Individual at Wandsworth

Investigation into the circumstances surrounding
the death of a man at
HMP Wandsworth in October 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2010
This is the report of the investigation into the circumstances surrounding the death of
a man at HMP Wandsworth in October 2009. Staff found him hanging from the
window bars in his cell and, sadly, attempts to resuscitate him were unsuccessful.
He was 28 years old when he died.
I offer my sincere condolences to the man’s family and partner, and all those
touched by his death.
The investigation was carried out by one of the Ombudsman’s investigators. I would
like to thank the Governor of Wandsworth and his staff for their assistance. I am
also grateful for the co-operation of the Governor of HMP Pentonville and his staff. I
offer particular thanks to the investigation liaison officers at Wandsworth and
Pentonville respectively.
The local Primary Care Trust commissioned a clinical reviewer to undertake a review
of the clinical care the man received. I am grateful for his timely review.
In July 2009, the man was remanded into custody having been charged with a
serious offence. He had never been in prison before and it is clear that he was
daunted by the experience. He had a history of depression and anxiety and this,
undoubtedly, made it all the harder for him to adapt to the situation.
Initially he was remanded to HMP Pentonville and, within days of arriving, tried to
hang himself. As a result he was placed on suicide and self harm monitoring.
However, having transferred to Wandsworth, staff thought they saw a gradual
improvement in his demeanour. By mid-August, they were satisfied that he no
longer posed a risk to himself.
The man was still on remand when he apparently took his own life. This is a sad
story of a man who seems not to have been able to cope with the strain of life in
prison and the uncertainties he faced in the future.
I make five recommendations concerning assessing prisoners’ mental health and the
operation of the personal officer scheme and suicide and self harm monitoring. The
man was the 12th apparently self-inflicted death to occur at Wandsworth since the
Ombudsman began investigating all deaths in custody in 2004. In the past, the
Ombudsman has made recommendations that reviews of prisoners on suicide and
self harm monitoring take place as planned. Otherwise, there are no particular
similarities between the circumstances of this and other investigations at the prison.
At the draft report stage, the man’s partner and parents provided detailed feedback.
We are very grateful for their contribution to the investigation. Some changes have
been made to reflect their comments, which have been annexed to the report. The
family continue to have considerable concerns about the level of care he received
while in prison and think that his death could have been prevented.
2
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Acting Prisons and Probation Ombudsman July 2010
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CONTENTS
Summary
The investigation process
HMP Wandsworth and HMP Pentonville
Key events
Issues
Conclusion
Recommendations
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SUMMARY
The man was arrested and charged with a serious offence on 3 July 2009. He was
held in police custody until he appeared in court three days later and was remanded
into the custody of HMP Pentonville. It was his first time in prison. On his arrival, he
told a nurse that he suffered with asthma and eczema and needed medication for
both. He was assessed by the prison doctor who prescribed the appropriate
medications. He told the nurse and doctor that he had no mental health problems
and no thoughts of deliberately harming himself.
The man was placed in a shared cell on the vulnerable prisoners’ unit, due to the
nature of the alleged offence. During the night of 9 July, his cellmate awoke to find
that the man had tried to hang himself. The following day, he was examined by a
mental health nurse on the wing. He told the nurse that he felt he had let people
down and admitted trying to kill himself. As a result of his actions, an officer opened
an Assessment, Care in Custody and Teamwork document (ACCT - the system for
monitoring and supporting prisoners at risk of suicide or self harm).
On 11 July, the man was interviewed by another officer as part of the ACCT process.
He said he had suffered with depression in the past and had cut his arms some
years previously. He said he was glad he had not succeeded in killing himself. The
officer decided that he should be assessed by the prison’s mental health team and
referred him that day. (For unknown reasons, the mental health team did not receive
the referral until 20 July when he had already been transferred to HMP Wandsworth.
As a result, his mental health was not assessed at Pentonville.)
The man appeared in court again on 16 July, when he was remanded into custody
once more. Because he appeared in court in South London, he was remanded to
Wandsworth rather than returning to Pentonville. Staff at Wandsworth knew that he
was on an open ACCT document and that he had tried to kill himself at Pentonville.
On his arrival he saw the prison doctor who referred him to the mental health team
and the prison counselling team.
On his first night at Wandsworth, the man moved to a cell on the Onslow Centre,
which accommodates vulnerable prisoners. He was placed in a shared cell with a
sentenced prisoner. It appears that his cellmate was a source of support and
friendship during his time at the prison.
Towards the end of July, a psychiatric nurse assessed the man’s mental health. He
concluded that he required no further input from him or the mental health team. That
same day, the man met one of the prison’s counselling psychologists who assessed
him as suitable for further counselling sessions. He told the counsellor that he
frequently suffered with depression and anxiety and found it hard to interact with
people.
Onslow Centre staff noticed that the man spent a great deal of time in his cell. They
encouraged him to mix with other prisoners and become involved in activities on the
centre. He told some staff that he preferred to read or watch television in his cell.
However, he began attending IT classes and said he would like to work while in
prison.
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The man remained subject to suicide and self harm monitoring until 11 August, when
staff conducting an ACCT review decided that his risk to himself had decreased
sufficiently and the ACCT could be closed. It seemed that he had settled into life at
the prison and staff thought his mood had improved. They noted that he was
spending a little less time alone in his cell. A post-closure ACCT review should have
been held a week later, but did not take place.
On 17 September, the man’s cellmate became concerned about him and asked a
senior officer on the centre to talk to him. The officer spent some time with him and
thought that, by the end of their conversation, his mood had improved. He
considered opening a second ACCT but decided that this was not necessary.
The man began counselling sessions, generally on a weekly basis. The counsellor
started work to address his low self-confidence and self-esteem. She, and other
staff who had contact with him on the Onslow Centre, had no concerns that he might
be thinking of harming himself. In the days immediately prior to his death he
received visits from his family and his criminal defence solicitor, none of whom raised
any concerns with prison staff.
During the early evening of 1 October, some prisoners were unlocked from their cells
to go to work around the centre. The man’s cellmate was one such prisoner, but the
man remained locked in their cell. At 7.40pm, the prisoners were to return to their
cells for the night. Staff attempted to open the man’s cell door but found it
barricaded by the two single bed frames. Eventually, they managed to open the
door and found him hanging from the cell window bars, with a ligature made from a
bed sheet around his neck.
Staff and paramedics tried to resuscitate the man, to no avail. His death was
pronounced at 8.29pm by staff from the Helicopter Emergency Medical Service.
I make five recommendations. The first is directed to the Governor and Head of
Healthcare at Pentonville and concerns referring prisoners for mental health
assessments. The remainder are for the attention of the Governor and Head of
Healthcare at Wandsworth. They concern conducting formal mental health
assessments on prisoners who make a serious attempt to harm themselves and the
operation of the personal officer scheme and the ACCT process.
I conclude however, that in the weeks and days leading to the man’s death, staff had
no cause to suspect that he might be thinking of harming himself. I judge that his
tragic actions were not foreseeable and, therefore, not preventable.
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THE INVESTIGATION PROCESS
1. The Ombudsman’s office was notified of the death of the man on 1 October
2009. The investigation was allocated to an investigator the following day. She
visited HMP Wandsworth on 6 October to open the investigation. She met a
representative of the Independent Monitoring Board (IMB) and the Prison
Officers’ Association and other staff and prisoners who knew the man.
2. The investigator issued notices inviting staff and prisoners to contact her with any
information they felt might be relevant to the investigation. There was no
response to the notices. The investigator and an Assistant Ombudsman
interviewed staff and prisoners at Wandsworth between December 2009 and
January 2010. Three members of Pentonville staff who had contact with the man
while he was there were also interviewed in January 2010. The prisoner with
whom the man shared a cell at Pentonville was contacted by telephone and
provided information about events that occurred there. Additionally, the
investigator made telephone contact with the man’s criminal defence solicitor.
3. The local PCT commissioned a clinical reviewer to undertake a review of the
clinical care the man received at Wandsworth. He also considered the care
provided at Pentonville. The investigator and the clinical reviewer carried out
some joint interviews with members of staff.
4. The investigator was provided with relevant documentation covering the man’s
time at Pentonville and Wandsworth, including his prison records, medical record
and staff incident reports written after his death. Unfortunately, part of the prison
file relating to his time at Pentonville is missing and searches at both Pentonville
and Wandsworth have failed to locate it.
5. HM Coroner for the Inner West London District was informed of the nature and
scope of the investigation. A copy of this report will be sent to the Coroner to
assist with his inquiries.
6. One of the Ombudsman’s family liaison officers contacted the man’s parents and
partner to invite them to be involved in the investigation process. His parents
expressed a number of concerns during telephone conversations with the family
liaison officer. The investigator and another family liaison officer also visited the
man’s partner in March 2010. The concerns expressed by his family and partner
about his time in prison have been considered during the investigation. In
addition, one of the man’s friends wrote to the Governor of Wandsworth following
his death. His letter was passed to the investigator and, with the man’s family’s
permission, his concerns have also been considered. His family and friend
asked:
(cid:127) Whether he was given support to understand life in prison?
(cid:127) What action Pentonville staff took in response to his suicide attempt on 9
July?
(cid:127) What information was passed between Pentonville and Wandsworth?
(cid:127) What sort of assessment of his mental health was attempted and whether any
treatment was offered as a result?
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(cid:127) Why was he sharing a cell with a long term convicted prisoner?
(cid:127) What action Wandsworth staff took in response to his cellmate reporting
concerns about him?
(cid:127) Whether anything was done to encourage him to come out of his cell and to
lessen his isolation?
(cid:127) Whether the prison obstructed a planned visit by a psychiatrist?
(cid:127) Whether his counsellor or any other member of staff noticed any deterioration
in his mood and behaviour?
(cid:127) How someone with a history of mental health problems and self harm had the
opportunity to take his life?
(cid:127) Whether all letters written and sent by prisoners are screened by prison staff?
(cid:127) What procedures are in place to identify prisoners in distress, and whether
those procedures are reviewed and updated regularly?
(cid:127) How he had the opportunity to make a ligature from his bedding, given that
this must have taken him some time?
I hope that my report helps to answer their questions.
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HMP WANDSWORTH
7. HMP Wandsworth is the largest prison in the United Kingdom, holding up to
1,658 adult male prisoners. It is a local category B prison, accepting prisoners
on remand, convicted and sentenced from courts within the catchment area. The
prison is formed of five residential wings and two specialist units, one of which is
the Onslow Centre. This unit holds around 360 vulnerable prisoners, most of
whom are convicted sex offenders. The original prison buildings date from 1851,
but since 1989, the prison has been undergoing extensive refurbishment and
modernisation.
8. The National Offender Management Service (NOMS) publishes quarterly
performance ratings for all prisons in England and Wales. The ratings are based
on a set framework and prisons can be rated from one to four (with four
indicating ‘exceptional’ performance). Wandsworth has achieved a rating of
three (‘good’ performance) for the last four published quarters.
HM Inspectorate of Prisons
9. HM Inspectorate of Prisons conducted a full announced inspection in June 2009.
The Inspectorate noted the “troubled” modern history of the prison, remarking
that during the 1990s and the beginning of the present century the prison
received several “highly critical” inspection reports.
10. In her introduction to the inspection report, HM Chief Inspector of Prisons
commented that it
“ … could have been an inspection report that focused on continuing
progress and improvement … considerable steps had been taken to
change a previously resistant staff culture, increase the quality and
quantity of activities, and improve prisoners’ resettlement chances. “
However, the inspection revealed that following “irresponsible, pointless and
potentially dangerous actions instigated at managerial level” a small number of
prisoners perceived to be potentially “difficult” had been transferred from
Wandsworth to another local London prison, HMP Pentonville, for the duration of
the inspection. (Although the man also transferred from Pentonville to
Wandsworth in July 2009, there is no suggestion that his transfer was one of
those criticised by the Inspectorate.)
11. Aside from this important finding, the inspection highlighted that the suicide
prevention strategy was “comprehensive” if “not user-friendly”. While staff were
aware of the value of the Assessment, Care in Custody and Teamwork (which I
explain below), the quality of the documentation was “variable and sometimes
poor”, in spite of quality assurance systems.
12. On the wings, relationships between staff and prisoners were “mostly relaxed
and supportive”. While staff “understood their role” as personal officers, the
system was not found to be functioning fully. The allocation of three personal
officers to a block of cells on some wings (including the Onslow Centre) “resulted
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in no one taking specific responsibility for individuals”. As a result, the
Inspectorate recommended that a single personal officer has the primary
responsibility for named individuals. The inspection team identified that most
files showed a “good number of reasonable quality entries, but these were rarely
by a dedicated personal officer”. There was also “minimal” personal officer
engagement in sentence planning or other key processes. Prisoner perceptions
of personal officers were particularly negative on the Onslow Centre and the
Inspectorate recommended this be investigated and remedied.
Independent Monitoring Board
13. Prisons in England and Wales are also subject to monitoring by an IMB, made
up of volunteers from the local community. Members of the IMB have access to
every part of the prison and each prisoner there. They produce an annual
report, the latest available for Wandsworth covers the period June 2008 to May
2009.
14. The IMB report was generally positive, noting the continued performance
improvement over the previous year. Members were particularly pleased to
report that staff treated prisoners “fairly and with respect” and that relationships
between the two had much improved as a result.
15. Overcrowding was still a concern, as was the availability of drugs and mobile
telephones in the prison. The provision of healthcare “appeared to be moving in
the right direction”. The IMB highlighted their concerns of a potential “systems
failure” in the Onslow Centre, the scheduled rebuild or refurbishment of which
has been delayed by the Ministry of Justice. The report also mentioned that the
personal officer scheme still “left room for improvement”.
HMP PENTONVILLE
16. HMP Pentonville is a large local prison in North London, with capacity for 1152
adult male prisoners coming from courts within the catchment area. The prison
was last inspected by HMIP in an unannounced visit in May 2009. The report
noted the “undoubted improvements” at the prison but again highlighted the
“unnecessary and pointless” transfer of vulnerable prisoners between
Pentonville and Wandsworth during both prison’s inspections. The inspection
found there had been a “strong focus” on safer custody procedures.
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Assessment, Care in Custody and Teamwork
17. Assessment, Care in Custody and Teamwork (ACCT) is the Prison Service
process for supporting and monitoring those prisoners thought to be at risk of
harming themselves. An ACCT document can be opened by anyone working in
the prison if they are concerned that a prisoner might have tried or, in the future,
might try to harm himself. The purpose of ACCT is to determine the level of risk,
the steps that might be taken to reduce risk and the extent to which staff need to
monitor and supervise the prisoner. Levels of observations (when staff must
check the prisoner) and interactions (when staff have a conversation with the
prisoner) are flexible and should be set according to the assessed risk of harm.
If staff perceive the risk of harm to be very high, the prisoner may be constantly
observed, with a member of staff positioned outside their cell at all times. When
the perceived risk is lower, the level of observations may be several times an
hour or day.
Personal officers
18. Personal officer schemes are in place across the majority of prisons in England
and Wales. Under the scheme, individual officers are allocated a small number
of prisoners, often according to their cell numbers. Personal officers are
expected to forge good working relationships with their prisoners. They should
be the prisoner’s “first port of call” if they have a question or concern and should
be involved in sentence planning, the ACCT process and other important
aspects of the prisoner’s time in custody. Personal officers are expected to
make regular written entries in the prisoner’s file. In addition to their personal
officers, prisoners are encouraged to seek support from all staff.
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KEY EVENTS
19. On 3 July 2009, the man was arrested by the police on suspicion of attempted
rape. The risk assessment carried out by a police officer in the custody suite at a
police station recorded that the man’s front tooth was missing and that he had
cuts on his right knuckles and right elbow. (The document does not record
where or how he received these injuries.) He told the police officer that he had
drunk seven pints of strong beer over the course of that evening. He said he
was not dependent on drugs or alcohol and was not prescribed any medication.
(His blood was not tested for the presence of drugs while he was in police
custody.) The police officer asked him if he had ever tried to harm himself or
take his own life. He replied that he had not and that he had no such thoughts at
the time. He said he had no mental health problems or depression. He was
treated by a police doctor for the cuts to his hand and elbow.
20. The man appeared at the local magistrates’ court on 6 July, charged with
attempted rape, actual bodily harm and possession of a bladed article in a public
place. Due to the seriousness of the charges, he was remanded into the custody
of HMP Pentonville until 16 July when he would appear at the crown court. He
arrived at Pentonville late that afternoon.
21. On his arrival, the man underwent a routine First Reception Healthscreen with a
nurse. (The healthscreen is designed to identify any immediate physical or
mental health problems needing referral to the doctor or other specialist service.)
The man told the nurse that he suffered with asthma and eczema and had been
prescribed medication for both conditions by his community doctor. The nurse
recorded that the man had no mental health problems and no thoughts of
harming himself. Because he needed prescription medication, she referred him
to see the doctor in reception.
22. The prison doctor assessed the man following the nurse’s referral and prescribed
an inhaler for his asthma, an antihistamine (for hay fever, which he said he also
suffered with) and white paraffin cream for his eczema. The doctor recorded that
the man did not currently have any visible eczema but that he should return for
further assessment if his skin condition worsened. He told the doctor that he had
punched someone and, as a result, had a cut on his right fist. The doctor noted
that he had been prescribed antibiotics while he was in police custody and that
his hand was slightly red and swollen. He prescribed a further course of
antibiotics and told him to keep an eye on the wound and return for further
treatment if it did not heal. The doctor noted that he had “no other mental health
issues, no thoughts of suicide or dsh [deliberate self harm]”. He wrote that he
made good eye contact during the appointment and demonstrated “appropriate
speech and behaviour”.
23. While in reception, an officer carried out the Cell Sharing Risk Assessment
(CSRA). (This assesses the risk the prisoner poses to other prisoners and
whether they are suitable for sharing a cell. It also provides a further opportunity
to assess whether the prisoner shows any signs of being a risk to himself.) The
officer recorded that the man had no previous convictions for violent offences but
was currently charged with one. The man told the officer that he had never
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misused alcohol or drugs. He said he had no concerns about sharing a cell and
that he was not someone who got angry or frustrated easily. The officer wrote
“no concerns at this time” on the form and concluded that the man posed a low
risk to other prisoners. One section of the CSRA is completed by a member of
healthcare staff. The nurse completing the assessment also judged him to be
suitable for sharing a cell and recorded that there were no indications that he
might harm himself.
24. The man was given a cell on G1 landing, the part of the prison set aside for
vulnerable prisoners. (Vulnerable prisoners, also often called Rule 45 prisoners,
are usually kept separate from the general prison population. They may be
deemed vulnerable because of the nature of their offence, or because they are
less able to cope with prison life.) Unfortunately, part of the prison file relating to
his time at Pentonville is missing and so relatively little is known about his time
on G1.
25. During the course of the investigation, the investigator spoke to a former
Pentonville prisoner by telephone. He said that he had shared a cell with the
man from 7 to 16 July. He described him as a “nice man” who was “intelligent
and open”. He said the man had seemed comfortable talking to him but not to
other prisoners. When asked why he thought this was, he replied that the man
“felt bad about what he had done”. He did not think that he was someone who
found it easy to talk about how he felt. While sharing the cell, the former prisoner
said that he noticed scars on the man’s shoulder. Neither man mentioned the
scars but he said he guessed that the man had harmed himself in the past.
26. Two days after they began sharing the cell, during the night of 9 July, the man
tried to harm himself. The former prisoner explained that he had seemed
“normal” during the course of the day and they had eaten their tea, chatted and
watched television until they went to bed at about 11.00pm. He was woken
during the night by a thud and found the man on the cell floor with something tied
around his neck. He said that the man had tried to hang himself but the material
he had used (he was not sure what this was) had snapped. (In fact, the man
later revealed to his cellmate at Wandsworth that he had attempted suicide twice
that night, but had failed on both occasions.) The former prisoner offered to talk
about what had just happened but the man did not want to. He told him that he
should talk to a member of staff the following morning and, if he did not, he would
not be prepared to share the cell with him any longer. He said that he would tell
staff what had happened if the man chose not to. The man agreed to talk to staff
the next day.
27. However, the following morning, the man changed his mind so the former
prisoner raised his concerns with a wing officer. As a result, the officer asked a
nurse to speak to him. He told the nurse he was “ok” and that he was a “loner”.
She asked him about the “crescent shaped, recent bruise” on his neck and he
replied that it was a “scratch”. The nurse told him it looked like an “attempt to
harm himself”. She wrote in his medical record that she “asked him directly if he
had something tied around his neck”. He then told her about his attempt to hang
himself the previous night.
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28. The nurse was interviewed as part of the investigation. She told the investigator
she is a registered mental nurse (who specialises in mental health problems) and
had been working at the prison for nearly ten years. Due to the passage of time,
she could remember little of her meeting with the man in July. However, she
recalled that initially he had been reluctant to talk about his actions, but later told
her he felt ashamed and that he had let people down. The nurse passed the
information about his attempted suicide to the wing officer.
29. At 5.10pm that day, the wing officer opened an ACCT document. She wrote that
the man had a “ligature mark around the neck” and that “this was confirmed by
his cellmate and the nurse”. He told her that he was “finding it difficult” being in
prison, particularly as it was his first time. The officer wrote that she had
encouraged him to “interact more with others” but that he said he was a “very shy
person”. She noted that he spent “all his time behind his door”, meaning inside
his cell. She ticked the form to indicate that he had tried to harm himself and
was very low in mood.
30. In interview, the wing officer explained that, although the man had only been on
G1 for a few days, she had noticed him because he was very quiet. He did not
come out of his cell much and she tended to keep an eye on such prisoners.
The officer said she encouraged him to come out of his cell more as she thought
this would help improve his mood. However, she recognised that many
prisoners found their first days in prison difficult and that staff have to be patient
and allow them time to settle. She and the mental health nurse, both of whom
are largely based on G1, agreed to monitor him over the following days.
31. Following the man’s attempt to harm himself, a form (known as an F213SH)
which details the injuries received should have been completed. The wing officer
said that, although she usually did fill in the form when necessary, she could not
remember whether she had done so in his case. The investigator was not
provided with a copy in the paperwork she received, but as some of the
Pentonville file is missing, it is not possible to verify whether one was completed
or not. The wing officer said she also recorded his actions in his prison file and
in the wing observation book. (In most prisons, staff record important events and
observations in a book, one of which is held on each wing. The wing observation
book provides a useful way of communicating between staff who work different
shifts.)
32. At 6.14pm, a senior officer (SO) completed the ACCT Immediate Action Plan
form. She recorded that the man should remain in his shared cell and be
checked once every hour. She reminded him that he could ask to speak to the
Samaritans by telephone or to a Listener (a prisoner trained and supported by
the Samaritans to offer a confidential listening service) at any time. The SO
directed that staff check him at least once an hour throughout the night.
33. At 2.50pm on 11 July (a Saturday), another officer, trained as an ACCT
assessor, carried out the ACCT assessment interview. He noted that it was the
man’s first time in prison and he was “feeling depressed”. He was worried about
the impact his actions would have on his family. He said that his partner and
family were supporting him but that this was making him feel even more guilty.
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The officer asked him about his attempt to harm himself two days earlier. He told
him that, once his situation began to sink in, he felt “dazed, as if in a dream” and
that he felt he had been in a dream when he tried to hang himself.
34. The ACCT assessor asked the man whether he had ever harmed himself in the
past and he said he had, ten years previously. He explained that he had been
subject to “(mild) bullying” because of a speech impediment. He said he was a
“sensitive person” and showed the officer scars on his arms “from deep cuts”.
He said he “did not want to do it now” and that he felt “a lot better”. He was
looking forward to seeing his partner. He said he suffered with depression,
which he described as “not severe”, saying that he sometimes “just feels low”.
He described himself as a worrier, particularly about his eczema and medication.
He told the officer that he was “glad” he had not succeeded in killing himself and
did not think he would try again. However, he agreed that the ACCT document
should remain open.
35. The officer told the man he would refer him to the prison mental health inreach
team (MHIT), and he agreed to this. The investigator has been provided with a
copy of the mental health referral form the ACCT assessor completed on 11 July.
The officer details that the man had attempted suicide but that the “ligature
failed”. He wrote that his assessment interview had “indicated mild depression
and anxieties”. The officer judged that he posed a “medium” risk to himself and
should be assessed by the mental health team “within one week”. Had the
officer wished to make an urgent referral, he could have done so by indicating
that the man needed to be seen in “24/72 hours”.
36. The date stamp on the referral form indicates that it was received by the mental
health team on 20 July, some nine days later, and after the man had been
transferred to Wandsworth. As a result, he did not undergo a mental health
assessment while at Pentonville. During the course of the investigation, the
investigator spoke to Pentonville’s Head of Healthcare by telephone. He
explained that paper referral forms should be delivered directly to the MHIT who
process them twice a day. As the ACCT assessor completed the form on a
Saturday, the MHIT should have processed it the following Monday, 13 July. It
has not been possible to discover why his referral was apparently not dealt with
until six working days later.
37. The Head of Healthcare told the investigator that he would expect staff (both
healthcare and discipline) to urgently refer any prisoner who has seriously
attempted to harm himself. Although the ACCT assessor had not marked the
referral as urgent, the Head of Healthcare thought, given the amount of detail the
officer provided, MHIT staff would have reassessed the urgency of the referral.
38. The ACCT assessor and the wing officer who opened the ACCT made entries on
the second page of the ACCT document, detailing the triggers or warning signs
which might change the level of risk the man posed to himself. The wing officer
recorded that it was the man’s first time in prison. The ACCT assessor wrote
that the progress of his court case was likely to be significant for him, as was
contact with his family.
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39. Immediately following the ACCT assessment interview, The ACCT assessor
briefed the SO on duty. The SO, the ACCT assessor and the man then met for
the first ACCT case review. The SO wrote that “it was the initial shock, fear and
embarrassment of coming into prison” that led the man to try to harm himself.
He continued that he was “becoming used to the situation” and “most of his fears
had been allayed by staff and other prisoners”. The SO concluded that he was
not thinking of harming himself “at present or in the future” and was trying to
cope. The officers decided that ACCT monitoring should continue. The SO
directed that the ACCT should be reviewed in a week but wrote that the man had
been told how to seek support if he needed it in the meantime. The SO ticked to
indicate that the current likelihood that he would try to harm himself again was
low (the other options are raised and high). He also indicated that a routine
referral to the MHIT should be made. The SO decided that the level of
observation could be reduced to once every three hours. The next ACCT case
review was to be held on 17 July.
40. The ACCT assessor could not remember the case review in question. However,
he explained that decisions about the level of risk a prisoner posed to himself
were made in the light of what the prisoner said and how he presented, as well
as information contained in his file.
41. Following the case review, the officers completed the ACCT Caremap, which
sets out the actions that should be taken to help reduce the risk the individual
poses to himself. The ACCT assessor recorded that the man’s
“anxiety/depression” required referral to the MHIT (he noted that he would do this
the following Monday, although the referral form is dated 11 July, the date of the
review). In order to combat his fears about being in prison for the first time, the
officer wrote that he had been encouraged to write to and telephone his family
and partner. He was also encouraged to make use of the prison library and
“other resources” to keep himself occupied.
42. The mental health nurse saw the man again on 12 July and completed the
Secondary Healthscreen. (This must be carried out within one week of the
prisoner’s arrival and assesses their general physical health. It also provides
another opportunity to assess the prisoner’s mental health and whether they
have any health related concerns.) The nurse recorded that he was on an ACCT
but that he was “feeling a bit better” particularly as his partner was due to visit
him the following day. She wrote that his mood was “depressed” and that he had
put the ligature around his neck because he was “feeling a sense of dread about
[his] situation and guilt for letting people down”. He told her that he no longer
had any desire to harm himself. In interview, the nurse said that she felt less
concerned about him because his mood seemed brighter; he was “cheerful” and
really looking forward to his partner’s visit.
43. The man was examined by a second prison doctor on 14 July, complaining of
eczema on his elbows. The doctor prescribed a different cream to that
prescribed on 6 July.
44. On 16 July, the man appeared at the crown court. The investigator spoke to his
criminal defence solicitor who explained that, due to workload pressures, the
16
magistrates’ court the man had first appeared at was, at the time, committing
cases to a crown court in south London, rather than any of the crown courts in
north London. The Person Escort Record (PER) that accompanied him noted
that he was on an open ACCT, might be violent and had been charged with a
sexual offence. (The PER assesses the risks an escorted person might pose, for
example physical and mental health problems, offence history and risk of suicide
or self harm. It also serves as a record of the person’s time under escort.)
Escort staff who supervised him while at court recorded that there were no
concerns about him during the day. He appeared in court at 2.00pm and the
case was adjourned. He was remanded back into custody but, as the crown
court is in south London, he was to be taken to Wandsworth rather than return to
Pentonville.
45. The man arrived at Wandsworth at 5.40pm. On his arrival, a reception officer
and nurse completed a second CSRA. The officer noted that the man was on an
open ACCT and that it was his first time in prison. She assessed him as posing
a low risk to other prisoners. The nurse recorded that he should see the doctor
(presumably because he was on an open ACCT, although this is not made
clear). She noted that there were concerns that he might harm himself. As a
result of her assessment, she judged him to pose a medium risk to other
prisoners.
46. While still in reception, the man was assessed by a prison doctor. She recorded
that he was on an open ACCT “after an attempted hanging at Pentonville”,
continuing that he was “glad it did not work but this feeling does vary”. He told
the doctor he was “reflecting a lot … on his crime”. He said he felt very well
supported by his partner and that he had no thoughts of harming himself. She
noted that he made “reasonable” eye contact and expressed himself well during
the appointment. He thought he would be able to sleep that night, as he had had
a “tiring, stressful” day in court. The doctor recorded that he should be referred
to the MHIT and for counselling, and that he was happy for this to happen. She
completed the referral form on 21 July, noting that she was referring him
because of his risk of suicide and self harm. She recorded that he was keen to
attend counselling.
47. At 8.20pm, an SO conducted an ACCT case review with the man on E wing, the
First Night in Custody Centre. The SO recorded that his risk to himself was
currently low and made no change to the level of observation (once every three
hours). He wrote that he was “relaxed and happy being here at Wandsworth”.
The man asked the SO if he could move to the Onslow Centre (for vulnerable
and Rule 45 status prisoners). The SO “explained the routine” and noted that the
man was “happy with what he hears”. He told the SO that he had no thoughts of
harming himself and mentioned his “strong ties” with his partner and family.
48. That night, the man was taken to the Onslow Centre. He was allocated cell
G4.06, sharing with a prisoner. One of the Onslow Centre managers (another
SO who also carried out the ACCT case review on 28 July), was interviewed as
part of the investigation and was asked how decisions about cell allocation are
made. He explained that the first part of the process is the CSRA, which
indicates whether the prisoner is suitable to share a cell. If the prisoner is
17
deemed suitable for sharing, the movements officer (who is responsible for
recording the available cell spaces and making sure they are put to best use) will
identify the most appropriate cell.
49. The SO was asked whether any consideration was given to the character,
offences or sentencing status of the prisoners being placed in together in a cell.
The cellmate had been convicted and given a long sentence, and had been in
prison for some time before sharing with the man. The SO explained that it can
be helpful for newly arrived prisoners, with little or no prison experience, to share
with someone who can help them understand the regime and reassure them
during their first weeks in the prison. He said that the cellmate was considered to
be a “solid, humble” young man, and staff thought that the man would benefit
from sharing with him. By all accounts, the man and the cellmate got on well.
Staff described him as finding it hard to mix with prisoners on the unit, but said
he spent a great deal of time with his cellmate.
50. First thing the following day, 17 July, the man met the induction orderlies
(prisoners who are trained to provide information to new prisoners) and received
further information about life at Wandsworth. At 3.30pm, another of the Onslow
Centre managers and the man met for another ACCT case review. This SO
wrote that the man was “still a little nervous” about being in prison, although he
said he was “happier to be at Wandsworth than Pentonville”. The SO explained
that he could seek support from Listeners or staff, or ask to use the Samaritans
telephone if he needed to. The man told the SO that he had spoken with his
family who knew he had been transferred. He said he would like to work while in
the prison. The level of risk he posed to himself was considered to be low. The
SO reduced the level of ACCT observations, directing that staff ensure they had
“three quality interactions” each day. (“Quality interactions” generally means that
staff should have a full conversation with the prisoner in order to assess their
frame of mind and address any concerns they might have. In fact, night staff
appear to have checked him hourly each night in any case.)
51. An officer completed the Local Initial Screening and Reducing Reoffending Tool
with the man on 18 July. (This is completed with all new prisoners and gathers
information about their likely needs in prison.) He said he had no
accommodation concerns, was in full time employment before coming to prison
and that his job was available to him on release. He said he was interested in
further education. The officer recorded that the man did not use drugs and drank
alcohol only moderately. He reported no history of mental health problems, but
said he was taking medication for asthma and eczema. He asked to see the
dentist while at Wandsworth but said he had no other health concerns. The
officer recorded that he was on an open ACCT and had recently thought of
harming himself. She noted that he was not interested in attending any offending
behaviour programmes because he was “not guilty”.
52. At 5.00pm that day, an officer working on the Onslow Centre made an entry in
the ACCT on-going record (where staff record their conversations with and
observations of the prisoner). She noted that “the man’s cellmate told me that
the man has said that if he gets the chance he is going to kill himself”.
18
53. The man’s cellmate was interviewed as part of the investigation. He confirmed
that he and the man had got on well as cellmates. He described him as quiet
and easy going, but clearly very anxious about being in prison and said he
“worried too much”. The cellmate said that the man tended to stay in their cell
reading. The investigator asked him about his conversation with the officer who
had made the entry in the on-going record. He said that the man had not
specifically told him he planned to kill himself, but “that was what he meant”.
54. The officer who made the entry in the on-going record was also interviewed. She
explained that she generally works on the 4s landing (where the man and his
cellmate’s cell was) of the Onslow Centre which means that she tends to get to
know the prisoners there a little better. She said that she tries to get to know the
quieter prisoners and encourages them to come out of their cells. She knew the
man arrived at Wandsworth on an open ACCT and that staff were, therefore,
keeping an eye on him. The officer said that when the cellmate told her of his
concerns, she wrote in the man’s ACCT, knowing that more senior staff, who
carry out regular ACCT management checks, would read it. The investigator
asked her if she had discussed the cellmate’s fears with any other staff.
Although she thought it likely that she would have, she could not remember if, in
fact, she had done so. Neither could she recall whether she also recorded the
comment in the wing observation book. (Unfortunately, the wing observation
book for the Onslow Centre on that date could not be located for this
investigation.) She did not note the concerns in his prison file.
55. In interview, the officer said that she had spoken to the man that day (although
she acknowledged that this might have been prior to her conversation with his
cellmate). He told her he was “fine” and she had no concerns about him. The
officer said she spoke to him regularly on following days, but never had any
cause to be concerned about him.
56. Another prison doctor wrote an entry in the man’s medical record on 21 July. He
had discussed his case with the primary care mental health nurse and said that
“it was agreed that [the patient] needs to be screened by primary care”.
57. On 28 July, the man attended an ACCT review with an SO and a member of the
chaplaincy team. In interview, the SO explained that, at Wandsworth, staff try to
ensure that ACCT case reviews are attended by staff from a variety of
departments. To assist this, generally, case reviews on the Onslow Centre are
held on a set day of the week. The review panel normally includes a member of
the Crisis counselling service (a team of psychologists who provide a counselling
service to prisoners), one of the chaplaincy team, a member of staff from the
mental health team and representatives from other specialist services, where
appropriate. If staff are unable to attend the review in person, they are invited to
contribute by email or telephone.
58. During the review, the SO recorded that the man’s risk to himself remained low.
The man said he had noticed a “slight improvement” with his anxiety and was
keeping himself busy by reading. The SO noted that he was “a bit tearful” during
the review when he talked about being in prison. The man said that he had tried
to harm himself once before when he was 16 years old. Again, he denied any
19
current thoughts of harming himself “although he still needs support”. The ACCT
remained open, with the same level of interactions. The investigator asked the
SO whether he remembered reading the officer’s entry in the on-going record on
18 July. He said that, although it was good practice for case managers to read
the on-going Record before conducting an ACCT review, he did not always have
time to do so. He could not remember whether he had read the officer’s entry or
asked the man about it during the review.
59. A psychiatric nurse also saw the man on the morning of 28 July. In interview, the
nurse explained that he acts as a “gatekeeper” to the MHIT and psychology
department. Any member of staff can refer a prisoner to him and he will conduct
an informal assessment before deciding the most appropriate course of action or
treatment. The main focus of his work is with prisoners suffering anxiety,
depression and “mild mental health problems”, while the MHIT largely work with
prisoners diagnosed with severe and enduring mental health problems. Due to
the large number of prisoners falling within his remit, he can make referrals to the
Crisis counselling service, psychology department or the MHIT as appropriate.
60. The psychiatric nurse explained the assessment process. He visits prisoners on
the wings and talks to them about, for example, whether they have any history of
mental health problems and whether they have been prescribed medication in
the past or seen a psychiatrist. As part of his assessment, he considers how the
prisoner presents himself and whether he is able to hold a conversation or make
eye contact. He emphasised the informal nature of the assessment, saying that
he does not follow a set assessment framework.
61. In interview, the psychiatric nurse said he could not remember assessing the
man. However, he recorded the assessment in the man’s medical record, noting
that he was “coping fairly ok” but was to remain on an ACCT. The man told the
nurse that his trial was due to start in October. He reiterated that he had a
supportive partner, who was able to visit him in prison. He was due to see a
trainee counselling psychologist from the Crisis counselling service later that day.
The nurse explained the various support systems available to the man, who said
that he found his cellmate supportive. He said he was managing to sleep and
would seek help if he needed it. The nurse could not recall having any particular
concerns about him and thought he would have recorded them in the medical
record if he had.
62. In the afternoon, following the reception doctor’s referral a week earlier, the man
had an appointment with the trainee counselling psychologist to assess whether
he was suitable for Crisis counselling. At the draft report stage, the Crisis
counselling team explained that all prisoners should undergo an assessment
interview within one week of referral.
63. The psychologist was interviewed as part of the investigation. She explained
that Crisis counselling is offered by a team of counselling psychologists and
focuses on providing short term counselling to help prisoners cope in prison.
The service offered by Crisis counsellors is separate from that offered by the
psychology department (who deliver some of the offence related programmes)
and the MHIT (who provide medical interventions, such as anti-depressant
20
medication). She said, however, that the three teams work closely with each
other, as well as with the general healthcare staff, normally by making entries on
the prisoner’s electronic medical record. She explained that prisoners who have
Crisis counselling might also be on the inreach team’s caseload or the forensic
psychologists, or both, as appropriate.
64. In order to assess whether the prisoner is suitable for Crisis counselling, the
psychologist or her colleague spend about half an hour with them. She
explained that the service prioritises prisoners who feel suicidal, have harmed
themselves or are not coping well. Generally, she said, unless the prisoner did
not want counselling, or it was felt that they would not be able to engage with a
counsellor, all referrals are accepted. She told the investigator that the
counselling sessions are confidential. However, all prisoners are warned that
information relating to risk of harm (either to themselves or someone else) will be
shared with other staff.
65. In their first meeting, the man told the psychologist that he had been feeling low
and had a history of depression and harming himself. He described his
depression as “coming in waves”. However, he said he was not currently
thinking of harming himself. She noted that he would plead not guilty to the
offence he was charged with. She wrote that he was concerned about his
speech impediment (although, in her view, it was difficult to notice) and generally
kept to himself, although he got on well with his cellmate. She noted that he was
“isolating himself from other prisoners and staff” and that he described himself as
“always [finding] it hard to interact with people”. She recorded that he “appeared
very anxious” throughout the assessment. He said he had not had counselling
before but “appeared motivated to give it a try”. She concluded that he would
benefit from counselling to “develop his coping skills in prison and to address his
low mood … and social anxiety”. He was placed on the waiting list (which, at the
time, meant that prisoners should be seen within two months of assessment) and
she noted this on the ACCT Caremap.
66. When the man arrived on the Onslow Centre, he was allocated three personal
officers. On 30 July, one of those officers made an entry in the man’s file noting
that he was “quiet …keeping himself to himself … no current issues”. This was
the only entry this officer made.
67. On 4 August at 10.45am, the SO who chaired the ACCT review on 28 July
chaired another ACCT case review. The man was present along with another
SO, the psychologist, the chaplain and a member from the MHIT. The group
concluded that his risk to himself remained low as he said he was feeling “slightly
better”. He said, however, that he found the thought of going to court “daunting”.
(The progress of his court case had been marked as a possible trigger when the
ACCT was opened by Officer A at Pentonville.) The SO chairing the review
noted that the man had been offered the chance to discuss his offence in
confidence with Crisis counselling. He told the review that he was still not
confident about mixing with others, which he “put down to shyness”. He told
them he was not going out on exercise but had started to attend IT classes. In
interview, the SO said his impression was that his mood remained much the
21
same as at the previous ACCT case review a week earlier. It was decided that
the ACCT should remain open.
68. That evening, another Onslow Centre officer recorded in the on-going record that
he had spoken “at length” with the man about “his current feelings”. The officer
wrote that he “advised him of the value of Listeners and [the Samaritans] phone
and also their availability”. The man told the officer he felt “fine” at the moment
and was “enjoying having the time to read”. In interview, the officer said that, on
checking him as he sat in his cell, he thought he did not seem his normal self and
so went into the cell to talk to him. He told the officer that he was not sure what
kind of sentence he would get if he was found guilty and that he was missing his
family. However, the officer was not unduly worried and had no concerns that he
might try to harm himself.
69. The officer explained that he is generally based on the 4s landing of the Onslow
Centre, and so is able to get to know prisoners with cells there a little better. He
said he had “quite a lot” of contact with the man, who he described as “very, very
quiet”, hardly leaving his cell. The officer agreed that such prisoners raise
concerns for staff and that he tends to work harder to get to know them as a
result. The officer tried to persuade him to come out of his cell more and mix
with others on the unit. However, he would tell him that he preferred to read or
watch television in his cell. The officer described him as seeming quite “cheerful”
about this and said that some prisoners prefer not to mix on the wing. He knew
that it was his first time in prison and that he was nervous, but also that he was
being supported by his cellmate.
70. The man’s mother and partner visited him on 8 August. An entry in the ACCT
ongoing record notes that, as a result, he was in “good spirits”. Two days later,
he had an appointment with the doctor to assess his eczema. The medical
record notes that he had a “dry rash” over his body, but there was no sign of
infection. He was prescribed cream to apply as necessary, which he kept in his
cell.
71. At 9.15am on 11 August, the man attended another ACCT case review. This
time, the review was chaired by a different SO, with another Onslow Centre
officer and a member of staff from the interventions team present. Unfortunately,
despite investigations, the third attendee was only identified as the draft report
was being issued and so has not been interviewed. Once more, the man was
assessed as posing a low risk to himself. He told the staff that he was happy on
the Onslow Centre and was settling in well. He said he was not as anxious and
worried as he had been. The SO chairing the review noted that he was waiting
for a response from the Activities department about work and that he would
pursue this. The SO described him as “calm and relaxed” during the review. He
said he wanted to come off the ACCT and that he would approach staff if he
needed any help or advice. All present agreed that the ACCT should be closed.
72. The SO chairing the review had not been involved in the man’s ACCT previously,
but knew why the ACCT had been opened and why staff were concerned about
him. He explained in interview that, when conducting a case review, he
generally starts from the beginning of the document checking the progress made
22
and any continuing areas of concern. He also checks the wing observation book
and the prisoner’s file for further information.
73. The SO explained that, over time, staff had seen an improvement in the man’s
frame of mind and demeanour. As an example, they noticed he had begun
taking more care of his appearance and shaved regularly. (The man’s partner
explained however that, on arriving at Wandsworth, he had spoken to prisoners
who offered haircuts to other prisoners and was told that he would have to pay
them with cigarettes. She said that, because of his anxiety and inability to ask
for help, he had not pursued this. Eventually, he bought hair clippers from the
prison shop and was then able to shave his own head.) Staff thought he seemed
much more cheerful in his interactions with them. They also noticed he was
coming out of his cell more and appeared to be more relaxed. (A number of staff
interviewed during the investigation noted this apparent change in him and felt
reassured that he had settled into life at the prison.)
74. Although the man had told the staff that he would like the ACCT closed, the SO
chairing the review explained that it would only be closed if all the staff present
agreed. The SO said that he, the officer and the third member of staff agreed
that the ACCT could be closed. The man was told, however, that staff would
continue to monitor him.
75. The officer who attended the review was also interviewed during the
investigation. He is normally based on the 4s landing on the Onslow Centre.
The officer explained that he had checked the man every day when he first
arrived at Wandsworth. He described him as looking “dishevelled” at first, which
he said could sometimes be an indication that the prisoner was more vulnerable.
The officer agreed that the man preferred to stay in his cell but said that was not
uncommon on the unit. However, he thought that he had preferred not to mix
with other prisoners due to anxiety. The officer tried to engage him in
conversation and encourage him to get involved with activities on the wing
because he wanted to “see him progress”.
76. The officer was asked about the decision to close the ACCT and explained:
“ … it was during, I’d say, the last ten days or so that he had started to come
out of his shell a bit and he was taking care of himself. He’d had a shave, he
was going for showers regularly and I saw him out and about, not really
talking to anyone but out and about, and I thought OK I think we’re getting
somewhere now, the ball’s rolling. And he was quite communicative in the
actual review itself and gave no indication of any real major concern that he
needed to be on this. It was almost, I mean I’ve been to loads of ACCT
reviews before and it went along the same lines as most of the ACCTs that
we’ve closed previously. He gave me no reason to think there was any
difference with this one. I thought he’d turned a corner and was sort of
settling into prison life … “
77. The SO chairing the review wrote on the ACCT document that it had been closed
and that a post-closure review should be held on 17 August. (The post-closure
review allows staff to reassess whether the ACCT should remain closed, and to
23
check whether there are any further concerns about the prisoner’s state of mind
or risk to himself.) It appears that no post-closure review of the man’s ACCT
document took place.
78. The man attended his first Crisis counselling session on 20 August (three weeks
after his assessment interview). He and the psychologist talked about his family
background, his history of low self-esteem and harming himself. By this point,
she thought his mood had “picked up” and was “quite different” to how he
seemed during the assessment. His second counselling session took place
seven days later. Again, they discussed his low self-esteem and lack of
confidence. He described himself as “quiet” and “odd”. He explained that he
tended to avoid social situations and said that, on the wing, he found it hard to
get staff attention. He told her that he found it particularly difficult to interact with
people in authority. In interview, she explained that she was working on this with
him during their sessions. She thought his anxiety would not have stopped him
seeking staff assistance if he had really needed it.
79. On 26 August, the man was assessed as suitable to work as a wing cleaner. He
was placed on a waiting list until a vacancy arose (which had not happened
before his death). At the draft report stage, staff confirmed that the only
application for work received from him was for the cleaning role.
80. Another of the man’s personal officers wrote in the man’s prison file on 2
September, noting that he was a “quiet” prisoner who kept to himself but said he
had no problems. He told the officer that he got on well with his fellow prisoners
and had “no concerns at present”. This was the last entry made in his prison file.
The third personal officer made no entries.
81. The personal officer who made the entry on 2 September was interviewed as
part of the investigation. He explained that he was the personal officer to about
20 prisoners who he tried to talk to every time he was on duty. The officer was
not aware that the man had tried to kill himself while at Pentonville, but did know
he was on an ACCT for some time. He told the investigator that he had no
concerns that he might try to harm himself.
82. The third Crisis counselling session took place on 3 September. The man talked
more about his feelings of failure and of being “odd”. He said he had had a
“mixed week with some ups and downs”. He was “feeling anxious” about his
court appearance the following week but was not sure whether it would go
ahead. (His court appearance scheduled for 8 September was adjourned until 6
October.) The psychologist wrote that he had applied for bail and was waiting to
hear the outcome.
83. The psychologist and the man met for the fourth time on 10 September. He told
her that his court case had been adjourned and that he was pleased as he had
been feeling anxious about it. He said he now felt more comfortable being in
prison.
84. Around 16 September, there was an outbreak of salmonella in the prison. As a
result, all visits to prisoners were cancelled. The man’s criminal defence solicitor
24
had arranged for a psychiatrist to visit and assess the man’s mental health. This
visit, and other visits by the solicitor and the man’s family, did not take place.
85. On 17 September, the man’s cellmate approached the SO who chaired the
ACCT review on 28 July, telling him that the man was “feeling down and was
tearful”. In interview, the SO said he went to speak to him “there and then”. The
SO recorded his conversation with him in a statement he made following his
death. He wrote that the man had seemed “withdrawn and thoughtful”, so the
SO sat down with him and asked how he was feeling. In interview, he
remembered that the man had also been tearful.
86. The man said he was “fine but wanted to keep himself to himself”. The SO told
the investigator that the man was “not forthcoming” despite his attempts to
encourage conversation. After a while, he stopped crying and seemed to
“brighten up” a little. The SO explained he had
“ … got him to promise me that if he needed help and he was in a really bad
way, that he couldn’t be on his own or wanted something done, to come and
find me out. I told him where my office was.”
87. The SO did not record his conversation with the man in either the wing
observation book or his prison file. In interview, he explained that prisoners were
quite often tearful and subdued, so his demeanour was not out of the ordinary.
In hindsight, he said there were steps he could have taken following their
conversation. He knew the ACCT had been closed, that his mood seemed to
have improved and that staff had no particular concerns about him. The SO was
asked whether he thought of re-opening an ACCT following their conversation.
He said he had considered it but, at the time, did not feel it necessary. The
following day, the cellmate thanked him for speaking to the man and reported
that he seemed to be “in better spirits”.
88. The man had his fifth counselling session on 28 September. The psychologist
told the investigator that there was a two week gap between the fourth and fifth
sessions due to the outbreak of salmonella and external training she had to
attend. They discussed his upcoming court appearance on 6 October. He told
the counsellor that his partner had not been able to visit due to the outbreak and
that this had made him depressed.
89. They went on to talk about his meeting with his criminal defence solicitors on 25
September. The man’s usual solicitor was on leave and a colleague visited in his
place. During that visit, the solicitor had discussed the victim impact report (a
statement by the victim, detailing how they have been affected by the alleged
offence) with the man. He reiterated his concerns to the psychologist that
people, including his solicitor, thought him “odd” and “a failure” because he had
done something “bad”. She encouraged him to recognise that other people,
including his partner, family and friends thought he was “okay”. She recorded in
her notes of the meeting that he had torn up the “thought record” she had
encouraged him to complete previously, because he had been feeling angry.
25
90. In interview, the psychologist said she had never had concerns that the man
might harm himself. Although he told her he had torn up the thought record, she
did not think that this marked a significant change in his demeanour. She was
clear that, had she had any concerns about him, she would not have hesitated to
open an ACCT document and speak to staff on the Onslow Centre.
91. The man’s solicitor visited him on 29 September. During the meeting, he told
him that he had arranged for him to undergo a psychiatric assessment at court
on 2 October. The solicitor, who spoke to the investigator by telephone, said that
the man had become increasingly anxious as his trial approached (it was listed to
begin on 21 October). He knew that if he was found guilty, he might receive a
lengthy prison sentence. The solicitor said he had never had concerns that the
man might harm himself whilst in prison, although there were concerns about his
mental health. He did not know that he had attempted suicide at Pentonville and,
when told by the investigator, was shocked, both by the man’s actions and that
he had not been told. He said that, had he known, he would have dealt with his
case differently.
1 October
92. By all accounts, 1 October was an unremarkable day on the Onslow Centre. No
staff interviewed recalled having any particular contact with the man and certainly
none remembered being concerned about him. The cellmate did not see him
much during the day as he left in the morning to undertake cleaning duties. He
returned to their cell at about 4.15pm, but then had a visit that ended at about
5.30pm. The man was in the cell leafing through a book. His cellmate asked
him if he was alright, at which point he began to cry. He told him he was upset
about his court case and said he had to see a psychiatrist at court the following
day. The cellmate told the investigator that the man had not wanted to talk about
what was upsetting him and so he had not pursued it. (After his death, the
cellmate told a governor that, over the previous two weeks, the man had been
“bothered” by his case and had seemed “suicidal”. In interview, the cellmate did
not mention raising any further concerns about him after 17 September.)
93. At 6.30pm, certain prisoners, including the man’s cellmate, were unlocked to
work around the unit. The man was not one of the prisoners unlocked and so he
remained in his cell. At 7.40pm, staff called for the prisoners to return to their
cells to be locked in for the night.
94. An Onslow Centre officer was responsible for locking up the prisoners on G4
landing. He and the man’s cellmate walked to cell G4-06 and, on arriving, the
officer unlocked and tried to open the cell door. It would only open “very slightly”,
even when the officer used force. Through the crack in the door, he saw that
one of the bed frames was blocking the door. He looked through the observation
panel but could see “very little”. The officer called to the man to move the bed
but got no response. For a short time, he continued to try to open the door by
pushing against it, to no avail.
95. At this point, the officer called for assistance from colleagues. Another officer,
who was locking up prisoners on the landing below, came to help. He also tried
26
to open the door, calling to the man at the same time. The cell light was off and
the curtains were drawn, so the cell was dark. By this time, two more officers
and an SO on duty had arrived to help. The officers realised that the two single
beds in the cell had been used to barricade the door. The SO called for the on
duty principal officer (PO) (who had the role of Orderly Officer and was in charge
of the prison at the time). The PO arrived and decided to use a “door enforcer”
to try to force the door open. However, before this could happen, one of the
officers managed to move the beds enough to open the door.
96. The officer who opened the door and the PO went into the cell and saw that the
decency curtain (which allows prisoners some privacy when using the toilet at
the back of the cell and is almost floor to ceiling length) was pulled across. The
officer found the man behind the curtain, hanging from the cell window bars with
a ligature made from a bed sheet tied around his neck.
97. The PO directed the officer to use his anti-ligature knife (which is specially
designed to safely cut ligatures from around a person’s neck) to cut the ligature.
The two officers laid the man on the floor and the officer began cardio-pulmonary
resuscitation (CPR). As there was blood coming from his mouth, the officers
used chest compressions only. The PO asked another member of staff to fetch a
hard plastic mouth shield (used to deliver mouth to mouth resuscitation) from the
wing office. Both the PO and the officer had recently received refresher first aid
training (in fact, the PO is a trained first aid instructor) and felt confident about
beginning CPR.
98. At 7.51pm (the approximate time when the officers managed to open the man’s
cell door), the PO used his radio to alert the prison to a ‘code 1’ medical
emergency and ask that the on-duty emergency response member of healthcare
staff attend. (A ‘code 1’ call indicates that a prisoner has been found hanging.
The use of the code system allows medical staff to bring the right equipment to
the incident.) The control room requested an ambulance at 7.55pm.
99. One of the nurses on duty, who was delivering medication to prisoners on the
Onslow Centre, arrived quickly with emergency medical equipment and joined in
the efforts to resuscitate the man. While the nurse maintained a clear airway,
one officer used an ambu bag (a hand held device which pumps oxygen to the
patient) to deliver breaths while the other delivered chest compressions. Shortly
afterwards, another nurse (the on-duty emergency response nurse), who was
delivering medication on the main prison wings, also arrived. She went to the
Onslow Centre treatment room and collected oxygen and a defibrillator (a
machine that reads whether there is any electrical output from the heart and can
deliver an electric shock to help restart the heart in certain circumstances). The
defibrillator found no shockable rhythm and instructed staff to continue with CPR.
100. The first paramedic arrived at the prison at 8.01pm. At this point, the PO also
asked for the doctor based in reception to attend. The paramedic reached the
man’s cell and asked staff to continue resuscitation attempts while he assessed
his condition. As the doctor had not yet arrived, a second radio call was made at
8.10pm. The doctor reached the cell at 8.12pm.
27
101. The Helicopter Emergency Medical Service (HEMS, the air ambulance) arrived
at the prison at 8.19pm. The paramedics, including an emergency response
doctor, took over care of the man and the PO and the officer left the cell. The
paramedics administered drugs to try to revive him and the incident log indicates
that medical staff managed to restore his heartbeat for a very short time
(probably as a result of the drugs they gave him). However, at 8.29pm, the
HEMS doctor pronounced that he had died.
Contact with the man’s family
102. A governor and a member of the chaplaincy team were allocated as family
liaison officers. They broke the news of the man’s death to his nominated next of
kin, his partner, that night.
103. The prison made an offer of financial support to assist with the cost of the man’s
funeral. His family were offered, and accepted, the opportunity to visit
Wandsworth, see his cell and meet his cellmate.
Support for prisoners
104. In interview, the SO who was present when the man was found explained that,
as staff and paramedics worked to resuscitate the man, he instructed other staff
to return all prisoners who had been unlocked for cleaning duties to their cells.
Prisoners who knew what had happened and were upset were offered the
services of Listeners and the Samaritans’ telephone.
105. The cellmate said that, on finding their cell door barricaded, he knew that the
man had made another attempt on his life. He was initially taken to the Listener
suite (a room designed for use by Listeners and prisoners using their services,
which is usually equipped with comfortable seats) and was supported by two
fellow prisoners. He said he was upset and shocked by the man’s actions.
Later, having been interviewed by the police, he was moved to share a cell with a
prisoner who he did not know. Following the man’s death, he was placed on an
ACCT. He told the investigator that he had been very well supported by wing
staff, who checked him regularly over the coming weeks.
106. Prisoners across Wandsworth were informed of the man’s death by way of a
notice from the Governor. A memorial service was arranged.
Support for staff
107. The SO present when the man was found led a ‘hot debrief’ shortly after the
man’s death. (A hot debrief is when staff involved in an incident are brought
together to talk about what happened and how they feel. It is a requirement of
Prison Service Order 2710 Follow up to deaths in custody.)
108. All staff interviewed as part of this investigation said they had been well
supported by their colleagues and senior managers in the aftermath of the man’s
death. This included those staff who had contact with him during his time at the
28
prison but were not present on 1 October. The prison Care Team contacted staff
who responded to the emergency.
29
ISSUES
Clinical care
109. Wandsworth PCT commissioned a clinical reviewer to review the clinical care the
man received in prison. His review highlighted that, following his suicide attempt
at Pentonville on 9 July, he was referred to the MHIT. The ACCT assessor
completed the referral form on 11 July but it was not processed by the team until
20 July, by which time he had been transferred to Wandsworth. The Head of
Healthcare explained that referrals to the MHIT are currently made via a paper
referral form, which must be placed in a box for processing by the team, who do
so twice a day. It has not been possible to establish why it took six working days
for the man’s referral to be processed.
110. The Head of Healthcare told the investigator that he was considering introducing
an electronic referral in addition to the paper form, to safeguard against referrals
going missing or being overlooked. I wholly support any changes which would
make the current system more robust, and, given that steps are being taken to
address the problem, make no formal recommendation in my report.
111. When completing the referral form, the ACCT assessor indicated that the man
should be assessed by the MHIT within one week of referral (the other options
being within 24/72 hours, or more than one week). The Head of Healthcare
indicated that he expected all staff, whether discipline or healthcare, to make an
urgent referral where a prisoner has made a serious attempt to harm himself.
The Governor and head of healthcare at HMP Pentonville should remind all
staff that, when a prisoner makes a serious attempt to harm himself, an
urgent referral to the MHIT should be made.
112. When the man transferred to Wandsworth, the open ACCT document
accompanied him. On his arrival, staff were aware that he had attempted suicide
the previous week. The doctor who examined him in reception referred him to
Wandsworth’s MHIT for assessment. On 28 July, the psychiatric nurse
conducted an informal mental health assessment with him, to consider whether
he needed further input from the MHIT or other specialist services. The clinical
reviewer concludes that, given the man had attempted suicide, it would have
been appropriate to carry out a formal mental health assessment, following a
recognised framework.
The head of healthcare should ensure that all prisoners who make a serious
attempt to self harm undergo a formal mental health assessment as a
matter of urgency.
Missing documentation
113. It is disappointing that two important pieces of documentation (the man’s
Pentonville prison file and the wing observation book for the Onslow Centre
covering his early weeks on the centre) could not be located during the course of
30
the investigation. Neither was found despite searches at both prisons. We share
the family’s concern that important documentation was able to go missing.
The personal officer scheme
114. On being allocated cell G4.06 on the Onslow Centre, the man was given three
personal officers. Wandsworth has a local personal officer scheme policy dated
March 2009. According to the policy, personal officers are expected to have a
“formal” conversation with their prisoners at least once a week, and to record this
in the prisoner’s file. The policy directs that particular reference be made to the
prisoner’s “… attitude and behaviour … willingness to help or mix with other
prisoners … any current concerns either in prison or in the community”. Informal
conversations should take place “whenever on duty”. If a prisoner is on an
ACCT, his personal officers are expected to speak to him “every day that [they]
are on duty, recording this in the ACCT document” (the text is in bold in the
policy). Personal officers also “must attend or make a contribution to [the
prisoner’s] ACCT case reviews”.
115. The man remained in the same cell from the day he arrived at Wandsworth, 16
July, until his death. However, his file contains just two personal officer entries
(by two of the three officers). One of the personal officers made three entries in
the man’s ACCT and the other two officers made none. None of the three
officers attended or made a recorded contribution to any of his ACCT case
reviews.
116. My investigation also highlights that senior and principal officers responsible for
G4 landing on the Onslow Centre were not fulfilling the requirements of the local
policy. The policy instructs that senior officers “will check and sign all wing files
monthly to ensure that personal officers are completing their weekly wing history
file checks … “. Principal officers are also expected to carry out monthly “quality
checks” and sign accordingly. The lack of entries in the man’s file was
highlighted to the SO who carried out the ACCT review on 28 July, the senior
officer responsible for G4 and the failings were also raised with the Deputy
Governor and governing Governor following staff interviews.
117. In the most recent inspection by HMCIP, the personal officer scheme at
Wandsworth, and particularly the allocation of three personal officers to each
prisoner on the Onslow Centre, was criticised and recommendations made.
When the draft version of this report was issued, no changes had yet been made
to the scheme in the light of HMCIP’s criticism. Given that this investigation has
also identified major failings, I urge the Governor to give proper consideration to
the effectiveness of the existing scheme.
The Governor should remind all staff of the local personal officer scheme
and satisfy himself that it is operating effectively across the prison.
31
Assessing and managing the man’s risk to himself
118. An ACCT document was opened by staff at Pentonville on 11 July following the
man’s admission that he had tried to hang himself. Staff at both Pentonville and
Wandsworth described him as a quiet and anxious man, who preferred to stay in
his cell and only seemed comfortable socialising with his cellmate. I am pleased
to find that, despite deficiencies with the personal officer scheme at Wandsworth,
other staff on the Onslow Centre took time to try to get to know him. Several
mentioned encouraging him to come out of his cell and get involved in activities
on the centre. They explained, however, that it is not unusual for prisoners to
prefer spending time in their cells, particularly when it is their first experience of
prison.
119. Staff knew that the man got on well with his cellmate, and received much support
from him. He was attending IT classes and his application to work was being
processed at the time of his death. The Crisis counsellor was working with him
to combat his low self-confidence and self-esteem. In time, this work might have
helped him feel more confident about mixing with other prisoners on the Onslow
Centre. Having considered the above, I do not think staff could reasonably have
done more to lessen his isolation.
120. On 11 August, staff present at the ACCT review agreed that the risk the man
posed to himself was sufficiently reduced to close the ACCT. Staff interviewed
for this investigation agreed that, in the weeks prior to the ACCT being closed,
his mood appeared to have improved. He seemed more cheerful, appeared to
be mixing more readily with other prisoners and was taking better care of himself.
The goals on his Caremap had been or were continuing to be addressed. I am
satisfied, therefore, that the decision to close the ACCT was reasonable.
121. The man’s partner expressed concern about the way his ACCT document was
closed. The man said that, during the final case review, a member of staff told
him that, if he attempted to kill himself or seriously hurt himself again, it would
cause them “hassle and paperwork”. She said he felt that staff did not really care
about him, or about keeping him safe. She thought he would have told staff he
was coping, although he was not, because he did not want another ACCT to be
opened. Evidently, staff must make decisions based on the information available
to them, much of which will come from the prisoner himself. As noted above, I
find the decision to close the ACCT was appropriate based on the information
available.
122. However, mandatory guidance contained in Prison Service Order 2700 on
Suicide prevention and self harm management, instructs that a post-closure
review be held after the ACCT has been closed, and that unit managers ensure
one takes place. The SO chairing the review on 11 August noted on the ACCT
document that the post-closure review would take place on 18 August. No post-
closure review was held with the man. It appears there is no robust system for
logging post-closure review dates and ensuring that they take place. It is
disappointing to note that the Ombudsman made a similar recommendation
about this in 2007.
32
The Governor should strengthen the system for logging post-closure review
dates and checking that they take place.
123. Consideration of the man’s ACCT document also highlighted that senior officers
and duty governors did not act in accordance with Wandsworth’s local suicide
prevention policy (dated September 2009 and updated annually). The policy
directs that senior officers must check ACCT documents every day and record a
comment. There are two clear senior officer management check entries in the
ongoing record. The management quality assurance sheet, at the front of his
file, shows that a senior officer checked the document on 15 of 24 days his
ACCT was open at Wandsworth. Only four checks took place in August. Two
checks were undertaken by a member of the senior management team, once on
28 July and once on 7 August. According to the local policy, members of the
team should also check all ACCT documents every week.
The Governor should remind staff of all grades of their responsibilities
under the suicide prevention policy to check ACCT documents.
124. On 17 September, after the ACCT had been closed, the man’s cellmate became
concerned about him. The cellmate told the SO who conducted the review on 28
July that the man was feeling down and tearful. The SO went to see him and
spent time talking to him. Following their conversation, the SO believed that his
mood had improved. He told the investigator that he considered opening an
ACCT but concluded that it was not necessary. I am pleased that the SO took
the cellmate’s concerns seriously and took time to speak to the man. Whether or
not to open an ACCT in such situations is clearly a matter of judgement for staff.
They must use their judgement to differentiate between prisoners who are
experiencing a short term, but nonetheless distressing, period of anxiety or upset
and those whose mood poses a serious risk. On the basis of the available
evidence, I think the decision not to place him on an ACCT that day was
understandable.
125. In interview, the SO said he decided not to record the cellmate’s concerns, or the
nature of his conversation with the man in either the wing observation book or his
prison file. He explained that this was, again, a matter of judgement. I think it
would have been sensible for the SO to have made a written record of his
contact with him. Undoubtedly, gathering together such pieces of information
helps staff to understand the prisoners they look after and identify changes in
their mood or behaviour which might signal increased vulnerability. I have
already raised concerns about the frequency of staff entries in the man’s prison
file. However, the investigator had sight of the Onslow Centre’s wing observation
book covering the period around and including 17 September. Generally, unit
staff make appropriate entries and several concerned similar contacts with
prisoners. On that basis, I make no formal recommendation.
126. In the weeks before his death, the man continued to attend IT classes, had
several sessions with the counsellor, was visited by his family and partner and
his criminal defence solicitor. No specific concerns about him were raised or
communicated to staff on the Onslow Centre. Staff on the centre who spent time
33
with him said they noticed no worrying changes in his demeanour and did not
think his vulnerability had increased. After his death, his cellmate told a member
of staff that he had seemed “suicidal” in the weeks before his death. The
cellmate did not, it seems, tell staff about these concerns.
127. As noted earlier, the man was due to attend the crown court on 2 October, for a
psychiatric assessment. Staff were asked in interview whether they are normally
told when prisoners have upcoming court dates. They confirmed that a list is
produced every day with the names of prisoners due to attend court the following
day. This ensures that the correct prisoners are woken and unlocked in time to
be collected by the escort service. However, they said that the current system
does not allow staff to offer increased support or additional monitoring in the
days preceding a court appearance. In the man’s case, the progress of his court
case had been identified as a source of anxiety in his ACCT document.
128. It is my view that, on the basis of the man’s behaviour and demeanour in the
weeks and day prior to his death, his actions could not have been predicted or
prevented by staff. However, I would urge the Governor to consider how staff
may be made aware of court appearances which are identified as triggers to self
harm.
Emergency response
129. Staff returning the cellmate to his cell at 7.40pm found that the cell door had
been barricaded by the two bed frames. After some minutes spent trying to open
the cell door, an officer was successful and he and the PO went into the cell.
They found the man hanging, cut the ligature and quickly began cardio
pulmonary resuscitation. Both members of staff were well qualified to attempt
CPR and I am pleased to find that they did so efficiently. Nursing staff arrived at
the cell within minutes and assisted with attempts to resuscitate him. Ambulance
staff arrived within 11 minutes of the emergency call and the HEMS team arrived
within half an hour. I am satisfied that extensive attempts, although sadly
unsuccessful, were made to resuscitate him.
Family concerns
130. During the course of the investigation, the man’s parents and partner raised a
number of concerns and questions about the circumstances of his death. I hope
that the majority of those questions have already been answered in my report.
They also asked what proportion of prisoners’ outgoing mail is screened by
prison staff. At Wandsworth, about 25 percent of both incoming and outgoing
mail is screened, on a random basis. There is no indication that the man’s mail
was screened, or that there was any particular reason to do so.
131. The man also told his partner that, during an interview with the officer who
conducted the LISSART shortly after he arrived at Wandsworth, the officer said
the man might be facing a life sentence, causing him great distress. At the draft
report stage, the investigator spoke to the officer by telephone. The officer
denied having told him he might be facing a life sentence. She said that it would
be very dangerous for staff to make such a comment as it might increase a
34
prisoner’s vulnerability. Quite clearly, staff are not in a position to, and should
not be, advising prisoners of the sort of sentence they might receive if found
guilty.
132. Due to concerns about the man’s mental health at the time of the alleged
offence, his criminal defence solicitor arranged for a psychiatrist to visit him at
Wandsworth and carry out a mental health assessment. The man’s partner was
concerned that the prison obstructed that visit, prevented the psychiatrist from
assessing him and caused him additional distress. The solicitor was asked
about this and said that the visit had been planned but it fell during the
salmonella outbreak. During that time, the prison cancelled all visits, both legal
and domestic, for all prisoners. Once visits had resumed, the psychiatrist tried to
rearrange the appointment but due to the backlog of legal visits and his prior
commitments, could not. As a result, the solicitor arranged for him to be
produced at court on 2 October for the psychiatrist to assess him there. The
solicitor confirmed that the prison had not objected to the psychiatrist visiting or
otherwise obstructed the visit.
133. The man’s partner was also concerned that he was not told why visits had been
cancelled during the salmonella outbreak. As a result, she said that when his
solicitor did not arrive for a scheduled visit, he became anxious and thought that
the solicitor did not care about his case. I understand that between 16 and 19
September, four Prisoner Information Notices (PINs) were produced and
distributed to all prisoners at Wandsworth. The notices informed prisoners of the
sickness outbreak and the resultant changes to the regime – including the
cancellation of all visits. Prisoners were told that visits had been reinstated on 19
September. I have been unable to find out whether he would have read the
notices.
134. The man’s family remain very concerned about the level of care afforded to him
while in prison. In particular, they raised concerns about:
(cid:127) How the ACCT process was managed and risk assessments made
(cid:127) Staff failing to record important information in the relevant documents
(cid:127) How staff interacted with him on a day to day basis and assessed his risk to
himself
(cid:127) The apparent failure of the Personal Officer scheme
(cid:127) The fact that his mental health was not assessed at Pentonville
(cid:127) Wandsworth’s failure to act on earlier recommendations made by HM Chief
Inspector of Prisons and the Prisons and Probation Ombudsman
The family urge the Governor to ensure that existing policies are followed
carefully and recommendations made are acted upon to prevent further deaths in
the prison. They believe that, had the proper procedures been followed, the
man’s death might have been prevented.
35
CONCLUSION
135. The man was remanded into custody on 6 July having been charged with a
serious offence. He had never been in prison before. Within days of his arrival,
he attempted to hang himself and, as a result was placed on the ACCT suicide
and self harm monitoring procedures. He remained on ACCT when he
transferred to Wandsworth on 16 July.
136. Staff working with the man found him to be a very quiet prisoner who spent a
great deal of time alone in his cell. He did not mix much with other prisoners,
except his cellmate who he appears to have got on well with. He told staff that
he suffered with depression and anxiety. He said he felt guilty about what he
had done and ashamed for letting his friends and family down.
137. However, over time, staff believed he had settled into life in prison and noticed
positive changes in his demeanour. The ACCT was closed in mid-August and
staff had no further concerns that he might harm himself after that date. On 1
October, he was found hanging in his cell and attempts to resuscitate him were,
sadly, unsuccessful. I make five recommendations, none of which, I think would
have prevented his death.
36
RECOMMENDATIONS
At the draft report stage, the Prison Service responded to the recommendations
made. The response to each recommendation is provided below.
To HMP Pentonville:
1. The Governor and head of healthcare at HMP Pentonville should remind all staff
that, when a prisoner makes a serious attempt to harm himself, an urgent referral
to the MHIT should be made.
This recommendation has been accepted. The Mental Health In Reach Team
(MHIT) eligibility criteria clearly states that any incidents of serious self harm will
be referred to the team for a mental state examination. All staff will be reminded
of this via staff briefings and as part of training delivered on a rolling basis by the
Safer Custody Manager about caring for prisoners at risk.
To HMP Wandsworth:
2. The head of healthcare should ensure that all prisoners who make a serious
attempt to self harm undergo a formal mental health assessment as a matter of
urgency.
This recommendation has been accepted. In partnership with the PCT will
develop clear guidelines and procedures.
3. The Governor should remind all staff of the local personal officer scheme and
satisfy himself that it is operating effectively across the prison.
This recommendation has been partially accepted. We are aware that the
personal officer scheme is not currently working effectively across all wings. This
has been an ongoing issue due to the fluid nature of our population and the
volume of movements of prisoners across areas. Also, the personal officer work
does not currently have any specific staff time profiled.
There will be some upcoming changes which are likely to impact this:
1. We are due to start a full re-profiling of officer’s roles.
2. P Nomis has just been introduced in Wandsworth, which is likely to have
some impact it terms of ownership and recording of personal officer entries.
When both changes are embedded, we will then conduct a review of the personal
officer scheme.
4. The Governor should strengthen the system for logging post-closure review dates
and checking that they take place.
This recommendation has been accepted. In January 2010, the ACCT document
in Wandsworth was updated to include a post-closure review sheet. Post-closure
ACCTs will be kept as live documents in which one daily summary will be
37
recorded until the post-closure review is held and the ACCT document is formally
closed.
5. The Governor should remind staff of all grades of their responsibilities under the
suicide prevention policy to check ACCT documents.
This recommendation has been accepted. In January, 2010, the ACCT
document in Wandsworth was updated. This included a specific section for
management checks with guidelines.
(cid:127) Management check guidance will be adapted to focus on main concerns that
continue to be highlighted.
(cid:127) Previously the Duty Governor was responsible for conducting weekly
management checks of ACCT forms. However, weekly checks would be more
suitably conducted by the unit manager of that area so that the can follow up
on whether the points raised have been dealt with.
(cid:127) An operational E grade manager will carry out a 10% quality check on a
weekly basis and raise issues directly with the unit manager and SMT where
required.
(cid:127) Safer prisons team will continue to produce a daily list of ACCT documents,
highlighting points that need to be actioned. Further in-depth checks will be
conducted on each wing to assess the general quality of ACCTs in that area
and feedback any ongoing concerns into the safer prisons meetings
A Governor’s order will be published to explain responsibilities in terms of
management checks.
38