Individual at Ozanam House

Investigation into the circumstances surrounding the
death of a man whilst a resident at Ozanam House
Approved Premises in Northumbria Probation Trust in
December 2009
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2010
This is the report of an investigation into the death of a man. He was found hanging
in woods in County Durham, in December 2009. At the time of his death he had
been reported missing from Ozanam House Approved Premises in Newcastle,
having broken the conditions of his licence, and procedures to recall him to prison
had been put in place. The man had been released from prison just five days before
his death. He was 45 years of age.
I extend my condolences and those of my colleagues to the man’s family. I hope
that my report goes some way to answering their questions.
The investigation was carried out on behalf of the Ombudsman by one of her
investigators. I would also like to take this opportunity to thank all of the staff at
Ozanam House and in particular the manager for their cooperation during the
investigation. This is the first apparently self inflicted death of an Ozanam House
resident since the Ombudsman started investigating such deaths in April 2004.
A clinical review was conducted by the clinical reviewer on behalf of the local
Primary Care Trust (PCT). The PCT is not obliged to carry out a clinical review
following deaths at approved premises and I am most grateful to him, whose review
is annexed to this report.
It is evident from the investigation that the man was a quiet man, who was affected
greatly by the loss of contact with his family. I have given much thought to his frame
of mind whilst he was in prison. He was supported by many members of staff and,
although he spoke of harming himself, I am satisfied that there was no need for
suicide monitoring to have been implemented. He suffered from depression
throughout his prison sentence he was remorseful about his offences and the way
that they had affected his family. My report concludes that staff who had contact
with him could not have reasonably foreseen his actions.
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 residents involved in my
investigation.
Jane Webb
Acting Prison and Probation Ombudsman August 2010
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CONTENTS
Summary
The Investigation Process
Ozanam House
Key Findings
Issues Considered
Conclusion
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SUMMARY
The man was remanded into custody at HMP Durham on 23 January 2009. Whilst
at the prison he was assessed by healthcare staff. He presented as low in mood
and emotional and was referred to the prison’s mental health in reach team. A
prison doctor prescribed mild antidepressants.
On 11 February 2009, the man was transferred to HMP Acklington. During his
induction at the prison, staff noted that although he appeared to be coping with
prison life, reference to his offending made him become emotional and upset. On 13
March, he was given a full mental health screening by one of the prison’s community
psychiatric nurses (CPN). The nurse observed that he was visibly tearful about the
loss of contact with his parents but concluded that no further mental health input was
required at that time.
Over the following months the man became more settled at Acklington. He denied
any thoughts of self harm but continued to feel depressed about the loss of contact
with his family. In August, he was seen by one of the prison’s doctors again after
saying that he was feeling much lower in mood. He had received a letter from his
parents advising him that they wanted no further contact with him.
On 1 September, a CPN completed a further mental health assessment on the man.
She suggested to him that he should take part in some cognitive behavioural
therapy, but he declined to participate. She continued to meet with him in a
supportive and monitoring role. During these meetings he expressed ongoing
worries about family matters.
As the man’s release date approached, arrangements were made for him to reside
at Ozanam House, an approved premises in Newcastle. He met with his offender
manager who would be monitoring him on his release from prison.
The man met the CPN for the last time on 27 November, when she provided him
with a letter for his GP which summarised his care. She noted that overall his
anxieties had reduced, that he was aware of coping strategies and knew how to
access help outside of prison. He was released on licence from Acklington to
Ozanam House on 7 December.
On arrival at Ozanam House, the man was given an induction. Over the following
days he met with his key worker, offender manager and other members of staff
whose job it was to monitor and provide support to him. On 8 December, he spent
the day with his girlfriend. The next day he registered with the local job centre and
local GP.
Later that day, at a meeting with his key worker, the man became upset about the
hurt he had caused to his victims and family. He remained low in mood but the key
worker noted that he expressed no intention of harming himself. Later that afternoon
he met his offender manager. In addition to discussing future targets and possible
employment, the offender manager had a brief discussion with him about his
parents’ request that he have no contact with them for the time being.
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On the morning of 11 December, the man told staff that he had felt unwell during the
night and had not slept well, asking if he could spend the day in bed. He left the
approved premises later that afternoon and he never returned.
When the man failed to return, breaking the requirements of his curfew, staff initiated
the process which would lead to his recall to prison custody. However, the following
day staff at the approved premises learned that he had been found, having
apparently taken his own life, in woods in County Durham.
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THE INVESTIGATION PROCESS
1. The investigation following the man’s death was carried out by one of the
Ombudsman’s investigators.
2. Notices announcing the investigation and its terms of reference were issued to
both staff and residents at Ozanam House. The notices were displayed around
the approved premises and invited staff and residents to contact the investigator
should they wish to do so. Although none of the residents came forward to
speak with the investigator, the approved premises manager did speak with
them shortly after the man’s death. I understand that other residents were
surprised and saddened by his apparent actions.
3. The investigator obtained documentation relating to the man’s time at Ozanam
House and visited the premises to conduct interviews with staff. During the
course of the investigation he provided verbal and written feedback to the
manager.
4. One of the Ombudsman’s family liaison officers contacted the man’s family to
discuss the purpose and scope of the investigation and to give them the
opportunity to raise any questions or concerns they had about his death. His
family asked whether he had settled in prison, what his attitude was like and
whether he showed any remorse for the things that he had done. I hope that this
report helps them to better understand what happened to him in the time leading
to his death.
5. The investigator spoke with a Detective Sergeant from Northumbria Police and
has been in contact with the coroner’s office. A copy of this report will be sent to
Her Majesty’s Coroner for Durham and Darlington, to assist him with his
enquiries. A copy will also be sent to the National Offender Management
Service, the organisation that oversees the Probation Service.
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OZANAM HOUSE
6. Ozanam House is an approved premises, formerly known as a probation and
bail hostel. The purpose of an approved premises is to provide an enhanced
level of residential supervision in the community, in a supportive and structured
living environment.
7. Ozanam House is located near the centre of Newcastle-upon-Tyne. It is
managed by a senior probation officer, who has overall responsibility for its
running. He is assisted by a deputy manager who is responsible for the day-to-
day management of residents. The frontline team is made up of three key
workers, one of whom works part time. There are ten support workers covering
evening and weekend shifts between them, as well as three night care workers.
8. The admissions policy at Ozanam House is based on an assessment of risk.
The residents profile is continually changing and the approved premises provide
resettlement to prolific lower risk offenders in addition to those who have
committed more serious or violent and dangerous offences. The majority of
residents are required to stay as a condition of a court order or prison licence.
9. Each resident is allocated a key worker. This member of staff acts as their
primary point of contact during their stay and assists them in sorting out practical
issues. Regular key work sessions also give residents the opportunity to discuss
their difficulties in depth. Although the sessions are not governed by a set
agenda, issues such as benefits, health and future accommodation are routinely
discussed. Residents at Ozanam House are all asked to register with a local
general practitioner (GP). Approved premises do not provide healthcare and a
resident’s medical treatment is a confidential matter between them and their
doctor.
10. Whilst at Ozanam House residents are required to pay rent and abide by the
rules and regulations which includes observing an overnight curfew. During the
day residents are free to go out unaccompanied, they are not required to tell
staff where they are going. Breakfast and dinner is provided to all residents.
11. Ozanam House has an established routine for inducting all new residents. The
induction is carried out by the member of staff who is on duty at the time a new
resident arrives. During the process residents are told about the local house
rules and their expected behaviour. Ozanam has a strict policy on alcohol and
drug use, the possession of which is strictly forbidden.
12. The man’s death was the first apparently self-inflicted death at Ozanam House
since the Ombudsman took on the responsibility for the investigation of deaths in
custody in April 2004. There have been two other deaths at the approved
premises since then, one due to apparent natural causes and the other to a
suspected overdose. There are no obvious similarities between those two
deaths and that of the man.
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KEY FINDINGS
13. The man was 45 years old at the time of his death. He had a history of minor
offences, including a conviction in 2008 for damage to property and disorderly
behaviour, and in 2004 a caution for battery. His last sentence was for a sexual
offence committed against a child. Appearing at Crown Court on 23 January
2009, he was sentenced to one year nine months imprisonment.
14. The man was received into prison custody at HMP Durham. During the
reception process a healthcare assessment was completed by healthcare staff.
It was noted that he had no previous history of suicide or of harming himself.
However, given the nature of his offence, that it was his first time in prison
custody and that he presented in an emotional state, a non urgent referral was
made for him to be reviewed by a member of the mental health in reach Team
(MHIRT) at the prison.
15. He was introduced to his personal officer at Durham on 5 February. The officer
explained prison life and the wing’s rules and regimes. He became tearful and
emotional as he explained to his personal officer that his parents were not
talking to him due to the nature of his offence. He said that he had not told them
anything about the charge or about his appearance at court, but that his
girlfriend had informed them. He said that people had made false allegations
against him.
16. One of the prison doctors at Durham saw the man after he complained of feeling
depressed. The doctor noted that he had been seeing his own GP due to
concerns surrounding his case and presented as being low in mood and
depressed. The doctor prescribed 15 mg of Mirtazapine, a mild antidepressant
which is used to improve the mood of people who are feeling low or depressed.
17. On 11 February, the man was transferred to HMP Acklington. At the time of his
transfer he had not been seen by members of the MHIRT at Durham. Staff at
Durham notified their colleagues at Acklington of the situation, requesting that a
new appointment be made for him. During his induction at Acklington staff noted
that although he appeared to be coping with prison life, reference to his offence
made him become emotional and upset. He was advised of the support systems
in place at the prison including the chaplain, Listeners and access to the
Samaritans. (Listeners are prisoners who have volunteered and have been
trained by the Samaritans to support prisoners who are in distress or crisis and
need to talk in confidence.)
18. On 16 February, the man was seen by another one of the prison’s doctors. The
doctor recorded in the medical record:
“Sleep pattern poor. Lying awake all night. Been in prison three weeks on 21
month sentence. First time in prison. Struggling. Family no longer want
anything to do with him. Worried about dog which has recently been his only
companion. Fleeting thoughts of self harm but no current plans. On snri
[Serotonin reuptake inhibitor – Mirtazapine, an antidepressant type
medication]. MHT [mental health team] review.”
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Later that day the man was registered with a member of the MHIRT.
19. The man was given a full mental health screening on 13 March, by a community
psychiatric nurse (CPN), from the MHIRT at Acklington. The nurse observed
that he was visibly tearful about his loss of parental contact and issues related to
his offence. He told the nurse that he was, “beating himself up” over negative
feelings and that these were having an effect upon his mood. She recorded that
he expressed no thoughts of self harm, but did have fleeting thoughts at times.
The nurse recorded that thinking about his family and dog prevented him from
carrying out such actions. She concluded that no further mental health input
was required at that time. He was again made aware of support services
available should he find himself struggling to cope or require them.
20. During the man’s first month at Acklington, staff at the prison wrote in his prison
records that he remained anxious and worried about his parents and dog. He
was especially concerned that his parents had not contacted him, despite him
writing to them. The prison chaplain reassured him that they probably needed
time to come to terms with the situation.
21. Over the summer months the man worked in the market gardens at Acklington.
He appeared to settle and was noted by staff as being a quiet prisoner who
complied with staff requests and wing routines. He received frequent visits from
his girlfriend. During this time he continued to tell staff that he was feeling down
because his parents were still not communicating with him. However, he hoped
to ‘turn things around’ when he was released four months later.
22. In August the man reported to healthcare that he was having problems. He was
struggling to cope and continued to suffer from depression. He denied any
thoughts of harming himself but again expressed concerns about his dog and
the fact that, despite writing to his parents, he had had no reply. On 18 August,
he was seen again by the second prison doctor. He noted that the man was
feeling much lower in mood, having recently received a letter from his parents
stating that they wanted no further contact with him. He felt he had nothing
further to live for and expressed thoughts of worthlessness, but said he had no
plans of suicide or of harming himself at that time. The doctor prescribed
Sertraline Hydrochloride, another anti-depressant medication used to treat the
symptoms of depression and anxiety, instead of the Mirtazapine that had
previously been prescribed. A further appointment was made for him to be seen
by the MHIRT at the prison.
23. A CPN, another member of the prison’s MHIRT, attempted to see the man on 26
August, but was unable to do so as he was receiving a visit. However, wing staff
reported that they had no concerns with regard to his presentation or behaviour
at that time. The CPN made a further attempt to speak with him on 28 August,
but was again unable to do so as he was at work.
24. On 1 September, the CPN carried out a further mental health review with the
man. He told the nurse that he was due to be released in December, and that
since his arrival at Acklington had gradually begun to feel worse. He explained
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that he had had no contact with his family since they learnt of his situation, and
worried about never seeing them again. During the assessment he denied
harming himself or having suicidal thoughts. However, he said that when
worrying he found himself repeating sentences in his head. The CPN planned a
further assessment and suggested that participation in some cognitive
behavioural therapy might be of benefit. She also arranged for some self help
information to be forwarded to him on the wing.
25. The second prison doctor saw the man on 3 September. He noted in the
medical record that he felt that his medication was making things worse. The
doctor advised him to continue with the medication for a further two weeks in
order to give it an opportunity to start working. On 8 September, the man was
seen again by the CPN. She noted that he was still depressed and there
appeared to be no change in his presentation. During the session he revealed a
little more of his family history and expressed that he might never get out of
prison. He said that he was experiencing feelings of guilt, blame and failure
which in turn prompted feelings of sadness, fear and worry.
26. On 23 September, the man’s personal officer wrote a report for a public
protection unit meeting held to prepare and plan for his release to an approved
premises in the community. He wrote that the man was a quiet prisoner who
was somewhat nervous and timid about his surroundings and had struggled to
cope on a few occasions. The personal officer added that he was always polite
and co-operative with staff and received regular visits from his girlfriend and
friends. However, since coming into custody, he had had no contact with his
family. The personal officer noted that when not working in the prison gardens
the man spent much of his time reading fishing magazines, which he said was
his main hobby outside prison.
27. At the public protection meeting on 24 September, preliminary preparations were
made for the man’s eventual release to an approved premises outside the
Sunderland area.
28. The CPN met with him again on 28 September. During their meeting he had
good eye contact and appeared more relaxed than before. Although the CPN
noted that he had decided not to participate in any cognitive behavioural therapy
at the time, she advised him that she would continue to see him in a supportive
and monitoring role.
29. On 12 October, the CPN met the man for a further review. During their meeting
he revealed his fear that his parents might have got rid of his dog and talked
about being punished by them for being in prison. Although he was tearful at
times, she reported that he denied any thoughts of harming himself. He told her
that he did not think the Sertraline Hydrochloride, which he had started five
weeks previously, was working and could not remember why he had been taken
off the Mirtazapine. She subsequently discussed his medication with the second
prison doctor and they decided that Mirtazapine would be re-prescribed as it
seemed to have helped him before.
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30. The offender manager met the man on 20 October to introduce himself as his
probation offender manager who would monitor him in the community on his
release from prison. He told the investigator that during the meeting the man
became tearful when talking about his offence. He said that he had been having
difficulty in coping with his time in prison, but was happy to talk openly about
aspects of his life. He said that the man was looking forward to his release and
hoped to continue further studies in horticulture or estate management and
overall appeared to be optimistic about the future.
31. On 22 October, the man was accepted by Ozanam House, pending a bed
becoming available, upon his release from prison.
32. The man saw the CPN again on 13 November. He told her that he had felt an
overall improvement since their last meeting and that he was to be released in
three weeks time to an approved premises. She discussed an onward referral to
the community mental health team on his release, but he stated that he was
happy to see his own general practitioner. She agreed that she would write a
summary letter to his GP and see him once again prior to his release.
33. The offender manager received telephone confirmation from Ozanam House on
17 November that a bed would be available for the man on 7 December.
34. In an e-mail of 19 November, from the Probation Victim Liaison Unit, the
offender manager was advised that the man’s parents had made it clear that
they did not wish to have any contact with him after his release from prison.
They hoped that he would respect their wishes, adding that they were happy to
return his dog should he wish it. (This information was not relayed to him at this
time.)
35. The man saw the CPN for the last time on 27 November. She noted that he was
bright and was looking forward to getting out of prison. He expressed some
anxiety with regard to his family’s reaction, but said he had support from his
girlfriend and friends. She handed him a letter summarising his care, which he
was to pass on to hostel staff or his GP. She wrote that overall his anxiety had
reduced. He was aware of coping strategies and how to access help outside
prison. He denied any thoughts of harming himself and said there were no
adverse side effects from his medication. He was discharged from the MHIRT’s
care.
36. On 7 December, the man was released from Acklington. His licence said that he
must reside at Ozanam House and report as and when required to the offender
manager, his offender manager. On his release from Acklington he made his
way directly to register with his local probation office, arriving around mid-
afternoon. From there he proceeded to Ozanam House.
37. Before his arrival at Ozanam House, the man’s key worker completed a Risk
Management Strategy. (The strategy highlights any concerns with regard to a
resident’s risk to staff, other residents, and themselves. Each week a meeting is
held at which risk factors are discussed further.) It was noted that, although
there were no mental or physical health concerns, he was at a medium risk of
11
harming himself, due to his release and the possibility of feeling low in his new
environment. The key worker noted on the assessment that checks should be
increased if staff became concerned about the man’s wellbeing.
38. At 5.45pm he was given an induction to the approved premises by a project
support worker. The rules and regime were explained to him and he was shown
to his room and issued with his medication. The project support worker noted
that the man appeared a little nervous but appeared to settle in well. A Resident
Information Form was also completed in which he provided his medication and
GP details and information about his next of kin, his mother. He left the
premises at around 7.00pm with a number of other residents, returning not long
after. In interview the project support worker told the investigator that the man
appeared quite shy and timid during the induction, but took an interest and
asked various questions. He said his initial reserve was understandable for
someone who had just been released from prison. When he interviewed him,
the project support worker said he had no concern with regard to his well being.
39. In the early hours of 8 December, one of the night care workers checked the
man in his room, reporting that there were no issues. The following morning he
left the approved premises early, returning at approximately 8.30pm.
40. The man’s offender manager visited him at Ozanam House at around 3.30pm for
a previously arranged appointment, but he was not there. The offender manager
was told by staff that the man had been informed about the appointment. He
rang the man leaving a message for him to contact him immediately. He called
the offender manager back shortly afterwards, informing him that he had spent
the day with his girlfriend and had not realised he had had an appointment,
saying that he had not been told by staff. The offender manager accepted the
confusion over the missed appointment but advised him that he would be given
a warning should the same thing happen again. During their conversation the
man said that that he was pleased to be out of prison and was looking forward to
continuing his education/training, possibly in estate/countryside management.
The offender manager arranged a further appointment for 18 December at
Ozanam House.
41. The man arrived back at the approved premises at 8.30pm. The project support
worker noted in his record that he spent most of the remainder of the evening in
his room and that no further issues were raised.
42. On 9 December, the man again left the approved premises, returning at around
9.15pm. Another project support worker observed that he had his supper and
took his medication at 9.25pm. She also noted that earlier in the day he had
registered with the local community GP and job centre. She told my investigator
that he was a quiet, well mannered resident who kept himself to himself. She
said that during her contact with him he gave no cause for concern and exhibited
no signs of harming himself or any suicidal ideation.
43. During his registration with the community GP, earlier in the day, the man was
seen by a GP. He recorded that the man had suffered from depression since
going into prison and been prescribed Mirtazapine. It was noted that he suffered
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from poor sleep and appetite and was very tearful and remorseful. However, the
GP thought that he was not suicidal. In his clinical review the clinical reviewer
says that there was no further contact with the man and a healthcare
professional and that there was no evidence to suggest that the CPN’s letter was
ever seen by the GP or a member of the community GP’s medical practice. The
GP made plans for him to be reviewed in early January 2010.
44. On the morning of 10 December, the man met again with his key worker. He
completed a self assessment form highlighting problems that he might face in
the community and addressing the likelihood or re-offending in the future.
During the meeting he confirmed that he had signed on at the local benefits
office. His key worker reminded him of the need to attend probation
appointments regularly.
45. During the session the man became upset about the hurt he had caused to his
victims and their families. He said that he was feeling a little down due to losing
contact with his own family, but had found his own girlfriend to be supportive.
His key worker explained to him that if he felt depressed he could, and should,
approach a member of staff, no matter what time it was. He noted that, when
tactfully prompted, the man had expressed no intention of harming himself. He
organised an education training and employment referral to be made in order to
give him access to Newcastle Futures, an employment and career advice charity
in the city.
46. The key worker told the investigator that the man was emotional during their
meeting. He was not clear whether he was upset about his own position, that of
his victims, or his family, saying that it was difficult to tell. He was satisfied that,
given his presentation, the man’s risk of harming himself had not increased since
his earlier completion of the risk assessment which had put him at medium risk.
The key worker said that the man wanted to engage in employment and was
looking to the future.
47. At around 4.30pm the offender manager, who in addition to being the man’s
offender manager also worked at the approved premises as a support worker,
met with him again. The man said that he had settled into Ozanam House, but
wanted to move to his girlfriend’s home as soon as possible. They discussed his
offence focussed work and possible programmes to be completed to assist him
to reach his targets. He again expressed his wish to continue with possible
employment in estate management or game keeping. During their meeting the
offender manager also had a brief discussion with him about his parents’ request
that he should not contact them for the time being. He noted that the man
appeared to accept this and did not appear distressed or tearful. During the
meeting he showed no indication that he might harm himself. However, he told
the offender manager that he was disgusted at what he had done and ashamed
at the disgrace he had brought on his parents by his offending.
48. The man briefly left the approved premises with another resident, then returned
and spent most of the evening in the lounge watching television. At 10.10pm he
was issued with his medication.
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49. At 7.40am on 11 December, the night care worker carried out a routine room
check on the man. He told her that he had been up all night feeling sick and had
not slept well. He asked if he could stay in bed. She told him that he could stay
in bed all day if he wished, but suggested that he should come down to the
kitchen for a drink and some toast. He declined the suggestion. At 1.02pm he
left the approved premises and he never returned.
50. A relief support worker said she received a call from a friend of the man at about
8.10pm asking whether or not he had returned to the approved premises. She
said his friend called again about half an hour later. When he failed to return
before his curfew time she notified the police, thus initiating the process that
would lead to his recall to prison custody.
51. At 4.10pm on 12 December, staff at the approved premises learned from the
police that a body, thought to be that of the man, had been found in woods in
County Durham. At 1.10am the following morning staff were informed that his
body had been formally identified and that his parents had been notified of his
death.
52. The approved premises manager contacted the man’s family the following day
inviting them to visit Ozanam House, but they declined.
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ISSUES CONSIDERED
53. In his report the clinical reviewer says that:
“It was clearly recognised from an early stage in the man’s custodial sentence
that he was not coping mentally with the circumstances that led to his
conviction or thereafter with the socio-domestic circumstances that were
compounded by his conviction. It is commendable that health care
professionals interacting with him in the custodial setting were able to
recognise such. It is also commendable that he felt able to trust the
healthcare professionals he was interacting with to be able to share with
them, not only the circumstances surrounding his conviction, but his family
circumstances which seemed to be a significant stressor causing him some
considerable mental pain.”
54. He goes on to say that the man would seem to have, “… focused hope on his
dog, his two children and his own parents as the light to aim for at what he saw
as a very dark tunnel”. He adds that it would seem that he was very remorseful
as to the circumstances that led to his conviction. He says that:
“Whilst the man seemed to accept that his liberty had been deprived for
good reason, this clearly did not prevent health care professionals at HMP
Acklington behaving in an appropriate, professional and commendable
manner, specifically the professionalism of the CPN who extended her duty of
care by preparing him for release and providing a letter which he could use to
bridge his care from the custodial to the community setting.”
He says that although there was no clear evidence that the GP saw the CPN’s
referral letter, it was clear from his consultation with the man that his depression
was recognised and that he had lost contact with his family due to his conviction.
The GP recognised other symptoms and but judged that he was not suicidal
when seen during the consultation.
55. In his report the clinical reviewer says that the man’s death would seem to be an
unfortunate event which was not as a result of lack of healthcare
professionalism. He says that it is unlikely that any other course of action would
have changed the eventual outcome. He highlights that the:
“… good practice of the CPN in attempting to bridge the gap between
custodial and community health care professional services went a long way in
attempting to prevent what would seem to have been the unpreventable.”
56. He concludes that, “The standard of clinical care afforded to the man at the
relevant time would seem to equate, if not exceed that afforded to a man of
similar age and circumstances in the community setting.” I concur with the
clinical reviewer’s opinions and I am satisfied that the man was managed
appropriately by staff. I make no recommendations.
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CONCLUSION
57. After the man was sent to prison he received continual support from healthcare
staff, initially at Durham, and then upon his transfer to Acklington. As the clinical
reviewer notes it was commendable that he was able to trust staff at the prisons,
sharing deep and personal information with them in order that they could assist.
58. The prison mental health nurse prepared a handover letter which she gave to
the man. There being no evidence to suggest the contrary, he appears to have
not handed over, either to his GP or to staff, the letter which provided a summary
of his care. It might be that the outcome would have been different had he done
so. However, given the remorse and guilt that he had obviously experienced it is
difficult to say whether or not his death could have been prevented even if he
had handed the letter over. I conclude that staff who had contact with him, both
at Acklington and Ozanam House, could not have reasonably foreseen his
eventual actions and untimely death.
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