usually lasts about four months and
then if they meet the DSPD criteria, there’s a set criteria concerning risk,
personality disorder and the link between risk and personality disorder, if
they meet those criteria they’re recommended to stay for treatment. So in
the man’s case, he completed the assessment process and had started on
the treatment programme. Some of the very first prisoners, it’ll take them
longer than five years but we expect the full treatment programme to take
about five years, so he was starting a long treatment programme.”
10
23. When the man arrived at the DSPD unit he underwent the 15 week
assessment, which was led by a consultant clinical psychologist. She
continued as his individual therapist until he died. My investigator asked her for
her impressions of him when he first arrived at the unit:
“… He initially, for about three weeks, was quite bombastic and projected
himself in rather a grandiose way and then that suddenly stopped and he
told me later he hadn’t needed the bombast any more. And there developed
a very good relationship I would say, we had a good working relationship.
He was a very intelligent man so he was quite sceptical at first of what we
could do but he also very much wanted to make changes in himself and I
think in probably about the three years before he came on the unit he had
gone through a fair amount of psychological change himself. So he was
actually really ready for treatment and he always, really, really worked which
is something a lot of the men find difficult.”
24. My investigator then asked her to describe the type of treatment that he
received. She replied:
“He was getting the treatment that we practise here which falls under a
model that we call cognitive interpersonal … and we combine an approach
which encourages them to think about their personalities, their childhood
trauma and how it’s linked to their offending but also to access their
emotions because it’s been found that people with personality disorders are
often very intelligent and can easily absorb a cognitive approach. But it
doesn’t actually necessarily change and we take the view that, because the
trauma has caused a lot of emotional dysfunction, it’s only by accessing that
emotion that you can actually bring about some modification. So in terms of
my work with him in individual therapy, as we all do here, I take a dynamic
approach. It involves making links between the past and the present and
what’s going on in the therapy, understanding the relationship with the
therapist and how the way they relate to you is reflected in their work in
therapy and he was very motivated to do this.”
25. The psychiatrist was asked for her opinion of how the man was responding to
the treatment he received:
“He was a very complex man. He was, had a very high level of social skills
and I think this combined with his American accent and his physical
presence, he was a huge man, made him really quite a commanding
presence really. When he was first on the unit, he was very polite but you
had a sense of this being his social skills and of not being sure whether this
was the real person. I don’t remember exactly when but at some point he
began to experience very real distress, he became really quite severely
depressed and at this point, it really became clear to me and to colleagues,
that he had a bipolar affective disorder, manic depression. From my reading
of his records, he had recognised depressive episodes before but it’s not
clear to me that anybody had ever considered that he really had full blown
bipolar affective disorder. I feel absolutely sure that that was so and I also
think that there were indications that there was a family history of this on his
11
father’s side. So he did experience some periods of really quite severe
depression and despair.”
26. The man successfully completed the assessment period. The assessment was
carried out by the psychologist, psychiatrist and some of the prison staff
working on the unit. The uniformed prison staff on the DSPD unit have all
requested to work there, and many have had additional training or ‘on the job’
training to better equip them for the task. Many of the staff take part in the
prisoner group sessions and they are encouraged to spend time and converse
with the prisoners. A number of the staff interviewed spoke of the man’s love of
chess and some played with him on occasion.
27. The man suffered from mood swings during his time on the unit. At the low
points he would be withdrawn, often weeping and reporting having suicidal
thoughts. When his mood was high he would often be loud and effusive,
described as being grandiose in manner and speech. He was prescribed
paroxetine for his depression and lithium as a mood stabiliser.
28. At 9.15am on 26 February 2007, the man was found lying in a chest freezer.
He was wearing only his underpants and he had a plastic bag on his head. He
said he was upset at the time about another prisoner having committed suicide
during the previous week. A fellow prisoner told my investigator that it was a
joke that the man decided to play on the psychologist, but the staff and his
clinicians believe that his action was a serious attempt to take his own life. An
ACCT was opened by Officer A. There were no further acts of self-harm and
the ACCT was closed on 4 April by a multidisciplinary group chaired by Senior
Officer (SO) A.
29. On 22 June, the psychiatrist opened another ACCT after a conversation with
the man in which he told her that he had moments of anguish and thoughts of
maiming himself. She prescribed additional medication for that night and over
the weekend. The following day he said he felt a lot better after taking the
additional medication. It was agreed by the staff and him that the ACCT should
be closed.
30. A progress report, written on 1 August, identified that the man had been
attending his one to one sessions with the psychologist regularly and taking
part in the group work. Despite having a cleaning job (he was responsible for
cleaning the ones landing on Red spur), he was easily bored as he felt there
were too few activities.
31. On 10 October, the psychologist put an entry in the man’s observation log
sheet:
“He became distressed and weeping in his individual session, not about an
event, but he is quite emotional as a consequence of shift in therapy. If he
should start wailing and weeping, however, he probably needs his meds
adjusting. Calmer at the time of writing.”
32. At 10.00am on 22 October, the man was seen to have pushed a drawing pin
into his forehead. The superficial injury was treated in healthcare and he was
12
told that he would be seen later for a one to one session with the psychiatrist.
At 2.30pm, just after the cells were unlocked, a prisoner saw him putting a one
inch screw into his forehead. He said that he needed to relieve the pressure.
He then began to try and force the screw further in by banging his forehead
against the wall. Staff arrived and when he was told he would need to see the
doctor he pulled the screw out. He then became very tearful.
33. The man was treated in healthcare (no stitches were required), before being
moved into a gated cell which has a clear Perspex covered metal barred gate in
place of the usual solid metal door. An ACCT was opened and as part of the
immediate action plan, SO B agreed with the duty manager that the man could
return to his normal cell and that he should be seen by the psychiatrist as soon
as possible.
34. The psychiatrist saw the man the following morning for a psychiatric review. He
told her he had been feeling down for the last few weeks and that his mind had
been scrambled at the time he self-harmed. She increased the dose of
diazepam for the next three days and also increased the regular dose of
olanzapine.
35. In the ACCT assessment interview the man made it clear that he did not feel
life had anything to offer him. Officer B asked him if he had been trying to
commit suicide. Officer B recorded the reply as follows:
“He wouldn’t describe the act as a suicide attempt nor an act of self-harm,
but a desire to pierce his skull to escape the dark depths [of] his suffering.”
36. SO B set the ACCT observation levels to be four times every hour, with a
quality entry made at every unlock. The man did not harm himself again and,
at the case review on 1 November, SO A wrote:
“Over the past few days he has picked up. He has been more humorous
and is mixing again. He has had an increase in meds and this is helping.
He said he does not feel in danger at this present time but also
acknowledged that this is not always going to be the case due to the work
being done on the DSPD.”
37. The psychiatrist wrote a short psychiatric report on 29 October. Concluding her
report she wrote:
“Since the severe depression and self-harm in February, he has been on a
low/medium dose of anti-psychotic medication (olanzapine) and on regular
diazepam. In the medium term I expect that he will continue some regular
medication with the aim of stabilising his mood but recognising that he will
remain vulnerable to depressive episodes with risk of self-harm or suicide.”
38. The man continued to improve and the ACCT was closed at the case review on
5 November.
39. At 8.10am two days later on 7 November, when his cell was unlocked, the man
showed staff the injuries he had caused to his hands punching the cell wall
13
during the night. He had multiple small wounds to both hands on his knuckles
and fingers. Nurse A opened another ACCT document. During the
assessment interview, the man told Officer A that he was feeling angry and
disillusioned at the system. He did not want to attend the case review the
following afternoon. Due to his low mood the officers decided to keep the
observation level at twice an hour in state A (State A refers to when the
prisoners are locked in their cells).
40. The man was also seen by the psychiatrist and Nurse B that day. He
complained of severe headaches since starting evening doses of lamotrigine
(used to treat bi-polar disorder and as a mood stabiliser) on 2 November. He
said that he punched the wall to relieve his mental pain. The lamotrigine was
stopped and a trial of pericyazine (an anti-psychotic) was agreed.
41. On 12 November, Officer C wrote in the man’s personal history sheet that he
was very animated and agitated because property belonging to one of his
friends who had been transferred to Broadmoor had not been sent on. He
threatened to smash up the snooker table and then the spur if the situation was
not resolved. He later withdrew his threats and, although he did not attend the
case review later that day, said that he would accept the recommendations of
those attending.
42. At the conclusion of her Individual Therapy Report dated 14 November, the
psychologist wrote:
“In summary, the man has made a surprising amount of progress in the first
six months in therapy. This has also been noticeable in his behaviour and
presentation on the spur. However, it has been at great cost to himself.”
43. The next few days passed without incident although the staff believed that there
were underlying concerns that needed addressing. That view was reflected in
the ACCT case review held on 16 November. The man again declined to
attend as he thought he did not need to be on an ACCT. SO A and Nurse B
agreed to keep the ACCT open and to try and re-engage him in the process.
44. The next case review was held on 21 November when all ACCT prisoners were
assessed after the death of another prisoner. The man said that he was
unaware of the person who died. He did not attend that review or go to the
next one on 26 November either. On that occasion he said that he was okay.
In interview, Nurse B said that, although he presented well, he felt that he was
still not mentally stable. The ACCT remained open. Throughout this period he
still participated in both group and one to one sessions as well as participating
in activities with other prisoners in the evenings.
45. In her interview with my investigator, the psychiatrist was asked whether the
man was at a high or low point in his mood during that period. She replied that
she thought his mood was below normal, although she added that he could “put
on a show”.
46. The man did attend the ACCT review on 5 December. SO B recorded the
following summary:
14
“He spoke about his signs that he is aware of prior to self-harm, which are
bodily sensations and wanted staff to know. However he struggles with
what he could do / talk to staff because of feeling worthless. He tried to
explain what happens at these times, which was powerful and very moving.
It became very difficult for him. He needed to leave the review due to
becoming distressed. Observations reduced during night state to observe in
line with Cat A check (once an hour). One quality entry from a conversation
in each period of unlock.”
47. The man spent that evening playing ‘spot the intro’ with other prisoners on the
wing and seemed in better spirits than earlier. He collected his breakfast the
next morning and then spent the rest of his time writing in his cell. He
occasionally came out of his cell and walked around the ones landing before
returning to his cell. During the afternoon he sat at a table on the landing
talking with another prisoner.
48. The next day Officer D put an entry in the ACCT document stating that the man
had spent the morning cleaning and sitting talking with other prisoners.
49. On 8 December, Officer E entered in the ACCT document that the man had
been in the kitchen cooking a cake for a prisoner’s birthday. According to the
prisoner, he and the man bought a number of paper wraps containing heroin
from another prisoner that day. The prisoner had ordered 30 wraps and the
man five. He explained to my investigator that, as he was better off financially,
he had bought more heroin. He said he had planned to share the drugs with
the man. They were not given all they had ordered that day, but both of them
took some heroin during the day.
50. At 7.00am on 9 December, Officer F recorded in the ACCT that the man had
been awake all night and had ignored him when the officer had tried to talk.
51. The Senior Charge Nurse on D wing (DSPD) began a handover sheet that
morning. Her entry for the man was:
“Mood appears low – night staff concerned as behaviour appeared bizarre
last night. States he is ok but a lot is going on in his head.”
52. In her interview with my investigator, she spoke about her own concerns for him
that morning:
“Well I think it actually started in the morning because when he came for his
medication in the morning, he looked dreadful … He looked awful, he was
slurring his words, he just looked, he looked like he was intoxicated …That
was probably eight, eight-thirty in the morning. He said he’d had a bad
night; he hadn’t slept because he’d over-indulged in food the day before. I
asked him if I could check his observations (pulse, blood pressure, pupil
dilation etc.) but he refused to let me do that.”
53. She said that his refusal was not unusual for him. She saw him again later that
morning when she gave him his lunchtime medication. The nurse explained
her concerns to my investigator:
15
“Later on in the morning I went again to see him and his presentation, he
appeared to me again like he was intoxicated. I asked him if he’d taken
anything he shouldn’t have done, he denied that. I raised my concerns with
the staff on the wing, gave him his lunchtime medication and he seemed
even more intoxicated, that’s a word I can use, under the influence of some
substance should I say.”
54. My investigator asked the nurse whom she had spoken to, but she could only
say that it was a conversation with the wing SOs and that she had requested
raised observation levels for the man. She did not make an entry in the ACCT
document, but agreed with my investigator that with hindsight she should have
done. My investigator has not identified any staff who recall such a
conversation with the nurse at that time.
55. Nurse A is an agency Registered Mental Nurse who has worked on D wing for
three and a half years. She told my investigator that she saw the man, the
prisoner whose birthday it was and another prisoner sitting at a table just
outside the man’s cell. She remarked on the enormous meals they each had in
front of them. They explained that it was to celebrate the prisoner’s birthday,
which was on the coming Wednesday. Nurse A explained that she was told
they were having the meal on Sunday as they were not allowed to cook on
Wednesday. When they had finished eating she went upstairs to the next
landing with the other prisoner, leaving the prisoner and the man sitting at the
table.
56. Two officers were on the landing above where the man was sitting. They could
see that the other prisoner appeared to be asleep and that the man was making
silly comments. The officers went down and were concerned about the
prisoner. At 2.47pm the officers alerted the control room that they had a
medical emergency.
57. Medical staff attended and saw that the prisoner was drifting in and out of
consciousness and having some difficulty breathing. The Senior Charge Nurse
said in interview that the man was having problems sitting up; he was loud and
over emphasising his speech. She asked him if he had taken any drugs but he
denied it. She relayed her suspicions to Nurse C who also asked him if he had
taken anything and received the same reply. Nurse C did not think that he was
under the influence of drugs, although she did describe him as being “a bit
wobbly and perhaps a bit unsure on his feet.”
58. A Principal Officer (PO) was the Orderly Officer, which meant that he was
responsible for the day to day running of the prison that weekend (There are
also two governor grade members of staff in charge of the prison over the
weekend). When he arrived on Red spur and saw the man he thought that he
was ‘fully up’ and jovial but alert and talking to staff. My investigator suggested
that it sounded as though he had been out for an evening of drinking but was
not drunk. The officer agreed that was a good analogy.
59. The man was clearly upset by what was happening to his friend and he talked
to the prisoner whilst staff attended to him. The other prisoners had been
locked back into their cells. A Healthcare Officer then found 23 paper wraps
16
containing heroin hidden in the prisoner’s left sock. The wing senior officer, SO
A, knew the man very well and thought that something was wrong. In his
interview he told my investigator:
“I looked at him, tried talking to him at the table. He wasn’t really
responding, he was watching the prisoner, although he was trying to help, it
was very – it wasn’t very much help at the time so my concerns started
raising then. I knew something was wrong, I asked the Senior Charge
Nurse to take his observations, she said he was tired. I said I know the
man, he’s not tired, he does sometimes stay up all night long and he can
cope with that, something was definitely not right. She said well he’s okay,
he’s just tired.”
60. At 3.15pm an ambulance was called for the prisoner, who was now lying on the
floor whilst staff made him comfortable and maintained a clear airway. The
orderly officer spoke to both the Senior Charge Nurse and Nurse C asking if
there was any reason for the man to be out of his cell. They agreed that at that
time there was not.
61. The orderly officer told two officers to return the man to his cell, and to search
him and the cell in case he had any drugs. SO A went into the cell with them.
A strip search was conducted by the officers but nothing was found. The man
said loudly that he had nothing on him throughout the search and became more
and more worked up. SO A then told him he was to be temporarily moved to
the crisis suite (a separate unit within D wing with three anti-ligature cells for
people in crisis) so that his cell could be searched. The man became more
volatile and began to pace the cell, pump his arms and generally work himself
up.
62. SO A decided to leave the cell rather than have an incident spill out onto the
landing where the paramedics were treating the prisoner. He asked Officer G
to stand outside the man’s cell and watch for him disposing of anything or signs
that he had taken the same as the prisoner. SO A reported back to the orderly
officer. The two men have different recollections of the conversation. SO A
says that he told the orderly officer that they had retreated from the cell search
due to the situation and that Officer G was watching the man. The orderly
officer recalls being told that the man had become irate but he made it clear
that both he and his cell were to be searched. He has no recollection of being
told that the cell was not searched.
63. Officer G spoke to my investigator about his conversations with the man from
outside his cell:
“I kept giving a running commentary what the paramedics were doing to the
prisoner and it seemed to calm him down. At one stage he did switch his
main light off so I put the night light on so I could see him, he asked me what
the effing hell I was doing, I told him I’ve got to stand here and keep you in
constant watch all the time, reasons why I’ve got to do it and he said, Officer
G, he said I’m telling you he says, I’m not going to do anything. He said as a
gesture of goodwill, I’m going to give you some blades and he actually
handed out one razor blade underneath the door. He says I’m not going to
17
do anything silly, he said all I’ve got is my word, I’ve got nothing,
everything’s been taken away from me, I’ve got my word, I’m going to
promise you now I’m not going to do anything. I said that’s fine by me but
I’ve got to stand here and talk to you, he says fine and he stood at the door.
And I was at the door well until actually the incident was over …”
64. At 4.35pm, the prisoner was transferred to the district hospital. En route to the
hospital, SO A spoke with him. The prisoner told the officer that he and the
man had taken some heroin before and after lunch. SO A passed the
information back to the prison when he arrived at the hospital.
65. The orderly officer maintains that he had a conversation with the Senior Charge
Nurse and Nurse C regarding what should happen with the man, and where he
should be located (possibly in a gated cell under constant observation). Nurse
C told my investigator that she cannot remember talking to the orderly officer.
The Senior Charge Nurse said that she told the orderly officer that if the man
did not either go to Healthcare or was taken out (of the prison) he should go to
a gated cell for close observation. She said that the orderly officer just nodded
and was non-committal. He maintains that the nurses were content for the man
to remain in his cell.
66. Before going off duty, the Senior Charge Nurse wrote the following on her
nurses’ handover sheet:
“Also becoming [increasingly] drowsy ? under the influence of illicit
substance though strongly denies using any drugs! HCC (healthcare) aware
– ACCT obs [increased] 4 per hour. On collecting meds [complained of]
back pain, still appears heavily under the influence of unknown substance.
Was searched by staff and he became extremely hostile when suggested he
was relocated to crisis suite – to remain in own location and reviewed later
by HCC.”
67. The orderly officer, who had left the wing to oversee the arrangements for the
prisoner’s transfer, instructed PO A to tell Officer C to review the man’s ACCT
and increase the observation levels to four times an hour. PO A was also told
to arrange a second escort in case the man needed to be taken out of the
prison.
68. Shortly before 5.00pm, the man was let out of his cell to collect his tea meal
from the servery. Officer G described his condition as follows:
“… he seemed to have gone into a bit of a curvature of the spine because
when he came out, at first he started walking straight and then he just
seemed to be going to one side and the best way to describe it is he started
to walk like a monkey, bent down and one hand dragging along the floor.
And he couldn’t actually stand up straight; he was white in pallor and starting
to sweat. When we got him to the hot plate, I think it was Officer E actually
carried his plate back to the cell. When we got back to the cell we said if
he’s okay, he was very apologetic. He asked to speak to Officer H who
searched him previously to apologise for his outburst, and while we were at
the door he also asked to see the nurse who gave him a quick examination
18
because of this way his back had gone. Then after that he’d asked to speak
to the chaplain … After we locked him up, we finally locked him up, we said
we’ll see you tomorrow and he said no problems gov, I’ll be here tomorrow.”
69. At 5.00pm, one of the prison chaplains spoke with the man when he returned to
his cell. Afterwards the chaplain spoke with Officer C and told him the man had
strong suicidal thoughts. The officer passed the information to the control room
where it was entered into the log sheet. The chaplain wrote the following in the
ACCT document:
“He asked to speak with me; during the conversation he declared having
strong suicidal thoughts and wants to end his life. From my observations he
is currently in poor condition and needs close observation.”
70. My investigator asked the chaplain if he thought the man’s death was
accidental. I think it is worthwhile to reproduce his reply in full here:
“I think it was actually. When I first saw the man that afternoon, he was in
his cell whilst the paramedics were dealing with the prisoner then there was
the organisation of serving the other prisoners their evening meal Sunday
afternoon. So I decided to stay put near the servery because obviously the
other men had all been locked up and they would be anxious about what
was going on. So I stayed put, some of them wanted to know some of them
just walked past, reassure them that everybody was alright at that point.
Then I was really shocked to find that they were bringing him out of his cell
to go to the servery to get his own meal. The man came out, he looked as
though he had been heavily drinking because he was staggering, he was
leaning to one side, sweating, slurred speech. He made a beeline straight
for me and said he wanted to see me and I was a bit surprised that the staff
were allowing him to attempt to walk. He got some food, went back to his
cell. I went back to the cell. I went in and staff stayed near the door. We
sat on the bed, he then asked for confession so obviously I can’t say much
more on that because it is a Sacrament, so we dealt with that. After I had
dealt with that it was then that he declared that he couldn’t go on and this
was the end. And I was under pressure from the staff to leave the cell
because they wanted to lock him up so I had to say, ‘Look, there is going to
be somebody outside the door every 15 minutes. If you are feeling more ill
tell them and I am sure they will get the medical team to you’ to reassure
him. But it was quite hard to leave the cell and have him locked up which is
why I put that entry in.”
71. Nurse A went into the man’s cell to examine his back. The examination is not
recorded in the ACCT document or his medical record. The only mention of
back pain is in the nurse’s handover sheet completed by the Senior Charge
Nurse. There is no record of any diagnosis or treatment given.
72. Officer G stopped his observation of the man in his cell at 6.00pm when his
shift ended. By that time the ACCT observation levels had been increased to
four times an hour. However, that fact is not written on the front cover of the
ACCT document, only in the on-going record section.
19
73. At 6.00pm, Nurse C wrote the following entry in the man’s medical record:
“Reported by wing to have taken ‘drugs’, seen on wing 14.50, mobile and
coherent but unsure and unsteady, denied taking any drugs and said he was
just tired. Did not want Healthcare intervention. To be watched closely for
signs of deterioration by wing staff, already on an ACCT.”
74. Officer D was one of three officers on the wing that evening. He told my
investigator that he and another officer carried out the ACCT observations on
the man until the night duty staff took over around 8.00pm. The orderly officer
said that he contacted the wing and spoke to Officer D. He said the officer told
him that the man was ‘sleeping it off’. He said that he instructed the officer to
get a response from the man during the checks. The officer replied that the
man was snoring so loudly he could be heard from the centre office, but they
were checking him anyway. Officer D said that he could not recall being given
the instruction to get a response by the orderly officer. In interview, the orderly
officer was asked if he thought hearing the man snoring was enough for the
checks. He replied:
“I think there’s two bits to it, obviously what I instructed was that they got a
response and I think there was two bits to it, a) I was content because he
was snoring however, Officer D had informed me that they were still getting
a response, now without actually being there and seeing what he designated
as a response, whether it was verbal or whether he was content that the
snoring was a response, I really can’t pass comment on that, I was content
that if there was still a noise coming from his cell and they were seeing
movement from the man then to use the terminology he was still alive and
he was still ok.”
75. From his interviews with staff, my investigator is inclined to accept that the
checks were being carried out four times every hour. However, there is neither
written evidence nor CCTV coverage on the wing to support it. The ACCT
document shows six entries between 6.50pm and 6.15am the next morning.
There is no requirement to record every check under the ACCT protocols.
76. The prisoner returned to the prison at 8.08pm and went straight to Healthcare.
The night duty Orderly Officer was briefed by the day orderly officer and told my
investigator:
“He had handed over and during that briefing he explained that there had
been an incident on Delta Wing at some time in the afternoon which involved
a prisoner and the man. That incident included that the prisoner had taken
an amount of heroin which was enough to render him unconscious and as a
result of that he was taken to outside hospital. He stated that they
suspected that the man had also taken heroin although his speech was only
slightly slurred and he was fine. He’d been seen by Healthcare, no
concerns had been raised that afternoon and he’d been placed in his cell
just as normal. He did go on to say that, just because they suspected he’d
taken heroin that he was on an open ACCT. And they’d increased his
observations to four per hour which is a routine occurrence if somebody is
suspected of self harming or anything like that. Other than that, no other
20
concerns were raised. He did say that there was an escort pack that had
been made up and left in Population Management should any problems
arise and we had to get him to outside hospital, so all the cuff bag and the
documentation was ready to go. But there was no reason to suspect that
that would become required.”
77. The night orderly officer said he was quite happy with the situation which was
handed over. He also said that he spoke to the night duty nurse at about
8.15pm. In her interview she described the healthcare briefing she received
when she came on duty:
“I was told that the prisoner, well he had actually been admitted to
Healthcare, he had been out to hospital and then on his return came to
Healthcare so that he could be observed during the night. And also that the
man had been seen but the nurse who gave me handover wasn’t the one
that had seen him in the afternoon and that he was as far as I am aware ok,
and I did just look in the IMR [medical record] and just read that but he had
denied taking any drugs and he was tired, did not want any healthcare
intervention. So as far as I was concerned that was it.”
78. At 9.00pm, the night orderly officer and night nurse went to the man’s cell and
saw that he was asleep. It should be noted that the last person to actually
enter his cell was Nurse A at about 5.30pm. All subsequent observations were
carried out through the observation window of the cell door in line with prison
policy.
79. The night duty officers were briefed about the afternoon’s events when they
came on duty. There was a prisoner on a constant watch in a gated cell a short
distance from the man’s cell. Although other officers carried out the required
ACCT checks on him, he could be heard snoring by the seated officer on the
constant watch.
80. Just after 6.00am, Officer I checked the man and saw that there was a small
amount of black/ brown liquid coming out of his mouth. The officer went
straight to the centre office and rang the night nurse. He was advised to try and
rouse him and get him to turn onto his side. The officer returned to the cell and
banged on the cell door and shouted. He told the man that he had been sick
and needed to sit up. Eventually, he mumbled something and began to try and
sit up. He then tried to stand, still mumbling. As he got to his feet he attempted
to support himself, but ended up on his back on the floor. Officer I saw more
liquid coming from his mouth.
81. Officer J watched the man while Officer I contacted the night nurse again. The
night orderly officer had been in the gate office when the first call was made,
and was walking back to the main prison when he got the radio call to attend D
wing urgently. He went via Healthcare and collected the night nurse. They met
the night SO and the three colleagues made their way to the man’s cell. The
night orderly officer said that they arrived at 6.15am.
82. The officers entered the man’s cell and immediately started cardio pulmonary
resuscitation (CPR). The night orderly officer requested an ambulance to
21
attend and began chest compressions, while the night nurse inserted an airway
and attached the oxygen and bag. With each chest compression more dark
fluid came from the man’s mouth. The night nurse attached the automatic
defibrillator which went through its checking cycle before advising that no shock
was required and to continue CPR.
83. According to the control room log the paramedics arrived at 6.36am. They took
over CPR from the prison staff and attached their own defibrillator. However,
their attempts were unsuccessful, and at 6.50am the paramedics confirmed that
the man had died.
84. Later that morning a ‘hot debrief’ was held for the staff involved. (The purposes
of a hot debrief are to acknowledge what happened and the role of the staff
involved and to ensure that the immediate staff needs have been met.) Officer
I said that there was some anger from a couple of the staff that the man had
been left on D wing rather than being moved to Healthcare.
85. When my investigator interviewed the prisoner he spoke about the heroin that
he and the man had taken on 9 December. He said that he had been trying to
work it out, but he estimated, having shared some of his own wraps of heroin
with him, that the man may have had between five and seven wraps left. The
prisoner said that he could not be certain, but thought it probable that, like him,
the man would keep his drugs on his person - unless he felt it likely he would
be searched, in which case he would hide them in the cell.
22
ISSUES
Clinical Care
86. As noted earlier, a clinical review was carried out on behalf of the
Cambridgeshire and Peterborough Foundation Trust by a panel chaired by the
clinical reviewer, a consultant psychiatrist. My investigator was invited to be a
member of the review panel which met at Whitemoor on 16 May 2008. The
review contains eight recommendations which I endorse and reproduce at the
end of this report. The review concludes as follows:
“As is clear from the information above, the man had a very troubled history.
He clearly had a serious bi-polar disorder. All the antecedents indicate it
was possible he could make a serious suicide attempt which might not be
preceded by obvious behaviour that such an act was imminent. His history
also indicated he would engage in erratic misuse of drugs but prior to this
incident, he was not known to have done so in a prison setting. The view of
the review team is that a serious suicide attempt by overdose or otherwise
was always possible though not predictable. As a result the review team do
not believe that the incident, which led to his death, was preventable.
“The review team did have serious concerns about the lack of action taken
in relation to the man’s apparent intoxication. It is clear the collapse of the
other prisoner preoccupied both operational and healthcare staff and
distracted them from responding more appropriately to the man’s needs.
However, there were a number of discrepancies in the clinical and
operational response to his needs once concern arose that he was
intoxicated. His preceding history and the available knowledge about his
involvement in the incident, should have led to a more vigorous and effective
clinical response in relation to his care. It was though recognised that his
behaviour throughout the preceding and subsequent period was not helpful
to staff but the review team were of the opinion that he should have received
medical attention. To prevent such an occurrence in future the review team
have made a number of recommendations for action, which must be
addressed.
“Overall the review team do not believe the incident leading up to his death
was preventable. It is though likely if there had been a more appropriate
response to his physical healthcare needs when it became evident the man
was intoxicated that he would have survived.”
The Senior Charge Nurse
87. The Senior Charge Nurse is both a registered general nurse and a registered
mental nurse, employed on the DPSD. Nursing staff on the unit administer
prescribed drugs, remove clinical waste, and assist with the various
assessment sessions. General healthcare and emergency first aid is expected
to be delivered by the nursing staff employed in the prison’s healthcare centre.
88. She told my investigator that she first became concerned about the man around
8.00am on 9 December, when he came to collect his medication. Although she
23
told my investigator she thought that he was intoxicated and he refused to allow
her to conduct any clinical observations, she did not take the matter further, nor
bring her concerns to the attention of anyone else. Her entry on the nurses’
handover sheet also made no mention of her concerns:
“Mood appears low – night staff concerned as behaviour appeared bizarre
last night. States he is ok but a lot is going on in his head.”
89. The clinical review panel considered the question of what action was taken that
morning when he showed signs of being intoxicated. They reported:
“Little action if any appears to have been taken. No formal observations e.g.
BP [blood pressure], TPR [Temperature, Pulse, Respirations] blood/urine
tests were done by the DSPD nurse. Whilst these checks are normally the
responsibility of the Healthcare Department there is no reason why initial
checks cannot be carried out by DSPD nursing staff. This would have been
particularly necessary at the time when the healthcare staff were fully
engaged in treating another prisoner who had collapsed. Clearer detailed
records must also be kept of contacts with healthcare staff re physical health
concerns. Healthcare staff must visit to assess the prisoner. Where there
is significant concern a medical assessment must be requested.”
90. The Senior Charge Nurse told my investigator that, when she next saw the man
at lunchtime, he looked even worse. On that occasion she said she actually
asked him if he had taken anything. He replied that he had not. Again there is
no written record of the concern. I would have expected entries in the ACCT
document, his medical record, and the wing observation book, as well as some
medical observations and possible intervention. She did say that at lunchtime
she spoke to staff on the wing and asked them to increase their observations of
him. Whether or not those conversations took place, she did not carry out her
duties as would be expected from her training and experience.
91. A memorandum of understanding between healthcare and D wing clinical staff
which was in use in December detailed the healthcare responsibilities of both
and made it clear that “D wing nursing staff will complete routine/non-routine
blood pressure, temperature, pulse, food/fluid/weight checks, keeping records
in the prisoner’s current clinical file that will later form part of the prisoner’s
healthcare record.” Regrettably in this case the checks were not carried out
and I draw the matter to the attention of the Governor.
92. The clinical review panel came to the following view:
“Where there are signs that a prisoner is intoxicated they must be placed
under physical health care observations. If transfer to the Healthcare
Department is not feasible for reasons of safety then the physical healthcare
observations must be available in the setting where the prisoner is
contained.”
24
Response to the man on 9 December
93. The clinical review panel and I share serious concerns about the lack of action
taken regarding the man’s apparent intoxication during and following the
afternoon of 9 December. My investigator reports that, almost without
exception, the staff he interviewed believed that he should have been moved to
Healthcare if not an outside hospital. The view of the clinical review panel is
reflected throughout their report and in their recommendations.
94. The man was put into his cell and searched. The intention was to search both
his person and the cell for any illicit drugs. The officers who were to carry out
the search all knew him well. Staff on the DSPD work closely with the
prisoners, help to carry out assessment procedures and take part in other
prisoner activities. He became verbally and physically threatening when he
was told he would be moved to the crisis suite while his cell was searched. He
had objected to being moved to the crisis suite before so that may have been
the reason on this occasion. However, the prisoner estimated that the man
could have had as many as seven paper wraps of heroin at that time. SO A
made a tactical decision to withdraw from the cell for the safety of the officers
and avoid interfering with the prisoner’s treatment just outside. A breakdown in
communication then occurred between SO A and the orderly officer. The result
was that the orderly officer believed that both the man and his cell had been
searched and that nothing had been found.
95. The man was left in his cell with Officer G watching him. He called the officer
by his first name and told him he was not going to do anything silly (meaning
self-harm) and handed out a razor blade. My investigator took the view that he
may have been trading on his relationship with the staff, both to ensure that his
cell was not searched and later to re-enforce the lack of any need to search
further by volunteering the razor blade. Of course, it cannot be known whether
he had any drugs in his cell (none were found after his death) or whether he
took any further drugs before his death. However, in a unit such as the DSPD,
staff must be constantly vigilant for any signs of conditioning (the manipulation
of staff behaviour by prisoners resulting in loss of vigilance on security matters)
of themselves or colleagues.
96. The orderly officer decided that the ACCT observations should be increased
from those in line with State A and one quality entry per unlock session to four
times an hour. Staff involved at the time agreed that the man was concerned
for his friend, but no one said that they were concerned about him harming
himself. The orderly officer told my investigator that the increase was for the
man’s welfare and I accept that. I also accept that the prevailing opinion at the
time was that he should be monitored for signs of deterioration in his condition.
My concern is that the ACCT observations were being used in place of medical
observations by trained professionals. I have learnt from other investigations
that even a trained nurse would find it difficult to tell from outside a cell if a
person inside is asleep or unconscious.
97. The following extract from the clinical review underlines the concerns:
25
“Whilst he [the man] received regular observation during the night, this was
by operational staff and his condition required that he at the very least be
transferred to healthcare so that he could be observed by trained clinical
staff.” (Emphasis in original)
The Governor and the Healthcare Manager should reinforce to all staff
that observations for healthcare reasons are required to be carried out by
medical staff.
98. The movement to an outside hospital of a category A prisoner is both time
consuming and manpower intensive, especially at the weekend. The orderly
officer told my investigator that the prisoner was his priority and that he actually
had no face to face dealings with the man. He was unaware that he had told
the chaplain that he had strong suicidal thoughts or that he had trouble walking
when he collected his tea meal.
99. As it turns out there were two emergencies, and not just one, for the staff to
deal with on the DSPD Red spur during the afternoon of 9 December, although
the gravity of the man’s condition was not appreciated at the time. The
condition of the prisoner and the logistical requirements of his transfer appear
to have overshadowed the care of the man. I think that as soon as it became
clear that the prisoner would have to leave the prison, the orderly officer should
have appointed another officer to assume responsibility for the man. My
investigator has been told that there is no contingency plan at Whitemoor to
cover the eventuality of two serious incidents happening at the same time. I
have been reminded by the Prison Service that the orderly officer was not alone
or in sole charge of the prison at this time. There were two governor grades on
duty as well, a manager E and a manager F, both experienced operational
managers.
The Governor should consider preparing a contingency plan relating to
two or more serious incidents occurring at the same time.
ACCT document entries
100. The orderly officer instructed that the ACCT observation levels were to be
increased to four times an hour, which was done. The staff on duty at the time
and those working the night shift were aware of the increase. However, the
increase was not written up as required by Prison Service Order (PSO) 2700 on
the front of the ACCT document, only in the on-going record section where it
could easily have been overlooked.
The Governor should review procedures to ensure that staff comply with
the requirement of PSO 2700, annex 8HH, section 4.
The man’s back problem
101. When the man was allowed out of his cell to collect his tea meal, he required
assistance to walk and a member of staff carried his food back to the cell for
him. He asked to see the nurse about his back and was examined in his cell at
about 5.30pm. There is no record of the complaint, examination, diagnosis or
26
treatment either in his medical record or the ACCT document. Nurse A said
that the only record would have been in the nurses’ handover sheet and indeed
amongst the general pm entry relating to him is “on collecting meds c/o
[complained of] back pain”. Here was another missed opportunity for the
healthcare staff to engage with him and move him to Healthcare where he
could be properly observed.
The Healthcare Manager should ensure that medical staff accurately
record examinations, diagnoses and treatments in a prisoner’s medical
record and other relevant documents.
Handover to night staff
102. As can be seen from the interviews with the night orderly officer and night
nurse, the full circumstances of the afternoon and in particular the man’s
involvement and condition were not made clear at the handover. When they
both went onto D wing at 9.00pm, he was already asleep in his cell. Nothing on
the nurse’s handover sheet instructs or advises the night nurse to carry out
clinical observations. The last part of the medical record entry by Nurse C at
6.00pm reads:
“To be watched closely for signs of deterioration by wing staff, already on an
ACCT.”
The first part of the entry made by the night nurse at 9.50am the next morning
reads:
“Whilst on wing last night, I told D wing night officers to contact me if they
had any concerns about the man during the night. He was on four checks
per hour for his ACCT.”
103. The night nurse would have been unaware of the extent of the back problem
from which the man appeared to be suffering at tea time as the details had not
been recorded. The night orderly officer would also not have been aware of the
back problem or that he was having strong suicidal thoughts at 5.00pm, as the
orderly officer, who briefed him, was unaware of those facts. The night orderly
officer may have read the entry by the chaplain in the ACCT document, but
there is no evidence that he did.
104. The information either given to or left for the night staff, especially the night
nurse, was minimal and did not truly reflect the actual circumstances. I accept
that, due to lack of communication, no one person knew the full circumstances.
After the events of the afternoon there should have been a de-briefing session
with the staff involved to ensure that correct and full information was available
to hand over.
The Governor should introduce a protocol to ensure the accurate
gathering and handover of information following a serious incident.
105. The apparent ease with which the man and the prisoner were able to obtain
heroin whilst on the DSPD unit is of great concern. However, I am aware that
27
the Governor and his staff take the matter very seriously. I also understand
that they are putting measures in place to try to minimise the availability of illicit
drugs throughout the prison. In support of the Governor, the Director of High
Security Prisons will wish to assure himself that all reasonable actions are
being taken to prevent the ingress of drugs into the DSPD and into Whitemoor
as a whole.
106. In conclusion, I agree with the findings of the clinical review panel,
“Overall the review team do not believe the incident leading up to his
death was preventable. It is though likely if there had been a more
appropriate response to his physical healthcare needs when it became
evident the man was intoxicated that he would have survived”.
I believe that the situation with the prisoner distracted and deflected staff from
what would have been their expected response to the man’s presentation.
28
RECOMMENDATIONS
1. The Governor together with the Safer Custody and Healthcare Managers
should reinforce to all staff that observations for healthcare reasons are
required to be carried out by medical staff.
The Prison Service partially accepted this recommendation saying:
Healthcare observations, diagnosis etc should be accurately recorded in the
IMR, and possible nurse shift handover sheets. They cannot be recorded in
the ACCT or prisoner history sheet for operational staff due to medical in
confidence; however any concerns raised by nurses as to the immediate
welfare of a prisoner will be annotated in the ACCT document.
All healthcare staff have been briefed on the requirements to record
information as required. DSPD staff have been informed that they need to
proactively apply for training through wing management.
2. The Governor should consider preparing a contingency plan relating to two or
more serious incidents occurring at the same time.
The Prison Service have not accepted this recommendation saying:
This has been considered but establishment are able to deal with this
operationally as a process is already in place.
3. The Governor should review procedures to ensure that staff comply with the
requirement of PSO 2700, annex 8HH, section 4.
The Prison Service accepted this recommendation saying:
Training is being undertaken to ensure all staff are fully aware of the
requirements of Annex 8HH. Guidance to all staff issued on P60. Training to
be conducted to ensure all staff are aware of recording equipment.
4. The Governor together with the Healthcare Manager should ensure that
medical staff accurately record examinations, diagnoses and treatments in a
prisoner’s medical record and other relevant documents.
The Prison Service partially accepted this recommendation saying:
Healthcare observations, diagnosis etc should be accurately recorded in the
IMR, and possible nurse shift handover sheets. They cannot be recorded in
the ACCT or prisoner history sheet for operational staff due to medical in
confidence; however any concerns raised by nurses as to the immediate
welfare of a prisoner will be annotated in the ACCT document.
All healthcare staff have been briefed on the requirements to record
information as required. DSPD staff have been informed that they need to
proactively apply for training through wing management.
29
5. The Governor should introduce a protocol to ensure the accurate gathering
and handover of information following a serious incident.
The Prison Service has accepted this recommendation saying:
A protocol has been put in place for all orderly officers to pass on the details
of serious incidents and any instructions from hot de-briefs to oncoming
orderly officers.
30
CLINICAL REVIEW RECOMMENDATIONS
1. DSPD nursing staff should be tasked with carrying out preliminary
observations including, blood pressure, Temperature-Pulse-Respirations,
urine tests in support of a request for primary healthcare staff to attend to
assess a prisoner.
This recommendation has been accepted. The Head of Healthcare has
already met with the DSPD lead nurse and produced a memorandum of
understanding.
2. Detailed records, including phone calls should be kept by both DSPD and
healthcare staff of requests and responses for assistance.
The Prison Service has accepted this recommendation and said:
The control room have charge of all phone calls made and maintain an
incident log. This is an ongoing action.
3. Where there is concern that a prisoner is unwell or intoxicated healthcare
staff must visit to assess.
The Prison Service accepted this recommendation saying:
A Security Information Notice has been published to remind staff of the need
to report suspicions of intoxication to healthcare for assessment. Healthcare
staff have completed overdose recognition training. Other staff are to be
trained with the role out of IDTS.
4. Any prisoner showing signs of intoxication must be placed under the care of
the Healthcare Department.
The Prison Service has accepted this recommendation saying:
Healthcare staff are to draw up a local protocol for admitting a prisoner for
observation following intoxication or overdose.
5. Stocks of antidote medication should be sufficient to respond to more than
one case.
The Prison Service has accepted this recommendation and said that by May
2010:
All areas will have a stock of antidote and also defibrillators following the role
out of IDTS. Training for its use is currently underway.
6. The lead nurse in partnership with a suitable medical expert and the prison
pharmacist must draw up a protocol for antidote medication in the prison
setting if it is required.
31
The Prison Service has accepted this recommendation and said that by May
2010 antidote medication would be available in all residential areas and the
gym following the role out of IDTS.
7. A medical assessment must always be requested where there is evidence a
prisoner is intoxicated.
The Prison Service has accepted this recommendation and said a Security
Information Notice would be published to remind staff of the need to report
suspicions of intoxication to healthcare for assessment.
8. The decision to transport a prisoner to the A&E department must be based on
medical grounds.
The Prison Service has accepted this recommendation and say:
All requests to transfer a prisoner to hospital are facilitated.
32