Individual at Send

INVESTIGATION INTO THE CIRCUMSTANCES
SURROUNDING THE DEATH OF
A WOMAN
AT HM PRISON SEND IN APRIL 2004
REPORT BY THE PRISONS AND PROBATION OMBUDSMAN FOR
ENGLAND AND WALES
NOVEMBER 2005
The woman died in HMP Send on 18 April 2004. She was just 23 years old.
I offer my deepest condolences to the woman’s mother and the other close relatives
who have been deeply saddened by her tragic death.
The investigation was conducted under the terms of the transitional arrangements
agreed between my office and the Prison Service, which came into effect on 1 April
2004. Guildford and Waverley Primary Care Trust gave clinical advice, but has not
provided a written review leaving a number of unanswered questions about the
woman’s mental health care. I am grateful to all the investigation team and to the
Governor and staff of HMP Send for their invaluable assistance.
This is a painfully sad story of a very damaged young woman. I note however, there
are a number of points raised by the woman’s family, regarding her clinical care, in
particular mental health provision, which remain unanswered. I have therefore
arranged for a supplementary clinical review to be carried out and will make this the
subject of a supplementary report, when it is available. The circumstances giving
rise to the woman’s arrest and to her death make hers a unique tragedy.
STEPHEN SHAW CBE NOVEMBER 2005
PRISONS AND PROBATION OMBUDSMAN
2
1. SUMMARY
The young woman was deeply distressed and had spent periods compulsorily
detained under the Mental Health Act. Her offence was committed at Beachy Head,
where she was wont to go and tell the police of her intention to jump from the cliff
and kill herself. No one knew how best to help her. She ended up in prison for want
of anywhere else.
At Holloway from August 2003 until she was sentenced in March 2004, the woman
was very well-known to the staff. For most of her time at Holloway she was
considered at risk of suicide and self-harm and monitored through the F2052SH
procedure. She often moved locations, sometimes being placed in healthcare,
sometimes in a special unit for prisoners finding it hard to cope, sometimes in
segregation for disciplinary reasons, sometimes on the ordinary wings. The woman
cut herself and tied ligatures many times.
Throughout her time in prison, the woman was taking anti-psychotic medication
which was changed from time to time.
After sentencing, the woman moved to Send on 26 March. She was not on an open
F2052SH at the time and expressed enthusiasm about the move. Staff at Send
were concerned about her because of her history and a fresh F2052SH file was
opened.
The woman died by means of a ligature attached to the bathroom door handle in her
cell on Sunday afternoon 18 April.
At the time, she should have been observed hourly but was not, and the time of the
last check before she died has been changed in the record. That afternoon, one
basic grade officer was responsible for supervising three wings, housing up to 120
women, while other staff were occupied with visits.
The woman was the first female to die at HMP Send. The prison has not been
accustomed to caring for acutely vulnerable women but the population has changed
because of pressure of numbers and the transfer of foreign national prisoners
elsewhere. I question whether the prison has an adequate infrastructure for the
demands now placed upon it. There are also training issues.
The report makes six recommendations.
3
2. MATTERS RAISED BY THE WOMAN’S FAMILY
1. When my investigators met the woman’s mother and other close relatives, they
said that when the woman was sent to prison they felt that at least she would
be safe there and get the psychiatric care she needed. They thought there
would be hospital wings and doctors and people who could sit down and talk.
They said they were not trying to apportion blame and felt guilt themselves that
they had not been able to meet her needs. But they raised questions which
they hoped the investigation would answer.
2. They asked what had been done differently at Holloway, which had been able
to protect the woman, whilst Send, though it seemed a much nicer place, did
not?
3. They asked about the woman’s medication. What medication was she
receiving? Was it dispensed and administered as prescribed? What were the
arrangements for administration of medication? Was ingestion supervised?
4. The family understood that the woman was taking Largactil. They said they
could not reconcile what they had been told about her ripping up a sheet and
hanging herself with their understanding of the mood-changing effects of
Largactil.
5. They asked about the provision for the woman’s mental health needs. What
psychiatric care did she receive in prison, particularly after January 2004? If
the prison could not provide appropriate care then why was she not in a mental
health facility instead? They wanted to see the psychiatric reports.
6. They asked many questions about the care of prisoners at risk of suicide.
Since the prison knew the woman was suicidal, why was she not given closer
care? Why was she in a single cell with a bathroom with a door and handle
and freestanding chair? Does the potential for CCTV to save lives outweigh
the invasion of privacy, in the case of prisoners known to be at serious risk?
The Wednesday before her death, the woman showed her mother she had
been cutting herself again. Did the prison know this? How did they respond?
Did her behaviour give no warning? How often was she being observed at the
time of her death?
7. The young woman’s family were appreciative of the care and concern shown
towards them by the Deputy Governor. They attended a tree-planting
ceremony at the prison in her memory and had valued the opportunity to talk
with prisoners who had known her.
4
3. REPORT OF THE INVESTIGATION
Holloway prison
8. HM Prison Holloway is a closed women’s prison in North London. It has the
function of a local prison, primarily housing prisoners on remand from courts in
London and the south-east. Its operational capacity in 2004 was 495. After
sentence, women who are to remain in prison are generally transferred out of
Holloway as soon as possible to release space for prisoners required to
appear in the local courts.
9. The woman stayed in a number of different locations in Holloway. At the time,
the healthcare unit was housed in C1. This had 25 places for medical and
psychiatric patients and prisoners considered to be at very high risk of self-
harm. H1 was the dedicated detox unit. Both the healthcare and detox units
had nurses on duty 24 hours a day.
10. D2 was a small unit for supporting prisoners who found it difficult to cope in the
general population. Small group activities such as art and drama therapy were
available there and the chaplaincy offered special support. Staff were detailed
to the unit consistently to provide continuity. The unit had places for 17
prisoners. The focus was to enable prisoners to move back into the general
population of the prison not to provide a permanent refuge. When D2 was
closed for refurbishment, alternative accommodation was provided on D3
which was otherwise the young offender’s wing.
11. A1 was the segregation unit where prisoners might be located to await
disciplinary hearings, for the punishment of cellular confinement, or if their
behaviour was too disruptive on an ordinary wing. B4, C3 and C5 provided
ordinary locations, respectively for remand, newly admitted and convicted
prisoners. However, population pressures or the needs of a particular prisoner
meant that the units would not always be used exclusively for prisoners of a
particular status.
12. In each location except the segregation unit, there is a mix of single and
shared accommodation, including dormitories housing four or five prisoners.
Send Prison
13. HM Prison Send in Surrey is a closed training prison for sentenced adult
women. It has an operational capacity of 220. The living accommodation is
divided into six separate wings: A, B, C, D, E and F. E and F wings are used
as resettlement units. Prisoners each have single rooms with en-suite
showers, except for D wing, which has used an older building and provides for
up to 20 places in a dedicated drug free environment. A, B and C wings form
the ’main block’. According to an inspection report by the Chief Inspector of
Prisons in 2001, each wing has some cells with interconnecting doors which
enable trained Listeners (prisoners trained by the Samaritans to provide a
confidential service to prisoners) to be available in the adjoining room. In
5
February 2004, a dedicated Listeners suite was being prepared by conversion
of an old staff room. All rooms have televisions installed.
14. The prison changed from a men’s to a women’s prison in June 1998. A variety
of education and vocational training courses are offered, including hairdressing
and information technology. Prisoners have the opportunity to obtain National
Vocational Qualifications, and there is also scope for work placements,
community work and outside education.
15. Healthcare provision at Send comprises a primary care service and visiting
specialists. There are no in-patient beds and no clinical staff on the premises
after 4pm on weekdays or after 2 pm at the weekend. A local GP practice
provides doctors for daily surgeries. An on-call doctor service is used for
medical requirements outside healthcare opening hours. On arrival at Send,
prisoners are assessed by nursing staff to check that they have no medical
needs requiring more intensive medical cover than Send can provide.
HMP Holloway 18 August 2003 to 26 March 2004
16. The woman was admitted to Holloway prison on remand on 18 August 2003
and remained there until 26 March 2004. This was her first time in prison. On
her arrival in Holloway, in accordance with normal procedures, the First
Reception Health Screen (F2169) form was used to record brief information
about the woman’s general health and drug and alcohol use. Her height was
5’3” and she weighed 98 kg (15 stones 4 lbs). The healthcare screening
process identified that she had suffered from asthma and an under active
thyroid, and had a history of both alcohol and drug misuse though said she
was not currently using street drugs and drank alcohol daily but in her view not
excessively. She had been treated for psychiatric illness and taken overdoses
several times and slashed her wrists. She said she was currently taking
prescribed Diazepam 5mg (a benzodiazepine) daily, Co-proxamol (an
analgesic containing paracetamol) and 50 mg Largactil (Chlorpromazine used
to treat psychotic disorders and symptoms such as hallucinations, delusions
and hostility. I am told that Largactil should be used with caution if there is
evidence of thyroid problems. Urine tests were positive only for
benzodiazepine (consistent with Diazepam). The woman was placed in
dormitory accommodation in H1, the detoxification unit, and prescribed
Chlordiazepoxide, a benzodiazepine used to relieve anxiety and to control
agitation caused by alcohol withdrawal. From 27 August, she was prescribed
4 mg Diazepam twice daily but as part of a programme for reducing her
reliance on benzodiazepines.
17. On admission to Holloway, the woman was also placed in the F2052SH
procedure of special care for prisoners thought to be at risk of suicide or self-
harm. This was initially because of the circumstances of her alleged offence.
The F2052SH file was opened by the escort service who received her into their
custody from Eastbourne police and placed her under constant watch. It was
said that police had attended Beachy Head on more than 40 occasions when
6
the woman had made threats to jump. Moreover, in the last few days she had
tried to cut her wrists, saying this was to release tension caused by her
children being taken from her. On 19 August, the record says that the
woman’s room-mates at Holloway told a psychologist she had been cutting
herself with a fork and putting ligatures round her neck. The residential unit
manager recommended that she see Psychology or a counsellor, Alcoholics
Anonymous, Education and an acupuncture group. She should be reviewed
three times an hour and during the night at irregular intervals.
18. The F2052SH was reviewed on 22 August by a Senior Officer. The support
plan was similar to before except that observations were to be four times an
hour, the woman would have access to the Listener scheme and she would
not be placed in a dormitory but in single accommodation.
19. On 27 August, furniture was removed from her cell when an officer reported
that she had been eating the screws and bolts from the furniture.
Subsequently she was said to be “eating anything she can get her hands on”.
The woman said it was because she wanted to die.
20. On 28 August, the woman was moved D2, a small unit dedicated to supporting
prisoners who were having difficulty coping.
21. On 3 September, staff contacted the woman’s psychiatrist and social worker to
confirm details of her medication and diagnosis in the community. A further
review of her vulnerability was held on 6 September with a Senior Officer, an
officer and the woman. The summary says she still felt suicidal but did not
want to talk about it. She wanted to talk to someone from Psychology and this
had already been arranged. The support plan says “Staff to monitor and
supervise, access to Listeners and Chaplaincy.”
22. The summary of the next review on 13 September is more detailed. An officer,
an Acting Senior Officer and the woman attended. The woman still stated that
she did not want to live, having nothing to live for, because she had lost her
children. She said she had had a breakdown the year before and was still not
considered well enough to have access to the children. She was attending an
Alcoholics Anonymous course and would like to have a course of counselling.
The support plan was to encourage purposeful activity, to observe at least
eight times during the day and half-hourly at night, to encourage her to speak
to Listeners and to use the Samaritans phones, to have access to the
chaplaincy, to have access to psychology and one-to-one counselling. Entries
in the record for 15 September refer to her talking to officers about wanting a
blade to kill herself and turning her bed on its end so she could hang herself.
She had also made superficial scratches on her leg with paint chips from the
window and spoke of feeling like opening old scars on her wrist to get at a
vein.
23. On 20 September, the woman said she wanted to be moved to C1 (the
healthcare unit) or A1 (the segregation unit) and was placed on report for
refusing to go into her room. Later that day she barricaded herself in her room
7
for having been put on basic regime. This followed three warnings in three
days for being rude and abusive to officers, and throwing water on a nurse.
The woman said she wanted to kill herself. She had thrown her mattress out
of the window and was given a fresh one. The furniture was removed from her
cell.
24. The next F2052H review, on 22 September, was again with one Senior Officer.
The woman appeared in good spirits although said she wanted to kill herself.
She said she had self-harmed in the last few days and told staff after she had
done this but could not tell them before. The support plan continued.
25. On 24 September, the woman was referred to the Community Mental Health
Team for assessment, at the request of her probation officer, and seen by a
doctor on 10 October. At that time her medication was said to be Diazepam 2
mg, Chlorpromazine (anti-psychotic) 75 ml and Procyclidine 5 mg.
Procyclidine hydrochloride is used to reduce the side effects of certain anti-
psychotic medicines.
26. On 25 September, she said she was being bullied on B3 so was moved to C3
for the time being.
27. The woman’s medical record says that on 28 September she “requested a
tablet of death” from nurses. Whilst she said she was not currently suicidal
she felt she had “no hope in life” and nothing to look forward to.
28. There was a further review of the F2052SH on 1 October when the woman
had moved to B4 (normal location for remand prisoners). The medical record
says that on 3 October she tied a ligature.
29. On 10 October, the doctor noted that the woman had a history of deliberate
self-harm and recent acts of self-harm, one of particular concern. The woman
seemed ambivalent about her drive to end her life, but her behaviour seemed
impulsive so there was some risk that she might attempt self-harm again.
However, she was aware that her court case was coming up soon and
believed she would be released, so although she stated that hanging was
better than prison she was looking forward to going back to her flat.
30. An entry in her file for 12 October says that she was very demanding of staff
time and, if she was told that staff could not respond immediately, she tended
to become abusive. Consequently, she was to remain on basic regime.
31. At a review on 15 October with a Senior Officer, the woman said she still had
thoughts of self-harm and had last “cut up” the previous week. She stated that
she regularly used the Samaritans phone and found this helpful. On 29
October there was a further multi-disciplinary review. The woman said she
wanted the F2052SH closed but admitted to self-harming in the court cell that
week. She was said to be settling down well on D3 (which was being used in
place of D2 as the supportive unit for prisoner having difficulties) and staff
arranged to meet again in a week’s time with a view to closing the F2052SH.
8
32. The woman was convicted on 17 October of making threats to kill. Sentence
was postponed for reports.
33. An entry in the file says that, although she was still on basic regime, a
governor had, exceptionally, authorised her going into a dormitory because
she could not cope on her own.
34. In a report dated 30 October, the doctor questioned the value of
Chlorpromazine (Largactil) for the woman. He advised that if there was no
evidence of it providing any significant benefit it should be stopped because of
the possibility of short-term and long-term side effects.
35. On 3 November, the woman received warnings for being rude and abusive to a
nurse and for throwing all her rubbish out of the dormitory window. On 5
November, at a review by a Senior Officer, the woman was said to be
“disgruntled” and unhappy to be on C3, which she said was too big and cold.
(C3 is a normal location primarily used for new prisoners going through
induction. It houses 46 prisoners.) She had not self-harmed for nearly two
weeks, the last occasion being at court, but she said that she now wanted to
die and her mind was made up. The F2052SH was kept open. On 6
November, the woman was placed on report for refusing an order to go to her
room.
36. The F2052SH support plan included trying to move her to a quieter unit. It is
not clear where she moved, but on 13 November she was said to be “still on
the 4s, but was reasonably happy”, apparently with no thoughts of self-harm.
The unit manager comments that he could not see the F2052SH being closed
although “with some effort we can integrate her fully into the regime in the 4s.
She is a pleasant talkative young lady and is making progress away from D3.”
It is clear that at this stage staff were working hard to try to motivate the
woman through encouraging her and rewarding constructive behaviour. File
entries for 16 November say she was making a big effort and had been really
helpful, getting on with the other women and making the best of her time. She
was moved from basic to standard regime.
37. On 24 November, at a review attended by a Senior Officer and an Officer, the
woman said that she wanted the F2052SH to be closed but she was unable to
say much to indicate how she was feeling. The review decided that the file
should remain open, with staff support, continuing contact with the chaplaincy
and activities off the unit. The review noted that she was to see someone from
Psychology the next day. The woman assured an officer of her determination
to be well-behaved.
38. On 2 December the woman was warned for being rude to an officer, throwing
her mattress out of the window and misusing the cell bell. The review by a
Senior Officer on 4 December noted that she was now on C5 (normal location
for convicted prisoners), “following a spate of self-harm and/or discipline
issues on other units.” The support plan was for single accommodation,
9
befrienders, Psychology, staff support and two-hourly entries in the file during
the day and half-hourly entries at night.
39. On 18 December, the woman was warned for being rude to staff, obstructing
the door hatch, continuously ringing the cell bell and continuously banging the
door after being told to stop. A file entry suggests that she found the
structured, more intensive, supervision of D2 challenging, whereas elsewhere
she said she could “do what she wants”. (D2 provided additional support for
prisoners finding it hard to cope.) The record in the 2052SH file on 19
December says that the woman had tied four ligatures and barricaded twice
since her court appearance the previous Monday. Later the same evening,
she set fire to papers and her clothing and was moved to A1 (the segregation
unit).
40. A case conference next day recorded that she said she felt like killing herself.
Her need to self-harm was said to be related to anniversaries of significant
events. It was her younger daughter’s birthday that week and Christmas was
coming. It was agreed that the woman needed to be admitted to healthcare for
a period and then to D2 after a case conference with D2 staff. She was to be
observed hourly throughout the day and night and reviewed on 24 December.
The review was attended by five staff including a probation officer. The
support plan included contact with the proposed personal officer from D2,
obtaining photographs and clothes from her stored property and sending a
birthday present to her daughter.
41. An entry in the medical record for 22 December says the woman said the
Chlorpromazine was helping her from hearing voices. She did not like
Procyclidine because it was given in tablets. She did not like tablets and
wanted only liquid medication.
42. On 23 December, in a one-to one session with a nurse, she said that she felt
she wanted to barricade herself in her room again. She said she felt bored
and isolated and that prisoners and staff did not like her. She had very low
self-esteem.
43. The following day, the woman attempted to barricade herself in her room and
refused to speak to staff. The same nurse spent time with her again. She
recorded that she was unable to explain her feelings and thoughts, other than
placing the blame on the way others interacted with her. They discussed how
she might use more positive coping skills. The woman was not expressing any
suicidal intent but remained impulsive. She was difficult to engage at times
and her concentration was poor when challenged about her behaviour and
interactions with others. The nurse made a referral to Psychology. On 25
December, the woman was moved to D2.
44. The next review was on 28 December. The woman was said to appear very
relaxed and she was applying for work to keep her mind off self-harming.
However, on 30 December she was warned for being extremely rude to staff.
10
45. On 1 January, the woman was warned for being verbally abusive to an officer
when told she would be moving to a single cell. She was placed back on basic
regime. That evening, in conversation with an officer, she acknowledged that
her behaviour had been unacceptable and promised to try hard to improve.
46. The unit manager and probation officer attended the review on 6 January
2004. The summary notes that the woman was not talkative but accepted that
she would stay on D2 as the safest place for her. A new personal officer had
been identified and was said to have managed to get her bathed and into
clean clothes. The unit manager commented, “There is always a high risk of
self-harm with her but I feel that on D2 we can reduce this risk.” The support
plan was for the 2052SH to remain open for staff support, to continue twice-
weekly contact with probation on Mondays and Fridays, the woman to be
encouraged to take part in as many off wing-activities as possible, and to use
Listeners as required.
47. On 7 January, the woman made superficial cuts on her leg. The medical
record says she was still keen on staying on medication (Chlordiazepoxide and
Chlorpromazine) but agreed to reduce them as planned.
48. On 15 January, a review was conducted by a Senior Officer. It records her
progress, with behaviour and mood noted to have improved. However, the
summary note says it remained to be seen whether this would be sustained
and the woman said she still suffered from mood swings so the 2052SH was to
remain open, with her remaining in a dormitory with support, including
psychology, and hourly entries during the day and half hourly at night.
49. On 21January, the woman saw healthcare staff about galactorrhea, a condition
in which the breasts lactate that can be caused by anti-psychotic drugs. The
record also says that she said she had thyroid problems and was probably
hypo-thyroid. On 22 January, she tied a ligature with a dressing gown cord
which was removed by staff. She was admitted to C1 healthcare and
remained there until 27 January. On 23 January, a doctor explained that she
was probably suffering side-effects from the medication. The record says that,
despite this, she wanted to continue the medications but agreed to change
from Chloropromazine to ‘Olanzapine’. (Olanzapine is an antipsychotic drug
that was less likely to cause lactation but may cause substantial weight gain.)
On 23 and 24 January, the woman tied several ligatures and refused to be
assessed for adjudication.
50. The doctor saw her again on 27 January in order to prepare a report for a court
hearing on 6 February. He commented that she said she wanted to be re-
admitted to a psychiatric hospital where she said she had lots of friends and
liked having staff available 24 hours a day. She had asked him if he could
“make up” a diagnosis to get her admitted. The doctor tested the woman’s IQ.
The score of 75 indicated a borderline learning disability. He recalled that he
had advised that her medication be reviewed. There was little evidence of her
having a psychotic illness and very limited data to support the use of her
11
current medication in people with personality disorder. He noted that she was
currently complaining of her breasts leaking milk, which was a side effect of
anti-psychotic medication. The discharge summary from C1 healthcare on 27
January says that her current medication was Olanzapine 5mg nocte.
51. At the F2052SH review on 2 February, the woman said she wanted the
2052SH closed. In particular, she said she was upset that the night patrol staff
kept waking her up with checks. However, she also said she still felt like tying
a ligature and was worried about her court hearing the following week. Staff
felt she was still vulnerable and the file was kept open. A review was
scheduled for the day before the court hearing. She was to continue to see a
counsellor once a week, and probation twice a week, and to be encouraged to
take part in activities.
52. The medical record relates episodes of self-destructive behaviour in early
February. On 7 February, the woman tied a ligature in the early hours of the
morning that was cut and removed by staff. Following this she was placed on
half hourly observations. She told the special watch nurse that she had come
back from court and was concerned about being on B5 (normal location) and
also about being assessed for “Castlefield Hospital”. The next entry, still on 7
February, says she tied ligatures to her bed and self-strangulated claiming she
wanted to die. She barricaded twice and wanted to go to A1, the segregation
unit. At 12 noon she was warned for using offensive language towards and
officer. On 8 February, she threw hot chocolate at a nurse and was abusive to
officers. On 9 February, she inserted tissue paper deeply into her right ear.
On 10 February, the woman tied two ligatures causing superficial redness. On
12 February, she tied a ligature but said she would not do it again and wanted
to be moved “upstairs”. At this point she was taking 5 mg Olanzapine once a
day.
53. At a review on 12 February with a Senior Officer, Officer and Special Watch
Nurse, the woman said she liked being able to talk to the Special Watch
Nurse. The summary says there had been some incidents of self-harm and
that she still got angry and frustrated and did not know what else to do. The
summary comments that she was likely to find it difficult when the watch was
reduced. She was expected to remain on H1. (H1 was the detox unit but was
also used for prisoners who needed nursing supervision but for some reason
could not be accommodated in healthcare.) In fact she moved to D2.
54. On 14 February, the woman threw a tablet of soap at an officer and swore. On
16 February, she was found lying under her bed having tied a ligature with a
bed sheet. An officer cut the ligature. She was said to be very aggressive and
demanding to go to A1 (segregation). On 17 February, she tied a ligature and
flooded her room and was moved to the segregation unit.
55. On 19 February, the woman was said to be very unresponsive. She had not
seen the counsellor for one-to-one counselling for a couple of weeks and
wanted this to resume. She had tied a ligature two days before and said this
was not because she wanted to die but because she wanted to go to A1 (the
segregation unit) for time on her own.
12
56. On 23 February, the woman was warned for standing in front of two D2 officers
constantly swearing at them. She maintained it was because she wanted to
go back to segregation. She was in the segregation unit from 26 February
until 1 March for disciplinary reasons.
57. On 4 March, the review noted that the woman had last self-harmed about two
weeks before. The counselling had resumed and she said it helped her. The
woman said she had had recent thoughts of self-harm and was worried about
her children and their well-being. The review said that she was still thought to
pose a danger to herself and it noted her tendency to violent mood swings.
The F2052SH was to remain open until after the next court date, with a review
on 18 March.
58. On 10 March, she met a consultant psychotherapist and psychoanalyst, who
was to assess her for the Cassel Hospital. His report for the court is dated 15
March and recommended that she would not be suitable for the Cassel
Hospital at that point. The court considered the report on 22 March.
59. On 14 March, the woman submitted a complaint that, when she had tried to
talk about feeling suicidal to a member of the night staff, they had threatened
disciplinary action if she did not shut up and go to sleep. A senior officer
acknowledged the complaint in a letter addressed to her at Send on 7 April,
apologising for delay caused by staff being on leave and saying he hoped to
be able to write with a further update on 26 April. The senior officer says that
he received the complaint only on 5 April and was told that the discipline office
was dealing with a backlog of requests and complaints. The member of staff
concerned replied on 21 April 2004 in a statement denying the woman’s
allegation.
60. The review on 18 March was attended by the woman, two Senior Officers, a
representative of Psychology and one of the prison’s Suicide Prevention Co-
ordinators. At the start, the woman was distressed and kicking her door
because she was missing free-flow (when prisoners move about the prison to
go to activities). She was calmer after being reassured she would be taken to
education after the review. According to the summary, she had not self-
harmed in the last four weeks and was feeling much better. She felt able to
manage on her own and wanted the F2052SH closed. The woman was
assured that all the support remained there for her to use if she needed it and
the F2052SH was closed. By this point, the woman said she no longer needed
such a high level of support so the F2052SH had come to feel intrusive rather
than supportive and the extent of observation was beginning to annoy her.
There is a note in her general file advising staff that the F2052SH had been
closed and she might need extra staff support, although there is no evidence
of any specific support plan being put in place.
13
61. Next day at 8.30pm, a Senior Officer who had been present at the review,
reopened the F2052SH when the woman handed him an apparent suicide
note and told him she could not cope on C5 and wanted to go to segregation
or hang herself. The next day, Saturday 20 March, the Unit Manager noted
that the woman had said she was now fine and wanted the file to be closed.
The Unit Manager was not convinced and decided it should remain open for
the time being.
62. The Unit Manager spoke to my investigators about the staff’s approach to
opening and closing F2052SH files. He said it was important not to keep them
open too long at one go because it could become simply automatic and a
crutch. The aspiration was that prisoners would move on and see themselves
doing so. If prisoners wanted to come off the F2052SH and staff resisted, that
could be seen as the staff saying that they expected the prisoner to self-harm
again. Instead, they tried to encourage prisoners by saying, for example,
“You’ve done two weeks without self-harm. Maybe you can do three or four or
five weeks.” The staff on their units would continue to be vigilant. They knew
that it might be necessary to open the file again but wanted to encourage
prisoners to progress.
63. On Monday 22 March, the woman was sentenced. In reception, on return from
court, she stated that she would cut herself, and appeared very subdued and
unhappy. The health care assessment for the F2052SH was completed that
evening. The nurse’s assessment was, “thinks she has nothing to live for and
nothing to go out for and therefore will kill herself – not actively suicidal.” At
8.45pm the woman was seen by a doctor, who knew her well from her time in
Holloway. The doctor’s assessment was “Frustrated. Says may attempt
suicide. Meantime asking for more medications. Not actively suicidal. No
intention to self-harm.” The records for that evening are detailed. Staff
offered her hot water and biscuits when she was admitted to the wing and she
was observed in the course of the evening engaging with her room-mates,
showing pictures of her daughters and watching television. Staff also gave
extra bedding when she said she was cold.
64. Next day the woman was said to seem in quite a happy frame of mind. At
9.35am the doctor again saw her and there were no indications of self-harm.
The woman had an outstanding disciplinary charge for endangering health and
safety. That was dealt with and she was given a punishment of three days
cellular confinement suspended for one month. At 11:00 she was discharged
to D2. Whilst on D2 wing at 12:45 the woman stated she would like to transfer
out of Holloway as soon as possible and she filled in an application form to do
so. It is normal practice for sentenced prisoners to be transferred from
Holloway to ‘training’ prisons soon after sentencing. The woman appeared to
be in a good frame of mind. At 3.00pm a case review was held, consisting of a
nurse from the Community Mental Health Team and a Senior Officer. The
summary by the nurse says that the woman stated that at times she wanted to
die and at others to live. There was no clear evidence currently of suicidal
ideation or thoughts of self-harm and she was feeling positive and upbeat
14
about being transferred to Send. The F2052SH was closed. On 25 March,
healthcare staff reported the woman was fit for transfer.
65. A Senior Officer told my investigators that sentenced prisoners were usually
moved out of Holloway very quickly; even three days’ delay was quite a long
time. He was clear that the closure of the F2052SH had no connection with
the anticipated transfer. If they had felt the F2052SH should remain open she
would have been transferred with an open file.
66. On 25 March, the woman submitted a further letter of complaint stating other
prisoners on C5 landing were bullying her. This was submitted on a prisoner’s
formal complaint form serial number 151. This was not investigated.
Transfer to HMP Send
67. On admission to Send, the woman was seen by a nurse then a doctor. Entries
in the medical record note that she was known to be hypothyroid and that she
should be taking thyroxine but had stopped because she thought it was not
working. She reported an allergy to paracetamol, which caused her to vomit.
She used Salbutamol and Beclomethasone for asthma. Her height was 5’2”
and weight 18st 4 lb (116 kg). She was considered fit for PE. She reported
some history of mental health problems with a diagnosis of personality
disorder and was currently taking 5 mg Olanzapine.
68. A nurse noted that the woman had been on an open F2052SH that had been
closed a few days before, and that she sometimes felt suicidal or liable to self-
harm. Considering her vulnerable, the nurse opened a new F2052SH. She
recommended that she be placed in normal accommodation on a wing and
supervised every three hours.
69. A doctor saw the woman after the nurse. He noted that she had a history of
deliberate self-harm and suicidal ideation with cutting and overdose but had no
recent wounds and reported that she had no desire to self-harm at present.
He noted the diagnosis of personality disorder and depression and that she
was known to be hypothyroid. He considered that the woman was not
currently at high risk of deliberate self-harm and confirmed that she should be
located in a normal residential unit. The doctor prescribed 5 mg Olanzapine
once a day for 28 days and noted that the young woman needed to have a
psychiatric review.
70. The woman was allocated to cell 12 on B -1. B wing is where all newly
received prisoners are housed during the induction programme, which lasts
between two and three weeks. A Senior Officer reviewed the F2052SH that
evening. She noted that reception staff were concerned when the woman told
them she had suicidal feelings. She instructed that residential staff should
monitor her at irregular intervals. The entry in the file does not say how
frequently.
71. The file records that the Senior Officer spoke to the woman on Sunday
evening 28 March, after she had told an officer she wanted to hang herself.
15
She noted that she was worried about a number of issues including what
would happen when she was released. The Senior Officer arranged for a
Listener to see the woman and instructed that she should be put on hourly
watch. The overnight monitoring from 22:00 to 06:00 is recorded as taking
place on the hour every hour.
72. The F2052SH was reviewed by two Senior Officers with the woman in the
evening on Monday 29 March. The summary says she was very down and
had decided “how she would like to go”. She was uncertain about what would
happen about her social worker and supported housing (which she expected to
lose when her Housing Benefit ran out.). The care plan says the woman would
see the Throughcare department about counselling, the visiting Psychiatrist
and Probation about social work and housing issues. Residential staff should
provide support and supervision, and consideration should be given to a work
allocation.
73. Entries during the following week show some indications of the woman settling
in at Send. As part of the standard induction programme, she visited the
library and education on Tuesday and gym on Wednesday.
74. On Thursday 1 April, the F2052SH records that she had a long chat with an
Officer. The woman was still expressing a wish to die, but also speaking more
positively about working, and seeing Throughcare “to get answers”. She also
had a long chat with the chaplain in which she talked about her tendency to
depression but “seemed quite happy”. She was allocated to work in the
gardens and seemed pleased with this. She had a chat with an officer at lock-
up, saying she was slowly settling in and had met some familiar faces but
found it hard to make friends.
75. Friday 2 April started badly, but improved. At 09:30 the woman was tearful.
She was unhappy with her medication (Olanzapine), saying her tablets were
not the same as at Holloway though the nurse said they were. According to
the F2052SH, she told the nurse that if she were to die it would be the nurse’s
fault. The medical record, apparently dated 2 April, says that the woman said
she could not swallow the Olanzapine tablets, but that she was “now on
Chlorpromazine”. (According to the Patientline website, Olanzapine is
available in tablets to swallow or tablets that dissolve on the tongue. Other
records indicate that her medication was not changed until later.)
76. On the wing, the woman declined a Listener and did not want to talk, but
subsequently talked to an Officer. At 10:30 she went to induction and seemed
happier. At 12:30 she was said to be “chatty and very smiley”. At 2.10pm she
went to Throughcare and “seemed in good spirits”. The Officer recorded his
conversation with the woman. She said she tended to get quite suicidal and
felt low about her weight and appearance. She was missing her children, but
left on a positive note after their chat. At 6.00pm the woman asked for a
Listener to be with her at lock up and one remained with her until 9.15pm.
Another Officer recorded in the file that at 9.15pm the woman asked whether
dead bodies smelled. During the night the file records checks on the hour
every hour.
16
77. The Observation Book for the main block (through which staff alert their
colleagues to matters of general concern) says that the woman had been
telling two other prisoners that she would kill herself and that she was jealous
when those two prisoners spent time together.
78. On Saturday afternoon, the woman requested a Listener and one attended.
79. In the morning, the woman went to the wing office requesting the Avon book
for ordering cosmetics. At 1.15pm she told an officer her medication was not
working. She said she wanted to see a doctor the next day and that it was
urgent and she was having hallucinations.
80. The Orderly Officer spoke to the woman for 15 minutes at 2.35pm. His entry in
the F2052SH says:
“States she feels fed up and that medication is not as productive as she would
like. Demanded to see doctor. Explained that Healthcare is not full-time. Very
manipulative. Used emotional blackmail in attempt to get more medication,
letters and use of computer! Reached agreement that I would discuss review
of medications with Healthcare on Monday and arrange appointment with the
doctor.”
81. That afternoon, the woman requested a Listener, who went to her cell. At
4.00pm the woman asked to be able to call the Samaritans that evening. This
was agreed. The entry also says that she was very grumpy, “constantly
moaning about anything and everything”. At 7.17pm she was offered the call
to Samaritans but she declined, saying she was trying to sleep.
82. The woman was due to start work in the gardens but could not do so because
the prison stores did not have work clothes in her size. At 10:15 she had an
appointment in healthcare. She told the nurse she was hearing voices and
seeing things. She said she suffered from depression and had been on
Chlorpromazine (Largactil) for some years. The nurse noted as ‘action taken’
that she was to see the psychiatrist on Thursday 8 April. Wing staff reported
that the woman came back from healthcare “all smiles”. At 1.30pm she told an
Officer that she felt a bit low but wanted to come off F2052SH. Shortly after
this she asked the same officer how long it took for an ambulance to get to
Send. Twenty minutes later she came back and apologised for being difficult,
explaining that she wanted to hurt herself. That evening at 8.40pm, she is said
to have been verbally abusive to an officer who came to check her in
accordance with the F2052SH.
83. First thing in the morning, the woman arranged with an Officer that she would
go to the stores about getting kit. However, the stores were still unable to
provide what she needed so at 09:50 she was waiting to go to the library.
Apparently there was also a difficulty about reconciling working in the
horticultural department with the requirement in the F2052SH for her to be
observed every hour by prison staff. The Prison Officer judged that, whilst she
still needed supervision, the benefit of constructive activity outweighed the
17
requirement for hourly observation. He noted that, in consultation with the
Suicide Prevention Co-ordinator, he had reduced the observation requirement
to three times morning, three times afternoon, three times evening and three
times overnight.
84. The Officer noted that at 12:10 the woman came to the wing office demanding
he find her lost property. He explained that reception staff and Holloway would
do this and she would be informed. At 2.15pm, she went to the stores for
garden kit.
85. That afternoon the woman met a CARATS worker, for the first time for an
initial assessment. CARATS is a staged programme for overcoming
substance abuse. The CARAT worker recorded that it was very hard to get the
woman to engage with her. The initial assessment normally takes about 25
minutes, but in fact took about one and a quarter hours to get very little
information. At one point the CARAT worker abandoned the assessment and
made the woman some hot chocolate to try to engage with her better. She
told my investigators that the woman seemed completely desperate for
attention and was quite concerned by her overall demeanour. The CARAT
worker says the woman told her that she started using alcohol regularly from
the age of six and cocaine from the age of 10. She said she had been drug
free when she was pregnant because being pregnant and caring for her
children had been a positive motivation.
86. On Wednesday 7 April the woman came back to the wing from work during the
afternoon because she was feeling unwell. She had been talking to an Officer
Support Grade about harming herself, but had also been laughing and joking.
An Officer arranged for the woman to be seen in healthcare, from which she
returned “seemingly miserable” and unwilling to talk. At teatime lock-up, she
told the Officer she would hang herself but an hour later when unlocked
seemed chatty and happy. There is no evidence that any action was taken to
safe-guard her following this statement. The medical record says that the
woman complained of a runny nose and headache and was signed off as unfit
for work. The nurse noted that the woman was suffering “low mood” and
“talking about killing herself”. The record also noted that the woman’s current
medication was Olanzapine 5 mg, ventolin and becotide (the last two were for
asthma) and that she was to see the psychiatrist next day.
87. In the morning of Thursday 8 April, the woman’s F2052SH was reviewed. The
case review was multi-disciplinary. The review notes that the woman was very
quiet initially and said she was uncomfortable with so many people present.
The woman said she was uncomfortable discussing things with men present.
She said she had felt down all week and considered hanging herself but felt
the “apparatus would not support her weight”. She said she felt worse after
lock-up and referred to the same concerns as the previous week.
88. The care plan noted that she was on a waiting list for counselling and was to
see the psychiatrist that afternoon. Observations were to be increased during
18
lock up (the file does not specify a frequency). It was requested that male
members of staff not be used in future reviews.
89. Half an hour or so after the review, the woman asked to speak to an Officer
about something important. She said she had been told to speak to an officer
if she felt like hurting herself. She told the officer she went to work in the
gardens so she could cut her stomach and wrist “across”. She said she would
harm herself, and she gave another officer a long piece of fabric which could
be used as a ligature. The Officer said he could not get much conversation
from the woman and she was very depressed at present. The Officer was with
her for about half an hour. The file notes that, later in the morning, the woman
spent time with a fellow-prisoner. After lunch she went to C wing, presumably
to see another prisoner, then to healthcare to see the visiting psychiatrist.
90. There are notes in the medical record which are not signed but appear to be
by the psychiatrist. He notes that the woman explained her offence by saying
that she “wanted to get sectioned.” His opinion was that she was not
depressed or psychotic, nor actively suicidal but suffered from a personality
disorder and was a drug and alcohol abuser. The psychiatrist advised that
Olanzapine should be stopped and replaced by CPZ (Chlorpromazine) 50mg
BD and that he should see her again in two weeks. (CPZ is also known as
Largactil and is used to treat psychotic disorders and symptoms such as
hallucinations, delusions and hostility.) It appears her medication was
changed that day. The F2052SH says her medication was “increased” to
Chlorpromazine 50mg twice a day.
91. On Friday 9 April, the woman did not go to work and was given linctus for a
cough. In the morning she had a chat with an officer who helped her with
applications and arranged for her to look through the cupboard of donated
clothes in reception. She then sat in with a fellow-prisoner, and was said to
seem “fine”. At 6.30pm she asked an Officer to lock her in her cell. She said
she was “OK” and would ring the bell if she had any problems.
92. On Saturday 10 April, the woman asked for permission to use a razor for
personal hygiene. Half an hour later she cut her left arm and wrist with the
razor. A prisoner alerted staff and the woman was taken to healthcare where
the wounds were cleaned and dressed. She then seemed better but in the
afternoon rang the cell bell having made further superficial cuts to her forearm.
She then sat in with a fellow prisoner. The woman told an officer she would
hang herself later but the officer records that her demeanour was that she
“seemed to find it all quite amusing”. At 2.35pm she asked to use the
Samaritans phone but it was found not to be working. She declined other
offers of help and again said she would hang herself. The Senior Officer
increased the mandatory monitoring to half-hourly observation. She and then
the Deputy Governor spent time talking with the woman, who told them she
had taken all her medication (four Largactil tablets issued for the weekend)
that morning. At 6.30pm the woman brought to the wing office a torn sheet, a
broken ashtray and half a razor blade and said she had changed her mind and
would not harm herself.
19
93. The woman was found to have secreted a fork from the dining room when she
returned from breakfast. The cuts she had made the day before were cleaned
and dressed in healthcare.
94. On Monday 12 April, the “superficial cuts” to the woman’s arm were checked
by healthcare. Staff were alerted in the Observation Book to a warning from
another prisoner that the woman was planning a number of self-harm attempts
the next day. The F2052SH records indicate that she seemed active, smiling
and engaged with other prisoners, for much of Monday, though she was in bed
at 4.10pm, took her tea, then asked to be locked up, was less communicative
and simply turned her back when an officer wished her goodnight.
95. On Tuesday, the woman went to work in the gardens. An Officer made
arrangements that staff would check every half-hour that she was all right and
report back to the wing. This was done. When the woman came back to the
wing at lunchtime she asked to go to healthcare where she told a nurse she
had pains in the stomach, nausea and felt dizzy. The nurse noted in the
medical record that the woman was taking Chlorpromazine. She was given
Gaviscon and advised to drink a lot of fluids and to breathe deeply to alleviate
the dizziness. According to the prescription chart, she was also given 400mg
Brufen.
96. In the afternoon, the woman met a CARATS worker, for a full assessment.
Her note in the F2052SH says that the woman constantly said she wanted to
hang herself or cut her arms. In the CARAT workers view, she was “clearly
extremely mentally ill and her needs were far in excess of what we prison
could support her with.” At interview, she told the investigators the woman
said she felt mentally ill, as if her mind and body were separated. She had felt
better at Holloway and wanted to go back there but also said frequently that
she wanted to go into residential psychiatric care. That evening, the woman
asked an Officer to lend her a pen and when he could only spare a red one
she verbally abused him.
97. On Wednesday, the woman seemed fine all morning at work in the gardens.
Her mother visited in the afternoon. The woman’s mother says she told her
she had started cutting herself again but they laughed and joked together
about the treats they would have when she was released. The woman also
talked about seeing the visiting psychiatrist, and said that she felt he did not
listen. The woman had made a tee-shirt for her daughter at Holloway and they
joked about opening an arts and crafts shop together. An officer recorded that
it was a good visit. Shortly afterwards, however, the woman shouted at an
officer and at 5.30pm she was said to be ripping up all her paperwork in her
cell and refused to speak to staff. She went to dinner alone and at lock- up at
8.25pm told an Officer she was OK.
98. In an entry in the main observation book for Thursday 15 April, the woman is
said to have asked how many officers were on duty and when asked why she
wanted to know, said only, “You’ll see.” The officer took her to be implying that
there would not be enough officers to cope.
20
99. Entries in the F2052SH say that at 09:00 the woman was “in a mood” and
complaining that officers were not responding immediately to her requests.
Apparently, the woman was making her displeasure with a particular officer
loudly known on the wing. In particular she is said to have wanted
paracetamol. On admission the woman had said she was allergic to
paracetamol which made her vomit, though on admission to Holloway the
woman had said she was taking co-proxamol which contains paracetamol. A
multi-disciplinary case review of the F2052SH was held at 12:10. Apologies
are recorded from Healthcare, although they had not been represented at any
of the previous reviews nor apologies recorded. At the review, the woman was
said to be “quite chatty”. She expressed a wish to have an opportunity to work
in a charity shop. An Officer explained how she could work towards that and
had also suggested she join a ‘Fine Cell’ (fine needlework) class to get out in
the evening and give her an interest other than watching television. A Senior
Officer told my investigators that the woman was positive about the future.
She wanted to lose weight before release and, at her request, the Senior
Officer arranged for the gym to lift a month’s ban, imposed because she had
failed to turn up for two gym sessions.
100. At 5.45pm the woman told an Officer that some prisoners were “moaning at
her”, because she had to wear lotion for head lice which had been given by
healthcare that morning. After a visit to reception and a chat with her key
worker, she seemed in a more positive frame of mind. The record says that
the Orderly Officer thought it might be necessary to “move one or more of her
tormentors”. An Officer recalled that two of the prisoners who the woman had
had conflict with were moved off the wing, but she said that she could also be
quite antagonistic to other prisoners herself.
101. On Friday 16 April, the woman went to work in the gardens. Another prisoner
says the woman approached her in the gardens to talk, especially about her
distress about her children, and said officers would not listen to her, in contrast
with Holloway where she had been assigned an officer round the clock and did
not have to go hunting for one. The woman also said she was being bullied on
the wing – “they take my chocolate and take the mickey ‘cos I’m fat”. She said
the only way to get an officer to listen was to harm herself. Then she began to
get angry and was kicking things. She seemed very stressed and said she
wanted to go to healthcare, that she would hurt herself with a plastic knife and
would hurt herself badly this time.
102. The work party leader told my investigators that the woman seemed angry and
frustrated, which was not unusual for her, but perhaps more so than usual. He
telephoned the wing office and was asked to arrange for the woman to go to
healthcare before coming back to the wing.
103. The medical record records that the woman complained of a stabbing pain in
her right side and said she felt suicidal and wanted to go back to Holloway.
She did not want to work and she made herself vomit after eating certain
foods. The nurse‘s assessment was that the woman did not appear to be
actively at high risk but should see the doctor again the following week. At
interview, the nurse said there were always concerns about the woman
21
because she talked about suicide regularly but that day they had sat and
chatted for a while and taken each other’s blood pressure.
104. An entry in the F2052SH says that when the woman came back from
healthcare she said that she had not “threatened” to hurt herself but said that
she “felt like hurting herself”.
105. In the evening of Friday, the woman asked a Senior Officer if she could have a
razor. It was agreed she could have it for 15 minutes. When staff went to
collect the razor they found she had caused superficial cuts to both wrists.
These were cleaned and dressed. The Senior Officer noted that the duty
Listener was called and that the woman needed to see healthcare on Saturday
morning. The incident was recorded in the main block observation book to
alert other staff. The F2052SH file noted that supervision was to be “hourly,
throughout the night, to be reviewed in the morning.” Observations during the
night were recorded as at: 2040, 2200, 2315, 0005, 0100, 0200, 0300, 0400,
0500, 0600 and 0730, thus they were sometimes at intervals greater than an
hour.
106. On Saturday 17 April, the woman’s wounds were cleaned and dressed by
healthcare. She asked for a Listener and an entry in the file says that when
the Listener left she seemed in good spirits. Entries in the record indicate that
she engaged with others during the day, including the prisoner in the next door
cell, but was very quiet in the afternoon and in the evening said she “had had
enough”. She was offered a Listener but declined.
107. On Sundays, according to Send’s core day, there is a handover and roll-check
at 07:30. Prisoners are unlocked from 08:00. There is a roll-check at 12:15.
Lunch is from 12:30 until 1.45 then prisoners are locked on the wings but not in
their cells. Visits run from 2.00pm to 4.15pm.
108. Entries in the F2052SH for the early morning are at 06:00, 07:30 and 09:10,
thus not adhering to hourly intervals. An Officer told the investigators that on
Sunday morning the woman went to reception to look at the donated clothing
because she had apparently been having some trouble on the wings about her
clothing and having head lice. She stayed in reception for about 20 minutes
and had a cigarette with staff there. The visit to reception is not recorded in
the F2052SH. Back on the wing at 10.15, an officer has recorded that the
woman seemed “cagey”. At 11.45 she came to the office for a chat and said
she was feeling low but was laughing at the same time.
109. Three other prisoners approached officers that morning to say that the woman
had been asking them to help her cut her wrists. One prisoner spoke to the
Principal Officer and said that the woman seriously needed to go to hospital, to
be somewhere she could be understood and looked after. The Principal
Officer explained at interview that he had heard angry shouting on the wing
and had come out of his office to see what was going on. A prisoner had told
him that the woman wanted her to help her kill herself. He had calmed that
prisoner down and a few minutes later went to speak to the Orderly Officer.
22
110. Another prisoner says the woman asked her through the cell grill to slice her
wrists. They had had a bit of a row two days earlier when the prisoner had told
the woman off for cutting herself. The prisoner responded to her request by
shouting and screaming at her outside the room. The prisoner saw the Senior
Officer to tell her the woman was going to cut her wrists and that she and the
woman had had a “massive row” about it. The prisoner says the woman said
that kind of thing consistently and she had not felt at the time that it was
different that day, though it was out of character that she did not go for her
midday meal. Another prisoner says that at about 12:00 or 12:15 the woman
got someone to shout up to A wing that she wanted to talk to her again. This
prisoner did not come down because she was taking care of a fellow prisoner
who was vulnerable and distressed. The woman did not come for lunch which
was unusual,
111. At about 12:15, the Senior Officer another Officer went to see the woman
about what the other prisoners had said. They were concerned for the other
prisoners since the woman tended to associate with women who like her were
vulnerable and on F2052SH. They found her talking to another prisoner but
spoke to her in her own room. The Senior Officer checked the F2052SH and
made an entry that the woman should be checked “as per the level of
supervision EVERY HOUR as she is vulnerable at this time”. Send has a local
system of placing an adhesive form on the front of the F2052SH stating the
frequency of check required. The Senior Officer placed the appropriate sticker
on the front of the file giving the level of supervision as every hour, from 12.20
on 18 April. The Senior Officer told my investigators that at her management
check on the file she had been concerned that the level of supervision was not
clear. Another Senior Officer had indicated on the Friday that supervision was
to be hourly though the night and reviewed the next morning. There were
frequent entries in the file throughout Saturday but the frequency of
observation had not been reviewed.
112. The prisoner the woman had been talking to that lunchtime had been at Send
only four or five days. The woman would come and sit in her room and they
got to know each other. The woman had wanted to go back to Holloway. At
Send other prisoners were bullying her and calling her names. The woman
talked about death quite a lot and that day had talked about ways of hanging
herself. The prisoner had asked the woman if she was coming to lunch but
she had said she was not hungry, which was unusual for her. After lunch, the
prisoner said she was going to have a shower. The woman left the room and
came back and gave her shampoo, hair conditioner and something else. The
prisoner gave the woman a hot chocolate then took her shower. When she
came out she went to knock on the woman’s door but there were officers
standing outside and then she heard the officers trying to resuscitate the
woman. The prisoner said she did not think the woman meant to kill herself
because she had not shut her door.
113. Another prisoner who was in room B1-19 said that the woman spent about
quarter of an hour with her in her probably from about 1.45pm. The woman
had not said much. She had been a bit tearful and said she was not having a
good day. Asked if she had any particular concerns about how the woman
23
was treated at Send, she said that other prisoners used to single her out and
“take the piss” because she was overweight.
114. In accordance with the Senior Officer’s instruction, an Officer went to the
woman’s cell at 12:40 and recorded that she responded to his enquiry by
swearing at him. The Officer normally worked on A wing but knew the woman
slightly and his impression was that her mood was very changeable. He had
not gone back to check on her again. This Officer was on early shift. Another
Officer took over from him for the afternoon. The early shift Officer could not
recall whether he had expressly briefed his relief about the immediate
concerns about the woman. The next entry in the 2052SH file is recorded as
being at “13:30” though the figure has apparently been changed from 14:30.
The entry states that she had seen the woman at the bottom of the landing and
she seemed OK. The Officer said that when she came back from treatments
she had been to A wing briefly then, on her way to the main block office, she
had seen the woman at the end of the corridor probably walking back to her
cell.
115. At 2.55pm the woman was found by an Officer hanging on the inside of the
bathroom door in her cell.
116. This Officer, who was the only Officer on the main block (A, B and C wings),
which houses up to 120 prisoners, was carrying out her checks on the
F2052SH prisoners. When checking on the woman, she found the cell
observation panel blocked by sanitary towels. The cell door was pushed
closed but not locked from the inside. She went into the room and found the
woman hanging from the inside of the bathroom door. The Officer called for
assistance on her personal radio and attempted to enter the bathroom area of
the room, but was unable to do so because there was a chair on the other side
and the woman was resting heavily against the door. After gaining partial
access, the officer attempted to support the woman’s body, but it was difficult
because she was standing at an awkward angle and the woman’s body was
heavy and limp. The Officer called for urgent assistance again.
117. After hearing the second call for urgent assistance at 2.55pm on her personal
radio, a Senior Officer, who was assigned to searching visitors at the gate,
arrived on the scene and assisted by supporting the woman, which enabled
them to attempt to release the sheet from the top of the door. When this was
released she was able to lie the woman down on the floor of the shower area.
Scissors were required to cut the ligature from around her neck, so the Senior
Officer called for the self-harm box and the Officer left the cell to get further
assistance. Staff do not carry ligature knives. There is one set of ligature
scissors in the main block office and one in each of the other wings. The
Senior Officer described the ligature as a sheet knotted to the outside of the
toilet door and going over the top of the door to inside the bathroom.
118. Another Senior Officer and an Officer ran to the wing from the visits hall when
they heard the call for assistance on the radio. The Senior Officer said that at
first she could not hear the radio call properly. At the cell, the Officer was
shouting for the self-harm box containing scissors. Another Officer arrived,
24
bringing the D wing self harm box with him. The ligature was a piece of green
sheeting, double knotted very tightly and difficult to cut. The Senior Officer felt
for a pulse in the woman’s wrist, but was unable to find one. The staff
attempted to revive the woman by performing Cardio Pulmonary Resuscitation
(CPR). This was continued until the Paramedics arrived at 15:13 hours, set up
equipment and then took over. The woman was taken to Royal Surrey County
Hospital at 3.38pm. She was pronounced dead at 4.05pm.
119. The Duty Governor and residential PO were also present at the cell whilst the
senior officers were attempting to revive the woman. They found a note
written by her, describing her sense of sense of isolation and despair.
120. When the ambulance crew left, the Senior Officer bagged and sealed the
ligature and the note, then sealed the cell. The Police arrived at 4.55pm hours
and were taken to the scene, conducted interviews and left the establishment
at 8.05pm.
121. Additional staff were called on duty to assist in supporting both the staff
involved in the tragedy and to provide as near as possible a full prison regime.
The prisoners at Send were later informed of the woman’s death.
122. The police conducted a preliminary investigation but found no suspicious
circumstances.
123. On Monday morning 19 April, the Deputy Governor, chaired a meeting where
all staff involved were asked to give their account of what happened. The
Deputy Governor also held a full staff meeting. The Governor was on leave
and was abroad when he was told of the woman’s death.
25
The capacity of the Prison Service to provide appropriate care
124. The account I have presented of the woman’s unhappy life in Holloway and
Send is shocking. People who have no reason to know what happens in
women’s prisons may think it uniquely shocking. Tragically, repeated self-
harm and mental distress are common among women prisoners. That does
not mean that prisons are necessarily equipped to provide appropriate care.
The court appears to have gone to some lengths to seek an alternative for the
woman. The National Probation Service’s advice that they could not manage
what they described as her “attention-seeking behaviour” in the community
was driven at least partly by concern about resources. Prison was the place of
last resort. The fact that there was nowhere else does not mean that prison
was suitable.
125. In particular, I am concerned that Send lacked a sufficient infrastructure to
provide adequate care. There is a contrast between the experience and
resources available at Holloway and at Send. At Send at the time of the
woman’s death, six women out of the 120 on the main block were subject to
open F2052SH files. When interviewed by the investigation team, a Senior
Officer said that at Holloway there were about 60 women on open F2052SH
files that day (out of a total population of about 500) and on his own unit there
were nine women at risk, for whom five 2052SH files were to be reviewed that
day. Holloway thus has a higher proportion of acutely vulnerable women, but
its larger size allows greater diversity of provision, on-site in-patient healthcare,
and a community mental health team, a refuge for prisoners finding it hard to
cope, and more scope among the larger staff to specialise, and to share and
rotate responsibilities.
126. At Send there was little specialist help available and the woman relied mainly
on support from the uniformed staff and other prisoners, particularly Listeners.
There was no Community Mental Health nursing in-reach, like that available in
many prisons, though the woman saw the visiting psychiatrist. She was also
on a waiting list for a counsellor. A senior officer told us prisoners might wait
eight or nine weeks to see one of the two part-time counsellors. There was no
in-patient healthcare or other refuge, and only single accommodation, although
apparently there were linked cells available to be used as Listener suites.
Nursing staff were on site only during office hours and weekend mornings,
which had implications for issuing medication.
127. When the investigating team visited Send, they perceived that the culture
within the establishment was positive, and there was a feeling of good
staff/prisoner relationships. Entries in the F2052SH show that the woman
seems to have derived support from her conversations with a number of
officers at Send. There are examples of relaxed and sensitive interaction.
However, there are also occasional entries in the F2052SH indicating a lack of
compassion or that seem to interpret the woman’s behaviour as wilfully
difficult.
128. It is clear that the woman was sometimes difficult to help. The patience of
members of staff can wear thin and it is to the credit of many members of staff
26
that they were able to sustain the woman as they did. Discipline staff are not
mental health professionals. They have many duties and women to take care
of, and it must be very frustrating not to know how to help, or to find one’s best
efforts repulsed or ineffective. The woman’s behaviour towards staff was not
always attractive and it must have been disconcerting for staff to find that
sometimes she seemed to propose her own death light-heartedly.
129. However, characterising difficult behaviour by vulnerable women as
“manipulative” or “attention-seeking” misses the point that such behaviour
flows from distress. Inconsistency in the woman’s own attitude towards self-
harm was only to be expected and surely reflected her own struggles with
herself. The woman may have seemed to demand a lot of attention from staff,
but often she seems to have been following advice to tell someone when she
felt like harming herself. That was probably the model she had learned in
hospital care and no doubt was also encouraged at F2052SH case reviews.
130. There are other aspects of the woman’s experience in prison that cause
concern. There are some indications that some prisoners bullied her though
she seems also to have formed some friendships. There is reference to
property lost when she transferred from Holloway and I have no more details
of this. The difficulty of finding suitable work clothes cannot have helped the
woman’s morale. I note that she gained nearly four stone in weight while she
was at Holloway. However, entries in the records at both Holloway and Send
suggest that the woman was at least as unhappy and apprehensive about
what was to become of her when released, as she was about her experience
in prison.
131. A number of people have said that they think the woman may not have
intended to die. Others have noted that she wanted to be sectioned. An
Officer says that essentially the woman wanted company 24 hours a day.
Healthcare and medication
132. The woman transferred to Send, the doctor prescribed a once a day 5-mg
dose of Olanzepine which, latterly, the woman had been taking at Holloway.
He also noted that she was hypothyroid and the medical record notes that the
woman told the nurse she had stopped taking Thyroxine because she thought
it was not working.
133. After a week, the woman complained that her medication was not the same as
at Holloway and by Sunday 4 April she was asking to see the doctor urgently.
It is conceivable this had some connection with her apparent difficulty in
swallowing tablets. On Thursday, the doctor changed the medication to
Chlorpromazine (Largactil) which she had taken in the past. The medication
was to be taken twice daily. On Saturday 10 April, the woman said she took
four tablets at once.
27
Arrangements for issuing medication
134. A nurse says that the woman was not given her tablets in possession, but
collected them from healthcare. She recalled that the woman had been
required to take her medication in sight of healthcare staff, but on reflection
thought this was probably after the occasion when she said she had taken four
tablets at once. She also recalled that sometimes healthcare staff would take
evening medication to the Orderly Officer so it could be given at night. It would
be taken to the Orderly Officer, in a sealed bag with the woman’s name and
the time it was to be taken clearly marked.
135. Medication was issued by nurses at Send at the healthcare centre in the
mornings and afternoons during weekdays and in the mornings at weekends.
When prisoners needed to take medication at times when no clinical staff were
in the prison, either the treatment was given to the prisoner in advance to take
later, or, where was concern that this might be unsafe – because of a risk of
overdose, failure to take medication as prescribed, or the possibility of trading
or bullying for medications - the only option was for medication to be issued to
prisoners by non-clinical prison staff. In the past, the prison had been
criticised for permitting secondary dispensing of medications by non-clinical
staff. Issuing medication in a sealed package identified as for a named
prisoner is not “secondary dispensing” but it raises other concerns. In
particular:
(cid:127) There is no protocol about the issuing of medication by officers.
(cid:127) There is no dedicated secure place for storing medication to be issued by
discipline staff.
(cid:127) No record is made when a discipline officer issues medication to a prisoner
or indeed when a prisoner fails to collect medication.
(cid:127) No system is in place to record medication being returned to the Healthcare
Department that has not been issued to prisoners.
136. Prison officers also issue paracetamol to prisoners on request. It is for a
clinician to say whether that might pose any hazard.
137. If medical care was needed out of office hours, the prison was able to call on a
locum service. At the time of the investigation, no member of staff had access
to medical records when the healthcare staff were not on duty. That too
seems not ideal given the vulnerability and widespread use of medications
among the female prison population.
138. The Governor told the investigation team he was working on extending nursing
cover to 8.00pm and to try to get the same GP five days a week instead of a
different GP each day. From April 2005, healthcare would be commissioned
by the local primary care trust.
28
The Head of Healthcare, in conjunction with the Primary Care Trust,
considers clinical aspects of this report and within four weeks advises
the Governor on actions required.
Compliance with F2052SH requirements
139. At 12:20 on 18 April, a Senior Officer instructed in the F2052SH file that the
woman was to be supervised every hour and was particularly vulnerable at the
time. She put a sticker on the front cover of the file confirming observations
were to be every hour. There is an entry that an Officer spoke to the woman in
her cell at 12:40.
140. Prisoners say that the woman did not go to lunch, which was unusual for her.
This was not remarked by staff. The next entry in the file has been altered
from 14:30 to 13:30. It is uninformative, saying only that the woman was seen
on the landing, and is on similar lines to entries in other F2052 files for the
same time. The time has been altered in the woman’s file and the times for
entries that afternoon have also been altered in other files. An Officer says
that when she came back from healthcare and was walking along the top
corridor to A wing and back she saw the woman at the end of B wing and
recorded the fact when she went into the office. The woman was not observed
every hour as the file instructed.
141. The F2052SH was not always clear about the frequency of observation
required. Although mere observation at frequent intervals should not be
regarded as a sufficient protection for a vulnerable prisoner, it is an important
underpinning safeguard and should be observed strictly.
142. It is good practice for observation under F2052SH procedures to be expressed
as a number of times within a given period (eg 12 in 12 hours) or as not less
than a given frequency (eg not less than 1 in 1 hour). Many of the overnight
entries are recorded as being on the hour every hour. If the records are
accurate, the checks would have been predictable to a prisoner intent on self-
harm.
143. I am indebted to the audit manager at HMP Downview who has advised me on
compliance with F2052SH procedures at Send. It identified some
shortcomings. In particular, he found that there were no lists of prisoners on
F2052SH held at the gate to be distributed to all areas of the prison each day.
Moreover, on the day of the woman’s death, the orderly officer’s report sheet
used to relay information at morning staff meetings showed only three
prisoners on F2052SH (including the woman) when in fact there were six.
144. At both Holloway and Send, it is notable that reviews were often not
multidisciplinary but conducted only by the discipline staff. At Send there was
little or no healthcare input into F2052SH processes after initial admission to
the prison. Reviews were not always conducted after incidents of self-injury.
145. At the time of the investigation Send had a current action plan following
deficiencies identified in an audit on suicide and self-harm prevention. The
29
investigation team was unable to obtain evidence of any systematic training
plan at Send.
The Area Manager satisfies himself as to Send’s progress on the
implementation of audit recommendations relating to suicide and self-
harm and in particular establishes whether targets set for October 2004
have been met.
Staffing arrangements
146. At the time of the woman’s death, the main block (wings A, B and C) which
houses up to 120 prisoners on two levels was staffed by only one officer.
Some prisoners were at visits. We were told there were about 20 visits that
day. Prisoners who were not at visits were on association which means cells
were unlocked and prisoners were free to come and go between cells on their
own wing. The officer on duty had to supervise all three wings. As well as
exercising general oversight, this involved taking and collecting prisoners who
had visits to and from the wing gates, responding to prisoners’ problems and
answering the phone. It also required the supervision of prisoners on open
F2052SH files, of whom there were six that day, and recording observations in
the file.
147. In the report on compliance with F2052SH procedures, the expectation that
one member of staff was sufficient to discharge these responsibilities was not
considered good practice. The officers’ “detail”, the deployment of basic grade
staff, for 18 April is appended. Only one officer allocated to the main block
during the afternoon. Four officers were on visits. One was on reception
where she was dealing with property brought in or handed out during visits.
There was one officer on D wing and one covering E and F wings.
148. A Principal Officer prepared the detail. He said the minimum staffing level for
a weekend afternoon was 13 members of staff of various grades in addition to
the Orderly Officer and Duty Governor. On 18 April there were 14: eight
officers, three officer support grades, a security officer, a senior security officer
and the PO. However, the staffing profile provided for higher numbers than
this and in particular for there to be two officers on the main block. The
shortages were caused by vacancies and sickness. There was little margin for
cross deployment. The Principal Officer said that he in effect doubled as a
second wing officer for the afternoon.
149. During interviews with my investigators staff frequently mentioned staffing
problems at the weekend. This was particularly so amongst the staff on duty
the weekend the woman died. There were three staff in the group on
maternity leave at the time. There were no written procedures covering staff
deployment or curtailing the regime when staffing levels were low. Staff also
commented that the relatively small size of Send meant that staff shortages
had a substantial impact because they were not able to redeploy staff from
other areas.
30
150. On Sunday 18 April, the Orderly Officer, in charge of the prison for the whole
‘A shift’, from 07:30 until 21:00. The wing officer was also working an A shift
and was detailed as A wing officer for the whole shift. A Senior Officer was on
the gate. The Principal Officer was on duty for residential PO duties and was
working in his office on the main block. The Duty Governor was also on the
premises working in E and F wing catching up with paperwork.
151. The Wing Officer explained that in the morning there was supposed to be one
officer on each of the three main block wings. She went to lunch at 1200 and
went straight to healthcare at about 1.00pm to supervise treatments. When
that was finished, she went back to the main block where everyone was
preparing for visits. When officers and prisoners went off to visits, she was left
as the only residential officer grade on the main block. The Officer understood
that the staffing profile provided for a minimum of two officers but recently it
had generally been one because of staffing levels. She said that the Orderly
Officer and PO would tend to be moving about the prison.
152. There is a handover book on each wing. There was no entry in the B wing
book about the woman and the book seemed little used. There were no
entries at all from 2 April to 19 April, though for 29 and 30 March the wing
handover book contained entries advising staff that particular prisoners were
upset and advising about support required. The Main Block Observation Book
was used more frequently for this purpose but contained no entry about the
woman on 18 April. A Senior Officer explained that at the weekend, when
there were fewer staff on duty than during the week, the wing diaries (the
handover books) and F2052SH files were moved from the wing office to a
central office. It was customary for staff to be briefed orally about prisoners on
F2052SH at morning meetings and the night staff would pass on anything of
note to the day staff.
153. An Officer said she spent half or three-quarters of an hour trying to arrange a
compassionate call to Wandsworth for the prisoner newly placed on F2052SH
who was very distraught. The Officer said she would try to get through to
Wandsworth intermittently while taking care of the prisoner concerned and
going to check the other prisoners at risk. It was usual for there to be a
handover of F2052SH files at change of shift, but the Wing Officer said that as
an A wing officer she would have been handed over the A wing people when
she came on duty. When she came back from treatments, she became
responsible for the main block and did a quick wander round. But everyone
was gathering prisoners up for visits and there was no direct handover. No
one spoke to her about the woman. The Officer said that she discovered the
woman when running round the three wings to check the prisoners on
F2052SH and being stopped by prisoners in between.
31
A Local Operating Instruction is introduced setting out the arrangements
for handing over F2052SH files to ensure all relevant information is given
to staff at the commencement of their responsibility. This should take
account of the need to hand over to staff who are taking on additional
areas of responsibility during the course of a shift.
154. My investigators asked whether there were any procedures to limit association
when only one member of staff was on duty. The Wing Officer said that
sometimes if there were two officers on duty they would make a request to “put
the spurs on”, (lock the spur gates). On the day the woman died, she said she
made no request, basically because there was no one to ask. It was “the
norm” for staff to be on their own at the weekends and “you just got on with it.”
155. A Senior Officer said there were procedures for dealing with staff shortage
during evening duties. If there were only nine staff they would lock prisoners
on the spurs. If there were only eight they would lock the prisoners in their
rooms. Other staff said this was an “unwritten rule”. The Orderly Officer had
discretion to limit association at the weekend but the staff would prefer not to
do that. It was better for the women to have free movement. If the women
were locked up the officer(s) on duty would be constantly responding to cell
bells. The Deputy Governor said it was easier to run the prison by co-
operation with the women than to bang everyone up. He expected the Duty
Governor at the weekend to make a decision according to the ambience of the
prison.
156. The Deputy Governor said he did not think it acceptable for a single officer to
have charge of the main block and it should not have happened. He said he
would have expected an officer placed in that position to consult the orderly
officer or the PO. The Deputy Governor said that there should have been one
officer on each of A, B and C wings to conform with minimum staffing levels.
He did not consider that the presence of management grades within the prison
meant that landing officer duties were being covered.
157. The Governor told the investigation team he believed Send’s profiled staffing
levels were low for the needs of the prisoners who were now coming to Send.
In the past, as a long-term closed training prison (with a resettlement function),
they had generally held women serving long sentences. However, population
pressures in women’s prisons and some changes to other establishments
meant they were now receiving women immediately after sentence, some
serving very short sentences. Also they had formerly had a high proportion of
foreign national prisoners. Their needs tended to differ from the domestic
prisoners and they seemed generally less prone to self-harm. Foreign national
prisoners were now concentrated in another prison. In September 2004, the
prison was to start working on new profiles to make the case for higher staffing
levels. Recruitment problems in an affluent area of Surrey meant that the
prison was carrying eight vacancies. The prison was tackling this with a
recruitment campaign including links with a local college, and also seeking to
make a case for public interest transfer of staff from other establishments.
32
158. Another problem was that a significant number of staff had been successful in
gaining promotion. This meant depletion of the basic grade ranks. The
Governor said it was part of the ethos of Send for staff to muck in and “act
down” as necessary. The Governor acknowledged that a single officer could
not be expected to cover the three wings in an afternoon with six prisoners on
F2052SH. He did not think the answer lay in locking prisoners up and he
made the point that women were more vulnerable in isolation. The minimum
staffing level was for the whole prison. It did not specify particular deployment
and it was for the Orderly Officer to determine this according to priorities at the
time.
159. On the afternoon of the woman’s death, searching of visitors was being
undertaken by a senior officer and an officer instead of by officer support
grades. One officer was in charge of three unlocked wings. The Principal
Officer was counted by some as fulfilling the role of an additional landing
officer, although working in his office. Two staff were issuing instructions for
managing the other prisoners while administering cardio-pulmonary
resuscitation. This is not a satisfactory state of affairs.
160. The Planning Manager at HMP Downview, has kindly advised me on staffing
profiles. He makes a number of useful observations.
The Area Manager, in conjunction with the Governor, undertakes a
review of staffing levels and profiles and the instructions to be followed
in the event of staffing levels being depleted.
Equipment
161. The Principal Officer was not carrying a radio. He said that during the week
there were not enough radios to go round. The Senior Officer said that there
were some areas of the prison where radio reception was poor. The Duty
Governor said he was not aware of difficult areas but some of the batteries
were poor.
Additional radios should be purchased and there should be a Local
Operating Instruction are in place for all Prison Officer Grades to carry a
radio enabling them to respond as and when required to incidents.
Thorough checks for black spots within the establishment need to be
carried out, and if required, booster equipment installed.
162. Staff do not carry ligature knives. There is one set of ligature scissors in the
main block office and one in each of the other wings.
The Area Manager, in conjunction with the Governor, considers whether
ligature knives should be issued to all prison officer grades at Send.
33
6. LIST OF RECOMMENDATIONS
1. The Head of Healthcare, in conjunction with the Primary Care Trust,
considers clinical aspects of this report and within four weeks advises
the Governor on actions required.
Area Managers response: A meeting took place between the Head of Healthcare
and the PCT on 1 June 2005. The following action points were identified, some of
which have been implemented, with others being followed up as part of the action
plan.
Mental Health - Improvements have been made to the in reach services and clinical
pathways. A new consultant has been recruited.
Medical transfer information – A lead nurse is now responsible for all transfers,
this will help to improve communications and will allow the nurse to deal with any
issues that arise immediately. This will also alleviate any problems with large
numbers of prisoners arriving at any one time.
Reception – Where no GP information is initially available, the GPs details will be
requested on reception.
Risk assessment tool – HMP Send currently operates the F2052SH system the
new risk assessment tool will be used in conjunction with ACCT (Assessment, Care
in Custody and Teamwork). ACCT is a new process of monitoring prisoners who are
at risk of self-harm and suicide. It allows staff to raise their concerns and to take
action for those prisoners they identify to be at risk of suicide or self-harm. Within
24hrs of the plan being opened the at-risk prisoner will be seen by an assessor and
have a case review. A care plan will be drawn up and a member of staff will be
nominated as a case manager, placing greater emphasis on supporting guidance
and training.
Mental Health Training – The Lead Nurse in the mental health department Steve
Norman will be providing a one-day training package for staff. Steve has offered to
provide the training at no extra cost to the prison.
All 2052SH, ACCT reviews – Healthcare staff attend all F2052SH and ACCT
reviews.
Bullying - A lead nurse forms part of the anti-bullying committee and attend
meetings.
Healthcare cover – Healthcare cover is now provided 7 days a week 07.30 to 21.00.
Response team – Plans are in place to ensure team of healthcare staff receive
training, which will enable them to attend emergency incidents. A defibrillator is now
in the establishment.
34
Ambulance procedure – There is an emergency protocol in place, and an
agreement has been made to ensure that all prisoners go to the Royal Surrey
Hospital for treatment.
Fish knives – All nurses have been issued with a ‘fish’ knife.
Complex medical issues - In order to address any complex medical issues, a
nurse will be identified for staff/prisoners to contact.
Safe cell – Funding has been allocated for the installation of a gated cell.
Zoned bed – Consideration is being given for a medical bed for emergency
transfers.
Medication pods – Consideration is being given for the purchase of medication
pods to hold paracetamol on the wings.
Drug supervision – Send now operates a system whereby a drug round takes place
four times a day to ensure medication is supervised.
2. The Area Manager satisfies himself as to Send’s progress on the
implementation of audit recommendations relating to suicide and self-
harm and in particular establishes whether targets set for October 2004
have been met.
Area Managers response: I am satisfied that all the recommendations have been
implemented and are now fully compliant. Staff training is on a rolling programme
and will be ongoing.
3. A Local Operating Instruction is introduced setting out the
arrangements for handing over F2052SH files to ensure all relevant
information is given to staff at the commencement of their
responsibility. This should take account of the need to hand over to
staff who are taking on additional areas of responsibility during the
course of a shift.
Area Managers response: A Governor’s Order has been issued and distributed to
all staff, which sets out clear guidelines for staff to follow to ensure they are familiar
and complaint with all handover procedures.
4. The Area Manager, in conjunction with the Governor, undertakes a
review of staffing levels and profiles and the instructions to be followed
in the event of staffing levels being depleted.
Area Managers response: A full review of staffing levels has taken place. Send
now has its required staff compliment. The prison has recently undergone a re-
profiling exercise, which is currently being discussed by the union.
To allow the Orderly Officer and Duty Governor flexibility to respond to depleted
staffing levels it would not be altogether feasible to commit to a set of rigid
35
instructions. However, it is accepted that in the event that staffing levels go down to
one below the Minimum Staffing Level then association would be confined to the
spurs, below that prisoners would remain in their own rooms.
5. Additional radios should be purchased and there should be a Local
Operating Instruction in place for all Prison Officer Grades to carry a
radio enabling them to respond as and when required to incidents.
Thorough checks for black spots within the establishment need to be
carried out and, if required, booster equipment installed.
Area Managers response: Additional radios have been purchased. Funding has
been approved for the purchase of a further ten radios which will ensure all
uniformed staff carry one. A Governors Order has been issued and distributed to
staff which sets out clear guidelines and responsibilities for staff who collect radios.
Additionally, a member of gym staff carries a radio enabling them to attend any
incidents that occur.
The report identified areas round the prison as ‘black spots’. This matter has now
been investigated, no black spots were found during the exercise, however this will
be monitored on a regular basis.
6. The Area Manager, in conjunction with the Governor, considers whether
ligature knives should be issued to all prison officer grades at Send.
Area Managers response: Fish knives have been issued to all Prison Officer
grades and nurses.
The Area Manager also added that:
Furthermore I wish to add that in order to improve the system of identifying prisoners
on F2052SH and raise awareness for staff, a daily updated list is displayed on the
Send home page of the Intranet.
With regards to the discrepancy in the Daily Supervision and Support Record where
it appears that the time was amended, the Governor has commissioned an
investigation. This is currently ongoing.
36