Individual at Isle of Wight

Investigation into the circumstances surrounding the
death of a man at HMP Camp Hill in July 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2008
This is the report of an investigation into the death of a man at HMP Camp Hill
on 14 July 2007. At 7.00am that morning, the man was found hanging in his
cell in the prison’s segregation unit. His death was pronounced at 7.15am.
I offer my deepest sympathy and condolences to the man’s family for their sad
and untimely loss. I also offer them my apologies for the time it has taken to
issue this report.
The investigation was conducted by my colleague. I also commissioned an
independent clinical review into the management of the man’s health while he
was in custody at Camp Hill. This was undertaken by a clinical reviewer of
the relevant Primary Care Trust. I am grateful to him for his contribution.
The man had not been in custody before, and he was anxious about cell
sharing as he had apparently been the victim of a sexual assault in his own
home. There are suggestions that his mood and behaviour may also have
been influenced by long years as a user of cannabis.
The investigation found significant systemic failures in relation to ACCT
procedures and the sharing of information about the man’s risk between HMP
Winchester and HMP Camp Hill as well as within HMP Camp Hill itself. I have
made a number of recommendations that I hope will help prevent a similar
tragedy occurring at Camp Hill or elsewhere in the Prison Service.
Stephen Shaw CBE
Prisons and Probation Ombudsman
July 2008
CONTENTS
Summary
Investigation process
HMP Camp Hill
Key events
Issues
Family concerns
Recommendations
SUMMARY
The man appeared at the Crown Court in June 2007 to face a charge of
possessing illegal drugs. He was sentenced to eight months imprisonment.
The man, who had not been in prison before, was initially taken to HMP
Winchester. On 2 July, he was transferred to HMP Camp Hill on the Isle of
Wight where he was allocated to a shared cell in the first night centre. Here,
he initially seemed to get on well with his cell mate. However, he told a
member of staff he had been sexually assaulted by another man in his flat
prior to being imprisoned and was fearful it could happen again in prison,
especially if he continued to share a cell.
Three days later, the man placed a noose around his neck without attaching it
to any ligature point and said he had swallowed a number of Propranolol
tablets given to him at Winchester for his anxiety. An Assessment, Care in
Custody and Teamwork (ACCT) form was opened and he was taken to a
hospital adjacent to the prison. Whilst there, he was assessed by a mental
health nurse. He told her about the sexual assault and about his continuing
fears. The nurse concluded that, if the man were to remain fearful, he might
experience further impulsive reactions. The man was discharged from
hospital to Camp Hill at about 9.00pm that evening. Details of the nurse’s
assessment were passed to a community psychiatric nurse (CPN) at Camp
Hill the following morning.
When he returned to the prison, the man was initially placed in the same cell
he had formerly occupied with another prisoner. However, a senior officer
who saw him that evening recommended he should move into a single cell in
St Patrick’s wing – which holds vulnerable prisoners – as soon as possible.
He was transferred into that unit at 10.00am the next morning. Shortly
afterwards, he was seen in his cell by another senior officer and a CPN who
together decided to close the ACCT form.
On 12 July, the man told staff he was being threatened by other prisoners.
His allegations were investigated by a senior officer who found them to be
without foundation. However, later that day he asked to be segregated for his
own safety and he was moved to the segregation unit. Two days later, he
was found hanging in his cell.
The investigation found evidence of poor transfer of medical information
between prisons, as well as a series of flaws in the ACCT procedures applied
at Camp Hill. There was poor communication between units about the events
that led to the opening of the man’s ACCT form. A mistake was made in the
assessment of his capacity to cope with segregation.
Although I criticise individual members of staff, I do not believe any one of
them can be held responsible for the man’s tragic death. However, I make a
number of recommendations that I urge the Governors of Winchester and
Camp Hill prison to implement as a matter of priority.
INVESTIGATION PROCESS
1. The investigation was opened at HMP Camp Hill on 18 July 2007. On
that day, my investigator met the Deputy Governor, the chair of the
local branch committee of the Prison Officers’ Association, the chair of
the local Independent Monitoring Board and the investigation liaison
officer. My investigator briefed the meeting on the nature and scope of
the investigation. The following day, notices were issued to staff and to
prisoners inviting anyone with information or concerns relating to the
man’s death to make themselves known to my investigator.
2. My investigator returned to Camp Hill on a number of occasions to
conduct interviews with a total of 19 members of staff and six
prisoners. A number of issues regarding the man’s management at
Winchester were examined through correspondence with the Governor
and Head of Healthcare. My investigator also conducted informal
discussions with a member of the healthcare team at Parkhurst and,
separately, with the Deputy Governor about matters raised by the
man’s sister. My investigator also spoke to the man’s legal
representative, who clarified matters about which the man’s sister was
concerned.
3. A clinical review of the management of the man’s health needs was
conducted by a doctor from the local Primary Care Trust. The clinical
reviewer dealt with a number of issues by correspondence with the
Governor and Head of Healthcare at Winchester. He also attended
some of the interviews conducted at Camp Hill.
4. On 29 August, my investigator and one of my family liaison officers,
met the man’s mother and sister to extend an invitation to express any
concerns about matters relating to his death. The questions they
raised about aspects of the man’s management at both Winchester
and Camp Hill prisons are addressed in this report.
THE MAN
5. The man’s sister has asked that the following text be used to describe
his background and personality:
“My brother was 36 years old when he left us, the
same age that our mum was when he came into the
world in Epsom in 1970. He was the fifth and youngest
child in the family. He leaves his two older brothers
and two older sisters, one of whom is me. Dad passed
away in 1999. He always kept a special look out for
my brother as he was always the most highly strung
and sensitive of the five of us. My brother was born
with a defect with one of his eyelids and underwent
several operations during his childhood to correct it.
These short periods away from the family for treatment
and self consciousness about his appearance during
this time sometimes led him to believe that he did not
quite ‘fit in’ with everybody else, however much we
tried to persuade him otherwise.
“My brother was sweet natured and very intelligent. He
was creative and thought deeply about everything he
did, or planned to do. He was forever using his
inquisitive mind and notorious fidgety fingers to take
things apart and put them back together, not always
successfully. He was deeply interested in science and
technology in all forms. After leaving school with good
passes in all of his exams he tried working in a bank
but eventually settled down to an apprenticeship as an
electrician at the age of 17. This suited his
technological and mathematical interests for a time
until his recreational interests started to impact on his
life.
“He set about everything he did with the best
intentions. He was warm and loving when given the
opportunity and usually had a wide varying circle of
friends. He wanted to see the best in people and
would often befriend those that others in his circle had
shunned, as he himself felt shunned at times.
Unfortunately for my brother, his trusting nature would
often be betrayed in some way or another, leading to
him taking solace in other ways. He himself admitted
that the first time he started using cannabis was from
the age of 17 and it was from this point that his ability
to deal with life’s challenges was affected.
“He became increasingly highly strung and was also
very easily influenced by those around him, from whom
he was always seeking acceptance. There were
instances of petty crime in his late teens and early
twenties and this eventually led to him giving up his
studies completely and moving up to Yorkshire away
from the family for several years. During this period he
developed an interest in becoming a club DJ which
satisfied his love for all things lively and technical.
Unfortunately, this lifestyle is often accompanied by
drug and alcohol misuse and I feel it took its toll on him
both physically and mentally.
“We retraced my brother eventually and he rejoined
myself and our parents. My brother did not look in the
best of shape at that time but he gradually regained his
health and was able to spend a few years working in
various creative jobs, enjoying his pastimes such as golf,
darts and snooker and serving on the committee of our
local social club. Golf was something he shared as an
interest with both our parents. He once secretly
collected vouchers from cigarette packets and surprised
mum with a pair of tickets to go to watch the Benson and
Hedges Open golf championship. They enjoyed a great
day out together. Secret gifts like this were typical of my
brother – they may not have cost much but were always
very personal and meant a great deal.
“He genuinely meant the best for everyone else whose
path he crossed in life. Unfortunately, he would usually
put himself last. After the death of our father, he began
to associate more with some friends who had followed
him from Yorkshire and, yet again, alcohol and cannabis
use took their hold over him. He still continued to work
in various positions in catering by this time but was
finding it harder to keep up regular work routines
because of his lifestyle.
“My brother’s last few years were spent living alone in a
cottage with his beloved pet dog and cat. He suffered
insomnia and anxiety and was deemed as unfit for work
because of his cannabis dependence. He was still the
same sweet, sensitive soul underneath but was also
prone to rages borne out of frustration that he wanted a
partner and children but seemed unable to sustain a
relationship. He loved children and was always
fascinated by how they remained uninhibited and natural
in everything they tried to do. My children were
delighted each year when he came to spend Christmas
Day with us. My son loved playing the PlayStation with
my brother because he ‘knew how things work’. My
daughter would sit and create art projects with him for
hours because of his patience and gentle nature.
“My brother had a close circle of friends who have told
me about the great knowledge and fascination he had
with the technicalities of the production of cannabis
plants at his home. He began this to sustain his habit
and it became a great labour of love for him to cultivate
and cross pollinate various varieties. Unfortunately, this
is where it all starts to unravel. His pastime and his
dependence led him to community supervision orders
and, ultimately, the custodial sentence where his journey
came to an end.”
HMP CAMP HILL
6. Camp Hill, a closed category C training establishment, is one of three
prisons situated near Newport on the Isle of Wight. At the time of the
investigation, Camp Hill could hold up to 595 adult male prisoners.
7. The prison comprises nine residential units ranging from Victorian style
galleried units to single corridor buildings. Some of the units have
specific functions. St Andrew’s is the First Night Centre and St David’s
is the Induction Unit. St Patrick’s holds vulnerable prisoners. St
Stephen’s holds prisoners who have reached the enhanced level of
privileges. There is also a segregation unit that can hold up to 19
prisoners.
8. The prison was last inspected by HM Chief Inspector of Prisons in
August 2006. The report of that inspection, published in January 2007,
was critical of the quality of some of the prison’s functions, including
suicide prevention. In their report on Camp Hill for the period 1 August
2005 to 31 July 2006, the local Independent Monitoring Board raised
no issues or concerns about suicide prevention or any other matter
relevant to this investigation.
9. I have investigated one previous self-inflicted death at Camp Hill. The
recommendations I made in the report of that investigation are not
relevant here.
KEY EVENTS
Background
Appearance in court
10. On 14 June 2007, the man appeared at the Crown Court charged with
possession of illegal drugs after police officers had found cannabis
plants in his flat. Court officials confirmed that the hearing had been
brought forward by a day. The man pleaded guilty and was sentenced
to eight months imprisonment. Although he had 21 previous
convictions, this was his first custodial sentence. He would have been
due for release four months later.
Journey to Winchester
11. After his court appearance, the man was taken to HMP Winchester, the
local prison that serves the Magistrates’ and Crown Courts. The
journey was completed in two parts. The man was initially taken to a
police station and held there overnight. The next day (15 June), he
was taken to Winchester.
12. The Prisoner Custody Officer (PCO), one of the people responsible for
escorting the man to Winchester, completed a Suicide/ Self Harm
Warning Form at 11.45am that day. The purpose of this form is to alert
other agencies, especially the Prison Service, to a perceived risk of
self-harm or suicide so that measures can be taken to monitor and
reduce the prisoner’s risk. The PCO wrote on the form:
“Shocked at sentence. States to have taken more
medication which was prescribed by GP. Taken in
May but did not overdose. Slept it off. More positive
after talking to his barrister. States he is not suicidal
at all.”
13. The warning form was posted to Camp Hill from Winchester on 7 August
2007, over three weeks after the man’s death.
14. A note was also made on the Prisoner Escort Records (PERs) for both
parts of the journey indicating that the man presented a risk of suicide.
Winchester: 15 June - 2 July
Reception procedures
15. The man told a member of the reception staff at Winchester that he
had been born in Surrey in 1970. He said he was single and gave the
address at which he had been living. He said his next of kin was his
mother who lived in the same area.
Health screen
16. As part of the normal reception procedures, the man underwent an
initial health screen. The record of that screen was passed on to Camp
Hill when he was transferred there on 2 July. The record reflected only
the man’s height, weight, blood pressure, the fact that he was a smoker
and that he had no known allergies. In fact, much more information
was entered in his electronic medical record, but this was not obtained
from Winchester until after his death. That electronic record contains
the following details:
“History of psychiatric disorder. Ongoing episodes of
depression. Has good insight into his condition.
Prescribed Propranonol 15mg OD. History of
attempted suicide. Patient has attempted to overdose 3
times in the last 3 years. States has no thought of
deliberate self-harm. Is aware he can talk to staff
should he feel unwell. Patient’s ex-partner has now
moved on, making his life less stressful. Presents with
good eye contact, is polite and communicative. History
of alcoholism. States binge drinker at weekend
otherwise drinks 10 units daily. Patient not presenting
with any sign of DTs [delirium tremens].”
17. The following day, the man was prescribed 28 10mg Propranonol
tablets. He was to take one tablet each day. However, it appears the
prescription was not dispensed at that time and the tablets were not
given to him until 25 June. The man was not subject to any formal self-
harm monitoring procedures.
Cell sharing risk assessment
18. A member of the reception staff also carried out a cell sharing risk
assessment. The purpose of this assessment was to measure the
man’s risk of harming others. The assessment informed the decision
as to whether he could be placed in a cell on his own or with another
prisoner. The assessor considered that the man presented a low risk
of harming others and could therefore share a cell.
Medical interventions
19. The following entries were made in the man’s medical record while he
was at Winchester:
17 June: “Alcohol detoxification. Alcohol score of 2 today. Coping at
present.”
18 June: “Seen by nurse. No changes. Due to be seen by Detox Dr
tomorrow as no time today.”
19 June: “Detoxification = drug chart was in HCC and was not returned
till late afternoon. Therefore missed afternoon dose of
chlordiazepoxide. Reviewed by Dr given double dose this nocte by s/n
as prescribed.” (Chlordiazepoxide is normally prescribed to relieve
anxiety and to control agitation caused by alcohol.)
20 June: “Detoxification CDP 20mg routine alcohol detox. No
problems.”
21 June: “Eczema NOS infected eczematous rash on shins.”
22 June: “Seen by nurse detox. Detox completed.”
25 June: “Seen by nurse. Seen at A wing meds room. States has
been asking for Propanolol 10 mg for over a week now and nothing has
been sorted. Explained that once drug round had finished would find
out what has happened. Propanolol not in trolley, chart not present
either.”.
(Propanolol is normally prescribed to help control the physical signs of
anxiety.)
25 June: “Seen by nurse. Discussed with pharmacy, the only thing
they have supplied is Fucidin. Propanolol not supplied as they have
not received a prescription. To inform GP.”
25 June: “Administration NOS script for propanolol re-done not
received from pharmacy.”
26 June: “Seen by nurse. Fit for transfer.”
Offender Assessment system (OASys) report
20. On 26 June, the man’s probation officer completed an OASys
assessment. This is a means by which prisoners’ sentence planning
needs can be ascertained. In the report that followed her assessment,
the probation officer wrote an extensive commentary on the man’s
social and criminal history. She said he was, by his known admission,
addicted to cannabis. He had produced his own supply of the drug in
order to feed his habit and because it was cheaper to grow his own
than to buy it on the streets. The probation officer also recorded that
the man was single and was content to remain so. Although he was an
intelligent man, he was currently unable to work because of poor
health. The probation officer wrote that the man was being treated for
depression and had previously taken an overdose of drugs. She said
he was “not currently medicated because his doctor was reluctant to
prescribe with his heavy cannabis use” which was “a link to his
symptoms”. The probation officer thought the man could benefit from
detoxification now that he had been imprisoned and could
consequently start the process of dealing with his depression. She
recorded her opinion that self-harm or suicide was a possibility,
although she did not think that was a current problem. She also
thought that a negative emotional state, exacerbated by misuse of
cannabis or alcohol, were factors that might increase his risk.
CARATs (Counselling, Assessment, Referral, Advice and Throughcare
service) assessment
21. The following day, a CARATs worker at Winchester interviewed the
man. He told her he had been living alone in a rented flat. The man
admitted that he normally spent between £30 and £60 a week on
cannabis and between £20 and £30 a week on alcohol. He said he
was registered with a doctor in his home area. He wanted support in
remaining drug free. The CARATS worker therefore referred him for a
one day drug awareness course and suggested he was a candidate for
the Short Duration Drug Programme.
Transfer to Camp Hill
22. On 2 July 2007, the man was transferred to Camp Hill prison on the
Isle of Wight. That day, the CARATS worker recorded in the man’s
transfer plan that she had sent his Drug Intervention Record (DIR) to
the Drug Intervention Programme on the Isle of Wight for support and
throughcare on release. the CARATS worker also recorded that she
had discussed harm minimisation, low tolerance and overdose
prevention with the man. Her concluding remarks were:
“Care plan and DIR completed 27June 07. Unable to
complete Comprehensive Substance Misuse
Assessment [CSMA] as transferred on 2 July. Not
completed 1 day drug awareness as transferred before
next course available.”
23. During the man’s brief stay at Winchester, he gave no indications that
he was at risk of self-harm or suicide.
Camp Hill: 2 - 14 July
24. The man left Winchester under escort at 10.35 am on 2 July and
arrived at Camp Hill at 1.40pm. The Prisoner Escort Record for the
journey between the two prisons carried no notation of any risk of self-
harm nor of any medical or security factors other than the abuse of
drugs. The journey was uneventful.
Health screen
25. Upon his arrival at Camp Hill, the man underwent a further health
screen. This was conducted by a nurse who pointed out to my
investigator that the details of the man’s medical history available to
her during the reception procedures were scant. She said some
medical information was sent to Camp Hill after his arrival. The health
screen nurse said the details recorded during the health screen were
therefore based largely on what the man told her. She made the
following comments in his electronic medical record:
“Seen in general medical clinic. Seen Camp Hill
healthcare. Fit 1B gym, 2 labour. Appears anxious in
mood. Is on promethazine 50mg nocte, has a supply in
possession (26 tabs). Requesting a review by MO.
Appointment given. Smoker tobacco consumption.
Weight 61kgs. Height 1.84 metres. Blood pressure
108/77.”
(Promethazine is normally prescribed to help relieve anxiety.)
26. The health screen nurse also completed a separate health screen form
on which she recorded that the man was not subject to an Assessment,
Care in Custody and Teamwork (ACCT) plan (this is used to monitor and
support prisoners who are considered to be at risk of self-harm or
suicide), had never been the subject of ACCT procedures and did not
currently feel suicidal. She also commented that he was currently on a
course of medication and that he wanted to see a doctor. There is no
evidence in his medical record to show whether this happened.
Cell sharing risk assessment
27. A cell sharing risk assessment was carried out the same day by an
officer. He ticked the box to indicate that the man had previously been
subject to a form F2052SH. (This is a document formerly used by the
Prison Service to monitor any prisoner considered to be at risk of self-
harm or suicide. It has now been replaced by the ACCT form.)
28. At interview, the officer who carried out the cell risk assessment said
he could not recall anything about the man. He was uncertain why he
had indicated on the cell sharing risk assessment form that the man
had been subject to F2052SH procedures. However, he thought that
as he had not been in prison before he might not have known what a
F2052SH was. The officer thought he might therefore have asked the
man if he had ever felt suicidal or had self-harmed. He thought the
way he had completed the form was likely to have reflected that the
man said he had self-harmed rather than that he had previously been
subject to F2052SH procedures. At the end of the process, the officer
judged that the man presented a low risk of harming others and could
therefore be allocated to a shared cell.
29. The officer who carried out the cell risk assessment said the healthcare
section of the cell sharing risk assessment form was always completed
in the adjacent healthcare centre rather than in reception. The health
screen nurse completed that task. She too concluded that the man
presented a low risk of harming others. However, in answer to the
question, “Following the self-harm assessment, have any concerns
been raised?”, she ticked neither the ‘yes’ nor the ‘no’ box. At
interview, she said she could not recall whether she looked at the
sections of the form completed by the officer before completing her
own section. The form was countersigned by a senior officer who
agreed with the judgement that it was safe for the man to share a cell
at that point.
Allocation to St Andrew’s wing
30. The induction wing at Camp Hill comprises two units: St David’s and St
Andrew’s. The latter operates as the prison’s First Night Centre. In
keeping with normal procedures, the man was allocated to St
Andrew’s. Here, he was placed in a cell with another prisoner. At
interview, this prisoner told my investigator he had travelled to Camp
Hill in the same vehicle as the man that day but they did not meet until
after they had alighted. He said they walked together from reception to
cell 19 on St Andrew’s wing at about 3.00pm. The man told the
prisoner he had not been in prison before. He said he was frightened
of being in prison and did not like confrontations. The man said he was
in prison because he had grown cannabis. According to the prisoner,
he and the man shared a cell for just under a week. During that period,
the man would sometimes tell jokes and at other times he was just
quiet. The prisoner said the man ate all his meals and was a tidy man.
The prisoner also said the man did not give him any impression that he
was suffering from abuse of drugs or that he was feeling suicidal.
Conversation with Listener
31. On 4 July, the man told an officer, who worked in the First Night
Centre, that he wanted to speak to a Listener - a prisoner trained by
the Samaritans to offer support to prisoners in distress. At interview,
the officer said the man seemed tense and impatient. He rang another
wing to ask for a Listener to see the man in the First Night Centre. At
about 11.00am, one of ten Listeners at Camp Hill at the time, saw the
man and spent about 90 minutes with him. My investigator later
interviewed the Listener in the presence of a Samaritan. The Listener
said the man told him he was depressed but was in a better frame of
mind by the time their discussion came to an end. However, because
of the confidentiality that exists between Listeners and their clients, he
was unable to offer my investigator any other details of his discussion
with the man.
Discussions with a Senior Officer
32. At the time of the investigation, a Senior Officer was the manager of
the induction unit. At interview, she told my investigator that the man
had approached her one morning in the First Night Centre but she
could not remember which day this happened. She said he had told
her that, although he was getting on with his cell mate, he preferred to
be in a cell on his own. The senior officer asked him what his problem
was. He told her he found it difficult to sleep in a cell with another
prisoner because of things that had happened to him in the past. At
that stage he did not explain what he meant. Despite this, he
reassured the senior officer he felt safe sharing a cell with his cellmate.
In light of this, the senior officer did not consider it necessary to take
any further action.
33. The senior officer told my investigator that on another occasion - again
she could not remember quite when – the man asked if he could tell
her something in confidence. She therefore took him into the
manager’s office. The man told her he found sharing a cell difficult
because he had been raped by another man in his own home before
he came to prison. The senior officer could see the man was
distressed. She therefore told him she would do her best to find him a
single cell in a smaller unit. The man told her he would be happy to
remain in the same cell as his current cellmate until an alternative cell
could be found. The senior officer thought she also told the man she
would refer him to a Community Psychiatric Nurse (CPN). She said
the next time she saw the man was on 6 July.
ACCT form opened after acts of self-harm
34. The cellmate told my investigator that on 5 July the man woke him up
at about 5.00am and said, “Can you get this off me? I’ve tied it too
tight.” At interview, the cellmate said he saw that the man had a
ligature round his neck made from a torn bedsheet but had not
attached the other end of the ligature to anything. The cellmate said:
“He was standing up when he woke me. I was shocked
and said, ‘What are you doing?’ He said, ‘I’ve just tried
to take my life by cutting off the air supply.’ There was
a red mark round his neck. There was nothing else
wrong with him. I took the cord away. He then rang the
cell bell. He put the ligature in the bin. He also said
he’d taken some tablets. They were for anxiety. I
believed him because I checked the box the tablets
were in. There were only about 12 tablets in there in
the beginning but there were none left. He was taken
straight out of the cell. The staff asked me what had
happened. I said I’d helped to get the ligature off his
neck. That night he came back into the cell. He was
apologetic. He said he’d left me a suicide note. He
found it and let me see it. He just said sorry. He put
the note back in his cupboard. I was shocked. I stayed
awake the whole of that night so I could offer him
support if he needed it. He fell asleep. He was put in
another cell on his own. He wanted his own space. I
feel he should not have been put in a single cell. No-
one shouted out of the window at him. No-one bullied
him. He wasn’t frightened of others. He did tell me
once or twice he thought people were talking about him.
I told him he was paranoid because of the effects of
cannabis. He promised me he would not self-harm
again.”
35. The note to which the cellmate referred was later handed to my
investigator by a member of staff. It contained a number of pictorial
images and the words:
“Sorry, I just can’t take being raped. (Name withheld)
who did it is guilty. Sorry [cellmate named], you’re a
nice bloke.”
36. The man’s prison record shows that, at about 6.45am that day, he had
pressed his cell bell. He reported to the member of staff on duty in St
Andrew’s wing, that he had placed a ligature round his neck and had
swallowed a number of Propanolol tablets that had been issued to
alleviate his anxiety. At first glance, there seems to have been a
significant delay between the time the man woke his cell mate and the
time he pressed his cell bell. However, it is possible that the cellmate
may have been woken up later than 5.00am. There was certainly no
evidence to suggest there was a delay in the response by staff.
37. The member of staff on duty in St Andrew’s wing saw no obvious signs
that the man had been physically harmed and noticed that a ligature,
made out of a piece of torn bedsheet, had been thrown into the rubbish
bin in the cell. The member of staff retrieved it. He decided to alert the
Orderly Officer.
38. At interview, the Orderly Officer explained that, when he arrived at the
cell, the man gave him the same version of events as he had earlier
given to the member of staff on duty in St Andrews wing. The Orderly
Officer then asked the cellmate if he could confirm what the man had
said. The Orderly Officer said the cellmate “denied any knowledge of
anything”, including removing the man’s ligature. According to the
Orderly Officer, the cellmate also denied seeing any red marks on the
man’s neck. The Orderly Officer checked the man’s neck himself and
saw no marks. My investigator suggested to the Orderly Officer that
there was a possibility that the man may have wanted to use the
bedsheet as a garrotte rather than as a ligature. The Orderly Officer
expressed his view that neither option was likely to have been
successful because of the flimsy nature of the ligature which, he
thought, would have snapped easily under pressure.
39. The Orderly Officer explained that, when the man told him he had
taken some pills, he asked him what they were. The man gave him the
package in which the pills had been issued. He said he had taken 24
pills. The Orderly Officer noticed that the package the man gave him
was empty. However, the Orderly Officer said the man did not appear
to be ill: he was not being sick and did not look pale. There were no
visible signs of any injury or symptoms of illness.
40. The Orderly Officer said he telephoned HMP Parkhurst to take advice
as to what, if any, danger the man might be in and what action should
be taken. (It is not unusual for such advice to be sought from
Parkhurst as it is the only one of the three prisons on the Isle of Wight
that has inpatient facilities.) The person to whom the Orderly Officer
spoke said he would call the hospital and would then ring back. The
advice the Orderly Officer received was that the man should be taken
to hospital.
41. As the end of the Orderly Officer’s shift was approaching at that stage,
he said he made arrangements for the man to be taken to the local
hospital before handing over to other staff. The Orderly Officer also
decided to open an ACCT form. (As noted, this is used to monitor and
support prisoners who are considered to be at risk of self-harm or
suicide.) He did so before he went off duty and before the man left the
prison for the hospital. At 6.45am, the Orderly Officer recorded in the
‘Concern and Keep Safe’ section of the form:
“[The man] stated he had tied a piece of torn sheet
around his neck and taken his supply of 24 Propranolol
pills. States he is unable to cope with this, his first,
custodial sentence.”
42. The Orderly Officer drew up an immediate action plan for the man in
which he set the following two targets:
(cid:127) The man was to remain in same location in a shared cell.
(cid:127) He was to be observed twice per hour.
43. It was recorded that the man did not require telephone access (e.g. to
his family, or to the Samaritans) at that stage.
Admission to hospital
44. The records show the man left for the hospital at about 7.30am. He
remained in the hospital all that day. Whilst there, he was seen by
Registered Mental Nurse (RMN). She wrote in the man’s notes:
“5 July. Seen on MAU ([Medical Assessment Unit]
following alleged overdose of Propanolol and allegedly
tying bed sheets around head. [The man] was seen in
the presence of prison officers, handcuffed. He is
currently serving an 8 month sentence in relation to
growing cannabis. He presented as relaxed and
assertive, able to give a convoluted and comprehensive
history. He gave appropriate eye contact, spoke with
some rapidity but not pressured and was able to stay
focussed, no flight of ideas, but spoke at great length
without pausing. He described his history in full,
relating a violent incident toward his brother at age 8,
his awareness that his physical appearance
predisposed him to taunting and bullying at school and
an adult history of persistent and perpetual drug use.
He has used cannabis daily since age 17, in his youth
dabbled with other drugs but has consistently used
alcohol and cannabis. He presented with no overt
clinical symptoms of mental illness, but was clearly able
to describe his fear associated with being in prison. He
feels constantly intimidated and related an incident prior
to his imprisonment of an attempted male rape, which
has left him disturbed by nightmares and a
preoccupation that he is vulnerable to being raped in
prison. He is able to state that he is motivated to
remain out of prison on his release and has clearly
identified factors that are both protective and motivating
for the future. Today’s events were directly related to
his anticipation of an assault, either sexual or physical,
whilst in prison and he is focussed on a substance free
life on his release.
“Whilst he remains fearful, his disposition to impulsive
reactions remains a risk. Discussed with [the man] and
the prison officers and all agree that steps can be taken
to minimise risks for him tonight and a review will
automatically take place in the morning within the
prison. Prison in reach team to be notified by fax in the
morning. [The man] will return to prison tonight when
verified medically fit.”
45. The man was also assessed by a doctor who recorded the following
comments:
“36 year old man with alleged OD of 20 Propranolol.
Examination showed pulse 56 otherwise unremarkable.
This gentleman is clearly preoccupied with his abuse
prior to conviction and is having nightmares, is anxious
and is suspicious of others. As he has overdosed three
times and given precipitating factors, he is at increased
risk of doing this again.”
Notification to the man’s sister
46. The Orderly Officer at Camp Hill that day told my investigator he took it
upon himself to telephone the man’s sister to let her know what had
happened to her brother. He told her he would ring her back later that
day to update her about her brother’s progress at the hospital. He told
my investigator he did this during the afternoon but could not remember
when.
Discharge to Camp Hill
47. The man was discharged from the hospital shortly after 9.00pm. The
hospital authorities considered he did not need to be placed in a
healthcare centre. When he arrived at Camp Hill, he was seen by the
Orderly Officer who made the following entry in the ACCT form at
9.30pm:
“[The man] has returned from the hospital and is in a
vastly improved frame of mind. I had a long discussion
with him and his demeanour and intentions are much
happier. He states and promises he will not harm
himself again. He asked to go back in with his original
cell mate who I also spoke to earlier and is happy to
help [the man]. I strongly recommend [the man] is
placed in St Patrick’s Hall at the earliest date and NOT
in any other wing. He is very vulnerable and needs the
support of St Pats for the rest of his short time to do
sentence. He is to be observed every 30 minutes as a
precaution during patrol state and prior to full review on
6 July.”
48. The man was returned to his former cell in St Andrew’s wing with his
cellmate.
Move to St Patrick’s wing
49. Entries made in the ACCT ongoing record show that the night of 5/6 July
was uneventful. However, at 7.25am on 6 July, the man rang his cell
bell to attract the attention of staff. An officer responded. He made the
following entry in the man’s ACCT ongoing record:
“At 07.25 rang his cell bell handing me this. I assume
he thinks he is being moved to St Patrick’s Wing
today. I am not sure if we have spaces there yet? I
will inform the Andrew’s staff of this.”
50. Appended to the ACCT ongoing record presented to my investigator was
a copy of the note handed to the officer who responded to the cell bell. It
read as follows:
“Please don’t talk! Morning Boss. It’s [the man]. I’m
ready to be moved when the SO is ready. As I said to
the night staff, I’m supposed to go before morning
unlock. Last night I heard some shouts to me. The
whole wing knows what happened!”
51. The manager of the induction unit said that as soon as she came on duty
that morning she rang St Patrick’s wing to arrange for the man to be
allocated a single cell in that unit as soon as possible. A second officer
took the call. He told my investigator the man was brought over to the
unit from St Andrew’s just after 9.00am. As far as he could remember,
the manager of the induction unit did not tell him what had happened to
the man the previous day. He said he did not know the man had placed
a noose around his neck or that he had taken some tablets. Neither did
he know the man had been taken to hospital. However, the second
officer said he could remember the manager of the induction unit telling
him the man was on an ACCT form and that the document was brought
across to St Patrick’s wing with him. The second officer said he did not
read its contents. He placed the man in a single cell and as he did so he
asked him why he needed to be on his own. The man told the second
officer he had been sexually assaulted before he came into prison and
was frightened it could happen again if he remained in a shared cell.
The man did not say anything to the second officer about the events of
the previous day. The second officer said he offered the man his
support and thought he seemed happy now that he was in a single cell.
He did not think the man was at risk of self-harm.
52. Shortly before 10.00am, the manager of the induction unit rang the CPN
to ask him to join her in St Patrick’s wing so they could see the man
together to check how he was. A little later they met at his cell. They
saw he was unpacking. The manager of the induction unit thought the
man looked “the happiest she had seen him at Camp Hill”. She
introduced him to the CPN and asked if he had any concerns. The man
said to her, “Thank you very much for getting me over here and I feel
now that I am safe, I am secure”. She said she reassured him that he
could talk to anyone on St Patrick’s wing because the staffing ratio there
was higher than in other wings. The manager of the induction unit said
she and the CPN spent quite some time with the man in his cell talking
to him. Towards the end of their conversation, she asked the man if he
wanted his ACCT form to remain open. She said the man told her he did
not. She told my investigator that the conversation she and the CPN
had with the man constituted an ACCT case review. She later made a
record in the ACCT form which was in the wing office. She wrote:
“At 0800hrs, [the man] was told he would be going to St
Patrick’s. He was calm and happy. At 10.05 hrs, he
was transferred to St Patrick’s. CPN has taken part in
the consultation and it’s agreed by the man that now he
has a single cell, he feels safe and secure. He is happy
to have the ACCT closed.”
53. Whenever it is decided to close an ACCT form, the person who takes the
decision should indicate in a box in the bottom right hand corner of the
form the date upon which the post-closure interview will take place. The
purpose of this interview is to enable staff to assess how the at-risk
prisoner has coped without being monitored. The manager of the
induction unit did not enter the date of the post-closure interview.
Instead, she used the box to record the date of the ACCT case review
she had just held. Thus, a post-closure interview date was not planned
at that point.
54. The CPN told my investigator that, after he had received the telephone
call from the manager of the induction unit inviting him to see the man,
he rang the crisis team at the local hospital. The person to whom he
spoke read out the report prepared by the Registered Mental Nurse
(RMN). The CPN asked for a copy of the report to be faxed to him
straight away. He said he received it and read it before he saw the man.
He was therefore aware of the fact that the RMN had expressed her
concern that, whilst the man remained fearful, his disposition to
impulsive actions remained a risk. The CPN interpreted the risk as that
of self-harm. He said that, when he saw the man, he was satisfied he
was no longer fearful because he had been moved to a single cell. The
CPN also confirmed the man said he would not harm himself again.
However, the CPN said he was not aware that the meeting he and the
manager of the induction unit had with the man constituted an ACCT
case review until it was over. Neither was the CPN aware that the man
had earlier told the Orderly Officer, who opened the ACCT form, that he
“could not cope with this, his first custodial sentence”. The CPN said
that, had he known this, he would definitely have questioned the man.
He said he could remember that, after he had left the man’s cell, he
discussed “issues of single cell, issues of the male rape” with someone
in St Patrick’s wing but could not remember which member of staff he
spoke to. He did not make a record of these details in the Staff
Observations Book. (This book is used as a means of communicating
important information about a prisoner between staff, including those on
different shifts.)
Letter to friend
55. On 11 July 2007, the man wrote to a friend outside prison. In his letter,
he said he was optimistic he would get his “tag” (Home Detention
Curfew) release in August. The man also said he had completed his first
“tag” a year earlier with no breaches and was not going to grow “weed”
again because he had had enough of prison. He commented that he
thought it was “not too bad at Camp Hill”.
Allegations of bullying and request to be segregated
56. However, at 03.15am on 12 July, the man passed a note under his cell
door to the night patrol officer. The note read as follows:
“Gov or Miss,
“Bear with me. I know it’s long. Please don’t speak out
loud as I am in fear for my life on this wing. A
completely false rumour is going round the whole wing
that I am a nonce (Paedophile!) and I have heard with
my own ears that they plan to kill me!. Either that or it’s
the bloke next door to me, who has a similar name to
me. I can’t be sure who they mean. So when I heard
‘noncey [the man]’ this afternoon, it could have been
‘noncey [man next door’s name]’ (cell 39). I thought
they had been talking about him as I’m definitely not
one! But at the beginning of association tonight, the
two guys playing table tennis, both shaven headed,
said, ‘there’s the nonce up there!’ when I went to refill
my hot water, and I was the only person on the landing.
The whole wing has been talking and saying direct
language about this for days now and the comments
are getting very direct as I said above. If it is me they
think is like that, then I will need to be moved to Rule 45
I think. I had a very traumatic incident at my house
before I got sent down, which is why I had to be moved
here to a single cell:- a so-called friend tried to rape me
and then tried to kill me when I phoned the police. This
man has left me unable to sleep in the same room as
other men without me having unbearable nightmares,
and I tried to take my own life on Andrews wing as a
result. That’s when, after leaving hospital, once I was
checked over thoroughly for heart and brain damage, I
was given this single cell on a ‘safer’ wing.
“I’ve had a gut full of stress and anxiety due to these
things. Do you know what I mean? And can you
please help me as I may start feeling suicidal again if I
can’t be sure of my not being the object of some kind of
witch-hunt. Thank you for being patient.
“Signed.”
57. The night patrol left the note for the man’s wing manager, who saw him
that morning and talked to him about its contents. The wing manager
told the man he would investigate his claims. He interviewed six
prisoners without making them aware that it was the man whose claims
he was investigating. Each of the prisoners seen by the wing manager
denied saying any derogatory or abusive remarks of any kind. However,
one of them admitted shouting out of his window to tell other prisoners to
shut up. During the course of the wing manager’s investigation, the man
told him he had talked to the prisoner in the adjacent cell, whose name
was similar to his,about “sexual matters”. It became evident that his
conversations had been overheard. The wing manager strongly advised
the man to avoid having such conversations, especially if they could be
overheard by other prisoners who could be offended. Having
investigated his allegations, the wing manager came to the conclusion
that the man was not under any threat. He told the man of his findings.
He wrote in the Staff Observations Book:
“After interviewing a number of prisoners re [the man]
feeling under threat, it was established that a
conversation between him and (name withheld) through
their cell windows was offensive to other prisoners as it
was of a sexual nature. [The man] told that this was
inappropriate behaviour. In my judgement he is not
under threat and has been told to distance himself from
(name withheld).”
58. Later that day (12 July), the man asked to be segregated from other
prisoners. In his application form, he wrote:
“I have had trouble with the wing I am on as it has
become rumour that I could be a paedophile, but this
rumour is completely false. I was placed on this wing
after it became necessary for me to have a single cell
due to having repeated nightmares about a male rape
that took place at my house before I got sent down.
The rumours were spread by a lot of the inmates on the
wing for the last few days that my next door cell bloke
was a ‘nonce’ and the comments had become very
direct. Then yesterday I was pointed out as ‘noncey-
[man’s name]’ by two inmates for talking to him about
his sexual habits out of my window. I was merely trying
to ascertain what he was really like, but it had been
taken the wrong way by inmates below us and a plan
was afoot to get both of us as a ‘pair of nonces’!
“Therefore I now don’t feel safe here. I keep myself to
myself in prison so they took that as me being scared to
mix with them and jumped to the conclusion it was
because I am like the man in the next door cell. I don’t
fight or stand up to bullies well, so I’m vulnerable. The
whole situation has become life threatening. I heard
their plans.”
Segregation safety algorithm
59. A nurse completed an initial segregation safety algorithm. This process
is designed to ensure that a proper assessment is made of a prisoner’s
ability to cope with segregation. A number of questions must be
answered by the person filling in the form. One of those questions is,
“Has the person self-harmed in this period of custody/are they on an
open F2052SH/ACCT or is the person currently taking any anti-psychotic
medication?” The answer to this question given by the nurse was “No”.
In fact, the man had self-harmed on 5 July, as a result of which he was
taken to the local hospital and an ACCT form had been opened for 24
hours.
Authorisation of segregation
60. The algorithm was countersigned by the Head of Residence. In so
doing, the Head of Residence confirmed that he had read the initial
segregation safety assessment on the front page of the form and agreed
that the man’s segregation was “appropriate for operational reasons”.
61. At interview, the Head of Residence explained that he did not have any
background knowledge of the man when he signed the algorithm. He
said he therefore had no reason to question any of the responses
provided by the nurse. The Head of Residence said he was certainly
unaware of the fact that the man had self-harmed on 5 July and that he
had been spent that day in hospital.
62. The Head of Residence authorised the man’s application for
segregation. He was moved from St Patrick’s wing to the segregation
unit at about 2.20pm that day.
Events of 13 July
63. The officer on duty in the segregation unit on 13 July, at interview, told
my investigator he had infrequent contact with the man. The officer
described him as quiet and polite. According to the officer, the man
collected his meals and seemed quite normal. The officer said he was
aware the man had applied to be segregated in his own interests and
that an ACCT form had been opened and closed. The officer said he did
not know the reasons for the ACCT being opened.
64. Although no date had earlier been set for a post closure ACCT review, a
Senior Officer held one that afternoon. No-one else was present at the
review.
65. The following table shows the Senior Officer’s summary of the review:
Question Summary
How is the prisoner feeling now? The man states he is OK.
Have they any problems? States he felt threatened on St Pats and is
happier in seg.
Are they maintaining contact with family or Has not contacted family as yet but said he may
friends? If so, how? If not, why not? tomorrow.
Are they engaged in purposeful activity? Declined exercise today.
Are they settled in their location? More than on St Patrick’s.
Do they feel supported by cell mate, other Has access to Listener and Samaritans phone.
peers, Listeners, Samaritans phones?
Do they feel supported by staff? Yes.
Can they approach staff if circumstances Yes. States he will.
change?
Is a further interview required? Not at this point.
66. As can be seen from the table, the senior officer drew the conclusion
that a further interview with the man was not needed.
67. The officer on duty in the segregation unit said the man asked him for
writing paper at about tea time so that he could write some letters. The
officer obliged. The man wrote to his sister later that day. In his letter he
expressed his concerns for his safety but said he was looking forward to
seeing her and other members of his family on Saturday 14 or Sunday
15 July.
68. When the officer gave the man his writing paper, he told him he was
going to be moved to another part of the segregation unit where he could
have a television set in his cell. He was moved at about 6.00pm that
evening.
69. Amongst the property removed from the man’s cell after his death was a
personal diary. The last entry in the diary made by him on the eve of his
death was as follows:
“Canteen day! Had good sleep. So tired I didn’t even
attempt to read. Breakfast at 8am, then cell clean.
Showers Monday Wednesday and Friday only, but I’d
had proper good sink wash cuz didn’t think showers
would be segregated but they are. I’ll get one on
Monday definitely … [sister] spose to be visiting me
today but can’t cuz no visits at Camp Hill on Thurs or
Fri - I got told visits every day! Can’t wait to get into
proper cell with R-K this is so boring! Get visit
tomorrow or Sunday – Good! F***in seg is shite. But
only one month to go now! Wrote to [sister] today and
handed letter to screw then chilled out in my new
‘surroundings’ for afternoon. Fish and chips lunch was
nice and got nuff sugar for two in tea! I think I just
heard that the screws plan to make me go on exercise
tomorrow to get me beaten up! But I am not a nonce.
Might do myself tonite!”
70. It is not possible to suggest what time the man wrote these comments. It
is highly unlikely that any members of staff would have had cause to
read his diary. If they had, they would have had difficulty in deciphering
what he had written as his handwriting was so small.
71. The officer on duty in the segregation unit said he did not see the man
after he was moved to his new cell at 6.00pm. He told my investigator
he had no reason to believe the man was contemplating taking his own
life. Neither did he hear any shouting or conversations between him and
other prisoners.
72. That evening an officer was deployed to the segregation unit as
assistant Night Orderly Officer. He came on duty at 8.00pm. The
assistant Night Orderly Officer told my investigator his duties involved
not only working in the segregation unit but also completing a number of
tasks in other areas of the prison on the Night Orderly Officer’s behalf.
He said he was probably in the segregation unit for no more than a total
of about two hours. However, the assistant Night Orderly Officer said
the man did not press his cell bell during the night. He also said the man
did not shout through his door.
Events on 14 July
73. In a statement given to the Governor on 14 July after the man had died,
an officer confirmed that at approximately 5.40am that day he carried out
a roll check in the segregation unit. He said in his statement he saw
nothing untoward.
74. At approximately 6.55am, the assistant Night Orderly Officer carried out
a routine check of the segregated prisoners. When he looked through
the observation panel in the man’s cell door, the assistant Night Orderly
Officer saw him hanging from the top bunk in his cell. The man was in a
sitting position and was suspended by a ligature made from a piece of
his bed sheet. The assistant Night Orderly Officer used his radio to
summon assistance from other staff. Very soon afterwards, the
assistant Night Orderly Officer was joined by an OSG who had been
working in St Andrew’s wing, immediately adjacent to the segregation
unit. The OSG cut a section of the ligature between the man’s neck and
the point where it was secured to the bed, using a ligature knife.. It
appeared to both the assistant Night Orderly Officer and the OSG that
the man was dead. As a consequence, no attempts were made to
revive him.
75. At this point, the assistant Night Orderly Officer and the OSG were led
away from the cell by the Orderly Officer who had also arrived. The
Orderly Officer then examined the man in an attempt to find signs of life.
However, he could find no pulse or any evidence of breathing. As he did
so, the remainder of the ligature came away in his hand. The Orderly
Officer also thought the man was dead.
76. An ambulance crew arrived at 7.09am. They pronounced the man dead
at that time but his death was formally confirmed by a doctor at 8.38am.
77. A note written by the man to his mother and sister was later found in the
cell. It read as follows:
“Sorry Mum, [sister’s name] Everyone, I’ve got no
choice. The whole prison thinks I’m a nonce. There’s
no other way but to finish my life myself, not at the
hands of some bloody kangaroo court. I’m really
terrified of what I’m hearing out of my window. My old
wing is within earshot and it’s silent outside. I’m going
to have to do it because otherwise I will be let out for
exercise in the morning even though I don’t want to go.
I’m going to be killed then if I’m still alive. Hopefully I
won’t be. I’m not a nonce but what else can I do?
Proper terrified, it’s on! Goodbye. Xxx
“[name], look after [name] and [name]. Sorry mate.
Why me?”
78. The man’s criminal record shows that he had never been convicted of a
sex offence. Neither the interviews my investigator conducted nor the
documents he studied threw any light on the credibility of his beliefs that
he was being taunted or that he was going to be killed.
Informing the next of kin
79. A Governor, the Family Liaison Officer (FLO) at Camp Hill, broke the
news of the man’s death to his mother in person at her home at about
11.00am on 14 July. The FLO was accompanied by another Governor
from HMP Parkhurst.
80. The Governor of Camp Hill met the costs of the man’s funeral. He sent
a letter to his family in which he expressed his condolences. He also
arranged for flowers to be sent to the undertakers. A memorial service
was conducted at the prison on the day after the man’s funeral. His
sister was able to attend the service and to visit the cell in which her
brother died. The man’s belongings were later passed to his family.
ISSUES
81. Here I examine:
(cid:127) Whether the man’s health needs were adequately met at
Winchester and Camp Hill prisons.
(cid:127) Whether his risk of suicide was properly assessed, monitored and
managed.
(cid:127) Whether the response to the discovery of him hanging was prompt
and effective.
(cid:127) Whether staff at Camp Hill prison afforded appropriate courtesies
and support to the man’s family in the aftermath of his death.
82. I also provide responses to the concerns raised by the man’s mother and
sister.
Were the man’s health needs met?
Winchester
83. When the man entered HMP Winchester on 15 June 2007, he
underwent an initial health screen. This showed he had a history of
psychiatric disorder and that he had attempted to overdose on
prescribed medication on three occasions in the previous three years. It
also revealed he had a history of alcohol abuse. The man had been
convicted of a drug related offence and had not been in prison before.
84. The day after he arrived, the man was prescribed 28 10mg Propanolol
tablets. These were prescribed to alleviate his anxiety. He was to take
one tablet each day. However, the investigation found that he did not
receive the medication until 25 June when he complained about the
matter. This reflects very poorly upon HMP Winchester. Given that the
medication was prescribed for anxiety, the implications in terms of safer
custody speak for themselves.
85. The man was placed on a detoxification regime consisting of a
chlordiazepoxide prescription. This was terminated on 22 June 2007.
Three days earlier, the following entry was made in the man’s clinical
record:
“Detoxification – drug chart was in healthcare centre
and was not returned till late afternoon. Therefore
missed afternoon dose of chlordiazepoxide. Reviewed
by the doctor given double dose this nocte (night) by a
Staff Nurse as prescribed.”
86. Although steps were taken to administer to the man the missed dosage
of chlordiazepoxide, the absence of a drug chart should not cause a
prisoner to miss his medication.
The Primary Care Trust should review arrangements to ensure
that prescribed medication is administered to prisoners on time,
especially in the context of detoxification programmes.
87. The man was transferred to Camp Hill prison on 2 July 2007.
Substantial and important medical information about him that had been
stored electronically at Winchester was not included in the clinical record
sent to Camp Hill that day. One of the items of information missing from
the man’s notes was the fact that he had a history of self-harm. Thus,
the health screen conducted upon his arrival at Camp Hill was based on
very limited information most of which he volunteered himself. This is a
second example of poor administration that must not be repeated.
The Primary Care Trust must take urgent steps to ensure that
medical information stored electronically accompanies prisoners
at the point of their transfer to another establishment.
At paragraph 6.1 of the clinical review the following further
recommendation is made:
“During the first part of 2008, the PCT should consider
conducting a brief audit to ensure that the complete electronic
medical record is being transferred with prisoners from
Winchester.”
88. The man was assessed as being fit for his transfer to Camp Hill almost a
week before the transfer took place. Although the investigation found no
evidence that this was to his detriment, I consider that the time lapse
between the assessment of his fitness to transfer and the date of his
move was too long. In such circumstances, the possibility of a change
in the prisoner’s physical health or state of mind is, in my view, too great.
The Primary Care Trust should ensure that the assessment of
prisoners’ fitness to transfer takes place as near as possible to
the date of the transfer.
89. Whilst at Winchester, the man was referred to the CARATs team. His
case was taken up by a CARATS worker on 27 June. Recognising that
the man was to be transferred to Camp Hill on 2 July, the CARATS
worker drew up a transfer plan and sent his Drug Intervention Record to
the Drug Intervention Programme on the Isle of Wight so that the man
could receive throughcare and support on release. Had the man
remained at Winchester, the CARATS worker would have been able to
complete a comprehensive substance misuse assessment (CSMA).
However, this was not possible in the timescale available. The CARATS
worker noted in the man’s CARATs file that the CSMA had not been
completed and that the man had not been able to complete a one-day
drug awareness course because of the fact of his transfer. I am
impressed by the help and support the CARATS worker offered to the
man in the short time available to her and commend her for doing so.
Camp Hill
90. Upon his arrival at Camp Hill the man underwent a further health screen.
The fact that his medical notes were, at that point, incomplete, has
already been made. A nurse conducted a full health screen and
recorded that the man was at that time on a course of medication and
wanted to see a doctor. There is no evidence in his medical record to
show whether he in fact saw a doctor. The nurse also contributed to the
cell sharing risk assessment process. The healthcare professional with
responsibility for the completion of the assessment is required to tick a
‘yes’ or a ‘no’ box in answer to the question, “Following the self-harm
assessment, have any concerns been raised?” The nurse ticked neither
box. At interview, she could not recall whether she had studied the
information on the previous page of the form used. Although this
omission caused the man no detriment, I do not think it can pass without
comment:
The Governor should remind all his staff of the requirement to be
meticulous in their completion of cell sharing risk assessment
forms, especially in respect of the assessment of a prisoner’s risk
of harming himself or others.
91. The man was to spend only 12 days at Camp Hill before he died. In that
time, he came to the attention of the prison’s nursing and medical staff, a
representative of the mental health in-reach team, and the A&E staff and
specialists at the hospital as a result of an act of self-harm that occurred
three days after he arrived. I comment below on the manner in which
the man was managed at that critical time.
Was the man risk of suicide properly assessed, monitored and
managed?
Winchester
92. Before the man arrived at Winchester on 15 June 2007, the staff who
escorted him from court to the prison thought he presented a risk of self-
harm. A Prisoner Custody Officer (PCO) completed a suicide warning
form in order to bring his concerns about the man’s risk to the attention
of the reception staff at Winchester. However, the PCO concerned
wrote on the form that the man said he did not feel suicidal. I believe the
decision not to place him on self-harm monitoring procedures was
reasonable. At no stage during his brief stay at Winchester did the man
indicate any obvious signs that he was at risk of self-harm or suicide.
93. However, the investigation found that the suicide warning form was not
placed in the man’s prison record before he transferred to Camp Hill on
2 July. In fact, the form arrived at Camp Hill three weeks after his death.
I am seriously concerned at this administrative failure.
The Governor of Winchester should review the practices and
procedures in place in his establishment for the handling of
suicide warning forms in order to ensure that they:
(cid:127) are properly received from private security staff in reception;
(cid:127) are studied by reception staff;
(cid:127) attract a prompt and appropriate management reaction;
(cid:127) are filed promptly and securely in an appropriate place in the
prisoner’s record in a manner that makes for easy access if
required at a later stage, for example when the prisoner is
transferred to another establishment.
Camp Hill
94. The PER for the journey between Winchester and Camp Hill on 2 July
carried no notation of any risk of self harm. The man’s presentation
during the subsequent reception procedures at Camp Hill was such that
he was judged not to be at risk of self-harm. I believe that judgement
was reasonable.
95. It was not until three days later that the man gave staff cause for concern
about his state of mind. In the early hours of 5 July 2007, the man
placed a noose around his neck (albeit without attaching the other end to
anything) and claimed he had taken an overdose of Propanolol tablets.
As a result, he was immediately placed on ACCT monitoring and was
taken to the local hospital for assessment. I applaud the staff concerned
for their prompt and decisive action.
96. The man was discharged to Camp Hill at about 9.00pm that evening.
The hospital authorities did not consider it necessary for him to be kept
in a healthcare environment in the prison. With the man’s agreement, he
was initially returned to St Andrew’s wing where he shared a cell with his
original cellmate. The ACCT document remained in force. He was seen
by the Orderly Officer. The Orderly Officer noted that the man was in an
improved state of mind but was of the view that he should be moved to
St Patrick’s wing “at the earliest date” because of his vulnerability. The
Orderly Officer instructed that the man was to be observed every 30
minutes, “as a precaution during patrol state and prior to full review on 6
July”. I applaud the Orderly Officer’s judgement.
97. The man remained in St Andrew’s wing overnight. Arrangements were
made the following morning for him to transfer to St Patrick’s wing. He
was moved at about 10.00am. As this unit was principally for vulnerable
prisoners, it was in my view entirely appropriate for the man to be
located there. It is also my view that, given his fear of becoming the
victim of a further assault, it was appropriate for him to be placed in a
single cell. (I should emphasise that the investigation found no evidence
that any form of assault on him was likely to take place. It seems that
his fear was based solely on the trauma caused by the sexual assault
that had allegedly occurred in his flat prior to his imprisonment.)
98. However, from that point onwards, things started to go wrong. Although
my investigator believed those members of staff who had most contact
with the man upon his return from hospital had his best interests at
heart, he discovered a series of significant flaws in the way the ACCT
procedures were carried out. He also found evidence of poor
communication between individual members of staff and between units.
These were in relation to the events that preceded the man’s transfer
from St Andrew’s to St Patrick’s wing and with regard to events that
occurred during the few days the man was in St Patrick’s wing.
99. First, I provide a full examination of the quality of the ACCT procedures
carried out.
100. The ACCT system requires that a number of measures are taken.
These are the completion of the following:
(cid:127) The completion of a Concern and Keep Safe form
(cid:127) The completion of an immediate action plan
(cid:127) The completion of an initial assessment of the at-risk prisoner by a
trained assessor
(cid:127) The completion of a care and management plan, otherwise known
as a care map
(cid:127) The completion of the first ACCT case review within 24 hours
(cid:127) A post ACCT closure review should take place.
The Concern and Keep Safe form
101. The purpose of this form is to assist staff to elicit from the at-risk prisoner
the main problems that are causing the risk of self-harm or suicide. The
man’s record shows that the form was completed by the Orderly Officer
at 6.40am on 5 July. Significantly, the Orderly Officer noted that the man
had said he could not cope “on this, his first custodial sentence.”
102. I believe the Orderly Officer used the Concern and Keep Safe form
correctly. However, as I shall say later, the investigation found that staff
who were subsequently involved in managing the man, or in making key
decisions about him, seemed not to have taken any account of his
underlying anxiety as described by the Orderly Officer.
Immediate Action Plan
103. Using this form, staff are required to consider and record the most
appropriate environment and regime to support the prisoner at risk prior
to the first case review. The Orderly Officer devised the man’s plan.
The following objectives were set:
(cid:127) location: to remain in same location/shared cell
(cid:127) frequency of staff support: two observations per hour during patrol
state
(cid:127) phone access: not required at this stage.
104. I consider this plan was appropriate for the circumstances which the
Orderly Officer found.
Initial Assessment Interview
105. Paragraph 15.3 of the Suicide Prevention Policy document for Camp Hill
sets out the following policy for initial assessments:
“A trained assessor will conduct an assessment with
the at-risk prisoner unless there are exceptional
circumstances in that the prisoner has been admitted to
outside hospital and is too ill to be interviewed. In such
a case, this exceptional circumstance must be recorded
in the ACCT documentation.”
106. This policy statement is drawn from national guidelines that are
contained within the ACCT document. The guidelines stress that the
exceptional circumstances are that the prisoner must have been
admitted to outside hospital and is too ill to be interviewed.
107. The ACCT document sets out the structure for the conduct of the
assessment interview. The interviewer should make comments in
relation to the following matters:
(cid:127) the individual’s perception of the problems related to current
distress
(cid:127) issues relating and leading to the act of self-harm
(cid:127) previous acts of self-harm
(cid:127) current mental state
(cid:127) current suicidal thoughts and intentions
(cid:127) reasons for living and coping resources
(cid:127) any other areas for discussion, and
(cid:127) agree what is to happen now with the interview.
108. The matters discussed and recorded at the initial assessment should
then set the agenda for the first ACCT case review. This should
normally take place within 24 hours of opening the ACCT document.
109. The fact that no initial assessment was carried out was a significant
failure. It deprived prison staff of an opportunity to draw out of the man
the reasons behind his self-harm and, thereafter, accurately to measure
the risk he presented of further similar behaviour. It reduced the ability
of staff properly to set out a care plan against which they could monitor,
manage and reduce his risk. It also deprived the man himself of the
chance to become directly involved in that process from the outset.
110. The guidance I have quoted above is clear: the only circumstances in
which an initial assessment interview is not advised is when the at-risk
prisoner is in hospital and is too ill to be interviewed. I do not believe the
man fell into that category. I suspect the reason for the omission was
that the interview was simply overlooked because he was admitted to
hospital.
The Governor should make clear to all staff at Camp Hill that
ACCT initial assessment interviews must be conducted within
prescribed timescales unless the at-risk prisoner has been
admitted to hospital and is too ill to be interviewed. The Governor
should emphasise the importance of ensuring that at-risk
prisoners who are admitted temporarily to hospital do not slip
though the net.
The Governor may wish to consider whether this and my
subsequent recommendations about ACCT procedures should be
the subject of staff training.
111. The underlying problems that caused the man’s risk of self-harm were
assessed by the RMN when he was in hospital. The RMN came to the
conclusion that the man would be at further risk if he remained fearful of
an assault of the sort he claimed had occurred prior to his imprisonment.
112. The RMN’s assessment compensated for the fact that the same exercise
was not conducted by Camp Hill staff by means of an assessment
interview. However, the details of the RMN’s assessment were poorly
communicated within the prison.
The Governor should review his local suicide prevention policy in
order to ensure that it legislates for the prompt and effective
communication of information about an at-risk prisoner between
hospital authorities and prison staff as well as between relevant
units in the prison.
Care and management plan (care map)
113. The care map should set out how best to deliver the care and support
needed by the at-risk prisoner. The plan should have the agreement of
the prisoner concerned. The Prison Service has issued the following
guidelines for the creation of an effective care map:
(cid:127) it should engage the person at risk
(cid:127) it should identify the most urgent and pressing issues (i.e. the
problems that are causing the person at risk the most pain, the
resources that have most potential to support the person at risk,
and the level of risk itself, including any suicidal intent or plan)
(cid:127) it should set a small number of realistic and achievable goals
(cid:127) it should state clearly who will complete which action
(cid:127) it should be implemented
(cid:127) it should be reviewed and changed over time.
114. The Suicide Prevention policy document at Camp Hill requires the first
case review team to draw up a care map for the at-risk prisoner. The
investigation found that no care map was drawn up for the man. This
was because the ACCT had been closed at the first and only ACCT case
review on 6 July, the day after he returned from the hospital, and only 24
hours after it was opened.
The Governor should make clear to all his staff that a Care and
Management Plan (Care Map) must be drawn up in respect of all
at-risk prisoners as a matter of course, including those who are
temporarily admitted to outside hospital.
Closure of the ACCT form on 6 July
115. The ACCT document contains the following national guidelines for
closing the ACCT document and for the care of prisoners after their
ACCT documents have been closed:
“A significant number of people have killed themselves after
coming off the ACCT. To prevent this happening,
- encourage the person at risk to build up their own support
networks and coping strategies over the course of the
reviews. Reduce levels of support gradually.
- close the ACCT plan at a case review, when the case review
team judges that the level of risk has dropped sufficiently and
the individual’s resources and ability to cope with remaining
difficulties are adequate.
- at the closing case review, check whether the problems that
caused the ACCT plan to be opened have been resolved or
reduced in intensity, and that the person has access to at
least some resources that they find ‘life promoting’.”
116. I consider that these guidelines were not followed at the one and only
ACCT case review that was conducted on the morning of 6 July.
117. Although it was appropriate to place the man in a single cell in St
Patrick’s wing, more attention should have been paid to the effects this
would have upon his state of mind. His location in a cell on his own
must have increased his sense of isolation. Measures should have been
taken to monitor his ability to cope with that isolation over time. No
thought was given to a gradual reduction in the level of support he
required. Instead, the close supervision and support available was
suddenly withdrawn because the ACCT form was closed.
118. The manager of the induction unit and the CPN took the man at his word
when he told them he was content for the ACCT to be closed. As the
ACCT guidelines suggest, numerous prisoners go on to kill themselves
after the closure of their ACCT form.
119. Although the Prison Service offers no guidance as to how quickly an
ACCT form can be closed, I take the view that in the man’s
circumstances it was inappropriate to close it only 24 hours after he had
taken an overdose of prescribed drugs and placed a noose around his
neck. In that period, he had spent a day in hospital being assessed by a
doctor and a mental health nurse who considered that, as long as he
remained fearful (of being raped again), he was at risk of further
impulsive behaviour.
120. I suggest that more consideration should have been given to the man’s
underlying fears rather than to his overt behaviour when the manager of
the induction unit and the CPN reviewed his case on 6 July. The
investigation found no evidence that any ‘life promoting’ measures, such
as encouraging the man to mix with other prisoners and to take part in
constructive activities, were put in place either in St Andrew’s wing or in
St Patrick’s. Rather, there was a tacit acceptance that all that was
needed was to put him in a single cell.
121. But I have other serious concerns about the manner in which the case
review was conducted. These are as follows:
(cid:127) The review was held in the man’s cell. Although this offered the
advantage of being out of the sight and hearing of other prisoners, it
afforded little formality or authority to the proceedings. The review
should have been held in an office or room that was comfortable
and more spacious.
(cid:127) The man had only just arrived in St Patrick’s when the review was
conducted. He had just unpacked his belongings and been given
no time in which to adjust to his new environment. No thought was
given to allowing him to settle before judging the extent to which his
risk of self-harm had reduced.
(cid:127) The CPN told my investigator he did not know until the meeting was
drawing to a conclusion that it constituted a case review. If this was
the case, the manager of the induction unit should have made clear
to him from the outset the purpose of their meeting with him.
(cid:127) The manager of the induction unit conducted the review in the
absence of any members of staff from St Andrew’s wing in which
the events that led to the opening of the ACCT form had taken
place the day before. She could have chosen to invite a member of
staff in St Andrews wing, who was the first to respond when the
man said he had self-harmed, or the Senior Officer, who had
opened the ACCT form. It would also have been wise to have
invited a representative of St Patrick’s wing to the review, such as
the officer who saw the man when he arrived in the wing.
(cid:127) The CPN and the manager of the induction unit both believed that,
because the man had been placed in a cell on his own, the threat of
an assault had disappeared. Indeed, the man told them he felt safe
and secure and would not harm himself again. However, no
account was taken of the comments made in the Concern and Keep
Safe form by the Orderly Officer at 6.40am on 5 July that the man
could not cope with this, his first, prison sentence. This comment
was, in my view, an indication of a fear that was unlikely to diminish
within 24 hours. The comment was clearly recorded in the man’s
ACCT record for all to see.
122. The local procedural policy document for suicide prevention sets out the
following clear requirements for the conduct and timing of ACCT case
reviews:
(cid:127) all reviews will consist of a minimum of three people, at least
one of whom should be from outside the unit but who has some
knowledge of the prisoner
(cid:127) the initial review follows as soon as possible after assessment
but in any case within 24 hours of the concern being raised
(cid:127) the timing of further case reviews will be decided by each case
review team, based on the individual’s risk. A case review will
be conducted before transfer to another establishment or
residential unit.
123. The same document also sets out the following requirements for the
closure of ACCT forms:
“The ACCT document must only be closed where a multi-
disciplinary team, together with the prisoner, agree that any risk
has diminished sufficiently. The Care map will be updated
based on the individual’s needs and to assist him in developing
coping strategies to help reduce the risk of further self-harm or
suicide. Details in the Care map will be entered in the wing
observation book.”
124. The manner in which the case review was conducted was in
contravention of the national guidelines contained within the ACCT
form and the Governor’s own suicide prevention policies.
125. It is for the Governor to decide what, if any, action he wishes to take in
respect of those staff who did not follow the requirements that are
clearly set out in his policy document for the conduct of ACCT case
reviews and for the closure of ACCT documents.
The Governor should consider adding the following further
guidance to staff about the manner in which ACCT case reviews
should be conducted:
(cid:127) ACCT case reviews should not take place in a prisoner’s cell
other than in exceptional circumstances
(cid:127) The timing of ACCT case reviews should take account of the
specific circumstances of the at-risk prisoner under
consideration
(cid:127) The ACCT case manager should make clear the purpose of
each review in advance of the meeting.
The wing manager’s investigation into the man’s claims that he was
being threatened by other prisoners
126. The investigation found that the enquiries made by the wing manager
into the man’s claims that he was being threatened by other prisoners
were thorough, and that his conclusions were appropriate. However, in
the note the man passed under his door at 3.00am on 12 July that
gave rise to the wing manager’s investigation, he said he might start to
feel suicidal again if he could not be sure of not being the subject of
some kind of witch hunt. This significant comment was lost to the wing
manager and was not passed on to the staff in the segregation unit.
Whilst I make no formal recommendation, I believe the comment
should have been interpreted as an indication of the man’s continuing
risk of self-harm or suicide. Consideration should have been given to
re-opening the ACCT form.
The authorisation and management of the man’s segregation
Segregation safety algorithm
127. Before the man’s segregation could be authorised, a segregation
safety algorithm had to be completed. A nurse, who normally worked
at Parkhurst prison, undertook this task on 12 July.
128. The following table shows the questions posed in the algorithm:
1. Is the prisoner awaiting transfer to/being assessed for a bed in an NHS secure setting?
2. Has the prisoner self-harmed in this period of custody/are they on an open ACCT form or
is the prisoner currently taking any anti-psychotic medication?
3. Does the prisoner show any signs of being acutely unwell (e.g. psychotic/withdrawal from
drugs/significant physical injury) at the present time?
4. Do you think that the prisoner will be unable to cope with a period of segregation?
129. The nurse replied ‘no’ to each of these questions. Her answer to
question two was incorrect as the man had self-harmed on 5 July. The
nurse told my investigator over the telephone that she asked staff in
the segregation unit what they knew of the man’s background before
she completed the form. She said she was given no details of his self-
harm on 5 July or of his admission to the hospital that day.
130. Under the heading on the safety algorithm proforma, “Notes for
Healthcare” the following instructions are included for registered
nurses:
Complete the screen after:
(cid:127) a discussion with the prisoner
(cid:127) reference to his/her clinical record and any other relevant
documentation, e.g. incident report and ACCT if appropriate
(cid:127) gathering information from other members of the care
team/discipline staff
(cid:127) reviewing the nature of the incident which led to segregation
being necessary to check for indicators of mental distress.
131. The nurse was in error if all she did was to ask other staff whether the
man had self-harmed or had been subject to ACCT procedures. She
should have known she was required to make the full checks listed
above. Whoever she asked did not say that the man had self-harmed
on 5 July. This is clear evidence of a breakdown of communication
between key staff with regard to the events that led to the opening of
the man’s ACCT document, his move to a single cell in St Patrick’s
wing and his subsequent application for segregation.
132. The nurse told my investigator there had been a significant shortage of
healthcare staff in the three Isle of Wight prisons. This meant those on
duty were less likely to have any detailed knowledge of individual
prisoners.
133. I consider that the nurse could have been more diligent with regard to
the completion of the man’s segregation safety algorithm, irrespective
of staffing difficulties at the time.
The Governor, together with the Primary Care Trust, should
examine whether healthcare staffing levels are sufficient for the
provision of proper healthcare for prisoners.
134. The fact that the person in the segregation unit, to whom the nurse
spoke, seemed to know of the man’s recent history highlights the need
for there to be a structured means of communicating information about
vulnerable prisoners between units as well as between individual staff
in each unit. This is especially important in circumstances where an
ACCT form for an at-risk prisoner has recently been closed.
The Governor of Camp Hill should review his local suicide
prevention policy to ensure that the recent history of at-risk or
vulnerable prisoners is properly communicated to unit staff,
especially when a prisoner is moved from one unit to another.
The review should place special emphasis on the
communications structure to be followed in respect of those
prisoners who are poor copers.
135. The CPN told my investigator that segregation reviews are held once a
month, in keeping with the provisions of Prison Service Order (PSO)
1700. The purpose of the reviews is to enable staff and managers to
assess how each segregated prisoner is coping with the effects of
segregation and to take steps to offer prisoners support through the
provision of appropriate activities. The CPN thought that the man
might not have had a review board as the schedule of reviews might
have fallen outside the period he was in the unit. A senior manager at
Camp Hill, later told my investigator this was not the case. He said full
segregation review boards were held every two weeks, normally on a
Wednesday, and all newly segregated prisoners were reviewed after
72 hours. The Head of Residence confirmed that he scheduled the
first segregation review for 2.20pm on 15 July. The CPN did not see
the man again. I conclude that the provisions of Prison Service Order
1700, which sets out the policies for the management of segregated
prisoners, were about to be put into effect. The man’s first segregation
review board had been scheduled for 15 July, 72 hours after his initial
segregation.
136. At 6.00pm on 13 July, the man was moved to another cell in the
segregation unit in which it was possible for him to have a television
set. This was a positive development. The man was also given writing
materials so that he could send letters to his family. He immediately
wrote a letter to his sister in which he said how much he was looking
forward to seeing her and their mother on the forthcoming weekend.
There was no evidence in that letter to indicate that he was about to
take his own life.
Post closure review on 13 July
137. The following guidance with regard to post closure reviews is set out in
the ACCT document:
“Offer one and possibly more follow up interviews. The timing
will vary, e.g. a week and a month after closure may be
appropriate but it is for the case review team that decides on
closure to agree this.
At the post closure interview(s) discuss:
- how the prisoner is feeling now
- how they are managing with the problems that led to their
episode of distress
- whether they are now in contact with friends, family or some
other support
- whether they have now got something in their lives that they
feel positive about (e.g. work, art, exercise, education,
hobbies, something they enjoy that gives them a sense of
purpose)
- whether they can see alternative ways of dealing with a
similar problem should it arise in the future.”
138. By the time his post closure review was convened on 13 July, the man
had been located in the segregation unit for his own safety. The unit
manager conducted the review. He did so alone. The man told him he
had felt threatened in St Patrick’s wing but was more settled now that
he was segregated.
139. The investigation found no evidence that the unit manager was aware
of the comment the man wrote on 12 July in which he talked of the
possibility of being suicidal again. Moreover, the man’s presentation at
the post closure review gave him no reason to believe the man was at
risk of suicide at that point. He concluded that a further interview with
the man was not required at that stage.
140. However, the post closure review should have been conducted by a
multi-disciplinary team. I suggest that team could have included a
member of staff from St Patrick’s wing, the CPN or a member of the
healthcare staff, and another member of the segregation unit staff.
141. The unit manager asked the man many of the questions listed above.
The man’s answers clearly persuaded him that he was coping.
However, the post closure review took place only 24 hours after the
man had been moved from St Patrick’s wing into the segregation unit.
I believe it was too early to draw any firm conclusions as to whether it
was necessary to review him again. Whilst I make no formal
recommendation on this matter, I suggest that staff should err on the
side of caution when considering the need for more than one post
closure interview.
142. The events of 5 July were clearly recorded in the man’s ACCT
document but this information was not available to the segregation unit
staff as the document was closed on 6 July. Although the unit
manager knew the man had been subject to ACCT procedures, there is
no evidence that when he conducted the post closure review on 13
July he had the original ACCT form with him. It seems that for the
purpose of the post closure review he was required only to complete a
form and pass it to the Safer Custody Manager who then filed it with
the man’s ACCT document.
The Governor should review his local suicide prevention policy
and ensure that ACCT post closure interviews are conducted on a
multi-disciplinary basis and that the closed ACCT document
should be available for staff to study before and at the post
closure review.
Was the response to the discovery of the man hanging on 14 July
prompt and effective?
143. It was the assistant Night Orderly Officer who found the man hanging in
his cell at about 6.55am on 14 July. The officer immediately
summoned assistance and entered the cell. With assistance from
colleagues, he removed the ligature and checked for signs of life.
None was evident. The staff who entered the cell all believed the man
was already dead. Although no attempts were therefore made to
revive him, an ambulance was called. A paramedic crew arrived in the
cell at 7.09 am and immediately pronounced the man dead. Death was
confirmed by the prison doctor shortly after 8.30am.
144. I believe that in the circumstances, the decision not to attempt to revive
the man was reasonable.
Were appropriate courtesies and support afforded to the man’s family in
the aftermath of his death?
145. The man’s mother was informed of his death at approximately 10.00am
on 14 July, in person at her home by a Governor, the appointed Family
Liaison Officer at Camp Hill. As the man’s sister is a member of staff at
Parkhurst prison, the Governor was accompanied by a second
Governor, a senior manager at that establishment.
146. The man’s family have expressed their appreciation for the manner in
which they were informed of his death, and at the way they were
supported by Camp Hill and Parkhurst staff thereafter. I deal with their
remaining questions in the final section of this report.
FAMILY CONCERNS
147. Here I list the concerns expressed by the man’s family together with my
responses.
1. What victim support was offered to the man after the attack on him
in his home (believed to be on 14 February 2007) which led to the
discovery of his cannabis plants by the police attending the assault?
This attack had a profound effect on hiss confidence and fragile state
of mind as it was of a sexual nature by someone in his own home. He
subsequently complained of panic attacks and insomnia after cell
sharing with a succession of different men that brought the memories
of that night to him.
No evidence was made available to my investigator with regard to the
level of support offered to the man prior to his arrest, the investigation
of which would be beyond my terms of reference. He shared a cell
with only one prisoner whilst at Camp Hill. The investigation found
there was no conflict between the man and his cellmate. However, it is
clear that the man had a phobia about cell sharing which he made
known to staff. The manner in which this was handled is dealt with in
the main body of the report.
2. Why was the man’s court sentencing date brought forward by 24
hours at short notice? {This meant that no family member was in court
to see him at a very vulnerable time.]
The man’s solicitor told my investigator that officials at the court did
indeed bring forward by one day the man’s sentencing hearing. She
explained that this often happened and that she was not told of the
change until the day of the hearing.
3. Was any consideration given the fact that the man’s sister works as
an OSG at Parkhurst during the decision to transfer him to Camp Hill
so quickly into his sentence and after his initial detox? His sister was
opposed to the man being transferred to HMP Camp Hill as she did not
think that the regime there would suit him in his rehabilitation. She
feels that her position of employment at Parkhurst may have led to
some decisions being made that may have not been in the man’s best
interests. On the day of his first overdose attempt after three days at
Camp Hill, he was kept in hospital all day for treatment and
assessment. His sister was informed by telephone at 5:00pm that day
that he may well be transferred to E3 healthcare wing at Parkhurst for
some form of constant watch due to his state of mind at that time. This
would have impacted on her ability to carry out her duties at Parkhurst
and she is concerned that the man may not have been placed on E3
for that reason. This underlines the complications of partial clustering
of services between prisons of close geographical proximity, i.e. Camp
Hill and Parkhurst may currently be seen as separate, but their
healthcare services are the same. There was always a risk of a
situation like this occurring with the man being transferred into a prison
partially clustered with the one where his sister works.
The man was allocated to Camp Hill from Winchester because he was
a category C prisoner and because he was apparently keen to serve
his sentence on the Isle of Wight. The investigation found no evidence
that the allocation decision was made hastily. Neither was there any
evidence that the regime at Camp Hill was inappropriate for the man.
The employment of his sister as a member of staff at Parkhurst, a
higher security prison adjacent to Camp Hill, was not a factor in the
allocation decision. The investigation found no evidence that the man
brought this matter to the attention of staff at Winchester. My
investigator spoke to the Deputy Governor of Parkhurst who confirmed
that no conflict of interests arose during the brief time the man was at
Camp Hill.
With regard to the possibility of admitting the man to the inpatient unit
(E3) at Parkhurst, the investigation found no evidence that the man
was considered for admission. The Deputy Governor of Parkhurst told
my investigator she consulted the staff in the unit who confirmed they
had not been asked to consider his admission. She also confirmed
that, had he been admitted, she would have changed the shifts and/or
responsibilities of the man’s sister to ensure she would not
inadvertently come into contact with him. However, the investigation
found that after the man had told a member of staff at Camp Hill on 5
July that he had self-harmed, that member of staff telephoned a
colleague at Parkhurst to check what system should be followed to
move him to outside hospital.
4. How long was the man on an ACCT document after the first attempt
at self-harm?
The man’s ACCT form was opened at approximately 6.40am on 5 July
and closed at approximately 10.00am the next day. This matter is
dealt with in the main body of the report.
5 The man’s sister requested of the Deputy Governor via email to be
able to visit her brother on Tuesday 10 July at short notice as it was
her only rest day and she felt it important to see him by herself before
she was due to visit their mother on 15 July. Was any consideration
given to this request?
During the course of the investigation, my investigator wrote to the
Deputy Governor about this matter. He replied as follows:
“I interpreted [the man’s sister] email as an intention to visit and
not as a request for this to be authorised. Given the tragic
incident that went on to occur, I am obviously disturbed that [the
man’s] sister was possibly waiting for me to organise a visit for
her on 10th July. However, in honesty, I would still interpret that
email the same way reading it again today. I have checked the
Gate book entries for that date (10 July) and his sister is not
listed as visiting that day. Unfortunately, I cannot locate the
original bookings sheet. Had I been able to do so, I would have
been able to ascertain if she had telephoned to make a booking
herself.”
6. When the man refused to go out on association and requested a
move to the segregation unit on Thursday 12 August, was there any
consideration of his ACCT being re-opened or for the chaplain or a
counsellor to speak to him? The man mentioned in the last letters we
received (dated Tuesday 10 August) that he had been advised by a
CARATs counsellor that he would greatly benefit from counselling to
deal with his anxiety to do with the assault on him in his home, but said
he had been told he would receive this after his release and not before.
This is covered in the main body of the report. However, my
investigator was unable to clarify whether the man was told he would
only receive counselling after his release from prison.
7. When the man was actually moved down to the segregation unit
was he offered the opportunity to phone friends or family to ease his
mind in its state at that time? His sister strongly feels that if he had
been able to speak to herself or his mother on the phone it may have
calmed his panicked state of mind at that time. His sister asked the SO
in the segregation unit who showed me to the scene of the man’s death
about access to phone calls and was informed that prisoners there only
have access to the phone at weekends. Is this true?
The Deputy Governor has explained that domestic phone calls are
normally only permitted to prisoners in the segregation unit at
weekends. However, he said such calls are exceptionally authorised if
circumstances permit. The Deputy Governor was unable to confirm
whether the man was allowed to make any calls from the segregation
unit. His PIN phone record shows that the last call he made was at
8.29 on 11 July when he was still in St Patrick’s wing. The manner in
which the man was managed in the segregation unit is dealt with in the
main body of the report. However, I believe that prisoners segregated
at their own request should not be disadvantaged in respect of
telephone contact with their family. Indeed, given that they may have
requested segregation because they are fearful, such contact is all the
more important:
The Governor should review arrangements to ensure that
prisoners segregated at their own request are able to use the
telephone daily.
8. Was the information that the man had taken an overdose and was
in possession of a ligature on his attempt nine days previously passed
on to the segregation unit staff when he was transferred from St
Patrick’s wing?
This is covered in the main body of the report.
9. Was that information taken into consideration when the man was
moved from a single bed cell to one with double bunks on the night he
took his life?
Had there been only one bed in the man’s cell on the night he died, it
would still have been possible to find a ligature point elsewhere.
However, I understand the Governor of Camp Hill has since removed
double bunks from all the segregation unit cells. Given the risks of self-
harm in all segregation units, I believe this is a sensible action.
RECOMMENDATIONS
To the Governor of Winchester:
1. The Primary Care Trust should make arrangements to ensure that
prescribed medication is administered to prisoners on time,
especially in the context of detoxification programmes.
2. The Primary Care Trust must take urgent steps to ensure that
medical information stored electronically accompanies prisoners
at the point of their transfer to another establishment.
3. The Primary Care Trust should ensure that the assessment of
prisoners’ fitness to transfer takes place as near as possible to
the date of the transfer.
4. The Governor of Winchester should review the practices and
procedures in place in his establishment for the handling of
suicide warning forms in order to ensure that they:
(cid:127) are properly received from private security staff in reception;
(cid:127) are studied by reception staff;
(cid:127) attract a prompt and appropriate management reaction;
(cid:127) are filed securely in an appropriate place in the prisoner’s
record in a manner that makes for easy access if required at a
later stage.
Commendation
I am impressed by the help and support the CARATS worker offered to
the man in relation to the management of his drug abuse in the short
time available to her and commend her for doing so.
To the Governor of Camp Hill:
1. The Governor should remind all his staff of the requirement to be
meticulous in their completion of cell sharing risk assessment
forms, especially in respect of the assessment of a prisoner’s
risk of harming himself or others.
2. The Governor should review his local suicide prevention policy to
ensure that the recent history of at-risk or vulnerable prisoners
are properly communicated to unit staff, especially when a
prisoner is moved from one unit to another. The review should
place special emphasis on the communications structure to be
followed in respect of those prisoners who are poor copers.
3. The Governor should make clear to all his staff that a Care and
Management Plan (Care Map) must be drawn up in respect of all
at-risk prisoners as a matter of course, including those who are
temporarily admitted to outside hospital.
4. The Governor’s local suicide prevention policy should include
clear and detailed guidance to staff about the conduct and timing
of ACCT case reviews and about the factors to be taken into
consideration before decisions are made to close the document.
The Governor should consider what additional staff training may
be required in this subject area.
5. The Governor should consider adding the following further
guidance to staff about the manner in which ACCT case reviews
should be conducted:
(cid:127) ACCT case reviews should not take place in a prisoner’s cell
other than in exceptional circumstances
(cid:127) the timing of ACCT case reviews should take account of the
specific circumstances of the at-risk prisoner under
consideration
(cid:127) the ACCT case manager should make clear the purpose of
each review in advance of the meeting.
6. The Governor, together with the Primary Care Trust, should
examine whether healthcare staffing levels are sufficient for the
provision of proper healthcare for prisoners.
7. The Governor should review his local suicide prevention policy to
ensure that the recent history of at-risk or vulnerable prisoners is
properly communicated to unit staff, especially when a prisoner is
moved from one unit to another. The review should place special
emphasis on the communications structure to be followed in
respect of those prisoners who are ‘poor copers’.
8. The Governor should review his local suicide prevention policy to
ensure that ACCT post closure interviews are conducted on a
multi-disciplinary basis and that the closed ACCT document
should be available for staff to study before and at the post
closure review.
9. The Governor should review arrangements to ensure that
prisoners segregated at their own request are able to use the
telephone daily.
At consultation stage, the Prison Service confirmed that they accepted
all recommendations.