Individual at Leeds

Investigation into the circumstances surrounding the
death of a man at HMP Leeds
in February 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2009
This report considers the circumstances surrounding the death of a man at HMP
Leeds in February 2007. The man, who was 35 years old, was found on his bed with
a ligature around his neck at 4.00am.
I would like to offer this public expression of sympathy and condolences to his family
and friends on their loss.
The investigation was led by two of my investigators. They were assisted by another
investigator. A review of the man’s clinical care in prison was carried out by Leeds
Primary Care Trust. I am very grateful to the clinical reviewer for his review. I also
thank the Governor and staff of HMP Leeds for their cooperation, and in particular
the prison’s liaison officer for carrying out his role to a high standard.
A key objective of all my investigations is to ensure that the bereaved family has the
opportunity to raise any concerns and contribute to my inquiries. The man’s mother
raised a number of issues with one of my family liaison officers and the investigators.
I hope my investigation begins to offer answers to her questions.
This investigation was suspended for over 12 months whilst the police carried out an
investigation into allegations that were made concerning the actions of prison staff
on the night the man died. (No criminal proceedings have ensued.) In these
circumstances there has been a regrettable but unavoidable, delay in my
investigation and the subsequent completion of this report.
The investigation has revealed both some excellent care of the man who died,
particularly regarding the mental health support that he received, but also some
wholly unacceptable care on the night he died. Like previous reports for which I
have been responsible, it raises questions about the circumstances under which staff
feel able to enter cells at night. All of my recommendations were accepted by the
prison at draft stage.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman December 2009
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CONTENTS
Summary
The Investigation Process
HMP Leeds
Key Findings
Issues
Conclusion
Recommendations
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SUMMARY
The man who died had suffered with mental health problems for several years.
Psychiatric and medical support is well documented as far back as 1992.
In the time leading up to November 1992, the man had taken three overdoses and
had been admitted to hospital on several occasions. He was increasingly irritable,
impulsive and had often punched and banged doors and got into fights in the street.
A consultant psychiatrist considered that the man was suffering from bipolar affective
disorder. In January 1993, he received a course of Electro-Convulsive Therapy
(ECT). In August of the same year he threatened to cut himself and was admitted to
hospital.
Over the next few years the man was seen by a number of mental health specialists,
his mother often paying for private consultations and treatment. She was concerned
about his mental state and that he had impulses to be violent to himself and others.
In 2001, the man was diagnosed with Crohn’s disease. This was the start of the
man’s anxiety about his physical illness affecting his mental health, and he would
often reduce the dosage of his prescribed medication in the belief that it was making
him feel worse. In 2005, his consultant was still warning him against this practice.
On 16 September 2005, the man was remanded into custody at HMP Leeds charged
with murder. The first of seven ACCT plans were opened on his reception into
prison. (ACCT plans are designed to support those prisoners who have been
identified as being at risk of self-harm or suicide.) The man who died spent more
than 50 per cent of his time at HMP Leeds being supported by an ACCT plan. The
man did not think that he should have been sent to prison, believing that it was his
condition, and/or the treatment of his condition, that was the cause of all of his
problems. He continued to suffer with mental health difficulties.
On 7 April 2006, the man was sentenced to life imprisonment with a
recommendation that he should serve a minimum of 20 years. He remained at
Leeds prison. On 7 February 2007, his appeal against sentence was refused. When
he returned to Leeds from the Appeal Court on 10 February, he was placed on
another ACCT plan.
On the evening of 21 February, the man passed a handwritten letter to Senior Officer
(SO) A and asked him to sign it as a witness. The letter was intended to change his
will in the event of his death. The man was at that time being monitored hourly
through the day, and half hourly through the night, as part of the ACCT plan. The
SO sought advice from Officer A, who advised him to speak to the duty governor.
The duty governor told him to arrange for the man to be assessed by a mental health
nurse. The nurse was unaware that the man had recently been refused an appeal,
although the information would have been available if he had checked his medical
computer record. He asked the man if he intended to harm himself, asking how he
was at that time, what the change of will was about, and whether he had any
intention of hurting himself. The man said he was okay and it was just to keep his
family in touch. He said that he was moving on to another prison and wanted to get
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everything in order before he transferred. The nurse accepted the man’s response
that he would not harm himself. He knew that the man was located in a ‘safer cell’ (a
cell designed to have reduced or no ligature points). The nurse also knew what his
ACCT observation levels were and believed that he was not at risk. The observation
levels on the ACCT remained unchanged.
The man returned to his cell. The SO signed the letter (his will) and asked the Night
Orderly Officer (NOO) to sign it as well. The man was in cell D2-18, where he was
the only occupant. Officer A, the wing night officer, made an entry in the ACCT at
8.15pm that the document had been “handed over to night staff”. A management
check was made by the SO at 9.05pm.
The man who died should have been observed every half hour and these
observations should have been recorded. However, only hourly entries regarding
the observations were made between 9.00pm and 3.00am. An OSG made three
consecutive entries between 12.00am and 3.00am. He said that Officer A was
asleep during this time. A final entry, recorded at 4.00am, was made by Officer A.
This entry was made after the man’s death.
At approximately 4.00am on 22 February, the OSG saw the man in his cell. He was
immediately concerned about the way he was lying on the bottom bunk. He tried to
get a response by calling the man’s name and kicking the cell door. There was no
response and he could see no signs of breathing. He was concerned and went to
tell Officer A. Officer A went to the cell with the OSG and tried unsuccessfully to get
a response from the man. Officer A knew the man and that he had recently been
refused his appeal. He also knew about the will. Although he had a cell key for use
in an emergency, and access to a radio with which he could quickly summon
assistance, he walked off the wing to speak to the night orderly officer.
When the NOO was briefed by Officer A, there was no indication of urgency in his
briefing. She telephoned the Healthcare Centre and spoke to a Healthcare Officer to
ask him to send a nurse to D Wing as she was going to open a cell. The NOO then
returned to the man’s cell with Officer A and another officer. When she reached the
cell she too tried to get a response from the man. She then opened the cell door.
She found the man had a ligature attached tightly around his neck and fixed to the
bed. It was removed. Nurse B arrived at the cell, and examined the man and felt a
very weak pulse. He was placed on the floor and the nurse commenced CPR (chest
compressions). She asked for a radio call to be made for further medical assistance.
Shortly afterwards, two more nurses arrived and CPR continued until the paramedics
took over resuscitation. Sadly, the man was not revived and was pronounced dead
at 4.49am.
I am satisfied that, in the months leading up to 21 February 2007, staff at HMP
Leeds did everything they reasonably could to care for the man’s physical and
mental health and to respond to the concerns raised by members of his family.
However, I am not satisfied with the level of attention provided on the night of his
death. The delay in gaining entry to the man’s cell was, in my view, wholly
unacceptable.
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THE INVESTIGATION PROCESS
1. The investigators opened the investigation on 27 February 2007. They
discussed the circumstances surrounding the man’s death with the Police
Liaison Officer at HMP Leeds. Due to concerns about the staff response on
finding the man, a police enquiry was undertaken and presented to the Crown
Prosecution Service (CPS). The allegations were not proceeded with and no
staff were formally charged.
2. On 26 April, an investigator, accompanied by one of my Family Liaison
Officers, met the man’s mother, brother and family solicitor to discuss the
investigation and to be briefed on the concerns raised by the family. Many of
the concerns raised have been responded to in the Issues section of my
report.
3. During this period my investigation was suspended so as not to compromise
the police enquiries. A Detective Constable provided the investigator with a
full set of documents used by the police, including witness statements. My
investigators resumed their investigation in July 2008.
4. A post mortem examination was carried out. The report, dated 4 July 2007,
concluded that the man death was caused by hanging.
5. During November 2008, the investigators interviewed discipline and
healthcare staff. On 9 December, lead responsibility for the investigation was
given to another investigator.
6. In January 2009, the investigator and the clinical reviewer, interviewed three
nursing staff, two at HMP Leeds and one at HMYOI Wetherby. During
February, the investigators interviewed another 17 staff at Leeds. They
included nursing staff, discipline staff, a governor and a member of the
Independent Monitoring Board.
7. My investigators met with a member of the IMB at Leeds. She informed them
that the IMB had not received any applications from the man who died and
had no recollection of him being brought to their attention.
8. On 11 March 2009, the investigator, accompanied by the Family Liaison
Officer met the man’s mother and her solicitor to provide a briefing on the
progress of the investigation and respond to earlier concerns raised by the
family.
9. Some further staff interviews were carried out in April. A total of 30 staff were
interviewed in the course of my investigation.
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HMP LEEDS
10. HMP Leeds is a category B local prison, dating from 1847. It accepts adult
male prisoners from courts in West Yorkshire and has 680 cells, plus rooms
and wards for 26 in the Healthcare Centre. The prison has an operational
capacity (maximum crowded capacity) of 1,150 prisoners, and always
functions at or near this figure. It expanded from four to six wings in 1994.
11. The ‘Safer Custody Programme’ was introduced as a pilot programme in
Leeds in October 2003. The multidisciplinary programme is four weeks long
and takes referrals according to a needs-based scoring system. Although
detoxification plays a significant part in the programme (some 80 per cent of
the prison population have substance use problems when they arrive), there
are said to be good indications that prisoners who self-harm benefit from
attending. The Safer Prisons Committee incorporates violence reduction,
anti-bullying and suicide prevention into their monthly meetings and takes a
broad view of safer custody issues. The meeting is multidisciplinary and
attended by managers and Listener representatives.
12. A prison’s Independent Monitoring Board (IMB) is appointed by the Secretary
of State for Justice from members of the community. Their role is to satisfy
themselves that the prisoners are treated humanely and justly and that there
are adequate programmes for preparing prisoners for release. The IMB
report directly to the Secretary of State if they have any concerns. They also
submit annual reports on how the prison has met the standards and
requirements placed on it. Members of the IMB have access to every
prisoner, every part of the prison and every prison record. The following
extracts have been taken from the Leeds IMB annual report for the period 1
February 2006 to 31 January 2007:
”Healthcare is a well managed and forward thinking department. The
Healthcare Manager has excellent working relationships with, and feels
well supported by the Governor and Deputy Governor. The Mental Health
In-reach Team, in house Mental Health nurses and counsellors have
weekly case meetings and we are glad to report that mental health
problems are well treated in the prison.”
“The policy of group input works well towards the aim of safer custody at
HMP Leeds. Members of the group include the responsible Governor,
Suicide Prevention Coordinator, staff from Safer Custody Section, Anti-
Bullying team, psychology department, Healthcare, Chaplaincy
department, Wing Liaison officers, Samaritans, Prisoner Listeners from
each wing, Listener Coordinator and GSL. Feedback is discussed and
actions are decided at the monthly meetings. The opening and closing of
ACCT self-harm files is monitored and statistics are produced for each
monthly meeting. The opening and closing of ACCT self-harm files is
monitored and statistics are produced for each monthly meeting. Staff are
trained fully in the completion of the details which need to be endorsed on
the files. Incidents of self harm are recorded in numbers and in types of
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harm. To assist the work of the Suicide Prevention Officer, the role of
Listener Coordinator was established and this has been very useful.”
“Staff encounter difficulties in moving life/IPP prisoners on the first stage
lifer unit. The Board understands that places are available but not
necessarily within the area. Out of area transfers seem very difficult to
arrange and the board feel that this is an issue that needs to be addressed
nationally.”
13. The IMB report concluded that HMP Leeds is a local prison always operating
at full capacity, dealing with incidents on a daily basis, with a caring and
dedicated staff working together, plus a good senior management team.
14. Dame Anne Owers, HM Chief Inspector of Prisons, carried out an
unannounced full follow-up inspection of HMP Leeds between 22 and 26
August 2005. Her report described Leeds as:
“… a large and overcrowded local prison. It is operating at 75 per cent
above its certified normal accommodation, with a transient and usually
short-stay population. It exhibits, in acute form, some of the problems
associated with our overcrowded prisons. The prison had managed to
sustain good first night procedures and most prisoners felt safe on
reception into the prison. There were some good safer custody
procedures and a well-regarded Listener scheme, which was effective and
valued by prisoners and staff. The ACCT procedures had been introduced
in March 2005 and interviews were taking place promptly, although there
was some concern about the quality of the entries. There were 25 life-
sentence prisoners in custody at the time of the inspection. Nine of these
had spent over 12 months waiting to be transferred to a first stage lifer
prison. A repeat recommendation was made that this process should be
accelerated.”
15. An area of good practice was the Leeds prison visitors centre, a charitable
organisation set up and run with the support of the prison. It was described
as an innovative and creative link between the prison, families and the
community. My investigators support the view that this is good practice.
16. The number of prisoners in the prison when the man died was 995.
17. There had been eight deaths at HMP Leeds between April 2004 and February
2007 and a further 11 since that date. This is the first self-inflicted death to
occur in a safer cell at Leeds. In another case I investigated in 2007 I made
the following observations and recommendations:
“When the man was found, the alarm was raised via the prison radio net.
The SO was in charge of the prison at the time. He added that as he
approached the cell he shouted to Officer A to break into his sealed pouch
and open the cell door. Officer B arrived at about the same time as the
SO. He told my investigator that Officer A was still outside the cell at that
time.
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“In interview, the SO told my investigator that he would not expect any
member of staff to enter a cell on their own at night. He added that
officers are expected to wait for another member of staff to arrive. The
Prison Officers’ Association (POA) representative who accompanied the
SO advised at the interview that, “It’s down to the individual person’s
discretion, as long as they don’t think it’s a set up, I mean if there’s only
one person in the cell it’s a bit clearer.”
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KEY FINDINGS
18. On 16 September 2005, the man was remanded into custody and taken to
HMP Leeds. An ACCT plan was opened and he was located in the
Healthcare Centre to be checked every half hour. The Prisoner Escort Report
noted that the man suffered from depression and Crohn’s disease. The Cell
Sharing Risk Assessment recorded that he was very low in mood and had
been receiving antidepressants for the previous 15-16 months.
19. Four days later on 20 September, an ACCT assessment was carried out and
the man insisted that he did not feel suicidal or at risk of self-harm. He was
described as detached from events, showing no emotion and very calm. It
was decided that he should remain on the ACCT plan and he was referred to
the Mental Health In-Reach Team (MHIT).
20. On 22 September, the man’s previous medical records were faxed to Leeds
MHIT. They confirmed a diagnosis of anxiety, depression and somatic
physical symptoms. It was also confirmed that he had been prescribed
Prozac 40mg. As there was no evidence of acute mental illness, plans were
made to discharge the man to the main prison on 6 October. It was noted that
he continued to be obsessed with his physical condition.
21. On 11 October, the man who died was seen by a psychiatrist who confirmed
that he was fit to be moved from the Healthcare Centre to the main wing.
Later that same day the man became aggressive and abusive and so it was
decided that he should remain in the Healthcare Centre. The next day (12
October), the man barricaded his cell door. He eventually removed the
barricade and was taken to the Segregation Unit and placed on a disciplinary
report. The adjudication was later dismissed.
22. Although there is no specific record, it appears that when the man’s mother
and his two brothers went to visit him for the first time, the visit was not
allowed to go ahead as the man was located in the Healthcare Centre and
was only allowed to be unlocked by three staff. The family met a woman, Ms
A, in the Visitors Centre. (Ms A woman was employed by a charitable agency
and her role was to offer reassurance, information, advice and support to the
families of prisoners.) Ms A was allowed access to the prison and its
prisoners and she went to the Healthcare Centre to speak to the man at the
request of his family. He signed a letter that was needed for his legal
defence. Ms A informed the family that the man did not make eye contact
with her, would not engage in conversation and seemed to be highly
medicated.
23. On 24 October, the man broke two windows in his cell with his fist. He was
moved to D Wing. The following day (25 October), the man was seen by Mr A
from the Mental Health In-Reach Team. He told Mr A that he had smashed
the windows because he felt an “inner turmoil”. Mr A carried out a mental
health assessment and described the man as displaying paranoid behaviour,
but not showing any other psychotic ideas. No risks were highlighted and the
man said that he felt fine about being moved to another wing.
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24. The ACCT plan was closed following a review on 27 October which the man
attended. The review concluded that, although the man’s thoughts were
disordered, he appeared to be managing well. He had not given any
indication that he would deliberately harm himself since coming into custody.
25. On 2 November, the man’s mother spoke to Mr A about her concerns. She
was told by Mr A that he intended to see the man each week to monitor his
condition.
26. Four days afterwards, on 6 November, the man’s mother wrote to the prison
asking for a meeting to discuss her son’s mental and physical condition. She
felt that he was not getting the help that he needed, his medication had been
stopped, and he was deteriorating. This letter was followed by a further
telephone call to the prison on 8 November.
27. Governor A wrote back to the man’s mother on 11 November. He confirmed
a conversation he had had with her by telephone on 8 November. He
reassured the man’s mother that her son’s medication had not been stopped.
He asked her to contact him if she had any further concerns. On the same
day a second ACCT plan was opened as the man had made a small cut to his
wrist whilst being seen by the psychiatrist. He stated that he was frustrated
that his physical health needs were not being met and wanted something
done quickly. He said that he had no suicidal thoughts or intentions.
28. During adjudications on 16 November and 18 November, the man was fined
for damaging his cell furniture and denying staff access to his cell. The ACCT
plan was subsequently closed following a review on 25 November.
29. On 28 November, the man was seen again by Mr A who thought he appeared
more rational than on previous visits. The man’s father also telephoned the
prison as he was worried that he had not been contacted by his son since an
earlier visit. The man was spoken to and said that the visit was not a good
one, but that he was okay and would telephone his father.
30. The man who died next saw Mr A on 1 December when he said that he was
concerned about what would happen at court. He denied any suicidal
thoughts but said that might change depending on what happened at court.
the man appeared at Court for the first time the next day and was remanded
in custody for trial at a later date.
31. On 13 December, a third ACCT plan was opened on the man. He had
scratched his wrists during the night and then told his mother. Again he said
that he had thought about harming himself, but could not do it. (This ACCT
plan remained open continuously for five months until 2 May 2006 and the
man continued to have regular support from Mr A.)
32. The man often complained about his medication, stating that he self-harmed
for this reason. It was reviewed by a doctor on 31 December, who agreed to
his request to increase the Olanzapine and also prescribed Librium for his
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anxiety. The man remained dissatisfied and asked for another review two
weeks later.
33. During January 2006, educational material was arranged to be taken to the
man as he did not want to attend education classes within the main prison.
He wanted another review of his medication, not being satisfied with the one
planned for 24 January. On 26 January, he was described as distressed, still
unhappy about his medication and saying that Prozac would be better for him.
34. On 1 February, a risk profile assessment was completed by Leeds MHIT. It
identified the man as a potential risk to staff and noted that he required a
more detailed risk assessment. (Further psychological assessments were
carried out on 18 September and 15 November by a clinical psychologist.)
The man was displaying high levels of anxiety and was voicing concerns of
being “unable to carry on”. The assessment stated that the man was to be
considered dangerous if his mental health was not continually monitored.
Ongoing support was in place, including regular meetings with MHIT staff,
medical reviews, access to Listeners, and referral for psychological work.
35. The man who died continued to be agitated during February, complaining that
his medication was ineffective and wanting to change it. His mood was
changeable, at times he did not cope or sleep well, and he asked for stronger
medication. At other times his mood would improve. His mother wrote to the
prison as did the woman from the Visitors Centre, and both voiced their
concerns about him. Their letters were responded to by the Head of
Healthcare, who said that the man was receiving the appropriate medical
supervision. He continued to see Mr A on a regular basis.
36. On 15 February, the man told an officer that he was expecting a three year
sentence when he went to court. He seemed very down and agitated and
said that if he got a longer sentence he would not be able to cope.
37. The next day (16 February 2006), the man went to a Care Programme
Approach (CPA) meeting. This was attended by several staff including Mr A ,
a Consultant Psychiatrist, Ms A, and the man’s Personal Officer. The man’s
mother and brother were also there. The meeting had been arranged to
discuss the man’s physical and mental needs and to plan his care for the next
few months. Minutes were produced and it appears that everyone present
had the opportunity to contribute and voice any concerns. The meeting
concluded that the man’s complaints about his medication were more to do
with his anxiety levels than with his medication. The man’s mother asked that
he return to the Healthcare Centre where she believed he would be more
closely monitored. The consensus was that this would not help his anxieties
and that the man could be monitored adequately on the wing where he would
see the wing nurse every day. A Care Plan was agreed which included a
short-term prescription of sleeping medication, the man was to try to engage
in activities and Mr A would provide the man’s family with regular updates.
Ms A was to continue offering family support. An application made the same
day by the man for a cleaning job on the wing was approved. However, on 22
February, he told staff that he no longer wanted to be a cleaner.
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38. Despite the agreement reached at the CPA meeting, the man was seen the
following day by the MHIT manager about a complaint he had submitted
regarding his medication. He was advised that he should commit to his
current treatment, but the man said that he no longer wished to take it. Self-
harm was discussed and, although the man maintained that he felt suicidal,
he had made no recent attempts to harm himself and had used some coping
strategies. He asked to be admitted to the Healthcare Centre and was again
told that this was not appropriate at the time.
39. March was similar in some respects to the previous month with the man
complaining about his medication and wanting it to be changed. He often
appeared distressed and asked to move to the Healthcare Centre. On 6
March, the man’s mother rang the prison to say that he had called her and
told her that he was going to kill himself because of his medication (he was
currently prescribed Venlafaxine). He was spoken to by an officer but refused
to repeat what he had said to his mother. The ACCT observations were
increased from hourly to half hourly and a request was made for him to see
someone from the MHIT the next day.
40. The man who died was seen the next morning at 8.00am by a nurse and
again at 10.30am by Mr A. The man was agitated and at one point became
hostile and was told to calm down. He was moved to the Healthcare Centre
for a period of observation but continued to be preoccupied with his
medication. Numerous comments, which indicate a positive attitude of staff in
response to his anxieties, were documented. On 14 March, he was
discharged from the Healthcare Centre and moved to E Wing. He was
supervised when taking his medication (Venlafaxine) and ongoing
appointments continued. He spoke with Listeners (prisoners trained by the
Samaritans to support other prisoners who are at risk of self-harm) and settled
on E Wing.
41. On 20 March, the man’s trial started at Crown Court. He remained on ACCT
monitoring but at 10.00pm the same day he cut his wrist with a razor blade.
He was moved to a safer cell in the Healthcare Centre and was checked
every 15 minutes. He said that he was worried about his trial but was not
sure why he had harmed himself.
42. The man went to his trial each day until 4 April 2006 when he was found guilty
of murder. He was spoken to by staff about how he felt and said that he felt
emotionless, which he blamed on his medication. Staff talked to him
throughout the evening and he was given medication to help him sleep.
43. The man who died refused to eat on 5 April, saying that he was not well and
was on hunger strike. The next day he refused his medication and the
opportunity to have a shower. He was seen by a Listener, and then collected
his lunch. He was worried about his pending court appearance when he
would be sentenced. He had a visit from his brother.
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44. Two days later, on 7 April, the man was sentenced to life imprisonment with a
recommendation that he should serve a minimum of 20 years. He was
shocked by the sentence. When asked about his feelings about harming
himself, he said “It’s a thousand times worse,” and claimed that he had
committed the offence because of the effects of taking Prozac. An ACCT
review was carried out and, due to the increased risk, he was checked every
15 minutes. The man appeared calmer over the next few days and he
discussed his feelings openly with staff. ACCT observations were reduced to
every 30 minutes. However, he had difficulty coming to terms with his
sentence and was reluctant to accept his situation. He began to focus on the
possibility of a reduction in sentence. The next two weeks saw a gradual
improvement in his mood.
45. An ACCT review was held on 19 April. The man discussed his appeal and
the need to “survive”. It was agreed that he should be discharged from the
Healthcare Centre to D Wing.
46. On 26 April, the man went to the Safer Custody Unit to begin the Safer
Custody course. He began asking why he was on the ACCT and said that he
wanted to come off it as he had no intention of harming himself. The ACCT
plan was subsequently closed following a review on 2 May. On 10 May, the
man who died was observed in group work, rocking backwards and forwards,
repeatedly saying “20 years”. Staff on the unit were concerned about his
behaviour and he was seen by Mr A. They discussed his anxiety levels and
Mr A noted that the man was “warm and engaging”.
47. The ACCT document was reopened on 12 May after the man who died had a
visit with his probation officer. He had become very upset when his sentence
was explained. The probation officer was concerned about his welfare and
state of mind. The man was moved to a safer cell and placed on hourly
observations. He told staff that, if his appeal did not come through, they
“would find him dead”. He did not want to talk about how he would kill himself
as he “did not want to be saved”. It was agreed that the man would benefit
from more time out of his cell, but he refused to consider educational activities
as he found that they made him more agitated.
48. When the man was seen on 19 May by the Consultant Psychiatrist, he said
that he felt much better, was not anxious or depressed, and had no
complaints about his medication (Flupentixol and Venlafaxine). Paradoxically,
he said he remained distressed about his sentence and blamed Prozac for
everything. An ACCT review took place on 24 May and it was noted that the
man continued to struggle with settling in a closed environment. At the end of
May, the man was moved to E Wing at his own request.
49. On 6 June, the man went to court and received a further sentence of nine
months for an assault carried out on 10 May 2005. An ACCT review was
held. Although he was frustrated by the additional sentence, he had begun to
go to education which took him out of his cell, and he said he had no more
thoughts of harming himself.
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50. ACCT plan reviews were carried out on 13 and 20 June. The man still
complained about his medication, saying it was wrong and that he should be
in a hospital and not a prison. He mentioned that his solicitor was talking
about him going to Rampton.
51. The man who died was seen by the Consultant Psychriatrist on 23 June. He
was very low, tearful, emotionally isolated and showing a lack of will. He felt
hopeless about his future in prison and said that he wanted to give up. He
was distressed that his crime had led to a life sentence and felt that he had
not been thinking correctly at the time of the offence. He asked to return to
the Healthcare Centre. The Consultant Psychriatrist increased the
Venlafaxine, looked to increase his activity on the wing and said that wing
staff and Mr A would support him.
52. Further ACCT plan reviews were carried out on 27 June and 4 July. There
was no change in the man who did not want to do anything productive. It was
noted that his medication had been increased and that he had no current
thoughts of self-harm.
53. On 4 July, the Head of Healthcare Services, wrote to the man’s mother in
response to her letter dated 24 June. She told her that her son’s condition
had been fully investigated and that he was receiving appropriate medication.
The Head of Healthcare Services had talked to Mr A and was assured that he
had been seen on numerous occasions by the Consultant Psychiatrist. She
wrote that the man was being encouraged to participate in prison activities
such as education, and asked the man’s mother for her support and
encouragement. The Head of Healthcare Services ended the letter by saying
that she hoped that a joint approach towards the man would help him and, if
she had any further concerns, she should contact her.
54. The man met the Clinical Psychologist on 6 July, for the first of a number of
sessions. She had been asked by Mr A to assess the man. He met the
Clinical Psychologist again a week later. She noted that he was “brighter” and
they discussed goals for therapy. The man was happy to work on his
thoughts which might help reduce his agitation, alongside other interventions,
such as medication and daily activity. The man missed his next appointment
on 20 July as he did not get out of bed, but later insisted that staff had not
called for him.
55. ACCT reviews were carried out on 18 July, 21 July and 4 August. The man
was feeling better and staff were trying to organise a job for him. He felt that
his ACCT observations could be reduced to hourly as he had no more thought
of self-harm. He appeared to be responding to staff encouragement by
coming out of his cell more often and going to association and exercise.
56. The man met the Clinical Psychologist again on 7 August. He was noted to
be agitated and low in mood. His sleep pattern was disrupted and he slept
through the day but not at night. He said that he did not like being in prison
and was waiting for his court appeal. He felt negative and had thought of
ending his life, although he denied any self-harm. He was not motivated or
15
interested in any activities and continued to link his medication with his
stomach and bowel problems. He agreed to a change in his medication and
the Flupentixol was stopped.
57. On 8 August, another ACCT review took place. The man’s mother had told
him that his appeal had been refused. He had built up his hopes on the
appeal and now felt hopeless. He said that he did not feel like getting out of
bed or taking care of himself, and did not know if he could move forward. The
ACCT observations were increased to 30 minute intervals. A further review
was carried out the next day when the man was initially stable, but then
became more and more upset. He was focussed on his anxieties about his
health and thought that if they were addressed he would be able to face the
future. He was assured that he would not be alone.
58. The next day a friend of the man sent a letter to the Governor. He had visited
the man and was concerned that he was not receiving the right attention, that
he had deteriorated, and that he believed him to be suicidal. The friend
thought that the man should be sent to a secure hospital. (My investigator
has found no evidence of a response to this letter.)
59. The man’s mother wrote the same day to the Consultant Psychiatrist and the
Head of Healthcare enclosing copies of a psychiatric report from Doctor A and
a letter from Doctor B (a friend of the family). Dr A’s report had been
completed in February 2006 and was prepared at the request of the man’s
defence solicitors. The report concluded that the man displayed
characteristics of a number of personality disorders, which were not however
sufficient to justify compulsory hospital treatment and did not constitute a
mental illness. The man’s mother was asking for the medical help that she
felt her son needed in a hospital environment. The Head of Healthcare
Services responded on 11 August, saying that the man had received all of the
clinical care possible whilst he was a prisoner at HMP Leeds and would
continue to do so. In respect of a secure unit, she wrote that this would
require the man to be compulsorily admitted under the Mental Health Act by
two consultant psychiatrists. She commented that Dr A did not agree with this
course of action at the time.
60. An ACCT review was carried out on 10 August. The man was reportedly
much brighter, had had a haircut, and talked about the future and a further
appeal. He also discussed interventions by the MHIT and was happy to
engage with them. His ACCT observations were reduced. He met the
Clinical Psychologist the same day. They talked about his physical symptoms
and the Clinical Psychologist noted the man’s severe anxiety about his health.
They discussed how to focus on the psychological factors that affected it.
She also discussed his early years. The man said that he was keen to pursue
an appeal against his sentence, which he would be discussing with his
solicitor.
61. Another ACCT review was held on 22 August. The man was tearful and
asked for help from the MHIT and a transfer to a psychiatric facility. An ACCT
review was held a week later at which the man who died appeared more
16
stable. He said he was feeling good and had no more thoughts of self-harm
or suicide. After a lengthy discussion it was agreed that his observations
should be reduced to hourly.
62. On 31 August, a receipt for a renewal for leave to appeal was received. The
man met with the Clinical Psychologist the same day when he seemed upbeat
and not as agitated as usual. He said he would eventually like to come off his
medication. He discussed his teenage years.
63. An ACCT review was held on 5 September when the man said that he had no
more suicidal thoughts. The review considered whether to close the ACCT
plan and the man agreed that it should happen. The ACCT plan was closed
that day.
64. On 7 September, the man met the Clinical Psychologist again. He was very
focussed on his stomach problems and linked them with his Flupentixol
medication. He appeared to realise that there were techniques that could
reduce his physical symptoms and to accept that the symptoms of Crohn’s
could not be cured. A further meeting with the Clinical Psychologist took
place a week later. The man said that he was not sleeping very well and
wanted to stop taking his medication. They discussed methods of coping,
such as relaxation, distraction and exercise. He mentioned the ringing in his
ears again.
65. The Clinical Psychologist completed a Clinical Psychology Assessment
Report on the man on 18 September. She reported that he had attended ten
one-hour sessions with her. The conclusion to her four page document was
that she intended to continue working with the man. Although he was not yet
convinced of the benefits of psychological work, he was beginning to see the
link between his experiences and his current symptoms. He continued to
blame his symptoms and his anxiety on the medication, but recognised that
thinking negatively affected his mood and his health.
66. The man who died next met the Clinical Psychologist on 21 September. He
said that he had stopped taking some of his medication (Flupentixol), but had
not told the Consultant Psychiatrist. He said he did not feel agitated since
stopping the medication and had noticed that the ringing in his ears had
lessened.
67. Another ACCT plan was opened on 27 September as the man said he felt
suicidal and was pacing around his cell. He said he could not control his
feelings, was not sleeping, was depressed and had problems with his
medication. He was moved to a safer cell on D Wing, with hourly
observations. The man said that he had tried to kill himself, and that he was
tired and worn out.
68. The following day, an ACCT review and a second CPA meeting were held.
The man’s mother and brother were present at the latter, along with Governor
A, the Consultant Psychriatrist, Nurse A (RMN), Ms B (Probation), Mr B
(MHIT), Officer B (Personal Officer), and other MHIT staff. They discussed an
17
assessment for his suitability to transfer to the Dangerous and Severe
Personality Disorder Unit at HMP Frankland. This assessment had not been
fully completed at the time of the man’s death, but it was unlikely to have been
the appropriate place for him to transfer to. The man said that the safer cell
had no benefit to him and there was no air in it. Suggestions were made
about attending the gym and trying to engage in meaningful activity. The man
felt that his problems were caused by his stomach and that this affected the
rest of his body. He did not believe that his stomach problems had been
properly investigated. He wanted to continue the antidepressants
(Venlafaxine) but said he did not feel suicidal. He said that he used being on
ACCT monitoring as a means of seeing Governor A.
69. Officer B commented during the meeting that the man spent most of his time
in his cell as he did not work. Work on different wings had been offered, but
he felt that none of the jobs were appropriate. Officer B believed that being
on an ACCT plan might actually be hindering the man’s progress. He
highlighted that the previous ACCT had been closed several days previously
on 5 September, and that the current ACCT was opened due to the man’s
frustration about his medication and physical condition. At interview, Officer
B described this as shortcutting the system as some prisoners believed that
they could get quicker access to governors and doctors if they were on ACCT.
Governor A said that he had seen the man on many occasions and was
happy to see him whenever he made an application. He believed that the
man was “giving in” and needed to try harder to help himself and admit to
himself that most of his problems were related to anxiety. Governor A also
believed that the man did not need to be on an ACCT. The Care Plan noted
that the man was to see the doctor, go to the gym for remedial work, and
move to another cell with a larger window. The man met with the Clinical
Psychologist again the same day.
70. The man’s next weekly meeting with the Clinical Psychologist took place on 5
October. She noted, “conspiracy theories, medication and physical
symptoms”. An ACCT review was held on 9 October. The man said that he
had seen the doctor that morning (although there is no record of the
consultation). He claimed that he was still receiving medication, felt well but
was not yet ready for the gym, and could still hear ringing in his ears. The
man who died was mixing with others on the wing, felt less stressed and was
sleeping a lot better. He also said that he felt he had a lot going for him.
71. The man was next seen by Mr A on 10 October. He was very jovial and
recognised the link between his low mood and his preoccupation with his
physical symptoms. An ACCT review was also held. The man said that he
had seen the doctor that morning and was feeling well, and repeated what he
had said to Mr A.
72. The man met the Clinical Psychologist on 19 October. He was animated and
spoke at length about the effect of antidepressants on his symptoms (ear,
nose and throat problems as well as Crohn’s disease). He said that he felt let
down by the National Health Service and should not be in prison.
18
73. On 23 October, a letter was sent for an ear, nose and throat appointment at a
hospital to investigate the “ringing” in the man’s ears. The man who died also
met Mr B (MHIT) and Mr A. His conversation was entirely focussed on his
physical symptoms, medication and his efforts to appeal against his sentence.
74. The next day, the man met Ms C. Ms C works on the Safer Custody Unit as a
drug and alcohol therapist in a multi-disciplinary team. She had been
approached by one of the Listeners and asked to speak to the man because
of his emotional state (during interview she could not recall the interaction with
the Listener nor remember his identity). The man repeated what he had said
to the MHIT regarding his medication problems and the ringing in his ears,
and asked to see Governor A. Ms C believed that it might be beneficial for
the man to attend the Safer Custody programme again. He agreed and it was
arranged for him to go on 30 October. Ms C said that she would speak to Mr
A about this.
75. On 26 October, the man met the Clinical Psychologist again. He brought
several pieces of paper with him, with lists of symptoms and explanations
about why he felt unwell. The Clinical Psychologist noted that there was no
clear rationale or evidence in what he produced, other than his personal
interpretation. The man talked about wanting to sue the professionals
responsible for his problems and said that he wanted to see his solicitor. The
Clinical Psychologist challenged how the issues were linked. He said that he
was thinking more clearly since stopping his medication (Flupentixol and
Venlafaxine). He said that he had started to “put it all together”. The man
later said he was now taking his medication again.
76. The Clinical Psychologist concluded that the man’s thought processes were
extremely disordered and he had deteriorated mentally. She noted that she
would inform the Consultant Psychiatrist. The man saw the Consultant
Psychriatrist a few days later on 30 October when he was co-operative, not
anxious or agitated, and said that he felt better. Although preoccupied with
his thoughts, there was no evidence of hopelessness, self-harm or suicidal
ideas and no delusions or hallucinations were noted. The man who died had
started taking his medication again, and it was reassessed. The Flupentixol
was increased to 0.5 mg and Venlafaxine continued as before.
77. The man met the Clinical Psychologist on 2 November. He talked about the
conspiracy against him in his criminal case. He did not talk about his physical
symptoms and was preoccupied with his case. He wanted reassurance that
he was not talking rubbish. The Clinical Psychologist said that it was difficult
for him to prove any of his allegations and they discussed his role in the
offence. He had moved from accepting that he was partially responsible,
saying that the victim’s family were 100 per cent to blame. He was unwilling
to consider that he was responsible.
78. The man’s next meeting with the Clinical Psychologist was a week later. He
was more relaxed than in previous sessions, but continued to talk about a
conspiracy by the police, government, officials and medical staff. The Clinical
Psychologist asked how he thought he would cope with his 20 year tariff if his
19
appeal was not successful. He said that he would keep his head down, and
keep fit because “he has a job to do”. The Clinical Psychologist asked him
what this job was but he said that he preferred not to say. He indicated that
justice would be done with his victim’s family. He said he would win his
appeal and did not entertain the idea that he would have to complete his
sentence. He blamed the offence on his medication, the police, the
government and the victim’s family. He apportioned only a small amount of
blame to himself.
79. The Clinical Psychologist arranged a psychological assessment on 15
November in order to better understand the man’s personality. The
assessment was carried out by Mr Adams. In summary, the man said he was
being open and honest during the assessment. He presented as over-
emotional with severe personal difficulties. The Clinical Psychologist believed
that this could either be a reflection of his personality, or a reaction to being in
prison and having a long sentence. He seemed unable to talk about his
feelings and often reverted to focussing on symptoms or blaming others for
his offence. He was agitated, preoccupied and low on occasions. His profile
suggested that he was prone to chronic depression. His outlook on life was
negative and fatalistic. There was an undercurrent of anxiety and he was
emotionally detached, whilst dependent on key figures (such as his mother
and family) to help him cope with difficulties and problems.
80. The next day, the man met the Clinical Psychologist again. They talked about
how angry he felt towards authority figures and how his symptoms seemed to
be linked. The man said that his sessions with the Clinical Psychologist were
helping. They met again the following week. On 23 November, the man was
in good spirits and told the Clinical Psychologist that he was thinking about
reducing his Venlafaxine again as he believed it was linked with his physical
problems. She advised against reducing his medication without first
discussing it with the Consultant Psychiatrist, and the man who died agreed.
They talked about his offence and he said he wanted his victims to pay. He
felt that his offence would not have taught the family a lesson and wanted
compensation from the victim.
81. On 29 November, the man was seen by a locum doctor. He had reduced his
Venlafaxine by breaking open the capsules and taking half the contents
(75mg down to 37.5mg) so the doctor prescribed 37.5mg tablets to replace
the 75mg capsules.
82. The man saw the Consultant Psychiatrist on 4 December. The man said that
he felt well and had no problems with his mood or anxiety. He was coping
well and was bright and reactive during the interview. They discussed his
medication and he agreed to continue taking the reduced dose. He continued
to link his medication with his throat and catarrh problems. He was
preoccupied with his offence and said that his solicitor had told him that new
information had come to light. He felt hopeful about his appeal and that he
would not have to spend the next 20 years in prison.
20
83. Mr B (MHIT) met the man’s mother in the Visitors Centre on 5 and 11
December.
84. The man was seen on a number of occasions during December by different
medical professionals, including Dr A regarding his Crohn’s disease. He
complained about his medication and the effect it had on his health. He
refused to take the Flupentixol as he believed it was causing rectal bleeding.
He signed a disclaimer to this effect on 16 December.
85. At 5.00 pm on 17 December, another ACCT document was opened. The man
had been seen rolling about on his bed in his cell, saying he wanted to be “put
down”. He was allowed to telephone his mother and also talked to a MHIT
nurse and the wing Listeners. The man complained about how his health was
affecting his state of mind. Initially he said he was not suicidal and would not
harm himself. However, when he saw the MHIT nurse, he spoke at length
about his physical and mental problems and that he “wanted to end it”. He
said that he would end his life that night as he could not carry on any more.
He asked to see the doctor the next day. The Healthcare Centre was
contacted but it was decided not to admit him. The man was placed on hourly
ACCT observations. He spent a large part of the day with Listeners and
access to a Listener overnight was arranged if required. Mr A was asked to
review the man.
86. At 3.00 pm the next day, an ACCT assessment interview was carried out. the
man complained of feeling generally unwell and bloated. He said that he had
passed blood and felt that his stomach was on fire and so wanted to change
his medication. He said that he had felt low the previous day and that, if he
had had the means to do so, he would have killed himself. Instead he chose
to seek the help of the Listeners. He went on to say that he now felt good,
had seen the doctor that morning and felt much more confident and positive.
He believed that things would get better. Dr A had reviewed his medication
and noted, “will continue same medication pro temp. All seems on a relatively
even keel at present.” The man was no longer having suicidal thoughts and,
when asked if he wanted to kill himself, responded “No, I can sort this out.”
87. The man was seen again at 4.00 pm for an ACCT case review. It was carried
out by Senior Officer (SO) C, but no other members of staff were present.
The man told SO C that he felt a lot better and that he had no feelings of self-
harm or of attempting suicide. He appeared to be in better spirits and
admitted that he felt better about himself, largely due to his medication being
“sorted out”. SO C closed the ACCT. There is no record of a post closure
interview, which should happen whenever an ACCT document is closed.
88. At approximately 7.45 pm on 20 December, the man was assaulted by
another prisoner whilst he was queuing to use the telephone. He was struck
on the face and his jaw was fractured. Staff did not witness the assault and
no prisoners came forward with any information. The man was unable to
identify his assailant, as he was struck from behind. The prison’s Police
Liaison Officer spoke with the man shortly after the incident and he said that
21
he did not want to pursue the matter. The man was taken to hospital for
surgery to repair the damage to his fractured jaw.
89. Principal Officer (PO) A wrote to the man’s cousin on 9 January 2007, in
response to a letter she had sent to the prison on 23 December. PO A
outlined the circumstances of the assault and said that he had spoken to the
man, who had told him he had no idea why it had happened nor who had
struck him. PO A had told the man that the prison would investigate any
information and would also pass the matter to the police, but the man who
died had maintained that he did not wish to pursue it.
90. The man telephoned his mother on 8 and 9 January. He told her he was
becoming ill again, could not get help and was very upset. He said he did not
want to live anymore. (The man’s telephone conversations were not being
monitored at the time.) On 10 January, an officer noticed that the man was in
an emotional state after making a telephone call. He said that he always got
upset when he talked to his family, but that he had no feelings of self-harm. A
note was made in the wing observation book by Officer C and night staff were
asked to “keep an eye on him”. An ACCT was not opened.
91. On 10 January, the man’s mother talked to Mr B. She told him that her son
was very upset and quite suicidal (presumably from the earlier telephone call).
He said he was not getting an “update” on his medication. Mr B said he would
speak to the man to tell him that he would get his medication the next day.
The following morning, the man was seen by the Consultant Psychiatrist who
prescribed 500 micrograms of Flupentixol. Mr B later explained to the man
the changes in his medication (he had previously refused to take the
Flupentixol).
92. A week later (17 January), the man rang his mother. She felt that he was
“very suicidal” and rang Mr B to tell him. The man was seen by the Clinical
Psychologist and Mr A the next day. They discussed the assault in December
and he said that he did not know who had hit him, but felt he might be at risk
again. Despite this comment, the man said he was unaffected by the assault
and cared only about his physical health. The man who died gave permission
for the MHIT to contact his father with a view to interviewing him for the
RAMAS assessment. (Risk Assessment Management and Audit Systems,
known as RAMAS, is a system of case planning, treatment and management
of people posing a risk to themselves or others.)
93. On 23 January, the man rang his mother and he begged her for help. She
rang Mr B again and asked him to see her son. The next day, the man rang
his mother once more. He was very upset and crying and said he was poorly.
94. The man was seen by the Clinical Psychologist two days afterwards on 25
January. He was low in mood and said that he was fed up with his medication
causing stomach problems. He said that he felt powerless to do anything as
he had no future. The Clinical Psychologist asked if he felt suicidal to which
he replied he had done since coming to prison. She asked if he had any
present thoughts of suicide. The man replied that he did not, but he was fed
22
up with his situation. He spoke continuously about his health throughout the
session. He talked about nightmares that he was having and cried when he
described them. The Clinical Psychologist said she would ask the Consultant
Psychiatrist to review his medication (which at that time was Venlafaxine
37.5mg and Flupentixol 500 micrograms).
95. A letter was received from the Criminal Appeal Office confirming that the
man’s appeal date had been set for 7 February.
96. On 6 February, the man transferred to HMP Brixton in order that he could go
to his appeal hearing. The next day the man attended the Court of Appeal
Criminal Division where his appeal was refused.
97. The man returned to Leeds on 10 February. He was seen in Reception by
Nurse C and told her he had lost his appeal. Nurse C opened an ACCT plan
at 3.52pm as she was concerned that he had previously contemplated
suicide, had lost his appeal and was very low in mood. She wrote that the
man had a history of mental health problems and had previously been on an
ACCT plan. The Immediate Action Plan was completed by SO D at 4.35pm.
It specified hourly observations during the day, with documented interactions
in the morning, afternoon and evening, and half hourly observations during
the night. The man remained on the induction landing on D wing.
98. Two days afterwards (12 February), Officer D carried out an ACCT
assessment interview (this assessment should have been carried out on 11
February). The man said that the doctors were not prescribing the right
medication for him. He did not think they knew what was wrong with him and
he knew that he should not be in prison. He said he had previously harmed
himself and was really fed up. He said that he was in prison due to doctors
“fucking” his life up with the wrong medication. He told her that he had been
diagnosed with Crohn’s disease, depression and social anxiety disorder. He
was not getting much sleep and not really eating at the time. When asked if
he had any current thought of suicide, the man told Officer C to write down
that he was “happy”. Officer C wrote the comment “obviously not”. The man
who died said that he wanted to see someone from the MHIT.
99. On 12 February at 2.05pm, an ACCT case review was carried out by SO E
accompanied by three other officers, including Officer D. The man asked for
someone from the MHIT to come and see him. The team was contacted and
the message left for Mr A, his case manager. The man seemed very quiet
and withdrawn in the review. SO E wrote:
“He has returned from the Court of Appeal with no change in his status
and still blames the doctors for not prescribing him the correct medication.
I asked him how he felt and he said he was 50/50. He said he was not
going to do anything and he last harmed himself 16 months ago. After
lengthy discussion we have decided to leave this document open.”
100. SO E completed the CAREMAP, listing medication and mental health as
issues for the man. He included the action points that he was to be seen by a
23
doctor and was waiting to see the mental health case worker. SO E also
completed the observation section at the front of the ACCT plan. He
recorded:
“3 x conversations per day, 1xam 1xpm 1xE.D. All documented plus
hourly observations during the day and ½ hourly at night, plus
documented handovers. All documented.”
101. On 13 February, the man met the Clinical Psychologist again. He spoke
about his appeal and said that he felt very disappointed that his sentence was
not reduced. He discussed his health and said that he had no feelings at all.
He said he wished he could feel sad and happy but just felt numb. He
believed that it was the ECT that made him feel that way, as well as the
various medications he had tried. He said he had reduced his medication.
102. At 11.30am the same day, the man who died was seen by Mr A who noted in
the ACCT plan that the man:
“Denies any suicide or self-harm ideation, seems quite up-beat in mood,
continues to believe he is on the wrong medication.”
At 4.00pm the same day, Mr A noted in his ACCT plan that the man had:
“Stated that he was fine when asked. Whether he could have some clean
clothes before he had a shower. Informed him that I would try and sort it
out for him. No problems at present.”
103. The next ACCT case review was carried out three days later on 16 February
by SO E, accompanied by three staff. SO E noted,:
“The man returned from his visit with his mother and stated that it went
well although he seemed subdued and unhappy. I asked him how he felt
and he said that he was fine and did not want to be on this document and
we did not need to keep an eye on him. His main problem stems from his
medication and he still says that the prison is not giving him the correct
medication. The man is relocating upstairs and I have informed him to get
a job and keep himself active but he said he was too ill. After lengthy
discussion we have decided to keep this document open.”
104. The man who died saw Mr A on 19 February. He talked initially about the
side effects of his medication, and then moved on to his belief that he had
been given an excessive sentence. He believed that the independent review
of his treatment prior to committing his offence would somehow get his
sentence reduced. Mr A explained that the review was about his community
care and would have no bearing on his sentence but the man disagreed. He
denied any thoughts of self-harm.
105. Later at 7.30pm the man saw Nurse D. Her note in the ACCT says:
24
“Seen this evening at request of Governor B, who states that officers are
concerned about him. The man’s presentation is no different, he remains
anxious and sometimes tearful, but soon calms down when given
reassurance, which is what he seeks all the time. Advised about his
medication, he wants to come off supervised medications but has been
advised that this will not happen at the moment, due to his open ACCT. I
have told him that I will ask MHIT Mr A to see him tomorrow. He appears
quite happy with this.”
At 7.30pm an entry was made in the ACCT:
“Spoke with Samaritans at length. States he feels reassured to a point
but still anxious. Handover given to night staff.”
The night of 21 and 22 February
106. On 20 and 21 February 2007, a note by Nurse B indicates that the man
refused to take his Flupentixol. A note made at 7.20pm in the man’s ACCT on
21 February states, “The man was feeling down tonight” (the name of the
person who made this entry cannot be determined).
107. Between 7.20pm and 8.00pm, the man who died passed a handwritten letter
to SO A and asked him to sign it as a witness. The letter was intended to
change his will in the event of his death. (The man was at that time being
monitored hourly through the day and half hourly through the night.) SO A
sought advice from Officer A who was just arriving for his night shift duty.
Officer A advised him to speak to the duty governor, Mr C, who told SO A to
arrange for the man to see a mental health nurse.
108. The man was taken to see Nurse A at about 8.00pm. The nurse assessed
the man as an extra patient during what was a busy evening reception and
saw him in a clinic room. Nurse A had little background information, although
it was available on the medical computer record. The nurse did not know that
the man’s appeal had recently been refused and he had refused to take his
medication for the past two nights. Nurse A asked the man if he intended to
harm himself and how he was at the moment. He also asked what the
change of will was about and whether he had any intention of hurting himself.
The man who died replied that he was okay, and that it was just to keep his
family in touch as he was moving to another prison and wanted to get
everything in order beforehand.
109. Nurse A accepted the man’s response that he would not harm himself. The
nurse knew that the man was already located in a safer cell and what the
man’s ACCT observation levels were. The observation levels were continued
at the same level and the man returned to his cell.
110. Nurse A made an entry in the ACCT, but not on the medical record. SO A
signed the man’s letter and asked the NOO to sign it as well. The NOO talked
to the man later on in the evening at about 9.00pm when she went to the wing
to make the management checks. (Management checks require the NOO to
25
visit every accommodation area at random, speak to the staff and check and
sign various documents including ACCT’s.) She had had previous
conversations with the man about his will. He told her that he was “not letting
the banks have my money, it’s my mum’s money”. She was aware that the
duty governor, SO A, and Nurse A had all discussed the letter and believed
that they had considered any change to his risk level. SO A and Nurse A
went off duty at 8.30pm.
111. During the evening and night of 21 February, D wing was patrolled by Officer
A and an OSG. (An OSG is an Operational Support Grade. They do not
carry out the same range of duties as officers and are not trained to the same
level.) This was their third night on the wing out of a set of seven. D wing had
nine prisoners on open ACCT forms that night, including the man who died.
Each prisoner’s observation levels were different and the man’s were half
hourly. All checks should have been recorded, but the man’s ACCT plan only
includes a record of one check per hour. In interview, both Officer A and the
OSG said they made the checks every 30 minutes, but mistakenly thought
they only needed to record alternate checks.
112. An entry made by Officer A at 8.15pm indicates that a handover from day to
night staff took place. The NOO made an entry at 9.05pm that she had
conducted a management check. The ACCT ongoing record pages indicate
that Officer A checked the man at 9.00pm, the OSG at 10.00pm and Officer A
again at 11.00pm. This last entry reads, “Observed resting on bed”. The next
entries are made by the OSG for the checks recorded at 12.00am, 1.00am,
2.00am and 3.00am. They all read, “Observed, looks to be asleep”.
113. The OSG said in his interview with my investigator and the police that Officer
A had told him that they would split the night into two. Officer A would carry
out all of the duties, including ACCT checks, until 1.00am. The OSG would
take over until 4.00am or 5.00am. Officer A told him that he would go to sleep
when the OSG was carrying out the checks. He told the OSG that he could
sleep when it was Officer A’s turn to carry out the checks. (The OSG said
that, on the previous evening, Officer A had slept in D2 office for part of his
shift.)
114. The OSG said that Officer A did not give him any specific information
regarding any concerns about the man or tell him about the letter changing his
will. He only knew that he was on an ACCT plan. At about 11.00pm, Officer
A intended going to sleep but received a telephone call. The OSG said he
was on the telephone for over an hour. After the call was finished he told the
OSG that he was going to go to sleep.
115. Although the OSG said he checked on the man every half hour, he also said
he had been told that he did not have to record half hourly observations in the
ACCT. He made hourly entries in the ACCT, and the last was recorded at
3.00am. Both this entry and the one for 2.00am were written in the margin of
the ACCT ‘Ongoing record of observations sheet’. The OSG explained during
interview that this was because he had run out of continuation sheets and did
not want to wake Officer A by going into the office for more of them.
26
116. At 4.00am, the OSG saw the man in his cell and was concerned about the
way he was lying on his bed. He first thought that he had fallen asleep in an
awkward position and spent a minute observing him, looking for any signs of
breathing or movement. He could not see any and so kicked the door a
couple of times and called out, without a response. The OSG estimates that
he spent three to four minutes trying to get a response from the man.
Although he had been told that a safer cell was suicide proof, and he could
not see a ligature, the OSG was concerned about the man.
117. The OSG went across the landing to the office where Officer A was. The
OSG said the door was closed and the lights were off. He stood outside and
called out Officer A’s name.
118. Officer A responded straightaway and came out of the office. (It is not clear if
they went straight to the cell, or if the OSG briefed Officer A outside the
office.) When they arrived at the cell, Officer A tried to get a response from
the man. He called his name, kicked the door and looked to see if there was
a response. Officer A did not have a radio as he had given it to the OSG. He
said he would go and get the Night Orderly Officer and washed his face
beforehand.
119. The OSG stayed at the cell watching the man. He was there for a couple of
minutes before Officer A returned. He recalls that the NOO was either with
Officer A or arrived very shortly afterwards with other officers.
120. Officer A has denied that he was asleep. When asked during interview why
he had made no entries after 11.00pm he said, “I think it must have just been
the way we decided to work the evening between us …” Officer A said that
he was doing some paperwork when the OSG came into the office at about
4.00am. He said that the OSG appeared anxious and concerned about the
man who was lying in an “unusual position” and that he could not get a
response from him. He said that they went to cell D2 – 18, which is about 20
yards from the wing office (on the same landing). Officer A looked through
the door hatch and saw that the man was lying at an angle on the bottom
bunk, with his body face-down, his feet nearest the door. His head and neck
were obscured from sight by the ladder that gave access to the top bunk and
one of his legs was “dangling” off the bed. Officer A described this as “an
unusual position”.
121. The officer began to try to rouse the man by kicking on the door and calling
his name. Officer A said that he did have a radio and that he told the OSG to
stay at the door and continue to try to get a response from the man. Officer A
said that he “quickly made my way to the orderly officer’s office, which is on
the Centre just at the end of D wing”. The officer said he “walked briskly” and
got to the Centre where the NOO was. He told her that they had been trying
to raise the man because they were concerned about the way he was
positioned in bed. He said that the NOO immediately went to D wing with him
and that another officer accompanied them.
27
122. In fact, the NOO rang the healthcare unit first and asked for a nurse to go to D
wing as well. When the NOO was briefed by Officer A, she said there was no
indication of urgency and he had told her, “I can’t get a response out of the
man”. She telephoned healthcare where she spoke to a Healthcare Officer
and asked him to send a nurse to D Wing as she was going to open a cell.
No urgency was mentioned in this request either. The Healthcare Officer
asked Nurse B to go to D Wing.
123. Nurse B said she was in H3 in-patients at 4.10am when the Healthcare Officer
received the call from the NOO. He told Nurse B that there did not appear to
be any reason to hurry. However, the nurse said she immediately made her
way to D2 landing and that she was carrying a radio. At no point was the
radio used to summon assistance. Nurse B said she knew that her radio
worked because there had been a net test call (when all staff carrying a radio
are asked to reply to the radio centre operator) a short while earlier.
124. The NOO, Officer A and another officer, Officer E, made their way to cell D2-
18 where the OSG was still standing. The NOO looked through the hatch,
called the man’s name and then opened the cell door. (My investigator
estimates that between six and eight minutes had elapsed from the time that
the OSG had his first concerns and the cell being opened.) Upon
approaching the man, the staff could see that there was a small ligature
around his neck made of a thin piece of green sheet. Officer A said that the
ligature was attached to a screw that was holding the bed frame to the wall.
The officer used his anti-ligature knife to cut the ligature. Nurse B had also
come into cell by this time.
125. Nurse B said that as she went through the Centre gate onto D2 landing she
saw the staff outside the cell. No one called or gestured to her to quicken her
pace. The NOO told her when she arrived that it was a blue call “hanging”.
Nurse B said she ran inside the cell and saw the man lying on the bottom
bunk. In her police statement she said that she felt a weak carotid pulse.
Both of his pupils were fixed.
126. Nurse B asked for assistance from the other nurses and the emergency
equipment. The call was logged in the control room at 4.17am. Officer E
helped her to move the man onto the floor. Nurse B rechecked for a pulse,
found none, and then commenced chest compressions. In interview, the
nurse described signs of cyanosis around his lips, nose and ears. (Cyanosis
refers to the bluish coloration of the skin due to the presence of deoxygenated
blood in blood vessels near the skin surface. It can occur in the fingers and
extremities (called peripheral cyanosis), or in the lips and face (central
cyanosis). Central cyanosis suggests the problem is to do with the heart's
ability to pump blood, or the state of the blood itself.1) She said that the man
was still warm to the touch.
127. Staff Nurse E and the Healthcare Officer arrived shortly afterwards and cardio
pulmonary resuscitation continued. A defibrillator had been brought and this
1 English Wikipedia.
28
advised not to administer an electric shock to the man at any stage. (A
defibrillator is a machine that administers a controlled electric shock to the
chest or heart to correct a critically irregular heartbeat that cannot drive the
circulation.) The paramedics arrived at the prison at 4.27am and they
continued the efforts to resuscitate the man. Sadly, they were unsuccessful
and he was pronounced dead at 4.49am.
29
After the man’s death
128. The prison’s death in custody contingency plan was put into action. All the
relevant parties were contacted with the exception of the Independent
Monitoring Board (IMB). A hot debrief was immediately carried out by the
duty governor. Minutes were not taken and it is not known how many staff
attended or if a member of the duty care team was present.
129. The man’s mother was visited at home at 9.20am on 22 February by Dr B, the
Chaplain and SO F. The police were already there, as were the man’s
brother and some family friends. The family were provided with details of
what had happened and the chaplain said prayers. A prison contact number
was given to the family. At 10.40am, the man’s father was informed of his
death by the same prison staff. The prison subsequently offered to make a
contribution towards funeral costs.
30
ISSUES
130. In this section I consider all the issues arising during the man’s imprisonment,
including his healthcare, and the issues raised by his family.
Clinical Care
131. The clinical review carried out by Leeds Primary Care Trust concludes that
the man had a long history of mental health problems. He suffered from
severe anxiety, low mood, thoughts of suicide, and poor compliance with
treatment which he believed affected his physical health problems. He had
harmed himself on several occasions over a long timescale. He believed that
his treatment with Fluoxetine at the time of his offence had contributed to the
impulsive aggressive behaviour. He had major difficulty in coming to terms
with his offending and its consequences. The clinical reviewer judges that the
man was treated appropriately with anti-depressants, major tranquillisers and
psychological support.
132. The man had Crohn’s disease and believed that his psychiatric medication
aggravated this condition. The clinical reviewer judges that he was
appropriately referred for specialist review and treated with the correct
medication.
133. The psychiatric care provided by the prison In-reach Team is described by the
clinical reviewer as exemplary and should be commended.
The mental health in-reach team deserve special praise for the diligent,
professional and focussed work which they undertook with the man who
died and his family. This is good practice and should be encouraged.
134. Care Programme Approach meetings were held to discuss the man’s ongoing
care. These meetings were attended by a multi-disciplinary group of staff
including medical professionals, uniformed staff and governors. The man’s
family were invited to and attended these meetings.
The level of support provided by the Care Programme Approach
meetings for the man, and the involvement of his family, is good
practice and should also be encouraged.
135. Nevertheless, in the two months prior to his death the man had significant
physical, psychological and social problems to cope with. He had sustained a
serious fracture to his jaw requiring surgery. He was troubled by his Crohn’s
disease, blaming it on his psychiatric medication. He lost his appeal against
sentence in early February 2007. He was seen regularly by the psychologist.
She noted that he seemed to have ‘lost his fight’ on 25 January 2007 and he
cried when describing his nightmares.
136. The man’s family have asked about the assessment of the member of staff
from the mental health in-reach team who saw the man on the night he died.
The member of medical staff who saw the man during the evening was Nurse
31
A. He is not from the in-reach team, but is a registered mental health nurse.
He was interviewed by my investigators. He was unaware that the man’s
appeal had recently been refused, although the information would have been
available to him if he had checked his computer record. He asked whether
the man intended to harm himself. The man who died replied that he was
okay. Nurse A accepted the man’s response that he would not harm himself
and so did not change the existing ACCT plan level of observations (which
were half hourly through the night).
137. The clinical reviewer comments that writing his will should have alerted the
prison to a heightened suicide risk and, although Nurse A made an entry in
the ACCT on-going record, this entry makes no reference to any
consideration given to increasing his level of observations. Nurse A assessed
the man as an additional patient during a busy evening reception clinic in his
clinic room, without knowing of recent events, or that he had refused to take
his medication, or of the work of the Clinical Psychologist and her colleagues.
He was not aware of the man’s refusal to take his night medication.
The healthcare manager should arrange a clinical review when prisoners
refuse or change their psychotropic medication themselves.
Medical staff carrying out assessments should consult the prisoner’s
medical record before making recommendations regarding their care.
All consultations should be recorded.
138. Nurse A believed that the man would be observed twice every hour
throughout the night, and he knew that he was located in a safer custody cell.
Consideration should have been given to increased observations and this
should have been documented appropriately.
139. The nurse assessment at this time should have been more thorough and
properly recorded in the medical record. Reference should have been made
to the recent clinical entries on the medical computer record. The clinical
reviewer also comments that the completion of the on-going record in the
ACCT plan on 22 February was of a poor standard.
The ACCT observations log should be completed contemporaneously,
accurately and after an appropriate observation of the prisoner. The
ACCT observations should be recorded in the correct place and format
to remove any doubt as to the thoroughness of the process.
Family concerns about the man’s care in the community
140. The man who died had a long history of psychiatric support in the community.
The family were concerned that more could and should have been done for
him and that he could have been prevented from committing the offences.
Whilst it is not within my remit to respond to these concerns, I do
acknowledge the depth of feeling that the family have on this matter. The
independent inquiry commissioned by the Strategic Health Authority,
32
supported the view that the man’s offence and his mental health difficulties
were unrelated.
Allegation by another prisoner
141. My investigators were asked by the man’s family to enquire into an allegation
made to them by an ex-prisoner who had been a Listener at Leeds. The
allegation was that on a particular day during July/August 2006, the man had
spent some time with a Listener. The Listener was concerned about the
man’s frame of mind and, later in the evening, spoke to an officer to ask him
to “keep an eye” on him. The officer is alleged to have responded that the
man could “rot in Hell as he had murdered my best mate’s son”. This
comment was also alleged to have been overheard by a senior officer. The
same allegation was made to the police when they interviewed the Listener.
142. My investigators interviewed the officer, Officer F, who was asked about his
knowledge of the man who died. He described the man as: “Quite an
intelligent lad. He could put himself over, he could come across quite well
when you were speaking to him, very emotional.” He confirmed that he knew
the victim of the man’s offence as he had gone to school with him and they
were friends from the age of 12 to 15 although they had lost contact when
they left school.
143. When the specific allegation was put to him, Officer F denied making the
comment. He said that he was not the victim’s best friend and had not had
contact with him for several years. Officer F said that, if he had thought his
professionalism would have been affected by the man’s presence on the unit,
he would have spoken to the Governor.
144. My investigators were unable to identify the senior officer who was alleged to
have witnessed the alleged remarks of Officer F. The only person working on
the wings with the same name at that time was an officer who was
interviewed but had no knowledge of the alleged incident.
145. The man’s family are understandably concerned by the allegation. They felt
that, if true, this officer could have influenced the attitude of other staff in their
management of the man. However, there is no supporting evidence that the
attitude of anyone directly responsible for the man’s care was influenced by
Officer F. The allegation made by the Listener remains just that: an allegation
and one person’s word against another’s.
Monitoring the man’s letters and telephone calls
146. The man’s family have asked whether his letters and telephone calls were
monitored and, if they were, whether any action was taken in response. Only
a small proportion of letters and calls in a prison are monitored at random.
Specific targeting of a prisoner’s mail and calls is restricted and the man did
not come within the criteria for his communications to be monitored.
33
Assessment for transfer to HMP Frankland
147. The man was being assessed by the mental health in-reach team for
consideration for the Dangerous and Severe Personality Disorder Unit at HMP
Frankland. This assessment was close to completion at the time of his death.
His family have asked whether his suitability for transfer to the unit could have
been accomplished without a lengthy assessment process. My investigator
discussed these issues with the member of staff at Leeds who was
responsible for transfers.
148. After a prisoner is given a life sentence, the Lifer Section at Prison Service
Headquarters determines where the prisoner serves their sentence. Initially it
was appropriate for the man to be held at Leeds as this was the prison that
received him from court. He was sentenced on 7 April 2006 and it was not
unusual that he was still at Leeds ten months later. At that particular time
there were a significant number of prisoners serving an indeterminate
sentence who were awaiting transfer. It was not unusual for life sentenced
prisoners to remain at their first prison for 18-20 months before being
transferred. Even if the assessment had been completed and the man found
suitable, a transfer to Frankland would have to have been agreed with Lifer
Section. The assessment process being carried out by the MHIT would not
have replaced this.
ACCT monitoring
149. Assessment, Care in Custody and Treatment (ACCT) was implemented at
Leeds on 28 March 2005. The man was subject to an ACCT plan on seven
different occasions. The time spent on each ACCT ranged from one day to
141 days. He spent more than 50 per cent of his period in custody on an
ACCT plan. The clinical reviewer comments that the prison records contain
approximately 500 pages of ACCT documentation throughout his detention
which represent a high level of concern and vigilance. However, there were
some deficiencies in its implementation.
Carrying out ACCT assessments/reviews
150. The assessment interview for the ACCT plan opened on 10 February 2007
was not carried out until 12 February. The first case review was also not
carried out until 12 February. According to PSO 2700 annex 8G, both the
assessment and the case review should have been carried out within 24
hours of the ACCT being opened. My investigator was told that, at that time,
the assessor’s rota was covered by contract supplementary hours which are a
form of overtime. The rotas operated Monday to Friday but did not include
weekends. This meant that trained staff were not always available to
complete the ACCT plans within the prescribed timeframe.
There should be arrangements in place, seven days per week, to ensure
that there are sufficient trained staff available to complete the prescribed
assessment and review stages of ACCT plans.
34
Entries in the ACCT on-going record
151. The front cover of an ACCT plan records the required frequency of
conversations and observations. The last instruction regarding the man’s
observations was both clear and unambiguous. He should have been
observed every half hour during the night and these observations should have
been recorded. The ongoing record of the ACCT shows a number of
occasions when staff did not record observations in accordance with the
instructions. On 21/22 February, the overnight observations have been
recorded hourly. Both Officer A and the OSG state that they checked the man
every half hour, yet there is no record to support their comments. I am
concerned that the man who died may not have been observed in accordance
with the instructions.
The Governor should remind staff that instructions regarding the
recording of observations of prisoners on an ACCT must be complied
with.
Closing an ACCT
152. At 5.00pm on 17 December, an ACCT plan was opened. At 4.00pm the next
day, the man was seen at an ACCT case review which was carried out by SO
C with the man but without any other staff. The man who died told SO C that
he felt a lot better and had no thoughts of self-harm or of attempting suicide.
He appeared to be in better spirits and admitted that he felt better about
himself, largely due to his medication being ‘sorted out’. SO C closed the
ACCT. There is no record of a post closure interview. Nor were any
enquiries made of healthcare to determine if the man’s issues with his
medication had been resolved.
153. SO C carried out the review on his own, when Prison Service policy [PSO
2700 Suicide Prevention and Self-Harm Management] clearly states that:
“The Unit Manager must chair the first Case Review and appoint a Case
Manager (it may be the same person - minimum grade of Senior Officer or
Band 5 Nurse). Where the at-risk prisoner has severe mental health
problems, the case manager can still be from the unit on which they are
located. However in this event, the mental health professional must be
invited to case reviews (and given as much notification as possible of the
review time) and the Case Manager must seek their advice about how the
individual is managed.”
154. I believe it was inappropriate for the ACCT document to be closed so quickly,
and for the decision to be made by one member of the staff on his own.
Staff should be reminded of the need to carry out case reviews in
accordance with PSO 2700, Suicide Prevention and Self-Harm
Management. Where there are mental health issues, a mental health
professional must be invited to attend the review and the Case Manager
must seek their advice about how the individual is managed.
35
Post closure reviews
155. A post closure review should be carried out within seven days of closing an
ACCT plan. This is intended as a follow-up review to ensure that the person
remains safe after closing the plan. My investigators were not provided with
any evidence of post closure reviews having been carried out for any of the
man’s six ACCT plans. They were told that at that time the wings were
responsible for completing the reviews and keeping them with the wing history
sheets, but it was accepted that many were not carried out. A new system
was introduced in May 2008 that was designed to address this issue.
Post closure reviews should be carried out in accordance with Prison
Service Order 2700. Records of these reviews should be retained.
Safer cells
156. The man’s family have asked how he managed to kill himself when he was in
a safer cell. (These are cells designed to have reduced ligature points. They
contain bed(s), storage area, toilet and sink. A cell of this design makes it
more difficult for someone to use a ligature point, but does not eliminate the
risk completely.)
157. Many of the staff interviewed at Leeds believed that it was impossible to self-
harm in a safer cell by using a ligature. This is not a realistic view. Safer cells
contain furniture and fixtures which are designed to make the attachment of
ligatures difficult. The design provides accommodation that offers heightened
protection from impulsive or spontaneous self-harm and suicide attempts.
However, it is possible for a prisoner to damage the fabric, furniture or fixtures
in a safer cell if they are determined to do so and thereby create a ligature
attachment point.
158. The family also asked whether anyone heard the man chip away at the mastic
in the cell. Although it was originally thought that the man had removed the
material that sealed the bed to the wall (mastic), a subsequent investigation at
the prison identified that by pushing against the ladder attached to the foot of
the bunk bed, pressure would be applied to the bracket and bolts that held the
frame to the wall. In doing so, the bolts that fixed the bed to the wall would
loosen and a gap could be created between the bracket and the wall. A
ligature could be put around this gap. The immediate action after the man’s
death was to attach the plates back to the wall with extra bolts in all of the
safer cells in use at that time.
159. The prison has subsequently reviewed the design of the bed, and on 25 June
2007 work was carried out to strengthen the fixture. My investigator has
confirmed that this work was carried out. The type of bed on which the man
who died slept has now been replaced at Leeds.
160. Although safer cells can provide a safer environment for prisoners at risk of
self-harm, it does not mean that it is impossible for a prisoner to harm
36
themselves. It is important that safer cells are carefully examined daily for
any damage that may increase the risk of self-harm. Although I make no
recommendation, the Safer Custody Offender Policy Group may wish to
consider whether this examination should be documented separately from
other cell fabric checks.
161. The man’s family have enquired about the reason he had a bed sheet rather
than special suicide risk bedding, given that he used a thin piece of torn up
green sheet as a ligature. However, prisoners who are monitored by an
ACCT plan should be treated as normally as possible. Replacing a bed sheet
with an anti-tear quilt, or indeed, removing other items of clothing or
possessions, is not encouraged by the national instruction (PSO 2700) on
caring for those at risk of suicide or self harm. I share that view.
162. Furthermore, taking away a prisoner’s normal bedding changes the
designation of the cell to temporary special accommodation (the conditions for
which are laid down in Prison Service Order 1700). For someone who is
subject to ACCT monitoring, this would only be done in the most extreme
circumstances when the prisoner was violent towards himself or the things in
his cell. I am satisfied that the man who died did not meet this threshold.
The letter changing his will
163. On 21 February 2007, the man passed a handwritten letter to SO A and
asked him to sign it as a witness. The letter was intended to change his will in
the event of his death. The man was at that time being monitored hourly
through the day and half hourly through the night as part of the ACCT plan.
SO A sought advice from Officer A and the duty governor, Governor A. He
spoke to the Night Orderly Officer who also signed the letter as a witness. He
also arranged for the man to be seen by Nurse A. All of these actions indicate
a heightened level of concern, but the only record is an entry in the ACCT
plan from Nurse A: “Spoken to this evening. States letter written is for
attention of his mother and states not any intentions of taking his life at this
time.”
164. The NOO was made aware of the letter during the evening handover before
the change of shift and she spoke to the man at approximately 9.00pm. She
found him to be in a low mood, which she later told the police was typical of
him. She said that she had never seen the man who died in anything other
than a low mood. The NOO told the man that she had seen his letter and was
aware that he had lost his appeal, but he did not engage in conversation. She
said during her police interview that the man found it difficult to talk to female
staff.
165. The entry made by Nurse A in the ACCT plan was inadequate. It did not
provide a proper account of the concerns raised, as discussed in paragraph
118, nor did it make any reference to an increased risk or to increasing the
observation levels. SO A made no entry whatsoever. The NOO talked to the
man later in the evening, but she did not record her conversation either.
Prison Service policy [PSO 2700 Suicide Prevention and Self-Harm
37
Management] clearly states that, “Significant events, conversations with and
observations of the at-risk prisoner must be recorded in the On-Going Record,
and accompanied by the recording member of staff’s printed name and
signature.”
Staff involved in monitoring prisoners on an ACCT Plan should be
reminded of the need to record significant events and conversations in
the on-going record.
A significant event, such as a prisoner discussing changes to his will,
should be documented in the ACCT and should detail what
considerations were given to increased risk and increasing the
observation levels.
Events on 21/ 22 February
166. The man’s family have asked what the two prisoners in the cells either side of
him knew about the night that he died. There is no record of the police
interviewing any prisoners during the course of their investigation. Further
consideration to this question was not given until my investigator took over my
investigation in December 2008. He asked for information about prisoners in
adjoining cells. However, given the time that had elapsed due to the
investigation having been suspended, Leeds were unable to tell him. Cell
movement and location information is only retained for a short period. I regret
that I am unable to answer the family’s question.
167. They have also asked what checks were made and recorded on the night of
the man’s death and, in particular, when the last check was made before
4.00am on 22 February when he was found. As we have seen, the ACCT
document instructed staff to observe the man every half hour during the night,
and to record these observations, but only hourly observations were
documented. Both staff on duty that night, Officer A and the OSG, said during
interview that they did observe the man every half hour, even though they
only recorded hourly observations. The last recorded entry prior to 4.00am
was at 3.00am. The entries at 12.00am, 1.00am, 2.00am and 3.00am all said
that the man appeared to be asleep.
168. The man’s family also want to know whether he was offered contact with a
Listener during his last night, and whether any contact took place. If he
refused to see a Listener, they wonder why he was not transferred back to the
Healthcare Centre.
169. Listeners are available 24 hours per day, seven days per week. It is a
voluntary service in that a prisoner may ask to speak to a Listener and
arrangements are made for this to happen. Although there is no record of
contact with a Listener on the night of 21/22 February, it is clear from the
man’s earlier ACCT plans that he was aware of the Listeners and had spoken
to them on a number of occasions. There is no evidence, either from the
records or from interviewing staff, that consideration was given to re-locating
38
the man in the Healthcare Centre that evening and the staff did not think the
man’s risk level had changed.
Response when The man was found hanging
170. The family have asked about the use of emergency procedures. They wonder
why the procedures were not activated by using a radio and summoning help
by calling a Code Blue. This code is used in a radio transmission to indicate
that a prisoner requires medical assistance for problems specifically related to
breathing e.g. asthma attack, ligature. Medical staff then attend, bringing
equipment including oxygen and a defibrillator with them.
171. As I will go on to discuss in greater detail, I believe there was a serious error
in judgement when the man was first seen by Officer A in not going straight
into the cell to determine the man’s condition and calling a Code Blue
emergency, particularly as Nurse B’s initial assessment when she did arrive
was of a possible faint carotid pulse.
172. At approximately 4.00am on 22 February, the OSG saw the man his cell. He
was immediately concerned about how he was lying on the bottom bunk. The
OSG estimates that he spent three to four minutes trying to get a response
from the man and then went to speak to Officer A. (It is at this point that the
OSG’s and Officer A’s evidence differs significantly. Officer A states that he
was in the office preparing documents, but the OSG believes that he was
asleep.)
173. Officer A said there was no sign of injury and no blood. During interview with
my investigators, Officer A went on to say:
“That led me to feel that there was a great risk here. I had a feeling of risk,
for potential hostage situation; a feeling of risk for myself and indeed for
the OSG. I was not confident at all that what I was observing was
necessarily the situation …”
174. My investigator asked Officer A whether he weighed his fear of it being a
hostage situation against the knowledge that the man was on an ACCT, had
just had his appeal refused, and had that evening spoken about signing a new
will. Officer A replied that his “decision process was primarily one of safety …
I had a potential hostage situation here …” Officer A went on to say that,
although there was the potential risk to the man, he felt that the risk to himself
and his colleague was paramount. Officer A said, “I knew that it would be a
matter of a number of seconds before the people [additional officers to unlock
the cell] would be there with me.”
175. Prison Service Order 2710 (Follow up to deaths in custody) says in section 2:
“The first person on scene must summon help and request local
emergency clinical assistance. If establishments use codes to alert clinical
staff to the type of emergency and type of first aid equipment that will be
needed, local contingency plans must explain clearly the code definitions.
39
Local contingency plans must provide for the summoning of an ambulance
and alerting key personnel and state clearly who should do this. If the
apparent death has taken place in a cell, the first person on scene must
enter the cell as soon as possible, following the local strategy for safely
doing so. Local protocols must contain clear instructions covering cell
entry, especially for Night Patrols.”
176. Leeds’ local instructions say: “Where there is, or appears to be, immediate
danger to life, cells may be unlocked with one member of staff”. The local
instructions for staff observing prisoners on an ACCT state that: “If it is
impossible to view the prisoner, every effort must be made to gain a
response. If this is not possible, the Night Orderly Officer must be contacted.”
177. Decisions about whether to enter a cell in what appears to be an emergency
occur many times in my investigations. I understand the dilemma facing an
officer working alone when he or she has to make a quick judgement about
whether to unlock a cell at night. There are several factors that an officer may
consider, such as the height, build and offence of the prisoner, whether there
is a cell mate, how the emergency situation appears, and any information
about the prisoner, such as whether they are on an ACCT, on frequent
observations and so on. It is a difficult decision to make and I do not readily
criticise staff.
178. However, I find it hard to view Officer A’s decision not to go into the man’s cell
as reasonable. He was not alone and the OSG was present. He could see
that the man was lying in an unnatural position and that attempts to get a
response had failed. He knew the man was being checked frequently and
was on an open ACCT. He knew that the man’s appeal against his 20 year
life sentence had recently been refused. He also knew that the man had, that
very night, changed his will. All this was apparently outweighed by a feeling
of risk to himself and the OSG.
179. I would have thought it reasonable for the officer to have called for emergency
assistance on his radio (which by Officer A’s own admission would have
arrived “in a matter of seconds”), broken the seal on his cell key pouch,
unlocked the cell and gone inside. Back-up would have been moments
behind. Instead, Officer A decided to walk off the wing in order to speak with
the night orderly officer. The OSG said in his interview that Officer A went to
wash his face first. Officer A’s actions are even more unacceptable if this is
true. The clinical reviewer also comments that the man’s care on the night of
his death was unsatisfactory and that the delay in gaining entry to the cell to
begin resuscitation was unacceptable.
180. The NOO was briefed by Officer A but there was no apparent sense of
urgency in his briefing.
181. Nurse B states that, when she arrived at the cell, the NOO and the officers
were outside the cell, the door was open and the man was lying on the bottom
bunk. The NOO and Officer A state that Nurse B arrived as they cut the
ligature. Clearly there would be an issue if the man was not receiving
40
attention when the nurse arrived. From the timings taken by my investigators,
had the NOO spent two or three minutes trying to get a response from the
man, opening the cell door and then checking his condition before realising
that there was a ligature, it is possible that the Nurse arrived at about the
same time as staff found the ligature.
182. My investigators timed the interval between the OSG being initially concerned
about the man, and the time taken to open the cell door. Allowing a minimum
time for walking backwards and forwards, briefings, and attempts to get a
response from the man, I estimate that a period of between of six and eight
minutes passed before the cell door was opened.
183. Furthermore, a call for more healthcare assistance was not made for at least
a further four minutes and was prompted by Nurse B after she reached the
cell. Additional medical support would have taken another four minutes to
arrive from the Healthcare Centre. The time before CPR was started was
therefore at least ten minutes and probably somewhat longer – the OSG said
he first saw the man at 4.00am, Nurse B said she received the telephone call
at 4.10am, and she asked for additional healthcare support at 4.17am and
commenced chest compressions at the same time. So it is more likely that
the time which elapsed was about 15 minutes.
184. Nurse B submitted a written incident statement within one hour of the man’s
death. She stated that when she first examined the man, she “initially felt a
very weak carotid pulse”. Her recollection when interviewed by my
investigators was “that it was like a flutter and I’m not sure to be honest if I
imagined it. I wasn’t sure then and I’m not sure now if I imagined it but if there
was a pulse it would mean that his heart was still beating or it had just finished
beating.” She checked again for a pulse after the man was placed on the
floor and before starting resuscitation, but by then it was absent.
185. A statement was submitted by Professor A dated 18 January 2008 in
response to a request from West Yorkshire Police. Professor A was asked to
comment specifically whether early intervention by prison staff might have
prevented the man’s death. Professor A says that the man could have
hanged himself any time from 3.00am to 4.00am and that death may have
taken a matter of seconds or minutes. He comments that, if he had hanged
himself shortly before he was found, it is possible that releasing the noose
and starting resuscitation immediately might have given a slim chance of
recovery.
186. We cannot know whether the man’s life might have been saved had the cell
door been opened quickly by Officer A. But the description of the sequence of
events and unnecessary delays in opening the door, should in my view, lead
to steps being taken by the Prison Service to ensure that this does not
happen again.
The Governor should review the protocols for opening cell doors during
Patrol State. Consideration should be given to providing specific
instructions on opening the cell door of a prisoner subject to an ACCT
41
plan to ensure that these cells can be opened without undue delay.
Staff on patrol should be instructed to contact the Night Orderly Officer
by UHF radio immediately if they have any concerns about the personal
safety of a prisoner.
In light of the findings of this report, and of others for which I have been
responsible, the NOMS Safer Custody and Policy Group should consider
if additional national guidance on the opening of cell doors for those on
open ACCTs would be desirable.
187. The allegation that Officer A was asleep on duty was investigated by the
police. They concluded that there was insufficient evidence to prove, beyond
reasonable doubt, that he was asleep.
188. Being asleep would not have caused the man’s death as the OSG had
already carried out the required observations. However, notwithstanding the
inconclusive nature of the police investigation, I must consider for myself the
possibility that Officer A was asleep on duty. If a member of staff were
asleep, there could have been a delay obtaining medical assistance at the
earliest time. It would also highlight an issue about the management
supervision of night staff.
189. From the entries in the man’s last ACCT it is clear that there are six nights
when no entries were made by a manager. There are six more nights when a
night manager has only made one entry. The latest of the entries is at
11.10pm and the earliest is at 5.30am. As night managers are instructed to
make entries in ACCT plans whenever they visit a wing, I can only conclude
that night managers did not visit the wing on six nights, only visited the wing
once on the other six nights, and that their visits did not happen in the middle
of the night.
190. There is a pattern in the entries made by Officer A during the three nights
when he was on duty. They show that there was a four hour period between
midnight and 4.00am when he did not make an entry but the OSG did.
191. If Officer A had to be woken from sleep and then wash his face before
speaking to the Night Orderly Officer, this would have caused a further delay
in opening the cell door. There does not appear to be a reason why the OSG
would fabricate an allegation that Officer A was asleep. All the evidence – the
lack of entries in the ACCT record between midnight and 4.00am on each of
the three nights they worked together, the absence of management checks
during this time, and the fact that the OSG wrote his last two observations in
the margin of the observation sheet rather than go into the office to get new
sheets - point to the likelihood that Officer A was indeed asleep.
192. I make no recommendation in respect of Officer A on the basis that he is no
longer employed by the Prison Service.
The Governor should review the Night Operating Procedures to ensure
that Night Orderly Officers visit all the prison wings frequently during
42
the night and that at least one of their visits should be between midnight
and 3.00am. These visits should be recorded in the night locking up
sheets and in individual’s ACCT documents.
All staff working in prisoner accommodation areas during the night
should carry radios and respond individually to radio net test calls
carried out by the Control Room during the night.
193. Cut-down tools are implements designed to cut ligatures. They are also
known as anti-ligature knives. All unified and uniformed staff should be
provided with their own personal issue tool and carry them on duty in line with
PSO 2700 (section 11.3). On 22 February 2007, the NOO did not carry a cut-
down tool.
The Governor should make sure that, in accordance with Prison Service
policy, all uniformed staff are provided with, and carry on duty, their
own personal issue cut-down tool.
Support for the family
194. The man’s family received a great deal of support from Ms A who worked in
the Visitors Centre. Ms A would regularly go and see the man who died in
response to concerns raised by his mother. She became the family’s main
point of contact at the prison and was able to provide them with emotional
support. She not only spent time talking to them in the prison but also on the
telephone.
The level of support and liaison with family members provided by Ms A
and the Visitors Centre is good practice and should be commended.
Training for night staff
195. The OSG joined the Prison Service in September 2006. He had little
experience of night duties, having only served one set of nights prior to
February 2007. He benefited from no formal training for night duties and
received guidance from a colleague OSG on how to check prisoners in their
cells and make entries in the ACCT plans. His duties included using an
electronic pegging device at set times throughout the night to prove that
rounds were being carried out. He was also told to carry out regular checks
on prisoners who were on ACCT plans. The OSG’s training record shows
that he received 2.5 hours suicide awareness training on 5 September 2006,
shortly after he first joined the prison. He recalls this as being for about two
hours out of a two week training course.
Appropriate guidance should be provided for staff prior to carrying out
night duties for the first time. This training should include specific
instructions relating to prisoners on ACCT plans.
43
After the man’s death
196. The prison’s death in custody contingency plan was put into action. All
relevant parties were contacted with the exception of the Independent
Monitoring Board (IMB). The incident log incorrectly recorded that the duty
IMB member was telephoned at 5.30am. After a complaint by the IMB and
checking telephone records, it was confirmed that the call did not take place.
The incident log was amended and an apology offered to the IMB.
The IMB should always be notified at the earliest opportunity of a death
in custody.
197. A hot debrief was carried out by the duty governor immediately after the man
was found. Minutes were not taken and it is not known how many staff
attended or if a member of the duty care team was present.
198. An extraordinary suicide prevention meeting attended by representative staff
and Listeners from across the prison was held on 23 February.
199. The prison completed a death in custody checklist in accordance with its
contingency plans. (This checklist is an action plan intended to evidence
actions taken following a fatal incident.) The checklist notes that a Critical
debrief was held at 6.30am on 22 February. I believe that this was in fact the
Hot debrief that was led by the duty governor and that the Critical debrief is
referring to a Critical Incident debrief. A Critical Incident debrief gives the staff
involved in an incident the opportunity to discuss the personal impact of the
incident with others, encourages and enhances mutual support, provides
information on the effects of post trauma stress and encourages coping
strategies and support networks. A Critical Incident debrief was not requested
or held following the death of the man.
Critical Incident Debriefs should be held following every death in
custody.
200. Operational debriefs are designed to check that contingency plans are
correctly followed and changes are made in light of any lessons to be learned.
An Operational Debrief was not held to review the establishment’s
contingency plans.
An Operational Debrief should be carried out following a death and the
contingency plans updated where necessary.
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CONCLUSION
201. The investigation has revealed both some excellent care of the man who died,
particularly regarding the mental health support that he received, but also
some wholly unacceptable care on the night he died.
202. Leaving aside the exact actions or inactions of the staff on duty at the time, it
is manifest that a delay of just a few moments in providing emergency care
can mean the difference between life and death. It is impossible to say
categorically when staff should enter a cell at night because circumstances
will differ. I also acknowledge that some staff may be reluctant to enter a cell
alone for fear that the prisoner might attempt to overpower them. However, in
the circumstances described in this report it is difficult to see how anyone
could reasonably conclude other than that the level of risk to staff was low. If
two prison staff lack the confidence to go into a single cell when a prisoner is
on an open ACCT, is clearly unresponsive, has no history of assaulting staff,
and has just asked for a letter changing his will to be signed, it is difficult to
imagine any circumstances when they would feel safe to do so. It is for this
reason, that the sad death of the man raises issues not just for HMP Leeds
but for the Prison Service as a whole.
45
RECOMMENDATIONS
The Head of Healthcare
1. The mental health in-reach team deserve special praise for the diligent,
professional and focussed work which they undertook with the man and his
family. This is good practice and should be encouraged.
The prison accepted this recommendation at draft consultation stage and said, “The
head of healthcare to send a memo to the MHIRT to acknowledge their work. In
addition, primary care mental health were involved in the man’s care so a ‘well done’
will be extended to them”.
2. The level of support provided by the Care Programme Approach meetings
for the man, and the involvement of his family, is good practice and should
also be encouraged.
The prison said that this good practice will be acknowledged.
3. The healthcare manager should arrange a clinical review when prisoners
refuse or change their psychotropic medication themselves.
The prison accepted this recommendation at draft consultation stage and said, “An
email will be sent reminding all clinical staff of the requirement for wing nurses to
inform the relevant agencies if a prisoner is refusing medication. It is also a
requirement that refusals should be recorded in medical records”.
4. Medical staff carrying out assessments should consult the prisoner’s medical
record before making recommendations regarding their care. All
consultations should be recorded.
The prison accepted this recommendation at draft consultation stage and said, “All
staff have now completed Health Record Training. Health records are audited
annually and peer reviews also take place. All consultations are recorded on
SystemOne and a read coding system is in the process of being introduced to
enhance the accuracy and robustness of clinical reporting from the assessment
process”.
The Governor
5. The ACCT observations log should be completed contemporaneously,
accurately and after an appropriate observation of the prisoner. The ACCT
observations should be recorded in the correct place and format to remove
any doubt as to the thoroughness of the process.
The prison accepted this recommendation at draft consultation stage and said, Staff
have received training in the completion of ACCT documents. Comprehensive
management checks are now completed weekly by the Safer Custody team.
Additionally wing managers complete 100% daily checks, Duty Governor’s 10% daily
check and Group Managers 10% weekly checks”.
46
6. There should be arrangements in place, seven days per week, to ensure that
there are sufficient trained staff available to complete the prescribed
assessment and review stages of ACCT plans.
The prison accepted this recommendation at draft consultation stage and said,
“Leeds now have 39 trained ACCT assessors (the team are multi disciplined) who
provide 7 day cover...this is done via a rota which is co-ordinated and published by
the Safer Custody team”.
7. The Governor should remind staff that instructions regarding the recording of
observations of prisoners on an ACCT must be complied with.
The prison accepted this recommendation at draft consultation stage and said, “Staff
Information Notice (SIN) 345/2009 ACCT Observation has been issued to reinforce
the requirements of PSO2700 in regards to recording of observations”.
8. Staff should be reminded of the need to carry out case reviews in
accordance with PSO 2700, Suicide Prevention and Self-Harm
Management. Where there are mental health issues, a mental health
professional must be invited to attend the review and the Case Manager
must seek their advice about how the individual is managed.
The prison accepted this recommendation at draft consultation stage and said,
“Governor’s Order 14/2007 ACCT Reviews has been published. This is
complemented with the management checks outlined in (recommendation 5) above”.
9. Post closure reviews should be carried out in accordance with Prison
Service Order 2700. Records of these reviews should be retained.
The prison accepted this recommendation at draft consultation stage and said,
“When closed ACCT documents are sent to the Safer Prisons team. A case review is
scheduled for the seven day stage. The ACCT together with a post closure review
form is taken to the relevant unit and collected following the review”.
10. Staff involved in monitoring prisoners on an ACCT Plan should be reminded
of the need to record significant events and conversations in the on-going
record.
The prison accepted this recommendation at draft consultation stage and said,
“Guidance notes have been placed in all staff area’s which provide simple advice on
how to open ACCT documents and what should be recorded. SIN 132/07 introduced
the notes”.
47
11. A significant event, such as a prisoner discussing changes to his will, should
be documented in the ACCT and should detail what considerations were
given to increased risk and increasing the observation levels.
The prison accepted this recommendation at draft consultation stage and said,
“Senior Officers have received ACCT case managers training which covers decision
making and the need to record.
ACCT foundation training covers identifying risk factors. The establishment is
working towards ensuring that all contact staff have received this training”.
12. The Governor should review the protocols for opening cell doors during
Patrol State. Consideration should be given to providing specific instructions
on opening the cell door of a prisoner subject to an ACCT plan to ensure that
these cells can be opened without undue delay. Staff on patrol should be
instructed to contact the Night Orderly Officer by UHF radio immediately if
they have any concerns about the personal safety of a prisoner.
The prison accepted this recommendation at draft consultation stage and said,
“Night Operating procures were completely overhauled in April 09. They include the
requirement to immediately inform the NOO of any concerns about prisoners and
gave instructions of risk assessment processes about opening cell doors during the
night state”.
13. The Governor should review the Night Operating Procedures to ensure that
Night Orderly Officers visit all the prison wings frequently during the night
and that at least one of their visits should be between midnight and 3.00am.
These visits should be recorded in the night locking up sheets and in
individual’s ACCT documents.
The prison accepted this recommendation at draft consultation stage and said,
“Revised Night Operating Instructions include this requirement”.
14. All staff working in prisoner accommodation areas during the night should
carry radios and respond individually to radio net test calls carried out by the
Control Room during the night.
The prison accepted this recommendation at draft consultation stage and said, “All
night staff working in prisoner areas now carry radios. Local security instructions
require a radio check to be conducted. This is recorded”.
15. The Governor should make sure that, in accordance with Prison Service
policy, all uniformed staff are provided with, and carry on duty, their own
personal issue cut-down tool.
The prison accepted this recommendation at draft consultation stage.
48
16. The level of support and liaison with family members provided by Ms A and
the Visitors Centre is good practice and should be commended.
The prison accepted this recommendation at draft consultation stage.
17. Appropriate guidance should be provided for staff prior to carrying out night
duties for the first time. This training should include specific instructions
relating to prisoners on ACCT plans.
The prison accepted this recommendation at draft consultation stage and said, “A
national OSG induction programme has just been launched which new starters will
attend.
“Local support is provided by the NOO to all night staff. ACCT guidance notes are
provided on all wings.
“It is intended that all contact staff will receive ACCT foundation training (see 11).
Job descriptions have been updated as part of the Night Operating Instructions
Review”.
18. The IMB should always be notified at the earliest opportunity of a death in
custody.
The prison accepted this recommendation at draft consultation stage and said, “All
contingency plans make this requirement clear. The requirement is frequently
endorsed by the Governor at operational briefings. IMB clerk publishes the IMB rota
and contact number”.
19. Critical Incident Debriefs should be held following every death in custody.
The prison accepted this recommendation at draft consultation stage and said,
“Critical Incident Debriefs are a requirement in the establishment’s DIC contingency
plan and are coordinated with Employee Support. This is in addition to hot debriefs”.
20. An Operational Debrief should be carried out following a death and the
contingency plans updated where necessary.
The prison accepted this recommendation at draft consultation stage and said, “The
Head of Operations has the responsibility for reviewing contingency plans following
any incident where they are deployed”.
National recommendation
21. In light of the findings of this report, and of others for which I have been
responsible, the NOMS Safer Custody and Policy Group should consider if
additional national guidance on the opening of cell doors for those on open
ACCTs would be desirable.
The prison accepted this recommendation at draft consultation stage and said,
“Safer Custody and Offender Policy, in consultation with Security Group, will
consider how best to disseminate all the lessons learned from this investigation”.
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