Individual at Norwich

Investigation into the circumstances surrounding the
death of a man
at HMP & YOI Norwich in July 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2010
This is the report of an investigation into the death of an inmate at HMP & YOI
Norwich. This man died after being transferred from HMP Norwich to a hospital in
Norwich in July 2009. He was 38 years old. The man was only in prison for a few
hours before he took his own life. He had been charged with murdering his
estranged wife (an offence which is known to increase the risk of self harm). He was
being monitored by the Prison Service’s monitoring procedures at the time.
I would like to add my personal condolences to those already expressed to the
man’s family by one of our office’s Family Liaison Officers. I apologise for the delay
issuing my report, and hope this did not cause too much extra distress.
This investigation was undertaken a senior investigator. Both he and I would like to
thank the Governor of HMP Norwich and his staff for their participation in the
investigation.
A clinical reviewer was identified by NHS Norfolk to undertake a review of the man’s
clinical care, and I appreciate both her assistance throughout the investigation and
her final report. The clinical reviewer makes several recommendations relating to
healthcare procedures. In particular, I draw the Head of Healthcare’s attention to the
clinical reviewer’s recommendations about training and the use of assessment tools.
I am however satisfied that, even had any of these changes already been in place,
that it would not have altered the outcome for this man. But if improvements are
made, they may lessen the likelihood of a similar tragedy in the future.
I make five further recommendations. Two relate to identifying mental health
concerns in reception, and effective communication between the healthcare and
mental health teams at Norwich. Other recommendations relate to razors for
prisoners who are subject to self harm monitoring, the supply of first aid materials
and effective critical incident debriefs. I am pleased to see that the Prison Service
accepted four of my recommendations and partially accepted the other. The man’s
family did not make any comments in relation to the draft report.
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 June 2010
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CONTENTS
Summary
The Investigation Process
HMP & YOI Norwich
Key Findings
Issues
Recommendations
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SUMMARY
The man was a Polish national who lived in the UK. He was arrested on suspicion of
murdering his estranged wife on Friday 24 July 2009. Whilst in police custody, he
suffered from alcohol withdrawal and required frequent medical monitoring. He was
prescribed medication, and requests were made for his mental health to be
assessed. However the psychiatrist, who made two attempts to see the man, was
told that the assessment was no longer necessary and so did not see him.
On Tuesday 28 July, the man appeared in court and was remanded in custody. He
was taken to HMP Norwich. It was his 38th birthday.
The psychiatrist contacted the head of the mental health team at the prison to pass
on his concerns. The head of the mental health team at the prison tried to contact
medical staff on A wing, where new prisoners enter the prison and are medically
assessed, but was unable to do so.
The man was assessed at reception where staff judged that he was at risk of
harming himself. He was therefore placed on special monitoring procedures. He
underwent the standard medical screening, but was not judged to be in need of a
mental health assessment. He was allocated to a cell which he shared with another
prisoner. During the evening the man asked staff for extra razors, as he had not
shaved for a few days and had grown a short beard.
As part of the monitoring arrangements, staff checked on the man through the
evening. Although his English was poor, the man and his cellmate held basic
conversations, and there were no signs of any problems.
Shortly after 1.00am on the morning of the man’s death, the man’s cellmate was
awoken by some noise. He switched on the light, and saw that the man was lying on
the cell floor, bleeding heavily. He activated the emergency bell, and staff came to
the cell. They provided emergency first aid whilst an ambulance made its way to the
prison. At one point the man stopped breathing, but staff managed to revive him.
The ambulance arrived and paramedics continued to provide medical aid. He was
transferred to hospital, but unfortunately the man died at 3.18am.
The man’s cellmate was supported by several members of staff and other prisoners
at risk of harming themselves were checked. A debrief was held with staff after the
man was taken to hospital. Staff were offered support from the Care Team if they
felt that they needed it. However, the subsequent critical incident debrief meeting
was arranged when a number of those who had been involved were not available.
After some initial difficulty, the prison managed to make contact the man’s family in
Poland. The prison arranged his funeral, and provided his family with details of
where he was buried.
I make five recommendations. Two relate to the identification of mental health
issues in reception and communication between healthcare and mental health teams
at Norwich. Other recommendations are made about providing at-risk prisoners with
razors, the configuration of first aid boxes and attendance at debrief sessions.
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THE INVESTIGATION PROCESS
1. My colleague formally opened the investigation at HMP Norwich on 30 July
2009. He spoke to a number of staff, including the Governor, and was shown
extensively around the prison. He later returned to the prison and formally
interviewed six members of staff. The interviews were recorded and
interviewees were asked to sign a copy of their transcripts confirming the
accuracy of the record. Three signed copies were returned. My colleague also
spoke to the head of the mental health team on the telephone. Copies of all the
transcripts and a note of the telephone conversation are annexed to this report.
2. Notices were posted to staff and prisoners about the investigation, inviting
contributions. No responses were received.
3. My colleague studied all available relevant prison records relating to the man,
including medical records and statements made by staff.
4. NHS Norfolk identified the clinical reviewer to review the man’s clinical care. I
am grateful to her for undertaking the review. My colleague discussed aspects
of the man’s treatment with the clinical reviewer, and they conducted joint
interviews of staff. My colleague also attended the clinical review panel which
NHS Norfolk held to discuss the man’s clinical care.
5. The 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.
Upon completion, my report will be sent to the Coroner to assist his enquiries
into the man’s death.
6. The man was a Polish national. One of the Ombudsman’s family liaison officers
wrote to the man’s parents in Poland to offer the opportunity to raise any
questions or concerns for the investigation to consider. The man’s parents
asked if the report could clarify how their son had died. They also asked for
details of where he was buried, and we have arranged for that information to be
passed on to them. They requested a copy of my report when available, and a
translated copy will be provided for them.
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HMP & YOI NORWICH
7. HMP & YOI Norwich is a multi-functional prison, predominantly serving the
courts of Norfolk and Suffolk. The prison has occupied its current site
overlooking the city of Norwich since 1887. The prison accepts adult men and
young offenders, both convicted or on remand. It has an operating capacity of
557 prisoners. A wing includes the induction unit, First Night Centre, and drug
treatment areas. B and C wings contain category C prisoners. D wing is the
resettlement unit. E wing is the vulnerable prisoner unit. F and G wings are the
local discharge unit for low risk prisoners serving shorter sentences. L wing is
the Elderly Lifer Unit, and M wing holds prisoners serving sentences of two years
or less. There is also a segregation unit, and a healthcare centre which provides
24-hour nursing cover.
Mental health services
8. The mental health in-reach service provides staff cover in the prison from
9.00am to 5.00pm on weekdays. There is no out-of-hours service for mental
health.
Assessment, Care in Custody and Teamwork (ACCT)
9. Assessment, Care in Custody and Teamwork (ACCT) procedures are used by
the Prison Service to monitor and support prisoners assessed as at risk of
suicide or self-harm. Once placed on ACCT, the prisoner is observed at pre-
determined intervals according to the perceived level of risk. Each prisoner
should be assessed within 24 hours of the ACCT being opened, and then
reviewed at intervals decided on a case by case basis.
Night state
10. When prisoners are locked in their cells in the evening, the prison is in what is
known as night state. Staffing levels are reduced, with patrols on each wing.
The Night Orderly Officer is in charge of the operation of the prison, and is the
only one with keys to access all areas. Staff carry keys, held in sealed pouches,
which they can use to access cells in the event of an emergency.
Cell call bells
11. Each cell has an emergency call bell. Prisoners push a button in the cell, and a
buzzer goes on in the wing office to alert staff. In addition, a light goes on to let
staff know which landing the emergency is on. It does not specify which cell has
had its emergency bell activated. Once staff go to the landing indicated, a light
outside the door indicates the cell with the emergency. Staff can only cancel the
call by using a button outside the cell door and it cannot be cancelled from the
office. In July 2009, there were no records maintained of cell bell activation in E
wing.
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Previous deaths at Norwich
12. Before this gentleman, 31 prisoners had died in Norwich since the Ombudsman
became responsible for investigating deaths in custody in 2004. There have
been a further two deaths there since. The prison contains the country’s only
unit adapted for older prisoners and, as a consequence, has a high number of
deaths due to natural causes. But of these deaths, 10 prisoners died, like this
man, after apparently harming themselves. Two of these prisoners were on
special monitoring measures when they took their own lives, and two others died
less than 30 hours after arriving in prison.
13. A number of previous reports from this office have contained recommendations
about the healthcare provision in the prison. These recommendations include
issues around the reception process, mental health services including triggers
for assessments.
Her Majesty’s Inspectorate of Prisons
14. The last report on Norwich published by Her Majesty’s Chief Inspector of Prisons
was the report on an unannounced follow-up inspection in November 2006. The
report found that previous criticisms relating to suicide and self-harm procedures
had been fully addressed by senior managers.
15. The report recommended that the PCT and healthcare should undertake a full
review of all healthcare services to ensure that appropriate services are
provided. The report also recommended that the mental health team should be
involved in the care of prisoners subject to self-harm monitoring procedures.
Independent Monitoring Board
16. Every prison in England and Wales has an Independent Monitoring Board (IMB)
responsible for monitoring day-to-day life in the prison and to ensure that proper
standards of care and decency are maintained. The Norwich IMB annual report
for 2009 does not contain anything which is relevant to the death of the man.
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KEY FINDINGS
Previous imprisonment in HMP Norwich
17. On 11 March 2009, the man was convicted of drink driving and common assault.
He was sentenced to two months and 23 days imprisonment. Initially in HMP
Hollesley Bay, he was transferred to Norwich on 13 April. The Prisoner Escort
Record (PER) contained a warning that the man was potentially at risk of
harming himself, so an ACCT document was opened. The man told staff that he
was depressed. He remained on the ACCT until 16 April. Staff noted that his
mood fluctuated, and felt that he would need to be monitored if he was at “a very
low point”. He told staff that he had considered harming himself.
18. Bailed on 24 April, the man was again remanded to Norwich prison on 4 May.
An entry on his medical record shows that the man said he was upset to be back
in prison after such a short period. A note on his medical record shows that he
said he had previously been prescribed anti-depressants. He told staff that
whilst he had no thoughts of harming himself at the time, he did not feel able to
say how he might feel about this the next day. He was once again placed on
ACCT observations on 4 May and they remained in place until 13 May. He was
released on bail on 24 May.
In police custody
19. The man was arrested on 24 July on suspicion of murdering his wife. Whilst still
in police custody, he was medically reviewed and, complaining of chest pain,
was sent to hospital for further assessment and treatment. He returned to the
police station just after midnight. He was seen by a doctor at 9.40am who noted
that the man was probably alcohol dependent, and was showing signs of
withdrawal. He was not known to the local psychiatric services, but declared
mental health issues in the past. The doctor advised that he should undergo a
mental health assessment. In the meantime, he was prescribed diazepam.
(Diazepam is a sedative and is a common medication given to those withdrawing
from heavy alcohol usage.)
20. A further review was held at midday by another doctor. The man told the doctor
that he had a history of depression, suicidal thoughts, and auditory and visual
hallucinations. He was not, however, suffering any current hallucinations and
said that he had no intention of taking his own life. The doctor concluded that
the man was not suffering from any acute psychiatric problems which required
urgent action. Having discussed the case with a community psychiatric nurse
from the local emergency psychiatric care team, the doctor advised that the
team would arrange a psychiatric review the following Monday 27 July.
21. Another doctor assessed the man later that day. The doctor noted the risk of
self-harm as high/medium, and recommended that he should continue to be
prescribed diazepam, and be constantly observed by police staff.
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22. On Monday 27 July, whilst still in police custody, the man was given a further
medical review. He complained of abdominal pain, and the doctor said that he
would need to go to hospital the following morning, either before or after his
court appearance. The man was prescribed painkillers.
23. At 7.15pm, a nurse from the mental health service’s criminal justice liaison team
received a telephone request to assess the man at the police station. However,
when the nurse and a forensic consultant psychiatrist arrived at the police station
they were told that an assessment was no longer required.
24. A police medical report at 9.10am the following morning, 28 July, noted that the
man was showing signs of depression. He admitted that in the past he had tried
to harm himself, and the form was marked “constant cell watch suicide risk”.
The man also said that he still had abdominal pain, and the next dose of
painkillers was administered early. He was advised to speak to the prison doctor
when he arrived.
25. Another request was received by the mental health team for an assessment of
the man at the police station. However, on arrival at the station they were told
that the assessment should take place at court. They went to the court, but were
once again unable to obtain access to the man.
26. The man was remanded to HMP Norwich. The court’s Prisoner Custody Officer
completed the man’s prisoner escort record (PER), and one section of the form
asks if the prisoner is exhibiting signs of “bizarre behaviour, or other signs of
mental disorder”. The Custody Officer indicated that he was, and that he had
had a reaction to the outcome of his court appearance. The form also shows
that he had threatened to harm himself in police custody.
HMP Norwich
27. According to the PER form, the man arrived at HMP Norwich at 3.15pm. It was
his 38th birthday. He was seen on reception by a female officer, and she noted
the risks contained in the PER form. In addition to this, the female officer noted
that the man was charged with the murder of his wife (which has been identified
as a factor in prisoners attempting to harm themselves), and appeared agitated.
She therefore opened an ACCT document. He was to be observed by staff at
least once an hour and would be reviewed within 24 hours. Norwich’s Safer
Custody Policy states that the safer custody team will inform mental health
services when an ACCT is opened, but due to the lateness of the ACCT being
opened on the man, Safer Custody were not informed (they would have been
informed the next morning). The man underwent a cell sharing risk assessment,
and was judged to present a low risk of harm to anyone else.
28. Having twice been unable to gain access to the man to conduct a mental health
assessment, the forensic consultant psychiatrist from the mental health service’s
criminal justice liaison team telephoned the head of the prison’s mental health
team. The call was made at approximately 4.00pm. The forensic consultant
psychiatrist explained what had happened and told the head of the prison’s
mental health team that the man may have in the past suffered from depression.
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Believing the man to not yet have arrived in the prison, the head of the prison’s
mental health team telephoned the treatment room in the prison’s reception wing
to pass on the information. However, there was no answer. The head of the
prison’s mental health team knew that the man would be assessed on arrival at
the prison and was confident that any risk would be identified. He or one of the
mental health team would visit the man the following day.
29. As part of the reception process, prisoners at Norwich undergo a health
screening by a member of the healthcare team. The man was seen by a nurse
who shall be referred to in this report as Nurse A. In interview, Nurse A
mentioned the time-pressured environment that reception staff work in.
Prisoners often arrive late in the afternoon, after appearing in court, which can
mean a large influx of people shortly before staff shifts are due to end.
30. The reception screening is conducted using the prison’s medical computer
system, SystemOne. Using this system, Nurse A had access to the man’s
medical records from his previous stay in Norwich. Nurse A also had access to
his medical forms from his detention in police custody. She noted his threats to
harm himself whilst he had been in police custody, and that he had been placed
on an ACCT in reception. As the man’s first language was Polish, and his
English was limited, Nurse A communicated with him using a telephone
interpreting service. She noted that he appeared calm, was co-operative and
good-humoured. He made no mention of wanting to harm himself. He told her
that he had no history of mental health problems. He said that he had suffered
chest pains for two days over the previous weekend. He had a Salbutamol
inhaler, which he said he was given in police custody. He claimed not to drink
alcohol, but Nurse A noticed from the medical record that one of his previous
periods in Norwich was due to a charge of drink driving. She also made a note
that no medical or psychiatric report was required, and she did not request a
mental health assessment. A referral was made for the man to see a doctor
about insomnia.
31. A fellow inmate arrived in Norwich at the same time as the man. The two men
did not know each other, but in interview for this investigation the fellow inmate
said that he noticed the man whilst they were in the reception area. After the
reception process they found themselves in the same room (along with some
other prisoners) when served their evening meal. The fellow inmate did not want
his food, and gave it to the man. In interview, the fellow inmate said that he
remembered the man wondering aloud about how heavily a person would bleed
if they cut their wrist with a razor blade. The fellow inmate was then taken to cell
E1-03 on E wing (which is the wing where prisoners spend their first night in
prison). A few minutes later, the man was allocated to the same cell and joined
him. An entry on the man’s ACCT document notes at 7.00pm that there were
“no issues”.
32. The fellow inmate said that the man’s English made communication difficult, but
they talked a little as best they could. As part of the kit provided to prisoners,
they were each given two disposable razors. The fellow inmate said that the
man had a short beard, so asked if he could have more, and staff brought him
another two. At one point the fellow inmate noticed that the man was prising
10
open one of his razors with a plastic knife, and advised him that he would be in
trouble if he was seen. The man said that he wanted to cut some paper and was
making an implement with which to do so.
33. The day staff on the wings went off duty at 8.00pm, and night shifts began. On
E wing, the night shift consists of one officer and one operational support grade
(OSG). The staff on E wing that night were an officer, who shall be referred to
as Officer B in this report, and an OSG. They were briefed about any issues on
the wing that evening, including being made aware of any prisoners subject to
ACCT procedures. They noted that the man was subject to ACCT monitoring
and was to be checked at least once an hour.
34. E wing has two landings, and staff patrol each of these, including a check on all
prisoners in their cells, at least once an hour. As they complete each check,
they record it on an electronic logging point at the end of each landing. This is
known as pegging. Observations of prisoners on the ACCT procedures are
carried out in addition to the standard checks. Moreover, they are made at
irregular intervals, so that prisoners cannot predict when they will be checked.
35. On taking over from the day staff, the OSG undertook a roll-check, looking in on
the prisoners on the wing and ensuring that the correct number of prisoners
were present. He did this at 8.30pm, and noted on the ACCT form that the man
was making his bed. The OSG asked him if he was okay, and the man replied
that he was. The OSG noticed that his English was not very good.
36. The OSG and Officer B made a number of further checks on the man. At
9.15pm he was sitting in a chair watching television, and at 10.00pm he was
moving about his cell, talking to his fellow inmate and watching television.
37. At 10.55pm the man was in bed, and the OSG noted movement. He was still in
bed at 11.52pm, and again at 12.30am, when once again the OSG noted
movement.
38. At some time shortly after 1.00am, the fellow inmate was awoken by a sudden
noise. Being on the top bunk, he looked over the edge of his bed, and saw the
man rocking and mumbling in Polish. He told him to be quiet and lay back down.
He had noticed that the man had an inhaler and wondered if he was having
some sort of fit. The man continued to make noise, and after approximately five
minutes the fellow inmate heard him drop to the floor. At this stage he switched
on the cell light, and was able to see that the cell was heavily bloodstained and
the man was lying on the floor.
39. The fellow inmate pressed the cell call bell. He said in interview that there was a
delay of some minutes before staff attended the cell. There were no means of
recording the times that cell bells were activated on E wing, but Officer B
estimated that it was approximately 1.15am. The OSG went immediately to the
cell. He looked through the observation panel and saw the man sitting on the
floor with his back against the door. There was a lot of blood in the cell. The
OSG called to Officer B that this was a Code Red emergency (indicating that a
prisoner was suffering from blood loss).
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40. All staff in the prison during night state carry radios. Emergency requests for
assistance can be made via the radio or telephone. When the OSG said that
there was an emergency, Officer B was very close to the telephone in the office.
She telephoned the control room to say that there was a code red emergency.
This call was made at 1.16am. A call was then put out over the radio network.
Officer B quickly joined the OSG at the cell.
41. Having tried and failed to get a verbal response from the man, the OSG broke
the seal on his cell key pouch and unlocked the door. The man was leaning
back against the door so they had to push hard to gain entry, but they managed
to get the door open and enter the cell.
42. The OSG propped the man up on the side of his bed and saw a large wound on
the side of his neck. He told Officer B that he needed a pad or something similar
to stem the flow of blood, and she went to the office and opened the sealed self-
harm kit. In interview, she said that she could not find any dressings appropriate
for an incident involving heavy bleeding in the kit. She therefore picked up a
towel and took that back to the cell. The OSG pressed the towel on the wound,
and then he and Officer B checked the man for other wounds. It was obvious to
them that there were other wounds, and this was a very serious incident. Officer
B saw numerous cuts to the man’s wrists, inside his elbows, face and chest.
However, because of the amount of blood loss he had already suffered, he was
not bleeding much at this stage. He mumbled incoherently and tried to get up,
so the OSG and Officer B tried to calm him and keep him lying down. His
breathing was very laboured, and his skin pale.
43. A nurse, who shall be referred to in this report as Nurse D, was the member of
the medical team on emergency response, and was in the treatment room.
When the prison is in night state, the only member of staff carrying keys to
access all parts of the prison is the Night Orderly Officer. On this occasion this
was a Principal Officer, who shall be referred to in this report as Principal Officer
E. On hearing the emergency call, Nurse D picked up the self-harm emergency
bag and made his way to the door. At the same time Principal Officer E also
responded to the emergency call and made his way from his office to collect
Nurse D and escort him to E wing. Principal Officer E estimated that this would
have taken about three minutes before they arrived at the man’s cell.
44. Nurse D went into the cell and immediately saw that the man had lost a large
amount of blood. Principal Officer E instantly saw the seriousness of the
situation and radioed to the control room to call an emergency ambulance. The
control centre requested it at 1.17am. Principal Officer E radioed for another
member of staff to go to the main gate to escort the ambulance. He went to the
gate to organise the necessary keys. He also identified two members of staff to
escort the man to hospital.
45. Nurse D went to the wing office and collected the wing’s emergency bag,
containing further medical equipment including an oxygen cylinder and machines
to monitor blood pressure, oxygen saturation levels, and heart rate. He and the
OSG continued to provide first aid, but whilst they were doing so, the man
12
stopped breathing. They therefore commenced cardio-pulmonary resuscitation
(CPR), with the OSG managing the man’s breathing and Nurse D providing
heart massage. They managed to restart the man’s breathing and continued to
provide first aid.
46. The fellow inmate asked if he could do anything to help. But, seeing that he was
in a fair amount of distress, Officer B took him out of the cell and away from what
was happening. Principal Officer E had identified a cell for the fellow inmate,
and Officer B took him there. She waited a while with him, reassuring him. She
offered him the opportunity to use the Samaritans’ telephone, but he declined.
Officer B told him that she would check on him through the rest of the night. She
then went back onto the wing, and made a precautionary check on the other
prisoners who were on ACCT documents.
47. A first response paramedic arrived at 1.30am and was taken straight to the
man’s cell. He was appraised of the situation and radioed to the ambulance
service to provide an emergency ambulance as soon as possible. He then
provided medical treatment, assisted by the OSG and Nurse D. Principal
Officer E ensured that staff remained in position to escort the ambulance through
to E wing on arrival.
48. The ambulance arrived at 1.40am, and the crew were taken directly to the man’s
cell. Medical staff continued to provide emergency treatment to the man until
they decided to try to take him to hospital. He was transferred to the ambulance,
which left at 2.10am. Nurse D obtained the man’s medical records so they could
accompany him to hospital. Two prison officers went with him, but no handcuffs
or other physical restraints were used.
49. At 2.40am, Principal Officer E held a debrief with staff involved, although Nurse
D was not present. Staff were offered support from the care team if they felt that
they needed it. (Nurse D said that he also was offered support, even though he
was not at the debrief.) Staff noted that neither the self-harm response box nor
the first aid box on E wing contained any large pads that could have been used
to stem the man’s bleeding. Staff then returned to their duties.
50. Sadly, the emergency team at the hospital were unable to revive the man.
Principal Officer E received a telephone call from one of the escorting officers at
the Norfolk and Norwich Hospital informing him that the man had died at
3.18am.
51. Staff remained concerned about the fellow inmate. Officer B went and spoke to
him, and a member of the chaplaincy also spoke to him. An ACCT document
was opened the following day, and in the following weeks the fellow inmate was
visited and informally counselled by members of the chaplaincy team. He was
also offered formal sessions with a counsellor.
52. When Principal Officer E heard that the man had died, staff began to implement
the procedures required when someone dies in custody which include informing
the Independent Monitoring Board (IMB). There seems to have been some
confusion on this occasion. A telephone call was made to a gentleman at
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3.30am. The call was not answered, so staff left a message. They then tried to
contact the same gentleman via his mobile telephone, but the number had been
noted on the records incorrectly. The IMB were therefore not aware of the man’s
death until it was mentioned in a meeting at the prison later in the day.
53. Staff at the prison initially had some difficulty obtaining contact information for
the man’s family. But, after contacting the Polish Embassy, they managed to
contact the man’s mother. The man’s family were unable to come to the United
Kingdom, so the prison arranged his funeral.
54. The prison subsequently arranged a further critical incident debriefing meeting.
However, the session was set for a date when the OSG was not in the prison,
and Officer B was on annual leave. Nurse D received a letter notifying him of
the meeting a week after the event.
14
ISSUES
At reception
55. Escort papers which arrived in prison with the man were marked to indicate that
he had exhibited signs of bizarre behaviour or mental disorder. He had
threatened to harm himself whilst in police custody, and been remanded to
prison on a serious charge. He was identified as vulnerable and an ACCT
document had correctly been opened.
56. It does appear, though, that this was based largely, if not solely, on the
information received from the court. An ACCT was opened, so I do not make a
recommendation. But I would suggest that there is a learning point for reception
staff. Prisoners accused of certain offences, including domestic murders, are
particularly vulnerable to self-harm. Moreover, the papers do not indicate that
staff realised that he arrived in prison on his birthday. Personal anniversaries
can be another trigger for emotionally vulnerable prisoners. Reception staff
must be aware of, and sensitive to, potential warning signs that might indicate
newly-arrived prisoners are at risk. As the ACCT was opened, I have not made
a recommendation, but the Governor might wish to remind staff of the need to be
aware of potential trigger points for self harm.
57. It is always of concern if a prisoner who is subject to special monitoring
procedures is nevertheless able to take their own life. I have considered the
procedures put in place for this man. In the circumstances I think that the
opening of the ACCT document was correct and the level of monitoring, which
was carried out as instructed, was reasonable in the circumstances.
58. As the man had previously been in Norwich, his electronic medical record was
available to reception staff during his initial healthcare screening. This included
details of his having previously been subject to ACCT procedures, mention of his
depression, and of his use of alcohol. Nurse A assessed him but even with the
information available did not feel that there were any mental health issues to
necessitate referral for mental health assessment. Although he had been
prescribed diazepam whilst in police custody, the papers do not show that he
was assessed as to whether he required further medication.
59. Although the man arrived at Norwich at 3.15pm, reception was busy and a
number of prisoners had to be booked in. All prisoners have to go through the
reception process, and prisoners often arrive from court near to the end of staff
shifts. This obviously causes some pressure. I do not make a formal
recommendation, but the Governor may wish to consider the shift patterns of
staff working in reception areas to ensure that all prisoners receive the proper
time in reception without staff having to work beyond their scheduled shifts.
60. Mental health services are only available in the prison from 9.00am to 5.00pm,
and it was after 6.00pm when Nurse A signed the man’s ACCT form. Mental
health services would therefore not have been available to assess the man that
evening even if he had been referred for assessment.
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61. In her clinical review, the clinical reviewer notes that there was no structured use
of a mental health assessment tool at reception. It was at the discretion of the
member of healthcare staff who saw the prisoner, and whether or not they had
any mental health training. Whilst I do not think it likely that it made any
difference to the sad outcome in this situation, the mental health assessments at
reception seemed to be quite arbitrary. The man was on an ACCT, charged with
a serious offence, with indications of previous depression. The clinical reviewer
recommends that a holistic approach be taken into consideration of the triggers
for mental health assessment. I would agree that a more coherent approach to
mental health assessment should be in place, in particular for prisoners subject
to ACCT procedures.
The Head of Healthcare should make sure that vulnerable prisoners, like
this man, are referred for mental health assessment.
Passing on information
62. Whilst the man was in police custody, the criminal justice mental health team
made two attempts to assess him. On being unable to do so, when the man was
remanded to Norwich the team contacted the head of the prison’s mental health
team to pass on their concerns. The head of the prison’s mental health team
noted the information and attempted to contact reception healthcare staff by
telephone. However, he was unable to gain a response.
63. The head of the prison’s mental health team was unaware that the man was in
the prison at that time, and knew that he would be assessed by medical staff at
reception. He told my colleague that he was confident that any risks would be
identified there, and he or one of his team would assess the man the following
day.
64. In this instance, I do not think that, even had the head of the prison’s mental
health team been able to speak to a member of healthcare staff at reception, it
would have made any difference to the man. But the lack of communication is
worrying. The Governor and the Head of Healthcare may wish to consider the
flow of information between the mental health team and healthcare staff in
reception. If there are mental health concerns about a new prisoner, it is
obviously important that the chances of such a breakdown in communication
recurring are minimised.
The Governor and the Head of Healthcare should consider the means of
communication between the mental health team and healthcare staff at
reception.
Supplying razors
65. The induction pack provided to prisoners includes razors. I have to consider
whether it was reasonable to issue razors to a prisoner on ACCT procedures
because of the risk of him harming himself.
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66. Sadly, if a person wishes to harm themself then there are a number of ways that
they could do so. It would not be reasonable to expect the prison to remove any
possible means that a prisoner could use. Additionally, there are questions that
could be asked about the effect on a prisoner’s morale if he were not allowed
basic toiletries. Unless there are specific indications that a prisoner may use a
razor to harm himself, or if a prisoner on an ACCT has used razors to do so in
the past, I do not think that the prison should withhold them.
67. However, the fellow inmate said in interview that the man had requested, and
was given, extra razors once he was in his cell. He also said that the man was
tampering with one of his razors. Amongst the man’s property removed from the
cell by the police were pieces of broken razor, a razor handle, a blade and two
more razors.
68. Whilst it appears reasonable not to withhold ordinary supplies from prisoners, I
am a little more concerned that a prisoner on an ACCT requested extra razors
and appears to have been given them without question. The papers do not
show that extra razors were provided, but the fellow inmate’s statement and the
police property records do point to at least one extra razor being given to the
man. The fact that the man already had razors in his possession, which as I say
above I consider reasonable, means that this probably did not have a great
bearing on what happened later in the night. But the fact that he was on an
ACCT and asked for extra razors should have raised some questions. Requests
for extra razors by prisoners on ACCT documents need to be carefully
considered, and not just handed out as routine.
The Governor should ensure that staff are advised to carefully consider
and document requests for extra razors from prisoners on ACCT
documents.
First aid equipment
69. When staff needed medical equipment to treat the man, the first aid packs did
not contain anything that could be used to stop the bleeding. Officer B had to
use a towel to stem the man’s bleeding. Also, once the packs had been opened
and some equipment removed, they were not replenished until the morning.
Had there been another emergency before then, there would have been even
less equipment available for staff to use. I appreciate that most prisoners who
harm themselves do so by using a ligature and that wounds such as the man’s
are unusual. Nevertheless I suggest that the composition of first aid boxes is
reviewed.
The Head of Healthcare should review the contents and restocking of all
first aid boxes.
70. In other respects I have found that the response to the emergency was
excellent. The staff actions were swift, proficient and co-ordinated. In what must
have been difficult circumstances, staff acted with the utmost professionalism.
Informing the Independent Monitoring Board of a death in custody
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71. There was a problem relating to the IMB being informed of the man’s death.
Staff at the prison did attempt to contact a board member, leaving an
answerphone message on his landline. But when they followed this up with a
call to a cellphone they found that they had the wrong number on their records. I
do not make a recommendation, but would suggest that the Governor ensures
that staff have sufficient contact information for members of the IMB for use
when necessary.
Support for staff
72. The post-incident debrief session was scheduled for a time when key members
of staff were unavailable or had not yet received notification. I note that Nurse D
was also not involved in the hot debrief session held when the man was taken to
hospital. Dealing with an incident such as this can be extremely traumatic. It is
important that staff have the opportunity to both raise any issues they feel need
to be considered, and to be offered support if they feel they would benefit from it.
The Governor should ensure that debrief sessions include all necessary
staff.
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CONCLUSION
73. The man was brought to Norwich prison having been charged with a serious
offence. He was identified as possibly posing a risk of harming himself, and
placed on the ACCT suicide and self harm monitoring procedures. Attempts to
conduct a mental health assessment on him had failed whilst he was in police
custody, and these concerns were passed on to prison medical staff. However,
a breakdown in communication meant that their concerns were not reported at
the time.
74. He was seen by healthcare staff, who found no immediate concerns about the
man’s health. He was not referred for mental health assessment. He was put in
a shared cell, where he was monitored frequently by staff in accordance with the
requirements of his ACCT assessment. Although there was a language barrier,
his cellmate said that he gave no indication of being depressed.
75. In the early hours of the morning, the man’s cellmate was awoken by a noise.
On switching on the cell light, he saw that the man was bleeding heavily. The
cellmate alerted wing staff who, in my view, responded quickly and efficiently in
their attempts to save him. From the staff providing first aid in such difficult
circumstances, to the arrangements which gave the paramedics swift access, to
those looking after the welfare of his cellmate, I believe that the staff acquitted
themselves in an exemplary manner.
76. The investigation and clinical review identify some areas in which there might be
some improvements. However, I find it unlikely that they would have prevented
the man from taking his own life.
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RECOMMENDATIONS
1. The Head of Healthcare should make sure that vulnerable prisoners, like this
man, are referred for mental health assessment.
The Prison Service accepted this recommendation. All new receptions now
undertake a Mental Health risk assessment as part of their reception screening.
Depending on the score, they may then be referred to Primary Care or Mental
health In-Reach Team by the nurse.
2. The Governor and the Head of Healthcare should consider the means of
communication between the mental health team and healthcare staff at
reception.
The Prison Service accepted this recommendation. Any information from any
area regarding new reception prisoners can now be given to the reception nurse
or the discipline reception team at any time. If there is no response, information
must be left with the duty manager or the response nurse.
3. The Governor should ensure that staff are advised to carefully consider and
document requests for extra razors from prisoners on ACCT documents.
The Prison Service accepted this recommendation. A Governor’s Notice to Staff
has been issued, directing that no prisoner on an ACCT document should be
given more than one razor at a time. If another razor is requested, this will be
given on a one-to-one exchange basis. Such requests must be noted on the
history sheet and on the ACCT document itself.
4. The Head of Healthcare should review the contents and restocking of all first
aid boxes.
The Prison Service partially accepted this recommendation. They have said that
the provision of first aid boxes on the wings is the responsibility of the prison
health and safety department.. This issue will be discussed at the next Health
and Safety Meeting. The prison point out that in audits in November 2009 the
self-harm boxes and the grab-bags used by staff in emergencies were found to
contain all the elements required by Prison Service Order 2700.
5. The Governor should ensure that debrief sessions include all necessary staff.
The Prison Service accepted this recommendation. Contingency plans will be
updated to show that all staff involved in a serious incident should be notified of
debrief sessions, whether they are in the prison or not. The Care Team will make
sure that staff are aware of debriefs before they are held.
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